PlugIT in a nutshell PlugIT:n tulokset pähkinänkuoressa PlugIT’s closing seminar, Kuopio, 30 Aug 2004 PlugIT: Healthcare Applications Integration, Mikko Korpela, Research Director, D.Tech., Docent University of Kuopio, IT Services, HIS R&D Unit (Healthcare Information Systems Research and Development Unit) Centre for IT Education and Research Centek All PlugIT personnel have contributed to this presentation National Technology Agency Tekes grants 40664/01, 40246/02, 90/03

Contents of the presentation Why the PlugIT project was needed? Objectives and scope of the project Implementors, partners, measures Approach Phases of the project Results 1: Interface specifications Results 2: Methods Results 3: Know-how and expertise Utilization of the results Experiences How should we be assessed?

Why the PlugIT project was needed – 1 Initial situation, spring 2001 Pasi Markkanen’s survey for Tekes: Integration on top of the healthcare software industry’s priority list of problems. In Kuopio University Hospital alone 180 information systems → new systems integrated to existing ones by tailoring, expensive, an obstacle to procurement by healthcare organizations. Increasingly in primary healthcare centres as well healthcare professionals need more than one software application to produce the care for a single patient. HL7 Finland and projects on regional information systems developed means for interorganizational integration, but no proper means available to the lack of interoperability experienced by users (cf. project scope re. integration needs within the healthcare delivery system).

Why the PlugIT project was needed – 2 Government initiatives (unofficial translations) National Project to Secure the Future of Health Care, recommendation no. 8, spring 2002: ”The interfaces between healthcare systems will be made obliging to all healthcare actors by degree by the Ministry of Social Affairs and Health by the year 2007.” Minister of Health and Social Services, Ms. Liisa Hyssälä, The Suomenmaa : ”Badly interoperable systems are an obstacle to efficient healthcare. Without integrating the information systems, the accessability of care will not improve in the way the National Health Care Project requires. The integration of expensive information systems used in thousands of organizations is no piece of cake.”

Objectives and scope of the project: ”Official definition” PlugIT is a national, Tekes-funded research and development project to produce (1) open application program interface (API) specifications as well as related (2) methods and (3) expertise for healthcare software companies and their customers. PlugIT will accordingly contribute to the implementation of the recommendation no. 8 of the National Health Care Project. The objective is to facilitate healthcare service activities through the software development service chain, by means of more interoperable clusters of software applications.

Integration needs in healthcare system 1.Intra-activity: e.g. electronic record – scheduling; PlugIT’s focus 2.Between activities within an organization: care dept. – service dept.; HL7 messages 3.Between activities along a service chain: e.g. referral – feedback, ”disease mgt systems”; HL7 4.Choice of services between organizations: regional information systems, portals 5.eGovernment/Business: eHealth, citizen’s records

The problem in focus in PlugIT: Cluster of software products A physician or another health care professional needs to use several software products to deal with a single patient’s problem. Each system has its own access codes, patient data, code sets, etc.

Healthcare software service chain: How integration research will improve services

Implementors, partners, measures – 1 Multidisciplinary and multiprofessional research group in Centek: Univ. of Kuopio, Health Policy and Management Dept., SHIFTEC (Research Director Pekka Turunen → Anneli Ensio): Healthcare professionals’ viewpoint Savonia Polytechnic, Savonia Business, Information Processing (Principal Lecturer Maritta Korhonen): Hospital Districts’ IT professionals’ viewpoint Univ. of Kuopio, IT Services, HIS R&D Unit (Research Director Mikko Korpela, research leader in charge): Method and tool developers’ viewpoint Univ. of Kuopio, Computer Science Dept., Software Engineering (Professor Anne Eerola): Software companies’ software professionals’ viewpoint

Implementors, partners, measures – 2 Representative group of competing software companies: 12 healthcare software companies: Commit; Oy, General Electric Healthcare / Deio Oy, Enfo Oy, Fujitsu Services Oyj, Mawell Oy, Medici Data Oy, Mediconsult Oy, Mediweb Oy, Mylab Oy, Suomen Posti / Atkos Oy, TietoEnator Oyj, WM­data Novo Oyj 3 software technology companies: BEA Systems Oy, Microsoft Oy, Oracle Oy Representative group of public healthcare providers: 6 hospital districts: Helsinki-Uusimaa, Pirkanmaa (Tampere), Pohjois-Savo (Kuopio), Pohjois­Pohjanmaa (Oulu), Satakunta (Pori), Varsinais-Suomi (Turku) Primary healthcare represented by City of Kuopio and Siilinjärvi­ Maaninka

Implementors, partners, measures – 3 Basic measures: Biggest software engineering research project funded by Tekes Budget 2 million euros (~ US$ 2.4 million) 84% from Tekes, iWell technology programme → mid-term research, business impact expected in 3–5 years Each company/hospital district paid 2–9 000 €/year Three years, October 2001 to August 2004 Employed simultaneously ~ 15 full and 15 part time researchers/developers, supervisors and trainees Neighbours and partners: HL7 Finland National Health Project’s subproject on electronic patient record systems Projects on regional information systems Sonetti partnership by hospital districts in Eastern Finland Health Kuopio programme

Approach – 1: Progressing from two directions International standards HL7, OMG Healthcare Domain Task Force (ex CORBAmed), CEN/HISA, ISO 215, IHE, HIPAA, … Terminologies, code sets, data structures WHO, OID, STAKES, Association of Local and Regional Authorities, National Healthcare Project, … Families of infrastructure technologies Corba family, Java family, Microsoft family, Web Services Healthcare process improvement initiatives Macro Pilot Project, Sonetti, Pirke, National Healthcare Project, …, …, … Proprietary and two-party solutions …, …, … Bottom upTop down

Approach – 2: Tripartite collaboration Research teams search for information and develop methods. Open interfaces are specified all together, driven by the teams. Hospitals order interfaces from companies according to specs. Pilot companies implement the interfaces and apply the methods in their products with the support of the research teams, other companies at their own cost. Research teams document and publicize. In practice: Semiannual seminars; presentations and workshops, ~70 pers. lists: Board, contact persons, project staff, supervisors Web pages: Public, contact persons’, internal, Board’s Several dozens of meetings with partner organizations Detailed report monthly, Board meetings twice a year

Phases of the project 1.October 2001 – April 2002: Evidence for funding decision –Recruitment, elaborating on the plans, gathering the consortium, raising funding for the main phases 2.May 2002 – October 2002: Foundations laying –Meetings with partners, surveys, self-education 3.November 2002 – April 2003: Full action, top down –Selection of targets, establishment of teams, action plans for specification teams, top down surveys, first pilot/prototype case, company survey, methods 4.May 2003 – October 2003: Bottom up, first specs –Establisment of pilot/prototype cases, bottom up work with companies, methodological development, first versions of three interface specifications approved 5.November 2003 – April 2004: Models, methods –Reference implementations, push to pilots, systematization of methods, new project proposals 6.May 2004 – August 2004: Packaging –Fine-tuning, documenting, publicizing the results

Results 1: Interface specifications Two new means for interoperability Desk top integration (Clinical Context Management): Context synchronization: Minimum level from HL7 CCOW Application launching and context exchange Shared core software building blocks (Common Services): User and access rights interface Patient data interface (person data set, clinical data sets) Terminology interface (diagnoses, tests, organizations, …) More service interfaces in further projects In practice: 6 teams, 14 integration objects, different needs 1+4 interface specification documents (from need to technology) 9 public reference implementations with documentation Testing procedure and test cases → ”PlugIT stamp” Training programme and teaching material for implementors

Results 1: Interface specifications Solution 1: Context management Example: Daisy Doctor has opened an EHR system and selected patient John Doe. EHR system sends user and patient IDs to context server. When the physician clicks on ”regional data”, EHR system launches a regional index system. The latter retrieves IDs from the context server, starts up with Daisy’s access codes and displays John’s data from the regional index data base.

Results 1: Interface specifications Solution 2: Common services Common data needed by all applications are in a core system. All applications can use the common services through standard ”plugs”. Duplicate programming will decrease. When e.g. a patient’s personal data are modified via one application, all other applications will ”see” the change immediatelly. All applications’ common code sets are updated from the national terminology server. Maintenance will decrease.

Core data sets defined by the National Health Project XML data structures defined by HL7 Open CDA Terminologies and code sets from Stakes’s national server Desk top integration and common service APIs from PlugIT HL7 messages are used between organizations Secure communication platform, consent practice, … Results 1: Interface specifications APIs as a part of the national set of means

Results 2: Methods Open integration specification process – the PlugIT process Activity-driven methods for requirements analysis: Exploring a ”gray area”, home care as a case Feasibility study to prioritize needs, maternity clinic as a case Application production and integration methods (requirements, user interface, testing, tools selection, data base, etc.): Prototyping with methods, Pakkanen as a case In practice: 3 teams and a common ”team-team” 8 reports on methods and the case results Training programme and teaching material for adopters Basis for further projects

Results 2: Methods Integration specification process Mykkänen et al., MEDINFO 2004

Results 2: Methods From a ”gray area” to software requirements Toivanen et al., AT in IT Design 2004

Results 3: Know-how and expertise Concentration of expertise: Multidisciplinary group of about 20 people with expertise, the only in Finland in applied research on healthcare software production In international comparison on a good European level Supported by the only concentration of education in information technology and information management in healthcare and social services in Finland: (in Finnish) In practice (preliminary figures): 49 persons employed during the project, 2 worked without pay 16 BSc/MSc studies, 5 forthcoming, 4 PhD studies in progress 20 international scientific papers and conference presentations, 12 forthcoming – MIE, MEDINFO, HL7, IFIP 8.2, STEP, IRIS, … 33 domestic papers and conference presentations 11 additional reports and working papers ~60 presentations at lectures, training and other events 8 new project proposals to Tekes, Ministry, TSR, Academy

Utilization of the results – 1: Indirect national impact (unofficial translations) National strategy on electronic patient records, Dec 2003: ”Desk top integration” will come from PlugIT HL7 → MoH, Open CDA specification document, 2 Feb 2004: ”CDA specifications are intended for document transfer. Other interactive support mechanisms are needed as well. PlugIT project has developed specifications and a mechanism for patient selection, based on Object Management Group’s PIDS service. It is proposed that PlugIT’s PIDS specification will be made an official open interface, so that the person data specification (profile) is based on the person data form specified in the Open CDA project.” Recommendation on national standards, Oskenet 7/2004: ”International interfaces should be used in application program interfaces as the first choice […]. If they are not available, national interface recommendations (like PlugIT interfaces) are to be developed. National recommendations are needed on …”

Utilization of the results – 2: National and international formal acceptance HL7 Finland, spring-autumn 2004: Common Services SIG established Technical Committee offers minimum-level context management for national acceptance Person data and terminology interfaces next? HL7 International, winter summer 2004: Common Services was introduced to the HL7 agenda PlugIT’s results will be presented in the HL7 conference in Acapulco, October 2004 Possible input to Common Services standards internationally? Will the HL7 CCOW community accept a cheaper version?

Utilization of the results – 3: Deploying the results into products and practice Implementations in products by the end of the project: Two implementations of context server, one ”stamped” – ~10 products in the market which could potentially act as servers (health centre systems, HIS core and comprehensive systems of hospitals, regional systems, portals) One implementation of Common Services announced in 2004 – ~10 products in the market which could potentially act as servers Client applications making use of the services in plans – several dozens of potential client products in the market Inquiries about using common service interfaces between legacy core systems and new clinical systems or vice versa Orders by hospital districts and health centres: ”Piloting orders” during the project Interest in using interface specifications in bids for tenders

Experiences – 1: Are the results what we planned to do? ”Desk top integration” and Common Services: Central role in the early plans, became unifying concepts and technically merged Business components → Web Services Multimedia components → generic application launching The role of CDA-coded storage of records became stronger Less work on design patterns and templates than planned Reference implementations and prototyping vs. piloting Activity/process development vs. software development: Including ”soft” requirements methods into the project was right Concentration of expertise was achieved, national collaboration needed Degree studies not sufficiently prioritized and supported

Experiences – 2: Did we do it in the right way? Subprojects by research units → multidisciplinary teams Tripartite collaboration is a must! But practical interaction is needed between professionals, not just management → contact person who distributes and filters information to others Government participation to be increased! The triade service providers – companies – researchers is needed in managing and implementing the National Health Project as well University-Polytechnic collaboration was important but hampered by bureaucratic obstacles (parallel funding) More contacts to research on software product business: Many problems and solutions are not domain-specific International perspective is weak in Finland: Export is 20% of healthcare software business, tendency towards two-party homegrown solutions, international visibility is weak

Experiences – 3: Making the most of research To reap benefits from research, you need to actively seek for benefits through active interaction! Some companies & hospitals were active, the majority tried to keep abreast, a couple did not enter into an interactive relation Corporate timeframe vs. research timeframe: ”Give us a fish, not a fishing hook” vs. ”Philosophy of fishing” – both are legitimate and need to be balanced. Pilots are the biggest problem – better as separate projects? In the beginning of a 3-year project you don’t know what to budget for practical integration projects during the last year. Research projects should produce reference implementations. Industry funding for research may become a bottleneck: Average-size non-pilot company paid for PlugIT’s €2 million and 3­year results less than for the cheapest new car – which one was a better investment? (Answer: Depends on the need)

”What will have changed in August 2004 as a result of the PlugIT project? How shall we be assessed? Do healthcare professionals have a more fluently interoperable software cluster in use (in pilot sites)? How can that be proved? Has software companies’ applications developers’ work become easier (in pilot companies)? How to prove that? Are applications and software components more transportable and deployable in Finland and more exportable? How to prove that? Has new research capacity emerged? How to prove that? Has it resulted in better healthcare services to citizens? How on earth will that be proved?!?” How should we be assessed: From PlugIT presentation at SoTeTiTe 2002