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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WWDC… The long, long, wait

Waiting in line is one of the many memorable events at WWDC. I’ve met several people from all over the world.

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Apple World Wide Developer Conference 2013

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In less than 24 hours, the first Apple event in at least 6 months will be underway.  There are a lot of eyes on Apple given their incremental product releases.  Rumors abound about what will be unveiled however it seems a safe bet given the signs that are posted in the Moscone center that Apple will focus heavily on the OS X and iOS.  Apple has released the innovative MacBook Pro with Retina Display and manufacturers have yet to really catch up with the design or hardware specs of this product so it makes sense Apple innovates in the software in their portfolio.

Follow-me on Twitter @cary_brown for updates…

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Certified ScrumMaster

I wrapped up training two weeks ago to be come a Certified ScrumMaster.  The course was a solid foundation on the fundamentals of Scrum and the process of product management and development in an agile environment.  While I’ve participated in Scrum sessions many times in the past this formal indoctrination into the process was very insightful and will prove very useful in future meetings with teams.  Most sessions you see in practice are variations of the real process which, to the Scrum Alliance’s credit, has evolved and been refined over the years is actually very good.  With some effort, practice, and discipline of your teams the breakdown of product backlogs, into deliverable sprints could prove fruitful for any product focused company.

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Book Review: REWORK

I just finished reading one of the most refreshing books I’ve come across in quite awhile.  The team from 37signals offer up a great perspective on creating a fast moving agile organization that focuses not on one-up’ing your competition but delivering services or products that actually make a difference to your employees and customers.  To borrow from the book what you don’t do is just as important if not more so as as what you do decide to offer in a design, product, or service.   Fried and Hansson show how easy it is to get lost in the mainstream of today’s larger organizations and how many organizations become handcuffed by many of the typical notions of how business should be run.

 

 

Rework offers a refreshing series of essays covering a variety of topics many startups and nascent entrepreneurs would be wise to follow.    From the cultivation of a “culture” to the core of what drives your business…the people and hiring those who are really driven and will help your organization grow by sparking a passion and desire to build not just profitable but exciting organizations your employees and customers can get behind.

You can find Rework on Amazon here

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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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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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San Antonio HIMSS August Meeting

Join us on August 19th Educational Session at Dave & Busters at 11:30 a.m.
To register online visit our website at www.sahimss.org or click Register Securely Online here

Our speaker this month is Bill Oldham, President & CEO, Evolvent Technologies, a rapidly growing provider of health IT services and solutions for the Military Healthcare Systems as well as online security services for government and commercial sectors. Since taking the helm in 2005, he has led Evolvent’s growth from a $5m company in 2004 to more than $60m in 2010 and expansion from its original location in Falls Church, VA to two additional Washington, DC area offices in the Dulles corridor and also San Antonio, TX. Mr. Oldham has an extensive background in technology and finance. His experience includes serving as Vice President of Technology Applications at Danya International; Project Director at MeduNet, a $100m international health information network project, as well as Chief Operating Officer of a Wall Street startup, IDEAglobal, providing online, real-time forecasting and analysis to the financial world. Mr. Oldham received his MBA from Manchester Business School in Manchester, England and has served as a management consultant to organizations as varied as Roche, Littlewoods plc, and Johns Hopkins University. Mr Oldham is the lead author of Better Data for Better Care, 2010, a book on leveraging technology to transform the management and delivery of care and he is also the co-author of Securing Business Intelligence – Knowledge and Cybersecurity in the Post 9/11 World, Evolvent, 2004.

We anticipate a large showing for Mr. Oldham’s presentation so please register today as we will close registration once all spaces are filled.

Don’t forget to follow our Twitter feed @sahimss or visit our website www.sahimss.org for future educational sessions and networking events.

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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…”