Department Informatik DEUS

Department Informatik Technical Reports / ISSN 2191-5008 Christoph P. Neumann, Florian Rampp, Richard Lenz DEUS: Distributed Electronic Patient File Update System Technical Report CS-2012-02 March 2012 Please cite as: Christoph P. Neumann, Florian Rampp, Richard Lenz, “DEUS: Distributed Electronic Patient File Update System”, University of Erlangen, Dept. of Computer Science, Technical Reports, CS-2012-02, March 2012. Friedrich-Alexander-Universitat¨ Erlangen-Nurnberg¨ Department Informatik Martensstr. 3 · 91058 Erlangen · Germany www.informatik.uni-erlangen.de DEUS: Distributed Electronic Patient File Update System Christoph P. Neumann, Florian Rampp, Richard Lenz Institute of Computer Science 6 (Data Management) Dept. of Computer Science, University of Erlangen, Germany [email protected] Abstract—Inadequate availability of patient information aging of western society affects the public health sector, is a major cause for medical errors and affects costs in chronic diseases and multimorbidity become the focus of healthcare. Traditional approaches to information inte- interest, and the cost pressure rises. Chronic diseases and gration in healthcare do not solve the problem. Apply- multimorbidity, like cancer, diabetes, asthma, and cardiac ing a document-oriented paradigm to systems integra- insufficiency, require more healthcare parties than com- tion enables inter-institutional information exchange in healthcare. The goal of the proposed architecture is to mon diseases. Coevally, the rapid advance in medicine provide information exchange between strict autonomous leads to an advancing specialization of physicians that healthcare institutions, bridging the gap between primary is an additional cause for the increasing number of and secondary care. involved parties regarding a single patient’s treatment. In a long-term healthcare data distribution scenario, For improving the treatment quality and in order to the patient has to maintain sovereignty over any personal avoid unnecessary costs, an effective information and health information. Thus, the traditional publish-subscribe communication technology is vital for the support of architecture is extended by a phase of human mediation inter-institutional patient treatment. within the data flow. DEUS essentially decouples the roles of An IT infrastructure for healthcare networks must information author and information publisher into distinct actors, resulting in a triangular data flow. The interaction respect and consider the autonomy of preexisting sys- scenario will be motivated. The significance of human tems in different institutions. At the same time some mediation will be discussed. DEUS provides a carefully dis- kind of integration is required, which helps to preserve tinguished actor and role model for mediated pub-sub. The inter-institutional data consistency. Closely integrated data flow between the participants is factored into distinct systems with a common database and terminological phases of information interchange. The artefact model is standards for database contents are unrealistic in this decomposed into role-dependent constituent parts. Both scenario. In particular, strict autonomy of the institu- a domain specific (healthcare) terminology and a generic tions requires the abdication of central infrastructure terminology is provided. From a technical perspective, like joint databases, transaction monitors, and central the system design is presented. The sublayer for network transfer will be highlighted as well as the subsystem for context managers. Shared communication requires min- human-machine interaction. imal standards avoiding full-fledged platform-specific Index Terms—Healthcare, information systems, inter- middleware frameworks. Instead, a document-oriented institutional, domain engineering, distributed applications, publish-subscribe paradigm is favored, which supports distributed data structures, document-orientation, publish- loose coupling of systems at different sites. subscribe, human mediation In any case, semantic agreements like healthcare on- tologies, terminologies, and clinical models evolve over I. INTRODUCTION time. Therefore, an adequate system design methodology In a systems analysis of adverse drug events, 18% for evolutionary information systems becomes impera- of the medical errors were associated with inadequate tive [2]. A layered approach for healtcare information availability of patient information [1]. The problem of sytems decouples system design processes on different inadequate availability of patient information as a ma- levels of abstraction, decreases complexity in each layer, jor cause for medical errors is aggravated by the rise and thereby supports system evolution and responsive of healthcare networks and the increasing number of infrastructures. In [3] such an approach with four layers healthcare parties that are involved in a treatment: The is proposed: generic framework layer, domain framework layer, application layer, and custom layer, with different anamnesis interviews with the patient. The sticking point people as key drivers for the different layers. This model, is that the discharge letters are frequently missing or however is an idealized picture, which is not yet related are insufficient in detail [7], either because they arenot to existing standards and frameworks. In this paper, the written by the physicians at all or because they are not research focus is on domain framework solutions as available to all involved parties [8]. Repeated anamnesis extensions to existing healthcare information systems. interviews are no alternative for document interchange This paper describes a publish-subscribe architecture between healthcare professionals. Redundantly applied for healthcare supply chain scenarios. This technical re- diagnostic methods by each distinct institution are the port is an extended version of a previous publication [4]. norm. As simple as order entry and result reporting There are two distinguishable features of the proposed may seem, it is still one of the most important issues in solution: to apply document-orientation as instrument healthcare information systems [9]. The data integration of inter-institutional integration and to allow patients of healthcare information systems will be addressed by to control information distribution. To put a mediated a document-oriented approach in the proposed solution. publish-subscribe architecture into practice requires a In order to foster the continuity of care [10], the systematic distinction of actors, roles, phases, and re- inter-institutional cooperation needs to bridge the current sponsibilities in the distribution scenario. The proposed gap between institutions of the primary and secondary architecture essentially decouples the roles of informa- care [11]. Such effort must not instrument regional stan- tion author and information publisher into distinct actors. dards, as it is done in regional healthcare information networks (RHIN) [12], but transregional standards. Ac- II. SUPPLY CHAINS IN HEALTHCARE complishing information exchange in distributed health- A short overview of the domain participants is given: care scenarios requires the integration of heterogeneous The focus of the medical supply chain in Germany are and strict autonomous IT systems. To allow for inter- the patients who are treated by office-based physicians institutional cooperation the support of distributed and foremost, collectively described as the primary care. The seamless flow of information is required, thus changing secondary care adds hospitals, laboratories, pharmacies, paradigms from closed and hegemonic to open and dis- and ancillary medical institutions as participants of the tributed architectures. The proposed architecture adheres medical supply chain. Accompanying participants are the to these boundary conditions. health insurance funds and the associations of statutory health insurance physicians. B. From Bilateral Information Exchange The whole interaction and collaboration is liable to to Information Distribution many technical, organizational, economic, and legal fac- Information interchange by letters is the way of tra- tors. The legal boundary conditions are critical for the in- ditional cooperation – a referral from one institution to formation provision and availability because warranty of another delegates responsibility and liability of diagnosis data protection is essential for patient-related data. The or therapy to the other institution. Yet, genuine physician patient has to maintain sovereignty over any personal teams from different institutions are upcoming [13]. For health information. This provides a basic motivation some years now, in Germany, the treatment of breast for the mediation approach that will be applied to the cancer is organized by accredited in-station breast cancer publish-subscribe pattern. treatment centers cooperating with manifold accredited partners like oncologists, radiologists, and the post- A. Inter-Institutional Problems operative care [14]. Collaborative treatment scenarios Considering the comprehensive medical supply chain, can be described as distributed medical treatment pro- functional integration and process integration between cesses with physician teams from different institutions the autonomous information systems of the several interacting closely meshed for treating complex chronic participants is still unsolved in organizational and diseases and multimorbidity. diagnostic-therapeutic processes [5].

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