BPM Enabled SOA to Maximize ROI for Healthcare Transformation

BPM Enabled SOA to Maximize ROI for Healthcare

Transformation

Jean Wang, Ph.D.1 Ajay Asthana, Ph.D.2

1

IBM Healthcare and Life Sciences Strategic Initiatives, IBM Corporation

8051 Congress Avenue, Boca Ration, FL 33487, USA

hjwang@us.ibm.com

2

IBM Healthcare and Life Sciences Strategic Initiatives, IBM Corporation

1551 S. Washington Av, Piscataway, NJ 08854, USA

asthanaa@us.ibm.com

Keywords: healthcare, revenue cycle, process reengineering, process transformation, process simulation, Business Process Management (BPM), Services Oriented Architecture (SOA)

Summary

While the doctors and the equipment that goes into healthcare are excellent there is lot to be desired of the care that comes out of it. Escalating costs, deteriorating quality and difficult access are contributing to this crisis. Streamlining the business processes and making technology more accessible at reasonable costs are possible solutions to emerge from this situation. While some healthcare organizations have taken the business perspective to improving their processes and operations (BPM) others have taken the technology perspective alone to create re-useable information technology services (SOA) Both the approaches have not been successful in delivering a timely return-on-investment (ROI) so far and have added to the confusion of connecting business and technology.

This paper demonstrates that doing BPM and SOA together, on a smaller project, will maximize the ROI by addressing the business and technology concerns simultaneously. The result is a streamlined process that can be executed using available technology and addressing the needs of senior management and information technology professionals. This paper is organized as follows: the first section describes BPM, SOA and the challenges in Healthcare that need for BPM and SOA to address them. The second section describes the business-driven-development methodology for accomplishing BPM and SOA at a customer location. The five steps of the approach are – modeling, assembling, executing, monitoring and governance. The third section deals with the platform and tools required to support the methodology. While several tools are available IBM’s Websphere and Rational software products will be used to demonstrate the value and benefit of tools. The next section deals with culture – the most difficult aspect of healthcare transformation. Incentives and governance strategies are discussed to ensure correct implementation. The fifth section describes how combining BPM and SOA can deliver financial benefits and faster ROI. The sixth section describes the transformation at a large ambulatory

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center by pointing the business objectives, technology solutions and the perfect match between them. Finally, conclusions are presented on how to use this approach iteratively to connect business objectives and information technology transparently.

Introduction

Business Process Management (BPM) itself is a process that intends to optimize operational business processes by bridging business objectives and information technology. It contains methods, techniques and tools to design, simulate, and analyze operational business processes.1

Business Process (BP) consists of a set of logical activities that when performed in a sequence produces a business outcome. Business Process Management (BPM) addresses how organizations can identify, model, develop, execute, manage and monitor their business processes. Business Process Management Systems (BPMS) is the technology that implements one or more of the core BPM functions. Today BPM is used to:

• ensure that technology matches the business needs,

• increase efficiency, effectiveness and productivity of resources, • increase flexibility and agility of business operations and

• reduce development costs and effort

Executing the process required connections to be built to existing applications and data. This was not robust as costly custom interfaces and wrappers needed to be developed. Further more changes were hard to incorporate and hence proving an ROI for BPM was difficult.

Service oriented architecture (SOA) is an IT architectural style that supports service orientation that allows integrating your business processes as linked services to support business agility. The primary goal of SOA is to align the business world with the world of information technology in a way that makes both more effective.2 Services Oriented Architectures (SOA) is an IT driven approach to identifying reusable business services that are consumed by process and applications. SOA is ideal for creating long term strategic value of IT. Services provide abstraction for:

• aligning business needs and technical capabilities seamlessly

• developing reusable coarse grained business functions and maps to business tasks • separating service interface from underlying implementation

• service bus, registry and repository to dynamically locate and use a service

Connecting the services to business processes and objectives was challenging as the business aspects were not considered in consolidating the services. While this approach reduces the development times of new systems proving ROI for the investment is a hot topic of discussion and controversy because of disconnect from business objectives.

BPM enabled SOA combines the strengths of BPM and SOA and reduces the weaknesses of them respectively by introducing an abstraction layer of process and services. This abstraction allows the services to be mapped to processes transparently.

The steps involved in this approach as illustrated in Figure 1 are:

1. identifying the business improvement objectives and their priority 2. select the most important objective for implementation

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3. 4. 5. 6. 7.

the business team performs the process modeling and choreographing the technology team identifies the applications and interfaces required

followed by developing services that can abstract implementation & technology process execution and monitoring is done next to ensure accurate implementation continuously improve the process by adding more objectives and benchmarking

Figure 1. Steps involved in BPM enabled SOA approach

Healthcare challenges

Similar to many of other service industries, the value of health care services is measured by a combination of service quality and cost. However, while the new diagnostic and therapeutic techniques have been advanced rapidly and the medical knowledge continues to accumulate in a significant way in recent decades, the general satisfaction to the patients is running to the opposite direction. According to a report from the National Academy of Engineering and Institute of Medicine there are nearly 100,000 preventable deaths per year, about a half-trillion dollars wasted annually through inefficiency, costs rising at roughly three times the rate of inflation, and 43 million people uninsured. Deaths due to medical errors exceed the number attributable to the 8th-leading cause of death.3 More people die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or AIDS.4 These negative findings in the U.S. health care services were contributed largely by neglecting engineering strategies and technologies that have revolutionized quality, productivity and performance in many other industries. This situation continues today. According to HIMSS Leadership Survey in 2006, patient satisfaction, safety, electronic records are among the top list of healthcare priorities.5 Healthcare industry today is facing ever high pressures from market and public. These pressures come from many directions such as high expectation of quality of care and better customer service, administrative burdens, financial constrains of providing care, requirement from payers for more automated claim submissions, technology deployment and government regulations.

To satisfy the healthcare market demand and overcome the pressures, clinical process

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transformation is imperatively required for health care organizations. Even though the fast advancement of information technology made changes possible such as to replace manual tasks with automated systems and improve communications and globalize collaborations, making strategic changes to the business processes does not come easy. It requires transform the traditional way of doing things, break existing business boundaries, adapt changed cultures, and adopt new technologies. During the course of applying information technology to transform healthcare some organizations have taken the business perspective to improving their processes and operations (BPM), others have taken purely the technology perspective to create re-useable information technology services. However, both approaches applied separately have failed to deliver the return-on-investment (ROI) so far and have added to the confusion of connecting business and technology.

Business Process Management (BPM) itself is a process that intends to optimize operational business processes by bridging business objectives and information technology. It contains methods, techniques and tools to design, simulate, and analyze operational business processes.6

BPM enabled SOA can overcome the shortage of each of them and extends the reach of both BPM and SOA technologies to benefit process transformation. There are three components of this approach that need a deep dive for successful implementations:

1. the methodology 2. tools and 3. culture

Handling them all at the same time has the novelty that is been uncovered today. Historically we had methodology but having a set of integrated tools and platform was challenging. Dealing with culture of the customer is the most difficult aspect of the transformation which was often left till the last moment which makes proving ROI difficult.

Methodology

The BPM enabled SOA approach is business-driven. The life cycle of this approach combines line of business with software development and operations. Taking business point of view, it starts from an understanding of the business goals and requirements by bringing in the healthcare domain and subject matter experts into the business service identification process at very early stage. It is an end-to-end iterative business service development process that is driven by business needs.7 Figure 2 illustrated the BPM enabled SOA lifecycle.

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Figure 2. The end-to-end iterative business service development process

This methodology enables all stakeholders across spectra to participate the

transformation the clinical processes, so that the vision can be shared, decision can be made based on the vision, and the execution can be carried with maximized support. The participants to clinical process transformation using BPM enabled SOA approach can be categorized based on the role they play. The tools for supporting each role will be described in the Tools section later.

1. The senior executives and manager are responsible for initiating strategies, projecting business objectives, aligning resources, making decisions, controlling investments, prioritizing projects, and governing the projects. 2. The business analyst is responsible for capturing business requirements, analyzing and designing the business process. They review existing business goals and objectives that drive the process enhancement request. They are also responsible for identifying repeated business tasks as business services candidates. 3. The software architect designs IT system based on business vision by create blue prints such as UML diagrams that can be built by developers. The architect also identifies service components that need to be implemented to make sure business goals are met. 4. Service developer constructs services based on the architectural design that fulfill business requirements and supporting overall business goals. 5. Integration developer begins with taking the business process model and converts into the Business Process Execution Language (BPEL) and

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choreographs all the tasks in the business world into technology. Finally, the developers connect all the services into the process model to get the executable code.

6. The testing engineer tests the IT system a set of testing tools to control the quality of the product and make sure the solution delivered truly meet business requirements.

1. Model the business

The first step in the BPM enabled SOA approach is to capture the current business processes, simulate and analyze it, decompose it to identify reusable business services, and then based on the findings propose new processes that will reduce inefficiencies and cost. The goal of process modeling is to capture business requirements at the initial design stage and make them available to the downstream development process. Figure 3 shows an example in which external services for clinical care were identified during process modeling.

Figure 3. External services identified during model clinical care process

2. Assemble the services

In parallel with capturing and analyzing business processes, identify the business-level data that will be exchanged among the tasks and the applications that will generate this data. Develop business services that have well articulated inputs and outputs, service level agreements, qualities of service (gold, silver, copper etc.) and security to create an abstraction between the applications and their implementations

3. Deploy the process

Deploying the process involves invoking the tasks of the processes models in correct order by applying the rules associated with business and connecting the data for transformation. It is necessary for the process engine to assign and route tasks to authorized users and systems. Monitoring the process execution and issuing alerts and triggers allows business users and IT administrators to control the process.

4. Monitor the business

Business activity monitoring analyzes events generated by the business processes and information collected about business processes to provide real-time feedback on higher level business function and business performance metrics. The business dashboards gives the stakeholders access to information to help their decision making and tracking key performance indicators. Pro actively

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controlling situation build-ups is the key advantage of this approach.

5. Governance

Proper governance is about establishing decision making rights associated with services and information technology. Governance is important to realizing the business benefits of BPM enabled SOA in terms of flexibility and reduced time lines, mitigating business risk and regaining consistency of service and improving team effectiveness by proper communications. Establishing a centre-for-excellence is the best approach for governance and management.

Tools

Methodology not equipped with tools cannot get executed. The radical re-design in complex healthcare system cannot be done without the help of employing software tools. For best practice, BPM enabled SOA approach endorse using the tools built on open platform based on industry standards, and can be integrated and in a plug-and-play fashion. Different users can choose the tool perspective most applicable to their role and yet be able to hand off the work product to other roles in the same environment. Figure 4 shows how to apply existing Commercial-Off-The-Shelf (COTS) software products during BPM enabled SOA lifecycle. For the work in paper, IBM tools are used, but that does not limit you to choose equivalents from other vendors. Due to the space limitation, we can only introduce some of the representative tools, while others are equally valuable.

Figure 4. Commercial-Off-The-Shelf (COTS) software products that can be used for BPM enabled SOA

1. Business Modeler and requirement tooling – Ex. Websphere Business Modeler and Rational RequisitePro

In order to visualize business operations and understand the workflow, resources utilization, time allocation, and to propose optimized process for re-design, it requires use business process modeling tool to capture and examine clinical operations. The business process modeling tool must be a graphical tool to document the process using collaborative design and development. It should allow business process simulation and animation. Business analyzer and report generator must be a feature of the modeling tool.

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The requirements identified for the process optimization must be converted into the tool to connect the business objectives with technology implementations. Requirement tooling in BPM we used is Rational RequisitePro. It enables you to manage requirements with flexibility, collaboration and communication capability, reusability, and traceability. In flexibility, it allows capture requirements with detailed user-defined parameters in multi-dimensions, such as priority, status, validation, cost, and cross-relationship with other elements. In collaboration and communication, it provides a platform for the extended team to systematically evaluate and review them and share the information across boundaries and manage changes. In reusability, many components and assets captured in the requirement model can easily be used by many projects, avoiding the duplicated efforts. More importantly, traceability enables you to establish the correlations between the high-level goals, detailed requirements, technologies, and other elements in consideration, and uses can query the information in many different ways. Therefore, the investment to the required capabilities of the system can be justified, and the technology to fulfil them can be identified.

A business process in general is a flow of invoking business services to accomplish the business goals. Business process modeling and requirement tooling also enables specify the relationship and dependencies of these services in the context of the business activity flows.

2. Services Builder and Assembler – Ex. RAD and WebSphere Integration Developer

To turn the service candidates identified in the previous sections into reusable building blocks and assemble them in the context of business work flow, appropriate software tools are required. Some of the tools like Rational Application Developer can be used to build services and transform services, some of them like WebSphere Integration Developer can be used to bring the services together into business activity flow. It requires such tools to embed industry standards (like XML, BPEL) and best practices. These tools, when used with BMP enabled SOA approach, can translate work products from business model into technical constructs so largely simplify the IT investment in the process transformation.

3. Deploy the process - ex. Websphere Process Server

To deploy the process a powerful process and riles engine is required. Handling sub processes, queues and group requests is an important. Four types of routing must be supported user-based, role-based, rule-based and ad hoc. Process recovery from failure is an important feature of the tool. Processing task delegations and compensating transactions are part of the tool to support process execution and deployment.

4. Monitor the business - Websphere Business Monitor

Monitoring business activities, processes and events allows decision makers to ensure smooth operations. Pre-defined dashboards allow uses to interact with the execution. Suspending and resuming, re-assigning processes along with altering the priority of processes is important.

5. Governance – Rational Method Composer and Portfolio Manager

Rational Method Composer provides capabilities for the development, management, and the publishing of processes. Rational Portfolio Manager allows for real-time qualification, management, and monitoring of proposed, on-going, and historical projects within an organization.

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Together they allow prioritize investment, control risks, and balance resources to achieve the success of the healthcare transformation under the principle of BPM enabled SOA principles with maximized ROI.

Culture

Process re-engineering is a fundamental re-thinking and radical re-design of business processes to achieve dramatic improvements in critical, contemporary measures of performance such as cost, quality, service and speed.8 The changes in these critical processes will impact large scope cross-functions, as well as at an enterprise level in both structure and roles of individuals and lead to transformation of the healthcare enterprise. Such radical transformation will inevitably cause on-going changes in culture and organizational environment. To be successful it requires a strong leadership and clear vision from high level management team, and it requires people across disciplines to support and execute the changes.

Four approaches to changing the culture are:

1. Obtain support from the top down – identify a senior executive to be the project champion

and act as change leader

2. Get services from the bottom up – identify critical services, ensure their availability and

spread the benefits

3. Choose the right people – identify motivated resources and get their support for adopting

the new approach of BPM and SOA to connect and enhance productivity

4. Promote communications – identify all the stakeholders of the project and send them

updates on progress and seek their feedback

The culture can be refined at an organization by providing the right incentives from the senior management to motivate people to use the right decisions. Establishing ownership of the process by the business team is a proven rule-of-thumb to control hundreds of people modelling and executing the processes. BPM enabled SOA is an iterative approach where improvements are obtained continuously allowing people to be patient is a key to the success for failure of the project.

Real World Example

A large teaching hospital in New York was planning to move from paper-based medical records to electronic medical records (EMR) to improve business flexibility, quality and safety. Despite clear documentation of benefits, the proposal was rejected by the steering committee due to shortage of upfront capital, competing information technology investment proposals, and “silos” in the minds of the c-level executives. This example describes how using the steps BPM enable SOA approach (as shown in Figure 1) the second time around was used to obtain unanimous approval from the steering committee and quick implementation.

The first step of the engagement was to interview the c-level executives and document their objectives. The CFO’s goal was obtain payment for all the services provided faster along with

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reduction in the number of no-shows. Improving the revenues was the hospital was critical to his short term survival. The CMO was keen on improving the outcomes and patient safety along with improving the morale of the doctors and nurses. The CEO wanted to provide access to all the people in the neighborhood and his motto was “does the right thing, always”. Reducing hospital’s exposure was one of the major concerns. The CIO was concerned with the number of applications and interfaces that needed to be built to support newer technologies, adding EMR package and developing adapters and services was discouraging the project. Finally, the COO indicated providing IT budgets to profitable divisions of the hospital (for example, surgery) and retaining critical nurses and doctors. The objectives of c-level executives were categorized into five main areas and these were used to validate the technology solution:

1. improve revenue and volume by reducing no-shows, denials and improving payment 2. reduce cost of operations by eliminating redundant activates and paper forms 3. improve outcome and quality by providing decision support to doctors and nurses 4. reduce risk and exposure by reducing the number of litigations 5. exceed regulation constraints to ensure proper auditing

These objectives were posed on the RequisitePro software to capture requirements as shown in Figure 5.

Figure 5. Requirements are traced down to identify healthcare IT assets

The second step involved building as-is and to-be process models for paper and electronic medical records in Websphere business modeler (WBM). Analysis and simulations identified all the bottlenecks and value of correcting these choke points. The EMR model reduced the cost, time and errors of the process by eliminating redundant steps, performing activities in parallel and automating difficult tasks such as coding, medical necessity and financial support. Figure 6 shows the paper and EMR processes for preparing the patient for doctor’s visit that he performs every day.

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Figure 6. Process models of paper-based ambulatory care vs. EMR enabled process

The third step involved in was to look at the applications, databases, access mechanisms and identifying the services that play a part in the implementation. Several reusable business functions were identified as candidate services, such as insurance eligibility service, translation service, medical record service, decision support service, referral service, lab service, scrubbing service, financial counselling service, etc. (Figure 7). Under SOA principle, these services should be made available in a loosely-coupled fashion and be able to plug-and-play in ambulatory care processes. The streamlined ambulatory care process will be able to invoke these services as needed during the workflow.

Figure 7. Services identified for clinical process

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The fourth step involved in developing a business case for BPM enabled SOA for healthcare using integrated process and financial modeling. The Excel spreadsheet-based tool was used to calculate the ROI, payback period, net present value, total cost of ownership; the simplicity of the tool along with ease of execution highlighted the financial side of the offerings. A 128% improvement with EMR with a payback period of being less than a year was observed (Figure 8).

Figure 8. ROI can be justified for clinical transformation using BPM enabled SOA

The fifth and final stage involved – implementing the process, testing the system and monitoring the execution to provide feedback for future role. The implementation is currently going and once it is completed the results will be shared by all the participants. A “sample” performance dashboard is demonstrated below (Figure 9):

Figure 9. Process performance dashboard displayed with WebSphere Business Monitor

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Conclusion

Bridging the gap between delivering healthcare services and adopting technology is a huge challenge during the course of the using information technology to advance the practice of medicine. When BPM and SOA applied separately, the obtained ROI was not as great as expected. BPM enabled SOA provides an effective approach to meeting the Information Technology challenges for creating the healthcare information exchange system in the game of healthcare process transformation. The encapsulation of BPM and SOA creates a symbiotic and synergistic relationship and better alignment between business and IT. With the methodology of BPM enabled SOA introduced in this paper and available COTS software tooling, and being prepared to adapt the on-going changes of corporate culture will help to link the business needs and the underlining technology and make the challenging healthcare process transformation succeed.

Acknowledgement

The authors would like to thank Anne Aldous, Ben Amaba and Ed Macko for their team work and support to set the strategy and vision of the future.

Biography

Huijuan (Jean) Wang, Ph.D. holds a Ph.D. degree in Chemistry from the University of Iowa, M.S. degree in Chemistry from South Dakota State University, M.S. and B.S. degrees from Beijing University of Chinese Medicine. She is currently employed by IBM as Solutions Architect in Software / Healthcare and Life Sciences organization, where she developed innovative solutions and approaches for healthcare and life sciences industry. Huijuan has worked in pharmaceutical and information technology industries and in academia in functional areas of scientific research and development, software development, education, and consulting. She is a member of American Chemical Society (ACS) and has spoken at major conferences such as IAMOT, ACS and the American Society of Pharmacognosy (ASP).

Ajay Asthana holds a Ph.D. degree from the Stern School of Business and a MS degree from the Courant Institute of Mathematical Sciences from New York

University. Ajay is a business architect in the Healthcare and Life Sciences solution organization of IBM where he develops value propositions for technology solutions using integrated process and financial modeling. He holds patents on his innovative approaches, which were presented at several conferences and published in prestigious management science and healthcare journals. Ajay has worked in retail, travel and transportation, process and petroleum, electronics, pharmaceuticals, provider and payer industries. Prior to joining IBM, Ajay was a Senior Principal at

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DiamondTechnology International and a Scientist at the Center for Strategic Consulting of Accenture. Reference:

1. van der Aalst, W.M.P., ter Hofstede, A.H.M. and Weske, M.: \"Business Process Management: A Survey\Springer Verlag, 2003.

2.Rob High, Jr., Stephen Kinder, Steve Graham, “IBM SOA Foundation”, http://www-128.ibm.com/developerworks/webservices/library/ws-soa-whitepaper/

3. Centers for Disease Control and Prevention (National Center for Health Statistics). Deaths: Final Data for 1997. National Vital Statistics Reports. 47(19):27, 1999.

4. Centers for Disease Control and Prevention (National Center for Health Statistics). Births and Deaths: Preliminary Data for 1998. National Vital Statistics Reports. 47(25):6, 1999. 5. HIMSS release, http://www.himss.org/pressroom/releaseDetail.asp?ContentID=65647

6. van der Aalst, W.M.P., ter Hofstede, A.H.M. and Weske, M.: \"Business Process Management: A Survey\Springer Verlag, 2003.

7. Asthana, A., Wang, H. and Amaba, B. (2006). “Aligning Information Technology with Health Information Exchange”, IAMOT 2006, 15th International Conference on Management of Technology

8. Re-engineering the Corporation - Manifesto for Business Revolution, Michael Hammer and James Champy, Collins Business Essentials, HarperCollins Publisher, 1993

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