Transcription
SOA at Intermountain Healthcare:New IDEAs and Progress Towardsa New PlatformSOA in HealthcareJuly 13, 2011Stanley M. Huff, MDHuff # 1
Acknowledgements Tom OnikiJoey CoyleCraig ParkerYan HerasCessily JohnsonRoberto RochaLee Min LauAlan JamesMany, many, others #2
Intermountain Medical CenterWomen’sandNewbornMain TowerHeart and LungHospitalCancerCenterOutpatientPavilion
Intermountain Healthcare 24 hospitals2,488 inpatient beds123,447 Acute admissions98,674 Ambulatorysurgeries160,306 Homecare visits502,327 Acute patientdays5,817,392 Outpatientvisits429,949 emergency roomvisits38,103 inpatient surgeries
Homer Warner and HELP The first version of theHELP (Health Evaluationthrough LogicalProcessing) system wasbuilt in 1967 From its inception, theHELP system was builtprimarily to provideadvanced decision supportDr. Homer Warner
Patient
Core Assumptions‘The complexity of modern medicine exceeds theinherent limitations of the unaided humanmind.’ David M. Eddy, MD, Ph.D.‘. man is not perfectible. There are limits toman’s capabilities as an information processorthat assure the occurrence of random errors inhis activities.’ Clement J. McDonald, MD
Clinical System ApproachIntermountain can only providethe highest quality, lowest costhealth care with the use ofadvanced clinical decisionsupport systems integrated intofrontline workflow
Total # moderate severe ADEsAdverse Drug 1280271300233200 Rates today (2008-9) at about 230 per year200100 Generates 1 million per year in net cost reductionsat LDS Hospital alone10000899091929394Year9596979899(3)
Neo-natal intensive care unit (NICU)admits by weeks gestationDeliveries w/o Complications, 2002 - 200310Percent NICU admissionsn 43.362.472.65220037383940Weeks gestation4142
Elective inductions 39 weeks303029 28.48.16.85.56.35.9 6.1 656.6 6.365.17.96.6 6.67.6 7.66.45.4 476382490430422430356372455n Jan02MarMaylJuMaynMar0010Ja% elective inductions 39 weeks26.726.9
2000200018001800160016001400140012001200Expected maternal and fetal combined variable costGoal: hold increase to no more than 6.85%Actual combined variable MarFeb100020031000JanAverage combined variable cost ( )Labor & delivery variable cost
ARDS evidence in actionDefining the best practice clinical protocolPhysician complianceARDS ventilator management: Survival 9.5% 44% 120,000 less cost per case!
Decision Support Modules Antibiotic AssistantVentilator weaningARDS protocolsNosocomial infectionmonitoring MRSA monitoring andcontrol Prevention of DeepVenous Thrombosis Infectious diseasereporting to public health Diabetic carePre-op antibioticsICU glucose protocolsVentilator disconnectInfusion pump errorsLab alertsBlood orderingOrder setsPatient worksheetsPost MI discharge meds
Infrastructure Vision Rapid application development environmentDynamic workflow configurationStandard data models and terminologyDecision support authoring and executionKnowledge asset management– Rules, alerts, protocols, reminders, reports End user preferences– Common lists, Hot text Service Oriented Architecture/Enterprise ServiceBusHuff # 15
Strategic Goals Minimum goal: Be able to shareapplications, reports, alerts, protocols, anddecision support with ALL GE customers Maximum goal: Be able to share applications,reports, alerts, protocols, and decision supportwith anyone in the WORLD
Order Entry API (adapted from Harold Solbrig)ApplicationInterfaceServiceDataVA OrderEntryUpdate Medication OrderCOSVAOrderServicesUpdate PharmacyOrderWHERE orderNumber “4674” MUMPSDatabase
Order Entry API – Different Client,Same Service (adapted from Harold seUpdate Medication OrderCOSVAOrderServicesUpdate PharmacyOrderWHERE orderNumber “4674” MUMPSDatabase
Order Entry API – Different Server,Same Client (adapted from Harold Solbrig)ApplicationInterfaceDeptofDefenseUpdate Medication OrderCOSGEServicesUpdate PharmacyOrderWHERE orderNumber “4674” ServiceDataGERepositoryOracleTables
Order Entry API (adapted from Harold Solbrig).ApplicationInterfaceServiceDataCOS
What Is Needed to Create a New Paradigm? Standard set of detailed clinical datamodels coupled with Standard coded terminology Standard API’s (Application ProgrammerInterfaces) for healthcare related services Open sharing of models, coded terms, andAPI’s
What are detailed clinicalmodels?Why do we need them?# 22
A diagram of a simple clinical modelClinical Element Model for Systolic Blood PressureSystolicBPSystolicBPObsdata138 mmHgqualsBodyLocationBodyLocationdataRight ArmPatientPositionPatientPositiondataSitting# 23
Need for a standard model A stack of coded items is ambiguous (SNOMED CT)– Numbness of right arm and left leg Numbness (44077006)Right (24028007)Arm (40983000)Left (7771000)Leg (30021000)– Numbness of left arm and right leg Numbness (44077006)Left (7771000)Arm (40983000)Right (24028007)Leg (30021000)# 24
What if there is no model?Site #137Hct, manual: 70%35: 70%37: 70%Hct, autoSite #2HctManualAutoEstimated# 25
HL7 V2.X Messages Site 1:OBX 1 CE 4545-0 Hct, manual 37 % OBX 1 CE 4544-3 Hct, auto 35 % Site 2:OBX 1 CE 20570-8 Hct 37 % . manual OBX 1 CE 20570-8 Hct 35 % . auto
Model fragment in XMLPre-coordinated representation observation cd Hct, manual (LOINC 4545-0 ) /cd value 37 % /value /observation Post-coordinated (compositional) representation observation cd Hct (LOINC 20570-8) /cd qualifier cd Method /cd value Manual /value qualifier value 37 % /value /observation # 27
Relational database implicationsPatientIdentifierDate and TimeObservation TypeObservationValueUnits1234567897/4/2005Hct, manual37%1234567897/19/2005Hct, auto35%PatientIdentifierDate and TimeObservationTypeWeight l37%1234567897/19/2005Hctauto35%If the patient’s hematocrit is 35 then .# 28
Isosemantic ModelsPrecoordinated ModelHematocritManual (LOINC 4545-0)HematocritManualModeldata37 %Post coordinated Model (Storage Model)Hematocrit (LOINC 20570-8)HematocritModeldata37 %qualsHematocritMethodModeldataHematocrit MethodManual# 29
More complicated items: Signs, symptomsDiagnosesProblem listFamily HistoryUse of negation – “No Family Hx of Cancer”Description of a heart murmurDescription of breath sounds– “Rales in right and left upper lobes”– “Rales, rhonchi, and egophony in right lower lobe”# 30
What do we model? All data in the patient’s EMR, roblem listsLaboratory resultsMedication and diagnostic ordersMedication administrationPhysical exam and clinical measurementsSigns, symptoms, diagnosesClinical documentsProceduresFamily history, medical history and review of symptoms
Model Subtypes Created Number of models created - 4384– Laboratory models – 2933– Evaluations – 210– Measurements – 353– Assertions – 143– Procedures – 87– Qualifiers, Modifiers, and Components Statuses – 26 Date/times – 27 Others – 400 # 32
How are the models used? Data entry screens, flow sheets, reports, ad hocqueries– Basis for application access to clinical data Computer-to-Computer Interfaces– Creation of maps from departmental/foreign system modelsto the standard database model Core data storage services– Validation of data as it is stored in the database Decision logic– Basis for referencing data in decision support logic Does NOT dictate physical storage strategy
Model Source Expression (CDL)model BloodPressurePanel is panel{key code(BloodPressurePanel KEY ECID);statement SystolicBloodPressureMeas systolicBloodPressureMeas erified);statement DiastolicBloodPressureMeas diastolicBloodPressureMeas optional .statement MeanArterialPressureMeas meanArterialPressureMeas optional .qualifier oodPressureMeasurementDevice DOMAIN ECID);qualifier lp.code.domain(BloodPressureBodyLocationPrecoord DOMAIN ECID);modifier Subjectsubjectoptional;attribution Observedobservedoptional;attribution on Verifiedverifiedoptional;}# 34
So that is the vision ofthe future, what ishappening right now?Huff # 35
HELPCare Flow(Inpatient HIS)(Outpatient)3MMisys LabGEHCGE/AGFA RadiologyTamtron Anatomic PathologyMcKesson PharmacyHELPDatabaseARUP Blood BankBlood Gas MachinesDictaphoneVaris OncologyMRS MammographyADT, Orders,Results, dulingeGateInterfaceEngine SunGE/Logicare ERClinicalWorkstationHELP2CDIHCHealth DataDictionary3MADT, Billing,Case MixBilling &FinancialADT, Results,OrdersRegistration,SchedulingComputrition Dietary3MADT,BillingHDM &Medrec3MIHCDataStageTuxedoCDRDatabase(HEMS) 3MDataWarehouseIHC
Application Explosion 4000 applications in the organization Applications being purchased or built includeapproximately 80% redundancy of functionalityData Explosion All new applications require duplication of data One example of data duplication––––49 copies of patient registration data294 million patient records online288 million or 97% are duplicate copies125,000 registration updates/day or 6.1 million total data updatesdaily
Information Delivery EnterpriseArchitecture
IDEA Governance StructureRESPONSIBILITESEARB Provides strategic oversight andguidance for IDEA Empowers IDEA subcommittee tospecifying standards, practices,guidelines and tools Approval of IDEA subcommitteeproposals Monitors and is accountable foradherence to approved standards,practices, guidelines and toolsChair: Chief Technology OfficerIDEAGOVERNANCEIDEA SubcommitteeChair: Enterprise Software ArchitectMEMBERSPMO, HELP1, HELP2, Migration,Financial, Tactical, eBusiness,Clinical Operations, Interfaces,EDW, ECIS, Informatics, Security,Select Health, Operations, RIM,KTMI, committeeRESPONSIBILITES Establish the Information Delivery EnterpriseArchitecture by specifying standards, practices,and guidelines and tools Build consensus and document softwarestandards, processes, tools, and infrastructure tobe approved by IDEA Governance Provides stewardship for respective teams Brings forth gaps, issues and solutions forIDEA
A Picture
Something More ConciseNew 3rd PartyApplicationIntermountainApplicationIDEA Enterprise Service BusIntermountainCentral Data RepNew 3rd PartyData Repository
Nursing ‘Medication Charting’workflow
Physician “Note Writing” workflow
Clinician ‘Data Review’ workflow
Potential Benefits Low risk Incremental changes - no “big bang”changes Gradual implementation of ESB Transition based on particular modules– Results review, text documents, allergies,documentation, order entry Slowly increasing use of the new database– Opportunity to tune performanceHuff # 45
Questions?Huff # 46
eGate Interface Engine Sun Clinical Workstation 3M ADT, Orders, Results, Billing HELP 2 CD IHC HELP Database. Application Explosion 4000 applications in the organization Applications being purchased or bu
