INTEGRATING CLINICAL INFORMATION FROM A PERSONAL

HEALTH RECORD INTO THE VIRTUAL HEALTHCARE RECORD

Andrei Vasilateanu, Luca Dan Serbanati

Universitatea Politehnica Bucuresti, Facultatea de Inginerie in Limbi Straine, Splaiul Independetei 313, Bucuresti, Romania

Mihai Isaroiu

Universitatea Politehnica Bucuresti, Facultatea de Inginerie in Limbi Straine, Splaiul Independetei 313, Bucuresti, Romania

Keywords:

eHealth, EHR, PHR.

Abstract:

In this paper we describe our proposed architecture for an integrated eHealth solution based on a patient-

centric electronic health record called Virtual HealthCare Record (VHCR). VHCR is a central, unifying,

internet-based entity acting as a ﬂagship in the eHealth ecosystem and integrating different sources of medical

information in a longitudinal record. The focus of this paper is how VHCR interacts and integrates data from

a Personal Health Record.

1 INTRODUCTION

In the previous years e-Health has become a ma-

jor concern in the academic, medical and business

worlds. In the context of an ageing population in the

developed countries e-Health promises to be a solu-

tion for the increasing costs demanded by healthcare.

An important concept in e-Health is the use of the

Electronic Health Record (EHR), that is an individual

patient’s medical record in digital format. It enables

a doctor to keep better track of her/his patients, to is-

sue documents that can be interpreted by other doc-

tors and other EHRs. EHR systems reduce medical

errors, increase physician efﬁciency and reduce costs,

as well as promote standardization of care.

Another concept is the patient empowering,

namely involving the patient in his/her treatment pro-

cess by giving him the means to make informed de-

cisions. One of the ways to support patient empow-

ering is the use of Patient Health Records (PHR), IT

applications designed to allow the patient to manage

his/her clinical information

From the many ﬁelds of e-Health we choose

to concentrate on improving the continuity of care,

by designing and implementing a shared, elec-

tronic record which we named Virtual HealthCare

Record.(Contenti et al., 2010) VHCR is a longitudi-

nal record, spanning over the whole life of the patient

and integrating distributed and heterogeneous sources

of information. VHCR is designed as a multiagent

system in which stakeholders involved in the health-

care process centered on a patient are represented by

agents organized in agencies cooperating to maintain

a complete and accurate virtual representation of the

patient‘s health state and clinical history as well as to

support distributed health care processes.(Luzi et al.,

2006)

From the many sources of information which the

VHCR mediates and integrates this paper focuses on

the interaction with a personal health care record,

managed by the patient, with the purpose of involv-

ing the patient as a proactive party in the health care

process.

In the following a more detailed view of VHCR is

presented and the PHR is introduced. Then we pro-

pose a methodology for the interoperability between

the PHR and VHCR highlighting advantages as well

as the factors resisting to change, the potential pitfalls

in implementation and usage.

2 VHCR

The Virtual HealthCare Record is the ﬂagship in

our envisioned digital health ecosystem(Kim et al.,

2007).VHCR is not a document repository; instead it

is a provider of electronic services supporting health-

521

Vasilateanu A., Dan Serbanati L. and Isaroiu M..

INTEGRATING CLINICAL INFORMATION FROM A PERSONAL HEALTH RECORD INTO THE VIRTUAL HEALTHCARE RECORD.

DOI: 10.5220/0003138405210524

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2011), pages 521-524

ISBN: 978-989-8425-34-8

 2011 SCITEPRESS (Science and Technology Publications, Lda.)

care processes. It holds data extracted from medi-

cal documents from various sources in a ﬁner grained

model than the documental model permits. The

model is derived from HL7 RIM v3 and European

Continuity of Care standards like CONTSYS and

based on a dedicated ontology. In this model medical

data is organized into episodes of care which are ini-

tiated or appended during encounters with the health-

care providers by accessing the VHR services.

VHCR‘s purpose is to maintain a uniﬁed, coherent

and consistent view on the clinical status of the patient

by integrating healthcare events generated through-

out the whole life of the patient by different enti-

ties. These documents can derive from the healthcare

applications of the healthcare providers like general

practitioners or specialists in the form of prescrip-

tions, procedures and referrals organized into care

plans, from laboratories in the form of blood tests or

x-ray images or from medical devices like intelligent

measurement devices for blood pressure of glicemy

which can send the results wirelessly to a proxy.

These documents are digitally signed by an au-

thorized healthcare provider before being integrated

within VHCR. Once the data has been integrated, and

a “snapshot“ of the patient clinical status is avail-

able, VHCR becomes a complex e-service provider,

generating and providing customized views on this

integrated status to the stakeholders involved in

the healthcare process and responding to complex

queries. Before presenting how we can also integrate

data from PHRs let us describe in detail what PHRs

represent.

3 PATIENT EMPOWERMENT

AND PHR

A trend in healthcare is to involve the patient as a

pro-active party in his/her own treatment. Patient em-

powerment involves raising the health literacy, pro-

viding customized, sanctioned medical information to

the patient as required by his/her condition or level

of training with the purpose of giving the patient

the means to make informed decisions regarding the

treatment. Health literacy denotes the skills neces-

sary to understand and use health information. Pa-

tients with chronic illnesses will be able to follow

and manage their diseases in cooperation with their

care providers, promoting earlier interventions when

they encounter a deviation or problem. Parents can

also monitor the immunizations, diet and treatment

of their children. Also, using evolved search engines,

they can search and retrieveinformation from credible

medical knowledge basis including advices regarding

emergency interventions in domestic accidents, sim-

ple medical conditions (common colds, indigestions)

or tending to very young children.

Another issue is supporting the patient in pre-

venting illness by raising the awareness to a healthy

lifestyle. Taking into consideration that while at the

turn of the last century most of the deaths were caused

by acute diseases while at the moment 2/3 of the

deaths are caused by chronic diseases and that these

chronic diseases are caused not by one but by many

risk factors, hard to quantify and deriving from the

environment and lifestyle of the patient, it becomes

ever more important to inform the patient in leading a

healthy lifestyle. These concerns are addressed by a

concept and family of products called Personal Health

Records or Patient-centered Health Records. A deﬁ-

nition for PHR can be the following:

an electronic application through which

individuals can access, manage, and share

their information, and that of others for whom

they are authorized, in a private, secure envi-

ronment.

(Brennan et al., 2007)

In addition to conditions, medications, appoint-

ments PHRs also provide a repository for self-

monitoring information or nutritional facts.

As we can see the main difference between an

EHR and PHR is the fact that in a PHR data is in-

troduced and governed mainly by the patient. At the

moment different commercial PHR solutions exist on

the market, from which we mention the products from

important players like Google - Google Health and

Microsoft -Microsoft Health Vault.

4 INTEROPERABILITY

BETWEEN PHR AND VHCR

Since VHCR aims to aggregate and integrate relevant

clinical information for a patient it is clear that the

PHR is an important source which should not be left

out. Also, since PHR represents the patient‘s view

into his health status, important clinical events from

the VHCR should be integrated as well into the PHR.

4.1 VHCR to PHR

The main concern when importing data from VHCR

to PHR is translating medical data from a health care

provider representation to a patient representation.

The data organization in VHCR into health issues,

episodes of care and contacts could prove not very

relevant to the patient and should be reorganized in a

HEALTHINF 2011 - International Conference on Health Informatics

522

more intuitive way. Also the speciﬁcity of medical in-

formation should be adapted to the health literacy of

each patient, health literacy which changes in time.

4.2 PHR to VHCR

The main obstacle is the fact that for clinical infor-

mation to be imported into VHCR it needs to be ap-

proved via signing by a healthcare professional, in

this case the general practitioner. The general prac-

titioner has objective but also subjective reasons to

refuse to do so:

• Not reimbursed to do it. Doctors can view spend-

ing time in ﬁltering information from the PHR to

VHCR as a waste of their time since it is an ac-

tivity for which they are not ﬁnanced. One way

to encourage doctors to guide their patient in us-

ing IT-enabled, patient empowering tools is to re-

imburse “e-Visits“ (Tang et al., 2006), namely

the virtual encounter between the doctor and the

patient. Moreover, even without reimbursement,

the previous virtual encounter with the healthcare

provider can make the actual encounter more pro-

ductive and more focused, using the provider‘s

time more effectively and lowering the commu-

nication barrier.

Also in the case of pediatric doctors with young

children registered in their care, the PHR can

prove very helpful as it frees them from contin-

uous domestic visits or visits of the parents with

their children to the cabinet, by being able to mon-

itor remotely the children evolution and to raise

the responsibility with the parents.

• Not willing to take responsibility for unchecked

data. Once a fact from the PHR is integrated into

VHCR via his signature, the doctor becomes re-

sponsible for that entry.

While some of these obstacles can be overcome by

changing legislation (e.g. reimbursing eVisits) we be-

lieve that technology can also play a part in assisting

the GP, by partially automizing the ﬁltering process

and using notiﬁcations.

5 IMPLEMENTATION

VHCR is implemented using a service oriented archi-

tecture(Serbanati and Vasilateanu, 2008). The POS

uses a wrapper that transforms the output from the

EHR application to a HL7 compliant message that

is sent to the intelligent broker which forwards it to

VHCR component. The broker is also responsible for

sending notiﬁcations to the interested parties.

In the present prototype we add to the POS a ﬁl-

tration subsystem based on an automatic, rule based,

system that analyzes the coherency of data (double

submits, submits with no body, etc) which commu-

nicates directly with the PHR. The PHR chosen for

this proof-of-concept was Google Health (McBride,

2008), which implements a partial subset of Continu-

ity of Care Record (CCR)(Ferranti et al., 2006).

The information inspected for validation is repre-

sented by the Problems element and Medication ele-

ment. The PHR used does not allow an asynchronous

retrieval of medical information introduced therefore

a synchronous retrieval of data must be implemented;

the data is retrieved by a worker thread created and

started on the start of the application. The POSDi-

gester is responsible for retrieving data for all pa-

tients marked as registered at the logged in physician,

afterwards for all new information it generates no-

tiﬁcations which are processed by the ﬁltration sys-

tem. The ﬂow of the validation process from PHR to

VHCR is presented in ﬁg 1. The system receives noti-

ﬁcations when in PHR either a new medicine is added

or a new symptom is added and these two types of

notiﬁcations are processed differently:

• If the notiﬁcation is a symptom and its syntax is

correct, it is displayed as an alert to the physi-

cian in charge; the physician can either classify

it medically irrelevant and the ﬂow stops, or it can

be classiﬁed medically relevant and an encounter

event is created (ADT) and sent to the VHCR.

The encounter can belater appendedto an existing

medical episode, or it can generate a new medical

episode on its own.

• If the notiﬁcation is a new medicine its counter

indications are checked; if there are no known in-

teractions between the medicine and other drugs

or conditions than it is disregarded. If the previ-

ous condition is not fulﬁlled then a check is made

to see if the new drug has interactions with an ex-

isting patient condition and if this is so then an

encounter(ADT) should be created automatically

and an alert displayed; if the medication has in-

teractions with other drugs , therefore this infor-

mation should be taken into account for further

prescriptions, the information is appended to the

VHCR and the physician is alerted.

To include data from VHCR to PHR, PHR must

the VHCR. To make a customized selections of what

types of events should be included in PHR, we have

devised a proxy service between the PHR and VHCR.

In effect the proxy registers to VHCR notiﬁcations

and it forwards them selectively to PHR. The proxy

also acts as a translator, transforming HL7 messages

INTEGRATING CLINICAL INFORMATION FROM A PERSONAL HEALTH RECORD INTO THE VIRTUAL

HEALTHCARE RECORD

523

Figure 1: PHR to VHCR validation.

to CCR standard, which can be interpreted and inte-

grated by Google Health. The process is described in

detail in ﬁg 2.

Figure 2: PHR notiﬁcation through proxy.

6 CONCLUSIONS AND FURTHER

IMPROVEMENT

PHR represents an important source of information

for having a comprehensive view on the patient‘s

health. It not only allows to raise the patient‘s re-

sponsibility to health issues in general, and his/her

treatment in particular, but it can be used to obtain

information from a primary, direct interested source.

Our prototype ﬁltration system and PHR proxy act

in fact as semantic mediators between the patient‘s

view and the healthcare professionals‘ views on the

curative process, overcoming the language barriers to

bring them together in a virtual, reconciled space.

Further improvements can be made in raising the

autonomy of the ﬁltration system by using intelligent,

adaptive agents, which can learn from the patient’s

preferences and previous choices. Also we are ex-

tending the number of PHR applications which can

be integrated in the system. Contemporarly we are

designing vocabularies and a general ontology de-

scribing concepts belonging to PHR functions, from

which a general ﬁltration system can be customized

autonomously.

REFERENCES

Brennan, P., Downs, S., Casper, G., and Kenron, D. (2007).

Project HealthDesign: Stimulating the Next Genera-

tion of Personal Health Records. In American Medical

Informatics Association.

Contenti, M., Mercurio, G., Ricci, F., and Serbanati, L.

(2010). The LUMIR Project: Developing the GPs

Network Pilot Program in the Basilicata Region. In-

formation Systems: People, Organizations, Institu-

tions, and Technologies, pages 255–263.

Ferranti, J., Musser, R., Kawamoto, K., and Hammond, W.

(2006). The Clinical Document Architecture and the

Continuity of Care Record. British Medical Journal,

13(3):245.

Kim, H., Lee, J., and Han, J. (2007). The Roles of Informa-

tion Technology in Business Ecosystems from a Flag-

ships Perspective. In Proceedings of the Korea Man-

agement Information Systems Fall Conference, pages

343–348.

Luzi, D., Ricci, F., and Serbanati, L. (2006). E-Clinical

trials supported by a service-oriented architecture. in

MedNet.

McBride, M. (2008). Google Health: Birth of a giant.

Health Management Technology, 29(5):8–9.

Serbanati, L. D. and Vasilateanu, A. (2008). Supporting

Continuity of Care with a Virtual Electronic Health

Record. In IHIC, pages 84–87.

Tang, P., Black, W., and Young, C. (2006). Proposed crite-

ria for reimbursing eVisits: content analysis of secure

patient messages in a personal health record system.

In American Medical Informatics Association.

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