Cost/Benefit and ROI aspects of Health Information Technology (HIT)

Whether or not EHR and other HIT systems benefits exceed costs is a question being discussed in many quarters today. A 2006 report { click here } based on research conducted by the Southern California Evidence-based Practice Center provides what I consider a good framework for a priori and a posteriori examination of the cost/benefit and ROI aspects of this question.

Despite the heterogeneity in the analytic methods used, all cost-benefit analyses predicted substantial savings from EHR (and health care information exchange and interoperability) implementation: The quantifiable benefits are projected to outweigh the investment costs. However, the predicted time needed to break even varied from three to as many as 13 years.

Many of the studies concerned HIT systems developed and evaluated by academic and institutional leaders in HIT.

• Regenstrief Institute in Indianapolis, IN
• Partners/Brigham and Women’s Hospital in Boston, MA
• Intermountain Health in Salt Lake City, UT
• Kaiser Permanente health care system
• Vanderbilt University in Nashville, TN
• U.S. Department of Veterans Affairs (VA) health care

As asserted above, you need to ask when a particular system will reach the break even point. You also need to examine any potential for a mismatch between who pays for and who accrues cost savings from HIT use. Private organizations deciding whether to invest in HIT must weigh the costs and benefits of doing so. Although the primary goal of nonprofit healthcare organizations may be to provide high-quality care, these organizations still need to watch the bottom line to survive, which includes understanding the costs of measures designed to improve quality. Such private return-on-investment (ROI) calculations can provide results that are quite different from those of societal cost-benefit analysis, which are often reported in clinical journals. For example, one study showed that a hospital that installed a computerized reminder system to alert providers when patients were not up-to-date on their immunizations increased pneumococcal vaccine orders by 8 percent. Another study showed that, among the elderly, each $12 vaccination averts $20.27 in hospital costs and increases life expectancy an average of 1.2 days. From society’s point of view, the reminder system saves money and improves health, so it is a win-win program. However, from a financial perspective, the hospital has spent money on a system that had no effect on the costs or revenues of current stays because the pneumococcal vaccine is not delivered in the hospital. To benefit from this intervention, the hospital must make a reputation for higher quality and convert it into profits. This is one example of the potential for a mismatch between who pays for and who accrues cost savings from HIT use. A more extreme example would be a hospital’s implementation of a HIT intervention that averts future hospitalization. In this case, HIT implementation both costs the hospital money and decreases hospital revenues, even if the HIT implementation has a net cost-savings from a societal (or Medicare) perspective.

For more, click here, here and here.

Decision Makers Are Not Always "Insiders"

Over the past year or so, this blog has bandied about terms like interoperability, open-source, disambiguation, security and databases. All of this has been from the points of view shared by most "insiders" concerned with the introduction of electronic health records (EHR) systems into their local, regional or even national computer networks. I'm talking about individuals (including me) who typically follow other blogs like http://i2b2-zak.blogspot.com and http://geekdoctor.blogspot.com.

However, there are many more individuals who follow (and whose thinking is influenced by) publications like The Wall Street Journal and The New York Times. What they read is reports like "In a paper published last year, Alessandro Acquisti and Ralph Gross (two researchers from Carnegie Mellon University) reported that they could accurately predict the full, nine-digit Social Security numbers for 8.5 percent of the people born in the United States between 1989 and 2003 — nearly five million individuals." that I believe are sometimes more likely to influence their thinking than are the reports that you and I read in the blogs (and other publications) written by "insiders." So, with this last thought in mind, I place the following links to a few recent articles read by many of the decision makers out there.

http://www.nytimes.com/2009/11/16/business/16records.html?_r=1&scp=4&sq=electronic%20health%20records&st=cse

http://www.nytimes.com/2010/03/17/technology/17privacy.html

http://www.nytimes.com/2010/04/13/opinion/l13privacy.html

http://online.wsj.com/article/SB10001424052748704259304575043572008622004.html

http://online.wsj.com/article/SB10001424052748703625304575116512173339800.html

http://online.wsj.com/article/SB10001424052748703580904575132111888664060.html?KEYWORDS=electronic+health+records

This is not meant to be a representative sample. Just a reminder that you and I may or may not be speaking the same language as the general public, which counts among its numbers many high-ranking decision makers. So, what else is new?

Costs and Benefits of a Unique Patient Identifier for The U.S. Health Care System

In the healthcare industry, misidentification errors are not restricted to diagnostics and therapeutics but also may affect documentation. So, my earlier posts on semantics, ontologies, interoperability and the like notwithstanding, all is for naught when a given document doesn't provide information about a given patient. A chain is only as strong as its weakest link and patient identification is usually the first link in the healthcare chain.

Complicating the issue, not everybody can participate to the same degree or in the same way in the process of identifying a patient uniquely. Neonatal and senile patients are two groups where health providers and technology are on their own, when it comes to identifying the patient. Naturally, readers of this post fall into neither of these groups.

See, for example, Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk at

http://pediatrics.aappublications.org/cgi/reprint/117/1/e43.pdf

which provides a rather thorough study of errors in the first of these three groups.

The information that is used routinely for patient identification is frequently similar but often not recognizably unique.

In my November 20, 2009 post, Biometric and Other Identification Technologies, I discuss some leading technologies.

Although widely touted as “great” in security circles, all biometric devices (i.e., fingerprint, palm outline, iris, retina, et al) used for unique identification produce false positives and false negatives.



For example, an episode of Fox's "24" last season showed a White House visitor placing her thumb on a fingerprint scanner, a type of screening that is not typically used at the White House.

Fingerprint: false positives or negatives with scars, calluses, cracks in the skin, dirt, household cleaners and other variables.



Retina scan: susceptible to diseases such as glaucoma.



At the same time, non-biometric technologies have their own sources of error.



For a widely discussed examination of the costs and benefits of a unique patient identifier for the U.S. health care system, see

http://www.rand.org/pubs/monographs/2008/RAND_MG753.pdf

This recent study says using unique patient identification numbers for U.S. citizens would reduce medical errors, make electronic health records simpler and protect privacy.

The study says that despite a potential cost of $11 billion to create unique patient ID numbers, the effort "would likely return even more in benefits to the nation's health care system."

Most health care systems use statistical matching to find EHRs, according to the study by RAND Health, a research division of the RAND Corp. Statistical matching looks for demographic information, including names, birth dates and all or part of Social Security numbers.

See my November 17, 2009 post, Unique Patient Identification Numbers, Electronic Heath Records (EHR), Electronic Medical Records (EMR), and Social Security Numbers (SSN).

RAND researchers, who reviewed past studies, said that method causes errors or incomplete results about 8% of the time and leaves patients more exposed to privacy breaches.

"Assuming every health care system would have these [ID] numbers, then you'd be more likely to pick up all of the person's information," said Richard Hillestad, PhD, the study's lead author. "It would certainly make a lot of things easier."Using demographic information to locate EHRs causes errors or incomplete results about 8% of the time.

But critics expressed concerns.

"It's an absolutely terrible idea," said Deborah Peel, MD, a psychiatrist and chair of the Patient Privacy Rights Foundation, a watchdog group based in Austin, Texas. "Any database that has these numbers is bound to be a treasure trove for identity thieves."

The study was funded by a group of health information technology and IT companies, but Hillestad said that didn't influence the outcome. Dr. Peel is skeptical. "The combination [of data] is really deadly," she said. "That's why I say this is a data miner's dream."

The American Medical Association advocates prohibiting the sale and exchange of personally identifiable health information for commercial purposes without a patient's consent. The AMA also advocated in 1999 in favor of legislative action to repeal the portion of the Health Insurance Portability and Accountability Act of 1996 that mandated use of a unique patient identifier.

Hillestad said privacy is a big issue, but touted the ID numbers as a security boost.

"You're not sending all of the name and demographic information through the line to get connected," he said. "[Privacy] would depend on how much you protect the numbers."

Technical Interoperability of Disparate Systems - An Electronic Health Record (EHR)-Centric System Implemented with a Service-Oriented Architecture

The independent organizations (a.k.a. silos) shown in Figure 1 typically implement their business processes on different computer systems (Unix, Windows, mainframes), on different platforms (J2EE, .NET) and with different vocabularies. Yet, they all need to communicate in a way that serves, in this case, a trauma victim at the time of his or her emergency, researchers who will later study cohorts of this trauma victim, and sundry others (most of whom are not shown in the simplified model).

This post will discuss an Electronic Health Record (EHR)-centric system implemented with a Service-Oriented Architecture (SOA) -- the business industry’s de facto standard for interoperability. The functions of this system are data collection, management and distribution for both the immediate situation and long term health care experiences.

I’ll address some of the challenges (and opportunities) of technical interoperability, holding off ‘til later posts any discussion of semantic interoperability.

Note: This rather lengthy post is not and is not meant to be a palimpsest on SOA. But, I have included a number of references (links to references) for anyone looking for a more detailed account of this topic.

Figure 1

Figure 2 shows a traditional implementation of the system shown in the use case drawn in Figure 1. When a change -- virtually any change -- is made in one part of this interconnected system, the overall system usually stops working, until system-wide adjustments are made. In short, the figure below shows a system that’s “hard wired.”

Note: For simplicity, these figures and this discussion omit a number of real-world details: for example, the voice communication often employed by police and EMS teams.

Figure 2

To remedy this problem, a new architecture, that of Service-Oriented Architecture (SOA), was devised. An SOA implementation of the system shown in the use case is outlined in Figure 3. At first glance, the SOA-based system might seem more complicated than the system shown in Figure 2. But, as the following discussion will attempt to show, it isn’t.

Figure 3

Note: The major part of this post will be based on a Web services implementation of SOA. However, before concluding this post, I’ll address the oft-heard view that SOA is now “dead.” SOA is indeed alive and kicking in many organizations.

The system in Figure 2, if fleshed out, would move toward becoming the fully connected system shown below (in practice, very few systems are fully connected). In such a system of computer applications, when one node is changed, all other nodes that connect to it would need a new interface to the changed node.

As shown, in a fully connected network with n nodes, there are n x (n-1) / 2 direct paths. That means 15 connections for 6 nodes, 45 connections for 10 nodes, etc.

In contrast, each node in the system in Figure 3 has only one connection – that to a bus, as represented in the figure below.



Service-Oriented Architecture

SOA relies on services exposing their functionality via interfaces that other applications and services can read to understand how to utilize those services.

This style of architecture promotes reuse at the macro (service) level rather than micro (classes) level. It can also simplify interconnection to – and usage of – existing IT (legacy) assets.

Designers can implement SOA using a wide range of technologies, including SOAP, REST, DCOM, CORBA, or Web Services. (I gave a brief overview of DCOM, CORBA and Web Services in my June 16 post and will discuss REST below.) The key is independent services with defined interfaces that can be called to perform their tasks in a standard way, without a service having foreknowledge of the calling application, and without the application having or needing knowledge of how the service actually performs its tasks.

Albeit in the distant past, I’ve used the Oracle SOA Suite to federate a unified system out of the disparate systems shown in the figures.

This suite, which includes JDeveloper, a robust Java IDE, is by no means the only solution; there are others, both proprietary and open source! For example,

Proprietary: http://i.zdnet.com/whitepapers/cape_clear_Principles_of_BPEL.pdf

Open source: http://orchestra.ow2.org/xwiki/bin/view/Main/

However, the Oracle SOA Suite is a complete set of service infrastructure components for creating, deploying, and managing services. It enables services to be created, managed, and orchestrated into composite applications and business processes. Additionally, you can adopt it incrementally on a project by project basis and still benefit from the common security, management, deployment architecture, and development tools that you get out of the box.

This Suite is a standards-based technology suite that consists of the following:

* Oracle BPEL Process Manager to orchestrate services into business processes
* ESB to connect existing IT systems and business partners as a set of services
* Oracle Business Rules for dynamic decisions at run time that can be managed by business users or business analysts
* Oracle Application Server Integration Business Activity Monitoring to monitor services and disparate events and provide real-time visibility into the state of the enterprise, business processes, people, and systems.
* Oracle Web Services Manager to secure and manage authentication, authorization, and encryption policies on services that is separate from your service logic
* UDDI registry to discover and manage the life cycle of Web services.
* Oracle Application Server that provides a complete Java 2, Enterprise Edition (J2EE) environment for your J2EE applications.

For an overview of the soon-to-be-released Version 11, see

http://www.oracle.com/technology/products/ias/bpel/techpreview/2008-05-01-whats-new-in-oracle-soa-suite-tp4.pdf

Business Process Execution Language (BPEL)

One of the key standards accelerating the adoption of SOA is Business Process Execution Language (BPEL) for Web Services. BPEL enables organizations to automate their business processes by orchestrating services (thus enabling developers to build end-to-end business processes spanning applications, systems, and people in a standard way). Existing functionality is exposed as services. New applications are composed using services. Services are reused across different applications. Services everywhere! For an account of Orchestration versus Choreography, see

http://www.oracle.com/technology/pub/articles/matjaz_bpel1.html

BPEL has emerged as the standard for process orchestration enabling you to build end-to-end business processes spanning applications, systems, and people in a standard way.

In the next figure, I show two pallets of drag-and-drop components available in version 10.3 of the SOA Suite for the development of a BPEL process. Version 11 will be availability shortly.

Introduction to the JDeveloper BPEL Designer

http://download-west.oracle.com/docs/cd/B31017_01/core.1013/b28938/design.htm#CHDIJCGH

Enterprise Service Bus

An Enterprise Service Bus (ESB) is an architectural pattern, not a software product. Different software products can form an ESB. In some cases, companies use multiple products in different areas, leveraging specific functionality to meet their unique requirements. These different products can be federated together as the realization of the ESB pattern.

In the next figure, I show two pallets of drag-and-drop components available in version 10.3 of the SOA Suite for the development of an ESB. As I mentioned earlier, Version 11 will be availability shortly.

Introduction to the JDeveloper ESB Designer

http://download-west.oracle.com/docs/cd/B31017_01/core.1013/b28938/design.htm#CHDIBCCC

Figure 3 introduced Business Activity Monitoring (BAM) and Business Rules to the architecture

Business Activity Monitoring – BAM satisfies a growing need to enable health care executives, and more specifically operations managers, to improve their decision-making processes by first getting a real time view of the business events occurring in their enterprise, and second using the derived intelligence to analyze and improve the efficiency of their business processes.

Understanding Business Activity Monitoring in Oracle SOA Suite
http://www.packtpub.com/article/business-activity-monitoring-in-oracle-soa-suite

Business Rules – Business Rules is one of the newer technologies (typically run from an application server) and is designed to make applications more agile. A business analyst can change business policies expressed as rules quickly and safely with little or no assistance from a programmer

Using Business Rules to Define Decision Points in Oracle SOA Suite

Part 1. http://www.packtpub.com/article/business-rules-define-decision-points-oracle-soa-suite-part1

Part 2. http://www.packtpub.com/article/business-rules-define-decision-points-oracle-soa-suite-part2

For detailed coverage of the Oracle Service Bus, BPEL Process Manager, Web Service Manager, Rules, Human Workflow, and Business Activity Monitoring. See

Oracle SOA Suite Developer's Guide
http://www.packtpub.com/developers-guide-for-oracle-soa-suite-10gr3/book

and

Getting Started With Oracle SOA Suite 11g R1 – A Hands-On Tutorial
http://www.packtpub.com/getting-started-with-oracle-soa-suite-11g-r1/book

When designing an SOA solution, it's not always clear whether you should use a Web services BPEL process or an ESB mediation flow (or both).

http://www.ibm.com/developerworks/websphere/library/techarticles/0803_fasbinder2/0803_fasbinder2.html

Building Event-Driven Architecture with an Enterprise Service Bus

http://www.oracle.com/technology/pub/articles/jellema-esb.html

Software frameworks

You should keep in mind that interoperability issues between platforms can arise when switching from one protocol to another and one software framework to another. Some examples include SOAP, REST, the .Net Framework, Enterprise Java Beans (EJB), and Java Messaging Service (JMS).

.Net Web services running over HTTP can be called in three different ways: HTTP GET operation, HTTP POST operation, and SOAP. The GET and POST operations are useful if you need to call a Web Service quickly and no SOAP client is readily available. You can use REST to perform GET, POST, PUT, and DELETE operations over the HTTP in a Perl script. In this script, you can specify SQL queries and simple message queues.

For a discussion of SOAP/REST in the .NET (Visual Studio 2008 SP1) ecosystem, see

http://www.pluralsight.com/community/blogs/scottallen/archive/2008/08/11/visual-studio-sp1-and-the-metification-of-rest.aspx

and

http://msdn.microsoft.com/en-us/library/dd203052.aspx

Often, services within an organization’s firewall are REST-based, while 3rd party partners use a mix of SOAP and HTTPS protocols to access their public services. By using REST for internal services, organizations are avoiding some of the overhead that the WS-* standards introduce.

If the SOAP client is available, here's how to make a simple choice between REST and SOAP. If the application is resource-based, choose REST. If the application is activity-based, opt for SOAP. Under REST, a client might request that several operations be performed on a series of resources over the HTTP. For SOAP-based requests, only one invoke operation is needed for each activity-oriented service that a client might request be performed.

REST requests do not depend on WSDL as SOAP requests do. Yet, REST and SOAP can co-exist as requests from a composite Web service application to an external Web service.

When to use REST based web services?

http://oracled.wordpress.com/2009/03/11/when-to-use-rest-based-web-services/

When Web services are outside the control of the organization (as in the figures at the top of this post), you need to ensure that they can interoperate externally with one another with respect to shared semantics and contractual obligations. Semantic misunderstandings and contractual loopholes contribute to interoperability problems between external enterprise Web services. Future posts will focus on these aspects of interoperability.

For presentations that includes the pros and cons of different protocols (SOAP and HTTP) and software frameworks (.NET and J2EE), see

http://www.esri.com/events/devsummit/pdfs/keynote_chappell.pdf

and

http://www.esri.com/events/devsummit/sessions/keynote.html

The oft-heard view that SOA is now “dead”

Once thought to be the savior of IT, SOA instead turned into a great failed experiment -- at least for many organizations. SOA was supposed to reduce costs and increase agility on a massive scale. In many situations, however, SOA has failed to deliver its promised benefits.

Yet, although SOA is understandably purported to be dead by many, the requirement for a service-oriented architecture is stronger than ever.

Adopting SOA (i.e., application re-architecture) requires disruption to the status quo. SOA is not simply a matter of deploying new technology and building service interfaces to existing applications; it requires redesign of the application portfolio. And it requires a massive shift in the way IT operates. The small select group of organizations that has seen spectacular gains from SOA did so by treating it as an agent of transformation. In each of these success stories, SOA was just one aspect of the transformation effort. And here’s the secret to success: SOA needs to be part of something bigger. If it isn’t, then you need to ask yourself why you’ve been doing it.

The latest shiny new technology will not make things better. Incremental integration projects will not lead to significantly reduced costs and increased agility. If you want spectacular gains, then you need to make a spectacular commitment to change.

Note: As of 2008, increasing numbers of third-party software companies offer software services for a fee. In the future, SOA systems may consist of such third-party services combined with others created in-house.

More on this can be found in “WOA: Putting the Web Back in Web Services.”

http://blogs.gartner.com/nick_gall/2008/11/19/woa-putting-the-web-back-in-web-services/

Also, here’s a link to one of my earlier articles on SOA

“The Economic, Cultural and Governance Issues of SOA”

http://www.cioupdate.com/reports/article.php/11050_3652091_1/The-Economic-Cultural-and-Governance-Issues-of-SOA.htm

Electronic Health Records (EHR) – Interoperability of Disparate Systems – Political

The top box in the figure below (adapted from the first figure in my June 16 post) contains the label "Political," and the video in my May 13th post (repeated below) shows excerpts from a recently held hearing in the United States Senate Committee On Finance, chaired by Senator Max Baucus. The latter motivated the former. But, I've had additional reasons to think about the influence of national politics upon the architecture of the upcoming IT-based EHR system.








Montana Senator Baucus is the Senate’s point man on healthcare reform. A new article in the Montana Standard finds that Senator Baucus has received more campaign money from health and insurance industry interests than any other member of Congress. The article says, “In the past six years, nearly one-fourth of every dime raised by Baucus and his political-action committee has come from groups and individuals associated with drug companies, insurers, hospitals, medical-supply firms, health-service companies and other health professionals.”

Moreover, it’s hard for even the most casual follower of the daily news to avoid finding his or her own reason to believe that national politics will play a major role in the rollout of our EHR system.

The vast majority of the funds within the HITECH Act (the health IT component of the American Recovery & Reinvestment Act) are assigned to payments that will reward physicians and hospitals for effectively using a robust, connected EHR system. Few should doubt that how these billions of dollars are distributed will have a profound impact on the shaping of our national EHR system.

In addition to funding EHRs (also called electronic medical records, or EMRs), HITECH adds some privacy-enforcement teeth to HIPAA, which has long been criticized for loopholes’ allowing the release of medical record information to health care vendors for marketing purposes. Pharmaceutical companies, for instance, have frequently used prescription information from these records to target their mailings for new or alternative drugs and treatments. HITECH now mandates that individual patients’ consent be obtained before releasing any information to vendors -- or to anyone not in the immediate health care loop that includes physicians and hospitals as well as insuring and billing entities (for a scary look at how easily this loop can expand, read “Health Privacy—The Way We Live Now”). The new provisions also require voluntary and affirmative disclosure of any breaches or violations of private records. However, as the final stimulus package wended its way through Congress, so many loopholes (five pages’ worth) were added that just about any group with political connections, or with loose medical affiliations, could gain access to everyone’s personal EHR just by asking for it or by paying for it.

While there are workgroups and committees of experts working diligently to shape an EHR that helps bring about a better healthcare system for the nation, the members of these groups don’t control the purse strings. Politicians do. Stay tuned.

Electronic Health Records (EHR) – Interoperability of Disparate Systems – Technical

As the title suggests, this post, the first in a series of continuations of my June 13 post, is about the technical aspects of interoperability. For your convenience, I’ve copied the figure below from the earlier post.




The word "interoperability" means different things to different people. To DBAs, for example, the ability of SQL Server, Oracle and DB2 to recognize each other’s commands is a sign of the interoperability of these databases. In the current post, however, I'll focus primarily on a distributed computing model that is capable of cross-platform and cross-programming language interoperability, Web services. In the process, I'll compare Web services with a couple of its predecessors, CORBA and DCOM, which are still being used widely.

Why CORBA and DCOM success is limited

Although CORBA and DCOM have been implemented on various platforms, the reality is that any solution built on these protocols will be dependent on a single vendor's implementation. Thus, if one were to develop a DCOM application, all participating nodes in the distributed application would have to be running a flavor of Windows. In the case of CORBA, every node in the application environment would need to run the same ORB product. Now there are cases where CORBA ORBs from different vendors do interoperate. However, that interoperability generally does not extend into higher-level services such as security and transaction management. Furthermore, any vendor specific optimizations would be lost in this situation.

Both these protocols depend on a closely administered environment. The odds of two random computers being able to successfully make DCOM or IIOP calls out of the box are fairly low. In addition, programmers must deal with protocol unique message format rules for data alignment and data types. DCOM and CORBA are both reasonable protocols for server-to-server communications. However, both they have severe weaknesses for client-to-server communications, especially when the client machines are scattered across the Internet.

CORBA overview

Common Object Requesting Broker Architecture (CORBA) provides standards-based infrastructure for interactions between distributed objects. It allows software components running on dissimilar hardware, hosted on different operating systems, and programmed in different programming languages to communicate, collaborate, and perform productive work over a network.

A CORBA system accomplishes this magical task by confining the interaction between objects to well-defined interfaces. To use the service of a distributed object, you must interact with it through the interface. How the interface is implemented -- or even where it is implemented -- is not known and doesn't have to be known by the client. The figure below illustrates the workings of a typical CORBA system.

Object interactions in CORBA




Achieving location transparency

In this figure, the client code makes use of a server object through its interface. In fact, the interface is implemented by a stub object that is local to the client. As far as the client can tell, it's only interacting with the local stub object. Under the hood, the stub object implements the same interface as the remote server object. When the client invokes methods on the interface, the stub object forwards the call to a CORBA component called the Object Request Broker (ORB). The calling code in the client does not have to know that the call is actually going through a stub.

DCOM overview

Distributed Component Object Model (DCOM) is a Microsoft proprietary technology for software components distributed across several networked computers to communicate with each other. However, it has been deprecated in favor of the Microsoft .NET Framework, which includes support for Web services.

Internet poses problems for CORBA and DCOM

DCOM was a major competitor to CORBA. Proponents of both of these technologies saw them as one day becoming the model for code and service-reuse over the Internet. However, the difficulties involved in getting either of these technologies to work over Internet firewalls, and on unknown and insecure machines, meant that normal HTTP requests in combination with web browsers won out over both of them.

Web services overview

Web services specifications such as SOAP, WSDL, and the WS-* family are currently the leading distributed computing standards for interfacing, interoperability, and quality of service policies. Web services are often called "CORBA for the Web" because of their many derivative concepts and ideas.

There are several ways to think about Web services when building applications. At the most basic level it is an advanced communications protocol family allowing applications to talk to each other. This level has progressed quite significantly over the past few years with many tools (e.g., Oracle’s JDeveloper and Microsoft's Visual Studio) that allow software developers to write interacting Web services and build complex applications. This level is often characterized by direct one-on-one interactions between services or relatively few services interacting with each other.

SOA overview

However, just using Web services as a communications protocol belies its true power, that of the service-oriented architecture (SOA). The SOA describes an entire system of services dynamically looking around for each other, getting together to perform some application, and recombining in many ways. This model encourages the reuse of technology and software that evolves the way applications are designed, developed and put to use. It brings the world of distributed computing to a closer reality. At this level software developers need to think of the SOA model and design their distributed application across the model. This level is characterized by the use of technologies to allow distributed communications of services such as the use of an Enterprise Service Bus (ESB), which is a common distribution network for services to work with. More on ESB in an upcoming post.

Finally, the highest level is to look at this SOA model and the many component services as building blocks that can be assembled in whole sections into full applications instead of the traditional method of writing line after line of code. By examining the connecting interfaces, we can build whole applications without ever really writing code. For that matter direct code may even get in the way since the services may be written in numerous different languages and platforms. The blocks can be put together into a workflow of operations that define how the application performs, and other tools can be used to monitor the effectives of the workflow at each service or group of services. At this level, developers can put away the use of regular programming languages and work in a Model-Driven Architecture that helps them to build applications more accurately to a design. More on workflow in an upcoming post.

Electronic Health Records (EHR) - Interoperability of Disparate Systems

As suggested in the figure below, there are technical, semantic, organizational, political and economic matters to consider when deciding how to move data and/or exert operations from one place to another. These challenges are present in the recently reinvigorated campaign to adopt and exchange electronic health records.



On February 17, 2009, President Barack Obama signed into law the American Recovery & Reinvestment Act (ARRA). The health IT component of the Bill is the HITECH Act, which appropriates a net $19.5 billion dollars to encourage healthcare organizations to adopt and effectively utilize Electronic Health Records (EHR) and establish health information exchange networks at a regional level, all while ensuring that the systems deployed protect and safeguard the critical patient data at the core of the system.

There are two portions of the HITECH Act -- one providing $2 billion immediately to the Department of Health & Human Services (HHS) and its sub-agency, the Office of the National Coordinator for Health IT (ONC), and directs creation of standards and policy committees; a second that allocates $36 billion that will be paid to healthcare providers who demonstrate use of Electronic Health Records.

The government is focused on two primary goals in this legislation: moving physicians who have been slow to adopt Electronic Health Records to a computerized environment, and ensuring that patient data no longer sits in silos within individual provider organizations but instead is actively and securely exchanged between healthcare professionals. Therefore, the vast majority of the funds within the HITECH Act are assigned to payments that will reward physicians and hospitals for effectively using a robust, connected EHR system.

In short, a great deal of largely-Government-funded IT work is about to be undertaken to enable often-disparate healthcare recordkeeping systems to interoperate. In the next few posts, I will address a number of the issues that need to be considered when planning such projects.

Electronic Health Records (EHR)

The health information technology provisions in the Obama administration's stimulus bill are a step toward the goal of nearly universal electronic health record adoption in the U.S. over the next 10 years (compared with 17 percent today). The central feature of the plan is incentive payments for using electronic records for improvements in health quality, efficiency, prevention and safety.

This kind of spending, if done wrong, can have the negative market consequence of interfering with rapid innovation by locking in today’s processes and technologies, which although well-intended, came about without a systemic view. And we risk locking out the very innovations we need for meaningful health information sharing to support better decisions.

The goal for health IT should not be primarily the creation of standards or the certification of software. Rather, standards and certification should support measurable health improvements. Health improvements are not achieved by the mere installation of software; they are achieved through the effective use of information for better decision-making.

At the same time, individual states -- for example Massachusetts, which has a newly passed law that requires hospitals and community health centers in the state to implement an electronic health record systems by Oct. 1, 2015 -- have also been moving to improve the delivery of better health care through the use of EHR.

To implement these programs, the healthcare industry seems poised to increase the adoption of EHR and electronic transmission standards to promote accuracy, transparency, and processing speed across disparate information systems. Today, they have a smorgasbord of health information technologies available to help them build a far better health system.

There are, in fact, too many standards and too many organizations writing them. There are the standards that support the systems we have in place today as well as the XML/Web-based standards that support newer web-centric systems and healthcare information exchanges.

While creating EHR data is an important first goal, an EHR is much more valuable if it can be summarized, moved, and shared. This and future posts will address EHR in that broader context. These discussions will address many technical, clinical, economic, political and managerial issues of electronic health record systems.

Perhaps the most difficult challenge is to bind the standards to structured vocabularies to ensure that there is the transfer of unambiguous knowledge of the meaning of the data among cooperating systems.

Before I get specific (sometimes talking about tools to facilitate implementation of these systems), I want to point out that building technology on U.S. standards alone would leave us with essentially a non-standard EHR platform. Remember that other countries, for example Canada and England, have single-payer health systems, while the U.S. does not.

A look back to before the PC, the Internet and all that

And, before looking ahead to how Electronic Health Records of the future will likely work, I thought I'd also display a pulmonary function test report produced at Yale New Haven Hospital (YNHH) several decades ago. While its underlying data (held in a PDP-8 computer) could be transmitted electronically -- analog modem to analog modem -- over a 128 bits/sec telephone line connection, these paper reports were generally sent from the laboratory where they were generated to the office of a YNHH physician via inter-office mail or to an outside physician via the U.S. Postal Service.



Computer-generated paper report: This photograph was produced by a Poloroid instant camera that was suspended over the front of a cathode ray tube (CRT). The CRT, along with a teletypewriter, provided human readable output for the PDP-8.

In subsequent posts, I'll include talk about safe wireless practices, Web services and other seemingly off-topic subjects, because they too are important parts of the EHR story.

Interoperability will be among these topics. The linking of vital information as patients receive care from a fragmented healthcare system is a problem that has consistently plagued interoperability efforts in healthcare. The privacy, technical, and policy issues involved need be addressed in order to effectively share information across multiple organizations. Making the information available will help to prevent drug interactions and adverse events, avoid medical errors, and help inform decision making for the patient and clinician. It will also enable the support of public health efforts, improvements in research, better physician and organizational performance and benchmarking, and greater empowerment of patients and families as active participants in their own healthcare, among other benefits.

In discussing these issues, I will sometimes cite my earlier writing on financial, legal and organizational issues that appears in articles available through links provided in my bibliography at the bottom of this page.

Finally, this might be a good time to introduce a few technical terms: HL7, HL7 mapping, HIPPA etc. They're central to the discussion of IT health records management.

Health Level 7 (HL7)

HL7 refers to both a standards organization and the set of healthcare messaging standards that it creates. Founded in 1987 to create a set of standards for hospital information systems (HIS), HL7 has expanded its reach to the creation of international standards that transgress hospitals to address clinical and administrative data in healthcare domains such as pharmaceutical, medical device, and insurance transactions. There are already a large number of countries that have mandated the use of HL7 for the transmission of healthcare data and there is an expectation that HL7 will become a part of the United State's Health Insurance Portability and Accountability Act (HIPAA) in the future.

For the large number of international healthcare organizations that are embracing the electronic transmission of healthcare data, there remain some formidable challenges. Though some compliance regulations specify the newer, XML-based HL7 v3.x, there are many jurisdictions that still need to update their legacy systems to handle this format, and many that even have multiple disparate data formats in the same system.

In the US, for example, many legacy HISs employ HL7 EDI messages alongside HIPAA X12N messages. Though these formats have quite a lot in common, syntactically speaking, they are by no means interoperable and must be mapped on-the-fly to create a dynamic workflow for managing healthcare transactions. Of course, the introduction of the XML-based HL7 v3.x adds EDI/XML mapping to the complication of mapping data from EDI to EDI.

HL7 mapping

There are off-the-shelf, any-to-any graphical data mapping tool (e.g., Altova MapForce) that supports mapping HL7 data, in its legacy EDI or newer XML-based format, to and from XML, databases, flat files, other EDI formats, and Web services. Mappings are implemented by simply importing the necessary data structures (MapForce ships with configuration files for the latest EDI standards and offers the full set of past and present HL7 standards as a free download on its Web site) and dragging lines to connect nodes. A built-in function library lets you add advanced data filters and functions to further manipulate the output data. MapForce can also facilitate the automation of your HL7 transaction workflow through code generation in Java, C#, or C++ and an accessible command line interface. Additional support for mapping HL7 data to and from Web services gives healthcare organizations the ability to meet new technology challenges and changing enterprise infrastructures as they unfold within internal and external provider domains.