Open Source Software Being Used for Health Information Exchange

Transcription

1 Open Source Software Being Used for Health Information Exchange A White Paper by the HIMSS Healthcare Information Exchange Open Source Task Force October, 2010 The views expressed in this white paper are those of the authors and do not necessarily reflect the views of HIMSS. The inclusion of an organization name, product or service in this white paper should not be construed as a HIMSS endorsement of such organization, product or service, nor is the failure to include an organization name, product or service to be construed as disapproval HIMSS 1

2 Contents Introduction... 3 Project Purpose... 3 Project Approach... 3 Results... 5 Mirth... 5 Redwood Mednet... 5 HealthBridge... 6 Long Beach Network for Health... 6 Misys Open Source Solutions ( MOSS ), LLC... 6 Transforming Healthcare in Connecticut Communities:... 6 OpenHRE... 7 East Kern County Integrated Technology Association... 7 Tolven... 8 Bravura Systems: Physician office EMR:... 8 TRANSCEND (Bridge between clinical care and clinical research):... 9 Rijnmondnet: Patient control of information flow through the PHR:... 9 Singapore National Healthcare Group (NHG): Creating a National CDR: Patients Know Best: PHRs for HIE: Follow-Up Questions Summary Acknowledgments HIMSS 2

3 Introduction In June, 2008, the HIMSS Health Information Exchange (HIE) Open Source Task Force released a white paper entitled Evaluating Open Source Software for Health Information Exchange. 1 As a follow-up task, this HIMSS task force focused on assessing how open source software is used or is planned to be used by HIE organizations. In July, 2009, the task force published a paper entitled Exploring the Use of Open Source for Health Information Exchange. 2 Project Purpose In , the Open Source Task Force continued to build upon the work effort of the last two years in the development of a meaningful and constructive commentary on open source utilization in the HIE environment. Open source software has been gaining attention in the HIE environment due to an acceleration in systems planning and deployments funded by the American Recovery and Reinvestment Act of 2009 (ARRA) and the Patient Protection and Accountable Care Act of 2010 (ACA). This task force focused attention on the actual deployment and utilization of open source by communicating with open source development organizations to discern how their software was being deployed in HIE projects. A majority of the Task Force s work effort occurred between September, 2009, and April, The results of this effort is in no way intended to reflect an exhaustive listing of open source deployment in the HIE environments. The timeliness of the Task Force s effort was recently underlined by the formation in June, 2010, of a technical expert panel (TEP) for the Study and Report on Open Source Health Information Technology Systems. The TEP panel has been organized on behalf of the Office of the National Coordinator for Health Information Technology (ONC). The ongoing study, mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act, is evaluating the availability, functionality, interoperability and value of health information technologies classified as open source for federal safety net providers. The results and conclusions ensuing from this study will be submitted as a report to Congress by the Secretary of the Department of Health & Human Services (HHS) by October 1, The TEP has already reviewed the task force s published white papers and is interested in reviewing the work for the current year. Project Approach The task force collected the names of open source development organizations from a variety of sources, and the list of organizations continued to expand over the course of several months. The task force made an effort to narrow the field to organizations that were solely devoted to healthcare information technology. This excluded some open source solutions available in the market place. Our final list included 28 organizations HIMSS 3

4 that fell into one of three groups. Each group was organized by type of contact information. When a healthcare open source organization was identified, task force members attempted to locate a specific contact person for that organization for purposes of this project. When such a person was identified, the task force sent an inquiry to that person. Organizations with an identified contact person were placed in Group A. Group A: Fifteen organizations identified with a named contact. In many cases, it was not possible to identify a particular person for participating in the project and returning answers to queries. In such cases, the task force sent a query to a generic inquiry to the open source organization whenever the website displayed such an option. These were placed in Group B. Group B: Five organizations identified with a generic contact. In some cases, the website failed to display any contact information and we placed these open source efforts into Group C. Group C: Eight organizations were identified as having no contact information on the website. The task force s initial query to these targeted open source vendors was a brief overview electronic outreach message. The following is excerpted from this initial inquiry: The HIMSS HIE Open Source Task Force is currently in its third year of work. In the coming year, we would like to explore how various organizations are using open source software for health information exchange (HIE) activities. In particular, we are focused on healthcare-specific open source software rather than generic open source software. In our view, HIE refers to any ongoing exchange of electronic clinical information between organizations such as hospitals, physician offices, clinics, clinical research groups, public health entities and quality assurance groups. In addition, HIE also includes ongoing exchange between care provider organizations and consumers personal health records (PHRs). We would be grateful if you would describe any HIE activity that your open source software is supporting or is planning to support. The task force received responses from five organizations in Group A and no responses from organizations in Group B and Group C. It is possible that the organizations that failed to respond are not actively engaged in HIE projects, which was the criteria for this project. In other words, those who did not respond could have open source software used by clinical care organizations for purposes other than health information exchange as defined by the project s criteria HIMSS 4

5 Results In the task force s first white paper, we made a recommendation that HIE organizations should determine whether there are one or more organizations that actually provide technical support for an open source software solution being considered for HIE use. We believe that failure to respond to simple queries is likely to be correlated with absence of any predictable ongoing technical support services. In contrast, the five organizations in Group A do have active technical support structures. The support may be provided by a parent organization of the particular software vendor or by other commercial organizations. The five organizations represent an interesting spectrum of functionality with remarkably little overlap. Four of the five organizations were able to provide us with contact information for customers using their open source software. The four open source organizations identified in this project for investigation are Mirth, Mysis, OpenHRE, and Tolven. The following sections cover information supplied by the software development organizations, information found on the organization s website, as well as information provided by their HIE partners regarding their ongoing activities in HIE. Mirth Mirth Connect, Mirth Match and Mirth Results support the technical architectural core of health information exchange activities including the interface engine functions, enterprise master patient index (EMPI) and Clinical Data Repository (CDR), respectively. Mirth also integrates its HIT tools with the CONNECT solution from ONC to form a comprehensive deployment stack that enables National Health Information Network (NHIN) connectivity. Mirth is actively continuing to further develop their existing HIT tools, develop new tools, provide commercial support, support HIE implementations and partner with HIE organizations. Three examples of HIEs utilizing Mirth include the following: Redwood Mednet This is a locally managed not-for-profit HIE in rural Northern California. Redwood MedNet operates production HIE services connecting small rural hospitals and outpatient practices. In July, 2010, Redwood MedNet processed 40,000 clinical messages connecting 6 laboratories and 3 imaging centers to 48 rural providers. They began production use of Mirth open source tools in 2007, and demonstrated the use of the Mirth with the CONNECT gateway in the Federal Health Architecture (FHA) booth at 2010 Annual HIMSS Conference & Exhibition in Atlanta HIMSS 5

6 HealthBridge HealthBridge is a not-for-profit HIE serving Greater Cincinnati and surrounding areas. Founded in 1997, HealthBridge provides connectivity for more than 28 hospitals, 5,500 physician users, 17 local health departments, 700 physician offices and clinics, as well as nursing homes, independent labs, radiology centers and others in the healthcare community. HealthBridge delivers approximately 3 million clinical messages (laboratory, radiology, transcription and ADT) to more than 5,500 physicians each month. HealthBridge began production use of Mirth open source tools in 2008, and demonstrated the use of the Mirth with the CONNECT gateway in the Federal Health Architecture (FHA) booth at HIMSS10 in Atlanta. 4 Long Beach Network for Health Long Beach Network for Health (LBNH) is a public-private collaboration of physicians, hospitals, other healthcare organizations, and consumers committed to promoting the highest quality healthcare for the Long Beach community by enabling a secure, consumer-centric, and information-rich healthcare delivery system. LBNH selected Mirth s open source solution to fit specific situations in order to provide a very costeffective solution for their clients who have a very limited budget. Mirth services utilized by LBNH include hosting services, interface support and professional services support. LBHN open source implementation supports HL7 messaging with use of the NHIN query and response identity messaging standard as well as XML which complies with other NHIN selected standards. This open source solution is deployed as part of the overall technical strategy and technical solutions suite supporting LBNH health information exchange activities. Misys Open Source Solutions ( MOSS ), LLC One of the Open Health Tools (OHT) partners and Board Members is Misys Open Source Solutions (MOSS). MOSS has undertaken to build out the Integrating the Healthcare Enterprise (IHE) server-based components needed to run a health exchange. Those core components reside on the OHT forge. Thus far, the IHE Patient Information Queries/Patient Demographics Supplier (PIX/PDQ) profile has been loaded and is accessible. The Cross Enterprise Document Sharing (XDS) Registry and Repository, Audit Trail and Node Authentication (ATNA) Integration profile and Basic Patient Privacy Consents (BPPC) profiles will be available for download after the IHE Connectathon in January, IBM is leading an effort around the creation of the IHE client components that are also available at the OHT site. One example of MOSS deployment is described below: Transforming Healthcare in Connecticut Communities: Transforming Healthcare in Connecticut Communities (THICC) is a collaboration of hospitals, physician practices, employer groups and insurers. It is seen as the first step in forming the physician office of the future by creating an HIE that will link electronic health records. The THICC includes 20 hospitals, several health centers and a number of HIMSS 6

7 physician organizations and group practices and is seeking to add more members. Coalition members include ProHealth Physicians, Hartford HealthCare, Saint Francis Care, the Connecticut MultiSpecialty Group, the Connecticut Surgical Group, HealthWise physicians and the Hospitals of Central Connecticut. THICC also includes plans for a Personal Health Record so that patients can participate directly in their own care. MOSS is providing an open source-based software solution so that participating community providers can view and exchange critical healthcare information. 5 In this engagement, MOSS provided HIE governance and policy consulting, built the IHE standards-based core HIE open source exchange platform, built the SOA compliant portal that handles patient context, single-sign-on, and roles-based access. Included in this work was the integration of a radiologic viewer and eprescribing. MOSS has also been engaged to support the applications. OpenHRE OpenHRE.org is an open source site dedicated to the proposition that in the NHIN patient records can be linked and exchanged using Free Open Source Software (FOSS). The "timely exchange of information" is the goal of the Open Source Health Records Exchange Organization (OpenHRE.org). OpenHRE.org believes that the best way to achieve an open and affordable health records exchange throughout the nation is through free open source software. OpenHRE hopes to enable the secure infrastructure through which both proprietary and open electronic health record (EHR) systems can exchange information. Through a BrowserSoft 6 implementation, OpenHRE is currently supporting standards based EMPI, XDS repository, NHIN gateway and Pentaho based HIE reporting for clients. 7 East Kern County Integrated Technology Association is an example of this type of HIE implementation: East Kern County Integrated Technology Association The purpose of the East Kern County Integrated Technology Association (EKCITA) is to demonstrate secure and appropriate sharing of electronic health files and clinical data for public health, patient care and research; and to develop, improve and assist in the implementation of health information technology for all physicians, caregivers, healthrelated institutions and consumers in, but not limited to, Kern. EKCITA is not a typical health information organization (HIO) in that it also holds the licenses for the EHR software solutions installed at various rural health clinics and private practices in the region; it holds the license for a custom designed, Web-based PHR; and it is responsible for the open source HIE system designed by the local providers. EKCITA s HIE will HIMSS 7

8 allow for not only the secure transmission of data, but will also support population-based quality improvement and research studies. At this time, EKCITA is comprised of a local critical access hospital, medical group, six private provider offices, and three rural health clinics. EKCITA is exchanging patient demographic information, encounter data, lab results, radiology transcription reports and medication and allergy lists. The functionality of EKCITA s HIE is growing on a daily basis as lessons are learned to improve its process. 8 Tolven Tolven s open source, enterprise software allows for healthcare information to be captured, secured, stored and shared among all relevant stakeholders (e.g., patients, clinicians, providers, insurers and researchers). The solution is internationalized to support multiple languages and deployment across different time zones. Implementations include supporting health information exchanges functions, electronic medical record (EMR) applications, PHR data exchange with clinicians and with HIE organizations, and clinical research application across multi-center HIE collaborative efforts. The solution works with any number of underlying technologies (e.g., database, application server and Internet browser), and is designed for deployment as a Software as a Service (SaaS) offering, avoiding the cost, complexity and maintenance issues associated with deploying software at a customer location. Also, the solution software supports a unique way of defining clinical content by leveraging industry informatics standards, semantic technologies and community involvement, which is believed to provide an approach to comprehensively addressing interoperability issues that currently plague the industry. Deployment can be either independent to meet a specific functional requirement, or as a wrapper around existing healthcare technologies to provide additional application capabilities while protecting investments in existing technologies. 9 Examples of this open source solution include the following: Bravura Systems: Physician office EMR: Bravura s client for the Tolven implementation is Novia CareClinics. 10 Novia hired Bravura Systems 11 in February, 2008, to perform due diligence on commercially available EMR systems. In May, 2008, Bravura decided to implement Tolven and extend it with LifeRay for a portal platform for extended applications such as scheduling/appointments, drug inventory management, reports, etc. and Pentaho for business intelligence and analytics. In January, 2009, the platform went in production and now supports 22 primary care clinics in four Midwestern states. NoviaCare Clinics exchange information with commercial laboratory systems as well as with the Indiana HIE. 12 NoviaCare Clinics is planning on offering information exchange with their patients through a PHR extension HIMSS 8

9 TRANSCEND (Bridge between clinical care and clinical research): The TRANSCEND (TRANslational informatics System to Coordinate Emerging biomarkers, Novel agents, and clinical Data) project, funded by the NCI, 13 grew out of two efforts centered at the University of California San Francisco Breast Cancer Center of Excellence (UCSF BCCE), headed by Laura Esserman, MD. The UCSF BCCE contracted Tolven to develop a clinical data input system, which became known as ecarenet that would encompass the documentation needs of surgeons, oncologists, radiologists and pathologists who are collaborating on the care of patients with breast cancer. During this work, the TRANSCEND project, itself an outgrowth of the I SPY Trial, 14 was formulated. The goal of TRANSCEND is to leverage the data created in ecarenet system to auto-populate (when possible) electronic CRFs for submission to the NCI. In addition, the project creates a pool of appropriately de-identified data for use by authorized research personnel in the 18 medical centers that collaborate in the I SPY 2 Trial. TRANSCEND was designed to be part of cagrid and operates to exchange information with catissue, caintegrator, and a subject randomization center at MD Anderson. Live use of TRANSCEND began in May 2010, and represents an HIE project exchanging de-identified clinical information between collaborating medical centers and the NCI. The flexibility of this specific application development framework, the continued adherence to information modeling standards such as HL7 RIM, and to vocabulary standards such as SNOMED CT, and the availability of technical support services have been critical for the overall success of this project. Rijnmondnet: Patient control of information flow through the PHR: The legal rules concerning the protection of health data in the Netherlands are laid down in detail in the Data Protection Act, which covers all personal information held on computer or otherwise systematically stored, and in the Medical Contract Act. That act provides for specific rules on the healthcare sector, in addition to the protection offered by the Data Protection Act. The patient's right to privacy is furthermore supported by the Dutch Constitution (Article 10) and several international treaties, for instance, the European Convention for the Protection of Human Rights and Fundamental Freedoms (Article 8). 15 The partner for this major health information exchange project in the Netherlands is Stichting Rijnmond. 16 They have configured the existing technical platform and application framework with help from the vendor s engineering and clinical informatics Dute JCJ: Protection of personal health information in the Netherlands: getting the balance right? Quality in Health Care. 1995;4: HIMSS 9

10 team to develop an HIE that adheres to Dutch standards for privacy. In this project, 17 the patient controls the distribution of his/her personal healthcare information outside of the organization that has created it. The project leverages a unique account functionality to create patient-controlled PHRs that can accumulate all of the clinical information that constitutes a lifetime EHR. Information, in the form of CDA r2 documents, is pushed from clinical care organizations through a health record bank to patient-controlled accounts. Authenticated copies may be sent from these accounts, by explicit patient action, to other clinical care providers or any other entities (e.g., clinical research data banks) that the patient wishes. CDA documents accepted by the patient into a PHR are both stored in their native form and processed by rules so that granular information (the payload ) can be inserted into standard relational database rows and columns for graphical display and to facilitate running clinical rules.this is believed to be the first successful implementation of a system that adheres to the principles formulated by the Health Record Banking Alliance. 18 Singapore National Healthcare Group (NHG): 19 Creating a National CDR: The selection of British Telecom (BT) 20 as prime contractor for the NHG Central Clinical Data Repository leveraged open source technology for the National Clinical Data Repository project. The open source solution approach was integrated with vocabulary standards and benchmarking at a national level. The open source solution supports movement to semantic interoperability through cross vocabulary mapping and binding of vocabulary to the HL7RIM. Patients Know Best: PHRs for HIE: Patients Know Best 21 is developing a PHR as a medium for HIE with care provider organizations in the United Kingdom. Follow-Up Questions The task force developed a series of follow-up questions that were based on work done in previous years. These questions were sent to the HIE organizations that had been identified by the open source development groups. Despite the availability and willingness of task force members to follow up with the HIE organizations, it was very difficult to get the information requested. In retrospect, the questionnaire was not equally relevant to the software solutions identified. Open source applications varied widely in terms of complexity and functionality. Since we did not obtain sufficient feedback to attempt statistical analysis, the following overview is a notional narrative only that is meant to convey some flavor of the experiences of the HIE organizations and 18 available for review at HIMSS 10

11 1. Did you choose the product because the standards that it incorporated were thought to be valuable for HIE? Every HIE that responded to this question said that incorporation of and use of standards was important. 2. What open standards (messaging, vocabulary, information model) does the product incorporate? Named standards included HL7 messaging, CCR, SNOMED, LOINC, IHE (including XDS document exchange), NHIN Query/Response identity messaging standard. 3. Can you tell us what open source components are used in the construction of the product? Named components included, PostgreSQL, LDAP, JBoss, Linux, J2EE, Struts, Spring, Apache Access, Open PIX/PDQ, OpenXDS, OpenATNA, (MOSS OpenExchange), Open LDAP, GlassFish, and Liferay. 4. Does the product require any proprietary software to work effectively? Nearly all responding HIE organizations either incorporated a proprietary component in the infrastructure or developed proprietary components to fulfill use requirements. 5. Has the product been developed in an open source environment from the outset? All responding HIE organizations thought that the product they were using had been developed in an open source environment from the outset. One HIE organization said that the main support organization for the product being used was now engaged in proprietary code development to gain additional revenue for licensing. 6. Does the product continue to evidence active engagement with the open source community? With a single exception, the responding HIE organizations thought that there was continuing active engagement. The exception (see answer to #5 above) made the following comment about the development organization: Their focus recently has been on their proprietary portlet. They do continue to update the OS products; however, it has been slow progress. 7. Does your organization add code to the product? It can be uncommon for an HIE organization to add code; it was more common for a commercial support organization to add code. a. If so, who can commit code to the main product development line? Only one organization said that someone outside of the development organization could actually commit code proposed for addition to the core. 8. Does the product have a full-time development organization? 2010 HIMSS 11

12 All responding HIE organizations said that their open source product had the attention of a fulltime development organization. 9. Is there an adequate menu of whitepapers and other documentation for the product? Only one responding HIE organization reported that there were enough white papers, but they also said that they were not reading the white papers because they assigned that responsibility to an outside support organization. Others reported that there were not enough. 10. Was the product easily installed? One half of the responding HIE organizations reported that the product in question was easily installed. Of interest is the fact that answers to this question varied for the same product. a. How long did the implementation take? Answers varied from 3 hours to 20 months. Even within the same product, there was substantial variability. Clearly we needed to know more about what product was being used and what degree of customization and/or configuration was required by the HIE organization. 11. Is the product supported by a full-time support organization? All HIE organizations said that the product was supported by a full-time support organization. 12. Does the product meet your organization s criteria for functionality, security and scaling? The answer was uniformly yes with a particular emphasis on security. 13. Will the product meet the core needs of all of your HIE organization stakeholders? Only one HIE organization said that the product being used would not meet their needs; the remainder said that the selected product would meet their needs. 14. Can the product be extended to meet the future needs of your organization? All responding organizations said yes. 15. Do you believe that your choice of an open source component approach has saved you money? All responding organizations said yes. 16. How much has your organization spent on the project? 2010 HIMSS 12

13 We did not obtain useful information in this area. The differences across solutions were too daunting, and some organizations refused to respond to this question although we were led to believe that professional services accounted for most of the costs. 17. Do you have any advice or observations about your specific implementation of open source software in general, and advice for other users who are preparing to use this product? The following comments were made by various HIE organizations: If you go this route it s a conscious choice so need to have faith in the vendor, but need to sweat the details (as you should with any vendor), but understand that they may take longer because it is more of a custom implementation. Pay attention to the OS vendor s business model, because that is also important you need them to remain in business hopefully their sustainability model will be solid. In addition, get to know and partner with other product users. It is irresponsible to store patient data without using open source software - the encryption must be transparent. Open Source is usable by organizations with in house development resources. Make sure whoever the OS vendor is has an active vibrant OS community with lots of activity and lots of adopting users, and has an active professional services organization with solid evidence of ongoing development. 18. Do you have any final closing thoughts about your experience in using open source healthcare products and whether or not, given the opportunity to revisit your decision to use open source, if you would change anything? Summary All responding HIE organizations said that they would stick with their decision to use the selected open source product. Some HIE organizations are using open source components that have been developed specifically for healthcare information technology. The components being used have very different functionality but all play pivotal roles in the various HIE organizations that we contacted. In general, the HIE organizations we surveyed: Said that standards were important in making their choice. Noted that open source components could be used in an environment that also used proprietary components. Believed that the product being used had both an active support organization and active community engagement. Thought that the product being used was subject to well-regulated governance although the HIE organization did not contribute code to the product. Thought that their decision to use open source software was cost effective. Expressed confidence that the open source product met the core needs of their stakeholders. Were satisfied with making the decision to use particular open source components. Encouraged other HIE groups to actively consider using open source components HIMSS 13

14 Requested open source development organizations to do much more in creating documentation (development guides, user guides, white papers, etc.) HIMSS 14

15 Acknowledgments Special acknowledgment and appreciation is extended to Tom Jones, Chair of the HIMSS HIE Open Source Task Force, for his time, leadership and content contribution in the development of this white paper. Members of the HIMSS HIE Open Source Task Force, who spearheaded the development of this white paper, include: Eric Freed IT Manager New Rochelle Radiology Tim Elwell Vice President Misys Healthcare Systems Tom Jones, MD (Chair) Chief Medical Officer Tolven Will Ross Project Manager Mendocino Informatics Wanda Gamble Business Development Director SRA International, Global Health Sector Kate Johnson, MHA, MS Team Lead, Management Systems, Information Technology H. Lee Moffitt Cancer Center Dave Minch HIPAA/HIE Project Manager John Muir Health Pam Matthews, CPHIMSS, FHIMSS Senior Director, Regional Affairs HIMSS Staff Support Holly Gaebel Coordinator, Regional Affairs HIMSS Staff Support 2010 HIMSS 15