Service-Oriented CDS in the Cloud
By Joel Amoussou, President, Efasoft, Inc.
Images in this presentation are being used for illustrative purposes
only; Any person depicted in this presentation is a model.
© 2011 Efasoft, Inc.
© 2011 Efasoft, Inc.
US Healthcare Expenditures
16% of GDP in 2008 or $2.3 trillions
Centers for Disease Control and Prevention - Health Expenditures
http://www.cdc.gov/nchs/fastats/hexpense.htm
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46 cents of every program dollar in Ontario
70 cents in 12 years if left unchecked
2010 Ontario Budget - Sector Highlights
http://www.fin.gov.on.ca/en/budget/ontariobudgets/2010/sectors/health.pdf
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The Quality Imperative
“Overall, participants
received 54.9% of
recommended care”
McGlynn EA, Asch SM , Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr
EA. "The Quality of Health Care Delivered to Adults in the United States". N
Engl J Med. 2003 Jun 26;348(26):2635-45.
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“Patients should receive care based on the
best available scientific knowledge. Care
should not vary illogically from clinician
to clinician or from place to place.”
Crossing The Quality Chasm
A New Health System for the 21st Century
The Institute of Medicine (IOM)
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Adults with Diagnosed Diabetes Ever
Attending a Diabetes Self-Management Class
Centers for Disease Control and Prevention – Preventive Care Practices
http://www.cdc.gov/diabetes/statistics/preventive/fY_class.htm
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Healthy Behaviour
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Patient-Centered Medical
Home (PCMH)
Personal Physician
Whole person orientation
Coordinated care
Quality and safety
Payment
Patient Centered Primary Care Collaborative - Joint Principles of the Patient
Centered Medical Home http://www.pcpcc.net/content/joint-principles-patientcentered-medical-home
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Care Coordination
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Pay-For-Performance (P4P)
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Accountable Care
Organization (ACO)
Reimbursements tied to quality metrics
and total per capita costs reduction
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Evidence-Based Medicine
“The great tragedy of Science - the slaying of
a beautiful hypothesis by an ugly fact.”
Thomas Henry Huxley (1825-1895)
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Economic burden of mental illness in 2002:
$317.6 billions or about $1000 for every person
Insel TR. Assessing the economic costs of serious mental illness. Am J
Psychiatry. 2008;165:663-5.
Mental Health Clinical Practice Guidelines
Quality Measures
Institute of Medicine. Improving the quality of health care for mental and
substance-use conditions. Washington (DC): National Academies Press; 2006.
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Translational Medicine
Bench-to-Bedside time: 17 years
Wise Young "Bench-to-bedside lag time: a major problem for SCI". Paraplegia
News. FindArticles.com. 10 Jul, 2011.
http://findarticles.com/p/articles/mi_hb4927/is_n4_v49/ai_n32003654/
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Advances in Genomics
Genotype & Phenotype
Proteomics
Pharmacogenomics
Large data sets
Computing resources
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Medical Errors in the
Emergency Department
96% are Cognitive Errors
Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan
TA, Studdert DM. Missed and delayed diagnoses in the emergency department:
a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med.
2007;49:196-205.
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Failure to order an appropriate
diagnostic test: 58%
Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan
TA, Studdert DM. Missed and delayed diagnoses in the emergency department:
a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med.
2007;49:196-205.
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Failure to perform an adequate medical
history or physical examination: 42%
Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan
TA, Studdert DM. Missed and delayed diagnoses in the emergency department:
a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med.
2007;49:196-205.
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Incorrect interpretation of a
diagnostic test: 37%
Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan
TA, Studdert DM. Missed and delayed diagnoses in the emergency department:
a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med.
2007;49:196-205.
© 2011 Efasoft, Inc.
Failure to order an
appropriate consultation:
33%
Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan
TA, Studdert DM. Missed and delayed diagnoses in the emergency department:
a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med.
2007;49:196-205.
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The number of objects an average human
can hold in working memory is 7 ± 2.
Miller GA. The magical number seven, plus or minus two: Some limits on our
capacity for processing information. Psychol Rev. 1956;63:81-97.
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18 millions article references in Medline
Typical CPG is 50-150 pages long
Genomics increases the number of data type that
can affect decision making
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MU Stage 1: From Paper to
EHR
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MU Stage 2: CDS Takes
Center Stage
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From One Expert's Brain
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To Computerized Decision
Support
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The Wisdom of a Team
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Interoperable Systems
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CDS Interventions
Cognitive Support for Clinicians,
Patients, and Caregivers
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Alerts & Reminders
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Health Behaviour Change
Free C, Phillips G, Felix L, Galli L, Patel V, Edwards P. The effectiveness of
M-health technologies for improving health and health services: a systematic
review protocol. BMC Research Notes. 2010;3:250.
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Care Pathways, Protocols
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Order Sets
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Personalized Medicine
Kawamoto K, Lobach DF, Willard HF, Ginsburg GS. A national clinical decision
support infrastructure to enable the widespread and consistent practice of
genomic and personalized medicine. BMC Med Inform Decis Mak. 2009;9:17.
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Scheduling
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“An evidence-based intervention resulted in a large and
sustained reduction (up to 66%) in rates of catheterrelated bloodstream infection that was maintained
throughout the 18-month study period.”
Pronovost P, Needham D, Berenholtz S, et al. (December 2006). "An
intervention to decrease catheter-related bloodstream infections in the ICU". N.
Engl. J. Med. 355 (26): 2725-32.
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Infobuttons
Linked to problem list
Code-driven
Question-driven
Point of care retrieval
Del Fiol G, Haug PJ, Cimino JJ, Narus SP, Norlin C, Mitchell JA. Effectiveness
of topic specific infobuttons: A randomized controlled trial. J Am Med Inform
Assoc. 2008;15(6):752-9.
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Disease Registries
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Predictive Data Mining
“Medicine is a science of
uncertainty and an art of
probability.”
-Sir William Osler (1849-1919)
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Data Visualization
Gill J, Chearman T, Carey M, Nijjer S, Cross F. Presenting patient data in the
electronic care record: the role of timelines. JRSM Short Rep. 2010 Sep 15;1(4):29.
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Documentation Template
Aggregated view of data entry, display, and
CDS interventions based on specific diagnosis
Supports workflow and usability
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Focus on Core Competency:
Medical Care
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The Cloud: Just a Buzzword?
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Apps Moving to the Cloud
Analytics,
CDS, EHR,
5010/ICD10
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Benefits of the Cloud
Elasticity
Quick provisioning
Usage-based payment
Massive scalability
Low up-front capital costs
Sharing resources
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Cloud-Enabled ACO
Analytics
Registries
CDS
Reporting
Risk
Financial
Providers
Payers
Government
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Rules & Analytics
De-Identification
Re-Identification
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Driving Quality and
Performance
Measurement - A
Foundation for
Clinical Decision
Support
Clinical Practice
Guidelines We
Can Trust
By the Institute Of
Medicine (IOM)
By The National Quality
Forum (NQF)
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NwHIN, Direct, HIE
HIE Adapter
Knowledge
Management
Service
Terminology
Service
Event Service
Infobutton
Service
Client
Adapter
Service
Resource
Locator
Service
Decision
Support
Service
Intervention
Service
CDR
KM/
Rules
Authoring
CDS
Interventions
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CDS Intervention Profile
Priority
Channel (SMS, Email, etc.)
Escalation logic
Clinical workflow
Message queue
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Clinical Knowledge
Management (CKM)
Collaborative
Governance
Metadata (HL7 DSS)
CKM Repository
Content lifecycle
CMS and Portal
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Privacy Regulations
HIPAA and HITECH Act
Federal Information Security
Management Act (FISMA)
Electronic Communications
Privacy Act (ECPA)
Patriot Act
Seek legal advice
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Security Threats
Isolation in Multinancy
DoS and DDoS
OWASP Top 10
CSA Cloud Top Ten Threats
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Cloud Security
Monitoring
Hardening & Patches
Host firewall
Intrusion Detection System
(IDS)
Encryption & Key
Management (NIST 800-57)
Guidance by CSA and NIST
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Identity and Access
Management (IAM)
SAML for SSO
XACML 3.0 Draft
XSPA Profiles for
Healthcare
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Security Management
Framework
ITIL & ISO 27002
Availability
Configuration
Vulnerability
Access Control
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Governance, Risk and
Compliance (GRC)
HIPAA
ISO 27001
SystTrust, WebTrust
SAS 70
CSA GRC Stack
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Storm in the Cloud
Stateless services
Multi-region resiliency
Choose the right storage
Allocate more than needed
Simulate failure
Automate recovery
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Demand transparency from your CSP
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DMTF Open Virtualization Format (OVF)
IEEE Cloud Portability and Interoperability
Profile
IEEE Intercloud Interoperability and Federation
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CDS Standards
Virtual Medical Record (vMR)
Decision Support Services (DSS)
Infobuttons
Order Sets
Guidelines Element Model (GEM)
Predictive Model Markup
Language (PMML)
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Definition of Cloud Computing
Synopsis and Recommendations
Cloud Reference Architecture
Guidelines on Security and Privacy
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Care First,
Technology Second
© 2011 Efasoft, Inc.
joel.amoussou@efasoft.com