Effectiveness and Implementation of mPATH-CRC: a Mobile Health System for Colorectal Cancer Screening

摘要 正如NIH数据科学战略计划中概述的那样，最近计算技术的进步改善了 能够使用Web服务创建可互操作和可扩展的电子健康记录(EHR)集成软件 (例如，应用编程接口、API)和基于云的计算架构。当前的领先标准 用于医疗数据交换的是由HL7®工作组发布的快速医疗互操作性资源(FHIR)。 FHIR是一种规范，提供用于管理医疗保健数据的标准化数据模型和API，并代表 对较早的HL7标准进行简化和扩展。Smart on Fhir标准允许将应用程序集成到 临床工作流程，包括上下文嵌入、授权和单点登录。随着技术的发展，EHR拥有 越来越多地采用平台角色，使第三方应用程序能够在 记录系统。可互操作的基于标准的信息系统，可促进安全而灵活的 数据对当代医疗保健服务至关重要。基于云的服务广泛应用于非医疗保健领域 域。电子病历集成的数字和移动医疗应用必须包括扩大智能医疗服务的使用范围 标准和基于云的体系结构，可跨医疗保健系统和医疗保健实现可扩展性和安装简便性 设置。我们的团队，包括董事会认证的临床信息学家和EPIC认证的程序员，拥有深厚的 创建针对患者、临床医生和医疗保健系统的多级别数字健康干预的专业知识 增加指南推荐的癌症筛查的接受度。在先前的多点随机对照试验中，我们的 非常成功的mPATHTM-CRC(移动健康患者技术-结直肠癌)iPad应用程序将 接受结直肠癌筛查的患者比例。我们目前正在进行一种混合实施- MPATHTM-CRC在28个社区诊所的有效性试验(R01CA218416-A1)。作为家长奖的一部分，我们 确定了在临床工作流程中整合mPATHTM-CRC的最佳方式。然后我们花了9个月的时间将mPATHTM- CRC从独立的iPad应用程序转变为与维克森林公司的Epic EHR完全集成的应用程序。迄今为止，我们已经推出了 在我们计划的28家诊所中的6家实施了新的EHR整合mPATHTM计划。在新冠肺炎之前，超过15,000名患者 使用mPATHTM，它确定了1100多名平均延迟10年进行结直肠癌筛查的患者。这个 本补充文件的具体目的是：(1)增强mPATHTM-CRC应用程序的互操作性，降低EHR- 通过利用WebServices和SMART on FHIR实现特定于供应商的依赖关系；(2)从 将集装箱化的本地架构转变为与服务无关的基于云的架构；以及(3)验证可互操作的 (智能FHIR利用OAUTH2.0)和基于云的架构通过严格的测试。实现这些目标将 极大地增加了平台的影响力，并为基于开放标准的软件的文献做出了贡献 发展。此外，该项目将为成功实施其他项目提供必要的信息 医疗保健环境中的技术中介干预。

Abstract As outlined in the NIH Strategic Plan for Data Science, recent advances in computing technology have improved the ability to create interoperable and scalable electronic health record (EHR) integrated software using WebServices (e.g., application programming interfaces, APIs) and cloud-based computing architecture. The current leading standard for health care data exchange is Fast Health Interoperability Resources (FHIR), published by the HL7® working group. FHIR is a specification that provides standardized data models and APIs for managing health care data, and represents a simplification and expansion of earlier HL7 standards. The SMART on FHIR standard allows the integration of apps within a clinical workflow, including contextual embedding, authorization, and single sign-on. As technology evolves, EHRs have increasingly adopted more of a platform role, enabling third-party applications to perform limited functions within the system of record. Interoperable standards-based information systems that facilitate the secure but agile exchange of data are critical to contemporary healthcare delivery. Cloud-based services are widely used in the non-healthcare domain. EHR-integrated digital and mobile health applications must include expanded use of the SMART on FHIR standard and cloud base architecture to allow for scalability and ease of installation across healthcare systems and care settings. Our team, which includes board-certified clinical informaticists and Epic-certified programmers, has deep expertise creating multilevel digital health interventions that target the patient, clinician, and healthcare system to increase the uptake of guideline-recommended cancer screening. In a prior multisite randomized controlled trial, our highly successful mPATHTM-CRC (mobile PAtient Technology for Health-Colorectal Cancer) iPad app doubled the proportion of patients who were screened for colorectal cancer. We are currently conducting a hybrid implementation- effectiveness trial of mPATHTM-CRC in 28 community-based clinics (R01CA218416-A1). As part of the parent award, we determined the best way to integrate mPATHTM-CRC in clinical workflow. We then spent 9 months converting mPATHTM- CRC from a stand-alone iPad app to one that is fully-integrated with Wake Forest’s Epic EHR. To date, we have launched the new EHR-integrated mPATHTM program in 6 of our planned 28 clinics. Prior to COVID-19, over 15,000 patients had used mPATHTM, which identified over 1100 patients who were overdue for CRC screening by a mean of 10 years. The specific aims of this supplement are to: (1) Enhance the mPATHTM-CRC application’s interoperability and decrease EHR- vendor specific dependencies by leveraging WebServices and SMART on FHIR; (2) re-engineer mPATHTM-CRC from a containerized, on-premise architecture to a service-agnostic cloud-based architecture; and (3) validate the interoperable (SMART on FHIR leveraging OAUTH2.0) and cloud-based architecture through rigorous testing. Achieving these aims will greatly increase the impact of the platform and contribute to the literature for open-standards based software development. Additionally, this project will yield essential information for the successful implementation of other technology-mediated interventions in healthcare settings.