transforming vista evolution through collaboration healthcare services platform … ·...

Transforming VistA Evolution Through Collaboration

Healthcare Services Platform Consortium Stanley M. Huff, MD, CMIO, Intermountain Healthcare

Oscar Diaz, CEO, Health Services Platform Consortium Jonathan R. Nebeker MS MD, Deputy CMIO, Veterans Health Administration

Learning Objectives 1. Identify the VA’s priorities and critical requirements for its health services platform 2. Articulate the vision for a portable notation for content for process- based Clinical Decision Support 3. Outline opportunities for public and private sector collaboration and partnerships 4. Share HSPC’s standards work for FHIR resources tooling and knowledge authoring to facilitate a new market for knowledge-driven content

Stanley M. Huff, MD, CMIO; Oscar Diaz, CEO; and Jonathan R. Nebeker, MS, MD, have no conflicts of interest regarding the material presented herein.

Conflicts of Interest

Agenda • Vision of Interoperability and Introduction to CIMI

– Stan Huff • Healthcare Services Platform Consortium

– Oscar Diaz • VA’s EHR modernization and Healthcare Services Platform

Consortium – Jonathan Nebeker

A Vision of the Future

4

Why? “To help people live the

healthiest lives possible.”

Current Situation

• Each EHR vendor uses a proprietary database schema, proprietary models and unique terminology to represent clinical data

– Some standardization of codes is now occurring, but – Data is not consistent between vendors, between organizations

with same vendor, or even within the same organization and multiple instances of the same vendor

• This means that: – Sharing of data, knowledge, and applications is difficult to

impossible – Costs are high from replicated or conflicting care or recreation of

knowledge content or applications to support workflows. – There are unmet needs for health care applications and decision

support

The Future Ecosystem • Industry defines standards that enable “truly” interoperable systems

(FHIR, SMART, etc.) • Providers buy a health management platform certified to comply with

reference architecture and standards for data and APIs – Includes auditing, security, authorization, patient selection, etc. – May include some core apps: order entry, results review,

notification, etc. • Providers buy the apps and knowledge content they need to support

workflows from a robust marketplace. • Patients receive better care at a lower cost because lower cost higher

quality apps are available as driven by market forces

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

“The health IT market will transition from being technology driven to being content driven. Dominant EHR and analytical systems will use portable, computable knowledge for seamless, high-quality healthcare delivery.” --- DCMIO of America’s largest IDN

The Value of “Truly” Interoperable Systems

9

What if there is no model?

70 Dry Weight:

Site #1 kg

Weight:

Site #2 Dry kg

Wet

Ideal

70

70 70

Relational database implications

How would you calculate the desired weight loss during the hospital stay?

Patient Identifier

Date and Time

Observation Type

Observation Value

Units

123456

7/4/2005

Dry Weight

70

kg

123456

7/19/2005

Current Weight

73

kg

Patient Identifier

Date and Time

Observation Type

Weight type

Observation Value

Units

123456

7/4/2005

Weight

Dry

70

kg

123456

7/19/2005

Weight

Current

73

kg

Clinical Information Modeling Initiative • CIMI Mission

– Improve the interoperability of healthcare systems through shared implementable clinical information models.

• CIMI models

– http://www.clinicalelement.com/cimi-browser/#/ – http://www.opencem.org/#/

http://www.clinicalelement.com/cimi-browser/#/

http://www.opencem.org/#/

Oscar Diaz, CEO, HSPC

HSPC is about more than just data virtualization THE FUTURE SYSTEMS MODEL

MISSION

Improve health by catalyzing vibrant markets for interoperable

software, content, and data.

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

• 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

• Facilitate vendors’ implementation of the standard services 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

16

Functions of the Consortium under consideration

• Enable development “sandboxes” • Manage a vendor neutral and provider neutral “App

Store” • Facilitate collaborative development • Facilitate investment in technologies and content

17

Accomplishments Highlights • SMART on FHIR at HIMSS

– Intermountain, Cerner, Harvard Medical School, Epic, Hewlett Packard-VA

• Healthe Decisions (HED), FHIR-based CDS & Order sets – Cognitive Medical Systems, Motive Medical

• Standards – FHIR implementations – HL7 (VA & Cognitive Medical Systems)

• Event Publish and Subscribe • Unified Communication Service • Order Service

– OMG (Allscripts, Cognitive Medical Systems, VA, many others) • Order Service RFP approved in September by the OMG

Commercial EHR

Heterogeneous Systems

Home Grown System

System Integrator Others…

FHIR Profiles from CIMI Models (using standard terminology)

19

Use-Case Driven Approach • Care Coordination and Clinical Pathways

– LSU Health and LSU Healthcare Services Division • Registry Architecture and Standards

– American College of Surgeons, VA, many others • Perioperative and Surgical Use Case

– American College of Surgeons • Perinatal and Maternal Health

– American College of Obstetricians and Gynecologists

21

SOA Services Layers

• Support common UI Standards • Provide services for imbedding application in existing EMR/EHR frameworks

UI

• Implement a multi-layered services architecture (SOA) • Support common Decision Support models (BPMN2/Drools) • Support common workflow models (BPMN2) • Data and vocabulary transformation Services • Context management services • Master Data Management Services • Identity Management Services

Orchestration of Services and Busines Layer

• Support FHIR/Restful Services models that support launch and forget applications and applications that support a full SOA services stack

• Deploy FHIR profiles in collaboration with Argonauts, the VA, Intermountain, Regenstrief, Mayo/ASU and LSU

Data Virtualization

29-Feb-16

Dat

a La

yer

SOA Foundation Data Governance and Model Driven Development

Clean hand-off to IT with Business

Models, Metrics

Business Modeling and Simulation

Integrated deployment of policies, rules, and services

based on an SOA platform

Real time collaboration

and management of

business processes

Feedback for continuous

improvement and

optimization

Collaborative Development

Business Monitoring, Dashboards, Analytics

Workflow and Choreography

Govern services throughout the SOA lifecycle,

find and reuse for IT flexibility

Workflow Patient visits the

physician Need referralProvider prints the letter and gives it

to the patient

Authorization neededprior to scheduling?

Identify the patient’s

insurance recorded in the

EMR

Yes

Yes

Insurance?

Yes

Method of obtaininginsurance information and

authorizations

Access applicable website - verify insurance

coverage and eligibilityWebsite

Call applicable insurance carrier - verify insurance coverage and

eligibility

Phone

Patient is eligible?

Authorization required?

No

Call specialty clinic for fax reciept

Yes

No

Cancel referral and notify provider and patient

No

Provider completes an

order request via the Centricity letters module

Provider routes it to the referral coordinator in

Centricity

Reason?Procedure

notcovered

Notify provider and patient, cancel referral

and request new referral request for different

facility/specialty provider

Ineligible facility/specialty provider

End

Refer patient to PFS Fax referral request to specialty clinic

Locate fax from referral coordinator Fax located? Check insurance

eligibilityYes Insured?Verify assess referral request

Referral complete and correct? Yes

Verify appointment preferences

Schedule patient’s appointment in IDS and send automated

notification letter

Yes

Visit type?Fax or send procedure

preparatory instructions to the patient

Procedure

Notify the referral coordinator of appointment date and time

Obtain authorization number via website

Patient acquiresfinancial assistance or

self-pay?Yes

Refer patient to PFS

Office visit

No

Contact referral coordinator for additional

information

No

Required information obtained?

Yes

Reject referral and notify referral coordinator

No

Notify provider of rejected referral EndNotify referral coordinator

of missing fax

No


self-pay?

Yes

No

Obtain authorization

number via phone

Patient is eligible?


is self-pay?Refer patient to PFSNo

Authorization neededprior to scheduling?Yes

Fax referral request to specialty clinic

No


Locate fax from referral coordinator Fax located? Yes Verify assess referral

request

Notify referral coordinator of missing fax

No

Check insurance eligibility Insured?Yes


information

No

Requiredinformationobtained?

Yes


Schedule patient’s appointment in IDX and send

automated notification letter

Visit type?

Refer patient to PFSPatient acquires

financial assistance or self-pay?

Yes

No

Yes

Re-fax referral request to specialty clinic

Obtain required information from referring provider


Notify referring provider and patient EndNo

Fax or send procedure

preparatory instructions to the

patient

Notify the referral coordinator of

appointment date and time

Procedure

Office visit

Refer patient to PFS Reject referral and notify referring provider and patient End


is self-pay?NoNo


Yes


Locate fax from referral coordinator Fax located? Yes Verify and assess referral

request

Referralinformation complete

and correct?


No


information

Requiredinformation obtained?

Obtain required information from referring

provider

Yes

No

Yes


Schedule patient’s appointment in IDX and send automated

notification letterVisit type?

Fax or send procedure preparatory instructions to the

patientProcedure

No

Notify the referral coordinator of appointment date and time

Office visit

Send appointment notification letter to the patient and attach

to patient’s chart

No


and correct?

No

Obtain authorization number via website

Yes



Locate fax from referral coordinator Fax located?


No

Verify assess referral request


and correct?


information

Yes

No


Authorization number obtained? Yes Check insurance eligibilityYes


Yes

Insured?

Verify appointment preferencesSchedule patient’s appointment

in IDX and send automated notification letter



self-pay?

YesNo

Yes


Notify provider of rejected referralNo

No

End

Visit type?Fax or send procedure preparatory instructions

to the patient



Procedure

Office visitSend appointment notification letter

to the patient

Obtain authorization number via phone

Authorization number obtained?Yes Fax referral request to

specialty clinicCall specialty clinic for

fax recieptLocate fax from referral

coordinator Fax located?


YesYes Verify and assess referral request

Referralinformation complete and

correct?

No

Yes

Contact referral coordinator for additional information

No


Check insurance eligibility


Yes

Yes

Insured?


No



self-pay?

Yes


No

Yes

Schedule patient’s appointment in IDS and

send automated notification letter

Notify provider of rejected referral End

Visit type?

Fax or send procedure preparatory instructions

to the patient



Procedure

Office visitSend appointment

notification letter to the patient

No

End

No

Await phone call from patient for

appointment scheduling

Referral Coordinator

Who requests appointment? Patient

Who requests appointment?

Await phone call from patient for appointment schedulingPatient



Await phone call from patient for appointment schedulingPatient





Patient





Patient


Reject referral and notify referring provider and

patientEnd

Reject referral and notify referring provider and

patientEnd

Cancel referral and notify provider and patientReason?

Procedurenot

covered

Notify provider and patient, cancel referral and request new

referral request for different facility/specialty provider


End

No

End

Cancel referral and notify provider

and patient

Authorization obtained?

No

Reason?Procedure

notcovered





End

End

End

Cancel referral and notify provider

and patient

No

Reason?Procedure

notcovered





End

End

Authorization obtained? Yes

Send appointment notification letter

to the patient

Notify specialty coordinator of authorization

number

YesSend appointment notification letter

to the patient

Notify specialty coordinator of authorization

number

PHASE II PHASE I

Referring provider

Specialty practice assistant

Specialty Nurse

Specialty clerk

Specialty coordinator

Referring coordinator

Specialty provider

Color Key




Visit Type?

Review referral for completeness

Review referral for completenessOffice visit

Procedure

Complete?

Complete?

Yes

Yes

Obtain information and fill in gaps

Call referring provider for additional

information

No

No

Obtain patient confirmation

(mostly automated)

Call patient to verify receipt of prep information/understanding

and review medications and conditions

Print referral summary

information

Complete prepIssues? No

Yes

Cancel appointment

Notify referral coordinator

Reschedule and notify patient

Notify referring provider

Update appointment as a

“no-show”

Patient contacted?

Collect co-payment

Issues?

Resolve issuesYesUrgent?

Cancel appointment and

reschedule

No

Notify referring provider

Notify referral coordinator

No

Yes

Nurse sees the patient for triage

Procedure is performed

Create specialist note

Send specialist note to referring

providerPerform office visit

Check patient’s vitals and place in

exam room

Procedure

Office visit Close referral End

Send letter to patient and

referral coordinator

Yes

No

End

Check appointment

schedule

Patient arrives?

No

Confirm insuranceYes

Immediately resolvable?

No

Yes

End

End

End

Send appointment notification letter

to the patient

number

PHASE II PHASE III Visit Type?

As-is

Should-Be

Integrated Notification, Review and Entry

Analytics

Insurance Verification Scheduling

Visit Management

Visit Management

Bus

ines

s M

odel

Pr

oces

s W

orkf

low

s

External Patient Referral Summary

Referral List Schedule Visit Report back to Referring Physician

User Interface (Portal)

Process Management

Application & Data WebServices

CHCs Referral Coordinators Specialty Clinic

Reconciliation Workflows

CH

F M

odel

On Board to Pathway Status and management

Visit outcome and Progress

Report back to Referring Physician/Clinic

CHCs Navigator Specialty Clinic

Reconciliation • Allergy • Problems • Meds

VA New Orleanais

Partners LSU

Idea to apply Care Path Evolution and Process Flow

VA and HSPC Jonathan Nebeker HSPC Helps VA modernize its EHR systems and share in markets

VistA Evolution and eHMP • Veterans Health Information Systems and Technology

Architecture (VistA) is an enterprise-wide information system with software modules for financial functions, infrastructure functions, and clinical care.

• VistA Evolution is the program for modernizing clinical and ancillary information management systems

• Enterprise Health Management Platform (eHMP) is the core clinical system for supporting point-of-care functions and some registry and population management functions.

eHMP Challenge and USH Priorities • Provide Veteran-centric, team-based, quality-driven healthcare • Undersecretary Priorities: How eHMP will help

– Access: dynamic management of clinical need with services in and outside VA

– Provider satisfaction: better, faster, less annoying UX – Standardized best practices: Nationally standardized clinical

pathways and CDS – High-performing networks: Data aggregation, care-plan sharing,

and quality monitoring – Restoration of trust: Provide reporting and management based

on clinical not abstracted administrated events.

VistA Exchange

eHMP

User Experience Framework

Health Services Platform

Authoritative Data

eHMP Future State

• Third Party Applets (From FTL / Platform Users)

• Advanced Team Communications / IM Capability

• Voice Input

Allergies

Vitals

Medications

Labs

Notes

Consults

Non-eHMP Applet

Non-eHMP Applet Non-eHMP Applet

Applet Repository

UI/UX Framework

Workspace Workspace

Workspace

• Existing OpenSource / COTS Components

• New Modular Components: COTS / OpenSource

• Event Driven Architecture • Services Enabled & Composable

Components

Composite Services

Complex Events

Semantic Engine

CDS Engine

Bus Rules Engine

Team Mgmt. Population

Health

Orders Mgmt.

Statistics Engine

NLP Engine

Activity Mgmt.

• VA & External Rules Content

• COTS / OpenSource Components

• VA Custom Component

• VA Specific Interfaces

• Normalize • Map • Enrich

Data Layer

CDS Rules

State SolR JDS

RPC RPC RPC

VistA VistA VistA

Authoritative Data

DAS DoD

Highlights of Open eHMP

• Development Kits

– Resources (RDK)

– UX applets (SDK)

– Available through Future Technologies Lab (FTL) (previously known as VHA Innovations VACI Sandbox)

• APIs

– Representational State Transfer (REST)

– Virtual Patient Record (VPR)

– Fast Healthcare Interoperability Resources (FHIR) Draft Standard for Trial Use (DSTU)2 APIs

– Working with standards development organizations and Health Services Platform Consortium on more

Activity Management • Key Characteristics

– Who, What, Where, When, Why, How – Closed loop tracked state including fail – Feedback to learning healthcare system – Used with scheduling systems to provide dynamic management

of access to care based on clinical need • Ordering Overlay

– Intention & Request – Accept and Define – Execute

34

Need for functional service standards with implementation standards • Human notification service

– HSPC – UX

• Activity management service – Portable/Computable plan of care – Clinical Process Notation

• BPEL/BPMN, CDS, State – Care Coordination

• Team management service • Ordering Service • Registry reference architecture and standards • Dynamic quality and safety monitoring

Interested in changing the world? • Wiki https://healthservices.atlassian.net/wiki/display/HSPC/Healthcare+Services+Platform+Consortium

• Website http://hspconsortium.org/#/

36

https://healthservices.atlassian.net/wiki/display/HSPC/Healthcare+Services+Platform+Consortium

https://healthservices.atlassian.net/wiki/display/HSPC/Healthcare+Services+Platform+Consortium

http://hspconsortium.org/#/

Questions • Dr. Jonathan Nebeker [email protected]

• Dr. Stanley Huff [email protected]

• Oscar Diaz [email protected]

Other VA Sessions at HIMSS: Wednesday, March 2: Enhanced Home Healthcare Coordination for Veterans: 1:00–2:00 PM VA’s Data Sharing & Interoperability Strategies: 2:30–3:30 PM Evaluating Semantic Technology to Enhance EHR Visualization: 4:00–5:00 PM Thursday, March 3: VistA Evolution EHR Initiatives in 2016-2018: 8:30–9:30 AM Achieving Interoperability with VA & Private Sector Partners: 2:30–3:30 PM *

* This is a DOD session on joint work.

mailto:[email protected]



transforming vista evolution through collaboration healthcare services platform … ·...

Documents