Connecting a digital platform to a complex IT portfolio across - - PowerPoint PPT Presentation

Connecting a digital platform to a complex IT portfolio across

• rganizations

Case from the Norwegian healthcare sector

IN5320

26.10.20 Kristoffer Fossum

Theme

Content of lecture:

• Provide you with an example of emerging complexity when a software

platform is to be established as part of a large existing IT portfolio across

• rganizations
• What does it take to connect the platform
• What happens with good platform characteristics when it is connected

Q&A:

• Interactive session on zoom 26th of October

A platform Core App App APIs – standards - policies A large portfolio of IT systems, organizations, routines etc. Is going to be connected to

The Norwegian healthcare sector

• About 17 000 autonomous enterprises
• Each enterprise is responsible for quality and safety of healthcare
• According to Norwegian laws, each enterprise has their own responsibility in establishing a

patient journal system

• Procurement of IT systems is the enterprise’s responsibility
• An enterprise is free to establish, choose and adopt standards
• Decades of implementation of IT systems has led to a plethora of systems that are not well

integrated with each other

• High variation in all types of standards in the systems
• Example:
• The Norwegian South-East Health Region currently has more than 5700 IT systems to support hospital
• perations

The challenge

“In a hospital in our health region, an elderly woman got a potentially fatal allergic reaction to muscle-relaxing medicine during prefaces of anesthesia, but was saved by skilled personnel. The same woman was later undergoing surgery at another hospital in the same health region. There, she received the same medicine, and experienced the same adverse reaction to it. The same happened again when she needed emergency surgery at our [the third] hospital”

• Why did this happen?
• Lack of information about what had happened with the patient in the first hospital at

the others – lack of information flow

• Can’t we just solve the problem?
• Of course! However…

Hospital 1 Hospital 2 Hospital 3

Information emerges in a lot of different places, and needs to be accessed in a lot of places

Patient received medication and got a severe reaction Patient received medication and got a severe reaction Patient received medication and got a severe reaction

Allergy info emerges in org 1 Allergy info emerges in org 2 Allergy info emerges in org 3 Allergy info emerges in org 4 Allergy info used in

• rg 1

Allergy info used in

• rg 2

Allergy info used in

• rg 3

Information flow requirements within each system

• The information needs to

reach all the way to the user interfaces users use naturally in their work

User interface/ decision support A User interface/ decision support B User interface/ decision support C User interface/ decision support D User interface/ decision support E User interface/ decision support F User interface/ decision support G

Admission report Radiology referral Surgery planning Electronic messages Prescriptions Message to municipality Care summary report

The challenge

“In a hospital in our health region, an elderly woman got a potentially fatal allergic reaction to muscle-relaxing medicine during prefaces of anesthesia, but was saved by skilled personnel. The same woman was later undergoing surgery at another hospital in the same health region. There, she received the same medicine, and experienced the same adverse reaction to it. The same happened again when she needed emergency surgery at our [the third] hospital”

• Why did this happen?
• Lack of information about what had happened with the patient in the first hospital at

the others – lack of information flow

• Can’t we just solve the problem?
• Of course! However…

Hospital 1 Hospital 2 Hospital 3

Case

• Introduction of a national care summary record to improve

accessibility of so-called «alert information» among healthcare professionals in hospitals in the Norwegian South-East health region.

• Planning and design of the care summary record
• Legislation and politics
• Development of information standards
• Implementation in hospitals
• There are many IT systems dealing with the same information already (more than 100

identified in the health region). How to deal with these when the platform is to be introduced?

• Healthcare professionals (tens of thousands in the health region) are used to do things in
• ne way, how to make them change what they do and how they think?

Alert information is

Information about a patient that in a healthcare provision setting may change planned and best practice procedures, and that may save patients’ lives or prevent severe harm to patients

• Allergies
• Complications from anesthesia
• Medical conditions
• Ongoing treatment and implants
• Changes in procedures
• Contagion

Care summary record as a solution for access to information

Care summary record

Allergy info emerges in org 1 Allergy info emerges in org 2 Allergy info emerges in org 3 Allergy info emerges in org 4 Allergy info used in

• rg 1

Allergy info used in

• rg 2

Allergy info used in

• rg 3

Developing the concept «care summary record»

Around year 2000, approximately 15 years before the care summary record was introduced one of those who worked with the initiation said:

• «With the continuous local introduction of electronic patient journal systems now, I foresee a

messy future. We now need some common national components that function across enterprises in the healthcare sector» 18 years later the same person said:

• «Within this sector, development does not advance as quickly as the pessimists think»
• The concept of a solution was established in y 2000, and was continuously developed as a

concept the next 10 years

• In competition with other types of information flow solutions – messages
• Legislation in Norway did not allow a national solution containing patient data
• However, gained gradual foothold through national policy documents during the 2000’s
• Reports and planning were developed

Planning and design

• Need for change in laws regulating patient data
• Parallel processes:
• Data definitions had to be included in the law texts before it was decided which data the

solution should contain

• Making a a new law was done in parallel with development of solution
• Process to define «alert information» in the national care summary record

as a national standard

• Exspert group from the sector
• «We were lucky. We had managed to include what the expert group found necessary

in the law before the group initiated its work to define standards»

• Assessment of potential standards existing in Norway and in other countries
• Consultative round with more than 40 «main actors» and interests organizations
• Was implemented in the solution

Implementation of the care summary record in hospitals

• A button in the main patient journal system
• Clinicians need to log in even though they are already logged in to

the patient journal system

• Takes around 30 seconds to log in
• Manual transferring of information between the patient journal

system and the care summary record

• Alert information has different definitions among all systems –

makes it difficult to transfer information correctly

• In practice, vast amounts of information is not transferred to the

care summary record – only about 2,5% of what is produced in the hospitals

• How can it be improved?

Need for solutions

• Automatic log-in via the local patient journal systems
• Automation of data transfer between patient journal systems and the care

summary record. Needs:

• Standardization of content
• Technical integrations
• Commmon understanding of what data means across all enterprises that use

and produce data from and to the care summary record

A hospital

Many different patients

IT systems support many functions

Many IT systems exist for the same functions

PAS/EPJ RIS/PACS LAB- Medisinsk biokjemi LAB- Mikro- biologi LAB - Patologi LAB- Blodbank Kurve og medikasjon Multi- media Medika- mentell kreft- behandling Ambulanse- journal Føde- journal

Oslo universitets- sykehus PasDoc Siemens Flexlab Swisslab DocuLive Patologi Prosang MetaVision Diverse Cyto- dose Cyto- dose Papir DocuLive Swisslab Papir Obstetrix Agfa Sectra Unilab Unilab Akershus universitets- sykehus DIPS Siemens Analytix Analytix DocuLive Patologi LabCraft MetaVision Diverse Cytodose Partus DIPS Sunnaas sykehus DIPS DIPS Lab Papir Diverse Vestre Viken DIPS Carestream Flexlab Miclis Sympathy LabCraft DIPS Diverse Papir Mobimed Partus (flere installasjoner) Papir Siemens Analytix Prosang Sykehuset Innlandet DIPS Siemens Analytix Analytix Sympathy LabCraft Papir Diverse Cytodose Partus Papir Sykehuset Østfold DIPS Sectra Netlab Miclis Sympathy Prosang Papir Diverse Papir Partus Sykehuset i Vestfold DIPS Sectra Unilab Miclis DocuLive Patologi Prosang PICIS Diverse Papir Partus PAPS PAPS Papir Sykehuset Telemark IMx Agfa Flexlab Sympathy LabCraft Papir Diverse Cytodose Partus Sørlandet sykehus DIPS DIPS RIS Sectra Unilab Miclis Sympathy Prosang Papir Diverse Papir Partus (flere installasjoner)

Many IT systems in hospitals

• 5700 in the south east

health region

• More than 100 IT

systems containing alert information across hospitals in the health region

Lots of integrations among systems

Flow of alert information among the IT systems and people in one hospital

Automatic log-in to the care summary record

• Dependencies to
• National infrastructure for access and identity management
• Under construction…
• Regional projects
• Regional access and identity management, all IT systems

Directorate for e- health Infrastructure program South east health region Regional clinical IT projects

Regional infrastructure program

Prosjekter Prosjekter Prosjekter Prosjekter Projects Prosjekter Prosjekter Prosjekter Prosjekter Projects Cooperation and prioritization

Automatic transfer of data between care summary record and patient journal systems in hospitals - standards

• New standards across care summary record and patient journal systems in

hospitals

• Autonomous enterprises – not automatically accepting nationally developed standards

Governance structures

• komm. løsninger
• Komm. direktør

MANAGEMENT GOVERNANCE

Funksjonellforvaltning Tekniskforvaltning

Systemeier fora Fag- nettverk

Fagforvaltning

Sirkel symboler symbolisere innspillsfora med deltakere fra alle HF inkl. Sykehuspartner og ev. private ideelle sykehus med avtale

Program board Program management Steering commitee EPJ Regional EPJ Standardization Steering commitee Radiology Regional radiology Steering commitee Laboratory Regional laboratory Steering commitee charting/medicati

• n

Regional charting/medicati

• n

Steering commitee Medical cancer treatment Medical cancer treatment Steering commitee Digital services for inhabitatants Digitale services for inhabitants

Architecture Common steering commitee Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Service provision manager Service provision manager Service portfolio manager

New national standard for alert information in the main patient journal systems at hospitals

• Dependent on new patient journal system

from provider

• New patient journal system dependent on

correctly defined data standards

• National standards governance for openEHR

archetypes defines standards in EPRs, based on voluntarily efforts among clinicians in the country

• Starting point: International archetype standards
• The Norwegian defined standard from the

directorate is made by clinician groups as part of developing the care summary record

• Which is different from the international archetype

standard

• -> Better coordination between National ICT and

the Directorate

• -> But have to wait for voluntary efforts from

clinicians anyway

Integration between care summary record and patient journal system

• Standards in the patient journal system must be implemented
• Someone has to pay for developing the APIs at both sides
• Directorate for e-health
• South east health region
• Another waiting game…
• Meanwhile:
• New European standard candidate…

Care summary record Patient journal system in health region

API API

National infrastructure Regional infrastructure

Regional integration platform

Andre systemer? Andre systemer? Other systems?

• komm. løsninger
• Komm. direktør

MANAGEMENT GOVERNANCE

Funksjonellforvaltning Tekniskforvaltning

Systemeier fora Fag- nettverk

Fagforvaltning

Sirkel symboler symbolisere innspillsfora med deltakere fra alle HF inkl. Sykehuspartner og ev. private ideelle sykehus med avtale

Program board Program management Steering commitee EPJ Regional EPJ Standardization Steering commitee Radiology Regional radiology Steering commitee Laboratory Regional laboratory Steering commitee charting/medicati

• n

Regional charting/medicati

• n

Steering commitee Medical cancer treatment Medical cancer treatment Steering commitee Digital services for inhabitatants Digitale services for inhabitants

Architecture Common steering commitee Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Receiving hospitals Service provision manager Service provision manager Service portfolio manager

Dependencies internally in IT systems and among several of them

• «Critical medical conditions»
• Diagnosis codes (ICD-10)
• A list of «absolutely necessary to document» diseases
• Does not exist in patient journal system. Diagnoses are typically

registered for other purposes – financial

• –> New functionality and traning among clinicians needed
• Implementation of process description. There are more

than the absolutely necessary that are necessary for some patients

• Diagnoses are now registererd in many IT systems from

many different system providers

• How to make all these implement required functionality?

IT systems support many functions

Dependencies internally in IT systems and among several of them

• «Critical medical conditions»
• Diagnosis codes (ICD-10)
• A list of «absolutely necessary to document» diseases
• Does not exist in patient journal system. Diagnoses are typically

registered for other purposes – financial

• –> New functionality and traning among clinicians needed
• Implementation of process description. There are more

that the absolutely necessary that are necessary for some patients

• Diagnoses are now registererd in many IT systems from

many different system providers

• How to make all these implement required functionality?

Dependencies to IT systems providers

• Alert information
• Many many IT systems need this information. For

instance:

• Radiology systems
• Medication management systems
• Charting systems
• Laboratoy systems
• Etc etc.
• Many IT system providers involved.
• But they also have other customers…
• Makking idiosyncratic standards for Norway means

that specific dependencies are made to all these IT system providers.

• Costly
• Time consuming
• Maybe they will not make it?

Alert information

Patient journal

Radiology Laboratory Charts Medication Andre Andre Andre Andre Andre Others

Other customers Other customers Other customers Other customers Other customers

A platform Core App App APIs – standards - policies A large portfolio of IT systems, organizations, routines etc. Is going to be connected to

Summary - Our starting point…

The platform

An important tension – loss of positive platform characteristics

• The freedom of change in «stand-alone apps» and a «clean core» vs

better integration for easier usage among clinicians

• The care summary record is now flexible because changes are technically

dependent only on the care summary record itself

• Monthly, and at some points weekly, changes
• With automatic data transfer (integration) changes can only happen at the

speed of change of all connected IT systems and organizational routines among tens of thousands of clinicians – this speed of change may be a slow

• ne – because…

Dependencies dependencies dependencies…

More challenges – but that’s for another time

• How to train tens of thousands of clinicians in the hospitals to make them

change routines that have been developing through decades?

• What about all the existing «alert information» in hundreds of IT systems that

are not defined as the new standard?