February 18 , 2008
Described as a meshing of collaborative services, service-oriented architecture vows to gather—and quickly deliver—pertinent data in a technology-neutral, standard form.
Healthcare providers have “been there, done that” so often with promising technologies that telling them service-oriented architecture (SOA) will allow them to reuse all that old legacy technology to meet new business demands seems unbelievable. Yet, that is exactly the promise SOA brings to healthcare.
Consumers such as physicians, patients, payers, and employers have been frustrated by the inability to easily access data in multiple systems across organizations and subsequently aggregate that data for a patient-centric view. Healthcare data have historically existed in “silos” that cannot be readily accessed.
Before SOA, there was “vendor lock-in,” according to Paul Cahill, a senior manager at Sun Microsystems. For example, specialty healthcare providers such as radiologists or sleep center specialists would have difficulty implementing best-of-breed applications or those specifically designed to deliver the best functionality for their specialized areas. Instead, they often had to settle for a vanilla, big-vendor application with a list of modules for each area. Although these modules were linked by the master application, they often delivered less-than-optimal functionality to specific clinical or business areas.
Alternatively, best-of-breed applications that were purchased from specialty vendors had to be linked to the master application by the development of point-to-point interfaces or the application of interface engine technology. During the last 30 years, a wide variety of systems and platforms have emerged to offer choices, but each system design included proprietary communication methods that let it talk to systems of the same design but not to other disparate systems.1 As healthcare organizations grew larger and more complex—often through mergers with other systems—the integration difficulties became increasingly expensive and complex. The resulting integration spaghetti introduced ever-increasing cost and complexity and reduced organizational agility.1
SOA’s development did not come about as an “a-ha” moment experienced by a reclusive IT genius but rather as a gradual evolution of technological experimentation. Pioneered by Sun Microsystems, SOA can enable integration of previously “siloed, redundant, and inflexible information systems while rationalizing and extracting greater value from existing technology assets.”2
SOA is an architecture that can be gradually developed over time. Through Web services, it creates the ability to allow systems to speak the same language. The elements in IT systems supporting various business and clinical applications—patient registration, claims management, member eligibility—that can be commonly used for more than the business or clinical function they support are organized into services.
These services are accessed through a Java-based Web application that allows the functionality to be obtained by multiple users for many purposes throughout entities and among organizations that may be distant from one another. A composite service application may access customer data held in customer relationship management, enterprise resource planning, financial, and legacy applications.2 In such a roundabout manner, a master patient index can be built using matching algorithms to recognize related customer information distributed across these applications.
In a more patient-focused scenario, a small, best-of-breed ambulance management system could access the motor vehicle department’s database to learn an accident victim’s identity through a license plate number, access a local health network database for any information relating to special conditions the patient may have, and treat a patient more specifically than previously possible before the patient arrives at the hospital. SOA’s ability to allow widely disparate systems to communicate with one another allows such a scenario to be realized in the not-too-distant future.
Reporting on the new combinations of services that can be crafted out of SOA, Medical Technology Report notes that “with the number of disparate data subsystems growing exponentially in the hospital, it makes sense to connect these systems via the network to allow communications and to distill and prioritize alarms coming.”3 In other words, being able to simultaneously tap data in numerous systems makes the possibility of raising patient safety alarms earlier quite foreseeable. The ability to repackage data from multiple applications means that immediate propagation of lab values will help providers to treat patients more quickly and accurately.3
These new composite applications or “services” will mean that clinical or business processes will no longer be dependent on specific applications but may sip from numerous data wells. The agility and competitive value offered by such an architecture could revolutionize healthcare.
Finding the Funds
Developing the return on investment picture to justify the purchase of SOA products is often built on selling chief information and chief financial officers on the benefits that will accrue from the preservation of an organization’s investment in existing applications, the elimination of redundant data entry, the development of better data quality, and the ability and agility to accommodate the business process management initiatives that are developing in many healthcare organizations.
Preserving and leveraging expensive existing IT assets is most attractive to finance departments. The opportunity to access the information assets in these older information systems and reconfigure the data to meet the needs of new business processes makes embracing SOA an appealing option.
Since data elements such as patient identifiers, membership numbers, and birth dates can be accessed in their native systems, they are available for use in business processes other than those for which they were originally collected. In simpler terms, it means that a patient may have to provide registration data only once, and it would be accessible for other processes that may be distant from patient care. What’s more, that particular data element will have to be collected only once, and ownership of each such data element can be standardized and assigned to the business owner of that particular source system to ensure that there is someone accountable for the quality and validity of every data element in the organization.
Liberated from the chains of maintaining hundreds of interface points and products, IT can be freed to work with the business sector to accommodate new processes that it would like to devise to more agilely respond to marketplace challenges. “Early standards like HL7 [Health Level Seven] were the first attempts to allow for the interchange of data among disparate systems, but SOA is the first offering of interactivity through a service,” says Lindsy Strait, chief technology strategy officer of Sun Microsystems Healthcare and Life Sciences division.
This means that as business processes are reengineered to adapt to new healthcare technologies, competition, or regulatory or legal requirements, IT can swing with the business process changes by taking the SOA-developed bank of services and reconfiguring it to the newly engineered business process. “Imagine presenting at your hospital for admission with all your demographics and insurance information passed directly from your doctor’s office, creating a virtual admission and saving valuable time for the patient, the registration clerk, and the healthcare providers,” explains Strait.
Cahill points to SOA’s ability to “wrap and reuse legacy systems” to achieve improved service and cost savings. This developed admission service would be shared by the physician’s practice management system but could also be accessed from the patient’s home through the Internet. Strait cites Sun’s SOA work with the United Kingdom’s National Health Service that created a service called choose and book in which patients can access their hospitals’ scheduling systems, see available appointments in the patient scheduling system, and schedule accordingly. Patients make their own appointments, saving healthcare organizations time and money, while promoting goodwill as patients feeling engaged when seeking scarce healthcare services. He points out that although the United States is not in a position to employ such a program, Sun has been a primary player in working with the U.S. regional health information organization RHIO developers.
The Electronic Health Record
One of SOA’s other attributes is that it will facilitate the development of a longitudinal view of the patient—the ability to see the patient from “womb to tomb.”
“Through protecting the patient’s information in secure Web services and by using identity management products, health information exchange [HIE] becomes a reality,” Cahill says. “By establishing authentication in a federated model, including the use of certificates, a longitudinal view of the patient is possible without the need for a centralized database.”
This may involve a number of hospitals and physician sources, but the response can be in real time. Each encounter can be aggregated to previous information, and providers can make decisions with a wealth of historical information from many sources. Through the use of probabilistic matching of identifiers, Cahill says that the physician will have the “single best record for that patient.” Also, a record locator service “maintains the pointers to all locations that have information about that patient,” according to Cahill. Through agreements, that information can go to the HIE.
For sensitive patient information such as behavioral medicine therapies, Cahill says that “information can be masked to the level that implied information such as admission to an AIDS treatment facility could also be deliberately obscured.”
One challenge of HIPAA compliance for organizations is the need to track the disclosure of patient information over multiple systems and often through external contracted vendors. With composite applications “that offer flexible and reliable means for the collection and exchange of disparate data, the management of HIPAA claims with accuracy and proficiency [can] occur within a single gateway.”2 The whole business process of release of patient information—whether for a HIPAA request; to fulfill a business office need; for a Medicare, Medicaid, or other payer demand; a utilization review; to meet a research requirement; or for continuing care at a distant site—can now become so convenient that it may again become common for release of information to become in-sourced.
With SOA, a composite service could be assembled to accommodate common disclosure data sets—ie, what information from which systems does the organization always need to gather to respond to a disability or workers’ compensation request? Rather than internal or vendor staff laboriously putting together information from half a dozen systems, the composite service can use identifier algorithms to quickly locate and assemble any pertinent information. Compliance with regulations such as HIPAA can be accommodated without ramping up staffing levels. In fact, decreases in less-skilled labor may become possible.
Achieving accreditation satisfaction can also be facilitated with SOA. It is not difficult to visualize The Joint Commission coordinator with her hands on a composite application designed to access all the databases and tables maintained in dozens of different departments to ensure compliance. The same would be true for other accreditation bodies such as the National Committee for Quality Assurance or the Commission on Accreditation of Rehabilitation Facilities.
New on the regulatory horizon are the worrisome Federal Rules of Civil Procedure, and the term e-discovery has joined the healthcare lexicon. SOA will be of particular value when the need to “discover” information in diverse systems, including messaging systems, to respond to an electronic subpoena within a tight time frame becomes the norm. Exhibit A provides a sample scenario of how a composite application could both serve various data consumers and also use components of the applications from each of these best-of-breed applications to receive data needed by other data consumers.
— Sandra Nunn, MA, RHIA, CHP, is a contributing editor at For The Record and the enterprise records manager at Presbyterian Healthcare Services in Albuquerque, N.M.
1. Mummah G. SOA cures healthcare integration headaches. Business Integration Journal. March 1, 2006. Available here.
2. Sun Microsystems. Implementing Sun Technology for health information exchanges. December 2006. Available here.
3. Medical Technology Report. Service oriented architecture (SOA) in the healthcare environment. October 12, 2006. Available here.