This episode features the second part of our interview with senior clinical advisor for interoperability at InterSystems, Russ Leftwich. Check out Episode 8 for the first half! In this portion of the interview, Adam and Russ carry the healthcare interoperability discussion into more specifics about InterSystems technologies and FHIR applications.
After the interview, we're also welcoming Jenny Ames back to the podcast to tell us about the upcoming FHIR Dev Days! Check out https://gettingstartedhealth.intersystems.com and https://www.devdays.com/us/event-info/ for more details.
For more information about Data Points, visit https://datapoints.intersystems.com
Derek Robinson 00:00:02 Welcome to Data Points, a podcast by InterSystems Learning Services. Make sure to subscribe to the podcast on your favorite podcast. App. Links can be found at datapoints.intersystems.com. I'm Derek Robinson.
Adam Coppola 00:00:16 And I'm Adam Coppola.
Derek Robinson 00:00:18 And today we feature part two of our interview with Russ Leftwich, Senior Clinical Advisor for Interoperability here at InterSystems.
Derek Robinson 00:00:39 Welcome to Episode Nine of Data Points by InterSystems Learning Services. We're going to go straight into part two of our interview with Russ Leftwich. This half of the interview features just Adam and Russ. To listen to the first half of the interview, you can check out the most recent episode before this one, Episode Eight. After part two of the interview, we'll come back and chat with Adam about some of the key takeaways as well as welcome Jenny Ames back to the podcast to discuss the upcoming FHIR Dev Days. Without further ado, part two with Russ Leftwich.
Adam Coppola 00:01:14 So as of 2020, InterSystems products support FHIR®. So that's InterSystems IRIS for Health™, which is meant to be a platform for app development, and HealthShare®, which is meant to be an interoperability engine for healthcare facilities. Can you talk to us a little bit about what some of the applications using FHIR might look like?
Russ Leftwich 00:01:35 So one of the principle advantages of FHIR is that you can access just small data sets, small pieces of data, because most of the time in healthcare, that's all you really need for the care of a patient or for that matter, that's all a patient needs at any one time is just what medicines are being prescribed right now. What are the lab results, the cholesterol levels for the past year? You don't want to know everything about a patient very often. You just want to know some particular piece of data, and that's what FHIR is particularly useful for, because of this idea of resources that are logical, but discreet data concepts. So a medication or a patient or a lab observation, those you can express in FHIR, and you can query for just those pieces of data with FHIR. That makes the possibility of having applications, and particularly mobile portable applications, a whole new paradigm with FHIR that wasn't possible, previously — wasn't possible 10 years ago, because you can just create an application around the small set of data that is of interest in a particular use case, either to a clinician, to a patient, or to somebody doing research even. Our technology in InterSystems goes a large step further by including the ability to transform data that's in existing legacy standards into FHIR resources. So we can take in data from a healthcare system, data that is in HL7® Version 2 message streams, which I mentioned earlier, that is the most used healthcare data standard in the world, still is the way most data is represented, in CDA documents, clinical document architecture, which is another HL7 standard. Data that's expressed in those clinical CDA documents can be consumed by InterSystems technology and transformed into FHIR resources. All those FHIR resources can be stored together in a repository of FHIR resources that is a part of our technology, and then can be queried by REST queries, to get just the data that an application needs for a particular purpose. That's really a very powerful quantum leap, I would say, in what we can do with healthcare data. InterSystems technology is also capable of dealing with all four of the current released published versions of FHIR. So we can go from legacy standards to FHIR. We can go back to the legacy standards because some systems can still only consume data in those formats. And we can deal with the different versions of FHIR that are currently implemented outside of InterSystems in the rest of the world.
Adam Coppola 00:05:26 So we've gotten a little bit into the technical details of how FHIR is implemented in InterSystems products and beyond. I want to take a quick step back and ask the question of: how will these changing standards impact patients and clinicians and administrators?
Russ Leftwich 00:05:46 So they have already started to impact clinicians, and to some extent, administrators, because it's fairly easy to create a FHIR application that works within your organization and lets you visualize the data that you already have. One of the big challenges for healthcare organizations is that it's not easy with the standard electronic health records of today to access the data that's in those systems, other than for a human to view it on a screen that shows an electronic version of a patient chart — paper chart — from the past. When you want to get to the data, only specific pieces of data, the FHIR applications that have been created allow clinicians to do that very readily, and provide a much more useful view of the data in a particular clinician specialist's workflow than the electronic health record would provide. Customizing an electronic health record for a particular specialty over the past couple of decades has been prohibitively expensive. So people had to sort of live with what they had, and it wasn't ideal for clinical workflows, especially as those workloads got more complicated and the data got more complicated. FHIR has already started to solve that problem. The same for patients, and we're just on the very leading edge of this, that patients are able to access their data in an electronic records system using a mobile app, and the government has recently produced new regulations that say that healthcare organizations absolutely must permit patients to access their own data with those kinds of applications. And the ideal technology to do that is FHIR. And the government has actually said in their regulations that were published just within the past two months that FHIR APIs are the required mechanism for patients to access their data, or to authorize an app to access their data on a clinician or some other entity's behalf. About two years ago, Apple Health Kit created the ability for patients to download a limited set of data to their iPhone as FHIR resources, with not really their entire record, as some of the articles that were published suggested; it was actually just a small but important part of their data, and it could only be downloaded to their iPhone where iOS apps could then access it. But that was the beginning. There are now hundreds of hospitals in the U.S. that offer that capability to patients with iPhones. But as I say, this is just the leading edge of it. Over the next two to three years, I think it will be commonplace for people that have apps on their mobile devices that access their own data, or share it with someone that they have authorized to consume their data, which might be another clinician, might be some analytics platform; it might be a researcher who's researching some condition that this patient has.
Adam Coppola 00:09:46 You've given us a lot to be excited about moving forward. Is there anything else that you want to add to what you've said?
Russ Leftwich 00:09:53 Yeah, let me mention one other way that FHIR is already being used and leverages that ability that I mentioned to just pick out particular pieces of data that are of interest. One of the already useful innovations with FHIR is around clinical decision support. Clinical decision support is increasingly important as the amount of data and the complexity of data increases, and the human mind just can't process all of that data in many instances on its own. Decision support is not new; it's existed for decades. Even before computers, there was decision support in the form of charts and manuals that doctors carried in their pockets to look things up. And then when electronic health records evolved, decision support became part of those electronic health record systems. But the problem was, the decision support was embedded in each implementation of each electronic health record. If some new information, some new guideline came along, it took a long time to update the decision support in all of those different systems. And to some extent, they were each customized for the organization they were in. Now, we come to the day, the era of FHIR, and decision support services can be web services outside the electronic record. So many different electronic records might use one decision support service that is specialized for a particular area of clinical care. And that decision support service can get the data about a particular patient that is needed. We call that the patient context. How old is this patient? What is their laboratory value for something, what is their gender, and so forth? What are their diagnoses? The decision support service needs to know some set of data about this individual to offer a recommendation. Now we have FHIR as a way to export that patient context data out of the electronic record in a consistent format using, as I've mentioned, a data model that all of the systems share, so that one decision support service is getting its context data from many different electronic health records in the same exact format, being FHIR. And then it can pass back a recommendation once again using FHIR as a standardized way to encode that recommendation, if you will, back to the electronic health record system where the patient's record exists.
Adam Coppola 00:13:11 I think this circles back to our earlier conversation about the range of standards in healthcare, because we started talking about terminology bindings, where you're coding specific pieces of data for descriptions. We've talked about FHIR, which is a data standard for resources. And now we're talking about CDS hooks, which is an entirely different type of standard. It's a support standard; it provides data, but it also consumes data while it's working.
Russ Leftwich 00:13:41 So yeah, CDS hooks is a part of the FHIR architecture that has evolved over the last three or four years. And CDS hooks is the part of the decision support that sits in the electronic record system and identifies events that are triggers for a decision support service, and knows what data is needed by that decision support service. So it collects that data from the EHR and passes it to the decision support service outside that EHR as FHIR data. So CDS hooks is the part of the of the decision support that sits in the EHR and runs in the background, if you will, looking for events that would trigger some particular piece of decisions for a medication order, and there is a concern about that particular medication being given to patients who have decreased kidney function. So the CDS hook checks to see if this individual has decreased kidney function, and invokes the decision support if they do. That's sort of the basic concept of CDS hooks, as a consistent way to link out to outside decision support using FHIR.
Adam Coppola 00:15:15. OK. It's been great to talk to you, and we will talk to you soon again.
Russ Leftwich 00:15:21 Yeah. Great. Thanks for the opportunity to talk about data standards. If I stop people on the street and say, I want to talk about data standards, they look at me kind of weird. (laughs)
Derek Robinson 00:15:37 All right. So thanks again to Russ and Adam for doing part two of that interview, which had a lot of interesting stuff. Adam, what were some of your key takeaways from part two specifically, but really the whole thing, if you have any major insights, takeaways, things that you found really interesting?
Adam Coppola 00:15:50 Thanks, Derek. Yeah. I think Russ did a great job of summarizing the new ONC and CMS final rules on interoperability. I think those are going to be pretty big moving forward. My understanding is that we won't see too many new requirements for providers or payers apart from the information-blocking aspects and the new APIs that are required to be exposed. A lot of these rules have been designed so that contracts don't have to be renegotiated, and users don't have to worry too much about their data getting into new hands, except for the third-party apps, which they, the end users themselves, have to authorize. So InterSystems IRIS actually will be able to support providers, payers, and these third-party apps at all levels with user and role-based security and InterSystems IRIS, and support for all these different APIs.
Derek Robinson 00:16:40 Very cool. And I think it was good to see after part one where, which was a lot of conceptual, a lot of the history, a lot of the evolution of the technology, to fold into part two, which kind of talked about InterSystems technology specifically. And I think another thing for me that jumped out in part two was the connection of what the impact is on clinicians and doctors and medical staff, right? Because like I had mentioned in part one of the interview that I have I have friends and colleagues that I went to school with that are in that field, and they don't know anything about the standards and all the technology that is underneath some of these front end systems. So it was interesting to hear Russ's perspective on that and kind of flushing out, you know, what's really involved, and where the impact kind of ripples through to the actual users and the end users of these applications and medical facilities.
Adam Coppola 00:17:28 I agree. I think we're going to see some really creative uses for this in the future.
Derek Robinson 00:17:33 Cool. So we're also joined by Jenny Ames, who is the Manager of the Online Learning Content for Data Platforms. Jenny, you might remember, was on Episode One. Jenny, how's it going?
Jenny Ames 00:17:42 Yeah. Hi, Derek! It's going well. How are you?
Derek Robinson Good. So we wanted to bring Jenny in as well for the topic that Russ and Adam interviewed about in part two specifically, but really the whole thing. And I know Jenny, you could offer your thoughts on the interview with Russ, but we also have some other topics that we're going to bring you in as the expert to discuss, with some interesting things that are coming up for InterSystems.
Jenny Ames 00:18:05 Yeah. well, first of all, Russ is fantastic. He knows his stuff and it's so great to have him be able to be on this podcast, and share some of the things that he says, you know, are going on now, and foresees in the future. So Russ is great to work with. One of the other things that we've worked with Russ on lately is kind of preparing for FHIR Dev Days, that's coming up. And that's coming up June 15th to the 18th, and we're pulling together a bunch of resources to be able to support this, but it's actually remote this year, which is really exciting, 'cause I think there might be some opportunities for other people who might be new to FHIR or experts in FHIR. It really spans the board on people being able to be there. So I'm really excited about this event coming up.
Derek Robinson 00:18:51 Yeah. So with a lot of events that were probably previously planned to be in-person onsite events, another challenge, obviously to create a virtual event, but what are some of the you know, A, it might remove some barriers for some people that maybe wouldn't have gone to an onsite event or, or traveled or whatnot. What are some of the reasons that people should look into attending this event if they can, to really get the benefits of FHIR Dev Days?
Jenny Ames 00:19:16 Yeah. so there's lots of really great benefits. First of all, there's experts from a ton of different organizations that are coming to speak, people that have built applications on FHIR. They start from basic to some really cool applications of how they're using FHIR to really impact their facilities. We actually have someone from InterSystems who's going to be speaking, Patrick Jamieson, who's the Product Manager for InterSystems IRIS for Health. And he's doing a presentation on API management with FHIR, which is a really interesting topic. So that's on Thursday at 2:45, but I've seen him do some presentations in the past on this topic in particular, and I think it's going to be a good one.
Adam Coppola 00:19:56 Jenny, can attendees of Dev Days expect anything from Learning Services?
Jenny Ames 00:20:00 Yes, actually. So, well, we've partnered with a few different other groups, so it's not just Learning Services, but we've put together a page specifically for those interested in FHIR and InterSystems technology to get started. That is on our new Getting Started Health site. It basically shows a bunch of resources, exercises, use case videos, and ways to get started with using FHIR with, specifically, InterSystems IRIS for Health. But yeah, I'm excited for how it's coming together, and I'm hoping that it will help people who are new to our technology, and also for people who are just interested in using FHIR with our products that haven't done so before.
Derek Robinson 00:20:38 Nice. And we'll, we'll make sure we put the URL to that in the podcast description so you guys can check that out, which as Jenny said is eventually probably going to just be a generic kind of place for information on FHIR within InterSystems IRIS for Health. So good stuff. Thanks for the update, Jenny. And thank you, Adam, for interviewing Russ. So that's all we have for Episode Nine, and we'll see you next time on Data Points.
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