California To Host Major Open Health Information Exchange (HIE) Conference

Leaders of major open source projects in healthcare and the open health HIE community are gathering for the annual Redwood MedNet Conference in Santa Rosa, CA next Thursday and Friday, July 24-25. While the focus of this conference is the growing open source HIE movement in California, the conference will feature successful open HIE implementations from around the world, including the extraordinary OpenHIE effort in Rwanda, and critical lessons for any HIE and health information organizations (HIOs) that want to develop cost-effective and successful interoperable solutions.

This conference comes in a timely manner as the Office of the National Coordinator (ONC) has run out of money to fund HIEs across the United States. Whatever support they will provide HIEs moving forward will be minimal. There are serious concerns about the survivability of most HIEs across the country. The conference will provide practical open solutions and approaches that have allowed California-based HIEs to succeed and can be used as models nationally. This conference is one of the two most important Open Health conferences this year, the other one being the OSEHRA Open Source Summit 2014 coming up in September in Behesda, MD.

Titled Connecting California to Improve Patient Care, this is an annual conference featuring subject matter experts on electronic health records (EHR) and on the use of national technology standards to establish interoperability for electronic patient health data. Conference presenters will explain practical solutions for securely sharing electronic clinical information between computer systems at unaffiliated health care facilities, such as outpatient practices, hospitals, laboratories, imaging centers, long term care, home health, public health, and also including patient engagement portals and mobile apps. Conference attendees will learn about best practices in health informatics. Speakers will explain the current status of health information technology California, national software road maps for standards and interoperability and patient safety, and emerging tools and opportunities for physician and patient engagement.

The California Open HIE experience

In order to get more details about the conference OHNews talked to Robert (Rim) Cothren, executive director of the California Association of Health Information Exchanges, a statewide group of community and enterprise health information organizations working together to advance safe and secure HIE throughout California, and co-sponsor of the conference. First question to Cothren was “why should people from all over the world attend the conference?” Cothren said that while the conference was primarily meant for California stakeholders, he emphasized that "California is an interesting ecosystem...a smaller version of the nation with all of the same issues and problems.” He said that that “makes California an interesting model and laboratory for how to make things work on a larger scale,” adding that “we take national models and implement them here, and things we implement here may be good national models.”

Robert CothrenCothren also pointed that “we also have a number of pockets of true, mature, health information exchange. They are different – offering different functionality to meet the needs of differing participants. But they are also part of a single community. That means there is real motivation among them to collaborate, exchange, and try new things. This conference will illustrate the models that might work elsewhere and the new things we are trying here.”

Speaking about the impact of the open source Redwood MetNet, a fully functional open source HIE developed over the past decade in Mendocino County, CA, under the leadership of Will Ross, Cothren said that the impact had been “huge.” Cothren said that “California stakeholders have long been supporters of open approaches – open standards, open source solutions, etc. And Will has always been a strong promoter, ensuring that through this Conference, and through more personal conversations, everyone is aware of what can be accomplished through open tools.”

Asked if what they were presented at the conference could be a “a national model,” Cothren answered that “It sort of is, but on a smaller scale.” Refering to the ecosystem mentioned above, he said that “the California Connects demonstration model is modeled after a concept in HIMSS’ Interoperability Showcase. What differs here – and is especially cool – is that these are not isolated demonstrations of what could be. These are demonstrations that are or soon will be, and many of the participants are interacting with each other. Again, the collection of demonstrations illustrates an ecosystem, not just how two or three players can interact.”

The collection of demonstrations refers to the California Connects Interoperability Exhibition, which is hosted concurrently as part of the Redwood MedNet Conference. This exhibition will feature practical kiosk demonstrations on interoperability. The kiosks will show the secure exchange of electronic health data, including patient engagement with the care team, in a hands on manner that allows one on one interaction with the kiosk presenters.

These exhibitions present combinations of solutions that are “open” as well as proprietary solutions that work with open source solutions and frameworks and are presented by a range of organizations and companies, open source and proprietary. One company representative said that “they were all about creating the pieces-parts that their customers could use – not solutions, but tools.” Cothren points out that “Given that HIE and the healthcare industry in general is in payment reform and searching for business models, there needs to be flexibility in what customers can do since they don’t know today what the functional needs and trading partners will be tomorrow.”

Cothren concluded that “I think what we are starting to see is that there are finally enough pieces-parts and flexibility provided by vendor tools that HIOs and care delivery organizations are starting to create real, interesting, and usable functioning solutions. I think California Connects shows that in many ways, without requiring those that are participating to fit into that model – it just happened.”

The Massachussetts Open HIE-The Mass HIway

It is not just California that is succeeding with open HIEs. Dr. John Halamka, CIO of Beth Israel Deaconess Medical Center and Professor at Harvard Medical School will be giving the keynote presentation. Dr. Halamka was one of the key leaders in the development of the Massachusetts Health Information Highway (The Mass HIway). It was launched in October 2012 when Massachussetts Governor Deval Partick hit the "send" button on the first electronic record transmission.

Dr John Halamka

The Mass HIway is not a data repository. Instead, it offers doctors’ offices, hospitals, laboratories, pharmacies, skilled nursing facilities, and other healthcare organizations a way to securely and seamlessly transmit vital data electronically. Mass HIway was founded on the principle of openness - any trusted participant can join, using any vendor/technology, and sending any payload. The cost is just $5/provider/month.

Dr. Halamka will speak at the conference about the lessons learned running an open, public utility health information service provider at a state level. Some of those lessons have already been discussed in Dr. Halamka's immensely popular blog, Life as a Healthcare CIO. However, this is the first time that Dr. Halamka will specifically address an open HIE conference. I should note that Dr. Halamka has been very kind to Open Health News readers and given us permission to reprint his blog posts that would be of most interest to our audience. We have posted a few and are in the process of going back in time to his posts where he talks about open source in healthcare.

Recently Dr. Halamka published an e-Book on his life experiences, including his "experiences with health IT leadership, infrastructure, applications, policies, anagement, governance, and standardization of data," as well as his life experiences including his current efforts at sustainable agriculture and healthy living through his Unity Farm in Massachussetts, a fascinating topic in his blog as he talks about all aspects of building his farm. The book, titled "GeekDoctor: Life as a Healthcare CIO," can be downloaded from Amazon.com.

Rwanda, OpenHIE, OpenMRS, and mHealth

One of the other presenters at the conference will be Dr. Paul Biondich a medical informatics researcher and pediatrician working at the Regenstrief Institute, a world-renowned institution in medical informatics research. Dr. Biondich has been working on clinical decision support systems and the use of large scale, consolidated electronic health information infrastructures in this regard. His focus is in resource poor environments throughout the world, currently leading the OpenMRS project, and helping develop national health information exchanges for Rwanda and other African countries. He also is the director of clinical informatics for AMPATH in Western Kenya, and the director of the Fogarty East African Health Informatics Fellowship program. 

Dr Paul Biondich

Created in 2004, OpenMRS (Open Medical Record System), an open source medical records system, has grown beyond all expectations, having been implemented in more than 40 countries around the world (see the OpenMRS Atlas). OpenMRS is a multi-institution, non-profit collaborative led by the Regenstrief Institute, and Partners In Health, a Boston-based philanthropic organization with a focus on improving the lives of underprivileged people worldwide through health care service and advocacy. This work is supported in part by many organizations including international and government aid groups, NGO’s, as well as for-profit and non-profit corporations.

The OpenMRS teams nurture a growing worldwide network of individuals and organizations all focused on creating medical record systems and a corresponding implementation network to allow system development self reliance within resource constrained environments. Open Health News has been covering OpenMRS (see here). A couple of good articles include this interview with Ben Wolfe, and a recent article by Darius Jazayeri on the release of OpenMRS 2.0, a major milestone for the open source EHR.

In addition to Dr. Biondich's presentation, there will be an exhibit of OpenHIE, a health information sharing platform that has emerged out of the OpenMRS work and is being currently deployed in Rwanda. The exhibit will include the participation of multiple international organizations that are supporting the OpenHIE project including IntraHealth International, IHE, CapacityPlus, and USAID. I am looking forward to this presentaino and exhibit as I see it as one of the most extraordinary stories of how to do health informatics right. Rwanda, a nation wracked by civil war and genocide in the 1990's, has been successfully implementing OpenMRS throughout the whole country and connecting these implementations into a national open source HIE. Compare this to the United States where federal agencies and healthcare facilities have spent over a trillion dollars in the past five years implementing and subsidizing proprietary EHRs and HIEs with minimal usability and nearly non-existent interoperability. Failure rates are staggering. As noted in this article, 40% of hospitals in the United States are currently scrapping their lousy and expensive proprietary EHRs and replacing them, with...lousy and expensive proprietary EHRs!

The efforts in Rwanda have not gone unnoticed. Last December the mHealth Alliance, an organization dedicated to advancing the use of mobile technologies to improve health outcomes in low- and middle-income countries, awarded Dr. Richard Gakuba of Rwanda the Holly Ladd mHealth Pioneer Award. This award is “designed to honor visionaries in the field of mHealth – individuals and organizations whose work serves as a shining example of what is possible when we use mobile technologies strategically to improve health outcomes in developing countries,” according to Dr. Patricia Mechael, executive director of the mHealth Alliance. This award was co-sponsored by the mHealth Alliance, FHI 360 and the Rockefeller Foundation.

According to the announcement, “Dr. Gakuba was honored for his pioneering work, which has led to the creation and implementation of a national e-Health strategy for Rwanda. This strategy has created a regulatory environment that is enabling mHealth projects and programs to flourish and scale. Dr. Gakuba’s work has helped to optimize the effectiveness of health care delivery and made health services more affordable in Rwanda.”

The SMART Platform and FHIR

This conference is truly filled with extraordinary presentations and exhibits. Hard to describe all important aspects of it. One particular presentat and exhibit I would like to point to is that of Joshua Mandel, architect of the SMART Platform. This platform has been evoliing rapidly and together with FHIR, it provides a set of open specifications to integrate clinical apps with Electronic Health Records, portals, Health Information Exchanges, and other Health IT systems. Andy Oram just wrote an extensive article for OHNews on this project titled "Standards and Open Source Make Advances in Apps and Data Exchange for Health." Following his presentation at the conference Mandel will do a demonstration that "will show the technology stack that powers the platform (FHIR; OAuth2; and OpenID Connect) and will outline what it takes for a Health IT system to become SMART."

Redwood MedNet Presentations and Exhibits

The Redwood MedNet conference is made up of a combination of presentations and exhibits. This provides the aucience with a talks and hands-on demonstrations. It also allows the participants to meet the project leads and companies that are involved in making open HIEs happen. Below we present both the list of speakers as well as summaries of the exhibits.

Conference Presenters

In addition to the main presentations, Redwood MedNet and CAHIE are co-sponsoring the California Connects Interoperability Exhibition. California Connects will feature hands on demonstration kiosks staged in an exhibition area adjacent to the plenary ballroom for the Redwood MedNet Conference. The California Connects kiosks will allow conference attendees to see clinical data interoperability solutions based on practical technology standards for electronic clinical data exchange services.

Interoperability Exhibition Schedule, Friday July 25, 2014

    9:30 AM to 10:15 AM - Morning Break - 45 minutes
    12:00 PM to 1:15 PM - Lunch Break - 75 minutes
    3:00 PM to 3:45 PM - Afternoon Break - 45 minutes

Exhibition schedule may evolve based on changes in Plenary session start and stop times. Kiosk demonstrations are open to the public during the 2014 Redwood MedNet Conference.

Interoperability Kiosks

Direct Provider Address Discovery and Document Delivery

  • Organized by RAIN Live Oak HIE and Telemedicine Network
  • Role in the demonstration HISP for Direct.
  • Serving as Interoperability Broker for participants
  • in the demonstration. (Oak Valley Hospital District and RAIN HIE).

Synopsis: Using robust, open-source interfaces RAIN Live Oak DIRECT will demonstrate a speedy and reliable process for a registered ambulatory or acute healthcare provider to search the CTEN federated provider directory to discover a Direct address and transmit medical documents and referral information.

Goals and Objectives: Direct is an increasingly integral part of California’s HIE ecosystem and Direct address discovery is vital to wide adoption and use of the standard. As the CTEN statewide federated directory grows in scope, polished and easy to use interfaces will be key to driving provider participation. A smooth, quick search-discovery-delivery cycle will demonstrate how use of Direct and a provider directory can improve workflow, not slow it down.

Query-Based Exchange via eHealth Exchange

Synopsis: Query-based exchange is demonstrated between Dignity Health's private HIE, "Mercy Health Information Exchange", and the UC Davis Epic EHR via the eHealth Exchange, allowing clinicians to access clinical information from another health system for a given patient. This exchange helps clinicians provide more efficient and comprehensive care for patients, improve outcomes, and help reduce the cost of healthcare through eliminated duplicative tests.

Goals/Objectives:

  • Demonstrate interoperability between a private Health Information Exchange and disparate EHR, Epic
  • Showcase query-based exchange via the eHealth Exchange; successfully executing the three distinct steps :
  • Patient Discovery Query (PD)
  • Query for Documents (QD)
  • Retrieve Documents (RD)

Success Criteria: Using the HIE, successfully search for a patient in the Epic EHR and retrieve their CCD.

Exchange and Direct Messaging Between VA and Private Sector

Synopsis: VA is using Exchange and the eHealth Exchange with 17 private-sector organizations to coordinate Veterans' care. Direct secure messaging is a new protocol currently piloted by VA to enable both provider-mediated and patient-mediated health information exchange.

Goals and Objectives: There are 3 goals to this demonstration:

  1. Care Coordination: Exchange between VA and several private sector organizations, seen from the point of view of a VA clinician
  2. Consult and referral: round trip using Direct secure messaging
  3. Patient engagement: use of patient portal (My HealtheVet) to obtain, view, download, and transmit a copy of their CCD to their iPhone

Using Direct and iBlueButton for Transitions of Care

Synopsis: Demonstrating coordination of care across disparate systems and care settings using the ClearExchange Interoperability Suite of solutions. The latest available standards and capabilities are on display including Blue Button+, Consolidated CDA, Direct Messaging, and Provider Directory.  

Goals and Objectives: ClearExchange will show the power of an HIE. The ability for all care team members to have access to all the data, all the time. Whether from within the providers EHR or by a portal to view the longitudinal health record. ClearExchange bridges the gap between traditional providers, hospitals, behavioral health, specialists, ancillary services, emergency services and beyond.

iBlueButton for Consumer-Mediated HIE

Synopsis: This demonstration shows a Veteran receiving care at the San Diego VA, at a private clinic, at a military treatment facility, and at the University of California San Diego (UCSD) using the Humetrix iBlueButton app to access, display, aggregate, and store health records from the VA, Medicare, and DoD with a UCSD C-CDA record transmitted to the app by Direct via the San Diego Health Connect HIE. At an Emergency Department in Santa Cruz, the Veteran transmits these records to the iBlueButton Professional iPad app of an ED physician who then sends back an encounter summary by Direct using the Santa Cruz HIE.

Goals and Objectives: The major objective of this demonstration is to show the audience how existing BlueButton+, Direct protocol and Meaningful Use standards enable a patient using a currently available commercial mobile app (iBlueButton for iOS and Android smartphones) in conjunction with existing California HIE infrastructure to now have online or offline 24/7 access to a comprehensive PHR bringing together records from the VA, DoD, multiple EMR systems with the Medicare Blue Button record. This demonstration will be a powerful illustration of “how new standards can enable improved, secure, and timely access to health information in a way that meets the workflow needs of providers and patients.”

Asthma Management with Wearable Device Linked to PHR

Synopsis: Bidirectional transport of patient data is demonstrated between provider HISPs and patient-owned PHRs using information from asthma patients. A UCSD School of Engineering device, "CitiSense", measures air quality in real-time with a geolocation and sends data to a smartphone. An additional device uses wireless inhaler monitoring to count the number of puffs a patient takes versus their geolocation in real-time. These two data elements are analyzed and return a summary document for the patient and provider using Direct, and custom treatment plans from the provider are returned to the patient via Direct.

Goals and Objectives: Those viewing the demonstration will see how to enable exchange by installing the NATE trust bundle that enables patient-mediated exchange with PHRs, and adopting their voluntary requirements for transparency and disclosure for sending data via Direct messaging, which includes:

  1. NATE policies that require uniqueness of the inbound Direct message address, not able to be re-purposed for another patient or other use,
  2. If provenance is available, it will be maintained,
  3. Agreeing to maintain the C-CDA as if immutable, or indicate if record has been changed by the patient, and
  4. Patient authentication is required for sending Direct messages.

They will also learn the value of baseline requirements for a participating HISP to provide an automatic reply: for example, contact your provider if your message is an emergency, and for a receiving provider to have local autonomy to accept or not accept any message.

Community Hospital Sends Patient Visit Alerts to PCMH

Synopsis: A patient visit to a community hospital triggers the Redwood MedNet visit alerting service. The patient registered in the hospital visit is compared to a PCMH (Patient Centered Medical Home) registry published and continuously updated by a nearby community clinic. If a hospital patient is also on the community clinic's PCMH registry, then a visit alert message is sent to the community clinic. The alert message is routed in the community clinic's EHR to the PCMH care team assigned to the patient. 

Goals and Objectives:

  • Support PCMH care team with patient visit alert from an unaffiliated healthcare facility.
  • Demonstrate use of classic HL7 push messaging.
  • Demonstrate value of community HIO service.

SMART on FHIR

Synopsis: SMART on FHIR provides a set of open specifications to integrate clinical apps with Electronic Health Records, portals, Health Information Exchanges, and other Health IT systems. The use cases will demonstrate Web-based SMART apps running against an open-source reference implementation as well as a commercial EHR (Cerner Millennium). The demonstration will show the technology stack that powers the platform (FHIR; OAuth2; and OpenID Connect) and will outline what it takes for a Health IT system to become SMART. 

Goals and Objectives: We introduce the audience to FHIR, an emerging resource-oriented standard and RESTful API for health data from HL7. We present FHIR in the context of SMART Platforms, a project funded by ONC's SHARP program to develop open standards-based app platform for Health IT. We demonstrate a set of real-world clinical apps running inside an open-source reference platform as well as a MU2-certified commercial EHR (Cerner Millennium). These apps support demonstrated clinical needs including the diagnosis of high blood pressure in children, as well as patient communication for non-English speakers.

  • Demonstration makes use of current or emerging national standards.
  • Demonstration illustrates how health information technology can improve patient care, reduce cost, and promote patient engagement, and is not limited to Meaningful Use criteria or metrics.
  • Demonstrated technology helps solve a real-world problem that clinicians or patients face today by providing better access to health data.

Provider and Patient Scheduling with Care Services Discovery (CSD)

Synopsis: This demonstration illustrates how the new Care Services Discovery (CSD) profile from IHE (Integrating the Healthcare Enterprise) can support various workflows for patient scheduling and follow-up care. 

Goals and Objectives: Show the flexibility of the Care Services Discovery (CSD) profile from IHE to meet a wide variety of workflows across the HIE including high priority workflows related to patient scheduling and follow-up across points of services.

Pushing Real Time Gap-in-Care Alerts to the EHR

Synopsis: IPAs, medical groups, health plans, and hospitals are delivering patient-specific "gap-in-care" alerts directly to the physician desktop. The transition from volume-based to value-based health care delivery relies on communication of critical information to the clinician in real time while the patient is present. This solution has been used to change a health plan's CMS Star rating from 3.5 to 5 Stars in less than 3 years, which led to increased reimbursement.

Goals and Objectives:

  1. Care Coordination: using tools to deliver critical gaps-in-care to a treating clinician while seeing a patient
  2. Reduce Costs: Early interventions for early detection
  3. Demonstrate National Quality Standards -- Solving the real-world problem of coordinated communication about a patient’s care needs facilitating critical gaps in care messages across multiple patient care enterprises (hospital systems, medical groups, surgical/diagnostic centers, etc.)

California Trusted Exchange Network (CTEN)

Synopsis: CTEN provides a lightweight infrastructure that facilitates health information exchange statewide among otherwise unaffiliated HIOs. Demonstrations that use CTEN services will illustrate how published Trust Bundles enable authentication of exchange services that comply with consensus policies, and how federated Directory Services enable discovery of Direct addresses and Exchange endpoints.

Goals and Objectives: The use of CTEN services in other California Connects demonstrations will show:

  1. How CTEN Trust Bundles provide a scalable means of establishing trust among participating Direct HISPs without the need to exchange trust anchors;
  2. How CTEN Trust Bundles provide a flexible means of establishing trust among participating Exchange gateways without a centralized certificate authority;
  3. How the federated CTEN Directory Services architecture facilitates simple Exchange service or Direct address discovery, while avoiding a centralized, statewide directory
  4. How Directory Services can extend beyond simple Direct address discovery to support other means of exchange and other use cases; and
  5. How Trust Bundles and Directory Services allow providers to exchange easily across organizational boundaries.

While CTEN services are compatible with other national initiatives, they enable a more complete set of exchange transactions than DirectTrust, Healtheway’s eHealth Exchange, or the National Association for Trusted Exchange (NATE).