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 www.netspective.com 2 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”

NETSPECTIVE www.netspective.com 3 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 www.netspective.com 4 VA, VHA, VistA, and OSEHRA Top-notch pedigree and a well funded buyer of innovation VHA OSEHRA Community VistA EHR Code Data 1 Facility 1 Facility 2 … Data 2 … OSEHRA Core IV&V (Test, Docs) Certify OSEHRA Add-ons Contributed Add-ons Contributed Core OSEHRA Deployment Contributed Tests/Docs Convergence, Refactoring 2011 2013 Free or Commercial 2013 Commercial Deployments VA FY2012 IT Spend: $3.1 B Innovation Coordination Delivery

NETSPECTIVE www.netspective.com 5 How OSEHRA makes the market bigger 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 Market generation and economic benefits

NETSPECTIVE www.netspective.com 6 How OSEHRA makes the market bigger 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. Market generation and economic benefits

NETSPECTIVE www.netspective.com 7 What does “disrupting healthcare” mean? This is $1 Trillion and the Healthcare Market is about $3 Trillion This is $1 Billion

www.netspective.com 8 No, your innovation will not disrupt healthcare. I promise. The good news is that doesn’t have to.

www.netspective.com 9 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.

www.netspective.com 10 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.

www.netspective.com 11 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.

www.netspective.com 12 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 www.netspective.com 13 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. What I mean by “actionable innovation” You can help your customers achieve practical, relevant, actionable solutions

The macro environment

NETSPECTIVE www.netspective.com 15 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 www.netspective.com 16 The realities of patient populations • 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 Prevention Management 26 % of Population 4 % of Medical Costs 35 % of Population 22 % of Medical Costs 35 % of Population 37 % of Medical Costs 4% of Population 36 % of Medical Costs Source: Amir Jafri, PrescribeWell

NETSPECTIVE www.netspective.com 17 How Digital Health helps in shift Successful Transitions of Care Reduced Hospital Readmissions Innovative Practice Models like Patient Centered Medical Homes Prevention, Wellness, Obesity intervention Behavior adjustments and modification Physician Marketing Personalized Concierge-Like Medicine Total Population Management

NETSPECTIVE www.netspective.com 18 How to best identify your customers 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! Help them stay away from market segmentation, focus on identifying PBU particpants Identifying your customers will depend on helping your customers identify theirs

NETSPECTIVE www.netspective.com 19 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 www.netspective.com 20 How will your customers get paid for innovation? 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 If you haven’t figured it out for them, customers will not figure it out for themselves

NETSPECTIVE www.netspective.com 21 Digitize biology Digitize chemistry Digitize physics Predict fundamental behaviors Digitize mathematics Digitize literature Digitize social behavior Predict human behavior We’re digitizing biology Last and past decades This and future decades Gigabytes and petabytes Petabytes and exabytes

NETSPECTIVE www.netspective.com 22 Data is getting more sophisticated Proteomics Emerging •Must be continuously collected •Difficult today, easier tomorrow •Super-personalized •Prospective •Predictive Genomics Since 2000s, started at $100k per patient, <$1k soon •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 Try to use existing data to create new diagnostics or therapeutic solutions Biosensors Social Interactions

NETSPECTIVE www.netspective.com 23 Healthcare industry / market trends PPACA “Affordable Care Act” ACO “Accountable Care Org” PCMH “Medical Home” MU “Meaningful Use” Health Home mHealth PCPCC “Patient Centered Care” 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

NETSPECTIVE www.netspective.com 24 Implications of healthcare trends PPACA ACO MU PCMH Health Home mHealth DATA Evidence Based Medicine Comparative Effectiveness Software Regulated IT and Systems Integration Services

NETSPECTIVE www.netspective.com 25 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 www.netspective.com 26 We’re in the integration age Source: Geoffrey Raines, MITRE We’re not in an app-driven future but an integration- driven future. He who integrates the best, wins.

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

NETSPECTIVE www.netspective.com 28 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 www.netspective.com 29 Application focus is biggest mistake Application-focused IT instead of Data-focused IT is causing business problems. Healthcare Provider Systems Clinical Apps Patient Apps Billing Apps Lab Apps Other Apps Partner Systems Silos of information exist across groups (duplication, little sharing) Poor data integration across application bases

NETSPECTIVE www.netspective.com 30 NCI App NEI App NHLBI App Healthcare Provider Systems Clinical Apps Patient Apps Billing Apps Lab Apps Other Apps Master Data Management, Entity Resolution, and Data Integration Partner Systems Improved integration by services that can communicate between applications The Strategy: Modernize Integration Need to get existing applications to share data through modern integration techniques

NETSPECTIVE www.netspective.com 31 Important needs of non-Gov clinical customers 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.) OSEHRA needs to get non-government clinical customers but there are important gaps

NETSPECTIVE www.netspective.com 32 Value-adds to clinical users More functionality Faster delivery Better integration Interoperability Free EHR The conceptual ROI for OSEHRA activities

NETSPECTIVE www.netspective.com 33 Important needs of engineering customers 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 OSEHRA needs to get non-government clinical customers but there are important gaps

NETSPECTIVE www.netspective.com 34 What’s being offered to users What users really want Needed: Reimagined User Interactions Data visualization requires integration and aggregation

NETSPECTIVE www.netspective.com 35 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 www.netspective.com 36 Needed: diagnostic quality mHealth

NETSPECTIVE www.netspective.com 37 Needed: predictive analytics

NETSPECTIVE www.netspective.com 38 Needed: care team involvement HEALTHCAR E PROVIDER PATIENT/ CONSUMER HOSPITAL FAMILY CAREGIVER ALTERNATE SITE OF CARE Care Team CALL CENTERS AND REMOTE SUPPORT

NETSPECTIVE www.netspective.com 39 Needed: automated diagnostics

www.netspective.com 40 Modern Microapps and Services Approach (Sample) Identity Manager LDAP Entity Services RDBMS Domain Services RDBMS Analytics SQL/Cube RDBMS Limited FK Constraints oData SQLV SQLV oData SQLV oAuth SAML oData LDIF Domain Services Widgets Entity Services CMS oData Micro Apps No Direct Table Access Separate Schemas No FK Constraints Bootstrap AngularJS Bootstrap AngularJS Backplane Reporting Apps Third Party Bootstrap Backplane RDFa HTML5 DA RDFa HTML5 Data Attrs RDFa HTML5 Data Attrs ETL Bootstrap Backplane Rich client only or tiny server frameworks (Mojo, Rack, etc.) XACML oData Search Service ElasticSearch iCal syslog Log/Monitor Service CalDAV Service Rules Service Doc/Blob Service oData Browser Accessible XMPP Service

How do we modernize integration?

NETSPECTIVE www.netspective.com 42 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 www.netspective.com 43 • 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 Don’t assume your EHR will manage your data The EHR can not be the center of the healthcare data ecosystem Why EHRs are not (yet) disruptive http://www.christenseninstitute.org/why-ehrs-are-not-yet-disruptive/

NETSPECTIVE www.netspective.com 44 • Clinicians usually go into medicine because they’re problem solvers • Today’s permissions- oriented culture now prevents “playing” with data and discovering solutions Encourage clinical “tinkering” and “hacking” It’s ok to not know the answer in advance

NETSPECTIVE www.netspective.com 45 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 www.netspective.com 46 Patients External HCPs HCP and Staff Evaluators Internal business users and HCPs IT Personnel Integration improves focus on the real customer Unsophisticated and less agile focus Sophisticated and more agile focus Inside-out focus Outside-in focus HCPs = healthcare providers

NETSPECTIVE www.netspective.com 47 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 . Implement industry-neutral ICAM Implement shared identities, single sign on (SSO), neutral authentication and authorization

NETSPECTIVE www.netspective.com 48 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. App-focused integration is better than nothing Structured data dogma gets in the way of faster decision support real solutions

NETSPECTIVE www.netspective.com 49 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’. Pushing data is more expensive than pulling it We focus more on "pushing" versus "pulling" data than is warranted early in projects

NETSPECTIVE www.netspective.com 50 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 Move to service-oriented (de-identifiable) data Don’t assume all your data has to go into a giant data warehouse

NETSPECTIVE www.netspective.com 51 Hard to secure data structures Easier to secure data structures An example of structuring data for analysis Preparing data is important http://www.ibm.com/developerworks/data/library/techarticle/dm-ind-ehr/

NETSPECTIVE www.netspective.com 52 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. Industry-specific formats aren’t always necessary Reliance on heavyweight industry-specific formats instead of lightweight micro formats is bad

NETSPECTIVE www.netspective.com 53 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. Tag all app data using semantic markup When data is not tagged using semantic markup, it's not securable or shareable by default

NETSPECTIVE www.netspective.com 54 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. Produce data in search-friendly manner Produce HTML, JavaScript and other data in a security- and integration-friendly approach

NETSPECTIVE www.netspective.com 55 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. Rely first on open source, then proprietary “Free” is not as important as open source, you should pay for software but require openness

www.netspective.com 56 Modern Microapps and Services Approach (Sample) Identity Manager LDAP Entity Services RDBMS Domain Services RDBMS Analytics SQL/Cube RDBMS Limited FK Constraints oData SQLV SQLV oData SQLV oAuth SAML oData LDIF Domain Services Widgets Entity Services CMS oData Micro Apps No Direct Table Access Separate Schemas No FK Constraints Bootstrap AngularJS Bootstrap AngularJS Backplane Reporting Apps Third Party Bootstrap Backplane RDFa HTML5 DA RDFa HTML5 Data Attrs RDFa HTML5 Data Attrs ETL Bootstrap Backplane Rich client only or tiny server frameworks (Mojo, Rack, etc.) XACML oData Search Service ElasticSearch iCal syslog Log/Monitor Service CalDAV Service Rules Service Doc/Blob Service oData Browser Accessible XMPP Service

NETSPECTIVE www.netspective.com 57 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 www.netspective.com 58 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

Thank You Visit http://www.netspective.com http://www.healthcareguy.com E-mail [email protected] Follow @ShahidNShah Call 202-713-5409