Strategic Informatics

A blog about the strategic application of technology

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Lessons Learned from Implementing a Service Oriented Architecture in Healthcare

I thought I would take the time to post some lessons learned over the past three years leading a ground-up initiative at WellMed Medical Management creating a service oriented enterprise application for physicians and medical management staff to treat and transition care for patients.  Service Oriented Architecture (SOA) is an often misunderstood concept even among the ranks of IT professionals.  While many SOA initiatives have manifested and exposed internal business logic in the form of web services the approach for SOA is actually very non-technical and is rooted in a deep understanding of the business and strategic goals and involves an ever evolving process of continuous improvement and refinement.  This makes the approach both strategic and operationally focused.  In this post I will outline what I feel are some critical components necessary for a successful SOA-based project.

 

Understand the Business Domain Model

While many companies evolve over time it is important to ensure your view of the business domain evolves with it.  Healthcare organizations are no different.  Communication is key especially in rapidly changing and evolving environments such as healthcare and defining a clear functional domain model will help pave the way for future development or shifts in business.  Find natural lines of separation within the business and look for natural service boundaries which allow you to build services that make sense.  By creating separation of services boundaries you help define sources for data and information and avoid duplication within your architecture.

Lines of separation can be found between:

  • Different lines of business (e.g.. Medical Management, Clinical, Research, Transportation, MSO, HMO, etc…)
  • Product & Service Lines (e.g., Transportation, Disease Management, Chronic and Complex programs)
  • Product Variations

Understanding the business is critical to ensuring that IT is aligned adequately to support business functions.  IT is often a common service that crosses multiple business functions.  Common services that cross boundaries include infrastructure, data warehouse, applications, development, etc…  Through this modeling effort many IT organizations can quickly identify gaps in existing service and support for the business community.

 

Maintain a Common Definition of Terms

In complicated environments like healthcare where efficiently managing risk for medically managed patients and members is critical to the success of your business you must take a solid look at the data flowing into and out of your organization.  Having a solid definition of what a bed-day is from a hospital visit, as an example, is important from both a financial perspective and a medical management perspective.  Stratifying patients based on acute events such as historic hospitalizations, lab results, HRA’s, or audits are equally important for the management of that patents care.   Both finance and medical management aspects of the business are critical to the patients care yet the consumption of information can be viewed and assessed slightly diffent unless a common method for defining data and terms associated with managing your business are clearly defined.

 

To effectively define these terms you must:

  • Build from business domain knowledge
  • Evangelize the terms and their correct usage
  • Introduce new terms slowly
  • Seeking definitions that are both
    • Unambiguous
    • Context insensitive

 

Maintain a Consistent View of the Ideal System

 

I’ve always been an advocate of having a strategic and long-term vision for a product.  Knowing where you are going will help you make day-to-day decisions that will ultimately help you get to where you need to be.  The ideal system will often seem unrealistic to many but setting the bar higher than others will help make your organization more agile and ready to change as market or other external factors shape your business.   Our approach to building a strategic enterprise application included components for mobile devices (pre-iPad) and both patient and provider portals.  They will not always manifest themselves as a product immediately but setting the groundwork and service breakdown will allow you to readily transition to other products or services.

 

The following items will help you build a consistent view of your ideal system:

  • High level design or model of the:
    • Goal system and
    • Intermediate steps
  • Consider all relevant aspects
    • Hardware/Networking
    • Services/Communication Protocols
    • Data/Access
  • Keep it in a maintainable form
  • Evangelize the roadmap

 

I’ve found that keeping a current copy of the ideal system will help you in many other aspects as well such as quickly describing the business to potential employees, vendors, partners, and even internal staff.

 

Seek Opportunities to Advance the System

 

Service Oriented Architecture is a concept and proposition you must be dedicated to and not a passing trend you can close as part of a project.  As such you must change your mindset and approach to all your projects.  Often SOA initiatives are grounded in major strategic initiatives.  Like any major IT initiative it should fundamentally support the businesses core objectives and strategic goals.  Your choices from a day-to-day perspective should seek to advance this strategic effort and build upon the shoulders of what has already been created.  A core tenant of SOA initiatives is the concept of re-usability.  When building new services or implementing new features you should always seek opportunities to advance the system as a whole.  Ways to do this include:

  • Avoiding Big Bang Architectural Changes
  • Implement the final system in small steps
  • Places to look for strategic opportunities include
    • New lines of business
    • New clients or partners
    • 3rd party software updates
    • New vendor software that complements your core products (i.e. Med Management & EMR)
  • Incorporate changes with the highest potential return
    • Looking for small changes with the highest amount of return
  • Seek to learn from each opportunity

 

Evangelize the Vision

The architect is a business leader and will often be your biggest advocate for driving business change using technology.  This is a very collaborative role and this person must work closely with executives and have a firm understanding of business trends, strategic initiatives and goals so changes or shifts are adequately made within the application and technology architectures supporting the business.  Ways to evangelize the vision include:

  • Continually show the company
    • Where the IT end of the business is headed
    • How it’s going to get there
    • Why it should go there
  • Create opportunities in
    • Design Meetings
    • Architecture, Development & Governance meetings
    • Hallway conversations within IT and with senior leadership

 

 

Continuously Improve Everything

 

Lastly, I would say continuous improvement is an overarching requirement and mindset you must install in all of your initiatives.  This can’t be drove from the architect or developers alone but must involve changes in processes of the business departments.  In our case it involved the close interaction of  infrastructure, executive management, line workers (nurses, case managers, health coaches, etc…).  Like the agile methodologies we put in place to develop our enterprise product you must have continuous interaction and have the mindset of continually improving your product and services.  To do this you and your entire team must:

  • Seek a to maintain a better understanding of the business even as it evolves and changes
  • Add and refine terms in the domain dictionary
  • Evangelize, Evangelize, Evangelize…. (E Cubed)
  • Seek alignment between the business and IT and use changes in business as opportunities

 

This is by no means an easy process but evoking change within an organization, especially a large one, is not a simple undertaking.  I’m sure I will have more to add as time goes on but take these little tokens of knowledge, go-forth and build your own agile enterprise applications.

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User Interface Design using Silverlight Rich Internet Application (RIA) Technologies

March 16th will mark one year since we generated our first formal wireframe comp for what has now become a very robust enterprise application for physicians and their clinical staff.  This journey through building an initial prototype, development of a solid service oriented architecture,  building the project, analyst and development teams, generating a solid user experience, engaging our customers and more importantly engaging everyone in a new agile methodology has been nothing short of an amazing journey to which I’m very proud of what we have all accomplished.  As we approach formal implementation of a project kicked off just one year ago I would like to recognize some great vendors who helped us along our journey…  Xby2, Seamgen, and Cynergy Systems and especially my development staff at WellMed who kicked us off in this new agile development effort.

My recent visit to HIMSS ’11 in Orlando, FL validated what I already knew…that our user interface, which sits atop the underpinnings of a service oriented architecture, is far and away more usable and interactive than anything else on the market today.  The tool our customers use does not need to get in the way of doing business…  Cynergy Systems has created a showcase video highlighting their approach to User Interface design with our product and shows how good UX design can go a long way in helping ease complex tasks.  Below is the showcase video they produced and demo’ed at the Health Information Management System Society (HIMSS) meeting last month.

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Doctors embracing iPads as a clinical tool

Wendy Rigby with KENS 5 News San Antonio just finished an article on iPad use in clinical settings and focused on the effort of our WellMed physicians.

Credit: Wendy Rigby / KENS 5
Dr. Robin Eickhoff of WellMed uses an iPad as she consults with her patient

The article highlighted our EMR and Care Delivery Platform development efforts and our President, Dr. Carlos Hernandez, mentioned something quite profound during the video interview this afternoon that wasn’t captured in the article or on the video and that is the “need to develop tools built around care delivery not delivering care around a tool” which is precisely what our application development efforts have focused around.

Our Service Oriented Architecture has enabled us to quickly embrace change in the mobile space.  The iPads have not been out an entire year yet we are able to quickly consume the core secure EMR services built into our flagship Care Delivery Platform and push data into the hands of providers using a very connected, very mobile device with a fundamentally different user interface.  By taking the time to develop and invest in a service oriented architecture we’ve prototyped this iPad app in a fraction of the time it has taken to develop our RIA (Rich Internet Application) EMR.  This has been a long and often exhausting journey to leverage and get to a state of reusable services but the goals of being more agile and leveraging on top of what is already built is a refreshing feeling and enabling WellMed Medical Management with opportunities to remain agile in our ability to deliver on strategic decisions and changes that benefit care for our seniors.

To check out the article and photos of physicians using the iPads within the clinic check out the link on KENS5:

http://www.kens5.com/news/Doctors-embracing-iPads-as-a-clinical-tool-115957794.html

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Apple’s Tablet iBook?

aaplnetbookmock

If we are to believe Apple then there is no intent on offering a slate based tablet platform.  However as evidenced by recent Chinese-language financial newspapers this week it is claimed that Wintek has been selected to manufacture touchscreens for a device targeted at the netbook category.  I’ll be the first to admit that I think Apple is poised to offer a device that picks up where Microsoft’s third-party device manufacturers left off.  It is clear to me that the capacitive touch screen on the iPhone/iPod is a great interface to a large screen slate based device.  While the above picture is surely a fake it does draw my attention to the fact that Apple’s recent Beta release of Safari has some very “Touch Friendly” features including the “Top Sites” at-a-glance preview of your favorite websites and Google Chromesque tab management which is uncharactaristic of Apples typicaly UI design within OSX. 

Safari 4 web browser demonstrating Top Sites feature
I became the recent receipient of Dell’s capacitive touch 12″ tablet and can assure you it does not compare to the iPhone’s interface.  Time will tell what Apple does in the coming months and if this rumor has any traction but for my work in developing applications I would love to see some well crafted UI’s sitting atop Apple’s hardware.  As novel as it may sound…”Flicking” through medical records using cover flow would be a pretty neat feature for managing a stack of patient medical records.

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Blackberry Storm First Impressions

Like most large enterprises we have our fair share of smartphones in use.  While IT tries to keep this limited to a select few, I did recently get a hands-on with the new touch screen Blackberry Storm from Verizon.  Being an iPhone user myself I can certainly say it was a different experience and RIM while taking advantage of the now popular touch screen enabled devices has set themselves apart from the iPhone.  For better or for worse the phone appears to be solidly built and well designed.  Several side-by-side comparisons with my iPhone revealed the Blackberry Storm to be a little shorter and thicker but weight was about the same and I would certianly have no problems carrying it in my pocket.  The higher-resolution camera would be a welcomed addition to my iPhone but my real test was trying to use the clickable touchscreen.  Being and iPhone user for the past year and a half didn’t help my experience as the Storm functions more like a tablet PC where the focus is constantly changing as you move your finger around the screen to select different options.  When you have moved your finger over the menu item or area you want to select you simply press down on the screen.  The feedback was intuitive enough but I made the mistake of using it in portrait mode where the web browser presented me with a condensed set of keys (two letters for each key).  Turning the unit sideways revelaed a full single letter per key layout which was better for writing messages.  I enjoyed the iPhones predective text features more and having the pop-up visual keys appear when you type on the iPhone.

The clickable test is not a show stopper but I imagine, that while effortless, a long session of typing would cause your thumbs to become a bit tired.  Granted these devices aren’t meant for long diatribes but should certianly meet the needs of most quick e-mail responses.  I think I’ll stick with my iPhone for now and hope that Apple continues along their roadmap and includes some needed enhancements to the existing software like landscape typing of e-mails, status screen separating unread messages into multiple accounts, more alert options for new messages.  Some of this may come about with the release of the push-messaging agent Apples been promising but if history is any indication I shouldn’t have to wait too long before Apple sends out another enhancement release.

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VMWare Fusion 2.0 for the Mac

About two weeks ago VMWare released the 2.0 version of their Fusion VM software for the Mac.  It is certainly worthy of a full point release with the level of integration between the host OS and the virtualized OS increased tremendously.

It is interesting to note that VMWare Fusion offers the option to install McAffee VirusScan Plus on windows virtual machines (even BootCamp) by mounting an install ISO on the virtualized Windows system.  This is interesting to note especially with increased integration and ability to access or share files from virtual to host as virus infected files can pass from one VM to the host without much effort by the user.  While it does not seem viable this could occur in a scripted way through the hypervisor from VM to the host it does have to be a consious effort by the user to move the files over so this provieds another layer of protection for the user who might not otherwise use this software on a freshly created Windows VM.

The visuals on the 2.0 version have also increased with a rather handy screen snapshot of the running VM provided in the Virtual Machine Library window.  This window is updated approximately every 10 seconds with a current view of the guest VM.

One other suprise with this upgrade occured when I tried to unzip a file on OS X and was prompted with the abilty to utilize WinZip within BootCamp to open the file.  This really starts to blur the line between the two OS’s and enables the end-user to utilize the best application for the job.  So far performance has been snappy and very responsive.  With the integration of optimized video drivers for the VM’s I tried to run Compiz 3D effects on my Ubuntu Hardy VM but unfortunately wasn’t able to get the visuals running as they do on my dedicated Ubuntu PC’s.

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HealthVault Connection Center Beta 1.2

Microsoft has just released HealthVault Connection Center Beta v1.2 which is a desktop utility that helps people upload data from health and fitness devices to their HealthVault account.  This is a good step in bridging the gap between a patient and physician between visits.  Having an updated list of blood pressure, weight, peak flow measurements, heart rate, among others is a great way to arm your physician with information germain to a patients health, especially for physicians trying to track and monitor chronic diseases.

The interface is pretty straight forward and matches the already easy to use HealthVault web based interface.

Once setup and configured for your device data can be uploaded automatically.
Microsoft has gone out of its way to ensure the SDK for HealthVault can interface with a wide variety of backend platforms by providing Java API’s and allowing others to communicate via standard web services based interfaces.  With all this cross platform communication whats lacking right now is a Mac version of the application.  With the integration of Nike+ with the newest version of the Apple iPod Touch it seems like a logical progression for easily allowing patients to send their exercise data to their PHR.

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Microsoft Developing Its Own App Store for Windows Mobile?

It appears that Microsoft, noticing the success of the App Store from Apple, is set to launch its own app store for windows mobile platforms given a recent job posting on computerjob.com. The description states the senior project manager will ead a team that will “drive the launch of a v1 marketpace service for Windows Mobile.” The success of the iPhone App Store is a sure way to drive traffic from a mobile platform. I must agree that searching the app store is far simpler than scouring the Internet in search of an applicaiton for your mobile smart phone. While I’ve certainly had my fair share of issues with the iPhone v2 firmware at least Apple has recognized and actively fixing issues which is a far cry from the issues I’ve experienced on Palm, Windows Mobile, and yes even Blackberry Mobile Operating Systems.

I’m seeing a steady increase in the use of iPhone’s in physician hands. With apps like ePocrates hitting the Apple App Store it won’t be long before more and more physicians take advantage of the quick search capabilities offered by Mobile Safari and reference tools such as ePocrates. At the Microsoft Health Users Group meeting this past week I would say I noticed about 1/3 of the users were iPhone owners. I spoke with the CIO of a healthcare portal company and he is actively developing an application interface for his product. If healthcare application developers would focus more on the interface of their apps I think physicians and clinicians alike would adopt the iPhone as a valid platform. The sheer number of developers for Windows Mobile is tremendous and Microsoft has made it very easy to develop in this platform regardless of your programming language of choice. The iPhone has several enterprise related issue to address before IT managers adopt this as a platform worthy of supporting in larger organizations.

Source: CNet

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Health Monitoring Solutions for Patients

Dr. Touch will soothe your HMO pains

Intel Health PHS5000 is not the first implementation of an in-house health monitor but if I were to judge by the looks of the User Interface I would say this device may have some promise for monitoring one’s health at home so long as you stay home most of the time. Currently being trialed in Asia this device will monitor and check for problems related to chronic diseases, diabetes, blood pressure, etc… Assuming that smiley faces are good and you know what the resulting charts mean in terms of your physicians plan for you I think this might prove useful in visualizing a patients health.

While I agree that devices like this are useful they do not address the primary issue of not being with the patient all of the time. I think devices such as the iPhone will prove far more useful in terms of being an enabler to patients to monitor their health. Its interface is more in tune with providing easy input and quickly being able to enter data, send progress updates to a personal health record, and of course contacting your physician office by phone if necessary.

iPhone Keyboard Typing Email

A mobile iPhone solution can easily offer patients:

  • Reminders and Alerts to take medication or perform blood-checks
  • Secure connections with PCP’s can enable physicians access to real-time data
  • Mobility will not confine you to your home but rather be in your pocket ready to go
  • Software updates via the App Store will also provide easy updates as necessary

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Microsoft and Apple strategies

I’ve started to take notice at the different business model approaches behind both Apple and Microsoft. Microsoft has a long history of providing backward compatibility with it’s software which, I believe, is one of the primary reasons why it has developed such a huge market share. Apple on the other extreme has complete control over the OS as well as the integrated hardware that it runs on top of. This, for many reasons, provides a fabulous method for managing the entire user experience. Having a limited and hand-picked chip set allows Apple to tweak and pull as much performance out of their hardware as they can. Microsoft has done a pretty good job at maintaining backward compatibility across many decades of releases, but they remain constrained by the breadth of commodity hardware that exists in the market and have been burned, unfairly, on many occasions due to “driver” issues that cause stability issues in the underlying OS. Apple is able to quickly resolve and address any issues that may come up rather quickly without having to go through so much regression and QA testing.


Many years ago Bill Gates was quoted as saying that software will never catchup to take full advantage of the software. What this translates to is the concept of efficiency in software design is moot as the hardware will be so powerful that software applications will find it difficult to keep up with the speed changes. While this concept was visionary it leads to the eventual outcome we see Microsoft in today with Vista which, in my own option has become a bloated piece of software that can’t possibly scale to the needs of multiple platforms like *inux or even OS X can. I can appreciate Microsoft’s efforts with their Windows 7 initiatives and think this is the right approach they need to take. Apple meanwhile is enjoying the rapid adoption of its OS and the stability they can provide by offering both HW and SW. Microsoft isn’t alone in this as Linux has this same approach but the open source community and early adopters don’t have the history or legacy application issues that Microsoft does so changes on this platform are accepted as norm. Looking from the perspective of an IT Director you want a stable platform that is supported and application that run atop of these systems that are also supported through multiple iterations of security updates, and OS enhancements. Many times in my career I’ve seen this lone server running in the back of the data center running some version of OS2/Warp that hasn’t been supported in years but runs this one small but important application… This is an IT managers worse nightmare and the motive for many enterprise development projects.


Apple, in many respects, has to function as sheep herders, but as their flock grows it will be much more difficult to wrangle their heard of consumers which is probably why Apple has stayed out of the Enterprise application market which is where Microsoft and even *nix variants to some extent have excelled.