Working toward Internet-integrated network applications

Healthcare Financial Management, May, 1998 by Edward Fotsch

At the Healthcare Information and Management Systems Society (HIMSS) meeting held in Orlando, Florida, this past February, it was apparent both from the educational presentations and the vendor exhibits that as far as healthcare information technology (IT) is concerned, the Internet has arrived. Nearly every vendor either demonstrated or discussed their Internet-enabled application and thin client approaches. Vaporware issues aside, does this mean that the quest for standards-based computing and cross-platform compatibility has finally come to health care? Probably not.

More likely, these Internet-enabled applications represent a first, important step in the development of network-based applications that will provide widespread access to clinical and administrative data across the Internet-accessible components of healthcare delivery and, most importantly, to IT-disenfranchised outpatient settings. This journey will, however, entail many such small steps and interim milestones and, as always in healthcare IT, the devil will be in the details.

As an example, browser accessibility of healthcare applications is but one of the technical and practical IT capabilities needed to ensure seamless data and information integration and access. And for applications to be able to interface and interact, they must be able to exchange and accurately recognize unique patient identifiers. At a minimum, this requirement would entail the use of a patient indexing system, preferably, one that would draw upon a network-based patient index with a network-centric registration system. Such a system would be used to front end other systems and allow identification and tracking of an individual patient and information relating to that patient across the continuum of care.

Better still, applications might pull information from a common database with a single data model. This approach would provide a higher level of potential integration, as all data and information derived from the applications would populate a single database and be readily accessible. In the past, such an approach was not feasible due to the lack of standards and the absence of a comprehensive network capable of delivering applications and database access to all healthcare providers and practice settings. The advent of Internet-based standards and access is rapidly eroding these obstacles.

Another of the challenges inherent in creating interoperable network solutions is the issue of the standards themselves. The vision of standards-based Internet languages and architectures has already begun to lose clarity as nascent would-be standards, such as Java[TM], are steered into socalled Microsoft-centric versions versus Sun Microsystems versions versus Hewlett Packard versions. Standards for middleware for object-based programming also have stratified into the COM standard versus the CORBA approach.

Despite the obvious utility and general benefit of expanding standards-based computing and architectures, organizations with substantial investments in proprietary applications development will view open architectures and standards-based computing as a threat to their business model - a threat against which they will defend until it becomes clear that the battle is lost, or until the benefits from switching to the standards-based camp become overwhelmingly apparent.

Other challenges remain for network interoperability. Even factors such as variation in graphic presentation and navigation between applications can have the practical effect of limiting interoperability. Beyond this, there exists a need for a common security model so that users need not memorize multiple log-on names and IDs. This security model should exist not only in the initial access layer of a network, but also in the middleware of the system so that individual authorizations, access, and provider roles (eg, attending physician, consultant, administrative assistant) can be respected and supported through the ability to customize access and views by user. Such a complex piece of database-driven middleware is now under construction at Baylor Health Care System, Dallas, Texas, for use in their progressive and rapidly expanding clinical intranet.

Network-centric application integration and interoperability will require cooperation between software and network developers and IT-savvy healthcare organizations that demand a high level of IT value. It is particularly critical for healthcare IT purchasers to identify and demand standards-based applications and network solutions, or they will continue to have their IT capabilities dictated by healthcare IT vendors that prefer to continue to develop closed and proprietary products. Browser-accessible applications development, while technically insufficient to achieve all of the goals of open architectures and interoperability, is a solid start.

Glossary of Terms

COM - Component Object Model. COM defines a binary standard to allow interoperability on any operating system or hardware platform, and a network standard for interaction on multiple platforms. These standards allow interoperability of objects and applications written by different programmers through the use of interfaces. If a generic component is designed, it can be reused, offering many interfaces for many programs.