Playing with FHIR IR How to Exploit the EHR Mark L Braunstein, MD Professor of the Practice School of Interactive Computing Georgia Institute of Technology Visiting Research Fellow E-Health Centre, CSIRO
Variable Results “ Australia ranks highest on Administrative Efficiency and Health Care Outcomes, and is among the top-ranked countries on Care Process and Access ” Commonwealth Fund (2017)
Common Trends Aging Population More Chronic Disease Increased Costs https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/gx-lshc-healthcare-and-life-sciences-predictions-2020.pdf
In Including Australia Australian Institute of Health and Welfare 2018 https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contents
Systems Not Designed for Chronic Care Medical Journal of Australia https://www.mja.com.au/journal/2007/187/2/care-patients-chronic-disease-challenge-general-practice
Poor Care Coordination https://www.commonwealthfund.org/publications/surveys/2015/dec/2015-commonwealth-fund-international-survey-primary-care-physicians
Lack of Continuity In Practice Nurses or Case 96 92 90 85 Managers 81 66 65 64 60 28 UK NETH NZ SWE AUS US NOR CAN SWIZ GER https://www.commonwealthfund.org/publications/surveys/2015/dec/2015-commonwealth-fund-international-survey-primary-care-physicians
Variable Use of f In Informatics 90 80 80 70 60 60 57 53 50 40 30 30 24 20 11 11 10 0 Email Record Sharing Australia NZ SWIZ US
Healthcare Professionals Want Digital Health Top 5 activities health professionals want to use digital technologies to help better support them to deliver health services Not using, g, but inter eres ested in using g Not interested ed in using ng a Current ently using ng a compute uter, a compute uter, , smart phone e or compute uter, smart phone ne or tablet et Activity smart phone ne or tablet et tablet et for this activity % % % Sharing health records with my patients 25 59 7 Transferring prescriptions to the pharmacy 25 56 8 Providing interactive decision-making support 32 53 6 Communicating with patients before or after consultations 33 49 7 Sharing health records with other practitioners 43 45 4 Courtesy Australian Digital Health Agency
EHRs Have “Issues” https://medicomp.com/whats-the-most-frustrating-about-ehrs/
Goals: IO IOM safe, effective, patient-centered, timely, efficient, equitable Learning Health System https://www.ahrq.gov/professionals/systems/learning-health-systems/index.html
Necessary ry In Informatics Substrate Open EMR Adoption Analytics Access to POC Interoperability
Variable EHR Readiness http://www.oecd.org/els/health-systems/health-statistics.htm
Current EHR Limitations No standards regarding discrete data No integrated communication Not user-friendly Big data but not smart data Lack of regulation Hospital CIOs Remember these are we proceed https://www.beckershospitalreview.com/healthcare-information-technology/the-problem-with-ehrs-5-complaints-from-cios.html
What to Do? Repair? Replace?
In Innovate! “Fostering third party apps creates a market where innovations compete with each other for purchase and use by providers (and patients), thus reducing dependency on updates and specific functions made by an EHR vendor .” -- Ken Mandl, Josh Mandel, Isaac Kohane https://www.sciencedirect.com/science/article/pii/S2405471215000046
How?
It It Works Quantitatively https://research2guidance.com/325000-mobile-health-apps-available-in-2017/
Proof of Effectiveness is Lacking but … 11 of 23 randomized controlled trials showed a meaningful effect on health or surrogate outcomes attributable to apps … the overall evidence of effectiveness was of very low quality … pilot studies … only one has progressed to a large clinical trial. https://www.nature.com/articles/s41746-018-0021-9
… Mostly “ Siloed ” Apps
Ext xtend the Phone App Model to EHRs?
Harvard’s SMART https://apps.smarthealthit.org/
Georgia Tech’s HDAP http://www.hdap.gatech.edu/apps/
Cerner/Epic …
Even the US Government! https://bluebutton.cms.gov/
What Will Happen Next xt? “These apps will give new life to data entered into EHRs and other health IT platforms by providing the ability to visualize risks, trends, and trajectories; mash up clinical records with external data sources; and deliver decision support to clinicians and patients during and between encounters .” -- Ken Mandl, Josh Mandel, Isaac Kohane https://www.sciencedirect.com/science/article/pii/S2405471215000046
A Better EHR?
Ju Juxly Timeline No standards regarding discrete data No integrated communication Not user-friendly Big data but not smart data
Ju Juxly Trends No standards regarding discrete data No integrated communication Not user-friendly Big data but not smart data
Coordinated, , Continuous Care
Within Cerner -
More Complete Patient View EHR Data No standards regarding discrete data No integrated communication Not user-friendly Big data but not smart data Patient Generated Data
Outcome Prediction
How?
HL7 Timeline Messaging (lab test results) Model Driven (patient record summaries) FHIR: V 3.0.1 April 19, 2017 … 2018?
A Common Data Model No standards regarding discrete data No integrated communication Not user-friendly Big data but not smart data
Condition: Human View
Condition: Machine View 73211009 Remember me!
Uniform API
“Just Like” Amazon! https://www.amazon.com.au/s/ref=nb_sb_noss?url=search- alias%3Daps&field-keywords=size+10+ladies+blue+sweater http://hapi.fhir.org/baseDstu3/Condition?code=SNOMED-CT|73211009 Population level query
Condition Specific Charting
Medication Reconciliation One entry Multiple dispensings RxNorm for different names
Clinical In Insights No standards regarding discrete data No integrated communication Not user-friendly Big data but not smart data
Lower Cost No standards regarding discrete data No integrated communication Not user-friendly Big data but not smart data
Precision Medicine No standards regarding discrete data No integrated communication Not user-friendly Big data but not smart data
What About Your Patients?
Patient Controlled Health Record
EHR Connected Mobile Apps
Over 500 Collaborating Hospitals/Clinics (J (June)
Sharing Models Opt Out - Centralized Opt In - Federated
Secondary ry Use?
Chart Review
Search Results
Drill Down: Conditions/Medications
Drill Down: Notes
Research “a historic effort to gather data from one million or more people living in the United States to accelerate research and improve health. By taking into account individual differences in lifestyle, environment, and biology, researchers will uncover paths toward delivering precision medicine .” FHIR App https://allofus.nih.gov/
Emory ry Artificial In Intelligence Sepsis Expert (A (AISE) Trained on 31,000 Emory ICU patients Validated on 52,000 MIMIC III patients Third International Consensus Definitions for Sepsis (Sepsis-3) 65 features (variables) calculated on hourly basis Can predict sepsis 4 hours in advance (ROC of .85)* *https://www.ncbi.nlm.nih.gov/pubmed/29286945
No standards regarding discrete data No integrated communication DeepAISE on FHIR Not user-friendly Big data but not smart data Drag/ Drop Automatic Text messaging Emory AISE Score Improvement Decline or the eICU application Philips DRS Score: Higher predicts readmission Submitted to AMIA 2018
eICU team adjudicates warnings
Medical Education on FHIR? We are partnering with UQ ITEE and Faculty of Medicine to offer an experimental course to explore the potential of using FHIR to digitize case based learning.
Diabetes Case Study
Burn Case Study Nathan and is alert and oriented with a GCS of 15
Nathan’s % total body surface area (%TBSA) of burn is calculated using a Lund-Browder chart to be 62% with 59% full thickness burns, 2% deep dermal and 1% partial thickness burns
Want to Try ry It It Yourself? http://cs6440.gatech.edu/
mark.braunstein@csiro.au
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