Erasmus Medical Center Netherlands

ENTERPRISE ARCHITECTURE

OF

DIABETES PATIENT PATHWAYS:

ERASMUS MEDICAL CENTER

Shirjeel Alam – 495357Marti Masters - 955568Ahmed Mubin Cevizci - 434869

Prof. M.T. SmitsTilburg Unversity, TiSEMP.O. Box 901535000 LE TilburgThe Netherlansds8/12/2014

CHAPTER ONE

1. INTRODUCTION

The patient pathway for modern healthcare generally involves multiple care givers at

different locations throughout a patient’s lifetime. This study focuses on patients with

diabetes in the greater Rotterdam area who receive hospital care at Erasmus Rotterdam

University Medical Center (Erasmus MC), either by referral for a specific treatment or

admission through the emergency room. The purpose of this study is to identify critical

pathways for diabetes patients in the context of creating an enterprise architecture

using the Picture Approach (Groot, Smits, and Kuipers, 2006) and developing a model

based on the theory authored by Ross and Weill (2006). along with analysis framed by

McDonald (2005), to discuss the relationship between healthcare processes and the

information systems which support them. Although not elaborated within this report,

business processes, such as billing and distribution of pharmeceuticals, also fall within

the scope of healthcare-related processes.

The goal of this study is to present recommendations in the context of enterprise

architecture for diabetes patient pathways with respect to Erasmus MC. In order to

provide a framework for our recommendations, we identified the electronic patient

heathcare medical record (EHR) as a critical information systems success factor because

it serves as common denominator for various diabetes patient pathways by facilitating

best medical services. Limitations of this study include the absence of empirical testing

for our recommendations because conducting a pilot test project and benchmarking key

performance indicators were beyond the scope of this assignment. However, based on

the results of similar case studies, where improvement of patient healthcare has been

measured after the deployment of patient pathways and related patient processes

supported by information systems, we will demonstrate that a similar positive outcome

may be expected for Erasmus MC and other healthcare providers in the greater

Rotterdam area.

2. WHAT IS DIABETES?

According to the MNT Knowledge Center (2014), diabetes is a metabolic health

dysfunction where the body fails to produce insulin or fails to react properly to insulin

production, commonly referred to as Type 1 and Type 2, respectively. The onset of

diabetes during pregnancy is denoted as Type 3 and other various causes are aggregated

together under Type 4.

Research conducted by the Center For Disease Control and Prevention (CDC) in the USA

indicates that 5 – 10 percent of patients diagnosed with diabetes are Type 1, which is

usually detected in young children (CDC, 2014). The cause is no insulin production

because the pancreas is not functioning properly. People with Type 1 diabetes have to

inject insulin multiple times every day to control blood sugar. They also have to monitor

their blood because if the sugar drops too low, they can go into shock and have a

seizure, which is life-threatening situation. According to the Mayo Clinic, a leading

research hospital in the USA, some Type 1 diabetes patients can use a pump instead of

an injection (Mayo Clinic, 2014). The pump has a terminus which is inserted into the

skin and insulin is injected at regular intervals. The pump is a small device worn around

the waist, which makes the device both inconspicious and fairly comfortable.

In a 2013 study, Boeren Medical in the Netherlands reported that although Type 2

diabetes has been traditionally associated with adults, the frequency of diagnosis in

children is increasing. The disease is characterized by the body failing to respond to

insulin, which is produced by the pancreas. People with Type 2 diabetes can usually

control their disease with proper diet and exercise.

According to the CDC (2014), over 380 millions people worldwide are afflicted with

diabetes and no cure exists for any diabetes type. Therefore, lifelong treatment is

required to regulate metabolic function by controlling glucose levels in the blood

through diet and exercise. Patients with diabetes depend on health care professionals,

such as a primary care physician, nurses, physician specialists, medical technicians,

nutritionists, and physical therapists, to assist with their treatments. A small percentage

of patients require mental health care to cope with anxiety or fears regarding treatment

procedures and/or complications of the disease. The MNT Knowledge Center (2014)

provides a comprehensive list of complications, which include problems with ciruclation

leading to leading to gangarene in the lower extremities, blindness, and heart attack.

Thus, diabetes is a serious medical condition requiring long-term health monitoring and

supportive care.

CHAPTER 2: METHODOLOGY

The framework for this study is based on the theories and models for enterprise

architecture proposed by several authors:

Groots, Smits, Kuipers (2006): The Picture Approach: A Method to Redesign the

IS Portfolios in Large Organizations.

Ross, Weill, and Robertson (2006): Enterprise architecture as a strategy. Creating

a foundation for business execution. HBS Press.

M.P. McDonald (2005): Architecting the Enterprise. An approach for designing

performance, integration, consistency, and flexibility. PhD thesis, Delft

University.

Qualitative research methodology provides a framework for this study. According to

Eriksson and Kovalainen (2008), “the business researcher is an interpreter who both

constructs the case and analyses [sic] it”. Specific elements of triangulation, namely:

data, investigator, theory, methodological, environmental (Guion, Diehl, & McDonald,

2011) were employed during the study to enhance robustness and validity. Exploratory

research involved canvassing available literature, online websites, and key artefacts,

such as official Erasmus MC enterprise architecture documents.

Data collection search techniques centered on keywords and phrases: patient medical

record, electronic health record, Erasmus MC, Rijnmond Portal, diabetes, EHR case study,

etc. Selected literature included academic peer-reviewed research studies, industry

journals, government and industry websites, and relevant news articles. Attempts were

made to locate case studies relating to diabetes patient pathways and EHR. To this end,

the EU Impact Report (2010) was selected as the single outstanding source for case

study research of regional healthcare information systems and EHR.

Empirical data was collected from the literature regarding financial statements, cost

analysis, patient care outcomes, and various statistics relevant to EHR. Although a

portion of the statistical data gathered was quantitative in nature, qualitative

interpretive analysis was employed to discover the meaning of the data and its

relevance to this study. An iterative process of analysis leading to further data collection

was followed until construction of an enterprise architecture for diabetes patient

pathways could be constructed and potentially useful, cost effective recommendations

with improved patient outcomes could be proposed. Due to the scope of this project,

these conclusions are limited, thus inviting future research.

CHAPTER 3: DIABETES PATIENT PATHWAY ENTERPRISE ARCHITECTURE

1. DIABETES PATIENT PATHWAYS

Several health care pathways are required to manage the complex, lifelong care of

diabetes patients. Erasmus MC has identified the following patient pathways:

2. THE PICTURE APPROACH EA DIAGRAM (see next page)

The current system complex deals with the patient care processes such as referral of patient

from primary care physician, appointment, registration, diagnosis of problem, in case it is

necessary, admission of the patient, treatment inside EMC, billing of the medical expenses

and aftercare treatment. These processes are covered only for diabetic patients.

Different modules within the EMC handle different parts of the process, while other tasks

are manually completed. Process handling in the system is focused around roles of internal

and external actors, including the patients themselves, as in some tasks are conducted by

the patients, such as transferring their referral letters and medical/prescription data

themselves from primary care physicians to EMC for non-integrated hospitals to EMC.For

the integrated hospitals, the data is transferred electronically. Data exchange in this future

system is done through centralized and standardized methods in order to minimizedata

transfer on paper between systems.Since EMC has got full control over internal system as

opposed to external partners, in this designed system, every data transfer between systems

are being done electronically.

The process we designed begins with patient going to primary care physician. After first

patient gets his/her diagnosis, there are 4 pathways for the patient treatment:

No Treatment; patient is doing ok with his/her current treatment.

Treatment Prescribed; patient receives a prescription for medication.

Glucose Test; primary care physicianasks the patient to get a glucose test from the nurse before leaving.

Referral to EMC; primary care physician finds something seriously wrong and refers the patient to a specialist.

After patient is referred to EMC, the process for treatment inside EMC begins. First, the

patient makes an appointment either via the “Reijmond Portal” by logging in or by calling

the Reception Desk at the hospital. In both activities, the appointment process is handled by

the “SAP Appointment System”. The “SAP Appointment System” uses “EMC Resource

Scheduling System” to fetch the list of available doctors and their schedules.

After patient’s arrival to EMC on appointment date, if patient has never registered in

“SORIAN Electronic Health Record (EHR) Management System”, then the patient registration

is performed. First “Reception Desk” checks whether patient’s provided information correct

or not and then registers the patient through “SAP Patient Administration System”.

If the referring health care provider is not integrated with EMC, the referral document is on

paper. Otherwise, the referral document is electronically transmitted to the “SORIAN

Electronic Health Record (EHR) Management System” from external health care providers.

After the registration, the patient waits in the waiting room until called to the examining

room, where the medical specialist is ready to begin treating the patient. During the

diagnosis process, the specialist can order lab tests. Lab results may be entered into

“Laboratory Management System” through integrated laboratory equipment electronically

or manually by laboratory technician. After the diagnosis, which results in updating the

patient’s EHR, the specialist may decide to perform one or more of the following actions:

Prescribe medication

Transfer of patient to another hospital due to lack of equipment or expertise in EMC

Admit the patient to EMC for in-patient care

Perform additional treatments, which may be out-patient services or require formal admission as an in-patient.

In case of in-patient admission the specialist or a medical assistant performs this action

through the “EMC Resource Scheduling System”. Next, the nurse or medical assistant in

charge of admission of patients admits the patient in either the “Acute Care Unit” or

“Intensive Care Unit”, based on the specialist’s designation.

As a result of admission or same day treatment, patient is assigned a presiding physician,

which could be the specialist who ordered additional treatment at the hospital. In ACU or

ICU, the presiding physician treats the patient and prescribes necessary medicine. This

hospital pharmacy supplies the appropriate medications, which the appropriate medical

personnel administer to the patient. All of the actions performed by presiding physician are

managed by “SORIAN Electronic Health Record (EHR) Management System”. As a result,

every action and treatment performed during patient’s stay is managed by a centralized

system used throughout EMC. During this process, in case of surgery or some other scenario

which prohibits visits of patient’s relatives, relatives can check the patient’s current situation

through “Reijmond Portal” if they have been granted the appropriate access permissions.

After successful treatment of the patient, the presiding physician can decide to discharge the

patient by using the “EMC Resource Scheduling System” which updates the patient’s EHR.

Upon discharge, the digital document of every medical service provided to patient and

recorded by the “SORIAN Electronic Health Record (EHR) Management System” is coded and

transferred to the “SAP Billing System”. For patients without insurance, the patient may

provide billing information, which is entered into the “Payment System” of EMC. For

patients with health insurance, the invoice is transferred to the “Bookkeeping System” of

EMC. The “Bookkeeping System” generates the financial statements of patients and sends

bi-weekly requests to insurance companies for request for payment.

Patients may also be treated by external health care providers, such as psychologists,

dieticians and physio-therapists. In this process, patients can use various applications like the

ones listed below:

Blood Pressure - provides blood pressure measurements to “SORIAN Electronic Health Record (EHR) Management System”.

Smart Watch App - reminds the patient to take his/her medicine and provides feedback data to “SORIAN Electronic Health Record (EHR) Management System”.

Questionnaire App - helps patient to self-diagnose his/her illness in order to decide whether he/she needs to see a doctor or not.

Online Medical Advisior App - which help patient to maintain wellness of his/her psychology which provides feedback data to “SORIAN Electronic Health Record (EHR) Management System”.

Digital Scale App - which provides digital measurement data of patients weight measurements into “SORIAN Electronic Health Record (EHR) Management System”.

Personal Organizer App - which gives medical advices and reminds patients to what he/she should do to stay healthy, which provides feedback data of patients lifestyle into “SORIAN Electronic Health Record (EHR) Management System”.

3. ELECTRONIC PATIENT HEALTH RECORD (EHR)

The flow of patient information in the Erasmus MC enterprise architecture proposed in

this report for diabetes patient pathways hinges on an electronic patient health record

(EHR) as the fundamental data artefact, which follows the patient from beginning to end

in each pathway. In Europe, the creation and maintenance of patient medical history in

a computer informtion system is formally termed the “Electronic Healthcare Record

(EHR)”. Häyrinen, Saranto, & Nykänen (2008) define the EHR as a “repository of patient

data in digital form, stored and exchanged securely, and accessible by multiple

authorized users.” The EHR is intended to provide a platform for multiple-user access by

authorized persons, including the patient, medical professionals, healthcare

administrators, pharmacies who distribute mediations, and billing agents, which includes

insurance companies. Compared to paper records, which for a single patient may be

scattered across different healthcare providers, the EHR offers the means to consolidate

patient medical information into one shared repository. In addition, the structure of

patient data in a pre-defined format allows for uniform record-keeping with the purpose

of fostering clear communication regarding a patient’s health and well-being.’

In 2010, the EU Commission launched Europe 2020, a 10-year strategy for economic

growth and social well-being, which included health care and support information

systems. According to Kierkegaard (2011), The Data Agenda for Europe (DAE) “focuses

on sustainable growth through ICT” by establishing an eHealth governance framework

and “… and thus encouraging the development and adoption of electronic patient

records throughout Europe.” Kierkegaard identifies sharing patient information as a key

benefit of eHealth. According to Carter (1999), an open health record can improve

medical care on many fronts, especially the doctor-patient communication. In particular,

improving the data flow between patients and care providers reduces the number of

medical errors and enhances overall care quality. (Institute of Medicine, 2001)

Unfortunately, establishing a uniform EHR in Europe has been complicated by the

passage of recent EU legislation. The Treaty of Lisbon was enacted on 1 December 2009

(EPHA, 2014). Intended to reform EU law to facilitate unity among EU member states,

its impact on uniform healthcare standards was eroded by Article 168 TFEU. According

to the European Public Health Alliance (EPHA), ”The Union shall fully respect Member

States responsibilities for the definition of health policies and organizing, delivering

health services and medical care, and... the allocation of the resources assigned to

them.” (www.epha.org) Although the purpose of the law was to preserve the type of

health care system preferred by individual nations, namely the bismark system versus

the beverage system, no legal addendum was included to allow for EU-mandated

standards for uniform EHR.

4. THE ROLE OF THE EHR IN THE DIABETES PATIENT PATHWAY

Central to the platform for modern quality healthcare is the creation and maintenance

of an electronic patient health record (EHR). The creation of the Rijnmond Portal plays

a key role in providing access to a standardized EHR for stakeholders in the Greater

Rotterdam Region of the Netherlands. Currently, the Rijnmond Portal is being

established as gateway for the exchange of patient information, online consultation with

primary care physicians and other healthcare providers, as well as a repository of videos

covering various medical conditions, and much more (Institute of Health Policy

Management, 2014). A fundamental assumption of this study is that the Rijnmond

Portal will service the EHR by providing for multiple views and real-time updates. We

will discuss how applications related to diabetes may be included in the software

portfolio supported by the Rijnmond Portal to enhance the treatment of diabetes

patients in chapter 5: RECOMMENDATIONS.

CHAPTER 4: ROSS & WEILL / McDONALD

Use the OM to define the current Enterprise Architecture and design the core diagram (see book for examples).

Erasmus Medical Center (EMC) is a provider of healthcare services. Their focus is to provide

an integrated patient care service across all care pathways and centers. For this purpose it is

required that the patient information be available centrally in the form of an Electronic

Health Record (EHR). In the core diagram we depict that the patient EHR is located centrally

as an operational data store and all stakeholders can get access to the data using a web

portal i.e. the Rijnmond Portal.

Coordination Core Diagram

Determine the Maturity Level of the current architecture. Can the organization increase its maturity level? If yes, how?

According to Ross & Weill, firms navigate a fairly predictablepath to achieve a foundation for

business execution and follow a consistent pattern for building out their enterprise

architectures. It states that an organization will pass through four stages of architecture

maturity. This capability mautrity model was developed by the MIT Sloan Center for

Information Systems Research. Each stage involvesorganisational learning about how to

apply IT and business process discipline as strategic capabilities. As companies move through

each stage they can realise benefits ranging from reduced IT operating costs to greater

strategic agility. The four stages are as follows:

Business Silos Architecture - company investment is focused on meeting individual business unit needs.

Standardized Technology Architecture - increase IT efficiency through technology

standardization. Optimized Core Architecture - standardizing data and processes as appropriate for

the operating model. Business Modularity Architecture - design loosely coupled IT-enabled business

process components which allows company to manage and reuse them.

The Maturity Level of the current architecture of EMC is at the Standardized Technology

level. The reason for this is that EMC has moved from the local view of the needs of each

department to a comprehensive enterprise view. They have focused IT investment in

Enterprise Systems. With the use of the Rijnmond Portal and the Patient EHR data has

become more standardized and less redundant. Moreover the data is stored centrally which

is accessible by all stakeholders.

The maturity level of EMC can be increased to OptimizedCore level by making use of an

Enterprise Application Integration (EAI). EAI can standardize communication between

medical partners using a set of available communication technologies. It will also help in

standardizing processes shared across multiple systems within the organization.

What is your advice on the IT engagement model?

Ross & Weill define an IT Engagement model as “the system of governance mechanism

ensuring that business and IT projects achieve both local and company-wide objectives”[1].

The authors of this report would advice EMC to follow a similar IT Engagement model that is

similar to the model of other large organizations. The illustration below is an example of

such an engagement model:

IT Engagement Model

IT engagement model in large companies has 6 stakeholders: senior management

(enterprise-level), middle management (business unit level), team management (project

management level). Each of which exist on both the IT and business side of the company.

Ross & Weill also defines three main ingredients in an IT engagement model as follows:

Companywide IT Governance

Project Management

Linking Mechanisms

Before developing a transparent IT engagement model EMC must tackle two challenges:

Coordination and Alignment.

With reference to IT governance, five major decision areas can be identified: IT principles,

enterprise architecture, IT infrastructure, business application needs and prioritization and

investment. IT principles apply to high-level decisions about the strategic role of IT in the

business. As for EMC, three decisions encompass IT principles. The first one concerns the

creation of a firm ICT foundation (“basis op orde”) (2a EMC Intro, 2014), the second refers to

the maximal use of the functionality embedded in current systems and the last focuses on

the innovation in e-health, collaboration and data management (2a EMC Intro, 2014).

IT infrastructure is an area in which centrally-coordinated IT services provide part of the

foundation for execution. Within IT infrastructure EMC aims to rationalize the application

landscape and attain the high-quality data management with the reusability of data. It puts

emphasis on rich in functionality and highly integratable systems. It seeks to achieve as

much standardization as possible (2a EMC Intro, 2014).

Business application needs describes the plan for purchased or internally developed IT

applications that build the foundation for execution (Ross, Weill & Robertson, 2006). EMC

strives to redesign best of breed solution and opts for suite solutions. Another objective is to

improve registration and patient data retrieval and strorage.

Lastly, prioritization and investment refers to the volume of investment in IT, project

approval and justification. EMCgives importance to the advancement of registration and

data management as well as the improvement of operational management processes within

ICT. Among others, some goals to be attained include Business Intelligence and Knowledge

discovery, eHealth and triple A integration: any device, any place, any time (2a EMC Intro,

2014).

In order to successfully fit IT into the business model, appropriate standardized project

methodologies need to be adopted (Ross, Weill & Robertson, 2006). These are clearly

defined process steps with distinct deliverables. EMC strives to achieve top-notch patient

health-care and innovation. To reach a satisfactory level EMC will align its IT infrastructure so

that it is better integratable and standardized and therefore can serve the above-mentioned

purposes. For this we recommend that EMC adopt a project methodology that has well

defined process steps. Furthermore that milestones be set in projects where deliverables

can be checked and reviewed against project plans. Lastly, it keeps track of good metrics for

project performance assessment.

Linking mechanisms present the third critical component of the IT engagement model and

comprise architecture linkage, business linkage and alignment linkage. The coordination of

the aforementioned parts ensures the incremental expansion of the company’s foundation

(Ross, et al., 2006).

On account of EMC having been identified at the standardized technology maturity level, it is

assumed that linking mechanisms exist at a very preliminary stage and are insufficient to

state that EMC possesses a complete IT engagement model. Some progess can be made

towards a better IT Engagement model by having clear, specific and actionable objectives,

along with motivation in the organization to meet its goals. This means that EMC should

engage IT groups in the early stages of development to assure the quality of developed

solutions by organizing an enforcement authority to facilitate and promote effective

communication among business units and IT across the organization.

Define the EA capabilities (McDonald) for EMC. Define the full set of capabilities needed for the value proposition to the client(s).

EMC, largest and one of the most authoritative scientific University Medical Centers in

Europe, works to offer the best service to its patients. EMC wants to aid its customers in the

best way possible to ensure a profound medical treatment. During this treatment process

many stakeholders and business processes are involved. In order to get a better view on

these processes and on EMC’s enterprise architecture, actors, capabilities and interactions

are mapped in several models. These models are based on the approach of McDonald

(2005), who lists three types of key models, namely: The Value Network Diagram, the

Capabilities Diagram and Capability Blueprint.

McDonald’s models show a collection of items and their relationships between them. In the

case of EMC the first model is a Value Network Diagram, which shows the enterprise and its

scope of operations involved in serving the business around it. The Capabilities Diagram is a

more in depth model which illustrates the interactions involved in supporting the Value

Network, in this model interaction between the different capabilities are described. An

example here is the interaction between medical treatment, billing the customer and

checking patient health insurance coverage with the insurance companies outside the EMC

environment. The last model is Capability Blueprint, which describes the business elements

within a capability, these business elements define how the capability operates, achieves its

strategy and meets its performance requirements.

To get a better understanding of what the capabilities of EMC are, we first analyzed what

value proposition EMC offers to its customers as well as what its current processes are

regarding their services. Moreover EMC’s strategic goals have also been taken into

consideration to guage its current capabilities and what they should be in the future. To

differentiate from other hospitals and in order to provide the right healthcare to its

customers EMC has the following value propositions:

Based on services and processes

o Cooperation and communication with health insurance companies.o Cooperation with other hospitals and medical professionalslike physician,

nurse, dietician, psychologist, physio-therapist etc.o Provide fast care with reasonable costs.o Research facility.o Create and maintain high expertise within EMC.

Based on EMC current vision

o Maintain and provide high quality of care.o Strategic alliances.o Added value for patients &personalized medicine.o Research and development. o Interpretation of the process instance history. o Raising patient empowerment.

These value propositions aid in the goal and future business of EMC. On the basis of given

and obtained information about EMC we define capabilities as follows:

Patient Appointment Patient Registration Patient Diagnosis Medical Laboratory Test Patient Referral Patient Admittance Patient Treatment (ACU & ICU) Medical Knowledge (Research) Patient Billing Patient Knowledge and Interaction

Which of these capabilities are internal, which are external?

There are two types of capabilities, internal and external. Internal capabilities represent the

internal capacity of the enterprise and external capabilties help maintain a good relationship

with external stakeholders:

Internal Capabilities

o Patient Appointment

o Patient Registration

o Patient Diagnosis

o Medical Laboratory Test

o Patient Admittance

o Patient Treatment (ACU & ICU)

o Medical Knowledge (Research)

External Capabilities

o Patient Referral

o Patient Billing

o Patient Knowledge and Interaction

Determine the Value Network Diagram (see book for examples), the capabilities diagram, and the capability blue print

A value network diagram provides a high-level orientation view of an enterprise and how it

interacts with the outside world. The diagram focuses on presentational impact. The

purpose of this diagram is to quickly on-board and align stakeholders for a particular change

initiative, so that all participants understand the high-level functional and organizational

context of the architecture engagement. An illustration of Erasmus MC is shown on the

following page.

Value Network Diagram

A capabilities diagram outlines the relationships between an enterprise’s capabilities. This

includes adding information flows between the internal capabilities and the interactions of

internal capabilities with the external actors. These flows and interactions represent how

the internal capabilities of the organization provide value (see next page for illustration).

The capability blueprint shows a palette of elements that integrate to deliver the required

performance and strategic outcomes regarding a specific capability.According to McDonald

(2005), each capability consists of parts defining the execution of that component, it’s

operational characteristics and capacities. Based on the value network and capabilities

diagrams, the capabilities blueprint provides the essential parts to implement each

capability in the organization. The strategy for EMC is to empower patients to control their

treatments and records, form strategic alliances for added value towards the patient and

have a streamlined organization. Subsequently, the capabilities are focused to provide care

to patients, balancing centralization and decentralization and abilities to connect to the

environment. This leads to aimed performance values by EMC of care quality, market share

and efficiency (see next page).

Capability Blueprint

Based on your answers on the previous questions, discuss how the Ross&Weill approach differs from McDonald

Though the Ross, Weill & Robertson and McDonald models bear some significant similarities

such as the design of operational behaviour (McDonald) and the identification of the

operating model (Ross, Weill & Robertson) they do differ in a distinct manner. First of all, at

the very beginning McDonald examines a functional decomposition that splits the problem

into components without investigation into their integration and cooperation. As opposed to

McDonald, Ross, Weill & Robertson begin with the evaluation of the operating model, which

comprises multiple scenario how enterprises handle integration and standardization.

Another fundamental difference is that Ross, Weill & Robertson start with the business

organization related to the customer (based on standardization and integration). On the

other hand, Mcdonald starts with the organization and its value network as basis, so more

than just the customer with less emphasis on the internal processes (standardization) and IT

(integration). Furthermore, a huge disparity in approaches relates to the scope of research.

Ross, Weill & Robertson aims to align IT to the business, whereas McDonald focuses on

consolidating capabilities in line with the value network and business strategy. Thus, in the

McDonald’s framework IT is considered a part of the business (not a major constituent

besides business component as it is in the Ross, Weill & Robertson model) and has several

connections with other elements/capabilities. Indeed, Ross and Weill’s attention boils down

to business and IT, McDonald’s model is much broader and incorporates a multitude of

perspectives. As such, Ross, Weill & Robertson can be perceived as a more technical-

oriented. Apart from this, Ross, Weill & Robertson present maturity levels that impact the

degree of standardization and integration. McDonald does not implement maturity levels at

all but concentrates on the development of capabilities to operate in the value network.

What integration strategies would you recommend regarding the connection with the external sources of information?

EMC wants to integrate with external sources of information in order to standardize patient

health records through better data and system integration. For the purposes of

recommending an integration approach we studied Laenen and Vennekens (2010). For EMC

the only external parties that they want to integrate with are other hospitals. This step is

necessary in order to improve both data standardization and system integration as both

systems want to share information for mutual benefit.

The integration strategies discussed in the paper are as follows:

Autonomy - Two actors stay as independent as possible from their counterpart. The

interaction between the parties is based on data exchange, instead of having a

deeper level of integration.

Interoperability - Following this strategy, actors use to communicate connection

possibilities to the outside world. There is no mutual alignment of the chain business

processes. The difference between Autonomy and Interoperability is that Autonomy

has an internal focus, but Interoperability has the external focus.

Integration - Adopting this strategy, an organization tries to increase the level of

maturity with its counterpart. Two actors try to coordinate their processes as much

as possible.

Since we are trying to improve the communication with other hospitals in order to offer a

higher standard to the patients, we assume the most appropriate strategy will be

integration. The reason being that the flow of information should be two-way between the

parties and a higher level of coordination will be necessary to strengthen the linkage points

between the organizations. Autonomy could also be an integration strategy between in this

case. However, as stated in the paper, this strategy does not offer a high level of maturity.

We believe the interaction between the hospitals will be intensive and having maximum

possible alignment is more convenient. For achieving the integration strategy, other

hospitals will have to use specific modules deployed on their EAI system that enables two-

way communication.

CHAPTER 5: CONCLUSION AND RECOMMENDATIONS 1. PROVIDE DIABETES VIEW TO EHR INTERFACE

According to the Rijnmond Portal technical specifications, (van Pelt, Stichting Rijnmondnet:

Technischekennissessie, [no date given]) the IHE Patient Care Coordination Profiles includes

a Care Management (CM) specification for the information exchange for managing specific

health conditions. Currently, a search method is proposed for creating views based on key

words, with an example, “CT of the Head”. The authors of this study suggest that a key-

word search for diabetes patients be replaced by a standard view based on a date range,

containing the following field data to facilitate rapid disemination of critical diabetes medical

information and ease-of-use:

DIABETES VIEW

name

birthdate

country of residence

primary care physician

primary care physician contact information

patient emergency contact

diabetes type (I, II, III, IV)

date of original diabetes diagnosis

current medications

allergies (general)

drug allergies

blood type

most recent blood glucose test results (pop-up window)

complications (blindess, amputations, seizure, etc. pop-up window)

other chronic health conditions

history of diabetes treatment in reverse chronological order (date range or ALL)

2. MAP THE PATIENT JOURNEY

According to the National Health Service Institute for Innovation and Improvement (NHS

Institute) in Great Britain, the objective of constructing patient pathways is to visualize

patient flow as a process within a health care provider and/or within a network of

healthcare providers. Regardless of whether the view is strictly internal to one

organization or includes externals views as well, the objective is to streamline the

patient flow to improve efficiency of the health care organization’s operations in the

belief that streamlining patient processes will result in positive treatment outcomes and

patient satisfaction. Typically, the steps outlined in the patient flow illustrate

movement of the patient from an enterprise-wide view without taking the clinician’s

perspective or the actual feelings and experiences of the patient into full account .

(NHS Institute, 2013). Researchers Layton, Moss, and Morgan (1998) conclude that

physicians and nurses view patient pathways as a series of medical protocols with a

limited understanding of the patient flow throughout the entire organization,

particularly in large health care institutions, such as regional hospitals. For the patient

himself, following a complex pathway involving several health care providers has an

emotional impact where “the patient as a traveler may feel more like an intrepid

explorer continually coming up against the unknown rather than a modern traveler

whose journey has been planned with a travel agent and who has possession of a

detailed written itinerary.” (Layton, Moss, & Morgan, 1998).

A 2014 study by the Medical Directorate, NHS England, reports the urgent need for

health care providers to “empower patients with information to support their choices

about their own health and care and support the development of IT solutions that allow

sharing of information between providers and people with diabetes.” (NHS England,

2014). According to the study, a survey conducted during a recent audit revealed that “

80% of people with diabetes in hospitals said that they weren’t involved in the design of

their care plan, and less than half had been allowed to self-administer insulin.” (NHS

England, 2014). It stands to reason that a patient who injects insulin at home several

times a day may view health care providers as condescending or feel like an object

instead of a person in a hospital, where multiple caregivers come and go in the course of

a patient’s stay. Therefore, it is critical for health care providers to engage the patient

and recognize patient self-care competencies during treatment at a healthcare facility.

We believe that The NHS England study is relevant when considering that the Global

Burden of Disease Study 2010 indicated that the United Kingdom enjoys the lowest early

mortality rate due to diabetes in a comparison of 19 highly developed countries (Lancet,

2013).

In a previous chapter of this report, the authors constructed several pathways for

diabetes patients from the viewpoint of an enterprise architect in the context of a

regional health care system. We discovered that our diagrams focus on health care

providers and related service providers, such as insurance companies and pharmacies.

This may result from our belief that by identifying these entities and their interactions

with the patient, an information system which supports the aggregated processes can be

properly envisioned. Although EA intends to streamline services with the goal of

providing the best level of health care for patients and strives to achieve all the benefits

of preventive health care, the whole system would collapse if one key stakeholder were

removed: the patient himself/herself. For lifelong physical ailments such as diabetes,

current trends in health care EA depict patient-centric diagrams and map the “patient

journey” in a holistic manner from the patient’s point of view. (New England Health

Care Institute Client Conference, 2008). This view is centered on the patient

himself/herself, who looks outward to heath care service providers, which is in direct

contrast to the traditional patient flow diagram, where the starting point is the patient

making an appointment with the primary care physician or arriving at the emergency

room in a hospital.

3. CREATE A DIABETES VIRTUAL MENTOR FOR THE RIJNMOND PORTAL

According to Ali, Rana, Hardisty, Subramaniam, & Luzio (2004), “effective management

of complex conditions like diabetes requires a more fastidious, continuous, personalized

approach.” With today’s modern information systems, interactive software provides a

means to share quality data between the patient and multiple health care providers. A

key success factor is empowering the patient to be an active participant. Specialized

software applications serve as virtual mentors, providing a host of services the patient

may utilize to support self-maintenance of their diabetes condition. According to Ali, et

al., (2004), “The challenge is to make this type of management routine and design the

‘right’ tools to support it in real-world situations.”

One of the fundamental activities is the administration of insulin multiple times a day.

Below is the administration of insulin from a patient’s point of view as described by

Michael P. Hall of Human Care Systems, Inc. (USA) in a 2011 presentation :

According to Hall, the patient journey approach focuses on all aspects of self-

management by asking the question, “What are the physical, cognitive, emotional,

behavioral, and social experiences the patient goes through?” Hall concludes that a

“multi-channel (web, mobile, live, printed) integrated engagement patient management

platform to connect data to effective patient self-management based on behavioral

science” is both cost-effective and results in better patient outcomes by increasing

patient adherence to self-maintenance (Hall, 2011). By adding specialized virtual

mental software applications to enhance the patient journey promotes patient well-

being in a cost-effective manner (NHS England, 2014).

A 2004 study, an integrated care pathways (ICP) “enables clinics to deliver health care

to patients based on their particular needs.” (Ali, Rana, Hardisty, Subramaniam, & Luzio

2004). The delivery of ICP through portals linking healthcare information systems is the

key driver for successful self-maintenance for diabetes patients. The study concludes

that diabetes software application functionality provides a pathway to manage

“individual patient needs, with their full understanding and active participation.” (Ali, et

al., 2004).

Example of Portal application for holistic diabetes patient care (Ali, et al., 2004):

In conclusion, the enterprise architecture presented in this report clearly shows viable

patient pathways, which include treatment at Erasmus MC. Contingent on the

succcessful implementation of such an EA in real life, the EHR and Rijnmond Portal must

be fully operational. Thus, the EA presented in this report is a future vision.

By analyzing the flow of information and understanding the processes involved in the

treatment of diabetes, the authors realized that a patient-centric pathway focusing on

the viewpoint of the patient, would lend a valuable dimension to the EA. Software to

support the patient journey also relies on the Rijnmond Portal. Our recommendations

include a “diabetes view” to enhance the EHR, including the “patient journey” as a

formal part of the EA for medical conditions such as diabetes, which require daily patient

self-maintenance, and the creation of a “diabetes virtual assistant”, which is an integrate

software application designed to motivate and support the patient as well as providing

important information updates to appropriate health care providers.

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