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Winning Trust, Minimizing IT Resources
1. Winning Trust, Minimizing IT
Resources: Key to Forming
RHIOs
The SEMRHIO Experience
Mark Singh MD, President, Clinicore
Kathleen Sullivan MPH, CEO, Salient Health
2. Introduction
• Hospitals: Greater demand for electronic
data delivery: EMRs interfaces, Portals
• Physicians: Clinical data from multiple
disparate sources
• RHIOs: a solution
– Significant Barriers: Trust/Security, Cost
• Hospital buy-in: Need to overcome these barriers
3. Our Experience in forming SEMRHIO
• South Eastern Massachusetts Regional Healthcare
Information Organization
Milton Hospital
Jordan Hospital
Quincy Medical Center
4. Overcoming Barriers
• Developed a model:
– Gain Trust
– Minimize Hospital IT infrastructure
• lower cost of entry
• Won Approval from Hospital Leadership
– SEMRHIO
5. Problems Addressed
• Need to support EMR adoption, electronic data
delivery, interfaces to hospital systems
– Immediate problem which needs a solution within
next 2-3 years
• Health care delivery is distributed through out
community
– Challenge to have the appropriate data available in
order to provide safe patient care
– Trying to keep; up with fax machines: tough
6. EMR Adoption
• More doctors implementing EMRs
• Hospitals being asked to provide
interfaces
– Need to serve small and large practices
– Can this this be done more efficiently by
hospitals as a “group”: RHIO?
7. Care Delivered at Multiple Sites
Patient
Doctor’s offices
Imaging Hospital
Labs
Center Surgi-center
8. Clinical Data is spread out
• When taking care of a patient, need to
have access to data from all the other
sites
– Care delivered in Physician's offices (multiple
specialists, PCP)
– Hospitals/Emergency Rooms
– Nursing Homes
9. Need to Solve:
• How do we deliver clinical data
electronically?
• How to consolidate clinical data set in real
from disparate healthcare entities in order
to care for patients?
10. Solving these Problems
• RHIO seems to makes sense:
– multi-stakeholder organization
– Allow shared costs of common IT
infrastructure
• Economies of scale
– Framework for data sharing among competing
organizations
11. RHIO: Challenges and Barriers
• Perceived Negatives regarding RHIOs
– Too costly, Lack of sustainability models
– Too many security and trust issues among
Competing entities.
• uncomfortable with concept of “Sharing” clinical
data
12. “California RHIO closes amid cost,
privacy concerns”
The closure of the Santa Barbara Co. Care Data
Exchange
eHealth SmartBrief | 07/11/2007
13. Given these significant barriers,
how do we get community
based, independent, competing
hospitals to form a RHIO?
14. Need to Address Potential Barriers
• Cost and Security issues:
– Lack of IT Infrastructure and Resources
• Hospitals have more immediate pressing issues:
– i.e., CPOE , eMAR
– Trust among disparate organizations
15. Trust in Forming a RHIO
• Issue of Architecture, business process
– When thinking about RHIOs, we consider
classic approach for RHIO architectures
– Classic Model is a “federated”, “Pull” based
architecture using a Record Locator Service
(RLS)
16. “PULL” based Model
Pull Based RHIO Model
Return only permitted data
Return data but exclude:
Drug
Addiction Patient
data with “HIV”, “Substance
Hx
2 has CAD,
Abuse”, “Mental Health”
CHF.
Hospital-A
Sodium
135,
Cholestero
l 187,
Glucose
Patient
has CAD,
CHF. Aso
HIV.
Patient
hasNaus
3
ea Aso
H
Hospital-B
h/o HIV.
Patient
has CAD,
CHF.
AIDS
1
RLS
User requests records
on patient
Hospital-C Get John Doe’s
Mental
data
Health Hx
Search for John
Doe’s data across
User not entitled to receive data hospitals
containing mental health, HIV,
substance abuse information
17. Pull Model
Complicates Trust issues
• Pull may work very well in a multi-site, single-
organization
• Has problems in a multi-organizational setting-
Problematic
– Introduces new Trust issues
– Each hospital (source) needs to determine what data
each user can access
– Model opens up a “can of worms”
– Can be a “show stopper” in forming RHIOs
18. “Best to automate an existing
business process and trust
relationship”
“The RHIO experience in Massachusetts”
John Halamka D. MD, CEO MA-SHARE
May 4, 2007
19. How do we build Trust ?
Use an existing Trust relationship
Use an existing Business Process
20. Existing Business Process and Trust Relationship
“PUSH” model
The directed
delivery of
clinical data
from to provider
Push
Healthcare entity
21. PUSH Model for Exchange
PUSH Based Health
Information Interchange
Had h/o
fall. Felt Sodium
Patientdizzine 135,
has CAD, ss. Sodium Cholestero
CHF. Aso 135, l 187,
h/o HIV. CholesteroGlucose
Sodium
130
PUSH to 135, l 187,
Glucose
Cholestero
Sodium 187, 130
Authorized l
135,Glucose
Cholestero 130
Recipient l 187,
Glucose
Patient 130
hasNaus
ea Aso
h/o HIV. Patient
has CAD, InBox
CHF. Aso
h.
Building Trust: quot;pushquot; model—A doctor or healthcare
entity decides what data to send to another doctor or
Patient
has CAD,
CHF. Aso
entity.
h/o HIV.
22. Proposed Model
• Adopt conservative approach: Don’t change the
current arrangement
– Hospital to send data to the legal recipient (“ordering”,
“primary” doctors) via RHIO (instead of fax/mail)
• Once received by doctor, ownership of data
goes to doctor
• Data sharing among doctors: “…for treatment,
payment, and healthcare operations” per HIPAA
guidelines.
23. SEMRHIO Security Model
Doctors can
exchange reports
Hospitals
securely with
Exchange
Doctors Hospital A
Confidential Data
via secure RHIO
consulting and
primary care
physicians
Dr Good
Doctor may
have their only share
own Dr Health
data with
secure Hospital B another
account Local RHIO
doctor for
Data
for data Exchange Dr Livelong “Treatment
sent to and
Hospital C
them by Dr Luck payment”
the per HIPAA
hospitals Local RHIO
guidelines
connects to State
RHIO Mega Medical
Group
STATE WIDE RHIO Mega
EMR
Confidential Clinical Data Exchange via Local RHIO which
reflects the local culture, physician relationships
24. IT Infrastructure Issues
• Hospitals wanted to commit minimal
resources
• Major Component of the RHIO: Hospital
Information System (HIS) Integration
– Need for HL7 Interface Engine
– Involved increased cost and complexity
26. Is there an easier solution?
– Studied other possibilities
• Extract desired data in near-real time, delimited
text format, using HIS query /reporting utility
• Proposed Model:
– Local: Extract hospital data using existing the HIS
query/reporting utility
– Central: Conversion to HL7 centrally using BizTalk.
28. Advantages of Hosted Services
Model
• Move infrastructure to the other side of the
“Cloud”.
– Simplify/minimize onsite infrastructure
– Existing Local IT staff able to manage onsite
needs without additional training needed
– Centralize interface management
– Allow hospitals to share in economies of scale
29. Hosted Services
• Evolving Model: SOA ,SaaS
• Trend towards Hosted services
– i.e., Salesforce.com, Google, Postini
– Hosted email
– Many Hospitals outsource their IT
infrastructure and support: e.g., Perot systems
30. Hosted Integration
• Minimizing IT resources
• There was also a desire by hospitals to commit
minimal resources
• Reluctance to install additional software/hardware locally.
• We studied the existing hospital IT infrastructure and
developed a centralized “Hosted-Integration” model using
BizTalk server.
• This was a “zero” local foot print implementation model which
did not require any additional software/hardware locally, and
was implemented using basic IT personal.
31. The Process
• Extract data from HIS use existing built-in
reporting/query utility
• Hosted BizTalk integration server
– BizTalk receive data at input ports
– Delimited data mapped to HL7 2.x,
• The disparate data is mapped to a standard terminology.
• Final data is stored in SQL 2005 for delivery to the
recipient physicians.
35. Clinical Results Viewer
• Labs
• Radiology
• Clinical Reports
An “EMR-Lite” client
application to view
the data was built
using .NET and
Microsoft’s
“Composite
Application Block”.
36. Clinical Events Viewer
Keeps track of
patient events:
-Hospital, ER
admissions
discharges
- Bed Census
37. Conclusion:
• By using a “push” model and a BizTalk based
“Hosted-Integration-Services” model:
– Able to gain trust and minimize hospital IT resources
• Demonstrated how:
– competing community hospitals can succeed in
winning approval for forming a RHIO by their hospital
leadership.
39. Technical Team
Hospital
• Mike Cosgrave
IT Infrastructure
• Brian Allen • Ed Powers, GlobalNet Solutions
– www.globalnetsolutions.com
• Anne Baker
• Jean Fernandez
• Crowley, Sheryl
BizTalk
Eric Stott, Information Architect, Clinicore
http://blog.hl7-info.com/
http://blog.biztalk-info.com
