Connected Health Interoperability Platform_White Paper_Cisco UCSF_2016

Empowering Digital Health InnovationThe Connected Health Interoperability Platform

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The Case for Connected HealthHealthcare organizations face increasing pressure to keep costs of care down while providing the highest quality care. Caring for a population of patients with a chronic disease, like asthma, CHF, or diabetes requires good data quality, data analytics, and data liquidity, as well as resource coordination. While no available population health tool can solve everything on its own, several applications working together seamlessly can. Improving the consumer experience and engagement with healthcare will similarly require a seamless end-to-end solution comprised of many different applications working together.

Imagine what will be possible when EHRs, mobile health apps and devices, and wearables all work together and pass data between them.

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ContentsThe Digital Healthcare Ecosystem Today

Connected Health Interoperability Platform

Cisco Digital Platform

Conclusion

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© 2016 Cisco and the Regents of the University of California. This document is Cisco Public.

Referral Management• What if primary care doctors were able to quickly identify the right specialist for each patient who needs one?

• What if all of the necessary information was sent with that referral so that a patient never again drove 400miles only to show up and waste a visit because an ultrasound report is missing?

• What if primary care doctors were always notified of specialist visits after the patient was seen?

• What if your hospital could report on, track, and analyze all referrals made and completed to optimize resourceallocation?

Care Collaboration• What if your primary care doctor, primary oncologist, consulting oncologist, palliative care doctor, physical

therapist, occupational therapist, neurologist, cardiologist, and orthopedist could all communicate together about your care through a chat tool so that you didn’t have to be the router of information?

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• What if your oncologist, radiologist, and pathologist could all view the same CT scan and laboratory data tomake a treatment decision together in that chat tool, despite being 250 miles apart?

• What if you could be part of that chat?

• What if the chat could immediately switch to a video conference to help make such an important decision?

Patient Experience• What if you had one portal to view all of your health data instead of having to log on to five different ones?

• What if you could schedule appointments with any of your doctors from that one portal? What if that visit couldbe an immediate video visit?

• What if the temperature, blood pressure, weight, blood glucose, and activity data that you’re tracking at homecould help your doctor diagnose you?

• What if the reminder sent to you to get a flu shot or colonoscopy was accurate?

Precision Medicine in the EHR• What if the application used to monitor your cardiac pacemaker automatically could pull in your medication list

and other medical history from the EHR?

• What if the application used to monitor your continuous glucose data and insulin pump data could write yourmost recent insulin pump settings directly into the EHR?

• What if your health data could be compared in real-time to thousands of other cancer patients like you to helpdecide what treatment to use next?

• What if while prescribing a medication, your doctor already knew how much each medication would cost youand what the chance of its effectiveness would be?

• What if your health data could automatically populate a system that matched you to the clinical trials that wereoptions for you?

Health Data Security and Privacy• What if you knew everyone who had access to your health data, all the time?

• What if you had one place from which you could allow people to access your health data?

• What if you got a notification every time somebody new accessed your health data?

The Digital Healthcare Ecosystem Today Existing technologies leave us unable to meet the needs presented above. EHRs were built to support episodic, fee for service care provided within a single institution. EHRs were not built to support population health, patient engagement, data from consumer apps and sensors, and collaborative patient-centered care across institutions. To realize these needs requires a seamlessly interconnected ecosystem of commodity technologies, such as electronic health record (EHR) systems, adjunct hospital information systems such as Lab Information Systems or Imaging Systems, medical devices, consumer health devices, sensors, smartphones, tablets and an array of computing, network, and storage infrastructure.

Institutions such as the Cleveland Clinic, Johns Hopkins, Duke University, and others have demonstrated capabilities to develop, integrate, and implement innovative healthcare applications. However, nobody has yet provided a solution that scales beyond just a small number of institutions. Inconsistencies of EHR implementations and lack of interoperability standards leave groundbreaking innovations stranded at their origin, unable to reach broad markets. The private sector is full of digital health startups, but they struggle with costly implementations due to unique integrations required at each institution. Partially to avoid this cost, many startups target their apps solely on the consumer market, losing out on the potential benefits of integrating these consumer health functions with the healthcare delivery system.


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Many healthcare organizations want to become more innovative in the way they deliver care and engage with their customers, but implementing and integrating new solutions are very costly. They thus shy away from experimentation, herding toward the solutions which already have the most proven ROI, stifling the potential validation of newer technologies.

Other industries have fueled innovation through a digital data and services exchange economy. Examples outside of healthcare are plentiful: Amazon.com in retail, Google for advertising, Twitter for media and Salesforce.com for sales & marketing. Open application programming interfaces (API’s) are the de facto method for exposing data and electronic services in those industries. There is increasing recognition that API’s are needed to accelerate healthcare innovation1.

Figure 1: Interoperability is the Challenge in Digital Health2 People Navigate the Healthcare Journey; Their Data Does Not

But healthcare is more complex than many other industries and there have been few widely-adopted interoperability standards for healthcare data. This has been a significant barrier to creating open healthcare API’s. Other barriers include the fear of heavy financial penalties from privacy breaches and the walled garden approach of many EHR vendors. Moreover, it has only been in the past few years that the majority of healthcare institutions have even implemented EHR systems, creating a system where health data is off of paper and into digital format5.

Health Level 7 (HL7), a global healthcare data interchange standards organization, has a loose interoperability data standard, eponymously named HL7, which has failed to enable semantic interoperability across the healthcare system. While all related patient data is available, there is no consistent, repeatable way to exchange that data across multiple organizations. While other specifications such as CCD and Direct and regional health information exchanges allow for limited interoperability amongst healthcare institutions, digital health innovators do not have a means to access patient information.

HL7 has been working on a new, lightweight standard called Fast Healthcare Information Resources (FHIR). FHIR simplifies the data model by breaking down the data into its simplest, usable form, e.g. Patient, Problem List, Medication List and Allergy List. More complicated data exchanges are possible by combining simpler objects into a Document construct. The data model is represented as either XML (eXtensible Markup Language) and/or JSON (JavaScript Object Notation), formats common in many other industries and well understood by modern software developers. FHIR also specifies an efficient, yet simple, approach called REST (REpresentational State Transfer) to exchange data resources between two systems.

HL7’s plan is to publish the official FHIR specification in 2017. As of September 2015, the second, draft version of FHIR is being utilized in pilot projects by several organizations. Several notable organizations are advocating


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* The US Department of Health and Human Services has a dashboard of Health IT statistics that reflects EHR adoption, which is currently >90% across the US:http://dashboard.healthit.gov/quickstats/quickstats.php

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FHIR: The White House; U.S. Department of Health & Human Services’ Office of the National Coordinator (ONC); the JASON Task Force, an independent group of scientists who advise various federal agencies; and the Argonaut Project, an alliance of EHR vendors, most notably Cerner and Epic and a few leading healthcare institutions. Epic and Cerner, two of the largest EHR system vendors, have minimal (read only) FHIR implementations in the latest version of their software.

Roadblocks to Digital Health InnovationWe believe that the adoption of FHIR as a standard is necessary, but not sufficient toward creating a scalable and interoperable health ecosystem to accelerate digital health innovation. In particular, we identify these roadblocks that are impeding digital health innovation and slowing adoption:

• Lack of Semantic Interoperability: Both HL7 and FHIR support what HIMSS calls foundational andstructural interoperability: data can be exchanged (HL7) and uniform & structured exchange is possible(FHIR). Semantic interoperability is the ability to exchange information and allow the information to be used6.While FHIR has been an improvement, it is only a stepping stone to semantic interoperability.

• Decentralized Patient/Consumer Data: Patient data today typically resides across different EHR’s. A patientcan be seen by his/her primary care doctor in a family practice clinic, visit urgent care at a regional healthsystem, and see specialists at an academic medical center. In addition, health data is no longer limited to theEHR. Consumer medical devices, wearables, apps, and sensors generate streams of data that contributeinformation about a patient’s health status. Data from these sources reside in the cloud or on a smartphone.Each system has its own set of patient/consumer identifiers as well as unique health data models and putting together a holistic picture of a patient has yet to be achieved.

• Hospital/Clinics IT Resource Limitations: Hospitals and healthcare systems have spent billions of dollarsover the past 5 years to implement EHR’s. Most healthcare IT organizations are stretched to keep these EHR’srunning. In other industries that participate in the API service exchange economy, significant resources are poured into supporting their API infrastructure. Very few hospitals and clinics can justify funding the resources needed tosupport a robust API infrastructure. Combine that with a lack of compelling digital health applications that easilyintegrate with EHR API’s, there is no way to justify the expenditure.

• Limited Healthcare API Enabled Solutions: The majority of interoperability solutions today still use HL7interface engines to exchange data from an EHR system. While some have API capabilities, the functionalityis limited. A hospital can readily share data to ancillary systems, e.g. lab systems or imaging systems yetthe majority of hospitals and clinics are unable to share information with one another. Many EHR vendorsare now providing API capabilities that allow access (typically read-only) to its EHR patient data, but withoutan interoperability standard, there are few hospitals that are utilizing those API services. As a result, only aminiscule number of digital health applications can be integrated with hospital EHR’s.

• HIPAA and Security: Many healthcare applications, especially those intended for clinical use, must followrigorous security practices in order to meet HIPAA requirements. Each institution that wishes to adoptthose applications must thoroughly review them for security vulnerabilities prior to implementation. With theexponential rise of IT security threats, hospital IT security offices are backlogged and have little bandwidth toconduct applications systems reviews, and are unwilling to take on additional risk.

Connected Health Interoperability Platform UC San Francisco’s (UCSF) Center for Digital Health Innovation (CDHI) and Cisco are working together to break down the barriers to digital health innovation. UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. CDHI’s mission is to improve health by collaborating with innovators from UCSF and beyond to envision, realize and evaluate game-changing digital health technologies. Cisco is the worldwide leader in IT that helps companies seize the opportunities of tomorrow by proving that amazing things can happen when you connect the previously unconnected.


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With our partnership, we are building a Connected Health Interoperability Platform (CHIP) that will connect digital health innovations with dispersed patient-consumer data and combine with powerful analytics to revolutionize healthcare. The CHIP will consist of a digital health application market place, a secure, cloud hosted data interoperability system across EHR’s/devices/apps and API services that enable feature rich, interconnected healthcare application development.

Figure 2: A Connected Healthcare Interoperability Platform

Health Applications MarketplaceThe CHIP Health Applications Marketplace will provide a selection of applications that address some of today’s pressing healthcare problems. We are initially focusing on Referral Management, Care Collaboration, and Population Health. Solutions come from UCSF, Cisco, and other partners who have built innovative healthcare applications that are reviewed and vetted by a combined team from UCSF’s and Cisco’s Healthcare teams. Any healthcare institution subscribed to the CHIP will have ready access to all applications in the marketplace. Utilizing a flexible and customizable access rules engine, any application in the marketplace will be able to securely consume data from or write data to the organizations subscribed to the platform.

Digital Platform ServicesThe CHIP provides core hardware and software services running on Cisco’s secure, scalable, cloud-computing infrastructure. As the global leader in IT, Cisco’s infrastructure is highly available and scalable with unparalleled security and performance. The same infrastructure is utilized in finance, retail, and energy sectors. Cisco’s Healthcare Advanced Services team and partners will engage with each subscribing hospital or clinic and connect their healthcare systems to the CHIP utilizing technologies available (HL7, SOAP, REST). Cisco manages and maintains the CHIP cloud infrastructure.

The core capabilities of the platform include the following:

Core Data Services• Holistic Patient Data Model: Patient data conforms to data models championed by the ONC. An extended

consumer data model contains health information from outside the EHR.• Normalized Health Content: Semantic interoperability will be achieved by utilizing healthcare data normaliza-

tion techniques developed by the University of California health system, so that CHIP presents patient informa-tion in a consistent fashion, even though underlying EHR’s may use different encoding mechanisms.


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• Provider Registry: All healthcare workers will have a unique identifier. Current US standards only support anational provider identifier (NPI) for standard transactions, which leaves out many types of healthcare workers, such as nurses.

• FHIR Server: API’s support the data models and services from the ONC’s Interoperability Roadmap and theProfile defined by the Argonaut project.

• Global Master Patient Index: A globally unique patient identifier links patient records across different institutions’EHR’s, as well as across consumer health apps and devices.

Security Services• Authentication: Single Sign On (SSO) authentication services use standards like OpenID so users can be

authenticated against existing EHRs and other systems containing user data (such as Google ID or Fitbit ID). This provides a seamless user experience.

• Authorization (OAuth 2.0 Services): Any external applications utilizing CHIP data must authenticate usingOAuth, that is, given permission by the user. The external applications must specify what data it is accessing and how it will be accessed. Permissions can be revoked by the user at any time.

Core Application Services• Patient-Consumer Portal: Allows a user to view an integrated set of his/her health information in one place.

Two factor authentication will be required for portal access.• Workflow Engine: Coordination of processes is a key capability needed to intelligently combine different appli-

cations in support of healthcare.

Infrastructure Services• Secure Networking and Data Access: All personal health data is encrypted in transit. Data remains at its

source accessed through data virtualization. All access is logged and audited, with advance analytics applied to find suspicious instances of data access.

Development SandboxCHIP aims to accelerate digital health innovation. To achieve this, a development environment will allow healthcare software developers to create software utilizing the CHIP API’s.

Our development site has all our API’s and data models documented. It contains sample code in Ruby, JavaScript, Java, .Net, Objective-C, and Swift. There is a development sandbox FHIR server available, populated with realistic patient and consumer data. Developers will be able to sign up and retrieve development keys to start coding immediately.

Once developed and tested, software can be submitted for eligibility review to the CHIP Healthcare Applications Marketplace. The software will be vetted, end-user tested, reviewed for security, and if necessary, recommended for scientific, clinical validation. Once approved, applications have access to data from every institution subscribed to CHIP.

Cisco Digital PlatformBuilt upon proven technology within the Cisco Portfolio and Cisco Partners, CHIP provides a comprehensive set of capabilities to solve interoperability.

• Service eXchange Platform (SXP) provides a comprehensive cloud solution for delivering business processand automation as a service. SXP rapidly connects users, applications and data to form a highly secure enter-prise-grade cloud that delivers business services faster, at lower cost and at scale.

• Data Virtualization brings agile data integration software that makes it easy to abstract and view data, nomatter where it resides. By utilizing the Data Virtualization Integrated Data Platform, CHIP can query all typesof data across the ecosystem as if it were in a single place.

• Cisco Integration Platform quickly connects and automates processes that span on-premise and cloud-based data, applications and IoT devices through a lightweight service bus and end-to-end API management.


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• Cisco Internet of Everything Data System (IDS) is infrastructure software focused on data handling withinan IoE system. It allows bidirectional communication between devices, processing modules and applications.Applications can consume source data in an event or query based fashion. Applications can also receive notifi-cations of events and state changes. The IDS has the ability to deploy logic throughout the CHIP with softwareand compute functions in a distributed manner at the edge, in a fog node, or in the cloud.

• Connected Analytics brings analytics platform that delivers predictive, actionable insights from high-velocitystreams of live data from multiple sources, enabling real-time governance and immediate actions.

• ServiceGrid brings an integration platform that connects the systems of providers, payors, and external ser-vice providers to enable end-to-end service delivery over entity boundaries. ServiceGrid captures and enforcesworkflow for complex multi-entity interactions (such as eReferral) to ensure compliance and seamless patientexperiences.

• Medical Device Exchange Service (MDES) provides an integrated end-to-end, standards-based solution thatfacilitates patient-centric access to medical records. As Cisco’s Health Information Exchange (HIE) solution,MDES gives healthcare professionals from multiple institutions access to patient data from previously discon-nected systems with incompatible formats and disparate medical terminology. Now providers can quickly andeasily access and review a patient’s medical data gathered by different applications and stored in separatelocations.

ConclusionThe Connected Health Interoperability Platform is currently under construction, but we are demonstrating our FHIR API’s at the API Bar of the HIMSS 2016 Interoperability Showcase. UCSF Health will be the first institution live on CHIP, targeted for late summer 2016. We know this is audacious and bold and we believe collaboration is needed to accelerate digital health innovation.

We invite you to join this exciting movement and become part of the health innovation ecosystem as:

• A healthcare institution or payor that wants to subscribe to the platform to give their patients and physiciansaccess to the best digital health applications

• A device or wearables maker that wants to connect your customer’s data to their electronic health record

• A software company with a great consumer health application that could benefit from patient data from acrossprovider institutions

• A clinical researcher with a new clinical decision support algorithm that s/he’d like to make widely available

• A citizen scientist or a student with a great idea for a healthcare app

Please, visit us at http://digitalhealthplatform.org and sign up to learn how you can join us in revolutionizing healthcare.


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References


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1. https://www.healthit.gov/sites/default/files/ONC10yearInteroperabilityConceptPaper.pdf

2. Walker, J., Pan, E., Johnston, D., & Adler-Milstein, J. (2005). The value of health care informationexchange and interoperability. Health Affairs, 24, W5.

4. Furukawa, M. F., King, J., Patel, V., Hsiao, C. J., Adler-Milstein, J., & Jha, A. K. (2014). Despitesubstantial progress in EHR adoption, health information exchange and patient engagement remainlow in office settings. Health Affairs, 10-1377.

5. http://www.fiercegovernmentit.com/story/healthcare-api-task-force-gets-work/2015-12-07

6. http://www.himss.org/library/interoperability-standards/what-is-interoperability

3. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_82.pdf

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