ETF/AMRESETF/AMRES

Transnational integrationof clinical and hospitalinformation systems

Prof. Zoran JovanovicProf. Zoran JovanovicCE&CS UoBCE&CS UoB

AMRES DirectorAMRES Director

ETF/AMRESETF/AMRES

Topics

Objectives and obstacles in integrating hospital Objectives and obstacles in integrating hospital information systemsinformation systems

IT standards for (exchanging) medical dataIT standards for (exchanging) medical data Mainstream in developing HISMainstream in developing HIS Web based access to medical dataWeb based access to medical data Computer networking infrastructural changesComputer networking infrastructural changes Transparent access to medical data worldwideTransparent access to medical data worldwide Integrating other servicesIntegrating other services

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Objectives in integrating hospital information systems

Saving moneySaving money Eliminating unnecessary examinationsEliminating unnecessary examinations Improving healthcare (more data)Improving healthcare (more data) TelemedicineTelemedicine Spreading best practices throughout the worldSpreading best practices throughout the world Introducing standards worldwide – open Introducing standards worldwide – open

competitioncompetition

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IT standards for exchanging medical data

Widely adopted standards in ICT (HTML, XML, Widely adopted standards in ICT (HTML, XML, UML, Multimedia standards – images, video, UML, Multimedia standards – images, video, sound, …)sound, …)

Medical data exchange formatsMedical data exchange formats Patient ADT (Admission, Discharge, Transfer), Patient ADT (Admission, Discharge, Transfer),

scheduling, clinical reports and resultsscheduling, clinical reports and results Patient medical record architecturePatient medical record architecture Reference information modelReference information model

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Widely adopted Medical standards

DICOM (Digital Imaging and Communications in DICOM (Digital Imaging and Communications in Medicine) – standards for images, waveforms, Medicine) – standards for images, waveforms, structured reports primarily in radiologystructured reports primarily in radiology

Health Level 7 – covering clinical and clinical/ Health Level 7 – covering clinical and clinical/ administrative issues and integrationadministrative issues and integration– Clinical – laboratory, pharmacy, radiology, patient Clinical – laboratory, pharmacy, radiology, patient

care, public health, dietary, reportscare, public health, dietary, reports

– Clinical/administrative – patient registration, Clinical/administrative – patient registration, admission, patient accounts, document life cycle, …admission, patient accounts, document life cycle, …

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DICOM (1)

From proprietary medical devices that need From proprietary medical devices that need proprietary software for acquiring medical proprietary software for acquiring medical data to a standarddata to a standard

Widely accepted – precondition for survival Widely accepted – precondition for survival of suppliersof suppliers

Precondition for wide adoption of RISPrecondition for wide adoption of RIS Worldwide exchange formatWorldwide exchange format

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DICOM (2)

Imaging products, PACS, diagnostic workstations, Imaging products, PACS, diagnostic workstations, archives, RIS (results and reporting and partially archives, RIS (results and reporting and partially ADT)ADT)

Areas : radiology (all modalities), cardiac and Areas : radiology (all modalities), cardiac and vascular information, nuclear medicine, vascular information, nuclear medicine, radiotherapy, ophtamology, ultrasound, MRI, 3D, radiotherapy, ophtamology, ultrasound, MRI, 3D, dermatology, …dermatology, …

Mature standard for integrating diagnostic devices Mature standard for integrating diagnostic devices and PACS, only partially covering RISand PACS, only partially covering RIS

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HL7 - basic

Health Level 7- Initially viewed as an application Health Level 7- Initially viewed as an application level standard for communication in health – level standard for communication in health – telecommunications viewtelecommunications view

Classical text messaging view without attention Classical text messaging view without attention for multimedia informationfor multimedia information

Data models are not defined – only message Data models are not defined – only message structures that indirectly define the data modelsstructures that indirectly define the data models

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Extending the HL7 to data modeling

Hierarchical system of document Hierarchical system of document architectures – Patient record architecturearchitectures – Patient record architecture

Defines semantic and structural constraints Defines semantic and structural constraints for management and data interchangefor management and data interchange

Extended Mark-Up Language (XML) Extended Mark-Up Language (XML) definition for interchange of structured definition for interchange of structured clinical documentsclinical documents

Flexible standardization and XML checkingFlexible standardization and XML checking Not plug and playNot plug and play

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Example in Serbia of XML in the pharmacies and Healthcare fund

XML format checkers for invoices of XML format checkers for invoices of pharmacies covering the whole countrypharmacies covering the whole country

All legacy pharmacy information systems All legacy pharmacy information systems have a XML modulehave a XML module

Easy upgrade of the standardsEasy upgrade of the standards Flexible interface between all pharmacy IS Flexible interface between all pharmacy IS

and all levels of hierarchy in the Healthcare and all levels of hierarchy in the Healthcare Fund of SerbiaFund of Serbia

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HL7 Reference Information Model (RIM)

Object oriented data modelObject oriented data model Consistent view of dataConsistent view of data Data relationship modelData relationship model Data exchange modelData exchange model Guideline for building the HIS object model Guideline for building the HIS object model

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HL7 CCOW (Clinical Context Object Workgroup)

Collaboration among Visual applications on Collaboration among Visual applications on workstationsworkstations

Synchronization on the same patientSynchronization on the same patient Enables distributed collaboration on Enables distributed collaboration on

distributed medical data of different distributed medical data of different applicationsapplications

IMSIG – integrating HL7 and DICOMIMSIG – integrating HL7 and DICOM

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Coverage of HL7 and DICOM

Only partially overlappingOnly partially overlapping Practical problems proved that the two basic Practical problems proved that the two basic

standards are not enoughstandards are not enough Missing guidelinesMissing guidelines Many missing parts for the whole systemMany missing parts for the whole system

– Example PKIExample PKI– Role based security evolutionRole based security evolution– Emerging standards in ITEmerging standards in IT

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IHE – Integrating the Healthcare Enterprise

Integration of imaging and information Integration of imaging and information systems without ambition to define new systems without ambition to define new standardsstandards

Leaving Modality and PACS systems as the Leaving Modality and PACS systems as the DICOM areaDICOM area

HIS systems and RIS are predominantly HIS systems and RIS are predominantly HL7, but the RIS is the area of HL7, but the RIS is the area of HL7/DICOM overlapHL7/DICOM overlap

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Mainstream in developing HIS

Implementing multi-tier technologiesImplementing multi-tier technologies Web browser as the basic and only component at Web browser as the basic and only component at

the workstation levelthe workstation level Multimedia interface developed for the WebMultimedia interface developed for the Web Low cost maintenanceLow cost maintenance Easy sharing of data worldwideEasy sharing of data worldwide Security solutions for Web based systems can Security solutions for Web based systems can

easily be extended to healthcare (example e-easily be extended to healthcare (example e-Banking)Banking)

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Presentation tier for EPR

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Infrastructural changes

WAN, MAN, LAN difference in capacity – is it WAN, MAN, LAN difference in capacity – is it true?true?

Extremely low price 1 Gbps and 10 Gbps Extremely low price 1 Gbps and 10 Gbps interfaces on routersinterfaces on routers

Networking worldwide is not any more the Networking worldwide is not any more the limiting issue – it seeks applicationslimiting issue – it seeks applications

Free capacity of the international link is typically Free capacity of the international link is typically larger than the speed of your interfacelarger than the speed of your interface

University hospitals on the GEANT networkUniversity hospitals on the GEANT network

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Serbia medical backbone

University hospitals and institutes – more University hospitals and institutes – more than 60 buildings with dark fiber to the than 60 buildings with dark fiber to the building and 1 Gbps interfacebuilding and 1 Gbps interface

Regional hospitalsRegional hospitals

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Transparent access to medical data worldwide – fiction or

possible? HL7 is NOT plug and playHL7 is NOT plug and play Patient identification worldwidePatient identification worldwide Worldwide hierarchy of certificate Worldwide hierarchy of certificate

authorities (not self signed)authorities (not self signed) Services for allowing easy access to dataServices for allowing easy access to data Regulatory issuesRegulatory issues

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DATABASE RESONSIBLEDATABASE RESONSIBLEFOR THE ENTITYFOR THE ENTITY

ENTITYENTITY

READINGREADING CHANGINGCHANGING

EXTRACTING EXTRACTING THE KEYTHE KEY

READING AND CHANGING DATA READING AND CHANGING DATA IN DISTRIBUTED GLOBAL DATABASES IN DISTRIBUTED GLOBAL DATABASES

Transparent access to medical data – fiction or possible?

DATA OFDATA OFTHE ENTITYTHE ENTITY

DATA OFDATA OFTHE ENTITYTHE ENTITY

DATA OFDATA OFTHE ENTITYTHE ENTITY

MetadataMetadata

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GRAPHICAL USER INTERFACE

Standard needed to reach data –Web Standard needed to reach data –Web browser in multitier systemsbrowser in multitier systems

Global level database for patients Global level database for patients medical resources – metadata medical resources – metadata regarding all institutions where he regarding all institutions where he has electronic medical recordshas electronic medical records

Dynamically building pages by using Dynamically building pages by using the metadata templatesthe metadata templates

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MEDICAL GLOBAL DATABASES

Key – somehow get approval for reaching Key – somehow get approval for reaching medical data in different institutions – medical data in different institutions – service providersservice providers

Databases (Personal Resource Data - Databases (Personal Resource Data - PRD) - data stored where generatedPRD) - data stored where generated

PRDD database - standards for each field PRDD database - standards for each field of medicine defined by MDof medicine defined by MD

Personal Resource Locator Database Personal Resource Locator Database (PRLD) responsible for the entity (PRLD) responsible for the entity

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Security and privacy

Only the patient can approve the MD to Only the patient can approve the MD to reach his medical datareach his medical data

Health insurance card with the possibility to Health insurance card with the possibility to make digital signatures is crucialmake digital signatures is crucial

HIS - identity management for the staffHIS - identity management for the staff During examination MDs create a request to During examination MDs create a request to

all personal resource data sites signed by the all personal resource data sites signed by the patientpatient

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Identity federations and single sign on

Hierarchy of identity federations - Pan-Hierarchy of identity federations - Pan-European Web Single Sign On (Web SSO)European Web Single Sign On (Web SSO)

Already exists in GEANT project – Already exists in GEANT project – eduGAINeduGAIN

Authentication and Authorization Authentication and Authorization Infrastructures AAI for global Infrastructures AAI for global collaborationscollaborations

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eduGAIN

https://www.youtube.com/watch?https://www.youtube.com/watch?v=x1YhuFPxMz8#t=184v=x1YhuFPxMz8#t=184

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Who is the identity provider?

Each hospital keeps data of personnel and Each hospital keeps data of personnel and only confirms identity and role – actually only confirms identity and role – actually identity provider through HIS identity provider through HIS

Federation of medical identity providers for Federation of medical identity providers for medical area at country level is neededmedical area at country level is needed

The hospital in the HIS has users and the user The hospital in the HIS has users and the user – MD is already logged in– MD is already logged in

He is already authenticatedHe is already authenticated

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Double authentication

For the patient – the healthcare card provider For the patient – the healthcare card provider ensures authenticationensures authentication

Any medical data resource provider must be able Any medical data resource provider must be able to verify the signature to verify the signature

In the signed data, the patient must define any In the signed data, the patient must define any restrictions – in attributes of SAML messagesrestrictions – in attributes of SAML messages

The medical data resource provider is the one The medical data resource provider is the one offering the service in SAML contextoffering the service in SAML context

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Transparent access

At each country level, federations of At each country level, federations of identity providers should be formed for identity providers should be formed for medical staffmedical staff

Local HIS to be used for transparent access Local HIS to be used for transparent access to remote medical datato remote medical data

Basically – Yes he/she is our employee and Basically – Yes he/she is our employee and he/she normally has access to medical data he/she normally has access to medical data

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HIS – SAML Model

relying relying party, party, RR

browser, browser, UU

assertingassertingparty, party, PP

resource, resource, XX messagemessage, M, M

(1)(1)

(3)(3)

SAMLreq(artif)SAMLreq(artif)

SAMLresp(M)SAMLresp(M)

artif is an artifactartif is an artifactreferencing Mreferencing M

1.1. U creates authenticated U creates authenticated session with P (Local HIS)session with P (Local HIS)2. U requests access to X – remote medical data (through P). 2. U requests access to X – remote medical data (through P). 3.3. P creates protocol msg, M, containing patients digitally signed approvalP creates protocol msg, M, containing patients digitally signed approval

for U, assertion about U, patient signed approval and an for U, assertion about U, patient signed approval and an artifact referring to Martifact referring to M

4. Access, containing artifact, is redirected from P to R through browser 4. Access, containing artifact, is redirected from P to R through browser 5. R pulls M (identified by artifact) from P5. R pulls M (identified by artifact) from P

(5)(5)

(2)(2)(4)(4)

SAML SAML protocolprotocol

site1site1site2site2

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Firewalls and remote HIS security

After receiving the request, the medical data After receiving the request, the medical data resource provider needs to open the firewall resource provider needs to open the firewall for a session from the defined source for a session from the defined source addressaddress

Role based security part of the HIS of the Role based security part of the HIS of the remote hospital opens a new user that can remote hospital opens a new user that can access data related only to that single access data related only to that single patient that digitally signed the requestpatient that digitally signed the request

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Three Dimensional Examination and VRML

3D Voxel set extracted from 3D diagnostic 3D Voxel set extracted from 3D diagnostic devicesdevices

Creating 3D surfaces through segmentation Creating 3D surfaces through segmentation algorithms: marching cubes, region growingalgorithms: marching cubes, region growing

Conversion into VRMLor 3D java to enable Conversion into VRMLor 3D java to enable access through Internetaccess through Internet

How to present 3D data How to present 3D data

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3D manipulation with a Web browser

Java based tools for manipulating 3D Java based tools for manipulating 3D objectsobjects

Data is not exchanged – only manipulation Data is not exchanged – only manipulation and presentation data is traveling across the and presentation data is traveling across the network during virtual examinationnetwork during virtual examination

Is there a network bottleneck – NO!!!Is there a network bottleneck – NO!!!

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3D Visualization Components

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Integrating other services

What can become a part of the patient What can become a part of the patient medical record?medical record?

Murmurs (sounds)Murmurs (sounds) Video (surgical intervention videos)Video (surgical intervention videos) ECG or EEG medical data in electronic ECG or EEG medical data in electronic

formform For each of them a Java viewer?For each of them a Java viewer?

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Conclusion

The Web based approach to integrating The Web based approach to integrating Healthcare reached maturityHealthcare reached maturity

Technical problems are less important than Technical problems are less important than the legal and economic issuesthe legal and economic issues

The right of the patient to own his data is The right of the patient to own his data is crucial to avoid legal obstaclescrucial to avoid legal obstacles