This is an opinionated look at why current health IT systems integrate poorly and how it’s a big opportunity for the systems integrators to profit from supporting the OSEHRA Community. Background: * EHRs are not the center of the healthcare data ecosystem. * Applications come and go, data lives forever. He who owns, integrates, and uses data wins in the end. * Never leave data in the hands of the application only. Key takeaways: * OSEHRA is major business opportunity for ISVs and systems integrators * There’s nothing special about health IT data that justifies complex, expensive, or special technology.

1. OSEHRA is a great business
opportunity for health IT vendors
and system integrators
2nd Annual OSEHRA Summit
Shahid N. Shah
Chairman of OSEHRA Advisory Board

2. NETSPECTIVE
Who is Shahid?
•
•
•
•
Chairman, OSEHRA Board of Advisors
20+ years of software engineering and
multi-discipline complex IT
implementations (Gov., defense, health,
finance, insurance)
12+ years of healthcare IT and medical
devices experience (blog at
http://healthcareguy.com)
15+ years of technology management
experience (government, non-profit,
commercial)
www.netspective.com
Author of Chapter 13, “You’re
the CIO of your Own Office”
2

3. NETSPECTIVE
What’s this talk about?
Background
•
•
•
EHRs are not the center of the
healthcare data ecosystem.
Applications come and go, data lives
forever. He who owns, integrates,
and uses data wins in the end.
Never leave data in the hands of the
application only.
www.netspective.com
Key takeaways
•
•
OSEHRA is major business
opportunity for ISVs and systems
integrators
There’s nothing special about
health IT data that justifies
complex, expensive, or special
technology.
3

4. NETSPECTIVE
VA, VHA, VistA, and OSEHRA
Top-notch pedigree and a well funded buyer of innovation
VA
FY2012 IT Spend: $3.1 B
VHA
OSEHRA
2011
VistA EHR Code
Community
Convergence, Refactoring
OSEHRA Core
Free or Commercial
2013
Contributed Core
Data 1
Facility 2
…
OSEHRA Add-ons
Contributed Add-ons
Data 2
Facility 1
…
IV&V (Test, Docs)
Contributed Tests/Docs
Certify
Commercial Deployments
Coordination
Innovation
OSEHRA Deployment
Delivery
www.netspective.com
2013
4

5. NETSPECTIVE
How OSEHRA makes the market bigger
Market generation and economic benefits
New businesses can be
created which service
OSEHRA code,
technologies, etc. and make
revenue from said services
www.netspective.com
New system integration
business or existing ones
can augment their products
/ services to include
OSEHRA capabilities
5

6. NETSPECTIVE
How OSEHRA makes the market bigger
Market generation and economic benefits
New or existing hosting /
datacenter businesses can offer
fully hosted OSEHRA capabilities
directly to clinicians or even at
some point VA/DoD/IHS
www.netspective.com
New revenue centers in existing
or new businesses can take
common certification criteria and
build tools around it for
automated testing,
documentation preparation, etc.
6

7. The macro environment

8. NETSPECTIVE
The realities of patient populations
Prevention
• Education
• Health Promotions
• Healthy Lifestyle Choices
• Health Risk Assessment
Management
• Obesity Management
• Wellness Management
•
•
•
•
•
•
•
Assessment – HRA
Stratification
Dietary
Physical Activity
Physician Coordination
Social Network
Behavior Modification
• Diabetes
• COPD
• CHF
•
•
•
•
•
Stratification & Enrollment
Disease Management
Care Coordination
MD Pay-for-Performance
Patient Coaching
•
•
•
•
Physicians Office
Hospital
Other sites
Pharmacology
• Catastrophic Case
Management
• Utilization Management
• Care Coordination
• Co-morbidities
26 % of Population
35 % of Population
35 % of Population
4% of Population
4 % of Medical Costs
22 % of Medical Costs
37 % of Medical Costs
36 % of Medical Costs
Source: Amir Jafri, PrescribeWell
www.netspective.com
8

9. NETSPECTIVE
Patient Collaboration Maturity Model
Accountable Care
Integrated Care
Coordinated Care
Connected Care
Independent
Care
www.netspective.com
Choosing a single EHR vendor as your
platform for connected care won’t work
beyond integrated care scenarios.
9

10. NETSPECTIVE
We’re digitizing biology
Last and past decades
Digitize
mathematics
Digitize
literature
Digitize social
behavior
Predict human
behavior
Gigabytes and petabytes
www.netspective.com
This and future decades
Digitize biology
Digitize
chemistry
Digitize physics
Predict
fundamental
behaviors
Petabytes and exabytes
10

11. NETSPECTIVE
We’re repurposing and enhancing health data
Try to use existing data to create new diagnostics or therapeutic solutions
Economics
Administrative
www.netspective.com
Phenotypics
Behavioral
Biochemical
Genomics
Proteomics
IOT sensors
11

12. NETSPECTIVE
Healthcare industry / market trends
Major market and regulatory trends that are causing customers and competitors to shift
You must learn and be able to talk to customers about all these terms
PPACA
ACO
PCMH
“Affordable Care
Act”
“Accountable
Care Org”
“Medical
Home”
Health
Home
www.netspective.com
mHealth
MU
“Meaningful Use”
PCPCC
“Patient Centered
Care”
12

13. NETSPECTIVE
Implications of healthcare trends
PPACA
ACO
Software
Regulated IT and Systems
Integration Services
MU
Health
Home
www.netspective.com
PCMH
mHealth
DATA
Evidence Based Medicine
Comparative Effectiveness
13

14. NETSPECTIVE
The new world order
General
Wellness
Specific
Prevention
Self Service
Physiologics
Self Service
Monitoring
Healthcare
Professional
Monitoring
Care Team
Diagnostics
Care Team
Monitoring
Self Service
Diagnostics
Healthcare
Professional
Diagnostics
Hospital
Monitoring
Hospital
Diagnostics
www.netspective.com
14

15. NETSPECTIVE
We’re in the integration age
We’re not in an
app-driven
future but an
integrationdriven future.
He who
integrates the
best, wins.
Source: Geoffrey Raines, MITRE
www.netspective.com
15

16. What are we doing wrong when it comes to health IT applications?
What’s the problem?

17. NETSPECTIVE
Why you can’t just “buy integration”
Myth
• I only have a few systems
to integrate
• I know all my data formats
• I know where all my data is
and most of it is valid
• My vendor already knows
how all this works and will
solve my problems
www.netspective.com
Truth
• There are actually hundreds
of systems
• There are dozens of formats
you’re not aware of
• Lots of data is missing and
data quality is poor
• Tons of undocumented
databases and sources
• Vendors aren’t incentivized to
integrate data
17

18. NETSPECTIVE
Application focus is biggest mistake
Application-focused IT instead of Data-focused IT is causing business problems.
Silos of information exist across
groups (duplication, little sharing)
Clinical
Apps
Billing
Apps
Lab
Apps
Other
Apps
Healthcare Provider Systems
Patient
Apps
Partner Systems
Poor data integration across
application bases
www.netspective.com
18

19. NETSPECTIVE
The Strategy: Modernize Integration
Need to get existing applications to share data through modern integration
techniques
Clinical
Apps
NCI
App
Billing
Apps
Lab
Other
Apps
Apps
NEI
App
Healthcare Provider Systems
Patient
Apps
NHLBI
App
Partner Systems
Master Data Management, Entity Resolution, and Data Integration
Improved integration by services
that can communicate between applications
www.netspective.com
19

20. NETSPECTIVE
Important needs of non-Gov clinical customers
OSEHRA needs to get non-government clinical customers but there are important gaps
Easy to install
packages that make it
possible to experiment
with OSEHRA code
Patient portal
integration
www.netspective.com
RCM integration
Interoperable with
existing systems (labs,
pharma, etc.)
20

21. NETSPECTIVE
Value-adds to clinical users
The conceptual ROI for OSEHRA activities
More
functionality
Faster delivery
Interoperability
www.netspective.com
Better
integration
Free EHR
21

22. NETSPECTIVE
Important needs of engineering customers
OSEHRA needs to get non-government clinical customers but there are important gaps
Easy to install
packages that make it
possible to experiment
with OSEHRA code
Common data model
Platform to build on
(APIs, etc.)
www.netspective.com
Common identity
management
Ability to build
mHealth apps on top
of OSEHRA
22

23. NETSPECTIVE
Needed: Reimagined User Interactions
Data visualization requires integration and aggregation
What’s being offered to users
www.netspective.com
What users really want
23

24. NETSPECTIVE
Needed: Self-service applications
Patient Scheduling
for Services
Secure Social Patient
Relationship
Management (PRM)
Patient
Communications,
SMS, IM, E-mail,
Voice, and Telehealth
Patient Education,
Calculators, Widgets,
Content
Management
Blue Button, HL7,
X.12, HIEs, EHR, and
HealthVault
Integration
E-commerce, Ads,
Subscriptions, and
Activity-based Billing
Accountable Care,
Patient Care
Continuity and
Coordination
Patient Family and
Community
Engagement
Patient Consent,
Permissions, and
Disclosure
Management
www.netspective.com
24

25. NETSPECTIVE
Needed: diagnostic quality mHealth
www.netspective.com
25

26. NETSPECTIVE
Needed: predictive analytics
www.netspective.com
26

27. NETSPECTIVE
Needed: care team involvement
PATIENT/
CONSUMER
HEALTHCAR
E PROVIDER
Care Team
FAMILY
CAREGIVER
CALL CENTERS AND
REMOTE SUPPORT
www.netspective.com
HOSPITAL
ALTERNATE
SITE OF
CARE
27

28. NETSPECTIVE
Needed: automated diagnostics
www.netspective.com
28

29. Modern Microapps and Services Approach (Sample)
Browser Accessible
Bootstrap
Backplane
Identity
Manager
Domain
Services
CMS
LDAP
oData
LDIF
Domain
SQLV
oData
RDFa
HTML5 DA
Services
RDBMS
Bootstrap
AngularJS
Entity
Services
SQLV
Limited FK
Constraints
Analytics
SQL/Cube
Service
www.netspective.com
Micro Apps
Services
Rich client only
or tiny server
frameworks
(Mojo, Rack, etc.)
oData
Bootstrap
AngularJS
Backplane
SQLV
RDBMS
Third Party
oData
Reporting
Apps
ElasticSearch
XMPP
RDFa
HTML5 Data Attrs
Widgets
Entity
RDBMS
ETL
No Direct Table
Access
Separate Schemas
No FK Constraints
oAuth
SAML
RDFa
HTML5 Data Attrs
Search
Service
syslog
iCal
Log/Monitor
Service
CalDAV
Service
Bootstrap
Backplane
oData
Doc/Blob
Service
Rules
Service
oData
XACML
29

30. How do we modernize integration?

31. NETSPECTIVE
Why health IT systems integrate poorly
•
•
•
•
•
Permissions-oriented culture
prevents tinkering and “hacking”
We don't support shared identities,
single sign on (SSO), and industryneutral authentication and
authorization
We’re looking for "structured data
integration" instead of "practical app
integration" in our early project
phases
We create large monolithic data
warehouses instead of small service
oriented databases
We “push" data everywhere instead
of "pulling" it when necessary
www.netspective.com
•
•
•
•
•
We assume EHRs the center of
the universe
We accept and reward vendors
that don’t care about integration
We have “Inside out” architecture,
not “Outside in”
We're too focused on heavyweight
industry-specific formats instead of
lightweight or micro formats
Data emitted is not tagged using
semantic markup, so it's not
securable or searchable by default
31

32. NETSPECTIVE
Don’t assume your EHR will manage your data
The EHR can not be the center of the healthcare data ecosystem
• Most non-open-source
EHR solutions are
designed to put data in
but not get data out
• Never build your data
integration strategy with
the EHR in the center,
create it using the EHR as
a first-class citizen
Why EHRs are not (yet) disruptive
http://www.christenseninstitute.org/why-ehrs-are-not-yet-disruptive/
www.netspective.com
32

33. NETSPECTIVE
Encourage clinical “tinkering” and “hacking”
It’s ok to not know the answer in advance
• Clinicians usually go
into medicine because
they’re problem solvers
• Today’s permissionsoriented culture now
prevents “playing” with
data and discovering
solutions
www.netspective.com
33

34. NETSPECTIVE
Promote “Outside-in” architecture
Think about clinical and
hospital operations and
processes as a collection
of business capabilities or
services that can be
delivered across
organizations.
www.netspective.com
34

35. NETSPECTIVE
Integration improves focus on the real customer
Inside-out focus
IT
Personnel
Outside-in focus
Internal
business
users and
HCPs
HCP and
Staff
Evaluators
External
HCPs
Patients
Sophisticated and
more agile focus
Unsophisticated and
less agile focus
HCPs = healthcare providers
www.netspective.com
35

36. NETSPECTIVE
Implement industry-neutral ICAM
Implement shared identities, single sign on (SSO), neutral authentication and authorization
Proprietary identity is hurting us
•
•
Most health IT systems create their own
custom identity, credentialing, and access
management (ICAM) in an opaque part of
a proprietary database.
We’re waiting for solutions from health IT
vendors but free or commercial industryneutral solutions are much better and
future proof.
www.netspective.com
Identity exchange is possible
• Follow National Strategy for Trusted Identities
in Cyberspace (NSTIC)
• Use open identity exchange protocols such as
SAML, OpenID, and Oauth
• Use open roles and permissions-management
protocols, such as XACML
• Consider open source tools such as OpenAM,
Apache Directory, OpenLDAP Shibboleth, or
,
commercial vendors.
• Externalize attribute-based access control
(ABAC) and role-based access control (RBAC)
from clinical systems into enterprise systems
like Active Directory or LDAP
.
36

37. NETSPECTIVE
App-focused integration is better than nothing
Structured data dogma gets in the way of faster decision support real solutions
Dogma is preventing integration
App-centric sharing is possible
Many think that we shouldn’t integrate
until structured data at detailed machinecomputable levels is available.
The thinking is that because mistakes can
be made with semi-structured or hard to
map data, we should rely on paper, make
users live with missing data, or just make
educated guesses instead.
Instead of waiting for HL7 or other structured
data about patients, we can use simple
techniques like HTML widgets to share
"snippets" of our apps.
• Allow applications immediate access to
portions of data they don't already manage.
• Widgets are portions of apps that can be
embedded or "mashed up" in other apps
without tight coupling.
• Blue Button has demonstrated the power of
app integration versus structured data
integration. It provides immediate benefit to
users while the data geeks figure out what
they need for analytics, computations, etc.
• Consider Direct for app-centric connectivity.
www.netspective.com
37

38. NETSPECTIVE
Pushing data is more expensive than pulling it
We focus more on "pushing" versus "pulling" data than is warranted early in projects
Old way to architect:
“What data can you send me?” (push)
Better way to architect:
“What data can I publish safely?” (pull)
The "push" model, where the system that
contains the data is responsible for sending the
data to all those that are interested (or to some
central provider, such as a health information
exchange or HL7 router) shouldn’t be the only
model used for data integration.
• Implement FHIR or syndicated Atom-like feeds
(which could contain HL7 or other formats).
• Data holders should allow secure authenticated
subscriptions to their data and not worry about
direct coupling with other apps.
• Consider the Open Data Protocol (oData).
• Enable auditing of protected health information
by logging data transfers through use of syslog
and other reliable methods.
• Enable proper access control rules expressed in
standards like XACML.
• Consider Direct for connectivity if you can’t get
away from ‘push’.
www.netspective.com
38

39. NETSPECTIVE
Move to service-oriented (de-identifiable) data
Don’t assume all your data has to go into a giant data warehouse
Old way to architect:
Monolithic RDBMS-based data warehouse
Better way to architect:
Service-oriented databases on RDBMS/NoSQL
The centralized clinical data warehouse (CDW)
model, where a massive multi-year project
creates a monolithic relational database that all
analytics will run off was fine when retrospective
reporting is what defined analytics. This old
architecture won’t work in modern predictive
analytics and mobile-centric requirements.
• Drive transactional ACID-based data
requirements to RDBMS and consider columnstores, document-stores, and network-stores for
other kinds of data
• Break relationships between data and store
lookup, transactional, predictive, scoring, risk
strat, trial associated, retrospective, identity,
mortality ratios, and other types of data based on
their usage criteria not developer convenience
• Use translucent encryption and auto-deidentification of data to make it more useful
without further processing
• Design for decentralized sync’ing of data (e.g.
mobile, etc.) not centralized ETL
www.netspective.com
39

40. NETSPECTIVE
An example of structuring data for analysis
Preparing data is important
Hard to secure data structures
Easier to secure data structures
http://www.ibm.com/developerworks/data/library/techarticle/dm-ind-ehr/
www.netspective.com
40

41. NETSPECTIVE
Industry-specific formats aren’t always necessary
Reliance on heavyweight industry-specific formats instead of lightweight micro formats is bad
HL7 and X.12 aren’t the only formats
Consider industry-neutral protocols
The general assumption is that
formats like HL7, CCD, and X.12 are
the only ways to do data integration
in healthcare but of course that’s
not quite true.
•
•
•
•
www.netspective.com
Consider identity exchange
protocols like SAML for integration
of user profile data and even for
exchange of patient demographics
and related profile information.
Consider iCalendar/ICS publishing
and subscribing for schedule data.
Consider microformats like FOAF
and similar formats from
schema.org.
Consider semantic data formats
like RDF, RDFa, and related family.
41

42. NETSPECTIVE
Tag all app data using semantic markup
When data is not tagged using semantic markup, it's not securable or shareable by default
Legacy systems trap valuable data
Semantic markup and tagging is easy
In many existing contracts, the
vendors of systems that house the
data also ‘own’ the data and it can’t
be easily liberated because the
vendors of the systems actively
prevent it from being shared or are
just too busy to liberate the data.
• One easy way to create semantically
meaningful and easier to share and
secure patient data is to have all
HTML tags be generated with
companion RDFa or HTML5 Data
Attributes using industry-neutral
schemas and microformats similar to
the ones defined at Schema.org.
• Google's recent implementation of
its Knowledge Graph is a great
example of the utility of this
semantic mapping approach.
www.netspective.com
42

43. NETSPECTIVE
Produce data in search-friendly manner
Produce HTML, JavaScript and other data in a security- and integration-friendly approach
Proprietary data formats limit findability
Search engines are great integrators
• Legacy applications only present
through text or windowed
interfaces that can be “scraped”.
• Web-based applications present
HTML, JavaScript, images, and
other assets but aren’t search
engine friendly.
• Most users need access to
information trapped in existing
applications but sometimes they
don’t need must more than access
that a search engine could easily
provide.
• Assume that all pages in an
application, especial web
applications, will be “ingested” by
a securable, protectable, search
engine that can act as the first
method of integration.
www.netspective.com
43

44. NETSPECTIVE
Rely first on open source, then proprietary
“Free” is not as important as open source, you should pay for software but require openness
Healthcare fears open source
Open source can save health IT
• Only the government spends more per
user on antiquated software than we do
in healthcare.
• There is a general fear that open source
means unsupported software or lower
quality solutions or unwanted security
breaches.
• Other industries save billions by using
open source.
• Commercial vendors give better pricing,
service, and support when they know
they are competing with open source.
• Open source is sometimes more secure,
higher quality, and better supported
than commercial equivalents.
• Don’t dismiss open source, consider it
the default choice and select commercial
alternatives when they are known to be
better.
www.netspective.com
44

45. Modern Microapps and Services Approach (Sample)
Browser Accessible
Bootstrap
Backplane
Identity
Manager
Domain
Services
CMS
LDAP
oData
LDIF
Domain
SQLV
oData
RDFa
HTML5 DA
Services
RDBMS
Bootstrap
AngularJS
Entity
Services
SQLV
Limited FK
Constraints
Analytics
SQL/Cube
Service
www.netspective.com
Micro Apps
Services
Rich client only
or tiny server
frameworks
(Mojo, Rack, etc.)
oData
Bootstrap
AngularJS
Backplane
SQLV
RDBMS
Third Party
oData
Reporting
Apps
ElasticSearch
XMPP
RDFa
HTML5 Data Attrs
Widgets
Entity
RDBMS
ETL
No Direct Table
Access
Separate Schemas
No FK Constraints
oAuth
SAML
RDFa
HTML5 Data Attrs
Search
Service
syslog
iCal
Log/Monitor
Service
CalDAV
Service
Bootstrap
Backplane
oData
Doc/Blob
Service
Rules
Service
oData
XACML
45

46. NETSPECTIVE
Primary challenges
•
•
•
•
•
Tooling strategy must be comprehensive. What hardware and
software tools are available to non-technical personnel to encourage
sharing?
Formats matter. Are you using entity resolution, master data and
metadata schemas, documenting your data formats, and access
protocols?
Incentivize data sharing. What are the rewards for sharing or penalties
for not sharing healthcare data?
Distribute costs. How are you going to allow data users to contribute
to the storage, archiving, analysis, and management costs?
Determine utilization. What metrics will you use determine what’s
working and what’s not?
www.netspective.com
46

47. NETSPECTIVE
Additional Information
• OSEHRA website: www.osehra.org
• HardHats.org: http://www.hardhats.org
• MUMPS
– http://en.wikipedia.org/wiki/MUMPS
– http://www.mcenter.com/mtrc/mfaqhtm1.html
• World Vista: www.worldvista.org
• Webnairs:
https://www.vxvista.org/display/vx4Learn/Recorded+
Webinars
www.netspective.com
47

48. Visit
http://www.netspective.com
http://www.healthcareguy.com
E-mail shahid.shah@netspective.com
Follow @ShahidNShah
Call 202-713-5409
Thank You