An opinionated look at why current health IT systems integrate poorly and how it’s a big opportunity for the OSEHRA Community  Topics Covered: * An overview of VA, VHA, VistA, and OSEHRA * The macro healthcare environment and why OSEHRA is am important participant * What’s needed by the industry that OSEHRA can provide 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
healthcare IT ISVs and system integrators
An opinionated look at why current health IT systems
integrate poorly and how it’s a big opportunity for
the OSEHRA Community

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
•
•
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An overview of VA, VHA, VistA, and
OSEHRA
The macro healthcare environment
and why OSEHRA is am important
participant
What’s needed by the industry that
OSEHRA can provide
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
VHA’s VistA is a successful EHR
General Facts
•
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VistA development started 25 years ago by
Department of Veterans Affairs to automate
their medical facilities
They named it DHCP (Decentralized Hospital
Computer Program), VISTA (Veterans Health
Information Systems and Technology
Architecture) and the suite consisted of over
168+ hospital Applications on top of the
Framework
VistA is not an all or nothing proposition.
Very large collection of applications and only
a portion of it may be relevant to the need
at hand
www.netspective.com
General Statistics
•
•
Provides care to more than 5 million
veterans per year
Diverse care settings, complete EHR
utilization in all facilities:
– 153 medical centers
– 745 outpatient clinics
– Many long-term care and homebased programs
•
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More than 7.8 million enrollees
The Veterans Health Administration (VHA)
has affiliations with 107 academic health
systems
Trains over 90,000 individuals annually in
numerous clinical disciplines
4

5. NETSPECTIVE
VistA Use Through 12/08
•
•
•
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Documents (Progress Notes, Discharge Summaries, Reports)
– +1.2 Billion…….. +760,000 each workday
Orders
– +2.0 Billion…….... +1,046,000 each workday
Images
– +1.0 Million……… +1,336,000 each workday
Vital Sign Measurements
– +1.4 Billion……… +811,000 each workday
Medications Administered with the Bar Code Medication Administration (BCMA) system
– +1.1 Billion……… +620,000 each workday
www.netspective.com
5

6. NETSPECTIVE
VistA Foundation & Frameworks
•
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M Technology – The M Language and Database
File Manager – Active Data Dictionary based
Database Management written in M
Kernel - Application framework, based on M and
File Manager, providing services such as menus,
device selection, background task scheduling,
MailMan (SMTP based), KIDS (powerful distribution
mechanism) etc
Applications - End-user software. VISTA supports
the development of these applications by providing
a framework of Kernel, Fileman and M (MUMPS)
Universal SQL access to VISTA Databases
M code is not compiled or linked: Thus allowing
incredible degree of integration between
applications
www.netspective.com
Source: http://www.hardhats.org/dhcptovista.html
6

7. NETSPECTIVE
What is OSEHRA?
• Open Source Electronic Health Record Agent(OSEHRA) supports
open, collaborative community of users, developers, and
companies engaged in advancing electronic health record
software and health information technology
• Formed in Sept. 2011 to unify the EHRs of DVA and DOD and take
advantage of the Open Source Communities
• OSEHRA’s responsibility is to facilitate the rapid rate of innovation
and improvements of VistA using open source community
• Provides framework for architectural direction, certification and
Testing of the Applications
www.netspective.com
7

8. 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
8

9. 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 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 system integration business
or existing ones can augment
their products / services to
include OSEHRA capabilities
New revenue centers in existing
or new businesses can take
common certification criteria and
build tools around it for
automated testing,
documentation preparation, etc.
9

10. The macro environment

11. NETSPECTIVE
The realities of patient populations
Prevention
•
Education
•
Health Promotions
•
Healthy Lifestyle Choices
•
Health Risk Assessment
Management
•
•
Obesity Management
Wellness Management
•
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•
•
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Assessment – HRA
Stratification
Dietary
Physical Activity
Physician Coordination
Social Network
Behavior Modification
•
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Diabetes
COPD
CHF
•
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Stratification & Enrollment
Disease Management
Care Coordination
MD Pay-for-Performance
Patient Coaching
•
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Physicians Office
Hospital
Other sites
Pharmacology
•
Catastrophic Case
Management
Utilization Management
Care Coordination
Co-morbidities
•
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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
11

12. 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.
12

13. 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
13

14. 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
14

15. 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”
15

16. 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
16

17. 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
17

18. 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
18

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

20. NETSPECTIVE
Why you can’t just “buy integration”
Myth
Truth
• 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
• 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
www.netspective.com
20

21. 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
21

22. 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
22

23. 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.)
23

24. NETSPECTIVE
Value-adds to clinical users
The conceptual ROI for OSEHRA activities
More
functionality
Faster delivery
Interoperability
www.netspective.com
Better
integration
Free EHR
24

25. 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
25

26. NETSPECTIVE
Needed: Reimagined User Interactions
Data visualization requires integration and aggregation
What’s being offered to users
www.netspective.com
What users really want
26

27. 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
27

28. NETSPECTIVE
Needed: diagnostic quality mHealth
www.netspective.com
28

29. NETSPECTIVE
Needed: predictive analytics
www.netspective.com
29

30. 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
30

31. NETSPECTIVE
Needed: automated diagnostics
www.netspective.com
31

32. How do we modernize integration?

33. NETSPECTIVE
Why health IT systems integrate poorly
Technology “Culture”
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Permissions-oriented culture prevents
tinkering and “hacking”
We don’t let patients drive data
decisions.
No scripting or customizing EHRs, lab
systems, etc.
Interoperability isn’t required for
transactions to be completed (ecommerce)
We have “Inside out” architecture, not
“Outside in”
www.netspective.com
Actual Technology
•
•
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We don't support shared identities,
single sign on (SSO), and industryneutral authentication and
authorization
We're too focused on "structured data
integration" instead of "practical app
integration“
We focus more on "pushing" versus
"pulling" data than is warranted early
in projects
We're too focused on heavyweight
industry-specific formats instead of
lightweight or micro formats
33

34. NETSPECTIVE
Promote “Outside-in” architecture
The IT department inside your organization cannot possibly do everything you’d like
Process and people consolidation won’t work in
the future
Defining and coordinating interactions across a
multitude of organizations is the new way
“For decades, businesses typically have been
rewarded for consolidation around standard
processes and stockpiling assets through
people, technology and goods.
Companies are discovering they need a new
kind of leverage – capability leverage – to
mobilize third parties that can add value.”
• Outside-in architecture asks you to think
about your operations and processes as
a collection of business capabilities or
services.
• Each individual service must be analyzed
and packaged to see who can deliver
them best. According to Deloitte, “this
architectural transition requires new skills
from the CIO and the IT organization.
CIOs who anticipate and understand the
opportunity are likely to become much
more effective business partners with
other executive leaders.”
Source: Deloitte “Outside-in Architecture”
www.netspective.com
34

35. 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
.
35

36. 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.
www.netspective.com
36

37. 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 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.
www.netspective.com
37

38. 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.
Microsoft Excel & Access, Google
Docs, etc. don’t have live access to
our data in transactional systems
such as EHRs.
•
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.
38

39. 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
39

40. 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
40

41. 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
41

42. 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
42

43. 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
43

44. 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
44

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