Service-Oriented CDS in the Cloud By Joel Amoussou | President, Efasoft, Inc. Presented at the 2011 SOA In Healthcare Conf...
Images in this presentation are being used for illustrative purposes only. Any person depicted in this presentation is a m...
 
US Healthcare Expenditures 17.6% of GDP in 2009 or $2.5 trillions Centers for Medicare and Medicaid Services - National He...
<ul><li>46 cents of every program dollar in Ontario </li></ul><ul><li>70 cents in 12 years if left unchecked </li></ul>201...
The Quality Imperative “ Overall, participants received 54.9% of recommended care” McGlynn EA, Asch SM , Adams J, Keesey J...
<ul><li>“ Patients should receive care based on the best available scientific knowledge. Care should not vary illogically ...
 
Centers for Disease Control and Prevention – Preventive Care Practices http://www.cdc.gov/diabetes/statistics/preventive/f...
Economic burden of mental illness in 2002: $317.6 billions or about $1000 for every person Mental Health Clinical Practice...
Healthy Behaviour
Patient-Centered Medical Home (PCMH) Personal Physician Whole person orientation Coordinated care Quality and safety Payme...
Care Coordination
Pay-For-Performance (P4P)
Accountable Care Organization (ACO) Reimbursements tied to quality metrics and total per capita costs reduction
Evidence-Based Medicine “ The great tragedy of Science - the slaying of a beautiful hypothesis by an ugly fact.” Thomas He...
Comparative Effectiveness Research (CER) Patient-Centered Outcome Research (PCOR)
Translational Medicine Bench-to-Bedside time: 17 years Wise Young &quot;Bench-to-bedside lag time: a major problem for SCI...
Advances in Genomics Genotype & Phenotype Proteomics Pharmacogenomics Large data sets Computing resources
Medical Errors in the Emergency Department <ul><li>96% are Cognitive Errors </li></ul>Kachalia A, Gandhi TK, Puopolo AL, Y...
<ul><li>Failure to order an appropriate  </li></ul><ul><li>diagnostic test: 58% </li></ul>Kachalia A, Gandhi TK, Puopolo A...
<ul><li>Failure to perform an adequate medical history or physical examination: 42% </li></ul>Kachalia A, Gandhi TK, Puopo...
<ul><li>Incorrect interpretation of a  </li></ul><ul><li>diagnostic test: 37% </li></ul>Kachalia A, Gandhi TK, Puopolo AL,...
<ul><li>Failure to order an appropriate consultation: 33% </li></ul>Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, ...
<ul><li>The number of objects an average human can hold in working memory is 7 ± 2. </li></ul>Miller GA. The magical numbe...
<ul><li>18 millions article references in Medline </li></ul><ul><li>Typical CPG is 50-150 pages long </li></ul><ul><li>Gen...
MU Stage 1: From Paper to EHR
Percentage of office-based physicians with EMR/EHR systems: United States, 2001-2009, and preliminary 2010-2011
MU Stage 2: CDS Takes Center Stage
From One Expert's Brain
To Computerized Decision Support
The Wisdom of a Team
Interoperable Systems
CDS Interventions Cognitive Support for Clinicians, Patients, and Caregivers
Alerts & Reminders
Health Behaviour Change Free C, Phillips G, Felix L, Galli L, Patel V, Edwards P. The effectiveness of  M-health technolog...
 
 
Care Pathways and Protocols
Order Sets
Personalized Medicine Kawamoto K, Lobach DF, Willard HF, Ginsburg GS. A national clinical decision support infrastructure ...
Scheduling
“ An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloo...
Infobuttons Linked to problem list Code-driven Question-driven Point of care retrieval Del Fiol G, Haug PJ, Cimino JJ, Nar...
Medication Dosing Calculation
Disease Registries
Predictive Data Mining “ Medicine is a science of uncertainty and an art of probability.” -Sir William Osler (1849-1919)
Data Visualization Gill J, Chearman T, Carey M, Nijjer S, Cross F. Presenting patient data in the electronic care record: ...
Smart Form Aggregated view of data entry, display, and CDS interventions based on specific diagnosis Supports workflow and...
Human Factors of Alert Acceptance   <ul><li>Display of the alert </li></ul><ul><li>Knowledge quality </li></ul><ul><li>Fre...
Focus on Core Competency: Medical Care
The Cloud: Just a Buzzword?
Apps Moving to the Cloud Analytics, CDS, EHR, 5010/ICD10
Elasticity Quick provisioning Usage-based payment Massive scalability Low up-front capital costs Sharing resources Benefit...
Cloud-Enabled ACO Providers Government Payers Analytics Registries CDS Reporting Risk Financial
Rules & Analytics De-Identification Re-Identification
Driving Quality and Performance Measurement - A Foundation for Clinical Decision Support  By The National Quality Forum (N...
Resource Locator Service Decision  Support Service Terminology Service Intervention Service Event Service Knowledge Manage...
CDS Intervention Profile Priority Channel (SMS, Email, etc.) Escalation logic Clinical workflow Message queue
Clinical Knowledge Management (CKM) <ul><li>Collaborative </li></ul><ul><li>Governance </li></ul><ul><li>Metadata </li></u...
Knowledge Representation and Reasoning <ul><li>Ontologies: OWL </li></ul><ul><li>Natural Language Processing (NLP) </li></...
HIPAA and HITECH Act Federal Information Security Management Act (FISMA) Electronic Communications Privacy Act (ECPA) Patr...
Security Threats Isolation in Multinancy DoS and DDoS OWASP Top 10 CSA Cloud Top Ten Threats
Cloud Security Monitoring Hardening & Patches Host firewall Intrusion Detection System (IDS) Encryption & Key Management (...
Identity and Access Management (IAM) SAML for SSO XACML 3.0 Draft XSPA Profiles for Healthcare
Security Management Framework ITIL & ISO 27002 Availability Configuration Vulnerability Access Control
Governance, Risk and Compliance (GRC) HIPAA ISO 27001 SystTrust, WebTrust SAS 70 CSA GRC Stack
Storm in the Cloud Stateless services Multi-region resiliency  Choose the right storage Allocate more than needed Simulate...
Demand transparency from your CSP
DMTF's Open Virtualization Format (OVF) SNIA's Cloud Data Management Interface (CDMI) OGF's Open Cloud Compute Interface (...
CDS Standards Virtual Medical Record (vMR) Decision Support Services (DSS) Infobuttons Order Sets Guidelines Element Model...
Definition of Cloud Computing US Government Cloud Computing Technology Roadmap Cloud Reference Architecture Guidelines on ...
Care First,  Technology Second
Thank You ! [email_address]
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Service-Oriented CDS in the Cloud

  1. 1. Service-Oriented CDS in the Cloud By Joel Amoussou | President, Efasoft, Inc. Presented at the 2011 SOA In Healthcare Conference
  2. 2. Images in this presentation are being used for illustrative purposes only. Any person depicted in this presentation is a model.
  3. 4. US Healthcare Expenditures 17.6% of GDP in 2009 or $2.5 trillions Centers for Medicare and Medicaid Services - National Health Expenditures 2009 Highlights https://www.cms.gov/NationalHealthExpendData/downloads/highlights.pdf
  4. 5. <ul><li>46 cents of every program dollar in Ontario </li></ul><ul><li>70 cents in 12 years if left unchecked </li></ul>2010 Ontario Budget - Sector Highlights http://www.fin.gov.on.ca/en/budget/ontariobudgets/2010/sectors/health.pdf
  5. 6. The Quality Imperative “ Overall, participants received 54.9% of recommended care” McGlynn EA, Asch SM , Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. &quot;The Quality of Health Care Delivered to Adults in the United States&quot;. N Engl J Med. 2003 Jun 26;348(26):2635-45.
  6. 7. <ul><li>“ Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.” </li></ul><ul><li>Crossing The Quality Chasm: </li></ul><ul><li>A New Health System for the 21 st Century </li></ul><ul><li>The Institute of Medicine (IOM) </li></ul><ul><li>Washington (DC): National Academies Press; 2001 </li></ul>
  7. 9. Centers for Disease Control and Prevention – Preventive Care Practices http://www.cdc.gov/diabetes/statistics/preventive/fY_class.htm Adults with Diagnosed Diabetes Ever Attending a Diabetes Self-Management Class
  8. 10. Economic burden of mental illness in 2002: $317.6 billions or about $1000 for every person Mental Health Clinical Practice Guidelines Quality Measures Insel TR. Assessing the economic costs of serious mental illness. Am J Psychiatry. 2008;165:663-5. Institute of Medicine. Improving the quality of health care for mental and substance-use conditions. Washington (DC): National Academies Press; 2006.
  9. 11. Healthy Behaviour
  10. 12. Patient-Centered Medical Home (PCMH) Personal Physician Whole person orientation Coordinated care Quality and safety Payment Patient Centered Primary Care Collaborative - Joint Principles of the Patient Centered Medical Home http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
  11. 13. Care Coordination
  12. 14. Pay-For-Performance (P4P)
  13. 15. Accountable Care Organization (ACO) Reimbursements tied to quality metrics and total per capita costs reduction
  14. 16. Evidence-Based Medicine “ The great tragedy of Science - the slaying of a beautiful hypothesis by an ugly fact.” Thomas Henry Huxley (1825-1895)
  15. 17. Comparative Effectiveness Research (CER) Patient-Centered Outcome Research (PCOR)
  16. 18. Translational Medicine Bench-to-Bedside time: 17 years Wise Young &quot;Bench-to-bedside lag time: a major problem for SCI&quot;. Paraplegia News. FindArticles.com. 10 Jul, 2011. http://findarticles.com/p/articles/mi_hb4927/is_n4_v49/ai_n32003654/
  17. 19. Advances in Genomics Genotype & Phenotype Proteomics Pharmacogenomics Large data sets Computing resources
  18. 20. Medical Errors in the Emergency Department <ul><li>96% are Cognitive Errors </li></ul>Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196-205.
  19. 21. <ul><li>Failure to order an appropriate </li></ul><ul><li>diagnostic test: 58% </li></ul>Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196-205.
  20. 22. <ul><li>Failure to perform an adequate medical history or physical examination: 42% </li></ul>Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196-205.
  21. 23. <ul><li>Incorrect interpretation of a </li></ul><ul><li>diagnostic test: 37% </li></ul>Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196-205.
  22. 24. <ul><li>Failure to order an appropriate consultation: 33% </li></ul>Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196-205.
  23. 25. <ul><li>The number of objects an average human can hold in working memory is 7 ± 2. </li></ul>Miller GA. The magical number seven, plus or minus two: Some limits on our capacity for processing information. Psychol Rev. 1956;63:81-97.
  24. 26. <ul><li>18 millions article references in Medline </li></ul><ul><li>Typical CPG is 50-150 pages long </li></ul><ul><li>Genomics increases the number of data types that can affect decision making </li></ul>
  25. 27. MU Stage 1: From Paper to EHR
  26. 28. Percentage of office-based physicians with EMR/EHR systems: United States, 2001-2009, and preliminary 2010-2011
  27. 29. MU Stage 2: CDS Takes Center Stage
  28. 30. From One Expert's Brain
  29. 31. To Computerized Decision Support
  30. 32. The Wisdom of a Team
  31. 33. Interoperable Systems
  32. 34. CDS Interventions Cognitive Support for Clinicians, Patients, and Caregivers
  33. 35. Alerts & Reminders
  34. 36. Health Behaviour Change Free C, Phillips G, Felix L, Galli L, Patel V, Edwards P. The effectiveness of M-health technologies for improving health and health services: a systematic review protocol. BMC Research Notes. 2010;3:250.
  35. 39. Care Pathways and Protocols
  36. 40. Order Sets
  37. 41. Personalized Medicine Kawamoto K, Lobach DF, Willard HF, Ginsburg GS. A national clinical decision support infrastructure to enable the widespread and consistent practice of genomic and personalized medicine. BMC Med Inform Decis Mak. 2009;9:17.
  38. 42. Scheduling
  39. 43. “ An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.” Pronovost P, Needham D, Berenholtz S, et al. (December 2006). &quot;An intervention to decrease catheter-related bloodstream infections in the ICU&quot;. N. Engl. J. Med. 355 (26): 2725-32.
  40. 44. Infobuttons Linked to problem list Code-driven Question-driven Point of care retrieval Del Fiol G, Haug PJ, Cimino JJ, Narus SP, Norlin C, Mitchell JA. Effectiveness of topic specific infobuttons: A randomized controlled trial. J Am Med Inform Assoc. 2008;15(6):752-9.
  41. 45. Medication Dosing Calculation
  42. 46. Disease Registries
  43. 47. Predictive Data Mining “ Medicine is a science of uncertainty and an art of probability.” -Sir William Osler (1849-1919)
  44. 48. Data Visualization Gill J, Chearman T, Carey M, Nijjer S, Cross F. Presenting patient data in the electronic care record: the role of timelines. JRSM Short Rep. 2010 Sep 15;1(4):29.
  45. 49. Smart Form Aggregated view of data entry, display, and CDS interventions based on specific diagnosis Supports workflow and usability
  46. 50. Human Factors of Alert Acceptance <ul><li>Display of the alert </li></ul><ul><li>Knowledge quality </li></ul><ul><li>Frequency of Alert </li></ul><ul><li>Mandatory acknowledgement </li></ul>Seidling, HM; Phansalkar, S; Seger, DL; Paterno, MD; Shaykevich, S; Haefeli, WE; Bates, DW Factors influencing alert acceptance: a novel approach for predicting the success of clinical decision support. JAMIA 2011;18(4):479-84.
  47. 51. Focus on Core Competency: Medical Care
  48. 52. The Cloud: Just a Buzzword?
  49. 53. Apps Moving to the Cloud Analytics, CDS, EHR, 5010/ICD10
  50. 54. Elasticity Quick provisioning Usage-based payment Massive scalability Low up-front capital costs Sharing resources Benefits of the Cloud
  51. 55. Cloud-Enabled ACO Providers Government Payers Analytics Registries CDS Reporting Risk Financial
  52. 56. Rules & Analytics De-Identification Re-Identification
  53. 57. Driving Quality and Performance Measurement - A Foundation for Clinical Decision Support By The National Quality Forum (NQF) Clinical Practice Guidelines We Can Trust By the Institute Of Medicine (IOM)
  54. 58. Resource Locator Service Decision Support Service Terminology Service Intervention Service Event Service Knowledge Management Service HIE Adapter Infobutton Service Client Adapter Service CDS Interventions KM/Rules Authoring Clinical Data Sources
  55. 59. CDS Intervention Profile Priority Channel (SMS, Email, etc.) Escalation logic Clinical workflow Message queue
  56. 60. Clinical Knowledge Management (CKM) <ul><li>Collaborative </li></ul><ul><li>Governance </li></ul><ul><li>Metadata </li></ul><ul><li>CKM Repository </li></ul><ul><li>Content lifecycle </li></ul><ul><li>CMS and Portal </li></ul>
  57. 61. Knowledge Representation and Reasoning <ul><li>Ontologies: OWL </li></ul><ul><li>Natural Language Processing (NLP) </li></ul><ul><li>Speech Recognition </li></ul><ul><li>Clinical Question Answering (CQA) </li></ul>
  58. 62. HIPAA and HITECH Act Federal Information Security Management Act (FISMA) Electronic Communications Privacy Act (ECPA) Patriot Act Seek legal advice Privacy Regulations
  59. 63. Security Threats Isolation in Multinancy DoS and DDoS OWASP Top 10 CSA Cloud Top Ten Threats
  60. 64. Cloud Security Monitoring Hardening & Patches Host firewall Intrusion Detection System (IDS) Encryption & Key Management (NIST 800-57) Guidance by CSA and NIST
  61. 65. Identity and Access Management (IAM) SAML for SSO XACML 3.0 Draft XSPA Profiles for Healthcare
  62. 66. Security Management Framework ITIL & ISO 27002 Availability Configuration Vulnerability Access Control
  63. 67. Governance, Risk and Compliance (GRC) HIPAA ISO 27001 SystTrust, WebTrust SAS 70 CSA GRC Stack
  64. 68. Storm in the Cloud Stateless services Multi-region resiliency Choose the right storage Allocate more than needed Simulate failure Automate recovery
  65. 69. Demand transparency from your CSP
  66. 70. DMTF's Open Virtualization Format (OVF) SNIA's Cloud Data Management Interface (CDMI) OGF's Open Cloud Compute Interface (OCCI)
  67. 71. CDS Standards Virtual Medical Record (vMR) Decision Support Services (DSS) Infobuttons Order Sets Guidelines Element Model (GEM) Predictive Model Markup Language (PMML)
  68. 72. Definition of Cloud Computing US Government Cloud Computing Technology Roadmap Cloud Reference Architecture Guidelines on Security and Privacy
  69. 73. Care First, Technology Second
  70. 74. Thank You ! [email_address]

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