Navigating The Interoperability Standards Maze

Vik Kheterpal, MD

Principal, CareEvolution, Inc.

April 13, 2015

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.

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What This Talk Is About: Our experience an agnostic, pure-play interoperability technology stack vendor. Agnosticism to:

• EMR / HIT Legacy vendor• Payer versus Provider versus another• Standards Themselves• Standards Bearers

REMINDER: STANDARDS ARE A MEANS NOT THE END – DONE WELL, THEY REDUCE THE FRICTION COSTS OF DATA EXCHANGE

OUR EXPERIENCE: INTEROP ACROSS PUBLIC, PROVIDER, PAYER AND RESEARCH MARKETS TO MANAGE POPULATIONS

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• Building the “interstate” for information exchange

• Millions of patients each• Integrating claims, clinical,

administrative data across stakeholders

• Advanced portals and applications

Public Market

• Helping IDNs get their own house in order

• Deep clinical data and workflow integration

• Patient and Provider Portals• Clinical alerting solutions

Provider and Research Market

Payers and Channel

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• Briefly share the range of “standards” available • And how to frame the questions correctly (hint:

it is usually not about picking winner/losers among the standards)

• To help organizations newly committing to interoperability to reduce FUD in getting started

• Using Use cases, demonstrate how the standards work together to ensure that information about patients moves as fast as patients do across our fragmented ecosystem

OBJECTIVES:

CalRHIO

CAeHC

SHIN-NY

What This Talk Is NOT About: The “Standard Bearers”

ROOT CAUSE OF CONFUSION: MASSIVE BODY OF WORK TO UNDERSTAND

VOCABULARY, CONTENT & STRUCTURE, TRANSPORT, SERVICES

Vocabulary Content & Structure

Transport Services

SNOMED HL7 2.x SMTP/SMIME “Direct”

NPI HL7 CDA HTTP/RESTful IHE XDR

ICD10 CDA BPPC Etc. SOAP PIX/PDQ

LOINC NCPDP / SCRIPT TLS XDS/XCPD

RxNorm HL7 2.5.1 FHIR/SMART

HCPCS/CPT DICOM HPD

HL7 Value Sets FHIR DICOM

A TYPICAL REAL WORD SCENARIO

• Patient information (CCDA) is pushed from a hospital discharge (XDS) to the PCP (identified using HPD) via Direct/XDR, available in the Direct inbox

• The CCDA is also now part of the patient longitudinal care record

• The granular information within the CCDA also fires off an alert that is received by the patient (PHR) and the Clinician

• The patient uses their mobile device to take a current BP reading (Bluetooth/Apple HealthKit)  which is transmitted securely to the clinician's EMR

• The data is also available in the integrated SMART/FHIR Cardiac Risk app.  

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Pars

e C

CD

A,

Gen

era

te a

lert

HOW THEY ALL WORK TOGETHERDEMONSTRATION AT ONC KIOSK

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HIEBus ™

CCDA(XDS)

Look

up P

CP

(HPD

)

CCDA

(Direct/XDR)

Dr. Harper

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4

5

Patient

CCDA

High BP Alert6

High BP Alert

Mobile App6

Apple HealthKit

Bluetooth

enabled BP cuff

Health

Kit D

ata

upload

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External

integration: FHIR

(data pull)

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SMART App

Collaborative Family Health Record (cFHR™)iPhone / Apple Watch

Be Well Clinic

Good Health Hospital

CC

DA

(pu

ll)2

Provider portal/EMR

REVIEW OF WHAT WE JUST DISCUSSED

• Leverage interoperability standards in a meaningful fashion in order to effect better information flow

• Demonstrate exchange between providers and between patients and providers

• “DIRECT”ed exchange as well as query-based exchange so history is available to any care provider involved in patient care

• Mobile application integration/Apple HealthKit• Demo mature standards like XDS/XDR/CCDA as well as emerging technologies like FHIR, SMART apps

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WE NEED STRICTER AND WIDER ADOPTION OF THESE NOT MORE OF THEM

Vocabulary Content & Structure

Transport Services

SNOMED HL7 2.x SMTP/SMIME “Direct”

NPI HL7 CDA HTTP/RESTful IHE XDR

ICD10 CDA BPPC Etc. SOAP PIX/PDQ

LOINC NCPDP / SCRIPT TLS XDS/XCPD

RxNorm HL7 2.5.1 FHIR/SMART

HCPCS/CPT DICOM HPD

HL7 Value Sets FHIR DICOM

CareEvolution cFHR™ App Sample Scenario Data Flow

HIEBus

Beacon

cFHR iPhone & Watch App

Clinical Inbox iPhone app

Apple Health

Third-partyBlood Pressure Monitor

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6

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1. Beacon sends an alert to the cFHR that Helen is overdue to check her blood pressure

2. At the same time as #1, Beacon sends an alert to the PCP’s Clinical Inbox, notifying Helen’s PCP that she is overdue

3. Helen uses a third party blood pressure monitor to take her blood pressure. The blood pressure is sent to Apple Health.

4. The cFHR app, which continuously monitors Apple Health for new data, receives the new blood pressure value

5. The cFHR sends the new blood pressure value to HIEBus6. Beacon detects that the new blood pressure value is high, and sends an alert to the

cFHR that Helen has high blood pressure7. At the same time as #6, Beacon sends an alert to the Clinical Inbox, notifying

Helen’s provider that she has high blood pressure

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STEP 1: Patient Receives Alert For Blood Pressure on Apple Watch and HealthKit Certified iPhone App – cFHR™ Helen has enrolled in a program through her provider for blood pressure monitoring.

Through Beacon, she is alerted when she is overdue to take a reading. She can receivethe alert in multiple ways, and can opt to be reminded later if she doesn’t want to take a reading immediately.

cFHR iPhone and Watch App

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STEP 2: Provider Receives List of Patients Who are Alerted for BP Monitoring

Since Beacon powers alerting for both patients and providers, a provider could also receive a list of enrolled patients who are overdue for blood pressure readings, in order to follow up with them.

Beacon Clinical Inbox Beacon Surveillance Reports

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When Helen is ready to take a blood pressure reading, she can use any Apple HealthKitcompatible device to send the data directly to her provider, through the cFHR app.

The cFHR iPhone App, which is continuously monitoring for new Apple HealthKit blood pressure readings, uploads the new Blood Pressure readings to HIEBus

Helen uses her third-party blood pressure monitor to take a reading.

The app for the blood pressure monitor stores the blood pressure reading into Apple HealthKit.

STEP 3: Patient Uses an Apple HealthKit compatible BP Monitor to Take BP Reading

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After receiving an alert that sheis overdue to take her blood pressure, Helen uses her HealthKit compatible blood pressure monitor to take a reading.

The new value is immediately uploaded, and she is alerted to makean appointment for her high blood pressure.

STEP 4: The HealthKit Certified cFHR™ on iPhone and Watch App Take BP Reading and Communicates Back

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Once we have received the blood pressure reading, we can analyze and possiblegenerate alerts. In this instance, Helen’s blood pressure reading was high, so we alerther to make an appointment with her doctor. Her provider can also be notified of herhigh blood pressure reading.

Beacon Clinical Inbox(provider-facing)

cFHR iPhone and Watch App(patient-facing)

STEP 5: HIEBus™ Uses Clinical Rules to Determine if Further Action is Needed

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APPENDIX

cFHR™ iPhone and Watch Apps – Extensions to HIEBus™ (Health Information Exchange BUS), a robust data aggregation and intelligence platform

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Confidential and Proprietary

Logging in

Once a provider has set up a user account for either a patient or provider user, the usermust download the cFHR (patient) or Beacon Clinical Inbox (provider) app from the app store. For the cFHR Watch app to function, a user must log into the cFHR app on theiriPhone.

Beacon Clinical Inbox(provider-facing)

cFHR iPhone and Watch App(patient-facing)

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HealthKit Support

The cFHR app supports exchange of data to and from Apple Health. Upon logging into the cFHR, a patient user will be able to enable this.

The exchange of data that occurs with Apple Health is continuous and requires nofurther user interaction. When another application stores a value into HealthKit,The cFHR will automatically be alerted to send the value to the patient’s provider.

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Family medical history

On both their iPhone and their Apple Watch, patients are able to view their family’scomplete medical record in an easy-to-use format.

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Alerting

Beacon alerting, built on top of HIEBus health information exchange, generates alerts for both patients and providers. When certain conditions (configurable by provider) are met, alerts can be send to patients, providers, or both.

Beacon Clinical Inbox(provider-facing)

cFHR iPhone and Watch App(patient-facing)

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HIEBusHealth Information Exchange

BeaconPatient Monitoring and Alerting

cFHR iPhone & Watch AppAllows patients to receive alerts andview their family’s health records

Clinical Inbox iPhone appAllows providers to receive alerts andview their patient’s health records

Apple HealthAllows collection and transfer of data to and from the ecosystem of Health apps on the iPhone

Third Party ApplicationsFitness applications, health monitoring devices, etc.

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