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)
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