For reasons we will dive into later, we want to transform healthcare, so we need to form a team or community with the required skills and experience to embrace this topic. We want to get our heads around it.

Looking for digital changes and innovation in healthcare can be a daunting task, let alone a whole digital transformation. It’s a complex world that makes it hard to know where to begin and what to expect during a given time. We must embrace this complex world, whether we are from a medical, social, technical, consulting, or managerial discipline, and seek actionable ways to make the transformation happen.

We have to set the stage for the transformation team or community in which we will be playing our parts: on the supply side for care professionals, teams, and organizations to provision all kinds of healthcare, and on the demand side, the persons receiving treatments for their health and ever-increasing lifestyle improvements, so that they can participate in society.

Exploring this complexity, getting a common understanding across the disciplines, and knowing where to begin and how to proceed is the purpose of Transformation into Sustainable Healthcare (TiSH).

For starters, and because this model will reappear in almost every chapter, we will introduce TiSH as an acronym, name, and model. The acronym is clear, the name is to make it personal and keep everything on a human level, and the model represents a placeholder for complexity, as demonstrated in this first figure:

Figure 1.1 – The TiSH staircase for digital transformation in seven treads

The transformation objects at the foundation are People and Technology. The transformation itself is performed, tread by tread, as follows:

1. Learning digital Skills by individuals
2. Enabling the Capabilities of teams with technology
3. Ensuring enough Capacity for teams and their technology enablers
4. Providing quality data-driven Treatments to patients
5. Resulting in better-observed Health
6. Prevention via a healthier Lifestyle
7. The best outlook to Participate in society’s activities

The lower four treads refer to the care provider’s organization to deliver treatments, and the upper four treads are about the patient and their care network to work on their Health and Lifestyle and be able to Participate.

Note that each of these treads is already happening right now in some form without much technology, standardized work, or processing. In this book, we will discuss how to improve each tread with digital transformation and accelerate the move to the highest tread in a sustainable way. Here, we mean sustainable as in the use of human, technological, and environmental resources.

Our approach is to build the digital transformation, tread by tread, by doing the right things, in the right order, and at the right pace. In other words, the right systematic approach. With this, you can ask questions regarding which tread we stand on today, which treads are our objectives in the short, medium, and long term, and what we have to do to reach the new tread. Each time, a higher tread is built on the lower treads, putting the new tread on top. It’s like building a staircase with pallets as building blocks, as represented in Figure 1.1, or rectangles with rounded upper corners. What these building blocks consist of will be revealed in the coming chapters.

The TiSH staircase forms a frame of mind to model the complexity of the transformation as a scaffold to fit knowledge, such as models and methods, into the transformation. In a way, it’s used to build a model of models for the digital transformation of healthcare.

But first, let’s start with the question of why? Why digital transformation, and why modeling?

Digital transformation is needed because of demographic, medical, technological, and especially digital advancements. We will explain the urgency of it in more detail later, where we will discuss what developments are driving these developments. Common or cross-disciplinary understanding is needed, as was already put forward in 1990 by Peter Senge in The Fifth Discipline. Here, systems thinking is the driving force realized through the shared modeling of complex developments, with a lot of disciplines working together.

In particular, it involves an combined understanding of the pillars of developing technology, business enabling, and providing care – in short, Technology, Enabling, and Care, as demonstrated in Figure 1.2:

Figure 1.2 – Common understanding between technology, enabling, and care

For this understanding, generic and cross-disciplinary models can be used. We have to look for the Goldilocks zone of models for this cross-disciplinary understanding:

• Metaphors are too generic but suit initial recognition
• Single disciplinary models from their respective bodies of knowledge are too specific but are needed to detail and specify solutions
• Just right are generic models with some similarity with specialized models to be used in bridging these specialized models from two or more different disciplines

This book is our contribution to describing this fabric of understanding in such a way that the reader gets a foundation and toolbox for the journey of embracing the complexity of the digital transformation of healthcare. With this contribution, we invite all disciplines to join the transformation and secure enough transformation agents and resources to make it happen on the scale required.

We started our common understanding by using metaphors such as staircases and pallets as building blocks to build a sound foundation. These metaphors are very generic with no further explanation needed. However, having a common understanding is a bit more complex, as demonstrated in the tale of the village of blind people who encounter an elephant and try to describe it. Metaphors can be easily searched on the web. If you want to know more about these metaphors, you can look for them yourself in your further reading. Try searching for the phrase “elephant metaphor.”

Additionally, cross-disciplinary generic models can be found relatively easily on the internet, as they are widely accepted by many disciplines. We will discuss how to apply them to the digital transformation process, referring to other sources for more information and further reading on the model itself or other usages.

Also, we will use some specific models to be able to bind the disciplinary bodies of knowledge. These will be explained in more detail as they form the main threads of reasoning and exploration to design jointly transformational solutions. By combining models, we get new insights to reason about and explore these solutions. Also, it helps to translate from one viewpoint or discipline to another, helping the process of common understanding.

Digital twins

Next to this modeling for common understanding of healthcare, it is useful to build a digital twin, a real-time virtual representation of real-world entities, activities, and processes. We can distinguish three of these digital twins:

• The digital landscape itself
• The medical and social processes
• The avatar of a person

Let’s talk about the avatar, which is a digital representation of the patient. We will follow the avatar as we go through the different stages of transforming healthcare. The avatar will help us in understanding what’s in it for the patient. We cannot predict the future, but we do think that we will have a digital twin of ourselves soon: an avatar that holds all the data about our health (known as a quantified self) and tells our doctors what they need to know, a simulation of a person for clinical diagnostics based on input from, for example, scans, examinations, and medication.

This will help a clinician set precise diagnostics and define precise interventions without heavily impacting the patient. The avatar will help them to stay focused on the patient. And that’s what this book is all about: the patient or, even better, how to prevent an individual from ever becoming one.

With modeling, you can specify and quantify the healthcare in all aspects so that simulations can be designed to explore different scenarios of the transformation. Based on this, better solutions can be made.

We hope these digital twins will create feedback loops to self-direct the actions to the desired state of common understanding, sustainability, and health.

The first big question we ask is why a digital transformation is needed. So, before we get to the transformation and the selection of methodologies themselves and plan the transformation, first, we need to understand why we (urgently) need the transformation and what drives this transformation.

In all the rapid advancements and increasingly overwhelming scientific and technological progress, we tend to forget that, at end of the day, it’s all about humans. So, what is in it for you personally, whatever your role is? That is the question we asked ourselves when we started writing this book. From our professional roles in healthcare technology, as a patient or the next of kin of a patient, and as members of society, it’s the human factor that really counts. Therefore, this book will be 100 percent person- or people-centric, meaning that we will look at healthcare from the patient’s and caregiver’s perspectives the entire time. This is our perspective for the following assessments and quest for understanding.

On one hand, we see many great opportunities in things such as big data, machine learning, and artificial intelligence in combination with bioengineering. However, we also see the potential undesired effect on people and society. We, as people and as a society, need time to digest the new possibilities before taking well-founded decisions. The consequences can be profound.

With that in mind, first, we must put a stake in the ground and understand what drives the urgency for changing healthcare. This urgency is mainly caused by demographic drivers and disruptive economic drivers.

Understanding demographic drivers

Although certainly not complete, we will give some examples in which to understand demographic drivers:

• One obvious driver is aging: we are getting older. That fact alone is already driving demand for care, in both emerging and developed economies. Figures from the United Nations show an increase in the global population by 1 billion people in 2025. That’s only 3 years from when this book was written. Of that 1 billion extra people, around 300 million will have reached the age of 65 or more.
• But there are more demographic factors that we need to consider. For instance, there will significant growth of the so-called middle class due to developments within countries. So, how’s that a driver for healthcare? The middle class will have greater and better access to a more luxurious lifestyle, which might lead to the occurrence of more obesity and other health problems that will burden the healthcare system.
• Growth is not equally divided across the planet. It’s expected that the population on the African continent will double by 2050, while the population in Europe will shrink.
• There’s a downside to the preceding point. With the growth of developing countries, there’s another trend that is becoming visible: the World Health Organization (WHO) calculated that, in 1990, breast cancer, diabetes, stroke, and other noncommunicable diseases (NCDs) formed 25 percent of the total amount of death and chronic illnesses in these countries. That number will rise to 80 percent by 2040 in some of the economically rising countries.
• Where people would likely die a century ago because of a certain disease that could not be treated, we are now able to cure a lot of these diseases due to immense scientific progress. Cancer is probably the best example here. Although it’s still life-threatening, a good number of cancers can now be treated with the prospect of good outcomes for the patient. Again, the issue is that access to cures and treatments is not evenly divided across the globe.
• Finally, a very important driver is the scarcity of staff in care. This is a global issue. In some countries, it has been calculated that, over the coming years, one-third of all jobs will be in healthcare, something that has been accelerated by the COVID-19 pandemic. This is not a sustainable model. To make it slightly worse, in some countries, care institutions are recruiting staff in other countries that need skilled personnel just as urgently as anywhere else, causing a “brain drain” in some parts of the world and enlarging the inequality of access to care.

The net result of all of this is that people will need complex, coordinated care for a longer period. There will be more people to take care of, and these people will live longer because we also have the capabilities to cure more diseases. On the other hand, there’s a huge risk that we can’t deliver that care because we don’t have the skilled staff to do so. This is causing the urgency to transform healthcare into a more sustainable model – a model that also allows us to scale it across the globe.

Understanding disruption in healthcare

Healthcare is already transforming, as we will discover in this section. Disruption is happening, as in almost any other industry, by highly innovative newcomers on the market. Global initiatives have been launched, disrupting traditional healthcare. We see non-healthcare industries expanding into this new market. This includes retail, wellness, and even telecom companies. They all have good business reasons for expanding into this market: healthcare is growing in the global market with tremendous opportunities. From a commercial perspective, healthcare is becoming a more and more attractive space to be in as a business.

On the other hand, we have no choice because of the increasing demand that traditional players can’t address sufficiently anymore. New entrants are leaping into the gap. It’s inevitable: a collaboration between the traditional stakeholders and new, private, commercial initiatives is required to meet the expectations of patients and clients. These patients and clients are getting used to on-demand and fast service, with the continuous improvement of products and services alongside comfort and convenience experienced with the likes of Uber, Booking.com, and other platforms. Healthcare is like any consumer market, acting with the same principles as, for instance, retail. The consumer sets the pace of innovation: on demand, ease of access, ease of use, reliability, always on, anytime, anywhere, and anyplace. This comes with a huge shift in the way healthcare must reshape its delivery model and become more agile.

At the same time, we need to control costs, so solutions need to be cost-effective. A shift to more prevention, on one hand, and more at-home care, on the other hand, are the North Stars here. Promoting wellness, a healthy lifestyle, and preventing diseases should, in the first place, benefit people and, at the same time, drive costs down – a very attractive perspective for payers and governments. Plus, the solutions are cost-effective when they are scalable. These solutions are developed once and deployed many times, preferably on a global scale.

Understanding the business context

The big change is the shift to prevention through lifestyle and behavior rather than cure. The WHO and many national government institutions have highlighted this more and more on their agenda. The COVID-19 measures on social distancing are a good example.

Therefore, a lot of new companies in healthcare are focusing on prevention by stimulating a healthy lifestyle. This is a global trend where we start to acknowledge that healthcare doesn’t start in the office of a doctor but in our personal lives and the way we take care of ourselves, for instance, with our lifestyle choices.

A well-known example is the various wearables that track movements – they monitor basic parameters such as your heart rate, sleep score, and activity points, and based on that data, provide advice for exercising. Some of these devices – think of the Apple Watch – already go the extra mile and make it possible to produce electrocardiograms (ECGs). Other apps measure an individual’s body fat percentage by using the camera on their smartphone – one of the features of the Halo View by Amazon.

Devices such as wearables and apps simply help people to maintain a healthy lifestyle. We probably all know what’s good for us and what’s not. Health is impacted by lifestyle:

• Inactivity
• Unhealthy diets
• Too much alcohol
• Smoking
• Not enough sleep
• Too much stress

We know all of this, but apparently, it helps if someone or something helps keep us to stay alert to these factors. The biggest alert that a person could get is a serious health issue that results from an unhealthy lifestyle. Therefore, lifestyle is a very important driver in overall healthcare architecture and the transformation to more sustainable healthcare.

A sense of urgency is about pace – the pace of change. Many industries already adopted this new paradigm some time ago and started changing their business models for mainly one reason: they were forced to because of disrupting models that had been introduced into their markets.

Famous examples include Uber, which disrupted the market for taxis, and Airbnb, which did the same with traditional leisure. Are we seeing this in healthcare, too? The short answer is yes. There’s a shift happening already. In this book, we will look at some of these disrupting initiatives, for example, Amazon Care and a famous Dutch initiative called Buurtzorg that has gone international. The message of Buurtzorg is to simplify the systems and start again from the patient perspective.

Tip

Although Buurtzorg started as a Dutch initiative, the model is marketed internationally. We will refer to Buurtzorg a few times in this book, but more information can also be found at https://www.buurtzorg.com/about-us/.

Healthcare made easy, says the website of Amazon Care, promising care when the patient wants it, in the way they want it, and at the time they want it, fully focusing on the health experience. It should not be a surprise that Amazon brought this to the market. It’s derived from the guiding principle on which Jeff Bezos started Amazon: the company and its employees are obsessed with the customers of Amazon. Amazon calls this customer obsessed. In the case of Amazon Care, this becomes patient obsessed, including quality time with your team of doctors and nurse practitioners – on demand.

One other factor that makes Amazon Care and Buurtzorg great examples for this book to study is that both concepts are fully scalable and work according to agile principles. In Chapter 8, Learning How Interaction Works in Technology-Enabled Care Teams, we will learn more about these principles.

Note

A number of books have been written explaining the development and management philosophy of Amazon. Recent books include comprehensive descriptions of the working backward methodology that Amazon uses to create new services and products. This method was also used in creating Amazon Care: starting with the patient or the client, and their need, and then working backward to solutions that would address this. It’s a fundamentally different methodology of doing architecture. Although we will use Amazon Care as an example in this book, we will not go into detail about working backward.

The question is how to determine what must be done for health, when, and where. This is where diagnostics come in. Let’s get some insights into that in the next section.

The Mayo Clinic in the United States is perceived to be a lighthouse in modern healthcare, although the clinic was already founded back in the late 19th century. The American-based clinic puts tremendous effort into getting diagnostics right from the very first moment, for a lot of different reasons.

In the book Management Lessons from Mayo Clinic, founder Dr. William Mayo (1895) says: Above all things let me urge upon you the absolute necessity of careful examinations for the purpose of diagnosis. My own experience has been that the public will forgive you an error in treatment more readily than one in diagnosis, and I fully believe that more than one-half of the failures in diagnosis are due to hasty or unmethodical examinations.

Dr. Mayo figured out that an inaccurate or even wrong diagnosis would cause serious further problems to a patient and the quality of care.

Diagnostics have a decisive impact on the quality of care and patient safety by highlighting the following:

• Disease prevention through early screening
• Discovery of any diseases at an early stage through the accurate diagnosis of early symptoms
• Prognosis of the course of the disease, including determining the effectiveness of treatments and medications such as antibiotics
• Decisions on follow-up treatments and monitoring the long-term effectiveness of those treatments

Diagnostics is aiming for improving patient care. Getting an accurate diagnosis is crucial. Getting an accurate diagnosis in a timely matter is even more crucial. Healthcare institutions are investing heavily in diagnostics. Let’s take the aforementioned Mayo Clinic as an example.

In April 2021, the clinic announced massive investments in a new platform to deliver AI-driven clinical decision support through remote monitoring. It cooperates with other companies that develop algorithms for the early detection of diseases and collect data from remote devices to support clinical decisions. These two companies – Anumana and Lucem Health – are both start-ups. This is what we will see in the future: traditional healthcare players seeking cooperation with start-ups that deliver cutting-edge technology to enhance care.

Mayo Clinic’s Platform President, Dr. John Halamka, is convinced that the upcoming technology in AI and data science will result in a breakthrough in disease detection and, with that, a better perspective for patients. However, in the statement, he added that this is not just about technology – he also stressed the importance of patient engagement and cultural changes in healthcare to make it happen (source: Healthcare IT News, April 2021).

So, diagnostics is important, but how is it driving transformation in healthcare? Getting better, faster results from diagnostics can save impactful interventions, long-term treatments, and more speedy recovery. Again, we need to keep the patient as the focus. Less impactful interventions, less need for long-term treatments, and speedy recoveries will, in the first place, benefit the patient. And, as a more than welcome side effect, it will drive the costs for healthcare down – at least that’s what economic specialists in the field expect.

With that, we are entering the field of precision diagnostics and precision medicine. A number of studies have been executed to show the cost-effectiveness of precision diagnosis and precision medicine. Precision diagnosis and precision medicine are decisive in the following ways:

• Reducing the risk of treatment by trial and error
• Reducing the risk of over-prescription
• Shortening the time before treatment is started
• Decreasing the time that a patient has to spend in hospital or care institutions

The contradiction lies in the fact that precision diagnosis and precision medicine require substantial investments. However, studies from the University of Utah (source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical) show that these upfront investments can save expenditures in the long run when it comes to the execution of treatment. More importantly, the studies show that the quality of life of the patient is improving with accurate, precision diagnosis and precision medicine.

Going back to the previous section, we can see that people have already invested in smartwatches that observe their vital signs and give advice or alerts when needed. This observation and subsequent prefiltering allow for the early detection of possible health conditions but will also limit the influx of people for screening and diagnostics.

There’s one driver that will benefit a person’s health even more, as we learned earlier, and that’s lifestyle – that is, preventing an individual from becoming a patient. We will explain this using the health experience shortened as HeX, similarly to UX for User eXperience in the DevOps world. This HeX is the first reference model we will use to understand each other.

First, we need to explain what the HeX is. It refers to the health activities of a person, varying from participating in daily life to being treated and (chronically) nursed as a patient. We use omniversal care to represent the lifetime journey through which a person, as a patient, travels in terms of required care from the cradle to the grave.

Note

We are using the word omniversal: omnidirectional and universal. This applies to all health activities from every direction at the same time.

The following diagram shows the omniversal care in the HeXagon for health experience:

Figure 1.3 – Omniversal care HeXagon to represent the Health eXperience (HeX)

The basic model is firmly patient-centric, with the activities of the person as a reference. At any given time, the person is participating in the daily life of society, conducting – more or less – prevention activities such as sports or walking, and getting regular check-ups or tests such as for colon cancer. A patient will probably visit the General Practitioner (GP). If required, further medical diagnosis is performed along with treatment such as intervention with medication, exercises, or an operation. The patient might receive either short-term or chronic nursing care. This can be for one or more diseases (co-morbidity).

The goal of any person is, implicitly or explicitly, to stay active on the upper half of the hexagon: participation, prevention, and early detection. That has a direct relation with lifestyle. Over the past few decades, medical science concluded that a healthy lifestyle is preventing a lot of commonly known diseases. An unhealthy lifestyle can lead to obesity, which, in turn, can lead to all sorts of health issues such as diabetes, cardiovascular diseases, or orthopedic problems.

Let’s get back to the demographic changes that have had an impact on global healthcare. In the first section, we discussed the rise of noncommunicable diseases in economically rising countries.

A study by Thomas J. Bollyky is a good example and reference for this topic. In his study, he relates the increase in cancers, diabetes, cardiovascular diseases, chronic respiratory illnesses, and other noncommunicable diseases in low-income countries to the increased prevalence of key modifiable behavioral risks, such as unhealthy diets and tobacco use, and reductions in the infectious diseases that disproportionately kill children and adolescents.

Worse still, these are also countries that are not well prepared to deal with these diseases because they hardly have any access to proper healthcare. However, again, it shows the major effect that lifestyle has on health.

Note

The full study, entitled Lower-Income Countries That Face The Most Rapid Shift In Noncommunicable Disease Burden Are Also The Least Prepared, is available at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0708.

The examples of Buurtzorg and Amazon Care can also be depicted in the omniversal care hexagon. The first extension of the HeX shows the principle of Buurtzorg.

The HeXagon on the right-hand side of Figure 1.3 shows how Buurtzorg is creating an inner supportive hexagon to avoid outer professional care, if possible, and rely on the local community.

Amazon Care is organizing the care ecosystem around the family of their employees to optimize participation, as shown in the following diagram:

Figure 1.4 – HeXagon of health experience showing the care ecosystem

Combining the two leads to the complete Omniversal Care HeXagon representing the patient-centric care ecosystem of self, social, and medical care. The hexagon on the right-hand side shows the complete HeX, the hexagon for health experience. Support comes from the social (the yellow or light circles) providers and medical care from (the blue or dark circles) providers.

HeX is the representation of the complete individual healthcare ecosystem. Every citizen on earth should have such an ecosystem available. So, that’s the stage on which we set our transformation challenge.

We have set our challenge. Who do we need? Looking at Amazon, they utilize their platform to provide the care needed for their employees with the same rigor of customer obsession as with their logistics services.

A platform creates value by enabling interactions between two or more groups. In the case of healthcare, this is the providers, patients, and people who want to stay healthy. A platform has two major parts. One is the digital technology and the other is the community of involved people, care workers, and patients alike. Building a platform requires disciplines to build the technology and communities:

Figure 1.5 – The platform consists of technology and communities to serve at the point of care 

The two disciplines that can build this are systems engineering with a technology approach for the platform and systems innovation for the community-building approach. So, how do we involve our transformation teams in these disciplines?

Working with system engineers on health

System engineers focus on how to design, integrate, and manage complex systems over their life cycles. For a successful transformation, we have to understand how they think and work, especially in their role as architects.

Getting to a model that supports HeX means that healthcare must adopt agile, highly scalable concepts and embrace DevOps as part of the transformation. It’s a guided, agile way of developing solutions to execute this transformation. Applying this to healthcare transformation leads to something that we call DevOps4Care. This is where technology architects and consultants from medicine and healthcare enterprises closely work together to find the best solutions for the patient.

Ultimately, this book is about DevOps4Care: an agile way to create new, sustainable solutions in a speedy manner that will improve healthcare. It requires a complex transformation. In Chapter 3, Unfolding the Complexity of Transformation, we will discuss the complexity of this transformation in much more detail.

Understanding the difference between the architect and medical or business consultants requires a common reference such as we already introduced with metaphors and the book-related reference models of TiSH and HeX. In this section, we will further discuss these references and models.

Architects shape structures. They do not predict the future, although enterprise and business architects have visions of the future just as real estate architects do. What collectively binds us – or better yet, what we have in common – is that all architects and consultants come from a perspective where something is needed or desired. In business, that typically starts with business requirements, usually expressed by the consultant representing the many stakeholders. The business sees a demand, formulates requirements to address this demand, and sets these requirements as a starting point for creating architecture that, in the end, will result in a solution or a product. Healthcare isn’t different from that general principle, the only difference is that we now have a lot of medical-oriented stakeholders.

As an architect, the architecture in healthcare also is derived from the medical and business perspective. It’s the reason why all enterprise architecture models start with the business view. The Open Group Architecture Framework (TOGAF), the enterprise architecture method of The Open Group, is a good example and an industry standard for architecture. TOGAF starts reasoning from the business: what are the requirements of the business, which, in our case, is healthcare? But TOGAF is a technology perspective. We need to build an understanding of the healthcare enterprise and medicine itself.

Each person will have their own way of picturing and reasoning the transformation. We need to find a way in which to get a common understanding as it will take some effort. How do we understand each other in the following questions? Why do we need to transform healthcare, and why is it so urgent to do something about it? How do we define that something?

You will understand by reading, reasoning (even while reading this book), exploring your ideas together with the other stakeholders, integrating them within the constraints given by the qualities of the environment, and finally specifying it in such a way that others also can understand it to do their tasks in the transformation. We can make good use of Architectural Reasoning to achieve this common understanding.

Tip

To make this book a more effective read, we advise you to have a look at Architectural Reasoning by Gerrit Muller. A link is provided in the Further reading section.

The takeaway from Architectural Reasoning is that you mostly reason in your own mind, going back and forth on all aspects, viewpoints, and details. By telling stories and/or interacting with someone who is telling stories, together, you explore what possible solutions could be considered. In these stories, metaphors and generic models are used. They are used in the next step to formally integrate the insights within the constraints of budget, laws, and required qualities leading to the description (specification) of the actual solutions based on selected and jointly understood specific models.

A common understanding can be advanced by using reference models to which the different disciplines can relate equally. From the common understanding the various disciplines can agree on joint insights and understand the real needs behind the wishes and demands of patients. As we mentioned earlier for the transformation, we need perspectives on the following three pillars:

• Technology to be developed and led by the architect
• Enabling business operations and healthcare enterprises led by business consultants
• Care activities led by the respective medical disciplines

As a side note, together, the first characters of the above pillar form the acronym Technology-Enabled Care (TEC). Remember this acronym for later.

These three perspectives are different. Let’s find out more by giving each perspective some attention and learning about their differences.

Understanding the architecture of technology

As mentioned earlier, architects are familiar with TOGAF when they are designing digital systems. Requirements management sits in the middle of this. TOGAF recommends working with business scenarios as a technique to discover and document business requirements and, by doing that, drive the architecture. Now, how would that work in healthcare? The answer to that question is that it works exactly the same.

Tip

Another thing that might draw attention is the fact that architecture is not driven by technology. On the contrary, architecture is driven by business and that results in requirements for the technology that can be used as an enabler to achieve your business goals. In other words, it’s never about technology in the first place.

Read the last sentence a few times over, and reflect on it. It’s an important point of departure in reasoning about and exploring the transformation.

In this book, we will look at the most important driver for doing architecture in healthcare: the needs of the patient. Our business objective is sustainable healthcare where we can take care of more people, improve their lives, and increase the quality of care. Where is the input for these requirements coming from? In the previous sections, we studied some of the most important drivers: demographic changes resulting in the aging of people and scarcity of staff, the impact of diagnostics resulting in more treatable diseases, and change in lifestyle. It’s all causing increasing pressure on the need for sustainable healthcare.

The architect is responsible for the overall quality of the architecture. But creating architecture is not an isolated process. The architect has to work with different requirements, coming from various stakeholders that are mostly represented or advised by consultants. These stakeholders all have different needs, concerns, demands, wishes, and expectations. The architect will have to meet the stakeholders’ views on what they perceive as a good outcome of architecture. Let’s make that a bit more tangible.

The stakeholders in healthcare are the care providers, such as GPs, hospitals, clinicians, and care staff. Then, we have regulatory bodies such as governments setting regulations, rules, and laws for the delivery of care. Next, we have the institutions that pay for the care, typically insurance companies or public funds. Another stakeholder is the suppliers of services and goods, such as pharmaceutical companies and companies that deliver high-tech equipment to hospitals. And of course, the patient is likely the most important stakeholder. At the end of the day, it’s all about their well-being.

Working with reference architecture to enable business operations

How do architects put all of this together: the requirements, the stakeholders’ views, the objectives, and the architectural methods? How do architects address technology, healthcare enterprise, and healthcare itself in the architecture?

For development, we refer to Agile and DevOps as a reference. Let’s concentrate on the healthcare enterprise enabling the operations of care activities.

Here, the reference architectures for healthcare might be of help. An example of such a reference architecture on the TOGAF side is the Reference Architecture for Health (RA4H) by Oliver-Matthias Kipf, as shown in the following diagram of health enterprise activities:

Figure 1.6 – Reference Architecture for Health (RA4H), used with the consent of O.M. Kipf

The key in this architecture is the position of the patient, who is the health user. The focus is on the personal health journey and how stakeholders in the ecosystem can provide services that ensure a better, healthier, and safer life for the patient. As Kipf rightfully explains, the ultimate aim of the architecture is to help improve healthcare, but from the health user’s perspective.

The reference architecture shows how the ecosystem around the user is built, who the stakeholders are, and where the requirements originate from in terms of people, services, processes, products, and data. The architecture connects the domains of the stakeholders, collects the inputs along the patient’s journey, and enables a structured way to get to the desired output – better health – as shown in the next diagram:

Figure 1.7 – The personal health journey, used with the consent of O.M. Kipf

Architecture is about setting goals and planning the transformation to achieve these goals. It’s about building, delivering services, managing these services, and continuously improving these services, while also managing the risks that threaten to derail the transformation. That can’t be done in isolation – you need all of the partners within the ecosystems to work together with a common understanding.

With such a reference model, it is possible to relate technological architecture with the business needs of the healthcare enterprise. But what about the care community?

Working with communities on medical outcomes

Also, for medical goals, we need a reference model, preferably omniversal with medical and social care combined if we want to have a successful transformation. There are many medical models out there, but for our purpose and to demonstrate getting a common understanding of the TEC pillars, we will show you how to relate to the care episodes of the personal health journey in Figure 1.7. Note that several care episodes can be in parallel and executed by different care providers, which have to be aligned in their desired output. These care providers form a community around the patient.

An example of such a reference model is Integrated Care (INCA), as shown in the next diagram:

Figure 1.8 – Integrated Care (INCA) spider diagram, used with the consent of Dr. Javier Asin

The preceding example of an INCA spider diagram depicts five interdependent health conditions, each with its own care provider and care episodes. The medical and social professionals coordinate the interventions within these episodes for each condition to maximize the overall outcome for the patient, which is better health. In this case, an improvement over one year is shown in this spider diagram. The color red refers to this year, and the color blue refers to last year. A lower score means a lower care intensity in the episode. The care intensity is either self-care, social care, ambulatory medical care, or medical care in a GP practice or clinic. This spider is used to define the person’s health journey in a patient-centric way by deciding which health condition is impacting their participation in society the most.

This spider method was successfully introduced in Suriname by Dr. Javier Asin. We will elaborate on this in Chapter 9, Working with Complex (System of) Systems, where we will talk about integration and integrated care that requires the building of a care community consisting of social and medical care.

In the next chapters, we will explore how to relate these three TEC pillars and get a common understanding between stakeholders on all levels.

The wicked challenge – thinking patient-centric

Patient-centric thinking adds much to the complexity and has to be addressed by the architecture, or otherwise, it leads either to chaos or excessive costs. Therefore, in this book, we will work with many reference architectures and models, all with the same goal: transforming healthcare to improve it for the patient from the perspective of the patient’s own activities.

Finding and linking these reference models with each other for common understanding is what we will address in the coming chapters to build the health experience with HeX.

We will look at different methodologies such as observe–orient–decide–act (OODA), Moment of Truth (MoT), and Ecosystem Micro Communities (EMC) to form shared mental models that help us align viewpoints in transforming healthcare. Chapter 7, Creating New Platforms with OODA, will introduce a way of working in such an architecture, Chapter 8, Learning How Interaction Works in Technology-Enabled Care Teams, covers how to realize MoT in the health experience, and Chapter 9, Working with Complex (System of) Systems, discusses EMC.

We promised to be completely human-centric. The Reference Architecture for Healthcare (RA4H), which is derived from TOGAF principles, does just that: it focuses on the person, the patient, or the health user.

But we are also setting the scene for the digital transformation of healthcare, for all the reasons that we discussed in the previous sections. We need to transform to get to a more sustainable model for the delivery of healthcare. TiSH will help us in getting our heads around this wicked challenge.

In summary, healthcare transformation is about the following:

• Creating platform solutions that address comfort and convenience for the patient – 100% patient-centric for the outcome of a healthy lifestyle with a positive outlook on participation
• Creating platform solutions that are continuously improving the enabling business by adopting agile principles and community building
• Creating platform solutions that are cost-effective by adopting scalability as a driver to cover the world over
• Above all, creating a common understanding between technology, enabling, and care

So, where’s the technology in all of this? Health technology can, and will, certainly enable the creation of sustainable solutions. In Chapter 2, Exploring Relevant Technologies for Healthcare, we will explore the innovations of technology in healthcare, but always with that one question in mind: what’s in it for the patient?

This chapter was an introduction to this book. We set our challenge for the transformation. We introduced the TiSH staircase with the seven treads of transformation. We studied the various inputs that will drive the transformation of healthcare. We learned that drivers come from major global trends. Demographic trends such as the aging population and scarcity of skilled staff cause and increase the upward pressure on global healthcare systems. Next, we studied how precision diagnosis, precision medicine, and lifestyle are proven methods to drive costs of healthcare down and, at the same time, help to improve the quality of life of patients.

The most important lesson that we learned in this chapter is that the transformation of healthcare must be about the patient. This is something that requires a common understanding between all stakeholders and an understanding of TEC. In the final sections, we introduced the architecture of healthcare systems, using enterprise architecture methodologies such as TOGAF, the RA4H, and the community for INCA as a reference to digitization, medicine, and health itself. We can use these models to collect the jointly understood requirements for changing healthcare, but always with the patient as the center of the architectural and community models that we use.

In this chapter, we also introduced HeX: the healthcare experience, showing how care really can be organized from the patient’s perspective, with scalable, even disruptive solutions. It forms a further introduction to this book in which we will study new models and agile ways of working to transform healthcare into a more sustainable system. It forms the introduction to DevOps4Care.

In the next chapter, we will explore the major emerging technology trends in healthcare.

• The Fifth Discipline, the art and practice of the learning organization, Peter M. Senge, 1990, Crown Publishing Group.
• Architectural Reasoning Explained, Gerrit Muller, University of South-Eastern Norway-NISE: https://www.gaudisite.nl/ArchitecturalReasoningBook.pdf.
• Management Lessons from Mayo Clinic by Leonard L. Berry and Kent. D. Seltman, 2008, McGraw-Hill.
• Oliver Matthias Kipf, 2020, The Open Group blog: https://blog.opengroup.org/2020/12/29/reference-architecture-for-healthcare-ra4h-core-capabilities/.
• The Value of Precision Medicine: https://learn.genetics.utah.edu/content/precision/value/.
• INCA model, the Netherlands, by Sanne Snoeijs, Verena Struckmann, Ewout van Ginneken: http://www.icare4eu.org/pdf/INCA_Case_report.pdf.
• The icons and personas used in the health experience and community figures in this book are courtesy of the Health and Youth Care Inspectorate of the Dutch Ministry of Health, Welfare and Sport, who kindly gave us their permission. The Inspectorate is supervising care networks and their position on care networks can be found in this position paper: Good care in care networks (https://english.igj.nl/binaries/igj-en/documenten/publication/2018/08/16/good-care-in-care-networks/Good+care+in+care+networks+IGJ+May+2018+DEF+%28002%29.pdf).