HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with permission.

CDS Hooks and SMART Web Messaging

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with permission.

November 20-22, Amsterdam | @HL7 @FirelyTeam | #fhirdevdays | www.devdays.com

Carl Anderson

Sr. Software Engineer, Microsoft

SMART Web Messaging https://github.com/smart-on-fhir/smart-web-messaging

Let's have a SMART refresher...

SMART Web Messaging:

• Allows pure "client" IO between the EHR and an app • App can inform the EHR that it's OK to "close me" • App can suggest navigation actions in the EHR • Allows pending EHR data to be read and modified

• Simple protocol • Based on HTML5 Web Messaging

The Goal

The goal of SWM is to enable

seamless integrations between the

EHR and a SMART app, saving

clinicians time and mental effort.

"The software should not get in my

way when I'm trying to practice

medicine."

- Josh Mandel

"Carl, you can make up (almost)

any quote you want and attribute it

to me."

- Josh Mandel

Scenario: Image Ordering in the Present Day

Order image #2

Radiology Dept

Clinic / Hospital

Scan patient

☢

Read image

Clinic / Hospital

Radiology Dept

Clinic / Hospital

Order image

Scan patient

☢☢☢

Read image

So, what's wrong with this system?

• Disconnect between ordering physician and radiologist, on several levels. • Indirect communication via EHR • Different sets of goals • Difficulty sharing context • Physical proximity (or lack

thereof)

• Mistakes are costly for patients, providers, and for facilities. ☢ € ⌚

• Possibly misaligned incentives. • Erring on the side of data

Is this Appropriate Use of the technology?

History Lesson

Sources https://youtu.be/QLENOcS65mE?t=167 https://www.ncbi.nlm.nih.gov/books/NBK82290/figure/background.f1/

PAMA - Protecting Access to Medicare Act (of 2014)

"If we in the United States could lower the prices and per-capita volumes of our CT scans, MRIs, and just the top 25 high-volume-high-price surgical procedures to those of the Netherlands, for example, we would see savings of about $425 per capita, or a total of $137 billion."

Ezekiel Emmanuel, March 2018 in JAMA

Source: https://nationaldecisionsupport.com/pama/

2020 2021

Program Timeline

Reprise: Consequences of Poor Diagnostic Orders

Order image #2

Radiology Dept

Clinic / Hospital

Scan patient

☢

Read image

Clinic / Hospital

Radiology Dept

Clinic / Hospital

Order image

Scan patient

☢☢☢

Read image

Prior Authorization Hell

Quick Recap

• Our users are IMPATIENT • Staying up-to-date on best-practices is HARD • Time, money, safety are at RISK • PAMA requires SOMETHING additional TO BE DONE in 2021

What is that SOMETHING?

Required Evidence of Guideline Consultation

Defined by

experts and researchers.

Implemented by

CDS software vendors.

Consulted by ordering

practitioners before orders are placed.

Appropriate

Use

Criteria

Provider Led

Entities

Qualified

CDS

Mechanisms Evidence of guideline

consultation is required for reimbursement.

External QCDSM

Ordering Clinician

1. Leaves EHR order entry 2. Signs in to QCDSM 3. Enters patient demographics 4. Selects indication 5. Selects service 6. Copies service code

7. Returns to EHR 8. Selects same service 9. Adds order note 10. Pastes service code 11. Signs order

Reprise: What's Good Here, Though?

Order image #2

Radiology Dept

Clinic / Hospital

Scan patient

☢

Read image

Clinic / Hospital

Radiology Dept

Clinic / Hospital

Order image

Scan patient

☢☢☢

Read image

Closing a Loop

Closing a Loop

Let's code!

Let's code!

https://github.com/microsoft-healthcare-madison/demo-auc-app

Goals

● Provide a simple example app that can be modified.

● Show milestones: ○ A regular, non-SMART app ○ Same app with SMART launch

○ Companion CDS Hooks ○ SMART Web Messaging app

● Provide companion helper materials (like codelab documents) ● Include exercises to teach concepts & skills.

Demo App - v1

A stand-alone demo AUC guideline consultation app.

Nothing fancy here.

https://github.com/microsoft-healthcare-madison/demo-auc-app/tree/v1.0

<form action="evaluate" method="POST"> <table>

<caption>Enter Patient Demographics</caption>

<tr>

<th><label for="gender">Gender</label></th>

<td>

<select name="gender" required> <option value="male">Male</option>

<option value="female">Female</option>

<option value="other">Other</option>

</select>

</td>

</tr>

<tr>

<th><label for="age">Age</label></th>

<td><input name="age" required></td> </tr>

Demo App v1 - Relevant Code - index.html <tr>

<th><label for="indication">Indication</label></th>

<td>

<input list="indications" name="indication" required> <datalist id="indications"> <option value="13213009">congenital heart disease</option>

<option value="25064002">headache</option>

<option value="279039007">lower back pain</option>

<option value="423341008">optic disc edema</option>

<option value="27355003">toothache</option>

</datalist>

</td>

</tr>

<tr>

<th><label for="procedure">Procedure</label></th>

<td>

<input list="procedures" name="procedure"> <datalist id="procedures"> <option value="75561">cardiac mri</option>

<option value="70450">ct scan - no contrast material</option>

<option value="71275">cta - with contrast material</option>

<option value="72133">lumbar spine ct scan</option>

<option value="70544">mra - head</option>

</datalist>

</td>

</tr>

</table>

<input type="submit">

</form>

app.post('/evaluate', function(request, response) { const reasons = cptReasons[request.body.procedure]; const indications = new Set([request.body.indication]); const rating = reasons.getRating(indications); response.status(200).send(rating).end(); }); const cptReasons = { ... [CPT.CARDIAC_MRI]: new Reasons([[SNOMED.CONGENITAL_HEART_DISEASE]], []), }; class Reasons { ... getRating(reasons) { if (this.appropriate.filter(s => Reasons.covers(s, reasons)).length) { return 'appropriate'; } if (this.notAppropriate.filter(s => Reasons.covers(s, reasons)).length) { return 'not-appropriate'; } return 'no-guidelines-apply'; } }

Demo App v1 - Relevant Code - server logic

Demo App - v2

Goal: The same app as before, but now capable of a SMART launch. https://github.com/microsoft-healthcare-madison/demo-auc-app/tree/v2.0

Objectives:

● Age and Gender fields will come from the 'current' patient selected in the EHR.

● No more login screen! Current EHR provider will be used. ● User now only selects Indication and Procedure in the form. ● Otherwise the same behavior.

Demo App - v2 - SMART App Launcher

http://launch.smarthealthit.org/

Launch Type

Patient

Provider

App Launch URL

Demo App - v2 - SMART Launch Endpoint

https://www.npmjs.com/package/fhirclient

$ npm install fhirclient

New endpoint: launch.html <html>

<head> <script src="./node_modules/fhirclient/build/fhir-client.js"></script><script> FHIR.oauth2.authorize({ client_id: "demo_auc_guideline_consultation_app",

scope: "launch patient/*.read openid profile" });

</script>

</head><body>Loading...</body>

</html>

Demo App - v2 - SMART App Launcher

Demo App - v2 - Apply Context to the Form

<script src="node_modules/fhirclient/build/fhir-client.js"></script> <script> async function getContext(client) { return { patient: await client.patient.read(), user: await client.user.read(), }; } function populateForm(context) { const patient = context.patient; const then = new Date(patient.birthDate), now = new Date(); const msPerYear = 365.25 * 24 * 60 * 60 * 1000; const age = (now.getTime() - then.getTime()) / msPerYear; document.getElementById('provider').value = context.user.id; document.getElementById('age').value = Math.round(age); document.getElementById(patient.gender).setAttribute('selected', 1); } if (typeof FHIR !== 'undefined') { FHIR.oauth2.ready() .then(getContext) .then(populateForm) .catch(console.error); } </script>

Demo App - v3

Goal: CDS Hook service to launch the SMART app when needed https://github.com/microsoft-healthcare-madison/demo-auc-app/tree/v3.0

Objectives:

● When an order or diagnosis is selected, the user sees our card ● Cards are appropriate and informative ● Clicking a card link launches the app ● Launched app has all fields pre-populated in the form

● App can update the EHR ● Closing the app returns us to the EHR

The New App Interface

The Cards We Want

CDS Hook Sandbox http://sandbox.cds-hooks.org/

cds-services.js

● discovery endpoint

○ hook: order-select

○ id: demo-auc-app

● hook handler endpoint

○ SMART launch card

○ Use AUC logic to rate selection

○ Serialize serviceRequest resource

into appContext

CDS Hook Discovery Endpoint

// Discovery endpoint.

app.get('/cds-services', function(request, response) { response.json({

services: [{ hook: 'order-select', title: 'Demo AUC Guidance Consultation - Click to Insert Evidence',

description: 'Click to insert evidence of AUC guidance consultation.',

id: 'demo-auc-app' }] })

});

CDS Hook Endpoint

app.post('/cds-services/demo-auc-app', function(req, res) { const draftOrder = req.body.context.draftOrders.entry[0]; const serviceRequest = draftOrder.resource; ... const cards = [{ indicator: card.indicator, detail: card.detail,

source: { label, url: sourceUrl, icon: card.icon }, links: [{ appContext: JSON.stringify({indications, orders, draftOrder}), label: 'Edit Order in Demo App', url: launchUrl,

type: 'smart' }], }]; res.json({ cards }); });

index.html

● FHIR.oauth.ready() => client

● read appContext from client

● use client to initialize form

● use AUC module to rate selections.

● provide new buttons

● targetWindow.postMessage

○ Send draftOrder back

○ Close window

index.html

<script src="node_modules/fhirclient/build/fhir-client.js"/> <script>

FHIR.oauth2.ready() .then(getContext) .then(populateForm) .then(showRating) .then(showButtons) .catch(console.error); let appContext = null; async function getContext(client) { const appContextStr = client.state.tokenResponse.appContext || '{}'; appContext = JSON.parse(appContextStr); ...

index.html

const messagingHandle = 'demo_auc_guideline_consultation_app';

const notParent = window.parent !== window.self;

const targetOrigin = 'http://sandbox.cds-hooks.org'; const targetWindow = notParent ? window.parent : window.opener;

function closeApp() {

targetWindow.postMessage({ messagingHandle,

messageId: uuidv4(),

messageType: 'ui.done' }, targetOrigin) }

index.html

function updateApp() {

const draftOrder = appContext.draftOrder; const rating = getRating();

applyFormData(draftOrder); addRating(draftOrder, rating);

targetWindow.postMessage({

payload: draftOrder, messagingHandle,

messageId: uuidv4(),

messageType: 'scratchpad.update' }, targetOrigin);

closeApp();

}

Roadmap?

What's next, after PAMA Imaging, for SMART Web Messaging?

● Better reference documentation & guides

● Navigation Activities

● Closed loop experiences

Community

Zulip: #smart

Argonaut: More info coming soon - tune in to Zulip

PSS: https://confluence.hl7.org/display/FHIRI/SMART+Web+Messaging+PSS

Questions

Notable Implementation Caveats

• Not having a body-parser in express

• CORS configuration

• Using https instead of http for the SMART App Launcher (causes Chrome to block

traffic)

• Using https instead of http for the launch URL :-\

• Issues with the CDS hooks sandbox

• no provider switcher

• UI quirks after update (update needs display data)

• no scratchpad.read supported in cds-hooks sandbox

• no order-sign hook support

• The SMART Web Messaging docs are between 90 and 100% correct

Link Library

Last year's DevDays presentation by Janet Campbell: https://docs.google.com/presentation/d/18DjhW1r80zgtheDqx-GwGn-YrfkaNCTi3JavYWMVnPo/present?slide=id.gcb9a0b074_1_0

CDS Hooks Slides from Dennis: https://github.com/cerner/code-learning-lab/blob/master/cds-hooks/Remote%20Decision%20Support%20with%20CDS%20Hooks.pdf

Project github site: https://github.com/smart-on-fhir/smart-web-messaging

SMART Apps Gallery: https://gallery.smarthealthit.org/

ACR Readme on PAMA: https://www.acr.org/-/media/ACR/NOINDEX/AC/PAMA-CDS-Flyer.pdf

HTML5 Web Messaging: https://en.wikipedia.org/wiki/Web_Messaging