Programming Healthcare Silos


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Slides for Vaibhav's OSCON Talk -

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Healthcare IT is characterized by various silos encompassing payment systems, labs management systems, medication management systems, imaging systems and various other hospital management systems. In addition to maintaining these systems, a Healthcare IT professional deals with multitude of standards for data protocols and terminologies.

It has been established that Healthcare can be streamlined and associated costs can be reduced drastically if a patient is able to have greater control in the current ecosystem. Several personally controlled health record systems have been proposed and implemented, including solutions from Google, Microsoft, and Dossia. Standards like CCR & CCD have been gaining ground. Recommendations and guidelines for preferable medical terminologies like SNOMED-CT or ICD-10 has been order of business at office of national coordination (ONC) of Health.

This talk will take a deep dive with practical examples of how to interface various Hospital systems through CCR &CCD to various Personally controlled health record systems. We will take specific examples from use cases encompassing explanation of benefits, labs, medications, imaging, H1N1 reporting and master patient indexes. The talk will weave all the above use cases in one simple application.

While discussing the working code and solution architecture we will touch on various aspects of privacy and security needed to be addressed while dealing with HealthCare data.

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  • Welcome!I’m Vaibhav Bhandari, Program Manager in Microsoft Health Solutions Group. Over the last three years I have worked various aspects of Microsoft HealthVault and Medical Terminologies. Over the next 20 minutes I’m going give you a feel of working with various healthcare technologies and interface them with customers! Programming “across” HealthCare Silos. Quick show of hands –How many of you have worked in HealthCare IT for more than 5 years? Well that’s a good number!
  • The healthcare landscape is very complicated and often times very disjointed. Silos are characteristic of data in the HealthCare Ecosystem. When you get sick you go your family Physician who (if at all) stores data for your visit in a local electronic medical record system.  Your prescriptions get filled by a prescriptions network and Labs by the Lab network, which have their own interchange protocols and data standards. The payers or Health Plans pay for you visit using their own Electronic data interchange based standards. There are consumer service like WebMD which you use to get information from. And then there are the big Enterprise Hospitals which have a set of Silos themselves!
  • Before I started working with Microsoft Software Health Solutions I was developer dealing with embedded Operating systems, file systems and device drivers! The whole world of HealthIT seemed a little overwhelming to me. Various terms like HL7, SNOMED-CT, Meaningful-use, ICD9-toICD10 Conversion, EMR & EHR were all new to me!OpenSoft Inc. has developed a solution which bridges various silos through open-source and first principles.
  • Meet Jim – he is just going to walk through a component developed by OpenSoft Health Inc. for an Emergency EMR system.Meet Jim, he just dropped down at a Bus stop with an acute gastric problem, and rushed to the ER. Jim visited an ER for a sudden gastric attack. Your software need to handle Jim’s fairy ride through the hospital and give him the details of visit once he is back! When Jim walks in to the hospital ER nurse gets his vital and order an lab-test for him.
  • Now HL7 is a enables disparate systems in the hospital to talk to each other. In this typical HL7 message what you see isMSH – Message Header, showing our fictitious company – EmergencyEMR.Patient Identifier – PID, showing patient identifiers for JoePV1 – Patient Visit details -OBR – Request for an observationPoint to note – this message is in HL7 2.x format which is currently the used widely. The next version, HL7 v3 is entirely based on XML instead of pipe delimited segments.
  • Note the new OBX segment.Talk about LOINC Code in the OBX showing code-system and code-value. LOINC is a medical terminology which is widely used for laboratories and observations.
  • This code uses the HAPI HL7 parser to transform data from emergency EMR system to a HL7 message when is sent to the Lab Order System.
  • You system also sends a simple message to the claims management.Briefly glance over the X12 message and talk about ICD-9 code used in this message to communicate the procedures and tests done on Jim.
  • You system also sends a simple message to the claims management.Briefly glance over the X12 message and talk about ICD-9 code used in this message to communicate the procedures and tests done on Jim.
  • Jim would love to get more information on the care. The labs feature application which you added to the outpatient system can now be extended to send the information to the patient through one of the Personally Controlled Health Records (Google, Dossia or Indivo).Why this is a bug business opportunity?
  • Now, that Jim is ready to go home – we want to send an CCR/CCD/C32 to his Personally Controlled Health record. Lets take example of HealthVault.Your application create a CCR for Jim’s visit which shows his Vital signs, Lab Results.For a developer HealthVault has a number community managed Open Source libraries, we will work with the Python library on or Jave on Codeplex.Our emergency EMR takes the information from its database and converts it to a CCR using CCR xsd.
  • This snippet show how the application can drop-off the CCR in to HealthVault
  • Once Jims get’s to his home computer or Mobile phone be can enter the code given to him by the Emergency EMR and receive this CCR in to his HealthVault account. He can choose further refine it by reconciling it to HealthVault data types...
  • This is a great opportunity for developers in general to enable a cheap and easy way for providers to send information directly to end users. Providers are eagerly looking for such capabilities as meaningful use requires that capability.Employer sends 834 to HealthPlan for enrolling a patient.HealthPlan or Mediclaim or Medicare maintain a member index which Hosiptal can query using 271.278 – Is authorization request (in some states and Canada this is pre-determination).The claims processing system sends message 837/835 (Claims Processing message) which includes patients demographics, details of plan and details of the transaction (how much the plan paid and how much is co-pay).Vendors in space – Unisys, ACS, MUMPs (open source).
  • Microsoft is actively participating and contributing to NHIN-D project. The process of moving clinical information to consumer silo will be as easy as initiating an e-mail transaction from the source system!
  • If your application wanted you could also have sent the medical images from Jim’s Visit to his HealthVault account. We have recently enabled storing large data in HealthVault.We have a detailed walk through for using this functionality with Java.
  • In addition to Medical Images your application can also use the Client Capability of HealthVault platform and in-fact create client applications for Android or Windows Mobile. Details of this can be found on my blog.May be the future phone can detect and transact with hospital devices to get a care record instead of going through a CCR/CCD hoops.
  • The data is now flowing out of the hospital in to HealthVault. A critical distinction is that its no longer HIPAA covered.
  • Summary of what we just saw – an end to end scenario of implementing a new capability in a complicated system and deliver it to the consumer!-- Lots of Silos-- Open Source Solutions Exist-- Consumers Matter-- HealthVault Plays a Role--
  • Programming Healthcare Silos

    1. Vaibhav, Health Solutions Group)<br />across<br />Programming Healthcare Silos<br />^<br />?<br />@vaibhavb#oscon #silostalk<br />
    2. Agenda<br />Challenges of Health IT<br />Standards exist but..<br />Open Solutions Exist<br />Opportunities in Health IT<br />
    3. Silos of Health Information<br />
    4. Silos in the Enterprise – “On the Floor” <br />Electronic Medical Record<br />Nursing Workflow/ Documentation<br />Clinical Notes<br />Emergency Department<br />Procedure Documentation<br />ICU/Critical Care<br />OR Management<br />Dictation<br />Pharmacy<br />CPOE<br />Advanced Analytics<br />Cardiology<br />Labs<br />Medication Administration<br />Hemodynamics<br />Pathology<br />Imaging<br />Charting<br />Medication Dispensing<br />RIS<br />Orders<br />Image Distribution<br />PACS<br />Mobile Data<br />
    5. Silos in the Enterprise – “Behind the Scenes”<br />Contract Management<br />Enterprise Scheduling<br />Claims Management<br />Financial/ERP<br />Business Decision Support<br />Inventory<br />Medical Records Coding<br />Purchasing<br />Revenue Management<br />Document Imaging<br />Bed Management<br />Registration<br />Transcription<br />Call Management<br />Staff/Nurse Scheduling<br />Outcomes Management<br />Physician Practice<br />Access Management<br />
    6. Meaningful Use<br />ICD-9 to ICD-10 Translation<br />SNOMED-CT<br />Master Patient Index<br />EMR/EHR<br />IHE<br />HL7<br />
    7. Meet Jim<br />
    8. Jim’s ER visit..<br />
    9. Lab<br />Emergency <br />EMR<br />HL7 Lab Order<br />MSH|^~&|EMERGENCYEMR|RC90|INSIGHT.LAB|GUH.ER|20080114085834||ORU^R01|H20010816374944.7274|P|2.1|1<br />PID|01||1430043|1572c552-f02b-49bf-b7e2-acc74765cb3e|SMITH^JIM||19790127|F||1||||||||cfd9ce6b-dc81-459d-9415-7913eb4635ec|804171277<br />PV1|01|O|TPC||||331|||||||HIS|||331|O||||||||||||||||||||||||||20060721|19990921<br />OBR|1||1234^LAB|88304<br />
    10. Lab<br />Emergency <br />EMR<br />Lab Result<br />MSH|^~&|EMERGENCYEMR|RC90|INSIGHT.LAB|GUH.ER|20080114085834||ORU^R01|H20010816374944.7274|P|2.1|1<br />PID|01||1430043|1572c552-f02b-49bf-b7e2-acc74765cb3e|SMITH^JIM||19790127|F||1||||||||cfd9ce6b-dc81-459d-9415-7913eb4635ec|804171277<br />PV1|01|O|TPC||||331|||||||HIS|||331|O||||||||||||||||||||||||||20060721|19990921<br />OBR|1||1234^LAB|88304<br />OBX|1|CE|88304|1|T57000^GALLBLADDER^SNM OBX|2|TX|88304&MDT|1|MICROSCOPIC EXAM SHOWS HISTOLOGICALLY NORMAL GALLBLADDER TISSUE<br />
    11. Creating & Processing Lab Order<br />HAPI HL7 Parsing Library <br /><br />
    12. X12 Message for Eligibility Request<br />ST*270*1234*005010X203~<br />BHT*0022*13*10001234*20060501*1319~<br />HL*1**20*1~<br />NM1*PR*2*ABC COMPANY*****PI*842610001~<br />HL*2*1*21*1~<br />NM1*1P*2*EMERGENCY CLINIC*****SV*2000035~<br />HL*3*2*22*0~<br />TRN*1*93175-012547*9877281234~<br />NM1*IL*1*SMITH*JIM****MI*11122333301~<br />DMG*D8*19430519~<br />DTP*291*D8*20060501~<br />EQ*30~<br />SE*13*1234~<br />Lab<br />Emergency <br />EMR<br />Health Plan<br />
    13. X12 Response for Eligibility Request<br />ST*271*1234*005010X203~<br />BHT*0022*13*10001234*20060501*1319~<br />HL*1**20*1~<br />NM1*PR*2*ABC COMPANY*****PI*842610001~<br />HL*2*1*21*1~<br />NM1*1P*2*EMERGENCY CLINIC*****SV*2000035~<br />HL*3*2*22*0~<br />TRN*1*93175-012547*9877281234~<br />NM1*IL*1*SMITH*JIM****MI*11122333301~<br />DMG*D8*19430519~<br />DTP*346*D8*20060101~<br />EB*1**30**GOLD 123PLAN~<br />…<br />Lab<br />Emergency <br />EMR<br />Health Plan<br />
    14. Jim’s Ready to Go Home<br />Lab<br />Emergency <br />EMR<br />Health Plan<br />
    15. CCR For Jim’s Visit<br />Lab<br />Emergency <br />EMR<br />Health Plan<br />
    16. CCD or C32<br />
    17. HealthVault Interaction<br />
    18. Direct To Clinical<br />
    19. Data In Jim’s Account<br />Jim<br />Lab<br />Emergency <br />EMR<br />Health Plan<br />Jim<br />
    20. NHIN-D<br />@ HealthVault address<br /> Easy integration through SMTP S-MIME<br />Exciting Future<br />
    21. HealthVault Medical Imaging<br /><ul><li>Applications can upload large files to a users’ HealthVault record
    22.</li></li></ul><li>HealthVault Client & Mobile Applications<br />Client Applications<br /><br />
    23. Leaving the Clinical Silo<br />Clinical Silo<br />While in enterprise your application need to comply with HIPAA 5010<br />When Jim log’s in to HealthVault then the data is flowing in to consumer domain<br />Lab<br />Emergency <br />EMR<br />Health Plan<br />
    24. HealthVault Open Source Resources<br />Community Promise<br />Open Source SDKs<br />Java : CodePlex<br />Ruby : RubyForge<br />Python : Google Code<br />PHP: SourceForge<br />Reference License .NET SDK<br /> <br />
    25. Connected Health Platform Open Source Resources<br />Microsoft Health Common User Interface (MSCUI)<br /><ul><li>Microsoft Public License (MS-PL):
    26. Main site:
    27. Toolkit:</li></ul>IHE Cross-Enterprise Document Sharing XDS.b <br /><ul><li>Microsoft Public License (MS-PL):
    28. Main site:
    29. Toolkit:</li></ul>Clinical Documentation Solution Accelerator (CDSA) <br /><ul><li>Reference License for CDSA Toolkit:
    30. Main site:
    31. Toolkit:</li></li></ul><li>Takeaway<br />Lots of opportunity to bridge the silos and empower the patient with open technologies and platforms!<br />
    32. Thank You<br />Be Well. Be Protected.<br />?<br /><br />@vaibhavb#oscon #silostalk<br />