OSEHRA Summit Highlights Health IT Opportunities

OSEHRA is a great business
opportunity for health IT vendors
and system integrators
3rd Annual OSEHRA Summit
Shahid N. Shah
Chairman of OSEHRA Advisory Board

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)
Author of Chapter 13, “You’re
the CIO of your Own Office”
www.netspective.com 2

NETSPECTIVE
What’s this talk about?
Background
• Is disruptive innovation in healthcare
possible?
• What does innovation in healthcare
mean and how do you help
customers make it happen?
• EHRs are not the center of the
healthcare data ecosystem.
Key takeaways
• OSEHRA is major business
opportunity for ISVs and systems
integrators
• OSS can satisfy most needs.
There’s nothing special about
health IT data that justifies
complex, expensive, or special
technology.

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 Community
VistA EHR Code
Facility 1 Facility 2 …
Data 1
Data 2 …
Convergence, Refactoring
OSEHRA Core
Free or Commercial
Contributed Core
2013
OSEHRA Add-ons Contributed Add-ons
IV&V (Test, Docs)
Certify
OSEHRA Deployment
Contributed Tests/Docs
2011
2013
Commercial Deployments
Delivery Coordination Innovation

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
New system integration
business or existing ones
can augment their products
/ services to include
OSEHRA capabilities

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
New revenue centers in existing
or new businesses can take
common certification criteria and
build tools around it for
automated testing,
documentation preparation, etc.

NETSPECTIVE
What does “disrupting healthcare” mean?
This is $1 Trillion and the
Healthcare Market is about
$3 Trillion
This is $1 Billion

No, your innovation will not
disrupt healthcare.
I promise.
The good news
is that doesn’t
have to.

No, your big data or mobile ideas
will not disrupt healthcare.
But if you can use them to add or extract value
from the existing system, you’ll do just fine.

No, your EHR/PHR or app will not
be used by enough doctors or
patients to disrupt healthcare.
But if you can get even a fraction of them
to use your software, you’ll do just fine.

No, your innovation will not be
accepted by permissions-oriented
institutions.
Find customers with a problem-solving culture
willing to accept risks and reward failures.

No, your innovation will not be
easily integrated into regulated
device-focused clinical workflows.
Incumbent vendors will not entertain the potential of
new legal liabilities without someone to share it with or
new competition without direct compensation.

NETSPECTIVE
What I mean by “actionable innovation”
You can help your customers achieve practical, relevant, actionable solutions
You have made the job of
identifying, diagnosing,
treating, or curing
diseases faster, better, or
cheaper for clinicians
through the use of
information technology
(IT) or business models.
You have made the job of
self-diagnosing, self-treating,
or preventing
diseases and improving
overall wellness of
patients through the use
of new incentives,
business models, or IT.

NETSPECTIVE
Shift from Fees for Service (FFS) to Value (FFV)
The Shift
The clinical model is shifting
away from treatment of
chronic conditions and
focusing more on prevention,
wellness, obesity intervention,
behavior and lifestyle
modification.
Implications
Clinical operations are shifting to hospital and
physician ‘centered’ services that will rely heavily
on health information technologies to monitor,
coordinate, and manage care.
• Successful Transition in Care resulting in
Reduced Hospital Readmission Rates
• Proactive population management
• Patient engagement and collaboration
• Disease prevention through wellness and
obesity management
• Chronic disease management
• Care coordination and collaboration
• Metrics and analytics

NETSPECTIVE
The realities of patient populations
Prevention Management
• Obesity Management
• Wellness Management
• Assessment – HRA
• Stratification
• Dietary
• Physical Activity
• Physician Coordination
• Social Network
• Behavior Modification
• Education
• Health Promotions
• Healthy Lifestyle Choices
• Health Risk Assessment
• 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
4 % of Medical Costs
35 % of Population
35 % of Population
4% of Population
Source: Amir Jafri, PrescribeWell

NETSPECTIVE
How Digital Health helps in shift
Successful Transitions of
Care
Reduced Hospital
Readmissions
Innovative Practice
Models like Patient
Centered Medical
Homes
Physician Marketing
Behavior adjustments
and modification
Prevention, Wellness,
Obesity intervention
Personalized
Concierge-Like
Medicine
Total Population
Management

NETSPECTIVE
How to best identify your customers
Help them stay away from market segmentation, focus on identifying PBU particpants
FFS vs. FFV?
Target health
sector?
Number of
employees?
Annual sales
volume?
Geography?
Number of
hospital beds?
Number of
patients?
Type of
patients?
The list goes on
and on…be
specific!
Identifying your
customers will depend
on helping your
customers identify theirs

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

NETSPECTIVE
How will your customers get paid for innovation?
If you haven’t figured it out for them, customers will not figure it out for themselves
Direct Payment
• Your best option
• Very few truly disruptive
technologies can be
directly paid for by
providers within the USA
• Limited adoption of
‘traditional’ pay for service
reimbursement for next
generation technology
Direct Reimbursement
• Second best option
• Improvements in
technology are outpacing
payer adoption
• Reimbursement will come
but its time consuming and
difficult
Indirect Reimbursement
• Emerging option
• Payer requirements for
improved quality and
efficiency are creating
indirect incentives to adopt
innovative solutions
• Solutions targeting new
value-based
reimbursement incentives
are highly useful to medical
providers

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

NETSPECTIVE
Data is getting more sophisticated
Proteomics
Emerging
•Must be continuously collected
•Difficult today, easier tomorrow
•Super-personalized
• Prospective
• Predictive
Try to use existing data to create new diagnostics or therapeutic solutions
Genomics
Since 2000s,
started at $100k
per patient, <$1k
soon
Social Interactions
Biosensors
•Can be collected infrequently
•Personalized
• Prospective
•Potentially predictive
•Digital
•Family history is easy
Phenotypics
Since 1980s,
pennies per
patient
•Must be continuously collected
•Mostly Retrospective
•Useful for population health
• Part digital, mostly analog
•Family History is hard
Admin
Since 1970,
pennies per
patient
• Business focused data
•Retrospective
• Built on fee for service models
• Inward looking and not focused
on clinical benefits

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
“Affordable Care
Act”
ACO
“Accountable
Care Org”
PCMH
“Medical
Home”
MU
“Meaningful Use”
Health
Home
mHealth
PCPCC
“Patient Centered
Care”

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

NETSPECTIVE
The new world order
General
Wellness
Specific
Prevention
Self Service
Physiologics
Self Service
Monitoring
Self Service
Diagnostics
Care Team
Monitoring
Care Team
Diagnostics
Healthcare
Professional
Monitoring
Healthcare
Professional
Diagnostics
Hospital
Monitoring
Hospital
Diagnostics

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

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

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
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

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

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

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
RCM integration
Patient portal
integration
Interoperable with
existing systems (labs,
pharma, etc.)

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

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
Common identity
management
Platform to build on
(APIs, etc.)
Ability to build
mHealth apps on top
of OSEHRA

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

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

NETSPECTIVE
Needed: diagnostic quality mHealth

NETSPECTIVE
Needed: predictive analytics

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

NETSPECTIVE
Needed: automated diagnostics

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

How do we modernize integration?

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 industry-neutral
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
• 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

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/

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 permissions-oriented
culture now
prevents “playing” with
data and discovering
solutions

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.

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

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 industry-neutral
solutions are much better and
future proof.
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.

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
Many think that we shouldn’t integrate
until structured data at detailed machine-computable
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.
App-centric sharing is possible
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.

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)
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.
Better way to architect:
“What data can I publish safely?” (pull)
• 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’.

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
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.
Better way to architect:
Service-oriented databases on RDBMS/NoSQL
• Drive transactional ACID-based data
requirements to RDBMS and consider column-stores,
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-de-identification
of data to make it more useful
without further processing
• Design for decentralized sync’ing of data (e.g.
mobile, etc.) not centralized ETL

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/

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
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.
Consider industry-neutral protocols
• 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.

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
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.
Semantic markup and tagging is easy
• 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.

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
• 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.
Search engines are great integrators
• 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.

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
• 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.
Open source can save health IT
• 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.

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

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?

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

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

OSEHRA Summit Highlights Health IT Opportunities

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