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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

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NETSPECTIVE 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 • 15+ years of technology management experience (government, non-profit, commercial) Author of Chapter 13, “You’re the CIO of your Own Office”

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NETSPECTIVE 3 What’s this talk about? Background • 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

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NETSPECTIVE 4 VHA’s VistA is a successful EHR General Facts • 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 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 home- based programs • 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

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NETSPECTIVE 5 VistA Use Through 12/08 • 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

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NETSPECTIVE 6 VistA Foundation & Frameworks • 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 Source:

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NETSPECTIVE 7 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

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NETSPECTIVE 8 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

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NETSPECTIVE 9 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 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

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The macro environment

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NETSPECTIVE 11 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

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NETSPECTIVE 12 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.

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NETSPECTIVE 13 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

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NETSPECTIVE 14 We’re repurposing and enhancing health data Proteomics Genomics Biochemical Behavioral Phenotypics Economics Try to use existing data to create new diagnostics or therapeutic solutions IOT sensors Administrative

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NETSPECTIVE 15 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

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NETSPECTIVE 16 Implications of healthcare trends PPACA ACO MU PCMH Health Home mHealth DATA Evidence Based Medicine Comparative Effectiveness Software Regulated IT and Systems Integration Services

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NETSPECTIVE 17 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

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NETSPECTIVE 18 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.

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

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NETSPECTIVE 20 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

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NETSPECTIVE 21 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

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NETSPECTIVE 22 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

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NETSPECTIVE 23 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

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

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NETSPECTIVE 25 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

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

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NETSPECTIVE 27 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

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NETSPECTIVE 28 Needed: diagnostic quality mHealth

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NETSPECTIVE 29 Needed: predictive analytics

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NETSPECTIVE 31 Needed: automated diagnostics

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How do we modernize integration?

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NETSPECTIVE 33 Why health IT systems integrate poorly Technology “Culture” • 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 (e- commerce) • We have “Inside out” architecture, not “Outside in” Actual Technology • We don't support shared identities, single sign on (SSO), and industry- neutral 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

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NETSPECTIVE 34 Process and people consolidation won’t work in the future “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.” Defining and coordinating interactions across a multitude of organizations is the new way • 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.” Promote “Outside-in” architecture The IT department inside your organization cannot possibly do everything you’d like Source: Deloitte “Outside-in Architecture”

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NETSPECTIVE 35 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

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NETSPECTIVE 36 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. App-focused integration is better than nothing Structured data dogma gets in the way of faster decision support real solutions

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NETSPECTIVE 37 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 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. Pushing data is more expensive than pulling it We focus more on "pushing" versus "pulling" data than is warranted early in projects

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

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NETSPECTIVE 39 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 • 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

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NETSPECTIVE 40 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

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NETSPECTIVE 41 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

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Slide 42 text 42 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

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NETSPECTIVE 43 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?

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NETSPECTIVE 44 Additional Information • OSEHRA website: • • MUMPS – – • World Vista: • Webnairs: Webinars

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Thank You Visit E-mail [email protected] Follow @ShahidNShah Call 202-713-5409