Green turning brown - Domain engineering for social and health services in Finland

G een Tu ning B own – Domain Enginee ing o Social and Heal h Se ices in Finland Reima Suomi a, Pi kko Nykänena,b, Tapio Vepsäläinena, Riina Hil unena a Depa men o Managemen and En ep eneu ship, Uni e si y o Tu ku, Finland b Facul y o Na u al Sciences, Uni e si y o Tampe e, Finland Abs ac Being able o design in o ma ion sys ems o an un ouched domain, wi hou he bu den o exis ing in o ma ion sys ems, especially legacy sys ems, is o en seen as a d eam o mos in o ma ion sys em p o essionals. Uncha ed domains a e anyway sca ce, and o en such g een ield p ojec s u n in o b own ield p ojec s, also o p ojec s whe e exis ing s uc u es se e ely cons ain he de elopmen o new sys ems. In his a icle we discuss he concep s o g een ield and b own ield domain enginee ing and so wa e de elopmen , and e lec hei possible messages o he e-enginee ing o he Finnish heal h- and social ca e ecosys em cu en ly unde way. In ou ieldwo k we could iden i y a lo o need and wish o g een ield domain enginee ing in he Finnish heal h and social se ices deli e y. As well we ound a lo o b own ield elemen s inhibi ing change. Ou p oposal o he u u e is a ecosys em app oach, whe e new and es ablished elemen s could li e oge he in a sel -go e ned balance. Keywo ds: Knowledge Managemen ; In o ma ion Sys ems; Decision Making In oduc ion Heal h and social ca e a e unde es uc u ing in many coun ies [1], including well-known p og ams like Obamaca e in he US [2] and e o m o Na ional Heal h Se ice in UK [3] and Sweden [4]. In Finland, he enewal o heal h and social se ices ( he Finnish SOTE- e o m) is cu en ly unde way, and i will demand a lo o new go e nance s uc u es, p ocesses and suppo ing ICT in as uc u e o become a eali y, he whole heal h and social ca e ecosys em will deeply ein en i sel in Finland. This pu s hea y p essu es on many domains, including, and no o he leas , in o ma ion sys ems in he indus y. Whe eas all would like o see his new ecosys em as a g een ield design, also a design wi hou es ic ions om he pas , in eali y we alk o a b own ield design: old s uc u es mus be aken in o accoun , and hey o en inhibi he implemen a ion o he bes a ailable solu ions. G een ield and b own ield e minology is eage ly used in land usage planning [5; 6], bu he me apho s o g een ield and b own ield ha e also ound hei way o he ield o o ganiza ional con ex [7; 8] and in o ma ion sys ems [9]. In his a icle, we e iew based on academic li e a u e wha b own ield and g een ield de elopmen means in o ganiza ional and indus y con ex , and wha i speci ically means in he design o in o ma ion sys ems. We look o insigh s ha could be used when edesigning in o ma ion sys ems in heal h and social ca e domain. To al ewo k o a la ge en i y can be called domain enginee ing. Domain enginee ing is o en seen as ocusing on so wa e. Domain enginee ing is ele an o he wo k equi ed o es ablish a se o so wa e a i ac s ha can be eused by he so wa e enginee . The pu pose o domain enginee ing is o iden i y, model, cons uc , ca alog and dissemina e a se o so wa e a i ac s ha can be applied o exis ing and u u e so wa e in a pa icula applica ion domain [10]. The e is anyway e idence ha domain enginee ing is mo e han jus so wa e wo k: Domain enginee ing aims o suppo sys ema ic euse, ocusing on modeling common knowledge in a p oblem domain [11]. The majo al e na i es o domain enginee ing a e g een ield and b own ield enginee ing. Mos o he sys em and so wa e equi emen s li e a u e assume de elopmen o sys em om sc a ch i.e. G een Field Sys ems [12]. New p oduc de elopmen o g een ield p ocess (which does no include cons ain s o de elopmen wo k like b own ield p ocess) has highe isks. Ma ke s usually ha e dominan designs, which a ec he cus ome beha iou . When a new p oduc has been de eloped, he e is a isk ha he cus ome s do no accep i . In es men s o in as uc u e o he o ganiza ion and exis ing esou ces ha e an e ec on he selec ion o whe he o de elop cu en p oduc s o highe le el o o de elop comple ely new p oduc s [13]. Leh onen e al. [13] de ine ha he b own ield (p ocess) s ands o he eusing o a ailable asse s and i includes no ions ha he e a e limi a ions o designing and solu ions because o exis ing s uc u es. Old p oduc solu ions, p oduc s uc u es o cus ome equi emen s limi designing o new p oduc s. Because o his, he b own ield p ocess is no he p e e ed solu ion om he designe poin o iew. Mos o ganiza ions in his e a ha e exis ing la ge-scale o medium-scale ope a ional sys ems. Wi h he e ol emen o new business equi emen s a ise o change in exis ing sys ems o mee e ol ing business demands and needs. In gene al, he challenges aced by indus ies a e mainly he cap u e o equi emen s o changes and e-enginee ing in ope a ional sys ems. Un o una ely, he e a e e y limi ed app oaches de ined o e-enginee ing and changes in exis ing B own ield ope a ional sys ems because mos o he sys em & so wa e equi emen s in he li e a u e assume he de elopmen o sys em om sc a ch i.e. G een Field Sys ems [12]. In as uc u e building is a key ask in domain enginee ing: a domain enginee ing p ocess should encompasses a leas h ee main ac i i ies: domain analysis, in as uc u e speci ica ion and in as uc u e implemen a ion [14]. MEDINFO 2017: P ecision Heal hca e h ough In o ma ics A.V. Gundlapalli e al. (Eds.) © 2017 In e na ional Medical In o ma ics Associa ion (IMIA) and IOS P ess. This a icle is published online wi h Open Access by IOS P ess and dis ibu ed unde he e ms o he C ea i e Commons A ibu ion Non-Comme cial License 4.0 (CC BY-NC 4.0). doi:10.3233/978-1-61499-830-3-803 803 A common scena io o b own ield sys em de elopmen can be a majo upg ade in cu en ope a ional sys em in e ms o he ollowing equi emen s [12]: • Inco po a ion o new business ules in exis ing sys em • Adding up new ea u e in exis ing sys em • Up-g ada ion o exis ing ea u e • Adop ion o new echnology • Legaliza ion/Ce i ica ion o p oduc o speci ic ea u e Today and inc easingly in he u u e, mos la ge so wa e- in ensi e sys em (SIS) de elopmen s will be cons ained by he need o p o ide con inui y o se ice while mig a ing hei se ices away om poo ly s uc u ed and documen ed legacy so wa e applica ions. Ye mos SIS p ocess models con ain unde lying assump ions ha an applica ion p ojec s a s om sc a ch in an uncons ained G een ield app oach [15]. We eel ha his is a mo e han co e desc ip ion o heal h and social ca e p ojec s in mos coun ies – including Finland. A heal h and social ca e sys em e o m has been on he agenda o se e al Finnish go e nmen s. P ime Minis e Sipilä´s cu en go e nmen has a plan o pu he new heal h and social ca e sys em in o ope a ion by 2019. One o he main a ge s o he ongoing heal hca e sys em e o m is o eo ganize se ice p o ide s in o la ge uni s called heal h and social ca e p o ide egions. The aim is a ull ho izon al and e ical in eg a ion o heal h and social ca e and he p ima y and seconda y le els o se ices. [16] New key ac o s in he new ecosys em will be egions, ha will o de he heal h and social ca e se ices om he ma ke s, whe e public, p i a e and hi d sec o se ice p o ide s compe e in equal e ms as much as possible. These new egions a e ye inexis en , and so a e hei in o ma ion sys ems. They need a o ally new ICT in as uc u e ha is ela ed o and buil on he cu en ly a ailable one, bu especially sys ems o manage con ac s wi h se ice p o ide s, and sys ems o o esee and plan o se ice demands, so ha hey can pu chase he igh amoun and quali y o se ices om he ma ke s. Simila sys ems a e a he unseen in he Finnish con ex a leas ; he e we a e no speaking o o dina y p ocu emen sys ems [17]. One o he domains whe e public au ho i ies ha e mos expe ience o pu chasing se ices migh be logis ics [18; 19]. Messages om B own/G een ield de elopmen o heal h- and social ca e wo k The p oblem a ea o B own ield sys em de elopmen seems o be a he spa sely unde s ood in heal h and social ca e in o ma ion sys ems ield. Much mo e unde s anding needs o be gained on how exis ing s uc u es inhibi he implemen a ion o bes new p ac ices. In heal hca e, especially he ponde ous pa ien eco ds sys ems a e a co e elemen , o which all new sys ems mus adjus . As well di e en o he sys ems, such as di e en coding sys ems and e minologies inhibi change. On op o e e y hing else, he indus y is hea ily egula ed. As said, domain enginee ing is abou modelling common knowledge in a domain. Knowledge in he a ea o medicine especially is ex emely ex ensi e, and he e is e y li le oom o g een ield enginee ing o modelling. Ye new ecosys em unc ions migh necessi a e a esh iew on knowledge oo. As a ep ie e o he p oblems, IS p ojec s mee wi h b own ield elemen s Boehm [15] p oposes inc emen al commi men building. All decisions conce ning he new sys ems a e no done a once, and hey a e no done by jus one pa y. In o de o apidly and success ully adap o he inc easing a es o change, p ojec s need o be able o concu en ly, a he han sequen ially, assess and manage (1) oppo uni ies and isks; (2) equi emen s, solu ions, plans, and business cases; and (3) ha dwa e, so wa e and human ac o s [15]. This kind o app oach is clea ly needed and o a g ea ex end also isible in he Finnish enewal o heal h and social ca e. B own ield de elopmen means ha he e a e es ablished s uc u es, expe s and solid knowledge o he domain a ea al eady a ailable. Ca e ul lis ening o expe s and aking hei ideas in o a en ion and p oduc ion is a key success ac o o b own ield p ojec s. I is impo an o emembe ha cus ome s and o dina y s a membe s a e o en he bes expe s in de ails, e en when hey a e no always able o s uc u e he o al pic u e. The chance o success o B own ield domain enginee ing is g ea ly enhanced i he people wo king oge he a e e ec i e communica o s, like wo king in eams, a e humble, and enjoy lea ning om o he s. All o hese a e impo an o help c ea e a “no blame” cul u e, whe e people a en’ a aid o help one ano he and do wha is igh o he p ojec [9]. In as uc u e de elopmen is a key ac ion in domain enginee ing. Again, in as uc u e in heal h and social ca e migh in many cases no be he mos sophis ica ed one, bu i is usually deeply oo ed and di icul o change. Di e en s anda ds o heal hca e message exchange a e a he co e o in as uc u e de elopmen in heal h and social se ices [20]. Table 1 summa izes ou main indings om he li e a u e on b own/g een ield enginee ing. Table 1- Main indings om he li e a u e on b own/g een ield enginee ing • G een ield domain enginee ing is always mo e isky han b own ield domain enginee ing • In as uc u e planning (a chi ec u e) and implemen a ion a e a he co e o domain enginee ing • Con uini y o se ice is a majo goal • Re-use o cu en esou ces and asse s is a goal o b own ield domain enginee ing • Lis en o expe s o he old sys em • In IS, g een ield enginee ing aims mig a ing se ices away om poo ly s uc u ed and documen ed legacy so wa e applica ions • Inc emen al commi men building is impo an in b own ield domain en g inee in g Me hods Ou ieldwo k ook ou mon hs in Decembe 2016 - Ma ch 2017 in Sou hwes Finland. Du ing ha ime we held 12 expe in e iews wi h Finnish expe s in social and heal hca e in o ma ion sys ems, and one wo kshop. The heo e ical backg ound o g een o b own ield domain enginee ing was no p esen in he empi ical discussions. Ou s udy app oach was explo a i e [21]. R. Suomi e al. / G een Tu ning B own – Domain Enginee ing o Social and Heal h Se ices in Finland804 Resul s In ou ieldwo k we could iden i y a lo o p essu es and change in agen s o he cu en si ua ion. Genuine in e es o design he whole in o ma ion go e nance in Finnish heal h- and social ca e clea ly exis s. The main iden i ied ac o s a e summa ized in Table 1. The mos clea b own ield elemen in Finnish heal h and social ca e domain o heal h and social ca e in o ma ion go e nance is he es ablished po olio o many clinical heal hca e in o ma ion sys ems. While he amoun o di e en sys em b ands can be coun ed in housands, a ew main sys ems – especially pa ien eco d sys ems – accoun o he main pa o cu en sys em po olio. The new and cen al Finnish main da abase o heal h and social ca e cus ome in o ma ion Kan a is on he edge – i can be in e p e ed as a new building block in an old b own ield landscape. The cu en si ua ion in heal h and social ca e IS can be desc ibed in Finland as wai ing. A lo o planning wo k goes on, bu eal in es men s in o new sys ems a e ew, because o he unclea si ua ion o he upcoming new heal h and social ca e go e nance. I is s ill widely unclea , wha kind o o ganiza ions will ope a e in he new domain, and wi h which kind o p ocesses and business models, and which kind o incen i es a e gi en o di e en playe s by go e nmen and ma ke o ces. In Finland, he e is al eady a lo o he y discussion on he u u e o he ixed p ope y, which will be mos likey dese ed in he new ma ke en i onmen – especially acili ies in u al a eas a e in dange . Less discussion has been on he same possible a e o hea y in es men s in cu en in o ma ion sys ems and in as uc u e. Finally, making G een ield domain enginee ing is made di icul because o e y adi ional easons: lack o inance, lack o ision and di ec ion, and lack o ma ke o o he new al e na i es ha would eally look like supe io ones as compa ed o cu en s a us. Table 2 - Main eeze s and change agen s o in o ma ion go e nance in Finnish heal h- and social ca e enewal Main eeze s – b own ield elemen s • Es ablished pa ien eco d sys ems wi h high ma ke sha e • Unclea go e nance • Unclea p ocesses • Unclea incen i e sys ems and business models • Hea y in es men s in cu en sys em po olio and in as uc u e • Lack o inance • Lack o ision and di ec ion • Lack o su p e io ma ke o e in g s Main change agen s – g een ield elemen s • Ambi ious poli ical goals • Ambi ious a chi ec u e plans • New egions as ac o s • Need o decision suppo • Need o seconda y da a use • New pa ien eco d ini ia i es • A i icial in elli g ence, IBM and Wa son Poli ical agenda se ing in Finnish heal h and social ca e ield has been ambi ious. Howe e he si ua ion ha he e would be a lo o esh esou ces and a eas o un ap, which is a key idea in g een ield domain enginee ing, is missing. The e also seems o be going on some ich and ambi ious wo k on new IS a chi ec u es o he heal h and social ca e domain. Un o una ely, howe e , he wo k seems o o m an a chipelago; he b idges joining he wo k i ems a e ew and a . The new egions should ac as main change agen s. Thei capaci y and capabili y o do so is s ill unde specula ion, as hey a e no es ablished ye . The goal is o ha e s ong and wisely led egions as a majo change agen s o Finnish heal h and social ca e domain and i s in o ma ion sys ems. The e seems o be a s ong consensus ha especially decision making in he new heal h and social ca e domain needs s eng hening. Decision make s a all le els should be ed wi h ele an and esh in o ma ion. The same holds ue o seconda y use o in o ma ion in esea ch and de elopmen domains. We can also see some new ini ia i es in he main sys em po olio. The na ion-wide Kan a-se ice was al eady men ioned. In addi ion, some egions plan o ambi ious esh pa ien eco ds sys ems and ela ed unc ionali ies. IBM seems o en e he ield s ongly wi h i s a i icial in elligence Wa son concep s, ha i seems o u ilize as a T ojan Ho se o mo e s ongly access he Finnish heal h and social ca e IS ma ke . Discussion A p omising app oach o go e nance and managemen o he complexi y, wide scope and b own/g een ield de elopmen o he social and heal hca e sys em is he ecosys em app oach. An eHeal h ecosys em is composed o heal hca e o ganiza ions, bo h public and p i a e, se ice p o ide p o essionals, cus ome s, ci izens and pa ien s, indus ial companies p o iding hei p oduc s and se ices, and echnology-media ed communica ion and in as uc u es ha in collabo a ion p o ide add-on alue o bo h se ice consume s and o he se ice p o ide s. In as uc u es and ne wo ks a e needed bo h o knowledge sha ing and managemen , and o exchanging and communica ing in o ma ion and da a. In an ecosys em, se ices and p oduc s a e de eloped and deli e ed o ul ill he cus ome s’ needs, o egula ion-s a ed needs, and he ole o ma ke ing and comme cializa ion is mino [22]. Cus ome s a e bo h heal h p o essionals and pa ien s, ci izens, and se ice p o ide s a e heal hca e o ganiza ions and a ious supplie s and indus ial companies o o e sys ems and se ices o be used by heal hca e o ganiza ions and pa ien s. This app oach suppo s e y well he egional model o he Finnish social and heal hca e e o m. Good examples o ecosys em applica ions and se ices a e elec onic heal h eco ds, pe sonal heal h eco ds, pa ien po als and heal h in o ma ion sys ems including heal h knowledge managemen and e-lea ning o heal hca e p o essionals. Fu he , hese sys ems include clinical decision suppo sys ems and emo e pa ien moni o ing and managemen applica ions o be used a home and on-mo e by pa ien s and ci izens. Wellnes and i ness applica ions should also be men ioned. An eHeal h ecosys em is e y dynamic sys em ha inco po a es a a ying numbe o s akeholde s. Ecosys em equi es enabling in o ma ion, communica ion, and empowe men mechanisms, which make i possible o in o ma ion and expe ise o be accessed quickly and R. Suomi e al. / G een Tu ning B own – Domain Enginee ing o Social and Heal h Se ices in Finland 805 accu a ely o in o m and guide he ecosys em ac i i ies and pe o mance. An eHeal h ecosys em is e y speci ic in he sense ha poli ical decision making has s ong e ec s on how he heal hca e se ices a e o ganized and unded, and also, he e is s ong legal and no ma i e egula ion on how he se ices can be deli e ed, accessed, disclosed, cha ged and unded [23]. Typical o an eHeal h ecosys em oday is ha he se ices, e.g. elec onic heal h eco ds, need o be deli e ed online, ac oss dis inc o ganiza ional, egional o e en na ional bo de s. This equi es ha an ecosys em is composed o in e connec ed s akeholde s, each one wi h a mission o imp o e he quali y o ca e. In his si ua ion, in o de o ensu e he pa ien sa e y and quali y ca e, he s akeholde s build new ela ionships, o en ou side he heal hca e o ganiza ion, e.g. de elop new ypes o public- p i a e pa ne ships [24]. The ecosys em app oach on eHeal h sys ems and applica ions, especially in his new na ion-wide social and heal hca e e o m con ex , helps heal hca e o ganiza ions and e-heal h s akeholde s o c ea e business models based on collabo a i e se ice p oduc ion and hus imp o e collabo a ion and communica ion be ween he s akeholde s. The ac o s, pa ne s o he ecosys em need o sha e he common objec i es o he sys em and bene i om collabo a ion, c ea e sha ed alue, and when hey ha e adequa e ools and means o communica ion, collabo a ion will be ac i e and suppo he ecosys em sus ainabili y. eHeal h ecosys em can p o ide many po en ial bene i s o he heal hca e p o essionals and o ganiza ions and pa ien s and ci izens and o indus ial supplie s. Howe e , c ea ing sus ainable eHeal h ecosys ems equi es ha all s akeholde s’ opinions and needs a e aken in o accoun o ecosys em success and sus ainabili y. Sus ainabili y is impo an because he bene i s o en can be achie ed only o e a pe iod o ime. This kind o app oach is e y ele an , essen ial, and necessa y o he success ul go e nance and managemen o ou planned social and heal hca e e o m. Conclusions Ou explo a i e jou ney con i med ha e minology and hinking on g een ield and b own ield domain enginee ing i s well e en o he social and heal hca e domain in o ma ion sys ems de elopmen . This o a g ea amoun in heal h and social ca e, IS de elopmen un apped heo e ical cons uc ion, and s eam o li e a u e and esea ch o e s new a enues and insigh s o esea ch in heal h and social ca e IS. In eali y heal hca e is plagued wi h b own ield elemen s ha hampe new openings o IS in he domain. Social ca e is ha ing less pas bu den, especially in IS go e nance, bu e en he e old adi ions migh hea ily hampe new de elopmen ideas. A lo o long- e m IS planning in he o m o a chi ec u es is aking place in he Finnish heal h- and social ca e domain. We can easily see ha he de elopmen ini ia i es a e o ming an a chipelago, wi h ew b idges be ween he di e en plans and a lo o o e lapping wo k. Inc emen al commi men building is a key o success in b own ield domain enginee ing p ojec s. Lis ening o di e en s akeholde s and allowing hem o make hei eal inpu o he u u e IS go e nance a angemen s is an enable o success, bu o cou se no ye a sil e bulle . The cos o his app oach is mos likely a lo o supe imposed wo k, bu his is he cos ha has o be paid o consensus. Allowing wide g oups o s akeholde s o co-p oduce he plans also se es educa ional and lea ning pu poses. Ou p oposal o a esh app oach is mo e unde lining he na u e o an ecosys ems o he heal h and social ca e domain. Ra ional op-down planning will ne e ha ness he eali ies o he domain – e en no in a small coun y like Finland. Ra he we need mo e ocus on he unde s anding on how he heal h and social ca e ecosys em wo ks, and how IS as a sub- ecosys em in he a ea wo ks. Re e ences [1] C. Ham, Heal h ca e e o m: lea ning om in e na ional expe ience, Nu sing Managemen 4 (1997), 26-30. [2] M.A. Hall and R. 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