Enabling the healthcare enterprise

An agile story

Radu Craioveanu, CPHIMSDirector Software Development, Clinical Systems, IT GroupFresenius Medical CareTuesday May 02, 2017

3

Advancesinmedicineandtechnology

Alltheresearchintheworldismeaninglessunlessitturnsintomeaningfulresultsforpatients,whichiswhyourresearchanddevelopmenteffortsaredesignedtoquicklyturnnewfindingsintomarket-readyproducts.Thisquicktimetomarketenablesustooffersaferandmoreeffectiveindividualizedtreatmenttoeachandeverypatient.Wefocusontechnologiestoreduceproductsizeandsimplifytheiruse,whileintegratingvarioustreatmentelementstocreateholistictherapysystems.

Sustainedgrowthinpatientnumbers

Itisestimatedthatby2020,therewillbe3.8millionkidneypatientsworldwide,fueledbyanincreaseinthenumberofpeoplewhosufferfromdiseasessuchashighbloodpressureanddiabetes.Asthenumberofkidneypatientsrises,healthcaresystemsacrosstheglobewillbechallengedtofindtheresourcestocareforthem.Meetingtheresultingdemandforsafe,effectiveandefficienttherapiesandassociatedtechnologiesandproductsiscentraltoourresearchanddevelopmentactivities.

Increaseinconcomitantdiseases

Oursocietyisagingoverallandtheriskofdevelopingend-stagerenaldiseaseincreaseswithage.Aspatientsagetheyalsoexperienceagreaterlikelihoodofdevelopingconcomitantdiseasessuchascardiacandvascularconditions.Treatingthesepatients’comorbiditiesisincreasinglyafocalpointofourresearchanddevelopmentefforts.

Risingcostpressureinhealthcare

Anagingpopulation,growthinchronicillnesses,andthedesiretooffernewandimprovedtechnologiesinpatientcareallpresentmajorlong-termfinancialchallengestohealthcaresystemsacrosstheglobe.Forthisreason,webelievesuccessfulproductinnovationsmustnotbenotonlyhighquality,butalsoaffordable.Basedonourexperienceoperatingdialysisclinics,weconsiderthesetwoprioritiestobeentirelycompatible.

FactorsdrivingchangeatFresenius

HIE

Fresenius External Apps…

DataLayer

DATAWAREHOUSEAPPLICATION DATABASES

Integration- ETL

DATA ACQUISITIONCONFORMANCE & INTEGRATIONS - PUBLISH...

PERIMETER SECURITY

§ Nephrologists § Other Providers§ Ancillary Services§ Hospitals§ Nursing Homes § SNIFs§ Health Plans§ CMS § Regulatory Agencies§ Social & Community

Services

EXTERNAL SOURCESEMPI

OTHERFRESENIUSLINESOFBUSINESSSpectraLabsFreseniusRxVascularCareUrgentCarePhysiciansGroups

FRESENIUSKIDNEYCARE

SharedServices

Security,ERP,HR,…HostedLocally

Oh wait… ours is a typical healthcare enterprisemultiplied by 100 J

ClinicalServices

EMR,PHRHostedLocally

FinancialServices

Admissions,BillingHostedLocally

PortalServices

ContentHostedLocally

Oursisatypicalhealthcareenterprise

Challenge:DisjointedUserExperience

Toperformtheirtasks,clinicstaffusenotonlycoreclinicalsystemsbutalsoalargenumberofdisparateinformationsystems,eachonewithadifferentUI.

Challenge:ClinicalInteroperability

Wherewehavemultiplesystems,theuserisoftenresponsibleformanagingthecoordinationofworkflowsacrossthosesystems,oftenwiththehelpofadditionalreports.

Goal:SeamlessUser-CentricWorkflow

ImprovetheclinicstaffworkflowbyintegratingthevarioustouchpointsintoamoreseamlessUser-Centricworkflowtoeliminateredundantdataentryandnavigation.Manageuser/patient/locationcontextacrosssystemsforaseamlessworkflow.MinimizethenumberofUIsthat usersmustmastertoperformtheirtasksEnableclinicstafftomanagedatainthemostappropriatesystembasedontheirtaskworkflow

Challenge

FreseniusFABRICisCollaborativeappdevelopmentSecureUserandbackendintegrationTransformativepoweroftechnologyHighperformanceandavailabilityinalldatacenters

FreseniusFABRICenablestoHarnesstheEncourageuserengagement

Transformasystemofrecordintoasystemofengagement

Unleashback-enddata

Reducedevelopmenttimeandeffort

FreseniusFABRICaSMARTHealthcareApplicationPlatformforPatients,Clinicians,PhysiciansAdherestoSMARTconcepts:SubstitutableMedicalApplications&ReusableTechnologies(SMART)

Challengeresponse

FABRICApplications

EnterpriseApplications

Web-basedApplications{External&Local}

BusinessIntelligenceReporting&Analytics

PortalServices

Applications

EnterpriseApplications

Web-basedApplications{External&Local}

BusinessIntelligenceReporting&Analytics

PortalServices

DATA

Fresenius Kidney

Partners

Spectra & Shiel

Fresenius Vascular

Care

National Cardio-

vascular Partners

. . .

FMCNALines of Business

. . .

FreseniusRx

FreseniusHealthCare

Medspring

SoundPhysicians

FMCNALines of Business

Workflow

RulesEngine

DataTransformation

Services(Restful,FHIR,API…)

Orchestration

DevelopmentPlatform

Clinical Financial Pharmacy others

Fabricconcept

9

CareCoordination

PatientPortal

OrderingCharting

ClinicianPortal

Admissions

PopulationCareManagement

SMARTOS

SMARTPaaS

SMARTESB

SMARTSOA

SMART DATA

SMARTAPPS

PointofCareEHR

Userprovision

EnterpriseDataAccessFramework

WorkflowCom

plexity

SMARTContainer

Fabricmanifestation

FABRIC=(ESB+PlatformasaService)

SECURITY – MONITORING – AUDITING _ DEPLOYMENT

WorkflowEngine(BusinessandService)

Messaging DataTransformation

Services(Restful,FHIR,API…)

Orchestration DevelopmentPlatform

SMART OS – RedHat 6.x

SMART PaaS - Platform as a Service (container manager) – FABRIC8

SMART Containers – OSGI, SPRING BOOT (JVM stacks – Oracle WebLogic, JBoss EAP, Tomcat, Node.js)

SMART ESB – Web Services Apache CXF, Apache Camel Routes, Persistence (Mongo DB), back ends MS SQL, Oracle DB..

SMART SOA – FHIR Healthcare API, User Authorization, Caching, Workflow

SMART DATA – FHIR Resources

SMART APPS – Angular Apps

SMART Paas – OpenShift 3.0

SMART Containers – Docker

SMART SOA – Data Virtualization

CurrentLayers EvolvingLayers

OpenSourcewithCommercialLicenseSupport

Fabriclayersunderthehood

FABRIC=(ESB+PlatformasaService)

SECURITY – MONITORING – AUDITING _ DEPLOYMENT

WorkflowEngine(BusinessandService)

Messaging DataTransformation

Services(Restful,FHIR,API…)

Orchestration DevelopmentPlatform

JBoss Keycloak - OpenID Connect, OAuth2.0 to AD & LDAP(OID, OAM)

JBoss Grid – HA DR distributed WS cache

JBoss Fuse - Lightweight ESB and SOA, HA DR

Apache Camel - Routing and mediation rules, Orchestration HA DR

Apache CXF - Services (HL7 FHIR, SOAP, XML/HTTP, RESTful HTTP)

Apache Active MQ - Transport Protocols (HTTP, JMS, JBI) HA DR

MONGO - Audit, Transaction storage and replay, HA DR

Fabric8 - CI/CD, Service registration and Discovery, HA, DR

OSGI - Managed containers, service versioning, hot deployments

Jboss EAP – JVM ontainers, service versioning, hot deployments

SpringBoot - containers, service versioning, hot deployments

Monitoring - Riverbed Opnet, BMC Coradient, Solarwinds

Jboss Data Virtualization – HA DR distributed federated data

Apache Kafka – Messaging System for containers/topics, HA DR

Apache Artemis MQ - Transport Protocols (HTTP, JMS, JBI), HA DR

JBoss BPM - Service and Business Rules develop and deploy, HA DR

OpenShift - CI/CD, Service registration and Discovery, HA, DR

Docker - Managed containers, service versioning, hot deployments

Monitoring - OpenShift, Riverbed Opnet, BMC Coradient, Solarwinds

CurrentFunctions EvolvingFunctions

OpenSourcewithCommercialLicenseSupport

Fabriccomponentsunderthehood

SMARTAPPSLight Angular,React,MobileFirst,MobileReadyFlexibleSwift,Android,Web,SMARTonFHIRDualDataCenterHAActive-Active

SpringBootContainer

SPA

SPAService

Jboss EAPContainer

MPA

SPAadvantagesoverMPA:FasterpageloadingtimesImproveduserexperiencebecausethedataisloadinginthebackgroundformserverNoneedtowritethecodetorenderpagesontheserverDecouplingoffront-endandback-enddevelopmentSimplifiedmobiledevelopment;youcanreusethesamebackendforwebapplicationandnativemobileapplicationSPAdisadvantagestoMPA:HeavyclientframeworkswhicharerequiredtobeloadedtotheclientUIcodeisnotcompiled,soit’shardertodebugandit’sexposedtopotentialmalicioususerSEO(searchengineoptimization) implications;sinceyourpagesarebuiltinthebrowser,thesearchenginecrawlerwillseeadifferentversionofthepagethanthatofyourusers

SpringBootContainer

SPAService

SPA SPA,SWIFT,Android

CareCoordination

PatientPortal

OrderingCharting

ClinicianPortal

Admissions

PopulationCareManagementPointofCareEHR

Userprovision

Appsunderthehood

OpenSourcefromHL7andFHIRCommunityOrg

•Ease of implementation•Leverages established IT standards•Leverages Web 2.0+ standards•Optimized for Cloud-based applications•Interoperable support for document, message, REST and SOA architectures

•HL7 FHIR supports a range of clinical and administrative healthcare interoperability scenarios ranging from simple RESTful mobile solutions to clinical documents to complex messaging-based EHR infrastructures.

SMARTDATAFHIRDualDataCenter HAActive-ActiveFHIRMedicalOntology,RESTAPI,OpenSourceHAPIFHIRJPAServerIntegrated BPMandCDSbuiltin

FHIRunderthehood

SMARTDATAFHIRDualDataCenter HAActive-ActiveFHIRMedicalOntology,RESTAPI,OpenSourceHAPIFHIRJPAServerIntegrated BPMandCDSbuiltin

Donethis

Donethis

Doingthis

Maydothis

FHIRstacksunderthehood

SMART DATA BPMFHIRWorkflow,BusinessProcessDualDataCenterHAActive-Active

JBPMSuite,KIEKnowledgeIsEverything(Drools,jBPM,OptaPlanner)

BPMN2.0,BEPLUser,RoleandCredentialBasedAuthoring,SimulationDataModelertiedtoFHIRObjectModelDeploymentManagement,Analytics

BPMunderthehood

SMART DATA BPMFHIRWorkflow,BusinessProcessDualDataCenterHAActive-Active

BPMandFHIRunderthehood

SMARTDATACLINICALPRECISIONDualDataCenterHAActive-ActiveonFABRICOutputs FHIRbasedDecisionSupportandClinicalQualityMeasuresInputsFKCDataandRules,CMSDataandRulesIntelligentComputeEngine RServerexecutingontopofApacheSpark

SMARTID(OpenIDConnectOAuth2)

GuidanceResponse,Measure,Measure

Report

CARE

COORD

INAT

ION

SpringBootContainer

SPA

SPAService

JbossEAPContainer

MPA

FinancialAdmissions

PointofCareEHR

ASP.NETContainer

MPA

ClinicalEHR

JbossEAPContainer

MPA

RealTimeReportingWebApp

FKC

FVC

……

MPAorSPASMARTonFHIR

DataLakeConnector

APACHESPARK

APACHESPARK

NationalProviderDirectory

RServer

CMS,othersources

SPA

SPAService

CareCoordination

SpringBootContainer

DATAWAREHOUSE

APACHESPARK

Patient,PhysicianClinicianPortal

Predictive,DescriptiveAnalyticsunderthehood

SMARTDATACLINICALPRECISIONDualDataCenterHAActive-ActiveonFABRICOutputs FHIRbasedDecisionSupportandClinicalQualityMeasuresInputsFKCDataandRules,CMSDataandRulesIntelligentComputeEngine RServerexecutingontopofApacheSpark

RServer

SparkandmongoDB datalakeunderthehood

SparkR

JavaSpark

SMARTSOAFHIREMPIIntegrated Contextual,OrganizationalDualDataCenterHAActive-ActiveUser,RoleandCredentialBasedSystemtoSystemAccessbasedonEMPIMultiSystemPatientSearchSystemtoSystemIDtranslation

EMPI

FKC FVC FreseniusRx

SMARTID(OpenIDConnectOAuth2)

EMPIandFHIRunderthehood

DMZF5

Load Balancer

Org1/App 1

PUBLIC Browser

MongoReplica3

HL7

EHR1SQLDBA,B,C

EHR

MongoReplica12

HL7writeSQLread JSONwriteJSONread

Replicaset

Fabric

FHIRDSTU-2EMPI

HIE Private

FaçadeFHIR

CamelOrchestrator

eCCFHIR

eCFFHIR

FRxFHIR

RcopiaFHIR

RcopiaFHIR

FaçadeFHIR

CamelOrchestrator

eCCFHIR

eCFFHIR

FRxFHIR

RcopiaFHIR

OAuth

RcopiaFHIR

OSGICONTAINERS

FaçadeFHIR

CamelOrchestrator

CLNICALFHIR

FINANCALFHIR

RXFHIR

ePRESCRIBEFHIR

OAuth

MongoFHIR

BrocadeApplication Delivery Controller

EHR2SQLDB EHR3SQLDB

HL7

FINANCIAL

SMARTAPPAngular

DomainServicesRESTJSON

SpringBootContainer

OpenIDConnect

SMARTID(OpenIDConnectOAuth2)

OAuth

SMARTSOASMARTIDIntegrated Contextual,Organizational,ExternalDualDataCenterHAActive-Active

InternalReverseWebProxy

ExternalReverseWebProxy

SMARTSecurityGateway

SpringBootContainer

Org2/App 2

SMARTIDDB

RedHat SSO, Keycloak upstreamSingle SignOn, ClusteringOpenID, Oauth 2.0, SAML 2.0

SSOandOAuthunderthehood

PHARMACY

SMARTSOASMARTIDIntegrated Contextual,Organizational,ExternalDualDataCenterHAActive-Active

FHIR, SMART on FHIR, Argonaut Security Use Cases

1. Patientusesprovider-approvedwebapplicationtoaccesshealthdata2. Patientusesprovider-approvedmobileapptoaccesshealthdata3. Clinicianusesprovider-approvedwebapplicationtoaccesshealthdata4. Clinicianusesprovider-approvedmobileapptoaccesshealthdata5. ClinicianinorganizationAusesEHRAtoaccesspatientdatainEHRB,

operatedbyorganizationB

FHIRsecurityunderthehood

SMARTSOAFHIRCACHEDualDataCenterHAActive-ActiveJBoss GRID,InfinispanIn-memorylocalandclusteredcacheClusteringExpirationEviction

BuiltintotheFHIRServiceResourcesListenersTransactionsPersistenceManagementandmonitoring

DataCenter1 DataCenter2

Cacheunderthehood

SMARTSOAFHIRCACHEDualDataCenterHAActive-Active

Cacheunderthehood

Node_1[12498]

Node_2[12498]

Node_3[558]

Node_4[558]

Node_5[12498]

FHIRResourcescacheMultiplenodesShardandCluster

SMARTESBFUSEDualDataCenterHAActive-Active

JBoss FUSEWebServicesApacheCXF,ApacheCamelRoutes,Persistence(MongoDB),backendsMSSQL,OracleDB

IntegrationpatternbetweenFHIRserversandotherdataandsystems

DataCenter1 DataCenter2

ESBunderthehood

SMARTESBFUSEDualDataCenterHAActive-Active

FUSECamelRoutesFHIRcallsbasedonresource(e.g.Medication,MedicationStatementandMedicationOrder…)

ESBCamelunderthehood

SMARTESBFUSEDualDataCenterHAActive-Active

FUSECamelEndpoints(e.g.Procedure,MedicationOrder,Observation,Patient,MedicationStatement…)

ESBEndpointsunderthehood

HAPERSISTENCESMARTESBOperationalPersistence –MongoDBDualDataCenterMaster-SlavetoTripleDataCenterActive-Active

Router/ArbiterRouter/ArbiterRouter/Arbiter

LEXINGTONDATACENTERDataCenter1 DataCenter2 DataCenter3

mongoDB underthehood

Whyallthistech?

ConsumerDirectedExchange,Interop,ONC,CARIN,SMARTonFHIR

• SMARTAppGallery• https://apps.smarthealthit.org/

• ArgonautInteroperabilityProject• http://argonautwiki.hl7.org/index.php?title=Main_Page• http://argonautwiki.hl7.org/index.php?title=Argo-sponsors

Whyallthistech?

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