Ebook: New Technologies in Hospital Information Systems

The conference “New Technologies in Hospital Information Systems” which is held in Ulm, Germany from 20–23 September 1997 focuses on architectural concepts for hospital information systems. It is hosted on behalf of the European Telematics Applications Project HANSA (Healthcare Advanced Networked System Architecture) with support of the GMDS WG Hospital Information Systems and the GMDS FA Medical Informatics.

Huge efforts have been undertaken in the last decade to define design criteria and to evolve the architectural layout of hospital information systems to meet rapidly changing user requirements, varying legal demands and the challenges of modern medicine. Internet Technology, Object Oriented Design, the Electronic Patient Record or Integrated Academic Information Management Systems are just some highlights which have moved into the focus of hospital information system design. Standardisation initiatives have also been carried out and are under way in Europe to provide a formal foundation for open systems in healthcare.

The conference will supply a broad overview upon such approaches and introduce into European efforts of standardisation in hospital information systems architecture. As one example, the HANSA project is based upon the European Prestandard for Healthcare Information System Architecture which has been drawn up by CEN/TC 251 PT01-13.

The proceedings contain 28 high quality papers dealing with architectural concepts, models and developments for hospital information systems. The conference contents and proceedings have been grouped in 7 sessions:

• Reference Architectures

• Modelling and Applications

• The Distributed Healthcare Environment

• New Technologies: Intranet Solutions

• New technologies: Object Orientation

• The State of Art: Networked Solutions

• Standards and Applications

A chapter with a short introduction to each of the 5 Tutorials has been included as well.

We wish to thank all, who contributed to this proceedings.

The editors, August 1997

J. Dudeck Gießen

B. Blobel Magdeburg

W. Lordieck Bielefeld

T. Bürkle Gießen

The integration and evolution of existing systems represents one of the most urgent priorities of healthcare information systems in order to allow the whole organisation to meet the increasing clinical organisational and managerial needs. This paper discusses how an open architecture, based on the introduction of a middleware of common healthcare-specific services not only reduces the effort necessary for allowing existing systems to interwork, but also automatically establishes a functional and information basis common to the whole organisation, on top of which also new applications can be rapidly developed, natively integrated with the rest of the system.

Such architecture has been already formalised through the proposed European preStandard, defined by the CEN/TC251/PT1-013 “Standard Architecture for Healthcare Information Systems” [1].

Through the utilisation of the DHE middleware, the effectiveness and validity of this approach is also being demonstrated in practice by several hospitals and healthcare industries from 13 European countries, which collaborate in the Hansa project, presently running under the Telematics Application Programme of the Commission of the European Communities.

Groupe RICHE is bringing to the market of health IT the Open Systems approach allowing a new generation of health information systems to arise with benefit for patients, health care professionals, hospital managers, agencies and citizens.

Groupe RICHE is a forum for exchanging information, expertise around open systems in health care. It is open to any organisation interested by open systems in health care and wanting to participate and influence the work done by its user, marketing and technical committees.

The Technical Committee is in charge of the maintenance of the architecture and impact the results of industrial experiences on new releases. Any Groupe RICHE member is entitled to participate to this process.

This unique approach in Europe allows health care professionals to benefit from applications supporting their business processes, including providing a cooperative working environment, a shared electronic record, in an integrated system where the information is entered only once, customised according to the user needs and available to the administrative applications.

This allows Hospital managers to satisfy their health care professionals, to smoothly migrate from their existing environment (protecting their investment), to choose products in a competitive environment, being able to mix and match system components and services from different suppliers, being free to change suppliers without having to replace their existing system (minimising risk), in line with national and regional strategies.

For suppliers, this means being able to commercialise products well fitted to their field of competence in a large market, reducing investments and increasing returns.

The RICHE approach also allows agencies to define a strategy, allowing to create a supporting infrastructure, organising the market leaving enough freedom to health care organisations and suppliers.

Such an approach is based on the definition of an open standard architecture. The RICHE esprit project defined in 1993 the three layered architecture, with four main components and their services of which the main principles have recently been adopted by the CEN TC251 as a european pre-standard. From this architecture specifications various implementations have been completed including the IMS DHE, the GESI DHE and the RÉFÉRENCE Kernel. However putting into practice this approach on a large scale is not so easy. Interesting lessons have been learned in the last years in different contries.

An important concern in distributed hospital information systems is the integration of information across heterogeneous subsystems. Consistent data replication is a central problem to be solved in this domain. The specific requirements and problems for integration of information within hospitals are discussed and a middleware architecture which has been designed according to these requirements is presented.

Communication servers are often deployed in hospitals to connect heterogeneous subsystems. This paper discusses some problems with this approach and presents a federated schema-based middleware architecture as an alternative solution for propagation of information updates across heterogeneous subsystems within hospitals.

The Electronic Healthcare Record will increasingly lie at the heart of the Healthcare Information Systems of the future, and the ability to share safely and meaningfully patient records between Hospital Information Systems depends crucially on an agreed architecture for EHCR. This paper describes the approach to providing access to Federated Healthcare Records as proposed by Synapses, a pan-European project funded under the EU Health Telematics Programme, through the use of a record server. The positioning of this server within the Healthcare Information Systems Architecture is discussed together with some suitable candidate technologies for implementation.

Regarding the need of change of both healthcare systems' structure and supporting information systems' architecture to the “Shared Care” paradigm, appropriate health information systems have to be distributed and interoperable, and will usually be based on middleware concepts. Structure and function of information systems meeting such requirements have been analysed in general. To describe, evaluate and combine distributed systems, a generic component model has been used. As a result, CORBA, DHE, and HL7 have been assessed systematically. A way to a common and harmonised middleware approach has been proposed.

This paper presents the novel Process Oriented Medical Information System Architecture (PROMISE) which has been developed in detail especially for the requirements of hospital information system engineering processes. The architecture is given in three colums and three layers along the following three dimensions: business process modeling, process specification and engineering. The heart of the architecture is a purpose-built framework for hospital information systems called PROSIGHT whose implementation can be used easily as a workbench. The single components can be customized according to detailed modeled hospital business processes which form in common a complete hospital information system. Any other framework can be used instead PROSIGHT if it can be used as a reference hospital information system in the same manner. Although the PROMISE architecture is presented in common with the given framework it can be seen as an open architecture. The hospital information system engineering process comprising the development as well as the adaptation process for a certain hospital will be skeched out.

Historically, many healthcare information systems (HIS) have been designed around monolithic architectures that rely upon a single organization to provide most, if not all, of the system's business logic. Recent advances in distributed systems technology and healthcare standards make a component-based architecture feasible in building today's HIS. The First DataBank Drug Toolkit is used as a case study for the role of components in the design of a HIS. Several technical challenges associated with building truly plug and play components are discussed.

Common objectives in the industrial countries are the improvement of quality of care, clinical effectiveness, and cost control. Cost control, in particular, has been addressed through the introduction of case mix systems for reimbursement by social-security institutions.

More data is required to enable quality improvement, increases in clinical effectiveness and for juridical reasons. At first glance, this documentation effort is contradictory to cost reduction. However, integrated services for resource management based on better documentation should help to reduce costs. The clerical effort for documentation should be decreased by providing a co-operative working environment for healthcare professionals applying sophisticated human-computer interface technology. Additional services, e.g., automatic report generation, increase the efficiency of healthcare personnel.

Modelling the medical work flow forms an essential prerequisite for integrated resource management services and for co-operative user interfaces. A user interface aware of the work flow provides intelligent assistance by offering the appropriate tools at the right moment.

Nowadays there is a trend to client/server systems with relational databases or object-oriented databases as repository. The work flows used for controlling purposes and to steer the user interfaces must be represented in the repository.

Increasingly, distributed, interoperable healthcare information systems, which meet the shared care paradigm, work across the boundaries of policy, organisational, and technological domains and are based on middleware concepts. Especially in healthcare with its sensitive personal and medical data, such systems require advanced data security measures. In the paper, a common object-oriented security model for middleware systems and advertisements for implementation are proposed, corresponding the security requirement of both the user and the application environment.

Organization of hospital information systems that are currently in use is characterized by a multitude of simple, unfortunately less integrated components. For the integration of the already available as well as new components into a hospital information system, the “Comitee European de Normalisation” (CEN) proposed a basic “Conceptual Architectural Framework”. Based on the CEN proposal, in this paper we present first results of a case study in order to investigate the usability of the Distributed Healthcare Environment (DHE), as a standard architecture for hospital information systems. Another aim of this case study was to design an Order Entry and Result Reporting System and implement it by using DHE.

This paper discusses some experiences with the integration of a tumor documentation system into a distributed healthcare environment using a new European middleware technology. Although the middleware already offers a considerable support to the software engineer further facilities have been developed in order to accelerate integrations. Such facilities arised from the software engineering principle of separating reusable parts and non-reusable parts.

The main topic of our research is health care unit (HCU) reengineering. To this aim, a guideline oriented conceptual model of HCUs was developed. In order to map this conceptual model into an information system with a client-server architecture, a guideline server is needed. The guideline concept and its life cycle are introduced and the main functions of the guideline server are presented.

The clinical information system architecture at the Columbia-Presbyterian Medical Center in New York is being incorporated into an intranet using Internet and World Wide Web protocols. The result is an Enterprise-Wide Web which provides more flexibility for access to specific patient information and general medical knowledge. Critical aspects of the architecture include a central data repository and a vocabulary server. The new architecture provides ways of displaying patient information in summary, graphical, and multimedia forms. Using customized links called Infobuttons, we provide access to on-line information resources available on the World Wide Web. Our experience to date has raised a number of interesting issues about the use of this technology for health care systems.

The explosive development of the Internet in recent years has lead to the production of massive collections of web-based tools and development know-how. Implementing an Intranet solution within a health care environment offers tremendous advantages for internal information management, distribution and collaborative computing. Easy adaptability, scalability and the low development cost allow easy integration into existing health care structures. A key aspect of the UZ Gent Intranet is its transparent interaction with the currently implemented HIS thus providing an open gateway to the future.

Several areas of HTML-applications using intranet-technology are presented, which are in routine use in our hospital: CBT for nurses and medical students, drug information, electronic literature retrieval systems and laboratory information systems.

The basic concept is an integration of commercial databases and local information. All applications are hardware-independent with the same user-interface and all use client-server-technology. By a central update it is ensured that everybody gets the most recent information.

As a result of these efforts synergy has developped. The training of the medical staff is supported which helps to improve the care of the patients.

A high level summarised description of the distributed clinical information system implemented in the hospital of the free university of Brussels (AZ-VUB) is described. It evolves towards a component based clinical distributed system that consists of a set of co-operating middelware software components running on a number of computers connected by a network that will foster the integration of applications, data servers and other resources in the medical field. This system is implemented in the University Hospital of Brussels (AZ-VUB) a full-service 800-bed university hospital that provides care for 23000 inpatients, supports over 300000 outpatient visits and receives 32000 emergency patients a year.

This paper summarizes recent work on the application of document processing technology, specifically, Standard Generalized Markup Language (SGML) to the problems of electronic exchange of healthcare related information. It includes a short description of the HL7 SGML SIG and current work on SGML standards for healthcare information exchange.

Communication standards are to facilitate the exchange of structured data and information between healthcare systems with different architectural concepts. Several national and international standard development organizations (SDO) are developing and maintaining standards, sometimes even for the same application. There is an increasing demand for a closer cooperation between SDO's and for a better harmonization of different standards going on. The current status of the most important standard application in healthcare is discussed and some further considerations for improving the harmonization process will be given.

Communication between departmental subsystems within a hospital information system (HIS) is more and more supported by dedicated communication servers (CS). One of the main advantages is a centralized and standardized flow of information. Beside this “classic” approach a communication server may be embedded on at least two other hierarchical levels in the architecture of healthcare information systems: in an organizational unit within a hospital (subsystem) but also in large scale healthcare information systems covering aspects of communication between the involved external healthcare providers.

The Erlangen communication hub allows medical subsystems to exchange data by two completely different methods. Since 1995 a communication data base, which is implemented using the relational data base system ADABAS D, contains data from the most important hospital systems. This data can be accessed by other medical systems.

Thus, the communication data base allows subsystems which do not have a standardised interface to implement proprietary system interconnections via access based on SQL. The capabilities of this interconnection are dependent on both the implementation and the data which is made available by the communication data base. This contains mainly basic patient data and the results of tests performed by various laboratory systems. In addition to this proprietary communication system we have since the end of 1996 a communication server which can also handle standardised message formats such as HL7, EDIFACT, DICOM3. Future subsystems which possess standard interfaces will be connected via this server. The connection of the patient management system IS-H and the central laboratory system to the database has been proceeding since the beginning of 1997.

The pro7-communication server is a new approach to manage communication between different applications on different hardware platforms in a hospital environment. The most important features are the use of OSF/DCE for realising remote procedure calls between different platforms, the use of an SQL-92 compatible relational database and the design of a new software development tool (called protocol definition language compiler) for describing the interface of a new application, which is to integrate in a hospital environment.