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Top1. Introduction
Healthcare is a complex adaptive system consisting of organizations, people, and technologies that are both independent and interdependent. As a complex adaptive system, it exhibits non-linear, dynamic, and indeterministic behaviors that are unpredictable and difficult to manage and control (Rouse, 2008). Figure 1 shows the many stakeholders and how each of them plays a different role in a complex relationship to deliver healthcare. Quality healthcare requires the collaboration and concerted efforts of all stakeholders through information sharing and coordination.
Figure 1. Stakeholders and interests in health care. Source: Healthcare as a complex adaptive system (Rouse, 2008, p. 19).
Clinical care decisions require complete and longitudinal patient health information at the right time and right place. Timely and unobstructed sharing of patient records between healthcare plans, organizations, and providers are critical for efficient and effective delivery of patient-centered care. A 2010 survey reported that the average U.S. patient sees 18.7 different doctors during their lives and for patients over 65 years of age, the average increases to 28.4 individual doctors, including primary care, specialists, hospital and urgent care providers (PR Newswire, 2010). Before comprehensive and longitudinal health records controlled by patients and accessible to all healthcare providers become a reality, the healthcare industry must rely on Health Information Exchanges (HIE) to enable trusted, secure, interoperable, and timely sharing of health information among disparate Electronic Health Record (EHR) systems.
HIEs come in a variety of forms and functions. Technically, a HIE can use push-based, query-based, or consumer-mediated communication technology. Geographically, a HIE can be operated locally, state-wide, regionally, or nationally. Organizationally, a HIE can be convened and governed by an EHR vendor, a community of healthcare organizations, or a single healthcare system. Architecturally, a HIE can be centralized, federated, or a hybrid of both. The variety and diversity in the organizational structure and technical architecture of HIEs make it difficult for practitioners and researchers to understand the intricate operations of a HIE and can be a barrier to effective adoption and utilization.
This paper aims to break down the complexity of HIE by using the System of Systems (SoS) framework to analyze and summarize the common characteristics. The SoS framework has been used in Systems Engineering discipline to guide the design and development of complex systems consisting of multiple independently owned and operated sociotechnical systems, typically seen in the defense and transportation industry. The SoS framework aligns well with various collaborative frameworks commonly practiced in business management and healthcare industry. The SoS model by Boardman and Sauser (2006) is particularly useful in exploring HIE. This model specifies five characteristics of an SoS using five mnemonics: A for Autonomy, B for Belonging, C for Connectivity, D for Diversity, and E for Emergence. These easy-to-remember mnemonics reflect the principle of user-centered design (UCD) and help create a shared mental model for practitioners and researchers in their effort to deliver and improve patient-centered healthcare through the effective adoption and use of EHRs and HIEs. To illustrate the five characteristics, this paper uses DirectTrust, a push-based secure messaging HIE, as a case study.