1 Collaboration, Open Solutions, and Innovation (COSI) in Healthcare Marc Wine, M.H.A New Roadmap for Health IT Interoperability January 10, 2008

2 Special Thanks Peter Groen, Former Director Peter Groen, Former Director VA Health IT Sharing VA Health IT Sharing Douglas Goldstein, President Medical Alliances Douglas Goldstein, President Medical Alliances Suniti Ponkshe, Project Director IBM Suniti Ponkshe, Project Director IBM Robert Connors, Sub-portfolio Manager DoD Robert Connors, Sub-portfolio Manager DoD Telemedicine and Advanced Technology Research Center Telemedicine and Advanced Technology Research Center

3 Mission to Mars Imagine a solar powered, wearable health information system used by astronauts on the planned mission to Mars in The wearable systems are connected wirelessly to the onboard eHealth Advisor Live (eHAL), onboard Robotic Surgeon, and an electronic Personal Health Record (ePHR) which in turn is interfaced with the more comprehensive master Electronic Health Record (EHR) system back on Earth, e.g. VistA. The master system includes a Medical Advisor module and a health data repository coupled with a genomic biorepository. The system is continuously being fed data by nano-technology bio- sensors that are embedded in the wearable systems used by the international crew of NASA astronauts. Implantable nano-sensors will be used to detect health problems and a micro chemical laboratory on a chip will control the creation and rate of delivery of drugs to correct problems or repair tissue as needed." Imagine a solar powered, wearable health information system used by astronauts on the planned mission to Mars in The wearable systems are connected wirelessly to the onboard eHealth Advisor Live (eHAL), onboard Robotic Surgeon, and an electronic Personal Health Record (ePHR) which in turn is interfaced with the more comprehensive master Electronic Health Record (EHR) system back on Earth, e.g. VistA. The master system includes a Medical Advisor module and a health data repository coupled with a genomic biorepository. The system is continuously being fed data by nano-technology bio- sensors that are embedded in the wearable systems used by the international crew of NASA astronauts. Implantable nano-sensors will be used to detect health problems and a micro chemical laboratory on a chip will control the creation and rate of delivery of drugs to correct problems or repair tissue as needed." - Goldstein, Groen & Wine - Goldstein, Groen & Wine

4 Beyond the Next Generation Medical & Health Informatics 2020 Linking Health Information Systems to other industries information systems, e.g. Banking, Insurance, Manufacturing, Entertainment, etc. Linking Health Information Systems to other industries information systems, e.g. Banking, Insurance, Manufacturing, Entertainment, etc. Breaking down industry silos of information Breaking down industry silos of information True transformation takes place: True transformation takes place: - Virtual Healthcare - Mobile Workforce - Self Care - Home Healthcare - Wireless Technology - Preemptive Care - NanoMedicine - Wearable Systems - Robotic Systems - ePHR Systems - Grid Solutions - Implantable eCare

5 Head Mounted Displays Inspired by Star Trek? American College of Healthcare Executives : 3D, 1080p HD, 150 degree view Virtual Training Tele-presence Combined virtual and real world display 1995: Surgical stereoscope prototype developed at Madigan Army Medical Center

6 Emerging/Enabling Healthcare Technologies and Standards To Watch Obsolete Before Reaching Maturity: –Personal Display Assistant (PDA) integrated with Computerized Patient Records –Direct Electronic Data Interface (EDI) Less Than 2 Years To Maturity: –Business Process Management Suites –Tablet PCs and Ultra- Mobile PCs –Clinical Context Object Workgroup American College of Healthcare Executives 6 Source: Barry Runyon, MD, GartnerResearch, 2007

7 Emerging/Enabling Healthcare Technologies and Standards To Watch 2-5 Years To Maturity –Blade PCs –Handwriting Recognition –Server Virtualization –Healthcare Work Flow and Business Process Management –Natural Language Processing (Document Classification) –Natural Language Processing (Text to Facts) –ASTM Continuity of Care Record Standards –National Provider ID –Biometrics –Service Oriented Architecture –Distributed Antenna Systems –HL-7 Clinical Document Architecture –Standard Controlled Medical Vocabularies –Voice over Internet Protocol (VOIP) –Enterprise Public Key Infrastructure (PKI) –Single Sign On (SSO) American College of Healthcare Executives 7 Source: Barry Runyon, MD, GartnerResearch, 2007

8 Emerging/Enabling Healthcare Technologies and Standards To Watch 5 to 10 Years To Maturity –Digital Microscopy –ICD-10 CM (US) –Health Product Data Utility –Robotics for Rounding –Continua –Medical Device Management/Standardization –Bluetooth –Grid Computing –Information Life Cycle Management >10 Years To Maturity –Semantic Interoperability –Semantic Web/RDF/OWL American College of Healthcare Executives 8 5 to 10 Years to Maturity HIE/EHR HL-7 Version 3 Messages SOA for Application Integration in Healthcare Speech Recognition (Once and Done) User Provisioning CDISC Operational Data Model Basic Web Services Profile HIPAA Claims Attachments Source: Barry Runyon, MD, GartnerResearch, 2007

9 Interoperability Components Attaining true, complete interoperability between systems requires computer accommodation for: Syntax: rules and grammar applied to human or computer language, structure Semantics: meaning expressed through signs or symbols Pragmatics: nuances of human language involving impact of speech utterances on meaning American College of Healthcare Executives 9

10 Gartners Thoughts on Interoperability Wes Rishel, Gartner Group Research, 29 Dec 2005, An Interoperability Roadmap for the Computer-Based Patient Record (CPR): A CPR system cannot fulfill its potential to make patient care better, safer and less costly without excellent interoperability. The requirements for extra-enterprise interoperability are evolving rapidly. American College of Healthcare Executives 10

11 Gartners Thoughts on Interoperability, continued Rishels Key Points : High quality healthcare requires collaboration among specialists and sharing of data with meaning between hospital internal and external systems Degrees of interoperability: Semantic interoperability where the information that is exchanged can be processed by a computer Document interoperability where textual information that is suitable for a person to view is exchanged along with a computer-processed header that enables the receiving system to file and appropriately display the text Incremental interoperability a hybrid approach that enables clinical information systems at differing levels of semantic sophistication to interoperate on a "best possible basis American College of Healthcare Executives 11

12 HL Reference Information Model (RIM) and Clinical Document Architecture (CDA), Release 2 (R2) HL-7 2.x messaging standard deals with syntactical/structrual file transformation issues HL-7 3.0, through use of the RIM and XML, provides for some semantic understanding DoD is focusing on using HL RIM and CDA R2 as a means to obtain an intermediate degree of semantic interoperability, across multiple projects Key is that CDA R2 is both machine readable, and also human- readable CDA now combined with Care Record Summary (CRS) standard Excellent summary at (Liora Alschuler)

13 Continuum for Semantic Representation and Processing American College of Healthcare Executives Metadata Taxonomy Thesaurus Conceptual Model Logical Domain Model Weaker Semantics Strong Semantics Modal Logic First Order Logic Description Logic DAML+OIL, OWL UML RDF/S XTM Extended ER ER Schema Relational Model XML Self-describing data structures Is subclassification of Has narrower meaning than Is subclass of Is disjoint subclass of with transitivity property General Classification Or Ontology Space 13 Source: Dave Reilly, Northrop Grumman Corporation

14 Medical Concepts and Controlled Medical Vocabularies for Normalization American College of Healthcare Executives COLD COLD COLD Concept Representation Concept Representation Concept Domain Concept Domain Concept Definition Concept Definition HDD Concept ID HDD Concept ID a sensory perception a pulmonary diagnosis an upper respiratory viral infection Im feeling cold Chronic Obstructive Lung Disease I have a cold SNOMED CT IDUMLS CUITripler IEN ICD9CM CodeWomack IEN 14

15 Terminology Service American College of Healthcare Executives Terminology Service Bureau TSB SNOMED CT (Core) PKC MEDCIN Other Civilian HCO VA DoD Computable Information -Intra-operability -Inter-operability 15

16 DoD/VHA Interoperability Products FHIE: Federal Health Information Exchange One-way transfer of health data from DoD to VA BHIE: Bidirectional Health Information Exchange Two-way exchange of viewable data CHDR: CDR/HDR Interface Synchronize data between CDR (DoD) & HDR (VA) American College of Healthcare Executives 16

17 FHIE Data is transferred from DoD, on separated service members, to the FHIE Data Repository at the VA Austin Automation Center (AAC). VA clinicians can access data on patients that have correlated with a patient in the VAs Master Person Index (MPI) Metrics: 191 million clinical messages on over 3.9 million individuals have been transferred American College of Healthcare Executives 17

18 BHIE Enables VA & DoD providers to view health data For shared patients who receive care at VA & DoD facilities In real time From all locations where data exists American College of Healthcare Executives 18

19 BHIE Sites: Current and Pending American College of Healthcare Executives BHIE operational BHIE implementations planned during FY2007 NCA LRMC Mike OCallaghan Federal Hospital David Grant MC Bassett ACH Elmendorf AFB Madigan AMC NHC Great Lakes Eisenhower AMC NHC Charleston 31 DoD host sites = 15 DoD Medical Centers, 25 DoD Hospitals & over 220 DoD Clinics 12 CIS Sites CHDR-BHIE Release 1 provides access to all DoD AHLTA Worldwide Sites (Access to over 2.2 Million correlated patients) Tripler AMC William Beaumont AMC NMC San Diego NH Camp Pendleton NH Camp Lejeune Womack AMC NH Pensacola Darnall AMC MacDill AFB NH Jacksonville NACC Groton NH Corpus Christi Wright-Patterson AFB Martin ACH NH Lemoore NMC Portsmouth Minot AFB BHIE-CIS operational Leonard Wood ACH Fox AHC Kirtland AFB Brooke AMC Wilford Hall Evans ACH Dewitt ACH Irwin ACH Malcolm Grow MC National Naval MC Walter Reed AMC 19

20 CHDR Synchronizes data between the DoD Clinical Data Repository (CDR) and the VA Health Data Repository (HDR) Data is pushed or synchronized to each repository Enables drug-drug and drug-allergy checks (DoD, VA, Retail) GAO report June 22, 2006 CHDR is Cornerstone for long term goal to achieve a virtual medical record based on the two-way exchange of computable data If pilot is successful, it will enable for the first time the exchange of computable information between the departments two data repositories American College of Healthcare Executives 20

21 BHIE-CDR (CHDR-BHIE) Accelerates DoD/VA patient data sharing while the VA HDR is still in development and standards in many areas are still maturing Provides a real-time bidirectional interface between DoDs AHLTA and the VAs VistA/CPRS health care systems Pulls data from the CDR & provides to VA via BHIE framework Increases number of DoD sites providing data to VA to ALL AHLTA sites Enables DoD providers to view VA data from AHLTA American College of Healthcare Executives 21

22 So, All of this Looks Promising, But Are We On the Verge of a Healthcare IT Technology Revolution? Secretary Leavitt, 2007 HIMSS Conference: …But while for many years healthcare information technology has been but a distant vision… we are close to achieving interoperable standards and a system-wide transformation. American College of Healthcare Executives (There is that interoperable word again, and as far as standards go, the good thing is that there are so many to choose from…!) 22

23 Imagine the Future … Create the Future –

24 A 20/20 Vision for the Future Imagine a future healthcare system that is customer-focused and patient-centered, one in which every American has health insurance and a secure, private Electronic Health Record (EHR) that is available whenever and wherever needed, enabling the highest degree of coordinated medical care based on the latest medical knowledge and evidence. Imagine a future healthcare system that is customer-focused and patient-centered, one in which every American has health insurance and a secure, private Electronic Health Record (EHR) that is available whenever and wherever needed, enabling the highest degree of coordinated medical care based on the latest medical knowledge and evidence.

25 A 20/20 Vision for the Future Imagine a healthcare system in which digital and mobile technologies, medical knowledge at the point of need, and collaboration among providers deliver safe, high-quality care for everyonea healthcare system that does not require the patient to complete the same forms at every access point. Imagine a healthcare system in which digital and mobile technologies, medical knowledge at the point of need, and collaboration among providers deliver safe, high-quality care for everyonea healthcare system that does not require the patient to complete the same forms at every access point.

26 A 20/20 Vision for the Future Imagine a healthcare system where primary care physicians have access to your specialty medical information and specialists have access to your primary care information via inter- connected smart EHRs that are integrated with personalized eHealth service providers and delivered directly to a multi-purpose, intelligent, mobile digital device that can be carried in ones pocket. Imagine a healthcare system where primary care physicians have access to your specialty medical information and specialists have access to your primary care information via inter- connected smart EHRs that are integrated with personalized eHealth service providers and delivered directly to a multi-purpose, intelligent, mobile digital device that can be carried in ones pocket.

27 Healthcare Industry – The Stats $1.7 trillion spent on U.S. health care in 2003 and still climbing. $1.7 trillion spent on U.S. health care in 2003 and still climbing. In 2005, the United States spent 16.3% of the countrys Gross National Product on health care services and it will continue to grow. In 2005, the United States spent 16.3% of the countrys Gross National Product on health care services and it will continue to grow. Healthcare in the U.S. is a trillion-dollar cottage industry!

28 An Epidemic of Medical Errors There is currently a human spawned epidemic of deadly, costly medical errors. Depending on which of three major studies you read, at least 44,000 people, and perhaps as many as 200,000 people, die in hospitals each year as a result of medical errors that could have been prevented. In addition to the cost in terms of human lives, medical errors have been estimated to result in total costs between $17 billion and $29 billion per year in hospitals nationwide According to the Journal of American Medical Association (JAMA), these are estimated : 106,000 Adverse reactions to properly prescribed Rx drugs 106,000 Adverse reactions to properly prescribed Rx drugs 80,000 Infections in hospitals 80,000 Infections in hospitals 20,000 Other errors in hospitals 20,000 Other errors in hospitals 2,000 Unnecessary surgeries 2,000 Unnecessary surgeries

29 And Finally… It was also estimated in a JAMA article that there were 199,000 deaths from medical errors in outpatient care alone, and there could be upwards of 424,000 annual deaths per year in the American medical system, which would make the system itself the one of the leading causes of death in the United States. The National Council for Patient Information and Education reported that an additional 125,000 deaths occur annually due to adverse reactions to drugs that the physician never should have prescribed. The annual death toll from synthetic prescription drugs, both from the correctly prescribed and the incorrectly prescribed, amounts to about 231,000 deaths every year. To put this into perspective, this is the equivalent of a World Trade Center disaster every week for over a year and a half, or the crash of two fully loaded 747 aircrafts every day of the year.

30 Key Solutions - Priorities #1 - Availability and widespread use of Electronic Health Record (EHR) Systems by Clinicians Across This Country ! #2 – Followed by the implementation of secure Health Information Exchange (HIE) networks. #3 – Real transformation occurs when widespread use of Personal Health Records (PHR) take hold.

31 COSI Strategies The COSI strategies of Collaboration, Open Solutions, and Innovation are absolutely essential for transforming the health and medical culture, the processes, the leadership and the technology necessary to support better, safer and higher quality care in the American healthcare system and other healthcare systems across the globe. The application of these strategies is already evident throughout other major industries. The COSI strategies of Collaboration, Open Solutions, and Innovation are absolutely essential for transforming the health and medical culture, the processes, the leadership and the technology necessary to support better, safer and higher quality care in the American healthcare system and other healthcare systems across the globe. The application of these strategies is already evident throughout other major industries.

32 Health Information Sharing Opportunities Standards – collaborating with other agencies and organizations on national health information standards Software Sharing - sharing health information systems software between organizations, e.g. VistA and other open software solutions. Information Sharing – sharing data or information needed for direct patient care or for research and population studies. Resource Sharing – contributing funding or other resources needed to support a mutually beneficial sharing initiative. Knowledge Sharing – sharing technical expertise or knowledge in the field of healthcare informatics. Community Support & Sharing – sharing contacts and helping to garner support within the healthcare community and other stakeholders for major mutually beneficial initiatives.

33 Open Solutions Open Source EverywhereSoftware is just the beginning... open source is doing for mass innovation what the assembly line did for mass production. - Thomas Goetz, Editor, Wired Magazine Open Source EverywhereSoftware is just the beginning... open source is doing for mass innovation what the assembly line did for mass production. - Thomas Goetz, Editor, Wired Magazine But, were not just talking about Open Source, were talking about Open Solutions But, were not just talking about Open Source, were talking about Open Solutions

34 Growth in Open Source Software In the last few years, the growth in OSS has accelerated significantly. Key contributing factors for this growth are: growing awareness of open source growing awareness of open source increased software functionality increased software functionality increasing adoption of OSS by many organizations, and increasing adoption of OSS by many organizations, and many OSS applications ability to now operate at the enterprise level, e.g. Linux, Apache, OpenOffice, Mozilla/FireFox, VistA, MySQL, etc. many OSS applications ability to now operate at the enterprise level, e.g. Linux, Apache, OpenOffice, Mozilla/FireFox, VistA, MySQL, etc. Initiatives such as OpenHRE transcend the enterprise, and offer real world proof that sharing, collaboration and open source values are not foreign concepts, but mandatory attributes to embrace for achieving cost effective and sustainable interoperability. Initiatives such as OpenHRE transcend the enterprise, and offer real world proof that sharing, collaboration and open source values are not foreign concepts, but mandatory attributes to embrace for achieving cost effective and sustainable interoperability.

35 The Bottom Line "The arguments for and against open-source software often get very trivialized. It's not a technology issue; it's a business issue." Companies with an external focus, which are used to working collaboratively with other organizations, and perhaps are already using collaborative technologies, stand to gain much more from Open Source than companies with an internal focus, which see the technology purely in terms of cost savings. Andy Mulholland, Chief Technology Officer for Cap Gemini Ernst & Young

36 The Perfect Opportunity: Convergence-New Capabilities Bridging the Quality Chasm! Evidence Based Medicine (David Sackett et. al.) Database Design/Retrieval/Query Electronic Medical/Health Record 24/7 access and computable data Decision support at the point of care Population health American College of Healthcare Executives Digital Man 36

37 Collaboration Innovation and Open Solutions Dare to Transform Marc Wine, M.H.A. Health IT Advisor, Author, Professor Cell Collective Intelligence of the Borg on the Horizon? Collective Intelligence of the Borg on the Horizon?