playing with fhir - hisa
TRANSCRIPT
Playing with FHIRHow to Exploit the EHR
Mark L Braunstein, MDProfessor of the Practice
School of Interactive ComputingGeorgia Institute of Technology
Visiting Research FellowE-Health Centre, CSIRO
”
“ Australia ranks highest on Administrative Efficiency and Health Care Outcomes, and is among the top-ranked countries on Care Process and Access
Commonwealth Fund (2017)
Variable Results
Common Trends
https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/gx-lshc-healthcare-and-life-sciences-predictions-2020.pdf
Aging Population
More Chronic Disease
Increased Costs
Including Australia
https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contents
Australian Institute of Health and Welfare 2018
Systems Not Designed for Chronic Care
https://www.mja.com.au/journal/2007/187/2/care-patients-chronic-disease-challenge-general-practice
Medical Journal of Australia
Poor Care Coordination
https://www.commonwealthfund.org/publications/surveys/2015/dec/2015-commonwealth-fund-international-survey-primary-care-physicians
Lack of Continuity
9692 90
8581
66 65 6460
28
UK NETH NZ SWE A US US NOR CA N SWIZ GER
https://www.commonwealthfund.org/publications/surveys/2015/dec/2015-commonwealth-fund-international-survey-primary-care-physicians
In Practice Nurses or Case Managers
Variable Use of Informatics
30
11
53
24
80
11
5760
0
10
20
30
40
50
60
70
80
90
Email Record Sharing
Australia NZ SWIZ US
Healthcare Professionals Want Digital Health
Activity
Currently using a computer,
smart phone or tablet
%
Not using, but interested in using
a computer, smart phone or
tablet
%
Not interested in using a
computer, smart phone or tablet
for this activity
%
Sharing health records with my patients 25 59 7
Transferring prescriptions to the pharmacy 25 56 8
Providing interactive decision-making support 32 53 6
Communicating with patients before or after consultations 33 49 7
Sharing health records with other practitioners 43 45 4
Top 5 activities health professionals want to use digital technologies to help better support them to deliver health services
Courtesy Australian Digital Health Agency
EHRs Have “Issues”
https://medicomp.com/whats-the-most-frustrating-about-ehrs/
Goals: IOM
safe, effective, patient-centered, timely, efficient, equitable
Learning Health Systemhttps://www.ahrq.gov/professionals/systems/learning-health-systems/index.html
Necessary Informatics Substrate
EMR Adoption Analytics Access to POCOpen
Interoperability
Variable EHR Readiness
http://www.oecd.org/els/health-systems/health-statistics.htm
Current EHR Limitations
No standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
Lack of regulation
https://www.beckershospitalreview.com/healthcare-information-technology/the-problem-with-ehrs-5-complaints-from-cios.html
Remember these are we proceed
Hospital CIOs
What to Do?
Repair?
Replace?
Innovate!
“Fostering third party apps creates a market where innovations compete with each other for purchase and use by providers (and patients), thus reducing dependency on updates and specific functions made by an EHR vendor.”
--Ken Mandl, Josh Mandel, Isaac Kohane
https://www.sciencedirect.com/science/article/pii/S2405471215000046
How?
It Works Quantitatively
https://research2guidance.com/325000-mobile-health-apps-available-in-2017/
Proof of Effectiveness is Lacking but …
11 of 23 randomized controlled trials showed a meaningful effect on health or surrogate outcomes attributable to apps … the overall evidence of effectiveness was of very low quality … pilot studies … only one has progressed to a large clinical trial.
https://www.nature.com/articles/s41746-018-0021-9
… Mostly “Siloed” Apps
Extend the Phone App Model to EHRs?
Harvard’s SMART
https://apps.smarthealthit.org/
Georgia Tech’s HDAP
http://www.hdap.gatech.edu/apps/
Cerner/Epic …
Even the US Government!
https://bluebutton.cms.gov/
What Will Happen Next?
“These apps will give new life to data entered into EHRs and other health IT platforms by providing the ability to visualize risks, trends, and trajectories; mash up clinical records with external data sources; and deliver decision support to clinicians and patients during and between encounters.”
--Ken Mandl, Josh Mandel, Isaac Kohane
https://www.sciencedirect.com/science/article/pii/S2405471215000046
A Better EHR?
Juxly Timeline
No standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
Juxly Trends
No standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
Coordinated, Continuous Care
Within Cerner
-
More Complete Patient View
EHR Data
Patient Generated Data
No standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
Outcome Prediction
How?
HL7 Timeline
FHIR: V 3.0.1 April 19, 2017 …
Messaging (lab test results)
Model Driven (patient record summaries)
2018?
A Common Data Model
No standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
Condition: Human View
Condition: Machine View
73211009Remember me!
Uniform API
“Just Like” Amazon!
http://hapi.fhir.org/baseDstu3/Condition?code=SNOMED-CT|73211009
https://www.amazon.com.au/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=size+10+ladies+blue+sweater
Population level query
Condition Specific Charting
Medication Reconciliation
RxNorm for different names
Multipledispensings
One entry
Clinical InsightsNo standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
Lower CostNo standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
Precision MedicineNo standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
What About Your Patients?
Patient Controlled Health Record
EHR Connected Mobile Apps
Over 500 Collaborating Hospitals/Clinics (June)
Sharing Models
Opt Out - Centralized Opt In - Federated
Secondary Use?
Chart Review
Search Results
Drill Down: Conditions/Medications
Drill Down: Notes
Research
“a historic effort to gather data from one million or more people living in the United States to accelerate research and improve health. By taking into account individual differences in lifestyle, environment, and biology, researchers will uncover paths toward delivering precision medicine.”
https://allofus.nih.gov/
FHIR App
Emory Artificial Intelligence Sepsis Expert (AISE)
Trained on 31,000 Emory ICU patients
Validated on 52,000 MIMIC III patients
Third International Consensus Definitions for Sepsis (Sepsis-3)
65 features (variables) calculated on hourly basis
Can predict sepsis 4 hours in advance (ROC of .85)*
*https://www.ncbi.nlm.nih.gov/pubmed/29286945
DeepAISE on FHIR
Decline ImprovementEmory AISE Score
Philips DRS Score: Higher predicts readmissionSubmitted to AMIA 2018
Text messagingor the eICU application
Drag/Drop Automatic
No standards regarding discrete data
No integrated communication
Not user-friendly
Big data but not smart data
eICU team adjudicates warnings
Medical Education on FHIR?
We are partnering with UQ ITEE and Faculty of Medicine to offer an experimental course to explore the potential of using FHIR to digitize case based learning.
Diabetes Case Study
Burn Case StudyNathan and is alert and oriented with a GCS of 15
Nathan’s % total body surface area (%TBSA) of burn is calculated using a Lund-Browder chart to be 62% with 59% full thickness burns, 2% deep dermal and 1% partial thickness burns
Want to Try It Yourself?
http://cs6440.gatech.edu/