Toward An Enterprise Reference Architecture for the Meaningful Use Era

Meaningful Use is not just about financial incentives. In fact, the financial incentives provided under the HITECH Act will only cover a portion of the total costs associated with migrating the healthcare industry to health information technologies. Consider the following Meaningful Use criteria:

• Submit electronic data to immunization registries
  
• Incorporate clinical lab-test results into certified EHR technology as structured data
  
• Submit electronic syndromic surveillance data to public health agencies
  
• Generate and transmit permissible prescriptions electronically (eRx)
  
• Provide patients with an electronic copy of their health information
  
• Exchange key clinical information among providers of care and patient authorized entities electronically.
  

These criteria are clearly designed to bridge information silos within and across organizational boundaries in the healthcare industry. This integration is necessary to improve the coordination and quality of care, eliminate the costs associated with redundancies and other inefficiencies within the healthcare system, empower patients with their electronic health records, and enable effective public health surveillance. This integration requires a new health information network such as those provided by state and regional Health Information Exchanges (HIEs) and the Nationwide Health Information Network (NHIN) initiative. HIEs and NHIN Exchange are based on a decentralized, service-oriented architecture (SOA) whereby authorized health enterprises securely exchange health information.

Health CIOs who see Meaningful Use as part of a larger transformational effort will drive their organizations toward success. Creating a coherent and consistent Enterprise Architecture for tackling these new challenges should be a top priority. Not having a coherent Enterprise Architecture will lead to a chaotic environment with increased costs and complexity. The following are some steps that can be taken to create an Enterprise Reference Architecture that is aligned with with the organization's business context, goals, and drivers such as Meaningful Use:

1. Adopt a proven architecture development methodology such as TOGAF.
   
   
2. Create an inventory of existing systems such as pharmacy, laboratory, radiology, patient administration, electronic medical records (EMRs), order entry, clinical decision support, etc. This exercise is necessary to gain an understanding of current functions, redundancies, and gaps.
   
   
3. Create a target enterprise service inventory to eliminate functional redundancies and maximize service reuse and composability. These services can be layered into utility, entity, and task service layers. For example, Meaningful Use criteria such as "Reconcile Medication Lists", "Exchange Patient Summary Record", or "Submit Electronic Data to Immunization Registries" can be decomposed into two or more fine-grained services.
   
   
4. Task services based on the composition of other reusable services can support the orchestration of clinical workflows. The latter previously required clinicians to log into multiple systems and re-enter data, or relied on point-to-point integration via the use of interface engines. These task services can also invoke services across organizational boundaries from other providers participating in a HIE in order to compose a longitudinal electronic health record (EHR) of the patient. Other services such as clinical decision support services or terminology services can be shared by multiple healthcare organizations to reduce costs.
   
   
5. Consider wrapper services to encapsulate existing legacy applications.
   
   
6. The Enterprise Reference Architecture should support standards that have been mandated in the Meaningful Use Final Rule, but also those required by NHIN Exchange, NHIN Direct, and the HIE in which the organization participates. These standards are related to data exchange (HITSP C32, CCR, HL7 2.x), messaging (SOAP, WSDL, REST, SMTP, WS-I Basic), security and privacy (WS-I Security, SAML, XACML), IHE Profiles (XDS, PIX, and PDQ), and various NHIN Exchange and NHIN Direct Specifications. While standards are not always perfect, healthcare interoperability is simply not possible without them.
   
   
7. Select a SOA infrastructure (such as an Enterprise Service Bus or ESB) that supports the standards listed above. Consider both open source and commercial offerings.
   
   
8. Consider non-functional requirements such as performance, scalability, and availability.
   
   
9. The Enterprise Reference Architecture should also incorporate industry best practices in the areas of SOA, Security, Privacy, Data Modeling, and Usability. These best practices are captured in various specifications such as the HL7 EHR System Functional Model, the HL7 Service Aware Interoperability Framework (SAIF), and the HL7 Decision Support Service (DSS) specification.
   
   
10. Finally, create a Governance Framework to establish and enforce enterprise-wide technology standards, design patterns, Naming and Design Rules (NDRs), policies, service metadata and their versioning, quality assurance, and Service Level Agreements (SLAs) such as the NHIN Data Use and Reciprocal Support Agreement (DURSA).