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Arizona Health-e ConnectionNovember 17, 2015Stanley M. Huff, MDstan.huff@imail.org
T H E H E A L T H C A R E I N N O V A T I O N E C O S Y S T E M
SHARING KNOWLEDGE AS EXECUTABLE PROGRAMS
2
Intermountain Healthcare ProfileAn Integrated Health System
1975 1983 1994
• 22 hospitals • 33,000 employees
• 600,000 members• 25% market share
• 200 clinics• 1,000 employed
physicians
What is HSPC?
3
OUR MISSIONImprove health by creating a vibrant, open ecosystem of interoperable applications.
5
Essential Functions of the Consortium
Select the standards for interoperable services
Standards for models, terminology, security, authorization, context sharing, transport protocols, etc.
Modeling: SNOMED, LOINC, RxNorm – FHIR Profiles – do it together
Provide testing, conformance evaluation, and certification of software
Gold Standard Reference Architecture and its Implementation We will work with an established company to provide this service
Implementation of the standard services by vendors against their database and infrastructure
Everyone does not have to do every service There must be a core set of services that enable a marketplace
6
HSPC History HSPC was incorporated as a not-for-profit corporation on August
22, 2014
Meetings May 2013 Salt Lake City August 2013 in Phoenix January 2014 Salt Lake City May 2014 in Phoenix July 2014 Salt Lake (Technical modeling meeting) August 21-22 2014, Washington DC, hosted by IBM February 4-6, New Orleans, Louisiana, hosted by LSU June 17-19, Washington DC August 10-13, Salt Lake City September 28-30, Phoenix January 20-22, New Orleans, Louisiana, hosted by LS
Why HSPC?
7
8
Homer Warner and HELP
Intermountain can only provide the highest quality, lowest cost health care with the use of advanced clinical decision support systems integrated into frontline clinical workflow
Dr. Homer Warner
Patient
9
Core Assumptions
‘The complexity of modern medicine exceeds the inherent limitations of the unaided human mind.’~ David M. Eddy, MD, Ph.D.
‘... man is not perfectible. There are limits to man’s capabilities as an information processor that assure the occurrence of random errors in his activities.’~ Clement J. McDonald, MD
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Clinical System Approach
Intermountain can only provide the highest quality, lowest cost health care with the use of advanced clinical decision support systems integrated into frontline
workflow
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Case Study
13
14
Perc
ent <
39 W
eeks
Elective Labor Induction <39 Weeks
15
Perc
ent <
39 W
eeks
Elective Deliveries <39 Weeks Intermountain Healthcare
0%
5%
10%
15%
20%
25%
30%
35%
J1999FMAMJJASONDJ
2000FMAMJJASONDJ
2001FMAMJJASONDJ
2002FMAMJJASONDJ
2003FMAMJJASONDJ
2004FMAMJJASONDJ
2005FMAMJJASONDJ
2006FMAMJJASONDJ
2007FMAMJJASONDJ
2008FMAMJJASONDJ
2009FMAMJJAS
Month
Per
cen
t <
39 W
eeks
Elective Delivers <39 Weeks
16
Decision Support Modules
Antibiotic Assistant
Ventilator weaning
ARDS protocols
Nosocomial infection monitoring
MRSA monitoring and control
Prevention of Deep Venous Thrombosis
Infectious disease reporting to public health
Diabetic care
Pre-op antibiotics
ICU glucose protocols
Ventilator disconnect
Infusion pump errors
Lab alerts
Blood ordering
Order sets
Patient worksheets
Post MI discharge meds17
We can’t keep up!
We have ~150 decision support rules or modules
We have picked the low hanging fruit
There is a need to have 5,000+ decision support rules or modules
There is no path from 150 to get to 5,000 unless we fundamentally change the ecosystem
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Strategic Goal
Be able to share data, applications, reports, alerts, protocols, data entry screens, and decision support modules with anyone
Goal is “plug-n-play” interoperability
The cost of medical softwareBecker’s Health IT & CIO Review
Partners HealthCare: $1.2 billionBoston-based Partners HealthCare is one of more recent implementations, going live the first week of June to the tune of $1.2 billion. This is the health system's biggest investment to date. The implementation process took approximately three years, and in that time, the initial price tag of $600 million doubled.
Intermountain Medical Center $550 million
20
More Reasons
Every useful piece of software has to be created in each EHR systemAs a society, we pay the cost of creating all of
those copies of useful programs
Agile developmentUsability of software, creativity, innovation
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A Vision for the Future
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Sharing Data by copying
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EHR1
Interface Engine
EHR2
StandardServices(APIs)
Sharing Data via Services
24EHR1 EHR2
CommercialEHR
Heterogeneous Systems
Home GrownSystem
SystemIntegrato
rOthers…
FHIR Profiles from CIMI Models
(using standard terminology)
25
Apps that address specific focused problems…
Provider-facing services Focused decision support Visualization Disease management Specialty workflows
National Shared Services Genomic testing & CDS Pharmacogenomic screening CDC Ebola screening? CDC immunization forecaster Prior Authorization / Appropriateness
App 1
EHR
App 2 App 3
Like Google Maps…
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Apps that enable data sharing…
Next-gen InteroperabilityPopulation Health integrationHIE integrationData capture for researchClinical Trial recruitingQuality Repositories EHR
2
App 1
EHR3
EHR1
Like Facebook…
27
Apps that empower patients / consumers…
Apps as PrescriptionsChronic disease
managementPt-Provider CommunicationRemote monitoringOutcome capture & Clinical
Effectiveness Monitoring
SMART Phone App
Pop Health
EHR
Like ???? …
28
2015 HIMSS Demonstrations
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SHARING KNOWLEDGE AS EXECUTABLE PROGRAMS
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o How I used to think it would
work
o The problems with the old
strategy
o Sharing knowledge
o Why the new way is better
(and might work)31
SAGE Project
HL7 Working Group MeetingApril-May 2003
Guy Mansfield, Ph.D.Health Informatics, IDX Systems
A collaborative project to
develop a universal framework
for encoding and disseminating
electronic clinical guidelines
“ “
32
SAGE Project
Feedback
Author
Encode
Publish
Import
Install
In Practice
Evaluate
o Guidelines would be routinely encoded in a standard, computable format, and would be widely available for downloading.
o Healthcare organizations would be able to import proven guidelines, and execute them via their local clinical information systems.
Research, meta analysis,
“crafting the guideline”
Disambiguation,
encoding, testing
Guidelines.net?Guidelines-R-Us.com?
Download to localcare delivery organization
Clinical editing,guideline set up
Guidelines activein local CIS
Outcomesresearch
Consolidatedfeedback
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Old Strategy Problems
1. The application had to be imported and compiled for each platform/facility/version
2. Local installation of knowledge resources
3. Small hospitals lack support
4. Disagreement
34
Knowledge Sharing via Executable Apps
Decision Support ApplicationTrigger Event
EHR System
help
!
the
answ
er
here
it
ism
ore da
ta
Standardized FHIR APIs
35
The New Way
1. One copy can service many requests
2. Logic only needs to be installed in one place
3. No need to import the decision module to the local EHR
4. If standard FHIR APIs are implemented by vendors, the module can be used by any EHR
5. The decision support language does not need to be standardized, just the APIs for interactions
36
37
HSPC Internet SitesWiki: https://
healthservices.atlassian.net/wiki/display/HSPC/Healthcare+Services+Platform+Consortium
Website: http://hspconsortium.org/#/
Q & A
Appendix
Characteristics of a new Ecosystem
Consistent and unambiguous data collection
Data stored and accessed through truly semantically interoperable services
Sharing of data for direct patient care, population based analytics, and research
Sharing of applications, executable clinical decision support and knowledge
40
What Is Needed to Enable a New Ecosystem?
Standard set of detailed clinical data models coupled with…
Standard coded terminology (SNOMED CT, LOINC, RxNorm, others)
Standard query language
Standard API’s (Application Programmer Interfaces) for healthcare related services
Open sharing of models, coded terms, and API’s
Sharing of decision logic and applications 41
HSPC Functions and Principles
43
Essential Functions of the Consortium
Select the standards for interoperable services Standards for models, terminology, security, authorization, context sharing,
transport protocols, etc. Modeling: SNOMED, LOINC, RxNorm – FHIR Profiles – do it together Publish the models, and development instructions openly, licensed free-for-
use
Provide testing, conformance evaluation, and certification of software Gold Standard Reference Architecture and its Implementation We will work with an established company to provide this service Fees that off set the cost of certification will be charged to those who
certify their software
Implementation of the standard services by vendors against their database and infrastructure Everyone does not have to do every service There must be a core set of services that enable a marketplace
44
Other Functions of the Consortium
Participation in “other” functions is optional for a given member Enable development “sandboxes”
Could be provided by companies or universities Could be open source or for-profit
Set up a vendor neutral and provider neutral “App Store” Many companies and provider organizaitons already have their own app stores Vendor certification that a given application can be safely used in their system Accommodate small companies or individuals that won’t have their own app
store
Create a business framework to support collaborative development Pre-agree on IP, ownership, co-investment, allocation of revenue Try to avoid unique contracts for each development project
Provide a way for people to invest (Venture capital)
HSPC is about more than just data virtualization
SOA Services Layers
46
• Support common UI Standards• Provide services for imbedding application in existing EMR/EHR
frameworks
UI
• Implement a multi-layered services architecture (SOA)• Support common Decision Support models (BPMN2/Drools)• Support common workflow models (BPMN2)• Data and vocabulary transformation Services• Context management services• Master Data Management Services• Identity Management Services
Orchestration of Services and Busines Layer
• Support FHIR/Restful Services models that support launch and forget applications and applications that support a full SOA services stack
• Deploy FHIR profiles in collaboration with Argonaut, the VA, Intermountain, Regenstrief, Mayo/ASU and LSU.
Data Virtualization
SOA Guiding Principles
47
Three tiered services model Maintain atomic services that are consistent in
performance and behavior Can be administered once in a framework Can be orchestrated under a true SOA governance Can be consumed by anyone implementing the HSPC
reference architecture Can be addressed by synchronous and asynchronous
service requests Are implementable out of the box Are supportable and documented to a standard Provide HSPC supported services as open source
48
The HSPC/VA USECASE
Key Organizational Relationships (not
exhaustive)
ArgonautsDon’t know for sure
A call is planned to discuss the relationship
Work together on HIMSS demonstrations?
Work together to create industry wide consensus for profiles to be used for “true” interoperability?
HL7HSPC will use HL7 FHIR for data services
CIMI plans to become a part of HL7
HSPC will use HL7 as the forum for creating industry wide agreement about:Detailed profiles for true interoperabilityConsensus of professional and clinical bodies
about data that needs to be collected and shared (workflow or process interoperability)
SMARTHSPC will use SMART as a EHR integration
strategy
HSPC will work together with SMART on all activities of mutual interest
We will create a written document (MOU?) to describe the relationship between the two organizations
Center for Medical Interoperability
Work for support of CIMI and HSPC as part of C4MI technical programs
Possible activities Host a vendor and provider neutral app store Create a reference implementation of HSPC services Host a development sandbox Logistic support
Meetings, websites, publicity Host a model repository (and other knowledge artifacts) Support online terminology services Tool development Conformance testing and certification
OUR MISSIONImprove health by creating a vibrant, open ecosystem of interoperable applications.
OUR VISIONBe a provider-led organization that accelerates the delivery of innovative healthcare applications that
improve health and healthcare.
OUR GOALOur goal is to create an open marketplace featuring the industry’s first vendor-neutral Healthcare App Store and to foster a vibrant entrepreneurial community to deliver the best solutions quickly, easily and seamlessly to improve the quality of today’s accountable care.
Achieving the gold standard of true semantic interoperability, our services platform seeks to dramatically augment today’s standards efforts by providing a ground-breaking collaborative platform and real world laboratory to advance the native interoperability of healthcare applications.
ABOUT HSPCThe Healthcare Services Platform Consortium (HSPC) is a provider-driven organization of leading healthcare organizations, IT vendors, systems integrators, and venture firms dedicated to unlocking the power of entrepreneurial innovation to improve healthcare outcomes.
Through HSPC’s open marketplace and services platform, we seek to foster a new level of provider-vendor collaboration and innovation to meet one of the industries’ greatest needs -- accelerating the creation, sharing and delivery of promising software applications at the point of care.
OUR MEMBERSHSPC’s founding members are established leaders in shaping the course of healthcare.
Intermountain Healthcare Department of Veterans Affairs LSU Health Regenstrief Institute Harris Corporation
They are joined by a growing membership of forward thinking providers, vendors, technology providers, researchers and venture firms, all committed to creating a new and open, market-based paradigm to drive innovation at the point of patient care.
HOW WE’LL DO ITCollaborate with members to create a specification
(based on existing industry standards where possible) Truly semantically interoperable data access specification Security standard for clinical applications and data access.
Authorization, Authentication, Application Launch Context, etc. Clinical Care Pathways Coordinated Care across multiple providers
Proactively seek new members
Provide a development sandbox representative of a real world hospital system.
Host an App Store
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