FHIR at

Cedars-Sinai®

Ray Duncan, MD, FAAP

Director, Tech R&D

Enterprise Information Systems

Cedars-Sinai Health System

Copyright © 2017 Cedar-Sinai Health System®

Agenda

•Cedars-Sinai Health System overview

•FHIR at Cedars-Sinai

•CARIN Alliance

•FHIR and the CS Accelerator

•FHIR in Custom Patient Portal App

•FHIR Concept Mobile Apps

2

Overview of Cedars-Sinai Health System

• Established 1902

•Main hospital 842 licensed beds, Level 1 Trauma Center

•2 smaller community hospitals

•13,000 employees

•2,500 medical staff, 400 residents and fellows, 3000 nurses

• Epic Systems HIS/EMR fully deployed

•HIMSS Stage 7 March 20143

• Research Institute

• Comprehensive Cancer Center

• Comprehensive Transplant Center

• Heart Institute

• Neurosurgical Institute

• California Rehabilitation Institute (joint venture with UCLA)

• Rapidly expanding outpatient footprint: urgent care centers, outpatient clinics, and specialty affiliates

• Active community outreach programs (e.g. COACH for Kids)

Culver City Urgent Care/IM

Kerlan Jobe

Santa Monica Orthopedic Group

Santa Monica GI

AngelesAngeles Clinic

VIMVIMValley Internal Medicine

Tower Heme-Onc

Cal Heart

LA Cardio

CSMG Robertson Offices

Playa VistaUrgent Care/IM

Access Medical Group

California Rehabilitation Institute

KJSC

SCOP

ECSM

Del Rey Surgical

Cedars-Sinai Health System

Cedars-Sinai Medical Center

20 Mi.

•Epic upgrade to version 2015 in November 2016.

•FHIR services implemented in pre-production environments in Dec.

2016

•FHIR and oAuth2 endpoint in production Feb. 2017 (one of only 10

Epic customers live with FHIR at that time)

•Since then multiple applications of FHIR –

–Participation in CARIN Alliance public demos with third party

B2C software vendors (CareEvolution, MedSavvy, Polyglot

Systems) at HIMSS, Health 2.0, ONC Medication List demo day,

etc.

–Infrastructure for our flagship patient portal application

–Internal application development

–Proxy’d FHIR services for healthcare IT startups in the Cedars-

Sinai Accelerator (more about this later)

•Currently published Epic FHIR services are a subset of DSTU2 and

all are read-only.

FHIR at Cedars-Sinai

•The CARIN Alliance is a bi-partisan, multi-sector alliance convened by

David Blumenthal, David Brailer, Aneesh Chopra, and Mike Leavitt, to

unite industry leaders in advancing the adoption of consumer-

directed exchange across the U.S.

•CARIN’s vision is to rapidly advance the ability for consumers and

their authorized caregivers to easily get, use, and share their digital

health information when, where, and how they want to achieve their

goals.

•Members include organizations in many categories – consumer

advocates, HPIAA-covered entities, standards organizations, HIE

networks, software developers, device vendors, etc.

•CSHS is a participant and board member in the CARIN Alliance and

has participated in multiple public demos of third-party consumer

apps accessing our EMR through the published FHIR services (Health

2.0, HIMSS, ONC Medication List Demo, etc.).

A Plug for the CARIN Alliance

For more information: http://carinalliance.com/

•The Cedars-Sinai Accelerator, operated in partnership with

TechStars, is focused on healthcare IT startups

•Twice a year, 10 companies are selected from 500+ applicants

to participate in a 90 day cycle of the accelerator.

•Cedars-Sinai clinicians, business owners, and technical experts

mentor the accelerator companies in healthcare business

processes, clinical workflows, and system integration.

•Accelerator companies are guided toward use of FHIR where

practical to minimize dependence on vendor-specific web

services.

•About 1/3 of the companies stay on after the 90 days to

conduct a production pilot in one or more Cedars-Sinai

inpatient units or clinics. Several have landed enterprise-wide

deployment contracts at CSHS.

The CS Accelerator

and FHIR

Cedars-Sinai Accelerator Powered by Techstars

2016 Q3 Class

Cedars-Sinai Accelerator Powered by Techstars

2017 Q1 Class

Cedars-Sinai Accelerator Powered by Techstars

2017 Q3 Class

• In the current 2017 Q3 Accelerator cohort, the following

companies are using FHIR services for EMR integration

•For more information, see:

http://www.techstarscedarssinaiaccelerator.com/

CS Accelerator and FHIR

CancerAidCancerAid is an app for oncology patients and their caregivers to provide individualized

cancer therapy information and resources.

ChoiceMapChoiceMap is building a tool to help clinicians and patients engage in shared decision

making about treatment options.

GYANTGYANT uses machine learning and AI to offer patients a bot-like triage tool that leads from

symptoms to information to recommended next steps.

Invio Invio is a cloud based platform for managing clinical trial documents and workflows.

Sway HealthSway Health has developed software to enable providers to deliver evidence-based

preventative behavioral counseling.

SeremediSeremedi has developed a platform for the exchange of information between providers

and patients to track and monitor treatment status.

•This functionality in the iOS version of our mobile

Patient Portal App allows the user to pull a CCDA

summary record from our Epic system and store it in the

Apple Health secure repository on the device via the

Healthkit API.

•The user can view the CCDA record, save it to a cloud

service such as Dropbox or BOX, or send it by text or

email as they choose.

•The app uses the FHIR DocumentReference API to get

the CCDA record from the Epic system. The usual

patient-facing filtering rules are honored (unreleased lab

results, sensitive notes, etc.)

“Download My Records”

MyCSLink is Cedars-Sinai’s mobile application for current and potential patients, and among other features, offers active patients a secure way to access office notes, medication lists, appointments, and more.

New “Download My Records” icon added to the MyCSLinkactivities page (“springboard”)

The user touches the “Download” button to transfer their CCDA record to secure storage in the Apple Health app.

Touch a report to select it

Touch the report icon to view the report as either XML or a parsed user-friendly “preview” with links to various sections.

Example of “preview” of CCDA imported from Epic, with hotlinks to each section of the report.

Touch the ‘send’ icon to email or text the report to a provider, Airdrop it to a nearby contact, import to Box or Dropbox, store in iCloud, etc.

When sending a CCDA document, all the usual destinations are available (same as for a photo, for example). The report is delivered as a ZIP file containing the CCDA document in its native XML format, which may be imported to another electronic medical record system, and a preview document in PDF format.

•This functionality in our mobile Patient Portal App allows

the user to pull a CCDA summary record from our Epic

system and send it securely to any physician or other

caregiver with a Direct Address (via Surescripts HISP).

•The app uses the FHIR DocumentReference API to get

the CCDA record from the Epic system. The usual

patient-facing filtering rules are honored (unreleased lab

results, sensitive notes, etc.)

“Send My Records”

The user touches the “Send to Provider” button to send their summary CCDA record to a provider via Direct Messaging.

The user can search for a physician by name, location, phone number, specialty, or any combination.

A list of physicians matching the search request is displayed. The user can select a physician by touching their name.

Finally, the user can add a free text message to the physician which will accompany the records in the secure email.

•FHIR Concept or Model Apps for iOS and Android are being

developed by the CSHS Technology R&D Team

•The apps will be Open Source, to be made available for free

on the Epic App Orchard and other download sites TBD

•Apps are read-only, configured for Epic FHIR sandbox by

default, but other endpoints and client IDs can be

configured in Settings

•Goals:

–Learning exercise for CSHS developer staff

–Practical demonstration of use of oAuth2 and FHIR for

B2C mobile apps

–Jump start for CS Accelerator companies becoming

familiar with FHIR web services

–Common starting point for internally developed FHIR

apps

FHIR Concept App

FHIR Concept App

FHIR Concept App

FHIR Concept App

FHIR Concept App

Demo

https://youtu.be/8YKO2zRpASM

Questions?

Ray Duncan, MD, FAAPEnterprise Information Services

Cedars-Sinai Health SystemRay.Duncan@cshs.org