© 2013 The MITRE Corporation. All rights Reserved.

Open Health Tools UI Platform

Approved for Public Release: XXXXX. Distribution Unlimited.

© 2013 The MITRE Corporation. All rights Reserved.

Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned

© 2013 The MITRE Corporation. All rights Reserved.

Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned

© 2013 The MITRE Corporation. All rights Reserved.

The OHT UI Team

Noah PedriniSoftware Engineer, PIIM

pedrinin@newschool.edu

Marine KoshkakaryanWeb Application Developer,

PIIM

koshkakm@newschool.edu

Ken RubinHealth Enterprise Architect,

Hewlett Packard

ken.rubin@hp.com

Yalini SenathirajahAssistant Professor,

Department of Medical InformaticsSUNY Downstate Medical Center

yalini@downstate.edu

Gail Hamilton

Software Consultant , MITRE

ghamilton@mitre.org

Mary GreerSoftware Engineer, MITRE

mgreer@mitre.org

Erik Sax

Software Engineer, MITRE

esax@mitre.org

Damian BenderskyInteractive Web Developer,

PIIM

bendersd@newschool.edu

© 2013 The MITRE Corporation. All rights Reserved.

Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned

© 2013 The MITRE Corporation. All rights Reserved.

UI Problem We are Trying to Solve:Allowing Clinician Access to Full Patient Health Record

EHR(s)

EmailFax

Scanned Records

Phone

Handhelds

Patient

EHR

EHR

• Siloed Health Data• Multiple data sources• ‘One size fits all’ User

Interface (UI)• EHR UIs

• lack of usability in non-standard EHR user interface design1

• Lack of Interoperability between• EHRs

• Components of Health IT stacks

• Cost to organizations Health IT Budget• Significant % of annual IT

budgets2

2. Open Health Tools Documentation

1. John Halamaka : http://geekdoctor.blogspot.com/2012/10/a-time-

for-boundless-energy-and-optimism.html?m=1

© 2013 The MITRE Corporation. All rights Reserved.

Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned

© 2013 The MITRE Corporation. All rights Reserved.

8

Open Health Tools UI Platform

• Enable an adaptable Health IT Infrastructure,

through providing an adaptable user interface

that is flexible enough to meet the needs of a

range of Health IT users as part of a suite of

Open Health Tools

• Provide an Open Source pilot of end to end

capability that demonstrates how to lower the

barriers to innovation

© 2013 The MITRE Corporation. All rights Reserved.

9

© 2013 The MITRE Corporation. All rights Reserved.

Open Health Tools UI Platform Solution

• An adaptable framework that enables a user to

build a personal view of a patient record, using a

palette of widgets, each of which is separable and

platform independent allowing for flexibility and

system evolution through substitutability.

© 2013 The MITRE Corporation. All rights Reserved.

Palette Based User Interface

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Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned

© 2013 The MITRE Corporation. All rights Reserved.

13

Planned Approach for OHT UI Platform

• Identify through OHT Meetings likely

participants

• Expectations that this would be volunteer

activity

• Set up standing weekly meeting

• Have frequent MITRE-led code-a-thon sessions

where majority of work would take place

• Develop solution to a OHT UI developed use

case

• Use hingX as a collaboration tool

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14

Key Challenges

• Geographically dispersed participants

• Volunteer activity

• Competing schedules and priorities

• MITRE: Funding change -> reduced resources

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15

What Happened?

• Had Weekly meetings

• False starts

• Tried to accommodate too many ideas

• Help of Ken Rubin

• Defined key principles of platform

• Gave everyone a common understanding of UI Platform goals

• Started building out some use cases

• Held a 2 day code-a-thon at MITRE

• Some interests were not aligned

• Lost some participants

© 2013 The MITRE Corporation. All rights Reserved.

16

OHT UI Approach

• Bring together interested parties through OHT to tackle

aspects of the UI problem that aligned with their self

interests

• MITRE team: Transition work, and ideas and platform

outside of MITRE

• Parson’s Institute : Move HealthBoard from Flex and

have back end infrastructure, transition design ideas

• Yalini Senathirajah: Bring evidence based research to

this approach, and bring this approach to a wider

audience.

• All: Finding collaborations to overcome resistance to new

UI concepts and design ideas

© 2013 The MITRE Corporation. All rights Reserved.

17

OHT UI Platform Principles

• Design to the 80%

• DO no(or minimal) harm in customization

• Integrated, adaptable and consistent across modality/

platform

• Portability of access. Has to across multiple data

repositories/ EHRs / products

• Palette of reusable, easily extensible and complementary

components

© 2013 The MITRE Corporation. All rights Reserved.

Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned

© 2013 The MITRE Corporation. All rights Reserved.

Two Complimentary Projects

• Shared goal of innovating presentation of medical

information

• medCafe - “One size fits all EHRs do not ‘fit all’; I believe in

composable interfaces that empower clinicians to lay out

information in way that suits them best!”

• HealthBoard - “Medical data can be presented better;

integrating strong information design principles,

visualization makes it easier to understand”

• Similarities: collapsible widgets, tabs, themes; both

open-source, available on OSEHRA and GitHub

© 2013 The MITRE Corporation. All rights Reserved.

HealthBoard

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HealthBoard

• Developed by Parson’s Institute of Information Mapping (PIIM), funded by TATRC, with design input from Walter Reed

• Presentation layer for “patient centered medical home”

• Goal: bridge geographical barriers to medical care via web-based system, increasing interactions and decreasing costs

• Project consists of patient and provider portal prototypes (Flash/Flex), as well as design assets

• Adds non-traditional components like messaging system, chat, nutrition manager, custom “trackers” (i.e. smoking cessation)

• Geared towards military personnel, but could easily be applied to broader healthcare community

© 2013 The MITRE Corporation. All rights Reserved.

medCafe

© 2013 The MITRE Corporation. All rights Reserved.

medCafe

• Developed by MITRE, framework for composable EHR system

• Provider-focused, allows users to build, modify, customize patient record to their liking

• Features• Customizable client (widgets) and server

(repositories)• Composable interface, customizations persist across

session

• Support for multiple data repositories (Vista, local db)

• Demonstrative of how customizability has potential to optimize system reach and adoption

• Built using Java, jQuery, jQuery UI, OVID (Java OpenVista access)

© 2013 The MITRE Corporation. All rights Reserved.

Though they felt complete, they knew there was

more...

Main Focus UX and design(front-end heavy)

System architecture (back-end heavy)

Data/PersistenceAll data static

Changes don’t persist across sessions

All data dynamicChanges to data and UI

configuration persist

Next steps Hook-up to real dataMake mobile version

Separate into client and server

Explore potential as service

© 2013 The MITRE Corporation. All rights Reserved.

• medCafe Team• Began developing query layer for reading/writing FHIR

data stored in MongoDB (built w/ Node.js and Backbone.js)

• FHIR - Emerging standard for representing healthcare concepts in consistent format and allowing access through RESTful interface

• HealthBoard Team• Familiarized ourselves with medCafe architecture

• Continued building out initial vitals module

• Updated prototype to load and parse test observation data (vitals) from sample FHIR server

Two Complimentary Projects, Two Days, 6 People

© 2013 The MITRE Corporation. All rights Reserved.

• medCafe• Build out FHIR server, separate into distinct project• Add HTTP response codes, sweep for FHIR compliance,

validation

• HealthBoard Mobile• Integrate with medCafe’s FHIR server• Integrate medCafe, Open Health Tools UI Group principles

• Widgetize views, make composable/customizable

• Make responsive, work on variety of devices

• Parson’s team plans on contributing back to medCafe

Two Complimentary Projects. Two Days, 6 People

© 2013 The MITRE Corporation. All rights Reserved.

Epilogue: Since our Meeting

• medCafe: Completed FHIR server support for reading/writing observations (vitals), patients and providers

• HBMobile• Reading/writing all in-app vitals (weight, bp, temp,

respiratory rate, heart rate) to/from FHIR server

• User login, signup and profile editing up and running

• AngularJS javascript framework integrated

• Working on medications (including FHIR server support)

• Wrote Python script to convert drugs in RxNorm db to FHIR-formatted flat file

© 2013 The MITRE Corporation. All rights Reserved.

Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned

© 2013 The MITRE Corporation. All rights Reserved.

RESTful ServicesUI Presentation

Enable Innovation

hData/ GreenCDA

VistA

HL7

© 2013 The MITRE Corporation. All rights Reserved.

Observations

MedicationsCareplanConditions

Patient

Procedures

JSON

RESTful Services

Provide Consistent Access to Data Pieces

http://localhost:8888/observation/search?subject=F001

VistA

hData/ GreenCDA

HL7

© 2013 The MITRE Corporation. All rights Reserved.

HTML AJAX

RESTful Services

Web Server

UI Platform: Enable Innovation

hData/ GreenCDA

HL7

© 2013 The MITRE Corporation. All rights Reserved.

Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned

© 2013 The MITRE Corporation. All rights Reserved.

User-composable EHRs – Research and Findings

Yalini Senathirajah, PhDSUNY Downstate Medical Centeryalini@downstate.edu

© 2013 The MITRE Corporation. All rights Reserved.

History

• Developed user-composable EHR (‘MedWISE’) in ~2007, as part of PhD work at Columbia University

• Real functional system built into New York Presbyterian Hospital existing system

• Tested with real patient cases and clinicians

• residents, attendings, physician assistants• Selected results:

• All users able to learn in a short training period and use system for real case review

• Most (>80%) of users enthusiastic, rated favourably on ease of use, usefulness

© 2013 The MITRE Corporation. All rights Reserved.

Findings

• Reduced repetitious navigation (70% decrease) suggests time savings

• Support for reduced cognitive load; reduced need to integrate information in mind

• Some users take advantage of new opportunities to improve system, adapt it to specific needs, fix existing problems

• Concerns about accuracy, possible errors;

• small studies show no difference in diagnostic accuracy from conventional system

• Philosophical issues regarding errors;

• See: Essential Questions: Accuracy, errors and user perceptions in a drag/drop user-composable Electronic Health Record. Senathirajah Y, Kaufman D, Bakken S. Stud Health Technol Inform. 2013;194:181-7. http://www.ncbi.nlm.nih.gov/pubmed/23941953

© 2013 The MITRE Corporation. All rights Reserved.

Agenda

• The Team• The Problem• The Solution• The Approach • The Projects• The Architecture• Research Findings• Lesson’s Learned• Next Steps

© 2013 The MITRE Corporation. All rights Reserved.

37

Lesson Learned

• Adaptable to changing circumstances• Move over new standard quicker

• Accept that will lose people / groups along the way• There will be attrition of groups

• More face to face meetings and have initial face to face meeting much earlier

• Collaboration• hingX was not well used: primarily as artifact repository• Need to work on how to use collaboration tools better

• Workshop• Have sooner or at least 2• Better preparation: transition of ideas/ technology before

the workshop• Better evaluation of two architectures prior to workshop

© 2013 The MITRE Corporation. All rights Reserved.

38

Next Steps

• FHIR Integration• Reconcile John Nolen work on FHIRMeteor with NodeOnFHIR• Reconcile with efforts underway at MITRE and OSEHRA

• S/W Integration effort to move medCafe to FHIR• Fully transition to Parsons Institute

• Licensing on FHIR • Apache 2

• Need more collaborators willing to work with us• At an exciting point, with FHIR integration – we don’t want

to see the work end now!

© 2013 The MITRE Corporation. All rights Reserved.

39

Open Health Tools UI Platform:How Did We Do?

• Enable an adaptable Health IT Infrastructure, through

providing an adaptable user interface that is flexible

enough to meet the needs of a range of Health IT users

as part of a suite of Open Health Tools

• Provide an Open Source pilot of end to end capability

that demonstrates how to lower the barriers to

innovation

© 2013 The MITRE Corporation. All rights Reserved.

Thank You!

Noah PedriniSoftware Engineer, PIIM

pedrinin@newschool.edu

Marine KoshkakaryanWeb Application Developer,

PIIM

koshkakm@newschool.edu

Yalini SenathirajahAssistant Professor,

Department of Medical InformaticsSUNY Downstate Medical Center

yalini@downstate.edu

Gail Hamilton

Software Consultant , MITRE

ghamilton@mitre.org

Mary GreerSoftware Engineer, MITRE

mgreer@mitre.org

Erik Sax

Software Engineer, MITRE

esax@mitre.org

Damian BenderskyInteractive Web Developer,

PIIM

bendersd@newschool.edu

Ken RubinHealth Enterprise Architect,

Hewlett Packard

ken.rubin@hp.com

© 2013 The MITRE Corporation. All rights Reserved.

Questions?For more information

.• medCafe

• Contact : Gail Hamilton : ghamilton@mitre.org• http://medcafe.org• Live demo• http://medcafe.org/medcafe• Login: guest1, Password: guest1

• HealthBoard• http://piim.newschool.edu/healthboard/

• Source code (GIT)• https://github.com/medcafe/medCafe

• OHT UI Platform Collaboration Site• http://hingx.org/GroupManagement/ViewProfile?groupId=46

© 2013 The MITRE Corporation. All rights Reserved.

42

Questions

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43

Background

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Palette of reusable, easily extensible and complementary components

• Many small, independent pieces that each run

‘standalone’

• Easy to deploy and add new capability through

adding new widgets

• User decides which components to use

depending upon patient

• Allows use of ‘Best of Breed’ components

• Replacing/ upgrading components is easy

© 2013 The MITRE Corporation. All rights Reserved.

Integrated, adaptable and consistent across modality/ platform

• Javascript framework on top of HL7 Standard

• Enables widgets to run independent of Platform

• Consistent display

• Laptop / Desktop Browser

• Mobile Device

• Tablet Device

• Lowering Barriers to Innovation

• UI developers only need to have knowledge of Javascript

• Add new widgets through simple Javascript API

© 2013 The MITRE Corporation. All rights Reserved.

46

Portability of accessHas to across multiple data repositories/ EHRs / products

• Normalize data to HL7 Standard

• hData

• Currently moving to FHIR

• UI developers only worry about one data format

• Less time and resources on taking care of underlying data

interoperability issues

• More time can be spent on creating better ways to display

the information to enable better and safer patient care

© 2013 The MITRE Corporation. All rights Reserved.

User Defined Interface

• Use Pre configured Interfaces• Components/ Template

• Template: predefined set of components arranged optimally

• Default templates are provided to align with common use cases

• Create/ add new templates as desired

• User/Clinician Defined Views• Customize view for patients

• Align with patient use cases

• Per Patient Views• Some patients do not ‘fit the mold’

• Modify a view for a specific patient and save record view

• Displays saved view on re-engagement with Patient• Speeds re-engagement with a patient

Speed Patient Data Re-Acquisition