the project started in August 2001 Project consortium members:

1. HEALTHCARE QUALITY ANALYSIS AND IMPROVED INFORMATION SYSTEM MODEL - BASED ON PORTABLE PATIENT RECORDS” the project started in August 2001 Project consortium members: • Department of Control Engineering and Information Technology Budapest University of Technology and Economics as project consortium leader • Bull Hungary Ltd. • Healthcare Network of the Hungarian Railway Co. More information: lovanyi@iit.bme.hu

2. Goal: Multidisciplinary e - Health Services The general goal of our project is to conceive and implement Unified Information System Services, based on multimedia applications, including portable record structures, shared/virtual workstations, creating a multidisciplinary e-health services space providing secure global access to medical information. Application cases are being identified concerning shared workspaces, security, database and image engineering. Our project deals with an important segment of the e society: HealthCare Information System, but all ICT results might be used in other application areas too. These tasks generate subprojects, aiming to fulfil the general requirements of the global strategy.

3. General challenges in the Hungarian Healthcare Information Systems • To improve the public health • To enhance the efficiency of the healthcare financial subsystem • To eliminate the regional differences in the quality of services

4. Developing a new concept of an Integrated Medical Information System

5. Our main development considerations • Using standard solutions • Portable record structures / virtual workplaces • Electronic document management • Secure web-based multimedia database accessed via Internet • Development of real-time image analysis algorithms • Implementation with real-time hardware-software • SmartCard technology increases data security, confidentiality and portability • Multi-level security and access (GP, patient, administrative staff, etc.) • Extensive use of networked imaging tools • Suitable mathematical interpretation of clinical objectives

6. Healthcare Information What kind of data is demanded? • Standard data types: • Patient acceptance / release • Diagnostics • Treatment • Information for patient • Quality Improvement • Management • etc.

7. Where the information is asked from? • System Models • Conventional • Extended • System Description Devices • Etc. • Processes • Patient administration • Diagnostics • Therapy • Economical aspects • Analysis • Etc. Virtual workplaces

8. Data level compatibility Data acquisition systems Data A B C

9. Interoperability Systems has to be capable to use data coming from other systems - in accordance to their own specific functionalities message Data2 Data1 B A

10. Portability Patient Record stored in a given Source Information System is considered to be portable only if it can be transported to another Target Information System preserving integrity, and it can be indexed and processed in asimilar way, compared with other records generated in the Target Information System itself.

11. Limitation 1. NOT Machine - Machine BUT Man - Machine - Machine - Man

12. Limitation 2. We do NOT deal with the multilanguage problem

13. Limitation 3. Portability is NOT a data security problem

14. Limitation 4. NOT „everybody with everybody” type communication

15. “State of art” HL7 CEN TC251 ISO TC215

16. Health Level 7 OSI Reference model

17. HL7≠P&P • Aiming to interpret a HL7 message, • a lot of agreements are needed • among sender and receiver type parties. • E.g.: • technical type • work-flow type

18. Local conventions Existing systems HL7

19. A further step • The Completeness Criteria: • „Every standard message has to contain (or at least has to refer to )all information necessary for receiver information system aiming to use the message in accordance with it’s specific system functionalities

20. HealthCare Information Health Directory Service Code System lists HDS query Service External sources Service Technical layer

21. The HDS zone file <?xml version='1.0'?> <!DOCTYPE HDS SYSTEM "HDS.dtd"> <HDS> <SERVER TYPE='primary' NAME='mav.hu' VERSION='0.1'> <OBJECT TYPE='provider' NAME='kozpont.mav.hu'> <SERVICE ADDRESS='Central.laboratory' TYPE='lab'> <!-- other possible address format Central.laboratoy@kozpont.mav.hu--> <REQUEST PID='taj@oep.hu' PORTFOLIO='oeno@gyogyinfok.hu' SAMPLE='barcode@kozpont.mav.hu' REQUESTER='intezmeny@antsz.hu'> <PORTFOLIO TYPE='include'>23011, 23100, 25000-25999</PORTFOLIO> <PORTFOLIO TYPE='exclude'>25998</PORTFOLIO> <ADDRESS> <TCPIP HOST='kplab.khz.mav.hu' PORT='ftp'/> <SNAILMAIL ADDR='1062 Budapest, Podmaniczky u. 111' MEDIA='1.44FD'/> <SNAILMAIL ADDR='1062 Budapest, Podmaniczky u. 111' MEDIA='CDROM'/> </ADDRESS> <PROTOCOL NAME='HL7' VERSION='2.3' RESOURCE='labor1@hl7.hu'/> <PROTOCOL NAME='CEN.ENV1613:1995' VERSION='1' RESOURCE='1613@TC251.CEN'/> </REQUEST> <REPLY> <ADDRESS> <TCPIP HOST='kplab.khz.mav.hu' PORT='http'/> </ADDRESS> <PROTOCOL NAME='HL7' VERSION='2.3' RESOURCE='labor1@hl7.hu'/> <CERTIFICATE RESOURCE='digiatalsignature@PKI.hu'/> </REPLY> </SERVICE> </OBJECT> </SERVER> </HDS>

22. 1. Question The communication scenario HDS Server 2. HDS query 7. Reply 3. HDS Response 5. Reaction A B 4. QUERY 6. Reply

23. New trends in Medical Informatics • The advent of unified healthcare information systems and portability of medical records increases the need for security • The use of the new tools in medical diagnosis multiplies the role of the image type data

24. Protection principles of healthcare data • According to the law in Hungary the owner of the medical data is the patient • It is not allowed to collect sensitive medical data in a central medical database • Image without personal data is not sensitive anymore but still useful: we may use them for diagnostical, educational, scientific and statistical purposes. • Doctors generally demand the original lossless image.

25. Conventional vs. IT-based image management • Film- / paper based • Non-standard, Hospital or Department - specific protocoles • Manual generation of patient identifier (exchange of name, wrong data entry, etc. possible) -------------------------------------------------------------------------- • Hierarchical access • Time stamp, audit trail • Data grouping • Backup and archiving • Automatic generation of unique global patient identifier • Interoperability • Data integrity • Information retrieval and compression • Platform / vendor independent image representation • General protocol for image-related data

26. Relevant standards • HISA – Healthcare Information System Architecture • DICOM - Digital Imaging and Communications in Medicine • NEMA - National Electrical Manufacturers Association PS 3.1 – PS 3.12 • HL7 – Health Level Seven, an Application Protocol for Electronic Data Exchange in Healthcare Environment • CEN TC251 – Comite Europeen de Normalisation, Technical Committee 251 • PACS - Picture Archiving and Communication Systems • HIPAA - Health Insurance Portability and Accountability Act • Dig35 – Metadata standards • The Dublin Core Metadata Initiative

27. Problems with standards • Overlapping or missing parts in standards created for networked imaging • No general archiving or indexing solutions are offered • Conformity with standards doesn’t mean interoperability! • At least there is no language – specific problem! • Security, image integrity

28. Medical image has almost no value without related data Related data types: • Patient data • Context of image acquisition • Parameters of image acquisition • Primary evaluation of image • Parameters of visualisation • Administrative data • etc. What might be an appropriate „electronic clip” to connect visual and related textual data?

29. Image integrity verification • A new watermark-based scenario is proposed • Brief unique digest is extracted from image and related data • Trusted Third Party is involved • Time stamping • Global identifier • Even most sophisticated attacks can be detected

30. Implementation - design considerations • Portability increases the need for security • The importance of medical images exponentially increases in diagnosis and therapy! • IT adaptation and implementation of results achieved in the previous phases • Use of up-to-date platforms (XML, UML, RDB,…) for portable patient record structure modelling • Adaptable, example - like system design

31. Implementation - current status • Buildup of the pilot project’s technical background • Realization of the portable record structure • data model • communication protokol • data transfer and storage • Implementation of different security solutions

32. Implementation - next steps In the frame of pilot applications: • Modul tests • Integration tests • Functional tests

33. Conclusion: Current Status of the project Completed tasks • Survey of the current situation in Hungarian Healthcare Informatics • Process analysis of healthcare IT workplaces • Analysis of services of existing healthcare IT platforms • Analysis of the current data archiving and security techniques • New concept of portable patient record structures • New concept of Virtual workplaces • IT-based image management