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Clinical Groupware: Platforms, Not Software

Kibbe

Clinical Groupware is rapidly gaining acceptance as a term describing a new class of affordable, ergonomic, and Web-based care management tools. Since David first articulated Clinical Groupware's conceptual framework on this blog early last year — see here and here — we've been discussing Clinical Groupware with a growing number of people and organizations who want to know what it is, where it's going, and what problems it may solve, particularly for small and medium size medical practices, their patients and their institutional/corporate sponsors and networks.

Clinical Groupware heralds a shift away from medical applications that are primarily based in local hardware and software. It creates a more fluid functionality in those applications, and empowers communications as well, by leveraging Internet connectivity, Web-based data resources, and new services (i.e., capabilities) performed upon these data by agents or applications.

In other words, Clinical Groupware is about platforms that can integrate modular applications, which in turn are supported by subsystems of data services. Although it is still in its infancy, Clinical Groupware is an end-to-end digital revolution in health IT.

It is still too early for a single best example of Clinical Groupware to have emerged. The creation of platforms, modules, and data services in health care has begun only recently, fueled by and borrowing from developments in popular computing that include search, social networking, geo-location, identity management, photo and music-sharing protocols, and remote storage.

Clinical Groupware is sometimes understood in terms of "remote hosting" or an "application service model" (ASP) of software. It is true that this might be a starting point for some users. But as a phenomenon, it is far more powerful than simply running a software program over the Internet instead of on your computer or local area network.

Tim O'Reilly uses "Internet as operating system" as a short-hand way of describing the robust complexity of features and functions available to users of today's browser-based and mobile computing platforms. This approach contrasts markedly with the older client-server computing model. In client-server arrangements, a computer-resident operating system coordinates access to applications and machine resources on a single or, at most, a few computers on a network. In the "Internet as OS" model, the Internet itself coordinates that access across large numbers of computers and users. 

The browser or the smart phone may be the means of gaining access to this new and rich "compu-cology," to coin a term. But what really matters most of the time is what is happening between your interfacing device and the many applications on the net that it can reach.

Consider the difference between the mere delivery of an application, such as an ePrescribing software program, over the Internet, versus the richness and complexity of two very popular, although very different computing platforms, Google apps and the iPhone with its app store.

Google's core competency is, of course, its search technology, which almost instantaneously takes the search string from your browser or mobile phone and serves it up to Google's proprietary software at one or more of its massive server farms.  But Google also offers free (or very inexpensive) applications such as calendaring, email, photo organizing and sharing, word processing and presentations, mapping, etc. most of which are capable of sharing, indexing, and processing several different types of information in the background in a connected manner. Thus, at the push of a button while in Picasa Web Album, Google's online photo storing/organizing application, one can publish individual photos, or whole albums, to groups of people in one's Gmail account, while also allowing those people to upload new photos to some albums, but not others. It is also easy to place photos on a map location, view both photos and maps in Google Earth, and then share these with others. In each case there are complex data look-ups and indexing occurring, mediated by Internet protocols for identity management and access permissions, in the background.

The iPhone is a more proprietary platform – a "walled garden" in the jargon of the day – that integrates multiple data processing activities, some of which are hardware resident and others that occur online. Its wireless capability supports access to the Web, which can integrate with the built-in GPS location services that are in communication with satellites circling the earth. This arrangement can tap into a world-wide technical infrastructure that can help you find the nearest Chinese food restaurant or get to a nearby hospital trauma center. It can allow you to search for a doctor, map the location of the doctor's office, and get performance ratings on that physician's or organization's quality and service. Many different applications "run on" the iPhone device, but they depend on what O'Reilly calls "network available services" for value creation that far exceeds the features of the phone itself.

In other words, these new Web-based platforms allow distinct functions to interact with and leverage one another, creating a robustness of capability and productivity that was unthinkable in earlier, more limited hosted arrangements. Thinking of these platforms as merely running remotely-hosted applications is to miss their possibilities. Clinical Groupware, a very powerful and practical medical application of this model, is the revolution ahead that will foster intense competition among vendors vying for platform real estate.

Still skeptical? In fact, the leadership at ONC/HHS have already realized that the future of Health IT lies in a whole that is greater than the sum of its parts.

In early April, ONC awarded $60 million to four institutions – Mayo Clinic, Harvard University, University of Texas Health Science Center at Houston and University of Illinois at Urbana-Champaign – through the Strategic Health IT Advanced Research Projects (SHARP) program. Each institution's research projects will identify short- and long-term solutions to address key challenges associated with health IT and meaningful use. John Halamka recently blogged about the Harvard research, which will "investigate, evaluate, and prototype approaches to achieving an “iPhone-like” health information technology platform model, as was first described by Mandl and Kohane in a March 2009 Perspectives article in The New England Journal of Medicine." Further, Halamka writes:

The platform architecture, described as a “SMArt” (Substitutable Medical Applications, reusable technologies) architecture, will provide core services and support extensively networked data from across the health system, as well as facilitate substitutable applications – enabling the equivalent of the iTunes App Store for health.

This new approach to a health information infrastructure was the focus of a June 2009 working group meeting at the Harvard Medical School Center for Biomedical Informatics and an October HIT meeting which brought together more than 100 key stakeholders across academia, government and industry in an exploration of innovative ways to transform the national health IT system.

One of the challenges facing the Clinical Groupware, modular application approach, is that of data exchange between apps and data integration among several different apps.  It is clear that the Harvard SHARP research grant will have these problems as high priorities for solutions during 2010 and 2011.

David C. Kibbe, MD, MBA and Brian Klepper, PhD write together on health care technology, market dynamics and innovation.

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K Si
Guest

Decent solution indeed.

Visio7
Guest
Visio7

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In my Opinion this Groupware Solution is some good Alternative for every Groupware Solution I had uses jet.
U can even get her for free up to 5 Accounts.
Firstclass Groupware

Surgical Instruments guy
Guest

“Web-based data resources” and software applications are definitely the wave of the future. But as “Joseph Stevens, MD” there still will not be an electronic substitute for the well trained and prepared medical professional. We need to keep our eye on the ball and ensure that the health, safety and welfare of a patient comes first even as we pursue efficiencies and new technologies.

Technoxsoft company
Guest

I’m with you that when research is focused on home home improvment.
Instructive, thanks…

Bert
Guest

Nice comprehensive list! I agree that every software application intended for human consumption is built based on the Model-View-Controller (MVC) paradigm. if religiously observed this gives a separation of interests where one could substitute each part of the MVC for another. The basic theme here is that if we want data to do research on, learn from and measure quality with, somehow, somebody, at some point, is going to have to get that data in there. You can also look for series provided by Simulation Medical to get more insights on to the topic. Intramuscular and subcutaneous injections are the… Read more »

Faisal Qureshi
Guest

Are we looking for a solution that’s only specific to Health IT? Or is it just the same 0s and 1s that just need a set of HC specific restrictions? Your article mentions the SHARP initiative. Although a transactional ‘framework’ specific to the new ONC rulings/policies doesn’t specifically exist, an ONC explanation of why research institutes were the right choice over existing data transactional companies / projects would shed some light as to the direction of what such a framework is to become. Development concepts like RAD (Rapid Application Development), mysql, mongodb and Margalit Gur-Arie’s mention of MVC are just… Read more »

bev M.D.
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bev M.D.

James;
If I am understanding structured narrative correctly, it is sort of a template in which one dictates to fill in the blanks? We used to use this in our gross pathology room for measurements of the specimen and other standard items. This has some possibilities, but what free text capabilites are there?

James
Guest
James

Bev: “But I am talking about truly clunky ways of doing things which take twice as long as the “old” way, and essentially convert the doc into a secretary. For example, could dictation be incorporated as a way to enter narrative, or something similar.”
I covered a presentation on this topic at a recent local HIMSS Chapter event. Technology based upon EHR structured text tools was being discussed. The presenter was from http://www.MD-IT.com. A link to the presenter bio and an overview of the presentation is here: http://www.austinhimss.org/

data junky
Guest
data junky

This vendor agnostic platform approach already exists and is in the early stages of implementation. Healthcare Interactive has developed a platform that allows all of the stake holders to communicate aggregate and provide third party applications to the consumers and providers of healthcare. All this is done securely and privately. Information is easily accessible by all parties based on system level permissions.
Communications, Organization, Efficiency, and Management Capabilities all in one platform.

Neo_L
Guest

“The old adage regarding real estate is that the top three value considerations are location, location and location. As healthcare transitions into more value-based payment designs, the same adage will hold true for health information technology.” – i really like this comment. I support this point of view.

Joseph Stevens, MD
Guest
Joseph Stevens, MD

Pardon me but where does the patient fit in with all of these dreams, especially the dead one at MGH, in January, or the dead one in Nebraska, in April, and dead ones reported here: http://www.huffingtonpost.com/2010/04/20/electronic-medical-record_n_545441.html
Also, please explain how it will work when the computers go blank like here: http://www.nytimes.com/aponline/2010/04/21/business/AP-US-TEC-McAfee-Antivirus-Flaw.html

Hal Amens
Guest

Agree on the general direction of the original post. Office based PC’s provide an interim solution to start collecting the data but they are way too limited to provide the benefits that are possible. I have just finished reading Safe Patients, Smart Hospitals by Peter Pronovost, M.D. In 10 years a child’s needless death from a center line catheter infection is leading to culture and data changes that are reducing costs and saving lives. The changes are reaching into more and more areas of medicine and more and more areas of geography including nationwide and international implementations. Among other issues,… Read more »