Architecture

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Architecture
Ivar Berge, Rådgiver, Rikshospitalet HF
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The vision of the paperless hospital is old

• As early as 1970 some authors predicted that
  computers would play a vital role in clinical
  practice in most hospitals
• Since then, the paperless hospital has benn
  just around the corner
• If you look back, the road is paved with
  disappointments and failures
• Are we looking for the gold at the end of the
  rainbow?

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What has gone wrong?

• Overestimated technology
• Cultural clashes and language barriers
• Organizational development
• Bloated benefits bad handling of the
  expectation level
• Too little commitment from administrators
• Too little end-user involvement

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Who have had success?

• Those not going for off-the-shelf solutions,
  but instead doing (and planning for) a lot of
  development and tailoring, down to the individual
  department - and in some cases down to
  individual users.
• Those who have truly understood that development
  and implementation of hospital-wide IT-systems
  not can be seen as an isolated process

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!!
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Arthur will almost surely

• Meet health professionals that know nothing (or
  very little) about him
• Meet health professionals with erroneous
  information bout him
• Receive contradictory information about what is
  going to happen and what he should do or not do
• Have to repeat his story again and again and
  again
• Have to repeat one or more examinations or tests
  because previous results are unavailable
• Be told to ask someone else about that particular
  question
• Be left with a lot of unanswered questions

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It all began on a cold winter morning
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Our mission was

• Rikshospitalet shall by 2007 have a complete
  electronic patient record, the paper record is
  history and we are a leading hospital nationally
  and internationally regarding the use of IT in
  hospitals

What does it take?
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Some questions popped up

• What is really a complete EPR?
• How can we solve this?
• What kind of competence do we need?
• What will it cost?
• Is it possible within the time-frame?
• Has anybody else done something similar?
• Is he out of his mind?
• Should I look for a different job?

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A very common model
EPJ/PAS
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A very common model
EPJ/PAS
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Physician Clinical Practice
Clinical Decision Support
Pharmacy/Medication Safety
Data Warehouse
Severity Adjustment
Physician Order Entry
Results Review
Rules and Alerts
Medication Order Entry
Outpatient Prescriptions
Report Writer
Order Sets
MAR
Comparative Database Access
Task Lists/ Workflow Tools
Outcomes Measurement
Resource Utilization
Substitution/ Cost Management
Provider Documentation
Formulary Management
Dosing Management
Pathways
Protocols
Provider Profiling
Ambulatory Practice Management
Positive Patient Identification
Access to Drug Databases
Credentialing
Patient History/Problem Lists
Patient Locator/Patient Lists
Rounding Tools
Drug Interactions
Enterprise Patient Access
Robot Interface
Core Information Management Components
Admission/ Registration
Enterprise Scheduling
Eligibility Verification
User Interface/Portal
Technical Denial Management
Data Aggregation and Reporting Tools
Request for Authorization
Consumer Portal
Departmental/Support Services
Common Medical Vocabularies
ClinicalData Repository
Master Person Index (MPI)
Radiology/ PACS
Research Repository
Lab
Cardiology
Clinical Documentation
Patient Assessment
I O Vital Signs
Flowsheets
Emergency Department
Surgery
Decision Support Repository
Standard CDM
Order Entry
Rules Engine
Pathology
Care Plans
Kardex
Task Lists
Other Departmental Systems
Blood Bank
Security Tools
Integration Tools
Consumer Content
PDA Support
Transition Planning
Non-MD Orders
Specialty Documentation
Health Information Management
Care Management
Critical Care Documentation
Interfaces to Monitors
Patient Education
Initial Concurrent Review
Clinical Denial Management
Discharge Planning
Chart Management (Deficiencies)
Precertification Authorization
Transcription/ Dictation
Coding Support
Supply Chain
InterQual Support for LOC
Payor Communication and Notes
Work Lists
Pathways
Document Imaging
Electronic Signature
Workflow Tools
Patient Supply Charges
Support for Product Standards
Tracking Reconciliation
Social Services Support
Post Acute Placement
Readmit Alerts
Disease Management
MRN Management and Merge
Release of Information
Interface to ERP System
CDMP (?)
Solution Components
Solution Sets
Kilde John Quinn, Ernst Young, 2002
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Add to this the heritage from the past

• More than 160 systems involved in the treatment
  of patients, almost none integrated
• Most of them bought or developed on local
  initiative with little or no involvement from
  the IT department and without being validated
  against an overall strategy/architecture
• This still happens (although to a much lesser
  extent)

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Some consequences

• You cant solve everything in one system without
  making too many compromises
• No vendor in the world can offer everything we
  need
• No vendor excels except in a few of these areas
• We obviously have no choice but integrating a lot
  of different systems, but how?
• We need to be innovative

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A (very) brief history of IT at Rikshospitalet

• 1992 The IT department has about 15 employees
  focusing mainly on administrative systems. The
  clinical departments themselves handle
  acquisitions/development, implementation and
  support for the systems they use including
  technical infrastructure. Its anarchy!
• 1993/94 The task of cleaning up the mess begins
  starting with infrastructure
• 1995 the first hospital wide information
  system - the patient administrative system is
  implemented
• 1996 implementation of electronic patient record
  starts the MEDAKIS project and is supposed to
  be completed in 1999 with the completion of the
  system DocuLive EPR 5.0 a planned mix of
  development and implementation
• 1999 implementation still ongoing, as is
  development
• 2000-2002 we see the need to change our strategy
  the concept of a clinical portal is borne
  were now supposed to become a digital
  hospital, not necessarily a paperless one
• 2004 The MEDAKIS-project is formally ended, with
  DocuLive version 4.7
• 2007 about 125 employees in the IT-department
  Clinical portal version 1.7.5 fully implemented.
  CSAM International established (in 2006) to
  commercialize the product. IDS (Implementation
  Digital Hospital) phase 3 ongoing

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What are the conditions we have to work with?

• Were doing it without braking (it has been
  compared to changing the systems of a plane in
  flight)
• We are peripheral and central to the organization
  at the same time
• We face a lot of isolationism
• An extremely dynamic organization (shooting at a
  moving target
• The field of medicine changes rapidly
• Endless turf wars
• Very tight financial conditions

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Important areas to focus on in order to gain
early benefits

• Reduce average length of stay through reducing
  idle time
• Reduce unnecessary tests and examinations
• Reduce information redundancy
• Optimize workflow with emphasis on planning and
  preparation
• Strengthen the quality and integrity of available
  information
• Reduce medical errors due to erroneous or lacking
  information
• Improve both patient and information safety
• Improve patients engagement
• Offer high quality data for research, quality and
  administrative purposes
• Stimulate (rather than force) innovation and
  change in the clinical environment

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Legacy systems

• Silo-thinking still dominating, e.g. if a
  laboratory needs a new system they tend to view
  this as a internal process and most available
  systems are not properly designed to function as
  part of an integrated environment
• Huge redundancy as to content and functions and
  little standardization (e.g. most systems have a
  patient index and a table with the organizational
  structure but each system in its own format)
• Acquisition of new systems, as well as the
  development and replacement of old systems needs
  to be done as part of a functional, architectural
  and technological strategy/vision
• The hospital must (and to some extent has
  already) determine demands to future (and
  current) vendors related to our architecture
  (such as web-services, access to source code
  etc.)
• We need to organize our work so this is well
  maintained, without creating bottlenecks we
  still lack a chief architect as well as
  methodology to quickly verify and decide whether
  or not a specific system or component fits our
  overall strategy. (It is important to understand
  that in many organizations this quickly becomes a
  very political role, which is one of several
  reasons we dont currently have one).
• One target is to better leverage previous system
  investments and achieve much more cost effective
  improvements or replacements of old systems

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Not one architecture many!

• Business architecture
• Security architecture
• Systems architecture
• Information-architecture
• Integration-architecture
• SOA
• Technical architecture
• ?

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What has happened so far?

• Were fairly successful, but
• We all the time have to compromise and the
  vision is suffering the most
• Externatl conditions as technological problems,
  politics and economics keep forcing us to choose
  the cheapest and easiest way out
• This puts focus on the individual building blocks
  and the complete picture becomes unclear
• Some of the architectures are considerably
  harder than others (such as for instance our
  security architecture which is firmly rooted in
  legislation) but it is still a continuous and
  difficult negotiation and alignment process
  between them.

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Some experiences

• All architecture must be clearly related to the
  overall vision and strategy for the hospital
  and relevant changes in this must be reflected
  back in the architectural work this isnt
  always the case and may cause us to spend a lot
  of time building a systems infrastructure that
  doesnt adapt well enough to future needs
• It is not enough to have excellent individual
  architects if theyre not part of a close team
  and this team needs a very close connection to
  key stakeholders
• A living, continuously updated and richly
  described vision that is commonly agreed upon is
  very difficult to achieve and takes a lot of time
  and resources to create and maintain

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More experiences

• We have had a lot more problems related to
  stability and performance than expected, but this
  has improved considerably. But it has cost us
  time, money and above al confidence
• We have not been good enough at information
  throughout the organization
• The organizations ability to absorb new
  functionality is very limited when they are
  understaffed, overworked and generally
  frustrated. IT is a very convenient target for
  aggression and frustration, whether justified or
  not.
• We have been forced to prioritize away very
  important functionality, something that among
  other things will negatively affect short term
  benefit realization.
• The concept has generally been very well
  received, but there is a risk that we will not be
  able to meet the expectations because of the
  functionality that has now been put on hold or
  removed from the concept.
• The unusual way our IT-department is organized
  and our competence profile (where approx. 40
  have a clinical background) is a key factor for
  success.
• One should never underestimate or Man må verken
  undervurdere eller nedvurdere kompleksiteten og
  heterogeniteten i helsevesenet, men ta høyde for
  den i løsningene

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We are really special, you know

• Is the healthcare system really unique in some
  aspects that are vital to systems development and
  implementation?
• Is the rather uncritical adoption of methodology
  and experiences from other sectors one of the
  reasons we struggle so much?

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With thousands of users and just as many opinions
of what is a good system you just cant make
everybody happy