The Argonaut Project: Accelerating the Next Generation of Interoperability

November 13, 2016

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All about me

Education: PhD Political Science and Economics (MIT)

Prior experience:• Boston Consulting Group• Indiana Health Information Exchange• US Department of Defense (Office of the Secretary of Defense, Navy, Air Force)

Other affiliations:• Sequoia Project (Board member)• FHIR Foundation (Board member)• Harvard University Berkman Klein Center for Internet and Society (Fellow)

CEO, Massachusetts eHealth Collaborative

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Agenda

Why do we need the Argonaut Project?

Who’s behind it and what do we want to do?

What have we done?

What’s next for the Argonaut Project?

What lessons have we learned?

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• Highly critical of the status and trajectory of US healthcare interoperability

‒ Blamed EHR vendor technology and business practices and lack of an architecture supporting standardized APIs

• Recommended a “unifying software architecture” to migrate data from legacy systems to a new centrally orchestrated architecture

‒ ONC should define “an overarching software architecture for the health data infrastructure” within 12 months

It all started with JASON

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JASON Task Force Recommendations

• Foundation of interoperability should be an orchestrated architecture employing Public APIs based on FHIR

• Current interoperability approaches need to be gradually replaced with more comprehensive API-based models

• Meaningful Use Stage 3 should be used as a pivot point to initiate this transition

Member Name Organization

David McCallie (Co-Chair) Cerner

Micky Tripathi (Co-Chair) MAeHC

Deven McGraw Manatt

Gayle Harrell Florida State LegislatorLarry Wolf Kindred HealthcareTroy Seagondollar KaiserAndy Wiesenthal DeloitteArien Malec RelayHealthKeith Figlioli Premier, Inc.Wes RishelLarry Garber Reliant Medical Group

Josh Mandel Boston Children’s HospitalLanden Bain CDISCNancy J. Orvis FHA/DoDTracy Meyer FHA/ONCJon White HHS

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What’s wrong with current standards?

• Document exchange (e.g., CCDA) is too broad• Data-level exchange (e.g., HL7 v2, NCPDP) is too narrow • No nationwide standards to support query-based use cases

Limited

• CCDAs are inefficient and cumbersome• IHE-based standards are complex

Complex

• Not based on modern internet standards, protocols, or conventions• Not scalable

Myopic

Implication• Standards and ecosystem don’t support a rich set of use cases• Cost and complexity of standards are barrier to adoption• Innovators from outside health care discouraged from entering

What’s really wrong with current standards: Clinician users despise the CCDA

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Why FHIR-based APIs?

Flexible to document-level and data-level exchange• Sometimes individual data elements are important, sometimes entire documents are

appropriate

Based on modern internet conventions• RESTful API – same browser-based approach as used by Facebook, google, twitter, etc• Infinitely extensible to detailed resources/profiles to meet any use case• Supports push and pull use cases

FHIR isn’t the only way to approach APIs, but it’s the leading candidate• Gaining rapid enthusiasm in the health information technology community• Supported by an existing health care SDO (HL7)

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An Industry Call to Action

Meaningful Use Stage 2 experience with Direct standard highlights difficulties created when forcing immature standards on the industry

Early and growing industry enthusiasm for FHIR raises concern about need for more market discipline in standards development processes

Industry expresses desire to swing the balance of responsibility for nationwide interoperability back to the private sector

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An Initiative is Born: The Argonaut Project

The Argonaut Project is a market-initiated code and documentation sprint to accelerate the market readiness of open industry FHIR-based APIs for patient- and provider-driven interoperability use cases

It is NOT:• an organization or entity• competitive with other existing

initiatives• proprietary

It is:• leveraging the work of other

initiatives such as the S&I framework, SMART, and HSPC

• accelerating the maturation of FHIR for the industry

• open to all participants

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Who’s behind the Argonaut Project?

athenahealthCernerEpicMEDITECHMcKessonSurescripts

Beth Israel Deaconess Medical CenterIntermountain HealthMayo ClinicPartners HealthcareSMART on FHIR at Boston Children’s Hospital

AccentureThe Advisory Board Company

Prime contractor – HL7FHIR Implementation Guide development: Grahame Grieve, Brett Marquard, Eric Haas, Josh MandelOAuth Implementation Guide development: Dixie Baker, Josh MandelProject management: Micky Tripathi, Jennifer Monahan

Staff

Founders

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Many Organizations Registered in Argonaut Implementation CommunityAccenture GE Office of National Coordinator (ONC)ActualMeds Corp. Geisinger Optum (UnitedHealth Group)AEGIS.net,Inc. Hackensack University Medical Center Orion HealthAetna Health Samurai/Aidbox OSIA MedicalAkana i2b2/Mass General Hospital Partners HealthcareAllscripts Iconic Systems Persistent System LtdAmerican Medical Association Infor Personal Medicine Plus Amida Technology Solutions Inpriva Pokitdok Inc.Apigee Intermountain Healthcare Practice FusionApplied Informatics InterSystems Corporation Premier Incathenahealth KaiRx QveraBespoke Systems Mana Health Redox EngineBIDMC Mayo Clinic Reliant Medical GroupCare at Hand McKesson/RelayHealth RxREVUCarebox Medfusion SMART Health ITCarefluence MedicaSoft SurescriptsCarolinas HealthCare System Medicity The Advisory Board CompanyCerner MEDITECH The Sequoia Project (formerly Healtheway)CipherHealth Medivo Trinity HealthClinical Cloud Solutions, LLC MITRE UC Santa CruzCommerce Kitchen MobileSmith UPMCDoD/VA ModuleMD US Postal ServiceDuke Medicine My Total Health Vetter SoftwareeClinicalWorks NavHealth VigiLanz CorporationEligible NaviNet VSeeEMR Direct Netsmart xG Health SolutionsEpic NextGen/QSI Xperterra

Mix of EHR vendors, providers, app developers, government agencies, and others....

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Why do we need the Argonaut Project to accelerate FHIR?

Standards development process, by design, values comprehensiveness over speed-to-market

SDOs not resourced to provide dedicated project management and SME support to implementation-oriented activities

• Identification of priority use cases to meet market needs• Development of well-packaged implementation guides• Facilitation of testing and implementation community• Coupling with other standards or protocols needed for implementation (e.g., security)

Implementers need to have greater input (i.e., deeper, earlier) into standards development

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Clinical Identification Workflow Infrastructure Conformance FinancialAllergyIntolerance Patient Encounter Questionnaire ValueSet CoverageCondition (Problem) Practitioner EpisodeOfCare QuestionnaireRespons ConceptMap Eligibil ityRequestProcedure RelatedPerson Communication Provenance NamingSystem Eligibil ityResponseClinical Impression Organization Flag AuditEvent StructureDefinition EnrollmentRequestFamilyMemberHistory HealthcareService Appointment Composition DataElement EnrollmentResponseRiskAssessment Group AppointmentResponse DocumentManifest Conformance ClaimDetectedIssue Location Schedule DocumentReference OperationDefinition ClaimResponseCarePlan Substance Slot List SearchParameter PaymentNoticeGoal Person Order Media ImplementationGuide PaymentReconciliationReferralRequest Contract OrderResponse Binary TestScript ExplanationOfBenefitProcedureRequest Device CommunicationRequest BundleNutritionOrder DeviceComponent DeviceUseRequest BasicVisionPrescription DeviceMetric DeviceUseStatement MessageHeaderMedication ProcessRequest OperationOutcomeMedicationOrder ProcessResponse ParametersMedicationAdministration SupplyRequest SubscriptionMedicationDispense SupplyDeliveryMedicationStatementImmunizationImmunizationRecommendationObservationDiagnosticReportDiagnosticOrderSpecimenBodySiteImagingStudyImagingObjectSelection

Patient nameSexDate of birthRaceEthnicityPreferred languageSmoking statusProblemsMedicationsMedication allergiesLaboratory testsLaboratory resultsVital signsProceduresCare team membersImmunizationsUnique Device identifiersAssessment and Plan of TreatmentGoalsHealth concerns

2015 Edition Common Clinical Data Set 93 FHIR DSTU2 Resources (17 Argonaut CCDS Resources in red)

Argonaut Focusing on FHIR Resources Supporting CCDS

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Argonaut Implementation Guides Based on DAF ProfilesFrom US Data Access Framework Implementation Guide

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Setting Practical Constraints on Server-Client Interactions

What search criteria can you use?

What type of data will you get in response?

How will that data be represented?

Scope of response

Examples:• Search for patient will get all

FHIR patient resources• Search for Procedures will

get all current and historical procedures or within specified date range

Content of response

Examples:• Patient search will get

name, identifier, gender, birthdate, birth sex, REL

• Procedures search will get type of procedure, date performed, and procedure status

• In some cases created Argonaut extensions and value sets

Search operations

Examples:• Can search for individual

patient by identifier (e.g., MRN) OR full name & gender OR full name & birthdate

• Can search for Procedures by patient or by patient & specified date range

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Argonaut Implementation Guides In a NutshellQuery Supported searches Scope of response Content of response

Patient Identifier (e.g., MRN) OR (Full name + gender OR Full name + birthdate)

FHIR patient resources • Name• Patient identifier• Gender• Birthdate• Birth sex• Race, ethnicity, language

Allergies Patient OR Patient + Date

All allergies • Type of allergy• Allergy status

Assessment and Plan of Treatment

PatientOR Patient + CategoryOR Patient + StatusOR Patient + Specified date range

All Assessment and Plan of Treatment information

• Care plan category (Argonaut extensions)• Care plan status• Narrative summary

Care Team PatientOR Patient + CategoryOR Patient + Status

All current Care Team members • Care plan category (Argonaut extensions)• Care plan status• Care team members• Care team provider roles

Goals PatientOR Patient + Specified date range

All patient goals • Narrative description of goals• Goals status

Immunizations Patient All immunizations • Immunization status (Argonaut valueset)• Date of administration• Type of vaccine• Indicator of vaccine given or reported

Medications (statements)

Patient All medications • Medication• Medication status• Date or date range

Medications (order)

Patient All medication orders • Medication• Order date• Order status• Prescriber

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Query Supported search operations Scope of response Content of response

Laboratory results (diagnostic reports)

PatientOR Patient + Diagnostic Report Code(s)OR Patient + Specified date range

All diagnostic reports • Laboratory code (LOINC)• Result• Status• Time of measurement• Time of report• Source of report

Laboratory results (observations)

PatientOR Patient + Laboratory Code(s)OR Patient + Specified date range

All observations • Laboratory code (LOINC)• Result value• Status• Time of measurement• Reference range

Problems and Health Concerns

Patient All problems and health concerns, current and historical

• Problem or health concern code• Problem or health concern category code (Argonaut

extension)• Problem or health concern status• Verification status

Procedures PatientOR Patient + Specified date range

All procedures, current and historical • Type of procedure• Date performed• Procedure status

Smoking status Patient Smoking status • Smoking observation status• Result value code (LOINC)• Date recorded• Smoking status

Vital signs PatientOR Patient + Specified date range

All vitals • Type of measurement (Argonaut value set)• Time of measurement• Result value (Argonaut value set)• Observation status

Implantable devices

Patient All UDIs for a patient’s implantable devices • Human readable form of barcode string• Type of device

Argonaut Implementation Guides In a Nutshell (continued)

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Query Supported search operations Scope of response Content of response

Provider Directory PractitionerOR Practitioner + SpecialtyOR Practitioner + Location (WIP)OR Organization IdentifierOR Organization NameOR Organization AddressOR Endpoint identifierOR Endpoint name

All practitioner, organization, and endpoint information

• Practitioner name• Practitioner Identifier• Practitioner Role and organization• Practitioner Qualifications• Organization name• Organization identifier• Organization status• Organization contact• Organization physical address• Organization endpoint address• Endpoint name• Endpoint status• Endpoint organization• Endpoint channel type• Endpoint address

Document DocumentOR Patient

All documents for a patient • Patient• Document HTTPS address• Document type• Document format• Document reference date• Status• Document identifier

Argonaut Implementation Guides In a Nutshell (continued)

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What will the Argonaut Project produce?

FHIR Implementation Guides map to FHIR DSTU 2

OAuth/OIDC Implementation Guides currently being developed outside of HL7 but will eventually be incorporated in HL7 balloting process

FHIR RESTful API Implementation Guides

• Data element query of the Common Clinical Data Set (STU2, Dec 2016)• Document (CCDA) query (STU2, Dec 2016)• Provider directory query (STU3, Q1 2017)

OAuth/OIDCImplementation Guides

• Authorization of enterprise-approved applications (Completed)• Single sign-on to enterprise-approved applications (Completed)

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Links to Argonaut Deliverables

Argonaut FHIR API deliverables• Argonaut FHIR Data Access Implementation Guide:

http://argonautwiki.hl7.org/index.php?title=Implementation_Guide• Argonaut FHIR Document Access Implementation Guide:

http://argonautwiki.hl7.org/index.php?title=Argonaut_Document_Access• Argonaut FHIR Provider Directory Implementation Guide:

http://argonautwiki.hl7.org/index.php?title=Provider_Registry_Implementation_Guide

Argonaut OAuth deliverables• Use Cases Description, Version 1.1 available at

http://argonautwiki.hl7.org/images/e/ec/Argonaut_UseCasesV1-1.pdf• Application Authorization Profile available at http://docs.smarthealthit.org/authorization/• Cross-Organizational Authorization Profile available at

https://github.com/smart-on-fhir/smart-on-fhir.github.io/wiki/cross-organizational-auth• DRAFT Risk Assessment Update

- Updates Risk Assessment through Phase 2- Available for review on Argonaut Auth: SMART on FHIR Google Drive (

https://drive.google.com/open?id=0B8NVHvNTY_HUWXp2NzRfX2tjbjA)

Argonaut Implementation Program• https://github.com/argonautproject/implementation-program/wiki

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What will Argonaut Implementation Guides allow people to do?

Within enterprise:• Patient or Provider uses authorized hosted

or mobile application to query for data or documents from a single enterprise EHR

Cross enterprise:• Provider uses hosted or mobile application to

query for data or documents from EHRs in other enterprises

Patient nameSexDate of birthRaceEthnicityPreferred languageSmoking statusProblemsMedicationsMedication allergiesLaboratory testsLaboratory resultsVital signsProceduresCare team membersImmunizationsUnique Device identifiersAssessment and Plan of TreatmentGoalsHealth concerns

2015 Edition Common Clinical Data Set

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What will Argonaut Implementation Guides allow people to do? (continued)

authenticate user

authorization server

FHIR resource server

health care organization A

hosted application

• register app

• authenticate app

• authorize app

• register app

• authorize app

mobile application

launch app

Within enterprise

access data & documents

access data & documents

Cross-enterprise

health care organization B

authenticate user

authorization server

FHIR resource

server

• authenticate enterprise

• authenticate federated user identity across enterprises

• authorize app for access scope

access data & documents

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Source: KLAS

FHIR: Have we hit the peak of the hype curve yet?

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Patient-Facing API Value Chain

App developer creates an app

Register app with provider or EHR vendor

Patient identifies, evaluates and decides to

use appEHR or Provider assures

patient identity

EHR grants time- and scope-limited access to

app

App development App terms of use

Patient validation Patient identity-proofing Patient availability

App developer agrees to EHR and/or provider

contract terms

Confirm app conformance with EHR

API standards

App conformanceApp registration

Patient authorizes app for user access to some type of data over some

period of time

Patient authorization

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An Emerging App Ecosystem….

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Argonaut Project: What’s next?

The value proposition of Argonaut seems to have changed• Originally was task-based: implementation guides for focused use cases• Seems to be shifting to forum- or process-based: a community of front-line implementers

who can make practical decisions to ensure that stuff works

Future focus area considerations• Go deep: Dig deeper into existing CCDS resources, such as more detailed lab profiling• Go broad: Add other resources important to clinicians such as scheduling & appointments,

or questionnaires & forms resources• Go broader: Add other stakeholders such as payers, pharma to focus on administrative

and research-relevant resources

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Lessons Learned

Define and maintain narrow focus on an end-point that is both urgent and important• Practical, specific goal that everyone cares about

Include the minimum number of organizations needed to make an impact on the market and raise the necessary resources

Include implementers who have a direct stake in the outcome and who are committed to building stuff

Know when to close the door, and when to leave it open

Hire dedicated SMEs and project management resources

Build on the work of others – alignment rather than replacement, celebration rather than competition

Continuously negotiate alignment and conformance

Have respect for the market, and worry about the ecosystem

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Join the Argonaut Project!

FHIR Technical Experts: Brett Marquard (brett@riverrockassociates.com), Eric Haas (ehaas@healthedatainc.com), Graham Grieve (grahame@healthintersections.com.au)

Project management: Micky Tripathi (mtripathi@maehc.org), Jennifer Monahan (jmonahan@maehc.org)

www.argonautproject.org