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News and Analysis: SOA Reengineers Healthcare

Originally published July 9, 2009

Just when the information technology (IT) analyst might have thought application integration has run its course, that SOA (service-oriented architecture) innovations are on a slope of diminishing returns and that all the users such as finance, retail, real estate, and manufacturing are too busy downsizing to care, a perfect storm of factors converge to rekindle productive SOA problem-solving in the healthcare market vertical.

The SOA in Healthcare Conference was held at the Hyatt Regency Chicago O’Hare in early June, sponsored by the SOA Consortium and the Object Management Group. James B. Peake, M.D., Lieutenant General, USA (Retired), former Secretary of Veterans Affairs, a cabinet-level position reporting to the President (of the USA), gave the keynote on putting service in service-oriented architecture. In comparison to the cross examination of Congressional hearings on Veteran Administration politics, this was “light duty” by a distinguished civil servant to a basically friendly audience. The take-away? “SOA is dead. Long live SOA!”

Healthcare data and information are highly distributed. The governance is intricate. The semantics are complex, and many of the installed applications are legacy systems, starved for resources by marginalization in the healthcare industry of IT. While medicine has benefited greatly from advances in science and technology, IT has not always been able to compete for scarce financial support when the choice came down to a fancy new MRI (magnetic resonance imaging) apparatus, capable of non-radioactively generating images at $5,000 an hour or new workflow software to ease coordination of care for which there was no Medicare reimbursement code until recently. Meanwhile, the political environment is wide open. The Obama administration has a near super-majority in Congress and has decided to make something happen. Even if the market is not awash in dollars, funds are available for the “meaningful use” of electronic medical healthcare records (EMR). So what?

Why SOA is Relevant

Three drivers make SOA relevant and a good fit for reengineering healthcare using IT.

First, the data is highly distributed. Islands of information characterize the data geography resulting from a multiplicity of single physician practices, free-standing clinics, ambulatory healthcare centers, including “urgent care” clinics attached to retail stores, as well as community, teaching and for-profit hospitals. The information required to coordinate patient care is needed in real time or near real time.

Second, regulators (FDA, CDC, NIH, etc.) are requiring healthcare groups to adopt and conform to IT standards and practices around messaging, data quality and information security. Furthermore, a Y2K-like event is looming for healthcare – the transition from master (and meta) data using International Classification of Diseases (ICD) version 9 to ICD-10. While the time frame has been extended from 2011 to 2013, it is not a trivial undertaking. Similar issues to Y2k are already evident. These changes will impact all domains – clinical (health delivery), research and administration (e.g., billing).

Third, advances in cloud computing are providing SOA with a boost. For example, the Department of Defense (DOD) has some 9.4 million beneficiaries who mostly use non-military healthcare providers local to where they are stationed when they get sick or require healthcare services. The DOD has developed an open source SOA tool called CONNECT that can integrate any existing electronic health information system with the National Healthcare Information Network (NHIN). According to Lieutenant Commander Steve Steffensen, M.D, Chief Medical Officer, the idea is basically to provide a computing “dial tone” across the cloud to service the personnel, some 25% of whom move at least once every three years in the line of duty.

Fourth, many run-your-hospital IT systems are new and shiny. Many are not. The commercial vendors’ response to the challenges of interoperability, according to Lynn Vogel, Ph.D., CIO, University of Texas, M.D., Anderson Cancer Center, has been the expansion of products into suites and continued reliance on what might be called archaic architectures. The response? In-house development using SOA for clinical, radiological, pathological, tissue and research applications (“stations”). A recurring theme among conference pundits was the buzz that the large vendors were conspicuous by their absence because they did not have the technology or architecture or a clue and are still resting on their installed base, if not their laurels. This was simply not accurate. I personally spoke with participants from GE, HP, IBM, Intel and HP, though the standards initiatives and business consulting services were most visible. I personally checked with the conference organizers and leaders such as Richard Soley, OMG President, confirming that a request for participation had gone out to the large run-your-hospital software providers.

Fifth, governance in healthcare is complex. Payers, providers, regulators and consumers (patients) all have occasionally overlapping, occasionally conflicting, agendas that must be navigated, interpreted and mediated while maintaining high standards of privacy, confidentiality and efficiency. A messaging broker is the ideal point in a system architecture to implement rules to translate between formats, check rules and regulations, and generate alerts about compliance exceptions. Furthermore, with SOA, the need to “rip and replace” existing legacy systems is strictly limited. If the legacy system can be encapsulated behind an interface with defined operations that can be exposed to an enterprise service bus (ESB), then the life of the application can be extended.

In short, this is “deja vu all over again.” As Sholom Cohen of the Software Engineering Institute pointed out, in 1984 the major concerns of medical providers were lack of coordination among healthcare providers, scheduling, lack of documented work flow and lack of effective feedback on interventions. Fast forward these twenty-five years, and, yes, you guessed it, the same issues of alerts, escalation, scheduling and follow through are on the critical path. Why will things be different this time around? The answer is … if the baby boomers do not get it right this time, it is the baby boomers who will suffer. Fear concentrates the mind in a powerful way, and SOA offers possibilities of reduced coordination costs that could not be imagined outside of proprietary networks. In addition, we can learn from what succeeded and what didn’t and implement to realistic requirements and expectations on the far side of the hype cycle.

Recommendations   

Informate, don’t just pave the cow path. When optimizing the exchange of information between distributed applications, do not just implement a layer of automation on top of the old, legacy way of doing things. Don’t just pave the cow path, automating the inefficiencies. Rather, look for ways to eliminate steps that no longer are needed because requirements have changed, reuse processes or combine functions that really do the same thing. In short, informate: add value through the inclusion of information that is needed to deliver superior service and improve quality. Though SOA is not reducible to workflow (or vice versa), SOA has a distinct workflow component in providing a step-wise progression from one island of information to another. (The expression “informate” was coined by Shoshona Zuboff in her book In the Age of the Smart Machine. It is as applicable today as it was way back then.)

SOA at the system boundary versus within the system. SOA is most immediately useful at the external system boundary for stand-alone organizations. At the point where an organization is required to exchange information with external regulatory agencies, payers and providers, and the universe of information “out there,” SOA makes sense and is appropriate. A stand-alone clinic or a hospital contained in a single physical location (and operating by a unified IT EMR) are examples of just such a boundary-oriented SOA implementation. Those enterprises that are themselves distributed – for example, large corporate hospital chains – will be able to exploit SOA both at the boundary and internally within the corporate walls.

Assess vendor packages according to SOA principles. Look for well defined interfaces that function as a reliable contract for information exchange; encapsulation of functionality behind loosely couple modules that can be swapped without creating software bugs in other parts of the system; a centralized metadata repository to design, manage, and reuse components and basic services such as patient registration, admission discharge, clinical notes, diagnoses and procedures, related diagnostic images; as well as services on the business side (billing and collections). Caution: such an assessment is not for the faint of heart. Vendors are not always forthcoming about the actual operation of features and functions. Even when they are, prospective users do not always appreciate the nuances that separate the contenders from the innovators. If a significant purchase is being considered, then it may be worth the slight extra expense to retain an objective third party – a consultant – who is already familiar with the market.


  • Lou AgostaLou Agosta
    Lou Agosta is an independent industry analyst, specializing in data warehousing, data mining and data quality. A former industry analyst at Giga Information Group, Agosta has published extensively on industry trends in data warehousing, business and information technology. He is currently focusing on the challenge of transforming America’s healthcare system using information technology (HIT). He can be reached at LAgosta@acm.org.

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