Toward A Universally Connected
Healthcare Network
By Jian (Jeff) Zhong
Chief Technology Officer (Acting)
Chief Architect for SOA & Cloud Computing
FUTREND Technology Inc.
Agenda
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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
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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
More expenditure does not mean better quality
HEALTHCARE IN THE UNITED STATES OF AMERICA
Healthcare in the United States of America
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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
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
Stage 7
Complete EMR; CCD transactions to share data; Data
warehousing; Data continuity with ED, ambulatory, OP
1.0%
Stage 6
Physician documentation (structured templates), full
CDSS (variance & compliance), full R-PACS
3.2%
Stage 5
Closed loop medication administration
4.5%
Stage 4
CPOE, Clinical Decision Support (clinical protocols)
10.5%
Stage 3
Nursing/clinical documentation (flow sheets), CDSS
(error checking), PACS available outside Radiology
49.0%
CDR, Controlled Medical Vocabulary,
CDS, may have Document Imaging; HIE capable
14.6%
Stage 2
Stage 1
Ancillaries – Lab, Rad, Pharmacy – All Installed
7.1%
Stage 0
All Three Ancillaries Not Installed
10.1%
Data from HIMSS AnalyticsTM Database N = 5,281 2011 HIMSS Analytics
TOP VENDORS OF ENTERPRISE EMR SYSTEMS
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%
Source: http://www.darkdaily.com/ranking-top-10-hospital-emr-vendors-by-number-of-installed-systems-32511
What does Wall Street expect from Healthcare IT?
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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
Source: Yahoo! Finance
The American Recovery and Reinvestment Act (ARRA)
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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)
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$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
Resurrection after the financial crisis
SERVICE ORIENTED ARCHITECTURE
Service Oriented Architecture
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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
Architecture – From Abstract Design to Concrete Results
The Great Architect
Oscar Niemeyer
Source: Wikipedia, the free encyclopedia
Designed public buildings in the city of Brasília, and
the United Nations Headquarters in New York City
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
SOA reduced cost, improved quality and streamlined business
NIH BUSINESS SYSTEM SOA CASE STUDY
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 FY 2011 Director Perspective
Source: NIH web site image bank
NIH Clinical Center
 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 Clinical Center 2011 Profile
Source: NIH web site image bank
Four years and Five Successful SOA projects at NBS
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NBS SOA Overview:
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Started SOA implementation in 2007
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NBS program holistic approach for entire enterprise-level integrations
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Followed NIH enterprise architecture (EA) and SOA guiding principles
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Utilized the existing NIH CIT/ISC and NBS infrastructures
Successful NBS SOA Implementations:
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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)
Major Milestones of NBS SOA Implementation
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2004: NBS conducted a 90-day study on how to integrate with Federal eTravel
services and developed a prototype using Apache Axis software
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2007: NIH CIO adopted SOA; NIH Integration Service Center (ISC) announced initial
availability of SOA hardware, software and governance based on TIBCO
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2007: NBS developed integration architecture for all future integration projects,
and decided to use ISC TIBCO and NBS Oracle products
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2007: NBS Requisition service went live with one Institute
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2008: NBS eTravel phase I went live with Purchase Order, Voucher services
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2009: NBS eTravel phase II went live with more Institutes and Centers (ICs)
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2009: NBS Requisition service enhanced and usage expanded to 26 ICs
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2010: NBS Grant Integration went live with enhanced Funds Check service
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2010: NBS Clinical Center Patient Expense Module went live with significant reuse
of Purchase Order, Voucher, and Funds Check services
NIH Enterprise Architecture and Governance for SOA
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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
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Conducted SOA assessment and
workshops
Assessed service design against service
design principles
Managed NIH Enterprise Architecture
Repository (NEAR) for service
metadata
Source: NIH Chief Architect Office presentation
Applying SOA Principles to Formulate a Solution
 Understand strategic
goals and analyze
business needs
Analyze strategic
goals and
business needs
Update/add to
reusable services
framework
Baseline design
for a servicesbased project
Leverage existing
or build new
services
Reuse or create
design patterns
Develop
appropriate test
plans
Identify options,
risks, tradeoffs
Factor in
non-functional
requirements
Implement to
production
 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
Service Reuse – Funds Check
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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?
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Solution Options:
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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:
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Fewer manual corrections on any failed financial transactions
End users get real-time funds check result instead of waiting hours for batch
consolidation results
Reduced Costs and Increased Service Quality
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Reduced Time to Services and Development Costs
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Reduce development time Patient Module - A web-based solution completed
within 12 weeks from requirements to deployment
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Reduced duplicated systems and data inconsistencies
Reduced Development and Maintenance Costs
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Projected savings: ~ $2.18M over five years for Patient Module service fees
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Purchase Order Module avoids double data entry, saves an estimated $1M
annually and won 2010 HHS Innovation award
Increased Service Quality
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99% accurate first-time transaction processing resulting in a reduction of
service desk tickets
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Avoided manual data consolidation from batch processes
Streamlined Traveler Profile Management
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
Who else is doing SOA?
RESEARCH ON PUBLISHED SOA CASE STUDIES
Federal Health Architecture Connect
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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:
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Department of Veterans Affairs
Social Security Administration
Kaiser Permanente
MedVirginia
Many federal and state government agencies
Harvard Medical School
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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
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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
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Diabetes Remote Monitoring
Connected Medical Devices
Harvard Pilgrim Health Care
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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
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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
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)
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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
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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
Source: http://www.dbmotion.com/UPMC.aspx
Medical Imaging and Computing for Unified
Information Sharing (MEDICUS)
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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
More SOA Case Studies
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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
SOA and Cloud Computing Enabled Healthcare IT
TOWARD A UNIVERSALLY CONNECTED HEALTH
NETWORK
The Wisdom of Connected Patients
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Jane Sarashon-kahn researched Healthcare and Social Media for California
Healthcare Foundation
Healthcare and Social media
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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
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Google Health
Microsoft Health Vault
Carestream Health: billion PACS images in Cloud
From SOA Integration to Universally Connected Health
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SOA Integration
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Prefer System Integration over Consolidation
Prefer Evolution over revolution
No one-size-fits-all solution
A Better Connected World
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Connected Doctors
Connected Patients
Connected Hospitals
Connected Medical Diagnosis Devices
Connected Patient Embedded Devices
Connected Medical Home
Connected Health Information Systems
Acknowledgements
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This presentation was reviewed and commented by :
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Charles Singleton, Director of NIH Business System Program
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Thomas Murphy, NIH Acting CIO
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Thomas Erl, Editor of the SOA Magazine
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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.
References
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Federal Health Architecture Connect Open Source http://www.connectopensource.org
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NIH Enabling National Networking of Scientists and Resource Discovery http://www.vivoweb.org
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NIH Semantic SOA Grid https://cabig.nci.nih.gov/
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US Federal Cloud Computing Initiative http://apps.gov
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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
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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
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Health Care IT Collaboration in Massachusetts by Halamka et al. J Am Med Inform Assoc.
2005;12:596–601. DOI 10.1197/jamia.M1866
Contact
Thanks!
Jeff Zhong
Email: jzhong@futrend.com
http://www.linkedin.com/in/jeffzhong
Website: http://www.futrend.com