I was given the opportunity to speak at our local HIMSS Chapter September Lunch & Learn session held at Dave & Busters.   The presentation was on “The Role of Accountable Care Organizations in the Evolution of Healthcare”.  In working with our chapters Program Director we thought a broad topic that encompassed many aspects of healthcare delivery would be a great way to kick-off our foundation series and serve to lay an educational foundation for our chapter members.

 We plan on offering this presentation and that of our other speakers on our website (www.sahimss.org) soon so stay tuned.  If you weren’t able to attend you can grab a copy of my presentation by clicking here.  I discussed a variety of topics specific to ACO’s including recent healthcare reform models, ACO formation,  care model and medical management capabilities and their impact on Healthcare IT (HIT).

It is clear to me our membership is interested in the impact of healthcare reform given the questions and interest after my presentation.  This is exactly the kind of dialog we wanted to create as our next several foundation series will focus on tertiary topics such as Health Information Exchanges, Medical Informatics.  Additional topics will include the EMR deployments & utilization in other countries, and military healthcare which San Antonio has a strong presence.

As always we love your feedback and I would encourage you to send us a message through the San Antonio HIMSS Chapter website (www.sahimss.org).  Don’t forget to register for a future event to secure your place.

 

 

 

I thought I would take the time to post some lessons learned over the past three years leading a ground-up initiative at WellMed Medical Management creating a service oriented enterprise application for physicians and medical management staff to treat and transition care for patients.  Service Oriented Architecture (SOA) is an often misunderstood concept even among the ranks of IT professionals.  While many SOA initiatives have manifested and exposed internal business logic in the form of web services the approach for SOA is actually very non-technical and is rooted in a deep understanding of the business and strategic goals and involves an ever evolving process of continuous improvement and refinement.  This makes the approach both strategic and operationally focused.  In this post I will outline what I feel are some critical components necessary for a successful SOA-based project.

 

Understand the Business Domain Model

While many companies evolve over time it is important to ensure your view of the business domain evolves with it.  Healthcare organizations are no different.  Communication is key especially in rapidly changing and evolving environments such as healthcare and defining a clear functional domain model will help pave the way for future development or shifts in business.  Find natural lines of separation within the business and look for natural service boundaries which allow you to build services that make sense.  By creating separation of services boundaries you help define sources for data and information and avoid duplication within your architecture.

Lines of separation can be found between:

  • Different lines of business (e.g.. Medical Management, Clinical, Research, Transportation, MSO, HMO, etc…)
  • Product & Service Lines (e.g., Transportation, Disease Management, Chronic and Complex programs)
  • Product Variations

Understanding the business is critical to ensuring that IT is aligned adequately to support business functions.  IT is often a common service that crosses multiple business functions.  Common services that cross boundaries include infrastructure, data warehouse, applications, development, etc…  Through this modeling effort many IT organizations can quickly identify gaps in existing service and support for the business community.

 

Maintain a Common Definition of Terms

In complicated environments like healthcare where efficiently managing risk for medically managed patients and members is critical to the success of your business you must take a solid look at the data flowing into and out of your organization.  Having a solid definition of what a bed-day is from a hospital visit, as an example, is important from both a financial perspective and a medical management perspective.  Stratifying patients based on acute events such as historic hospitalizations, lab results, HRA’s, or audits are equally important for the management of that patents care.   Both finance and medical management aspects of the business are critical to the patients care yet the consumption of information can be viewed and assessed slightly diffent unless a common method for defining data and terms associated with managing your business are clearly defined.

 

To effectively define these terms you must:

  • Build from business domain knowledge
  • Evangelize the terms and their correct usage
  • Introduce new terms slowly
  • Seeking definitions that are both
    • Unambiguous
    • Context insensitive

 

Maintain a Consistent View of the Ideal System

 

I’ve always been an advocate of having a strategic and long-term vision for a product.  Knowing where you are going will help you make day-to-day decisions that will ultimately help you get to where you need to be.  The ideal system will often seem unrealistic to many but setting the bar higher than others will help make your organization more agile and ready to change as market or other external factors shape your business.   Our approach to building a strategic enterprise application included components for mobile devices (pre-iPad) and both patient and provider portals.  They will not always manifest themselves as a product immediately but setting the groundwork and service breakdown will allow you to readily transition to other products or services.

 

The following items will help you build a consistent view of your ideal system:

  • High level design or model of the:
    • Goal system and
    • Intermediate steps
  • Consider all relevant aspects
    • Hardware/Networking
    • Services/Communication Protocols
    • Data/Access
  • Keep it in a maintainable form
  • Evangelize the roadmap

 

I’ve found that keeping a current copy of the ideal system will help you in many other aspects as well such as quickly describing the business to potential employees, vendors, partners, and even internal staff.

 

Seek Opportunities to Advance the System

 

Service Oriented Architecture is a concept and proposition you must be dedicated to and not a passing trend you can close as part of a project.  As such you must change your mindset and approach to all your projects.  Often SOA initiatives are grounded in major strategic initiatives.  Like any major IT initiative it should fundamentally support the businesses core objectives and strategic goals.  Your choices from a day-to-day perspective should seek to advance this strategic effort and build upon the shoulders of what has already been created.  A core tenant of SOA initiatives is the concept of re-usability.  When building new services or implementing new features you should always seek opportunities to advance the system as a whole.  Ways to do this include:

  • Avoiding Big Bang Architectural Changes
  • Implement the final system in small steps
  • Places to look for strategic opportunities include
    • New lines of business
    • New clients or partners
    • 3rd party software updates
    • New vendor software that complements your core products (i.e. Med Management & EMR)
  • Incorporate changes with the highest potential return
    • Looking for small changes with the highest amount of return
  • Seek to learn from each opportunity

 

Evangelize the Vision

The architect is a business leader and will often be your biggest advocate for driving business change using technology.  This is a very collaborative role and this person must work closely with executives and have a firm understanding of business trends, strategic initiatives and goals so changes or shifts are adequately made within the application and technology architectures supporting the business.  Ways to evangelize the vision include:

  • Continually show the company
    • Where the IT end of the business is headed
    • How it’s going to get there
    • Why it should go there
  • Create opportunities in
    • Design Meetings
    • Architecture, Development & Governance meetings
    • Hallway conversations within IT and with senior leadership

 

 

Continuously Improve Everything

 

Lastly, I would say continuous improvement is an overarching requirement and mindset you must install in all of your initiatives.  This can’t be drove from the architect or developers alone but must involve changes in processes of the business departments.  In our case it involved the close interaction of  infrastructure, executive management, line workers (nurses, case managers, health coaches, etc…).  Like the agile methodologies we put in place to develop our enterprise product you must have continuous interaction and have the mindset of continually improving your product and services.  To do this you and your entire team must:

  • Seek a to maintain a better understanding of the business even as it evolves and changes
  • Add and refine terms in the domain dictionary
  • Evangelize, Evangelize, Evangelize…. (E Cubed)
  • Seek alignment between the business and IT and use changes in business as opportunities

 

This is by no means an easy process but evoking change within an organization, especially a large one, is not a simple undertaking.  I’m sure I will have more to add as time goes on but take these little tokens of knowledge, go-forth and build your own agile enterprise applications.

Book Review: REWORK

23 May
2011

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

 

 

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

You can find Rework on Amazon here

Just kicked off the Texas Regional HIMSS conference in Austin, TX.

20110428-124808.jpg

March 16th will mark one year since we generated our first formal wireframe comp for what has now become a very robust enterprise application for physicians and their clinical staff.  This journey through building an initial prototype, development of a solid service oriented architecture,  building the project, analyst and development teams, generating a solid user experience, engaging our customers and more importantly engaging everyone in a new agile methodology has been nothing short of an amazing journey to which I’m very proud of what we have all accomplished.  As we approach formal implementation of a project kicked off just one year ago I would like to recognize some great vendors who helped us along our journey…  Xby2, Seamgen, and Cynergy Systems and especially my development staff at WellMed who kicked us off in this new agile development effort.

My recent visit to HIMSS ’11 in Orlando, FL validated what I already knew…that our user interface, which sits atop the underpinnings of a service oriented architecture, is far and away more usable and interactive than anything else on the market today.  The tool our customers use does not need to get in the way of doing business…  Cynergy Systems has created a showcase video highlighting their approach to User Interface design with our product and shows how good UX design can go a long way in helping ease complex tasks.  Below is the showcase video they produced and demo’ed at the Health Information Management System Society (HIMSS) meeting last month.

Wendy Rigby with KENS 5 News San Antonio just finished an article on iPad use in clinical settings and focused on the effort of our WellMed physicians.

Credit: Wendy Rigby / KENS 5
Dr. Robin Eickhoff of WellMed uses an iPad as she consults with her patient

The article highlighted our EMR and Care Delivery Platform development efforts and our President, Dr. Carlos Hernandez, mentioned something quite profound during the video interview this afternoon that wasn’t captured in the article or on the video and that is the “need to develop tools built around care delivery not delivering care around a tool” which is precisely what our application development efforts have focused around.

Our Service Oriented Architecture has enabled us to quickly embrace change in the mobile space.  The iPads have not been out an entire year yet we are able to quickly consume the core secure EMR services built into our flagship Care Delivery Platform and push data into the hands of providers using a very connected, very mobile device with a fundamentally different user interface.  By taking the time to develop and invest in a service oriented architecture we’ve prototyped this iPad app in a fraction of the time it has taken to develop our RIA (Rich Internet Application) EMR.  This has been a long and often exhausting journey to leverage and get to a state of reusable services but the goals of being more agile and leveraging on top of what is already built is a refreshing feeling and enabling WellMed Medical Management with opportunities to remain agile in our ability to deliver on strategic decisions and changes that benefit care for our seniors.

To check out the article and photos of physicians using the iPads within the clinic check out the link on KENS5:

http://www.kens5.com/news/Doctors-embracing-iPads-as-a-clinical-tool-115957794.html

Linked-In Labs has a new data visualization feature that shows the links between your different contacts and relationships within LinkedIn.  Simply log-in to inmaps.linkedinlabs.com and you can see the relationships unfold.

Above is a copy of my map of contacts and their corresponding relationships primarily in the healthcare and IT fields grouped by relationship types, affiliations, and general experience domains.  You can find other inventive concepts at www.linkedinlabs.com.

Some big ideas come from asking pretty simple questions…

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

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

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

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

That’s absurd…

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

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

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

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

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

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

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

As the HIE Liaison for the local San Antonio HIMSS chapter I’m very happy to announce our next chapter meeting with feature Dr. Steve Steffensen, MD a Professor of Neurology, JHU Chief Medical Information Officer, TATRC.  Dr. Steffensen is one of the key individuals working National Health Information Network (NHIN) issues for the Department of Defense.  Dr. Steffensen will speak this month on the CONNECT open source toolkit for implementing Health Information Exchanges (HIE) and moving toward the NHIN.

Date: October 21, 2010
Venue: Dave & Busters
440 Crossroads Blvd, San Antonio, TX 78201

Agenda:
11:30-12:00 – Registration / Food
12:00-12:30 – Introduction / Speaker
12:30-12:45 – Speaker Q&A, Announcements
12:45-1:00 – Networking

Dr. Steffensen is a board certified Neurologist and former active duty Navy officer with current duties that include Assistant Professor of Neurology at Johns Hopkins University and Chief Medical Information Officer at the Telemedicine and Advanced Technology Research Center (TATRC). He has been involved in numerous health IT projects related to the Armed Forces Health Longitudinal Tracking Application (AHLTA) and is recognized across the Military Health System as a physician advocate in electronic medical record business process integration and innovation.

Please join us Thursday, October 21st by going online and registering at www.sahimss.org

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