Toward A Universally Connected Healthcare Network By Jian (Jeff) Zhong Chief Technology Officer (Acting) Chief Architect for SOA & Cloud Computing FUTREND Technology Inc.
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Toward A Universally Connected Healthcare Network
By Jian (Jeff) ZhongChief Technology Officer (Acting) Chief Architect for SOA & Cloud Computing
FUTREND Technology Inc.
Agenda
Healthcare In the United States of America
Service Oriented Architecture after the 2008 Financial Crisis
National Institutes of Health SOA Case Study
Research on Published SOA Case Studies Federal Health Architecture Connect Open Source
Harvard Pilgrim Health
Harvard Medical School
University of Pittsburgh Medical Center
Medical Imaging at University of Chicago Hospitals
MEDICUS for 200+ Sites at Children’s Oncology Group
The Vision of Universally Connected Health
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HEALTHCARE IN THE UNITED STATES OF AMERICA
More expenditure does not mean better quality
Total spending: $2.5 trillion in 2009
Per person: $8047 in 2009
17% of GDP in 2009
Medical causes were cited by 50%+ bankruptcy filings
Medical adverse events:
3rd leading cause of death in USA
Direct economic cost of over 53 billion a year
Medical tourism: in 2007, 750000 Americans traveled to other countries for medical care
Healthcare quality not the best, behind England, Taiwan and many others
Healthcare in the United States of America
Source: http://en.wikipedia.org/wiki/Health_care_in_the_United_States
Top 10 Healthcare Systems by Revenue
2008 (in millions) 2011 Market Cap
1. U.S. Veterans Affairs Dept $40,686.5 Government
2. HCA, Inc. (HCA) $28,374.0 17.84 Billions
3. Ascension Health $12,720.6 Private
4. Community Health Systems $10,840.1 Private
5. NY Presbyterian Healthcare Sys $8,458.3 Private
6. Tenet Healthcare Corp. (THC) $8,348.0 3.14 Billions
7. Catholic Health Initiatives $7,817.1 Private
8. Catholic Healthcare West $7,596.2 Private
9. Sutter Health $6,874.0 Private
10. Mayo Clinic $6,143.5 Private
Top Ten’s Cumulative Revenue: $137,858.3
Source: http://www.darkdaily.com/nations-list-of-top-ten-largest-healthcare-systems-include-some-surprises-113
EMR Adoption ModelSM
Q3 2010 – 2010 Final
Data from HIMSS AnalyticsTM Database N = 5,281 2011 HIMSS Analytics
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
Stage 7
Stage 1
Stage 0
CDR, Controlled Medical Vocabulary,
CDS, may have Document Imaging; HIE capable
Nursing/clinical documentation (flow sheets), CDSS
(error checking), PACS available outside Radiology
CPOE, Clinical Decision Support (clinical protocols)
Closed loop medication administration
Physician documentation (structured templates), full
CDSS (variance & compliance), full R-PACS
Complete EMR; CCD transactions to share data; Data
warehousing; Data continuity with ED, ambulatory, OP
Ancillaries – Lab, Rad, Pharmacy – All Installed
All Three Ancillaries Not Installed
1.0%
3.2%
4.5%
10.5%
49.0%
14.6%
7.1%
10.1%
TOP VENDORS OF ENTERPRISE EMR SYSTEMS
Source: http://www.darkdaily.com/ranking-top-10-hospital-emr-vendors-by-number-of-installed-systems-32511
Vendor Name Total Installations Percent of Installations
• Meditech 1212 25.5%
• Cerner 606 12.8%
• McKesson 573 12.1%
• Epic Systems 413 8.7%
• Siemens Healthcare 397 8.4%
• CPSI 392 8.3%
• Healthcare Management Systems 347 7.3%
• Self-developed 273 5.8%
• Healthland 223 4.7%
• Eclipsys (Bought by Allscripts) 185 3.9%
What does Wall Street expect from Healthcare IT?
Source: Yahoo! Finance
CERNER Corp
Founded in 1979, headquartered in North Kansas City, Missouri
Over 8000 employees
Industry: Healthcare Information Services, second largest EMR vendor
Mission: transforming health care by eliminating error, variance and waste for health care providers and consumers around the world
Stock price $0.4 in 1990 and now is about $120
Total market cap about 10 billion
ARRA: Public Law 111-5 and was signed on February 17, 2009 by President Barack Obama
Title XIII of ARRA: Health Information Technology for Economic and Clinical Health Act (HITECH)– $20.819 billion in incentives through the Medicare and Medicaid
reimbursement systems to assist providers and organizations in the adoption of electronic health records.
– $4.7 billion for National Telecommunications and Information Administration’s Broadband Technology Opportunities Program.
– $2.5 billion for the U.S. Department of Agriculture’s Distance Learning, Telemedicine, and Broadband Program.
– $2 billion for the Office of the National Coordinator (ONC).
– $1.5 billion for construction, renovation, and equipment for health centers through the Health Resources and Services Administration.
– $1.1 billion for comparative effectiveness research within the Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health (NIH), and the Department of Health and Human Services (HHS).
Source: http://www.ahima.org/advocacy/arrahitech.aspx
Image Source: The Economist
The American Recovery and Reinvestment Act (ARRA)
SERVICE ORIENTED ARCHITECTURE
Resurrection after the financial crisis
Service Oriented Architecture
A new paradigm of distributed computing
About 8 design principles and numerous design patterns
Pronounced dead in 2009
Resurrected after financial crisis
Become more business driven and agile
RESTful services into mainstream
Complement with Cloud Computing
Infrastructure, Platform, Software as Services
Better integration and improved interoperability
The Great ArchitectOscar Niemeyer
Designed public buildings in the city of Brasília, and the United Nations Headquarters in New York City
Source: Wikipedia, the free encyclopedia
Architecture – From Abstract Design to Concrete Results
The Medical SOA Analogy
SOA as Food or Medicine
Fully tested for efficacy and safety
Prototype and Pilot before mission critical usage
No one-size-fit-all panacea, specific solutions for specific problems
A medicine can be used/reused for patients with similar problems
Source: NIH web site image bank
NIH BUSINESS SYSTEM SOA CASE STUDY
SOA reduced cost, improved quality and streamlined business
National Institutes of Health (NIH)
World’s foremost medical research organization
Begun as a one-room Laboratory of Hygiene in 1887
Annual grants of more than $25 billion (US)
Supports 325,000+ research personnel at 3,000+ institutions located in 90+ countries
More than 130 researchers funded by NIH received Nobel Prizes
Source: NIH web site image bankSource: NIH FY 2011 Director Perspective
Largest hospital devoted to clinical research in the United States
Located in Bethesda, Maryland, USA
6,000 inpatient admissions annually
95,000 outpatient visits annually
Some 1,200 credentialed physicians, dentists, PhD researchers; 620 nurses
Patients travel from the United States and around the world for care
Source: NIH web site image bank
NIH Clinical Center
Source: NIH Clinical Center 2011 Profile
NBS SOA Overview:
Started SOA implementation in 2007
NBS program holistic approach for entire enterprise-level integrations
Followed NIH enterprise architecture (EA) and SOA guiding principles
Utilized the existing NIH CIT/ISC and NBS infrastructures
Successful NBS SOA Implementations:
Travel – the first successful SOA implementation in eTravel among all Federal agencies (average 8,000 transactions/month)
Federal Acquisition (two contracts) – the first NBS SOA implementation (average 20,000 transactions/month)
NIH annual grant commitments and obligations (average $20-25 billion US/year)
Clinical Center – Expense reimbursement system integration (average 3,000 transactions/month)
Four years and Five Successful SOA projects at NBS
2004: NBS conducted a 90-day study on how to integrate with Federal eTravel services and developed a prototype using Apache Axis software
2007: NIH CIO adopted SOA; NIH Integration Service Center (ISC) announced initial availability of SOA hardware, software and governance based on TIBCO
2007: NBS developed integration architecture for all future integration projects, and decided to use ISC TIBCO and NBS Oracle products
2007: NBS Requisition service went live with one Institute
2008: NBS eTravel phase I went live with Purchase Order, Voucher services
2009: NBS eTravel phase II went live with more Institutes and Centers (ICs)
2009: NBS Requisition service enhanced and usage expanded to 26 ICs
2010: NBS Grant Integration went live with enhanced Funds Check service
2010: NBS Clinical Center Patient Expense Module went live with significant reuse of Purchase Order, Voucher, and Funds Check services
Major Milestones of NBS SOA Implementation
NIH Enterprise Architecture and Governance for SOA
Source: NIH Chief Architect Office presentation
Adopted SOA and Integration vision
Established NIH Integration Service Center
Created NIH strategic SOA initiatives
Increase level of integration with and between Enterprise Systems
SOA as standard software architecture
Conducted SOA assessment and workshops
Assessed service design against service design principles
Managed NIH Enterprise Architecture Repository (NEAR) for service metadata
Analyze strategic goals and
business needs
Leverage existing or build new
services
Identify options, risks, tradeoffs
Factor in non-functional requirements
Reuse or create design patterns
Update/add to reusable services
framework
Baseline design for a services-based project
Develop appropriate test
plans
Implement to production
Understand strategic goals and analyze business needs
Make decisions based upon SOA principles
Embed principles into the design patterns
Reuse and iteratively enhance SOA framework
Be flexible and agile with SOA principles
Applying SOA Principles to Formulate a Solution
Problem: Funds control requires that funds availability be checked before transaction is submitted to the financial system. How does a source system use funds check/control that are available in financial system?
Solution Options:
Data warehouse can generate daily or hourly funds availability reports
The financial system real-time funds check web service can be called by the source system software before submitting and committing financial transactions
Apply SOA principle: Service reuse
SOA Design Pattern: Single source of data and real-time web service lookup.
Results:
Fewer manual corrections on any failed financial transactions
End users get real-time funds check result instead of waiting hours for batch consolidation results
Service Reuse – Funds Check
Reduced Time to Services and Development Costs
Reduce development time Patient Module - A web-based solution completed within 12 weeks from requirements to deployment
Reduced duplicated systems and data inconsistencies
Reduced Development and Maintenance Costs
Projected savings: ~ $2.18M over five years for Patient Module service fees
Purchase Order Module avoids double data entry, saves an estimated $1M annually and won 2010 HHS Innovation award
Increased Service Quality
99% accurate first-time transaction processing resulting in a reduction of service desk tickets
Avoided manual data consolidation from batch processes
Reduced Costs and Increased Service Quality
NIH Automated Process
1. Profile automatically synchronized via web services
2. User accounts automatically generated when profile is created
3. Single sign-on automatically configured when account is created
4. User logs into NIH portal, clicks a link and goes directly to eTravel service
Non-NIH Manual Process
1. Administrator creates user profile
2. User self-registers and creates Login ID and password
3. Administrator provides the user an account token
4. User logs in, links the self-created user account with the administrator-created profile via account token
5. User configures challenge questions
6. Now user can login to eTravel Service
Streamlined Traveler Profile Management
RESEARCH ON PUBLISHED SOA CASE STUDIES
Who else is doing SOA?
Federal Government developed open source software
Based on Service Oriented Architecture principles and Web Services
Platform independent, tested on Windows XP, Solaris and Linux
Uses EJBs and Open Enterprise Service Bus
Runs on GlassFish Enterprise Server
MySQL Community RDBMS 5.1
Adopted by: Department of Veterans Affairs
Social Security Administration
Kaiser Permanente
MedVirginia
Many federal and state government agencies
Federal Health Architecture Connect
Google key words: John Halamka, geekdoctor, Joe Kvedar, connectedhealth, Blackford Middleton, Adam Wright, CDSC, SANDS
Halamka about Service Oriented Architecture for Healthcare
Halamka 4 reasons for Online Medical records Issues with storage
Compliance benefits
Patient access
Better sense of community
Middleton about Clinical Decision Support
Wright about SANDS (Service-oriented Architecture for NHIN Decision Support)
Kvedar: Founder and Director of the Center for Connected Health Diabetes Remote Monitoring
Connected Medical Devices
Harvard Medical School
Harvard Pilgrim Health Care
– The oldest nonprofit health plan in New England
– 800,000 members
– 22,000 doctors and 130 hospitals
Similar Technology Stack as NIH Business System Tibco SOA Platform
Extensive use of Oracle Infrastructure, platform and applications software
SOA Benefits
– better service, fewer claims rejections, and significant cost savings for both providers and the health plan
– Improved quality and timeliness of data for providers reduces errors and speeds service
– improving customer satisfaction for Harvard Pilgrim plan members
Harvard Pilgrim Health Care
Source: harvard-pilgrim-health-care.pdf from Dell Case Study and ss-harvardpilgrim_tcm8-757.pdf Tibco Case Study
University of Pittsburgh Medical Center (UPMC)
– 40,000 employees and 4,000 doctors
– 19 hospitals and 400 smaller sites throughout western Pennsylvania
– Over 200 clinical systems
Technology Stack IBM servers
dbMotion SOA based solution
SOA Benefits
– Integrated and aggregated data from more than 25 major clinical systems
– Connected to best-of-breed systems such as Cerner, Epic, McKesson, MEDITECH, Siemens, Misys, Quest Diagnostics, HBOC Star, Dictaphone, and Spheris
– Project finished in 8 months
University of Pittsburgh Medical Center (UPMC)
Source: http://www.dbmotion.com/UPMC.aspx
Google key words: Stephan Erberich, SOA, MEDICUS
Open Source Funded by NIH
Support collaboration and data exchange among multiple clinical trial centers
Expanded to Children’s Oncology Group of more than 200 facilities to link to Image Data Center at the University of Southern California (USC).
MEDICUS created an abstract layer between data, meta-data and users linking DICOM storage service providers and registries.
Federation of DICOM medical imaging devices into healthcare Grids
Patient-centric authorization will use X509 SAML assertions
Medical Imaging and Computing for Unified Information Sharing (MEDICUS)
Implementing SOA at Duke University Health System by Boyd Carlson
The CDC Public Health Grid by Joseph D. Rogers
The National Cancel Institute caBig SOA Case Study by Ken Buetow
Impact of SOA Initiatives on Business-IT Alignment and Business Agility by BlueCross BlueShield
Using Service Oriented Architecture to Support Meaningful Use at DOD Military Health System by Chuck Campbell
SOA in Medical Imaging at University of Chicago Hospitals by Paul Chang
More SOA Case Studies
TOWARD A UNIVERSALLY CONNECTED HEALTH NETWORK
SOA and Cloud Computing Enabled Healthcare IT
Jane Sarashon-kahn researched Healthcare and Social Media for California Healthcare Foundation
Healthcare and Social media Patientslikeme.com – the power of collective wisdom
Thehealthcarescoop.com – patients reviews from people like you, by BlueCross and BlueShield
Sermo.com – forum to share medical insights for physicians
Doximity.com – linking medical minds
Healthcare Cloud Google Health
Microsoft Health Vault
Carestream Health: billion PACS images in Cloud
The Wisdom of Connected Patients
SOA Integration
Prefer System Integration over Consolidation
Prefer Evolution over revolution
No one-size-fits-all solution
A Better Connected World
Connected Doctors
Connected Patients
Connected Hospitals
Connected Medical Diagnosis Devices
Connected Patient Embedded Devices
Connected Medical Home
Connected Health Information Systems
From SOA Integration to Universally Connected Health
This presentation was reviewed and commented by :
Charles Singleton, Director of NIH Business System Program
Thomas Murphy, NIH Acting CIO
Thomas Erl, Editor of the SOA Magazine
John Halamka, CIO of Harvard Medical School and Beth Israel Deaconess Medical Center
Some slides were presented to NIH EATS in February 2011, the 4th International SOA Symposium and the 3rd Cloud Computing Symposium in April 2011 and NIH CIT Service Seminar Series in June 2011
Disclaimer: All authoring and reviewing efforts are personal. Some content may be sanitized or incomplete. Content usage is granted but no usability is claimed.
Acknowledgements
Federal Health Architecture Connect Open Source http://www.connectopensource.org
NIH Enabling National Networking of Scientists and Resource Discovery http://www.vivoweb.org
NIH Semantic SOA Grid https://cabig.nci.nih.gov/
US Federal Cloud Computing Initiative http://apps.gov
A Case Study on SOA and Process:Integrating E-Gov Travel Services with Federal Agency Financial Systems (Part II) http://soamag.com/I33/1009-4.php
A Case Study on SOA and Process:Integrating E-Gov Travel Services with Federal Agency Financial Systems (Part I) http://soamag.com/I32/0909-1.php
Health Care IT Collaboration in Massachusetts by Halamka et al. J Am Med Inform Assoc. 2005;12:596–601. DOI 10.1197/jamia.M1866
References
Thanks!
Jeff Zhong
Email: [email protected]
http://www.linkedin.com/in/jeffzhong
Website: http://www.futrend.com
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