Get to Green: A FHIR-enabled application for ventilator ... · Understand how FHIR specifications allow software developers to quickly create apps that connect with Cerner Millennium

Get to Green: A FHIR-enabled application for ventilator weaning using Cerner Ignite API

Robert E. Murphy, MDAssociate Professor and Associate Dean, Applied Informatics

University of Texas Health Science Center at Houston

Lee Ann Kincaid, MHADirector, Technical Solutions

Memorial Hermann Healthcare System

October 10, 2017

1 © Cerner Corporation. All rights reserved.1 © Cerner Corporation. All rights reserved.

Learning Objectives

1. Understand how FHIR specifications allow software developers to quickly create apps that connect with Cerner Millennium.

2. Understand how the cloud-based deployment enabled an iterative design process allowing appropriate adjustments to be made based on feedback throughout the build.

3. Understand the challenges that health systems should expect to prepare for when implementing FHIR-based apps.


A Fundamental Problem

>>>Ideas Resources


“I have an idea…”

•What problem does it solve?

•Who wants it?

• Is it a priority?

•Can it be done?

•Approved and “On the list”

•Wait in line…


The Excel Spreadsheet!

PASS

FAIL 18:35

Bed. No. 11Gender Male

DOB 01/18/1975Vent Start

Date/Time12/29/15 11:55 AM

MICU Arrival

Date/Time12/29/15 6:35 PM

Patient On

Paralytics No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100

Millennium ID # 100109891

12

/29

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Vent

Parameters

Last Test/Reading

Before MICU Arrival

29

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PEEP 10 10 10 10 8 5

FIO2 60 60 60 100 60 60 50 40 40

pH 7.46 7.46 7.32 7.13 7.4 7.4

RR 28 25 29 25 20 20

HR 111 118 109 111 93 96 97 101 106 100 88 83 85 94 90 91 100 106 104

HGB 11.7 10.1

MAP 127 136 107 108 101 56 70 74 78 107 79 63 68 80 81 68 87 101 114 136

Norepinephrine

RASS -1 -2 -4 1 1 1

Fourth Attempt at SBT Trial Hours From MICU ArrivalResult

First Attempt at SBT Trial Hours From MICU Arrival 17ResultPassed

MIC

U A

rriv

al T

ime

Number of Hours From MICU Arrival

Status

Indicator

Second Attempt at SBT Trial Hours From MICU ArrivalResult

Third Attempt at SBT Trial Hours From MICU ArrivalResult

Fourth Attempt at SBT Trial Hours From MICU ArrivalResult

SBT AssessmentSBT Trial Extubation


Ventilator Bundle

1. Head of bed elevated 30 degrees

2. Daily sedative interruption and daily assessment of readiness to extubate

3. Peptic ulcer disease (PUD) prophylaxis

4. Deep vein thrombosis (DVT) prophylaxis

5. Daily oral care with chlorhexidine

6 © Cerner Corporation. All rights reserved.

Ventilator weaning

RESPIRATORY CARE • JANUARY 2002 VOL 47 NO 173

• Removing patients from ventilator as soon as safely feasible

• Physician assessment +/-guidelines

• Concern for emergent reintubation and complications

GET TO GREEN : IMPROVING TEAM COMMUNICATION TO

REDUCE VENTILATOR HOURS

AL AMAN

BELA PATEL, MD

MCGOVERN MEDICAL SCHOOL AT UTHEALTH –HOUSTON

OVERVIEW

➢ Primary drivers for improvement include:

❖ Patient Safety

Prolonged mechanical ventilation is associated with an increased

risk of ventilator related complications and mortality.

❖ Cost

Extensive ventilator days leads to increased length of stay and

subsequently, higher total costs for both the patient and the hospital.

The average cost of stay for a typical ICU intubated patient is

approximately 2,500 dollars per day.

A multi-disciplinary team of physicians, respiratory therapists, nurses,

process improvement engineer, and applications analyst were formed to

address the length of ventilator hours in MICU by focusing on team

communication.

OUR GOALThe primary goal of this project was to decrease ventilators hours by 20% in

10 months by using a ventilator status communication board. In 2014,

average days a patient was on mechanical ventilator was 4.9 days.

Measures of Success:

Primary Measure:

Reduction of ventilator hours per patient.

Secondary Measure:

No increase in percentage of reintubation in extubated patients.

DEFINED VENTILATOR PARAMETERS

The following ventilation parameters with specified targets were Selected for the visual communication board:

1- PEEP

2- FIO2%

3- PH

4- RESPIRATORY RATE

5- HEART RATE

6- HEMOGLOBIN

7- MEAN ARTERIAL PRESSURE

8- VASOPRESSORS

9- RASS

10- PLATEAU PRESSURE

11- TIDAL VOLUME

PROCESS IMPROVEMENT INITIATIVES: Get To Green

PROCESS IMPROVEMENT INITIATIVES: Get To Green

RESULT: PRIMARY MEASURE

Average days on mechanical ventilation has decreased from 4.9 days in 2014 to

3.6 days in 2017 (36% improvement), therefore we exceeded our primary measure

goal of a 20% decrease in average vent days.

Start of Get To

Green Campaign

5,14,1

3,2

4,2 4,1 4,2 4,4

5,4 5,1

7,1

4,5

7,6

5,4 5,1

4,13,2

5,3

3,6 3,42,9 3,3 3,1 3,0

4,6

3,6 3,8

5,6

4,1

6,9

4,7 4,7

3,6 3,8 3,52,6

3,4 3,23,6 3,7

4,33,4

4,1

3,752,84

4,9

3,94,2

3,6

0,0

1,0

2,0

3,0

4,0

5,0

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7,0

8,0

9,0

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14

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4

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May

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Jul.

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g. '1

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Average Vent Days in MICU

Avg. Vent Days Rolling Average

RESULT: PATIENT REINTUBATION FREQUENCY

Average number of reintubations has not increased since the start of the “Get

to Green” initiative.

6,70% 6,70% 6,60%

5,60%

0,0%

1,0%

2,0%

3,0%

4,0%

5,0%

6,0%

7,0%

8,0%

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intb

atio

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4

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intb

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7

% Re-intubation Per Extubated Attempt


Problems and limitations

•Manual data entry…

•Timeliness of data entry

•Timeliness of analysis

•Timeliness of communication

•Inconsistent usage


Why can’t we have…

• A new flowsheet in Cerner?•How will people find it?

• A rule and alert?• Difficult

• High backload of new ambulatory content, refinements, >6 months

• Maintenance and upgrades

• A new mPage?• mPage Developer License


FHIR to the Rescue


Emerging standards make “apps” a reality

• FHIR = “Fast Health Interoperability Resources”

• An API standard for accessing health care data (“Resources”)

• ReSTful design leverages Internet standards (HTTP, etc.)

• Created by Health Level 7 International (HL7)

• Emerging support by most major HIT providers (e.g., Argonaut Project)

• Meets EHR Certification for MU3

• SMART = “Substitutable Medical Applications and Reusable Technology”

• A SMART App is a Web App

• HTML5 + JavaScript

• Typically embedded in EHR

• EHR Data Access is via FHIR

• OAuth2 for security and context passing

• Also supports smart-phone and patient-controlled apps


APIs have transformed many other industries

We believe they can do the same for health care!• Application Programming Interfaces

(APIs):• Allow technical solutions to talk to one

another in the same language

• Easily expose services to make them available inside and outside an organization

• Cerner’s open platforms expose standards that make it possible to connect apps or easily transfer discrete data.


APIs enable apps for providers and consumers

Provider-facing apps

can be developed that

leverage the

Millennium Platform

using APIs

Government regulation requires

more choices for

consumer-facing apps via APIs

Plan to attest for Meaningful Use Stage 3?

The Ignite API for Millennium addresses Objective 5, Measure 1


HITECH—In Retrospect and for the Future

Application programming interfaces & FHIR


HITECH—In Retrospect and for the Future

Application programming interfaces & FHIR!


Enabling innovation among clients and developers

Clients

Developers

Cerner

Open

Developer

Experience

Open Collaboration

Create

Application

Discover/Install

Ignite APIs for Millennium

Connect

Install

Publish

• Developer Site: code.cerner.com

• Free and open documentation of available API Resource endpoints

• Starter app and tutorials

• Sandbox on actual Cerner EHR back-end for patient and provider-facing apps (over 1,200 registered apps)

• Active Google Group (300+ members, 200 posts per month). Cerner Engineers are highest contributors.

Publish


Breakfast with the CIO

• Developed internal FHIR server and developed prototype ~ 10 days

• Demonstrated application prototype cycle can be fast

• Prototype is “simple”, “desired”, has great champion…

• CONTRACT!


Advantages of custom FHIR development

• Development by external team

• Infrastructure investment based on FHIR as an accepted standard

• Far less application interdependence; smaller team

• Springboard for future development

• Low(er) cost, low(er) risk

• Ability to support a strong clinical leader with history of proven quality improvement success• An innovative, determined physician leader with a good balance

of patience, persistence and perseverance


Arrangement

• 1/3 Memorial Hermann

• 1/3 McGovern Medical School

• 1/3 School of Biomedical Informatics

• Intellectual property held by University of Texas System

• Sticking point: Indemnification for research prototype


Design issues

•Parameter settings

•Team Workflows & Decision making

•Phase 1—data displays

•Phase 2—with notifications

•Clinical mappings!!


“Remove from ventilator”


Start time of spontaneous breathing trial (?)


Implementation Challenges and Considerations


FHIR Structure

oAuth2 Context

Service

FHIR

Services

Public / Internet

Private / Intranet


Build a Project Team

Clinical

Representative

Cerner Data

Expert

Application

Builder


When Scoping the Project

• Timeline• Allocation of Time for Cerner to Complete Testing and Validation in

Sandbox Server

• Allocation of Time for Mapping Data Elements

• Identifying Data Elements• Compile a list for Concept Mapping

• Review list of Cerner Mapped Data

• Include clinical event code for those without SNOMED or LOINC

• Consider App growth and determine best location• Existing Internal Website vs. Net New

• Future Applications to be developed

• User Authentication


Technical Challenges

• Cerner Sandbox vs. Memorial Hermann Domain


Technical Challenges

•Know your Firewall Settings

•Troubleshooting and Logging•Create a logging method

• What to log?

• Where to keep log files?

• How long to keep log files?


Where are we now?

• Monitor and address Issues as they arise

• Defining Long Term Support Model •Application Display Issues

•Data Issues

•Change requests

• Building Our FHIR Application team •Manage FHIR Apps

•Assist in Testing and Implementation

• Looking at other areas of FHIR Growth!

Future


HealtheIntent Platform

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00100011

00100011 11001011 001001100111 01010111111000111011

1 01010111111000111011 01001 010011001


HealtheIntent and SMART

SMART-capable HealtheIntentSM

applications

• HealtheRegistriesSM and HealtheRecordSM

SMART-specific applications

• Built on top of HealtheIntent APIs

• HealtheInsights

HealtheCare

• Built on Millennium®

and HealtheIntent

• Millennium extensibility via SMART

Tier 1

Tier 2


Future: HealtheIntent API

• Case of failure to see a specific lab result

• CDS Hooks with labs in HealtheIntent

• Partnership with a University development corporation

• Pursuing SBIR/STTR

CDSServices

EHR Med Order

Toprol XL50 mg daily℞

EHR triggers a CDS hookand invokes a remote

service

1

2CDS Service executesits own rules, leveraging FHIR data as needed

EHRFHIR

Server

3Returns CDS cards

(rendered and displayed by EHR)

$200 per month(patient pays $30)

Try HCTZ as first-line

Switch to HCTZ

Managing hypertension?Launch JNC 8 Rx Pro

information card

suggestion card

smart app link card

HealtheIntent

API?

Questions?


Documents

Get to Green: A FHIR-enabled application for ventilator ... · Understand how FHIR specifications allow software developers to quickly create apps that connect with Cerner Millennium