Clinical Decision Support (CDS) Project SOA Services Demonstration HL7 SOA September, 2014.

Clinical Decision Support (CDS) Project SOA Services Demonstration

HL7 SOA September, 2014

• Agenda• Review of Prior Work• Accomplishments since May • Services Demonstration – Security Labeling and Message

Escalation• Technical Highlights

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Welcome

Abbreviations Used

• SOA services– EPS– Event Publish & Subscription Service– OS – Order Service– UCS – Unified Communication Service

• Other abbreviations– CDS – Clinical Decision Support– PEP – Policy Enforcement Point– CPRS – Computerized Patient Record System– VistA – Veteran Health Information Systems and

Technology Architecture– FHIR – Fast Health Interoperable Resources

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EPSTopic

CDS

OS

UCS

HL7 May WG Meeting

VistA

Accomplishments Since May• Implemented core conformance profiles for the three SOA

service reference implementations• Refined order requirement model and interface definitions

based on feedback from the May demonstration and implementation experience

• Submitted DSTU ballot material for the three SOA services.• Enhanced the reference implementations to address:

– Stability– Scalability– API completeness

• Added two new security uses cases to the clinical scenario demonstration: Rule-based security labeling and security policy validation

• Also added an escalation use case to clinical the scenario demonstration

– escalation via failover– Implemented additional UCS adapters for SMS and Text-to-Voice

protocols 5

Enhanced Clinical Scenario

Patient Eighteen is admitted to the hospital and treated with Gentamicin for a urinary tract infection. The patient has a signed consent directive that limits disclosure of HIV and substance abuse information except for emergency situations.His attending physician, Dr. One Provider, orders a routine chemistry lab test in VistA. When the lab is completed, the hospital’s CDS system evaluates the results and recognizes that the patient is on Gentamicin. It then sends an alert to Dr. Provider informing him of the elevated creatinine level (1.8 mg/dL) and that an unsigned order for a Gentamicin dose adjustment has been placed in VistA. Dr. Provider is requested to either sign or cancel the recommended order.

The Core Story

The CDS Service also calls Dr. Provider on his desktop phone with a text-to-voice message. If Dr. Provider does not answer his phone, an SMS message is then sent to his registered SMS-enabled mobile device.

Escalating the communication

Based on the organization’s policy, two newly resulted labs for patient Eighteen (an HIV blood test and a cocaine drug screening) and their corresponding alerts are treated as protected content. Given the patient’s consent policy vis-à-vis protected content, these are not accessible except under emergency conditions. The creatinine lab result and its alert, however, are not so restricted.While the patient is awake and conscious in the hospital, the physician only sees the gentamicin alert.

The Security Context – Patient Able to Consent

Later, the patient develops florid urosepsis, becomes unconscious, needs mechanical ventilation and treatment for unstable hypotension. To ensure a comprehensive differential diagnosis, the physician elects to ‘break the glass’ in order to access any protected health information and advisories that may be relevant to the care required should such filtering exist.In this context, ‘break the glass’ overrides the patient’s consent directive, allowing the provider access to the full medical record, including restricted data and alerts.

The Security Context – Patient Unable to Consent

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EPSTopic

CDS

OS

Updated Scenario

Three Lab Orders

Cocaine, HIV, Creatinine

Three labeled messages sent

VistA

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CDS

UCS

TTV

PEP

• Event Publish and Subscribe Service (EPS)– VistA (via Mirth) is registered as an event publisher– VistA (via Mirth) publishes events– A CDS service subscribes to a topic– A CDS service receives event notification– A Publication Intervention intercepts the message to:

• Normalize the payload to FHIR• Add security metadata to the message

• Order Service (OS)– A CDS service creates an order using OS– OS invokes VistA’s order fulfillment system

• Unified Communication Service (UCS)– A CDS service issues three alert to the UCS carrying forward all

security metadata– The CDS service places a call to the physician’s work phone via

UCS– Should the clinician not answer the voice call the CDS service

reformats and escalates the message to SMS – The UCS delivers the alerts via the portal adapter

Use Cases

The updated scenario

• Demonstrates a powerful and extensible UCS API• Illustrates how UCS can provide more timely and

proactive notification• Showcases and validates new services in a live lab

environment– HL7 Security Labeling Service and the need for enforceable,

fine-gained access control of healthcare information– Mike Davis and the VA’s contributions to the HL7 Security

Working Group

• Illustrates how our three new services can be integrated with, and enhanced by, the Security Labeling Service to provide sophisticated functionality

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Technical Highlights

Mirth

<<Interface>>Publication Interface

EPS

CDS

<<Interface>>PSSubscription Interface

<<Interface>>Publication Intervention

• FHIR Normalization

• Security Labeling

Reference Implementation

VA Integration Points

Security Labeling

Health Care Classification

Service

if(observation.name IN {…}) …

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<feed xmlns="http://www.w3.org/2005/Atom"> <entry> <category scheme="http://hl7.org/fhir/tag"

term="http://hl7.org/implement/standards/fhir/v3/Confidentiality#N" label=”Restricted"/>

<content type="text/xml"> <DiagnosticReport xmlns="http://hl7.org/fhir"> <contained> <Patient id="patient">

Security Labeling – Leverages FHIR Tags

CDS

<<Interface>>Client Interface

UCS

Portal

<<Interface>>UCS Alerting

Reference Implementation

VA Integration Points

Security PolicyEnforcement

Rule-based Security Policy Enforcement

Endpoint

Input1. User type: MD/Allopath2. Purpose of use: Treat3. Patient information via FHIR resource

PeP4. Parses security labels5. Evaluates data against patient consent directives and org policy

Output6. Denied or Permitted7. Displays only if ‘Permitted’

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Escalation

CDS UCSTTV

Adapter

Text-to-VoiceMessage type sent

to UCS

Routed toText-to-Voice Adapter

CDS UCS

Exception forwarded back to caller

No response to call triggers timeout exception

via UCS Client Interface

CDS UCS SMSAdapter

SMSMessage type sent

to UCSRouted to SMS

Adapter

TelecomDevice

Invokes VoIP TTV Service

Invokes SMS Service

Next Steps

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• DSTU Ballot in Sept 2014 (DSTU Ballot Material Published)• OMG presentation after Sept WGM (TBD)• OMG RFP (TBD)• Proposal selection and standards definition phase (TBD)• OMG ratification (TBD)

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Service Specification Plan

• The three Service Functional Models and their reference implementations showcase the functional utility of the services, especially for patient care coordination activities across organizational boundaries

• Important in developing service functional requirements, APIs, and how they fit into the security and privacy fabric of healthcare.

• Also raise provocative questions for Clinical Decision Support:– As data flows through the information system

infrastructure, when and where should security and policy enforcement occur?

– Should a CDS system ever evaluate data that a patient might restrict by consent directives evaluate that data at all?

– Is the typical SAML / XCAML policy approach a scalable solution for building fine-grained access control systems

• The CDS Evaluation Lab provides a unique opportunity to better understand the functional, technical, and medical-legal implications of applying technology to healthcare

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Closing Remarks

Context Slides From May 2014 Demonstration

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• A lab order is placed using CPRS• Lab test results entered using scroll-n-roll• VistA pushes lab results to Mirth via its HL7 Streaming

Package as an HL7 V2 message

Triggering the Event Chain

Mirth

<<Interface>>Publication Interface

EPS

CDS

<<Interface>>PSSubscription Interface

<<Interface>>Publication Intervention

Reference Implementation

VA Integration Points

CDS

<<Interface>>Order Management

Order Service

VistA (via Cache)

<<Interface>>Fulfillment

Reference Implementation

VA Integration Points

CDS

<<Interface>>Client Interface

UCS

Portal

<<Interface>>UCS Alerting

Reference Implementation

VA Integration Points

• Physician view alert in inbox• Physician signs the order in CPRS

Human Intervention via the Universal Portal/CPRS

Reference Service Implementation Overview

• Improve the quality of patient care• Lower cost of care• Deliver higher patient/provider satisfaction

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Why SOA Services

• Brokered service• Topic-based• Decouples interface between providers and

consumers of new clinical content• Notification vs Polling• Content Intervention• Content brokering (e.g., deferred content

delivery, content negotiation)• Not a query interface to a data repository

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Event Publish and Subscribe Service (EPS)

• Common interface providing common governance and orchestration of orders and order-related artifacts.

• Covers the creation, update, monitoring, metadata discovery, and deletion of orders and related order components

• Catalog management services provide similar services for order items and order sets

• Provides facilities for order fulfillment and fulfillment updates

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Order Service (OS)

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Example Deployment

• Brokered communication service• Decouples sender from receiver• Supports the notion of a ‘conversation’• Standardized interface for message-based

notifications• Bi-directional communication• Dynamic routing and escalation• Supports multiple modalities through the use of

‘adapters’• Supports multiple message transport protocols

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Unified Communication Service (UCS)