design issues for electronics health records using cloud...

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Paul I-Hai Lin & Sayed Hassan, Nov. 8, 2013

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IEEE Conference onProfessional Development & Latest Trends in Emerging

Topics for Practicing EngineersNov. 8-9, 2013

Indianapolis Marriott EastOrganized by

IEEE Central Indiana Section/Computer Society Chapter

Design Issues for Electronics Health Records Using Cloud Computing Technologies

Sayed Hassan, Interactive Intelligence, [email protected] Paul I-Hai Lin, Department of Computer, Electrical, and

Information Technology, Indiana University-Purdue University Fort Wayne

http://www.etcs.ipfw.edu/~lin, [email protected]


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Design Issues for Electronics Health Records Using Cloud Computing Technologies

Topics of Discussion

An Introduction to HealthIT and EHR

Definitions: EHR (Electronic Health Record), EMR, Cloud Computing

Previous Research in EHR Interoperability and Health Information System Integration

Cloud-Based EHR System Architecture Design Issues

A Windows Azure-Based EHR Case Study

Conclusion

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Introduction

The integration of EHR in IT infrastructures supporting organizations enable

Improved access and recording of patient data

Enhanced ability to make improved decisions,

Improved quality and

Reduced errors in patient care.

Research has shown that the healthcare industry is plagued by Rapidly increasing

costs, Poor quality of

service, Lack of integration of

patient care, and Lack of information

access to Electronic Health Records (EHR)


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World-Wide Healthcare Spending and GDP Ratio [1]

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Definitions

EHR (Electronics Health Record), http://www.himss.org/library/ehr/• The Electronic Health Record (EHR) is a longitudinal

electronic record of patient health information generated by one or more encounters in any care delivery setting.

• EHR includes patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.

• The EHR automates and streamlines the clinician's workflow.

• The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface -including evidence-based decision support, quality management, and outcomes reporting.


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An Example EHR [2]

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EMRs and EHRs [3]

EMR (Electronic Medical Record)

EHR

Definition The legal record of clinical services for a patient within a Care Delivery Organization (CDO)

A subset of EMR from one or more CDOs where the patient received clinical services

Ownership Owned by the CDO Owned by patient or stakeholder

Consumer & Usage Supplied by enterprise vendors and installed by hospitals, health systems, clinics, etc

Run are community, state, or regional health related organizations


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EMRs and EHRs [3] (cont.)

EMR (Electronic Medical Record)

EHR

Right of Patient Patients can gain access to some EMR info authorized by the EMR owners

Provided with interactive access as well as the ability to append information

Interoperability with other CDOs

Each EMR contains only the patient’s info encountered in a single CDO.

Sharing information among multiple CDOs, connected by National Health Information Network (NHIN)

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The emergence of cloud computing services provides users with

flexible access,

large storage capability and

low costs,

However, securing EHRs in cloud is a major challenge. Several security properties need to be satisfied, such as

data privacy

fine-grained access control

and scalable access between different clouds

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Emergence of Cloud Computing

Options of EHR in Cloud

Applications in the cloud (Software as a Service – SaaS).

Infrastructure in the cloud (Infrastructure as a Service – IaaS)

Platforms in the cloud (Platform as a service –PaaS)

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Emergence of Cloud Computing

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Cloud-based EHR System Architecture Design and Issues

EHR System Life Cycle• Requirements, Analysis, Design, Testing, and

Installation

Storage Requirements Communication & Networking Bandwidth

Requirements Fault Tolerance and System Availability Security and Privacy Government Laws and Regulations


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System Design: Patient-Provider Interaction

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SOA-based Design

[4]


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System Design: Understand Primary Patient-Care Provide Interaction Process [4]

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System Design: EHR Service Candidates (SOA-approach) [4]

EHR Access Services

EHR Update Services

EHR Process Orchestration Services

EHR Business Rules Services


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System Design: EHR Service Identification [4]

InsertPatient GetPatient UpdatePatient

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Cloud-Based HER Design

SaaS-based EHR IaaS-based EHR

• Cloud Storage of EHR PaaS-based EHR


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Cloud-Based EHR vs. Client/Server Design Consideration

Features Infrastructure Type

EHR in a Cloud Client/Server

1. Location of system code and execution

Remote, usually at vendor’s premise

Local, usually at clinical office/hospitals

2. Control of SystemData

Less control More control

3. System migration and/or scalability in future, assuming the same vendor is used

Easier Harder and more complex

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Cloud-Based EHR vs. Client/Server Design Consideration (cont.)



4. Security (for small clinics with limited tech support & computer resources)

More security Less security

5. Hardware Requirements

Fewer More

6. Response time Dependent upon Internet service,provider, network provisioning, and HER vendors

Dependent upon system maintenance and configuration


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7. Remote access via Internet

Easy Possible, but security measures are needed t protect EHR servers

8. Maintenance Easier Harder

9. Data synchronization for clinic with multiple offices

Easier Harder

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10. Data backup and disaster recovery

Easies and cheaper Extra expenses and technical support are required

11. Initial cost Lower Higher

12. Total life-cycle cost (3-5 years)

Lower Higher


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Previous Research: EHR Data Interoperability and Interoperable Platforms) [4][5]

Platform independent data formatting and architectural

Enables automatic data exchange between care sits

The needs of Standards• Data structure, Messaging

and Communication, Architecture, Clinical Documents, Semantic Content, Security, Business requirements, etc

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HL7, www.hl7.org

EHRCom

DICOM (Digital Imaging and Communications in Medicine), http://medical.nema.org/

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EHR Standards

Visualization Format Signing Popularity

HL7 CDA + XML - +++

EHR Com - XML - ++

DICOM SR - Binary + +


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EHR System Life Cycle• Requirements, Analysis, Design, Testing, and

Installation

Storage Requirements• Privacy & Security • Achieving HIPPA regulatory compliance through

data centers with bank-level security and high-level encryption methods

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EHR System Life Cycle Storage Requirements Communication & Networking Bandwidth

Requirements (Factors to Consider)• Number of users• User locations• Real-time transactions• Hardware• Storage technology


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Fault Tolerance and System Availability• System Availability = MTTF/(MTTF + MTTR)

MTTF – Mean Time to Failure; MTTR – Mean Time to Repair

• Unplanned hardware, software, network components failures

• Planned shutdown• Partial vs. total failure• Cloud system tolerance to system failures

Hot Standby Server Clusters Active Takeover Clusters Failover Cluster

• Recovery Schemes: Backward recovery, Roll Back, Forward Recovery

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Security Threats and Responsibility [6]


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EHR System Life Cycle Storage Requirements Communication & Networking Bandwidth

Requirements Fault Tolerance and System Availability Security and Privacy Government Laws and Regulations

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EMR system functionalityKey TasksEHR Role

Memory Computation Decision Support CollaborationReview Patient History

Displays available history and demographics

Provides Contextual view of overall patient health

Recommend care based on patient characteristics.

Incorporate information from outside sources

Conduct Patient

assessment

Prompt for required information

Compute Statistics (BMI etc.)

Action oriented clinical reminders

Coordinate across multiple providers.

Determine Clinical Decision

Relate assessment to patient history

Display trends, reference ranges

Support based on outside research/ recommendations

Staff views/instructions

Develop treatment

plan

Standards of care, care plans, evidence based guidelines

Apply Standards of care based on patient characteristics

Evidence based care adjusted by patient characteristics

Patient Summary , educational tools

Order Additional Services

Review previous services/ results

Determine appropriate provider / location

Alignment with insurance requirements

Create referrals, facilitate provider communication

Prescribe Medicatio

ns

Medications history, allergies, formulary

Dose Calculation

Interactions, contraindications, effectiveness

Patient Instructions side effects and warnings

Document Visit

Diagnosis and treatment codes

Prompts/automatic population

Insurance guidelines Patient Education, coordination with multiple Providers.


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A Case Study of an Windows Azure-based EHR with Android Mobile Apps

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Windows Azure Platform

Filtering Routers

Firewalls

Cryptographic Protection of Messages

Monitoring

Network Segmentation


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Practice Fusion (free web based HER hosted on Cloud)

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Conclusion• An Introduction to HealthIT and EHR• Definitions: EHR (Electronic Health Record),

EMR, Cloud Computing• Previous Research in EHR Interoperability

and Health Information System Integration• Cloud-Based EHR System Architecture

Design Issues• A Windows Azure-Based EHR Case Study


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References1. “America’s Stunningly Overpriced Healthcare System in 2

Charts,” Business Insider. [Online]. Available: http://www.businessinsider.com/healthcare-spending-as-a-share-of-gdp-2012-11. [Accessed: 03-Dec-2012].

2. Sahavechaphan, N.; U-ruekolan, S.; Harnsamut, N.; Phengsuwan, J.; Aroonrua, K.; , "An efficient technique for aspect-based EHR access policy administration on ABAC," ICT and Knowledge Engineering (ICT & Knowledge Engineering), 2011 9th International Conference on , vol., no., pp.27-33, 12-13 Jan. 2012

3. EMR vs HER – What is the Difference?, http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/

4. “EHR Interoperability in the U.S. based on the HL7 and CDA and SOA Methods,” M.S. Directed Project Report, Joshua Prowant, Paul Lin (Advisor), May 2009

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References5. “A Study of an Integrated Healthcare Information System,”

M.S. Directed Project Report, Elhadi Eloma, Paul Lin (Advisor), May 2009

6. “Design Issues for Electronic Health Record Using Cloud Computing Technologies,” Sayed Nayab Hassan, Paul Lin (Advisor), Spring 2013.

7. K. Hwang, F. C. Geoffrey and J. J. Dongarra, Distributed and Cloud Computing From Parallel processing to internet of things, Newyork: Elsevier, 2012.