Creating a Flexible EMR Architecture

Doug Martin, MD

The Need for Innovation

• Traditional EMR architectures tend to be monolithic in design, which may limit configurability and extensibility

• Novel modular architectures support collaborative EMR development through– Built-in extensibility– High level of configurability– Flexible UI

The CareWeb Framework

What It Is

• A foundation for component-based applications

• Highly extensible through plugin modules

• Flexible, supporting user-designed layouts

• A coordinator of shared functions (events, contexts)

• A facilitator of collaborative development

What It Isn’t

• A standalone application (not an EMR)

• Specific to healthcare

• Dependent upon a specific domain model

The Road to CWF• 1998 Consortium of VA Hospitals fund VistAtion project

• Integrate commercial note authoring tool into CPRS• Monolithic, closed → open, modular, extensible architecture• Monopolistic → collaborative development culture• Needed a supporting framework (VistAtion Framework)• Modularize CPRS → VistAtion components

• 1999 VistAtion pilot commences at Atlanta VAMC• 2000 VA rejects VistAtion concept as “too open”• 2001 VistAtion VueCentric• 2002 VueCentric-based EHR piloted at Crow Indian Hospital• 2004 IHS adopts RPMS-EHR as its official EMR• 2008 RPMS-EHR deployed in over 120 IHS sites• 2009 VueCentric CareWeb Framework• 2010 CareWeb deployed across Indiana HIE• 2011 Gopher order entry system begins a new life as Gopher3

Rationale for Re-engineering

• Software platform reaching end of life• Systems reaching limits of extensibility• Difficulty recruiting engineers with relevant

experience• Diminishing compatibility with evolving

infrastructure• Limited ability to leverage contemporary tools• Complexity of maintaining multiple systems

Goals of New Platform

• Technology convergence• Web-based• Leverage existing open source technologies• Extensible architecture• Modular design• Emphasis on component re-use• Ease of development• Minimal configuration• Support our research mission!

What We Already Knew

• Component-based frameworks work• Separation of domain from framework is important• Given the proper tools, users will innovate• Don’t design to perceived workflows• Let users adapt software to workflow• Ability to share custom layouts is huge• Deployment can be a pain (lots of moving parts)

Challenges• Speed, speed, speed• Scalability• Cross browser support• UI richness• UI consistency• Session interference• Dependency management• Versioning• Workflow support

Key Technologies• Java• Spring Framework• Spring Security• ZK Framework• JQuery• JavaHelp• Apache ActiveMQ Server• Apache Tomcat• Apache Maven• CCOW

Exte

rnal

Serv

ices

Inte

rnal

Serv

ices

ArchitectureOrder Entry Chart Search

User Preferences

Web Resources

ContextManagement

EventManagement

HelpSubsystem

ElectronicSignature

PatientContext

DataAccess

SecurityServices

UserContext

LayoutManager

ThemeSupport

MessagingServices

Use

rIn

terfa

ce

LayoutDesigner

ComponentRegistration

Plug-inWidgets

FrameworkServices

Plug-inServices

FrameworkServices

CoreServices

WebServices

PatientSelection

ElectronicSignature

UserAuthentication

Plug-inServices

SMArtPlug-in

ClinicalFlowsheet Rule Authoring

Problem List Medication List Allergy List

What’s inside the new Gopher?• Data capture

– Order entry– Note Writing– Observations– Patient Letters– Document uploader– Electronic signature– Problem list management– Allergy Management– Order Sets– Natural Language Processing

• Results display– Recent results– Flowsheet– Clinical abstract– Clinical documents– Encounter display– Order summary– Appointment history– Patient dashboard– Medication summary– Chart search

• Clinical Decision support– Alert display– InfoPanel– Rule Authoring– Relevance Adjustment Module– FDB Integration

• Setting-specific functionality

– Outpatient– Inpatient– Emergency Department– Touch interface

• Administrative Tools– User management– Remote troubleshooting– Property management– Concept mapping– Disaster aid support

• System integration– McKesson portal– Relay Health portal– Docs4Docs integration

• Research– Randomization– Medication adherence– Medication reconciliation– Med profile visualization– ResNet study recruitment– SMART plug-ins

• Certifications– Meaningful Use Inpt / Outpt– NCPDP e-Prescribing

• Reporting– Population search

Summary

Modular architectures promote– Agile development– Collaboration within and across organizations– Best-of-breed approach– Code re-use– Incremental evolution

What’s Next?• Ongoing work

– SMART platform support– Clinical abstraction layer– EMR adaptors

• VistA• RPMS• OpenMRS• Commercial systems

• Open source– Community building– Infrastructure for collaboration