1. Brief Profile Proposal for 2015/16 Yr 9 presented to the Quality, Research & Public Health (QRPH) Planning Committee RPE for ICP Xen Santas | James Kariuki |Derek Ritz CDC |ecGroup Inc. 2014-10-10 October 2014

2. Background Integrated care pathways (ICPs) are long-running workflows that cross institutional barriers and involve multiple providers of person-centric care. At present, most clinical decision support (CDS) is implemented, in cases where it has been deployed, by local electronic medical records (EMR) systems with local scope. An ICP can be thought of as care guideline- specific CDS that is of system-wide scope. October 2014

3. Background ICPs are of crucial importance to effective and efficient chronic disease management, maternal care, and a number of infectious disease care workflows (such as HIV, TB and Malaria). There is compelling evidence that guideline- based care has a significant positive impact on health outcomes. Even so, there is alarming evidence that, in many jurisdictions, much of the care patients receive is not guideline-based. October 2014

4. The Problem At present, there is not a ready mechanism for a health information exchange (HIE) to: 1.Identify that a patient is enrolled in a defined “care programme” 2.Facilitate and help enforce the guideline-based care for that patient over time and across multiple care delivery sites 3.Systematically capture standards-based (coded) transactions to support the generation of guideline-based metrics and indicators. October 2014

5. The Value Proposition There is compelling evidence that guideline-based care leads to the best patient health outcomes. In low-resource environments, HRH is a significant challenge; ICPs support task shifting, which is an important HRH strategy in many LMICs. An HIE-based care “ICP engine” gives an MOH a ready way to operationalize new care workflows. If you know what was supposed to happen, you can raise an alert if it doesn’t. Adherences to guideline-based care can be employed as a provider payments metric. October 2014

6. Market Readiness Multiple commercial and open source enterprise- class, BPMN-capable workflow engines are available Many commercial and open source HIE products have orchestration capabilities A number of care guidelines (ICPs) have been modeled using BPMN IHE’s Retrieve Process for Execution (RPE) profile is in trial implementation; it defines a way for BPMN-defined care paths to be woven into clinical workflows October 2014

7. Existing Profiles & Risks October 2014 Interoperability Layer (IL) CR HWRFR SHR POS TS XDS, PDQ, CSD XDS CSD PDQ DTS OpenHIE

8. Existing Profiles & Risks October 2014 Interoperability Layer (IL) CR HWRFR SHR POS TS XDS CSD PDQ DTS ICP RPE XDS, PDQ, CSD OpenHIE

9. Existing Profiles & Risks October 2014 Interoperability Layer (IL) CR HWRFR SHR TS @@H? XDS CSD PDQ DTS ICP RPE OpenHIE

10. Existing Profiles & Risks October 2014 Orchestration Logic CR HWRFR SHR POS TS XDS CSD PDQ DTS ICP RPE SOA is not a requirement.

11. Existing Profiles & Risks Our prototype will be able to leverage existing IHE profiles for document exchange and client & provider & facility ID resolution (XDS, PDQ, CSD) We will use RPE to communicate with the ICP engine. (Risk: new use case) Presently, we use a proprietary spec for terminology services. (Risk: idiosyncrasy) We expect to leverage a companion IHE ITI work item (@@H) for alerting. (Risk: new profile) October 2014

12. “OECD” Use Case… Presently Derek has type II diabetes It has been 8 months since Derek has had an HbA1C test Derek is sitting at home reading a book Derek is one of the more than half of diabetic patients who is not receiving guideline- adherent care (Ontario, Canada) RPE4ICP Derek has type II diabetes It has been 8 months since Derek has had an HbA1C test Derek is sitting at home reading a book Derek gets a text message reminding him he needs to see Dr. Black to get an HBA1C test Derek gets back on track and better manages his illness October 2014

13. “LMIC” Use Case… Presently Mosa is pregnant Grace, the CHW in Mosa’s village, enrolls Mosa in the MOH’s maternal care programme Mosa goes to her first ANC visit; she tests HIV+ and is put on a PMTCT protocol Mosa is one of the nearly half of pregnant mums who doesn’t attend all 4 ANC visits RPE4ICP Mosa misses her 2 nd ANC visit Grace receives an SMS message indicating she should look in on Mosa Grace visits Mosa, who is bed- ridden with a fever Grace calls for an ambulance to come get Mosa and take her to the district hospital Mosa’s baby is one of the ~95% born HIV- to an HIV+ mum because of PMTCT October 2014

14. Discussion This work item is a white paper The white paper will document a prototyping effort based on using RPE to operationalize guideline-based care within the transaction processing logic of a standards-based HIE The target HIE, OpenHIE, leverages profiles from QRPH, ITI and PCC; as such, we anticipate cross-committee collaboration We estimate this to be a medium work effort Resources from CDC and ecGroup will be appropriately dedicated to the prototyping and the document authoring If warranted, the white paper may inform subsequent IHE profile development related to this topic October 2014

15. White Paper Authors CDC – Xen Santas – James Kariuki ecGroup – Derek Ritz – Justin Fyfe October 2014