Post on 22-Aug-2020
Get to Green: A FHIR-enabled application for ventilator weaning using Cerner Ignite API
Robert E. Murphy, MDAssociate Professor and Associate Dean, Applied Informatics
University of Texas Health Science Center at Houston
Lee Ann Kincaid, MHADirector, Technical Solutions
Memorial Hermann Healthcare System
October 10, 2017
1 © Cerner Corporation. All rights reserved.1 © Cerner Corporation. All rights reserved.
Learning Objectives
1. Understand how FHIR specifications allow software developers to quickly create apps that connect with Cerner Millennium.
2. Understand how the cloud-based deployment enabled an iterative design process allowing appropriate adjustments to be made based on feedback throughout the build.
3. Understand the challenges that health systems should expect to prepare for when implementing FHIR-based apps.
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A Fundamental Problem
>>>Ideas Resources
3 © Cerner Corporation. All rights reserved.3 © Cerner Corporation. All rights reserved.
“I have an idea…”
•What problem does it solve?
•Who wants it?
• Is it a priority?
•Can it be done?
•Approved and “On the list”
•Wait in line…
4 © Cerner Corporation. All rights reserved.4 © Cerner Corporation. All rights reserved.
The Excel Spreadsheet!
PASS
FAIL 18:35
Bed. No. 11Gender Male
DOB 01/18/1975Vent Start
Date/Time12/29/15 11:55 AM
MICU Arrival
Date/Time12/29/15 6:35 PM
Patient On
Paralytics No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Millennium ID # 100109891
12
/29
/20
15
18
:35
19
:00
20
:00
21
:00
22
:00
23
:00
0:0
0
1:0
0
2:0
0
3:0
0
4:0
0
5:0
0
6:0
0
7:0
0
8:0
0
9:0
0
10
:00
11
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23
:00
0:0
0
1:0
0
2:0
0
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0
4:0
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5:0
0
6:0
0
7:0
0
8:0
0
9:0
0
10
:00
11
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23
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0:0
0
1:0
0
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0
3:0
0
4:0
0
5:0
0
6:0
0
7:0
0
8:0
0
9:0
0
10
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0:0
0
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0
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5:0
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6:0
0
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0
8:0
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10
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16
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Vent
Parameters
Last Test/Reading
Before MICU Arrival
29
-De
c
29
-De
c
29
-De
c
29
-De
c
29
-De
c
29
-De
c
30
-De
c
30
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c
30
-De
c
30
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c
30
-De
c
30
-De
c
30
-De
c
30
-De
c
30
-De
c
30
-De
c
30
-De
c
30
-De
c
30
-De
c
30
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c
30
-De
c
30
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c
30
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c
30
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c
30
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c
30
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c
30
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c
30
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c
30
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c
30
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c
31
-De
c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
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c
31
-De
c
1-J
an
1-J
an
1-J
an
1-J
an
1-J
an
1-J
an
1-J
an
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2-J
an
PEEP 10 10 10 10 8 5
FIO2 60 60 60 100 60 60 50 40 40
pH 7.46 7.46 7.32 7.13 7.4 7.4
RR 28 25 29 25 20 20
HR 111 118 109 111 93 96 97 101 106 100 88 83 85 94 90 91 100 106 104
HGB 11.7 10.1
MAP 127 136 107 108 101 56 70 74 78 107 79 63 68 80 81 68 87 101 114 136
Norepinephrine
RASS -1 -2 -4 1 1 1
Fourth Attempt at SBT Trial Hours From MICU ArrivalResult
First Attempt at SBT Trial Hours From MICU Arrival 17ResultPassed
MIC
U A
rriv
al T
ime
Number of Hours From MICU Arrival
Status
Indicator
Second Attempt at SBT Trial Hours From MICU ArrivalResult
Third Attempt at SBT Trial Hours From MICU ArrivalResult
Fourth Attempt at SBT Trial Hours From MICU ArrivalResult
SBT AssessmentSBT Trial Extubation
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Ventilator Bundle
1. Head of bed elevated 30 degrees
2. Daily sedative interruption and daily assessment of readiness to extubate
3. Peptic ulcer disease (PUD) prophylaxis
4. Deep vein thrombosis (DVT) prophylaxis
5. Daily oral care with chlorhexidine
6 © Cerner Corporation. All rights reserved.
Ventilator weaning
RESPIRATORY CARE • JANUARY 2002 VOL 47 NO 173
• Removing patients from ventilator as soon as safely feasible
• Physician assessment +/-guidelines
• Concern for emergent reintubation and complications
GET TO GREEN : IMPROVING TEAM COMMUNICATION TO
REDUCE VENTILATOR HOURS
AL AMAN
BELA PATEL, MD
MCGOVERN MEDICAL SCHOOL AT UTHEALTH –HOUSTON
OVERVIEW
➢ Primary drivers for improvement include:
❖ Patient Safety
Prolonged mechanical ventilation is associated with an increased
risk of ventilator related complications and mortality.
❖ Cost
Extensive ventilator days leads to increased length of stay and
subsequently, higher total costs for both the patient and the hospital.
The average cost of stay for a typical ICU intubated patient is
approximately 2,500 dollars per day.
A multi-disciplinary team of physicians, respiratory therapists, nurses,
process improvement engineer, and applications analyst were formed to
address the length of ventilator hours in MICU by focusing on team
communication.
OUR GOALThe primary goal of this project was to decrease ventilators hours by 20% in
10 months by using a ventilator status communication board. In 2014,
average days a patient was on mechanical ventilator was 4.9 days.
Measures of Success:
Primary Measure:
Reduction of ventilator hours per patient.
Secondary Measure:
No increase in percentage of reintubation in extubated patients.
DEFINED VENTILATOR PARAMETERS
The following ventilation parameters with specified targets were Selected for the visual communication board:
1- PEEP
2- FIO2%
3- PH
4- RESPIRATORY RATE
5- HEART RATE
6- HEMOGLOBIN
7- MEAN ARTERIAL PRESSURE
8- VASOPRESSORS
9- RASS
10- PLATEAU PRESSURE
11- TIDAL VOLUME
PROCESS IMPROVEMENT INITIATIVES: Get To Green
PROCESS IMPROVEMENT INITIATIVES: Get To Green
RESULT: PRIMARY MEASURE
Average days on mechanical ventilation has decreased from 4.9 days in 2014 to
3.6 days in 2017 (36% improvement), therefore we exceeded our primary measure
goal of a 20% decrease in average vent days.
Start of Get To
Green Campaign
5,14,1
3,2
4,2 4,1 4,2 4,4
5,4 5,1
7,1
4,5
7,6
5,4 5,1
4,13,2
5,3
3,6 3,42,9 3,3 3,1 3,0
4,6
3,6 3,8
5,6
4,1
6,9
4,7 4,7
3,6 3,8 3,52,6
3,4 3,23,6 3,7
4,33,4
4,1
3,752,84
4,9
3,94,2
3,6
0,0
1,0
2,0
3,0
4,0
5,0
6,0
7,0
8,0
9,0
Jan
. '1
4
Fe
b. '
14
Mar
. '1
4
Ap
r. '1
4
May
'14
Ju
ne
'14
July
'14
Au
g, '1
4
Sep
. '1
4
Oct
. '1
4
No
v. '1
4
De
c. '1
4
Jan
. '1
5
Fe
b. '
15
Mar
. '1
5
Ap
r. '1
5
May
'15
Ju
ne
'15
July
'15
Au
g, '1
5
Sep
. '1
5
Oct
. '1
5
No
v. '1
5
De
c. '1
5
Jan
. '1
6
Feb
. '1
6
Mar
. '1
6
Ap
r. '1
6
May
'16
Jun
. '1
6
July
'16
Au
g, '1
6
Sep
. '1
6
Oct
. '1
6
No
v. '1
6
De
c. '1
6
Jan
. '1
7
Feb
. '1
7
Mar
. '1
7
Ap
r. '1
7
May
'17
Jun
. '1
7
Jul.
'17
Au
g. '1
7
Average Vent Days in MICU
Avg. Vent Days Rolling Average
RESULT: PATIENT REINTUBATION FREQUENCY
Average number of reintubations has not increased since the start of the “Get
to Green” initiative.
6,70% 6,70% 6,60%
5,60%
0,0%
1,0%
2,0%
3,0%
4,0%
5,0%
6,0%
7,0%
8,0%
Re
intb
atio
nP
erc
enta
ge2
01
4
Re
intb
atio
nP
erc
enta
ge2
01
5
Re
intb
atio
nP
erc
enta
ge2
01
6
Re
intb
atio
nP
erc
enta
ge2
01
7
% Re-intubation Per Extubated Attempt
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Problems and limitations
•Manual data entry…
•Timeliness of data entry
•Timeliness of analysis
•Timeliness of communication
•Inconsistent usage
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Why can’t we have…
• A new flowsheet in Cerner?•How will people find it?
• A rule and alert?• Difficult
• High backload of new ambulatory content, refinements, >6 months
• Maintenance and upgrades
• A new mPage?• mPage Developer License
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FHIR to the Rescue
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Emerging standards make “apps” a reality
• FHIR = “Fast Health Interoperability Resources”
• An API standard for accessing health care data (“Resources”)
• ReSTful design leverages Internet standards (HTTP, etc.)
• Created by Health Level 7 International (HL7)
• Emerging support by most major HIT providers (e.g., Argonaut Project)
• Meets EHR Certification for MU3
• SMART = “Substitutable Medical Applications and Reusable Technology”
• A SMART App is a Web App
• HTML5 + JavaScript
• Typically embedded in EHR
• EHR Data Access is via FHIR
• OAuth2 for security and context passing
• Also supports smart-phone and patient-controlled apps
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APIs have transformed many other industries
We believe they can do the same for health care!• Application Programming Interfaces
(APIs):• Allow technical solutions to talk to one
another in the same language
• Easily expose services to make them available inside and outside an organization
• Cerner’s open platforms expose standards that make it possible to connect apps or easily transfer discrete data.
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APIs enable apps for providers and consumers
Provider-facing apps
can be developed that
leverage the
Millennium Platform
using APIs
Government regulation requires
more choices for
consumer-facing apps via APIs
Plan to attest for Meaningful Use Stage 3?
The Ignite API for Millennium addresses Objective 5, Measure 1
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HITECH—In Retrospect and for the Future
Application programming interfaces & FHIR
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HITECH—In Retrospect and for the Future
Application programming interfaces & FHIR!
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Enabling innovation among clients and developers
Clients
Developers
Cerner
Open
Developer
Experience
Open Collaboration
Create
Application
Discover/Install
Ignite APIs for Millennium
Connect
Install
Publish
• Developer Site: code.cerner.com
• Free and open documentation of available API Resource endpoints
• Starter app and tutorials
• Sandbox on actual Cerner EHR back-end for patient and provider-facing apps (over 1,200 registered apps)
• Active Google Group (300+ members, 200 posts per month). Cerner Engineers are highest contributors.
Publish
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Breakfast with the CIO
• Developed internal FHIR server and developed prototype ~ 10 days
• Demonstrated application prototype cycle can be fast
• Prototype is “simple”, “desired”, has great champion…
• CONTRACT!
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Advantages of custom FHIR development
• Development by external team
• Infrastructure investment based on FHIR as an accepted standard
• Far less application interdependence; smaller team
• Springboard for future development
• Low(er) cost, low(er) risk
• Ability to support a strong clinical leader with history of proven quality improvement success• An innovative, determined physician leader with a good balance
of patience, persistence and perseverance
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Arrangement
• 1/3 Memorial Hermann
• 1/3 McGovern Medical School
• 1/3 School of Biomedical Informatics
• Intellectual property held by University of Texas System
• Sticking point: Indemnification for research prototype
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Design issues
•Parameter settings
•Team Workflows & Decision making
•Phase 1—data displays
•Phase 2—with notifications
•Clinical mappings!!
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“Remove from ventilator”
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Start time of spontaneous breathing trial (?)
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Implementation Challenges and Considerations
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FHIR Structure
oAuth2 Context
Service
FHIR
Services
Public / Internet
Private / Intranet
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Build a Project Team
Clinical
Representative
Cerner Data
Expert
Application
Builder
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When Scoping the Project
• Timeline• Allocation of Time for Cerner to Complete Testing and Validation in
Sandbox Server
• Allocation of Time for Mapping Data Elements
• Identifying Data Elements• Compile a list for Concept Mapping
• Review list of Cerner Mapped Data
• Include clinical event code for those without SNOMED or LOINC
• Consider App growth and determine best location• Existing Internal Website vs. Net New
• Future Applications to be developed
• User Authentication
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Technical Challenges
• Cerner Sandbox vs. Memorial Hermann Domain
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Technical Challenges
•Know your Firewall Settings
•Troubleshooting and Logging•Create a logging method
• What to log?
• Where to keep log files?
• How long to keep log files?
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Where are we now?
• Monitor and address Issues as they arise
• Defining Long Term Support Model •Application Display Issues
•Data Issues
•Change requests
• Building Our FHIR Application team •Manage FHIR Apps
•Assist in Testing and Implementation
• Looking at other areas of FHIR Growth!
Future
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HealtheIntent Platform
00100011
00100011 11001011 001001100111 01010111111000111011 01001 010011001
00100011
00100011 11001011 001001100111 01010111111000111011
1 01010111111000111011 01001 010011001
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HealtheIntent and SMART
SMART-capable HealtheIntentSM
applications
• HealtheRegistriesSM and HealtheRecordSM
SMART-specific applications
• Built on top of HealtheIntent APIs
• HealtheInsights
HealtheCare
• Built on Millennium®
and HealtheIntent
• Millennium extensibility via SMART
Tier 1
Tier 2
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Future: HealtheIntent API
• Case of failure to see a specific lab result
• CDS Hooks with labs in HealtheIntent
• Partnership with a University development corporation
• Pursuing SBIR/STTR
CDSServices
EHR Med Order
Toprol XL50 mg daily℞
EHR triggers a CDS hookand invokes a remote
service
1
2CDS Service executesits own rules, leveraging FHIR data as needed
EHRFHIR
Server
3Returns CDS cards
(rendered and displayed by EHR)
$200 per month(patient pays $30)
Try HCTZ as first-line
Switch to HCTZ
Managing hypertension?Launch JNC 8 Rx Pro
information card
suggestion card
smart app link card
HealtheIntent
API?
Questions?
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