Open Source is a great opportunity for EHR, Digital Health, and Health IT Integrators

OSEHRA is a great business opportunity for health IT vendors and system integrators

3rd Annual OSEHRA SummitShahid N. Shah

Chairman of OSEHRA Advisory Board

NETSPECTIVE

www.netspective.com 2

Who is Shahid?• Chairman, OSEHRA Board of Advisors• 20+ years of software engineering

and multi-discipline complex IT implementations (Gov., defense, health, finance, insurance)

• 12+ years of healthcare IT and medical devices experience (blog at http://healthcareguy.com)

• 15+ years of technology management experience (government, non-profit, commercial)

Author of Chapter 13, “You’re the CIO of your

Own Office”

http://healthcareguy.com/

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What’s this talk about?Background• Is disruptive innovation in

healthcare possible?• What does innovation in

healthcare mean and how do you help customers make it happen?

• EHRs are not the center of the healthcare data ecosystem.

Key takeaways• OSEHRA is major business

opportunity for ISVs and systems integrators

• OSS can satisfy most needs. There’s nothing special about health IT data that justifies complex, expensive, or special technology.

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VA, VHA, VistA, and OSEHRATop-notch pedigree and a well funded buyer of innovation

VHA OSEHRA Community

VistA EHR Code

Data 1

Facility 1

Facility 2

…

Data 2

…

OSEHRA Core

IV&V (Test, Docs)

Certify

OSEHRA Add-ons Contributed Add-ons

Contributed Core

OSEHRA Deployment

Contributed Tests/Docs

Convergence, Refactoring2011

2013

Free or Commercial

2013

Commercial Deployments

VA FY2012 IT Spend: $3.1 B

InnovationCoordinationDelivery

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How OSEHRA makes the market bigger

New businesses can be created which service

OSEHRA code, technologies, etc. and

make revenue from said services

New system integration business or existing ones

can augment their products / services to

include OSEHRA capabilities

Market generation and economic benefits

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How OSEHRA makes the market bigger

New or existing hosting / datacenter businesses can offer fully hosted OSEHRA

capabilities directly to clinicians or even at some

point VA/DoD/IHS

New revenue centers in existing or new businesses

can take common certification criteria and build tools around

it for automated testing, documentation preparation,

etc.

Market generation and economic benefits

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What does “disrupting healthcare” mean?

This is $1 Trillion and the Healthcare Market is about $3 Trillion

This is $1 Billion


No, your innovation will not disrupt healthcare. I promise.

The good news is that doesn’thave to.


No, your big data or mobile ideas will not disrupt healthcare.

But if you can use them to add or extract value from the existing system, you’ll do just fine.


No, your EHR/PHR or app will not be used by enough doctors or patients to disrupt healthcare.

But if you can get even a fraction of them to use your software, you’ll do just fine.


No, your innovation will not be accepted by permissions-oriented institutions.

Find customers with a problem-solving culture willing to accept risks and reward failures.


No, your innovation will not be easily integrated into regulated device-focused clinical workflows.

Incumbent vendors will not entertain the potential of new legal liabilities without someone to share it with or new competition without direct compensation.

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You have made the job of identifying, diagnosing, treating, or curing diseases faster, better, or cheaper for clinicians through the use of information technology (IT) or business models.

You have made the job of self-diagnosing, self-treating, or preventing diseases and improving overall wellness of patients through the use of new incentives, business models, or IT.

What I mean by “actionable innovation”You can help your customers achieve practical, relevant, actionable solutions

The macro environment

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Shift from Fees for Service (FFS) to Value (FFV)The Shift

The clinical model is shifting away from treatment of chronic conditions and focusing more on prevention, wellness, obesity intervention, behavior and lifestyle modification.

ImplicationsClinical operations are shifting to hospital and physician ‘centered’ services that will rely heavily on health information technologies to monitor, coordinate, and manage care.

• Successful Transition in Care resulting in Reduced Hospital Readmission Rates

• Proactive population management• Patient engagement and collaboration• Disease prevention through wellness and

obesity management• Chronic disease management• Care coordination and collaboration• Metrics and analytics

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The realities of patient populations

• Obesity Management• Wellness

Management

• Assessment – HRA• Stratification• Dietary• Physical Activity• Physician

Coordination• Social Network• Behavior Modification

• Education

• Health Promotions

• Healthy Lifestyle Choices

• Health Risk Assessment

• Diabetes• COPD• CHF

• Stratification & Enrollment

• Disease Management• Care Coordination• MD Pay-for-

Performance• Patient Coaching

• Physicians Office• Hospital• Other sites• Pharmacology

• Catastrophic Case Management

• Utilization Management

• Care Coordination• Co-morbidities

Well Patient At Risk Chronic Care Acute Treatment

Prevention Management

26 % of Population

4 % of Medical Costs

35 % of Population


35 % of Population


4% of Population


Source: Amir Jafri, PrescribeWell

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How Digital Health helps in shift

Successful Transitions of Care

Reduced Hospital Readmissions

Innovative Practice Models like Patient

Centered Medical Homes

Prevention, Wellness, Obesity intervention

Behavior adjustments and modification

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How to best identify your customers

FFS vs. FFV?

Target health sector?

Number of employees?

Annual sales volume?

Geography?

Number of hospital beds?

Number of patients?

Type of patients?

The list goes on and on…be specific!

Help them stay away from market segmentation, focus on identifying PBU particpants

Identifying your customers will depend on helping your customers identify theirs

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Patient Collaboration Maturity Model

Independent Care

Connected Care

Coordinated Care

Integrated CareAccountable Care

Choosing a single EHR vendor as your platform for connected care won’t work beyond integrated care scenarios.

EHRs

are

Usefu

l Her

e

EHRs are insufficient

by themselves

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How will your customers get paid for innovation?

Direct Payment

•Your best option•Very few truly disruptive technologies can be directly paid for by providers within the USA•Limited adoption of ‘traditional’ pay for service reimbursement for next generation technology

Direct Reimbursement

•Second best option•Improvements in technology are outpacing payer adoption•Reimbursement will come but its time consuming and difficult

Indirect Reimbursement

•Emerging option•Payer requirements for improved quality and efficiency are creating indirect incentives to adopt innovative solutions•Solutions targeting new value-based reimbursement incentives are highly useful to medical providers

If you haven’t figured it out for them, customers will not figure it out for themselves

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Digitize biology

Digitize chemistry

Digitize physics

Predict fundamental

behaviors

Digitize mathematic

s

Digitize literature

Digitize social

behavior

Predict human

behavior

We’re digitizing biology

Last and past decades This and future decades

Gigabytes and petabytes Petabytes and exabytes

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Data is getting more sophisticated

Proteomics

Emerging

•Must be continuously collected

•Difficult today, easier tomorrow

•Super-personalized•Prospective•Predictive

GenomicsSince 2000s,

started at $100k per

patient, <$1k soon

•Can be collected infrequently

•Personalized•Prospective•Potentially predictive•Digital•Family history is easy

Phenotypics

Since 1980s, pennies per

patient

•Must be continuously collected

•Mostly Retrospective•Useful for population health•Part digital, mostly analog•Family History is hard

AdminSince 1970, pennies per

patient

•Business focused data•Retrospective•Built on fee for service models

• Inward looking and not focused on clinical benefits

Try to use existing data to create new diagnostics or therapeutic solutions

Biosensors

Social Interactions

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Healthcare industry / market trends

PPACA“Affordable Care Act”

ACO“Accountable

Care Org”

PCMH“Medical Home”

MU“Meaningful

Use”

Health Home mHealth

PCPCC“Patient Centered

Care”

Major market and regulatory trends that are causing customers and competitors to shift

You must learn and be able to talk to customers about all these terms

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Implications of healthcare trends

PPACA ACO

MU PCMH

Health Home mHealth

DATAEvidence Based

MedicineComparative Effectiveness

Software

Regulated IT and Systems Integration

Services

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The new world orderGeneral Wellness

Specific Prevention

Self Service Physiologics

Self Service Monitoring

Self Service Diagnostics

Care Team Monitoring

Care Team Diagnostics

Healthcare Professional Monitoring

Healthcare Professional Diagnostics

Hospital Monitoring

Hospital Diagnostics

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We’re in the integration age

Source: Geoffrey Raines, MITRE

We’re not in an app-driven future but an integration-driven future.

He who integrates the best, wins.

What’s the problem?

What are we doing wrong when it comes to health IT applications?

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Why you can’t just “buy integration”

Myth

• I only have a few systems to integrate

• I know all my data formats

• I know where all my data is and most of it is valid

• My vendor already knows how all this works and will solve my problems

Truth

• There are actually hundreds of systems

• There are dozens of formats you’re not aware of

• Lots of data is missing and data quality is poor

• Tons of undocumented databases and sources

• Vendors aren’t incentivized to integrate data

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Application focus is biggest mistake

Application-focused IT instead of Data-focused IT is causing business problems.

Healthcare Provider Systems

Clinical Apps

PatientApps

BillingApps

LabApps

Other Apps

Partner Systems

Silos of information exist across groups (duplication, little sharing)

Poor data integration across application bases

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NCIApp

NEIApp NHLBI

AppHealthcare Provider Systems

Clinical Apps

PatientApps

BillingApps Lab

Apps Other Apps

Master Data Management, Entity Resolution, and Data Integration

Partner Systems

Improved integration by servicesthat can communicate between applications

The Strategy: Modernize Integration

Need to get existing applications to share data through modern integration techniques

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Important needs of non-Gov clinical customers

Easy to install packages that make

it possible to experiment with

OSEHRA code

RCM integration

Patient portal

integration

Interoperable with existing

systems (labs, pharma, etc.)

OSEHRA needs to get non-government clinical customers but there are important gaps

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Value-adds to clinical users

More functionality

Faster delivery

Better integration

Interoperability

The conceptual ROI for OSEHRA activities

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Important needs of engineering customers

Easy to install packages that make

it possible to experiment with

OSEHRA code

Common data model

Common identity

management

Platform to build on

(APIs, etc.)

OSEHRA needs to get non-government clinical customers but there are important gaps

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What’s being offered to users What users really want

Needed: Reimagined User InteractionsData visualization requires integration and aggregation

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Needed: Self-service applications

Patient Scheduling for Services

Secure Social Patient Relationship Management (PRM)

Patient Communications, SMS, IM, E-mail,

Voice, and Telehealth

Patient Education, Calculators,

Widgets, Content Management

Blue Button, HL7, X.12, HIEs, EHR, and HealthVault

Integration

E-commerce, Ads, Subscriptions, and Activity-based Billing

Accountable Care, Patient

Care Continuity and Coordination

Patient Family and Community

Engagement

Patient Consent, Permissions, and

Disclosure Management

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Needed: diagnostic quality mHealth

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Needed: predictive analytics

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Needed: care team involvement

HEALTHCARE PROVIDER

PATIENT/ CONSUME

R

HOSPITALFAMILY

CAREGIVER

ALTERNATE SITE OF CARE

Care Team

CALL CENTERS AND REMOTE SUPPORT

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Needed: automated diagnostics


Modern Microapps and Services Approach (Sample)

IdentityManager LDAP

EntityServices

RDBMS

DomainServices

RDBMS

AnalyticsSQL/Cube

RDBMS

Limited FK Constraints

oDataSQLV

SQLV

oData

SQLV

oAuth

SAML

oData

LDIF

Domain

Services

Widgets

Entity Service

s

CMS

oData

Micro AppsN

o D

irect

Tab

le

Acc

ess

Sep

ara

te

Sch

em

as

No F

K

Con

stra

ints

Bootstrap

AngularJS

BootstrapAngularJSBackplane

Reporting Apps

Third Party

BootstrapBackplane

RDFaHTML5 DA

RDFaHTML5 Data Attrs


ETL

BootstrapBackplane

Rich client only or tiny server frameworks (Mojo, Rack, etc.)

XACML

oDataSearchService

ElasticSearch

iCalsyslog

Log/MonitorService

CalDAVService

RulesService

Doc/BlobService

oData

Browser Accessible

XMPPService

How do we modernize integration?

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Why health IT systems integrate poorly

• Permissions-oriented culture prevents tinkering and “hacking”

• We don't support shared identities, single sign on (SSO), and industry-neutral authentication and authorization

• We’re looking for "structured data integration" instead of "practical app integration" in our early project phases

• We create large monolithic data warehouses instead of small service oriented databases

• We “push" data everywhere instead of "pulling" it when necessary

• We assume EHRs the center of the universe

• We accept and reward vendors that don’t care about integration

• We have “Inside out” architecture, not “Outside in”

• We're too focused on heavyweight industry-specific formats instead of lightweight or micro formats

• Data emitted is not tagged using semantic markup, so it's not securable or searchable by default

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• Most non-open-source EHR solutions are designed to put data in but not get data out

• Never build your data integration strategy with the EHR in the center, create it using the EHR as a first-class citizen

Don’t assume your EHR will manage your dataThe EHR can not be the center of the healthcare data ecosystem

Why EHRs are not (yet) disruptivehttp://www.christenseninstitute.org/why-ehrs-are-not-yet-disruptive/

HITECH and MU have

created false demand

and unwarranted

importance to EHRs

http://www.christenseninstitute.org/why-ehrs-are-not-yet-disruptive/

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• Clinicians usually go into medicine because they’re problem solvers

• Today’s permissions-oriented culture now prevents “playing” with data and discovering solutions

Encourage clinical “tinkering” and “hacking”It’s ok to not know the answer in advance

Dr. Wetzel said medicine is

inherently experimental

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Promote “Outside-in” architecture

Think about clinical and hospital operations and processes as a collection of business capabilities or services that can be delivered across organizations.

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PatientsExternal HCPs

HCP and Staff

Evaluators

Internal business users

and HCPs

IT Person

nel

Integration improves focus on the real customer

Unsophisticated and less agile focus

Sophisticated and more agile focus

Inside-out focus

Outside-in focus

HCPs = healthcare providers

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Proprietary identity is hurting us

• Most health IT systems create their own custom identity, credentialing, and access management (ICAM) in an opaque part of a proprietary database.

• We’re waiting for solutions from health IT vendors but free or commercial industry-neutral solutions are much better and future proof.

Identity exchange is possible• Follow

National Strategy for Trusted Identities in Cyberspace (NSTIC)

• Use open identity exchange protocols such as SAML, OpenID, and Oauth

• Use open roles and permissions-management protocols, such as XACML

• Consider open source tools such as OpenAM, Apache Directory, OpenLDAP, Shibboleth, or commercial vendors.

• Externalize attribute-based access control (ABAC) and role-based access control (RBAC) from clinical systems into enterprise systems like Active Directory or LDAP.

Implement industry-neutral ICAMImplement shared identities, single sign on (SSO), neutral authentication and authorization

http://www.nist.gov/nstic/



http://en.wikipedia.org/wiki/Security_Assertion_Markup_Language

http://openid.net/

http://oauth.net/

http://en.wikipedia.org/wiki/XACML

http://www.forgerock.com/openam.html

http://directory.apache.org/

http://www.openldap.org/

http://shibboleth.net/

http://en.wikipedia.org/wiki/Active_Directory

http://en.wikipedia.org/wiki/Lightweight_Directory_Access_Protocol

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Dogma is preventing integration

Many think that we shouldn’t integrate until structured data at detailed machine-computable levels is available. The thinking is that because mistakes can be made with semi-structured or hard to map data, we should rely on paper, make users live with missing data, or just make educated guesses instead.

App-centric sharing is possibleInstead of waiting for HL7 or other structured data about patients, we can use simple techniques like HTML widgets to share "snippets" of our apps. • Allow applications immediate access to

portions of data they don't already manage.• Widgets are portions of apps that can be

embedded or "mashed up" in other apps without tight coupling.

• Blue Button has demonstrated the power of app integration versus structured data integration. It provides immediate benefit to users while the data geeks figure out what they need for analytics, computations, etc.

• Consider Direct for app-centric connectivity.

App-focused integration is better than nothingStructured data dogma gets in the way of faster decision support real solutions

http://www.va.gov/bluebutton/

http://www.va.gov/bluebutton/

http://www.directproject.org/

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Old way to architect:“What data can you send me?” (push)

The "push" model, where the system that contains the data is responsible for sending the data to all those that are interested (or to some central provider, such as a health information exchange or HL7 router) shouldn’t be the only model used for data integration.

Better way to architect:“What data can I publish safely?” (pull)

• Implement FHIR or syndicated Atom-like feeds (which could contain HL7 or other formats).

• Data holders should allow secure authenticated subscriptions to their data and not worry about direct coupling with other apps.

• Consider the Open Data Protocol (oData).• Enable auditing of protected health

information by logging data transfers through use of syslog and other reliable methods.

• Enable proper access control rules expressed in standards like XACML.

• Consider Direct for connectivity if you can’t get away from ‘push’.

Pushing data is more expensive than pulling itWe focus more on "pushing" versus "pulling" data than is warranted early in projects

http://www.google.com/?q=FHIR

http://en.wikipedia.org/wiki/Atom_(standard)

http://www.odata.org/




http://en.wikipedia.org/wiki/Syslog

http://www.directproject.org/

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Old way to architect:Monolithic RDBMS-based data warehouse

The centralized clinical data warehouse (CDW) model, where a massive multi-year project creates a monolithic relational database that all analytics will run off was fine when retrospective reporting is what defined analytics. This old architecture won’t work in modern predictive analytics and mobile-centric requirements.

Better way to architect:Service-oriented databases on RDBMS/NoSQL

• Drive transactional ACID-based data requirements to RDBMS and consider column-stores, document-stores, and network-stores for other kinds of data

• Break relationships between data and store lookup, transactional, predictive, scoring, risk strat, trial associated, retrospective, identity, mortality ratios, and other types of data based on their usage criteria not developer convenience

• Use translucent encryption and auto-de-identification of data to make it more useful without further processing

• Design for decentralized sync’ing of data (e.g. mobile, etc.) not centralized ETL

Move to service-oriented (de-identifiable) dataDon’t assume all your data has to go into a giant data warehouse

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Hard to secure data structures

Easier to secure data structures

An example of structuring data for analysisPreparing data is important

http://www.ibm.com/developerworks/data/library/techarticle/dm-ind-ehr/

http://www.ibm.com/developerworks/data/library/techarticle/dm-ind-ehr/

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HL7 and X.12 aren’t the only formats

The general assumption is that formats like HL7, CCD, and X.12 are the only ways to do data integration in healthcare but of course that’s not quite true.

Consider industry-neutral protocols

• Consider identity exchange protocols like SAML for integration of user profile data and even for exchange of patient demographics and related profile information.

• Consider iCalendar/ICS publishing and subscribing for schedule data.

• Consider microformats like FOAF and similar formats from schema.org.

• Consider semantic data formats like RDF, RDFa, and related family.

Industry-specific formats aren’t always necessaryReliance on heavyweight industry-specific formats instead of lightweight micro formats is bad

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Legacy systems trap valuable data

In many existing contracts, the vendors of systems that house the data also ‘own’ the data and it can’t be easily liberated because the vendors of the systems actively prevent it from being shared or are just too busy to liberate the data.

Semantic markup and tagging is easy

• One easy way to create semantically meaningful and easier to share and secure patient data is to have all HTML tags be generated with companion RDFa or HTML5 Data Attributes using industry-neutral schemas and microformats similar to the ones defined at Schema.org.

• Google's recent implementation of its Knowledge Graph is a great example of the utility of this semantic mapping approach.

Tag all app data using semantic markupWhen data is not tagged using semantic markup, it's not securable or shareable by default

http://en.wikipedia.org/wiki/RDFa

http://dev.w3.org/html5/spec/global-attributes.html

http://www.healthcareguy.com/

http://googleblog.blogspot.com/2012/05/introducing-knowledge-graph-things-not.html

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Proprietary data formats limit findability

• Legacy applications only present through text or windowed interfaces that can be “scraped”.

• Web-based applications present HTML, JavaScript, images, and other assets but aren’t search engine friendly.

Search engines are great integrators

• Most users need access to information trapped in existing applications but sometimes they don’t need must more than access that a search engine could easily provide.

• Assume that all pages in an application, especial web applications, will be “ingested” by a securable, protectable, search engine that can act as the first method of integration.

Produce data in search-friendly mannerProduce HTML, JavaScript and other data in a security- and integration-friendly approach

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Healthcare fears open source• Only the government spends

more per user on antiquated software than we do in healthcare.

• There is a general fear that open source means unsupported software or lower quality solutions or unwanted security breaches.

Open source can save health IT• Other industries save billions by using

open source.• Commercial vendors give better

pricing, service, and support when they know they are competing with open source.

• Open source is sometimes more secure, higher quality, and better supported than commercial equivalents.

• Don’t dismiss open source, consider it the default choice and select commercial alternatives when they are known to be better.

Rely first on open source, then proprietary“Free” is not as important as open source, you should pay for software but require openness


Modern Microapps and Services Approach (Sample)

IdentityManager LDAP

EntityServices

RDBMS

DomainServices

RDBMS

AnalyticsSQL/Cube

RDBMS

Limited FK Constraints

oDataSQLV

SQLV

oData

SQLV

oAuth

SAML

oData

LDIF

Domain

Services

Widgets

Entity Service

s

CMS

oData

Micro AppsN

o D

irect

Tab

le

Acc

ess

Sep

ara

te

Sch

em

as

No F

K

Con

stra

ints

Bootstrap

AngularJS

BootstrapAngularJSBackplane

Reporting Apps

Third Party

BootstrapBackplane

RDFaHTML5 DA



ETL

BootstrapBackplane

Rich client only or tiny server frameworks (Mojo, Rack, etc.)

XACML

oDataSearchService

ElasticSearch

iCalsyslog

Log/MonitorService

CalDAVService

RulesService

Doc/BlobService

oData

Browser Accessible

XMPPService

NETSPECTIVE


Primary challenges• Tooling strategy must be comprehensive. What hardware and

software tools are available to non-technical personnel to encourage sharing?

• Formats matter. Are you using entity resolution, master data and metadata schemas, documenting your data formats, and access protocols?

• Incentivize data sharing. What are the rewards for sharing or penalties for not sharing healthcare data?

• Distribute costs. How are you going to allow data users to contribute to the storage, archiving, analysis, and management costs?

• Determine utilization. What metrics will you use determine what’s working and what’s not?

NETSPECTIVE


Additional Information• OSEHRA website: www.osehra.org• HardHats.org: http://www.hardhats.org• MUMPS

– http://en.wikipedia.org/wiki/MUMPS– http://www.mcenter.com/mtrc/mfaqhtm1.html

• World Vista: www.worldvista.org• Webnairs:

https://www.vxvista.org/display/vx4Learn/Recorded+Webinars

http://www.osehra.org/

http://www.hardhats.org/index.html

http://en.wikipedia.org/wiki/MUMPS

http://www.mcenter.com/mtrc/mfaqhtm1.html

http://www.worldvista.org/



Thank You

Visit http://www.netspective.com http://www.healthcareguy.comE-mail [email protected] @ShahidNShahCall 202-713-5409

Open Source is a great opportunity for EHR, Digital Health, and Health IT Integrators

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Transcript of Open Source is a great opportunity for EHR, Digital Health, and Health IT Integrators