singh m sullivan k 8 21 dt
TRANSCRIPT
Winning Trust, Minimizing IT Resources: Key to Forming
RHIOs
Mark Singh MD, President, Clinicore Kathleen Sullivan MPH, CEO, Salient Health
The SEMRHIO Experience
Introduction
• Hospitals: Greater demand for electronic data delivery: EMRs interfaces, Portals
• Physicians: Clinical data from multiple disparate sources
• RHIOs: a solution – Significant Barriers: Trust/Security, Cost
• Hospital buy-in: Need to overcome these barriers
Our Experience in forming SEMRHIO• South Eastern Massachusetts Regional Healthcare
Information Organization
Milton Hospital
Jordan Hospital
Quincy Medical Center
Overcoming Barriers
• Developed a model: – Gain Trust– Minimize Hospital IT infrastructure
• lower cost of entry
• Won Approval from Hospital Leadership– SEMRHIO
Problems Addressed• Need to support EMR adoption, electronic data
delivery, interfaces to hospital systems– Immediate problem which needs a solution within
next 2-3 years• Health care delivery is distributed through out
community– Challenge to have the appropriate data available in
order to provide safe patient care– Trying to keep; up with fax machines: tough
EMR Adoption
• More doctors implementing EMRs• Hospitals being asked to provide
interfaces – Need to serve small and large practices– Can this this be done more efficiently by
hospitals as a “group”: RHIO?
Care Delivered at Multiple Sites
Doctor’s offices
HospitalImaging Center Surgi-center
Labs
Patient
Clinical Data is spread out
• When taking care of a patient, need to have access to data from all the other sites– Care delivered in Physician's offices (multiple
specialists, PCP)– Hospitals/Emergency Rooms– Nursing Homes
Need to Solve:
• How do we deliver clinical data electronically?
• How to consolidate clinical data set in real from disparate healthcare entities in order to care for patients?
Solving these Problems
• RHIO seems to makes sense:– multi-stakeholder organization – Allow shared costs of common IT
infrastructure• Economies of scale
– Framework for data sharing among competing organizations
RHIO: Challenges and Barriers
• Perceived Negatives regarding RHIOs– Too costly, Lack of sustainability models– Too many security and trust issues among
Competing entities. • uncomfortable with concept of “Sharing” clinical
data
“California RHIO closes amid cost, privacy concerns”
eHealth SmartBrief | 07/11/2007
The closure of the Santa Barbara Co. Care Data Exchange
Given these significant barriers, how do we get community based, independent, competing hospitals to form a RHIO?
Need to Address Potential Barriers
• Cost and Security issues:
– Lack of IT Infrastructure and Resources• Hospitals have more immediate pressing issues:
– i.e., CPOE , eMAR
– Trust among disparate organizations
Trust in Forming a RHIO
• Issue of Architecture, business process– When thinking about RHIOs, we consider
classic approach for RHIO architectures– Classic Model is a “federated”, “Pull” based
architecture using a Record Locator Service (RLS)
“PULL” based Model
H
Hospital-A
1
Patienthas CAD,
CHF.
DrugAddiction
Hx
Sodium135,
Cholesterol 187,
Glucose
Pull Based RHIO ModelReturn only permitted data
RLS
Hospital-B
Patienthas CAD,CHF. Aso
HIV.Patient
hasNausea Asoh/o HIV.
Patienthas CAD,
CHF.AIDS
Hospital-C
MentalHealth Hx
2
3
User requests recordson patient
User not entitled to receive datacontaining mental health, HIV,substance abuse information
Get John Doe’s dataSearch for John
Doe’s data across hospitals
Return data but exclude: data with “HIV”, “Substance
Abuse”, “Mental Health”
Pull ModelComplicates Trust issues
• Pull may work very well in a multi-site, single- organization
• Has problems in a multi-organizational setting- Problematic
– Introduces new Trust issues– Each hospital (source) needs to determine what data
each user can access– Model opens up a “can of worms”– Can be a “show stopper” in forming RHIOs
“Best to automate an existing business process and trust
relationship” “The RHIO experience in Massachusetts” John Halamka D. MD, CEO MA-SHARE
May 4, 2007
How do we build Trust ?
Use an existing Trust relationship Use an existing Business Process
Existing Business Process and Trust Relationship
“PUSH” model
The directed delivery of clinical data from to provider
Healthcare entityPush
PUSH Model for Exchange
Patienthas CAD,CHF. Aso
h.
Had h/ofall. Feltdizzine
ss.
Patienthas CAD,CHF. Asoh/o HIV.
Patienthas CAD,CHF. Asoh/o HIV.
PatienthasNausea Asoh/o HIV.
Sodium135,
Cholesterol 187,
Glucose130
PUSH Based HealthInformation Interchange
PUSH toAuthorizedRecipient
Sodium135,
Cholesterol 187,
Glucose130
Sodium135,
Cholesterol 187,
Glucose130
Sodium135,
Cholesterol 187,
Glucose130
InBox
Building Trust: "push" model—A doctor or healthcare entity decides what data to send to another doctor or entity.
Proposed Model• Adopt conservative approach: Don’t change the
current arrangement– Hospital to send data to the legal recipient (“ordering”,
“primary” doctors) via RHIO (instead of fax/mail)• Once received by doctor, ownership of data
goes to doctor• Data sharing among doctors: “…for treatment,
payment, and healthcare operations” per HIPAA guidelines.
Local RHIO Data
Exchange
Dr Good
Dr Health
Dr Livelong
Dr Luck
Hospital A
Hospital B
Hospital C
Mega EMR
Mega Medical Group
STATE WIDE RHIO
Hospitals Exchange
Confidential Data via secure RHIO
Doctors can exchange reports securely with consulting and primary care physicians
Local RHIO connects to State
RHIO
Confidential Clinical Data Exchange via Local RHIO which reflects the local culture, physician relationships
SEMRHIO Security Model
Doctors have their own secure account for data sent to them by the hospitals
Doctor may only share data with another doctor for “Treatment and payment” per HIPAA guidelines
IT Infrastructure Issues• Hospitals wanted to commit minimal
resources• Major Component of the RHIO: Hospital
Information System (HIS) Integration– Need for HL7 Interface Engine– Involved increased cost and complexity
Onsite Integration
HL7 Engine
Integration Engine
Onsite setup and maintenance required
Specialized staff to manage interface
HL7
HL71
HL7 Engine
HL7 Engine
RHIO Software
HL7
HL72
HL73
HL7c
$
$
$
Is there an easier solution?
– Studied other possibilities• Extract desired data in near-real time, delimited
text format, using HIS query /reporting utility• Proposed Model:
– Local: Extract hospital data using existing the HIS query/reporting utility
– Central: Conversion to HL7 centrally using BizTalk.
Hosted Integration
BizTalk based
Integration
Engine
“Zero” local foot-print
HL7
Flat file
RHIO Software
Flat file
Flat file
$
Move HL7 integration infrastructure centrally
Advantages of Hosted Services Model
• Move infrastructure to the other side of the “Cloud”. – Simplify/minimize onsite infrastructure– Existing Local IT staff able to manage onsite
needs without additional training needed– Centralize interface management– Allow hospitals to share in economies of scale
Hosted Services
• Evolving Model: SOA ,SaaS• Trend towards Hosted services
– i.e., Salesforce.com, Google, Postini– Hosted email– Many Hospitals outsource their IT
infrastructure and support: e.g., Perot systems
Hosted Integration
• Minimizing IT resources• There was also a desire by hospitals to commit
minimal resources • Reluctance to install additional software/hardware locally. • We studied the existing hospital IT infrastructure and
developed a centralized “Hosted-Integration” model using BizTalk server.
• This was a “zero” local foot print implementation model which did not require any additional software/hardware locally, and was implemented using basic IT personal.
The Process
• Extract data from HIS use existing built-in reporting/query utility
• Hosted BizTalk integration server– BizTalk receive data at input ports– Delimited data mapped to HL7 2.x,
• The disparate data is mapped to a standard terminology. • Final data is stored in SQL 2005 for delivery to the
recipient physicians.
Source Lab data: Flat file ~delimited convert to HL7 v2x-XML
• 12222 ~01364999 ~000-00-0000 ~Doe,John ~11/30/39~67 ~F~3N ~367 ~ADM IN ~00966001~LITTLE ~RICHARD ~LITTLE,RICHARD M.D. ~1204:C00078R ~SODIUM ~T~BASIC METABOLIC PANEL ~CPT 4 ~84295 ~12/04/06~0717~12/04/06~0818~COMP ~136 ~135-145 ~mmol/L ~ ~
• 12222 ~01364999 ~ 000-00-0000 ~Doe,John ~11/30/39~67 ~F~3N ~367 ~ADM IN ~00966001~LITTLE ~RICHARD ~LITTLE,RICHARD M.D. ~1204:C00078R ~POTASSIUM ~T~BASIC METABOLIC PANEL ~CPT 4 ~84132 ~12/04/06~0717~12/04/06~0818~COMP ~4.2 ~3.7-5.2 ~mmol/L ~ ~
• <ns1:ORU_R01_231_GLO_DEF xmlns:ns2="AM.HL7.Schemas.Tables" xmlns:ns0="AM.HL7.Schemas.Segments" xmlns:ns1="AM.HL7.Schemas" xmlns:ns3="AM.HL7.Schemas.DataTypes">
• - <Sequence>• - <PID_PatientIdentificationSegment>• - <PID.2_PatientId>
– <CX.0_Id>064166</CX.0_Id> • </PID.2_PatientId>• - <PID.3_PatientIdentifierList>•
<CX.4_IdentifierTypeCode>MR</CX.4_IdentifierTypeCode >
• </PID.3_PatientIdentifierList>• - <PID.3_PatientIdentifierList>•
<CX.4_IdentifierTypeCode>MR</CX.4_Identifi erTypeCode>
• </PID.3_PatientIdentifierList>• - <PID.3_PatientIdentifierList>• <CX.0_Id>000-00-0000</CX.0_Id> •
<CX.4_IdentifierTypeCode>MR</CX.4_Identifi erTypeCode>
• </PID.3_PatientIdentifierList>• - <PID.5_PatientName>• - <XPN.0_FamilyLastName>•
<XPN.0.0_FamilyName>Doe</XPN.0.0_Family Name>
• </XPN.0_FamilyLastName>•
<XPN.1_GivenName>John</XPN.1_GivenNa me>
• </PID.5_PatientName>• <PID.7_DateTimeOfBirth>20331122</PID.7_DateTimeOf
Birth> • <PID.8_Sex>F</PID.8_Sex> • - <PID.18_PatientAccountNumber>• <CX.0_Id>49717259</CX.0_Id>
</PID 18 PatientAccountNumber>
Map FF to HL7 xml
Mapping Flat file to HL7 2x
BizTalk Orchestration
Clinical Results Viewer
An “EMR-Lite” client application to view the data was built using .NET and Microsoft’s “Composite Application Block”.
• Labs
• Radiology
• Clinical Reports
Clinical Events Viewer
Keeps track of patient events:-Hospital, ER
admissionsdischarges
- Bed Census
Conclusion:
• By using a “push” model and a BizTalk based “Hosted-Integration-Services” model:– Able to gain trust and minimize hospital IT resources
• Demonstrated how:– competing community hospitals can succeed in
winning approval for forming a RHIO by their hospital leadership.
Microsoft Technologies used:
– BizTalk 2006– Visual Studio 2005– SQL 2005– Composite Application Block
Technical TeamHospital• Mike Cosgrave• Brian Allen• Anne Baker• Jean Fernandez• Crowley, Sheryl
IT Infrastructure• Ed Powers, GlobalNet Solutions
– www.globalnetsolutions.com
BizTalkEric Stott, Information Architect, Clinicorehttp://blog.hl7-info.com/ http://blog.biztalk-info.com