Re-thinking the IT architecture of health and care

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. As a CIO of a large health system recently told me: "We have been struggling to solve these issues with interoperability for the last twenty five years, trying to make health data follow the patient. It is not working! We need a fundamentally different approach."

A shift in care provision

Advances in clinical approaches and technology, consumers who want convenience, and payers demanding lower costs are 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 from the hospital. In the UK, the NHS is reorganising around Integrated Care Systems to address the new reality. Unfortunately, the IT systems in use today were built for institutions, not patients, and are struggling to support the new requirements fully. 

Engaged and empowered patients

Access to information has enabled patients to play a more significant role in their health and wellbeing. Providers are empowering patients to share responsibility for managing their condition to improve medical outcomes and lower costs. Patients are demanding convenient and personalised services, a tall order for current IT systems. Most healthcare providers are struggling to keep pace with demands, adding to the backlog of undelivered solutions.

The COVID-19 pandemic

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

Existing solutions impede change

A Mayo Clinic paper talks about IT 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 these issues, IT architecture has to be based on an open platform that includes a clinical data repository and tools to accelerate building 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 as well as APIs and tools to quickly assemble personalised application experiences.

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

A unified application experience

Care teams' frustration with current IT systems is well documented. They use intuitive, personalised and efficient apps in their personal lives and expect no less from systems that help them do their job. 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, patient, and care setting. Adding adesign system is necessary to achieve consistency of the user experience across different modules.

Agile delivery of applications

As companies proceed with their digital transformations, software becomes increasingly strategic and pervasive. The demand for new and updated applications is 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, reducing the backlog. In addition to software engineers, end users are stepping up as "citizen developers" that have domain knowledge to rapidly assemble their application experience using low-code tools. Healthcare is again behind the curve, but this approach is one of the few options it has. To be clear, heavy lifting will still be done by software written by professional developers, but as new tools advance, they will handle more complex features and capabilities. 

A vendor-neutral data core

As care moves out of the hospital into communities, data needs to be stored around the patient. Unfortunately, current systems, built for institutions, store data in proprietary formats, creating silos and preventing data fluidity making 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 make only 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 - where can I buy applications that offer this approach? The good news is that many vendors are now adopting openEHR toseparate data from applications, storing it in an open, vendor-neutral format. This shift is evident in markets with the most advanced healthcare systems. All four leading Nordic vendors of EHR systems in Norway (DIPS, PatientSky), Sweden (Cambio) and Finland (TietoEvry) now use a data repository based on openEHR. In addition, cities (Moscow) and nations (Finland, Malta, Scotland, Slovenia, Wales) also base their health data infrastructure on openEHR. Just recently, Catalunya decided to do the same. Many of these are very advanced, with a lot of experience in collecting high-quality care data for decades, which is why they understand the limitations of current approaches.

Of course, we know current systems are hard to replace. The new architectures will need to coexist with legacy systems for quite some time. The Postmodern EHR describes a way to start your journey to 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 needed to unlock the power of digital technologies and create the connected health ecosystem of tomorrow. Today's solutions tightly couple data to applications. As health and care data is for life, it needs to outlive applications, so there is a clear need to separate them. Architectures for the future will have a vendor-neutral data layer at the centre, low code tools to accelerate application delivery and application experiences personalised for the user. To bridge the gap between current and future state, legacy EHRs and new open platform-based systems can coexist, enabling innovation during the transition.