What is #BlockChain? Implications for Healthcare by @msharmas

In my previous article I discussed about the benefits and barriers to the use of an Integrated Health Information Platform. In healthcare the need for presenting the Information to the Right Person at the Right Time has been proven to improve outcomes in patient treatment.

Will HIE 2.0 benefit from the use of Blockchain in presenting the information to the Right Person at the Right Time? 


What is Blockchain?
Various definitions of Blockchain have been put across based on the context of the use. Some of these definitions are: 

A digital ledger in which transactions made in bitcoin or another cryptocurrency are recorded chronologically and publicly.

“The blockchain is an incorruptible digital ledger of economic transactions that can be programmed to record not just financial transactions but virtually everything of value.” Don & Alex Tapscott, authors Blockchain Revolution (2016)


The Blockchain is a decentralized ledger of all transactions across a peer-to-peer network. Using this technology, participants can confirm transactions without the need for a central certifying authority. Potential applications include, fund transfers, settling trades, voting etc.


Blockchain is a distributed system for recording and storing transaction records. More specifically, blockchain is a shared, immutable record of peer-to-peer transactions built from linked transaction blocks and stored in a digital ledger. [1]


A Blockchain is a data structure that can be timed-stamped and signed using a private key to prevent tampering. There are generally three types of Blockchain: public, private and consortium. [6]

How is Blockchain different?

Traditional databases are proprietary to the entity that maintains them and owns them. And the information stored within these databases are accessed only by providing access via an application or shared by the entity in some form of a distributed architecture. 

On the other hand, “blockchain is enabling a database to be directly shared across boundaries of trust, without requiring a central administrator. This is possible because blockchain transactions contain their own proof of validity and their own proof of authorization, instead of requiring some centralized application logic to enforce those constraints. Transactions can therefore be verified and processed independently by multiple “nodes”, with the blockchain acting as a consensus mechanism to ensure those nodes stay in sync.” [2]

A quite often stated example for explaining Blockchain is the Google Doc example. Earlier, collaborating on a document involved a serial approach to making changes to a document. Only once the author has completed the document, can it be forwarded to the next person to edit and provide feedback. 

But consider the Google Doc (or any of the other collaboration tools), once you have created a google doc, you can start creating the document and also share the same document with other collaborators who can also make changes to the document at the same time allowing for reconciliation of changes to be incorporated within the document to finalise it. The author takes the comments from the collaborators and generates the finalised document.

Blockchain: How it Works?

A transaction is requested. The transaction is broadcasted to the peer-to-peer network consisting of computer nodes. The network validates the transaction and the initiating entity’s status using relevant algorithms.  The transaction record is then considered to be verified.

Upon verification, the transaction record is added with other transactions to create a new block of data for the decentralized ledger of all transactions across a peer-to-peer network.

The new Block is added to the existing ledger of all transactions, i.e., the Blockchain. The transaction is now complete.

Types of Blockchains

Permissionless or Unpermissioned Blockchain allows anyone to join the network and participate in the block verification. For instance, a permissionless blockchain example is the Bitcoin.

Permissioned Blockchains restricts the nodes in the network who can contribute to the consensus of the system. Only permissioned nodes have the rights to validate the block transactions.

For instance, most enterprise Blockchains are permissioned blockchain and allow for privacy, scalability and fine-grained access control. [5]
Interoperability in Healthcare

There are various use cases that come to mind, when we talk about interoperability in Healthcare. (most are N:N interactions)

  1. HIMS to Lab Equipment
  2. HIMS to PACS
  3. HIMS to HIMS
  4. HIMS to Apps
  5. HIMS to Portals (Patient, Physician, etc)
  6. Portal to Portal
  7. Stakeholders to HIE
  8. Hospitals to Insurance

You can consider the number of stakeholders in the Interoperability ecosystem and continue to add them to the above list of use cases. And that allows one to understand the current fragmented nature of the Patient’s Healthcare Information. 

Each of the above stakeholders, generate the patient care record and have the need at one time or another to share this information with others in the ecosystem. We have already seen the benefits and barriers to information exchange. 

For the purpose of this blog, lets consider the Healthcare Information exchange use case. HIEs’ share the patient information in a network that is accessed by participating entities. The Patient information available on the HIE can be accessed as and when required by the patients’ treating doctor. 

The availability of a patient information, at the right place and at the right time was (one of) the intended purpose of a Health Information Exchange. HIE frameworks relied on a centralised or federated or hybrid architectures [3] to make the information available to the participants in the exchange. The exchange is maintained by an entity.

In the nationwide Interoperability roadmap defined by the ONC (US) [1]. They define the critical policy and technical components required as

  1. Ubiquitous, secure network infrastructure
  2. Verifiable identity and authentication of all participants
  3. Consistent representation of authorization to access electronic health information, and several other requirements


Additionally, the ONC challenge stated Potential uses to include:[6]

  1. Digitally sign information
  2. Computable enforcement of policies and contracts (smart contracts)
  3. Management of Internet of Things (IoT) devices
  4. Distributed encrypted storage
  5. Distributed trust

In India, an Integrated Health Information Platform (IHIP) is being setup by the Ministry of Health and Family Welfare (MoHFW). The primary objective of IHIP is to enable the creation of standards compliant Electronic Health Records (EHRs) of the citizens on a pan-India basis along with the integration and interoperability of the EHRs through a comprehensive Health Information Exchange (HIE) as part of this centralized accessible platform. 

IHIP is envisaged to enable
  1. Better continuity of care, 
  2. secure and confidential health data/records management, 
  3. better diagnosis of diseases, 
  4. reduction in patient re-visits and even prevention of medical errors, 
  5. optimal information exchange to support better health outcomes

With the understanding of What is Blockchain, What is Interoperability in Healthcare and What are the use cases for Interoperability in healthcare, do you think Blockchain Technology can be used in Healthcare? Do share your thoughts and use cases.

In the next part of the blog, I will explore some of these use cases in healthcare and for the purpose of defining how Blockchain can help interoperability of Patient Transactions across healthcare facilities.


References

1. Blockchain Opportunities for Healthcare: https://www2.deloitte.com/us/en/pages/public-sector/articles/blockchain-opportunities-for-health-care.html


3. Health Information Exchange – Architecture Types https://corepointhealth.com/health-information-exchange-architecture-types

4. Bitcoin is the Sewer Rat of Currencies, interview of Andreas Antonopoulos by Mark Frauenfelder http://ow.ly/XDMe30bumBy

5. Blockchain – What is Permissioned vs Permissionless? by Deva Annamalai on Core Dump https://bornonjuly4.me/2017/01/10/blockchain-what-is-permissioned-vs-permissionless/

6. ONC Blockchain Challenge: https://www.healthit.gov/newsroom/blockchain-challenge
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Benefits of an Integrated Health Information Platform #IHIP by @msharmas

We have seen the benefits of Aadhar and how a public data repository can be used for public good. Population Health based clinical data repositories too can play a similar pivotal role in providing potentially great benefits


The use of Healthcare IT in the Indian context is picking up with most of the corporate hospitals going for the #EHRs and HIMS solutions. And these are present mostly in the Tier I cities and urban areas. There is a move now to get these solutions to the Tier 2 and Tier 3 centers as well. I would be looking to review reports that highlight percentage of IT enablement in Healthcare facilities, as part of follow up articles to this one.

The Center for Healthcare Informatics has rolled out an RFI detailing the requirements of an Integrated Healthcare Information Platform (IHIP). You can also visit the dedicated website to review the details of the IHIP RFI:
In this article I would like to highlight the benefits that will accrue from implementing such a solution in India. With no historic data of past implementations of such a system in India, I have reviewed the information available in journals and public domain regarding similar implementations across the world and what are the benefits and barriers in implementing an Healthcare Information Highway of patient healthcare data.


Benefits of Implementing an HIE

  1. Benefits of Implementing HIEs:
HIEs that have been implemented in the US have conclusively shown emergency departments gaining efficiency in patient visits with the use of HIE based solutions.
HIEs have shown to reduce the length of patient stay, readmission risk, and number of doctors involved in patient visits [1].
HLNY ER Dept Infographic_HIEGains.png
  1. Discharge Planning
One of the examples of benefits of an HIE, is the ability to generate alerts 24-hour to 48-hour prior to the patient’s’ discharge to Transportation services, Pharmacies at the patient’s location and alerts to help patient identify long term care and home care facilities. [2]
  1. Transfer of Radiology Images:
Currently the process of exchanging patient radiology images either does not exist or at best is time consuming with problems faced by the patients and providers treating the patients.
The ability to access and view radiology images is important for an accurate and timely patient diagnosis and treatment. Historically, the process of image exchange has happened via CDs with an understanding the receiving and reviewing physician will have the ability to view the PACS images leading to high costs and long time to diagnosis.
Enabling a Transfer to PACS capability helped in cutting these lacunae in the image sharing workflow, enabling providers to quickly share images with each other. [3]
  1. Vaccination and Immunisation details:
HIEs are now moving towards incorporating the exchange of patient immunisation details. Thereby enabling patient centered technology implementations.
  1. Disease Surveillance and Immunisation Records
IHIP will provide increased view of disease outbreaks and allow the governments at the state and national levels to deploy resources effectively and efficiently. IHIP based identification and surveillance of disasters and outbreaks is a big benefit of implementing a platform such as IHIP. And additional areas that provide a fillip to the IHIP-initiative needs to be identified and those aspects of the IHIP needs to be implemented in the initial stages.
  1. Medication Information Sharing via HIEs:
The ability for the patient to build and maintain an electronic Drug Profile is important for the continued care for the patient. Presence of a Comprehensive Patient Drug profile has direct correlation to improved patient safety. Improved medication information processing has a direct correlation to the benefits of an HIE like the IHIP since it will be able to provide a more complete clinical picture of the patient. [4]
  1. Telemedicine service enabled by HIEs:
Telemonitors will be able to provide patients a way to measure and record their vital signs daily from home using a touchscreen tablet/ mobile/ PC. The information will be then wirelessly transmitted to nurses monitoring the information for changes, giving patients with, complex disease states such as heart and respiratory conditions, a sense of empowerment around their health. Telehealth has far reaching benefits for specialists providing their services to patients in the rural, underserved and non-tier I cities. With the presence of digital payment gateways and transactions, Telemedicine is fast becoming a viable business model for certain types of visits(e.g., follow-ups, referrals). [5]
  1. New Use Cases for an HIE:
When HIEs have been implemented, new use cases can emerge that extend the usefulness of HIEs. For example, HIEs have been able to send hospitals alerts and reminders when patient transitions occur, device to device data transport, sending and receiving of claims attachments, and exchanges of documents for referrals [6]
  1. Security of Patient Information (PHI):
The greatest benefit of an IHIP-like solution is the Implementations of Security protocols for transport and transfer of patient information between healthcare facilities and between patients and hospitals. This ensures creation of “Trust” centers of patient data.
  1. Improves the Trust in sources of information
One of the reasons a physician would order for a repeat test for a patient in case of a referral, would be “Trust” on the presence of a similar/ same test result available for the patient in an earlier visit. Enabling information sharing via IHIP in a standardised and secure format will enable “Trust” between healthcare facilities as trusted sources of information. [7]
  1. Strategies to avoid Information Blocking:
Information Blocking has been known to be a major cause of hindrance to the benefits brought out by an HIE. Information Blocking is healthcare facilities not sharing patient healthcare record information causing holes in the episodes of care of a patient’s longitudinal record. To avoid this from happening, “Increasing transparency of EHR vendor business practices and product performance, stronger financial incentives for providers to share information, and making information blocking illegal were perceived as the most effective policy remedies,” wrote researchers. [8]
  1. Paradigm Shift in HIE from 1.0 to 2.0:
HIE 1.0 was characterized by a focus on “the noun,” that is trying to address perceived market failures by solving a wide variety of rich use cases through comprehensive interoperability.
By contrast, HIE 2.0 focuses on the verb that is trying to meet market needs most pressing to participating providers; HIE 2.0 has fewer legal challenges because it is trying to tackle less complex use cases and in many instances has the ability to marshal financial, technical and organizational resources. Tripathi also pointed out that HIE 2.0 comes in many shapes and sizes including point-to-patient; point-to-point; vendor-specific; transaction-specific national level; enterprise-level HIE organizations; State-level and regional collaborative HIE organizations and National level collaborative HIE organizations.
Three areas identified to spur innovation and move towards HIE2.0 were: Lab data transmission, Lightweight directed query of patient information, eCPOE and measures.

Problems Implementing HIE: A review of Global HIE Experiences

  1. Unspecified Interoperability Standards:
Barriers to HIE relate to incomplete and unspecific interoperability standards and the cost of interfacing the EHR with the HIE.  The lack of mature, agreed standards around interfaces, patient consent and patient identification are significant barriers to success.
  1. Accurate patient identification is not only a data management and data quality issue, it’s also a patient safety issue
  2. Clinical Information Generator and Vendor relations
In the India context, healthcare facilities like hospitals, laboratories, pharmacies deploy systems that are proprietary in nature and not necessarily standards based. In the event of strained relations between healthcare facilities and respective vendors, there is a need to consider addressing the need to have the patient related information to be relayed to the patient in a HIE readeable format. This information can then be uploaded by the patient thereby ensuring the continuity of care records are maintained in the IHIP, specific to the patient.
In this scenario, there could be a loss of updates to the public health based registries and the hospital based registries and it should be incumbant on the hospital to ensure the data is transmitted before the changeover of systems happens.
  1. Identifying ROI for various Stakeholders
A study needs to be enabled by the government at the national and state levels that will study the benefits of implementing interfaces that will share information between the Healthcare facilities and the IHIP. Potential savings can be quantified based on cost and projected savings in improved efficiencies enabled by the implementation IHIP towards patient safety and care coordination for the stakeholders.
Additionally, its important to quantify the cost of implementing HIE-based interfaces by the various healthcare entities (like Hospitals, Laboratories, Diagnostic centers, pharmacies, etc). It will be important to identify the Revenue Streams to sustain IHIP data sharing, and how can it be sustained by the stakeholders.
  1. Breach of Security of Data contained in IHIP or connected interfaces
We have seen various types of hacks that have breached the security of patient records stored in hospital systems. Enabling security at various levels needs to be ensured before any of the Stakeholders connect with the IHIP. Security guidelines will have to be defined and adhered to and reported on a regular basis as a regulatory requirement.
Security is also necessary at the IHIP level which has been defined as a main requirement for developing the IHIP infrastructure.
In the US Architecturally, RHIOs employ either the CHMIS approach of a centralized database, the CHIN model of federated independent databases, or some combination of the two, hybrid model.
  1. Usability & Access to Information Ok, so the data about a patient has been stored in the Data Repository for all to access and review at the time of emergencies, for enabling a continuity of care record for the patient and for generating population health management analysis. But, what if the data is not easily accessible, the functionality to access the care information of the patient, requires multiple access requests and clicks and permissions. What if, the data has now been stored in the public data repository, who can access it? Who can view it? Can there be an unauthorised data access by persons not connected to the health care of the patient? [25]
  2. Information Blocking:
For-profit EHR vendors have a natural vested interest in increasing revenue by limiting the flow of data.
“The specific forms of and perceived motivations for information blocking were harder to predict a priori,” Adler-Milstein & Pfeifer explain. “What we found in relation to specific forms is that EHR vendors appear to most often engage in information-blocking behaviors that directly maximize short-term revenue. Our respondents reported that EHR vendors deploy products with limited interoperability and charge providers high fees unrelated to the actual cost to deliver those capabilities or refuse to support information exchange with specific EHRs and HIEs.”
Hospitals and health systems likewise utilize information blocking as a means to prevent clients from seeking services elsewhere to keep from losing out to the competition.
“In our results, the most commonly reported forms of information blocking among hospitals and health systems point to their interest in strengthening their competitive position in the market by controlling patient flow, which has been reported in other studies,” they wrote.

Interoperability in Healthcare: Some thoughts to share

Having followed the implementations in India for sometime now, I always wonder why interoperability is not a top priority or not implemented in most systems. They are HL7 compliant, but are they really interoperable? And I dont mean the part from HIMS to Lab or Rad equipment, that part is fairly well defined and documented. 

– But from the Patient to Hospital to Patient
– Patient to Insurance to Patient
– Patient to app to hospital to Patient

Take for instance most systems are able to share the discharge summaries as emails to patients, and a print out, even today. But on discharge can the patient “share” her discharge summary from an app or application to another practitioner who takes care of the patient rehab? Are for instance, the systems involved in the above use case, interoperable? 

Another point, how many Healthcare Apps (the production versions) have any data sharing via standards? They can however email PDFs of the recorded data. So what can be done to enable out-of-the-box interoperability in the Healthcare Apps? With the growing number of mHealth Apps, we will soon find ourselves in another new set of “Data-Silos” being created on a daily basis.

Recently we moved from Cash to Cashless to Less Cash scenarios … so is it right to say, in healthcare context, we are working from a Paper to Paperless to Less Paper scenario in Healthcare before going totally paperless? 

And if so: 

1. What will be the business case for interoperability and for sharing the discharge summary/ medications in a format that is easily exchangeable?

2. Can a Healthcare IT think tank, work on defining the standards of “workflow” of the data being generated in healthcare today? Starting from the Patient through the healthcare ecosystem and back to the Patient?


3. Can the Healthcare IT vendors form a group of HIMS, LIMS, Pharma Apps, HomeCare solutions that enable a “Patient Data Workflow” exchange group (a mini-IHIP) that actually enables the “Interoperability” of patient data as a great showcase. It could perhaps be tied to the IHIP effort or NDHA. It adds onto the work that is being planned in the Phase 1 of the IHIP project, by being able to provide feedback on issues, solutions, recommendations, pain points etc.

Its important to note, that a system like IHIP has a potential to solve the accessibility of patient care problem in India. My view is that there is a need to see interoperability from a Patient’s point of view rather than from the point of view of “Systems”. There is a need to map the flow of data from the Patient and back to the Patient, and this can help in enabling a radically different approach to interoperability in Indian Healthcare.

With Aadhar based solutions allowing for the consumer information to be securely transmitted and verified, it only behoves well if we were to adopt an “HIE of Patient” approach to IHIP wherein the Information is exchanged between various stakeholders in the Patient’s Care Continuum and that information finally rests with the Patient’s Electronic Health Record (PEHR). With the EHR standards mandating the Healthcare Information belongs to the patient, it will be extending that mandate to IHIP.

References

  1. NY Health Information Exchange Improves ED Quality, Efficiency
  1. HIE Partnership to improve Health Data Exchange of Imaging
  1. Health information exchange and patient safety
  1. Vermont HIE adds telehealth component
  1. DirectTrust HIE growth shows priority of Interoperability
  1. Health information exchange: persistent challenges and new strategies
  1. Health Information Exchanges report Information Blocking
  1. Maine Rural Veterans Health Access HIT Strategies
  1. The Value Of Health Care Information Exchange And Interoperability (a must read paper on how the costing for HIEs can be done)
  1. Health information exchange: persistent challenges and new strategies
  1. Information Blocking: Is It Occurring and What Policy Strategies Can Address It?:
  1. What is HIE?:
  1. Health Information Exchange?:
  1. HIE Benefits?:
  1. Guide to Evaluating Health Information Exchange Projects
  1. HIMSS Library for Information on HIEs
  1. Health Information Exchange – Overview
  1. 10 things to know about health information exchanges
  1. Selecting & Using a Health Information Exchange | AMA
  1. The Sequoia Project eHealth Exchange
  1. What is Health Information Exchange? | HIMSS
  1. IHIP, India
  1. Are Data repositories set to become data dumps? https://www.digitalhealth.net/2017/04/another-view-neil-paul-21/
  2. Powering the Patient Relationship with Blockchains: https://www.healthit.gov/sites/default/files/7-29-poweringthephysician-patientrelationshipwithblockchainhealthit.pdf
  3. Lessons from the UK | Healthcare IT News


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#PatientSafety is the key in the era of #DigitalHealth by @Drvikram

India has just seven registered allopathy doctors per 1,000 people; Indian healthcare was ranked 112th in the world by WHO; It takes almost 133 people to take care of 1 patient in a tertiary care hospital; There are now 133 touch points where patient safety can be compromised; Our healthcare system is unable to measure Patient safety, a very important parameter, mostly due to lack of longitudinal records;


India has just seven registered allopathy doctors per 1,000 people. Indian healthcare was ranked 112th in the world in a survey by the WHO. It is therefore unsurprising that most discussions in the healthcare sector today are focused around ways and means to build more infrastructure and increase access to care. 

Many startups have sprung up in the healthcare space promoting better health and preventive care. Investments are pouring into the country and new state of the art hospitals are being set up. But one must wonder are we doing the best we can with the existing system of doctors, hospitals, clinics and processes? How efficient is our system of care and what are the current outcomes we are seeing? Does a patient come out healthier and better than when he went in? Or was it just a case of good fortune that nothing untoward happened to him? What exactly are our priorities for safer care?

As per the Indian Confederation for Healthcare Accreditation (ICHA) it takes almost 133 people to take care of 1 patient in a tertiary care hospital. This is right from the time the patient decides to access healthcare in the hospital and till the time (s) he is discharged. Though the numbers seem interesting but it also gives us an idea about the complexity of the current healthcare system. Digital transformation, Modern technology and techniques might have made healthcare more effective but it has also made care more complex and unsafe – There are now 133 touch points where patient safety can be compromised.

Patient safety is a very important parameter. Somehow our healthcare system is unable to measure it, mostly due to lack of longitudinal records, as India has still not really adopted electronic medical records. Also key contributory factors are over diagnosis and reducing Hospital Acquired Infections (HAIs)

The solution to this issue could be in changing the approach to quality or excellence in healthcare. The traditional approach is to set rigid and stringent specifications against which service providers are benchmarked to see the extent of conformance. This “Outside – In” approach works well where the variables are mechanical and predictable. Unfortunately, healthcare is a sector where uncertainty is high and compounded by each patient’s unique condition and his/ her ability to respond to treatment. In such circumstances, the “Inside – Out” approach that begins with the patient’s needs and requirements may be a better fit.

“Optimum quality of healthcare delivery can be ensured by working backwards to align processes in tandem to meet these requirements” Says Dr Akhil Sangal, CEO of ICHA. “Healthcare has processes that have some predictable and many uncertain variables, and thus a mixed need based customized approach may be desirable,”

One example of the “inside-out” approach is the new infusion system introduced at the Virinchi Hospitals in Hyderabad. Patients going through invasive procedures and surgeries are more prone to infections. The risk of HAIs, including catheter associated infections, is common in patients due to various reasons, mostly the use of plastic or glass bottles in infusion therapy. 

The normal practice, which the nurses follow with these bottles, is to get a needle into the plastic bottle or open the air inlet of the IV sets with glass bottles for the fluid to flow into the patient’s body. This may lead to infection from the micro-organisms, that enter the bottle & may cause severe infection to the patients.

Dr. Srinivas Samavedam, Head of Critical Care Medicine, Virinchi Hospitals, Banjara Hills, Hyderabad added that “To prevent this type of infections from the infected air going inside the bottle, some medical institutions & hospitals have started to use the new-state- of the art German technology for IV solutions. These new IV containers are very advanced and do not require any needle prick for collapsibility thus ensuring high patient safety.”

No venting is necessary with this closed infusion system made by German Technology, as this collapses completely when emptying and therefore there is no need of needles to allow entry of air and hence any external infection.

International bodies like CDC & NIOSH also recommend risk free drug admixture, which reduces potential microbiological contamination. Accurate fluid delivery to the patient is also very important. The latest technology design of Closed Infusion System should facilitate dosage accuracy & should also be compatible with all pharmaceutical drugs.

Another example of the inside – out approach, is the launch of the Azurion from Philips. Philips’s new-generation image guided therapy platform is developed in collaboration with leading global hospitals allowing clinicians to easily perform a wide range of routine and complex procedures, helping them to optimize interventional lab performance and provide superior care. Azurion is built upon Philip’s redesigned operating system ConnectOS, which provided a real-time multi-workspot technology and a user-friendly interface for Physicians, Radiologists and Technicians. The Azurion platform also features over 1,000 new components, including an enhanced flat-panel detector, which provides a functionality to seamlessly integrate advanced interventional tools into the Azurion platform to support the clinical workflow.

It is clear that using the new infusion technology and using image guided therapy platforms like the Azurion there is a greater chance of improving patient safety. 

As always we would love to hear your views on the topic. Comments, suggestions and questions are welcome.

The article is authored by Dr. Vikram, it is reproduced here with the authors permission
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Dr Vikram Venkateswaran is a healthcare thought leader who writes and speaks about the emerging healthcare models in India and the role technology plays in them.
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Successfully Implementing #HealthIT: A Health Informatician’s perspective by Dr. Thanga Prabhu, @thangas

A fresh approach to HCIT product development is required where the product can quickly meet the clinician’s need. Actively involved clinicians, HCIT trained manpower and HCIT aware clinicians can transform healthcare today; it is not an option but an idea whose time has come


IT is an enabler of change and not the change itself. When customers look at IT as the one solution to all their problems, it is set up for failure from the beginning. Introducing an IT system necessitates an in­-depth study of existing workflows, roles and responsibilities and change management aspects in every speciality.
Healthcare IT implementation is complex, interlinked, domain­ sensitive and clinician­ focused, thereby being different from other IT implementations. The generally high failure rate for IT implementations tends to be higher in healthcare due to this complexity.
Clinicians need to be involved actively from the requirements gathering phase and given ownership of clearly defined sub areas within the project to be successful. IT should be a tool to transform healthcare delivery model and not expected to be a solution by itself.

HCIT ­ Domain intensive

Healthcare is an environment of trust wherein many actions are performed without being specifically asked for. The single point of focus for all clinicians is the patient and roles are synchronized, each one playing a small but significant part in the care process. A study found that when a patient walks into a healthcare facility, is registered, vitals taken by nurse, seen by doctor, takes medicine from pharmacy and walks out 50+ people have to work in harmony for this to happen successfully.
Intensive training ensures that the personnel on the ground know exactly what is expected of them and they do that role with conscience. In contrast transactions in banking or the travel industry are simple and straightforward. Clinicians ranging from doctors, nurses, pharmacists, technicians in lab, operation theatres, dialysis centres, and emergency services have varying data needs and data recording responsibilities.
When a doctor charts his patient for the first time he goes into details on illness, past history, allergies, drugs being taken by patient, builds a problem list, identifies/ lists differential diagnosis, plans lab/ radiology investigations and prescribes initial treatment. The methodology followed is standardized during his training and practice over the years ensures that it comes naturally while examining a patient.
Nurses also train on similar lines to examine and document key information on the patient initially and then as patient moves through the system. The data that is recorded by each clinician is useful to take decisions for the patient and is used by the entire team. As clinicians become experienced most of this data processing is done without actually recording it on paper and it is known that consultants record only key points in their patient records.
When HCIT requirements have to be gathered in such an environment they should be involved early as only clinicians understand the significance of each piece of information. Many tools are available to assist the clinicians during the course of their work and it is important to note that none of them are mandatory. HCIT is also a tool, which if not user friendly tends to be ignored.
HCI (human computer interaction) has to offer better ways to input data as the traditional mouse/keyboard system does not fit into the busy healthcare environment. Speech recognition is now being used in radiology reporting and touch screen systems are being deployed in operation theatres and ICUs to gather data without the clinician having to actually sit and type.

Change management

Clinicians have been known to be resistant to change for ages. As an example, usage of stethoscope amongst the medical community took almost 100 years. If the systems that they are expected to use in their day­to­day work is unfamiliar to them and takes too much of their time, without tangible benefit, there is a very serious risk of non usage. Every clinician has to see clearly the benefit that will accrue to his / her work to adopt a new system. Resisting change is natural and it is seen in a greater degree within healthcare.
‘Clinician champions’ have to be identified within the customer’s staff who will lead the implementation and support their colleagues later on. The resistance to change is often because of three broad reasons: political, technical and attitude. If the new system upsets an existing hierarchy or even gives an impression of doing so, it can be a serious risk.
Technical reasons such as lack of training, not being comfortable with using technology, HCI (human computer interaction) factors such as clinicians in the operation theatres being expected to remove their sterile gloves to type can also jeopardize a project.
Attitude is a subjective phenomenon and usually can be overcome by peer pressure and strict enforcement of policies. Once clinicians see the benefits they tend to voluntarily train their teams and the rate of knowledge transfer then goes up significantly. This is after all the existing culture within healthcare where peer support and sharing of best practices is common.

Interoperability

HCIT procurement should be done by knowledgeable personnel who see the big picture and can build a system incrementally. In the western countries it has been seen that departments usually acquire systems individually starting from radiology, cardiology then laboratory and finally the HIS / EMR. None of these systems are expected to communicate with each other initially and after significant cost, effort and time has gone into implementing it the results could be diverse systems that cannot communicate.
Rather than follow a big bang approach it has been observed that incremental adoption with the larger picture in focus assures success. It is imperative today that all systems communicate freely amongst themselves and also with external systems. Most facilities have homegrown basic billing HIS systems but clinicians are not exposed directly to these systems. Technology savvy specialties such as Radiology, Cardiology, Anaesthesia and Lab medicine should be starting point for a HCIT solution. Such pioneers are excellent ‘User Champions’ for future more complex specialties.

Benefits

It is futile to incessantly discuss the many reasons of why HCIT solutions are not useful in healthcare. Success stories and proven benefits of HCIT implementation need to be highlighted to build customer’s confidence in adopting a HCIT solution. It has been seen that instead of trying to force fit a solution on existing workflows, a system that can adapt to and respond dynamically to end user needs is liked and used by clinicians. Existing HCIT solutions have limitations on their configurability, nevertheless when products are extensively customized; it becomes difficult to maintain the product over time.
A fresh approach to building HCIT solutions which are easy to customise, can be hosted on a cloud and paid for on a utility model (pay­as­you­go/case by case) and preferably allow clinicians to tailor on their own with minimal IT support is required. With the advent of Web 2.0 (Read and Write) and Web 3.0 (Read, Write and Run) technologies and customers using Facebook, Twitter, YouTube, Apple iStore etc. the same is now expected from HCIT vendors. Author has personal experience of Anaesthetists requesting data mining features with drag­drop tools to create queries/reports on their patient data which is then used for research and academic presentations.

Government initiatives

The government has to play a regulatory role and help identify ‘EMR Interoperability standards’ after studying the globally available standards and identifying those that are relevant, affordable in the long run without any strings attached and mandate their use by HCIT vendors. Patient data has confidentiality and privacy implications which need to be covered by Government with a legal framework.
The newly enacted addenda to IT Act 2000 which mandate vendors to take necessary and reasonably good measures to protect patient data is timely. Ownership of patient data is an unresolved question globally but the consensus has been to retain ownership of data with patient with government being a guardian for that data.

Learning from Aviation / Nuclear / Space industries

We need to learn from our predecessors who have taken the failure bull by its horn and controlled what was given up as impossible earlier. Aviation industry had some depressing statistics before FAA (Federal Aviation Authority) stepped in to rein in the problem. The FAA conducted due diligence and created open reporting mechanisms to identify problem areas which then went on to become starting points for other interventions.
Nuclear industry by nature is risky and allows no scope for slip­ups. Enforcing safeguards, defined protocols, on­going training to keep personnel updated on latest skills has resulted in safety. Space industry is intrinsically dangerous and failure rates were high initially. NASA today has managed to mitigate these risks and regularly sends rockets and shuttles to space. The key is to take a holistic view of systems and blame the system and not the user of that system when failures do occur.

Transforming healthcare with IT

IT is an enabler of change and not the change itself. When customers look at IT as the one solution to all their problems, it is set up for failure from the beginning. Introducing an IT system necessitates an in­-depth study of existing workflows, roles and responsibilities and change management aspects in every speciality. IT is but another tool available to transform healthcare and when its role (and limitations) is understood the chance of success increases.
A clinician who leads HCIT implementation on a full time basis starting with initial seeding of idea amongst clinicians, brainstorming with them implications of introducing the system into workflows, hand holding during the implementation and ongoing support post ‘Go Live’ should be minimum criteria in HCIT implementations. 
Just mapping the paper based workflows to IT and replicating it does not allow clinicians to fully utilise the complete capabilities that IT brings in. New ways of working such as real time chat on social networking sites such as Twitter and SMS can allow clinicians to interact and mutually support each other while delivering care. Document once and reuse infinitely, auto calculating all variables, adding layers of security to ensure role based access are all possible only with HCIT.

HCIT manpower

The realisation that has dawned on health informaticians today and backed up by research is that HCIT implementation should not be treated as another IT implementation. The domain is complex, most work happens like clockwork without much communication (for example when a surgeon operates, the nurse assisting him knows exactly what instrument he needs next). Thus clinician­ lead HCIT implementations are realising higher success rates. Medical Informatics workforce is non­existent today. A separate cadre of foot soldiers who can man the posts is required as bridging clinical and IT worlds, is difficult. ONCHIT is spending billions to encourage academic centres to churn out this workforce in USA.
NHS in UK supports employees to acquire additional informatics skills as it is clearly required to practice in tomorrow’s healthcare world. India has the opportunity to recognise this need and use our excellent educational system in public and private sectors to train HCIT manpower at different skill levels using modern teaching resources such as on demand learning and online delivery systems. The demand for this manpower has always been much higher than what the system has been able to provide.

Conclusion

HCIT is no different from other IT implementations in that it is also force fitted on existing systems without understanding fully all the ramifications of doing so. The interlinked and mutually supportive healthcare environment where trust on peers and a single minded focus to work for one goal – patient care without direct orders is an amorphous beast to an outsider to healthcare: the IT person.
A fresh approach to HCIT product development is required where the product can quickly meet the clinician’s need. Actively involved clinicians, HCIT trained manpower and HCIT aware clinicians can transform healthcare today; it is not an option but an idea whose time has come.
The article has been published here with Dr. Thanga Prabhu’s permission
Author

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Dr. Thanga Prabhu

Dr. Thanga Prabhu has 20+ years of healthcare experience working in India, Abu Dhabi and United Kingdom. Clinical leader evangelizing medical informatics, Communications leader-regular speaker in all major HCIT events. He has authored a paper for the UK Parliament Health Select Committee in 2005 titled ‘The utilizations of telemedicine (telecare) and its future potential for improving services’. Dr. Prabhu is currently the VP of the Indian Association for Medical Informatics (IAMI)

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Shift in US Healthcare by Srinath Venkat, @ConnectSrinath

The adoption of EHR is growing rapidly because of billions of dollars spent by the government to incentivize providers for EHR usage.
Also, there is a greater commitment by government to reduce the drug related adverse events in healthcare by recommending e-prescribing to the providers

Transformation in US Healthcare through EHR and Personalized Healthcare
Healthcare has undergone series of changes in last few decades. From passive, reactive, one size fits all approach, it has moved towards more customized, responsive, real-time care administration. Electronic Health Record (EHR) is systematized longitudinal collection of patient health data which gives the complete record of clinician-patient encounter. 

It also streamlines the clinical workflow, thereby improving the health outcomes through decision support, quality management and reporting of information across the continuum of care. There are various vendors who provide EHR services based on the care setting (Ambulatory, Hospital, Clinic or Physician office), and the major ones include EPIC, Cerner, McKesson, Allscripts and GE.
 

The Health Maintenance Organization (HMO), which provides managed care by giving access to providers in its network for self-financed and insured individuals, were first started in 1931 by Farmer’s Union of Oklahoma, where flat fee is collected irrespective of the services rendered. By 1951, it was estimated that 45% of the Americans were insured, and in 1965, Medicare which covers the older people above 65 years of age and younger people with disability was introduced. 

In 1996, Health Insurance Portability and Accountability Act (HIPAA) was introduced, which helps in protecting the healthcare information and reducing the healthcare administrative costs. In 2010, Patient Protection and Affordability Care Act (PPACA) was introduced which helped the people to purchase health insurance through Health Insurance Exchanges.
 

The Four Ps of Healthcare (Patient, Provider, Payer and Public) benefit from the EHR which helps in integration of healthcare information, reducing the duplication, avoiding redundancy, thereby reducing the administrative and treatment cost in healthcare. 

The Meaningful use of EHR is the usage of certified (Certification Commision for Healthcare Information Technology) health information systems and software for improving the health outcomes and reducing the cost. EHR has both provider and payer component. Doctors, Hospitals, Laboratories, Pharmacy and other ancillary services use provider systems, which includes, practice management, EHR, Revenue Cycle Management (RCM), Document management and E-prescribing. 

There is a shift in healthcare towards retail-like scenario leading the consumer driven healthcare, where the patient is well-informed and shops for different treatment options using web portals like Web MD. Remote medical practice, real-time data collection, information integration and transfer, and collaboration among providers using EHR, creates significant improvement in overall health outcomes and cost. 

The adoption of EHR is growing rapidly because of billions of dollars spent by the government to incentivise providers for EHR usage. Also, there is a greater commitment by government to reduce the drug related adverse events in healthcare by recommending e-prescribing to the providers. The shift from pay for volumes / pay per visit towards pay for performance / outcomes which is encouraged by creating Accountable Care Organizations (ACOs) is a motivational factor for meaningful use of EHR in healthcare.

The article was first published on Srinath Venkat’s LinkedIn Pulse page. The article has been republished here with the authors’ permission

Author

Srinath Venkat

Srinath Venkat is a Healthcare Management Professional with qualifications in Public Health, Healthcare Technology Assessment and Entrepreneurship in Emerging Market Economies. He has been in to research and consulting roles with leading healthcare research firms in activities like Market study, Go To Market strategy, Technology Mapping and Business Model evaluation. He is passionate about innovative business models, startup ecosystem and the evolving landscape.

Workflow, Usability, Safety & #Interoperability Perspectives by Dr.Charles Webster, @wareflo – Part1 #AMIA2016

BPM-based Population Health Management & Care Coordination: Part – 1

“Workflow is a series of tasks, consuming resources, achieving goals.”

This article has been re-published with the authors permission. The article was first published by Dr. Charles Webster on his blog here

Just in time for the 2016 AMIA Symposium, I’m delighted that Manish Sharma, the force behind @HCITExperts, is republishing my five-part series on workflow technology in healthcare. Thank you Manish!

– by Dr. Charles Webster

I blog and tweet a lot about healthcare workflow and workflow technology, but in this first post I’ll try to synthesize and simplify. In later posts I drive into the weeds. Here, I’ll define workflow, describe workflow technology, its relevance to healthcare and health IT, and try not to steal my own thunder from the rest of the week.

I’ve looked at literally hundreds of definitions of workflow, all the way from a “series of tasks” to definitions that’d sprawl across several presentation slides. The one I’ve settled on is this:
“Workflow is a series of tasks, consuming resources, achieving goals.”
Short enough to tweet, which is why I like it, but long enough to address two important concepts: resources (costs) and goals (benefits).
What is workflow technology?
Workflow technology uses models of work to automate processes and support human workflows. These models can be understood, edited, improved, and even created, by humans who are not, themselves, programmers. These models can be executed, monitored, and even systematically improved by computer programs, variously called workflow management systems, business process management suites, and, for ad hoc workflows, case management systems.
Workflow tech, like health IT itself, is a vast and varied continent. As an industry, worldwide, it’s probably less than a tenth size of health IT, but it’s also growing at two or three times the rate. And, as both industries grow, they increasingly overlap. Health IT increasingly represents workflows and executes them with workflow engines. Workflow tech vendors increasingly aim at healthcare to sell a wide variety of workflow solutions, from embeddable workflow engines to sprawling business process management suites. Workflow vendors strenuously compete and debate on finer points of philosophy about how best automate and support work. Many of these finer points are directly relevant to workflow problems plaguing healthcare and health IT.
Why is workflow tech important to health IT?
Because it can do what is missing, but sorely needed, in traditional health IT, including electronic health records (EHRs). Most EHRs and health IT systems essentially hard-code workflow. By “hard code” I mean that any series of tasks is implicitly represented by Java and C# and MUMPS if-then and case statements. Changes to workflow require changes to underlying code. This requires programmers who understand Java and C# and MUMPS. Changes cause errors. I’m reminded of the old joke, how many programmers does it take to change a light bulb? Just one, but in the morning the stove and the toilet are broken. Traditional health IT relies on frozen representations of workflow that are opaque, fragile, and difficult to manage across information system and organizational boundaries.
Well, OK, I’ll steal my own thunder just a little bit. Process-aware tech, in comparison to hardcoded workflows, is an architectural paradigm shift for health IT. It has far reaching implications for interoperability, usability, safety, and population health.
BPM systems are ideal candidates to tie together disparate systems and technologies. Users experience more usable workflows because workflows are represented so humans can understand and change then. Process-aware information systems are safer for many reasons, but particularly because they can represent and compensate for the interruptions that cause so many medical errors. Finally, BPM platforms are the right platforms to tie together accountable care organization IT systems and to drive specific, appropriate, timely action to provider and patient point-of-care.
The rest of my blog posts in this weeklong series will elaborate on these themes. I’ll address why so many EHRs and health IT systems are so unusable, un-interoperable, and sometimes even dangerous. I’ll argue that modern workflow technology can help rescue healthcare and health IT from these problems.
Additional Blog Posts by the Author
  1. Five Guest Blog Posts On EHR & HIT Workflow, Usability, Safety, Interoperability and Population Health
  2. Interoperable Health IT and Business Process Management: The Spider In The Web
  3. Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible
  4. Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions!
  5. Population Health Management and Business Process Management
Author

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Dr. Charles Webster

HIMSS14, HIMSS15, and HIMSS16 Social Media Ambassador! If you’ve got a healthcare workflow story, I want to tell it, blog it, tweet it, interview you, etc. Dr. Webster is a ceaseless evangelist for process-aware technologies in healthcare, including Workflow Management Systems, Business Process Management, and dynamic and adaptive case management.

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@IFTTT you could in Healthcare by @msharmas


Was reading this article published in a leading newspaper sometime back,

Naturally, I tried thinking of usecases to apply the technology in a Healthcare setting. 

About IFTTT
IFTTT works with a series of simple recipes using channels.  

IFTTT stands for IF this then that

Channels are “connected” apps, like Gmail, Google Calendar, Google Contacts, Twitter and many others supported by IFTTT. You can download IFTTT for android or iOS and start connecting channels to your account.  

Recipes
IFTTT allows you cook up your own recipes. Recipes are composed of this and that. Once you have connected the apps to your IFTTT account, you can start creating recipes. 

“this” in the recipe stands for a Trigger Condition or criteria, much like the IF condition you would create in an excel sheet, or in code.
“that” is the action that would be performed when the Trigger condition is met. Based on this condition being TRUE, IFTTT will execute that Trigger Action.
Lets take an example now, assume you are attending a conference and you would like to keep a list of tweets that you liked, and you want to retweet these out later or incorporate these in a blog. Given this scenario, you could do the following steps in IFTTT

  1. Download the App on your phone and create an account
  2. In the IFTTT app enable the Twitter & Google Drive “channels” by connecting to your Twitter and Google Drive credentials
  3. Once you have connected the channels, lets head over to Create a recipe
  4. Click Create recipe and it will ask you for a Trigger Channel, select Twitter
  5. Next, select the Trigger Conditions from the list of possible options provided by IFTTT based on the channel selected
  6. For our usecase we will select “New Liked Tweet by you” as the Trigger Condition
  7. Next we want IFTTT to save the “Liked” tweet in an excel file, for that we will select the trigger Action channel as Google Drive
  8. And we will select the Trigger Action as “Add row to spreadsheet”
  9. IFTTT will keep adding all the tweets you liked to the spreadsheet that you have selected

IFTTT you consider Healthcare Use cases 
OK, so we now have some understanding and agreement in terms how we are able to very simply, and with no coding, able to create a logic statement and get some work done. In fact you have just “Integrated” two apps and got them to “interoperate”

Lets now assume, IFTTT you could use in Healthcare use cases, What would you do?

What IFTTT offers is a set of features that allows for the end-user to create some of the rules based on their day-to-day circumstances. Lets say a nurse wanted the EHR system to Alert a doctor based on a certain specific parameter, but incorporating that logic would require a “code-change” to be done by the EHR vendor. The process is long-drawn to bring in such changes. 

Instead IFTTT the EHR system can incorporate the ability for the nurse to create her own recipe by providing Channels corresponding to various modules in the EHR system, and also provide the end users Trigger Actions  and Trigger Conditions (pre-defined by the EHR vendor).

Lets consider some of the usecases that can be enabled for an IFTTT type functionality in Healthcare

  • appointment reminders for doctors based on urgency of care
  • reminders to the nurse to change patient medication dosage based on doctors suggestion of lab results
  • pharmacy requisitions based on quantity on hand value defined
  • checking and validating medical actions for medical errors
  • patient discharge process alerts to all departments


IFTTT app allows for the end user to create her own “recipes” and “share” these within the community. And considering every patient’s treatment circumstances are different, clinical teams can setup trigger and action criteria that are active for a particular patient and can be continuously changed based on patient condition. Additionally, it also provides the end-user the ability to make enhancements to the system’s in-built logic by enabling customisation at the user end and instantaneously.

Once the patient gets discharged the clinical staff can have the ability to save all the tasks related to similar disease “patients like” scenario, to be templated for future
 

IFTTT you could Connect Healthcare Devices
Thinking a bit ahead to the future, one could control certain medical devices based on trigger based activities. So imagine, the nurse comes along with the doctor for the ward rounds and she is able to adjust the IV flow based on a doctor’s recommendations

IFTTT patients’ could

Patients too can be allowed to use IFTTT-like functionality by allowing them to create a folder in her google drive that contains all her electronic records emailed to her or her doctor

Patients can also setup reminders for their appointments since their hospital app enables the IFTTT-like functionality.
 
Patients can be sent alert notifications on their wearables or phones, about daily Medication reminders using IoT-based devices that dispense their medications

The power of IFTTT is in the simplicity and custom trigger and action criteria it provides it’s users

While writing the above article I recalled the time I was working in a Healthcare IT Product development company in Bangalore and we were looking to incorporate an Alerts & rules engine into our HIMS product. While defining the requirements for the solution, we had discussions with our end users in terms of how they would like the notifications from the system to be delivered. They all reported “Alert Fatigue” to be a factor in terms of how they went about using the system. They wanted to be able to control what alerts they saw and how they would like to view these alerts. 

An IFTTT-esque functionality incorporated within EHR systems will go long way in helping the end-users “customise” the solution based on their current requirements. They would be able to create focussed alerts based on their daily work. 

Afterall, the workflows in the hospital undergo a constant change and an EHR should be able to allow the end-users to incorporate customised workflow and rules

Author

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Manish Sharma

Founder HCITExpert.com, Digital Health Entrepreneur

Connect with me via any of my Social Media Channels

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