POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Impact of Information TechnologyImpact of Information Technology on the Quality of Health Services
RADU DOBRESCU
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
A draft vision for eHealthOverall goal to improve health and quality of health-related
information
Integrated eHealth systems for everyone, everywhere to improve access to quality health services, and allow for better health and well being of all citizens and better health systems management.
We believe eHealth should support: – Personal, family, community, public health services and
preventative interventions, particularly in resource-poor environments
– The most relevant health research, information and education, for health providers, researchers, policy makers and citizens
– Appropriate, complete, consistent and interoperable health information systems, that integrate public health and clinical requirements for overall health systems management and stewardship.
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POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
“eHealth” a broad and diverse realm of efforts
eHealth:
the use of information and communication technologies (ICT) to improve health
Different types of eHealth initiatives include, but not limited to:Different types of eHealth initiatives include, but not limited to:
Health information systems• Public health informatics:
• Support for disease prevention• Disease and intervention surveillance (e.g. PDAs to community health
workers for disease surveillance)• National health info systems to detect/track global threats to public health
• Health and clinical informatics:• Electronic health records (EHR), electronic medical records (EMR), patient
health records (PHR)• Decision support for healthcare professionals
• Health system administration and operations• Pharmacy and supply chain management systems• Laboratory systems (e.g. electronic ordering, transmission processing)• Clinical administration software (e.g. billing)
Healthcare and expertise• Telemedicine / telehealth
Health research, advisories and education• eLearning for physician, nurse, healthcare personnel training• Access to research for healthcare personnel• Patient support and information (SMS reminders for drug compliance, online
health information, etc.)• Decision support for healthcare professionals
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Variety of challenges to reaching vision
Barriers and impediments
to eHealth advancement
Little capacity for developing and managing health information technology
Prohibitive policy environment
Optimal eHealth
development path unclear
System is fragmented – donors and other stakeholders push for narrow, specific solutions without interoperability considerations
• Leads to inefficient use of funds• Creates program stovepipes
Lack of private sector providers due to low market incentives threatens sustainability, independence
Immaturity and youth of
eHealth effort in developing
countries
Lack of awareness about value of eHealth and breadth of possible solutions
Lack global forums with all relevant stakeholders in which to discuss progress, issues and learnings
STOVEPIPINGSTOVEPIPING
The most common types of intelligence collection, and to some extent processing, which are commonly found in "stovepipes", include signal intelligence (SIGINT), imagery intelligence (IMINT), and human intelligence (HUMINT)
Stovepiping is a metaphorical term which recalls a stovepipe's function as an isolated vertical conduit,has been used, in the context of intelligence, to describe several ways in which raw intelligence information may be presented without proper context. The lack of context may be due to the specialized nature, or security requirements, of a particular intelligence collection technology.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Solution areas grounded in domains of eHealth applications
“Path to Interoperability” -finding optimal development path to maximize eHealth potential•“eHealth Policies” and “Capacity Building” address the enabling environment to lower the barriers and impediments to eHealth diffusion and advancement•“Electronic Health Records”, “mHealth”, “Public Health Informatics” and “Access to Information” provide grounding in applications that strengthen health systems
EHR mHealth PHI A2K
Interop. Markets
Optimal development path
eHealth applications
PoliciesCapacit
y building
Enablers
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Connected health information network will require interoperability across several dimensions
Across programs Across geographies
Across points of care Across technologies
Census
TB
Malaria
HIV/ AIDS
Hospital
Health clinic
Community health worker
Metcalfe’s LawMetcalfe’s Law Examples of dimensions to be addressedExamples of dimensions to be addressed
The value of a network (e.g. Telecomm) is proportional to the square of the number of users of the system (n²)
Early stage of eHealth in much of developing countries is an advantage – possible to take action now
Hypothesis: Collaborative action necessary for Hypothesis: Collaborative action necessary for successsuccess
• Collaboration can achieve synergy through united action– Branding: uniting all eHealth-related efforts to increase awareness– Funding coordination: drives alignment on key issues, reduces redundant activities– Mitigate HR constraint: limited group of experts in this field
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• Technology companies• Biopharmaceutical companies• Entrepreneurs• Research and academia• Others?
Fostering spread of eHealth requires multiple, interconnected efforts• HCIT capacity building required to support many eHealth efforts• National policies needed to support all types of programs• Emerging platform technologies, e.g. mobile health, span multiple areas of focus public
health, clinical and patient-centered informatics
Multi-player, multi-sectoral initiative needed• Ministries of health and other
representatives of target countries• Private donors/foundations• Non-governmental organizations• Multilateral donor/aid organizations
Goal : engage stakeholders on collaborative action Goal : engage stakeholders on collaborative action to address challenges facing eHealth effortsto address challenges facing eHealth efforts
Capacity building
• help countries build and sustain HR capacity to manage, maintain and develop eHealth solutions
Policy advocacy• develop enabling policy guidelines• advocate to and/or advise countries on policy development
Standards support
• identify/advocate/implement critical data standards to ensure data quality and interoperability
Funding coordination
• raise funds for eHealth, reduce redundant activities and increase pool of funding
• align funders on key issues (e.g. interop. standards), channel funding as needed
Market-making
• connect “buyers” and “sellers” of eHealth solutions– educate consumers on portfolio of available
applications– aggregate demand for eHealth solutions– potentially provide base level of freeware / starter kits
Key collaborative actionsKey collaborative actions
Enablers
Policy
Cap. build.
Optimaldevelopmentpath
Interop
Market
Com
mu
nic
atio
nst
and
ard
s
Info
rma
tion
stan
dar
ds
Example: hierarchy of eHealth standards Example: hierarchy of eHealth standards supported by communication standardssupported by communication standards
SNOMED
TCP
XML
HL7 v2.51
IP
HTTP
TermTerm
Systematized Nomenclature of Medicine
Health Level Seven
eXtensible Markup Language
Hypertext Transfer Protocol
Transmission Control Protocol
Internet Protocol
DescriptionDescription
Systematically organized collection of medical terminology covering most areas of clinical information
Enables the exchange, management and integration of healthcare information
Facilitates sharing of structured data across different information systems
Used to transfer or convey information on the World Wide Web
Provides reliable, in-order delivery of a stream of bytes
Data-oriented protocol used for communicating data across the internet
Standard Standard First useFirst use
1987
2003
1997
1996
1974
1977
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
11(#total)
• The Future of Healthcare - The banking metaphor• Existing Health on the Web• eHealth - terminology• Transmural Care• Electronic Medical Records (EMR)• Medical Records - Access• Clinical Decision Support Systems • Telemedicine - Case Studies• eHealth Standards • eHealth / eScience : Cancer Diagnosis• Benefits of eHealth• Medical Errors• Why is eHealth Adopted Slowly?• New sources of "health"
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
12(#total)
eHealth - The Future of Healthcare The banking metaphor
• Most transactions carried out by the customer
• Centralisation of specialist services
• Decentralisation of non-specialist services
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
13(#total)
Existing Health on the Web
Access to accurate information can lead tomore knowledgable, empowered, less anxious patientsmore participatory health decisionsbetter care as patient and doctor become partners
Mis-information can lead to confused and angry patientsbad decisions, mis-placed hope, worse care, harm
Privacy violations can cause emotional and economic damage
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
14(#total)
eHealth
“Healthcare which is supported by electronic processes”
Other terms:– Healthcare informatics or Health Information Technology (HIT)– Medical Information Systems (MIS)– Biomedical informatics (also includes Bioinformatics: gene
sequencing etc.)
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
15(#total)
“Healthcare which is supported by electronic processes”
eHealth includes:
– Electronic Medical Records: easy communication of patient data between different healthcare professionals (GPs, specialists, care team, pharmacy)
– Telemedicine: do not require a patient and specialist in same physical location.
– Decision support systems in healthcare • Data can be analysed to provide alerts, reminders and real-time decision aids
– Evidence Based Medicine: • The application of the scientific method to medical practice• Check if diagnosis is in line with scientific research. • Data can be kept up-to-date.
– Citizen-oriented Information Provision: for both healthy individuals and patients
– Specialist-oriented Information Provision: best practice guidelines from latest medical journals.
– Virtual healthcare teams: collaborate and share information on patients through digital equipment (for transmural care).
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
16(#total)
Transmural Care
Transmural: Care should not stop at the walls of the hospital– Both intra- and extra-mural, thus ‘transmural care’.– Care before, during and after the hospital stay. – Cooperation and coordination among local practitioner,
hospital, home care and rehabilitation centres– Patient part of an agreed programme - protocols and
standards.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
17(#total)
Electronic Medical Records (EMR)(also called Electronic Health Record (EHR))
– Access of patient data by clinical staff at any given location – Accurate and complete claims processing by insurance companies – Building automated checks for drug and allergy interactions – Clinical notes – Prescriptions – Scheduling – Sending and viewing labs
Two types of record:– “Born digital" record : information originally entered in electronic format– “Digital format” record : originally produced in a hardcopy form (x-ray film, photographs, etc.),
scanned or imaged and converted to a digital form.
Also: Personal Health Record (PHR) - stored and maintained by the patient.– Issue: Home computer vulnerable to attack
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
18(#total)
Electronic Medical Records (EMR)
Maintaining Records– May be required many years after a patient’s death
• Insurance claims or murder investigation• Investigate illnesses within a community
– industrial or environmental disease – doctors committing murders
– need for periodic conversion and migration to ensure the formats they were captured in remain accessible
– Media degrades– Media becomes obsolete– protection of privacy is a major concern - need privacy and security
policies
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
19(#total)
Clinical Decision Support Systems
• Software to aid clinical decision-making: characteristics of patient are matched to knowledge base,
recommendations are presented to the clinician/patient
• Objectives:– Diagnostic support– Drug dosing– Preventive care reminders– Disease management (diabetes, hypertension, AIDS, asthma)– Test ordering, drug prescription
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
20(#total)
Clinical Decision Support Systems
• Methods:– rule-based, bayesian network, neural network, fuzzy logic, genetic
algorithms, case-based reasoning, etc.
• Forward reasoning (data-driven) use if sparse data– start with data, execute applicable rules, see if new conclusions
trigger other rules:• if high WBC AND cough AND fever AND etc. => pneumonia• if pneumonia => give antibiotics, etc.
• Backward reasoning (goal-driven) use if lots of data– start with “goal rule,” determine whether goal rule is true by
evaluating the truth of each necessary premise • patient with lots of findings and symptoms• is this lupus? => are 4 or more relevant criteria satisfied?
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
21(#total)
Telemedicine
“The delivery of medicine at a distance.”
Two basic forms:– Live telemedicine - videoconference link– Store-and-forward telemedicine - transmit for assessment offlineTypical Telemedicine interaction: store and forward followed by live
interaction.
Data types– text (e.g. patient's notes)– image (e.g. x-ray) Telemedicine often relies on images (still or moving)
Equipment– general purpose (e.g. PCs)– specialist (e.g. electronic stethoscope)
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
22(#total)
Telemedicine (contd.)
Telemedicine most useful when – Specialist services are in very high demand or– Patients are extremely isolated
Home care is often delivered by telemedicine– Automatic monitoring and pill dispensing etc.
Telesurgery may also be considered as a subset of telemedicine.
– Patient operated on by remotely controlled robotic arms etc.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
23(#total)
eHealth / eScience : Cancer DiagnosisTelemedicine on the Grid– Multi-site videoconferencing – Real-time delivery of microscope imagery– Communication and archiving of radiological
images• Supports multi-disciplinary meetings for the
review of cancer diagnoses and treatment.
Remote access to computational medical simulations of tumours and other cancer-related problems
Data-mining of patient record databasesImproved clinical decision making.
Currently clinicians travel large distances
Grid technology can provide access to appropriate clinical information and images across the network.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
24(#total)
Benefits of eHealth– Reduced record keeping expenses– More accurate data
• No poor handwriting problems– Automated sharing among patients and provider
• Empower the patient to manage their own health - via Internet information and decision support tools
– Reduced office visits to get results– Avoidance of duplicating tests– Automatic summarisation/graphical displays of context-
relevant information to the physician
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
25(#total)
Benefits of eHealth (contd.)
– Decision Support Tools -> Improved decisions– Remote access to data - e.g. ill while travelling– Improved workflows– Decreased risk of malpractice suits– Ability to mine large record databases
• Research causes of disease• Assess effectiveness of treatment programmes/drugs• Monitor outbreaks of diseases• Easier to conduct clinical trials and rapidly incorporate research results
in decision support tools
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
26(#total)
Why is eHealth adopted slowly?
– Lags behind other industries by 10-15 years – Complex regulations - e.g.
• Patient records• Privacy laws
– Lack of interoperability/standards– Doctors reject IT systems
Risks– Potential for errors due to software bugs– Highly coupled systems - greater risk of catastrophe– Decision support systems could lead to mass produced
mistakes– Privacy - data vulnerable to attack
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Presentation
• HL7• MITA, HL7, CMS, DHHS, ONC, FEA -> alignment of healthcare architecture• MITA Business Architecture -> Information Architecture
– MITA Enroll Provider (HL7 MITA WG Example)– MITA Inquire Member Eligibility (Gateway 5010 Project)
Business Architecture
Technical Architecture
Information Architecture
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
HL7• An international standard development organization established
more than 20 years ago.• Enables interoperability of healthcare information.• Creates standards for the exchange, management, and
integration of electronic healthcare information.• Develops specifications, e.g., a messaging standard that
enables disparate healthcare applications to exchange key sets of clinical and administrative data. (HL7 does not develop software).
• Why Health “Level Seven”? – this refers to the highest level of the International Organization for Standardization (ISO) communications model for Open Systems Interconnection (OSI) – the application level.– The seventh level supports such functions as security
checks, participant identification, availability checks, exchange mechanism negotiations and, most importantly, data exchange structuring.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
HL7 TodayVersion 3 Reference Information Model (RIM v3)• Messages evolved over several years using a "bottom-up" approach that
has addressed individual needs through an evolving ad-hoc methodology. • Many optional data elements and data segments, making it adaptable to
almost any site. • The optionality forces implementers to spend more time analyzing and
planning their interfaces to ensure that both parties are using the same optional features.
• Well-defined methodology based on a reference information (i.e., data) model. It will be the most definitive standard to date.
• Rigorous analytic and message building techniques and incorporating more trigger events and message formats, resulting in a standard that is definite and testable, and provide the ability to certify vendors' conformance.
• Uses an object-oriented development (OOD) methodology and a Reference Information Model (RIM) to create messages. The RIM is an essential part of the HL7 Version 3 development methodology, as it provides an explicit representation of the semantic and lexical connections that exist between the information carried in the fields of HL7 messages.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Steering Divisions: Foundations & Technologies
Provides fundamental tools and building blocks– Conformance
– Infrastructure & Messaging
– Implementable Technology Specifications (ITS)
– Java
– Modeling & Methodology
– Security
– Services Oriented Architecture (SOA)
– Templates
– Vocabulary
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
HL7 DiversifiedHL7 started with and is traditionally thought of as “messaging”. For most
of its life, however, HL7 has also produced more than messaging standards.– Electronic Data Exchange in Healthcare Environments (i.e.
“messaging”) (v2 and v3)– Visual/Context Integration (CCOW)– Version 2.x XML (XML encoding of HL7 messages)
• Clinical Context Documentation Implementation Guide (CCD)– Electronic Health Record System (EHRS) Functional Model– Personal Health Record System (PHRS) Functional Model– Services (i.e., Services as related to a Services Oriented
Architecture
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Cooperation with Other Standards Developing Organizations
HL7 cooperates closely with other standards developers, such as:– Accredited Standards Committee X12N (AXC X12N)– Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT)– Digital Imaging and Communications in Medicine (DICOM)– eHealth Initiative (eHI)– Logical Observation Identifiers Names and Codes (LOINC)– National Council for Prescription Drug Programs (NCPDP)– Object Management Group (OMG)– Health Information Technology Standards Panel (HITSP) – Continuity of Care Document (CCD) – XML standard for medical
information summarization
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Work Group; TeamsHL7 MITA Work Group (HL7 MITA WG)
The HL7 MITA Project Work Group is focused on creating the initial MITA Business Process Models and Information Model which will become the MITA Information Architecture.
– HL7 MITA Project Work Group• Business Process Team
– Use Cases, Storyboards, additional requirements for v2.01 business process templates
• Data Analytics Team– Information Model Data analysis and database
• Modelers Team– Diagrams and models for business processes
• Vocabulary Team– Medicaid specific vocabulary
• Education and Training Team– Documentation and assistance for newcomers; lessons learned; best
practices
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
MITA Architecture Governance Structure
MITA Architecture Review Board
MITA Business Architecture
Review Board
MITA Information Architecture
Review Board
MITA Technical Architecture
Review Board
•Business Process
•Business Capability
•S-SA process
•Data Models
•Vocabulary
•Mapping to Standards
•Data Management Strategy
•Service definitions
•Infrastructure definitions
•Technical processes
•Technical capabilities
•Mapping to Standards
•MITA Standards
•Framework updates
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Supporting Review Organization Activities
• Supporting Organization – TAC• Activities –
– Technical function recommendations– Technical Function capability level recommendations– Technical Function Information Model
recommendations– Technical Service WSDL recommendations– Harmonization recommendation between MITA and
Technical – Interface between MITA and technical industry
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Multi-Architecture Impact
NMEH
HL7-MITAProject
TAC
BARB
IARB
TARB
ARB
MITA Users
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
The Big Picture
NMEH
HL7-MITAProject
TAC
BARB
IARB
TARB
ARB
MITA Users
STAG
New Bus Proc
Other DSMOs
HL7 HL7Healtth DataCommunity
Technical Implementer
IndependentInformation Spec.
State BusinessSMEs
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Federal Enterprise Architecture (FEA)
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Healthcare Standards EnvironmentFEAParticipates in
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
HL7 MITA Work Group Process Flow (Draft)
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Framework is Essential
Healthcare Development Framework (HDF)
Version 1.2Published on: April 23rd, 2008
HL7 Development Framework
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
MITA Information Models• The Business Process Model is derived by analyzing the
Medicaid Business Requirements in terms of the Concept of Operations.
• The Business Process Model is neutral with respect to any organization, location, staff, outsourcing, and automation.
• Applying the Medicaid Maturity Model (MMM) to the Business Process Model yields the Business Capabilities.
• Business Capabilities show the evolution of Business Processes over time.
– UML
– Use Case models
– Activity models
– Message schemas (HMD, CMET)
– Information models (DMIM, RMIM)
– Abstract WSDL
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
HL7 V3 Message Development Methodology: How
• Use Case Modeling– Produce a storyboard example– Generalize the storyboard example into a storyboard
• Information Modeling– Define classes, attributes, datatypes, and relationships– Define vocabulary domains, code systems, and value sets– Define states, trigger events, and transitions
• Interaction Modeling– Define application roles– Define interactions
• Message Design– Define D-MIM, CMETs, and R-MIMs– Define HMD and Message Types
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
MITA Information Architecture Models• The Business process/ Business capability combinations are the
cornerstone of the Business Architecture and the driver for the Technical Architecture.
• Business Capabilities map to the Conceptual Data Model.• The Conceptual Model is the basis for the Logical Data Model.• New functional requirements may change the Business Capabilities.• Business Capabilities may update the Conceptual Data Model, and
thereby evolve the Logical Data Model.• The Logical Data Model can be expressed as a WSDL.• The Logical Model will be implemented via a Physical Model via a
information technology specification such as Java or XML.– Business Model– Conceptual Model– Logical Model– Physical Model
Note: CMS will provide Medicaids with specifications for making their systems interoperable, and reusable.CMS does not mandate types of software.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Business Area
Technical Area
Technical Function
Technical Capability
Conceptual Data Model
LogicalData Model
Business Capability
Business Process
Medicaid Mission and Goals MITA Principles, Goals, and Objectives
Physical Data Model
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Business Capability Matrix
Provider enrollment staff spend hours verifying provider
credentials or fail to do primary credentialing verification
because of difficulty and liability risk
Provider enrollment staff use automated, web-based, online credentialing and sharing of
primary source verification with other state health programs and
other Medicaid agencies
The enrollment process is automated by an interface with
the RHIO Provider Directory which invokes a credential
verification service
5 YEARS
LE
VE
L 1
LE
VE
L 3
LE
VE
L 5
NOW5 YEARS 10+ YEARSNOW
Provider Enrollment – Credentialing Step
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Evolving Enroll Provider Business Capability
Level 1
Level 2
Level 3
Level 3
Level 4
Level 4
Level 5
Receive paper enrollment application; verify via phone; manual processing
Real time rules driven enrollment /verification; one-stop collaboration
Outcomes based enrollment; continuous verification against national databases
NOW 5 YEARS 10+
Example of Maturing Business Capabilities…
Use proprietary EDI for enrollment /verification; legacy MMIS hard coded rules
Enrollment/verification via RHIOs; access clinical record
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
Challenges with the Art/Science of Modeling
• Evolution to Unified Modeling Language (UML)– Object-Oriented Analysis (OOA)– Object-Oriented Design (OOD)– Object-Oriented Analysis and Design (OOAD)– Object-Oriented Software Engineering (OOSE)
– UML» General purpose modeling language that tries to
achieve compatibility with every possible implementation language.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
UML v2.0
UML Modeling
Structure Diagrams: what things must be in the system being modeled.
Behavior Diagrams: what must happen in the system being modeled.
Interaction Diagrams: subset of behavior diagrams that emphasize flow of control and data among the things in the system being modeled.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
HL7 Modeling Hierarchy
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
RIM
(1)Define aD-MIM
D-MIM
(2)Define aR-MIM
R-MIM
(3)Create
an HMD
HMD
RIMReference Information Model
D-MIMDomain Message Information Model
R-MIMRefined Message Information Model
HMDHierarchical Message Definition
HL7 V3 Message Design Models
• Select RIM classes to be included in D-MIMSelect RIM classes to be included in D-MIM
• Clone subset classes of the RIMClone subset classes of the RIM
• Select a subset of class relationshipsSelect a subset of class relationships
• Select a subset of class attributes Select a subset of class attributes
• Select a subset of attribute data types and domainsSelect a subset of attribute data types and domains
• Create clones of D-MIM classes and attributesCreate clones of D-MIM classes and attributes
• Assign alias class and relationship role namesAssign alias class and relationship role names
• Eliminate unnecessary class hierarchiesEliminate unnecessary class hierarchies
• Finalize class relationships and cardinalityFinalize class relationships and cardinality
• Finalize attribute data types and domainsFinalize attribute data types and domains
• Select a root class for the messageSelect a root class for the message
• Arrange classes and attributes hierarchicallyArrange classes and attributes hierarchically
• Declare inclusion and repetition constraintsDeclare inclusion and repetition constraints
• Declare data type and domain value constraintsDeclare data type and domain value constraints
• Assign message element namesAssign message element names
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
ReferenceInformation
Model
ReferenceInformation
Model
DatatypeSpecification
DatatypeSpecification
VocabularySpecificationVocabulary
SpecificationReference
Models
InteractionModel
InteractionModel
DesignInformation
Model
DesignInformation
Model
CommonMessage Type
Model
CommonMessage Type
Model
DesignModels
HierarchicalMessage
Definition
HierarchicalMessage
Definition
MessageType
Definition
MessageType
Definition
ImplementationTechnology
Specification
ImplementationTechnology
Specification
MessageSpecifications
MessageProfile
Specification
MessageProfile
Specification
LocalizedMessage
Specification
LocalizedMessage
Specification
MessageConformanceStatements
MessageConformanceStatements
ConformanceProfiles
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
ReferenceInformation
Model
ReferenceInformation
Model
DatatypeSpecification
DatatypeSpecification
VocabularySpecificationVocabulary
Specification
Reference Models
The HL7 Reference Information Model is the information model from which all other information models and message specifications are derived.
The HL7 Vocabulary Specification defines the set of all concepts that can be taken as valid values in an instance of a coded attribute or message element.
The HL7 Datatype Specification defines the structural format of the data carried in an attribute and influences the set of allowable values an attribute may assume.
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and Computers
InteractionModel
InteractionModel
DesignInformation
Model
DesignInformation
Model
CommonMessage Type
Model
CommonMessage Type
Model
Design Models
An Interaction Model is a specification of information exchanges within a particular domain as described in storyboards and storyboard examples.
A Domain Information Model is an information structure that represents the information content for a set of messages within a particular domain area.
A Common Message Type Model is a definition of a set of common message components that can be referenced in various message specifications.
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HierarchicalMessage
Definition
HierarchicalMessage
Definition
MessageType
Definition
MessageType
Definition
ImplementationTechnology
Specification
ImplementationTechnology
Specification
Message Specifications
An Hierarchical Message Definition is a specification of message elements including a specification of their grouping, sequence, optionality, and cardinality.
A Message Type Definition is a specification of a collection of message elements and a set of rules for constructing a message instance.
An Implementation Technology Specification is a specification that describes how to construct HL7 messages using a specific implementation technology.
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MessageProfile
Specification
MessageProfile
Specification
LocalizedMessage
Specification
LocalizedMessage
Specification
MessageConformance
Statement
MessageConformance
Statement
Conformance Profiles
A Localized Message Specification is a refinement of a HL7 message specification standard that is specified and balloted by an HL7 International Affiliate.
A Message Profile Specification is a description of a particular or desired implementation of an HL7 Message standard or Localized Message specification.
A Message Conformance Statement is a comparison of a particular messaging implementation and an HL7 message standard, localization, or profile.
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HL7 V3 Methodology:
What and How
Use Case Modeling
Interaction ModelingService Definition
Message Design
Information Modeling
RIM
Restrict
R-MIM
Serialize
HMD
Restrict
MessageType
Example
Storyboard
StoryboardExample
D-MIM
Derive
ApplicationRole
Sender Receiver
TriggerEvent
Triggers
Content
InteractionReferences
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Domain Analysis Model (DAM)
class 3.7 DAM Artifacts
Domain Analysis Model (DAM)
«optional»Use Case Analysis
Story board
Information Model (Analysis)
Process Flow
«optional»Business Rules Description
Business Trigger Analysis
«optional»Glossary of Classes and Attributes
class 3.7 DAM Artifacts
Domain Analysis Model (DAM)
«optional»Use Case Analysis
Story board
Information Model (Analysis)
Process Flow
«optional»Business Rules Description
Business Trigger Analysis
«optional»Glossary of Classes and Attributes
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Domain Analysis Model (DAM)
class 4.2: Context
Specification DesignRequirements Analysis
Domain Analysis Model
Stakeholder/Business Requirements
Business Process Model Analysis
Process Flow (Activity Diagram)
Use Case Model
Information Model
Business Trigger Analysis
(from Annex A. Domain Analysis Example)
Specification Dev elopment
Requirements Analysis
Specification Design
Domain Analysis Model
Design Information Model - DIM
Message Structure - CIM
Localization - LIM
Dynamic Model
Technology-Specific Artifacts
(from Annex A. Domain Analysis Example)
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Design Dynamic Modelact 4.4.2: Design Dynamic Model
Analyst :Business Analyst Facilitator :HL7 Modeling Facilitator
Domain Analysis Model (DAM)
(from 3.7 Artifacts)
DefineInteractionsTriggers
Specify the type ofinteractions and system
roles
Design Information Model (DIM)
(from 4.7.1 Information Modeling Artifacts)
«UML State chart»State Transitions
(from 4.7.2 Dynamic Modeling Artifacts)
«UML Activity Di...Sending Process
Description
(from 4.7.2 Dynamic Modeling Artifacts)
Document notificationtriggers
Document query or request pre-conditions
«UML Sequence Diagra...System Interaction Description
(from 4.7.2 Dynamic Modeling Artifacts)
Document receiv er's responsibilities
«UML Activity Di...Receiv ing Process
Description(from 4.7.2 Dynamic Modeling Artifacts)
Rev iew Dynamic Model Design
Constrained Information Model
(CIM)
(from 4.7.1 Information Modeling Artifacts)
Interface Specification
(from 4.7.2 Dynamic Modeling Artifacts)
Publish Design Model andReports
(from 4.4 P rocess)
Dynamic Model Artifact
Process Activit y
Information Model Artifact
Runtime Artifact
Legend Generate TechnologySpecific Artifacts
(from 4.4.1 Information Model Design )
Deriv e System Functions
Functional Model
(from 4.7.2 Dynamic Modeling Artifacts)
«input»
«input»
«input»
«input»
parameter specification
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Medicaid Business Process Model
Medicaid Business Process Model
Care Management
Contractor Management
Operations Management
Member Management
Provider Management
Program Management
Program IntegrityManagement
Business Relationship Management
Enroll MemberDisenroll Member
Inquire Member EligManage Member Info
Manage Member Comm
Award ContractClose out Contract
Manage Contractor CommManage Contractor InfoInquire Contractor Info
Identify Candidate CaseManage Case
Apply AttachmentAudit Claim-EncounterManage Drug Rebate
Prepare EOBCalculate Spend-down
Enroll ProviderDisenroll Provider
Manage Provider CommManage Provider Info
Perform Provider Outreach
Establish CaseManage Case
Manage Medicaid Pop Health
Establish RelationshipManage RelationshipManage Relationship
CommunicationsTerminate Relationship
Maintain State PlanFormulate Budget
Manage Rate SettingManage 1099sManage FFP
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Use Triggers to Reference the Process
New Enrollment
Triggers
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Static Model• Collect relevant "data in motion" for a business process.
• Example: For the Enroll Provider business process, collect relevant provider data from NPI, X12 transaction, and MMIS data dictionaries.
• Develop Conceptual Data Model (CDM) - e.g., provider is a role class (with attributes) played by an entity class with attribute and scoped by one or more entities (credentialing, supervision, enumeration etc.)
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Dynamic Model – Use CaseStart with MITA Business
Process Templates
• Consider Use Case Diagram
• Consider Business Process Diagram
• Actors = Application Roles
• Inputs and Outputs = Messages
• Events = Trigger Events prompting interchange
Staff/MMIS verifies provider’scredentials and checks NPS,NPDB and HIPDB status real
time before enrolling
NPS, NPDB, HIPDBMMIS
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Dynamic Model
NEXT:• Develop activity diagram for the
business process steps and exceptions
• Determine – Pre-condition– Post-condition
• Add – Trigger Events– Receiver Responsibilities
(Role of Receiving Application)
– Update requirements
ad Activ ity Diagram
MMIS NPS
Initiate NPS Query Interface
NPS Query
Receive Query
Find NPI & PT
«datastore»
NPS Prov ider Record
Provider Indenti ty Confirmed?
Prov ider Enroll Info
Reject Query
Receive Reject Query
Provider Enrol lment Rejection
AggregateNPS Data
Query Response
Receive Query
Response
NPS PT Align with MITA PT?
«datastore»
Prov ider Record
Xw alk toMITA PT
Activi tyFinal
Load NPI
Provider Enrol lment Accepted
Activi tyFinal
Yes
No
Yes
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MessagingFinding the correct data element from HL7 RIM
Example of Enroll Provider Step 12: Request that the Manage Administrative and Health Services Contract business process negotiate contract and send enrollment determination notifications.
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Example of HL7 to MITA Messaging
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HL7 v3 Static Models = MITA Logical Model
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Serialize –> The Physical Model
Serialize into Message Types from which XML Schema is generated.
Transform
Serialized Table Format XML Schema
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Inquire Member Eligibility Input Messages (Class Diagram)
POLITEHNICA University of BucharestPOLITEHNICA University of BucharestFaculty of Control and ComputersFaculty of Control and ComputersInquire Member Eligibility Business
Process (Activity Diagram)
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Accomplishments• Defined the Technical Services needed to completely implement
several MITA business services.• Demonstrated the ability to coordinate with at least one other
major industry initiative.• Demonstrated a working proof of concept.• Collaborated with the MITA HL7 Work Group.
– Reviewing CAQH Provider DataSource, which has over 600K+ providers, and is free of charge to providers. Its mission is to reduce the administrative burdens of provider data collection processes like credentialing; HITSP. Others are considering uses for this database, e.g. emergency response, that providers could opt-into.
• Define the process of adopting a MITA Technical Service
7373© 2002-2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Off
HL7 and Service-oriented HL7 and Service-oriented Architecture (SOA)Architecture (SOA)
TopicsTopics
• HL7 Vision and Mission• Understanding Service-oriented Architecture
(SOA)• The case for Healthcare SOA Standards • Introducing HSSP• Status of Standards Work
First, A Few Terms…First, A Few Terms…
• DSTU = Draft Standard for Trial Use• HL7 = Health Level Seven • HSSP = Healthcare Services Specification Project • OMG = Object Management Group• OHT = Open Health Tools• SOA = Service-oriented Architecture
SOA SOA ≠≠ Web Services Web Services
SOA Web Services
Is a technology platform? No Yes
Is a transport protocol? No Yes
Primary ownership is business-line owned?
Yes No
Affects workflow and business processes?
Yes No
Is an enabler for business and IT transformation?
Yes Yes
Is an industry standard? No Yes
How How is is SOA different from messaging?SOA different from messaging?
• A common practice in healthcare, just not yet in healthcare IT• Many key products use them but do not expose interfaces • Ensures functional consistency across applications• Accepted industry best practice • Furthers authoritative sources of data• Minimizes duplication across applications, provides reuse• Messages can be either payloads in or infrastructure beneath
services• Service-oriented architecture provides the framework for
automation of common services• Still, SOA has to be done well. It is cheaper and easier than
ever to create badly designed applicationsSo:
Why SOA Healthcare Standards?Why SOA Healthcare Standards?
Why develop healthcare SOA standards?Why develop healthcare SOA standards?
• Healthcare organizations are being driven to interoperate
• “Messaging” is not the ideal approach for every interoperability challenge
• SOA has demonstrated viability and benefits for many organizations and in many vertical-markets
Understanding InteroperabilityUnderstanding Interoperability
Ab
ilit
y to
Int
erop
erat
e
High
Low
SOA In Action…SOA In Action…An Identity Management ExampleAn Identity Management Example
Local/Regional Domain 2
Regional Identity Service (EIS)
service client
Implementation
Interface
National Identity Service
National/Master Domain
service client
Interface
Implementation
External organization’s system
Local/Regional Domain 1
“Local” Identity Service
service client
Implementation
Interface
1. Query local domain: entity found locally
2. Query local domain: entity not found locally, retrieve from master domain
3. Query master domain: retrieve linked entities from master domain
Scenarios
4. External System Query: Retrieve from master domain
1.1
1.2
1.3
1.4
2.1
2.2
2.3
2.5
2.6
2.4
3.1
3.2
3.3
3.4
4.1
4.2
The Healthcare Services Specification Project The Healthcare Services Specification Project (HSSP)(HSSP)
• An effort to create common “service interface specifications” tractable within Health IT
• A joint standards development project involving Health Level 7 (HL7) and the Object Management Group (OMG)
• Its objectives are:– To create useful, usable healthcare standards that address
functions, semantics and technologies– To complement existing work and leverage existing
standards – To focus on practical needs and not perfection– To capitalize on industry talent through open community
participation
The Benefits of HSSP Standards… The Benefits of HSSP Standards…
• Define industry standard behaviors for healthcare-oriented service functions
• Eliminate “different flavors” of web services from occurring in different organizations
• Rapid-pace stds development: ~18-24 months• Methodology embracing cross-group standards
development
HSSP is part the bigger HIT landscape…HSSP is part the bigger HIT landscape…
HSSP
HL7 Domain Committees
OMG
HITSP
National Programs (e.g. ONC, NEHTA)
CEN
OpenEHR
OHT
IHE
Methodology (SSF),DSTU Feedback,
Consultative support
SFMs, Info Models,
Requirements,Service Profiles
Policy
Service Profiles
Methodology,HL7/SOA Harmonization
SOA Interoperability Specifications
Use Cases,Requirements
TechnicalSpecifications,RFP process
Use Cases,Candidate Standards
Info Models,Semantic Profiles
SOA Interop Specs
RFPRequirements
Integration Profiles,Conformance Testing,
Interoperability Validation
TechnicalSpecifications
Open SourceRef Implementations,
Tools
SOA Interoperability Specifications,
Use Profiles
Cross-Organizational Standards DevelopmentCross-Organizational Standards Development
OMG
HL7
HL7 Draft Stds for Trial Use
Service Functional Model
OMG Request for Proposal
(RFP)
Technical Specification
ANSI Standard
SummarySummary
““How do you know that the How do you know that the [web-] services you’re [web-] services you’re building are not just the next building are not just the next generation of stovepipes?”generation of stovepipes?”
““How do you know that the How do you know that the [web-] services you’re [web-] services you’re building are not just the next building are not just the next generation of stovepipes?”generation of stovepipes?”
Stovepiping is a metaphorical term which has been used, in the context of intelligence, to describe several ways in which raw intelligence information may be presented without proper context.
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Thank youThank you