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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2014 Consumer Electronics Show

While I can’t attend CES 2014 myself this year the blogosphere is awash with updates of the new and innovative consumer electronics on display in Vegas this year.  I’m fortunate to have colleagues there who are live sharing some amazing pictures and video’s from the floor so I thought I would share…

IMG_3695

I anticipated a huge uptick in the number of health conscious iDevices….  but CES appears to be overflowing with new “wearable” devices that track every aspect of your daily life.  Hope their security is good so no-one knows when you go out of town or out for a long run and decide to steal your 105 inch curved OLED 5k display?  (see below)


IMG_3704

 

Just when you thought you had 4k televisions understood manufacturers start promoting a wider aspect ratios like 21:9 and add another 1k pixels to the screen and create 5k Televisions…  Television is such a dated term…  Why don’t we call them retina-searing monstrosities…  I can totally justify one of these in a network operations center… and by corporate network operations center I mean my living room…but really!?!

Head over to Engadget for the play-by-play or GeekBeat.TV 

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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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What makes a successful mobile device?

I typically don’t title my posts with a question but it begs to be answered with the imminent release of Apple’s iPad.  Frankly… I’m frustrated with all the media fanfare around how tablet based computing is “now” going to revolutionize the industry.  Tablet PC’s have been around for for 10-15 years.  It’s not the hardware in as much as it is the software running on these devices that have been the problem with adoption.  Software also being inclusive of the operating systems that power the devices.  Initial incarnations of the slate based devices tried to take a desktop OS like Windows, and with the help of some task bar utilities (and who doesn’t love more of those cluttering your interface) would create a platform for mobile professionals.  The result was that year over year software vendors continued to make their mouse and keyboard driven desktop applications function in the confines of a cumbersome keyboard and mouse driven OS by pecking at a temperamental resistive touch screen display on a mobile device.  And we wonder why software solution have a hard time getting used by providers and clinicians.

What was needed was a truly mobile and touch driven OS and SDK like Apple provided in their iPhone to help developers conform to building applications that did not rely on technologies that didn’t exist on the hardware like a mouse.  This was needed because no one had stepped up to the challenge in a market dominated almost exclusively by Microsoft.  Linux was in its infancy in the mobile space back then but today the Android OS has certainly stepped up to the challenge the iPhone has presented in the mobile device space and is providing a competitive platform against which Apple may have a hard time competing if the innovations in the open source world continue to leapfrog apple.

My issues with mobile computing in healthcare revolve around technologies that get in the way of providers and clinicians doing their core job which is attending to patients and not fumbling through hundreds of check boxes and interfaces designed to be used on a desktop.  Vendors need to realize just because you can run your application on a tablet PC doesn’t mean you should.  Let me repeat….Just because you CAN run your application on a tablet based device DOESN’T mean you should.  If an application is architected properly then there should always be a layer of abstraction between the interface and the underlying core enterprise services that drive that interface.  I’m not hating on Microsoft for providing Windows Tablet OS as I think they have considerably innovated in this area to help vendors use their legacy applications on mobile slate and convertible based platforms.  Multiple modalities for inputting data such as handwriting, voice, and predictive text recognition are all very good tools.  I think they were smart to merge these functions into the standard Windows 7 build and not offer a separate OS as they have in the past.

More interesting is the total rewrite of their mobile platform with Windows Mobile 7.  This ground-up initiative from Redmond is akin to becoming more like iPhone and Android operating systems but paves the way for more svelte hardware with mobile chip sets that can extend battery life without sacrificing performance.  Microsoft is bringing XAML to the mobile platform and leveraging their gaming SDK for development which eliminates any backward compatibility with pre-Windows Mobile 7 apps but I don’t view this as a bad thing.  New platform new apps…  Microsoft has long since reached the breaking point at which they need to support legacy applications and this new direction and outlook toward supporting the mobile user should be a refreshing change for developers.  A lot of our new development revolves around innovating in the user interface with Rich Internet Application (RIA) technologies such as Silverlight.  It makes us think differently about how applications are used and more importantly how it enables our users (physicians and clinical staff)  to do their job more effectively not insert yet another technology that gets in their way.

It has been a while since I posted an entry but my entire team and I have been hard at work maintaining existing applications and plugging away at UI and WCF service development.   Stay tuned…as we plug through our iterations and get ready to deploy our app I’ll share with you some of what WellMed is doing to “change the face of healthcare for seniors…”

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Motion Computing Brings New Upgrades To Their Tablet PC’s


It has been a while since Motion Computing updated their slate style Tablet PC’s.  Since then Panasonic has creatively borrowed the unique and “healthcare oriented” design to their line of rugged devices also targeted at healthcare professionals.  The new upgrades include a new black exterior and more interesting outside of aesthetics are the support for Verizon Wireless’ EV-DO network and built in 802.11 a/g/n network connectivity.  The Core 2 Duo CPU is a nice bump in performace but I will wait for the real-world affect on battery performance before making a determination if this is a worthy upgrade.   I’m sure to get a hands on at HIMSS next week with both Panasonics new entry as well as Motion’s upgraded slate PC’s.

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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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Panasonic releases new slate based Toughbook

 

The  ruggedized healthcare targeted slate is built on a 1.86 GHz Intel Atom CPU, 1GB of RAM, an 80GB SSD, a 10.4-inch 1024 x 768 resolution LCD display, and 802.11a/b/g/n which is very similar to current netbooks. Available in January of 2009 for $2,999.  While the price is steep its ruggedness typical with most Toughbooks will ensure you aren’t replacing it anytime soon.   The video below give a good overview of features and options specific to a healthcare enviornment and you will probably get a laugh at the actors trying to recreate an actual clinical environment which in my experience requires much more chaos…  The wireless features are pretty valuable for mobile professionals who require seamless access between WiFi networks and cellular data networks.

Specs:

* Genuine Windows Vista® Business with Service Pack 1 (with Windows XP Tablet downgrade option)
* Intel® Atom™ processor (1.86GHz) Z540 with 533MHz FSB, 512KB L2 cache
* 1GB standard RAM configuration
* 80 GB 1.8-inch shock mounted hard drive
* 10.4” XGA sunlight viewable 500 NIT Dual Touch LCD screen (1024 x 768 resolution), InPlay Technologies digitizer
* Anti-reflective screen treatment
* Integrated 2.0 megapixel auto-focus camera with dual LED lights
* Fingerprint scanner
* Contactless smartcard reader
* RFID reader
* Fully rugged
o MIL-STD-810F and IP54 compliant
o 3 foot drop approved
o Magnesium alloy chassis
o Sealed all-weather design
o Rain-, spill-, dust- and vibration-resistant
* Intel® WiFi Link 5100 802.11a/b/g/draft-n
* Bluetooth® v2.0 + EDR
* Integrated docking connector
* Integrated options:

o Optional integrated WWAN / Gobi™-enabled mobile broadband (EV-DO and HSPA)

o Global position system (GPS) receiver
o 2D barcode reader (also reads 1D barcodes)
* 6 hour battery life
* Twin Hot-swappable batteries
* 3.4 lbs (with batteries)
* 10.4” (W) x 10.6” (H) x 1.3” – 2.3” (D)

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Alcatel-Lucent Announces TikiTag RFID Reader and Tag Kit for Developers

An Alcatel-Lucent backed product called Tikitag is an RFID tagging system set to go live on October 1st . Much along to the same lines as my last RFID post this product has a lot of applicability for linking physical tags with websites. The first thing that comes to mind is the use of such tags for identifying patients during check-in and allowing emergency room physicians easy access to vital patient records during an acute care visit. Anyone can pick up a reader and ten tags for $50 on October 1st.

At this price point creating a simple application to match an RFID tag to a specific patient portal entry point would not be to difficult to implement. Access can be location based and limited to certain functions such as check-in or emergency access by a physician to critical medical information in an ER.

In terms of providing ease of patient interaction with a clinic the applications seem endless. The tags appear small enough to apply to a card or stand alone as part of a keychain. Patients can keep their demographic information current via a patient portal and have the information validated when the patient presents with their RFID tag at the front desk. If the patient has several locations to go to the tag can be used at a wayfinding kiosk to guide the patient to their next appointment. The tikitag utilize passivie RFID technology and active readers to activate the 13.56 MHZ signal within the tag which is also compatible with the Near Field Communication standard beinging implemented in several Nokia mobile phones. While I think the US is far behind Europe in implementing such integrated features from cell phones it is not out of the realm of possiblity that a progressive clinic could implement such tagging technology to ease patient flow or provide a valuable service to their patients.

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USB and RFID Unite… Has Potential To Form An Innovative Solution for Patient Access

http://www.neowave.fr/images/weneo_opened_and_closed.png

The French Public transportation company will begin employing RFID-enabled USB keys this coming fall allowing passengers to plug the unit into their PC’s to fund their cards at home as part of their home-payment effort. This combination of RFID and USB key has several other applications outside of transportation. Of course what immediately comes to mind is the ability for patients to have access to their personal health record via such a USB key while at home as well as allowing physicians and clinicians the ability to identify patients within a clinic when they check-in. A patient merely has to approach an RFID enabled kiosk wave their specific key and follow some on-screen prompts to authenticate and validate any necessary information prior to check-in. This enables front desk staff to know current patient volume and allows administrators and physicians insight into wait times, no-shows, walk-ins, etc… during the course of the day. This data can be aggregated and trended allowing administrators to take a proactive approach to monitoring and controlling patient wait times.

While some existing kiosk based vendors offer an intuitive interface and integration with specific backend practice management systems the older the patient is the more often they suffer from arthritic conditions making it difficult for them to type onto a keyboard or even operate a touch screen. Having a device which can at the very least notify front-desk that a patient has arrived would offer a very forward thinking approach compared with existing solutions. In RFID equipped buildings it could be easy to track patients in larger hospitals or clinic settings as they manage multiple appointments for their care. This solution would also allow empower way finding solutions to guide patients to their next clinic appointment, lab or radiology visit by simply approaching a Kiosk. Two factor authentication can easily be implemented by utilizing something the patient knows (password, SSN, DOB, etc…) with something the patient has which is the RFID/USB key.

The USB functionality of course offers patients easy access to their personal health record as well as offers emergency room professionals access to potentially life-saving patient data as well. I’ve learned of at least one large clinical practice in San Antonio spear heading a similar initiative with USB keys for the elderly population, which is a very forward thinking initiative. This has far reaching effects not just for ambulatory care but also for inpatient monitoring as well.

Source: RFID Journal

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