Achieving Clinical Transformation with an Interoperable Health IT Infrastructure

Transcription

1 Achieving Clinical Transformation with an Interoperable Health IT Infrastructure April 12, 2015 Stanley M. Huff, MD CMIO, Intermountain Healthcare DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Stanley M. Huff, MD Has no real or apparent conflicts of interest to report. HIMSS 2015

3 Learning Objectives Describe how quality measures, accountable care, and other models of advanced healthcare enable clinician transformation. Illustrate standard based infrastructure models, including Fast Healthcare Interoperability Resources (FHIR) profiles, that enable the development and use of interoperable applications in healthcare. Demonstrate real projects underway at a healthcare transformation lab that are supporting an interoperable health IT infrastructure.

4 Acknowledgements Lee Pierce R. Scott Evans Brent James

5 Intermountain Healthcare Profile An Integrated Health System 22 hospitals 33,000 employees 600,000 members 25% market share 200 clinics 1,000 employed physicians

6 MEANINGFUL USE

7 Positive Effects of MU We got money a net of ~$29 million so far More physicians used the system From 6% to 89% of physicians meeting all measures From 10% to 86% with electronic orders From 61% to 92% with coded problems CPOE and eprescribing development were accelerated A more robust infrastructure for health information exchange

8 Unexpected consequences Formulary checking Problems with no problems Immunization interface Finding denominators Delay of other more valuable projects

9 A Retrospective Opinion Knowing what we know now And if we were not under the threat of increasing penalties We probably would not have pursued the MU incentives And our patients would be receiving better care and our clinicians would be happier

10 From the Office of the National Coordinator We are not the office of meaningful use.

11 Beyond Meaningful Use

12 Suggested Strategy Develop truly interoperable data exchange standards We need development to get to truly interoperable standards; everything we need does not exist today Certify messages and services (not applications) Mandate the use of the standards Hold people accountable for outcomes (not process measures)

13 Intermountain s Core Business Perfecting the Clinical Work Process

14 Foundational Leaders Dr. Homer Warner Medical informatics founder 1950s computer assisted CV decision support 1970s HELP system developed Dr. Brent James CQI - Standardization of clinical care through data analysis

15 Intermountain s Clinical Programs Aligns care team in the process of care (9 Clinical Programs) Physician specialists Nurses Data experts Administrators IT Other caregivers Develops, implements, and sustains evidence-based care using information systems and data Goal is to deliver the best care to every patient every time

16 Transforming Patient Care Clinical Claims Device Financial Pt. Satisf & More Data Integration Research Decision Support Patient Care Data Ideas EDW Improved Care Insight Action 16

17 EDW Conceptual Architecture Data Sources Internal Enterprise Data Warehouse Data Access Finance External Lab Claims Pharmacy EMR OTHERS SOURCE Data Marts EMR Patient Acct Claims Supply Chain Patient Sat. Cardiovascular Primary Care Women & Newborn AHR Surgical Serv SUBJECT Data Marts BI Tools State/Federal Master Reference Data

18 Data Warehouse Profile 15 TB Oracle Data Warehouse ~9000 queriable tables ~150,000,000 queries per month 95,000,000,000 rows of data 40 FTEs 29 data architects (data input) 11 business intelligence developers (data for reports) Coordination with clinical and business areas

19 Case Studies

20 Elective Induction CPM

21 Percent <39 Weeks Elective Labor Induction <39 Weeks

22 Elective Induction CPM

23 Elective Induction CPM

24 Elective Delivers <39 Weeks 35% Percent <39 Weeks 30% 25% 20% 15% 10% 5% 0% JFMAMJJASONDJ FMAMJJASONDJ FMAMJJASONDJ FMAMJJASONDJ FMAMJJASONDJ FMAMJJASONDJ FMAMJJASONDJ FMAMJJASONDJ FMAMJJASONDJ FMAMJJASONDJFMAMJJAS Month

25 Colon Surgery: Evidence Based Interventions and Associated Measures Intervention Patient Education Early Mobilization After Surgery Appropriate IV Fluid Admin Narcotic Sparing Analgesia Early enteral nutrition Measure Enrollment Activity PT / Nursing walking, transfers, etc. Fluid Administration Med Administration, Morphine Equivalence Diet Administration Bowel/Emesis/Flatus Financial Measures

26 Colon Surgery Care Process Report 26

27 Colon Surgery Care Process - Financials 27

28 Colon Surgery Results: $1.2 million annual savings, LOS decreased from 8.44 to 6.75, while maintaining or improving clinical quality 2010 Computerworld Business Intelligence Award Driving Process Change with BI 28

29 Care Delivery in the US: Three Problems Lack of evidence-based medicine Hospitals and physicians are paid for volume Patients are (far too often) not engaged

30 Lead to Massive over utilization

31 Shared Accountability Goals Goals: 1.Better care (for patients); 2.Better health (for the population we serve); 3.Sustainable costs (for patients and other payers).

32 Intermountain Healthcare, 2013 Engage Patients Align Incentives Provide Evidence-based Care

33 Business Model Implications FFS PHM

34 Payment Model Implications Providers will be paid for value Efficient delivery Efficient utilization Prevention Wellness These become part of the job

35 Physician Payment Model Beta Current Model FFS Productivity Service Quality Total Cost of Care Beta Payment Model

36 Quality: Performance Measures

37 Quality: Patient List

38 Cost: Population-Based Measurement

39 Service

40 Population Health: Patient-Level Detail

41 STANDARDS BASED SERVICES FOR SHARING DATA, APPLICATIONS, AND ADVANCED DECISION SUPPORT

42 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 Diabetic care Pre-op antibiotics ICU glucose protocols Ventilator disconnect Infusion pump errors Lab alerts Blood ordering Order sets Patient worksheets Post MI discharge meds

43 We can t keep up! 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 unless we fundamentally change the ecosystem

44 HSPC Mission Statement Improve health by creating a vibrant, open marketplace for healthcare applications

45 Heterogeneous Systems Commercial EHR Home Grown System System Integrator VA System

46 Applications Being Built Neonatal Bilirubin Protocol Pediatric Growth Chart & BP Centiles Pulmonary Embolism Protocol Problem Management

47 What other kinds of Apps are likely to appear? Decision support Complex or evolving logic Visualization Patient -- Provider data sharing Simultaneous provider s view & patient view Integration of external data into EHR workflow Population Health bilateral data flow Real time HIE integration National scale services Genomics (Smarter ordering, PGX, etc.) mhealth / mobile apps Connecting consumer apps to their EHR data! Counterpart to Apple s HealthKit? Informatics Research Clear IP rights (vs. source code approaches) Local or multi-site

48 Like Google Maps Apps that address specific focused problems Provider-facing services Focused decision support Visualization Disease management Specialty workflows App 1 App 2 App 3 National Shared Services Genomic testing & CDS Pharmacogenomic screening CDC Ebola screening? CDC immunization forecaster Prior Authorization / Appropriateness EHR

49 Like Facebook Apps that enable data sharing Next-gen Interoperability Population Health integration HIE integration Data capture for research Clinical Trial recruiting App 1 EHR 1 EHR 2 EHR 3

50 Like???? Apps that empower patients / consumers Apps as Prescriptions Chronic disease management Pt-Provider Communication Remote monitoring Outcome capture & Clinical Effectiveness Monitoring EHR SMART Phone App Pop Health

51 Questions Stanley M. Huff, MD Chief Medical Informatics Officer Intermountain Healthcare Salt Lake City, UT

52 Appendix

53 Current Situation Each EHR vendor uses proprietary models and terminology to represent clinical data Some standardization of codes is now occurring, but Data is not consistent vendor to vendor, or even organization to organization within the same vendor This means that: Sharing of data is difficult Sharing of executable software across vendors is impossible Each useful application is created or re-created on each different platform There are unmet needs for health care applications and decision support Software costs are higher than they need to be

54 Characteristics of a new Ecosystem Consistent and unambiguous data collection Data stored and accessed through truly semantically interoperable services Sharing of data for direct patient care, population based analytics, and research Sharing of applications, executable clinical decision support and knowledge

55 IsoSemantic Models Example of Problem e.g. Suspected Lung Cancer (from Dr. Linda Bird)

56 Data Comes in Different Shapes and Colors Finding Suspected Lung Cancer Finding Suspected Cancer Location Lung Finding Cancer Location Lung Certainty Suspected (Let s say this is the preferred shape)

57 Data Standardized in the Service Application Application and User Data in preferred shape Shape and code translation Shape and color of data in the local database

58 Partial Interoperability Application Application and User Standard Terms (Non-standard Structure) Term Translator s Local databases, CDA, HL7 V.2, etc.

59 Preferred Strategy Full Interoperability Requirements Application Application and User Standard Structure AND Standard Terms (As defined by CIMI Models) Term and Structure Translators Local databases, CDA, HL7 V.2, etc

60 Reasons to do it on the server side Person writing the translation is most likely to understand the meaning of the data in their own database. The person writing the translation only has to understand their own data and the preferred model. They can optimize query execution for their own system The query for the data is simpler. If the application has to write a query that will work for all shapes, the query will be inefficient to process by every system.

61 Services based on Formal, Logical Models Applications, including advanced decision support, protocols and guidelines using Standard Services Different Physical EHR Implementations

62 FHIR The Public API for Healthcare? FHIR = Fast Health Interoperability Resource Emerging HL7 Standard (DSTU 2 soon) More powerful & less complex than HL7 V3 ReSTful API ReST = Representational State Transfer basis for Internet Scale Resource-oriented rather than Remote Procedure Call (nouns > verbs) Easy for developers to understand and use FHIR Resources Well-defined, simple snippets of data that capture core clinical entities Build on top of existing HL7 data types Resources are the objects in a network of URI reference links

63 FHIR: Core Resources (99 in DSTU2) AdverseReaction CarePlan Condition Device DiagnosticOrder DiagnosticReportt Encounter FamilyHistory ImagingStudy Immunization MedicationAdministration MedicationDispense MedicationPrescription Observation Order Organization Patient Practitioner Procedure More.

64 HL7 FHIR Resources and Profiles FHIR Resource Observation Lab Obs Patient Obs Family Hx Obs FHIR Profiles Qn Lab Obs Qual Lab Obs Titer Lab Obs Hematocrit Serum Glucose Urine Sodium Invariant Profile Structure CIMI Leaf Node Content # 64

65 The Risk competing proprietary FHIR profiles Women, FHIR, and other Dangerous Things

66 EHR as Platform: Market Forces EHRs are becoming commodity platforms. The winner will be the EHR vendor that provides the best platform for innovation the most open and most extensible platform. --- CEO of a major IDN Self determination ability to meet own needs Desire for vendor independence Don t want to rely on proprietary extensions or process Need clean separation of IP rights (commercialization)

67 EHR as Platform: Government Forces JASON Report: A Robust Health Data Infrastructure Use atomic data elements, not just documents Require EHRs (vendor/provider) to expose open APIs Dismissive of current (MU1 & MU2) efforts Design systems for research uses, not just clinical care Focus on Apps not monolithic solutions Give the patient more control over uses of his data

68 JASON Task Force Recommendations A Coordinated National Architecture Modeled on Internet principles (loose coupling) for scale Data Sharing Arrangements (DSA) for governance All EHRs should deploy a Public API Implement Core Data Services & Profiles FHIR Expectation to deploy the API Permit non-discriminatory access to the API API becomes part of CEHRT Measures and transparency for usage of the APIs

69 The Healthcare Services Platform Consortium (HSPC)

70 Sample of Participants HL7 FHIR Grahame Grieve SMART Josh Mandel Cerner David McCallie, Marc Overhage Epic Janet Campbell VA Jonathan Nebeker, Paul Nichol openehr Thomas Beale Open Health Tools David Carlson Harris Vishal Agrawal Intermountain Healthcare Systems Made Simple Viet Nguyen LSU Frank Opelka, Wayne Wilbright, John Couk Center for Medical Interoperability Todd Cooper RelayHealth Arien Malec NLM Clem McDonald Infocare Healthcare Herb White Mayo Clinic Cris Ross Clinical Architecture Shaun Shakib Cognitive Medical Systems Doug Burke IBM Jeff Rogers, Dennis Leahy ASU Aziz Boxwalla, Robert Greenes Regenstrief Institute Douglas Martin

71 Essential Functions of the Consortium Select the standards for interoperable services Standards for models, terminology, security, authorization, context sharing, transport protocols, etc. Modeling: SNOMED, LOINC, RxNorm FHIR Profiles do it together Publish the models, and development instructions openly, licensed free-for-use Provide testing, conformance evaluation, and certification of software Gold Standard Reference Architecture and its Implementation We will work with an established company to provide this service Fees that off set the cost of certification will be charged to those who certify their software Implementation of the standard services by vendors against their database and infrastructure Everyone does not have to do every service There must be a core set of services that enable a marketplace

72 72 HSPC wiki rvices+platform+consortium

73 Open Is Happening 73

74 Boston Childrens: SMART Growth Chart

75 SMART Growth Chart Parent s View

76 Intermountain: SMART Neonatal Bilirubin Alerts

77 Commercial: VisualDX 77

78 Commercial: VisualDx 78