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Healthcare IT: Why is this so hard ? Can we build meaningful solutions?

“The great thing about standards is that there are so many to choose from.” --- anonymous. Healthcare IT: Why is this so hard ? Can we build meaningful solutions?. Charles Mead, MD, MSc Senior Director, Healthcare Strategy Oracle Corporation charlie.mead@oracle.com

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Healthcare IT: Why is this so hard ? Can we build meaningful solutions?

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  1. “The great thing about standards is that there are so many to choose from.” --- anonymous Healthcare IT:Why is this so hard?Can we build meaningful solutions? Charles Mead, MD, MSc Senior Director, Healthcare Strategy Oracle Corporation charlie.mead@oracle.com Health Informatics Society of Ireland (HISI) Dublin, Ireland November 16-17, 2005

  2. What is the (perceived) problem? • Ineffective, inconsistent, inefficient, non-efficacious healthcare delivery • Too much information for timely integration • Ever-changing information base • Mobile patients/global society • Complex payment/reimbursement frameworks • Time-consuming bureaucracy • Increasing financial pressures • ?? Unrealistic expectations ?? HISI, Dublin, Nov 16-17, 2005

  3. What is the (envisioned) solution? • ?? Networks, Email and Web Browsers ?? • The United States National Health Information Infrastructure (NHII) • Inform clinical practice • Interconnect clinicians • Personalize care • Improve population health • “The Electronic/Enterprise Health Record” • “Bedside to Bench and Back” HISI, Dublin, Nov 16-17, 2005

  4. A caBIG Example(from Covitz et al, Bioinformatics, V19, N18, P2404) • Patient presents with headache, focal weakness, history of seizures • Workup reveals glioblastoma multiforma subtype astrocytoma • Is this tumor histology is associated with gene expression abnormalities? • Yes, in the p53 signaling pathway including BCL2, TIMP3, GADD45A, CCND1 • Is there documented evidence of aberrant expression of (e.g.) CCND1? • Yes, SAGE tags for cyclin D1 appear with 3x greater frequency in cancerous vs normal brain tissue • Are any gene products of the p53 signaling pathway known targets for therapeutic agents? • Yes, TP53, RB1, BCL2, CDK4, MDM2, CCNE1 • Are any of the agents known to target these genes being specifically tested in glioblastoma patients? • Yes, trials xxx and yyy are currently underway • “Research data at the point of care, Clinical data at the point of research” HISI, Dublin, Nov 16-17, 2005

  5. Cut to the Chase • Implementing an Enterprise/nation-wide anything is hard • Implementing an Enterprise/nation-wide EHR is particularly difficult because… • …the essence of the problem is about “computers processing data that has traditionally been processed by people”(e.g. clinicians, researchers, administrators, accountants, etc.), • …human beings will still be involved in any successful (‘relevant’) Enterpriseion/na-wide EHR implementation, • …and so enter the dreaded concepts ofUsabilityRelevanceEfficiencyCost**Computable Semantic Interoperability** HISI, Dublin, Nov 16-17, 2005

  6. Two Types of Tools Are Needed • Networking/connectivity tools • “Enterprise-wide” means moving data in time and space between multiple sources • Variable hardware / software profiles • Synchronous / Asynchronous communication • Persistence requirements (“archiving”) • Auditing requirements (“audit trails”) • Software Development / Data interchange tools • “The patient gets chest pain when they walk past the frozen food section of the store” ====“Patient has angina aggravated by cold.” HISI, Dublin, Nov 16-17, 2005

  7. The Good News • The network/connectivity tools exist • Hardware / Firmware • Networks and Exchange Protocols (e.g TCP/IP) • The Internet and its derivative technologies • Email, Intranets, VPNs, etc. • Software • Browsers reading XML / HTML • The data interchange standards exist • HL7 Version 3 (and its various ‘equivalence mappings’) • Terminologies (SNOMED, LOINC, etc.) • Domain-specific representation standards (DICOM, MAGE) HISI, Dublin, Nov 16-17, 2005

  8. The (Pretty) Good News • The Software Engineering techniques and tools exist to build ‘usable, relevant’ system • Unfortunately, within healthcare, they are most often not applied correctly or to the degree that they need be to ensure that a truly ‘relevant’ system is designed and built • Requirements definition and management • “Quality requirements” poorly defined (e.g. usability, performance, etc.) • The ‘Communication Pyramid’ • Project Management HISI, Dublin, Nov 16-17, 2005

  9. The (not so) Bad News • Even with contemporary tools and expertise, it’s still a difficult problem to solve • Expensive • Requires specialized expertise • Modeling, requirements specification, interface design, etc. • Requires a ‘top-down’ commitment to standards that is often not ‘natural’ to many healthcare providers, institutions, etc. • Market pressures in combination with government incentives • Use of Guidelines / Outcome-based reimbursement • Unique person identifier / suspicion of goverment • However, other industries have adopted standardization and built complex systems HISI, Dublin, Nov 16-17, 2005

  10. The Really Bad News • The inherent problem is hard, i.e. it will never be easy!!! HISI, Dublin, Nov 16-17, 2005

  11. (Concept) Symbol “Shark” Thing Concept 1 “Delicious with cabernet.” Concept 2 “A guy who hustled me.” Concept “A predator.” Thing 1 Symbol “Shark” Symbol “Shark” Thing Thing 2 The Semiotic Triangle:How Humans Communicate Protocol Example HISI, Dublin, Nov 16-17, 2005

  12. Concept 1 Concept 2 “We need to sign off on the protocol by Friday” “Protocol XYZ has enrolled 73 patients” Thing 1 Thing 2 Study Document Concept 3 Thing 3 “Per the protocol, you must be at least 18 to be enrolled” Plan “Protocol” and the Semiotic Triangle Symbol “Protocol” Source: John Speakman/Charlie Mead HISI, Dublin, Nov 16-17, 2005

  13. Semanticinteroperability Syntacticinteroperability (interchange) Interchange vs Interoperability • Main Entry: in·ter·op·er·a·bil·i·ty: ability of a system ... to use the parts or equipment of another systemSource: Merriam-Webster web site • interoperability: ability of two or more systems or components toexchange information and to predictably use the information that has been exchanged. Source: IEEE Standard Computer Dictionary: A Compilation of IEEE Standard Computer Glossaries, IEEE, 1990] Syntax  Structure Semantics  Meaning HISI, Dublin, Nov 16-17, 2005

  14. The Pillars of(Computable Semantic) InteroperabilityNecessary but not Sufficient • Common reference model across all domains-of-interest • Information model vs Data model • Model grounded on robust data type specification • Methodology for binding terms from concept-based terminologies • A formally defined process for defining specific structures to be exchanged between machines, i.e. a “messaging standard” The Version 3 Tool Kit HISI, Dublin, Nov 16-17, 2005

  15. 0..* 1 0..* 1 HL7 V3 Reference Information Model (RIM) “An instance of an Entity may play zero or more Roles. Each instance of a Role may, in turn, play zero or more instances of a Participation in the context of an instance of an Act. Each instance of a Participation participates in a one and only one Act for the ‘duration’ of that Act. Acts may be related to each other through instances of Act Relationship.” ActRelationship Has component Is supported by 0..* 0..* 1 1 Entity Role Participation Act 1 1..* • Organization • Place • Person • Living Subject • Material Patient Member Healthcare facility Practitioner Practitioner assignment Specimen Location Referral Transportation Supply Procedure Consent Observation Medication Administrative act Financial act Author Reviewer Verifier Subject Target Tracker HISI, Dublin, Nov 16-17, 2005

  16. Collection, Context, and AttributionBuilding Complex RIM-based structures A diagnosis of pneumonia (observation Act) related to three other observations Acts. Each Act is fully attributed with its own context of Entity-Role-Participation values. AR: “is supported by” OBS: Temp 101F Attribution is source for has target OBS: Dx Pneumonia AR: “is supported by” OBS: Abnormal CXR Attribution has target is source for AR: “is supported by” is source for Attribution OBS: Elevated WBC has target PARTICIPAT: Subject ENTITY: Person ROLE: Clinician Attribution PARTICIPAT: Author ROLE: Patient HISI, Dublin, Nov 16-17, 2005

  17. Information Model Common StructuresforShared Semantics Information vs Terminology ModelsIntersecting and interleaving semantic structures Terminology Model Domain-Specific Terms specifying Domain-Specific Semantics Binding/Interface Information Model Terminology Model Common Structures bound toDomain-Specific Structures specifyingDomain-Specific Semantics Domain-Specific Terms specifying Domain-Specific Semantics HISI, Dublin, Nov 16-17, 2005

  18. Summary • Computable Semantic interoperability is essential if we are to solve the myriad of problems facing national healthcare delivery system revision • Computable Semantic interoperability is difficult • Computable Semantic interoperability is possible if the ‘Four Pillars’ are addressed • HL7 Version 3 and the associated RIM provide a framework satisfying the ‘Four Pillars’ • Oracle is building HTB, a standards-based interoperability value-add platform based on HL7 v3, the RIM, and the ‘Four Pillars’ HISI, Dublin, Nov 16-17, 2005

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