Welcome!

Microservices Expo Authors: Automic Blog, Elizabeth White, Dalibor Siroky, XebiaLabs Blog, John Katrick

Related Topics: @CloudExpo, Java IoT, Microservices Expo, Containers Expo Blog

@CloudExpo: Article

Middleware Solutions | @CloudExpo #DataCenter #BigData #M2M #IoT #API

While there has been much ado about interoperability, there are still no real solutions

While there has been much ado about interoperability, there are still no real solutions, same as last year and the year before that. The large EHR vendors who continue to dominate the market still maintain that interoperability is all but solved, still can't connect EHRs across the continuum causing frustration by providers and a disservice to patients. The ONC pays lip service to the problem, but that is about it. It is time for the healthcare industry to consider alternatives like middleware which has been proven in other industries such as finance, retail and hospitality.

The lack of EHR interoperability continues to pose a serious threat to healthcare initiatives, according to a recent report published by the American Hospital Association (AHA). The report discusses the various aspects of the healthcare industry and care delivery that are negatively impacted by a lack of interoperability.

The report notes that the exchange of health information is critical for the coordination of care. When patients receive care from multiple different providers, physicians should be able to securely send relevant patient information to the practicing physician. However, that tends not to be the case because EHR systems are not interoperable and cannot exchange information.

Last year, The ECRI Institute released a survey outlining the Top Ten Safety Concerns for Healthcare Organizations in 2015. The second highest concern was incorrect or missing data in EHRs and other health IT systems caused by interoperability. For the second year in a row, EHR data is identified as a concern.

The Partnership for Health IT Patient Safety, a branch of the ECRI Institute, has released safe practice recommendations for using the copy and paste function in EHRs that can adversely affect patient safety, such as the use of copy and paste that can overpopulate data and make relevant information difficult to locate, according to the partnership's announcement.

Meanwhile, a survey of 68 accountable care organizations conducted by Premier, Inc. and the eHealth Initiative found that despite steep investments in health information technology (HIT), they still face interoperability challenges that make it difficult to integrate data across the healthcare continuum.

The survey found that integrating data from out-of-network providers was the top HIT challenge for ACOs, cited by almost 80 percent of respondents. Nearly 70 percent reported high levels of difficulty integrating data from specialists, particularly those that are out-of-network.

User Frustration Over Lack of HIE and Interoperability Standards
The Office of the National Coordinator for Health Information Technology (ONC) is once again asking the health care community for its thoughts on establishing metrics to determine if or to the extent to which electronic health records are interoperable. The push to achieve interoperability is in response to last year's mandate by Congress, contained in the Medicare Access and CHIP Reauthorization Act (MACRA). Among provisions of that law is a requirement to achieve "widespread" interoperability of health information by the end of 2018.

When it comes to how Health Information Exchanges (HIEs) handle the challenges associated with interoperability, a recent Government Accountability Office (GAO) report cites the following barriers - insufficient health data standards, variations in state privacy rules and difficulty in accurately matching the right records to the right patient. In addition, the costs and resources necessary to achieve interoperability goals, and the need for governance and trust among entities that facilitate sharing health information.

In its annual interoperability survey of hospital and health system executives, physician administrators and payer organization IT leaders released in April 2016, Black Book Research found growing HIE user frustration over the lack of standardization and readiness of unprepared providers and payers.

Of hospitals and hospital systems, 63% report they are in the active stages of replacing their current HIE system while nearly 94% of payers surveyed intend to totally abandon their involvement with public HIEs. Focused, private HIEs also mitigate the absence of a reliable Master Patient Index (MPI) and the continued lack of trust in the accuracy of current records exchange.

Public HIEs and EHR-dependent HIEs were viewed by 79% of providers as disenfranchising payers from data exchange efforts and did not see payers as partners because of their own distinct data needs and revenue models. Progressive payers are moving rapidly into the pay-for-value new world order and require extensive data analytics capabilities and interoperability to launch accountable care initiatives.

Those looking at touted standards such as Fast Healthcare Interoperability Resources (FIHR) point out that it is only capable of connecting one medical facility to another and requiring specific end point interfaces to even do that. For every additional facility, a customized interface must be built. At the end of the day, FIHR is really a point-to-point customized interface requiring extra steps and ties developers to specific hospitals or EHRs and without universal access.

"Progressive FHIR standards can allow EHRs to talk to other EHRs should standard definitions develop on enough actionable data points as we enter a hectic period of HIE replacements, centering on the capabilities of open network  alliances, mobile EHR, middleware and population health analytics as possible answers to standard HIE," says Doug Brown, Managing Partner of Black Book. "We see middleware vendors such as Zoeticx leading the struggle to bring interoperability into healthcare IT networks by integrating with larger EHR vendors."

Middleware Can Replace HIEs
Patients are at risk, common interoperability solutions are not solving the problem and health care providers are not given the best life-saving tools. Some 2.0 healthcare vendors are turning to middleware solutions that have proven themselves in other industries. Vertical markets such as retail, banking, transportation, and others have long ago solved interoperability with middleware.

"Middleware is the technology to drive change, innovation and disruptive transformation to solve EHR interoperability challenges," says Donald M. Voltz, MD, Department of Anesthesiology and Medical Director of the Main Operating Room at Aultman Hospital in Canton, OH who is an advocate and authority on middleware. "We base patient's lives on it and in some cases their lives willdepend on it."

"Middleware architecture has been shown to be the best technological solution for addressing the problem of EHR interoperability. The middleware platform facilitates the transparent, yet secure, access of patient health data, directly from the various databases where it is stored. A server-based middleware framework supporting access to the various patient health data stores allows for a scalable, unified and standardized platform forapplications to be developed upon.  The middleware architectural design has been successfully used to link data from multiple databases, irrespective to the database platform or where the database is located," says Voltz.

He believes middleware should be the standard operating system for EHRs to finally bring lack of interoperability to an end with the risk of HIEs. Most importantly, he challenges the medical community to provide a better solution to a problem that can be addressed today rather than waiting for the ONC's standard to be issued in 2018.

"Every stakeholder in the healthcare continuum cannot establish the infrastructure needed to support interoperability, as evidenced by 83% of physician practices responding and 40% of hospitals that currently admit they are still in the planning and catch up stages of sending and sharing secure, relevant data. The challenge of turning silos of medical and financial information into a linked, complete, accurate secure lifetime medical record is still tenuous," says Brown in his survey.

"However, middleware is gaining popularity fast by hospitals using EHR-dependent HIE systems with extremely expensive custom development for data sharing outside the network," Brown noted in his survey. Black Book evaluated middleware vendors in an associated Q1 2016 user survey, ranking HealthMark, Zoeticx, and Arcadia Healthcare Solutions highest in satisfaction among new users.

Middleware Being Considered by 16% of Hospital System IT Leaders
To alleviate concerns of HIEs with poor connectivity outside their IDNs and hospital systems, interoperability middleware is also a fast-growing consideration according to 16% of hospital systems IT leaders with EHR-dependent HIE grievances. Middleware software sits within the data pipeline and translates data from disparate EHRs which shows promise for private HIEs, particularly payer-centric enterprise models. It creates a business intelligence layer that provides information to all stakeholders in real time.

Promises made in the recent interoperability pledge for three core commitments from EHR developers (providing patient access, eliminating information blocking, and implementing federal connectivity standards) won't be the reason why interoperability succeeds, predicts Black Book's survey results.

The global healthcare analytics market is projected to grow to $18.4 billion in 4 years (by 2020) and the need for that complex data will propel the interoperability needs of providers and payers. "The only way to accomplish that is robust bidirectional interoperability and that's what will ultimately force comprehensive interoperability into reality, not government-scripted vendor pledges," says Brown.  "57% of providers also confirm their beliefs that the whole interoperability industry will evolve by leaps by 2018 if some basic issues are addressed, with or without a vendor pledge".

Frost & Sullivan issued a report in January of this year stating that lack of interoperability in healthcare IT and devices, along with a push from the Office of the National Coordinator for Health Information Technology will lead to middleware, connectivity, and application program interface (API) platform vendors seeing a jump in their revenue.

"Middleware should be the heart of an EHR's operating system. It will enable medical institutions to seamlessly connect multiple EMRs, resulting in a convenient, consistent and universal view of patient records from a single platform, regardless of where they reside," says Tiffany Casper, CEO of

EMR Consultants, Inc.  She implements EHR systems for medical facilities and has used the Zoeticx Patient-Clarity platform.

Ten reasons to consider middleware as an open source standard.

  • Application Developers Can Focus on Healthcare Apps-Enables medical record app developers to focus on their healthcare solution by freeing them from dealing with a diverse, complex EHR infrastructure.
  • Inspires the Next Generation of Healthcare Innovative Solutions-These solutions are inspired by expanding the market for the next generation of healthcare applications rather than being tied down to a stack approach, depending on the particular EHR vendor.
  • Improves Patient Care Outcomes-Patients will receive better healthcare outcomes when application developers can inspire more applications. Patients will also benefit from the next generation of applications as they will address providers' specific needs in diverse operational care environments.
  • Saves Healthcare IT Dollars-Focuses the healthcare IT budget on addressing providers' needs instead of building and re-building the patient record infrastructure.
  • Proven Technology-A proven technology used for decades in many industries such as financial, retail, manufacturing and other markets.
  • Easy Integration-Enables healthcare integration with diverse, deployed legacy systems, including EHR systems. It addresses EHR interoperability as part of overall integration challenges.
  • Passive to Active Healthcare IT Environment-It turns passive healthcare IT environments into active ones to enhance communication and collaboration among care providers.
  • Avoids Data Duplication-Cost efficient, simplified administration. Offers a better privacy protection solution than HIEs by addressing EHR interoperability while fulfilling the demand to support the patient care continuum in an operational care environment.
  • Eliminates Wastefulness-Addressing healthcare IT integration is much more cost efficient than the "Rip-and-Replace" approach.
  • Extends EHR Usefulness-Protects and extends healthcare IT investments in EHR and EMR systems.

More Stories By Thanh Tran

Thanh Tran is the CEO of Zoeticx, Inc., a medical software company located in San Jose, CA. He is a 20 year veteran of Silicon Valley’s IT industry and has held executive positions at many leading software companies.

@MicroservicesExpo Stories
The nature of test environments is inherently temporary—you set up an environment, run through an automated test suite, and then tear down the environment. If you can reduce the cycle time for this process down to hours or minutes, then you may be able to cut your test environment budgets considerably. The impact of cloud adoption on test environments is a valuable advancement in both cost savings and agility. The on-demand model takes advantage of public cloud APIs requiring only payment for t...
"Codigm is based on the cloud and we are here to explore marketing opportunities in America. Our mission is to make an ecosystem of the SW environment that anyone can understand, learn, teach, and develop the SW on the cloud," explained Sung Tae Ryu, CEO of Codigm, in this SYS-CON.tv interview at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
High-velocity engineering teams are applying not only continuous delivery processes, but also lessons in experimentation from established leaders like Amazon, Netflix, and Facebook. These companies have made experimentation a foundation for their release processes, allowing them to try out major feature releases and redesigns within smaller groups before making them broadly available. In his session at 21st Cloud Expo, Brian Lucas, Senior Staff Engineer at Optimizely, discussed how by using ne...
Many enterprise and government IT organizations are realizing the benefits of cloud computing by extending IT delivery and management processes across private and public cloud services. But they are often challenged with balancing the need for centralized cloud governance without stifling user-driven innovation. This strategy requires an approach that fundamentally reshapes how IT is delivered today, shifting the focus from infrastructure to services aggregation, and mixing and matching the bes...
"CA has been doing a lot of things in the area of DevOps. Now we have a complete set of tool sets in order to enable customers to go all the way from planning to development to testing down to release into the operations," explained Aruna Ravichandran, Vice President of Global Marketing and Strategy at CA Technologies, in this SYS-CON.tv interview at DevOps Summit at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
While we understand Agile as a means to accelerate innovation, manage uncertainty and cope with ambiguity, many are inclined to think that it conflicts with the objectives of traditional engineering projects, such as building a highway, skyscraper or power plant. These are plan-driven and predictive projects that seek to avoid any uncertainty. This type of thinking, however, is short-sighted. Agile approaches are valuable in controlling uncertainty because they constrain the complexity that ste...
Cavirin Systems has just announced C2, a SaaS offering designed to bring continuous security assessment and remediation to hybrid environments, containers, and data centers. Cavirin C2 is deployed within Amazon Web Services (AWS) and features a flexible licensing model for easy scalability and clear pay-as-you-go pricing. Although native to AWS, it also supports assessment and remediation of virtual or container instances within Microsoft Azure, Google Cloud Platform (GCP), or on-premise. By dr...
"This all sounds great. But it's just not realistic." This is what a group of five senior IT executives told me during a workshop I held not long ago. We were working through an exercise on the organizational characteristics necessary to successfully execute a digital transformation, and the group was doing their ‘readout.' The executives loved everything we discussed and agreed that if such an environment existed, it would make transformation much easier. They just didn't believe it was reali...
"We're developing a software that is based on the cloud environment and we are providing those services to corporations and the general public," explained Seungmin Kim, CEO/CTO of SM Systems Inc., in this SYS-CON.tv interview at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
It’s “time to move on from DevOps and continuous delivery.” This was the provocative title of a recent article in ZDNet, in which Kelsey Hightower, staff developer advocate at Google Cloud Platform, suggested that “software shops should have put these concepts into action years ago.” Reading articles like this or listening to talks at most DevOps conferences might make you think that we’re entering a post-DevOps world. But vast numbers of organizations still struggle to start and drive transfo...
Agile has finally jumped the technology shark, expanding outside the software world. Enterprises are now increasingly adopting Agile practices across their organizations in order to successfully navigate the disruptive waters that threaten to drown them. In our quest for establishing change as a core competency in our organizations, this business-centric notion of Agile is an essential component of Agile Digital Transformation. In the years since the publication of the Agile Manifesto, the conn...
The cloud revolution in enterprises has very clearly crossed the phase of proof-of-concepts into a truly mainstream adoption. One of most popular enterprise-wide initiatives currently going on are “cloud migration” programs of some kind or another. Finding business value for these programs is not hard to fathom – they include hyperelasticity in infrastructure consumption, subscription based models, and agility derived from rapid speed of deployment of applications. These factors will continue to...
While some developers care passionately about how data centers and clouds are architected, for most, it is only the end result that matters. To the majority of companies, technology exists to solve a business problem, and only delivers value when it is solving that problem. 2017 brings the mainstream adoption of containers for production workloads. In his session at 21st Cloud Expo, Ben McCormack, VP of Operations at Evernote, discussed how data centers of the future will be managed, how the p...
Let's do a visualization exercise. Imagine it's December 31, 2018, and you're ringing in the New Year with your friends and family. You think back on everything that you accomplished in the last year: your company's revenue is through the roof thanks to the success of your product, and you were promoted to Lead Developer. 2019 is poised to be an even bigger year for your company because you have the tools and insight to scale as quickly as demand requires. You're a happy human, and it's not just...
Enterprises are adopting Kubernetes to accelerate the development and the delivery of cloud-native applications. However, sharing a Kubernetes cluster between members of the same team can be challenging. And, sharing clusters across multiple teams is even harder. Kubernetes offers several constructs to help implement segmentation and isolation. However, these primitives can be complex to understand and apply. As a result, it’s becoming common for enterprises to end up with several clusters. Thi...
DevOps teams have more on their plate than ever. As infrastructure needs grow, so does the time required to ensure that everything's running smoothly. This makes automation crucial - especially in the server and network monitoring world. Server monitoring tools can save teams time by automating server management and providing real-time performance updates. As budgets reset for the New Year, there is no better time to implement a new server monitoring tool (or re-evaluate your current solution)....
We just came off of a review of a product that handles both containers and virtual machines in the same interface. Under the covers, implementation of containers defaults to LXC, though recently Docker support was added. When reading online, or searching for information, increasingly we see “Container Management” products listed as competitors to Docker, when in reality things like Rocket, LXC/LXD, and Virtualization are Dockers competitors. After doing some looking around, we have decided tha...
"Opsani helps the enterprise adopt containers, help them move their infrastructure into this modern world of DevOps, accelerate the delivery of new features into production, and really get them going on the container path," explained Ross Schibler, CEO of Opsani, and Peter Nickolov, CTO of Opsani, in this SYS-CON.tv interview at DevOps Summit at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
The benefits of automation are well documented; it increases productivity, cuts cost and minimizes errors. It eliminates repetitive manual tasks, freeing us up to be more innovative. By that logic, surely, we should automate everything possible, right? So, is attempting to automate everything a sensible - even feasible - goal? In a word: no. Consider this your short guide as to what to automate and what not to automate.
identify the sources of event storms and performance anomalies will require automated, real-time root-cause analysis. I think Enterprise Management Associates said it well: “The data and metrics collected at instrumentation points across the application ecosystem are essential to performance monitoring and root cause analysis. However, analytics capable of transforming data and metrics into an application-focused report or dashboards are what separates actual application monitoring from relat...