“It is not just that more and more software will become a service delivered online. More importantly, applications, web-based or not, will no longer come as a big chunk of software, but will be made up of a combination of electronic services—a shift that has picked up a lot of speed since computing began moving into the cloud.

To understand this new way of building applications, known as “service-oriented architecture” (SOA), think of a culinary analogy. Whereas the old chunk of software resembles a precooked meal that just has to be popped into the oven, the new architecture is more like a restaurant. It is a service in itself but also a combination of sub-services. There is the waiter who takes the order and conveys it to the kitchen. There is the cook who prepares the food. And there are the cleaners who keep the place tidy. Together they create the “application”: a restaurant.”

The “silo” model may be depicted as:

And it becomes the "cloud" model, depicted as:

Why should IISs care about technology advances?  Does this have anything to do with ARRA (the other “AIRA”) – commonly known as “the stimulus package”?  What is the impact on the IIS mission to eradicate vaccine-preventable diseases?

Why Should IISs Care?

The First Federal Chief Information Officer, Vivek Kundra, 34, is expected to oversee a push to expand uses of cutting-edge technology, and will have wide powers over federal technology spending.   Kundra is widely recognized for his advocacy of "cloud computing", and for using Service-Oriented Architecture (SOA) to reduce costs and improve communication with the public.

Cost reduction is clear from the above two drawings.  Note that many application functions are repeated in each “traditional” system:  decision support, for example.   In SOA, these services need be constructed only once.  Furthermore, systems have to be connected point-to-point.  For each of 50 states to connect to 49 other states, up to 49 * 50 / 2 = 1225 connections are needed to create a fully linked network!  This is in addition to each provider connection to the IIS.   In SOA, everyone connects to the Internet “bus” only once.

What Does This Have to Do with ARRA?

The largest Healthcare IT expenditure – for ‘meaningful use’ of ‘qualified EHRs’ - $34B – means that use of EHRs to store demographic and clinical data, to perform decision support and to interact with others through the use of Health Information Exchanges (HIEs) will dramatically increase (see HIMSS presentation March 18, 2009 by Jonathan Teich).  Thus, there will be more and more incentive for  users to look up patients, retrieve and enter data, run vaccine forecasts on their EHRs and not on IIS user screens.  

Communication with IISs will be more via HIEs.  In fact, HIEs may provide access to all types of clinical data, not just immunization data.  Once data is available “in the cloud”, the barriers to patients viewing and analyzing their own data will rapidly come down.  The “center of the immunization universe” will shift from IISs to providers to patients. 

How Does This Affect the IIS Mission?

To date, the IIS mission along with  Section 317 programs overall has been to increase immunization coverage. 
How much attention has been given to balancing increased coverage with detecting when children should not be vaccinated?   Detecting contraindications is much more complicated than scanning an immunization history for missing shots.  How will a busy doctor or nurse do it without complete medical histories and advanced decision support?  A patient-centric health IT world will enable them.

Such a world will open new opportunities for IISs even as some of the old functions fall away.   IISs can use data generated elsewhere to serve public health immunization goals by:

• educating,
• serving pockets of need,
• balancing increased coverage with careful detection of contraindicated patients, and
• providing far more interesting and useful feedback to the medical community than has been available in the past.
  

Alean Kirnak
President, Software Partners LLC
MS Computer Science, University of California, San Diego
Co-chair, AIRA Messaging Workgroup
Co-chair, HL7 Public Health and Emergency Response (PHER) Workgroup

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This article originally appeared on the website of the American Immunization Registry Association (AIRA)