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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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