leveraging the hl7® fhir® standard to drive improvement in … · 2018-11-14 · leveraging the...
TRANSCRIPT
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Leveraging the HL7® FHIR® Standard to Drive Improvement in Clinical Care
November 14, 2018
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Agenda
• Welcome • Jennifer Covich Bordenick, CEO, eHealth Initiative and Foundation
• Discussion & Comments• Russell B. Leftwich, MD, Senior Clinical Advisor, Interoperability,
InterSystems• Dan Gottlieb, Product Specialist, InterSystems• Laura Heermann Langford, PhD, RN, Nurse Informaticist, Homer
Warner Center for Informatics Research, Intermountain Healthcare; COO, Healthcare Services Platform Consortium
• Q & A
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Housekeeping Issues• All participants are muted
• To ask a question or make a comment, please submit via the Q&A feature and we will address as many as possible after the presentations
• Technical difficulties:• Use the chat box and we will respond as soon as possible
• Questions:• Use Q&A feature
• Today’s slides will be available for download on eHI’s Resource page www.ehidc.org/resources
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Our Mission
eHealth Initiative's mission is to serve as the industry leader convening executives from multi-stakeholder groups to identify best practices to transform healthcare through use of technology and innovation. eHI conducts, research, education and advocacy activities to support the transformation of healthcare.
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Multi-stakeholder Leaders in Every Sector of Healthcare
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Current Initiatives and Member Meetings
• Technologyand Analytics to Improve Patient Care
• Workflowfor Quality Improvement• Data Governance: A Framework for Value-Based Care• Addressing Privacy in Non-HIPAA Covered Entities
• Effects of Prior Authorization in Healthcare• Sharing Behavioral Health Information in Light of the Opioid
Epidemic• Clinical Data Drives Success in VBC for Medicaid MCO• Leveraging Patient Data to Improve Outcomes and Reduce
Costs• Influence of Artificial Intelligence on Healthcare
• Improving Pop Health by Addressing SDOH With A Multi-StakeholderApproach
• Electronic Medication Adherence and Patient Safety
Convening Healthcare Executives to Conduct Research & Identify Best Practices
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eHealth Resource Center AvailableWith Best Practices & Findings
Best Practice Committees contribute to the eHealth Resource Center
www.ehidc.org/resources which provides assistance, education and
information to organizations transforming healthcare through the use
of information, technology and innovation. The Resource Center is a
compilation of reports, presentations, survey results, best practices and
case studies from the last16 years.
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This webinar was made possible through the generosity and support of
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Leveraging the HL7® FHIR® Standard to Drive Improvement in Clinical Care
Russell B Leftwich, MD
Senior Clinical Advisor, Interoperability – InterSystems
Webinar – November 14, 2018 2:00 PM
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Patient
Medication
Family History
List
Document
Care Plan
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Leveraging HL7 FHIR to Drive Improvement in Clinical CareDan GottliebProduct Specialist
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30 | © Inter Systems Cor poration. All r ights r eserved. |
Agenda
Bulk Data
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31 | © Inter Systems Cor poration. All r ights r eserved. |
FHIR for Apps
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32 | © Inter Systems Cor poration. All r ights r eserved. |
SMART on FHIR
Extends the FHIR standard to support the development of web and mobile apps that can
plug-and-play across clinical systems
Layers on support for
• User Authorization via “scopes” (OAuth 2.0)
• Single Sign On (OpenID Connect)
• Context passing on app launch (current patient, encounter, etc.)
Healthcare Apps Cl inical Systems
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33 | © Inter Systems Cor poration. All r ights r eserved. |
Common Clinical Dataset
• Patient demographics (name, birthdate, race, ethnicity, …)
• Allergies and intolerances
• Immunizations
• Lab results
• Medications (administrations, dispensations, orders, statements)
• Patient documents (*)
• Problems
• Procedures
• Smoking status
• Vital signs
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Patient Facing Apps
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35 | © Inter Systems Cor poration. All r ights r eserved. |
App Clinical System (Patient Portal)
Access Request
FHIR API Query with Access Token
FHIR Data
Display Data
Access Token
Log in
SMART Patient App Flow
Authorize
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36 | © Inter Systems Cor poration. All r ights r eserved. |
Apple Health
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Apple Health
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38 | © Inter Systems Cor poration. All r ights r eserved. |
National Institutes of Health (NIH)
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CMS – SMART on FHIR Data Provider
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Provider Facing Apps
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“… we had this wonderful population health tool, but we couldn’t get the [EHR] system to interface with it, so we had to enter information by hand. We just had to give up on that because we couldn’t physically keep up.”
Physician, Interview with KLAS Research, 2017
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42 | © Inter Systems Cor poration. All r ights r eserved. |
App Clinical System (EHR)
Display Data
Choose App (from registered apps)
Launch information (including server URL)
SMART EHR App Flow
Access Request
Access Token
FHIR API Query with Access Token
FHIR Data
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43 | © Inter Systems Cor poration. All r ights r eserved. |
SMART App Gallery (apps.smarthealthit.org)
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44 | © Inter Systems Cor poration. All r ights r eserved. |
SMART App Gallery (apps.smarthealthit.org)
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45 | © Inter Systems Cor poration. All r ights r eserved. |
First Databank - Meducation
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Duke Medicine - Pillbox
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Prototype – Joint Tenderness (ClinDat)
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48 | © Inter Systems Cor poration. All r ights r eserved. |
FHIR for Clinical Decision Support
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CDS Hooks (cds-hooks.org)
Make it easy to incorporate external advice into clinical workflows
• Uses FHIR and SMART defined API (“hooks”)
• Response types (“CDS Cards”)
― Information (display to clinician)
― Suggestion (proposed action to impact clinical workflow)
― App Link (SMART app that’s relevant to the task)
• Next
― Official version 1.0 balloted through HL7
― Pilots and roll-out
― New hook definitions and use cases
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50 | © Inter Systems Cor poration. All r ights r eserved. |
Clinical System (EHR) Decision Service
Display CDS Card
CDS Hooks Flow
Invoke Service (passing Access Token)
FHIR API Query
FHIR Data
CDS Card
User Action
Managing
hypertension?
Launch JNC 8 Rx
Pro
Decision Logic
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Alert on Azathioprineprescription based on patient's expression of TMPT enzyme
Normal metabolizer
Intermediate metabolizer
Poor metabolizer
CDS Hooks Prototype - Pharmacogenomics
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Bulk Data
FHIR for Population Level Data
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Use Cases for Transferring Population Data
Large AMC syncing progress notes from a third party clinic into EHR
Integrating population health system with EHR system
Machine learning startup obtaining training data from cloud EHR
Payer database to assess care quality
Claims in EHR to provide comprehensive view
Internal clinical data warehouse for study cohort identification
Reportable disease submission or other registry
Many more!
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54 | © Inter Systems Cor poration. All r ights r eserved. |
FHIR for Population Level Data
Draft “bulk data” extension to FHIR to support efficient access to data on large groups of
individuals
• Leverage FHIR to eliminate the manual and repetitive work involved with proprietary APIs and custom data mapping
• Standard FHIR data model, Standard FHIR Operation API, Standard SMART security model
• Queries return data on all patients that the client’s account has access to, all patients in a nominated group, or all data in the system since the starting date time provided
• Can restrict to specific FHIR data models (resource types)
Bulk Data
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55 | © Inter Systems Cor poration. All r ights r eserved. |
Bulk Data Client Clinical System (EHR)
Bulk Data Flow
Request Access Token (signed with private key)
Access Token
FHIR Dataset Query (with access token)
URL to Pol l for Status
Verify token with
registered public
key
Status Request (may repeat)
Lis t of FHIR Data Files to Download
Generate Data Files
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Google BigQuery Example
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Google BigQuery Example
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Resources
HL7 FHIR hl7.org/fhir
SMART on FHIR dev.smarthealthit.org
SMART App Gallery apps.smarthealthit.org
CDS Hooks cds-hooks.org
FHIR Bulk Data github.com/smart-on-fhir/fhir-bulk-data-docs
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Laura Heermann Langford PhD, RN
Slide Acknowledgements:
Scott Narus, PhD Intermountain Healthcare
Ken Kawamoto, PhD University of Utah
FHIR® Advisory
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Why do we care about all of this?
To help people
live the healthiest lives possible
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Core Challenges and Value Proposition
• Healthcare faces many critical challenges
• Patients receive only ~55% of recommended care1
• As many as 440,000 patients die each year from preventable medical errors2
• US healthcare costs are the highest in the world by far,3 and not sustainable
• Physicians spend up to 2 hrs on administrative tasks (including EHR use) per 1 hrspent in direct patient care, leading to high burnout4
• Interoperable apps and services could enable innovative solutions to be widely scaled across EHRs to address these challenges
• While early, rapidly becoming a viable strategy for improving patient care
1. McGlynn EA et al. N Engl J Med. 2003. 348:2635-2645.2. James JT. J Patient Saf. 2013. 9:122-128.3. Papanicolas I et al. JAMA. 2018. 319:1024-1039.4. Shanafelt TD et al. JAMA. 2017. 317:901-902.
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Tomorrow: Plug and Play Interoperability
EHR2
Best DM Care APP
EHR3
EHR1
Care Registry
#1 Super Specialis
t
This is today….
EHR2
Best DM Care APP
EHR3
EHR1
Care Registry
#1 Super Specialist
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Imagine….Semantically Interoperable Healthcare focused Apps
Healthcare App Store
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Decision Support Modules
Antibiotic Assistant
Ventilator weaning
ARDS protocols
Nosocomial infection monitoring
MRSA monitoring and control
Prevention of Deep Venous Thrombosis
Infectious disease reporting to public health
Patient worksheets
Diabetic care
Pre-op antibiotics
ICU glucose protocols
Ventilator disconnect
Infusion pump errors
Lab alerts
Blood ordering
Order sets
Post MI discharge meds
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We can’t keep up!
At Intermountain• We have ~150 decision support rules or modules
• We have picked the low hanging fruit
• There is a need to have 5,000+ decision support rules or modules
• There is no path from 150 to get to 5,000+
We have to fundamentally change the ecosystem
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Intermountain Healthcare
Integrated Health Delivery Organization• HQ in Salt Lake City, UT
• Spans all of Utah and Southern Idaho
23 Hospitals, 185+ clinics
Strong Hx of Informatics Innovation (homegrown solutions)
Recent implementation of Cerner EMR
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A New Direction for Health IT
iCentra
• Create an open, standards-based API to iCentra
• Support standards efforts for interoperability
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Coincidentally…
• DSTU 1 published by HL7 in Feb 2014• Intermountain & Cerner agree on
FHIR as API standard
• Intermountain & Cerner agree on SMART as app interop standard
• Joint support for SMART on FHIR• Participation (w/ other vendors) at
HIMSS 2014, demonstrating interoperable SMART on FHIR apps
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®
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Accomplishments
• FHIR DSTU 2 dev & production servers
• OAuth support
• SMART app integration in iCentra
• Production release of 3 SMART on FHIR apps• PE Diagnostic/Treatment app in development
• Sharing of app enhancements across orgs/EHRs
• Use of FHIR resources for HIE, Telehealth, PH reporting
• Implementation of Publish/Subscribe services*
• SMART on FHIR sandbox development environment
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Example: Pediatric Growth Chart App
First developed by Boston Children’s
Target users: NICUs and Peds Clinics, as well as Parents• Direct patient care
Provides visual display of patient’s growth (development) data against an appropriate cohort
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Growth Chart App Description
SMART on FHIR App• Open Source
• Stand-alone or Integrated
Uses FHIR resources to access growth data from EMR• Height/Length, Weight, Head Circumference, BMI
• DOB, EDD/Gestational Age, Sex
Current State: In Clinical Use in NICUs and Peds Clinics• Replaces Cerner module & in-house developed app
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Growth Chart
Concise, interactive view of a child’s growth over time
Interactive Graphs, Data Table, Parent View
Percentile/bone-age/mid-parental height estimates
CDC/WHO/Fenton charts (expandable)
Support for Ambulatory and NICU uses with:• Gestation corrections
• Bone Age presentation
• Growth point comparison with velocity
• Print-out formats for Graphs, Data Table, and Parent View
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Lessons Learned I
EMR Vendor provides a fairly extensive set of FHIR resources…
…Vendors are cautious & conservative at this point
…Need support for additional use cases and Write capability
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Lessons Learned II
Still need some expertise on vendor data
Data are not always where you think they are, and they don’t always come back as expected
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Lessons Learned III
Lack of specificity in FHIR Resources
• US Core FHIR Profiles not enough
• Need true semantic interoperability (FHIR Profiles)
FHIR supports single patient/subject queries• Working on population-based queries and formats (FHIR Bulk Data)
• Registries and Research-related efforts?
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Lessons Learned IV
Differences in Vendor implementations of FHIR• Data Models
• Search parameters and approaches
Differences in terminology support• Local term mapping probably needed
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IsoSemantic Models – Example of Problem
e.g. “Suspected Lung Cancer”
(based on example from Dr.Linda Bird)
EHR Vendor ABC EHR Vendor XYZEHR Vendor 123
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© K E N S A K U K A W A M O T O , 2 0 1 8
University of Utah Exemplar Apps and Services
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© K E N S A K U K A W A M O T O , 2 0 1 8
Neonatal Bilirubin App• Pulls in baby and mother’s EHR data
• Near universal use in inpatient setting; estimated to save >300 MD hrs/year
Procedure Capacity Management App
• Calendar visualization of capacity vs. scheduled procedures• Capacity based on business rules and any over-rides• Facilitates efficient capacity management
Surgical Referral Dashboard App• Support post-surgical care transition• ONC High Impact Pilot project (PIs: Brooke, Del Fiol)• Desire for enhanced data interchange with existing
documentation
Diabetes Rx Outcome Prediction App
• Col laboration with Hitachi
• Data-driven Rx guidance (predictive model, AUC 0.87)• Accounts for insurance for cost info• In pi lot cl inical use
Opioid Decision Support
• Goal: provide point-of-care support for CDC Guideline for Prescribing Opioids for Chronic Pain
• CDC-sponsored effort. Contributors: ONC, AHRQ, Ya le, SRS, ESAC, Epic, and many others.
• CDS Hooks services and SMART on FHIR app
MDCalc Integration
• MDCalc: leading calculation tool; > 1 mi llion monthly users; 79% of res idents
• Top 20 priority ca lculators in production use• Auto-population using EHR data• 1-cl ick integration with dot phrase• Next: many more calculators, CDS Hooks integration
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The Vision
• Imagine as a clinician…• It is a joy to use the EHR
• The EHR is constantly saving you time, leaving you more time for your patients and your family
• There is no need to hunt through the record – everything you need is right there
• It is easy to do the right thing, every time
• When you imagine how the EHR should work, it soon becomes how it does work
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Key Challenges and Potential Solutions
Challenge Potential Solutions
Need for additional FHIR APIs(e.g., gestational age, detailed smoking history)
Top-down (e.g., expand US Core FHIR profiles)Bottom-up (e.g., develop and share FHIR profiles
as well as their implementations)
Differences in vendorimplementations of standards
Tighten standardsImprove conformance testing
Ever-evolving standards(e.g., FHIR STU 2/3/4, profiles)
Define core logical data model (e.g., CIMI) and map to different flavors of FHIR, other models
Healthcare organizations are innately inward-looking
External funding to promote collaboration and sharing
Commercialization
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Rationale for FHIR-based Innovations
• Enables tackling important problems for which native EHR functionality is
inadequate
• Provides an alternate strategy to “ask and hope”
• Feasible to accomplish as a part of a holistic EHR optimization strategy
• Epic, Cerner, and other major EHR vendors are supportive
• Can harness the innovation of others
• Local stakeholders, other institutions, vendors
• Could potentially commercialize solutions
• Powerful enabler for externally funded R&D
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More Reasons to Pursue
Efficient software development
• Widely distributed
• Directed daily by front line clinicians
• Increased usability of software, creativity, innovation
Increased choice in software
• Thousands of independent developers
• Centrally planned economy vs free market
• Think “app store for healthcare” or of innovations like Uber
The start of a Learning Healthcare System is accurate, computable, data.
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To help people live the healthiest lives possible
FHIR® Advisory
• Interoperability of apps still in early stages
• Models and profiles will be different and limit interoperability without specific attention
• Open source apps are NOT free
• Prioritization and Governance are key
• The prospect of a new ecosystem to support the vision of information systems contributing to providing the best healthcare widely is REAL and is worthy of investment
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Thank you!
Acknowledgements to:
Stan Huff, MD
Scott Narus, PhD
Susan Matney, PhD, RN
Peter Haug, MD
Ken Kawamoto, PhD, MD, MHS
Rick Freeman
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Q&A
Russell B. Leftwich, MD Laura Heermann Langford, PhD, RN
Dan Gottlieb
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To learn more about how InterSystems technology supports SMART on FHIR contact Russ or Dan
or visit their FHIR microsite
www.intersystems.com/fhir
• Russ Leftwich: [email protected]
• Dan Gottlieb: [email protected]
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This webinar was made possible through the generosity and support of