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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Designing an Electronic Medical Record

Some big ideas come from asking pretty simple questions…

As it turns out the inspiration and vision for the development of an innovative Care Delivery Platform at WellMed was born out of necessity.  A necessity to accurately and efficiently deliver timely information about patients health status to caregivers at the point of care and document in a way that did not inhibit the caregivers ability to deliver quality care to seniors.

Many physicians are burdened with a mass of paperwork detailing patient activity.  The simple idea of putting relevant and timely information in the hands of a physician when it is most important to help manage risk and provide adequate decision support at the point of care is a goal many EMR vendors have tried to achieve by simply aggregating and archiving data.  There are several decision support tools available for physicians that manifest themselves in different ways such as ePrescribing applications, Reference Material, Patient Education Handouts, Risk Adjusted Payment Attestations, Document Management Repositories, Clinical Protocol sheets, etc… some within a single application, many others completely disconnected and disjointed requiring the user to log into multiple applications to perform seemingly simple functions.

When you think about it clinicians and many tertiary healthcare providers live and work in an environment where the vast majority of documents sent and received are in paper form and it is still growing.  When you add electronic information in the form of e-mail, document management systems, and patient data to the mix it becomes inefficient and cumbersome for providers to effectively manage.

We’re two decades into the internet revolution, and despite many efforts to create an all electronic clinic, paper is still the predominant method of healthcare communication in this country.  It’s 2010 and many providers get their documents more or less the same way we did 200 years ago!!!

That’s absurd…

While we can’t change an entire industry we can start by looking at ourselves and how we deliver healthcare to seniors.  When I started with WellMed 2 years ago I was inspired by our CEO’s vision and approach to wanting to leverage technology to gain efficiencies and better manage risk for our patients to keep them healthy and out of the hospital.  At the same time I saw his frustration with current solutions that did not allow us to progress to the next level of patient care.  The truth is we will never completely get rid of paper, this is a common misnomer, but we can manage it more effectively and make it more accessible to clinicians.  What the our clinics needed was a new, complementary approach for managing patient information.

So here is the simple questions that led to the creation of the Care Coordination Platform:

What would it take to deliver quality information to physicians at the point of care?

What would empower physicians to help deliver quality care for seniors and help improve outcomes?

After much thought and effort we think we’ve got an approach that nails these things.  It brings efficiency, new benefits for both business and physicians and more importantly our seniors.  So far the feedback and the demand for a solution have been terrific.

As we get ready to bring the solution we started developing a year ago to physicians we will continue to evolve the platform to include many other data elements in the patients continuum of care.  We have not been sitting idle and have solicited feedback from many providers and will continue to be engaged with all users of this new system.  Initial feedback has been great and we’ve got lots more work ahead, but we are off to a great start.

When we introduce the EMR Preview in 1Q 2011, it will have exceeded our current EMR functionality in many ways and plan on quickly following with quarterly releases of additional functionality including ePrescribing, and document management integration in subsequent iterations.  I’m very proud of what our team has created in such a short amount of time and will continue to develop as we forge new ground and develop new integrations with other custom and vendor solutions.  I would love to show you more than just a teaser image as the user interface takes full advantage of rich internet application (RIA) functionality.   I truly believe what we have designed will empower our providers to delivery quality care to seniors.  Until such time we make our internal development efforts widely available to contracted providers I will instead focus future posts on our approach to architecture, user interface, SOA, and agile development.

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Panelist on Healthcare Security & Privacy at the The Texas Lyceum

I’ve been asked to participate in the Texas Lyceum in San Antonio, February 6th, 2010.  The title of the event is “Our Growing Lives Online:  Safe or Not?” and will attempt to tackle the risks associated with our connected society.   The weekend event which I will participate includes interactive and team activities to help Lyceum Directors better understand how these privacy and security risks affect their day-to-day lives.  The goal is to raise awareness regarding public policy involving security and privacy.  San Antonio is a great backdrop for this event as it is quickly becoming a central hub of computer security with the Air Forces locating its 24th Air Force Cyber Command at the city’s Lackland air force base.  There is an invisible war going on that we don’t even see involving cyber security and the public needs to understand how companies are protecting their information as it moves online.

Events kick off on Thursday and continue through Sunday afternoon.  I will be joining is the “Healthcare Security & Privacy” panel from 1:30 p.m. – 2:30 p.m. at the International Center, 203 S. St Mary’s, Third Floor (Two blocks away from the Hotel Contessa).  Joining me in this panel are David Finn, Health Information Technology Officer, Symantec and William Phillips, Chief Information Officer, University Health System.  Moderating the event is Dr. Adolfo Valadez.

I look forward to the event and engaging the Lyceum Directors on the virtues and risks associated with exchanging healthcare information online.  Coming from both the payer and provider sides the importance of efficiently exchanging information online not only helps manage rising cost but more importantly can drive better healthcare for our members and patients.  Our primary member demographic at WellMed Medical Management includes Medicare eligible seniors.  Over the past 5 years I’ve seen an increasing number of seniors flock to the Internet to educate themselves on health related issues.  The Internet has ushered in a new age of convenience in sending digital information.  These electronic tools and applications are an extension of your organization and your ability to deliver quality care to patients.  The same level of trust your patients have with you to manage their health in a clinic should carry through to your ability to maintain the security and delivery of their personal health information to those specialists and care providers .   I believe that technology can play a huge part in the delivery of care.  As both healthcare payers and providers we are trusted sources for our seniors and are constantly evaluating new ways to empower our seniors with the tools necessary to manage their care.

Please join our discussion…  You can find the site online at www.texaslyceum.com

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Are Online Health Sites Turning Us Into Hypochondriacs?

Can online tools from the likes of WebMD and MayoClinic.com help you find what ails you?  I’m overstressed, overweight, losing my hearing and not sleeping enough. Even worse, I have a low IQ and my “real” age (taking into account my bad habits and so on) is 10 years older than my actual age.  ComputerWorld shows how many consumer focused websites offer online health assessment tools don’t really offer the same level of diagnosis that can be obtained by an actual office visit.  I can recall when we deployed healthanswers.com as a consumer portal for health information we were very much a content focused company that offered online tools to help manage specific aspects of a disease but we did not attempt to diagnose health related problems.  In the online world where instant gratification and information is available at the click of a mouse I think consumer focused health care portals today should tread lightly when offering such online ailment tools as most today are not inclusive of the patient history and can’t zero in on the more critical aspects of a patients complaint.   At Northwestern my informatics professor called this the hand on the door diagnosis or the “oh, by the way” portion of the clinical assesement.  What the patient “feels” may be a problem and what the physician “knows” is a problem are two totally different things.  Will this prevent patients from using these tools?  No, but consumers should be made aware of the caveots for using such tools online and at the very least should stick to reputable sites for their health information.

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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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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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Microsoft Health Users Group Tech Forum 2008


Today’s keynote was given by Steve Aylward, General Manager, Health & Life Sciences for Microsoft Corp. He discussed how focused Microsoft is in the healthcare space and how they really see this as a long-term investment to which they are investing a large portion of their resources to this vertical. While he couldn’t disclose exactly how much he did say it was significant and historically once Microsoft puts its weight behind something they usually do it full force. I had no reason to believe this wasn’t true as their focus is clearly providing the framework by which healthcare transactions are completed. While Microsoft is prevalent in many industry verticals healthcare historically has not been a strong suit. The inpatient Amalga hospital information system they acquired and developed is being implemented overseas in countries where single solutions prove the most value. Healthcare companies in the U.S. are notorious for having fragmented and disparate islands of applications and data most of which are critical to the overall IT infrastructure and thus merit’s a different strategy that Amalga’s single solution product can’t easily satisfy. Therefore, Amalga will be marketed and sold as the Amalga Unified Intelligent System incorporating existing healthcare application and data stores into the mix as a different platform.

Below is a video of Microsoft’s “vision” for the future:





HealthVault also received a lot of attention during this forum. I sat in on the Health Payers track which outlined in great detail Microsoft’s take on providing PHR’s and becoming the central hub by which information can be passed between providers, payers, and patients. It is clear that Microsoft want’s to own this space by providing the infrastructure by which the data flows and allowing as much integration with existing and future applications as possible. You can access the framework through technology neutral API’s or web services. They have even gone so far as to offer a set of Java API’s opening the doors to other non-Microsoft solutions. It is certainly possible to offer such solutions but they are leaving the integration and development including data and vocabulary translations to system integrators and providers to offer end-users. There were several comments from valued partners that Microsoft brought this out a little early due to pressure from Google’s offering in the same space. I was skeptical of their framework offering however I walked away impressed with the thought that went into this and allowing a platform agnostic interface into the HealthVault cloud.

One thing is clear after this first day and that is Microsoft is looking to providers to utilize the tools they have provided within Visual Studio, and other server offerings such as BizCom, SharePoint, Office, Vista, Communication Server, etc… to create solutions in this space at least until they can develop vertical specific solutions such as Patient Server 2009. How will Microsoft succeed? I think the most successful case studies will be those that show integration between all applications and if Microsoft continues development in this area and makes it easy to implement core solutions using their technology as the underlying platform. Their vision is expansive and sounds great but the challenge remains in addressing the how people can implement and integrate Microsoft technologies into their healthcare practice.


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Intel Health Guide gets FDA approval


Intel takes steps to improve patient health by gaining FDA approval for the “Intel Health Guide”, an 8 lb. unit that operates as a personal health management system at home and runs the equivalent of portal software to access various functions. Patients interface with the unit via a touch screen interface. Its goal is to improve doctor patient communications by prompting and encouraging patients to take their medications even going so far as to send inspirational messages to patients.

I think this is certainly a novel idea but would require an ubiquitious network infrastructure or cellular network to operate easily and reliably. Moving the management of health care to the patients will certainly go a lot further to reduce the already high costs of healthcare. Intel expects the Heath Guide to become commercially available from health care providers either late 2008 or early 2009. More information and a video can be found here.

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What about Patient Portals?

What makes a patient portal successful? Is it really worth the time and effort involved in integrating multiple systems into one cohesive view? Should you allow patients to view their medical records online? Will patients sign-up and use such features? Is the workflow change for my staff worth the effort?

These are common questions I commonly hear from our clients…My response is “What would your patients say?” I like being in a strategic position with our clients where we don’t have a product to sell or a framework for developing a cookie cutter solutions. Most vendor portal’s that I have seen are very much tied to a specific product and can’t take full advantage of all the features most requested by patients and their family members. As most who read this blog know both Google and Microsoft have made strides in providing a repository for your health data. This is not a new concept as we were designing this functionality back at HealthAnswers.com in the late 90’s (yes before the bubble burst).  Patients have come to expect online services from the vendors it visits most.  I hear age and patient demographics as common reasons as to why such initiatives would not be of much value.  Nonsense.  This may have been true 8-10 years ago but regardless of your social or economic stature most patients have or know of someone who has Internet access and uses it frequently to access information online.   I’ve worked on projects for several Academic Medical Centers in Houston, Indianapolis, and Richmond and have seen and interviewed the full spectrum of patients that have great payer mixes to the indigent population that depend entirely on care from residents at a nearby teaching hospital.  Navigating health care services is far more difficult when you are poor and unemployed than it is when you are a middle-class taxpayer with a good insurance policy.  The value from patient portals comes in the diverse range of patients you can serve effectively with the integration of a patient portal.

I spoke at length with the Microsoft team at HIMSS (Health Information Managment Systems Society) about their efforts in the PHR space. Not surprisingly they opted out of providing a front end solution to capture this information but chose instead to let third-party vendors create front-end solutions and letting Microsoft provide the infrastructure for storing and transmitting this data securely from system-to-system. My experience with this is that a lot of vendors provide export capabilities in their product for patient information however there are not a lot that import this data making it a one way street. Microsoft and Google are hoping to change this and create a more extensible way to exchange this data. One of our clients purchased a portal product for GE’s Ambulatory EMR application which provided export capabilities compatible with the Continuity of Care Record (CCR) Standard (E2369-05). The problem with this is that the patient doesn’t know what to do with a text file full of XML tags. I designed a web enabled reader for our client that would parse this data and format it in such a way that would at the very least allow the patient to view their personal health record instead of opening IE or notepad to stare at seemingly endless strings of data. Vendors need to enable the inclusion of style sheets (XLST) into the CCR document so that patients can have this data formatted for them properly and it wouldn’t be a stretch to embed formatting and logo references to tailor it to a specific customer.  Again, this is a little effort would make a big difference in the overall patient experience.