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NHII Educational Seminar SeriesHubert H. Humphrey BuildingAugust 5, 2004
John WaltonProject [email protected]
Will RossChief Technology [email protected]
Mendocino SHARE
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Mendocino County, California
Northwest coast of California
Two hours north of San Francisco
Population 87,000
3,500 square miles
Low population density (24 / sq. mi.)
Long distances between rural communities over mountain roads
Economically depressed
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ARCH Consortium
Clinic Type Encounters
Anderson Valley Health Center RHC 7,000
Potter Valley Community Health Center FQHC Look Alike 14,000
Long Valley Health Center FQHC 20,000
Redwood Coast Medical Services FQHC 22,000
Mendocino Coast Clinics FQHC 25,000
Mendocino Community Health Clinics FQHC 135,000
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Mendocino SHARE Project
Securing Health Access and Records Exchange
Modeled after Santa Barbara County Care Data Exchange
Target Population 32,000 +
Under 200% of poverty level
48% uninsured
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SHARE Objectives
Health Records Exchange
Coordinated chronic disease case management
Patient enrollment
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SHARE Collaborative
All six ARCH Community Health Centers
Consolidated Tribal Health Project, an IHS clinic
All three local hospitals
Ukiah Valley Medical Center
Howard Memorial Hospital
Mendocino Coast District Hospital
Mendocino County Department of Public Health
Mendocino County Department of Social Services
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Governance and Participation
Administrative Committee
Program Committee
Technical Committee
Solutions Workgroup
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SHARE Staff
John Walton, Project Director
30 years clinical and administrative experience in community and hospital settings
Will Ross, CTO
12 years in production agriculture and horticulture
15 years in technology project management
Greg Wenneson, Technical Project Manager
25 years in software development and software project management at NASA Ames, Autodesk and other commercial settings
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HCAP All Grantee Meeting
Sustainability highly valued
Doing well valued over rapidly making mistakes
Met other communities with MPI projects
Most MPIs were Enterprise, not Federated
Most HCAP projects featured a large, well funded partner
Open source software development is acceptable
Other projects were interested in collaboration
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Community Clinics Initiative
CCI Grant from the Tides Foundation in 1999 to build an enterprise ASP model Practice Management System
Phase One Anderson Valley Health Center (AVHC)Mendocino Coast Clinics (MCC)Mendocino Community Health Centers (MCHC)
Phase Two Long Valley Health Center (LVHC)Potter Valley Community Health Center (PVCHC)Redwood Coast Medical Services (RCMS)
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Enterprise ASP Plan
Host enterprise servers at MCHC Data Center
PMS on Windows NT
Thin client via a Citrix Server
56K fractional T1 circuits
Internet access to remote sites through Citrix desktop
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Enterprise ASP Result
Good News
Phase One enterprise ASP live in 2000
Patient scheduling, registration and billing
But there's trouble in paradise
Bad News
T1 lines intermittent
Disagreements on ASP priorities
ARCH Executive Director and CIO quit
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New Decentralized Direction
Site level servers for each clinic
No ASP model
No enterprise WAN
Every site made whole, no dependence on another site
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Lessons Learned
Enterprise ASP failed for social not technical reasons
Remote sites uncomfortable with distant support
Governance model unable to avoid frustrating all participants
Collaboration across separate institutions is possible
Decentralised solutions are optimal
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Santa Barbara County Care Data Exchange
July 2003
SBCCDE Interim Report
Loosely coupled p2p decentralised solution to PHI data sharing
Functionally consistent with decentralised IT collaboration model in ARCH consortium
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No HRE without EHR
R = “Records”
EHR is not just automation, it is workflow redesign
EHR requires
Secure Internet Access
Redundant journaling file system
Not just email, but secure clinical messaging
Facile presentation, clinical interaction and decision support
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Making EHR Possible
Clinical Records
Regular Email
Simple File System
Regular Internet Access
Common Knowledge
Paper records feel secure
Email not secure
Drives crash
Access intermittent
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Preconditions for MPI & HRE
All four layers above a PMS must be present before content can be made available to an MPI & HRE
Mendocino SHARE will help deliver all three upper layers
ARCH clinics have accomplished Secure Internet Access and PMS
*
EHR
Clinical Messaging
Document Management
Secure Internet Access
Practice Management System
* Potential for MPI, HRE and other NHII goals
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Federated Master Patient Index
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Health Records Exchange
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A Modest Technology Proposal
August 2003
Innocent ProposalScaled down clone of SBCCDE as a technology component in a $2 million HCAP grant application
Is This Wise?
ARCH has no idea that this proposal is way larger than HCAP funds
Funded, October 2003
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Primary Care Coalition
Primary Care Coalition of Montgomery County Third year HCAP grantee Open Source PMS & EHR (“CHLCare”) Needs a federated MPI
Mendocino SHARE First year HCAP grantee Building Open Source federated MPI Need a PMS & EHR solution
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Seeking an MPI Vendor
HCAP List of MPIs
MPIs built by previous HCAP grantees
77 MPIs listed
None free or open source
Almost all are Enterprise, not Federated
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Browsersoft
RFP Published, February 2004
12 vendors submitted bids
Extensive negotiations
Viewed 5 full demos
Browsersoft, April 2004
Overland Park, Kansas
An IBM Development Partner
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Browsersoft Builds SHARE Prototype
Dave Forslund's OpenEMed used during first prototype phase
Try loading PIDS files totaling over 50,000 patients from multiple domains, in some cases multiple files from a single domain
Has trouble scaling past 10,000 records
Due to HIPAA constraints our files have simulated data, false name pairs and false birthdates
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SHARE Prototype
Patient Lookup
Three value limit during prototyping phase
August 2004
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SHARE Prototype
Correlating Multiple Patient Listings
“Show Grouped”
August 2004
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SHARE Prototype
Viewing a Patient
August 2004
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SHARE Prototype
Graphing a Result
August 2004
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Discovery Process
We Learned
Vision > Funding
Not yet scalable
Productizing needed
Not ready for production
Needs architecture
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System Level Architecture MeetingJuly 14 & 15, 2004System Level Architecture Meeting (SLAM)
Two day brainstorming session
Review lessons learned in iterative Year One discovery process
Include Open Source experts from outside Mendocino SHARE
Imagine an optimal technology road map for Year Two
Meeting funded by the BPHC
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SLAM #1 Participants
Invitees
David Forslund, LANL
Jie Wang, Stanford University
Guy Fisher, Primary Care Coalition of Montgomery County
David Uhlman, Pennington Firm
Tom Passim, Mitretek Systems
ARCH
Will Ross
John Walton
Greg Wenneson
Browsersoft
Don Grodecki
Paul Misner
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Mendocino SLAM #1 Outcomes
Technology to Test in Next Iterations (August - November)
Run PIDS index as OpenLDAP
Run PIDS with POJO (can do WS when needed)
Use MySQL to manage PIDS updates
UCLA DataServer for population data de-identification
Test lexicon transformer based on Mayo Clinic LQS
Launch portal for virtual SLAM
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Clinic A(export only,
non-integrating simple systems)
HealthPro
PECS
export PIDS
BrowserPortal
SHARE
export PIDS and Clinical
Clinic B (bigger)(non-integrating
simple systems)
HealthPro
PECS
export PIDS
expo
rt P
IDS
an
d C
linic
al
Pharmacy
Clinics A and B – export data from systems only (not bi-directional). Access to SHARE is by Browser not integrated into clinic systems . If datacomm link goes down , no access to SHARE .Clinic/Hospital C – access to/through SHARE via hospital local MPI (bi-directional). DataComm goes down, still have local MPI .
expo
rt PI
DS
and
Clin
i cal
BrowserPortal
Hospital C, Enterprise
System (eg. Cerner)hopefully SHARE integrated
Enterprise System
export (or exchange?)
PIDS and Clinical
local MPI
export PIDS /
Clinical
export/importPIDS and clinical
non-integratedsystem
?? how does other data
get back to “C” system/
user??
Mendocino SLAM #1
IllustrationGreg Wenneson
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NHII
July 2004
Mendocino SHARE network design matches proposed designs from major national studies
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NHII
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NHII Strategic Framework
Before Conference Mendocino SHARE is an LHII
Mendocino SHARE is developing free LHII software
At ConferenceMendocino SHARE is less than a full LHII
Free LHII software projects
Mendocino SHARE
Massachusetts SHARE
Indiana Patient Care Network
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NHII Strategic Framework
Inform Clinical PracticeIncentivize EHR adoption
Reduce risk of EHR investment
Promote EHR diffusion
Interconnect CliniciansFoster regional collaborations
Develop a national health information network (Mendocino SHARE fits here)
Coordinate federal health information systems
Personalize CareEncourage use of Personal Health Records
Enhance informed consumer choice
Promote telehealth systems
Improve Population HealthUnify public health surveillance architectures
Streamline health status monitoring
Accelerate dissemination of evidence
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NHII in the Public Domain
Why Open Source?
Because there are enough collaborators to succeed
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OpenHRE.org Portal
Place development content on portal
Launch in August 2004
OpenHRE.org available to host access to any free or open source (FOSS) software solutions contributing to LHII solutions
OpenHRE.org will use the NHII technology framework to identify FOSS projects
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Mendocino SHARE Challenges
Technology
Collaboration
Funding < Vision
EHR
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Mendocino SHARE Vision
Federated solution
Feature complete LHII components
Using Open Standards
Free
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Mendocino SHARE
thank you!
to contribute to our enterprise software projectwww.openhre.org
questions or commentsWill Ross, Chief Technology OfficerAlliance for Rural Community [email protected]