Re-Thinking the Architecture of Healthcare IT

4th March 2021

Author: Tomaž Gornik

Care provision is shifting from acute settings into communities, and even homes. At the same time, citizens are demanding more control over their health and wellness. Finally, the COVID-19 pandemic has forced health and care organisations to accelerate innovation and embrace new models of care delivery. This has created a perfect storm, forcing health and care organisations to re-think the architecture of their IT systems.

A Shift in Care Provision

Advances in clinical approaches and technology, consumers who want convenience, and payers demanding lower costs are all accelerating the shift of care provision from hospitals to outpatient clinics, community care, and even the home. At the same time, our focus is no longer just on disease and treatment, but mostly on prevention and wellness, reinforcing the shift of care away from the hospital. In the UK, the NHS is reorganising itself around Integrated Care Systems to address this new reality. Unfortunately, the IT systems in use today were built for institutions, not patients, and are struggling to fully support these new requirements. 

Engaged and Empowered Patients

Better access to information has enabled patients to play a more significant role in their health and wellbeing. Providers are actively empowering patients to share responsibility for managing their conditions in order to improve medical outcomes and lower costs. As a result, patients are now demanding convenient and personalised services, a tall order for current IT systems. Most healthcare providers are struggling to keep up with these demands, and this is adding to the backlog of undelivered solutions.

The COVID-19 Pandemic

Healthcare is among the last of the big industries to embrace digital technologies, but the COVID-19 pandemic has catalysed the adoption of many digital healthcare applications, such as telehealth and remote monitoring. The pandemic has also provided an imperative, driving us to accelerate the data agenda in health care. It quickly became painfully evident that, in a crisis such as this, accessible, high-quality data was a critical asset. And, that health data is exponentially more powerful if it is connected, combined, and shared. These are all trends which have been observed before, but were greatly accelerated by the pandemic. 

Existing Solutions Impede Change

Mayo Clinic paper talked about how IT was underserving care teams: “The usability of current EHR systems received a grade of ‘F’ by physician users when evaluated using a standardised metric of technology usability. A strong dose-response relationship between EHR usability and the odds of burnout was observed.” Similarly, Gartner Group’s recent research states: “With inflexible IT portfolios, the ability for business differentiation dissolves and the capacity for innovation and agility shrink. Monolithic and uneconomical electronic health record (EHR) solutions are now impeding digital transformation efforts for many healthcare delivery organisations. The dissatisfaction with monolithic EHR systems and their inability to quickly respond and support new clinical and regulatory requirements has never been more obvious.” I fully agree!

An Architecture for the Future

To address the issues presented above, IT architecture has to be based on an open platform that includes a clinical data repository and the tools necessary to accelerate the building of new applications. This view is now shared by leading consultancies like EY and Gartner Group. EY writes about “a cohesive technology stack, giving a unified experience for clinicians, professionals and patients and an extensible, vendor-neutral data layer at the centre, accessed by all applications in real-time”. Gartner Group defines the Digital Health Platform as “an architectural approach that enables a healthcare provider to nimbly adapt their business and operating model in response to external disruption and change in business strategy”. Their proposed architecture relies on a shared data layer, an inventory of applications and APIs, and the tools needed to quickly assemble personalised application experiences.

Both EY and Gartner agree on three fundamental tenets for the architecture of the future: a unified application experience, the agile delivery of applications on top of a vendor-neutral data core. Let’s take a closer look.

A Unified Application Experience

Care teams’ current frustration with current IT systems is well documented. These care professionals use intuitive, personalised, and efficient apps in their personal lives, and expect no less from the systems that are intended to help them do their jobs. Gartner’s solution is a model of application design that imagines applications as experiences assembled by or for its users. The key benefit is personalisation: features and capabilities tailored to the specifics of the care team, the patient, and the care setting. Adding a design system is necessary in order to achieve consistency for the user experience across different modules.

The Agile Delivery of Applications

As companies proceed with their digital transformations, software is becoming increasingly strategic and pervasive. The demand for new and updated applications is practically exploding, and professionals who can build and run such software are in short supply. To mitigate this, other industries have adopted the low-code approach to accelerate the delivery of applications, as this helps to reduce the backlog. In addition to software engineers, end-users are also stepping up as “citizen developers” with the domain knowledge needed to rapidly assemble their desired application experience using low-code tools. Here, healthcare is again behind the curve, but this approach is one of the few options it has. To be clear, the heavy lifting will still be done by software which is written by professional developers. However, as new tools advance, these developers will mainly handle the more complex features and capabilities.

A Vendor-Neutral Data Core

As care moves out of the hospital and into the communities, data needs to be stored around the patient. Unfortunately, the current systems, which were built for institutions, store data in proprietary formats. This creates silos, preventing data fluidity and making the general use of data difficult. Future applications, apps, and algorithms will be based on a vendor-neutral clinical data repository that provides a cradle-to-grave, longitudinal patient record, and serves as a single source of “truth” for the lifetime of the patient. As long as data is tightly coupled with applications, like in today’s leading EHRs, we will only be able to make incremental improvements.

How do we get there?

I have never met a healthcare CIO who did not want health data in an open format. The question has always been the following: Where can I buy applications that offer this approach? The good news is that many vendors are now adopting openEHR to separate data from applications, storing it in an open, vendor-neutral format. This shift is now evident in markets with the most advanced healthcare systems. All four leading Nordic vendors of EHR systems – Norway’s DIPS and PatientSky, Sweden’s Cambio, and Finland’s TietoEvry – now use a data repository based on openEHR. Entire cities (Moscow) and even nations (Finland, Malta, Scotland, Slovenia, and Wales) now base their health data infrastructure on openEHR. Just recently, Catalonia decided to do the same. Many of these areas are very advanced, with a lot of experience collecting high-quality care data for decades, and this is why they understand the limitations of the current approaches.

Of course, we know that the current systems are hard to replace. Any new architectures will need to coexist with legacy systems for quite some time. So, the Postmodern EHR describes a way to start your journey into the future today without replacing existing systems. It is perfectly aligned with the Bi-Modal IT approach, combining agility and innovation with stability to run the business at the same time.

Summary

New information architecture is key to unlocking the power of digital technologies and creating the connected health ecosystem of tomorrow. Today’s solutions tightly couple data to their applications. As health and care data is for life, it needs to outlive applications, so there is a clear need to separate the two. The architectures of the future will have a vendor-neutral data layer at the centre, low code tools to accelerate application delivery, and application experiences which are personalised for the user. To bridge the gap between the current and future state, legacy EHRs and new open platform-based systems will have to be able to coexist, and this will enable innovation during the transition process.

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