October 2014

Brief Profile Proposal for 2015/16 Yr 9presented to the

Quality, Research & Public Health (QRPH) Planning Committee

RPE for ICPXen Santas | James Kariuki |Derek Ritz

CDC |ecGroup Inc.2014-10-10

October 2014

Background

• Integrated care pathways (ICPs) are long-running workflows that cross institutional barriers and involve multiple providers of person-centric care.

• At present, most clinical decision support (CDS) is implemented, in cases where it has been deployed, by local electronic medical records (EMR) systems with local scope.

• An ICP can be thought of as care guideline-specific CDS that is of system-wide scope.

October 2014

Background

• ICPs are of crucial importance to effective and efficient chronic disease management, maternal care, and a number of infectious disease care workflows (such as HIV, TB and Malaria).

• There is compelling evidence that guideline-based care has a significant positive impact on health outcomes.

• Even so, there is alarming evidence that, in many jurisdictions, much of the care patients receive is not guideline-based.

October 2014

The Problem

• At present, there is not a ready mechanism for a health information exchange (HIE) to:1. Identify that a patient is enrolled in a defined

“care programme”2. Facilitate and help enforce the guideline-based

care for that patient over time and across multiple care delivery sites

3. Systematically capture standards-based (coded) transactions to support the generation of guideline-based metrics and indicators.

October 2014

The Value Proposition

• There is compelling evidence that guideline-based care leads to the best patient health outcomes.

• In low-resource environments, HRH is a significant challenge; ICPs support task shifting, which is an important HRH strategy in many LMICs.

• An HIE-based care “ICP engine” gives an MOH a ready way to operationalize new care workflows.

• If you know what was supposed to happen, you can raise an alert if it doesn’t.

• Adherences to guideline-based care can be employed as a provider payments metric.

October 2014

Market Readiness

• Multiple commercial and open source enterprise-class, BPMN-capable workflow engines are available

• Many commercial and open source HIE products have orchestration capabilities

• A number of care guidelines (ICPs) have been modeled using BPMN

• IHE’s Retrieve Process for Execution (RPE) profile is in trial implementation; it defines a way for BPMN-defined care paths to be woven into clinical workflows

October 2014

Existing Profiles & Risks

Interoperability Layer (IL)

CR

HWR FR

SHR

POS

TS

XDS, PDQ, CSD

XDSCSD

PDQ

DTSOpe

nHIE

October 2014

Existing Profiles & Risks

Interoperability Layer (IL)

CR

HWR FR

SHR

POS

TS

XDSCSD

PDQ

DTS ICPRPE

XDS, PDQ, CSD

Ope

nHIE

October 2014

Existing Profiles & Risks

Interoperability Layer (IL)

CR

HWR FR

SHR

TS

@@H?

XDSCSD

PDQ

DTS ICPRPE

Ope

nHIE

October 2014

Existing Profiles & Risks

Orchestration Logic

CR

HWR FR

SHR

POS

TS

XDSCSD

PDQ

DTS ICPRPE

SOA is not a requirement.

October 2014

Existing Profiles & Risks

• Our prototype will be able to leverage existing IHE profiles for document exchange and client & provider & facility ID resolution (XDS, PDQ, CSD)

• We will use RPE to communicate with the ICP engine. (Risk: new use case)

• Presently, we use a proprietary spec for terminology services. (Risk: idiosyncrasy)

• We expect to leverage a companion IHE ITI work item (@@H) for alerting. (Risk: new profile)

October 2014

“OECD” Use Case…

Presently • Derek has type II diabetes• It has been 8 months since

Derek has had an HbA1C test• Derek is sitting at home

reading a book• Derek is one of the more than

half of diabetic patients who is not receiving guideline-adherent care (Ontario, Canada)

RPE4ICP• Derek has type II diabetes• It has been 8 months since

Derek has had an HbA1C test• Derek is sitting at home

reading a book• Derek gets a text message

reminding him he needs to see Dr. Black to get an HBA1C test

• Derek gets back on track and better manages his illness

October 2014

“LMIC” Use Case…

Presently • Mosa is pregnant• Grace, the CHW in Mosa’s

village, enrolls Mosa in the MOH’s maternal care programme

• Mosa goes to her first ANC visit; she tests HIV+ and is put on a PMTCT protocol

• Mosa is one of the nearly half of pregnant mums who doesn’t attend all 4 ANC visits

RPE4ICP• Mosa misses her 2nd ANC visit• Grace receives an SMS message

indicating she should look in on Mosa

• Grace visits Mosa, who is bed-ridden with a fever

• Grace calls for an ambulance to come get Mosa and take her to the district hospital

• Mosa’s baby is one of the ~95% born HIV- to an HIV+ mum because of PMTCT

October 2014

Discussion

• This work item is a white paper• The white paper will document a prototyping effort based on

using RPE to operationalize guideline-based care within the transaction processing logic of a standards-based HIE

• The target HIE, OpenHIE, leverages profiles from QRPH, ITI and PCC; as such, we anticipate cross-committee collaboration

• We estimate this to be a medium work effort• Resources from CDC and ecGroup will be appropriately

dedicated to the prototyping and the document authoring• If warranted, the white paper may inform subsequent IHE

profile development related to this topic

October 2014

White Paper Authors

• CDC– Xen Santas– James Kariuki

• ecGroup– Derek Ritz– Justin Fyfe

October 2014