1 Collaboration, Open Solutions, and Innovation (COSI) in Healthcare Marc Wine, M.H.A New Roadmap...

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Collaboration, Open Solutions, and Innovation Collaboration, Open Solutions, and Innovation (COSI) in Healthcare(COSI) in Healthcare

Marc Wine, M.H.AMarc Wine, M.H.ANew Roadmap for Health IT InteroperabilityNew Roadmap for Health IT Interoperability

January 10, 2008January 10, 2008

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Special Thanks Special Thanks

Peter Groen, Former Director Peter Groen, Former Director VA Health IT Sharing VA Health IT Sharing Douglas Goldstein, President Douglas Goldstein, President

Medical AlliancesMedical Alliances Suniti Ponkshe, Project Director IBMSuniti Ponkshe, Project Director IBM Robert Connors, Sub-portfolio Robert Connors, Sub-portfolio

Manager DoDManager DoD Telemedicine and Advanced Telemedicine and Advanced

Technology Research CenterTechnology Research Center

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Mission to MarsMission to Mars

“ “Imagine a solar powered, wearable health Imagine a solar powered, wearable health information system used by astronauts on the information system used by astronauts on the planned mission to Mars in 2020. The wearable planned mission to Mars in 2020. The wearable systems are connected wirelessly to the onboard systems are connected wirelessly to the onboard eHealth Advisor Live (eHAL), onboard Robotic eHealth Advisor Live (eHAL), onboard Robotic Surgeon, and an electronic Personal Health Record Surgeon, and an electronic Personal Health Record (ePHR) which in turn is interfaced with the more (ePHR) which in turn is interfaced with the more comprehensive master Electronic Health Record comprehensive master Electronic Health Record (EHR) system back on Earth, e.g. VistA. The master (EHR) system back on Earth, e.g. VistA. The master system includes a Medical Advisor module and a system includes a Medical Advisor module and a health data repository coupled with a genomic health data repository coupled with a genomic biorepository. The system is continuously being fed biorepository. The system is continuously being fed data by nano-technology bio-sensors that are data by nano-technology bio-sensors that are embedded in the wearable systems used by the embedded in the wearable systems used by the international crew of NASA astronauts. Implantable international crew of NASA astronauts. Implantable nano-sensors will be used to detect health problems nano-sensors will be used to detect health problems and a micro chemical laboratory on a chip will and a micro chemical laboratory on a chip will control the creation and rate of delivery of drugs to control the creation and rate of delivery of drugs to correct problems or repair tissue as needed." correct problems or repair tissue as needed."

- - Goldstein, Groen & WineGoldstein, Groen & Wine

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Beyond the Next Generation Beyond the Next Generation

Medical & Health Informatics 2020Medical & Health Informatics 2020

Linking Health Information Systems to Linking Health Information Systems to otherother industries information systems, e.g. Banking, industries information systems, e.g. Banking, Insurance, Manufacturing, Entertainment, etc. Insurance, Manufacturing, Entertainment, etc. Breaking down industry ‘silos’ of informationBreaking down industry ‘silos’ of informationTrue transformation takes place:True transformation takes place:

- Virtual Healthcare - Mobile Workforce - Self Care- Virtual Healthcare - Mobile Workforce - Self Care- Home Healthcare - Wireless Technology - Preemptive Care- Home Healthcare - Wireless Technology - Preemptive Care- NanoMedicine - Wearable Systems - Robotic Systems - NanoMedicine - Wearable Systems - Robotic Systems - ePHR Systems - Grid Solutions - Implantable eCare - ePHR Systems - Grid Solutions - Implantable eCare

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Head Mounted Displays

Inspired by Star Trek?

American College of Healthcare Executives 5

2007: 3D, 1080p HD, 150 degree viewVirtual TrainingTele-presence

Combined virtual and real world

display

1995: Surgical stereoscope prototype developed at Madigan Army Medical

Center

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Emerging/Enabling Healthcare Technologies and Standards To Watch

• Obsolete Before Reaching Maturity:– Personal Display

Assistant (PDA) integrated with Computerized Patient Records

– Direct Electronic Data Interface (EDI)

• Less Than 2 Years To Maturity:– Business Process

Management Suites

– Tablet PCs and Ultra-Mobile PCs

– Clinical Context Object Workgroup


Source: Barry Runyon, MD, GartnerResearch, 2007

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Emerging/Enabling Healthcare Technologies and Standards To Watch

• 2-5 Years To Maturity– Blade PCs

– Handwriting Recognition

– Server Virtualization

– Healthcare Work Flow and Business Process Management

– Natural Language Processing (Document Classification)

– Natural Language Processing (Text to Facts)

– ASTM Continuity of Care Record Standards

– National Provider ID

– Biometrics

– Service Oriented Architecture

– Distributed Antenna Systems

– HL-7 Clinical Document Architecture

– Standard Controlled Medical Vocabularies

– Voice over Internet Protocol (VOIP)

– Enterprise Public Key Infrastructure (PKI)

– Single Sign On (SSO)American College of Healthcare Executives 7


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Emerging/Enabling Healthcare Technologies and Standards To

Watch

• 5 to 10 Years To Maturity– Digital Microscopy

– ICD-10 CM (US)

– Health Product Data Utility

– Robotics for Rounding

– Continua

– Medical Device Management/Standardization

– Bluetooth

– Grid Computing

– Information Life Cycle Management

>10 Years To Maturity– Semantic Interoperability– Semantic Web/RDF/OWL


5 to 10 Years to Maturity HIE/EHR HL-7 Version 3 Messages SOA for Application Integration in Healthcare Speech Recognition (Once and Done) User Provisioning CDISC Operational Data Model Basic Web Services Profile HIPAA Claims Attachments


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Interoperability Components

Attaining true, complete interoperability between systems requires computer accommodation for: Syntax: rules and grammar applied to

human or computer language, structure Semantics: meaning expressed through

signs or symbols Pragmatics: nuances of human language

involving impact of speech utterances on meaning


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Gartner’s Thoughts on Interoperability

Wes Rishel, Gartner Group Research, 29 Dec 2005, “An Interoperability Roadmap for the Computer-Based Patient Record (CPR)”: “A CPR system cannot fulfill its potential to

make patient care better, safer and less costly without excellent interoperability.

The requirements for extra-enterprise interoperability are evolving rapidly.”


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Gartner’s Thoughts on Interoperability,

continued Rishel’s Key Points:

High quality healthcare requires collaboration among specialists and sharing of data with meaning between hospital internal and external systems

Degrees of interoperability: Semantic interoperability — where the information

that is exchanged can be processed by a computer Document interoperability — where textual

information that is suitable for a person to view is exchanged along with a computer-processed header that enables the receiving system to file and appropriately display the text

Incremental interoperability — a hybrid approach that enables clinical information systems at differing levels of semantic sophistication to interoperate on a "best possible” basis


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HL-7 3.0 Reference Information Model (RIM)

and Clinical Document Architecture (CDA),

Release 2 (R2) HL-7 2.x messaging standard deals with syntactical/structrual file transformation issues

HL-7 3.0, through use of the RIM and XML, provides for some semantic understanding

DoD is focusing on using HL-7 3.0 RIM and CDA R2 as a means to obtain an intermediate degree of semantic interoperability, across multiple projects

Key is that CDA R2 is both machine readable, and also human-readable

CDA now combined with Care Record Summary (CRS) standard

Excellent summary at http://www.alschulerassociates.com/cda/?topic=quick-start-guides (Liora Alschuler)

http://www.j-amia.org/cgi/content/abstract/8/6/552

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Continuum for Semantic

Representation and Processing

American College of Healthcare Executives

Metadata

Taxonomy

Thesaurus

Conceptual Model

Logical Domain Model

Weaker Semantics Strong Semantics

Modal LogicFirst Order Logic

Description Logic

DAML+OIL, OWLUML

RDF/SXTM

Extended ER

ERSchema

Relational Model

XML

Self-describing data structures

Is subclassification of

Has narrower meaning than

Is subclass of

Is disjoint subclass of with transitivity property

General ClassificationOr Ontology Space

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Source: Dave Reilly, Northrop Grumman Corporation

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Medical Concepts and Controlled Medical Vocabularies for

Normalization


COLD COLD COLD

ConceptRepresentation

ConceptRepresentation

ConceptDomain

ConceptDomain

ConceptDefinition

ConceptDefinition

HDDConcept ID

HDDConcept ID

a sensory perception

a pulmonary diagnosis

an upper respiratory

viral infection

“I’m feeling cold”

Chronic Obstructive

Lung Disease

“I have a cold”

68215 1005480 1005313

SNOMED CT ID UMLS CUI Tripler IEN

ICD9CM Code Womack IEN

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Terminology Service


Terminology Service Bureau

TSB

SNOMED CT(Core)

PKC

MEDCIN OtherOther

CivilianHCO

VA

DoD

Computable Information

-Intra-operability-Inter-operability

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DoD/VHA Interoperability

Products FHIE: Federal Health Information

Exchange One-way transfer of health data from DoD to

VA

BHIE: Bidirectional Health Information Exchange Two-way exchange of viewable data

CHDR: CDR/HDR Interface Synchronize data between CDR (DoD) &

HDR (VA)American College of Healthcare Executives 16

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FHIE Data is transferred from DoD, on

separated service members, to the FHIE Data Repository at the VA Austin Automation Center (AAC).

VA clinicians can access data on patients that have correlated with a patient in the VA’s Master Person Index (MPI)

Metrics: 191 million clinical messages on over 3.9 million individuals have been transferred


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BHIE Enables VA & DoD providers to view

health data For shared patients who receive care at

VA & DoD facilities In real time From all locations where data exists


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BHIE Sites: Current and Pending


BHIE operational

BHIE implementations planned during FY2007

NCA

LRMC

Mike O’Callaghan Federal Hospital

David Grant MC

Bassett ACH

Elmendorf AFB

Madigan AMC

NHC Great Lakes

Eisenhower AMC

NHC Charleston

31 DoD host sites = 15 DoD Medical Centers, 25 DoD Hospitals & over 220 DoD Clinics

12 CIS Sites

CHDR-BHIE Release 1 provides access to all DoD AHLTA Worldwide Sites

(Access to over 2.2 Million correlated patients)

Tripler AMC

William Beaumont AMC

NMC San Diego

NH Camp Pendleton NH Camp Lejeune

Womack AMC

NH Pensacola

Darnall AMCMacDill AFB

NH Jacksonville

NACC Groton

NH Corpus Christi

Wright-Patterson AFB

Martin ACH

NH LemooreNMC Portsmouth

Minot AFB

BHIE-CIS operational

Leonard Wood ACH

Fox AHC

Kirtland AFB

Brooke AMCWilford Hall

Evans ACH

Dewitt ACH

Irwin ACH

Malcolm Grow MC

National Naval MC

Walter Reed AMC

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CHDR Synchronizes data between the DoD Clinical

Data Repository (CDR) and the VA Health Data Repository (HDR) Data is “pushed” or synchronized to each

repository Enables drug-drug and drug-allergy checks

(DoD, VA, Retail) GAO report June 22, 2006

CHDR is “Cornerstone” for long term goal to achieve a virtual medical record based on the two-way exchange of computable data

“If pilot is successful, it will enable for the first time the exchange of computable information between the departments’ two data repositories”American College of Healthcare Executives 20

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BHIE-CDR (CHDR-BHIE)

Accelerates DoD/VA patient data sharing while the VA HDR is still in development and standards in many areas are still maturing

Provides a real-time bidirectional interface between DoD’s AHLTA and the VA’s VistA/CPRS health care systems Pulls data from the CDR & provides to VA via

BHIE framework Increases number of DoD sites providing

data to VA to ALL AHLTA sites Enables DoD providers to view VA data from

AHLTAAmerican College of Healthcare Executives 21

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So, All of this Looks Promising, But Are We On the Verge of a

Healthcare IT Technology Revolution?

Secretary Leavitt, 2007 HIMSS Conference:

“…But while for many years healthcare information technology has been but a distant vision… we are close to achieving interoperable standards and a system-wide transformation. “


(There is that interoperable word again, and as far as standards go, the good thing is that there are so many to choose from…!)

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Imagine the Future …Create the Future – Health@Anywhere

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A 20/20 Vision for the FutureA 20/20 Vision for the Future

Imagine a future healthcare system that is Imagine a future healthcare system that is customer-focused and customer-focused and patient-centeredpatient-centered, one in , one in which every American has health insurance and a which every American has health insurance and a secure, private secure, private Electronic Health RecordElectronic Health Record (EHR)(EHR) that is available whenever and wherever needed, that is available whenever and wherever needed, enabling the highest degree of coordinated enabling the highest degree of coordinated medical care based on the latest medical medical care based on the latest medical knowledge and evidence. knowledge and evidence.

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Imagine a healthcare system in which digital Imagine a healthcare system in which digital and and mobile technologiesmobile technologies,, medical knowledge medical knowledge at at the point of need, and the point of need, and collaborationcollaboration among among providers deliver safe, high-quality care for providers deliver safe, high-quality care for everyone—a healthcare system that does not everyone—a healthcare system that does not require the patient to complete the same forms require the patient to complete the same forms at every access point. at every access point.

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Imagine a healthcare system where primary Imagine a healthcare system where primary care physicians have access to your specialty care physicians have access to your specialty medical information and specialists have access medical information and specialists have access to your primary care information via inter-to your primary care information via inter-connected connected “smart” EHRs“smart” EHRs that are integrated that are integrated with with personalized eHealthpersonalized eHealth service providers service providers and delivered directly to a multi-purpose, and delivered directly to a multi-purpose, intelligent, mobile digital device that can be intelligent, mobile digital device that can be carried in one’s pocket. carried in one’s pocket.

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Healthcare Industry – The StatsHealthcare Industry – The Stats

$1.7 trillion spent on U.S. health care in 2003 and $1.7 trillion spent on U.S. health care in 2003 and still climbing.still climbing.

In 2005, the United States spent 16.3% of the In 2005, the United States spent 16.3% of the country’s Gross National Product on health care country’s Gross National Product on health care services and it will continue to grow.services and it will continue to grow.

“Healthcare in the U.S. is a trillion-dollar cottage industry! ”

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An Epidemic of Medical ErrorsAn Epidemic of Medical ErrorsThere is currently a human spawned epidemic of deadly, costly There is currently a human spawned epidemic of deadly, costly medical errors. Depending on which of three major studies you medical errors. Depending on which of three major studies you read, at least 44,000 people, and perhaps as many as 200,000 read, at least 44,000 people, and perhaps as many as 200,000 people, die in hospitals each year as a result of medical errors that people, die in hospitals each year as a result of medical errors that could have been preventedcould have been prevented. .

In addition to the cost in terms of human lives, medical errors In addition to the cost in terms of human lives, medical errors have been estimated to result in total costs between $17 billion and have been estimated to result in total costs between $17 billion and $29 billion per year in hospitals nationwide$29 billion per year in hospitals nationwide

According to the Journal of American Medical Association According to the Journal of American Medical Association (JAMA), these are estimated(JAMA), these are estimated:: 106,000 Adverse reactions to properly prescribed Rx drugs106,000 Adverse reactions to properly prescribed Rx drugs 80,000 Infections in hospitals80,000 Infections in hospitals 20,000 Other errors in hospitals20,000 Other errors in hospitals 2,000 Unnecessary surgeries2,000 Unnecessary surgeries

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And Finally…And Finally…It was also estimated in a JAMA article that there were 199,000 It was also estimated in a JAMA article that there were 199,000 deaths from medical errors in outpatient care alone, and there deaths from medical errors in outpatient care alone, and there could be upwards of 424,000 annual deaths per year in the could be upwards of 424,000 annual deaths per year in the American medical system, which would make the system itself the American medical system, which would make the system itself the one of the leading causes of death in the United States. one of the leading causes of death in the United States.

The National Council for Patient Information and Education The National Council for Patient Information and Education reported that an additional 125,000 deaths occur annually due to reported that an additional 125,000 deaths occur annually due to adverse reactions to drugs that the physician never should have adverse reactions to drugs that the physician never should have prescribed. The annual death toll from synthetic prescription prescribed. The annual death toll from synthetic prescription drugs, both from the correctly prescribed and the incorrectly drugs, both from the correctly prescribed and the incorrectly prescribed, amounts to about 231,000 deaths every year. To put prescribed, amounts to about 231,000 deaths every year. To put this into perspective, this is the equivalent of a World Trade this into perspective, this is the equivalent of a World Trade Center disaster every week for over a year and a half, or Center disaster every week for over a year and a half, or the crash the crash of two fully loaded 747 aircrafts every day of the year. of two fully loaded 747 aircrafts every day of the year.

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KeyKey Solutions Solutions - Priorities- Priorities

#1 -#1 - Availability and widespread use of Availability and widespread use of

Electronic Health Record (EHR) SystemsElectronic Health Record (EHR) Systems

by Clinicians Across This Country !by Clinicians Across This Country !

#2 – Followed by the implementation of secure #2 – Followed by the implementation of secure Health Information Exchange (HIE) networks.Health Information Exchange (HIE) networks.

#3 – Real transformation occurs when widespread #3 – Real transformation occurs when widespread use of use of Personal Health Records (PHR)Personal Health Records (PHR) take hold. take hold.

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COSI StrategiesCOSI Strategies

The COSI strategies of The COSI strategies of Collaboration, Open Solutions, Collaboration, Open Solutions, and Innovationand Innovation are absolutely essential for are absolutely essential for transformingtransforming the health and medical culture, the the health and medical culture, the processes, the leadership and the technology necessary processes, the leadership and the technology necessary to support better, safer and higher quality care in the to support better, safer and higher quality care in the American healthcare system and other healthcare American healthcare system and other healthcare systems across the globe. The application of these systems across the globe. The application of these strategies is already evident throughout other major strategies is already evident throughout other major industries. industries.

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Health Information Sharing Health Information Sharing OpportunitiesOpportunities

Standards – collaborating with other agencies and organizations on national health information standards

Software Sharing - sharing health information systems software between organizations, e.g. VistA and other open software solutions.

Information Sharing – sharing data or information needed for direct patient care or for research and population studies.

Resource Sharing – contributing funding or other resources needed to support a mutually beneficial sharing initiative.

Knowledge Sharing – sharing technical expertise or knowledge in the field of healthcare informatics.

Community Support & Sharing – sharing contacts and helping to garner support within the healthcare community and other stakeholders for major ‘mutually beneficial’ initiatives.

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Open SolutionsOpen Solutions

““Open Source Everywhere—Software is just the Open Source Everywhere—Software is just the beginning . . . open source is doing for mass beginning . . . open source is doing for mass innovation what the assembly line did for mass innovation what the assembly line did for mass production.” production.” - Thomas Goetz,- Thomas Goetz, Editor, Wired MagazineEditor, Wired Magazine

But, we’re not just talking about Open Source, But, we’re not just talking about Open Source, we’re talking about we’re talking about Open SolutionsOpen Solutions

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Growth in Open Source SoftwareGrowth in Open Source Software

In the last few years, the growth in OSS has In the last few years, the growth in OSS has accelerated significantly. Key contributing factors accelerated significantly. Key contributing factors for this growth are: for this growth are:

growing awareness of open source growing awareness of open source increased software functionality increased software functionality increasing adoption of OSS by many organizations, increasing adoption of OSS by many organizations, and and

many OSS applications ability to now operate at many OSS applications ability to now operate at the enterprise level, e.g. Linux, Apache, the enterprise level, e.g. Linux, Apache, OpenOffice, Mozilla/FireFox, VistA, MySQL, etc.OpenOffice, Mozilla/FireFox, VistA, MySQL, etc.

Initiatives such as OpenHRE transcend the Initiatives such as OpenHRE transcend the enterprise, and offer real world proof that sharing, enterprise, and offer real world proof that sharing, collaboration and open source values are not collaboration and open source values are not foreign concepts, but mandatory attributes to foreign concepts, but mandatory attributes to embrace for achieving cost effective and embrace for achieving cost effective and sustainable interoperability. sustainable interoperability.

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The Bottom LineThe Bottom Line

"The arguments for and against open-source "The arguments for and against open-source software often get very trivialized. It's not a software often get very trivialized. It's not a technology issue; it's a business issue." technology issue; it's a business issue."

“Companies with an external focus, which are “Companies with an external focus, which are used to working collaboratively with other used to working collaboratively with other organizations, and perhaps are already using organizations, and perhaps are already using collaborative technologies, stand to gain much collaborative technologies, stand to gain much more from Open Source than companies with more from Open Source than companies with an internal focus, which see the technology an internal focus, which see the technology purely in terms of cost savings.”purely in terms of cost savings.”

Andy Mulholland, Chief Technology Officer for Cap Gemini Andy Mulholland, Chief Technology Officer for Cap Gemini Ernst & YoungErnst & Young

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The Perfect Opportunity:Convergence-New

Capabilities Bridging the Quality Chasm!

Evidence Based Medicine (David Sackett et. al.)

Database Design/Retrieval/Query Electronic Medical/Health Record

24/7 access and computable data Decision support at the point of care Population health


Digital Man

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Collaboration Innovation andCollaboration Innovation andOpen SolutionsOpen Solutions

“Dare to Transform”“Dare to Transform”

Marc Wine, M.H.A.Marc Wine, M.H.A.Health IT Advisor, Author, Health IT Advisor, Author,

ProfessorProfessor202-821-2124 Cell202-821-2124 CellEmail: [email protected]: [email protected]

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