SOA and Healthcare

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Abstract

Healthcare services consist of a wide mesh of health professionals who need to coordinate service delivery. They also need to share patient records and procedure outcomes, and view them in similar cases. The first step in healthcare is a patient taking an appointment and the last is the final insurance claim being paid. Between these two, there can be thousands of procedures and steps.

Service Oriented Architecture (SOA) provides an architecture that saves time and delivers information. It integrates the above mentioned procedures and processes while addressing the critical privacy and security issues within the healthcare information management system.

Key Words:

Service, Architecture, Healthcare

Introduction

The challenge today for healthcare organizations is to manage a growing set of systems. The demand of the users is increasing while the cost of adopting, integrating and sustaining the software is on the rise. Enterprises must take into account the changing requirements as well as assist the revenue cycle and administrative business functions. Also, the demands for interoperability are increasing with these enterprises to locally support care delivery. SOA offers a system pattern and management guidelines that assist reuse and sharing of the system resources across the healthcare establishment. SOA does not need any reengineering of systems. The fundamental principle of SOA is that it combines the existing processes with new business objects or capabilities to build a database of services that can be used to provide a partial or complete solution. The unit of SOA is a service that can be provided, irrespective of their location, to achieve a solution that can be offered beyond the PCs, departments and organizations. They can be made available over the network with the help of interoperability systems and hence the location is no bar for the services.

SOA application in healthcare cuts down the complexity and redundant processing of clinical information significantly. It assists in simplifying and reducing the cost of involvement in the area of care health information networks (HINs), and helps in improving the cost and usability of the e-medical records.

2. Background Concepts and Definition

A service-oriented architecture, as the name suggests, is fundamentally a collection of services. These services can communicate with each other. The communication can be simple in a way that data could be transferred from one service to the other or more than one service could coordinate in an activity/event. A service is a fundamental unit of work defined by SOA that is complete and has well defined and well understood capabilities. This unit of work may differ according to different perspectives and implementation. It could be a process thread, a block of function that supports a thread process or a logical business processing step.

Data integration problems are being addressed with the help of Healthcare Information Networks (HINs). Various groups like the hospitals, pharmacies, labs, insurance agencies and the government have collaborated to form HIN so as to provide a mesh of data exchange. Important health information needs to be exchanged over a network accurately and this is achieved with the help of pathways that are used for shared information, strong interfaces and data repositories that are fast and reliable.

Related technology & Work:

SOA and Cloud in health care industry.

Below is a brief description of some of the important tasks must be taken into consideration for the reason why we need cloud architecture in health care application.

ü Electronic Health Record (EHR)

Doctor or nurse creates a health record for a patient. After it is created, doctor & nurse can update it with patient's examination. Patient must not create or update their health record, but they can only read the record.

ü Health Information Exchange (HIE)

Health Information Exchange (HIE) Application's main focus is on exchanging health record of patient across different health care providers, i.e. if patient seeks some other kind of treatment then all his electronic health records can be exported to that care provider. Records must be Exchanged using NHIN (Nationwide Information Health Network) standard.

ü Account Management

Account Management is important as it will create and authorize users (actors of the application) for accessing the system. As the health record is a sensitive data, one must make sure authorize user can only see the complete details. Also there can be invoicing and billing application might interact with insurance company which might be geographically located in different location.

ü Generating Report

A consolidated report must be generated for a patient or a date range or parameterized search can be specified in order to see total number of results of records created, export/import of records. As per the HL-7 standard this report generation is important and law can require it. The report can also be hosted in cloud based environment. Reporting system can be service based architecture so that the report can be accessed by anyone in the cloud.

3. Observations, Suggestions & Approaches
Health care service application

Health care is an important part of everybody's life. Each of us has a set of medical records, which contains complete medical history, allergies and various type of medical information. These medical records are typically stored on physical media such as film (X-ray), paper (notes) or photographs. Physical storage comes with its own issues like non-interoperability, non-portability and the worst being that these physical records are very vulnerable to theft or damage caused by natural or man-made disasters. Because of these issues, now, more and more health care providers/ hospitals are keeping health records electronically. These electronic records are referred to as Electronic Health Record (EHR) or Electronic Medical Records (EMR).

Even though health care providers have started to transition from physical records to EHRs, they are still confined to the local health care providers. Access to these records is limited to providers within the premises of the care provider. If a patient is travelling from California to New York and for some reason needs some medical attention urgently, the care giver would have no or little access to patient's data like medical history of the patient, medicines, allergy lists (like immunization status), laboratory test results etc. In absence of this information it becomes very difficult if not impossible for care giver to prescribe the optimal treatment for the patient.

This project is to develop an application, which allows accessing EHRs using Cloud. By Cloud we mean service oriented architecture. All health records are stored in the storage space provided by the service providers as per the HL7 (health layer 7) standard. The purpose is to implement a Record system based on cloud computing which can be stored and retrieved efficiently as per the requirement of the user.

Electronic Health care System

A person's health record consists of complete medical details, allergies, medication, hereditary conditions and other medical information. These health records are stored on physical media such as paper, film (X-ray) etc. In order to save these important health records from natural calamities or man-made disasters health care providers are storing health records electronically. These are referred to by different names like Electronic Health Record (EHR) or electronic medical record (EMR). Another issue with the health records is that they are confined to a local health care provider and cannot be shared across different care provider locations.

In any Heath care application store the health records electronically and these health records can be exchanged among different health care providers at different locations.

If the health care service, health care labs, and other health care services are located geographically different places, patient records are scattered in different place.

For the above said reason in order to integrate different application, health care application must be hosted in the cloud and must be a SaaS (Software as a Service) based application. The format of the health record is based on the health industry HL-7 (Clinical Document Architecture) standard. For exchange of health records among different care providers must use NHIN (Nationwide Health Information Network) standard that will help in secure data exchange nationwide.

HL7 EHR-system Standard:

As per the HL7 EHR-system standard, electronic health record must consists of details like patient and doctor identifiers, creation date of the health record, present illness, observation by the care provider, medication prescribed, lab results. There are many other areas specified in HL7 standard, but due to the scope of this topic we are limiting these to some of the specific fields of a health record.

The functional requirement from HL-7 EHR –System for electronic health record format and exchange of secure health record among different care providers using NHIN standard are few of the proposed areas of study. One must understand EHR and some of the important standards in healthcare industry like HL-7 and NHIN.

SOA and Cloud is State of Art:

Cloud based centralized electronic health record system. This section will provide state of the art in the field of centralized electronic health record. In [1] author describes about what is an electronic health record, advantages of having EHR. It also consists of some statistics on EHR, like how much percent of hospitals in United States have EHR. In [2] Ebadollahi et al, mentions about the structure of EHR. As per their study, it is unstructured or in other words it is in a raw format. They have presented the idea of organizing health records around concepts and also mentioned what is involved in concept-based representation. Their study will help to standardize the health record structure so that it can be successfully integrated across all

Considering standard part for EHR in [2], [3] mentions about HL7 standard for exchange of clinical and administrative data among healthcare information systems. As Health Insurance Portability and Accountability Act of 1996 (HIPPA) by US government, the security of electronic health records is of paramount importance. HIPAA required various technical, physical and administrative security measures be combined to protect the privacy, integrity and availability of a patient's clinical records. HL7 standard is used for clinical documents, clinical document architecture (CDA) and incorporates HIPAA guidelines. [4] Talks about the company who have developed browser based customizable solution for EHR for care providers. Some of the features of this product are health history, electronic prescription, lab interfaces. [5] is a company who are into developing software for health care providers. They have specialty EMR like cardiology, dental etc. in these records they use HL7 standards.

Cloud/SOA Architecture in Health Care System:

The health care application must be designed with a distributed architecture with two major components. First, there must be an instance of the application on premises of health care provider. This instance must be the local repository of the data and will provide implementation of all use cases for the health care provider. The system should have support of multiple such instances.

Second component is a centralized component called health information exchange (HIE) must be hosted in the cloud. This exchange will not store any patient data; however will be the central repository for all Meta information. HIE is the central data exchange and provides syndication of data across multiple data repositories without actually storing any medical records.

The communication between on-premise instances and HIE will use SOAP over HTTP in SOA environment to provide maximum interoperability.

Health care sub-system architecture in SOA

One of the main components of health care system is account management, invoicing and billing. This is important because application handles the exchange of confidential health care record. This component has features like admin and authenticates User account, Edit account, Delete account, and Login. All this functionality can be created as Service based APS's in SOA Environment. ‘Create User' Service creates the account for user based on their roles and authorization like Doctor, Nurse, Patient and Technician. ‘Login' sub-component can be as a Web Service which enables the user to login into the system and perform other operations within the application. The functionality of deleting the user also can be a Web Service call which is only provided to the administrator. User can edit their accounts by using ‘Edit' service function in the application under my profile tab. Invoicing, billing has to interface with insurance company for patient billing, the billing information has to authenticate using web service authentication in SOA environment.

The second component of the health care application is Electronic Health Record. It facilitates functionalities related to the Health record such as Create Health Record, Update Health Record, and Access Health Record and generates report for any health record. So once the account is created the Health record is created by the user. The health record can be obtained either from the same health care service pr from different health care service hospital. Doctor, Nurse and Lab technician are authorized to interface from different service center to get the patient health record. Service Oriented report generation system can be implemented which is used to generate a report for any health record which already exists with-in the system or outside the system.

The last component of the application is Health Information exchange. It has various interface used for the exchange of Electronic Health records. These interfaces have been used mainly by the Health Care providers. By using ‘retrieve record' service the provider retrieves the health record of any user. Health care provider exports the record of a user if requested by any other provider using the export interface and imports the required record from other health care provider using the import interface. Also the imported records are saved in the system by using the Save service

SOA for Health Information Networks (HINs)

When it comes to healthcare, integration of data and interoperability between the systems becomes a key requirement.

HINs are implemented to support the following important usage models:

* Patient information like medical history, allergies, sustained medical problems, medication and on-going treatments can be obtained by exchanging patients' electronic medical record between one care provider and another.

* Exchange of referrals between primary and secondary care providers or labs as well as the medical results of those referral visits.

* Electronic pre-authorization of treatment can be done in order to quickly learn if a treatment of drug is supported by the insurance plan of the patient.

* For speedy and accurate flow of cash of medical care, electronic claims filing and payment can be used.

* A means to electronically order and monitor consumption of prescriptions

* A consolidated data repository of key healthcare information for legally mandated bio-surveillance activities (such as influenza or other disease outbreak)

* A portal for the patient and healthcare stakeholders means for accessing appropriate data

Implementing HIN does not come without challenges. The most important challenge is to create a sustainable financial model where the involved risks and costs to bring up a network are bearable by the community of healthcare and that there is a revenant source of value to justify the ongoing operational costs of maintaining the network. Even in communities where the government (local, regional, or national) is providing the funding for the greater good of the community, these issues of cost, value, and sustainability are still material considerations.

Using legacy mechanisms of healthcare data integration are simply not financially feasible to implement and sustain a HIN over the long term. If every time a new hospital, pharmacy, or government agency was brought on to the HIN a new point-to-point/broker interface is developed the architectural and cost problem is created, and the number of systems interfaces grows exponentially relative to the number of participants in the HIN.

Guidelines for Applying SOA to a HIN

When using SOA for HIN integration architectures, the cost of integration can be reduced significantly and a sustainable source of value to the community of care can be established. To accomplish this, the service architecture of the HIN must:

* Simplify and reduce the number of interface points to create data interoperability in the network.

* Address the architecture, infrastructure, software, and related business services as a cohesive unit.

* Be deployable within the hospital, lab, pharmacy, and insurance company as well as within the shared HIN network.

* Support legacy systems, including current and evolving standards in healthcare data representation.

* Be scalable from small to large scale healthcare organizations in terms of cost, complexity, utility, and adaptability.

The first key benefit that an SOA technique applied to a HIN will provide is to simplify the data interoperability problem. Although there are industry standards for data representation in healthcare, such as HL7, a fundamental problem with those standards is their varied interpretation in software. Therefore, the very first objective for a HIN should be to standardize the software interpretation and therefore implementation of representation and translation of healthcare data on the network. The most cost-effective way to do this is through a standardized set of core business services that represent healthcare data.

Instead of each participant in the HIN and the HIN data center having to create and sustain an system interface for each participant in the network, all a participant needs to do is transform their systems representation to the one specified by the service, which defines the canonical form for the specific data being exchanged (such as patient, provider, order, referral, and so on).

The canonical data representation that the SOA core business service manages establishes:

* An independent structure from any specific end-point application

* Independence (separation) of the information architecture and the technical infrastructure upon which it is implemented

* Precise message definition to assure consistent implementation

* Visibility into the data that drives business processes

* Clear definition of unique applications for a particular business transaction

Leveraging services that are built on canonical data representation allows for the HIN network to rely on a standardized software interpretation of data and therefore allows the network to support the shared instantiation and consumption of system functions by all participants of the network. This allows the HIN to provide shared services such as provider registries, medical vocabulary translation, master-person index, and record locator services on behalf of the entire community of care they represent without those services having to be deployed or duplicated in the data center of each organization which participates in the HIN.

Using the enterprise service bus technology described in both the HIN data center and each participating organization in the Health Information Network can publish and consume each other's services and establish orchestrated workflows to rapidly support new business transactions and interactions among network participants. Additionally, the service container construct on the service bus architecture allows for existing, in-place clinical and administrative systems within a hospital, lab, pharmacy, or insurance organizations to be "fronted" with XML web services and participate in this architecture. This allows for realizing the benefits of SOA in an incremental and iterative fashion thereby leveraging existing technology investments.

As seen in these examples, using SOA techniques can substantially reduce the costs of implementing a HIN in any scale. SOA also delivers features to the community of care as software services that provide a source of ongoing value beyond hosting a simple portal and database of integrated data records on patients.

Extending Electronic Medical Records through SOA

SOA techniques can help improve integrating healthcare information systems and reducing the cost significantly. But unfortunately, the volume of electronic information related to healthcare is not large. Applying SOA to this field requires voluminous amount of data so that appropriate services could be made available.

In order to automate the collection, distribution and validation of medical records of the patients, many healthcare organizations around the globe are planning to put Electronic Medical Records in place. Some organizations have also been actively putting it to use. Statistics show that even though the similar technology has been available commercially for 30 years, the average worldwide acceptance of EMRs by clinicians in their mundane, day to day work is less than 20 percent.

4. Current Problems or Issues (in Security, Quality, Performance, Reliability, and Privacy)

Rather than creating security problem, SOA intends more at solving them. Service consumers have the right to address the questions like what are the different kinds of services that he/she is using, who undertakes the security issues or service related issues etc. The healthcare industry often faces problem associated with their data and communications of their data across the network.

The quality of data sent across the network is also a huge concern for the SOA. Quality of the care can be improved in Healthcare industry. The data on one department cannot be accessed across on a different department. For example, a nurse cannot access a data of a patient sitting on a outside network. This type of inaccessible data often leads to hindrance of quality provided to the patients. The healthcare industry is the slowest of all industries to adopt the SOA policies and principles. They are slow in adopting the technologies used by the IT industries. The business processes used in healthcare industry seems to be very complicated, thus complicating the communication at both ends, both at the healthcare as well as the IT processes. Hence performance and reliability both are affected.

Data privacy and location privacy play an integral part in SOA. It is important to maintain the privacy of the patient in a healthcare industry. The data which is moved across from one network to another in service oriented architecture of a healthcare industry is vital to the customer as well as the business processes.

7. Lessons Learnt

SOA governance defines the new set of rules and policies defined to develop and design the services of service oriented system. It also describes the roles and responsibility of the new set of user or a process. A healthcare industry is said to be a substantial one when it reaches a state of maturity. It means the healthcare industry interacts with all business processes and departments. It means a person sitting in Administrative department can easily interact with a person sitting in Clinical department.

The technology used in one department can be vital to the whole industry. Data in such department is protected and all the processes pertaining to this department is properly taken care of. With the advent of tight budget line, it is important to implement to start a small budget SOA adoption model and then increase on top of it. In this way, we can focus more on the important business processes needed to maintain the privacy across networks.

SOA is all about implementing the technology methodology. It is not about setting up the right tool or devices for the healthcare industry. It focuses more about the approach needed for evaluating the organizations evaluation model. The most common and easiest method of implementing a SOA is by the use of web services like HTTP or XML. SOA is a simple way of extracting the data; develop the application and finally deploying the application.

8. Conclusions

In order to achieve realistic goals, healthcare industry must opt for latest IT industry practices. By governing the business processes to maintain the industry standard, they should adopt some realistic strategy. By adopting the SOA methodology, the standard of the healthcare industry can be raised to benefit the cost-efficiency and with the usage of agile business methods, new healthcare needs can be met.

SOA adoption is not one day process. Various levels and business processes are set and healthcare industry has to maintain an effective governing process. Healthcare industry can further benefit by choosing the right SOA implementation strategy.

Healthcare industry has good prospects for SOA adoption, thus increasing their efficiency, quality improvement and more reliable process. By following the SOA adoption, most of the healthcare industry will identify the core SOA principles and develop better SOA principles.

12. References

Retrieved April 30, 2009 from 1. http://en.wikipedia.org/wiki/Electronic_health_record

2. This is an example of a reference to a website article. In this article author discuss about electronic health record, its background & advantages. There are certain standards for EHR, which are also mentioned in this article. There are comparison of different HER software that is available in the market today.

3. Ebadollahi,S., et al (2006). Concept-based electronic health records:

4. Opportunities and challenges. Proceedings of the 14th annual ACM international conference on Multimedia, Santa Barbara, CA, 997- 1006. doi: 10.1145/1180639.1180859

5. 3. Hooda, J.S., Dogu, E. & Sunderraman, R. (2004). Health Level-7 compliant

6. Patient records system. Proceedings of 2004 ACM symposium on Applied Computing, Cyprus, 259-263. doi: 10.1145/967900.967957

7. In this article author mentions about the advantages of using HL7 standard for clinical patient records system (CPRS). CPRS application uses a role based security model rested on HL7 security infrastructure. This model is strictly based on Microsoft provided Windows 2003 server security model for web application.

8. 4. Retrieved April 30, 2009 from http://www.curemd.com/curemdehr.htm.

9. CureMD EMR is a browser based, customizable solution designed for care providers. Some of the features of this product are health history (present illness, family, social, medical), electronic prescriptions, lab interfaces. There are personalized workflows and process implementation. It eliminates paper by consolidating information into electronic charts. Add consultation letters, patient files, insurance IDs, consent forms and electronic billing. It transmits and receives lab orders as well as consultation letters to referring providers electronically.

Retrieved April 30, 2009 from http://www.emrexperts.com/

10. EMR experts offer easy to use and powerful EMR & Medical Billing Software vendors in the industry. Some of the feature of these products is HL7 Lab interface, electronic prescription, HL7 custom interfaces and E&M coding assistance. One of the important features they offer is specialty EMR like cardiology, dental, general surgery, internal medicine etc. They offer both ASP and Client/server for EMR.

11. http://hl7.org - this website has helped in deciding on the format of electronic health record and other functional requirements.

12. http://www.ciohealthcaresummit.com/media/pdf/solution_spotlight/intel_conceptual.pdf

13. http://www.sun.com/products/soa/healthcare.jsp

14. http://www.infoq.com/articles/soa-healthcare

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