CHC Briefing: OSEHRA is a great business opportunity for healthcare IT ISVs and system integrators

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
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”

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NETSPECTIVE
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
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
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
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: http://www.hardhats.org/dhcptovista.html

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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

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NETSPECTIVE
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
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
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
35 % of Population
4% of Population
Source: Amir Jafri, PrescribeWell

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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.

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NETSPECTIVE
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Needed: diagnostic quality mHealth

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NETSPECTIVE
Needed: predictive analytics

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

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NETSPECTIVE
Needed: automated diagnostics

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How do we modernize integration?

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NETSPECTIVE
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
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
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
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
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
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
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

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NETSPECTIVE
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

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NETSPECTIVE
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
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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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
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
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

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

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CHC Briefing: OSEHRA is a great business opportunity for healthcare IT ISVs and system integrators

CHC Briefing: OSEHRA is a great business opportunity for healthcare IT ISVs and system integrators

Shahid N. Shah

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