Virtually Priceless Thoughts

NOTE: This post is a follow up from the overall post on what does a clinical architect need to know.

I think understanding some of the common approaches to software engineering is important for a clinical architect. At the least, you’ll need to participate in a process. Likely, you’ll have some influence on that process. As Clinical Architect you may be called upon to help (re)define some or all of the process of development of a Clinical Information System, especially if you have worked on the Enterprise Architecture.

One does not need to be a guru in RUP or a SCRUM master, but it helps to know the differences between waterfall approaches, agile methods, and even some of your vendor’s processes (where there is a dominant vendor in the organization and the system is not locally built).

The waterfall approach to development has a fantastic elegance to it. (See figure on left) You move from top to bottom, completing each step in logical order. You completely define your requirements before moving on to design. That way nothing is missed and effort is not wasted building pieces incorrectly.

Only thing is, it does not work.

Especially in healthcare, where there are complex systems in play with complex systems, it is not possible to “complete” a step. That is, you will never define all your requirements. You cannot get all your requirements “correct” as they are attempting to define ill defined needs that are often in conflict between groups or users (e.g. health planners may need something that providers do not need). Get a requirement wrong early in a pure waterfall approach and you do not realize it until later. Later means more expensive to fix. Often much more. Sometimes more than can be afforded at the end of a project (especially when the planning does not include changes of that magnitude).

Iterative approaches, of various kinds, begin with the admission that you cannot know it all. You have to learn through action. Thus, you iterate through increasingly refined understandings of the problem and solution space. High impact / high risk areas are addressed first, so those have the most time to be refined and improved. Approaches are used that lessen the impact of rework.

How you iterate depends on the approach. Most groups adopt aspects of different methods into their own custom fit agile method. I think that is a good idea. It is hard to justify a truly extreme programming approach in healthcare that includes putting semi-functional content into production with live patients. However, being able to iterate aspects of systems, test them, refine assumptions, work with providers to allow them to provide feedback and to mentally adapt to new ideas is key. Iterative approaches can support that process. It can be done in pre-production environments or even offline (paper prototyping can even work), and then allow for careful testing prior to production go-lives.

The challenge with iterative approaches is they often do not fit well into waterfall thinking. As I said earlier, waterfall is elegant. That elegance is easily understood by steering committees and executive sponsors. Why wouldn’t you plan out everything in advance and then just build it right the first time? I mean, that’s what they did when then built the bridge, isn’t it? Software is different, and that is especially true at this stage in the evolution of clinical information systems. We do not have the same experience as a bridge builders and there are more variables to consider.

One of the roles, then, of a Clinical Architect, is to ensure that the right process for the job is used, that standards are adhered to, that content is appropriately tested, AND that sponsors understand why projects should iterate and why it is important to learn through action.

Finally, if your organization has a dominant vendor product (e.g. your hospital information system is a vendor product), you will need to know their development processes. This is important to be able to make suggestions / feature requests, but also incase you are hiring / contract additional services.

NOTE: This post is a follow up from the overall post on what does a clinical architect need to know.

Being able to consider the full scope of design is, I think, an important piece for someone who – as an organization’s Clinical Architect – is leading the decision making around how the clinical systems fit together (or consciously do not fit together) to meet the organization’s goals.

While clinical leaders often think of systems from a care perspective, they often have not had training in the areas of information systems. With the complex CISs in play in many large organizations today, this kind of structured thinking is key.

Enterprise Architecture is the logic, processes, and products that connects the organization’s operations to its ICT infrastructure design.

This architecture should span the organization, not just IM/IT.

National Institutes for Health have their description of Enterprise Architecture.

There are many approaches to Enterprise Architecture. For organizations that are developing their architecture capabilities, it does not make sense to go too heavy, nor invest in a proprietary approach when there are good, published, open approaches. TOGAF, for example, is a good, open standard to enterprise architecture. It can be tailored to be light enough for early use and can the grow with organizations as they are ready to grow. Version 9 is available online. The figure on the side is a nice cyclical approach to EA management from TOGAF.

The Zachman Framework (wikipedia link) was developed in the 1980s at IBM and has been adopted, adapted, and revised since then. The Enterprise Architecture Center of Excellence now is its home. There are several tools to members (I am not a member). I have always thought of the Zachman Framework as something that is heavier to implement than other frameworks, such as TOGAF. I do like how the Zachman Framework ensures goals are explicit in the modelling processes.

I think what is important to keep in mind, for me, is that this level of architecture is much more socio-technical in its approach than simply a technical architecture.

There are others, certainly, but I thought I would list two. Please suggest others that you think are applicable to healthcare.

I have been asked a question by a colleague at the regional health authority where I have been consulting. Effectively, this question boiled down to:

What should I learn to become a Clinical Architect?

This is a tricky question, especially as the job descriptions for “Clinical Architect” are so variable, if they exist in organizations at all. Let’s use this brief job description:

The Clinical Architect will provide design leadership of major clinical information systems. Design leadership scope will include assessment and transformation of clinical processes, CIS functionality, clinical content modelling, CIS interoperability, and evaluation. Clinical domains would span all areas within the organization as well as major interfaces with other organizations (local, regional, or jurisdictional).

The clinical architect supports and mentors leadership (project and operations) on topics of informatics related to the choice, design, implementation, and refinement / adaption of clinical information systems over time. Is involved in the planning process, at an organizational level and project level. Assists in the development of standardized development / configuration processes within the organization.

I see the clinical architect a leadership role, with a small design team working with him or her. The one that I have recommended for the health authority looks like the diagram. While in this diagram everyone is an “architect”, those are just names. This is a design team that can span many areas of clinical information system needs.

Here are some of my initial suggestions for topics to cover if one is to be a Clinical Architect:

1. General Enterprise Architecture
2. Software Lifecycle and Design Methodologies
3. Requirements Design / Engineering
4. Modelling Notations
5. Information / Data Modelling
6. Health Information / Data Standards
7. Standardized Nomenclatures
8. User Centred Design / User Experience
9. Privacy and Security Principles
10. Evaluation and Benefits Realization

I will work to pull together additional posts on some of the topics over the coming weeks with some links.

I’m curious as to other’s thoughts as to what should be included in a curriculum for clinicians looking to lead the selection / design / customization / implementation of information systems. Please feel free to post a comment.

The blog has been quiet for a little while and I am glad to say with good reason – today I successfully defended my PhD dissertation:

Circle of Care Modelling: Improving Continuity of Care for End of Life Patients.

I have posted some of the findings previously and will post other components and findings in the future. I learned a great deal through this (both about my area of study and about myself) and am pleased to have taken the steps to get my PhD. The future looks exciting!

Today, however, I am going to rest and see my family.

Thank you everyone for your support on my journey. To my committee for being fair, supportive and asking good questions. To Francis, my supervisor, for pushing me that much more along the way.

And to my family.

–Morgan

1. Yes, this is a sad mis-quote from Austin Powers. I know what you are thinking “Oh, behave!”

Thank you everyone for your feedback to my previous post on learning in 2010 – both in the comments and by email (some of you were shy and preferred to give me great feedback directly).

The day after I posted the previous post, Zen Habits posted a little piece on Focus and Passion, which was timely. I agree, somewhat, with what the post is saying, but not entirely. I agree that passion and excitement is key. Also that being great is important. BUT, I think you can become great at something by bringing together a few diverse skills to create that unique specialization rather than focusing on something singularly until you are great at that (although that can work as well). With the idea of tying pieces together uniquely…

…On to my personal learning objectives for this year.

I have broken down my five personal objectives into three groups:

Leadership:

• Become more clear on types of team function / team leadership – particularly looking at successful and creative teams. Put learning into practice at work.
• Explore the Evidence-based Anecdote (my term) in leadership. This objective relates to use of story-telling in leadership and change. Put learning into practice in grant writing / presentations.
• Look into other experiences on adapting agile software development methods into research teams and clinical practice. I think there is something here… not sure where / when to apply this, yet.

Health Informatics Standards: (1)

• Review Core documentation on openEHR and archetypes, with a focus on content related to chronic disease data modelling.

Board Games / Game Playing:

• Review game mechanics / how to build board games.
• This one is partly for fun (and to get me ready for my son in a few more years) but also to explore why we play games for fun and how can we imbue some of that fun into learning, work and research methods. Not only will I spend some time playing with game pieces, but I will look into mechanics and why they work to see if they can be included in some of our work / design processes in the future.

My learning plan will be to dedicate a month to each topic. I will take the “free” months to learn about fatherhood or to either delve more deeply into one of these topics above or to add an additional topic, based on what I have learned or what I have lived.

I will build out more specific reading / activities for each month and share what I have learned through some blog posts.

If anyone is interested in joining me for any one of these activities, please let me know. It would be fun to have a learning group.

January is team leadership month!

1. I have other projects this year that will pull me into SNOMED CT more deeply, if not, I would have put that on my list.

I usually take time each holiday season to think about what to learn over the next year.

This year, I have decided to ask, publicly, for advice on what to learn.

I have always had personal learning activities related to work that keep stretching me. My learning program is meant to be fun and – at the same time – useful. It provides some additional direction into areas that I would want to extend myself to know about or apply. It complements my “required reading” for the various projects, papers, and books I am working on as part of my normal work.

When I was an animator, my personal projects would stretch me in areas I had not animated before, for example. Since medical school, my personal learning program has included: learning about leadership and leaders, adult learning techniques, public speaking and presentation skills, user interface patterns, management techniques, and even how comic books work(1).

There are many areas that I could pursue that I am interested in. Some include (in no order):

• Visual Thinking / Visual Modelling Research in Healthcare
• Prototyping and GUI Design Methods / Best Practices / Tools
• Learn a modern programming language
• Do a deep dive into to some Health Information Standards / Models
• Focus more on various management and leadership methods

I thought it might be interesting to pose the question to those that know me and see where you think I should spend my learning time. You can recommend topics, specific books, resources, courses, or conferences.

I’d love suggestions that start with something like “It would be amazing if you…” or “Imagine having more…” or “You are good at X, and Y would really will take you to the next level”. You could even add a few extra bits like “It would be fun because…” and “You’d find it useful because…” You can make suggestions based on past experience (“If only Morgan was better at X”) or future trends (“Personalized Health 3.0 is the next big thing”).

Please feel free to post a comment. I am really looking for ideas from you.

I will, in return, record my learnings here on the blog as I go.

Thanks,

– Morgan

PS – And YES! Before you say it, I will most definitely be spending time with my family this year and learning what I need about being a good father. This question is just focused on my own, quiet, learning time when everyone is sleeping.

PPS – Feel free to register under a fake name / email if you are not comfortable using a name I would recognize.

1. I highly recommend “Understanding Comics” by Scott McCLOUD as a place to start. I read it only last year.

A great colleague and friend is moving on to bigger and better things next week.

I was lucky enough to meet Glen when he was still an undergraduate student — he was experimenting with building prototype clinical decision support tools around the time I was receiving a grant to build a standards-based CDSS tool. He was keen, but was I noticed was his desire to make a difference with what he spent his time on. It was not long after that that I managed to get Glen to join our little EGADSS research team as a Masters student. He was instrumental throughout that work and developed some excellent skills, which only added to his fantastic approach to healthcare IT.

After our research project ended and Glen moved on to other work, we stayed in touch.

Two years ago I had the opportunity to recruit Glen back to work with me on some clinical architecture projects for Vancouver Island Health Authority. He has become a true colleague. Together, we have worked with VIHA to establish a greater understanding for the importance of clinical design, data design / standards, and process improvement. He helped to shape – and increase people’s understanding – of the clinical information architecture principles among other things.

It has been wonderful for me to work with Glen, not once, but twice. I have learned much from him over the years and hope that I will find ways to continue to collaborate with him.

Glen,

I want to wish you all the best in this next opportunity, one that I think is an important step for you and one I fully support. Make sure we stay in touch so our kids can play at the playground by the lake.

– Morgan

PS – For people reading this, who might be interested in applying for Glen’s position at VIHA, one piece of advice comes to mind. When applying for a job, it helps to be better than the person before you. This might be hard to do, filling Glen’s shoes. I suggest you think about ways of getting creative (like below).

Here is an interesting conference on line from Mayo. I’ve just watched Clay Christensen’s keynote on disruptive technologies and healthcare.

He spends time comparing business and healthcare and does it quite well.

An interesting piece at about 21 minutes, where he talks about non-disruptive competition leading to increased prices. He gives examples in the Boston-area and others where head on competition results in increased prices. Competing groups tend compete on features, driving up costs.

He argues that disruptive technologies come in that are simpler and cheaper. They enter the marker in a related, but more decentralized market that could not afford the incumbent’s full product but could use some features (his big example was the mainframe computer being disrupted by the minicomputer being disrupted by the personal computer). Each one was increasingly cheaper, less powerful, and more widely available – they were increasingly decentralized and thus were able to provide value in markets that where the others could not / would not compete and then provided more over time.

In healthcare this means enabling outpatient services and primary care to do many of the things that hospitals do. IV antibiotics, for example, could be given at my clinic much cheaper than they could in the Emergency Department, with all of its overhead, skills and equipment that are there, designed to manage acute traumas and heart attacks.

Today, our nurse practitioners and nurses in my clinic do many of the things I might have done in my private office (or might still be done in a typical family physician office without nursing support).

This decentralization ultimately would extend out far beyond the walls of hospitals directly to patients, providing them with the technology for self management.

Three Enablers for disruption to be successful:

• Simplifying Technology – that can maintain quality
• Business Model allows for innovation
• New Value Ecosystem that can consume the disruptive technology

At around 39 minutes, he makes a statement that general hospitals are not a viable business model and spends some time talking about types of business models and how general hospitals are really a mush of all three major types of models. No wonder that hospitals and the flows of patients through hospitals are so complex.

He ends with an interesting piece on where chronic disease management is best situated, in terms of motivation. While I have concerns about heavily engaging employers in patient care, I found his mapping of motivation and requirements for behavioural change something that resonating both my clinical experience and my work on PHRs at the National Research Council.

Here’s a version of his chart from my notes:

(click for larger version)

I found this an hour well spent – thanks KL for the link to this excellent talk.