Clinical Architecture Blog

Clinical Architecture at HIMSS 2015

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At Clinical Architecture we are gearing up for the HIMSS conference next week. 

We will be in booth #2074 and would be delighted if you stopped by and said hello.

If you are attending, we know you will be busy and there are a lot of booths to visit.  
Here are the top ten reasons YOU should visit the Clinical Architecture booth.  

Top Ten Reasons to Visit the CA Booth at HIMSS15

10            

Experience Symedical, a modern commercial terminology management platform, in action.
 
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9


Try to beat Symedical in a map challenge. 
(Can you map 10 before it maps 1000? 10,000?...puny human)


 
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8


Check out the new SIFT engine and see the future of Clinical Language Processing

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7


Terminology Themed Chocolate

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6

Meet members of the Clinical Architecture team and ask questions… for FREE!

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5

Learn how true software assisted semantic mapping can improve quality and reduce your costs.
 
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4


Visit with our smart and savvy neighbors in the Apelon booth.
 
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3

Check out our new Content Cloud and see how simple staying current can be.
 
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2

See how you can easily manage terminologies across your entire enterprise or client base with our Content Governance Architecture.

 
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1


Learn show how you can leverage the best commercial semantic platform in your solution with our powerful API’s.

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Fabulous Prizes

For my blog readers I am doing a little something special. 

If you register here and visit our booth (2074), you will receive an Amazon Fire TV stick. 
 
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Supplies are limited so be quick about it.   

We will also be raffling off a $500 donation to the charity of one lucky winners choice, each day of the show.

Regardless of the reason, you should stop by booth 2074, meet some nice people, see some cool software and talk about healthcare terminology. 

That’s right… we know how to party.

I hope to see you there!

Charlie


Posted: 4/6/2015 10:09:37 PM by Charlie Harp | with 1 comments

Understanding ICD-10-CM - Part I - Origin Story

 
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Lately I have taken some interest in ICD-10-CM.  Be advised that I tend to write these blogs for the clinical engineer or architect, not for the informaticist, clinician, or nosologist (though I am happy to have them as readers as well).

To understand any terminology you first need to understand its history; why was it built and how has it evolved or mutated over time.

ICD-10-CM, along with other "international" classification taxonomies are curated by the World Health Organization or WHO (not to be confused with "The Who" … though you can see signs of classification in many of their song titles).

The ICD in ICD-10-CM stands for “international classification of diseases”, the “10” is the revision, and the “CM” stands for “Clinical Modification”.

(It should be noted that there are other ICDs as well, ICD-O-3 is an oncology classification used by cancer registries.  They are not related ontologically in any way.  But that is the subject for another post).

Along Time Ago in a Green House Far Far Away…

The origin of the ICD goes back to the late 1700s.  French physician and botanist, François Boissier de Sauvages de Lacroix, published his treatise, "Nosologia Methodica" in 1763.  Sauvages, as he was known, was one of the early nosologists (nosology = the branch of medical science dealing with the classification of diseases) that inspired many who followed in his footsteps.  The drivers for many of the early attempts at establishing these classifications schemes were related to tracking morbidity statistics (take that population health!). Sauvages died at the age of 59, three years after his treatise was published.  In a twist of irony, I was unable to find a record of his cause of death.

Jump forward to 1860.  At the International Statistical Congress held in London, Florence Nightingale made a proposal that ultimately resulted in the first model of systemic collection of hospital data for the purposes of tracking causes of death. 

In 1893, the “Bertillon Classification of Causes of Death” was introduced by Jacques Bertillon, a French physician.  This classification system was based on the principle of distinguishing between general diseases and those localized to a particular organ or anatomical sites.  In 1900, it was adopted by the American Public Health Association (APHA) and was re-branded as the “International Classification of Causes of Death”.  At this time the ICD contained 161 primary codes (some with modifiers).  The code was a number and the modifier was a letter. For example:

146. Burns
A) by fire
B) by corrosive substance

What is interesting is that this common way of presenting a list (that we all use) has over time become the pattern for structuring an identifier.

I have included a few excerpts from the “prefactory” of the pamphlet provided to the assembled reviewers.

“The time is especially suitable for the general adoption of a uniform classification of causes of death, to the end that the mortality data of the coming century may be more thoroughly comparable than at present.”

“The Bertillon classification is not presented as by any means a perfect system of classification of causes of death. No perfect system has ever been devised, and should there be, the progress of medical science would in time render it obsolete.”

When you reflect on it, it is both amazing and terrible to consider that the topics and issues we discuss today are not that different than those discussed over a century ago.  I especially like the last sentence as it shows they understood that terminologies in healthcare are not static and will undoubtedly drift over time … a concept many people fail to grasp in healthcare IT today.

At the conference in 1900 they also decided that they would meet every 10 years to review and revise the ICD.

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What we have here is an origin story.  Like every good origin story you examine the event that created our hero (or villain) to determine why they chose the path we find them on today.  For ICD, it started out about death.  “What killed these people?” was the question it was meant to answer and track.  It was also about statistics, not about a patient (they were already dead…).  This makes sense because at that time the available technology (paper) could only be used retrospectively and with much effort.

So, like time, the ICD marches on…

For many cycles minor revisions were made.  In 1946 the 6th revision (ICD-6) was released. This revision expanded the ICD to include morbidity as well as mortality conditions and was renamed accordingly to “International Statistical Classification of Diseases, Injuries and Causes of Death”.  The addition of injuries and diseases also introduced the need to add new modifiers for anatomic location.  This revision also introduced the alphabetic index to accompany the tabular index to aid in finding the appropriate code as the number of terms had increased significantly.   

This is the point at which ICD shifted from a focus on death to a focus on people's problems … and death.  This allowed people that were tracking statistics retrospectively to evaluate not just what killed people but also what was hurting and afflicting people. This was especially useful when assessing the labor force or your military capabilities.

The 7th (1955) and 8th (1965) revisions were limited mostly to corrections and minor updates. 

ICD-9

The 9th revision (ICD-9) was introduced in 1975 and once again ICD was expanded.  This time there was a contingent who wanted to use the ICD to evaluate medical care.  To do this they wanted to revise the taxonomy itself to have an organ system focus and wanted additional detail. This was in part due to the advent of data processing systems (and might be loosely related to the popularity of disco … but I have no evidence to support that).

Up to this point, consumers had been using ICD for statistics and retrospective reporting for decades.  Now, a new group of consumers are introduced who need a code system in order to document what is happening to a patient for tracking and billing.  One use is population reporting and the other is, arguably, clinical.  The two groups disagreed about how they should proceed at the time, based upon the two different use cases.  In the end, they decided to compromise and leverage the ICD for these two distinctly different purposes.  This is the point, dear reader, when our hero became a villain. (Insert ominous music of your choice here).

Why would I say this? I believe when you take a terminology designed to solve a specific problem and try to use it to solve another, different, problem you create an architectural compromise. Once compromised, the appropriateness of that terminology for either use case becomes fuzzy, as each end pulls aspects of the architecture to suit their disparate purposes.  After a while, the terminology is so compromised that it becomes unwieldy and is not suitable for any purpose. (Climbing down from my soapbox…)

It has been almost 40 years since ICD-9 was introduced and we, here in the United States, are still essentially on that revision. The most recent version has about 17k terms.

ICD-10

ICD-10 was introduced in 1990 (yes – a quarter century ago).  This international version of the classification is used in about 100 countries for cause of death reporting and statistics.  Some countries, like Australia and Canada have modified versions.

The current version of the standard international ICD-10 has just shy of 18,000 terms.  It's major difference from ICD-9 is the coding scheme which has shifted from numeric to alpha-numeric. (because remembering codes is like cheating...). 

ICD-10-CM

Today in the United States we are set to adopt an expanded version of ICD-10 called ICD-10-CM, where the CM stands for Clinical Modification.  The "modified" version is significantly different from ICD-10 in that it expands each of the standard ICD-10 codes with additional granularity (like laterality, trimester, encounter type and complications).  It also adds a number of causes, places, activities and other healthcare codes.  The net result is a classification system with over 90,000 codes.  

ICD-10-CM is the version we will explore in the next post in this series.

Here is a graphical timeline showing the classification name, focus and polulation.  I am not a historian so if I missed something or got something wrong, feel free to let me know.

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Posted: 3/30/2015 11:50:27 PM by Charlie Harp | with 1 comments

Stage 3 Meaningful Use – Objectives and Measures Summary

On Friday the Centers for Medicare and Medicaid Services released the proposed rule for Stage 3 Meaningful Use Criteria.  The full text of the 301 page document can be found here.

A downloadable version of this summary is available here.

The document outlines eight program objectives, their scope and how they intend to measure them. 
The timeframe of the new measures is the end of 2017.

What follows is a high level summary of the proposed rule.   If you wish to examine the details or the context for each item summarized please refer to the full document as referenced above.

Objective 1: Protect Patient Health Information (Page 60)

Protect electronic protected health information (ePHI) created or maintained by the certified EHR technology (CEHRT) through the implementation of appropriate technical, administrative, and physical safeguards.

Proposed Measure: Conduct or review a security risk analysis in accordance with the requirements for administrative safeguards (under 45 CFR 164.308(a)(1)), including addressing the security of data stored in CEHRT in accordance with requirements of technical safeguards (under 45 CFR 164.312(a)(2)(iv)) and general rules (under 45 CFR 164.306(d)(3)), implement security updates as necessary, and correct identified security deficiencies as part of the provider's risk management process.

Under this proposed measure, a risk analysis must assess the risks and vulnerabilities to ePHI created or maintained by the CEHRT and must be conducted or reviewed for each EHR reporting period, which, as proposed in this rule, would be a full calendar year, and any security updates and deficiencies identified should be included in the provider's risk management process and implemented or corrected as dictated by that process.
 
They propose the timing or review of the security risk analysis to satisfy this proposed measure must be as follows:
  • Eligible providers, eligible hospitals, and critical access hospitals must conduct the security risk analysis upon installation of CEHRT or upon upgrade to a new Edition of certified EHR Technology. The initial security risk analysis and testing may occur prior to the beginning of the first EHR reporting period using that certified EHR technology.
  • In subsequent years, a provider must review the security risk analysis of the CEHRT and the administrative, physical, and technical safeguards implemented, and make updates to its analysis as necessary, but at least once per EHR reporting period.

Objective 2: Electronic Prescribing (page 67)

Eligible providers must generate and transmit permissible prescriptions electronically, and eligible hospitals and critical access hospitals must generate and transmit permissible discharge prescriptions electronically (eRx).  The objective has different measures for eligible providers and hospitals.
 
Proposed Eligible Provider Measure: More than 80 percent of all permissible prescriptions written by the eligible provider are queried for a drug formulary and transmitted electronically using CEHRT.
 
Measure Denominator: Number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the EHR reporting period or Number of prescriptions written for drugs requiring a prescription in order to be dispensed during the EHR reporting period.
 
Measure Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary, and transmitted electronically using CEHRT.
 
Measure Threshold: The resulting percentage must be more than 80 percent in order for an EP to meet this measure.
 
Measure Exclusions: Any EP who: (1) writes fewer than 100 permissible prescriptions during the EHR reporting period; or (2) does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his or her EHR reporting period.
 
Proposed Eligible Hospital/Critical Access Hospital Measure: More than 25 percent of hospital discharge medication orders for permissible prescriptions (for new and changed prescriptions) are queried for a drug formulary and transmitted electronically using CEHRT.
                            
Measure Denominator: The number of new or changed prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances for patients discharged during the EHR reporting period.
 
Measure Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary and transmitted electronically.
 
Measure Threshold: The resulting percentage must be more than 25 percent in order for an eligible hospital or CAH to meet this measure.
 
Measure Exclusion: Any eligible hospital or CAH that does not have an internal pharmacy that can accept electronic prescriptions and there are no pharmacies that accept electronic prescriptions within 10 miles at the start of their EHR reporting period.
 

Objective 3: Clinical Decision Support (page 75)

Implement clinical decision support (CDS) interventions at a relevant point in clinical workflows focused on improving performance on high-priority health conditions.
Providers are encouraged to implement CDS related to quality measurement and improvement goals on the following areas:
  • Preventive care.
  • Chronic condition management.
  • Heart disease and hypertension.
  • Appropriateness of diagnostic orders or procedures such as labs, diagnostic imaging, genetic testing, pharmacogenetic and pharmacogenomic test result support or other diagnostic testing.
  • Advanced medication-related decision support, to include pharmacogenetic and pharmacogenomic test result support.
Proposed Measures: EPs, eligible hospitals, and CAHs must satisfy both measures in order to meet the objective:
 
Measure 1: Implement five clinical decision support interventions related to four or more CQMs at a relevant point in patient care for the entire EHR reporting period. Absent four CQMs related to an EP, eligible hospital, or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions.
 
Measure 2: The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period.
 
Measure 2 Exclusion: For the second measure, any EP who writes fewer than 100 medication orders during the EHR reporting period.
 

Objective 4: Computerized Provider Order Entry (page 81)

Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical record per state, local, and professional guidelines.
 
Proposed Measures: An EP, eligible hospital or CAH must meet all three measures.
 
Proposed Measure 1: More than 80 percent of medication orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: Number of medication orders created by the EP or authorized providers in the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of orders in the denominator recorded using CPOE.
 
Measure Threshold: The resulting percentage must be more than 80 percent in order for an EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusion: Any EP who writes fewer than 100 medication orders during the EHR reporting period.
 
Proposed Measure 2: More than 60 percent of laboratory orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: Number of laboratory orders created by the EP or authorized providers in the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of orders in the denominator recorded using CPOE.
 
Measure Threshold: The resulting percentage must be more than 60 percent in order for an EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusion: Any EP who writes fewer than 100 laboratory orders during the EHR reporting period.
 
Proposed Measure 3: More than 60 percent of diagnostic imaging orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: Number of diagnostic imaging orders created by the EP or authorized providers in the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of orders in the denominator recorded using CPOE.
 
Measure Threshold: The resulting percentage must be more than 60 percent in order for an EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusion: Any EP who writes fewer than 100 diagnostic imaging orders during the EHR reporting period.
 

Objective 5: Patient Electronic Access to Health Information (Page 89)

The EP, eligible hospital, or CAH provides access for patients to view online, download, and transmit their health information, or retrieve their health information through an API, within 24 hours of its availability.
 
Proposed Measures: EPs, eligible hospitals, and CAHs must satisfy both measures in order to meet the objective:
 
Proposed Measure 1: For more than 80 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23): (1) The patient (or patient-authorized representative) is provided access to view online, download, and transmit their health information within 24 hours of its availability to the provider; or (2) The patient (or patient-authorized representative) is provided access to an ONC-certified API that can be used by third-party applications or devices to provide patients (or patient-authorized representatives) access to their health information, within 24 hours of its availability to the provider.
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: The number of unique patients seen by the EP or the number of unique patients discharged from an eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of patients in the denominator who are provided access to information within 24 hours of its availability to the EP or eligible hospital/CAH.
 
Measure Threshold: The resulting percentage must be more than 80 percent in order for a provider to meet this measure.
 
Measure Exclusions: An EP may exclude from the measure if they have no office visits during the EHR reporting period. Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measure. Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50 percent or more of their housing units with 4Mbps broadband availability according to the latest information available from the FCC at the start of the EHR reporting period.
 
Proposed Measure 1:  Alternate Proposals for discussion
These three alternate proposals would represent different use cases for the CEHRT function to support view, download, and transmit and/or API functionality. They note that under these proposed alternates the following mix of functions would be applicable:
  • Alternate A would require both functions to be available instead of allowing the provider to choose between the two.
  • Alternate B would require the provider to choose to have either both functions, or just an API function.
  • Alternate C would require the provider to only have the API function. For Alternate C, the use of a separate view, download, and transmit function would be entirely at the provider's discretion and not included as part of the definition of meaningful use.
 
Proposed Measure 2: The EP, eligible hospital or CAH must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more than 35 percent of unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: The number of unique patients seen by the EP or the number of unique patients discharged from an eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of patients in the denominator who were provided electronic access to patient-specific educational resources using clinically relevant information identified from CEHRT.
 
Measure Threshold: The resulting percentage must be more than 35 percent in order for a provider to meet this measure.
 
Measure Exclusions: An EP may exclude from the measure if they have no office visits during the EHR reporting period. Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measure. Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50 percent or more of their housing units with 4Mbps broadband availability according to the latest information available from the FCC at the start of the EHR reporting period.
 

Objective 6: Coordination of Care through Patient Engagement (page 103)

Use communications functions of certified EHR technology to engage with patients or their authorized representatives about the patient's care.
 
Proposed Measures: We are proposing that providers must attest to the numerator and denominator for all three measures, but would only be required to successfully meet the threshold for two of the three proposed measures to meet the Coordination of Care through Patient Engagement Objective.
 
Proposed Measure 1: During the EHR reporting period, more than 25 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) actively engage with the electronic health record made accessible by the provider. An EP, eligible hospital or CAH may meet the measure by either:
  1. More than 25 percent of all unique patients (or patient-authorized representatives) seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period view, download or transmit to a third party their health information; or
  2. More than 25 percent of all unique patients (or patient-authorized representatives) seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period access their health information through the use of an ONC-certified API that can be used by third-party applications or devices.
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure 1 Option 1: View, Download, or Transmit to a Third Party
 
Measure Denominator: Number of unique patients seen by the EP, or the number of unique patients discharged from an eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of unique patients (or their authorized representatives) in the denominator who have viewed online, downloaded, or transmitted to a third party the patient's health information.
 
Measure Threshold: The resulting percentage must be more than 25 percent in order for an
EP, eligible hospital, or CAH to meet this measure.
 
Measure 1 Option 2: API
 
Measure Denominator: The number of unique patients seen by the EP or the number of unique patients discharged from an eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of unique patients (or their authorized representatives) in the denominator who have accessed their health information through the use of an ONC-certified API.
 
Measure Threshold: The resulting percentage must be more than 25 percent in order for an EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusions: Applicable for either option discussed previously, the following providers may exclude from the measure: Any EP who has no office visits during the EHR reporting period may exclude from the measure. Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude from the measure. Any eligible hospital or CAH operating in a location that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude from the measure.
 
Proposed Measure 2: For more than 35 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient's authorized representatives), or in response to a secure message sent by the patient (or the patient's authorized representative).
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: Number of unique patients seen by the EP or the number of unique patients discharged from an eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of patients in the denominator for whom a secure electronic message is sent to the patient, the patient's authorized representatives, or in response to a secure message sent by the patient.
 
Measure Threshold: The resulting percentage must be more than 35 percent in order for an EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusion: Any EP who has no office visits during the EHR reporting period may exclude from the measure. Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude from the measure. Any eligible hospital or CAH operating in a location that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude from the measure.
 
Proposed Measure 3: Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for more than 15 percent of all unique patients seen by the EP or discharged by the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: Number of unique patients seen by the EP or the number of unique patients discharged from an eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
 
Measure Numerator: The number of patients in the denominator for whom data from non-clinical settings, which may include patient-generated health data, is captured through the certified EHR technology into the patient record.
 
Measure Threshold: The resulting percentage must be more than 15 percent in order for an EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusion: Any EP who has no office visits during the EHR reporting period may exclude from the measure. Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude from the measure. Any eligible hospital or CAH operating in a location that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude from the measure.
 

Objective 7: Health Information Exchange (page 116)

The EP, eligible hospital, or CAH provides a summary of care record when transitioning or referring their patient to another setting of care, retrieves a summary of care record upon the first patient encounter with a new patient, and incorporates summary of care information from other providers into their EHR using the functions of certified EHR technology.
 
Proposed Measures: We are proposing that providers must attest to the numerator and denominator for all three measures, but would only be required to successfully meet the threshold for two of the three proposed measures to meet the Health Information Exchange Objective.
 
Proposed Measure 1: For more than 50 percent of transitions of care and referrals, the EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care: (1) creates a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record.
 
To calculate the percentage of the first measure, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP or eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) was the transferring or referring provider.
 
Measure Numerator: The number of transitions of care and referrals in the denominator where a summary of care record was created using certified EHR technology and exchanged electronically.
Threshold: The percentage must be more than 50 percent in order for an EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusion: An EP neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period.  Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measures. Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50 percent or more of their housing units with 4Mbps broadband availability according to the latest information available from the FCC at the start of the EHR reporting period.
 
 
Proposed Measure 2: For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital or CAH incorporates into the patient's EHR an electronic summary of care document from a source other than the provider's EHR system.
 
To calculate the percentage of the second measure, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: Number of patient encounters during the EHR reporting period for which an EP, eligible hospital, or CAH was the receiving party of a transition or referral or has never before encountered the patient and for which an electronic summary of care record is available.
 
Measure Numerator: Number of patient encounters in the denominator where an electronic summary of care record received is incorporated by the provider into the certified EHR technology.
Measure Threshold: The percentage must be more than 40 percent in order for an EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusion: Any EP, eligible hospital or CAH for whom the total of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, is fewer than 100 during the EHR reporting period is excluded from this measure.  Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measures.  Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50 percent or more of their housing units with 4Mbps broadband availability according to the latest information available from the FCC at the start of the EHR reporting period.
 
Proposed Measure 3: For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital, or CAH performs a clinical information reconciliation. The provider must implement clinical information reconciliation for the following three clinical information sets:
  • Medication. Review of the patient's medication, including the name, dosage, frequency, and route of each medication.
  • Medication allergy. Review of the patient's known allergic medications.
  • Current Problem list. Review of the patient's current and active diagnoses.
 
To calculate the percentage, CMS and ONC have worked together to define the following for this measure:
 
Measure Denominator: Number of transitions of care or referrals during the EHR reporting period for which the EP or eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) was the recipient of the transition or referral or has never before encountered the patient.
 
Measure Numerator: The number of transitions of care or referrals in the denominator where the following three clinical information reconciliations were performed: medication list, medication allergy list, and current problem list.
 
Measure Threshold: The resulting percentage must be more than 80 percent in order for an
EP, eligible hospital, or CAH to meet this measure.
 
Measure Exclusion: Any EP, eligible hospital or CAH for whom the total of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, is fewer than 100 during the EHR reporting period is excluded from this measure. Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measures.  Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50 percent or more of their housing units with 4Mbps broadband availability according to the latest information available from the FCC at the start of the EHR reporting period.
 
 

Objective 8: Public Health and Clinical Data Registry Reporting (page 135)

The EP, eligible hospital, or CAH is in active engagement with a PHA or CDR to submit electronic public health data in a meaningful way using certified EHR technology, except where prohibited, and in accordance with applicable law and practice.
 
Active Engagement Option 1 – Completed Registration to Submit Data: The EP, eligible hospital, or CAH registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP, eligible hospital, or CAH is awaiting an invitation from the PHA or CDR to begin testing and validation.
 
Active Engagement Option 2 - Testing and Validation: The EP, eligible hospital, or CAH is in the process of testing and validation of the electronic submission of data.
 
Active Engagement Option 3 – Production: The EP, eligible hospital, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.
 
Proposed Measures: We are proposing a total of six possible measures for this objective. EPs would be required to choose from measures 1 through 5, and would be required to successfully attest to any combination of three measures. Eligible hospitals and CAHs would be required to choose from measures one through six, and would be required to successfully attest to any combination of four measures.  The measure are as shown in the table below:

Measures for Objective 8
Measure Maximum Times Counted for EP Maximum Times Counted for Hospital
Measure 1 – Immunization Registry Reporting
1 1
Measure 2 – Syndromic Surveillance Reporting 1 1
Measure 3 - Case Reporting 1 1
Measure 4 - Public Health Registry Reporting 3 4
Measure 5 – Clinical Data Registry Reporting 3 4
Measure 6 – Electronic Reportable Laboratory Result Reporting N/A 1
 
Measure 1 – Immunization Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).
 
Measure 2 – Syndromic Surveillance Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit syndromic surveillance data from a non-urgent care ambulatory setting for EPs, or an emergency or urgent care department for eligible hospitals and CAHs (POS 23).
 
Exclusion for EPs for Measure 2: Any EP meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the EP: (1) does not treat or diagnose or directly treat any disease or condition associated with a syndromic surveillance system in their jurisdiction; (2) operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs at the start of the EHR reporting period.
 
Exclusion for eligible hospitals/CAHs for Measure 2: Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the eligible hospital or CAH: (1) does not have an emergency or urgent care department; (2) operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from eligible hospitals or CAHs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from eligible hospitals or CAHs at the start of the EHR reporting period.
 
Measure 3 - Case Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit case reporting of reportable conditions.
 
Exclusion for Measure 3: Any EP, eligible hospital, or CAH meeting one or more of the following criteria may be excluded from the case reporting measure if the EP, eligible hospital, or CAH: (1) does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the EHR reporting period; (2) operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data at the start of the EHR reporting period.
 
Measure 4 - Public Health Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit data to public health registries.
 
Exclusions for Measure 4: Any EP, eligible hospital, or CAH meeting at least one of the following criteria may be excluded from the public health registry reporting measure if the EP, eligible hospital, or CAH: (1) does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the EHR reporting period; (2) operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no public health registry for which the EP, eligible hospital, or CAH is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period.
 
Measure 5 – Clinical Data Registry Reporting: The EP, eligible hospital, or CAH is in active engagement to submit data to a clinical data registry.
 
Exclusions for Measure 5: Any EP, eligible hospital, or CAH meeting at least one of the following criteria may be excluded from the clinical data registry reporting measure if the EP, eligible hospital, or CAH: (1) does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the EHR reporting period; (2) operates in a jurisdiction for which no clinical data registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no clinical data registry for which the EP, eligible hospital, or CAH is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period.
 
Measure 6 – Electronic Reportable Laboratory Result Reporting: The eligible hospital or CAH is in active engagement with a public health agency to submit electronic reportable laboratory results. This measure is available to eligible hospitals and CAHs only.
 
Exclusion for Measure 6: Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the electronic reportable laboratory result reporting measure if the eligible hospital or CAH: (1) does not perform or order laboratory tests that are reportable in their jurisdiction during the EHR reporting period;  (2) operates in a jurisdiction for which no public health agency is capable of accepting the specific ELR standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no public health agency has declared readiness to receive electronic reportable laboratory results from an eligible hospital or CAH at the start of the EHR reporting period.
 
CMS welcome public comment on these proposals.  
 
 
Posted: 3/22/2015 3:18:38 PM by Charlie Harp | with 0 comments

The Road to Precision Medicine – Part VII – The Road Not Taken

On September 12, 1962, President John F. Kennedy delivered a memorable speech at Rice University in Houston, Texas.  It is sometimes referred to as the “We choose to go to the moon” speech. (The full transcript and a video can be found here.)
 

 
The speech was made during the Cold War and “Space Race” with the Soviet Union. The president explained to the American people his reasons for supporting a manned expedition to the moon.  It is a good speech and I recommend giving it a listen. 

I am referencing it for two reasons. 

The first is because the speech contains several great lines that speak personally to me, specifically when I think about why I put down roots in this challenging and frustrating industry.  Here are a few of them:

“All great and honorable actions are accompanied with great difficulties, and both must be enterprised and overcome with answerable courage.”

“We set sail on this new sea because there is new knowledge to be gained, and new rights to be won, and they must be won and used for the progress of all people. For space science, like nuclear science and all technology, has no conscience of its own. Whether it will become a force for good or ill depends on man”

And the most famous Quote:

“We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.”

My favorite quote:

“But if I were to say, my fellow citizens, that we shall send to the moon, 240,000 miles away from the control station in Houston, a giant rocket more than 300 feet tall, the length of this football field, made of new metal alloys, some of which have not yet been invented, capable of standing heat and stresses several times more than have ever been experienced, fitted together with a precision better than the finest watch, carrying all the equipment needed for propulsion, guidance, control, communications, food and survival, on an untried mission, to an unknown celestial body, and then return it safely to earth, re-entering the atmosphere at speeds of over 25,000 miles per hour, causing heat about half that of the temperature of the sun--almost as hot as it is here today--and do all this, and do it right, and do it first before this decade is out--then we must be bold.”

That brings me to the second reason I am referencing this speech… they did it.


That speech was made in 1962.  The first manned landing on the moon took place in July of 1969.  The last Apollo Mission was launched in 1972.

This herculean undertaking was completed and they landed men on the moon before the end of that decade.   Granted, it was a priority of a galvanized nation that was willing to spend $25.4 billion on it over 10 years, but it is still an amazing achievement.

Fun fact: In 2015 dollars, that would be $155 billion over 10 years or $15.5 billion a year.  According to the Government Accountability Office, duplication of federal programs and services costs taxpayers $45 billion annually.


A few more interesting facts about project Apollo:
  • The Apollo program was before personal computers and electronic calculators.  Slide rules were used extensively to perform the calculations for mission planning.
  • The Apollo Guidance Computer (or AGC, pictured at right) was more basic than the electronics in modern toasters.  The ACG had approximately 64 KB of memory and operated at 0.043MHz and sported and intuitive user interface called the DSKY (which sttod for Display and Keyboard... see told you it was intuitive).
  • The Goddard Space Flight Center used IBM System/360 Model 75s (with over 1 MB of RAM!) for communications across NASA and the spacecraft. 
  • At the time, IBM described the 6 MB programs it developed, to monitor the space crafts’ environmental and astronauts' biomedical data, as the most complex software ever written.
  • At its peak, the Apollo program employed 350 engineers.

Essentially, a 1 GB USB memory stick is more powerful than the computers that put us on the moon. 

Perspective

In a span of less than 10 years, a team of engineers did something amazing.  They invented technologies that did not exist.  They solved problems that could only be speculated about; like what it would take to land on the moon surface…

It begs the question…why is it so difficult to create a clinical platform with the characteristics necessary to assist a provider in a meaningful way?

Is it money? 

According to a 2013 report by Technology Business Research, spending on Healthcare IT in that year exceeded $30 billion dollars.   That seems like a lot of money to me.

Is it technological limitation?

Of course not.  I have a super computer in my back pocket that knows where I am, how many flights of stairs I have climbed and if it is supposed to rain tomorrow.

Is it the people?

I have worked in other industries.  My empirical assessment is that the people who work in our industry are some of the most innovative, brightest, passionate and dedicated people I have encountered in my professional career. 

Is it the subject matter?

Healthcare is difficult and scary, it’s true; but I have to say that I have seen people more upset about a banking application losing a penny than a healthcare application losing a critical patient allergy.  Part of this is due to the fact that we still rely on the human provider to do all of the heavy lifting and the human patient to remind the provider by filling out forms…over and over again. 

Building smarter and more helpful solutions in healthcare is a solvable problem.  I am not talking about software practicing medicine.  I am talking about software that can accurately store, share and represent patient information in a useful way and periodically give the provider advice and help them avoid critical mistakes.  This is not rocket science (you see what I did there…).

Is it momentum?

Change is difficult.  Change in an environment where you are always “on” is even more difficult.  I have worked in hospitals and to say they are complex orchestrations of systems and software would be an understatement.  It is also easy to take comfort in the known, even if the known is antiquated and limited.  

Is it incentives?

Perhaps.  Historically we built systems in Healthcare that were driven by revenue; charge capture and billing for services.  This resulted in less than wonderful clinical capabilities because the clinical aspect of healthcare was not our focus.  That was a problem for the human provider in the equation. 
Today, I fear we are doing something similar.  We are providing incentives for things like specific outcomes and mandating “meaningful use” standards based interoperability.  These things are done with the belief that the tail can, in fact, wag the dog.   I am not so sure.  I think our priority should be assisting the provider in caring for patients and helping them scale their ability to provide that care.  Directing our intention elsewhere is a distraction, even if it is a lucrative one.  I believe if we do our jobs well and providers do their jobs well, patients will have better outcomes.  I am not sure this is something we can legislate.  

The Road to Precision Medicine

Regardless of what barriers have stopped us, it is time we begin our journey down the road that leads to a clinical platform that can assist providers. It will be difficult, and innovation will require periodic failure to work its magic.  If we could land a man on the moon in less than 10 years, we should be able to have  smarter clinical platforms in five. (Technically, we have been talking about CPOE since 1998…).  

All of us, in Healthcare IT, have an opportunity and an obligation to create solutions that usher in a new era of provider efficiency, patient satisfaction, clinical understanding and improved outcomes.

At Clinical Architecture we will do our part.  Our mission is building foundational components for smarter clinical platforms that will enable our partners to accomplish amazing things.

If you are interested in exploring how Clinical Architecture could work with your team to continue your journey, we would love to hear from you.  Drop us a note and let’s see what we can accomplish together.

I hope this series has been interesting and entertaining.  I appreciate any feedback, comments or observations.  
 

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.
                                           
Frost, Robert. “The Road Not Taken.”
The Norton Anthology of Poetry. 4th edition. 

Posted: 3/18/2015 10:15:59 PM by Charlie Harp | with 0 comments

The Road to Precision Medicine - Part VI - Orchestrated Intelligence

A true clinical platform starts with a foundation of two primary supporting pillars.  The first is the ability to accurately represent medical information and the second is the ability to share both patient specific information and knowledge.  In this post we will explore the third pillar, which is the platforms ability to integrate patient information with medical knowledge, reason over it and deliver appropriate insight and advice to the provider.  This ability to organize information, knowledge and logic in a meaningful way is essentially the brain of our clinical platform.  This brain provides the orchestrated intelligence necessary to help the platform shoulder part of the cognitive burden necessary for precision medicine. 

 
whybrain.png
Why does the provider need a platform with a brain?
 
There are a number of contributing factors that make providing care for patients challenging.  Here are three significant ones.
 
Too much information
No matter how smart, dedicated and knowledgeable a provider is, they are still only human.  They have the same 24 hours per day and seven days a week everyone else does.  The vast amount of new and existing medical knowledge far exceeds the human mind’s capability for acquisition, storage and retrieval.  In a paper posted in the Journal of the Medical Library Association  it is estimated that approximately 7200 articles relevant to primary care are published each month.  The time to read these articles would average around 675 hours per month.  The total time available in a 30 day period is 720 hours.  That would leave 45 hours for non-reading activities. If the provider gets to sleep for an hour a night that leave 30 minutes per day to see patients (assuming other biological imperatives could be resolved while still reading...). 
 
Not enough time
Even without the burden of staying current with medical literature, providers experience significant time famine.  According to the 2014 Physicians Foundation survey:
  • Physicians work an average of 53 hours per week.
  • 81% of physicians said they were overextended or at full capacity
  • 44% of physicians plan to take one or more steps that would reduce patient access to their services.
  • 72% of physicians believe there is a physician shortage.
  • A majority of physicians on average see 20 patients per day.
 
Too many ways of doing something
Whether they are from the institution, the government or and affordable care organization, shifting policies and guidelines can result in rework, frustration and non-payment.
 
Orchestrated Intelligence

Computers were designed to perform the heavy lifting of information processing.  The brain of a true clinical platform would be designed to complement the intellect, training, experience and intuition of a provider by rapidly assessing the patient against a curated medical and policy knowledgebase and provide orchestrated, intelligent information that is relevant and appropriate.    I am going to call this ability to assess and reason over available information “orchestrated intelligence”.

Orchestrated Intelligence is not Skynet… notskynet-(1).png
 
Please note that orchestrated intelligence does not access the internet or peruse medical journals.  It does not google the patient in an attempt to determine their social history.   It is not an artificial intelligence bent on the domination of human kind as we know it (you can remove your tinfoil hat…). It is only allowed to know what we tell it, and it is only allowed to reason using the knowledge we have enabled and approved.  Orchestrated intelligence is intended to be an assistant to the provider, not a replacement.  Like with the GPS metaphor, the driver needs to retain control of the vehicle.

Does orchestrated intelligence exist today? 

The closest thing we have to an orchestrated intelligence today is something we refer to as “clinical decision support” or CDS.  The architectural limitations of today’s CDS, coupled with our inability to represent patient information and express knowledge in a granular, post coordinated way, results in a blunt, clunky, hit or miss experience for the provider. No, todays CDS will not be adequate in a true clinical platform.
 
What are some of the characteristics necessary to support Orchestrated intelligence?

An orchestrated intelligence is central to the architecture of the clinical platform.  It is designed to have real-time access to patient information, evaluate approved clinical knowledge and policies and interact with the provider and medical staff.  In order to do this in a meaningful way it will need to exhibit a minimum set of characteristics:
 
There can be only one
In many systems today CDS is divided across domain or functional silos that are invoked based on different events.  This results in inconsistent and duplicated messaging to the provider.  An orchestrated intelligence should be a central mechanism that evaluates patient information and provides feedback and advice to the provider.  
 
Let the best content win
In many systems today CDS is single source.  An orchestrated intelligence should be able to integrate the content and services the steward of the environment wants, regardless of its source.  This could be from multiple content vendors, web service providers, open standards and locally created wisdom.
 
Constant vigilance
In many systems today CDS is invoked only at certain provider events.  An orchestrated intelligence should be constantly monitoring “active” patients to see if there is something that should be brought to the attention of the provider.   Providers need to sleep, computers do not.
 
Provide the right information
In many systems today CDS provides alerts that are not relevant for the patient.  This results in alert fatigue and undermines provider confidence.  An orchestrated intelligence needs to be able to embrace a more granular, post-coordinated representation model and deliver advice that is attenuated to the details of the patient. 
 
Know your audience
In many systems today CDS provides alerts that are not appropriate for the provider. An orchestrated intelligence should be able to deliver advice in a way that is appropriate to the type of user.
 
Embrace localization
In many systems today localizing CDS is difficult and can impact the ability of the platform to continue to get updates from external knowledge sources.  An orchestrated intelligence must be designed to embrace the idea that healthcare is local.  An institution wanting to leverage external knowledge does not want to give up control over how they practice medicine.
 
Measure performance
An orchestrated intelligence will need to monitor its own performance.  This allows the steward of the environment to see how often certain knowledge is engaged and examine the result of that engagement.  If you want to improve something, you have to measure it.
 
Understand the intent of your advice
An orchestrated intelligence must have the ability to understand and articulate the desired outcome related to each piece of advice it renders.  Without this ability it has no way to determine if the advice is actually working in a reasonable timeframe.
 
Predict the future
An orchestrated intelligence needs to think about more than what is happening right now.  It must have the ability to provide a framework that supports predicting the future based on trends and patterns in the patient information over time.  To do this it must have a sense of temporality.
 
Ask the right questions
An orchestrated intelligence needs to have the ability to ask for information when it is needed.  This information then needs to be integrated into the patient’s clinical context for future reference.
 
These are some of the core characteristics that, along with the first two pillars, will enable a clinical platform to provide intelligent, appropriate advice at the point of care.  It could also result in an environment where the data stewards can measure and assess the efficacy of the advice and policies being used in their environment in real-time.
Pillars_CP-(2).png
Comments are welcome and appreciated. 

Posted: 3/9/2015 11:05:50 PM by Charlie Harp | with 0 comments