OSEHRA Summit 2012 Lunch Keynote: Current health IT systems integrate poorly and that's a big opportunity for the OSEHRA community

The Myth of Health Data Integration
Complexity
An opinionated look at why current health IT systems integrate
poorly and how it’s a big opportunity for the OSEHRA
Community
By Shahid N. Shah, CEO

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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
• A deluge of healthcare data is being
created as we digitize biology,
chemistry, and physics.
• Data changes the questions we ask
and it can actually democratize and
improve the science of medicine, if we
let it.
• While cures are the only real miracles
of medicine, big data can help solve
intractable problems and lead to more
cures.
• Healthcare-focused software
engineering is going to do more harm
than good (industry-neutral is better).
Key takeaways
• Major opportunity for systems
integrators
• Applications come and go, data lives
forever. He who owns, integrates, and
uses data wins in the end.
• Never leave your data in the hands of
an application/system vendor.
• There’s nothing special about health IT
data that justifies complex, expensive,
or special technology.
• Spend freely on multiple systems and
integration-friendly solutions.

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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
What’s creating “data deluge”?

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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
How can data help?
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
Economics
Since 1970,
pennies per
patient
•Business focused data
•Retrospective
•Built on fee for service models
•Inward looking and not focused
on clinical benefits
Biosensors
Social Interactions

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NETSPECTIVE
Data changes the questions we ask
Simple visual facts Complex visual facts Complex computable
facts

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NETSPECTIVE
Implications for scientific discovery
The old way
Identify problem
Ask questions
Collect data
Answer questions
The new way
Identify data
Generate questions
Mine data
Answer questions

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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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Recognizable Data Sources
Where is all the data coming from?

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NETSPECTIVE
Data is hidden everywhere
Clinical trials data
(failed or successful)
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
More hidden sources of data
Clinical systems
Consumer and
patient health
systems
Core transaction
systems
Decision support
systems (DSS
and CPOE)
Electronic
medical record
(EMR)
Managed care
systems
Medical
management
systems
Materials
management
systems
Clinical data
repository
Patient
relationship
management
Imaging
Integrated
medical devices
Clinical trials
systems
Telemedicine
systems
Workflow
technologies
Work force
enabling
technologies

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NETSPECTIVE
Unstructured patient data sources
Patient Health
Professional
Labs &
Diagnostics
Medical Devices Biomarkers /
Genetics
Source Self reported by
patient
Observations by
HCP
Computed from
specimens
Computed real-
time from patient
Computed from
specimens
Errors High Medium Low
Time Slow Slow Medium
Reliability Low Medium High
Data size Megabytes Megabytes Megabytes
Data type PDFs, images PDFs, images PDFs, images
Availability Common Common Common Uncommon Uncommon

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NETSPECTIVE
Structured patient data sources
Patient Health
Professional
Labs &
Diagnostics
Medical Devices Biomarkers /
Genetics
Source Self reported by
patient
Observations by
HCP
Specimens Real-time from
patient
Specimens
Errors High Medium Low Low Low
Time Slow Slow Medium Fast Slow
Reliability Low Medium High High High
Discrete size Kilobytes Kilobytes Kilobytes Megabytes Gigabytes
Streaming size Gigabytes Gigabytes
Availability Uncommon Common Somewhat
Common
Uncommon Uncommon

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What’s the problem?
What are we doing wrong?

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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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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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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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OSEHRA Summit 2012 Lunch Keynote: Current health IT systems integrate poorly and that's a big opportunity for the OSEHRA community

OSEHRA Summit 2012 Lunch Keynote: Current health IT systems integrate poorly and that's a big opportunity for the OSEHRA community

Shahid N. Shah

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