Healthcare // Leadership
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11/20/2013
09:05 AM
Jason Burke
Jason Burke
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Where Is Enterprise Architecture In Healthcare?

Implementing healthcare technologies is just the beginning. We need to plan how they will fit together.

Integration, interoperability, data quality, process automation analytics -- these ideas are simple to describe but can be quite hard to execute in today's business environments. The road to building information-driven businesses far from well-paved.

Yet over the past two decades, enterprise architecture (EA) has gradually emerged to help institutions in many markets build new operating models and connect their as-is and to-be business strategies and IT capabilities. Though the discipline still lacks industrywide consistency, EA advocates in both academia and industry readily point to successful EA frameworks offering business-IT governance, standardization, and more sophisticated software and information infrastructures.

(Source: Horia Varlan/Creative Commons, Attribution)
(Source: Horia Varlan/Creative Commons, Attribution)

So where is it in healthcare?

A Certification Commission for Health Information Technology report on accountable care never mentions the concept of enterprise architecture. It generally avoids describing any actual IT framework. And a Patient-Centered Primary Care Collaborative report (registration required) offers a health IT shopping list with more than 10 items but overlooks the obvious status quo challenges: lots of software with very little process and data orchestration.

In fact, virtually all of today's healthcare buzzword initiatives -- population health, health information exchanges, health analytics, medical neighborhood models, performance and quality management -- share common capabilities manageable through EA.

The industry's current preoccupation with electronic medical records (EMRs) is a necessary precursor to more cost-effective, data-driven healthcare. But technology veterans know that buying more software and dumping data into warehouses does nothing to orchestrate sustainable business performance. Information availability does not equate to usability, and databases filled with electronic versions of paper document structures do not naturally improve health outcomes or financial performance.

Delivery innovation initiatives such as Accountable Care Organizations (ACOs) -- which numbered more than 400 at last count -- have challenged clinical leaders to make headway against both real and perceived deficits in internal infrastructure. Those leaders are turning to a growing market of external service and technology partners to support their accountable care and patient-centered medical home (PCMH) programs. These partners offer three things health leaders desperately need: additional people to get work done, knowledge from other health institutions, and the promise of usable intelligence that may seem unattainable. But is it really so unattainable?

Many clinicians rightly point out that the way we provide care under ACOs should not be all that different from the way we provide all care. Similarly, EA opportunities transcend the business model du jour. Regardless of where an institution might be on its transformational journey, there are clear reasons why EA should be at the top of every health enterprise project portfolio.

  1. Improving performance and health outcomes: The quality of an organization's process execution and analytical insights is directly dependent on interoperability, automation, data quality, and timeliness. If you want to build a performance-oriented health delivery machine, EA provides the engine and fuel.

  2. Controlling costs: EA has a proven track record of helping organizations control operational expenditures and increase return on assets through reductions in hardware purchasing, software licensing, staff training, and support costs. EA is good business regardless of transformational goals.

  3. Protecting profitability: Health organizations are increasingly carrying higher financial risks. These risks are compounded when spending does not address sustainable capability creation and instead erodes margins.

  4. Managing security and risk: For all the right reasons, ACOs and PCMHs often increase the number of people, processes, and systems involved in care delivery. But complexity is the enemy of security. EA offers a means of controlling risks.

  5. Encouraging better planning: Quality and consistency go hand in hand. In the face of rising care practice and business model diversity, frontline practitioners need consistent processes for treating and managing patients. EA provides a common framework for both defining and operationalizing the to-be state of the business.

So why isn't EA more prominent in the eyes of health leaders? One reason is the current preoccupation with operational issues; both people and funding are so heavily tied to EMRs and quality metrics that organizations are struggling to find capacity for much else. Another reason is the industry's general preference for buying as opposed to building (except real estate). Unlike many other technology-related areas, EA is not a commodity, and it can only be matured through internal investment. It's also not just a technology issue. Let's be honest -- EA is not broadly understood yet.

But the question is this: Can health care effectively transform without a stronger emphasis on enterprise architecture? After all, every organization has an enterprise architecture. It may not be well designed, well managed, comprehensive, capable, or cost effective, but it exists.

But that is the point of health transformation, isn't it? If the data journey to population health management -- including care coordination, health information exchange, health analytics, and more -- seems arduous, maybe it's time to consider a different path, even if it's unpaved.

Remote Patient Monitoring: Don't let all those Fitbits fool you. Though remote monitoring technology is sound, it's still far from widespread clinical adoption. Read the new InformationWeek Healthcare Digital Issue.

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Jason Burke
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Jason Burke,
User Rank: Apprentice
11/21/2013 | 9:17:03 AM
Re: Explicit vs Hidden
Great comments, your points are very well made.  Common traits I've seen in EA failures include EA as an ivory tower, EA as a policy board only, and EA as a documentation function.  When EA is not connected to the on-the-ground issues of the organizations (such as solution development), it is a meaningless function.  However, I would also argue that a purely bottoms-up approach cannot deliver scalable capability in the areas where we see so many challenges in health care (for example, master data management).  So I believe in the need for a distinct function that bridges the top-down and bottom-up perspectives, but I think your first statement is spot on: there should not be EA-specific goals. EA's role should be focused on enabling business and IT goals, not creating new goals of it's own.  And whereas the strategy and governance should be top-down, virtually all of the execution should be bottom-up (i.e., where value is derived).
MatthewP956
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MatthewP956,
User Rank: Apprentice
11/20/2013 | 5:32:14 PM
Explicit vs Hidden
My experience with EA has been, unfortunately, negative in that where EA has been called out as a specific function with EA-specific goals, it has failed.  I believe that the failure is resultant of the separation of EA and its domain-specific activities from strategy, solution development and performance management.  Where I've seen it successful, is when it is built into the solution development model and has business goals attached.  The methods of delivery will be modified and the deliverables will also change to accomodate EA necessities - and this is a good thing - as those artifacts can then be reused for other solution-specific work.  The downside to this "bottom-up" method is that rework may result as the EA view will necessarily be incomplete.  This risk, IMO, is worth it as at least some progress will be made and the EA will be effectuated and developed through work that is meaningful to the organization.  In other words, please stop calling it out as "EA" - no one wants it as a separate, check-the-box, stage gate and when allowed, EA practioners can get carried away to no immediate positive result.
Jason Burke
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Jason Burke,
User Rank: Apprentice
11/20/2013 | 12:48:23 PM
Re: Who does this right?
Great question.  Not surprisingly, there are not a lot of great examples in health care yet.  Commonly cited examples outside health care include FedEx, John Hancock, and Dow. Payoffs are typically found in 3 general categories: cost avoidance (e.g., fewer software licenses, hardware, support resources), operational efficiency (e.g.,support simplification, staffing flexibility), and upside financial performance (e.g.,faster time to market, novel partnership enablement).  MIT's Center for Information Systems Research (MIT CISR) has some great additional background reading for those interested.
David F. Carr
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David F. Carr,
User Rank: Author
11/20/2013 | 9:55:03 AM
Who does this right?
I'm curious about your experience with organizations that really do this right (or more right than most) and what kind of difference it makes. Who would you point to, and what have the payoffs been?
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