1. Navigating The Interoperability Standards Maze Vik Kheterpal, MD Principal, CareEvolution, Inc. April 13, 2015 DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2. 2 What This Talk Is About: Our experience an agnostic, pure-play interoperability technology stack vendor. Agnosticism to: EMR / HIT Legacy vendor Payer versus Provider versus another Standards Themselves Standards Bearers REMINDER: STANDARDS ARE A MEANS NOT THE END – DONE WELL, THEY REDUCE THE FRICTION COSTS OF DATA EXCHANGE

3. OUR EXPERIENCE: INTEROP ACROSS PUBLIC, PROVIDER, PAYER AND RESEARCH MARKETS TO MANAGE POPULATIONS 3 Building the “interstate” for information exchange Millions of patients each Integrating claims, clinical, administrative data across stakeholders Advanced portals and applications Public Market Helping IDNs get their own house in order Deep clinical data and workflow integration Patient and Provider Portals Clinical alerting solutions Provider and Research Market Payers and Channel

4. 4 Briefly share the range of “standards” available And how to frame the questions correctly (hint: it is usually not about picking winner/losers among the standards) To help organizations newly committing to interoperability to reduce FUD in getting started Using Use cases, demonstrate how the standards work together to ensure that information about patients moves as fast as patients do across our fragmented ecosystem OBJECTIVES:

5. CalRHIO CAeHC SHIN-NY What This Talk Is NOT About: The “Standard Bearers”

6. ROOT CAUSE OF CONFUSION: MASSIVE BODY OF WORK TO UNDERSTAND

8. VOCABULARY, CONTENT & STRUCTURE, TRANSPORT, SERVICES VocabularyContent & Structure TransportServices SNOMEDHL7 2.xSMTP/SMIME“Direct” NPIHL7 CDAHTTP/RESTfulIHE XDR ICD10CDA BPPC Etc.SOAPPIX/PDQ LOINCNCPDP / SCRIPTTLSXDS/XCPD RxNormHL7 2.5.1FHIR/SMART HCPCS/CPTDICOMHPD HL7 Value SetsFHIRDICOM

9. A TYPICAL REAL WORD SCENARIO Patient information (CCDA) is pushed from a hospital discharge (XDS) to the PCP (identified using HPD) via Direct/XDR, available in the Direct inbox The CCDA is also now part of the patient longitudinal care record The granular information within the CCDA also fires off an alert that is received by the patient (PHR) and the Clinician The patient uses their mobile device to take a current BP reading (Bluetooth/Apple HealthKit) which is transmitted securely to the clinician's EMR The data is also available in the integrated SMART/FHIR Cardiac Risk app. 9

10. Parse CCDA, Generate alert HOW THEY ALL WORK TOGETHER DEMONSTRATION AT ONC KIOSK 10 HIEBus ™ CCDA (XDS) Look up PCP (HPD) CCDA (Direct/XDR) Dr. Harper 1 3 4 5 Patient CCDA High BP Alert 6 Mobile App 6 Apple HealthKit Bluetooth enabled BP cuff HealthKit Data upload 8 7 External integration: FHIR (data pull) 9 SMART App Collaborative Family Health Record (cFHR™) iPhone / Apple Watch Be Well Clinic Good Health Hospital CCDA (pull) 2 Provider portal/EMR

11. REVIEW OF WHAT WE JUST DISCUSSED Leverage interoperability standards in a meaningful fashion in order to effect better information flow Demonstrate exchange between providers and between patients and providers “DIRECT”ed exchange as well as query-based exchange so history is available to any care provider involved in patient care Mobile application integration/Apple HealthKit Demo mature standards like XDS/XDR/CCDA as well as emerging technologies like FHIR, SMART apps 11

12. WE NEED STRICTER AND WIDER ADOPTION OF THESE NOT MORE OF THEM VocabularyContent & Structure TransportServices SNOMEDHL7 2.xSMTP/SMIME“Direct” NPIHL7 CDAHTTP/RESTfulIHE XDR ICD10CDA BPPC Etc.SOAPPIX/PDQ LOINCNCPDP / SCRIPTTLSXDS/XCPD RxNormHL7 2.5.1FHIR/SMART HCPCS/CPTDICOMHPD HL7 Value SetsFHIRDICOM

13. CareEvolution cFHR™ App Sample Scenario Data Flow HIEBus Beacon cFHR iPhone & Watch App Clinical Inbox iPhone app Apple Health Third-party Blood Pressure Monitor 1 2 3 4 5 6 7 1.Beacon sends an alert to the cFHR that Helen is overdue to check her blood pressure 2.At the same time as #1, Beacon sends an alert to the PCP’s Clinical Inbox, notifying Helen’s PCP that she is overdue 3.Helen uses a third party blood pressure monitor to take her blood pressure. The blood pressure is sent to Apple Health. 4.The cFHR app, which continuously monitors Apple Health for new data, receives the new blood pressure value 5.The cFHR sends the new blood pressure value to HIEBus 6.Beacon detects that the new blood pressure value is high, and sends an alert to the cFHR that Helen has high blood pressure 7.At the same time as #6, Beacon sends an alert to the Clinical Inbox, notifying Helen’s provider that she has high blood pressure © CareEvolution, Inc.

14. STEP 1: Patient Receives Alert For Blood Pressure on Apple Watch and HealthKit Certified iPhone App – cFHR™ Helen has enrolled in a program through her provider for blood pressure monitoring. Through Beacon, she is alerted when she is overdue to take a reading. She can receive the alert in multiple ways, and can opt to be reminded later if she doesn’t want to take a reading immediately. cFHR iPhone and Watch App © CareEvolution, Inc.

15. STEP 2: Provider Receives List of Patients Who are Alerted for BP Monitoring Since Beacon powers alerting for both patients and providers, a provider could also receive a list of enrolled patients who are overdue for blood pressure readings, in order to follow up with them. Beacon Clinical InboxBeacon Surveillance Reports © CareEvolution, Inc.

16. When Helen is ready to take a blood pressure reading, she can use any Apple HealthKit compatible device to send the data directly to her provider, through the cFHR app. The cFHR iPhone App, which is continuously monitoring for new Apple HealthKit blood pressure readings, uploads the new Blood Pressure readings to HIEBus Helen uses her third-party blood pressure monitor to take a reading. The app for the blood pressure monitor stores the blood pressure reading into Apple HealthKit. STEP 3: Patient Uses an Apple HealthKit compatible BP Monitor to Take BP Reading © CareEvolution, Inc.

17. After receiving an alert that she is overdue to take her blood pressure, Helen uses her HealthKit compatible blood pressure monitor to take a reading. The new value is immediately uploaded, and she is alerted to make an appointment for her high blood pressure. STEP 4: The HealthKit Certified cFHR™ on iPhone and Watch App Take BP Reading and Communicates Back © CareEvolution, Inc.

18. Once we have received the blood pressure reading, we can analyze and possible generate alerts. In this instance, Helen’s blood pressure reading was high, so we alert her to make an appointment with her doctor. Her provider can also be notified of her high blood pressure reading. Beacon Clinical Inbox (provider-facing) cFHR iPhone and Watch App (patient-facing) STEP 5: HIEBus™ Uses Clinical Rules to Determine if Further Action is Needed © CareEvolution, Inc.

19. APPENDIX

20. cFHR™ iPhone and Watch Apps – Extensions to HIEBus™ (Health Information Exchange BUS), a robust data aggregation and intelligence platform © CareEvolution, Inc. Confidential and Proprietary

21. Logging in Once a provider has set up a user account for either a patient or provider user, the user must download the cFHR (patient) or Beacon Clinical Inbox (provider) app from the app store. For the cFHR Watch app to function, a user must log into the cFHR app on their iPhone. Beacon Clinical Inbox (provider-facing) cFHR iPhone and Watch App (patient-facing) © CareEvolution, Inc.

22. HealthKit Support The cFHR app supports exchange of data to and from Apple Health. Upon logging into the cFHR, a patient user will be able to enable this. The exchange of data that occurs with Apple Health is continuous and requires no further user interaction. When another application stores a value into HealthKit, The cFHR will automatically be alerted to send the value to the patient’s provider. © CareEvolution, Inc.

23. Family medical history On both their iPhone and their Apple Watch, patients are able to view their family’s complete medical record in an easy-to-use format. © CareEvolution, Inc.

24. Alerting Beacon alerting, built on top of HIEBus health information exchange, generates alerts for both patients and providers. When certain conditions (configurable by provider) are met, alerts can be send to patients, providers, or both. Beacon Clinical Inbox (provider-facing) cFHR iPhone and Watch App (patient-facing) © CareEvolution, Inc.

25. HIEBus Health Information Exchange Beacon Patient Monitoring and Alerting cFHR iPhone & Watch App Allows patients to receive alerts and view their family’s health records Clinical Inbox iPhone app Allows providers to receive alerts and view their patient’s health records Apple Health Allows collection and transfer of data to and from the ecosystem of Health apps on the iPhone Third Party Applications Fitness applications, health monitoring devices, etc. © CareEvolution, Inc.