Using Tolven to Establish an Information Ecosystem
Introduction
The Tolven platform and application development framework have been developed to enable
partners to establish robust healthcare information ecosystems that will allow all stakeholders in a
broad healthcare environment to interact with one another in a seamless and secure way.
The information ecosystem will take advantage of all aspects of Tolven software, most notably:
 Incorporation of electronic data input from all relevant systems
 Processing of electronic data input formats to extract granular payloads of re-usable
healthcare information (clinical, administrative and financial)
 Creation of scalable relational data bases of analytical quality clinical information
 Transmission of data from the data repository to other systems; the format for transmission
can be either the original input format or a format that facilitates aggregation of data from
a variety of inputs
 JBoss Rules for ease of implementing alerts, notifications, transactional clinical decision
support, and external communications
 Robust account configurations that allow logical groups of users to view and create
information relevant to their needs
 Certified security, audit, and access control mechanisms (including role-based permissions)
 Plug-in framework for ease of developing modules that can be introduced at any time for
any particular set of requirements
 API s for ease of development of and interaction with third party applications
 Layered technology for ease of new application development that can continue to take
advantage of underlying consistency of behaviors of healthcare information objects
 Incorporation of vocabulary and information model standards for ease of extensibility into
all domains of healthcare
 Knowledge access architecture for ease of presentation of context-aware knowledge to any
group of participants
 De-identification services for creation of research data bases
Using Tolven to Establish an Information Ecosystem
Establishing the Ecosystem
In order for any clinical enterprise to effectively manage its business, it must manage an array of
healthcare information that has traditionally been created in many locations (Figure 1).
Figure 1: Representative sources of healthcare information
Of course, information is not easily shared when it resides in existing electronic (or paper) silos.
Merely establishing “connectivity” between disparate systems is not sufficient. Transformation and
consolidation of information from disparate sources facilitates information re-use, efficient
decision making, and robust analytic activities. The consolidation of relevant healthcare
information in a Tolven-based system will also allow an organization to provide specialized views of
information to authorized groups of stakeholders without having to resort to inefficient “queryresponse” exercises. The Tolven ecosystem will be an overall standards-based environment in
which each group of users can be comfortably and accurately represented
Page | 2
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Data Flow in the Ecosystem
Rules will facilitate data flow into, through, and out of the ecosystem. The following diagram
(Figure 2) illustrates, at a high-level, data flow in a Tolven-based health information ecosystem.
Figure 2: High level representation of data flow in the ecosystem
Starting on the left and moving toward the right, data is accepted from external applications and
immediately stored as a “document” exactly as it was received. Tolven then calls each one of the
processors that have been configured for particular document types.
The processors that recognize the document format can then parse that document using a
technique of their choice (many are in XML format, but that is not required). This processing
enables semantic normalization because, at this point, the differences among different data sources
sending in the same data can be resolved. For example, a serum glucose test result may come from
one of many different sources such as independent clinical laboratories, hospitals, and even the
patient. Without disturbing the source document, the processor creates what Tolven calls
“placeholders” which is a catch-all term representing the various kinds of data objects used in
healthcare: patient, problem, allergy, medication order, laboratory result, vital sign observation,
etc.
Page | 3
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Placeholders are instantiated in harmony with the HL7 Reference Information Model, a discipline
that facilitates semantic interoperability. Key clinical information is thus redundantly stored in the
ecosystem: once as the original document and then again as the placeholder. The link between
placeholder and original document is always maintained to assure fidelity of context and
provenance.
If a message is very simple, it may only create or update a single placeholder. Complex messages
may affect many placeholders. For example, a lab result may affect only a single or small number of
placeholders of a single type (lab result) whereas a CCD document may affect many placeholders
of different types.
After semantic processing, all affected placeholders are subject to rule processing. In Tolven, rules
are used to maintain “truth” by reasoning over patient data with the affected placeholders in
context. For example, when a laboratory result is received and the rules determine that that claim
should be place on a list of new results for a particular patient, then Tolven will add the item to
the list of laboratory results for that patient which can then be reviewed by authorized personnel in
the appropriate account. All rules are stated in the positive so that if a rule does not support an
item being on such a list, then it will automatically be removed from that list. This style is called
truth maintenance. Rules can be, and usually are, added to specific accounts in order to implement
desired user interface and decision support behavior in that account.
Rule consequences are not limited to the creation of lists. Outbound messages, such as for other
EMRs, case management systems and utilization review systems, can also be triggered by rules. This
allows for multiple approaches to integration with other systems. For example, data can be written
to non-Tolven tables or to completely different databases.
Some external applications may only send data into the ecosystem (such as “Application a” above);
other external applications (such as “Application d” above) may only be recipients of data from the
ecosystem.
The lower section of the diagram shows how data from applications developed on the Tolven
framework submit data to the ecosystem. All data from Tolven-based applications is formatted in
an xml structure call a TRIM (Templated Reference Information Model). TRIMS are taken in and
processed by the ecosystem in exactly the same way as messages from external systems.
Page | 4
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Representing Groups of Users
Within the ecosystem, many groups of users, organized into logical accounts (Figure 3), will use
data viewing applications. In addition, developers will utilize Tolven to develop data entry
applications that also will be used by members of logical accounts, each of which will have its own
packages of rules while, at the same time, sharing an overarching standards- based clinical
information system.
Figure 3: Accounts for groups of users in the ecosystem
Each individual user will have his/her own identity in the implementation, and each individual
user can be a member of more than one account. Separation between accounts is essential for
preserving privacy and is also essential for documenting when and what information is shared
between accounts. Sharing information between accounts (Figure 4) takes place through explicit
“copy,” “send,” “acknowledge,” and “receive” actions. All such actions documented in an “audit
trail.”
Page | 5
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 4: Sharing information between accounts via Tolven “copy” functions
As we have already seen, the ecosystem will be able to be integrated with outside applications (nonTolven systems) in a variety of ways, including standard and non-standard messaging and APIs.
Information created in outside systems will be conveyed to the ecosystem and distributed to
appropriate accounts for further action (Figure 5).
Page | 6
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 5: Integrating information from applications outside of the ecosystem
Page | 7
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Developing New Applications
As the system matures, the need for additional applications to support particular clinical domains
has been anticipated. Such applications (Figure 6) can be developed for use in the established
ecosystem, through use of the Tolven plug-in framework.
Figure 6: New application development using Tolven technology
In all cases, modules developed for various groups of users in various domains can take advantage
of a universe of common healthcare information objects and work flows that have already been
established by Tolven.
Page | 8
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Taking the First Steps: Example 1 (Consolidate electronic record for clinicians)
In the initial steps of the implementation, information about authorized users will be loaded into
the system (Figure 7). User information can be programmatically transmitted from an existing
directory (top entry point) or it can be entered via existing Tolven application modules (lower entry
point). The enterprise will establish the information requirements for various categories of users
(specified demographics, etc). Such information will provide the foundation for a user directory.
Figure 7: Initial load of user information
End users are organized into logical accounts that are synchronized with clinical responsibilities for
care groups. Within the ecosystem, patient records begin to be created by either importing of
demographic information from outside systems or by use of existing Tolven application modules
to enter demographic data in compliance with government standards (Figure 8).
Page | 9
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 8: Creating patient records
Clinical information will be pushed from various systems in the enterprise, usually via HL7
messages. Summarized clinical information can also be imported from other clinical enterprises,
usually via CCD, into the ecosystem where it will be appropriately processed (Figure 9). In
addition, clinical staff will use current Tolven 2.1 application functionality to add critical clinical
information to the patient records. All information is retained in the data repository of the
ecosystem. Rules enable presentation of this new information to appropriately authorized
members of the clinician accounts.
Page | 10
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 9: Taking in, storing, processing, and displaying information
Rules can facilitate the transmission of clinical information to outside systems such as those
maintained by public health entities or by other government agencies. While rules determine the
appropriate outside system “targets” for clinical information, clinicians can also explicitly designate
targets for receipt of information within the parameter established by patient consent. The outside
EMR “targets” will be available in a directory maintained in the ecosystem (Figure 10). All
transmissions of information are audited, and the audit trail is visible to any authorized member of
the account that is sending or receiving such information. The outbound CCD (which complies
with standards for data format and data content) aggregates information that has accumulated in
the patient record from all sources. Careful programming allows for preservation of provenance
for transmitted data.
Page | 11
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 10: Transmitting information to outside applications
Page | 12
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Facilitating Clinical Research
With patient consent, information held in the clinical enterprise data base can be de-identified
and stored in a separate research database with viewing access provided to authorized users
through Tolven-based applications in Tolven style accounts (Figure 11)
Figure 11: Organizing information for clinical research
Page | 13
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Taking the First Steps: Example 2 (PHR-centered Health Information Exchange)
While Tolven software can be used to establish traditional clinical data repositories as well as to
support health information exchange systems controlled by clinical provider organizations, some
partners have been exploring how to use Tolven to implement patient controlled health
information systems, some of which are referred to as Health Record Banks. Because such
exchanges are under the explicit control of patients, many of the stumbling blocks surrounding
current heath information exchange constructions can be avoided. The approach to such systems
re-uses nearly all of the application functionality that we have already discussed, so much of this
will be familiar.
In the initial steps of the implementation, information about members in the targeted group(s) will
be loaded into the system (Figure 12). The sponsoring enterprise for the HIE will establish the
information requirements for members (specified demographics, etc). Such information will
provide the foundation for a member record.
Figure 12: Initial load of member information
Page | 14
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Within the ecosystem, PHR accounts will be created for members and authorized family members
or “agents” (Figure 13).
Figure 13: Creating end user PHR accounts
Clinical information will be pushed from the medical care provider organizations to the ecosystem
where it will be appropriately processed (Figure 14). All information is retained in the data
repository of the ecosystem. Rules enable presentation of this new information to appropriately
authorized members of the PHR accounts.
Page | 15
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 14: Taking in, storing, processing, and displaying information
The PHR application will also allow patients (and any other authorized member of a patient’s
account) to enter key clinical information such as OTC medications, allergic reactions to drugs,
etc.
While rules determine the appropriate PHR “targets” for clinical information, the patient will
explicitly designate targets for receipt of information. We have thus introduced the term “patient
control” rather than continue to reference “patient consent”. The EMR “targets” will be available
in a directory maintained in the ecosystem (Figure 15). All transmissions of information are
audited and the audit trail is visible by the any authorized member of the account sending or
receiving such information. The outbound CCD aggregates information that has accumulated in
the PHR from all sources.
Page | 16
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 15: Transmitting information to outside applications
Page | 17
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Facilitating Clinical Research
With the exercise of patient control, information held in the HIE data base can be de-identified
and stored in a separate research database with viewing access provided to authorized users
through Tolven-based applications in Tolven-style accounts (Figure 16)
Figure 16: Organizing information for clinical research
Page | 18
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Tolven Architecture
Tolven is assembled from many components, but it begins with a slender infrastructure framework
(Figure 17). The Tolven technology framework has three primary components with others added
for specific needs:



The Tolven infrastructure
The database
One or more LDAP servers
Tolven has embedded security at every level of the infrastructure. Encryption, authentication, and
authorization are common services to most aspects of Tolven. The Tolven Gatekeeper, provides
user authentication, authorization, and single sign on. Transactions are processed reliably using
RDBMS technology.
Figure 17: The Tolven healthcare framework
Page | 19
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
The Tolven Application Server is added to the infrastructure and contains a number of
components including the Tolven Web Application and the HTTP-based APIs. All of these
components make use of a common library of “backend” application behavior. Each component
can be deployed to the same or different server hardware. All communication between Tolven
components is TCP/IP in the standard configuration.
The Tolven plug-in architecture (Figure 18) allows maximal flexibility for application development
by partners while preserving the Tolven core and allowing for easier maintenance and
customization. Plug-ins facilitate easy updates and extensions of a Tolven-based solution. The
Tolven plugin architecture allows partners (Tolven itself uses this same mechanism) to configure
alternate and/or additional behavior into the system at all architectural levels. Plug-ins can be
horizontal, such as database, LDAP and application server choices or vertical, such as adding
additional types of clinical data. An installation of Tolven will have one or more “plug-in catalogs”
from which to draw. The assembly process, with the aid of a configuration file, draws from these
catalogs to construct a complete application server and related components. At runtime, core
Tolven code and customer-specific code work side-by-side.
Tolven provides HL7 ANSI Data types and abstract HL7 Reference Information Model
components in order to support virtually any type of healthcare application development.
Page | 20
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 18: Tolven healthcare application plug-in architecture
Tolven Architecture Layers
In order to guard against rigidity and the attendant inability to evolve, Tolven utilizes a technology
stack that includes components that can be exchanged without either loss of function or loss of
data.
Within the diagram seen below (Figure 19), we have made component choices for the current
Tolven release. The diagram shows the layers in which those choices have been made.
• Web browser – using Ajax
• Web server – using JSF
• Application server – JBoss or Glassfish
• Database – PostgreSQL or Oracle
• LDAP – OpenDS or OpenLDAP
Page | 21
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Figure 19: Tolven’s component layers
Page | 22
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Tolven Security
Tolven operates in a “security by design” environment with multiple layers. All documents, public
keys and secret keys are protected (Figure 20).
Figure 20: Tolven approach to security
Page | 23
Company Confidential
October 2013
Using Tolven to Establish an Information Ecosystem
Performance
In Tolven, there are three main data flows affecting scalability (the ability to handle a specific
workload):
1. Query transactions from the user interface
2. Message processing transactions
3. Analysis queries
The execution environment includes:
1. Tolven application server
2. Tolven database
3. Tolven authentication server (Tolven Gatekeeper)
4. Tolven's document store
A typical installation is likely to have additional software running as well which must also be
considered when measuring scalability.
Within the first two years of Tolven’s development, benchmarking was conducted in partnership
with Sun Systems. The published benchmark demonstrated scaling to millions of records with
excellent user response times (200 simultaneous users) and affordable hardware. In more recent tests
and with the availability of low-cost cloud computing, we have used Amazon EC2 servers for
testing. Since Tolven does not sell hardware, and desires to remain hardware platform
independent, the virtual computing environment allows us to dynamically expand or contract the
resources utilized in a given test in a way that can be easily reproduced and translated to other
computing environments - and at a relatively low cost. In our tests, a single thread executing on
Amazon EC2 virtual environment was very close to a single thread running on a well-configured
three-year-old desktop machine.
Performance (measure of elapsed time and resources used to accomplish a given task) and
scalability (ability of a system to handle increased workloads) have always been critical
considerations for Tolven. We can supply a more detailed white paper, if desired.
Summary
Tolven is able to work with partners and clients to establish a healthcare information ecosystem for
that will meet needs for information storage, information transformation, information exchange
and data analytics. The standards-based, rules enabled ecosystem will provide efficient data
throughput, cost effective new application development, and real time patient stratification and
case management functions that have been cumbersome to implement in other technologies.
Page | 24
Company Confidential
October 2013