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With Great Data
Comes Great Health
Michelle Brush
Director, HealtheIntent Architecture
Cerner Corporation
(I am not a doctor.)
I had an encounter.
It triggered a claim.
Encounters are the
bread and butter of the
healthcare system.
”pay for procedure”
We pay a lot.
$10,348
per person
$1 out of every $6
is spent on healthcare.
$3.3 trillion total
$672.1 billion in Medicare
$565.5 billion in Medicaid
$3.3 trillion total
1 trillion is hospital expenditures
I have a condition.
I broke 3 ribs.
They performed a procedure.
A practitioner made observations.
She prescribed medications.
I paid for…
the tests (observation)
the visits (encounter),
the shots (procedure),
the medications (just medication)
the tests (observation)
the visits (encounter),
the shots (procedure),
the medications (just medication)
private
personal
valuable
data-driven
HITECH2009 Health Information Technology
for Economic and Clinical Health
(I am not a lawyer.)
observation
practitioner
medication
procedure
claim
condition
2008 2009 2010 2011 2012 2013 2014 2015
9.4%
83.8%
Adoption of Electronic Health Record Systems
among U.S. Non-Federal Acute Care Hospitals:
2008-2015
ONC Data Brief 35 | May, 2016
Congressional mandate
does drive modernization.
1.Get data into computers.
2.???
3.Profit!
medication reconciliation
drug interaction checks
physician order entry
finger pointing
What do we do now?
black hole
observation
practitioner
medication
condition
procedure
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
demographic
observation
procedure
medication
condition
claim
Encounters are the
bread and butter of the
healthcare system.
pay when you
encounter the
healthcare system
”pay for procedure”
You have to be sick before
someone can care.
44 million
Americans go in for
annual physical exams.
It costs us, $10 billion a year.
proactive, not reactive
I broke 3 ribs.
proactive, not reactive
• My runs were getting shorter.
• I stopped taking the stairs.
• I was getting less oxygen.
• I was having trouble sleeping.
• I went to the clinic 5 times for
a cough.
Early Warning Signs of
Asthma
• Frequent cough, especially at night
• Losing your breath easily or shortness of breath
• Feeling very tired or weak when exercising
• Wheezing or coughing after exercise
• Feeling tired, easily upset, grouchy, or moody
• Decreases or changes in lung function as measured on
a peak flow meter
• Signs of a cold or allergies (sneezing, runny nose, cough,
nasal congestion, sore throat, and headache)
• Trouble sleeping
WebMD, https://www.webmd.com/asthma/guide/asthma-symptoms#1
(I am not a doctor.)
proactive, not reactive
• My runs were getting shorter.
• I stopped taking the stairs.
• I was getting less oxygen.
• I was having trouble sleeping.
• I went to the clinic 5 times for
a cough.
What if instead of
paying for procedures,
we paid for health?
HITECH2009 Health Information Technology
for Economic and Clinical Health
(I am not a lawyer.)
observation
practitioner
medication
procedure
claim
condition
Meaningful Use2009 Health Information Technology
for Economic and Clinical Health
Meaningful Usethe reason you get asked to sign into
patient portals all the time
MACRAMedicare Access and CHIP
Reauthorization Act of 2015
(I am not a lawyer.)
MIPSMerit-Based
Incentive Payment
(I am not the CMS.)
Financial incentives for meeting
Quality Measures
patient engagement
remote patient monitoring
device data
Like smartversions of these….
Like the ones made by Garmin…
But we need more than just
smart devices.
We need data coming
in, and we need to
see value coming out.
healthcare
interoperability
consistent way of talking to each other
Fast
Healthcare
Interoperability
Resources
FHIRis a standard for sharing
healthcare information via RESTful web
services.
observation
practitioner
medication
procedure
claim
condition
observation
practitioner
medication
procedure
claim
Fast
Healthcare
Interoperability
Resources
condition
Yes, it is pronounced “fire.”
It allows for all sorts of puns.
”This system is On FHIR!”
”Jenni is our goddess of FHIR.”
“Debugging services is FHIR fighting?”
I apologize for the
momentary
divergence from
theme, but I just
had to share this.
(I am not a firefighter.)
Let’s get technical.
(I am an engineer.)
Alphabetical
A-D:
•AllergyIntolerance
•Appointment
•AppointmentResponse
•AuditEvent
•Basic
•Binary
•BodySite
•Bundle
•CarePlan
•Claim
•ClaimResponse
•ClinicalImpression
•Communication
•CommunicationRequest
•Composition
•ConceptMap
•Condition (aka Problem)
•Conformance
•Contract
•Contraindication
•Coverage
•DataElement
•Device
D-L:
•DeviceComponent
•DeviceMetric
•DeviceUseRequest
•DeviceUseStatement
•DiagnosticOrder
•DiagnosticReport
•DocumentManifest
•DocumentReference
•EligibilityRequest
•EligibilityResponse
•Encounter
•EnrollmentRequest
•EnrollmentResponse
•EpisodeOfCare
•ExplanationOfBenefit
•FamilyMemberHistory
•Flag
•Goal
•Group
•HealthcareService
•ImagingObjectSelection
•ImagingStudy
•Immunization
I-P:
•ImmunizationRecommen
dation
•List
•Location
•Media
•Medication
•MedicationAdministration
•MedicationDispense
•MedicationPrescription
•MedicationStatement
•MessageHeader
•NamingSystem
•NutritionOrder
•Observation
•OperationDefinition
•OperationOutcome
•Order
•OrderResponse
•Organization
•Patient
•PaymentNotice
•PaymentReconciliation
•Person
P-Z:
•Practitioner
•Procedure
•ProcessRequest
•ProcessResponse
•ProcedureRequest
•Provenance
•Questionnaire
•QuestionnaireAnswers
•ReferralRequest
•RelatedPerson
•RiskAssessment
•Schedule
•SearchParameter
•Slot
•Specimen
•StructureDefinition
•Subscription
•Substance
•Supply
•ValueSet
•VisionPrescription
{
"resourceType" : "Practitioner",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // A identifier for the person as this agent
"active" : <boolean>, // Whether this practitioner's record is in active use
"name" : [{ HumanName }], // The name(s) associated with the practitioner
"telecom" : [{ ContactPoint }], // A contact detail for the practitioner (that apply to all roles)
"address" : [{ Address }], // Address(es) of the practitioner that are not role specific (typically home address)
"gender" : "<code>", // male | female | other | unknown
"birthDate" : "<date>", // The date on which the practitioner was born
"photo" : [{ Attachment }], // Image of the person
"qualification" : [{ // Qualifications obtained by training and certification
"identifier" : [{ Identifier }], // An identifier for this qualification for the practitioner
"code" : { CodeableConcept }, // R! Coded representation of the qualification
"period" : { Period }, // Period during which the qualification is valid
"issuer" : { Reference(Organization) } // Organization that regulates and issues the qualification
}],
"communication" : [{ CodeableConcept }] // A language the practitioner is able to use in patient communication
}
practitioner
{
"resourceType" : "Observation",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // Business Identifier for observation
"basedOn" : [{ Reference(CarePlan|DeviceRequest|ImmunizationRecommendation|
MedicationRequest|NutritionOrder|ProcedureRequest|ReferralRequest) }], // Fulfills plan, proposal or order
"status" : "<code>", // R! registered | preliminary | final | amended +
"category" : [{ CodeableConcept }], // Classification of type of observation
"code" : { CodeableConcept }, // R! Type of observation (code / type)
"subject" : { Reference(Patient|Group|Device|Location) }, // Who and/or what this is about
"context" : { Reference(Encounter|EpisodeOfCare) }, // Healthcare event during which this observation is made
// effective[x]: Clinically relevant time/time-period for observation. One of these 2:
"effectiveDateTime" : "<dateTime>",
"effectivePeriod" : { Period },
"issued" : "<instant>", // Date/Time this was made available
"performer" : [{ Reference(Practitioner|Organization|Patient|RelatedPerson) }], // Who is responsible for the observation
// value[x]: Actual result. One of these 11:
"valueQuantity" : { Quantity },
"valueCodeableConcept" : { CodeableConcept },
"valueString" : "<string>",
"valueBoolean" : <boolean>,
"valueRange" : { Range },
observation
http://www.hl7.org/FHIR/
• JSON
• Example usage
• Supported terminologies
Organizations choose to implement FHIR.
57 have expressed interest in FHIR.
https://code.cerner.com
• Documentation
• Learning labs
• Supported resources
+( )+
data from smart devices FHIR services
= get data to the practitioner
+( )+
data from smart devices FHIR services
= Remote Patient Monitoring
+( )+
data from smart devices FHIR services
observations
+( ) observations
Activity Data:
“Is the patient becoming less mobile over time?”
+( ) observations
Sleep Data:
“Is the patient having trouble sleeping?”
+( ) observations
Heart Rate Data:
“Do we see a decline in your cardiovascular health?”
Do we know what
to look for?
My dad had been living with
heart failure for over a
decade.
(I am not a doctor.)
In 2012, he started fainting
at weird times.
In 2012, his blood pressure
kept dropping.
They thought it was his
heart.
It was his blood.
Septic Shock
If you hear hoof
beats, thinks horses,
not zebras.
Sepsis is a zebra.
The CDC estimates
sepsis affects
1.5 million people
annually.
Intervention within 3-6
hours improves the
chance of survival
significantly.
With my dad, it was
3 days.
Cerner’s St. John
Sepsis Agent
observation
practitioner
medication
procedure
claim
condition
observation
practitioner
medication
procedure
claim
condition
observations
execute evidence-based
rules in near real-time
identify patients at risk for
sepsis
gather
observations
execute evidence-based
rules in near real-time
identify patients at risk
gather
Evidence-based
healthcare rules are
programmatically expressed in a
language called Clojure, and
evaluated via a rules engine
called Clara.
Pattern
How do we detect the
real zebras?
400
350
300
250
200
150
100
50
0
1950 1980 2010 2020
73 daysThe time it will take the world’s
medical knowledge to double by
2020.
What if we could bring
together the world’s
healthcare data?
EMR + Device insurance coverage
and payments
social determinants
of health clinical
documents
fitness center
activity
genomic data
family history
employee
absenteeism
build a full picture of
a person’s health
80,000,000
people in all
7 petabytes
of data in all
HealtheIntentSM
Michelle Brush
Director HealtheIntent Architecture
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
Let’s talk about big data.
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
Let’s talk about big data.
Imagine the work a computer
does is analogous to a horse
pulling a wagon.
If you have a really big load,
you can’t make a bigger
horse.
You have to hitch up
multiple horses.
It used to be that if you had a
lot of data, you’d buy a
bigger computer.
But like horses, computers
still have physical limits.
Big datais when you
have so much data, you have
to have more than one
computer to deal with it.
1800computers
Hadoop
Kafka Storm
Spark
HBase
Jupyter
JupyterMySQL
Oozie
Solr
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
A rose allergy is a
rose allergy is a
rose allergy.
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
A patient by any
other name...
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
This patient is at risk.
This patient is not.
”pay for procedure”
Alternative
Pay
Models
”pay for risk reduction”
This practitioner
follows best
practices.
”pay for quality of care”
normalize
standardize
match
aggregate
calculate
stratify
discover
analyze
search
proactive, not reactive
(somewhat)
Appointments
8:00
8:30
9:00
10:00
10:30
11:00
11:30
12:00
12:30
1:00
1:30
2:00 2
2:30
3:00
3:30
A doctor will see roughly
18patients a day.
They will spend roughly
14minutes with each of them.
What can we learn
from the data?
data science &
machine learning
heart failure
juvenile diabetes
pediatric asthma
medication adherence
heart failure
juvenile diabetes
pediatric asthma
medication adherence
heart failure
juvenile diabetes
pediatric asthma
medication adherence
12%of patients don’t fill their
prescriptions.
Another 12%doesn’t take them.
73 daysThe time it will take the world’s
medical knowledge to double by
2020.
How do we keep up?
We give it to
the machines.
This will be a big
adjustment.
Practitioners
and patients
value cogency.
We’re on the
cusp.
There are some
bugs to work
out.
We want to detect
the issue before
you’ve encountered
the health system.
Use the data to
reach the patient
where they are.
behavior
change
5%of the population uses
50% of healthcare
dollars spent
stroke
heart disease
type 2 diabetes
obesity
cancer
arthritis
Your zip code says more
about your health than
your genetic code.
50%of adults do not
get enough aerobic
physical activity.
90%of adults ingest
too much sodium.
40%of adults
don’t eat fruit.
17%of adults
regularly engage in
binge drinking.
behavior
change
change
habits
behavioral
economics
trigger
action
reward
The Power of Habit
by Charles Duhigg
trigger
Work is stressful.
I hit happy hour with friends.
Alcohol calms me.action
reward
trigger
I’m bored.
I watch a movie and eat popcorn.
My brain is happy.action
reward
trigger
I’m bored.
I hit the gym.
My brain is happy.action
reward
Change the cycle.
trigger
Work is stressful.
I meditate after work
Meditation calms me.action
reward
Change the cycle.
trigger
I see I’m not active.
I stand or walk for a bit.
My device rewards me.action
reward
Create new cycles
trigger
I see my heart rate is high.
Meditate
I see my heart rate go down.action
reward
Create new triggers
trigger
I see I’m sitting too long.
Get up and move.
My digital pet is happy.action
reward
Create new triggers
My Day 24
ActiFace
Step Monkey
Meditate
Heart Alarm
NightscoutWatch
Eat! Drink! Reminder!
Steptris
closed loop intelligence
Reach people
where they are.
Do we have an
obligation to reach the
audience?
Reach people
who they are.
Do we have an
obligation to craft an
actionable story?
(My mom thinks
I’m the family
doctor.)
I’ve told a few
personal stories.
Healthcare,
it’s personal.
HIPAAHealth Insurance Portability and
Accountability Act of 1996
(I am not a lawyer.)
I’ve got one
more personal
story.
People own their
own health data.
With Great Data
Comes Great Health
(I am not a doctor.)
I do believe this.
With Great Data
Comes Great Health
(I am not a doctor.)
ὄμνυμι Ἀπόλλωνα ἰητρὸν καὶ Ἀσκληπιὸν καὶ Ὑγείαν καὶ Πανάκειαν καὶ θεοὺς πάντας τε καὶ πάσας, ἵστορας
ποιεύμενος, ἐπιτελέα ποιήσειν κατὰ δύναμιν καὶ κρίσιν ἐμὴν ὅρκον τόνδε καὶσυγγραφὴν τήνδε:
ἡγήσεσθαι μὲν τὸν διδάξαντά με τὴν τέχνην ταύτην ἴσα γενέτῃσιν ἐμοῖς, καὶ βίου κοινώσεσθαι, καὶ χρεῶν
χρηΐζοντι μετάδοσιν ποιήσεσθαι, καὶ γένος τὸ ἐξ αὐτοῦ ἀδελφοῖς ἴσον ἐπικρινεῖν ἄρρεσι, καὶ διδάξειν τὴν
τέχνην ταύτην, ἢν χρηΐζωσι μανθάνειν, ἄνευ μισθοῦ καὶ συγγραφῆς, παραγγελίης τε καὶ ἀκροήσιος καὶ τῆς
λοίπης ἁπάσης μαθήσιος μετάδοσιν ποιήσεσθαι υἱοῖς τε ἐμοῖς καὶ τοῖς τοῦ ἐμὲ διδάξαντος, καὶ μαθητῇσι
συγγεγραμμένοις τε καὶ ὡρκισμένοις νόμῳ ἰητρικῷ, ἄλλῳ δὲ οὐδενί.
διαιτήμασί τε χρήσομαι ἐπ᾽ ὠφελείῃ καμνόντων κατὰ δύναμιν καὶ κρίσιν ἐμήν, ἐπὶ δηλήσει δὲ καὶ ἀδικίῃ
εἴρξειν.
οὐ δώσω δὲ οὐδὲ φάρμακον οὐδενὶ αἰτηθεὶς θανάσιμον, οὐδὲ ὑφηγήσομαι συμβουλίην τοιήνδε: ὁμοίως
δὲ οὐδὲ γυναικὶ πεσσὸν φθόριον δώσω.
ἁγνῶς δὲ καὶ ὁσίως διατηρήσω βίοντὸν ἐμὸν καὶ τέχνην τὴν ἐμήν.
οὐ τεμέω δὲ οὐδὲ μὴν λιθιῶντας, ἐκχωρήσω δὲ ἐργάτῃσιν ἀνδράσι πρήξιος τῆσδε.
ἐς οἰκίας δὲ ὁκόσας ἂν ἐσίω, ἐσελεύσομαι ἐπ᾽ ὠφελείῃ καμνόντων, ἐκτὸς ἐὼν πάσης ἀδικίης ἑκουσίης καὶ
φθορίης, τῆς τε ἄλλης καὶ ἀφροδισίων ἔργων ἐπί τε γυναικείων σωμάτων καὶ ἀνδρῴων, ἐλευθέρων τε καὶ
δούλων.
ἃ δ᾽ ἂν ἐνθεραπείῃ ἴδω ἢ ἀκούσω, ἢ καὶ ἄνευ θεραπείης κατὰ βίον ἀνθρώπων, ἃ μὴ χρή ποτε ἐκλαλεῖσθαι
ἔξω, σιγήσομαι, ἄρρητα ἡγεύμενος εἶναι τὰ τοιαῦτα.
ὅρκον μὲν οὖν μοι τόνδε ἐπιτελέα ποιέοντι, καὶ μὴ συγχέοντι, εἴη ἐπαύρασθαι καὶ βίου καὶ τέχνης
δοξαζομένῳ παρὰ πᾶσιν ἀνθρώποις ἐς τὸν αἰεὶ χρόνον: παραβαίνοντι δὲ καὶ ἐπιορκέοντι, τἀναντία
τούτων.
With Great Power
Comes Great Responsibility
Take care.
Thank you,
Michelle Brush
@michellebrush

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With Great Data Comes Great Health

Editor's Notes

  1. Centers for Medicare and Medicaid Services
  2. Digital signature, legal records
  3. $227 a pop?
  4. Symptoms of Sepsis are things like… heart rate higher than 90 beats per minute breathing rate higher than 20 breaths per minute problems breathing abnormal heart functions extreme weakness Low blood pressure
  5. It is estimated that the doubling time of medical knowledge in 1950 was 50 years; in 1980, 7 years; and in 2010, 3.5 years. In 2020 it is projected to be 0.2 years—just 73 days. 
  6. From the tiny bits of data coming from home devices,
  7. From the tiny bits of data coming from home devices,
  8. From the tiny bits of data coming from home devices,
  9. From the tiny bits of data coming from home devices,
  10. From the tiny bits of data coming from home devices,
  11. Heart failure, but only if you’ve already had a MRI or an echocardiogram. UTI, but only if you’ve visited a certain lab within the clinic.
  12. ROBERT CALIFF Duke University