Model-Centric Approaches for the Development of Health Information Systems
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1 Model-Centric Approaches for the Development of Health Information Systems Mika Tuomainen a, Juha Mykkänen a, Heli Luostarinen a, Assi Pöyhölä b, Esa Paakkanen a a HIS R&D Unit, IT Services Centre, University of Kuopio, Finland b Shiftec, Department of Health Policy and Management, University of Kuopio, Finland Abstract Modeling is used increasingly in healthcare to increase shared knowledge, to improve the processes, and to document the requirements of the solutions related to health information systems (HIS). There are numerous modeling approaches which aim to support these aims, but a careful assessment of their strengths, weaknesses and deficiencies is needed. In this paper, we compare three model-centric approaches in the context of HIS development: the Model-Driven Architecture, Business Process Modeling with BPMN and BPEL and the HL7 Development Framework. The comparison reveals that all these approaches are viable candidates for the development of HIS. However, they have distinct strengths and abstraction levels, they require local and project-specific adaptation and offer varying levels of automation. In addition, illustration of the solutions to the end users must be improved. Keywords: health information systems, modeling, information systems development Introduction The understanding of healthcare activities is central for the development and integration of health information systems (HIS). The specification and improvement of healthcare processes is pursued in relation to complex activities which involve lots of communication in the changing healthcare environment. To support these needs, health care actors are increasingly applying methods and best practices of business process development and enterprise modeling for analyzing care activities and clinical routines, building patient-centric processes and improving the knowledge and understanding of health care organizations [1, 2]. Models are used to illustrate, identify improvements or simulate organizational processes and individual activities in healthcare. Modeling also supports the specification of requirements and creates a basis for the implementation or integration of health information systems. Modeling is used widely in software engineering and information systems development projects. Models are produced to aid the communication between users, healthcare managers, architects, designers and developers. Models add clarity to the application domain and the design, providing formalization and abstraction to the understanding of problems and solutions. Good models support complexity, cope with changes in the requirements, are economically implementable and promote information and knowledge longevity [3]. Models contain observations, requirements and assumptions about the current or prospective state and solutions of a specific domain. Numerous approaches, methods, notations and tools have been suggested and used in modeling. However, an analysis of different modeling approaches is needed for identifying a suitable approach for given development needs of HIS. It is also necessary to identify which aspects are covered by different modeling approaches and which features of different modeling approaches support the specific needs of healthcare. In this study, we compare three model-centric approaches in relation to the development and integration of health information systems. The aim is to identify the strengths and weaknesses of different types of approaches and to bridge the gap between the healthcare knowledge and software development. The comparison is based on the use of a conceptual framework, the literature, and our experience of applying these approaches in service-oriented HIS development and integration. Materials and Methods In this section we introduce three model-centric development approaches and a framework for the analysis and comparison of these approaches. For this analysis, we have selected three very different model-centric approaches which have been applied varyingly in our projects and which can be applied in the development and integration of health information systems. An analysis framework for modeling approaches To provide a systematic approach for this study, we are using a structured framework for assessing different modeling approaches. The main purpose of each approach is a viable starting point for such an assessment. In addition, we especially consider the support provided by each approach in different phases of an information systems development (ISD) value chain [4]. This chain initiates from the understanding of the target domain. It then proceeds to the specification of goals and requirements and to the design and development of solu-
2 tions. The solutions are then used in the healthcare environment. To assess the completeness of the approach, we consider distinct aspects of information systems [5]: structure (which concepts and entities are included), function (which tasks are performed), and behavior (when and using what kind of interactions the tasks are performed). Each aspect has different features in different phases of the ISD chain. We argue that a modeling chain which supports the traceability of these aspects in different phases reduces the distance between healthcare knowledge and software development [4]. Other aspects which improve the traceability should also be considered in relation to HIS [4]. Due to the informationintensive nature of healthcare, special emphasis should be paid to semantic elements and entities in different phases to achieve a shared understanding of complex health information and processes. In addition, the illustration of solutions to the end users already in the early phase of the process is beneficial. Furthermore, the support for accurate, consistent, atomic and unambiguous documentation of the requirements promotes the utilization of tacit knowledge and shared understanding. In addition, we consider how definitive the approach is, or how many local and project-specific extensions are needed or allowed, and if there are guidelines to produce the results on a specific abstraction level. Furthermore, the visibility of end users or process participants in the models is considered. Traceability and productivity can also be improved by providing automatic transformations or generation of implementations from the models. Finally, the specific usage contexts and the dissemination situation of the approach are considered. Model-Driven Architecture (MDA) The Model-Driven Architecture (MDA) by the Object Management Group (OMG) supports software development through modeling techniques such as Unified Modeling Language (UML) [6]. Its abstraction levels separate logical and technological models: computation independent (CIM), platform independent (PIM) and platform specific (PSM). Three primary goals of the MDA are portability, interoperability and reusability through architectural separation of concerns. A computation independent model (CIM) shows the system in its operation environment. The structure of the system, however, remains hidden or undetermined. The domain model of CIM helps in presenting exactly what the system is expected to do. A CIM often consists of several UML models, some providing more detail than others, or focusing on particular concerns. The primary user of the CIM is the domain practitioner, and it aims to bridge the gap between domain and IT experts. CIM is used as an aid to understanding the problem, but also as a source of a shared vocabulary for use in other models. A platform independent model (PIM) describes the system without showing aspects which are specific to the platform, or the technology that is used to realize the system. A PIM might consist of various enterprise, information and computational models. A PIM is suited to one or more architectural styles. Concepts such as technology-neutral virtual machines can be used for platform independence in PIMs [6]. A platform specific model (PSM) is produced by transforming a PIM. It combines the specifications in the PIM with details which specify how the system uses a particular type of platform to provide an implementation [6]. Transformations between PIMs and PSMs can also be repeated: each new platform provides new features to the implementation. Thus there can actually be several levels of PIM and PSM descriptions and several definitions of a platform even within one system. In an MDA specification of a system, the requirements in the CIM should be traceable to the PIM and PSM constructs that implement them, and vice versa. An MDA tool might transform a PIM directly to deployable code, without producing a PSM that would be visible to the user. This requires models on a very detailed level or many tool-specific assumptions. In practice, the application of MDA requires specific interpretations which are not provided in the MDA specifications. For this study, we have used the approach of an MDA toolkit [7] which defines the use of UML models on CIM, PIM and PSM levels and the phases of the software development lifecycle. Process Modeling with BPMN and BPEL Business Process Modeling Notation (BPMN) [8] is a graphical notation for process modeling. It aims to be understandable by different users from business analysts to developers and people who manage and monitor business processes. Business Process Execution Language for Web Services (BPEL) [9] provides an XML-based language for the specification of business processes and interaction protocols. BPMN specification contains a mapping to BPEL. Hence, BPMN and BPEL can be used together for the modeling and web services-based implementation of processes. There are three basic types of BPMN process models. The private processes are internal to one organization and often describe accurate workflows. Private processes can be transformed to executable BPEL descriptions. Public processes describe the interactions and messages between the private processes and other participants, displaying the communication activities and the flow control mechanisms. Collaboration processes in BPMN describe interactions between two or more business entities (public processes). Collaboration process can be potentially mapped to collaboration protocols of electronic business such as ebxml or RosettaNet. BPMN can be extended using BPMN artifacts that provide extra information in modeling tools. Such artifacts can be used to support the requirements of a vertical domain such as healthcare. Although the graphical diagram is the most notable part of BPMN, nongraphical attributes play an important role when BPMN models are mapped to execution languages. BPEL descriptions aim to support the automated execution of processes, defining the process from the standpoint of one participant only [9]. External partners of the process are defined as web services and contacted through interfaces described using WSDL (Web Services Definition Language). The external view of a BPEL description is also a web service.
3 Public BPMN processes can also be transformed to abstract BPEL descriptions which describe interactions and hide other than communication-related aspects of the executable process. The BPEL specification does not include a graphical notation, but the notations have been mostly tool-specific. BPMN has been suggested as a generic graphical notation for BPEL [8]. HL7 Development Framework (HDF) The Health Level 7 (HL7) Development Framework Methodology Specification (HDF) [10] is a framework for analyzing, designing, and documenting the processes, tools, actors, rules, and artifacts of the HL7 version 3 standards development. The approach is based on the use of a model-driven methodology and the derivation of specifications and other work products from a common set of reference models. It supersedes the earlier Message Development Framework [11]. An essential element in the HL7 Version 3.0 and the HDF is the HL7 Reference Information Model (RIM). All information models in the HL7 version 3 standards are based on the RIM and follow structural vocabulary specifications. The RIM is described using UML class diagram notation [11]. In addition, other modeling practices of the HDF apply some UML models directly. The HDF UML profile also defines extensions to the meta-model of the UML. The development process of the HDF has seven phases [10]: project initiation, requirements analysis and documentation, specification modeling, specification documentation, specification publication, specification approval, and standard profiling. The requirements analysis and documentation, specification modeling and standard profiling phases are within the scope of this work. Several diagram types, models and design and documentation tools are utilized in these phases. The requirements analysis and documentation phase produces artifacts which describe the healthcare business in a given domain using its terminology. In this phase, the business processes are described using storyboards, use cases and activity diagrams. In addition, spreadsheets and class models are used for message contents and domain analysis models (DAMs). The business rules are described by defining relationships, triggers and constraints to the exchange of data, and state diagrams. The domain experts usually develop these specifications and a glossary which are then used by technology experts for developing HL7 v3 messaging specifications. In the specification modeling phase, the reference models are constrained into design models, based on the artifacts from the previous phase. Some of the artifacts produced in this phase can be balloted as standards. Central information design models include domain information model (DIM), constrained information model (CIM), and serialized constrained information model. In addition, sequence and collaboration diagrams are used to describe the needed interactions and application roles and to link them to specific messages. The reuse of design model components and the harmonization of design models with the RIM are also considered. In the standard profiling phase, the specified standard can be profiled: its elements are annotated, constrained, extended, or left unchanged. This leads to a set of specification profiles and conformance statements. The specifics of the information exchanged, the dynamic model and the acknowledgement responsibilities are defined. In addition, this phase considers user documentation and Implementation Technology Specifications (ITS) such as XML schemas for the developers. Results The analysis of the three model-centric approaches is presented in Figure 1 and Table 1. Figure 1 relates the suggested modeling artifacts of each approach to the ISD value chain. Table 1 organizes the other considerations of our framework. In addition to these considerations, some specific features of each approach were observed during the analysis. The MDA is an overarching approach. It aims to support all aspects of application development in a way which isolates technology changes from the logical solutions. The other approaches in this comparison could be included in an MDAbased approach. The MDA has been used in very different ways, and the meta-level foundations for the MDA are not required in various tools or projects. Hence, there is no "one Figure 1. The modeling artifacts of the three approaches in relation to the information systems development value chain.
4 Consideration Main purpose Structure & information Functionality Interactions Main users of the method Semantic specification details Illustration to the end users Requirements quality Definitiveness Abstraction levels Visibility of users / health professionals Automated implementation Dissemination Other relevant aspects Table 1. Summary of the comparison of the three model-centric approaches. Model-Driven Architecture Business Process Modeling with HL7 Development Framework BPMN and BPEL model-based software development, insulation of business from the changing technology class and other UML diagrams on CIM, PIM and PSM levels use case, class and other UML diagrams sequence, activity and other UML diagrams CIM: domain practitioners, PIM, PSM: IT experts CIM focuses on information viewpoint, including vocabulary, more specific in PIM and PSM CIM: vocabulary, environment, functionality documentation identified but not specified for the requirements very loosely defined, accurate methods and tools needed CIM, PIM and PSM, lots of freedom within levels evident in use case models, CIM and PIM emphasize communication with users transformations of models to executable code emphasized, various different possibilities promoted widely, solutions mostly tool-specific requires more detailed methods, has been interpreted varyingly in different tools and methods process modeling notation and process execution BPMN: little description, BPEL: through XML/WSDL interfaces on process level only, internal functionality in private BPMN abstract and collaboration BPMN: generic, BPEL: specific business analysts, business process owners and designers little emphasis on information or semantics other than parameters of interfaces BPMN: visualized processes can be examined many requirements are implicit in the process descriptions not in notations and languages but in tools and methods BPMN: private, public and abstract; BPEL: execution level BPMN: user interactions, lanes, pools, activities; BPEL: no distinction between user and system steps BPEL can be generated from private BPMN; BPEL is executed in workflow engines promoted for business process management, increasing support focuses on process modeling and management, relationships to other aspects remain undefined model-based production and management of interoperability standards RIM, domain analysis and information models, constrained models, XML schemas for messages interaction names, receiver responsibilities for messages triggers, application roles, interactions, UML diagrams accurate user roles specified for different phases glossaries, data types and vocabularies specified for more rigorous information support storyboards, use cases and activity diagrams on generalized level (for all standards), but clearly traceable accurate phases and outcomes specified, messaging presumed models and tools defined for all specification phases and steps storyboards, use cases, activity diagrams, indirectly through application roles and triggers implementation based on the specifications, little automation due to local variability healthcare-specific, mostly used for standardization only currently under revision, new dynamic and static model approaches being refined MDA" but its application depends on situation-specific needs. Process modeling with BPMN excludes many aspects of the holistic systems development, such as organizational structures and resources, functional breakdowns, data and information models, strategies and business rules [8]. Users are not especially considered beyond "user tasks" in BPMN. On the other hand, BPEL engines provide valuable information about the activities related to the processes. As the user interactions are typically required as a part of the processes, the approach can be complemented with models for user interface design. The HDF focuses on the information aspects, and the functionality is mostly implicit in the application roles and their responsibilities. The dependencies of the related interactions and triggers are illustrated in some domains, but they are not always specified. The HDF process has clear participation roles, but the requirements dilemma of standards is evident: the requirements are generalized, and it is not always easy to find the origin of the solutions. HDF does not provide many guidelines or automated tools to support the implementation. Discussion The three modeling approaches clearly support the documentation and communication purposes and shared understanding in
5 the development of HIS. However, none of the studied approaches covers all the necessary aspects, or they do not provide a detailed support for different phases of the ISD chain. The description of processes, relationships and activities in healthcare is supported by clear notations and abstraction levels in the modeling approaches, but models do not generally suffice to provide atomic or unambiguous requirements. Furthermore, the reference from the solution models to the actual needs of the healthcare domain easily remains unclear. In particular, improvements or local solutions are needed in the illustration of the solutions to the end users and stakeholders, the identification of aspects which are not covered by the approach and in the selection of graphical or textual notations for these aspects. The graphical models can always be introduced to the users, but this does not illustrate all the necessary aspects to them. In addition, the accurate specifications of the semantic aspects and the careful referencing to the needs and requirements are mostly left to the users of the approach. The most notable differences in the studied approaches are related to the level of detail in the information models, functionality definitions, support for automated implementations and the definitiveness of the approach. These differences mainly stem from the different purposes of the approaches. All the approaches, however, have identified the distinction between the domain and IT expertise in the modeling efforts. The many applications of the MDA to various specific needs make it an attractive approach as a reference framework, but also require detailed refinements which are not commensurable. The process modeling with BPMN and BPEL provides a lightweight and clear approach for end-to-end specification of processes, but leaves many aspects of the solutions unspecified. The HL7 Development Framework naturally provides the most advanced support for healthcare-specific requirements. It also emphasizes semantic aspects and provides most support for different phases of the ISD process. However, it focuses on standardization and messaging, and does not provide advanced automation or clear functional specifications. Conclusions The compared approaches are all viable modeling candidates for HIS. Their distinct scopes and strengths guide the selection according to different requirements. The approaches are extensible and non-exclusive. Besides the main scope, the selection depends on how definitive a guidance for the specification process and what kind of automation is desired. All the approaches, however, require additional semantic definition and the illustration of the solutions to the end users. The approaches should be locally combined or complemented with the documentation of these aspects. In the future, accurate ontology-based approaches, user interface illustrations or domain-specific modeling extensions should be included in them. Many additional approaches such as two-level information modeling and various domain-specific modeling approaches have also been suggested to support accurate semantics and domain-specificity. They could be included in a comparison using the specified analysis framework. Acknowledgments This work is part of the SerAPI project, funded by the Finnish Funding Agency for Technology and Innovation TEKES grants no /06, 40353/05 and 40437/04, together with a consortium of companies and healthcare organizations. References [1] Staccini P, Joubert M, Quaranta J-F, Fieschi D, and Fieschi M. Modeling health care processes for eliciting user requirements: a way to link a quality paradigm and clinical information system design. Int J Med Inf 2001: 64 (2-3): [2] Szirbik NB, Pelletier C, and Chaussalet T. Six methodological steps to build medical data warehouses for research. Int J Med Inf 2006: 75(9): [3] Rubin KS, Beale T, and Blobel B. Modeling for Health Care. In: Demetriades JE, Kolodner RM, and Christopherson GA, eds. Person-Centered Health Records - Towards HealthePeople. Springer, 2005; pp [4] Mykkänen J, Minkkinen I, Pöyhölä A, and Riekkinen A. Improving Traceability of Functional Requirements to Information Needs and Applications in Healthcare. Abstract. In: Doupi P, ed. Proceedings of the 6th Nordic Conference on ehealth and Telemedicine - NCeHT2006. Helsinki: Valopaino Oy, 2006, pp [5] Iivari J. Object-oriented information systems analysis: A framework for object identification. In: Shriver BD, ed. Proceedings of the 24th Annual Hawaii International Conference on Systems Sciences, Vol. II. IEEE Computer Society Press, 1994; pp [6] Miller J, Mukerji J, eds. MDA Guide version OMG document omg/ OMG, [7] Fado DH. A review of the MDA toolkit. MDA Implementers' workshop, May 17-20, Orlando. OMG, [8] Business Process Modeling Notation Specification. OMG document dtc/ OMG, [9] Thatte S, ed. Business Process Execution Language for Web Services version 1.1. Accessed 20 Nov [10]HL7 version 3, September 2006 ballot package, HL7 Development Framework. Health Level Seven, Inc, [11]Beeler GW. HL7 Version 3 - An object-oriented methodology for collaborative standards development. Int J Med Inf 1998: 48 (1-3): Address for correspondence Mika Tuomainen University of Kuopio, IT Services Centre, HIS R & D Unit P.O.B. 1627, Fin Kuopio, Finland mika.tuomainen@uku.fi
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