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“Reducing Clinician Burden” Ageing in Community AiC

International Patient SummaryPågående standardsarbeten HL7, ISO, CEN

Björn-Erik Erlandsson, Professor, Senior Advisor

ISO/TC215 Convenor WG1 Architecture, Frameworks and ModelsKTH/CBH/Medicinsk teknik och Hälsa

[email protected]; 070-551 4330

mailto:[email protected]

“Reducing Clinician Burden” Project Overview

Gary Dickinson, Director

Health Level Seven (HL7)Electronic Health Record Work Group (EHR WG)

April 2019

15 April2019 HL7 EHR WG - "Reducing Clinician Burden"Project 3


• 3 out of 4 physicians believe that EHRs increase practice costs, outweighing any efficiency savings – Deloitte Survey of US Physicians, 2016

• 7 out of 10 physicians think that EHRs reduce their productivity – Deloitte

• 4 in 10 primary care physicians (40%) believe there are more challenges with EHRs than benefits – Stanford Medicine/Harris Poll, 2018

• 7 out of 10 physicians (71%) agree that EHRs greatly contribute to physician burnout – Stanford/Harris

• 6 out of 10 physicians (59%) think EHRs need a complete overhaul –Stanford/Harris

• Only 8% say the primary value of their EHR is clinically related –Stanford/Harris

• [Physicians express that EHR] systems had detracted from professionalsatisfaction (54%) as well as from their clinical effectiveness (49%) –Stanford/Harris

Quantifying the EHR Burden

Surveys Say...



WHAT/WHEN – Burden Targeted WHO – Might Best Address Burden

In Clinical Practice – At Point of Care Providers, Clinical Professional Societies

With

Engag

ed

Clin

icia

ns

In Health Informatics Standards, e.g.

• HL7 EHR System Functional Model and

Profiles• Messages (HL7 v.2x), Documents (HL7

CDA), Resources (HL7 FHIR)

• Implementation Guides (C-CDA, IPS)

Standards Developers/Profilers:

• HL7, DICOM, IHE, ISO TC215, NCPDP,

ASC X12N...Standards Coordinating Bodies

• Joint Initiative Council

In Regulation, Policies Government, AccreditationAgencies

In Claims, Payment Policies Public and Private Payers

During System/Software Design EHR/HIT System Developers/Vendors

During System/Software Implementation EHR/HIT System Implementers

Reducing Clinician Burden

Stakeholders


Reducing

(reduce)

• “To bring down, as in extent, amount, or degree; diminish”, and “To gain control of... [to] conquer”, and “To simplify the form of... without changing the value”, also “To restore... to a normal condition or position” – The Free Dictionary

• “To lower in... intensity” – Dictionary.com• “To narrow down”, also “To bring to a specified state or condition” – Merriam-Webster

Clinician

• “A health professional whose practice is based on direct observation and treatment of a patient” – Mosby's Medical Dictionary

• “An expert clinical practitioner and teacher” – Miller-Keane Encyclopedia and Dictionary ofMedicine, Nursing, and Allied Health

• “A health professional, such as a physician, psychologist, or nurse, who is directly involved in patient care” – American Heritage MedicalDictionary

Burden

• “A source of great worry or stress”, and “[Something that] cause[s] difficulty [or] distress”, also “To load or overload” – The Free Dictionary

• “Something that is carried, [as in a] duty [or] responsibility”, also “Something oppressive or

worrisome” – Merriam-Webster Dictionary


Defining Terms (DRAFT)


Clinician

Burden

Anything that hinders patient care, either directly of indirectly [such as]:

1) Undue cost or loss of revenue,

2) Undue time,

3) Undue effort,

4) Undue complexity of workflow,

5) Undue cognitive burden,

6) [Uncertain quality/reliability of data/record content,]

7) Anything that contributes to burnout, lack of productivity, inefficiency, etc.,

8) Anything that gets in the way of a productive clinician-patient relationship.

-- Peter Goldschmidt


Defining Terms (DRAFT)

Source: Health Data Management


Source: Annals of Internal Medicine –Physician Burnout in the Electronic Health Record Era:Are We Ignoring the RealCause?

N Lance Downing MD, David W Bates MDMSc,

Christopher ALonghurst MD MS, 8 May 2018




Burden Sometimes leads to Burnout

• “’Physician burnout’ has skyrocketed to the top of the agenda in medicine. A 2018 Merritt Hawkins survey found a staggering 78% of doctors suffered symptoms of burnout, and in January [2019] the Harvard School of Public Health and other institutions deemed it a ‘public health crisis.’”

• Fortune and Kaiser Health News: “Death by a Thousand Clicks: Where Electronic Health Records Went Wrong”, Erika Fry and Fred Schulte, published 18 Mar 2019

From: Physician stress and burnout: the impact of health information technologyJ Am Med InformAssoc. 2018;26(2):106-114. doi:10.1093/jamia/ocy145

12

From: Physician stress and burnout: the impact of health information technologyJ Am Med InformAssoc. 2018;26(2):106-114. doi:10.1093/jamia/ocy145

13




Assessing the Burden

• Our primary focus is on clinician burdens including time and data qualityburdens associated with:

• Use/engagement of EHR/HIT systems

• Capture, exchange and use of health information

• Considering:• Clinical practice – at the point of care

• Regulatory, accreditation, administrative, payor mandates

• EHR/HIT system design, functionality, usability and implementation

• Data quality and usability

• Gather details from many reference sources:• Trade publications, professional society journals, articles, studies, personal experience

• Our goal is not to boil the ocean, rather to understand the substance and extentof the burden, to recognize root causes and identify successstories.


Reducing Clinician Burden – Breaking It Down

Topics/Categories

2) Patient Safety (and Clinical Integrity)

3) Administrative tasks

4) Data entry requirements

5) Data entry scribes and proxies

6)Clinical documentation: quality and usability

7)Prior authorization, coverage verification, eligibility tasks

8) Provider/patient face to face interaction

9) Provider/patient communication

10)Care coordination, team-based care

11) Clinical work flow

13)Clinical decision support, medical logic, artificial intelligence

14) Alerts, reminders, notifications, inbox

1) Clinician Burden – In General management

2) Clinician Burnout – Sometimes the Result15) Information overload

16) Transitions of care

17)Health information exchange, claimed “interoperability”

18) Medical/personal device integration

19) Orders for equipment and supplies

20)Support for payment, claims and reimbursement

21) Support for cost review

cost, utilization

23) Support for public and population health

24) Legal aspects and risks

12) Disease management, care and treatment25) User training, user proficiency plans

26) Common function, information andprocess models

27) Software development and improvement

priorities, end-user feedback

28) Product transparency

29) Product modularity

30) Lock-in, data liquidity, switching costs

31) Financial burden

32) Security

33)Professional credentialing

34.1) Identity matching

34.2) Identity and credential management

22) Support for measures: administrative, 35) Data quality and integrityoperations, quality, performance, productivity,

36) Process integrity

1) Problem list

2) Medication list

3) Allergy list

4) Immunization list

5) Surgery, intervention and procedure list



Project Plan

• Now• Continue environmental scan – to documentburdens

• Engage focus teams to address burden topics

• Focus on root causes

• What is the problem and its source?

• Why did it happen?

• What will be done to prevent it from happening (now and in thefuture)?• Who (stakeholder(s)) might best address burden?

• Have burden(s) already been tackled?• Are there RCB proposals and/or successful solutions that can be referenced?

• Then• Publish findings and work to implement solutions



Additional Considerations

• What are the risks if burden is not reduced?• e.g., clinician burnout, clinicians choosing other roles/assignments

• If clinician burdens are reduced...• Are burdens increased elsewhere (e.g., to other members of the

healthcare team)?

• Are benefits to other aspects of the health/healthcare business model also reduced?

• What is the trade-off: Safety? Cost? Time? Efficiency? Effectiveness?


Reducing Clinician Burden Project

Outreach + Expressed Interest

• Joint Initiative Council (JIC), comprising HL7, ISO TC215 (HIT), CEN TC251 (HIT/Europe), DICOM (Diagnostic Imaging), CDISC (Clinical Research), GS1 (IDs/Labeling), SNOMED (Clinical Vocabulary), IHE(Standards Profiling), PCHCA (PersonalConnectivity)

• International Healthcare Community• Australia, Canada, Finland, Italy, Netherlands, New

Zealand, Sweden, United Kingdom

• Government• US Centers for Medicare and Medicaid Services (CMS)

• US Office of National Coordinator for HIT (ONC)

• US National Institutes of Health (NIH)

• US Veterans Administration (VA)

• UK National Health Service (NHS)

• Accreditation Bodies• Joint Commission

• Standards Developers • Clinical Professional Societies• American College of Physicians (ACP)• American College of Surgeons (ACS)• American Medical Informatics Association (AMIA)• American Nurses Association (ANA)

• Providers• Adventist Health, Beth Isreal/Deaconess, Cedars-Sinai

Medical Center, Duke University, Intermountain Healthcare, Kaiser Permanente, Loma Linda University, Mayo, Sutter Health, University of Arkansas, University of Nebraska, VA

• Payers• UnitedHealth Group

• EHR/HIT System Developers• CentriHealth, Cerner, Epic, TLD Systems

• Consortia• Health Record BankingAlliance• Health Services Platform Consortia• Clinical Information Interoperability Council

Ageing in Community AiCPågående standardsarbeten HL7, ISO, CEN


ISO/TC215 Convenor WG1 Architecture, Frameworks and Models

KTH/CBH/Medicinsk teknik och Hälsa



AiC Report to CAG2

From Lillehammer 2016 to Paestum 2018 to …

AiC Report 1.0

Recommendations to CAG2

Toward Daegu 2019

21

From Lillehammer 2016

to Paestum 2018 to …

2016-11 “Ageing in Community” AHG Formed in Lillehammer

2017 – 18 Workshops, web meetings, TC215 report outs

2018-12 AiC Report 1.0 Published

2019-04 TC215 CAG2 Review of (6) Recommendations

2019-11 Target AiC Report 2.0 + NPs + Joint TF’s +

Conference in Daegu, South Korea

See 2018 Paestum AiC report for additional detail.22

23

Ageing in Community ISO/TC 215 Ad-Hoc Group Report

(Revision 1.1)

Table of Contents

Introduction _________________________________________________________________ 3

Understanding the Challenges ___________________________________________________ 4

A Global, Personal & “Wicked Problem” _________________________________________________ 4

Global Dialog Around Ageing Communities ______________________________________________ 6 ISO/TC 314 Ageing societies _________________________________________________________________ 6 IEC/Systems Committee – Active Assisted Living ________________________________________________ 8

Scenarios & Use Cases Abound ________________________________________________________ 8

Regional / National Perspectives _____________________________________________________ 11 European Activities ______________________________________________________________________ 11 Perspectives in the United States ___________________________________________________________ 14

From Business Cases to Implementable Standards ______________________________________ 15

Intelligent “Life Coordination” Communities ___________________________________________ 16

Care Delivery Model … Discontent ___________________________________________________ 17

Establishing Caregiver-Centered Network Informatics ____________________________________ 19

Evolving Digital Technology World ______________________________________________ 20

Changing Digital Health Landscape ___________________________________________________ 20

Architecture: Navigational Health ___________________________________________________ 21

Architecture: Digital Home for the Elderly _____________________________________________ 22

Recommendations for TC 215 __________________________________________________ 26

Overview ________________________________________________________________________ 26

Recommendation 1: Establish an “enhanced liaison” with ISO/TC 314 ______________________ 27

Recommendation 2: Establish a joint AiC-AAL task force with IEC/SyC AAL __________________ 27

Recommendation 3: Advance the TC 215 Digital Home Care System for Elderly Wellness Project 27

Recommendation 4: Advance the TC 215/TMsTF Lifestyle Work Item Proposal _______________ 27

Ageing in Community AHG Report

Page 2

Recommendation 5: Consider a Long-Term Roadmap to an Ageing in Community RSP _________ 27

Recommendation 6: Continue Ageing in Community AHG ________________________________ 28

Appendix A: ISO/TC 314 Ageing societies _________________________________________ 29

Appendix B: Additional Informatics Models _______________________________________ 30

Appendix C: Terms & Definitions ________________________________________________ 31

Appendix D: Bibliography _____________________________________________________ 33

Appendix E: Additional Collaboration Organizations _______________________________ 34

Appendix F: TC 215 AiC AHG ___________________________________________________ 37

Table of Figures Figure 1 Olav's Story ................................................................................................................................... 5 Figure 2 Capacity based eHealth architecture roadmap ............................................................................. 7 Figure 3 IEC/SyC AAL Architectural Model .................................................................................................. 8 Figure 4 AiC AHG Representative Use Case Catalog .................................................................................... 9 Figure 5 IEC/SyC AAL Use Cases ................................................................................................................ 10 Figure 6 EU Progressive Standards for ICT/AHA Fact Sheet ...................................................................... 12 Figure 7 What really matters as we age? .................................................................................................. 15 Figure 8 Use Case Analysis: From Business Cases to Profiles ................................................................... 16 Figure 9 Key Actors in the Ageing in Community Landscape .................................................................... 16 Figure 10 WHO What impacts human health most? ................................................................................ 17 Figure 11 Dr. Hammond: Health Tech in 10 Years .................................................................................... 18 Figure 12 InfoSAGE Family-Centered Network Tool .................................................................................. 19 Figure 13 Future Health - Leverage Cybernetic Technology to Create Personal Models 16 ...................... 21 Figure 14 Jain's Navigational Health Architecture .................................................................................... 22 Figure 15 Model for Elderly Wellness (Kim / Lee) ..................................................................................... 23 Figure 16 Integrating a Primary Caregiver in Support of Elderly Wellness ............................................... 23 Figure 17 Integration of health and social care information system services for the support of the care of

the elderly .................................................................................................................................................. 25 Figure 18 SyC AAL Proposal Supporting a Connected Home for the Elderly ............................................. 26 Figure 19 ISO/TC 215 Reference Standards Portfolio (RSP) Development Approach ............................... 28 Figure 20 Rural Healthcare Framework .................................................................................................... 30

Recommendation #1

#1: Establish an “enhanced liaison” with ISO/TC 314

1st Meetings in 2018 – next 2019 meetings: June @ Berlin, November @ SydneyInterest expressed by TC314 leadership to TC215 members Joint scope and collaboration opportunities need to be developedNext Steps: Establish a joint task force to engage TC314 and establish an enhanced liaison

24

Recommendation #2

#2: Establish a joint AiC-AAL task force with IEC / SyC AAL

Dr. Taehwa Han, Liaison to IEC / SyC AAL Interest expressed in establishing a joint task force to identify Next steps: Resolution to advance task force creation

25From Korean proposal to IEC/SyC AAL

Recommendation #3

#3: Advance the TC215 Digital Home Care System for Elderly Wellness Project

TS 23536 “Digital elderly home care system (DECS)” – Approved 2019-FebruaryInterest expressed from ISO/TC 314Coordinate with IEC/SyC AAL

26

Recommendation #4

#4: Advance the TC215 / TMsTF Lifestyle Work Item Proposal

“Categorical structure for representation of lifestyle in TM” (Dr. Hyunchul Jang)Engage others in the lifestyle informatics arena Include social care informatics (Dr. Värri) Factor in geriatric care assessments based on

lifestyle factorsNext Steps: Update in AiC Report 2.0

27

ANewPerspectiveforHealth

Health

PersonalModelsand

Cybernetics.

Focus on:

Source: Prof. Ramesh Jain; includes Lifestyle & Social informatics contributors to health.

Recommendation #5

#5: Consider a Long-Term Roadmap to an Ageing in Community RSP

AiC RSP remains an appealing objective, but still too soon to begin draftingRoadmap to an RSP could be developed in 2019Especially with broader collaboration & TC engagementNext Steps: Include RSP “roadmap” in AiC Report 2.0

28

Recommendation #6

#6: Continue Ageing in Community AHG

Development of a TC 215 AiC Framework / model that can be used for communications & roadmapping purposes

Identification of other collaboration and joint work opportunities

Specifically target organizations such as JTC1 and the HIMSS / PCHAlliance that have indicated interest in both this area and working with TC 215

Develop subsequent versions of this report, broadening the content for other TC 215 member countries as well as additional research and identification of standardization opportunities

Seeking to collaborate with, and draw on the experience of, multilateral agencies such as World Bank Group, United Nations for Ageing

AiC Report 2.0 should be planned for the November 2019 ISO/TC 215 meetings in Korea

29

International Patient SummaryPågående standardsarbeten HL7, ISO, CEN


ISO/TC215 Convenor WG1 Architecture, Frameworks and Models

KTH/CBH/Medicinsk teknik och Hälsa



*CEN Funded by the European Commission

Introducing the IPS Standards

Background: Context and Landscape

CEN IPS Strategy-Goals-Aims-Objectives

eHN Guidelines for Patient Summary and Requirements

CEN IPS & HL7 IPS: a shared Vision

Status of the IPS standards at this time and projected time-lines

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Context and Landscape

The concept of a Patient Summary (PS) is not new; arguably, in existence since record

keeping began

Ubiquitous, the PS is part of the fabric of healthcare

Everyone seems to have their own idea about what it is, and what it should do

The PS is simple in concept …

But the PS come with its own baggage

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This Photo by Unknown Author is licensed under CC BY-NC-ND

http://www.onyxtruth.com/2014/02/02/dear-bag-men/

https://creativecommons.org/licenses/by-nc-nd/3.0/

The last Decade… PS Intense

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In Europe…The epSOS projects, cross-border pilot for PS and eP Exchange, 2009-2014... and several others (EXPAND, OpenMedicine,…)eHealth Network Guidelines 2013-2016

Cross-Atlantic…2010 EU US EU/US MoU: ONC Standards and Interoperability Framework (ONC S&I) EU/US eHealth Cooperation Initiative; EU Trillium Project; 2013 The INTERPAS Project, HL72015 Transatlantic eHealth/health IT Cooperation Roadmap: enforcement of the IPS concept.

In JIC, 2015 the PS Standards Set work was begun to provide informative guidance

But prior to this, back in 2009 in ISO…

ISO Technical Report, 2009

Patient

Summary

Health record extract comprising a standardizedcollection of clinical and contextual information(retrospective, concurrent, prospective) thatprovides a snapshot in time of a subject of care’shealth information and healthcare

SOURCE: ISO/TR 12773-1:2009 (en) Business requirements for health summary records — Part 1: Requirements]

What is a Patient Summary...

What is the IPS ?

Patient

Summary

It emphasizes the need to providegeneric solutions for global applicationbeyond a particular region or country.

Health record extract comprising a standardizedcollection of clinical and contextual information(retrospective, concurrent, prospective) thatprovides a snapshot in time of a subject of care’shealth information and healthcare

SOURCE: ISO/TR 12773-1:2009 (en) Business requirements for health summary records — Part 1: Requirements]

International

Introduction to CEN IPS

CEN TC/251 is a regional SDO

It had no funding to engage with PS initiatives, (despite CEN’s plan to target ISO outputs where possible)

it was being left behind…In 2014 TC/251 presented a PS proposal to eHN

The proposal was submitted and accepted by the EC in 2015

Work started September 2016 on the IPS

CEN IPS: Strategic Goal

To provide a harmonised specification i.e., a formal, coherent and consistent, PS specification

that builds upon existing European work, contributes to global activity (e.g. ISO & WHO)and helps to establish better continuity and coordination of care.

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The IPS Project: the HL7 Int. CEN/TC 251

agreement (April, 2017)

Vision

• “In order to further the care for citizens across the globe, we agree to collaborate on a single, common International Patient Summary (IPS) specification that is readily usable by all clinicians for the (cross-border) unscheduled care of a patient.”

Scope

• “The IPS specification shall focus on a minimal and non-exhaustive Patient Summary, which is specialty-agnostic and condition-independent, but still clinically relevant.”

Implementable

Applicable for global use

Extensible and open

Sustainable

IPS P

rincip

les

CEN IPS prEN 17269

...formalises the dataset required to share information about the medical background and history of a patient ….

.. It uses the European guidelines (version 2, November 2016) as an official source for the requirements….

The dataset is minimal and non-exhaustive <…> specialty-agnostic, condition-independent and usable by all clinicians for the unscheduled care of a person…

…usable as a valuable subset of data items for scheduled care…

It is implementation independent.

This international standard does not cover workflow processes of data entry, data collection, the summarisation act nor subsequent data presentation. ..

The Patient Summary for Unscheduled, Cross-border Care

CEN IPS prTS 17288

The IPS: Guidance for European Implementation Technical Specification (TS)

…. provides European implementation guidance for the International Patient Summary (prEN 17269).

… it is also intended to be usable for more localised deployment, <…> as an additional benefit, its components may be reused to improve the interoperability of EHRs through common exchange formats.

..it addresses: Jurisdictional requirements; Governance, Privacy and data protection and Conformance.

..it includes examples of transport formats…

Out of Scope: recommend a particular delivery platform/service/template.

HL7 IPS CDA

Implementation Guide

The Four IPS Project Deliverables

eHN EU PSGuidelines

CEN/EN 17269IPS

CEN/TS 17288IPS

HL7 IPS CDA IG

HL7 IPS FHIR IG

refer refer

implement

Provide guidance for EU

refine

The Four IPS Project Deliverables

eHN EU PSGuidelines

CEN/EN 17269IPS

CEN/TS 17288IPS

HL7 IPS CDA IG

HL7 IPS FHIR IG

refer refer

implement implement

Provide guidance for EU

refine

EU standard Global aspiration

EU scope

Global Standards

IPS Progressive Approach

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Re

solu

tio

n

HIGH

Scale LARGE

…refining constraints, consider local and scheduled care

Today..

..tight focus: Cross-border, Unscheduled care…

FUTURE

IPS

…SoC assumed to be adult, on Business/for pleasure…


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Re

solu

tio

n

HIGH

Scale LARGE

The IPS Dataset matures…

..increasing detail as required by stakeholder community…

… and recognising different capacities andpotential gain/pain!

FUTURE

IPS

IPS


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Re

solu

tio

n

HIGH

Scale LARGE

FUTURE

IPS

IPS

Subjects of Careconcerns are amplified impacting data description anduse of IPS

Acceptance & adoption

Education and skills

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Extending the IPS Use Case

Local Needs

The IPS is not an EHR !

49

..but it could be the basis for the future EuropeanEHR exchange format (EU EHR-xF) ..


22/05/2019

The IPS is a document !

as a document

Current Intended Use Expected Future Use

as a document and a as a library

IPS as Collaboration Framework

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IPS value operates at the strategic and operational levels of the life cycle

IPS provide a collaboration framework for harmonising and for conformance

CG

A m

eth

od

olo

gy(f

rom

eSt

and

ard

s)IP

S Life C

ycle(fro

m e

Stand

ards)

Time-Lines

CEN documents:

both in Ballot, deadlines end October and December 2018.

need to dispose comments and verify possible remaining gaps between the two documents and between 17269 and the HL7 implementations. Time-line for this phase March 2019

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Time-Lines

HL7 Implementation Guides.

HL7 CDA IPS IG , STU publication approved (Oct. 2018);

HL7 FHIR IPS IG, 2nd ballot passed, expected STU publication end of 2018.

We have requested 24 months STU period.

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The IPS as

The HL7 and CEN collaboration on IPS has worked

superbly well with 4 specifications near completion

in just 2 years !

Hopefully, to be extended..

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IPS Project and ISO

CEN Perspective…

Update the Standards Knowledge Management Tool (SKMT) with IPS definitionsUpdate JIC PSSS Synchronise and test dataset EN17269; once mature (enough) move it into the ISO space

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