By Jason Lee (The Open Group), Scott Sloan (Kyndryl), Laura Hugill-Belken (Impact Advisors) David Gordon (Gordon Consulting), and Tony Black (Kyndryl)
The Open Group® Healthcare Forum is now working on a Snapshot of what is intended to become its Value-Based Architecture™ or O-VBA™ for Healthcare standard. The standard will offer Enterprise Architects working in healthcare delivery settings a reusable, extensible, and scalable tool for continuously improving the value and efficiency of patient-centered care. It will apply to all medical specialties and clinical ecosystems. Architects will be able to use the O-VBA for Healthcare standard to help create and sustain value-based healthcare systems.
Need for a Value-Based Architecture for Healthcare
Studies of geographic variation in healthcare outcomes following hospitalization (common measures are mortality, 30-day readmissions, and hospital acquired conditions) show that more care is not always better care.[1] Yet, traditional fee-for-service (FFS) payment schedules reward the provision of more care and result in unsustainable healthcare cost escalation.[2] Alternatively, fixed payment schedules (“capitation” or per member per month payments) promote the opposite incentive; namely, withholding medically necessary care.[3]
To help determine the optimal balance between the provision of care and the payment for it, payers, providers, and policy makers are increasingly promoting the use of Value-Based Healthcare (VBHC).[4] Value-based programs reward healthcare providers with incentive payments for the quality (not quantity) of care they provide patients. Today, VBHC is the central driver of healthcare delivery and payment reform in numerous countries globally.
To the degree healthcare is provided and paid for on the basis of value, system architectures should be analyzed on that basis. This explains the need for a standardized Value-Based Architecture for Healthcare systems.
Origins of the Standard
In 2018, The Open Group Healthcare Forum published a framework – the Healthcare Enterprise Reference Architecture, or O-HERA™ – to help payers, providers, vendors, and consultants identify the key high-level relationships in healthcare enterprises (see Figure 1). The O-HERA uses “Plan-Build-Run” terminology to weave together a dozen key management, architecture, and operations cycles used by healthcare enterprises to deliver value to customers while demonstrating agility, person-centricity, and modularity in a secure environment.[5]
Figure 1. The O-HERA™ Framework
Evolution of the Standard
Although the O-HERA™ provides a useful “big picture” perspective, it is not sufficiently detailed to show healthcare architects and analysts how to develop value-based solutions to everyday business problems. To address this need, the Healthcare Forum decided to focus first on the hospital, for reasons described in the footnotes.[6],[7]
Surprised not to find an existing open-source, English-language hospital architecture, the Forum developed a collaboration with the National Competence Center for Health IT in the Netherlands (Nicitz) to translate their best-in-class hospital reference architecture, the Dutch ZiRA (www.ziraonline.nl), which had been developed and used by large and small hospitals in The Netherlands for about a decade.[8]
Contributions from the Dutch Hospital Reference Architecture
The ZiRA provides two of three key building blocks for the O-VBA for Healthcare standard. The first is the focus on the patient journey. Figure 2 presents the ZiRA’s layered architectural model of the hospital, with the Core Level specified in three domains: Research, Healthcare Delivery, and Teaching.
Figure 2. The Hospital Layered Architecture Model
The ZiRA further subdivides the healthcare domain—its main focus—into five clinical subdomains consisting of business functions that must be performed by the enterprise to provide services to patients (See Figure 3).
Figure 3. The Patient Journey
As the template in Figure 3 shows, it is useful for mapping the end-to-end patient journey in the hospital.
The second building block the ZiRA contributes to the O-VBA is the Diagnostic Therapeutic Cycle (DTC) shown in Figure 4.
Figure 4. The Diagnostic Therapeutic Cycle
It is hard to overstate the importance of the DTC because:
a) it was empirically derived from hospital architects and clinical staff during the development of the ZiRA , and
b) it applies to all medical disciplines/departments in the healthcare delivery domain of the hospital.
The DTC is a process diagram of the flow of care starting with the determination of care needs, through diagnosis and giving advice or treatment, to transfer. And again, as noted in (b), It applies to all specializations (for example, internal medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry).
Contributions from the TOGAF® Standard, a Standard of The Open Group
The third key building block of the O-VBA standard under development was derived from a 2022-2023 collaboration with the Business Architecture Work Group (BAWG) of the Architecture Forum of The Open Group. In 2023, the “Business Capability Planning” TOGAF® Series Guide was published, which incorporated value stream mapping, and the Healthcare Forum adopted the approach in its development of the O-VBA for Healthcare standard.[9] Figure 5 shows how the ZiRA’s patient journey perspective and its DTC are incorporated in the value stream mapping approach developed by the BAWG (and widely used by the Alberta Health Service in Canada.)
Figure 5. Clinical Care Value-Stream Map
The Clinical Care Value Stream Map portrays the end-to-end patient journey from left to right, with each value stream stage (circled in red) representing one or more of the seven DTC processes. Completing this map is the architect’s first step toward providing a detailed elaboration of the capabilities required to accomplish the target goals (in purple) for each value stream. A fully elaborated O-VBA value stream map includes not only capabilities, but also the elements required to produce a capability (e.g., IT applications, objects, work processes, data, etc.).
In Part 2 of this blog, we will demonstrate how to use the O-VBA to answer specific business questions based on an illustrative use case from a NHS Cancer Center that sought to ensure business continuity for chemotherapy patients in the event of a digital disruption.
Conclusion
The Open Group Healthcare Forum is developing a value-based architecture for healthcare standard. The focus on value is consistent with the VBHC model that providers and payers use to optimize healthcare delivery throughout the enterprise.
The O-VBA for Healthcare™ discussed in the blog—and in a second blog that will demonstrate its use in a cancer care/business continuity instance—can be applied in other areas within the broad set of enterprises in the healthcare community. For instance, using different value stream stage headings (and capabilities), it can apply to revenue cycle management, customer relationship management, and assorted aspects of the pharmaceutical and medical device industries.
Dr Jason Lee – The Open Group Healthcare Forum Director. A Healthcare professional with deep experience in research and policy. Named by the “Almanac of the Unelected” as health policy counsel responsible for the Medicare program. Recipient and funder of numerous Federal grants. Respected researcher, writer, group facilitator, collaborator, and speaker.
Scott Sloan Chief Technical Officer, Kyndryl. Scott Sloan is a Healthcare Architect and Paramedic. With extensive experience across healthcare providers, payers, and life sciences, Scott has centered his efforts on co-creating, with his clients, innovative solutions to business problems through the use of leading-edge technology. In his more than 30 years with IBM, Scott held a breath of leadership roles, including the Global Healthcare Industry Technical Leader.
Laura Hugill Belken is an accomplished Founder/CEO of enterprise architecture & higher education boutique agency, Belken Consulting. Laura is also the Co-Founder/CTO of an international non-profit with over 20 years of experience. Laura has partnered with Amazon/AWS leveraging FinOps in Enterprise Architecture. Laura also consulted for Mayo Clinic using Google Cloud Platform to meet compliance regulations and ensure the security of patient data. As the State of Wisconsin Architect for DXC/Gainwell, she designed with the Open Group’s healthcare reference architecture, OHERA that assisted in increasing Medicaid accounts. UnitedHealth Group executive architect for United Healthcare commercial portfolio, as well as the M&A architect for OptumServe-Logistics Health Inc.
David Michael Gordon is a Business Continuity (BC) consultant who is driven by a passion for delivering tangible outcomes, with an ability to identify key issues, devise actionable plans, and implement sustainable strategies. David’s professional achievements include the induction into British Computer Society (BCS) as ‘Chartered Information Technology Professional’ (CITP) member in 2005 based on the merits of a “Disaster Recovery Planning” paper. This degree equivalent qualification enabled him to emigrate and obtain Australian citizenship. David’s experience spans engagements with some of the most reputable companies in the world that include the third largest employer; the richest charity; the most diversified services company; the most recognised sportswear apparel manufacturer, and within Australia both the largest Superannuation and Mutual Funds. As part of this esteemed work David has delivered very complex projects covering a range of industries and disciplines. Following thorough assessments and interviews, David’s BC plans have received regulatory and compliance status from both the Australian Prudential Regulatory Authority (APRA) and the NHS Audit Commission.
Tony Black is a Healthcare/Life Sciences Technical Leader for Kyndryl Inc. As a professional with close to 30 years of technical expertise, sales, and management experience, he has created, managed, and sold many innovative solutions to clients. Tony is particularly strong in Application infrastructure and architecture, as he has spent a large part of his career in the Application performance, management, and monitoring space.
At Kyndryl, Tony works with healthcare payers, providers, pharmaceuticals, and partners to create solutions which address the business needs and challenges of the clients. Additionally, he is the global leader for the Technical Specialist profession which includes those individuals responsible for IT infrastructure solution construction, implementation, systems integration, and management. He is also a global co-leader for the Healthcare/Life Sciences Guild.
[1] “Understanding Geographic Variation in Health Care Delivery,” John Wennberg, N Engl J Med 1999; 340:52-53.
[2] “Fee-for-service Payment—An Evil Practice That Must be Stamped Out?,” Naoki Ikegami, Int J Health Policy Manag., 2015, doi: 10.15171/ijhpm.2015.26.
[3] “How to Pay for Health Care,” Michael Porter and Robert Kaplan, July-August 2016, Harvard Business Review.
[4] In their seminal 2006 book, Redefining Health Care, Michael Porter and Elizabeth Teisberg defined value as “the healthcare outcomes achieved per dollar of cost compared to peers.” Moreover, they argued, “[v]alue is created at the level of medical condition across the full cycle of care” (p.47).
[5] “Healthcare Enterprise Reference Architecture” 2018, S182, p. v.
[6] First, hospitals employ a wide variety of architects: enterprise architects, solutions architects, IT architects, business architects, data architects, cloud architects, and security architects.
[7] Second, the Forum decided to focus on hospitals over other types of healthcare enterprises (pharma, device manufacturers, EHR vendors, etc.) because hospitals account for the largest share of the healthcare dollar and are in need of assistance as they constantly change, get larger, merge, integrate new technologies, and align with the growing variety of other external care delivery systems.
[8] “Hospital Reference Architecture Guide: The Complete and Expanded English Translation of the Dutch ZiRA,” prepared by Members of The Open Group Healthcare Forum, in collaboration with Nictiz and the ZiRA Governance Board, 2023, available online at www.opengroup/library/G23a and in print from Van Haren Publishing. See also www.opengroup.org/forum/healthcare-forum for access to open-source, fully executable files that provide templates for building your own hospital reference architecture.
[9] “Business Capability Planning,” 2023, available at https://pubs.opengroup.org/togaf-standard/business-architecture/business-capability-planning.html.
