ENTERPRISE ARCHITECTURE

OF
DIABETES PATIENT PATHWAYS:
ERASMUS MEDICAL CENTER

Shirjeel Alam 495357

Marti Masters - 955568
Ahmed Mubin Cevizci - 434869
Prof. M.T. Smits
Tilburg Unversity, TiSEM
P.O. Box 90153
5000 LE Tilburg
The Netherlansds
8/12/2014

CHAPTER ONE
1. INTRODUCTION
The patient pathway for modern healthcare generally involves multiple
care givers at different locations throughout a patients lifetime. This
study focuses on patients with diabetes in the greater Rotterdam area
who receive hospital care at Erasmus Rotterdam University Medical
Center (Erasmus MC), either by referral for a specific treatment or
admission through the emergency room. The purpose of this study is
to identify critical pathways for diabetes patients in the context of
creating an enterprise architecture using the Picture Approach (Groot,
Smits, and Kuipers, 2006) and developing a model based on the theory
authored by Ross and Weill (2006). along with analysis framed by
McDonald (2005), to discuss the relationship between healthcare
processes and the information systems which support them.

Although

not elaborated within this report, business processes, such as billing

and distribution of pharmeceuticals, also fall within the scope of
healthcare-related processes.
The goal of this study is to present recommendations in the context of
enterprise architecture for diabetes patient pathways with respect to
Erasmus

MC.

In

order

to

provide

framework

for

our

recommendations, we identified the electronic patient heathcare

medical record (EHR) as a critical information systems success factor
because it serves as common denominator for various diabetes patient
pathways by facilitating best medical services.

Limitations of this

study

testing

include

recommendations

the

absence

because

of

empirical

conducting

pilot

test

for

our

project

and

benchmarking key performance indicators were beyond the scope of

this assignment. However, based on the results of similar case studies,
where improvement of patient healthcare has been measured after the
deployment of patient pathways and related patient processes
supported by information systems, we will demonstrate that a similar
positive outcome may be expected for Erasmus MC and other
healthcare providers in the greater Rotterdam area.

2. WHAT IS DIABETES?
According to the MNT Knowledge Center (2014), diabetes is a
metabolic health dysfunction where the body fails to produce insulin or
fails to react properly to insulin production, commonly referred to as
Type 1 and Type 2, respectively.

The onset of diabetes during

pregnancy is denoted as Type 3 and other various causes are

aggregated together under Type 4.
Research conducted by the Center For Disease Control and Prevention
(CDC) in the USA indicates that 5 10 percent of patients diagnosed
with diabetes are Type 1, which is usually detected in young children
(CDC, 2014). The cause is no insulin production because the pancreas
is not functioning properly. People with Type 1 diabetes have to inject
insulin multiple times every day to control blood sugar. They also have
to monitor their blood because if the sugar drops too low, they can go
into shock and have a seizure, which is life-threatening situation.
According to the Mayo Clinic, a leading research hospital in the USA,
some Type 1 diabetes patients can use a pump instead of an injection
(Mayo Clinic, 2014). The pump has a terminus which is inserted into
the skin and insulin is injected at regular intervals. The pump is a small
device worn around the waist, which makes the device both
inconspicious and fairly comfortable.
In a 2013 study, Boeren Medical in the Netherlands reported that
although Type 2 diabetes has been traditionally associated with adults,
the frequency of diagnosis in children is increasing.

The disease is

characterized by the body failing to respond to insulin, which is

produced by the pancreas.

People with Type 2 diabetes can usually

control their disease with proper diet and exercise.

According to the CDC (2014), over 380 millions people worldwide are
afflicted with diabetes and no cure exists for any diabetes type.
Therefore, lifelong treatment is required to regulate metabolic function
by controlling glucose levels in the blood through diet and exercise.
Patients with diabetes depend on health care professionals, such as a

primary

care

physician,

nurses,

physician

specialists,

medical

technicians, nutritionists, and physical therapists, to assist with their

treatments. A small percentage of patients require mental health care
to cope with anxiety or fears regarding treatment procedures and/or
complications of the disease.

The MNT Knowledge Center (2014)

provides a comprehensive list of complications, which include problems

with ciruclation leading to leading to gangarene in the lower
extremities, blindness, and heart attack. Thus, diabetes is a serious
medical condition requiring long-term health monitoring and supportive
care.

CHAPTER 2: METHODOLOGY
The framework for this study is based on the theories and models for
enterprise architecture proposed by several authors:

Groots, Smits, Kuipers (2006): The Picture Approach: A Method

to Redesign the IS Portfolios in Large Organizations.

Ross, Weill, and Robertson (2006): Enterprise architecture as a
strategy. Creating a foundation for business execution. HBS

Press.
M.P. McDonald (2005): Architecting the Enterprise. An approach
for

designing

performance,

integration,

consistency,

and

flexibility. PhD thesis, Delft University.

Qualitative research methodology provides a framework for this study.
According to Eriksson and Kovalainen (2008), the business researcher
is an interpreter who both constructs the case and analyses [sic] it.
Specific elements of triangulation, namely: data, investigator, theory,
methodological, environmental (Guion, Diehl, & McDonald, 2011) were
employed during the study to enhance robustness and validity.
Exploratory research involved canvassing available literature, online
websites, and key artefacts, such as official Erasmus MC enterprise
architecture documents.
Data collection search techniques centered on keywords and phrases:
patient

medical

record,

electronic

health

record,

Rijnmond Portal, diabetes, EHR case study, etc.

Erasmus

MC,

Selected literature

included academic peer-reviewed research studies, industry journals,

government and industry websites, and relevant news articles.
Attempts were made to locate case studies relating to diabetes patient
pathways and EHR.

To this end, the EU Impact Report (2010) was

selected as the single outstanding source for case study research of

regional healthcare information systems and EHR.
Empirical

data was collected from the literature regarding financial

statements, cost analysis, patient care outcomes, and various statistics

relevant to EHR. Although a portion of the statistical data gathered was

quantitative in nature, qualitative interpretive analysis was employed

to discover the meaning of the data and its relevance to this study. An
iterative process of analysis leading to further data collection was
followed until construction of an enterprise architecture for diabetes
patient pathways could be constructed and potentially useful, cost
effective recommendations with improved patient outcomes could be
proposed.

Due to the scope of this project, these conclusions are

limited, thus inviting future research.

CHAPTER 3: DIABETES PATIENT PATHWAY

ENTERPRISE ARCHITECTURE
1

DIABETES PATIENT PATHWAYS

Several health care pathways are required to manage the complex,

lifelong care of diabetes patients. Erasmus MC has identified the
following patient pathways:

THE PICTURE APPROACH EA DIAGRAM (see next page)

The current system complex deals with the patient care processes such as
referral of patient from primary care physician, appointment, registration,
diagnosis of problem, in case it is necessary, admission of the patient,
treatment inside EMC, billing of the medical expenses and aftercare
treatment. These processes are covered only for diabetic patients.
Different modules within the EMC handle different parts of the process,
while other tasks are manually completed. Process handling in the system
is focused around roles of internal and external actors, including the
patients themselves, as in some tasks are conducted by the patients, such
as

transferring

their

referral

letters

and

medical/prescription

data

themselves from primary care physicians to EMC for non-integrated

hospitals to EMC.For the integrated hospitals, the data is transferred
electronically. Data exchange in this future system is done through
centralized and standardized methods in order to minimizedata transfer
on paper between systems.Since EMC has got full control over internal
system as opposed to external partners, in this designed system, every
data transfer between systems are being done electronically.
The process we designed begins with patient going to primary care
physician. After first patient gets his/her diagnosis, there are 4 pathways
for the patient treatment:

No Treatment; patient is doing ok with his/her current treatment.

Treatment Prescribed; patient receives a prescription for medication.

Glucose Test; primary care physicianasks the patient to get a

glucose test from the nurse before leaving.

Referral to EMC; primary care physician finds something seriously

wrong and refers the patient to a specialist.

After patient is referred to EMC, the process for treatment inside EMC
begins. First, the patient makes an appointment either via the Reijmond
Portal by logging in or by calling the Reception Desk at the hospital. In
both activities, the appointment process is handled by the SAP
Appointment System.

The SAP Appointment System uses EMC

Resource Scheduling System to fetch the list of available doctors and

their schedules.
After patients arrival to EMC on appointment date, if patient has never
registered in SORIAN Electronic Health Record (EHR) Management
System, then the patient registration is performed.

First Reception

Desk checks whether patients provided information correct or not and

then registers the patient through SAP Patient Administration System.
If the referring health care provider is not integrated with EMC, the referral
document is on paper. Otherwise, the referral document is electronically
transmitted to the SORIAN Electronic Health Record (EHR) Management
System from external health care providers.
After the registration, the patient waits in the waiting room until called to
the examining room, where the medical specialist is ready to begin
treating the patient. During the diagnosis process, the specialist can order
lab tests. Lab results may be entered into Laboratory Management
System

through

integrated

laboratory

equipment

electronically

or

manually by laboratory technician. After the diagnosis, which results in

updating the patients EHR, the specialist may decide to perform one or
more of the following actions:

Prescribe medication

Transfer of patient to another hospital due to lack of equipment or

expertise in EMC

Admit the patient to EMC for in-patient care

Perform additional treatments, which may be out-patient services or

require formal admission as an in-patient.

In case of in-patient admission the specialist or a medical assistant

performs this action through the EMC Resource Scheduling System.
Next, the nurse or medical assistant in charge of admission of patients
admits the patient in either the Acute Care Unit or Intensive Care Unit,
based on the specialists designation.

As a result of admission or same day treatment, patient is assigned a

presiding physician, which could be the specialist who ordered additional
treatment at the hospital. In ACU or ICU, the presiding physician treats the
patient and prescribes necessary medicine.

This hospital pharmacy

supplies the appropriate medications, which the appropriate medical

personnel administer to the

patient.

All of the actions performed by

presiding physician are managed by SORIAN Electronic Health Record

(EHR) Management System. As a result, every action and treatment
performed during patients stay is managed by a centralized system used
throughout EMC. During this process, in case of surgery or some other
scenario which prohibits visits of patients relatives, relatives can check
the patients current situation through Reijmond Portal if they have been
granted the appropriate access permissions.
After successful treatment of the patient, the presiding physician can
decide to discharge the patient by using the EMC Resource Scheduling
System which updates the patients EHR.
Upon discharge, the digital document of every medical service provided to
patient and recorded by the SORIAN Electronic Health Record (EHR)
Management System is coded and transferred to the SAP Billing
System.

For patients without insurance, the patient may provide billing

information, which is entered into the Payment System of EMC.

patients with

health

insurance,

the invoice

is transferred

For

to the

Bookkeeping System of EMC. The Bookkeeping System generates the

financial statements of patients and sends bi-weekly requests to insurance
companies for request for payment.
Patients may also be treated by external health care providers, such as
psychologists, dieticians and physio-therapists. In this process, patients
can use various applications like the ones listed below:

Blood Pressure - provides blood pressure measurements to

SORIAN Electronic Health Record (EHR) Management System.

Smart Watch App - reminds the patient to take his/her medicine

and provides feedback data to SORIAN Electronic Health Record
(EHR) Management System.

Questionnaire App - helps patient to self-diagnose his/her illness

in order to decide whether he/she needs to see a doctor or not.

Online Medical Advisior App - which help patient to maintain

wellness of his/her psychology which provides feedback data to
SORIAN Electronic Health Record (EHR) Management System.

Digital Scale App - which provides digital measurement data of

patients weight measurements into SORIAN Electronic Health
Record (EHR) Management System.

Personal Organizer App - which gives medical advices and

reminds patients to what he/she should do to stay healthy, which
provides feedback data of patients lifestyle into SORIAN Electronic
Health Record (EHR) Management System.

3. ELECTRONIC PATIENT HEALTH RECORD (EHR)

The flow of patient information in the Erasmus MC enterprise
architecture proposed in this report for diabetes patient pathways
hinges on an electronic patient health record (EHR) as the fundamental
data artefact, which follows the patient from beginning to end in each
pathway. In Europe, the creation and maintenance of patient medical
history in a computer informtion system is formally termed the
Electronic Healthcare Record (EHR). Hyrinen, Saranto, & Nyknen
(2008) define the EHR as a repository of patient data in digital form,
stored and exchanged securely, and accessible by multiple authorized
users. The EHR is intended to provide a platform for multiple-user
access

by

authorized

persons,

including

the

patient,

medical

professionals, healthcare administrators, pharmacies who distribute

mediations, and billing agents, which includes insurance companies.
Compared to paper records, which for a single patient may be
scattered across different healthcare providers, the EHR offers the
means to consolidate patient medical information into one shared
repository. In addition, the structure of patient data in a pre-defined
format allows for uniform record-keeping with the purpose of fostering
clear communication regarding a patients health and well-being.
In 2010, the EU Commission launched Europe 2020, a 10-year strategy
for economic growth and social well-being, which included health care
and support information systems.

According to Kierkegaard (2011),

The Data Agenda for Europe (DAE) focuses on sustainable growth

through ICT by establishing an eHealth governance framework and
and thus encouraging the development and adoption of electronic
patient records throughout Europe.

Kierkegaard identifies sharing

patient information as a key benefit of eHealth. According to Carter

(1999), an open health record can improve medical care on many
fronts, especially the doctor-patient communication. In particular,
improving the data flow between patients and care providers reduces
the number of medical errors and enhances overall care quality.
(Institute of Medicine, 2001)

Unfortunately, establishing a uniform EHR in Europe has been

complicated by the passage of recent EU legislation.

The Treaty of

Lisbon was enacted on 1 December 2009 (EPHA, 2014). Intended to

reform EU law to facilitate unity among EU member states, its impact
on uniform healthcare standards was eroded by Article 168 TFEU.
According to the European Public Health Alliance (EPHA), The Union
shall fully respect Member States responsibilities for the definition of
health policies and organizing, delivering health services and medical
care, and... the allocation of the resources assigned to them.
(www.epha.org) Although the purpose of the law was to preserve the
type of health care system preferred by individual nations, namely the
bismark system versus the beverage system, no legal addendum was
included to allow for EU-mandated standards for uniform EHR.

4. THE ROLE OF THE EHR IN THE DIABETES PATIENT

PATHWAY
Central to the platform for modern quality healthcare is the creation
and maintenance of an electronic patient health record (EHR).

The

creation of the Rijnmond Portal plays a key role in providing access to a

standardized EHR for stakeholders in the Greater Rotterdam Region of
the Netherlands. Currently, the Rijnmond Portal is being established as
gateway for the exchange of patient information, online consultation
with primary care physicians and other healthcare providers, as well as
a repository of videos covering various medical conditions, and much
more (Institute of Health Policy Management, 2014). A fundamental
assumption of this study is that the Rijnmond Portal will service the
EHR by providing for multiple views and real-time updates.

We will

discuss how applications related to diabetes may be included in the

software portfolio supported by the Rijnmond Portal to enhance the
treatment of diabetes patients in chapter 5: RECOMMENDATIONS .

CHAPTER 4: ROSS & WEILL / McDONALD

Use the OM to define the current Enterprise Architecture and

design the core diagram (see book for examples).
Erasmus Medical Center (EMC) is a provider of healthcare services. Their
focus is to provide an integrated patient care service across all care
pathways and centers. For this purpose it is required that the patient
information be available centrally in the form of an Electronic Health
Record (EHR). In the core diagram we depict that the patient EHR is
located centrally as an operational data store and all stakeholders can get
access to the data using a web portal i.e. the Rijnmond Portal.

Coordination Core Diagram

Determine the Maturity Level of the current architecture. Can the

organization increase its maturity level? If yes, how?
According to Ross & Weill, firms navigate a fairly predictablepath to
achieve a foundation for business execution and follow a consistent
pattern for building out their enterprise architectures. It states that an
organization will pass through four stages of architecture maturity. This
capability mautrity model was developed by the MIT Sloan Center for
Information Systems Research. Each stage involvesorganisational learning
about how to apply IT and business process discipline as strategic
capabilities. As companies move through each stage they can realise
benefits ranging from reduced IT operating costs to greater strategic
agility. The four stages are as follows:

Business Silos Architecture - company investment is focused on

meeting individual business unit needs.
Standardized Technology Architecture - increase IT efficiency
through technology standardization.
Optimized Core Architecture - standardizing data and processes
as appropriate for the operating model.
Business Modularity Architecture - design loosely coupled ITenabled business process components which allows company to
manage and reuse them.

The Maturity Level of the current architecture of EMC is at the

Standardized Technology level. The reason for this is that EMC has moved
from the local view of the needs of each department to a comprehensive
enterprise view. They have focused IT investment in Enterprise Systems.
With the use of the Rijnmond Portal and the Patient EHR data has become
more standardized and less redundant. Moreover the data is stored
centrally which is accessible by all stakeholders.
The maturity level of EMC can be increased to OptimizedCore level by
making use of an Enterprise Application Integration (EAI). EAI can
standardize communication between medical partners using a set of
available communication technologies. It will also help in standardizing

processes shared across multiple systems within the organization.

What is your advice on the IT engagement model?

Ross & Weill define an IT Engagement model as the system of
governance mechanism ensuring that business and IT projects achieve
both local and company-wide objectives[1]. The authors of this report
would advice EMC to follow a similar IT Engagement model that is similar
to the model of other large organizations.

The illustration below is an

example of such an engagement model:

IT Engagement Model

IT engagement model in large companies has 6 stakeholders: senior

management (enterprise-level), middle management (business unit level),
team management (project management level). Each of which exist on
both the IT and business side of the company. Ross & Weill also defines
three main ingredients in an IT engagement model as follows:

Companywide IT Governance
Project Management
Linking Mechanisms

Before developing a transparent IT engagement model EMC must tackle

two challenges: Coordination and Alignment.
With reference to IT governance, five major decision areas can be
identified: IT principles, enterprise architecture, IT infrastructure, business

application needs and prioritization and investment. IT principles apply to

high-level decisions about the strategic role of IT in the business. As for
EMC, three decisions encompass IT principles. The first one concerns the
creation of a firm ICT foundation (basis op orde) (2a EMC Intro, 2014),
the second refers to the maximal use of the functionality embedded in
current systems and the last focuses on the innovation in e-health,
collaboration and data management (2a EMC Intro, 2014).
IT infrastructure is an area in which centrally-coordinated IT services
provide part of the foundation for execution. Within IT infrastructure EMC
aims to rationalize the application landscape and attain the high-quality
data management with the reusability of data. It puts emphasis on rich in
functionality and highly integratable systems. It seeks to achieve as much
standardization as possible (2a EMC Intro, 2014).
Business application needs describes the plan for purchased or internally
developed IT applications that build the foundation for execution (Ross,
Weill & Robertson, 2006). EMC strives to redesign best of breed solution
and opts for suite solutions. Another objective is to improve registration
and patient data retrieval and strorage.
Lastly, prioritization and investment refers to the volume of investment in
IT, project approval and justification. EMCgives importance to the
advancement of registration and data management as well as the
improvement of operational management processes within ICT. Among
others, some goals to be attained include Business Intelligence and
Knowledge discovery, eHealth and triple A integration: any device, any
place, any time (2a EMC Intro, 2014).
In order to successfully fit IT into the business model, appropriate
standardized project methodologies need to be adopted (Ross, Weill &
Robertson, 2006). These are clearly defined process steps with distinct
deliverables. EMC strives to achieve top-notch patient health-care and
innovation. To reach a satisfactory level EMC will align its IT infrastructure
so that it is better integratable and standardized and therefore can serve
the above-mentioned purposes. For this we recommend that EMC adopt a

project methodology that has well defined process steps. Furthermore that
milestones be set in projects where deliverables can be checked and
reviewed against project plans. Lastly, it keeps track of good metrics for
project performance assessment.
Linking mechanisms present the third critical component of the IT
engagement model and comprise architecture linkage, business linkage
and alignment linkage. The coordination of the aforementioned parts
ensures the incremental expansion of the companys foundation (Ross, et
al., 2006).
On account of EMC having been identified at the standardized technology
maturity level, it is assumed that linking mechanisms exist at a very
preliminary stage and are insufficient to state that EMC possesses a
complete IT engagement model. Some progess can be made towards a
better IT Engagement model by having clear, specific and actionable
objectives, along with motivation in the organization to meet its goals.
This means that EMC should engage IT groups in the early stages of
development to assure the quality of developed solutions by organizing an
enforcement authority to facilitate and promote effective communication
among business units and IT across the organization.
Define the EA capabilities (McDonald) for EMC. Define the full set
of capabilities needed for the value proposition to the client(s).
EMC, largest and one of the most authoritative scientific University
Medical Centers in Europe, works to offer the best service to its patients.
EMC wants to aid its customers in the best way possible to ensure a
profound

medical

treatment.

During

this

treatment

process

many

stakeholders and business processes are involved. In order to get a better

view on these processes and on EMCs enterprise architecture, actors,
capabilities and interactions are mapped in several models. These models
are based on the approach of McDonald (2005), who lists three types of
key models, namely: The Value Network Diagram, the Capabilities Diagram
and Capability Blueprint.

McDonalds models show a collection of items and their relationships

between them. In the case of EMC the first model is a Value Network
Diagram, which shows the enterprise and its scope of operations involved
in serving the business around it. The Capabilities Diagram is a more in
depth model which illustrates the interactions involved in supporting the
Value Network, in this model interaction between the different capabilities
are described. An example here is the interaction between medical
treatment, billing the customer and checking patient health insurance
coverage with the insurance companies outside the EMC environment. The
last model is Capability Blueprint, which describes the business elements
within a capability, these business elements define how the capability
operates, achieves its strategy and meets its performance requirements.
To get a better understanding of what the capabilities of EMC are, we first
analyzed what value proposition EMC offers to its customers as well as
what its current processes are regarding their services. Moreover EMCs
strategic goals have also been taken into consideration to guage its
current capabilities and what they should be in the future. To differentiate
from other hospitals and in order to provide the right healthcare to its
customers EMC has the following value propositions:

Based on services and processes

o
o

o
o
o

Cooperation and communication with health insurance

companies.
Cooperation
with
other
hospitals
and
medical
professionalslike physician, nurse, dietician, psychologist,
physio-therapist etc.
Provide fast care with reasonable costs.
Research facility.
Create and maintain high expertise within EMC.

Based on EMC current vision

o
o
o
o
o
o

Maintain and provide high quality of care.

Strategic alliances.
Added value for patients &personalized medicine.
Research and development.
Interpretation of the process instance history.
Raising patient empowerment.

These value propositions aid in the goal and future business of EMC. On
the basis of given and obtained information about EMC we define
capabilities as follows:

Patient Appointment
Patient Registration
Patient Diagnosis
Medical Laboratory Test
Patient Referral
Patient Admittance
Patient Treatment (ACU & ICU)
Medical Knowledge (Research)
Patient Billing
Patient Knowledge and Interaction

Which of these capabilities are internal, which are external?

There are two types of capabilities, internal and external. Internal
capabilities represent the internal capacity of the enterprise and external
capabilties help maintain a good relationship with external stakeholders:

Internal Capabilities
o
o
o
o
o
o
o

Patient Appointment
Patient Registration
Patient Diagnosis
Medical Laboratory Test
Patient Admittance
Patient Treatment (ACU & ICU)
Medical Knowledge (Research)

External Capabilities
o Patient Referral
o Patient Billing
o Patient Knowledge and Interaction

Determine the Value Network Diagram (see book for examples),

the capabilities diagram, and the capability blue print
A value network diagram provides a high-level orientation view of an
enterprise and how it interacts with the outside world. The diagram
focuses on presentational impact.

The purpose of this diagram is to

quickly on-board and align stakeholders for a particular change initiative,

so

that

all

participants

understand

the

high-level

functional

and

organizational context of the architecture engagement. An illustration of

Erasmus MC is shown on the following page.

Value Network Diagram

A capabilities diagram outlines the relationships between an enterprises

capabilities. This includes adding information flows between the internal
capabilities and the interactions of internal capabilities with the external
actors.

These flows and interactions represent how the internal

capabilities of the organization provide value (see next page for

illustration).

The capability blueprint shows a palette of elements that integrate to

deliver the required performance and strategic outcomes regarding a
specific capability.According to McDonald (2005), each capability consists
of parts defining the execution of that component, its operational
characteristics

and

capacities.

Based

on

the

value

network

and

capabilities diagrams, the capabilities blueprint provides the essential

parts to implement each capability in the organization. The strategy for
EMC is to empower patients to control their treatments and records, form
strategic alliances for added value towards the patient and have a
streamlined organization. Subsequently, the capabilities are focused to
provide care to patients, balancing centralization and decentralization and
abilities to connect to the environment. This leads to aimed performance
values by EMC of care quality, market share and efficiency (see next
page).

Capability Blueprint

Based on your answers on the previous questions, discuss how

the Ross&Weill approach differs from McDonald

Though the Ross, Weill & Robertson and McDonald models bear some
significant similarities such as the design of operational behaviour
(McDonald) and the identification of the operating model (Ross, Weill &
Robertson) they do differ in a distinct manner. First of all, at the very
beginning McDonald examines a functional decomposition that splits the
problem into components without investigation into their integration and
cooperation. As opposed to McDonald, Ross, Weill & Robertson begin with
the evaluation of the operating model, which comprises multiple scenario
how

enterprises

handle

integration

and

standardization.

Another

fundamental difference is that Ross, Weill & Robertson start with the
business organization related to the customer (based on standardization
and integration). On the other hand, Mcdonald starts with the organization
and its value network as basis, so more than just the customer with less
emphasis on the internal processes (standardization) and IT (integration).
Furthermore, a huge disparity in approaches relates to the scope of
research. Ross, Weill & Robertson aims to align IT to the business, whereas
McDonald focuses on consolidating capabilities in line with the value
network and business strategy. Thus, in the McDonalds framework IT is
considered a part of the business (not a major constituent besides
business component as it is in the Ross, Weill & Robertson model) and has
several connections with other elements/capabilities. Indeed, Ross and
Weills attention boils down to business and IT, McDonalds model is much
broader and incorporates a multitude of perspectives. As such, Ross, Weill
& Robertson can be perceived as a more technical-oriented. Apart from
this, Ross, Weill & Robertson present maturity levels that impact the
degree of standardization and integration. McDonald does not implement
maturity levels at all but concentrates on the development of capabilities
to operate in the value network.
What integration strategies would you recommend regarding the
connection with the external sources of information?
EMC wants to integrate with external sources of information in order to
standardize patient health records through better data and system
integration. For the purposes of recommending an integration approach
we studied Laenen and Vennekens (2010). For EMC the only external

parties that they want to integrate with are other hospitals. This step is
necessary in order to improve both data standardization and system
integration as both systems want to share information for mutual benefit.
The integration strategies discussed in the paper are as follows:

Autonomy - Two actors stay as independent as possible from their

counterpart. The interaction between the parties is based on data
exchange, instead of having a deeper level of integration.

Interoperability - Following this strategy, actors use to communicate

connection possibilities to the outside world. There is no mutual
alignment of the chain business processes. The difference between
Autonomy and Interoperability is that Autonomy has an internal

focus, but Interoperability has the external focus.

Integration - Adopting this strategy, an organization tries to increase
the level of maturity with its counterpart. Two actors try to
coordinate their processes as much as possible.

Since we are trying to improve the communication with other hospitals in

order to offer a higher standard to the patients, we assume the most
appropriate strategy will be integration. The reason being that the flow of
information should be two-way between the parties and a higher level of
coordination will be necessary to strengthen the linkage points between
the organizations. Autonomy could also be an integration strategy
between in this case. However, as stated in the paper, this strategy does
not offer a high level of maturity. We believe the interaction between the
hospitals will be intensive and having maximum possible alignment is
more convenient. For achieving the integration strategy, other hospitals
will have to use specific modules deployed on their EAI system that
enables two-way communication.

CHAPTER 5: CONCLUSION AND RECOMMENDATIONS

1. PROVIDE DIABETES VIEW TO EHR INTERFACE
According to the Rijnmond Portal technical specifications, (van Pelt,
Stichting Rijnmondnet: Technischekennissessie, [no date given]) the IHE
Patient Care Coordination Profiles includes a Care Management (CM)
specification for the information exchange for managing specific health
conditions.

Currently, a search method is proposed for creating views

based on key words, with an example, CT of the Head. The authors of

this study suggest that a key-word search for diabetes patients be
replaced by a standard view based on a date range, containing the
following field data to facilitate rapid disemination of critical diabetes
medical information and ease-of-use:
DIABETES VIEW
name
birthdate
country of residence
primary care physician
primary care physician contact information
patient emergency contact
diabetes type (I, II, III, IV)
date of original diabetes diagnosis
current medications
allergies (general)
drug allergies
blood type
most recent blood glucose test results (pop-up window)
complications (blindess, amputations, seizure, etc. pop-up window)
other chronic health conditions
history of diabetes treatment in reverse chronological order (date range or
ALL)

2. MAP THE PATIENT JOURNEY

According to the National Health Service Institute for Innovation and
Improvement (NHS Institute) in Great Britain, the objective of
constructing patient pathways is to visualize patient flow as a process
within a health care provider and/or within a network of healthcare
providers.

Regardless of whether the view is strictly internal to one

organization or includes externals views as well, the objective is to

streamline the patient flow to improve efficiency of the health care
organizations operations in the belief that streamlining patient
processes will result in positive treatment outcomes and patient
satisfaction.

Typically, the steps outlined in the patient flow illustrate

movement of the patient from an enterprise-wide view without taking

the clinicians perspective or the actual feelings and experiences of the
patient into full account .

(NHS Institute, 2013). Researchers Layton,

Moss, and Morgan (1998) conclude that physicians and nurses view
patient pathways as a series of medical protocols with a limited
understanding of the patient flow throughout the entire organization,
particularly in large health care institutions, such as regional hospitals.
For the patient himself, following a complex pathway involving several
health care providers has an emotional impact where the patient as a
traveler may feel more like an intrepid explorer continually coming up
against the unknown rather than a modern traveler whose journey has
been planned with a travel agent and who has possession of a detailed
written itinerary. (Layton, Moss, & Morgan, 1998).
A 2014 study by the Medical Directorate, NHS England, reports the
urgent need for health care providers to empower patients with
information to support their choices about their own health and care
and support the development of IT solutions that allow sharing of
information between providers and people with diabetes.

(NHS

England, 2014). According to the study, a survey conducted during a

recent audit revealed that 80% of people with diabetes in hospitals
said that they werent involved in the design of their care plan, and less
than half had been allowed to self-administer insulin. (NHS England,
2014).

It stands to reason that a patient who injects insulin at home

several times a day may view health care providers as condescending

or feel like an object instead of a person in a hospital, where multiple

caregivers come and go in the course of a patients stay. Therefore, it
is critical for health care providers to engage the patient and recognize
patient self-care competencies during treatment at a healthcare facility.
We believe that The NHS England study is relevant when considering
that the Global Burden of Disease Study 2010 indicated that the United
Kingdom enjoys the lowest early mortality rate due to diabetes in a
comparison of 19 highly developed countries (Lancet, 2013).
In a previous chapter of this report, the authors constructed several
pathways for diabetes patients from the viewpoint of an enterprise
architect in the context of a regional health care system.

We

discovered that our diagrams focus on health care providers and

related

service

providers,

such

as

insurance

companies

and

pharmacies. This may result from our belief that by identifying these
entities and their interactions with the patient, an information system
which supports the aggregated processes can be properly envisioned.
Although EA intends to streamline services with the goal of providing
the best level of health care for patients and strives to achieve all the
benefits of preventive health care, the whole system would collapse if
one key stakeholder were removed: the patient himself/herself. For
lifelong physical ailments such as diabetes, current trends in health
care EA depict patient-centric diagrams and map the patient journey
in a holistic manner from the patients point of view.

(New England

Health Care Institute Client Conference, 2008). This view is centered

on the patient himself/herself, who looks outward to heath care service
providers, which is in direct contrast to the traditional patient flow
diagram,

where

the

starting

point

is

the

patient

making

an

appointment with the primary care physician or arriving at the

emergency room in a hospital.
3. CREATE A DIABETES VIRTUAL MENTOR FOR THE RIJNMOND
PORTAL
According to Ali, Rana, Hardisty, Subramaniam, & Luzio (2004),
effective management of complex conditions like diabetes requires a
more fastidious, continuous, personalized approach.

With todays

modern information systems, interactive software provides a means to

share quality data between the patient and multiple health care
providers.

A key success factor is empowering the patient to be an

active participant.

Specialized software applications serve as virtual

mentors, providing a host of services the patient may utilize to support

self-maintenance of their diabetes condition. According to Ali, et al.,
(2004), The challenge is to make this type of management routine
and design the right tools to support it in real-world situations.
One of the fundamental activities is the administration of insulin
multiple times a day.

Below is the administration of insulin from a

patients point of view as described by Michael P. Hall of Human Care

Systems, Inc. (USA) in a 2011 presentation :

According to Hall, the patient journey approach focuses on all aspects

of self-management by asking the question, What are the physical,
cognitive, emotional, behavioral, and social experiences the patient
goes through?

Hall concludes that a multi-channel (web, mobile,

live, printed) integrated engagement patient management platform to

connect data to effective patient self-management based on behavioral
science is both cost-effective and results in better patient outcomes
by increasing patient adherence to self-maintenance (Hall, 2011).

By

adding specialized virtual mental software applications to enhance the

patient journey promotes patient well-being in a cost-effective manner
(NHS England, 2014).
A 2004 study, an integrated care pathways (ICP) enables clinics to
deliver health care to patients based on their particular needs. (Ali,
Rana, Hardisty, Subramaniam, & Luzio 2004).

The delivery of ICP

through portals linking healthcare information systems is the key driver

for successful self-maintenance for diabetes patients.

The study

concludes that diabetes software application functionality provides a

pathway

to

manage

individual

patient

needs,

with

their

full

understanding and active participation. (Ali, et al., 2004).

Example of Portal application for holistic diabetes patient care (Ali, et

al., 2004):

In conclusion, the enterprise architecture presented in this report

clearly shows viable patient pathways, which include treatment at
Erasmus MC. Contingent on the succcessful implementation of such an
EA in real life, the EHR and Rijnmond Portal must be fully operational.
Thus, the EA presented in this report is a future vision.

By analyzing the flow of information and understanding the processes

involved in the treatment of diabetes, the authors realized that a
patient-centric pathway focusing on the viewpoint of the patient, would
lend a valuable dimension to the EA. Software to support the patient
journey also relies on the Rijnmond Portal. Our recommendations
include a diabetes view to enhance the EHR, including the patient
journey as a formal part of the EA for medical conditions such as
diabetes, which require daily patient self-maintenance, and the
creation of a diabetes virtual assistant, which is an integrate software
application designed to motivate and support the patient as well as
providing important information updates to appropriate health care
providers.

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