Describes legal epidemiology and an assessment of laws relating to electronic health information.Office for State, Tribal, Local and Territorial Support, Centers for Disease Control and Preventio

Menon, Akshara

Ramanathan, Tara

Schmit, Cason

Texas A&amp;M Repository

Assessing Electronic Health Records LawsTara Ramanathan, JD, MPHPublic Health Analyst, Public Health Law ProgramAkshara Menon, JD, MPHSenior ORISE Fellow, Public Health Law ProgramCason Schmit, JDORISE Fellow, Public Health Law ProgramOffice for State, Tribal, Local and Territorial SupportCenters for Disease Control and Prevention201 CSTE Annual ConferenceJune 17, 2014Office for State, Tribal, Local and Territorial SupportPublic Health Law ProgramDisclaimerThe contents of this presentation do not representofficial CDC determinations or policies. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of CDC.The contents are for educational purposes only and are not intended as a substitute for professional legal advice.   Always seek the advice of an attorney or other qualified professional with any questions you may have regarding a legal matter.Presentation Overview Background 50-state assessment of laws addressing electronic health information (EHI) Mapping the legal landscape Evaluating the impact of laws Next steps Questions and answersBACKGROUND: LAW AND EHILegal Epidemiology and Impact Research Definition  Systematic analysis of the characteristics, scope, implementation, and impact of public health laws Goals Increase the evidence base for laws’ impact on systems, outcomes, and economics Identify and encourage use of current legal epidemiology research methods Create a national platform for the study of laws among public health practitioners at CDC and other organizationsLegal Epidemiology and Impact Research: Services “Legal assessments”—through legal research, collect, analyze, and code STLT laws that impact public health “Policy surveillance” –longitudinal, scientific collection, coding, and analysis of laws important to health across jurisdictions “Legal evaluations”—link findings from legal research to public health data Return on investment and economic data Health statistics Organizational behaviorLEGAL ASSESSMENT OF EHI Objectives for Research Objective 1: Identify the EHI legal landscape Objective 2: Analyze laws pertaining to specific public health studies and existing data Objective 3: Provide foundation for future impact research in legal epidemiologyStudy Focus: EHI EHI—not electronic health records (EHR) alone Legal assessment addressing EHI• Applicable to additional data uses• Useful to draw legal analogies for emerging EHI issues• Consistent with trend to harmonize public health and healthcare goalsElectronic Health Information: Research Question Unique questions Differing perspectives Differing effectsImprovements to the Health SystemElectronic Health DataLawPublic Health ProgramsElectronic Health Information: Methodology What we did: Created a 2-phase assessment with tiered analysis Includes policy surveillance to capture new provisions in real time How this helps: Reflects use catagories with primary and secondary referencing Allows multi-functional or cross-sectional assessments Provides flexibility andreproducibilityPreliminary Results States have passed a significant number of EHI-related laws Approximately 2,000 statutes and regulations State legal frameworks also vary qualitatively Content covered by statutes and regulations creates differing legal environments Laws often relate to more than one area of public health importance Definitional Provisions Legal definitions  Related code sections Equivalence Health information technology (HIT) standards Data Control Storage and security Privacy and confidentiality Patient access Health department access Reporting and data collection Healthcare provider use Other data usesPreliminary Results—EHI Legal LandscapePreliminary Results—EHI Legal Landscape (Cont.) Implementation and Infrastructure Oversight Incentives Sustainability Enforcement and crimes Health Information Exchange (HIE) Opt-in/opt-out provisions Specific Contexts Research Immunization Laboratory testing Insurance enrollment and claims Workers’ compensation Vital records Telemedicine Mental/behavioral health Developmental disability services Substance abuse Education Detention/correctionsPreliminary Conclusions: SIM Example CMS State Innovation Model Round 1 states have different legal landscapes than non-SIM states Generally, SIM states have more laws related to certain EHI uses than non-SIM states0102030405060GU SD DC SC WV NE WI NC AK MO GA WY NJ LA NM HI RI MI NH ME ID AR MA CT WA TN CA EHR-Treatment (Main Code)  EHR-Treatment (Cross-Reference Code)Non-SIM < SIMPreliminary Conclusions (Cont.) Quantity is not everything! The number of laws in a state by itself does not appear related to certain outcomes  • Ex: EHR adoption rates What about the content of the laws???01020304050600 20 40 60 80 100Total Laws Relating to EHI used for Treatment Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system by U.S. State, 2014R² = 0.333505101520253035400 50 100 150 200Total Laws Relating to HIEs and HIOs (SIM Round 1 States)% change in the number of non-federal acute care hospitals that electronically exchanged health information with outside ambulatory providers or hospitals by U.S. state …Preliminary Conclusions (Cont.) The law is related to important healthcare objectives Positive relationship were found between • Number of HIE laws and an increase in HIE activity among SIM Round 1 states• Number of HIT Oversight laws and reporting public health data*Correlational relationships are statistically significant (p < 0.05).R² = 0.1102-5051015202530350 20 40 60 80 100Laws Related to HIT Oversight by StatePercent of eligible Stage 2 hospitals’ electronic reporting of laboratory results, syndromic surveillance and immunizations to local public health agencies, as reported through the Medicare EHR Incentive Program in 2014Next Steps: Assessment of Single Domains• Laws in a particular domain may include reference to electronic health information• For example, ealthcare-associated infection reporting may include electronic reporting mechanisms between facilities, states, and public payersDRAFT assessment—PHLP 2014; in development; please do not distribute.PORTRAYING THE EHI LEGAL LANDSCAPEMaking Data Available Open data provides expanded utility  Data.cdc.gov A publicly available repository of CDC public health data sets• Data available through Application Programming Interface (API)o Allows users to use data for other applications Utility of an EHI Legal Map Organizes complex data Includes 2,000 provisions and dozens of legal subject matters of public health concern (in effect as of January 2014) Orients users to the big picture Depicts relationships to other relevant material Allows users to explore details Identifies specific provisions that relate to evidence-based subjects Helps identify legal authorities For public health law research For public health law practicePHLP EHI MAP PROTOTYPELEGAL EVALUATION OF EHI Legal Epidemiology and Impact Research: Logic Model The impact of public health law can be seen as a continuum with drivers, outside influences, and effectsDRAFT logic model—PHLP 2013; in development; please do not distribute.• Legal provision• Administrative law• Administrative structure• Appropriations• Authority• Responsibilities• Behavior incentives• Organizational capacity• Budgeting• Enforcement• Moral force of law• Resource distribution• Process capacity• Program changes• Behavior changes• Organizational changes• Costs• Health outcomes• Organizational outcomesLegal Drivers Implementation Intermediaries Outcomes ImpactCulture, Values, and Socio-Historical ContextLegal Epidemiology and Impact Research: Legal Evaluation Case Study Studying the impact of laws granting health departments access to electronic health information on outbreak response Background: 2012 fungal meningitis outbreak Issues presented: remote access, query capability, data validation, home rule, what data? Study partners: CDC (National Center for Emerging and Zoonotic Infectious Diseases/Division of Healthcare Quality Promotion, Center for Surveillance, Epidemiology and Laboratory Services/Division of Health Informatics and Surveillance), Association of State and Territorial Health Officials Present and Future Data Utility Potential applicability of EHI to CDC data sources Demonstration pilots using Behavioral Risk Factor Surveillance System data for automated detection and reporting of disease and monitoring population health through patient surveys1 Use of administrative data for surveillance2 Advanced molecular detection and surveillance31 CDC. Feasibility Testing: Using a Survey Participant’s Responses and Electronic Health Record [website]. Updated Aug 21, 2013. Available at www.cdc.gov/brfss/rd/enhancing/connect_with_medicine.html.  2 Amanda Elliott et al. Use of electronic health records and administrative data for public health surveillance of eye health and vision-related conditions in the United States. American Journal of Ophthalmology 2012;154(6):S63–70.3 CDC. Public Health Grand Rounds: Advanced Molecular Detection for Improving Public’s Health. Dec 3, 2013. Available at www.cdc.gov/about/grand-rounds/archives/2013/pdfs/GR_AMD_Dec3.pdf.Present and Future Data Utility (Cont.) Potential big data applications Big data will have a role in 21st century public health practice4 National Health Care Surveys: use of blended data,5 among many other examples EHI legal scan can support future state and local programmatic activity by identifying applicable authorities and functions4Nathaniel Schenker. Big Data: Uses and Limitations. CDC; Sep 19, 2013. Available at www.cdc.gov/nchs/data/bsc/bscpres_schenker_091913.pdf.5CDC. National Health Care Surveys [website]. Updated Dec 12, 2013. Available at www.cdc.gov/nchs/dhcs.htm.Next Steps Launch legal mapping tool Legal evaluation of EHI Specific uses of EHI• EHR access during outbreaks: qualitative interviews with stakeholders from 15 states Literature review for other uses of EHI• Survey data analysis in collaboration with study partners Select issue briefs Match legal data sets to existing or proposed public health data sourcesFor more information, please contact CDC’s Office for State, Tribal, Local and Territorial Support4770 Buford Highway NE, Mailstop E-70, Atlanta,  GA  30341Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail:  OSTLTSfeedback@cdc.gov Web:  http://www.cdc.gov/stltpublichealthThe findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.Thank you!Office for State, Tribal, Local and Territorial SupportPublic Health Law ProgramTara RamanathanTRamanathan@cdc.gov(404) 498-0455Akshara MenonAMenon@cdc.gov(404) 498-0419Cason SchmitCSchmit@cdc.gov(404) 498-2387

Assessing Electronic Health Records Laws

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Assessing Electronic Health Records Laws

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Assessing Electronic Health Records Laws

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