All levels of government across Canada are experiencing similar pressures today to cut healthcare delivery costs while increasing patient safety and care. With this growth in managed care and capitation, eHealth Portals are quickly evolving to meet new and more complex requirements, with significant benefits to medicine and healthcare in general.
As the practice of medicine is inherently dependent upon healthcare technology, the sustainability of our healthcare system depends, to an extent, on its ability to find ways to gain efficiencies and effectiveness in every aspect of our daily activity. Canadian Healthcare providers need to find ways to work smarter, not harder.
Building the future is really about building the present.
Marshall McLuhan once observed that too often people steer their way into the future while staring into the rear-view mirror---because the past is so much more comforting than the present. The problem with history however, is that our love of certainty and continuity often causes us to draw the wrong conclusions. To this end, in the past, the acquisition of technology had been viewed as an end in and of itself. Decisions about technology and usage were typically driven by the question of how to improve the effectiveness of what hospitals were already doing. Today’s information systems should be viewed as a vehicle to transform what Hospitals actually do. Moreover, there is a demonstrated understanding of the need to evolve healthcare informatics toward a more open, standards-based, patient-centric model that brings together all imperatives: clinical, administrative, financial, managerial, and human resources---in a meaningful way that concentrates on patient outcomes as the primary goal of the organization (and the method by which other parameters, such as financial efficiency, are to be judged.)
Lessons from False Starts
Whether an early-adopting visionary or a more cautious pragmatist, with the myriad of messaging from analysts, researchers, and pundits—concerns about implementing seemingly new or nascent eHealth Portal technologies is understandable. The sheer volume of new technologies coming to market only adds to the confusion and it’s a real challenge for most healthcare organizations to create a tactical plan to ensure that their IT capabilities support current and future objectives. To overcome these barriers and eliminate false starts, part of doing it right the first time requires an understanding of a.) the clear differences in the eHealth Portal solutions available in our Canadian market and b.) the new (transinstitutional model) horizontal architectures.
"Federated" and "Centralized" database models REDUX
When a healthcare organization sets out to extend a longitudinal ‘cradle-to-the-grave’ patient record (readily accessible via the Internet) linked to clinical protocols and guidelines—most people picture only one scenario. In this scenario, a user enters a query about a patient. That query goes to one source where all the patient information has been stored in a single “centralized” database (or vertical architecture.) The system searches that one database and returns the answer to the user. But information does not have to be accessed in this manner, as the patient data already resides somewhere in existing systems. Instead of duplicating that data in a new centralized system, the healthcare organization could leave the existing data in place. Then, when the user asks a question, the system gathers the appropriate patient data from wherever it is stored. This approach — leaving the data in place and retrieving it on demand — is called a “federated” database model (or horizontal architecture.) By definition, a federated database is a collection of data stored on multiple autonomous computing systems connected by a network that is intuitively presented to users as one integrated database.
Years ago, the centralized approach represented the more attainable of two limited choices — even though a massive initial investment of time and money was required (to build, load, and integrate a centralized database coupled with the painful patchwork of disparate legacy systems, brokers, and related integration and maintenance problems.) A good example of this is Trillium Health Centre’s $100 million dollar, seven year initiative to integrate all patient information into a single record. However, advances in technology and new product capabilities have made the federated approach a far more practical and significantly more cost-efficient option. Compared to a centralized eHealth Portal built on a single “centralized” database (or vertical architecture,) a “federated” database (or horizontal architecture) can achieve equivalent or better results at a fraction of the cost and time. Given our Canadian healthcare funding reality — this is an option that more and more healthcare organizations are likely to choose.
The real value: A fraction of the cost and time.
Anyone who uses the Internet takes the delivery of content from multiple systems for granted. Almost every Web page on a major commercial site is assembled automatically from multiple sources. Click a button and data is retrieved from other databases and servers. Users may not be aware of this, but it goes on constantly. Federated databases operate by means of a similar principle, except that each data resource is defined by means of a database schema or view, and the user has much more power to access and manipulate the data. With the federated Portal approach, the economics are significantly different and can be extremely advantageous. You don't buy the massive database server (or related brokers) and you leave all your data where it is. You don't need to build systems to update the database, as the integrated database is virtual. It exists only in the form of the views presented to the users. When a user submits a request for data, the federated database system performs extraction, cleansing and transformation, and the equivalent of loading for only that data needed to satisfy the user's request.
One of the greatest advantages of a distributed (federated) architecture is that it naturally lends itself to supporting a large variety of connected systems and guarantees the scalability of the portal system at the enterprise level. Moreover, a federated portal approach allows bandwidth, hardware, administration, and other infrastructure costs to be distributed over time, keeping pace with the development and deployment of the facility. This can significantly reduce networking and system-interfacing costs and opens up a number of added functional possibilities by extending data to the organization’s value chain delivering clear, tangible benefits for your short and long term needs.
Follow the leaders
The use of eHealth Portals has gained significant traction as a cost-effective way to transform healthcare delivery. Whether physician, nurse, technician, or administrator, eHealth Portals offer a proven, quick and efficient way of accessing, sharing and organizing hospital information and patient records. Portals also extend process-integrated decision support and a clear stepping stone to a national electronic health record. However, what has become clear, is that all portals are not created equal. As a result, identifying the right portal approach and architectural model, is critical for healthcare delivery organizations to maximize tax dollars and return on investment.
Examples of Canadian Hospitals who have successfully implemented an eHealth Portal initiative (whether Physician, Patient, or other) using a “federated” database model (or horizontal architecture) are Hamilton Health Sciences “ClinicConnect” initiative and Mississauga Halton's (LHIN 6) "REACH" initiative. An overview of the “ClinicConnect”solution is available at: http://www.hamiltonhealthsciences.ca/quicktour.htm
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