By James Griffith (NTT DATA Services), Jason Lee (The Open Group), Gerda Meijboom (Nicitz), Michael van der Zel (Groningen University Medical Center)
What comes to mind when you think of the Netherlands? For many it may be a field of vividly colorful tulips. Others may conjure images of historic windmills. An appreciator of the arts may recall the elegant line work and beautiful paintings of Rembrandt Van Rijn. Others may think of the capital city, Amsterdam, or the food and beer exported worldwide. Perhaps in time, some will come to associate innovative healthcare with the Netherlands.
A Standard Frame of Reference for Hospitals
The purpose of this blog is to introduce one such Dutch healthcare innovation—known as ZiRA—to a broad audience of English-speaking architects. In Dutch, a hospital is a “Ziekenhuis,” thus ZiRA means a “hospital reference architecture (RA).” Specifically, it is a set of interlocking components (templates, models, and downloadable files) that provide architects, managers, and high-level decision-makers tools they can use to a) understand and describe the current state of their hospital and b) transform virtually any aspects of their business to achieve desired states. The ZiRA can help users accomplish necessary, mission-critical objectives, including constantly evolving to provide high-quality health services, to improve patient outcomes, to enhance patient experience, and, generally, to operate efficiently and effectively.
The Power of Public and Private Partnerships
ZiRA is a product of Nictiz, the Dutch competence center for electronic exchange of health and care information. Nictiz is an independent foundation that is funded almost entirely by Holland’s Ministry of Health, Welfare, and Sport. For over a decade, Nictiz has encouraged ZiRA adoption by facilitating the establishment of collaboratives such as iHospital, a group composed of and led by key stakeholders from hospitals and related stakeholders across the Netherlands.
Bringing ZIRA to a Broader Audience
Heretofore, ZiRA has been available in Dutch only. It stands to reason that this fact alone has precluded its broader adoption. Through the efforts of The Open Group Healthcare Forum (HCF) in collaboration with Nictiz and the ZiRA Governance Board, a complete English translation and clarification is underway. As of June 23, 2022, the first of two parts, entitled Hospital Refence Architecture. Understanding and Using the Dutch Ziekenhuis Referentie Architectuur (ZiRA), Part 1 is available at no charge in The Open Group Library here. In the Preface to this White Paper, the HCF discusses how Enterprise Architecture can help hospitals deliver higher value to patients and increase their functional efficiency.
Relating ZiRA to The Open Group Healthcare Enterprise Reference Architecture
The Open Group O-HERA™ standard, an industry standard healthcare reference architecture, provides a high-level conceptual framework that is relevant to all key stakeholders across all healthcare domains. Thus, the O-HERA standard is presented at a higher level of abstraction, whereas ZiRA is tailoredto address specific needs and objectives of hospitals. The O-HERA standard makes it possible to create a crosswalk between the principles and objects modeled in ZiRA (primarily focused on the Architecture Model) with a variety of other emerging and possible less mature healthcare reference models worldwide.
10,000 Foot View: Applying Reference Architectures to the Health Enterprise Level
In 2018, The Open Group published the O-HERA Snapshot. This resource provides a cognitive map and conceptual guide that helps healthcare professionals consistently define their enterprise architectures for the benefit of effectively aligning information technology and other resources to solve business problems.
As depicted in Figure 1 below, the O-HERA is based on the conventional “plan-build-run” concepts gainfully employed by many industries for decades. In the “PLAN” phase (or “management model”), the organization focuses on vision, mission, strategy, capability, and transformational outcomes. In the “BUILD” phase (or “management model”), the organization addresses processes, information, applications, and technologies. Finally, the “RUN” phase (consistent with an “operations model”) emphasizes operations, measurement, analysis, and evolution. Security, ever so essential to the effective exchange of healthcare information, pervades the entire model. As demonstrated in the center of the diagram, the O-HERA standard is based on agility, a person-centric focus, and a strong preference for modular solutions.
Figure 1. The Open Group Healthcare Enterprise Reference Architecture – O-HERA™
The Vital Importance of Industry Standards
A notable success factor for ZiRA’s adoption in The Netherlands has been the country’s development and use of standards as a strategic method of ensuring that the best interests of its residents are met. Nictiz plays an active role in contributing to standards development and sharing information about best practices. ZiRA was built, starting about a decade ago, using The Open Group ArchiMate® modeling language.
ArchiMate provides the ability to create diagrams or pictures that explain the relationships among concepts and that this, in turn, improves communication and therefore understanding of complex ideas related to the architecture of enterprises, in this case the hospital enterprise.
Effective standards are essential to the establishment of information exchange in healthcare and this, in turn, is necessary to improve healthcare delivery and healthcare outcomes. When each hospital adopts its own preferred terminology and proprietary approach to describing the systems that support clinical care, significant barriers form against efforts to exchange health information effectively. We discuss this issue further at the end of this blog, in the context of a health care interoperability use case.
Without information flow, complex and expensive crosswalks and mapping exercises must be performed simply to correlate such basic yet essential data as individual patient identifiers. Data sharing agreements are equally costly and challenging to implement, as fundamental concepts and terminology must be exhaustively defined to ensure comprehensive mutual understanding between parties. Extensive reliance on such efforts at translation between proprietary systems also tend to be quite brittle and tedious to maintain.
How A Reference Architecture Benefits Communication
When a Hospital Reference Architecture such as ZiRA is adopted, a foundation is established to help hospital enterprises bridge challenges of communication between disparate internal and external systems. Nictiz established the foundation for this common basis of understanding by defining a “Five-Layer Interoperability Model”, as shown in Figure 2. Definition of standard terminology and explicitly related concepts helps advance common understanding within and between hospitals. For example, agreement on the meaning of “Business Functions,” “Services,” “Business Processes,” and “Business Activities,” helps reduce opportunity for ambiguity or misinterpretation.
Figure 2. Nictiz Five-Layer Interoperability Model
ZiRA further expands on the standard concepts expressed by Nictiz in the metamodel displayed in Figure 3. Here we see that reliance on The Open Group ArchiMate® modeling language, an international standard, is a key strategic success factor for ensuring the effectiveness of ZiRA.
The ZiRA illustrates, with rich context from the healthcare industry, how adoption of The Open Group standards helps assure that a reference architecture is directly consumable by Enterprise Architecture practitioners, not only within the healthcare industry, but across all industry verticals and domains.
Using the same concepts from the ArchiMate standard across hospitals facilitates common understanding and makes it easier to compare differences when, for example when a merger is considered or systems need to collaborate to support care shared along the healthcare continuum.
Figure 3. ZiRA Metamodel
A ZIRA Use Case: Interoperability
ZiRA presents a conceptual and practical framework for undertaking a wide variety of hospital improvement objectives. It provides a common frame of reference and a unified modeling language uslng the ArchiMate standard. It promotes collaboration among participating hospitals via standardization, sharing best practices, and accelerating architecture and agile development processes. Of particular note is the objective to expand the establishment of interoperability in the healthcare chain between and among hospitals, health information networks (HINs), and a host of other providers.
Interoperability, or rather the lack of it, is an international challenge, primarily involving difficulties in establishing data sharing agreements and in resolving data ownership and translation obstacles between and even within healthcare organizations. In the United States, “information blocking” has become such a challenge that legislative mandates such as the US Office of National Coordinator of Health IT’s 21st Century Cures Act have been adopted that require covered entities to support interoperability. Other countries have established similar rules and regulations. In such a climate, a ZiRA success story based on more effective collaboration provides valuable insights that other countries and other health systems might learn from.
*The authors wish to thank Padma Roy (DXC), Ashley den Toom (Philips), Tony Black and Scott Sloan (IBM), Oscar Miranda (Armis Security), Laura Hugill Belkin (Mayo), Kishore Ravilla (OhioHealth), Oliver Kipf, and Chimeless Baltcha for contributing to the development of ideas expressed in this blog.