MOBILE HEALTH WG “STATE OF MOBILE”

MOBILE HEALTH WG “STATE OF MOBILE” • Presented by: • Gora Datta gora@cal2cal.com • HL7 International Ambassador • Co-Chair HL7 Mobile Health Work Group • Co-Lead HL7 EHR Interoperability Group • Co-Lead HL7 Meaningful Use Functional Profile Team • HL7 Tutorial Speaker on Meaningful Use • HL7 2009 Volunteer of the Year Award Winner • US Delegate to ISO/TC215 • IEC 62 - Expert Member • Vice Chair, IEEE Orange County Section • HIMSS Ambulatory Committee Member (2014-15) • HIMSS14 Speaker • mHIMSS Task Force Member • Senior Member IEEE • Senior Member ACM • World Bank ICT Expert • ADB eHealth Specialist • Group Chairman & CEO of CAL2CAL Corporation HL7 WGM Phoenix, AZ May 7, 2014 – Q1

HL7 MH AGENDA • INTRODUCTION • MISSION, CHARTER, STAKEHOLDER1 • MH in Action • SCENARIOS/USE CASES2 • Meaningful Use (MU) & Mobile Health • Functional Challenge! • MH WG ROADMAP • Next Steps • Deep Dive! • Upcoming 2014 MH Projects • SUMMARY

HL7 MOBILE HEALTH WG MISSION • The HL7 Mobile Health Work Group creates and promotes health information technology standards and frameworks for mobile health. • http://wiki.hl7.org/index.php?title=Mobile_Health

HL7 MOBILE HEALTH WG CHARTER • Identify (and develop, as applicable) data standards and functional requirements that are specific to the mobile health environment • Identify and promote mobile health concepts for interoperability as adopted and adapted for use in the mobile environment • Coordinate and cooperate with other groups interested in using mobile health to promote health, wellness, public health, clinical, social media, and other settings. • Provide a forum where HL7 members and stakeholders collaborate in standardizing to enable the secure exchange, storage, analysis, and transmission of data and information for mobile applications and/or mobile devices.

MOBILE HEALTH STAKEHOLDERS Source: HL7 Mobile Health Newsletter V1Is1

MH SNAPSHOT! • MOBILE HEALTH • Not a vertical domain • But a horizontal framework that cuts across and impacts all health care domains • Tremendous interest and participation not only in the US but all over the globe • TRULY A DISRUPTIVE FRAMEWORK!

Mobile Health in Action Scenarios illustrating the scope and benefits of Mobile Health

EHR System services follow providers around a hospital Moving around a hospital

Scenario • Physicians, nurses, therapists and others move from ward to clinic to ward to care for patients • Mobile devices and wireless connectivity ensure that the EHR system and other ICT support is as mobile as the health professionals themselves • As a senior physician moves from ward round to outpatient clinic, the day’s appointments appear on their device through location sensitive services • A patient needs urgent attention at night, and a physician is called from another part of the hospital

Assisted living drawing on a range of mobile services independent living

Scenario • Paul is frail and elderly with both physical and mental difficulties, and lives alone at home with his dog • The challenge is to help him stay independent and out of hospital • His formal support services include regular visits from a nurse, timed reminders for self-care, a “call for help” alarm, and a blood pressure monitor that feeds data to a monitoring centre • He also has an informal network of care and friendship: • Paul’s son calls by and helps with household chores and dog walks • Paul has a friend living nearby who is also old and frail; they walk their dogs together, visit each other for lunch, etc., when they can

Support for long term conditions across a wide range of lifestyles Patient empowerment

Scenario • Corinne is a senior executive with a lifestyle full of travel and a high workload...and is diabetic. • She manages her condition by diet and medications, and takes daily measurements on her blood which she records to share with her physician. • If a measurement is out of range, she has a contact to ring for advice. • Corinne’s husband Mike also works full-time, though with less travel. Their 7-year old daughter Evie is asthmatic and has her own programme of care.

Behavioural health support anytime, anywhere - especially there! Help when I need it

Scenario • Jo is working at resolving the lifestyle issues that lead him into problem drinking & aggressive behaviour • His access to his children is at risk if he goes to his ex-partner Maia’s apartment at any time other than prearranged visit times, or if he is drunk, abusive or threatening during a visit. • Maia works in a restaurant a few streets away from where she lives • Jo has a job, helping to deliver heavy household items • He is at risk of losing his job if he is absent or if he is drunk or aggressive at work • He needs specific help if his work takes him near Maia’s apartment or place of work

Resolving the last mile challenge…. Getting the message(s) n child health to hard-to-reach families TRUSTED MESSAGES

Scenario • Asha Rani lives in one of the most crowded slums in Dhaka city. She lives with her husband, children and in-laws and has love and practical support from her family. • She registered on the “Aponjon” health messaging service after hearing about it from a local health worker. • Asha and her husband share the same mobile phone. Every week he receives SMS text messages –one for him, two for his wife –containing practical and relevant child health advice and information. • Both of them are becoming more knowledgeable and confident about their children’s health. • Asha is encouraging others in her community to subscribe to the service.

NEXT STEPS for MH WGA ROADMAP…

Next Steps for HL7 MH WG? • Impact of MH Standards: • Messaging • Document Architecture • Functional Model • Services • Modeling (DAM, DIM) • Impact of MH: • Security - Social Media • Usability - LMIC • Affordability - Interoperability

MH: A Closer Look #1 • MH Messaging Standards: • think of using mobile devices to send short but structured chucks for information for rapid turnaround • MH Functional Models/Profiles: • “apps…apps all around but non talks with another” • MH Functional Profile derived from both the EHR-S FM and the PHR-S FM!

MH: A Closer Look #2 • Document Architecture: • at a first glance this might not apply but think of this use case: • you are on the road, in a foreign place, out of your meds • You go the local pharmacy, zap (NFC) your mobile device with the kiosk and the kiosk prints out your prescription (in the local language) • You get your meds!

MH: A Closer Look #3 • Services: • many possibilities….patient education is the first that comes to mind...."Info Button" service request, appointment service request, etc. • Modeling: • a Domain Analysis Model (DAM) for Mobile Health and then a Domain Information Model (DIM) for mobile health • STORYBOARD development • MODEL development (UML representation of Use Case Diagram, Activity diagram, etc.)

MH WG 2013-14 Activities & Projects • MH Security SWG & FAQ • http://wiki.hl7.org/index.php?title=MHWG_Security • MH Newsletter (#1, #2…) • MH (EHR-S FM) GAP Analysis Project • MH Rural/LMIC SWG & Service Framework • In 2014 – 5 PSS (project scope statement) under development

PSS#1: MHR-S FUNCTIONAL FRAMEWORK Problem: • There are over ~200,000 mobile apps • “mobile, mobile everywhere….none talk to each other” Options: • Mobile Health F-Profile derived from EHR-S FM • Mobile Health F-Profile derived from PHR-S FM • Mobile Health Hybrid Profile derived from both EHR-S FM and PHR-S FM • Mobile Health Functional Model

PSS#2: LMIC/Rural Health Service Framework • Leverage standardized health information technologies to help increase the quality and safety of healthcare within LMIC/Rural Health settings • Identify strategies and best practices for employing accessible and interoperable mHealth-based solutions • Investigate medium and messaging constraints of LMIC/Rural Health settings

LMIC/RH SWG Recent Activities • Updating project plan to a more focused gap analysis of mHealth technologies in use and bandwidth constraints • Investigating baseline payloads of current HIE standards and the implications for use within low-bandwidth mHealth use cases • Updated LMIC scope to include rural health settings due to similarities in settings and constraints

PSS#3: mFHIRframe • Set of open source Libraries/APIs that would facilitate the implementation of mobile health applications based on FHIR (Fast Healthcare Interoperability Resources) standards • These Libraries/APIs will provide platform independent, real-time, standardized means to access health information from/to mobile devices. • Class libraries will be created that support a variety of mobile/portable platforms, including iOS, Android, .NET, and Arduino. These class libraries will contain APIs that ease the incorporation of FHIR resources into their corresponding application interfaces; facilitate interaction with EHR systems; manage workflows and use cases set forth by IHE. • The work will be built upon existing FHIR artifacts

mFHIRframe

PSS#4: mFHIRsideChat • Develop a SMS/Twitter type short standardized messaging protocol for fast exchange of information between a low-resource device/setting and a back-end/cloud environment • This type of data flow may also be between devices and a data aggregation unit (joint with DEV WG). • Solutions in rural health settings, with existing infrastructure, will be able to leverage this to send MU messages • Such standardized messages may be used by NASA during space missions (for example: MARS mission) where health information may need to flow from/to space to earth. • Use of such protocol in EMS, disaster response, public safety & publc health situations, LMIC settings is also envisaged

The project consists in bringing GS1 closer to HL7 experts by using some useful tool to capture and document their participation to the mHealth WG sessions. Ideally, the project should be scalable, so that it grows along the time and continues interesting the experts. If/when successful, the solution could be expanded to the full HL7 Working Groups. PSS#5: MH-GS1 Pilot

MU SUMMARY • As we transition to a digital record framework (access, capture, dissemination of information), use of Mobile Health will continue to rise • As Mobile Devices become more and more ubiquitous, accessing our Health Information is only a few tap/swipe away!

THANK YOU gora@cal2cal.com

HL7 Mobile/PHR Gap Analysis:Summary of Findings Mobile Health Workgroup March 2013

Context Mobile device use by consumers is widespread, in both developed and developing countries. For example, in the United States there are over 320 M mobile phones in use, more than one for everyone in the population*, and over half of new devices sold are smartphones. In consumer health, smartphones and tablets are presently being used to access personal health information, often in place of using personal computers. Some Personal Health Records systems (PHR-S) now available are designed solely for use on mobile devices. The HL7 standards for Personal Health Records (PHRs), as written, did not anticipate this change. As such, questions have been raised concerning the adequacy of these standards in providing vendor guidance and in certifying modern PHR systems. *mobithinking.com, December 2012 data

Problem Overview Background • The PHR/Mobile Gap Analysis Sub-group was established to determine the extent of changes needed in the PHR-S Functional Model to accommodate the use of mobile devices (i.e., smartphones, tablets) within the model. Scope • Review the recently balloted PHR-S functional model to determine how the introduction of mobile devices as actors within the model may result in changes to the model. • Make recommendations to the PHR-S functional model in terms of additional conformance criteria and/or creation of a mobile-specific profile for the PHR-S.

Key Finding One The functional aspects of HL7’s Personal Health Record System Functional Model (specifically, Function Names, Statements, Descriptions, and Conformance Criteria) DO NOT need to be modified in any way to accommodate the use of mobile devices and platforms in relation to PHR applications and data. For example: “The system SHALL capture the PHR Account Holder’s demographic information”applies equally to mobile and desktop-based technology.

Key Finding Two Certain PHR-S FM functionality can be tailored to mobile-based PHRs and mobile-based use cases based on • Mobile device properties • Context of mobile device use • Behaviors of individuals using mobile devices For example: Geo-location services can inform a consumer of nearby emergency room services. If a mobile device containing consumer information is lost, remote wipe functionality could also trigger backing up data to a pre-specified location.

Recommendation One Create one or more mobile-informed profiles for the PHR-S FM that account for use of mobile devices, including device use within specific contexts. For example: If a mobile device is used in a military theatre, the following PHR-S FM Conformance Criterion might be modified within a functional profile to read (added language in red): The system SHOULD provide the ability for the PHR Account Holder to control access to demographic information. Specifically, demographic information will not be displayed on a mobile device for military personnel who are in active combat zones; in non-combat zones, demographic information may be displayed on a mobile device.

Recommendation One Considerations Creation of functional profiles is a critical activity as products can only be certified against HL7 profiles, not functional models. Mobile-informed profiles can help industry deal with common issues in a standardized manner. In the absence of PHR-S mobile functional profiles, vendors using the PHR-S FM to create PHR systems should account for mobile devices as actors when determining product scope. Special care should be given to addressing security controls. For example: • Availability and control of location data. • Security in relation to device loss or compromise.

Recommendation Two As mobile devices can be actors in many health-related scenarios, expose these findings to other HL7 workgroups where mobile devices are significant system actors for consideration as to how models and methods might be affected. For example: • EHR uses of tablets and smartphones by clinicians. • Structured data entry where mobile devices are used for data collection. • Collection of family history information through structured forms on mobile devices to support Meaningful Use (MU) 2 standards. The appendices to this presentation include lists of mobile device characteristics, contexts of mobile device use, and user behaviors which may affect models and system functionality and are a starting point for examining current HL7 standards.

Appendix 1: Mobile Device Characteristics which May Affect Models and System Functionality • SMS messaging • Camera use • Geo Location functions • Near Field Communications capabilities • Device reliability • Role of continuous data collection and processing vs. at time of system sign-on (e.g., real-time alerts and notifications which can make escalated medical decisions, changes in expected behaviors based on longitudinal data, speed and immediacy of data used for clinical decision support) • Use of “basic” vs. “smart” mobile devices • Capabilities of mobile devices that lend to enhanced methods for detecting possible fraudulent system use • Capabilities of mobile devices that enable enhanced interactions with rules engines • PHI and PHII contained on devices • Unique device identifiers for available for audit and device identification

Appendix 2: Contexts of Uses of Mobile Devices which May Affect Models and System Functionality • Context of using services and transmitting data (mobile is changing the point of care—no longer just home/hospital—it is the place a person is at) • Social media impact and transfer of personally-identifiable data between patients, “friends”, family and providers (shares issues with PCs, however, access and use of social media platforms is often, if not predominately, mobile-centric) • Enterprise-provided devices vs. “Bring Your Own Device” (BYOD) • Audit considerations when devices are used for data collection and transmission • System non-functional requirements may need more flexibility based on context of use (e.g., temperature, humidity, battery life, bandwidth—both WiFi and G3/G4-- availability) • Context of use that may affect data reliability and integrity

Appendix 3: User Behaviors which May Affect Models and System Functionality • Mobile devices are prone to be lost more readily than PCs • consider how “data at rest” standards may need strengthening. • Consider need for data back up in relation to “remote wipe” scenarios • Consider “corner cases” in assumptions about user behaviors that may reduce mobile system security (e.g., typically a user has a mobile device under singular control, but with some regularity the device is shared with others)

Acknowledgements Key Sub-Group Contributors • Elaine Ayres eayres@nih.gov • Joe Ketcherside joeketch@me.com • Tim McKay tim.a.mckay@kp.org • John Ritter johnritter1@verizon.net HL7 Mobile Workgroup Co-Chairs • Gora Datta gora@cal2cal.com • Matthew Graham mgraham@mayo.edu • Nadine Manjaro nadine.manjaro@verizonwireless.com

HL7 Mobile/PHR Gap Analysis:Summary of Findings THANK YOU Tim McKay tim.a.mckay@kp.org

MOBILE HEALTH & • MEANINGFUL USE (MU) (US realm)

MU BACKGROUND • 2004 US Presidential Executive Order • majority of Americans to have access to electronic health records (EHRs) by 2014 • 2006 US Presidential Executive Order • promote quality and efficient delivery of health care through the use of health IT • 2009 ARRA: HITECH ACT • program to improve health care quality, safety, and efficiency through the promotion of health IT, including electronic health records and private and secure electronic health information exchange

“MEANINGFUL USE (MU)”? • GOAL: to promote the spread of electronic health records to improve health care in the United States • WHAT: A set of “rules” defined by the CMS Incentive Program that governs the use of electronic health records • BENEFITS • Complete & accurate information • Better access to information • Patient Empowerment

MU: 3 Stage of Implementation 2011 2014 2017 • Meaningful use implemented in 3 Stages • All “Eligible Providers” (EP) and “Eligible Hospitals” (EH) must achieve meaningful use by 2015 or face sanctions Health IT Enabled Health Reform Stage 1 Capture Data in Coded Format Stage 2 Expand Exchange of Information in Structured Format Possible Stage 3 Improved Outcomes: Focus on Clinical Decision Support for High Priority Conditions, Patient Management, and Access to Comprehensive Data

MH meets MU • Stage 1 – set the “stage” for Mobile Health • Nothing explicit but subtle nudge towards MH! • In particular, encouraging Patient engagement in the CARE process • Stage 2 – builds upon and creates opportunity for Mobile Health • Stage 3 & beyond – MH WG predicts: “MH will be key and central to healthcare delivery and access by one and all”!

MOBILE HEALTH WG “STATE OF MOBILE”