september 13, 2018 · 2018-09-18 · hl7 fhir profiles practicing clinical ... • july 2016...
TRANSCRIPT
HSPC and CIIC
September 13, 2018
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Agenda
• Why semantic interoperability?• What would the architecture of an interoperable system look like?• Background and history of HSPC and CIIC• The merger of HSPC and CIIC• Current activities and future plans
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Why?
“To help people live the healthiest lives possible.”
Why interoperability ?
• Improve the quality and safety of care• Decrease the cost of care• Enable a Learning Health System•Make providers happier and more effective•Make patients happier and healthier• There are many more reasons…
Patient
5
Sir Cyril Chantler
James # 6
Medicine used to be simple,ineffective, and relatively safe
Now it is complex, effective, and potentially dangerous.
Neal G. Reducing risks in the practice of hospital general medicine. In Clinical Risk Management, 2nd edition. British Medical Journal, 2001.
Chantler, Cyril. The role and education of doctors in the delivery of health care. Lancet 1999; 353:1178-81.
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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Medical errors
Deaths during inpatient admissions: ~251,454
Heterogeneous Systems
Others…
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FHIR Profiles fromCIMI detailed clinical models
Real Impact• Occult sepsis• Community Acquired Pneumonia• Pulmonary Embolus• ICU Glucose • Ventilator management
Real Impact• Occult sepsis• Community Acquired Pneumonia• Pulmonary Embolus• ICU Glucose • Ventilator management
Imagine….Semantically Interoperable Healthcare focused Apps
Healthcare App Store
Repository ofShared Modelsin an approvedFormalism
Model Review
SOLORSNOMED CT
LOINCRxNorm
Core Reference Model
Standards Infusion
Model Dissemination
Translators
HL7 FHIR Profiles
Practicing Clinical Subject Matter Experts
ACOG – OPAmodeling
FPAR ApplicationDevelopment
FPARApplication
Open, shared repository of detailed models
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The Interoperability Pyramid (voluntary adherence to a higher standard)
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HL7 Version 2 Compliance
HL7 FHIR Compliance
Argonaut Compliance
HSPC Compliance
Structure, No terminology Constraints
Structure(s), Generic LOINC
Common resources, extensions and some specific LOINC and SNOMED
1 Preferred structure, standard extensions, explicit LOINC and SNOMED, units, magnitude, …
About HSPC and CIIC
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HSPC History
• HSPC was incorporated as a not‐for‐profit corporation on August 22, 2014
• Meetings (two or three each year)• May 2013 Salt Lake City• …• July 2016 Washington DC, hosted by the ACS• November 2016 New Orleans, hosted by LSU Health• March 2017, New Orleans, hosted by LSU Health• August 2017, Washington DC, hosted by the ACS• November 2017, Indianapolis, hosted by Regenstrief Institute
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Improve health by creating a vibrant, open ecosystem of interoperable applications, content, and services.
Be a provider‐led organization that accelerates the delivery of innovative healthcare applications that improve health and healthcare.
HSPC Mission
HSPC Vision
Organizational Guiding Principles Provider‐driven Patient‐centered Standards based Business focused Open Architectures Accelerated Innovation Vendor‐agnostic Collaborative Adaptable Sustainable
Clinical Information Interoperability Council(HL7 hosted first meeting in 2009)
• We want to create ubiquitous on demand sharing of standardized data across the breadth of medicine for:
• Direct patient care• Research and learning• Public health• Clinical trials• Data from devices• Post market surveillance• Quality and disease specific registries• Billing and health administration• Any where that we share health related data and information …..
The July 13th 2017 CIIC meeting in Bethesda
• Jointly sponsored by HL7 and HSPC• Keynote speaker – Don Rucker, MD (National Coordinator for HIT)• About 120 attendees• Representing – AAN, AAO, ACOG, ACS, ACC, ACP, APTA, ANA, FDA, CDC, NCI, AHRQ, NIAID, DoD, VA, PCPI, AMIA, SPM, HIMSS and many other organizations
• Presentations and breakout groups• Conclusion: There was important work we could do and we should continue
Tasks for expert clinicians
• Determine what data should be collected• It will be different for different situations
• Determine a preferred information model for a given kind of data• How should the data be modelled? Two fields or one (the degree of pre and post coordination)
• Define what the data means• Make computable definitions for diabetes mellitus, myocardial infarction, heart failure, chronic renal failure, etc.
How do we relate to other interoperability activities?• Argonauts
• We build on the HL7 FHIR profiles that the Argonauts create
• Sequoia• We depend on Sequoia to create the network,
trust agreements, and data exchange infrastructure
• SMART• We depend on SMART for integration into EHRs
• HL7• FHIR – the approved API for sharing patient data• CIMI – provides the detailed information models
that are essential for interoperability• Federal Health Information Model (FHIM)
• We use FHIM classes as the patterns for CIMI models
• NLM Value Set Authority Center (VSAC)• we are aligning and placing SOLOR refsets in
VSAC• SOLOR
• SOLOR is the source of coded concepts used in CIMI models
• SDOs (HL7, OMG, NCPDP, X12, ISO, CEN)• We use their standards whenever possible
• Commonwell, Center for Medical Interoperability, AMA Integrated Health Model Initiative, CDEs, openEHR, OMOP (OHDSI)
• We want to work together as partners with all groups with whom we have overlapping interests
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Merger Background and Context
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High Level Motivation for the Merger• Achieving “true” interoperability requires many activities• Three key activities are:
• Front line clinical expertise and support (as represented by CIIC)• Technical innovation including modeling, terminology, SOA, platform, tooling, and knowledge sharing (as represented by HSPC)
• TEFCA, security, privacy, access, policy, regulation, legislation and other issues• High degree of overlap in leadership and activities of the two organizations
• CIIC needed a business entity to transact business and hold IP• Conclusion:We neednto merge the two activities and get more done and make faster progress
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Merger Committee• 12 individuals agreed to be part of merger committee• April 19, 2018 face‐to‐face meeting in Washington• Conference calls every two weeks• Topics of discussion
• Adding clinical representatives to the HSPC Board• Purpose of the Board• Organizational structure of the merged organization• Staffing• Funding and financial stability• A (new) name for the merged organization
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Merge Discussion Participants
• Oscar Diaz ‐ HarmonIQ• Emory Fry ‐ Cognitive• Steve Hasley ‐ ACOG• Stan Huff – Intermountain• Chuck Jaffe – HL7• Laura Heermann Langford ‐Intermountain
• Russell Leftwich ‐ Intersystems• Jonathan Nebeker ‐ VA• Frank Opelka ‐ ACS• Jimmy Tcheng – Duke, ACC• Steve Waldren ‐ AAFP• Keith White – Imaging, Intermountain
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Transition Board• Current board members approve additional new members• Current HSPC board members remain
• 3 Benefactors and CEO Ex Officio (Stan Huff, Wayne Wilbright, Jonathan Nebeker, Oscar Diaz)
• Initial board for approximately 2 years• The Initial board will then select new board members as the organization evolves
• Proposed new Board members• Clinical representatives = 3 (Frank Opelka – ACS, Steve Waldren – AAFP, Jimmy Tcheng – ACC)• 2 board advisors (Steve Hasley – ACOG, Keith White – Imaging (I4)
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Board
Technical Steering Committee
Nominates Candidates to Board
Executive Leadership
• Develop and ensure that the mission and values of the organization are carried out
• Drive strategy• Ensure financial viability• Advocacy • Hires and fires senior management• Audit • Represents entity back to external
community• Board members represent the entity,
not the stakeholder group that they come from
Clinical Steering Committee
Specialty SocietiesProvider Organization
Nominates Candidates to Board
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Merger things that we plan to work on next• Governance and organizational structure
• Including staff positions and organization• Plan for funding and financial sustainability• Evolve and strengthen the organization
• Engagement with Weber Shandwick• Supported by contributions from the American College of Surgeons
• Three phase plan for growing the organization• Create a new name for the combined organization
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Key Technical Activities
• Development of consistent information models• HL7 Clinical Information Modeling Initiative• FHIR Profiles
• Definition of reference SOA platform architecture• Creation of reference implementation• Application development site (sandbox)• Strategy for conformance testing• Development of a healthcare community cloud and vendor neutral ecosystem
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Key Clinical Projects
Improving Healthcare Data Interoperability ‐
Duke Clinical Research Institute Pew ProjectJames E. Tcheng, MD
Rebecca Wilgus, RN, MSN
Grant support provided by the Pew Charitable Trusts
Improving Healthcare Data Interoperability – The Pew Project
Convening the Registry Community
Current state of registries How well are data standards implemented?
Current state of national data models [same question!]
Authoring the “Easy Button” All in one package of best practice
recommendations (for db developers)
Scope• Patient ID (family name, given name)• Sex (birth sex)• Date of birth• Race, ethnicity• Smoking status, EtOH, illicit substances • Risk factors• Vital signs• Laboratory results• Medications• Care team members (attending physician, physician operator)• Procedures• Unique device identifiers (UDI)• Vital status (alive / dead)
OPA/ACOG FPAR 2.0 projectSteve Hasley, ACOG CMIO
7.2 million encounters annually
4.1 million clients
4,127 Service delivery sites
1,134 Sub recipients
50+ States & territories funded by
94 Grantees monitored by
20 Regional OPA FTEs supported by
10 Regional Health Administrators
5 National Training Centers
1 OPA HQ
Title X: A diverse and wide network
34Source: Family Planning Annual Report: 2014 (Aug 2015)
The 10 HHS Federal Regions
Converge: Draft 2.0 Data Elements• Client ID• Provider ID• Visit date• Date of birth• Sex• Ethnicity• Race• Limited English Proficiency status
• Household size• Income• Health insurance coverage
• Pregnancy intention
• Current pregnancy status• Sexually active status• Contraceptive method at entry & exit or Reason for no method
• Date of last pap and/or HPV test
• Screening tests for Chlamydia, Gonorrhea, and HIV
• HIV positive test result• Linkage to HIV medical care• Systolic and Diastolic BP• Height and Weight• Smoking status
7.2 million encounters annually
4.1 million clients
4,127 Service delivery sites
1,134 Sub recipients
50+ States & territories funded by
94 Grantees monitored by
20 Regional OPA FTEs supported by
10 Regional Health Administrators
5 National Training Centers
1 OPA HQ
Title X: A diverse and wide network
Source: Family Planning Annual Report: 2014 (Aug 2015)
The 10 HHS Federal Regions
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Approved for Public Release; Distribution Unlimited. Case Number 16-1988
Cancer Data Interoperability Project
Every patient’s journey improves all future care
Steve BrattLeader, Health Standards and Interoperability GroupThe MITRE [email protected]
Presented at the 17th General Meeting of HSPC Joint with CIIC / Bethesda, MD / 31 July 2018
| 38 |
Approved for Public Release; Distribution Unlimited. Case Number 16-1988
Cancer Data Interoperability Project[integrating the MITRE-funded Standard Health Record (SHR) for Oncology initiative]
Flux Notes
Capture: Collect and VisualizeGoal: Demonstrate low burden, incentivized collection of high-quality, standardized treatment data at point of care
ICAREdata Study
Use: Validate ApproachGoal: At cancer centers, demonstrate that collection of real-world data (RWD) can be as complete and accurate as clinical trials data
Oncology Spec
Breast Cancer
Define: Right Data in Standard FormatGoal: Advance detailed clinical model and FHIR IG for breast cancer as HL7 standard (CIC, CIMI)
Objective Enable capture of structured cancer care data (Real World Data) that is as
high-quality complete, accurate and computable as clinical trials data
The incredible value of interoperability?
• Save 100,000 lives a year?•Make the right decision 80% of the time?• Save $5 billion in chart abstraction costs?• Learn something from the $3.2 trillion that we spend each year on healthcare?
• Install a new EHR for millions instead of billions?
HSPC Internet Sites• Website: http://hspconsortium.org
• Wiki: https://healthservices.atlassian.net/wiki/display/HSPC/Healthcare+Services+Platform+Consortium
• Developer Website: http://www.developers.hspconsortium.org/
• Sandbox: https://sandbox.hspconsortium.org
Questions and Discussion
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www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006
Scott StuewePresident and CEO, DirectTrust
Autumn 2018
Introduction and Update
www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006
What is DirectTrust?A Network.
• A growing, federated network for healthcare data exchange
– 1.7 Million individual accounts, nearly 250,000 consumer accounts
– Over 120,000 provider organizations
– Over 400 EHRs (any CEHRT) can send and receive direct messages
– 200 million direct messages sent annually, 431 million sent to date
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www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006
• Ensures secure healthcare exchange– Network Rules of the road
– Technical Public Key infrastructure for:• Identity credentials
• Message encryption
– Accreditation of organizations that operate on the network• Health Internet Service Providers
– (HISPs operate like an ISP on the open internet)
• Certificate Authorities and Registration Authorities (for digital certificates and identity proofing)
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What is DirectTrust?A Trust Framework.
www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006
• A not for profit trade association (501c-6)– 120 members including HIT companies, provider organizations,
governmental agencies and others
– Some members operate or support the network • Health Internet Service Providers, Certificate Authorities and Registration Authorities
– Others want to help shape the direction of the trust framework
Members
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What is DirectTrust?A Membership Organization.
www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006
Metrics Demonstrate Consistent Growth (20%)
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1.7 Million Addresses!
200 Million Messages a Year!
www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006
ONC 2nd Interoperability Forum
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CMS Administrator Seema Verma calls for an end to physician fax machines by 2020
"If I could challenge developers on a mission, it's to help make doctors' offices a fax free zone by 2020," Verma said to applause.
www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006
Your Help with Seema’s ”#AxeTheFax” Vision
• Advocate with your EHR Company for Improvements to Direct Workflows– Some companies implemented only what was necessary for
Meaningful use – need support for clinical messaging
– An ability to send and receive both patient specific and general messages including all attachment types
– Send documents as attachments and store them when received
• Do referrals by Direct with anyone you can– It’s easier for you – just need to see which partners can do it
• Advocate for communication with payers via Direct– It’s WAY easier than logging onto their web-site and uploading charts
or reports.
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www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006 8
DirectTrust Success Stories
www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006 9
DirectTrust Success Stories
www.DirectTrust.org1629 K Street NW, Suite 300, Washington, DC 20006
Discussion
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Scott Stuewe
President and CEO, DirectTrust.org
913-222-0630
David C. Kibbe MD MBA
Senior Advisor
913.205.7968
Interoperability and
TeleHealthBrian Levy MD
Agenda -
Telehealth
Interoperability
Bio
Sample Cases
Telehealth
Interoperability
Problem
Use cases
Solutions
Conclusion
William Osler
It is much more
important to know
what sort of a patient
has a disease than
what sort of a disease
a patient has.
Bio
Physician Informatacist
Internist
Telehealth provider
Hospitalist
Interoperability specialist –
former CMO at Health Language
for 17 years
Member of HIMSS HIE and
Interoperability Committee
Case 1
CC: Rash
HPI: 55 yo man complains of a rash for the last couple of days. Before the rash started, he had pain in the area. The rash is limited to one area on the back.
PMH: HTN
ALL: PCN
Meds: HCTZ
Objective:
Assessment: Likely shingles. Differential: contact dermatitis, tinea, cellulitis, folliculitisPlan: Valacylovir
Case 2
CC: Sore biceps
HPI: 45 year old man who did 100 pullups yesterday and is very sore. He also complains of red urine.
PMH: None
MEDS: None
ALL: Penicillin
Objective: On the video, appears in no acute distress.
Assessment: RhabdomyolysisPlan: Send to ER right away.
Telehealth Definitions
‘Telehealth encompasses a broad variety of technologies and tactics
to deliver virtual medical, health, and education services. Telehealth
is not a specific service, but a collection of means to enhance care
and education delivery.’ (from CCHPCA)
‘The use of electronic information and telecommunications
technologies to support long-distance clinical health care, patient and
professional health-related education, public health and health
administration.’ (from HRSA)
http://www.cchpca.org/what-is-telehealth
Telehealth is
Broad
Live video
Phone calls
Store and forward
Remote patient monitoring
Mobile health
Telehealth
Use Cases
Urgent care
Specialists
Behavioral health
Telestroke
Dermatology
Kiosk
Hospital
Clinic
Home
Kiosk
Telehealth State Laws
Telemedicine advancing faster
than States can keep up
SOURCE: American Telemedicine Association
What is Interoperability
‘Electronically exchanged information’
HIMSS: Interoperability is the ability of different information technology
systems and software applications to communicate, exchange data, and use
the information that has been exchanged.
ONC: Interoperability: the ability of a system to exchange electronic health
information with and use electronic health information from other systems
without special effort on the part of the user.
Foundational Structural Semantic
What should be
Interoperable?
Allergies
Appointments/scheduling
Devices
Event Notification
Medications
Notes
Orders
Prescriptions
Problem Lists
Encounter summaries / Patient summaries
Challenge
Lack of interoperability
Disparate data spread across
multiple patient charts
Separate platforms - even
in the same hospital system
Duplicating documentation
practices
Timing is critical for Telestroke
Telehealth visits will become just as important as
in person
Medical Device Interoperability
Putting it into Practice – Personal
Experience
Secure video
Phone
Scheduling
Waiting room
EMR
Patient portal
Billing
Medical malpractice
EMR – Getting stuff in and out…
HL7
FHIR
SMART on FHIR
CDAs
Proprietary APIs
Foundational Interoperability
PDF Images
Core
Syntactic
Standards
• Demographics
• ADT
• MDM
• Test results
HL7
• API access
FHIR
• Progress notes
• Discharge
• Patient summaries
CDA
What is
FHIR?
Fast Healthcare Interoperability Resources (FHIR) is a standard describing data formats and elements (known as "resources") and an application programming interface (API) for exchanging electronic health records.
Faster to learn and implement, Lower cost, Scales well from simple to complex, Flexible, Free
SMART on FHIRSubstitutable Medical Applications and Reusable Technologies
SMART on FHIR is a set of open specifications to integrate apps
with Electronic Health Records, portals, Health Information Exchanges,
and other Health IT systems.
Core Semantic Standards
SNOMED
LOINC
RxNORM
Proprietary pharmacy
terminologies
ICD-10-CM CPT
Proprietary order catalogs
Problem Lists
Lab results
Medications
Allergies
CPOE
Billing
Lab,
Radiology
Orders
More Terminology Standards
Value sets of existing standards
CVX
Race and Ethnicity (CDC, OMB)
FDA Device Identifiers
Unified code for units of measure
CDISC
NCI
HCPCS, APC, DRG
Allergy ExampleCDA
Allergy - FHIR
Allergy – FHIR JSON
How would your order a procedure and pass
it into the EMR to fulfill?
Order a MRI using SNOMED
MRI of left hip
MRI of hip
MRI of left lower limb
Procedure on hip
MRI of lower
extremity
MRI
Left hip region structure
MRI - action
LateralityLeft
Entire hip region
CPT 73721: MRI extremity lower joint W/O
contrast knee, ankle, mid/hindfoot, hip
CPT 73723: MRI extremity lower joint W W/O
contrast knee, ankle, mid/hindfoot, hip
MRI of left hip
with contrast
FHIR as the Information Model
There is overlap between the terminology and information model
The FHIR information model can also be used to represent anatomy context
For example, the Procedure Request resource (https://www.hl7.org/fhir/procedurerequest.html) has a slot for bodySite with location values that can used the SNOMED Body Structures.
Thus body site can be represented using the terminology model (SNOMED Procedure Site) or the information model (FHIR bodysite)
Laterality context can be represented in the terminology concept itself, in the terminology model, or the FHIR information model
MRI of left hip is a pre-coordinated SNOMED concept
MRI of left hip uses a laterality relationship (where laterality itself is a SNOMED concept) to left
FHIR also has a laterality object which uses the SNOMED concepts of left, right, and bilateral as its terminology binding
FHIR Procedure Resource
Most EMRs though would have a proprietary code for ordering the procedure
Terminology and Information Models
Grey area between information model and terminology where the context of
a concept can be represented in either model
Consider
Use terminology model for concepts (MRI, left, hip)
Use information model for context (laterality, allergy, family history)
Interesting Interoperability Options
HIEsUniversal
EMRBlockchain
Conclusion
Telehealth is here to stay
But adds to the
multiple records for a patient
Existing interoperability standards can
be used.
