1 NHII Educational Seminar Series Hubert H. Humphrey Building August 5, 2004 John Walton Project...

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www.ruralcommunityhealth.org

NHII Educational Seminar SeriesHubert H. Humphrey BuildingAugust 5, 2004

John WaltonProject [email protected]

Will RossChief Technology [email protected]

Mendocino SHARE

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Mendocino County, California

Northwest coast of California

Two hours north of San Francisco

Population 87,000

3,500 square miles

Low population density (24 / sq. mi.)

Long distances between rural communities over mountain roads

Economically depressed

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ARCH Consortium

Clinic Type Encounters

Anderson Valley Health Center RHC 7,000

Potter Valley Community Health Center FQHC Look Alike 14,000

Long Valley Health Center FQHC 20,000

Redwood Coast Medical Services FQHC 22,000

Mendocino Coast Clinics FQHC 25,000

Mendocino Community Health Clinics FQHC 135,000

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Mendocino SHARE Project

Securing Health Access and Records Exchange

Modeled after Santa Barbara County Care Data Exchange

Target Population 32,000 +

Under 200% of poverty level

48% uninsured

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SHARE Objectives

Health Records Exchange

Coordinated chronic disease case management

Patient enrollment

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SHARE Collaborative

All six ARCH Community Health Centers

Consolidated Tribal Health Project, an IHS clinic

All three local hospitals

Ukiah Valley Medical Center

Howard Memorial Hospital

Mendocino Coast District Hospital

Mendocino County Department of Public Health

Mendocino County Department of Social Services

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Governance and Participation

Administrative Committee

Program Committee

Technical Committee

Solutions Workgroup

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SHARE Staff

John Walton, Project Director

30 years clinical and administrative experience in community and hospital settings

Will Ross, CTO

12 years in production agriculture and horticulture

15 years in technology project management

Greg Wenneson, Technical Project Manager

25 years in software development and software project management at NASA Ames, Autodesk and other commercial settings

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HCAP All Grantee Meeting

Sustainability highly valued

Doing well valued over rapidly making mistakes

Met other communities with MPI projects

Most MPIs were Enterprise, not Federated

Most HCAP projects featured a large, well funded partner

Open source software development is acceptable

Other projects were interested in collaboration

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Community Clinics Initiative

CCI Grant from the Tides Foundation in 1999 to build an enterprise ASP model Practice Management System

Phase One Anderson Valley Health Center (AVHC)Mendocino Coast Clinics (MCC)Mendocino Community Health Centers (MCHC)

Phase Two Long Valley Health Center (LVHC)Potter Valley Community Health Center (PVCHC)Redwood Coast Medical Services (RCMS)

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Enterprise ASP Plan

Host enterprise servers at MCHC Data Center

PMS on Windows NT

Thin client via a Citrix Server

56K fractional T1 circuits

Internet access to remote sites through Citrix desktop

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Enterprise ASP Result

Good News

Phase One enterprise ASP live in 2000

Patient scheduling, registration and billing

But there's trouble in paradise

Bad News

T1 lines intermittent

Disagreements on ASP priorities

ARCH Executive Director and CIO quit

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New Decentralized Direction

Site level servers for each clinic

No ASP model

No enterprise WAN

Every site made whole, no dependence on another site

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Lessons Learned

Enterprise ASP failed for social not technical reasons

Remote sites uncomfortable with distant support

Governance model unable to avoid frustrating all participants

Collaboration across separate institutions is possible

Decentralised solutions are optimal

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Santa Barbara County Care Data Exchange

July 2003

SBCCDE Interim Report

Loosely coupled p2p decentralised solution to PHI data sharing

Functionally consistent with decentralised IT collaboration model in ARCH consortium

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No HRE without EHR

R = “Records”

EHR is not just automation, it is workflow redesign

EHR requires

Secure Internet Access

Redundant journaling file system

Not just email, but secure clinical messaging

Facile presentation, clinical interaction and decision support

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Making EHR Possible

Clinical Records

Regular Email

Simple File System

Regular Internet Access

Common Knowledge

Paper records feel secure

Email not secure

Drives crash

Access intermittent

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Preconditions for MPI & HRE

All four layers above a PMS must be present before content can be made available to an MPI & HRE

Mendocino SHARE will help deliver all three upper layers

ARCH clinics have accomplished Secure Internet Access and PMS

*

EHR

Clinical Messaging

Document Management

Secure Internet Access

Practice Management System

* Potential for MPI, HRE and other NHII goals

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Federated Master Patient Index

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Health Records Exchange

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A Modest Technology Proposal

August 2003

Innocent ProposalScaled down clone of SBCCDE as a technology component in a $2 million HCAP grant application

Is This Wise?

ARCH has no idea that this proposal is way larger than HCAP funds

Funded, October 2003

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Primary Care Coalition

Primary Care Coalition of Montgomery County Third year HCAP grantee Open Source PMS & EHR (“CHLCare”) Needs a federated MPI

Mendocino SHARE First year HCAP grantee Building Open Source federated MPI Need a PMS & EHR solution

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Seeking an MPI Vendor

HCAP List of MPIs

MPIs built by previous HCAP grantees

77 MPIs listed

None free or open source

Almost all are Enterprise, not Federated

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Browsersoft

RFP Published, February 2004

12 vendors submitted bids

Extensive negotiations

Viewed 5 full demos

Browsersoft, April 2004

Overland Park, Kansas

An IBM Development Partner

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Browsersoft Builds SHARE Prototype

Dave Forslund's OpenEMed used during first prototype phase

Try loading PIDS files totaling over 50,000 patients from multiple domains, in some cases multiple files from a single domain

Has trouble scaling past 10,000 records

Due to HIPAA constraints our files have simulated data, false name pairs and false birthdates

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SHARE Prototype

Patient Lookup

Three value limit during prototyping phase

August 2004

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SHARE Prototype

Correlating Multiple Patient Listings

“Show Grouped”

August 2004

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SHARE Prototype

Viewing a Patient

August 2004

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SHARE Prototype

Graphing a Result

August 2004

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Discovery Process

We Learned

Vision > Funding

Not yet scalable

Productizing needed

Not ready for production

Needs architecture

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System Level Architecture MeetingJuly 14 & 15, 2004System Level Architecture Meeting (SLAM)

Two day brainstorming session

Review lessons learned in iterative Year One discovery process

Include Open Source experts from outside Mendocino SHARE

Imagine an optimal technology road map for Year Two

Meeting funded by the BPHC

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SLAM #1 Participants

Invitees

David Forslund, LANL

Jie Wang, Stanford University

Guy Fisher, Primary Care Coalition of Montgomery County

David Uhlman, Pennington Firm

Tom Passim, Mitretek Systems

ARCH

Will Ross

John Walton

Greg Wenneson

Browsersoft

Don Grodecki

Paul Misner

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Mendocino SLAM #1 Outcomes

Technology to Test in Next Iterations (August - November)

Run PIDS index as OpenLDAP

Run PIDS with POJO (can do WS when needed)

Use MySQL to manage PIDS updates

UCLA DataServer for population data de-identification

Test lexicon transformer based on Mayo Clinic LQS

Launch portal for virtual SLAM

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Clinic A(export only,

non-integrating simple systems)

HealthPro

PECS

export PIDS

BrowserPortal

SHARE

export PIDS and Clinical

Clinic B (bigger)(non-integrating

simple systems)

HealthPro

PECS

export PIDS

expo

rt P

IDS

an

d C

linic

al

Pharmacy

Clinics A and B – export data from systems only (not bi-directional). Access to SHARE is by Browser not integrated into clinic systems . If datacomm link goes down , no access to SHARE .Clinic/Hospital C – access to/through SHARE via hospital local MPI (bi-directional). DataComm goes down, still have local MPI .

expo

rt PI

DS

and

Clin

i cal

BrowserPortal

Hospital C, Enterprise

System (eg. Cerner)hopefully SHARE integrated

Enterprise System

export (or exchange?)

PIDS and Clinical

local MPI

export PIDS /

Clinical

export/importPIDS and clinical

non-integratedsystem

?? how does other data

get back to “C” system/

user??

Mendocino SLAM #1

IllustrationGreg Wenneson

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NHII

July 2004

Mendocino SHARE network design matches proposed designs from major national studies

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NHII

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NHII Strategic Framework

Before Conference Mendocino SHARE is an LHII

Mendocino SHARE is developing free LHII software

At ConferenceMendocino SHARE is less than a full LHII

Free LHII software projects

Mendocino SHARE

Massachusetts SHARE

Indiana Patient Care Network

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NHII Strategic Framework

Inform Clinical PracticeIncentivize EHR adoption

Reduce risk of EHR investment

Promote EHR diffusion

Interconnect CliniciansFoster regional collaborations

Develop a national health information network (Mendocino SHARE fits here)

Coordinate federal health information systems

Personalize CareEncourage use of Personal Health Records

Enhance informed consumer choice

Promote telehealth systems

Improve Population HealthUnify public health surveillance architectures

Streamline health status monitoring

Accelerate dissemination of evidence

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NHII in the Public Domain

Why Open Source?

Because there are enough collaborators to succeed

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OpenHRE.org Portal

Place development content on portal

Launch in August 2004

OpenHRE.org available to host access to any free or open source (FOSS) software solutions contributing to LHII solutions

OpenHRE.org will use the NHII technology framework to identify FOSS projects

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Mendocino SHARE Challenges

Technology

Collaboration

Funding < Vision

EHR

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Mendocino SHARE Vision

Federated solution

Feature complete LHII components

Using Open Standards

Free

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Mendocino SHARE

thank you!

to contribute to our enterprise software projectwww.openhre.org

questions or commentsWill Ross, Chief Technology OfficerAlliance for Rural Community [email protected]

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1 NHII Educational Seminar Series Hubert H. Humphrey Building August 5, 2004 John Walton Project...

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