6. Events trigger transitions between states STATE 1 STATE 2 STATE 3 STATE 4 EVENT 1 EVENT 2 EVENT 3

7. Transitions form patterns & pathways STATE 1 STATE 4 STATE 2 EVENT 2 EVENT 1 EVENT 5 STATE 5

8. Leaving breadcrumb trails of patient movement

9. Breadcrumbs create visualizations for populations

10. And visualizations for patients

11. Revealing previously unseen insights

14. ERS Platform EVENT TRANSLATOR (TCP/IP, FTP, HTTP, SOAP) SYNDICATION INTERFACE EVENT QUEUE EVENT EVENT STATE MACHINE ENGINE EVENT BUSINESS RULES ENGINE MEMBER STATES EVENT DISPATCHER EVENT HANDLER Patterns/Pathways Research Ergo Widgets External Applications CLIENT DATA SOURCES ADMINISTRATIVE, CLAIMS, CLINICAL, SURVEY, BIOMETRIC, GENETIC TEXT, XML, X12N, HL7, EDI, EDIFACT, RSS EVENT Devices

17. Event structure <EVENT EventID=123309 Type=Diagnosis> <ERS_MEMBER_ID>19902</ ERS_MEMBER_ID> <EVENT_DATE>20050912</ EVENT_DATE> <SYSTEM_DATE>20060620</ SYSTEM_DATE> <CODE> <TYPE>ICD9</TYPE> <CODE_VALUE>250.02</ CODE_VALUE> </CODE> … . </EVENT> A rich, flexible and standard way of defining healthcare data XML structures provide the flexibility events need Events have attributes both generic and specific Events can become the foundation for standardized data exchange Events can be easily mapped to other standards such as HL7

19. Business rules engine STATE MACHINE ENGINE EVENT EVENT DISPATCHER Subscription Rules: govern the delivery of events to target state machines Transition Rules: govern state transitions based on the arrival of events State Rules: govern actions based on states reaching thresholds Data Rules: govern the translation of data sources into events and enforce Data Quality and Referential Integrity BUSINESS RULES ENGINE EVENT TRANSLATOR

23. Sample state machines: HEDIS Breast Cancer Screening UNILATERAL MASTECTOMY 1 BILATERAL MASTECTOMY 3 4 6 2 5 1. PROC EVENT (UNILATERAL MASTECTOMY) 2. PROC EVENT (UNILATERAL MASTECTOMY) 3. BIRTH DAY EVENT AGE=69 {GENDER=‘F’} 4. BIRTH DAY EVENT AGE=69 {GENDER=‘F’} 5. PROC EVENT (BILATERAL MASTECTOMY) 6. BILATERAL MASTECTOMY EVENT CREATED 1. NEW MEMBER EVENT {SYSDATE - MEM.DOB >= 50 AND GENDER=‘F’}, EXPIRE: +365 DAYS 1. BIRTH DAY EVENT AGE=50 {GENDER=‘F’} , EXPIRE: +365 DAYS 2. STATE EXPIRATION 3. PROC EVENT (BCS) EXPIRE: +365 DAYS 4. STATE EXPIRATION 5. BIRTH DAY EVENT AGE=69 {GENDER=‘F’} 5. BILATERAL MASTECTOMY EVENT 6. BIRTH DAY EVENT AGE=69 {GENDER=‘F’} 6. BILATERAL MASTECTOMY EVENT 7. BIRTH DAY EVENT AGE=69 {GENDER=‘F’} 7. BILATERAL MASTECTOMY EVENT 8. PROC EVENT (BCS) EXPIRE: +365 DAYS 1 4 5 2 7 3 6 PENDING GAP NO GAP 8 Screening Gap Mastectomy

24. Syndication Interface The syndication interface makes state and event data available to entities accessing the ERS platform External Devices External Apps Patterns & Pathways SYNDICATION INTERFACE Request/Response Publish/Subscribe ERS DATABASE XML, CCR, openEMR, HL7

26. Consideration of technologies and tools Java JBoss (Platform) Eclipse (RDE) MySQL (Database) OSMQ (Queue) Tomcat JSP Ruby on Rails Ajax Esper (CEP) UNIMOD (State Machine) Simulink (State Machine) ruleCore Thingamy iLogic ruleML BPEL BRML Middleware & Backend Frontend State Machine Rules & Workflow

28. Social Modeling Health care is intrinsically social – people , not machines 1. Capture and analyze social aspects of health care as data 2. Understand and act upon all data in social environments

29. Ingenium (Latin): personal attributes or qualities , disposition Social tendencies Value hierarchies Behavioral triggers Psychological attributes Care preferences Decision processes Learning styles Emotional processes

30. Ingenium Matrices Internal (Emotions) External (Information) Support (Community) System (Navigation) Mainstream Maximizer Naturalist Minimalist Moderate Intentional Sporadic Specific Distrust Ease Quantity Necessity Quality Systematic Low Programmatic Ad hoc Gain Self Security

31. Methodology A B D C Lit E=MC 2 Data Sources Demographic Survey HRA Case Management Websites Ethnography State Machines Bread crumb trails Ingenium Archetypes Outcomes Data Literature/Science Pattern Analysis / +

32. Whole Twins Physiology Ingenium + = Whole Twin

34. Opportunities Bring THEM TOGETHER to help build 1 You built IT and no ONE came

36. Methodology 08454328211199999454545313131272727 146454328885546464646463333334763982 239388543223856552090098744886660111 444388543885567023145006898823224660 901388543001119999934337656888222781 082900032300455601198987232732050069 727963088333098903222561149077226398 331963088444609609877232323011098934 865774777668866889049049043338788788 State machines produce Bread crumb trails over time Patterns inform archetypes Bread crumb trails allow us to discover patterns

37. Multi-dimensional archetypes form ‘care chromosomes’ Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 for patients…

38. And care chromosomes for… physicians treatment protocols geographies facilities

39. Care chromosomes do what? Predict future pathways & Connect ‘Twins’

40. Care chromosomes: other applications ‘live’ and change over time Patient 1 Start date: End date: 03.01.2005 10.01.2005 Snapshot Patient 1 Start date: End date: 03.01.2005 Today Live t = 1 t = 2

41. Care chromosomes: other applications mapped to visualize health care delivery practice patterns shape: ‘geography of care’—physicians, physician groups, hospitals colors: variable of interest - cost - rate of treatment - rate of diagnosis - re-admissions - etc.

43. Algorithms applied One state machine Many state machines Person Population

45. Action Everyone spoke of an information overload, but what there was in fact was a non-information overload. Richard Saul Wurman, What-If, Could-Be (1976)

46. Syndication Interface External Apps Patterns & Pathways SYNDICATION INTERFACE Request/Response Publish/Subscribe ERS DATABASE Controls External Devices Model View ergo widgets Record Set Queue List Measure

47. Widgets for people I can create my own or plug&play with existing apps Personal Health Record Patient panel manager Health Coaching application My Application Existing Application

50. What we could do… Simple standards that allow easy exchange of events & measures global community program: communities partner across the globe to collaboratively improve health Medical research program: make data, ERS platform, and pattern library available to medical researchers Work with Mozilla foundation to create a “health” browser Health communities &quot;scrapbook&quot; online about ways they are taking control of their own health What can we take that is currently 'closed' and make it 'open' P2P health insurance: rewards for 'buddy' team Sponsor an open competition to devise new insurance models Widget maker: allow user to create new widgets towards a widget library