Getting SMART with FHIR Grahame Grieve, Mark Braunstein, Michael Lawley, Brett Esler, Reuben Daniels, Kate Ebrill, Steve Badham, Andrew Patterson, Danielle Bancroft, Brian Postlethwaite August 2019 Australia’s National Science Agency
Agenda 1. FHIR rapidly spreading around the World- Grahame Grieve 2. Fueling FHIR for change in the US- Mark Braunstein 3. Quick FHIR: initiatives across Australia o HL7 Au - Brett Esler o SafeScript - Danielle Bancroft o Federated Provider Directory - Brian Postlethwaite o National Children’s Digital Health Collaborative - Steve Badham o Queensland Clinical Terminology Service - Reuben Daniels o Genomics Alliance’s supported by FHIR - Andrew Patterson o Primary Care Data Quality and Practice to Practice Exchange - Kate Ebrill
Mentimeter- getting to know who is in the room
FHIR: Spreading around the world Grahame Grieve 13-Aug 2019 Melbourne (IHE/HIC)
FHIR: The web, for Healthcare Open Community Open Standard • Describes how to exchange • Make it easier to exchange healthcare information healthcare information • A web API - web standards • Open Participation - uses where possible web infrastructure (social • Continuity with existing media) healthcare standards • Lead by HL7 - deeply • Public Treasure connected to world wide (http://hl7.org/fhir) health community
FHIR History Standards History Implementation History • Sept 2012: 1 st Connectathon • July 2011 - Conception • June 2014: Commonwell (1 st Prod) • May 2012 - First Milestone • Sept 2014 - R1 (Trial Use) • Sept 2014: Reorientate • Oct 2015 - R2 • Dec 2014: Argonaut • April 2017 - R3 (CC0) • May 2016: FHIR Foundation • Dec 2018 - R4 (1 st Normative) • Jan 2018: Apple Healthkit • Oct 2020? - R5 • Late 2019?: R4 required in US Regs
Three Legs of the Standards Process • Base Standard • Establish Capabilities • Common Engineering • V2, FHIR, DICOM, LOINC, SNOMED, XDS? • Profiling for Communities • Common Use Cases, Smaller communities (Wishel Rule) • Adapt / Combine • IHE, Argonaut / Da Vinci, ADHA / IT-14 • Driving Solutions into the Market • Regulation, Incentive Payments – ONC, ADHA, etc • Trade Associations - HIMSS / HISA,
Overall Progress
Where adoption is happening • Secondary Data Repositories • Patient access to data • Big Data • Specific Clinical Data Repositories • National Health Records / Sharing frameworks • Application Extension • Argonaut / EHR Plug-ins • Decision Support Integration • Primary Apps: SaaS (health) • Interaction between Payers and Providers (pre-auth, approval, review processes)
Adoption: USA / Argonaut • Clinical Summary Query (R2 -> R4) • Provider Directory • Scheduling • Clinical Notes • Questionnaire • Active Health Nodes – provide services to enable a distributed healthcare system • Clinical Summary (R4) required in next regulations
Adoption: USA / Da Vinci • Prior Authorization • Coverage Decision • Payer Data Acquisition • Care Plan / Medicine Formulary Exchange • Clinical Data/Documentation/Record Exchange • Alerts
Adoption: USA / Federal • Blue Button (2) – Government + Payer reporting of payment information) • Quality Measure (Data Collection / Reporting) • National Provider Directory • NIH Endorsement • Public Health / Death reporting • VA Clinical care projects
Adoption: US Vendors • Many personal health projects • Apple Healthkit – expanding scope & range • Many Data Analytics / Repository Projects • Google Brain Project • Many Toolkits / Frameworks • SmileCDR (HAPI!) • Microsoft Azure FHIR Server
Adoption: Europe • International Patient Summary • “Document” – clinical summary for a patient • Corresponds roughly to Argonaut scope • Packaged as a document, not an API (push) • Makes rules about terminology (SNOMED CT) • Not just Europe
Adoption: Netherlands • MedMij - Personal health data in the palm of your hand • Mobile access to all medical data over life time • MedMij covers legal, organizational, financial, semantic and technical aspects • 4 year initial project – 2016 - 2020
Adoption: England / UK • Interopen Project • Renal Clinical Repository • Many vendor projects
Adoption: Australia • National Clinical Terminology Service (on Ontoserver) • Provider Directory Project (supporting secure messaging) • Document access to MyHR for mobile apps • Agency strongly interested in FHIR documents going forward • Lots of internal use in vendors (Telstra Health, Alcidion) • Some classic interop in GP space • Appointments / decision support • Not in common use in institutions yet
Common Production Uses for FHIR • Exchanging Clinical Summary / Clinical Transfer • EHR Extensibility • Patient / provider registration • Data Analytics / Surveillance • Quality Measures / Clinical Performance
Join Us • FHIR is a critical infrastructure enabler • A community solution for the IT requirements • But FHIR is not a solution to anything itself • Need new community infrastructure at many levels • Governance is critical: Build confidence and trust – open community treasure • Needs stable Governance foundations with consistent transparency • Join the community (FHIR, or others) • http://hl7.org/fhir, http://fhir.org
Fueling FHIR for Change in the US Mark L Braunstein, MD Visiting Scientist Australian eHealth Research Centre Professor of the Practice School of Interactive Computing Georgia Institute of Technology
US Federal Interoperability Mandate EHR Adoption and Meaningful Use 2014: Argonaut Project 2019: Promoting Interoperability (PI) program 2009: American Recovery and Reinvestment Act Interoperability Data blocking Patient access (APIs) 2016: 21st Century Cures Act
Using FHIR! “ By identifying the FHIR standard to implement our policies, we are promoting scalable data sharing, not just an individual patient record from hospital to hospital but a model that supports the flow of information across the entire healthcare system.” --CMS Administrator, Seema Verma, HIMSS 2019
Industry is Aboard “…we are fortunate to work with many teams and partners that draw on experiences across industries to support and accelerate the delivery of FHIR APIs in healthcare. Moreover, we are committed to introducing tools for the healthcare developer community. After the proposed rule takes effect, we commit to offering technical guidance based on our work including solution architecture diagrams, system narratives, and reference implementations to accelerate deployments for all industry stakeholders. We will work diligently to ensure these blueprints provide a clear and robust path to achieving the spirit of an API- first strategy for healthcare interoperability.” Amazon, Google, IBM, Microsoft, Oracle, and Salesforce CMS Blue Button 2.0 Developer Conference, July 30, 1019 http://blog.hl7.org/cloud-providers-unite-for-healthcare-interoperability-fhir 24
App Ecosystems for Providers
… and for Patients FHIR Gateway SMART Apps 26
What Problems?
EHRs: Mixed Results https://med.stanford.edu/content/dam/sm/ehr/documents/EHR-Poll-Presentation.pdf
Notes
CC/HPI: Abdominal Aortic Aneurysm Case
Problem Specific Structured Documentation
Key Findings Highlighted
PE: Abdominal Aortic Aneurysm Case
Procedure Reports
Varicose Veins Assessment/Plan
Procedure Note
Questionnaires/Scoring Quality of Life Score
Notes Management
Timeline Display
Timeline Standalone
Write-back FHIR Documents Diagnoses/Problems (ICD-10) via FHIR or Proprietary API • Epic • Cerner • Allscripts • Athena • Nextgen
Vault: Hierarchical Condiiton Coding Each HCC is mapped to an ICD-10 code. Along with demographic factors (such as age and gender), insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score.
PCPs Needs versus Capabilities
Continuous, Coordinated Care EHR Data Integrated patient messaging (provider coming) Patient Generated Data
Targeted Information
Trend Insights
Suggested Evidenced-based Goals
Predictive Analytics Estimated A1C on current versus proposed therapy
Personalized Clinical Decision Support
Automatic Attribution
Medicare Reduce patient burden A research organization can pre-populate a medication lists for a patient during clinical trial enrollment. Streamline information about different kinds of care over time A primary care physician can access information on other patient care (e.g. related to behavioral health) to better inform treatment. Uncover new insights that can improve health outcomes A pharmacy can determine if a beneficiary gets healthier over time due to medication adherence. Access and monitor health information in one place A health application can aggregate data into a health dashboard for beneficiaries.
VA API
NIH
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