Developing a Micro Services Architecture Platform to Solve...
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Developing a Micro Services Architecture Platform
to Solve For Radiologist Capacity Challenge
Mirza Baig
VP, Software Development
Keith Pinter
SVP, Chief of Staff , Envision Physician Services
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ABOUT ENVISION HEALTHCARE
• Fortune 500 healthcare provider ($8B annual revenue)• 900+ facilities in 45 states (+ 284 ASCs)
• Envision Physician Services (EVPS) is the largest provider of hospital-based
EM/HM, Anesthesiology, Women’s & Children’s, Acute Surgical and Radiology
Services (24,000 employed clinicians)
• Recognized leader in Quality Clinical Outcomes, working on
providing tools, resources & technologies needed to deliver high-
quality patient care, profitably:» Quality and performance reporting
» Operational support
» Dedicated lean process improvement teams
» Risk management resources
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BUSINESS SEGMENT HIGHLIGHTS
> 500
Anesthesia Sites
> 800
Emergency Medicine
and Hospitalist Sites
12M
Radiology
Studies
80
Neonatology
Programs
3
Focus for this
discussion
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THE RADIOLOGY ECOSYSTEM & OPPORTUNITY
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RADIOLOGY IS A CRITICAL FUNCTION IN HEALTHCARE
80% patients depend on radiology
results before treatment
SOURCES: Malnick, Stephen, et al. "Routine chest X-ray on hospital admission: does it contribute to diagnosis or treatment?." 12.6 (2010): 357;
IBIS World; Transparency Market Research; Jeffries; Health, United States, 2009_U.S. Dept. of Health & Human Services 2014.
Clinically…
70% of hospital admissions come
through the ED where Radiology
turnaround times drive throughput
Operationally (for hospitals)…&
Takeaway
• Critical for hospital systems and often the bottleneck for ED
throughput
• Critical component of integrated care networks and at risk dollars;
data acquisition opportunity between service lines
• Needed for Envision to win system wide multi physician service
contracts (“lighthouse accounts”)
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STAKEHOLDERS HAVE SIGNIFICANT PAIN POINTS TODAY
Patients
Average report
turnaround time
16 hours
Physicians
40%
Time spent on
non-clinical work
Hospitals
Varying Subsidy
By Hospital
Quality
Unnecessary tests
Inconsistency in findings
30%
SOURCES: John-Paul, J. Yu, et al. "The radiologist's workflow environment: evaluation of disruptors and potential implications." Journal of the American College of Radiology 11.6
(2014): 589-593; Smith-Bindman, Rebecca, et al. "Rising use of diagnostic medical imaging in a large integrated health system.“ Health Affairs 27.6 (2008): 1491-1502; Medscape
Radiologist Compensation Report 2015
Represents potential for large player such as Envision
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MARKET OVERVIEW: DIAGNOSTIC IMAGING
$100B, Growing Imaging Market ($B)
111102
94878175706561
47
2014 2015 201820162012
+10%
2013 20172009 2010 2011
$20B Professional Radiology Market (%)
80%
Technical
Professional
20%
3 Major Professional Radiology Segments Highly Fragmented Market (%)
On-Site
Imaging
Center
On-site Hospital55%35%
10%
Teleradiology
100% = $20B EstimatesNational ProvidersEnvision
2%
3%
95%
Rest of Market
100% = $20B
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INDUSTRY ”HEADWINDS”
Accelerating Consolidation
30
40
56
71
31
40
55
77
29
41
56
83
30
40
56
86
28
41
58
80
26-36 35-49 50-65 65+
2012 2013 2014 2015 2016
Radiology FTE By Practice Size
$340,000
$351,000
$375,000
$396,000
2014 2015 2016 2017
Rising Physician
Compensation
MedScape Radiologist Survey Data
Takeaway
Growing shortage of radiologists, market consolidation, declining
reimbursement and rising physician compensation presents significant barriers
Scale and a technology enabled model can turn these headwinds into a
competitive advantage for Envision
Potential Radiologist
Shortage
30,000
32,000
34,000
36,000
38,000
40,000
42,000
2000 2005 2010 2015 2020
Supply Demand
HRSA Radiologist Supply vs. Demand
Projections
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EVPS IS “SHAPING THE OPPORTUNITY ARENA” – CREATING THE
INDUSTRY’S FIRST PHYSICIAN CENTRIC DISTRIBUTED
RADIOLOGIST ECOSYSTEM
Unique Local / National Partnership Model
EVPS strategy: combine radiologist scale, domain
expertise and clinical outcome data with
technology to “flip the script”
Benefits
✓ Faster turnaround
times improve ED
throughput
✓ 24/7 access to sub
specialists
✓ Lower unit cost
✓ Productivity based
comp models
Onsite Teleradiology
AI
RPA
Big Data
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ENVISION HEALTHCARE – COMMITMENT TO DIGITALIZING
OUR BUSINESS
INFO TECH’S ROLE IN ENABLING DIFFERENTIATION STRATEGY
OPERATIONAL CHALLENGES EVPS IS SOLVING FOR
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MEETING THE NEEDS OF KEY CONSTITUENCIES
Customers
Radiologists
Operators
• “Clean” work environment that promotes productivity;
including access to leading tools (e.g. viewer, VR, etc.)
• Access to studies in area of expertise
• Transparency into performance
• Access to consistent radiology outcomes (TAT, subspecialty
reads, etc.); resulting in faster ED throughput, IP discharge
• Availability of true quality data, performance reporting analytics
and performance measures
• Able to comply with CMS regulations
• Ability to “connect the 12 pods” (route cases to appropriate
Rads) & unlock capacity/maximize utilization of resources
• Tools to project outcomes and optimize workforce
• STRATEGIC DIFFERENTIATION – accelerating our hospital
system clients transition from ”fee for service” to Value Based
Reimbursement & preparing for “consumerism”
Ecosystem
and Platform
to deliver
these
competencies
and help our
stakeholders
actively
differentiate
Key needs
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Technology Enabled Distributed Radiology
(TEDR) Platform
“TEDR” MIGRATES RADIOLOGISTS READING EXCLUSIVELY ON
HOSPITAL PACS TO READING ANY IMAGE IN OUR ECOSYSTEM
Hospital A
Hospital B
IDN Hospital A
IDN Hospital B
Gateway
Gateway
GatewayRegional
PACS
Vendor Neutral Archive
Worklist
Thin Client
Viewer
Zero Footprint
Viewer
HL7 Engine
IDN Data Center
EVPS Technology-Enabled Distributed
Radiology (TEDR)
Cloud Based
Customer Imaging Studies
EVPS Radiologists
Images are load-balanced and reinforce sub-
specialties
1 2 3
order
order
order
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Platform Challenges
• .NET shop (2/3 of onshore dev resources); 1/3 open source
• Captive offshore dev (70+ resources are .NET only)
Tech Skills
• Different implementations of Scrum
• Varied Product Mgmt. rigorProcess
• Limited # of Platform SMEs
• Adequate Domain ExpertsKnowledge
Base
• Inherent bottlenecks in platform
• Could not scaleVolume
• Clinical Routing Rules Engine configuration is cumbersome
• IFTTT
Workforce optimization
• Long lead to onboard new sites
• ~ 6 months from acceptance to release
Onboard
Team Challenges
BUSINESS CHALLENGE
Need to “transform” Connect platform to TEDR, while collapsing 3 other ecosystems
into it AND still delivering on sub 30 min TAT SLAs and onboarding 20% new growth
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Strategic Goals
Enable business to scale 4x in 4 years
Support entry into new markets
Differentiate via "applied innovation"
Architecture Principles
Reduce inertia
Eliminate accidental complexities
Consistent interface and data flows
No silver bullets
Design & Delivery Practices
Standard HTTP/REST/AMPQ
Encapsulate legacy
Eliminate integration DBs
Cleanse & master data
Published integration model
Small independent services
Continuous Integration
Minimal SaaS/COTS customization
TECHNOLOGY ENABLED DISTRIBUTED RADIOLOGY
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Detangle into Micro Services
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Micro Services Architecture
Microservice
Monolithic Architecture
UI
Data
Access
Layer
Business
Logic
MicroserviceMicroservice
UI
Microservice
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Inter-operability
Smart Worklists
Analytics
PACS
RIS/HIS
HL7/DICOM
Routing
End User
DevicesVoice Rec
Hosted Location
Machine-learning
Quality Support
Viewer
LOOSE COUPLING & HIGH COHESION
Core Context
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Detangle into Micro Services
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SERVICE ECOSYSTEM
AGILE
ORGANIZATION
COMPOSABLE
SYSTEMS
MONOLITHS
HIERARCHICAL
ORGANIZATION
MONOLITH
SYSTEMS
MICROSERVICES
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Embrace Diversity!!
A ProjectHeartbeat
IterativePlanning
Most ImportantFeatures
UnfinishedFeatures
HonestPlans
Daily Communication
TeamEmpowerment
WorkingSoftware
Product Backing
Sprint & Backlog
Sprint Working increment if the software
30days
24h
Backlog Doing (x) Done
Kanban
XP
Scrum
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Cloud Agnostic Platform
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EMBEDDED OS
DYNAMIC ROUTE SERVICES / API MANAGEMENT
CLOUD ORCHESTRATION
SERVICEBROKER
API
Spring Boot
SteeltoeSpring Cloud
Services
Spring CloudData Flow
CloudCache
RabbitMQ
MySQL
IsolationSegments
PAS forWindows
PCFMetrics
AppAuto scaler
ContainerOrchestrat
ionBuildpack
Win Linux
AmazonWeb
Services
GCP & Healthcare
MSFT Azure Open Stack VMware
APP MICROSERVICES TECHONOLOGY
DATA MICROSERVICES TECHONOLOGY
CREDHUB
PIVOTALCLOUD FOUNDRY
BOSH
MULTI CLOUD
PIVOTALCLOUD FOUNDRY
BOSH
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ROSETTA HEALTH’S HEALTHBUS 2.0 PLATFORM
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Facility
ORM
ADT/FHIR
Transaction
Validation
Data
Transformation StandardizationRules
Processing
Audit &
Reporting Support
Integration
SupportEDI EDW
TEDR Dictation Billing
Standard
Data
Model
(JSON)
ORU
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Micro Services on Cloud Foundry
with HealthBus 2.0HealthBus
Transaction
Validation
Data Transformation
Standardization
Rules Processing
Audit & Reporting
Support
Integration
ADT/FHIR
+ ORM
Facility
Quality
Billing
Support
EDW
Standard Data
Model
(JSON)
ORU
21
Microservices on
Pivotal Cloud Foundry
TEDR
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OBJECTIVES & KPI
• 22% increase in releases Q3 vs Q2
• Release management: 30% reduction in lead and process
time (fewer steps and hand-offs).
• Improved operational metrics: MTTR (< 30 mins), support
tickets (< 0.5% of overall transactions)
• Improved security: Faster patching, zero downtime
upgrades(> 99.9% Availability)
• Infrastructure usage: Higher density compute, auto-scale
and license reductions (Cost/Study < Agreed Upon $
figure)
• Leveraging the big data & algos native to GCP PAAS
(while utilizing RDS & Lambda functions in AWS)
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WHERE ARE WE IN THE JOURNEY
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Foundational
• Breakdown silos
• Consolidate platforms
• Align with Business Strategy
Competitive
• Keep up with Business scale
• Streamline operations
• Culture Change
Differentiating
• Deliver core strategic components
• Improve productivity & capability
• Deliver small ‘innovation’ wins
Breakaway
• Deliver Scale
• Drive Innovation
• Establish Industry thought leadership