The real value of Medical Device Interoperability (MDI) in ...
The Value of Interoperability - lpca.net Value of... · • 60% Build Standing Structures ......
Transcript of The Value of Interoperability - lpca.net Value of... · • 60% Build Standing Structures ......
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The Value of Interoperability Adele Allison, Director of Provider Innovation Strategies
October 7, 2015
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Disclaimer
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The Value of Interoperability
• Activity
• Building Blocks
• Use Cases
• New Developments
• Questions
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Interop and Workflow Redesign
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Use Technology as a Change
Agent!
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The Marshmallow Challenge
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• Team-up and get 1 Kit:
• Build the Tallest Freestanding Structure
• The Entire Marshmallow Must be on Top
• Use as Much or as Little of Kit as Desired
• Break-up the Spaghetti, String or Tape as Desired
• You have 10 Minutes
The Rules
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Classroom Timer
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Ta-Da!
Lesson 1
Prototyping Matters!
− Worse Performers?
− Best Performers?
− Why?
Business School Graduates!
Kindergarten Graduates!
……………………………..
0 10 Orient Plan Build
……………………………..
Source: www.MarshmellowChallenge.com
Oh-Oh!
Iterative Design Process
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Lesson 2 Diverse Skills Matter
Source: www.MarshmellowChallenge.com
0
10
20
30
Height (Inches)
Average Business Students
Lawyers Kinder- garten
Architects & Engineers
CEOs CEOs & Exe-cutive Asst.
Spec. Skills + Facilitation Skills = Success!
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Lesson 3
• Incentives Magnify Outcomes
• 60% Build Standing Structures
• Add Incentive Alone?
• 100% Failed
• Add Incentive with Value of “Prototyping” and Skills?
• Conversion from “Worst” to “Best”
• Incentives alone are NOT sufficient →
Must pair with good skills (E.g.,
Specialists or Facilitator) and
knowledge
Source: www.MarshmellowChallenge.com
Incentives + Prototype + Skills = ↑ Success
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In the End – Every Project has its own Marshmallow!
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The Value of Interoperability
• Activity
• Building Blocks
• Use Cases
• New Developments
• Questions
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• Narrative Text − Examples: Cut/Paste Dictation, Voice Recognition, Typing
− Pro: Personalizes patient encounter information, “Say it the way you want”
− Con: Not machine readable, no conducive to research and reporting
• Structured, User-Defined Fields − Examples: Customizable Drop-down Lists
− Pro: Customizable, reportable within organization
− Con: Not conducive to aggregated research and reporting
• Codified, Object-Oriented Data − Examples: ICD, CPT, SNOMED, LOINC
− Pro: Machine readable, consistent across country or world, very
researchable and reportable
− Con: Rigid structure, hard to personalize to individual patient
3 Essential Types Of Data Capture
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Machines Read in Code
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• Definition: − Standardized, machine-readable
terms
− Describes clinical problems,
procedures and other information
− Coded for easy comprehension
and consistency
Meaningful Use Defined
Vocabularies/Code Sets
Best Practice: Use codified
data capture for reporting
Block 1: Vocabulary and Code Sets
24 Adapted from HHS Interoperability Basics at
http://www.healthit.gov/public-course/interoperability-basics-training/HITRC_lsn1069/wrap_menupage.htm
Code Sets Used to Define …
OMB Standards
Race, Ethnicity
ISO 639-2 Alpha-3
Preferred Language
SNOMED CT Smoking Status
ICD or SNOMED CT
Problems
HCPCS and CPT
Procedures
RxNorm Medications and Medication Allergies
LOINC Lab tests, values and results
CVX Immunizations
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Block 2: Content Structure
25
• Definition: − Message format/architecture specific to the digital environment
− Delineates the information contained in the message
− Defines the structure of the information to be exchanged
− Allows disparate machines to communicate
• Used in interop and interfaces
• Examples: − HL7 2.5.1 format for Lab Results
− Clinical Document Architecture (CDA) for Care Summaries, Care Plans
− Admission, Discharge and Transfer (ADT) for Demographics
• 2014 Edition EHR Testing and Certification helps insure
capabilities, compliance
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CCDA
MU2 Consolidated CDA Template
• MU2 sets forth “Clinical Concepts”
Content Structure (Block 1)
• CCDA is the document “Template”
that must be used (Block 2) o Standardizes how “Clinical Concepts”
(Words) are used / re-used
o Templates put it into a “Package”
o Packages are arranged to create a
clinical “Document” that is purpose-
oriented
Demographics Medications
Allergies Problems
Lab Results Vitals
Smoking Status
Procedures
2014 Edition CEHRT
EHR
Dat
a C
aptu
red
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• Humans read in document format → CCD
• Machines read in code → CDA
Human vs. Machine Readable Data
EHR - A EHR - B
Problems
Problems
Meds
Meds
Smoking
Smoking
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Human vs. Machine Readable Data
EHR - A EHR - B
Problems
Problems
Meds
Meds
Smoking
Smoking
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Block 3: Transport
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• Definition: − Moves the message securely between different electronic systems
• 2 Federal Standards − Direct messaging
− Messaging through HIE participating with HealtheWay (National Exchange)
• Direct − Does not require a HIE engine
− Works like simple email → Pushes message/attachments over Internet
− Must uses a 2014 Edition Certified Health Information Service Provider
(HISP)
• The Sequoia Project f/k/a HealtheWay HIE participant − HIE does not have to be “certified”
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Direct Messaging
Dr. Clay Jones [email protected]
Dr. Ann Smith [email protected]
Integrated into EHR software
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HIE Direct Messaging
Dr. Clay Jones [email protected]
Dr. Ann Smith [email protected]
ABC EHR
HISP
Acme EHR
HISP
1. Authenticate recipient
2. Encrypt data
1. Authenticate sender
2. Decrypt data
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HealtheWay Alternative
HealtheWay Example
1.EHR generates CCDA 2.EHR sends CCDA to eHealth Exchange Participant 3.eHealthExchange Participant sends to Provider B
Provider A Provider B
CEHRT
eHealth Exchange Participant (formerly NwHIN Exchange)
An eHealth Exchange Participant does not have to be certified in
order for Provider A’s transmissions to count for MU.
However, Provider A must still use CEHRT to generate a standard
summary record in accordance with the CCDA.
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• Ensures that health information is safe, secure and private
• Facilitates trusted exchange over something insecure →
Internet − Locates health information exchange participants
− Uses registration and certificate authorities
− Managed by the HISP
Block 4: Security Services
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The Value of Interoperability
• Activity
• Building Blocks
• Use Cases
• New Developments
• Questions
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=
User Satisfaction with Technology…
=
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36
Done right, interoperability should be very underwhelming!
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Moving Data Between Systems
• 3 Ways to Move Data
• Point-to-Point → Interface / Direct
− When does it add complexity?
− When does it make sense?
PCP
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• 2 Ways to Move Data
• Point-to-Point → Interface / Direct
− When does it add complexity?
− When does it make sense?
PCP
• Health Information Exchange (HIE)
− “Normalizes” Data
− All HIE Participants can communicate
− Requires Participation by stakeholders for “value”
− Emerging Technology
− Typically, Data Repository
HIE
Moving Data Between Systems
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• To do what? → Use Case
• Provides a Business Model Framework − Step 1 – Identify the Problem (Problem Statement)
− Step 2 – What are the needs? (E.g., Care Coordination, Data
Capture)
− Step 3 – Who has the need? (Actors)
− Step 4 – Map the Solution (To meet needs for each Actor)
− Step 5 – What technology is needed? (E.g., Interface, Direct, HIE)
− Step 6 – Determine Financial and Operational Impact (E.g., Initial
and Ongoing costs, Workflows, etc.)
“I want to connect!”
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2. Improve Patient Care Safety
3 Interoperability Guiding Principles
1. Improve Patient Quality of Care
3. Increase Operational Efficiency to
lower clinic costs
Use Case
Guiding
Principles
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• Referral Management → PCP sends Care Summary
to SCP
• Clearly Specify Workflow
• Consider Various Technical Requirements − 2014 Edition CEHRT
− Mechanisms for patient identification / matching
− Multiple Direct addresses?
• Guiding Principles − Quality: Improves privacy/security
− Safety: Timely, reliable and precise communication
− Efficiency: Reduced phone call referrals, awaiting faxes, easily uploaded
PCP Direct Use Case
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Use Case Scenarios
Patient Gets Injured PCP Physician
• Cleaning Yard • Pain in calf and knee • Over evening leg swelled • Next day → Fever • Health Home
• Performs I&D • Collects specimen • 48 hours on cultures • Determine sensitivity • Interim Antibiotic • Suspected Spider Bite • Follow-up in 48 hours • Sooner if problems • Discharged
EHR / HIE
• Antibiotics cross-referenced in EHR Rx database
• Appropriate Antibiotic • EHR confirms last date
of tetanus-diphtheria • Avoids unnecessary immunization
Source: ONC Interoperability Basics – www.healthit.gov/providers-
professionals/interoperability-training-courses
Quality,
Safety,
Efficiency
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Use Case Scenarios Patient Spikes Fever
• No Follow-up • Travels with friends • Fever peaks at 104 • Ends up in ED • Gets admitted
Hospital Physician
• IV Antibiotics • Fever continues • Unknown etiology • Deep leg pain develops • New culture → +48 hrs • Results needed NOW, or • Surgical excision of infected tissue
EHR / HIE
• HIE used by Hospital • Obtains culture results
quickly from PCP • Susceptibility identified
Quality,
Safety,
Efficiency
Source: ONC Interoperability Basics – www.healthit.gov/providers-
professionals/interoperability-training-courses
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Use Case Scenarios Physician
• Culture shows MRSA • Sensitive to different
Antibiotic than using • Doctor immediately
switches • Rapid improvement • Discharge home
Patient RTW
• What’s MRSA? • Didn’t know it could get so bad! • Glad my MD got a culture and results • Need to RTW asap!
EHR / HIE
• MRSA “Notifiable” Dz. • HIE send notice to State
Health Dept.
Quality,
Safety,
Efficiency
Source: ONC Interoperability Basics – www.healthit.gov/providers-
professionals/interoperability-training-courses
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The Value of Interoperability
• Activity
• Building Blocks
• Use Cases
• New Developments
• Questions
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• $30 Billion in federal HITECH funding
• 2014 ONC received 60 unsolicited reports of “Information
Blocking” − Dominant complaint was cost
− Examples:
EHR vendor charging > $2.00/patient/year + transactional fee for Direct
EHR vendor charging $30,000 to interface to HIE in CT
• 113th Congress → Consolidated and Further Continuing
Appropriations Act (enacted Dec. 2014) − Authorizes ONC to de-certify any EHR vendor found practicing
“information blocking”
• HIMSS15 Conference – Vendor Announcements − athenahealth and Epic to eliminate fees
Warning Against “Information Blocking”
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• Fast Healthcare Interoperability Resources (FHIR®)
• HL7 Interoperability Standard − Leverages “Resources” a/k/a “Models” → E.g., Patient, Condition, Procedure,
Medication, Appointment, etc.
− Resource = Properties → E.g., DOB, Gender, Name under the Patient Resource
− Resources are bundled with related resources
• Resources can be: − Created (HTTP POST)
− Retrieved (HTTP GET)
− Updated (HTTP PUT)
− Removed (HTTP DELETE)
FHIR®
47 Source: Orion Health, White Paper, FHIR ignites healthcare sharing, Dr. David Hay, Mar. 31, 2015,
http://ehidc.org/resource-center/white-papers/2015-03-31-FHIR-Ignites-Healthcare-Sharing.pdf
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• FHIR uses Application Programming Interfaces (APIs) → Tells
computers how to locate and exchange Resources
• Some Key Benefits − Removes some cost barriers
− Speedy to Implement
− Adaptable to changing requirements
− No vendor “lock-in” due to no proprietary interfaces
− Support mobile, device and Internet technologies
• Only a draft interop standard today, even though broadly supported − Strong industry enthusiasm
− No regulatory requirement
− Not prominent in tech vendor’s near-term product roadmaps
− 2-5 year ramp-up for industry use and availability
FHIR®
48
Sources: Orion Health, White Paper, FHIR ignites healthcare sharing, Dr. David Hay, Mar. 31, 2015,
http://ehidc.org/resource-center/white-papers/2015-03-31-FHIR-Ignites-Healthcare-Sharing.pdf;
Chilmark Research, https://www.chilmarkresearch.com/2015/07/23/new-insight-report-on-moving-to-
open-platforms-now-available/
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FHIR®
49
Condition
Patient
Encounter
Procedure
Practitioner
Diagnostics
Medications
Re
sou
rce
s
FHIR
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• Evolving Standards → HL7 Fast Health Interoperability
Resources (FHIR®) − Recommended by 2013 Jason task force report to ONC
− Uses open application program interfaces (APIs) with intermediary
applications
− Industry excited, but …
− All policy, legal, governance, development and business barriers must be
overcome to implement
• Patient Matching − Policy says no unique patient identifier
− Technology using algorithms with error rate of 8-20%
• Lack of resources, expertise
• Balancing process and innovation with data use ethics
Cost Not Only Barrier
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ONC Interoperability Roadmap
51 Source: ONC, HIMSS15, Listening Session: Advancing
Interoperability and Standards
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• Learning Health Network by 2024 − Patients, families, providers and stakeholders
− Send, receive, find and use health information
− Appropriately, securely, timely and reliably
• ONC → Today 6 Questions when talking about interoperability − For what purpose?
− With whom?
− With what data?
− Via what infrastructure?
− By when?
− Toward what expected benefits?
• Answer? Use Case!
ONC Interoperability Roadmap
52 Source: ONC, HIMSS15, Listening Session: Advancing Interoperability
and Standards
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• CommonWell Health Alliance – Industry-driven Initiative for
“best practices” in Interoperability − Members include: Allscripts, athenahealth, Cerner, Greenway,
McKesson, Aprima, CVS Caremark, Meditech and others
− Exploring FHIR
• Carequality – Convener and Consensus point for Technical
Specifications − Public-private, multi-stakeholder collabration
− Members include: AMA, eClinicalWorks, Cerner, Epic, Greenway, Kaiser
Permanente, Surescripts, Walgreens and others
− Focused in 3 elements
Common rules
Technical Specs
Participant Directory
Industry Collaborations
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Questions?
Thank You!
Adele Allison [email protected]
Follow me on Twitter:
www.twitter.com/Adele_Allison