Advanced tool kits for EPR security

Responding to the challenge for efficient and high quality health care, the shared care paradigm must be established in health. In that context, information systems such as electronic patient records (EPR) have to meet this paradigm supporting communication and interoperation between the health care establishments (HCE) and health professionals (HP) involved. Due to the sensitivity of personal medical information, this co-operation must be provided in a trustworthy way. To enable different views of HCE and HP ranging from management, doctors, nurses up to systems administrators and IT professionals, a set of models for analysis, design and implementation of secure distributed EPR has been developed and introduced. The approach is based on the popular UML methodology and the component paradigm for open, interoperable systems. Easy to use tool kits deal with both application security services and communication security services but also with the security infrastructure needed. Regarding the requirements for distributed multi-user EPRs, modelling and implementation of policy agreements, authorisation and access control are especially considered. Current developments for a security infrastructure in health care based on cryptographic algorithms as health professional cards (HPC), security services employing digital signatures, and health-related TTP services are discussed. CEN and ISO initiatives for health informatics standards in the context of secure and communicable EPR are especially mentioned.     

The mantra of modeling and the forgotten powers of paper: A sociotechnical view on the development of process-oriented ICT in health care

The recognition that restructuring care processes is central to effective and efficient health care will result in the emergence of process-oriented electronic patient records (EPRs). How will these technologies come into being? Within informatics, it is often stated that to informate something, we should first model it. This paper queries whether a detailed modeling of work processes and data flows is the primary step that needs to be completed before such EPRs can be developed or tailored. Building upon a sociotechnical understanding of ICT development, we argue for a reinterpretation of 'models' in such development processes. We do so through a reverse engineering of parts of the paper-based medical record, which has received little attention in medical informatics. In process-oriented EPR design, we argue, modeling should not be conceived as the crucial first step in this design, but rather as an intervention in the organizational change-processes that constitute proper ICT development.     

Cross-institutional data exchange using the clinical document architecture (CDA)

PROBLEM: Although electronic communication of clinical data between various actors in the healthcare domain seems crucial for a cost-effective patient treatment, it is mostly restricted to paper based documents. In order to meet the growing need for improved data communication, it is necessary to overcome the barriers of software heterogeneity and lack of standards, especially in cross-institutional shared care communication. HL7's clinical document architecture (CDA) is a new and promising tool to exchange any clinical document. In this paper we show how CDA can be used to (1) share electronic discharge letters and other clinical data generated and stored in the hospitals electronic patient record (EPR) with general practitioners and (2) to transfer these clinical data to a personal electronic health record (EHR). The latter scenario is in routine use. Ease-of-use and data security and integrity were the main design principles in both scenarios. METHODS: Within the electronic patient record a data extraction and exporting mechanism has been built. For both scenarios appropriate data processing and transmission methods have been developed, and the receiving information systems have been prepared for the CDA based data input. RESULTS: Although there still remain technical and organizational issues to be solved, this is a promising method in order to enhance data exchange between hospital and primary care and to move towards an electronic patient record (EPR) and an electronic health record (EHR) crossing institutional borders. This paper describes the design and current implementation and discusses our experiences.     

Security of health care records in Belgium. Application in a University Hospital

Access rules to electronic patient records (EPR) have been issued by the Belgian Council of Physicians. Access to identifiable data of the EPR is restricted to anyone responsible for diagnosis, treatment and continuity of care of the patient. By delegation, associated personnel, like secretaries, can also be authorised to have access. A new perspective is given by the availability in 2003 of a national identification card allowing electronic signature of patients. It could not only authorise but also forbid some accesses. A law in 2002 gives right to patients to access to their own record. Health personnel can also be identified by cards but the system is not yet implemented. In the meantime, local measures have been made. We describe practical solutions that have been taken as priorities in a University Hospital. It was felt more important to allow access to lifesaving EPR data than to restrict its access by too strictly theoretical rules. A pilot study (S3 project) is also in progress for interinstitutional communication in Belgium, using the unique identification number of the patient and a "third server".     

Monitoring Reasons for Encounter via an Electronic Patient Record System: the Case of a Rural Practice Initiative

The objective of this brief communication was to tabulate common reasons for encounter in a Greek rural general practice, as result of a recently adopted electronic patient record (EPR) application. Twenty encounter reasons accounted for 3,797 visits (61% of all patient encounters), whereas 565 other reasons accounted for the remaining 2,429 visits (39%). Number one reason for encounter was health maintenance or disease prevention seeking services, including screening examinations for malignancies, immunization and provision of medical opinion reports. Hypertension, lipid disorder and ischemic heart disease without angina were among the most common reasons for seeking care. A strengths/weaknesses/opportunities/threats (SWOT) analysis on the key role of an EPR system in collecting data from rural and remote primary health care settings is also presented.     

Health care quality management by means of an incident report system and an electronic patient record system

BACKGROUND: Quality management in health care services has not been as successful as in other industries. OBJECTIVE: To assess the potential contribution of an on-line incident reporting system (OIRS) and of an electronic patient record (EPR) system to quality management in hospitals. METHODS: The two approaches are being implemented in Osaka University Hospital. RESULTS: Analysis of the early use of the on-line reporting system indicates that this qualitative approach has been effective to avoid adverse medical events. The quantitative methodology with the EPR is still in the phase of developing. CONCLUSION: Direct data entry by medical staff and an EPR based on dynamic templates and a dynamic problem oriented approach could be useful for building clinical data repositories that can support clinical quality management.     

Runtime application of Hybrid-Asbru clinical guidelines

Clinical guidelines are a major tool in improving the quality of medical care. However, to support the automation of guideline-based care, several requirements must be filled, such as specification of the guidelines in a machine-interpretable format and a connection to an Electronic Patient Record (EPR). For several different reasons, it is beneficial to convert free-text guidelines gradually, through several intermediate representations, to a machine-interpretable format. It is also realistic to consider the case when an EPR is unavailable. We propose an innovative approach to the runtime application of intermediate-represented Hybrid-Asbru guidelines, with or without an available EPR. The new approach capitalizes on our extensive work on developing the Digital electronic Guideline Library (DeGeL) framework. The new approach was implemented as the Spock system. For evaluation, three guidelines were specified in an intermediate format and were applied to a set of simulated patient records designed to cover prototypical cases. In all cases, the Spock system produced the expected output, and did not produce an unexpected one. Thus, we have demonstrated the capability of the Spock system to apply guidelines encoded in the Hybrid-Asbru intermediate representation, when an EPR is not available.     

Security of the distributed electronic patient record: a case-based approach to identifying policy issues

The growth of managed care and integrated delivery systems has created a new commodity, health information and the technology that it requires. Surveys by Deloitte and Touche indicate that over half of the hospitals in the US are in the process of implementing electronic patient record (EPR) systems. The National Research Council has established that industry spends as much as $15 billion on information technology (IT), an amount that is expanding by 20% per year. The importance of collecting, electronically storing, and using the information is undisputed. This information is needed by consumers to make informed choices; by physicians to provide appropriate quality clinical care: and by health plans to assess outcomes, control costs and monitor quality. The collection, storage and communication of a large variety of personal patient data, however, present a major dilemma. How can we provide the data required by the new forms of health care delivery and at the same time protect the personal privacy of patients? Recent debates concerning medical privacy legislation, software regulation, and telemedicine suggest that this dilemma will not be easily resolved. The problem is systemic and arises out of the routine use and flow of information throughout the health industry. Health care information is primarily transferred among authorized users. Not only is the information used for patient care and financial reimbursement, secondary users of the information include medical, nursing, and allied health education, research, social services, public health, regulation, litigation, and commercial purposes such as the development of new medical technology and marketing. The main threats to privacy and confidentiality arise from within the institutions that provide patient care as well as institutions that have access to patient data for secondary purposes.     

The Mosoriot medical record system: design and initial implementation of an outpatient electronic record system in rural Kenya

Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.     

Scaling and contextualizing personalized healthcare: A case study of disease prediction algorithm integration

Today, advances in medical informatics brought on by the increasing availability of electronic medical records (EMR) have allowed for the proliferation of data-centric tools, especially in the context of personalized healthcare. While these tools have the potential to greatly improve the quality of patient care, the effective utilization of their techniques within clinical practice may encounter two significant challenges. First, the increasing amount of electronic data generated by clinical processes can impose scalability challenges for current computational tools, requiring parallel or distributed implementations of such tools to scale. Secondly, as technology becomes increasingly intertwined in clinical workflows these tools must not only operate efficiently, but also in an interpretable manner. Failure to identity areas of uncertainty or provide appropriate context creates a potentially complex situation for both physicians and patients. This paper will present a case study investigating the issues associated with first scaling a disease prediction algorithm to accommodate dataset sizes expected in large medical practices. It will then provide an analysis on the diagnoses predictions, attempting to provide contextual information to convey the certainty of the results to a physician. Finally it will investigate latent demographic features of the patient’s themselves, which may have an impact on the accuracy of the diagnosis predictions.     

Efficient high capacity technique to embed EPR information and to detect tampering in medical images

Abstract

Reversible data hiding (RDH) is one of the well-known and highly recommended method to enhance medical data security or electronic patient record (EPR), privacy and truthfulness. In clinical images, while hiding the data, care must be taken to maintain the confidentiality of the information that is to be hidden within the clinical images because the hidden information should not bring down the original quality of the image. Mostly, the investigations carried out for medical diagnosis are usually constructed on the basis of investigation systems used for diagnosis and are grounded on the images usually used for medical study. Magnetic resonance image (MRI), CR and CT, digital format images which are acquired are related to the patient’s data and information regarding their diagnosis study. In this presented approach, we introduce an RDH scheme that can also be combined with encryption and reversible watermarking techniques. Here, we use the data related to the patient diagnosis as the secret information to embed in medical images. Quality of the marked image after embedding the data is usually measured with metrics that are usually used in image processing such as PSNR and SSIM.     

Data security and protection in cross-institutional electronic patient records

This paper aims at identifying the specific legal requirements concerning data security and data protection of patient health data that apply to a cross-institutional electronic patient record (EPR) and describes possible solutions for meeting these requirements. In Germany, the legal framework for such records provide that disclosure of patient health information to physicians of third-party institutions is only allowed in case that it is necessary for the joint treatment of the patient, i.e. in case of a “treatment connection”. As a first step, the functionality of a remote-access architecture was proven allowing a one-way connection between the EPR systems of two health institutions in Germany, which jointly treat tumor patients. Besides, a signature system model for ensuring the integrity and authenticity of medical documents was developed and implemented in the existing information system architecture of the University Medical Center of Heidelberg. Especially in Germany, the legal framework for cross-institutional EPRs is very complex and has a considerable influence on the development and implementation of cross-institutional EPRs. However, its introduction is thought to be valuable, since a cross-institutional EPR will improve communication within shared care processes, and thus improve the quality of patient care.     

Governance and assessment in a widely distributed medical education program in Australia

The learning objectives, curriculum content, and assessment standards for distributed medical education programs must be aligned across the health care systems and community contexts in which their students train. In this article, the authors describe their experiences at Monash University implementing a distributed medical education program at metropolitan, regional, and rural Australian sites and an offshore Malaysian site, using four different implementation models. Standardizing learning objectives, curriculum content, and assessment standards across all sites while allowing for site-specific implementation models created challenges for educational alignment. At the same time, this diversity created opportunities to customize the curriculum to fit a variety of settings and for innovations that have enriched the educational system as a whole.Developing these distributed medical education programs required a detailed review of Monash's learning objectives and curriculum content and their relevance to the four different sites. It also required a review of assessment methods to ensure an identical and equitable system of assessment for students at all sites. It additionally demanded changes to the systems of governance and the management of the educational program away from a centrally constructed and mandated curriculum to more collaborative approaches to curriculum design and implementation involving discipline leaders at multiple sites.Distributed medical education programs, like that at Monash, in which cohorts of students undertake the same curriculum in different contexts, provide potentially powerful research platforms to compare different pedagogical approaches to medical education and the impact of context on learning outcomes.     

Sharing patient care records over the World Wide Web

In order to obtain appropriate medical care, patients can be referred or transported from one hospital to another based on the capacity, capability and quality of medical care provided by hospitals. Therefore, enabling patient care records to be shared among hospitals is essential not only in delivering the quality of medical care services but also in saving medical expenses. Currently, most patient care records are paper-based and not well organized. Hence, they are usually incomplete and can hardly be accessed in time. The authors in this paper present methods to structure and represent patient care records, design mechanisms for interpreting and integrating the XML-based patient care records into the existing hospital information systems. More importantly, in our approach, each significant piece of medical record is associated with a tag based on the syntax and semantics of the XML. The XML-based medical records enable a computer to capture the meaning and structure of the document on the web. The authors have developed a unified referral information system in which patient care records can be shared among hospitals over the Internet. It can not only facilitate the referral process but also maintain the integrity of a patient's medical record from distributed hospitals. The workflow of the system basically follows the existing manual system and can easily be adapted. The working group on integration of municipal hospital information systems, Department of Health, Taipei City Government, has decided to adapt this system for referral practice among the municipal hospitals.     

From a conceptual problem-oriented electronic patient record model to running systems: a nationwide assessment

BACKGROUND: The development of problem-oriented conceptual models for electronic patient record (EPR) systems can improve data communication between health professionals. But little has been done so far to investigate to what extent it is possible to implement such models in operational EPR systems. OBJECTIVE: In this paper, we measure the conformance between a conceptual model and the various ways it is implemented within general practitioners' (GPs') electronic patient records. METHODS: We started from a simple problem-oriented conceptual model and we defined an original discriminating method to assess its implementation. This method is scenario-based (dummy patient), functional, and relative (comparison between software systems). Each implementation is assessed by two evaluators and the final result is a "success/failure" score. The assessment was performed within the scope of the official Belgian accreditation procedure for GPs' electronic patient records, which is voluntary, publicly funded, and based on a dynamic quality improvement paradigm. Almost all Belgian GPs' software systems (17) were assessed. The robustness of our results was assessed through a sensitivity analysis. RESULTS: We found that 65% (11/17) of the software systems currently used succeeded in implementing the problem-oriented conceptual model with a high confidence level (error rate<10%). The results were widely accepted by the software developers. CONCLUSIONS: A problem-oriented conceptual model can be successfully implemented in many operational EPR systems. The quality of the implementation can be assessed. Our results could be used at the international level to improve semantic interoperability between patient information systems, for instance in relation to broader conceptual models such as the European CONTsys pre-norm.     

Rethinking the models and modes of diabetes education

Diabetes patient education has emerged as an integral component of comprehensive diabetes care during the past 50 years. The medical model of information transfer is now inadequate to support the variety of effective techniques which have been shown to influence patients' knowledge and health behavior. To cope with rapidly changing patterns of diabetes care, diabetes education must develop new models and modes. This article presents a re-evaluation of the traditional concepts of diabetes education and identifies new challenges and new directions for the 1990s.     

A probabilistic and decision-theoretic approach to the management of infectious disease at the ICU

The medical community is presently in a state of transition from a situation dominated by the paper medical record to a future situation where all patient data will be available on-line by an electronic clinical information system. In data-intensive clinical environments, such as intensive care units (ICUs), clinical patient data are already fully managed by such systems in a number of hospitals. However, providing facilities for storing and retrieving patient data to clinicians is not enough; clinical information systems should also offer facilities to assist clinicians in dealing with hard clinical problems. Extending an information system's capabilities by integrating it with a decision-support system may be a solution. In this paper, we describe the development of a probabilistic and decision-theoretic system that aims to assist clinicians in diagnosing and treating patients with pneumonia in the intensive-care unit. Its underlying probabilistic-network model includes temporal knowledge to diagnose pneumonia on the basis of the likelihood of laryngotracheobronchial-tree colonisation by pathogens, and symptoms and signs actually present in the patient. Optimal antimicrobial therapy is selected by balancing the expected efficacy of treatment, which is related to the likelihood of particular pathogens causing the infection, against the spectrum of antimicrobial treatment. The models were built on the basis of expert knowledge. The patient data that were available were of limited value in the initial construction of the models because of problems of incompleteness. In particular, detailed temporal information was missing. By means of a number of different techniques, among others from the theory of linear programming, these data have been used to check the probabilistic information elicited from infectious-disease experts. The results of an evaluation of a number of slightly different models using retrospective patient data are discussed as well.     

From a paper-based transmission of discharge summaries to electronic communication in health care regions

OBJECTIVES: In Austria, the general practitioner (GP) is the first point of contact for persons with health problems. Depending on the severity of the person's medical condition, a GP may refer her or him to a secondary care hospital consultant, who reports findings back to the GP in form of a paper-based discharge letter. Researchers report that paper-based communication of medical documents between different health care providers is insufficient in quality, error prone and too slow in many cases. Our aim was to develop and to realise a strategy for a stepwise replacement of the paper-based transmission of medical documents with a distributed, shared medical record. METHODS: In the first step of a three-steps strategy for development of a consistent, comprehensive and secure regional health care network, an electronic communication of discharge letters and diagnostic results between existing information systems of different health care providers in Tyrol, Austria, has been established: in the form of cryptographically signed S/MIME e-mail messages and, additionally, via a secure web portal system. In two further steps, an extension of the system by a bi-directional communication and by improvements of the web portal system is planned, leading to a comprehensive electronic patient record for shared care. RESULTS: After realisation of step 1, in October 2004, about 3500 electronic discharge letters were sent out from the Innsbruck University Hospital (IUH), which represents about 8% of the total number of discharge letters of the IUH. In addition, a lot of feedback was received and legal, organisational, financial and methodical difficulties were overcome. DISCUSSION: The stepwise approach to replace paper-based with electronic communication in the first step was helpful, since knowledge has been gained and cooperations were formed. For the realisation of a distributed, shared medical record (steps 2 and 3), it will not be sufficient only to replace paper-based transmission of medical documents with electronic communication technologies, but in the further steps, organisational changes will become necessary. As well, legal ambiguities must be resolved before a distributed medical record for cooperative care, used by several institutions as well as by patients, could be established.