This presentation was for a SERG seminar at the University of Auckland Department of Computer Science. I present why software maintenance is a barrier for adoption of IT in healthcare and the maintainability aspects based on ISO/IEC 9126 software quality standard quality model. I then present the preliminary results of my research here.

1. Why IT Fails in Healthcare? A look at Software Maintenanceand Maintainability Aspects Koray Atalag, MD, PhD23 Mar 2010

2. Agenda A look at Health IT Essential difficulties and implications Health Informatics – directions Maintenance burden in HIS openEHR Paradigm My research framework Development work Measurement & Evaluation Results Discussion & Conclusion

3. Healthcare – Burning Issues Cost increasing rapidly 16% GDP in US, ~8-9 in EU & NZ (Ref: OECD) Quality ? (far from measuring effectively) Safety (you don’t wanna know):appx 90,000 people die each year in US due to preventable medical errors! (Ref: Institute of Medicine) Equity / Accessibilitybig differences related with geography, political, socio-economic status

4. Health IT – What is it all about? Health Information Systems (HIS): ProviderGP systems, Hospital Information Systems, LIS, RIS, CIS, etc. etc. Regional/National PHO, DHB, NHI, ACC etc. Consumer oriented PHR: Microsoft HealthVault, Google Health, other. Patient portals: Mayoclinic.com, The LowDown.co.nz Research related Genome DB, Medline, Health Computational Systems: CT, MRI, ECG etc. Health Communication Systems: HealthLink, NPI, DICOM

5. Essential Difficulties Breadth and Depth of Medical Domain A medical student learns about 6000 new concepts (and sleeps much less than others!) >600,000 concepts, 1.2m relationships in SNOMED Complexity of concepts and processes Gene>Structure>Function? + Environment+Luck Variability in Medical Practice Medical conduct changes acc. to time/person and across different organisations and jurisdictions

6. Health Informatics Medical Informatics Nursing informatics Bioinformatics Biomedical Informatics HEALTH INFORMATICS: “ Health Informatics is the science and practice around information in health that leads to informed and assisted healthcare.” HISO – Australia $mostly public funding & secondary care (hospitals)$20b stimulus package for health IT in US£70b NHS CfH and Canada Health Infoway Project

7. Tackling These Difficulties? Standardised terminology Machine processable biomedical ontology Clinical guidelines & Decision Support Functional and Technical Standards: HL7, CEN/ISO, IEEE, ASTM, OMG – mostly open Open Source tools and libraries EHR Architectures Tools and methodologies to effectively use IT in healthcare: mHealth, VR, telehealth, robotics

8. Implications on Health IT Low market penetration (AVIS/ Visa/Foodtown) Increased cost: many projects either fail or over budget/schedule Decreased satisfaction Delivering on expectations? Improving healthcare? *** Maintenance & Interoperability major issues

13. Wrong requirementsChanging requirements? “handover”

16. Own company, employee, academician, freelance consultant and contractor

17. Main problem=maintenance

18. Case study: Endoscopy Reporting Application

19. Started 1999 as commercial project

20. Went well initially but then….

21. Became academic and served as PhD prototype

22. I have collated all CR over its usage

28. Established by UCL and Ocean Informatics in 2000 to own the IP

29. 800+ Members from 71 countries

30. All specifications & schemas publicly available

32. Minimal ‘handover’

33. Driven by Archetypes in run-time

35. openEHR Platform Queries Health Integration Platform Archetypes Health Information Platform EQL TOM Application Development Platform Knowledge Management Platform AOM ADL Templates Reference Model

36. How it works?

37. Current openEHR Specifications

38. Anatomy of DV_TEXT Data Type

39. Domain Specific Aspects of RM

40. EHR Folders Compositions Sections Entries Clusters Elements Data values Logical building blocks of EHR

42. Anatomy of an Archetype

43. Archetype Definition Language (ADL) OCL + DDL

44. My Research Framework Modelling of Endoscopy Domain Stage-1: SRS based on previous app (GST) Develop openEHR based GastrOS Stage-2: Select CR from past usage of GST Implement in GastrOS + check (repeat for some) in GST Determine metrics & measure Stage-3: New CR Implement changes in both applications Measure Results & Evaluation Look at internal>external quality attributes (test internal metrics in-vivo and assess their predictive power)

45. Modelling: The ‘Standard’ Endoscopy Report

47. openEhrV1 .Net C# Reference Model Library(from Ocean Informatics) + extended it

48. Standard MST Archetypes

49. Templates: for each endoscopy type

50. Introduced ‘GUI Directives’ for GUI generator

52. GST vs. GastrOS

54. ISO/IEC 9216 and 25000 Software Quality std.

55. External QualityMaintainability characteristic

56. Changeability Subcharacteristic

57. Two metrics: (mainly look at maintenance tasks)

58. Change cycle efficiency (CCE)time from initial request to resolution of the problem

59. Modification complexity (MC)sum of time spent on each change per size of software change divided by total number of changes

60. 10 CR – real ones from GST usage

63. First ‘quantitative’ software maintainability evaluation in HI Literature

64. Extra look at ‘faults’ in addition to ‘effort’

65. Next look at non-domain related aspects (i.e. performance, availability, reliability etc.)