HL7 CDS Hooks: Overview and Potential Application for Prior Auth, Price

Transparency, and Disease Management Kensaku Kawamoto, MD, PhD, MHS

Associate CMIO, University of Utah Health Board Member, HL7

HITAC Meeting, Washington, DC, March 20, 2019

Core CDS Hooks content from Kevin Shekleton, CDS Hooks Project Lead,available at https://github.com/kpshek/cds-hooks-presentation

This presentation is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License

~VL , , SM A RT®

Q)

CDS Hooks A vendor agnostic remote decision support specification

Originated from the Open source via the Emerging HL7 standard team behind SMART Creative Commons

Attribution 4.0 license

.. .... . l .

CDS Service

A service that is: invoked by the EHR via a hook, evaluates its own logic using FHIR data, returns decision support via cards

Example Hooks

patient-view When a patient’s chart is opened

order-select When a clinician selects one or more orders to place for a patient

order-sign When a clinician is ready to sign one or more orders for a patient

1 EHR Med Order

Toprol XL 50 mg daily ℞

EHR triggers a CDS hook and 2

invokes a remote service CDS Service executes its own rules, leveraging FHIR data as needed

3

CDS Services

information card

$200 per month (patient pays $30)

EHR FHIR Server

Try Propranolol instead Switch to Propranolol

suggestion card Returns CDS cards (rendered and displayed by EHR)

smart app link card

Managing hypertension? Launch JNC 8 Rx Pro

Other DataSourcesOther Data

Sources

Data Available to a CDS Service EHR

Push Prefetch FHIR data

Retrieve FHIR data Pull

CDS Service

Other Data Sources

Push Hook context data

••• ••• •••

~

covermymeds ~t~~ M~KESSON HSPC fn-fil ON"" :111: i ··:elimu

~=-N efNANTH EALTH - "'

ELSEVIER fd h·· ... the healthcare '\...Y I " UTH-,l~ th •• informatics •• • ••• --•• • •• services platform e ~

Fi rst Databank consortiumT"' QVl: RA ORION+ TheUniversityofTexas { , 1 HARMONIQ ~ • zynxhealth fl~ HEALT~ r' ,_,..,.;.~-,-•M·•-ffl• •

JILK INTEROPION Consli/liD!/i.a •~ PREMIER surescripts t~ v1sualDx. PIONETECHS ALCIDION "'llllf

ID OSEHRA arpage BSCO Health

~ff> (9 .l ... pic ~

~

IntermountainsM Oridashi healthw,se® for every health decision 9 global strategies Healthcare

t'i) Allscripts™ ~l athenahealth eC/inica/Works THEl "lsvsTEM A perspecta . \ 'I mcg RxREVU ■ • Wolters Kluwer J' ... /i lY Health >I '!".J

• pa . PH I LI PS . EN v1 s10N ~ Lush • .. s t a n s O n 0 h e a I t h Healthcare. ~ TECHNOLOGYPARTNERS

• HEALTH '1~ ,, SAMURAi ~v~~~lT~ \:!,I Group Inc. c:::o Clinical Cloud Solutions Medlmpact ,.. > ... ,

MITRE syapse ~~t ac~enture affl TABULARASA "polyglot"· m >Kmodal II • edlcal -objects MERCK H E ALTHCAR E. Cigna MANUALSCLINICALAPPLICATIONS. MESSAGING AND INTEGRATION

Health Through Understanding™

U ~ , ~ ~r

E

2019 Roadmap

Release a 1.0 specification with patient-view hook (now)

Launch production pilots

5 Providing the ability to reason about the healthcare process

Clinical Reasoning Library, ServiceDefinition & GuidanceResponse, Measure/ MeasureReport, etc

Wait, doesn’t FHIR already define an approach for CDS?

I

CDS H O OKS Clinical Reasoning

Local Decision Support

Remote Decision Support

---

References

Specification & documentation http://cds-hooks.org

Sandbox http://sandbox.cds-hooks.org

Source code https://github.com/cds-hooks

Potential Prior Authorization Example 1

EHR Med Order

Humira ℞ EHR triggers order-select

hook and invokes the Insurer CDS

Service

CDS Service executes remote service for the its own rules, leveraging

2

patient’s insurance FHIR data as needed

information card

Prior auth approved; Authorization #123.

Returns CDS cards (rendered and displayed by EHR)

smart app link card

3 EHR

FHIR Server

Request prior auth? Launch Humira PA App

Potential Price Transparency Example 1 2

EHR Med Order

Toprol XL 50 mg daily ℞

information card

$200 per month (patient pays $30)

suggestion card

Try Propranolol instead (patient co-pay $10) Switch to Propranolol

EHR triggers order-sign hook* and invokes the remote service for the

patient’s insurance

Insurer CDS

Service

Returns CDS cards (rendered and displayed by EHR)

3

CDS Service executes its own rules, leveraging FHIR data as needed

EHR FHIR Server

*order-select hooks could provide information earlier in decision making process, but all required information (e.g., # of pills) may not be available

Potential Disease Management/Prevention Example 1 2

Chart Open for Heavy Smoker

EHR triggers patient-view CDS Service

CDS Service executes hook and invokes the its own rules, leveraging

remote service FHIR data as needed

smart app link card Returns CDS cards (rendered and displayed by EHR) Conduct lung cancer

screening with low-dose CT Launch Lung Cancer

Screening App

3 EHR

FHIR Server

Key needs Expansion of EHR FHIR support for needed data (e.g., detailed smoking history)

Expansion of specified and supported hooks (esp. for ordering)

Regulatory guidance from HIPAA perspective (also needed for FHIR and SMART)

Standard EHR trigger guard specifications

Greater support for asking users questions and enabling order placement

Application to important use cases