mobile health wg “state of mobile”

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HL7 WGM

Phoenix, AZ

May 7, 2014 – Q1

MOBILE HEALTH WG

“STATE OF MOBILE”

Presented by:

Gora Datta [email protected] •HL7 International Ambassador•Co-Chair HL7 Mobile Health Work Group•Co-Lead HL7 EHR Interoperability Group•Co-Lead HL7 Meaningful Use Functional Profile Team•HL7 Tutorial Speaker on Meaningful Use•HL7 2009 Volunteer of the Year Award Winner•US Delegate to ISO/TC215•IEC 62 - Expert Member •Vice Chair, IEEE Orange County Section•HIMSS Ambulatory Committee Member (2014-15)•HIMSS14 Speaker•mHIMSS Task Force Member•Senior Member IEEE•Senior Member ACM•World Bank ICT Expert•ADB eHealth Specialist•Group Chairman & CEO of CAL2CAL Corporation

Presented by:

Gora Datta [email protected] •HL7 International Ambassador•Co-Chair HL7 Mobile Health Work Group•Co-Lead HL7 EHR Interoperability Group•Co-Lead HL7 Meaningful Use Functional Profile Team•HL7 Tutorial Speaker on Meaningful Use•HL7 2009 Volunteer of the Year Award Winner•US Delegate to ISO/TC215•IEC 62 - Expert Member •Vice Chair, IEEE Orange County Section•HIMSS Ambulatory Committee Member (2014-15)•HIMSS14 Speaker•mHIMSS Task Force Member•Senior Member IEEE•Senior Member ACM•World Bank ICT Expert•ADB eHealth Specialist•Group Chairman & CEO of CAL2CAL Corporation

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HL7 MH AGENDA

INTRODUCTION MISSION, CHARTER, STAKEHOLDER1

MH in Action SCENARIOS/USE CASES2

Meaningful Use (MU) & Mobile Health Functional Challenge! MH WG ROADMAP

Next Steps Deep Dive!

Upcoming 2014 MH Projects SUMMARY

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HL7 MOBILE HEALTH WG MISSION

The HL7 Mobile Health Work Group creates and promotes health information technology standards and frameworks for mobile health.

http://wiki.hl7.org/index.php?title=Mobile_Health

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HL7 MOBILE HEALTH WG CHARTER

Identify (and develop, as applicable) data standards and functional requirements that are specific to the mobile health environment

Identify and promote mobile health concepts for interoperability as adopted and adapted for use in the mobile environment

Coordinate and cooperate with other groups interested in using mobile health to promote health, wellness, public health, clinical, social media, and other settings.

Provide a forum where HL7 members and stakeholders collaborate in standardizing to enable the secure exchange, storage, analysis, and transmission of data and information for mobile applications and/or mobile devices.

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MOBILE HEALTH STAKEHOLDERS

Source: HL7 Mobile Health Newsletter V1Is1

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MH SNAPSHOT!

MOBILE HEALTHNot a vertical domainBut a horizontal framework that cuts across and

impacts all health care domains

Tremendous interest and participation not only in the US but all over the globe

TRULY A DISRUPTIVE FRAMEWORK!

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Mobile Health in Action

Scenarios illustrating the scope and benefits of Mobile Health

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MOVING AROUND A HOSPITAL

EHR System services follow providers around a hospital

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Scenario

Physicians, nurses, therapists and others move from ward to clinic to ward to care for patients

Mobile devices and wireless connectivity ensure that the EHR system and other ICT support is as mobile as the health professionals themselves As a senior physician moves from ward round

to outpatient clinic, the day’s appointments appear on their device through location sensitive services

A patient needs urgent attention at night, and a physician is called from another part of the hospital

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INDEPENDENT LIVING

Assisted living drawing on a range of mobile services

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ScenarioPaul is frail and elderly with both physical and mental

difficulties, and lives alone at home with his dog The challenge is to help him stay independent and out of

hospital

His formal support services include regular visits from a nurse, timed reminders for self-care, a “call for help” alarm, and a blood pressure monitor that feeds data to a monitoring centre

He also has an informal network of care and friendship: Paul’s son calls by and helps with household chores and dog walks Paul has a friend living nearby who is also old and frail; they walk

their dogs together, visit each other for lunch, etc., when they can

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PATIENT EMPOWERMENT

Support for long term conditions across a wide range of lifestyles

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Scenario

Corinne is a senior executive with a lifestyle full of travel and a high workload...and is diabetic.

She manages her condition by diet and medications, and takes daily measurements on her blood which she records to share with her physician. If a measurement is out of range, she has a contact to ring

for advice.

Corinne’s husband Mike also works full-time, though with less travel. Their 7-year old daughter Evie is asthmatic and has her own programme of care.

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HELP WHEN I NEED IT

Behavioural health support anytime, anywhere - especially there!

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Scenario

Jo is working at resolving the lifestyle issues that lead him into problem drinking & aggressive behaviour His access to his children is at risk if he goes to his ex-

partner Maia’s apartment at any time other than prearranged visit times, or if he is drunk, abusive or threatening during a visit.

Maia works in a restaurant a few streets away from where she lives

Jo has a job, helping to deliver heavy household items He is at risk of losing his job if he is absent or if he is

drunk or aggressive at work He needs specific help if his work takes him near Maia’s

apartment or place of work

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TRUSTED MESSAGES

Getting the message(s) n child health to hard-to-reach families

Resolving the last mile challenge….

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Scenario

Asha Rani lives in one of the most crowded slums in Dhaka city. She lives with her husband, children and in-laws and has love and practical support from her family.

She registered on the “Aponjon” health messaging service after hearing about it from a local health worker.

Asha and her husband share the same mobile phone. Every week he receives SMS text messages –one for him, two for his wife –containing practical and relevant child health advice and information.

Both of them are becoming more knowledgeable and confident about their children’s health.

Asha is encouraging others in her community to subscribe to the service.

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NEXT STEPS FOR MH WG

A ROADMAP…

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Next Steps for HL7 MH WG?

Impact of MH Standards:MessagingDocument ArchitectureFunctional ModelServicesModeling (DAM, DIM)

Impact of MH:Security - Social MediaUsability - LMICAffordability - Interoperability

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MH: A Closer Look #1

MH Messaging Standards: think of using mobile devices to send short

but structured chucks for information for rapid turnaround

MH Functional Models/Profiles:“apps…apps all around but non talks with

another” MH Functional Profile derived from both the

EHR-S FM and the PHR-S FM!

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Document Architecture:at a first glance this might not apply but think of

this use case: you are on the road, in a foreign place, out of your

meds You go the local pharmacy, zap (NFC) your mobile

device with the kiosk and the kiosk prints out your prescription (in the local language)

You get your meds!

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Services:many possibilities….patient education is the

first that comes to mind...."Info Button" service request, appointment service request, etc.

Modeling:a Domain Analysis Model (DAM) for Mobile

Health and then a Domain Information Model (DIM) for mobile health

STORYBOARD developmentMODEL development (UML representation of

Use Case Diagram, Activity diagram, etc.)

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MH WG 2013-14 Activities & Projects

MH Security SWG & FAQ http://wiki.hl7.org/index.php?title=MHWG_Security

MH Newsletter (#1, #2…)

MH (EHR-S FM) GAP Analysis Project

MH Rural/LMIC SWG & Service Framework

In 2014 – 5 PSS (project scope statement) under development

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PSS#1: MHR-S FUNCTIONAL FRAMEWORK

Problem:There are over ~200,000 mobile apps“mobile, mobile everywhere….none talk to each other”

Options:Mobile Health F-Profile derived from EHR-S FMMobile Health F-Profile derived from PHR-S FM Mobile Health Hybrid Profile derived from both EHR-S FM and PHR-S FMMobile Health Functional Model

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PSS#2: LMIC/Rural Health Service Framework

• Leverage standardized health information technologies to help increase the quality and safety of healthcare within LMIC/Rural Health settings

• Identify strategies and best practices for employing accessible and interoperable mHealth-based solutions

• Investigate medium and messaging constraints of LMIC/Rural Health settings

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LMIC/RH SWG Recent Activities

• Updating project plan to a more focused gap analysis of mHealth technologies in use and bandwidth constraints

• Investigating baseline payloads of current HIE standards and the implications for use within low-bandwidth mHealth use cases

• Updated LMIC scope to include rural health settings due to similarities in settings and constraints

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PSS#3: mFHIRframe

Set of open source Libraries/APIs that would facilitate the implementation of mobile health applications based on FHIR (Fast Healthcare Interoperability Resources) standards

These Libraries/APIs will provide platform independent, real-time, standardized means to access health information from/to mobile devices.

Class libraries will be created that support a variety of mobile/portable platforms, including iOS, Android, .NET, and Arduino. These class libraries will contain APIs that ease the incorporation of FHIR resources into their corresponding application interfaces; facilitate interaction with EHR systems; manage workflows and use cases set forth by IHE.

The work will be built upon existing FHIR artifacts

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mFHIRframe

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PSS#4: mFHIRsideChat

Develop a SMS/Twitter type short standardized messaging protocol for fast exchange of information between a low-resource device/setting and a back-end/cloud environment

This type of data flow may also be between devices and a data aggregation unit (joint with DEV WG).

Solutions in rural health settings, with existing infrastructure, will be able to leverage this to send MU messages

Such standardized messages may be used by NASA during space missions (for example: MARS mission) where health information may need to flow from/to space to earth.

Use of such protocol in EMS, disaster response, public safety & publc health situations, LMIC settings is also envisaged

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PSS#5: MH-GS1 Pilot

The project consists in bringing GS1 closer to HL7 experts by using some useful tool to capture and document their participation to the mHealth WG sessions.

Ideally, the project should be scalable, so that it grows along the time and continues interesting the experts. If/when successful, the solution could be expanded to the full HL7 Working Groups.

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MU SUMMARY

As we transition to a digital record framework (access, capture, dissemination of information), use of Mobile Health will continue to rise

As Mobile Devices become more and more ubiquitous, accessing our Health Information is only a few tap/swipe away!

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THANK [email protected]

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Mobile Health WorkgroupMarch 2013

HL7 Mobile/PHR Gap Analysis:Summary of Findings

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Context

In consumer health, smartphones and tablets are presently being used to access personal health information, often in place of using personal computers. Some Personal Health Records systems (PHR-S) now available are designed solely for use on mobile devices.

The HL7 standards for Personal Health Records (PHRs), as written, did not anticipate this change. As such, questions have been raised concerning the adequacy of these standards in providing vendor guidance and in certifying modern PHR systems.

In consumer health, smartphones and tablets are presently being used to access personal health information, often in place of using personal computers. Some Personal Health Records systems (PHR-S) now available are designed solely for use on mobile devices.

The HL7 standards for Personal Health Records (PHRs), as written, did not anticipate this change. As such, questions have been raised concerning the adequacy of these standards in providing vendor guidance and in certifying modern PHR systems.

Mobile device use by consumers is widespread, in both developed and developing countries. For example, in the United States there are over 320 M mobile phones in use, more than one for everyone in the population*, and over half of new devices sold are smartphones.

*mobithinking.com, December 2012 data *mobithinking.com, December 2012 data

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Problem Overview

Background• The PHR/Mobile Gap Analysis Sub-group was established to

determine the extent of changes needed in the PHR-S Functional Model to accommodate the use of mobile devices (i.e., smartphones, tablets) within the model.

Scope• Review the recently balloted PHR-S functional model to

determine how the introduction of mobile devices as actors within the model may result in changes to the model.

• Make recommendations to the PHR-S functional model in terms of additional conformance criteria and/or creation of a mobile-specific profile for the PHR-S.

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Key Finding One

The functional aspects of HL7’s Personal Health Record System Functional Model (specifically, Function Names, Statements, Descriptions, and Conformance Criteria) DO NOT need to be modified in any way to accommodate the use of mobile devices and platforms in relation to PHR applications and data.

For example: “The system SHALL capture the PHR Account Holder’s

demographic information” applies equally to mobile and desktop-based technology.

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Key Finding Two

Certain PHR-S FM functionality can be tailored to mobile-based PHRs and mobile-based use cases based on

• Mobile device properties• Context of mobile device use• Behaviors of individuals using mobile devices

For example:

Geo-location services can inform a consumer of nearby emergency room services.If a mobile device containing consumer information is lost, remote wipe functionality could also trigger backing up data to a pre-specified location.

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Recommendation One

Create one or more mobile-informed profiles for the PHR-S FM that account for use of mobile devices, including device use within specific contexts.

For example:

If a mobile device is used in a military theatre, the following PHR-S FM Conformance Criterion might be modified within a functional profile to read (added language in red):

The system SHOULD provide the ability for the PHR Account Holder to control access to demographic information. Specifically, demographic information will not be displayed on a mobile device for military personnel who are in active combat zones; in non-combat zones, demographic information may be displayed on a mobile device.

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Recommendation One Considerations

Creation of functional profiles is a critical activity as products can only be certified against HL7 profiles, not functional models. Mobile-informed profiles can help industry deal with common issues in a standardized manner.

In the absence of PHR-S mobile functional profiles, vendors using the PHR-S FM to create PHR systems should account for mobile devices as actors when determining product scope. Special care should be given to addressing security controls.

For example:

• Availability and control of location data.• Security in relation to device loss or compromise.

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Recommendation TwoAs mobile devices can be actors in many health-related

scenarios, expose these findings to other HL7 workgroups where mobile devices are significant system actors for consideration as to how models and methods might be affected.

For example:

• EHR uses of tablets and smartphones by clinicians.• Structured data entry where mobile devices are used for data

collection. • Collection of family history information through structured forms on

mobile devices to support Meaningful Use (MU) 2 standards.

The appendices to this presentation include lists of mobile device characteristics, contexts of mobile device use, and user behaviors which may affect models and system functionality and are a starting point for examining current HL7 standards.

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Appendix 1: Mobile Device Characteristics which May Affect Models and System Functionality

• SMS messaging• Camera use• Geo Location functions• Near Field Communications capabilities• Device reliability• Role of continuous data collection and processing vs. at time of system

sign-on (e.g., real-time alerts and notifications which can make escalated medical decisions, changes in expected behaviors based on longitudinal data, speed and immediacy of data used for clinical decision support)

• Use of “basic” vs. “smart” mobile devices• Capabilities of mobile devices that lend to enhanced methods for detecting

possible fraudulent system use• Capabilities of mobile devices that enable enhanced interactions with rules

engines• PHI and PHII contained on devices• Unique device identifiers for available for audit and device identification

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Appendix 2: Contexts of Uses of Mobile Devices which May Affect Models and System Functionality

• Context of using services and transmitting data (mobile is changing the point of care—no longer just home/hospital—it is the place a person is at)

• Social media impact and transfer of personally-identifiable data between patients, “friends”, family and providers (shares issues with PCs, however, access and use of social media platforms is often, if not predominately, mobile-centric)

• Enterprise-provided devices vs. “Bring Your Own Device” (BYOD)• Audit considerations when devices are used for data collection and

transmission• System non-functional requirements may need more flexibility based on

context of use (e.g., temperature, humidity, battery life, bandwidth—both WiFi and G3/G4-- availability)

• Context of use that may affect data reliability and integrity

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Appendix 3: User Behaviors which May Affect Models and System Functionality

• Mobile devices are prone to be lost more readily than PCs consider how “data at rest” standards may need

strengthening. Consider need for data back up in relation to “remote

wipe” scenarios

• Consider “corner cases” in assumptions about user behaviors that may reduce mobile system security (e.g., typically a user has a mobile device under singular control, but with some regularity the device is shared with others)

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Acknowledgements

Key Sub-Group Contributors

• Elaine Ayres [email protected] • Joe Ketcherside [email protected]• Tim McKay [email protected]• John Ritter [email protected]

HL7 Mobile Workgroup Co-Chairs

• Gora Datta [email protected]• Matthew Graham [email protected]• Nadine Manjaro [email protected]

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HL7 Mobile/PHR Gap Analysis:Summary of Findings

THANK YOUTim McKay [email protected]

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MOBILE HEALTH

&MEANINGFUL USE (MU)

(US realm)

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MU BACKGROUND

2004 US Presidential Executive Order majority of Americans to have access to

electronic health records (EHRs) by 2014

2006 US Presidential Executive Orderpromote quality and efficient delivery of health

care through the use of health IT

2009 ARRA: HITECH ACTprogram to improve health care quality, safety,

and efficiency through the promotion of health IT, including electronic health records and private and secure electronic health information exchange

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“MEANINGFUL USE (MU)”?

GOAL: to promote the spread of electronic health records to improve health care in the United States

WHAT: A set of “rules” defined by the CMS Incentive Program that governs the use of electronic health records

BENEFITSComplete & accurate informationBetter access to informationPatient Empowerment

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MU: 3 Stage of Implementation

2011 2014 2017

Health IT Enabled Health Reform

Stage 1Capture Data in Coded Format Stage 2

Expand Exchange of Information in Structured Format Possible

Stage 3Improved Outcomes: Focus on Clinical Decision Support for High Priority Conditions, Patient Management, and Access to Comprehensive Data

Meaningful use implemented in 3 Stages All “Eligible Providers” (EP) and “Eligible Hospitals” (EH)

must achieve meaningful use by 2015 or face sanctions

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MH meets MU

Stage 1 – set the “stage” for Mobile HealthNothing explicit but subtle nudge towards

MH! In particular, encouraging Patient

engagement in the CARE process

Stage 2 – builds upon and creates opportunity for Mobile Health

Stage 3 & beyond – MH WG predicts: “MH will be key and central to healthcare delivery and access by one and all”!

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MU STAGE 1 & MH

MU STAGE 1 Measures:

“Provide clinical summaries for patients for each office visit”

“Provide patients with an electronic copy of their health information, upon request “

“Send reminders to patients per patient preference for preventive/follow-up care”

We start seeing how Mobile Health may increase patient involvement and engagement

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MU STAGE 1 (cont.#1)A few more Measures:

“Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies)”

“Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate “

“Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request”

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MU STAGE 2 & MH

Let’ see how Stage 2 builds upon Stage 1:“Provide patients the ability to view online,

download and transmit their health information within”: 36 hours after discharge from the hospital Within four business days of the information being

available to the Eligible Provider (EP)

“More than 5% of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information”

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MU STAGE 2 & MH (cont#1)A few more….

“Record patient family health history as structured data” “More than 20% of all unique patients seen by the EP

during the EHR reporting period have a structured data entry for one or more first-degree relatives or an indication that family health history has been reviewed”

[!!! a “Family History” mobile app that the patient can prefill prior to the appointment!!!]

“Use secure electronic messaging to communicate with patients on relevant health information” AND “….5% of patients to communicate back”

mobile health wg “state of mobile”

Documents