MEDICAL TUTORIAL: PORTING OF A CLINICAL PORTAL
BETWEEN HEALTHCARE ORGANIZATIONS
Reuse of an Application in Health Informatics
Paolo Locatelli, Emanuele Baj
Fondazione Politecnico di Milano, Via Garofalo, 39, 20133 Milan, Italy
Gianni Origgi, Silvia Bragagia
A.O. Ospedale Niguarda Ca’ Granda – S.C. Siapri, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
Keywords: ICT solution porting, Reuse, eHealth, Healthcare management systems, Clinical portal.
Abstract: The aim of the paper is to discuss the application of a methodology for the structured evaluation of the
porting of an eHealth solution. In particular a web Information System in the area of Medical and Nursing
Informatics, the portal developed by an Healthcare Organization for supporting clinical management
processes, is taken as practical example of such a process. A procedure used for the evaluation of reuse in
public administration is brought forward and, through the example, it is shown how it could be applied to
Healthcare Management Systems.
1 INTRODUCTION
The main objective of this paper is that of finding a
way to define a path to be followed in order to
choose to reuse (i.e. the porting of an ICT
application in a different organization) a solution in
health informatics. Nowadays, some guidelines to
define reuse of information solutions have been
released in many sectors of public administration,
but none of them refers to health. The concept of
reuse implies some steps to be followed in order to
evaluate advantages and disadvantages of an
alternative, by jointly considering technical and
functional features. These steps should be evaluated
in health sector as well as done for other
environments (CNIPA, 2006).
It is worth considering the reuse of an application
only if the impact on procedures does not imply
excessive efforts to change the way people are used
to work. This and other aspects are analysed in the
following sections, through a method which
considers: requirements definition and selection of
an application, adequacy and convenience
verification, feasibility study. By analysing the real
case of porting of a clinical portal from one hospital
to another, this paper aims to show the aspects
which can position this solution as an example of
reuse of an application. By doing this, an empirical
demonstration of the possibility to extend this
concept to health informatics will be given, placing
the basis for the creation of a structured method to
evaluate it.
2 A REAL CASE OF REUSE IN
HEALTH INFORMATICS
The hospital “Azienda Ospedaliera Niguarda Ca’
Granda” is the leading public hospital in Milan since
1939. It is national reference hospital for emergency
events and the only regional point of care qualified
to perform any kind of tissue and organ transplant.
The Hospital employs 1.540 doctors and 740 nurses
and counts 54.000 yearly admissions (both ordinary
and Day Hospital) and 3 millions First Aid Station
treatments. The hospital has begun developing its
own portal as an internal application since 1991, in
order to fulfil the needing of digitalizing patients’
clinical dossiers, by updating in real time their health
history after their first access in the hospital,
tracking processes and supporting clinical activities
(Shepherd, 2000). From that year since now the
375
Locatelli P., Baj E., Origgi G. and Bragagia S. (2009).
MEDICAL TUTORIAL: PORTING OF A CLINICAL PORTAL BETWEEN HEALTHCARE ORGANIZATIONS - Reuse of an Application in Health
Informatics.
In Proceedings of the International Conference on Health Informatics, pages 375-380
DOI: 10.5220/0001780003750380
Copyright
c
SciTePress
portal has spread enormously, thus becoming an
instrument by which sanitary operators can feed
patients’ virtual clinical history, by visualizing and
inserting data required by their cure processes.
Today the portal, together with its various vertical
specifications, is widely used by physicians and
nurses in different units, with successful results and
great appreciation expressed by the users. The
excellent results gained in Niguarda have soon
become recognised as best practice in the regional
health environment and other hospitals are
beginning to consider Niguarda’s portal as a possible
solution for their own realities. That’s how a
solution originally developed with a simple digital
storage aim has come to compete with clinical
market packages and has placed the basis for the
definition of successful reuse experiences in health
informatics. What makes the solution really different
from traditional Health Information Systems is the
brand new approach followed by Niguarda of
rethinking the traditional concept of patient record,
conceiving it as a core instrument for supporting
extensively clinical management processes (Pollak,
2001). The main idea is to develop a web intranet
portal conceived as a virtually unique access point to
the HIS, networking the other vertical subsystems
and thus linking clinical processes that did not
communicate before, allowing new information
flows sharing patient data. Being based on a
centralized patient reference registry and on an open
network architecture, the portal is able to retrieve
and link both clinical and administrative patient-
specific data regarding its relationship with the
hospital, gathering them into a common and friendly
interface, standardizing communication and process
interaction between different hospital departments.
The lack of competences in analysing other
realities and spreading the solution is filled by
Niguarda with the continuous collaboration with
Fondazione Politecnico di Milano, which makes its
managerial competences available for managing the
transfer of the solution, taking care of all the aspects
concerning relationship with clients and engineering
additional features to satisfy their requirements.
Being known among the regional health
environment, Niguarda’s portal has been pointed out
as one of the possible alternatives for its clinical
information system by “Fondazione IRCCS Istituto
Neurologico Carlo Besta”, a centre of excellence for
care and scientific research of neurological diseases,
well known at national and international level.
Transferring the solution requires a deep
organizational change as well as a porting, which, by
definition, is “the process of adapting software so
that an executable program can be created for a
computing environment that is different from the
one for which it was originally designed” , but it is a
term more widely used to refer to “the changing of
software/hardware to make them usable in different
environments”(Mooney, 1997. Garey, 2007).
2.1 Requirements Definition and
Application Selection
The decision of making a change in the clinical
information system, has to be linked to requirements
emerging for different reasons, ranging from
difficulties in properly using current systems to legal
aspects. Requirements definition phase involves the
evaluation of procedures and definition of
functionalities, distinguishing them by priority. This
separation is useful in a reuse process when
evaluating the impact of personalization of the
original solution: the more fundamental features are
covered by the application, the less is the cost of
realization of new functions. Technological aspects
should be evaluated, in order to make a comparison
with those of the original solution; flexibility and
adaptability to changes of current technologies has
to be considered as well. (Magnis, 2000) Another
fundamental requirement is management’s
commitment, together with a cost-benefit analysis
and an evaluation of the level of protection which
has to be given to data. All this features have been
taken in consideration by Besta’s management, as a
first filter to alternatives which can be considered as
possible solutions.
A benchmark analysis is fundamental in order to
identify, among solutions already available on the
market, those compliant to the requirements
previously defined. In this way a cluster of solutions
is built, in which commercial solutions, such as
clinical market packages, are distinguished from “ad
hoc” solutions. Even if market packages have great
probability to cover a great part of requirements,
since they have been developed with the aim of
standardizing optimized clinical procedures, this
feature has to be evaluated since they lack
flexibility, so they require a change in the way
people work. On the contrary, “ad hoc” solutions
could be more appreciated, especially if they are
already successfully used in other structures. These
and other points are subject to further analysis, in
order to determine which solution is the one that best
fit functional, procedural and economic
requirements.
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2.2 Adequacy Verification
The analysis of a possible reusable solution starts
with a verification about its adaptability to
requirements. Selecting Niguarda’s application,
Besta needed to evaluate similarity of the
organizational context, features of functional and
technological factors as well as quality level of the
chosen alternative. For this activity the role played
by Fondazione Politecnico di Milano has revealed
fundamental, thanks to its ability in analysing
processes and quickly identifying required
evolutions and the more adequate technologies to
adapt a solution to different realities (Davenport,
1993).
2.2.1 Organizational Context
Organizations can find opportunities in reusing
applications already developed and tested by other
enterprises working in the same context. This is
Niguarda and Besta’s case, both working in health
area, with similar procedures and operating
processes, since subject to the same laws and rules at
national and local level. Being Niguarda the biggest
regional hospital and having developed portal’s
functionalities for many units, its application already
covers most of the features required by a specialized
clinical structure as Besta: starting from this point,
only few functions need to be fully developed.
Another important organizational feature is
managerial commitment towards the change in
procedures; since users are mainly physicians,
information systems are supposed to simplify their
procedures, not to introduce criticalities: reusing a
solution remarkably reduces this impact. The real
situation has shown adequacy on the organizational
side, proving Niguarda’s solution can be easily
integrated into other clinical organizations.
2.2.2 Functional and Technological Features
A detailed analysis over functionalities is
indispensable to determine whether key
requirements are satisfied or not by the target
application (Duplaga, 2004). The result Besta’s
management aims to reach is that of creating a portal
which not only allows digital handling of patients’
clinical data, but also gives the possibility to use
them into scientific research (Lehmann, 2006). This
aspect lacks in Niguarda’s solution, so it is necessary
an ad-hoc development, interoperable with the
portal; the stability of this kind of requirement,
assured by inner features of client’s structure,
guarantees that all the future maintenance will be
aligned to this aim, so, with the vendor continuously
supporting the solution, the impact of this feature
will be very low on the basic structure of the
developed system. Flow analysis and collaborative
approach towards integration with other existent
information systems are useful tools to prove that
Niguarda’s portal can be considered functionally
adequate to Besta’s reality.
A great effort for adequacy verification should
be dedicated to technological analysis. This activity
requires the evaluation of software, hardware and
network infrastructure, as well as the interoperability
with already existent solutions, especially those
required by law for regional and national data
interchange. Laws concerning health require the
possibility for physicians to digitally sign outpatient
reports they produce and to make them available for
other hospitals in the region to access them when
visiting patients already passed from other
structures; that is what the local government of the
region of Lombardy is making with SISS (the
Regional Social-Sanitary Information System)
platform. Besta’s current applications were
developed with a configuration suitable to this
platform, then, before installing a new one, it is
necessary to adapt the functioning environment and
to verify interoperability. In a case of reuse such as
ours, this checks are facilitated since the involved
structures belong to the same context and are
compliant to the same rules.
As far as hardware is concerned, a server farm
working in outsourcing will be used. An important
advantage for both client and vendor is represented
by the possibility to make some activities
converging, as in the case of test environment’s
optimization, first performed for Niguarda’s solution
and then replied for Besta. Contribution from
technological partners in this field would provide the
experience required to find the best way to lead this
activity.
On software side, analysis have been made to
evaluate possible incompatibilities with DBMS or
Application servers, revealing adequacy under this
aspect. The whole application has been developed
with open source technologies, assuring continuous
maintainability at low costs. The project will use the
DBMS technology of Oracle (compliant with the
technology of the Regional System – SISS) but the
data access, application and presentation
technologies will be completely open source based
to create a J2EE architecture: Java Server Faces
(JSF) and Java controllers in the web presentation
layer; Enterprise Java Bean in the application layer;
MEDICAL TUTORIAL: PORTING OF A CLINICAL PORTAL BETWEEN HEALTHCARE ORGANIZATIONS -
Reuse of an Application in Health Informatics
377
Java Data Access Object (DAO) Services and
Persistence Manager for the data layer.
Finally, support for daily activity is an important
feature: Niguarda will be part of Besta’s help desk.
Technical resources will be contacted directly from
Besta for higher level help desk, while maintenance
on the system will be enabled by remote network
access.
All these features contribute to judge the solution
adequate from technological point of view.
2.2.3 Quality Level
In order to complete the adequacy verification, a
further analysis should be conducted, evaluating the
compliance to some quality levels: compliance to
standards, maintainability, reliability, usability,
support’s quality, portability.
As far as standards are concerned, it has already
been said that Niguarda’s application has been
developed with standard open source languages.
Moreover, standard technologies have been used
also for application servers and communication
protocols. Interoperability is assured by the use of
HL7; using this language reduces the amount of
problems which has to be faced while configuring
the right communication between the parts of the
Health Information System (Aspden, 2004).
Compliance to standards is an important aspect also
in assuring maintainability of the application.
Concerning reliability, a reuse experience must
refer to success of previous uses. Wide appreciation
manifested by users in Niguarda is a symptom of
reliability; moreover, reliability is assured by the
fact that people who already follows development
and functioning of the original application and who
knows problems related to it are the same who will
follow the application reinstalled, so they are
supposed to be able to anticipate the more common
troubles they have already faced.
Usability is guaranteed by a structured training
program that Niguarda will hold to Besta’s users and
by the functionality of eLearning provided inside the
portal. Moreover, usability is improved by constant
monitoring of functionalities, based on users’
feedback, together with a perceptual interface,
developed to allow users to easily navigate through
patients’ clinical data and among different patients
with the lowest number of intermediate masks.
Portability is assured by definition, since the
whole project of reuse is based on the concept of
porting the application. Adaptability to operating
environments, ease of installation and compliance to
porting standards are therefore assured.
Niguarda’s solution appears strong under all
these points of view. It appears reasonable to say
that the level of quality held by this solution makes
the adequacy verification completed.
2.3 Convenience Verification
Selection of an application can’t be made without
considering the costs it will imply (Wager, 2005).
Realization costs could be evaluated on two
sides: those related to usability and those concerning
covering of functional factors.
Costs related to usability are those linked to time
spent by people on learning how to use the new
system. Since the impact of Niguarda’s solution on
Besta’s procedures will be low, users will have to
learn just where old functions are positioned in the
new system and how to use the new features. Other
costs related to usability are those involving the
analysis phase and the production of technical
documentation. Documents already available for the
original application make easier the flow analysis,
due to the similarity in the organizational context.
This documentation could be followed by users to
better learn how to become familiar to the new
system, requiring lower times and lower costs.
Covering of functional factors is strictly linked to
the costs of development, since the more new
functions have to be added the more costs will have
to be faced. The adequacy previously verified, as
regards new functions and low investment in
technologies, contribute to keep costs moderated.
The excellence of this project will also allow a
funding contribution of Italian Ministry of Health.
After the solution will be installed, it will be
subject to different maintenance activities.
Evolutionary maintenance concerns the development
of new features. Costs regarding this aspect are
reduced in Besta’s case, since requirements’ stability
assures that future interventions will be limited to
just few functionalities, generally made as
specifications of already developed functions.
Updating maintenance is related to adapting the
application to new software releases or to modifies
on the hardware platform. Corrective maintenance is
related to the correction of bugs in the developed
functionalities. Being used on two sides, actions
concerning these aspects could be optimized: costs
can be reduced since updating is made just once and
used for both the original and the reused application.
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2.4 Feasibility Study
All the previous analysis have to be summarized
inside a feasibility study, conducted in order to
understand whether a solution, selected after
adequacy and convenience verify, could really be
implemented and with which modality (Tan, 2001).
First of all, it should be evaluated if process
analysis could really be reused. As already assessed,
Besta’s flows are very close to Niguarda’s and to all
the other healthcare realities; it is important to notice
how modalities followed by Niguarda to fill in the
gaps from the “as is” to the “to be” situation could
be replied on Besta’s situation. This activity has
been conducted by Fondazione Politecnico in
Besta’s situation through empirical analysis of the
flows, evaluation of the procedures enabled by the
dismissed information systems, analysis of the real
requirements and evaluation of their adaptability to
original application’s functions, validation of the
proposed flows. Beside these activities, the
alignment with management has been kept through
periodical communication and an applicative demo.
This solution has been thought together with the
management of the client organization, in order to
directly involve users in suggesting new
functionalities and in expressing their opinion about
future criticalities.
The modality through which the reuse could be
implemented are linked to available resources, both
human and financial. According to Besta’s reality,
the better solution appear to be a reuse in facility
management, where Besta will have the operating
responsibility over the service supply, by providing
an adequate hardware structure for the environment
installation. On the other side, Niguarda assures
evolutionary maintenance and support for training
and help desk activities, as well as its support for the
functioning of the application. Both Besta and
Niguarda will cooperate in finding solutions for
enabling interoperability with already existent
solutions.
The reuse impacts on risk analysis: Niguarda’s
strong involvement in the application, which will
remain its property, contributes to keep a low effect
of risk factors on the application, since they have
been already evaluated on the original application.
2.5 Benefits Related to Reuse
The choice of an application provided as a reuse
solution is always subject to an evaluation of
benefits provided, in comparison to those reachable
through other tools, such as clinical market packages
(Sommerville, 2007; Chauldry, 2006). In this section
benefits are analysed in the form of financial savings
and intangible advantages.
As regards savings, some remarkable points have
to be analysed. First of all, project realization costs
are reduced, since the development is made through
open source technologies and some typical costs of a
best of breed solution bought on the market, such as
licences, are avoided.
Other costs remarkably reduced are those related
to maintenance and management of the application.
All the evolutionary maintenance realized for Besta
will be also part of updating in the original
application. In this way the costs of development are
shared between two companies and produce results
for two applications, even if they require the effort
for maintaining just one.
Human resources involved in this kind of
projects are far less than those involved by the
introduction of a “best of breed” system. Users will
go on working with a different application but
similar enabled procedures. Costs linked to training
are less than those implied by market packages,
since required hours are less and documentation has
to be subject to few modifies in comparison to that
already used for the training of Niguarda’s staff.
Intangibles advantages are related to
organizational procedures, since “ad hoc” solutions
are realized to fit real requirements, instead of giving
parameters towards which addressing procedures.
The implemented solution allows to collect clinical
data in a structured way, making them useful for
scientific treatments with research aim; in addition,
structured data allow an automated traceability of
people registered into the system, whose complete
clinical histories are visible 24 hours long.
Completeness is assured by a new structure given to
data, which links them to the clinical event and
associates each event to the patient involved in it.
Moreover, also administration systems can gain
benefits from structured data, since they are
constantly updated and create a precise clinical path
which allows the accurate identification of the cost
centres.
If Besta’s benefits appear quite clear, it is worth
underlining the advantage for Niguarda: the reuse of
its application is a way to share development costs
for widening the range of functionalities provided by
the portal. Proposing its solution as a “best way” for
healthcare applications will open the possibility to
spread it among other hospitals, bringing benefits,
savings and also prestige to the development unit
and the hospital in general.
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3 CONCLUSIONS
In Italian reality there is no mention to clinical
information systems as example of successful
reuses. Besta’s project provides a practical
demonstration of how to follow the steps required by
a structured method to evaluate the possibility of
reusing an information system in health
environment. Other projects involving the reuse of
health information systems could point it out as a
best practice and reply its successful experience to
gain similar results.
After the first roll-out of the system in the new
reality (go live: 22 October), benefits that were just
potential began to turn out to be authentic: the use of
a standard language to make possible the
communication with other applications revealed
efficient, providing the physicians with an updated
working list of patients to be visited each day. The
continuous monitoring of the process, held by
Fondazione Politecnico di Milano, assured an
uninterrupted flow of feedbacks from the users to
the developers, in order to quickly analyse and solve
“infancy problems” of the solution and also to
capitalize on flexibility provided by open source
technologies, beginning to work in order to improve
the solution with current users’ requirements.
These results will be the basis for further
development in the field of health information
management. An already planned evolution for
extending Besta’s current project has been financed
by the Italian Ministry of Health, by which a Web
Integrated Information System for the management
of clinical and research activities in the field of the
neuroscience will be created as a specialization of
the already existent clinical portal. New specific
features will be added to the portal in order to
implement an individual Electronic Health Record,
by connecting the local systems with the regional
(CRS-SISS) health system and with specific
networks of pathologies. The strategy followed in
developing the current solution will ensure the
possibility to adapt the portal to become a single-
entry point to the neurological area, in order to
support and assist healthcare professionals not only
in their day-by-day activities, but also for research,
and decision-support functions. Impacts of the
project will be felt in the areas of clinical processes
and data modelling, where information and results
will be transferred from research area to patient care.
The experience already made and the compliance to
users’ requirements will be exploited to challenge
the development of clinical pathways on patients, for
which a deep understanding of the system by the
physicians is required, in order to feed it with data as
much complete as possible. Usability of the system
and support’s quality will facilitate success in this
challenge.
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