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Healthcare IT: Why is this so hard? Can we build meaningful solutions? Charles Mead, MD, MSc Senior Director, Healthcare Strategy Oracle Corporation

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Presentation on theme: "Healthcare IT: Why is this so hard? Can we build meaningful solutions? Charles Mead, MD, MSc Senior Director, Healthcare Strategy Oracle Corporation"— Presentation transcript:

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

2 Slide 2 HISI, Dublin, Nov 16-17, 2005 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 ??

3 Slide 3 HISI, Dublin, Nov 16-17, 2005 What is the (envisioned) solution? ?? Networks, 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”

4 Slide 4 HISI, Dublin, Nov 16-17, 2005 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”

5 Slide 5 HISI, Dublin, Nov 16-17, 2005 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 of Usability Relevance Efficiency Cost **Computable Semantic Interoperability**

6 Slide 6 HISI, Dublin, Nov 16-17, 2005 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.”

7 Slide 7 HISI, Dublin, Nov 16-17, 2005 The Good News The network/connectivity tools exist –Hardware / Firmware Networks and Exchange Protocols (e.g TCP/IP) The Internet and its derivative technologies , 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)

8 Slide 8 HISI, Dublin, Nov 16-17, 2005 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

9 Slide 9 HISI, Dublin, Nov 16-17, 2005 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

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

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

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

13 Slide 13 HISI, Dublin, Nov 16-17, 2005 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 system Source: Merriam-Webster web site interoperability : ability of two or more systems or components to exchange 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] Semantic interoperability Syntactic interoperability (interchange) Syntax  Structure Semantics  Meaning

14 Slide 14 HISI, Dublin, Nov 16-17, 2005 The Pillars of (Computable Semantic) Interoperability Necessary 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

15 Slide 15 HISI, Dublin, Nov 16-17, 2005 HL7 V3 Reference Information Model (RIM) Referral Transportation Supply Procedure Consent Observation Medication Administrative act Financial act Organization Place Person Living Subject Material Patient Member Healthcare facility Practitioner Practitioner assignment Specimen Location Entity 0..* 1 Role 1 0..* 1 Act Relationship 1..* 1 0..* 1 ParticipationAct Author Reviewer Verifier Subject Target Tracker Has component Is supported by “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.”

16 Slide 16 HISI, Dublin, Nov 16-17, 2005 ROLE: Patient PARTICIPAT: Author 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. OBS: Temp 101F OBS: Abnormal CXR OBS: Elevated WBC AR: “is supported by” AR: “is supported by” AR: “is supported by” has target OBS: Dx Pneumonia is source for Collection, Context, and Attribution Building Complex RIM-based structures PARTICIPAT: Subject ROLE: Clinician ENTITY: Person Attribution

17 Slide 17 HISI, Dublin, Nov 16-17, 2005 Information vs Terminology Models Intersecting and interleaving semantic structures Common Structures for Shared Semantics Information Model Domain-Specific Terms specifying Domain-Specific Semantics Terminology Model Binding/Interface Common Structures bound to Domain-Specific Structures specifying Domain-Specific Semantics Information Model Terminology Model Domain-Specific Terms specifying Domain-Specific Semantics

18 Slide 18 HISI, Dublin, Nov 16-17, 2005 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’ Summary


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