A CASE STUDY

On Patient Empowerment and Integration of Telemedicine to

National Healthcare Services

Surayya Urazimbetova

Center for Pervasive Healthcare, Department of Computer Science, Aarhus University, Aabogade 34, Aarhus, Denmark

Keywords: Telemedicine, Integration, Security policy, Shared medicine card, National healthcare services,

Time-to-market, Small-medium size businesses, Presentation level integration, Decentralized access control.

Abstract: Patient empowerment in the digitalized healthcare can be supported by means of telemedicine. As opposed

to Electronic Patient Records developed by a few large business suppliers for healthcare professionals,

telemedical applications include innovative solutions of small-medium size suppliers and are targeted at

specific groups of patients (e.g., hip operated or dermatology patients) and their care network. Based on an

integration experiment we argue that in order to support the national visions for patient empowerment and

connectedness of healthcare at the same time, it is necessary to achieve the integration of telemedicine to the

national healthcare services on a business logic (functional) integration level. In this paper, (1) we identify

the lack of business logic (functional) level integration opportunities for patient oriented telemedical

applications with national healthcare services; (2) we summarize on processes, products and organizations

which are part of the integration procedure and provide places for shortening the time-to-market of SMBs.

(3) we identify the need of supporting telemedicine uptake by extending access rights policies of the

confidential patient data to decentralized citizens level access control.

1 INTRODUCTION

“Telemedicine is the use of medical information

exchanged from one site to another via electronic

communications to improve patients' health status”.

(American Telemedicine Association)

There exist different telemedical applications,

those that support professionals-to-professionals

remote collaboration and those that support remote

collaboration of a patient with his care network:

family members, volunteers and professionals. We

focus on the last type of telemedicine, as it allows

patients to be proactive users of health care services

i.e. through the use of remote patient monitoring

technologies.

(Wartena, 2009) and (CDH, 2007) argue that

patient monitoring systems promise to provide better

care for patients and help solving resource

challenges, such as limited human and financial

resources.

Among IT health care services, on a national

level, we take a look at Shared Medicine Card

(SMC), or Fælles Medicin Kort (FMK) (Trifork

SMC)(NSI) that allows citizens and health

professionals share the same medication prescription

of patients in Denmark.

It is important to note, that Shared Medicine

Card, fully deployed for all counties in 2012, is the

achievement of the lately established national

organization, known as National Sundheds

(Healthcare) IT (NSI), earlier known as Connected

Digital Health of Denmark.

Among telemedical systems we take a look at

stand alone Remote Rehabilitation Support (RRS)

(Aarhus, 2011) for hip operated patients. It allows

the patient and the care network: spouse,

physiotherapist and hospital staff, to control and

instruct treatment of the patient in the home. Among

other things, RRS offers the following functionality

for the patient: video conferencing, preview of

XRays, viewing medical

prescriptions, which can be

extended to remind him about the medicine intake in

time. In this paper, we focus on the integration of the

last functionality of RRS, namely the medicine

module, as it is explained below.

While RRS offers potential benefits for the hip

operated patient and the hospital (e.g., video

263

Urazimbetova S..

A CASE STUDY - On Patient Empowerment and Integration of Telemedicine to National Healthcare Services.

DOI: 10.5220/0003870902630269

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2012), pages 263-269

ISBN: 978-989-8425-88-1

 2012 SCITEPRESS (Science and Technology Publications, Lda.)

conferencing, training and future extension to

remind on medication), it is not adopted at any

hospitals, because there is no cost-reduction

evidence and it does not integrate with hospital

EPRs. However, RRS can bring new valuable

functionality for the patient and his family i.e.,

access to prescriptions and extension to remind on

medicine intake. The interoperability of RRS with

doctors’ EPR is essential for RRS adoption. This is a

common challenge for other telemedicine adoption,

for example as pointed in a Norwegian CheckUp

Care system (Larsen, 2011).

This paper approaches the integration problem of

RRS to EPRs’s medicine module at caregiver’s site,

by assuming that an EPR at the caregiver’s site

integrates to SMC. It is therefore only needed to

integrate RRS medicine module, with SMC at

patient site. The integration scenario will make RRS

“transparent” for health professionals and allow for

patient empowerment through RRS adoption.

Our hypothesis is therefore twofold:

(H1) it is possible to achieve integration of the

patients’ site of the medicine module of RRS to SMC

in a reliable way

(H2) integration can be achieved without

unnecessary expenditure of man hours.

Following sections present methodology of

integration process in Sec 1; overview of Danish

healthcare, the relevant Danish health initiatives and

related work in Sec. 2; integration experiment and

results in Sec. 3; experimental results, constrains of

time-to-market of telemedicine in Sec. 4;

2 METHODOLOGY

This paper is original, in the sense that there have

not been done any integration experiments of

telemedical applications to SMC. Also, SMC is the

first and so far the only representative of a family of

national services that connect clinical patient data

across Denmark. There is a plan to create “sister”

services, like SMC, in the future, for shared data

access (SDSD, 2009), e.g., to lab results.

The integration experiment is part of a larger

project, Net4Care, initiated by Caretech Innovation

(CI). The need for interoperability of telemedicine

with national healthcare services (NHS) based on an

example of RRS and SMC has already been

published in (Hansen et al., 2011). This paper

presents first results of the initiatives.

The project of integrating RRS to SMC has

started in February 2011 and lasted for more than 6

month, including two month of implementation and

experience gathering. During the project, we

attended a technical, held by NSI, and a mixed

clinical and technical organized by (AAU, 2011)

workshops on Shared Medicine Card and a

workshop on Continua Health Alliance, held at CI.

To explore the possibilities of the security policy of

healthcare services, there was held a seminar for the

security research group at Aarhus University on the

topic. Besides, several companies were contacted in

order to gain better insight into different

technologies. For example, suppliers of National

Service Platform, Security Token Service Identity

Provider, developers of SMC, Security group at

Alexandra Institute and Lægemiddelstyrelsen for

getting the permission to perform the integration

experiment. The implementation aspects of

integration were logged in a diary as follows: every

day when the integration task started or ended (not

including the breaks, meetings, emails, workshops)

there was noted the amount of hours spent. Diary

details are available in (Urazimbetova, 2011).

3 OVERVIEW

We start with a brief overview on facts of healthcare

in Denmark, the lack of interoperability in

healthcare, the initiatives on connecting patient data

across the systems, which resulted in Shared

Medicine Card service. We then present the related

work and argue why experiment and results of this

paper brings concrete places of improving current

state of telemedicine in Denmark.

3.1 Lack of Interoperability

Danish healthcare is a public healthcare system

primarily financed through general taxes. The

responsibility of providing healthcare services lies

usually with the county; there is free access to

healthcare services for all 5.4 million citizens.

Healthcare sector should be of high quality, efficient

and allow for free choice of provider by users. It

consists of primary care with self-employed general

practitioners (GPs) and hospital care.

Healthcare IT systems, e.g., EPRs for hospitals,

have been developed independently by different

counties, delivered by different suppliers, without

adoption of a common platform or standards, which

resulted in non-interoperability of EPRs. The same

holds for the standalone telemedical applications,

like RRS or the adopted Cure4you communication

system that integrate to some EPRs.

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3.2 Connecting Digital Health

“It should be clear that integration is not only a

technical problem. Rather, it also requires a good

level of organization and management in order to be

successful.”(Ruh, 2001)

In order to develop interoperability in the public

healthcare systems, there was created a new

organization in 2007 called “Connecting Digital

Health in Denmark” (CDH) now called National

Sundheds IT (NSI), whose task was to create a new

healthcare IT strategy, for digitalization of health

services (Bruun-Rasmussen, 2008). The main

strategic goals of the IT strategy 2008-2012 (CDH,

2007) are:

(1) digitalization that directly supports staff tasks

and functions, thereby creating a basis for improving

quality and efficiency; (2) digitalization aimed at

improving the healthcare service level for citizens

and patients

Table 1: Results of NSI initiatives.

Organiz. Products

NSI

Connectng

digital health

-Shared Medicine Card (SMC):SOAP based

web service and web client

-National Service Platform (NSP) (Enterprise

Service Bus, proxy to SMC, authentication

service and future services.

MedCom

Organization

-Den Gode Web Service (DGWS) or the

Good Web Service Standard

- Sundhedsdatanet closed Virtual Private

Network of healthcare

Open Source

Service Oriented System Integration (Esben

Dalsgaard, 2008)(SOSI). Imple ments

DGWS & Security service STS

Some of the results of NSI are the products and

standards presented in the table 1.

With the efforts of NSI, Denmark has achieved

interoperability of citizens medicine prescriptions in

EPRs, reducing the number of medication errors. In

order to achieve the integration, with the “gluing”

technology-SMC, suppliers of EPRs had to make

use of the products and technologies depicted in

table 1.

The following citation, presents strategic

perspectives of IT Strategy 2008-2012 for

telemedicine:

In addition to shared services making data

available, it may be relevant to establish shared

services making functionality available.

For example, shared services could make certain

telemedicine solutions available to all relevant

healthcare users. Such solutions will provide a

number of opportunities for cooperation. They will

enable faster and better diagnosing, less unnecessary

transport, new

opportunities to consult experts and

support a seamless transfer of tasks and development of

shared care, etc.

The above quotation is presented to support the

hypothesis that telemedicine should be a connected

part of digitalized Danish healthcare, just as it is the

case with connected medicine prescription modules

that integrate with EPRs.

3.3 Related Work

(Wartena, 2009) presents, The Continua Health

Alliance (CHA) and guidelines. CHAs goal is to

ensure interoperability of telemedical devices as

well as interoperability of these with EPRs, by

means of guidelines for standardisation. On

international level CHA have similar visions as NSI.

(Wartena, 2009) refers to Google Health, which is

out of the market, since mid 2011 and the Microsoft

HealthVault, as places for sharing Personal Health

Records. However, telemedicine requires trusted and

available services, which is achieved by

implementation of SMC. The paper also presents the

trends of patients being able to access EPR records

(created by health professionals) from web portals,

however, it does not raise questions of how

confidential data will be accessed given their

guidelines? In this paper, we do. Furthermore,

interoperability of medication prescription, in our

experiment is not achieved by use of HL7 protocol,

as proposed by CHA, but by means of national

standards. In this paper, we work our way out from

the local to the national implementations and

standards, and point out the places for improvements

of national healthcare services to support

telemedicine in a Danish context.

4 INTEGRATION EXPERIMENT

Below we present definitions of integration layers;

the experimental results, which identify the

integration levels, provided by SMC; present the

technologies that integrators work with during

integration; explain why H1 is a place for

improvements of national healthcare services.

(Ruh et al., 2001) present three different layers

of integration: presentation level integration,

business logic (functional) level integration and data

level integration and argue for pros and cons of the

models quoted below:

1) “The presentation integration model is based on

the concept of accessing the legacy application

through its existing presentation logic. Each user

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265

interaction, however, must ultimately map into the

old presentations in order to integrate.”

2) “Business logic is code written to perform

required business functions in an application. It

includes the processes and workflow as well as the

data manipulation and interpretation rules. … that

are required to properly interpret or construct the

data and that are not always available through the

presentation.

3) “Data integration model goes directly into the

databases bypassing the presentation and business

logic to create the integration”.

Figure 1 depicts the three horizontal layers of

integration and vertical columns for systems (from

left to right): SMC; authentication service for

citizens, known as NemID; authentication service

for employees, known as Security Token Service

(STS); National Service Provider (NSP) that acts as

proxy to SMC and STS; an example of EPR

integration for employees, and finally the RRS

integration for patients and citizens.

Shared Medicine Card, architecture details in

(Trifork SMC), consists of a database with medicine

records of all 5.4 mio. of Danish citizens on a data

level. The business logic implements the

functionalities such as: medicine prescriptions

mechanism, versioning and logging. The

presentation layer allows citizens (and health

professionals) access shared medicine card

functionality through a web client and is generated

by the business logic layer.

Figure 1: Levels of of integration for analyzed systems

SMC allows for integration of RRS at presentation level.

The horizontal connections seen in business logic

and presentation level integration show entry points

for integration. From the drawing, we can see, that

for an EPR system there is no way of establishing a

database connection to SMC therefore we do not

consider this level any further.

For example, at the business logic level, an EPR

can access shared medicine card and its functionality

by establishing SOAP based communication to its

web service interface. Hence, Shared Medicine Card

consists of a Web Service (WS) (Trifork software

pilots). However, to achieve successful integration

to SMC WS, an EPR system must be (1) part of the

closed VPN connection (Sundehedsdatanet) and (2)

the end users must be employees and own special

employee certificates, all dictated by national web

service standard, The Good Web Service (TGWS)

1.0 (MedCom, 2006). However, RRS on the

patient’s site does not fulfil these requirements and

cannot achieve business level integration, because

(1) RRS is not authorized as a member of the closed

network and (2) patients are not employees and have

no employee certificates, which TGWS asks for.

For RRS it is possible to integrate on

presentation level (once, an Open Source

Component, Smart Framing is released (Trifork

Software Pilots). The idea is based on the older idea

of web frames, where RRS can act as a host to the

guest fmk-online.dk web client. This is like a

redirect to fmk-online.dk web client from RRS.

Citizens from fmk-online.dk can authenticate with a

citizens digital signature, called NemID.

We can now argue, that given presentation level

integration possibility of SMC for patient oriented

RRS, we cannot satisfy H1, as quoted earlier in 2).

To support the argument we provide an example:

Assume, patient site RRS acts as a host application

to fmk-online.dk web client. RRS wishes to deliver

new medicine reminder functionality to the patient:

”intake 2 pills of a medicine 4 times a day” via

presentation level integration. RRS uses Smart

Framing to get PDF document of medicine

prescription of patient. The PDF document, or

(HTML of web client) does not contain the

semantics (meaning) of medicine data. Technically it

is possible that developer of RRS can guess the

meaning of values. However, the guessing of the

meaning and the fact that SMC user interface can

change with time, makes the new reminder

functionality of RRS not appropriate for ensuring

patient safety and software reliability.

5 CONSTRAINS AND

TIME-TO-MARKET OF

TELEMEDICINE

This section presents the general constrains on the

time-to-market of RRS adoption on top of the NHS.

The constraints include the ones connected to the

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integration process and the centralized access

control of the patient data. We start by testing the

boundaries of the integration process of H2, by

measuring the process in man-days and provide the

method used for analysis, using a tree based process

analysis. Thereafter, we summarize on other issues

that hold SMBs from creating new functionalities for

citizens and patients.

5.1 Integration Process

It is important to clarify the preconditions of the

hypothesis: assumptions made, products and

documents given to integrator; experience with

technologies. These preconditions impact the

volume (number of all paths) of integration process

tree, as described below.

The tree in figure 2 has the root, which is the

hypothesis H1, with its preconditions. The

intermediate nodes are the intermediate integration

activities that were identified as being important by

integrator. Only one integration path from the root to

the leaf is defined as a correct integration process

and results in the task completion (in our case partial

completion, details in next sec.) i.e., the correct path

for our hypothesis is the left most path that leads to

the leaf, called “Finish 1”. The tree in fig. 2 shows

all processes that integrator performed, before the

correct path towards integration completion was

discovered. The preconditions of the integration

process are lack of documentation and tutorials. For

example, integrator was given an executable

machine image, called NSP-in-a-box. The

installation guideline for installing and running the

image on a virtual machine, examples of http

requests one could execute on NSP-in-a-box; a

white-box architecture drawing with numerous

unexplained abbreviations as ones of table 1. All

these were questions to answer and things to learn

and influence the time-to-market, as argued below.

5.2 Man Days of the Integration

Process Tree

Getting back to the H2, our results show that

integration process takes 84,5 hours and could be

reduced to 43,5 hours to achieve a partial

integration. It is called partial because integration on

the business logic level cannot be achieved as stated

in sec. 4.3 (or achieved with employee signature

which patients don’t have) and RRS cannot provide

new functionality for patients in a reliable way.

Figure 3, gives an overview of the integration

subtasks. The tasks of the chart are mapped to the

tasks of the integration process tree, where (T3)

stands for a path from “Start of Task 3” in the tree to

its completion leaf, “Finish 3” and so on.

Figure 2: Execution of the “wrong” right sub tree is a

result of e.g., lack of experience with tbl. 1. Path to

“Finish 1” is partially correct.

Having got the tree and the chart it is easy to

calculate: How many man-days could be saved if the

integrator knew the right integration path? As we

can see in the chart, the activities connected to

solving the correct path problem, from bar 4 (from

left) to bar 2 (from right) would be estimated to take:

43,5 hours. Thus to achieve integration to national

health services, without unnecessary expenditure of

man hours, NSI may want to provide better

documentation, source code snippets, the right entry

points for integration, like in drawing in fig.1 and

fig. 2. Next section adds further constrains and

maybe most noticeable constraints on time-to-

market for telemedicine.

5.3 Security and Access Rights

As a result of the experiment following significant

barriers for telemedicine integration to national

healthcare services identified. First, the centralized

way of controlling access permission to the

confidential patient data of 5.4 mio. citizens of

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267

Denmark. Second, is the existence of the web

service standard that restricts the way web services

should be implemented in Danish healthcare and

includes employee signatures and excludes citizens

signatures.

Figure 3: Hours spent on the integration H1.

Allowing EPR suppliers to operate on SMC data

that contain confidential medicine information of 5.4

mio. citizens in a closed healthcare network,

Sundhedsdatanet, require that EPRs systems behave

well with respect to all data. Due to the fact that

EPR systems are the main actors and contributors

and have operated on most population data before

SMC was established, MedCom has to give access

to these systems. Current solution for access rights

to national services follow the concept “all or

nothing”. Hence, RRS with current security model

may have difficulties at getting access to the

confidential data for few hip operated patients.

The access problem can be solved on the

business logic level, by extending the centralized

“all-or-nothing” policy to a decentralized on

individuals based access control. For example, by

creating an SMC web service, where individuals can

authenticate with private NemID and give

permission for telemedical applications to operate on

their confidential data. For example, RRS would

prompt a confirmation window to a patient, where

patient would permit the application to access and

operate on medicine prescriptions. This model might

in turn require that 3rd party applications, like RRS,

can not i.e., steal the data from the patient site for

evil purposes and are reviewed on a code bases by

trusted organizations and approved to behave well

with respect to the confidential data, for each new

system version.

6 CONCLUSIONS

This paper presents issues of improvements of NHS

to better support development of telemedicine:

First, national healthcare services, like SMC

should support integration of patient oriented

telemedicine on a functional integration level.

Presentation level integration is not purposed for

creating new valuable functionalities in a reliable

way, which may keep third party developers from

innovating services for patients and care network.

Second, the time-to-market will depend on the

experience of a developer with applied domain

specific technologies. Though, we demonstrate that

in theory, it is possible to reduce the integration

expanses, measured in man-hours, by factor 2 by

providing better integration documentation for SMB.

Third, to support national visions for patient

empowerment by telemedicine, the standard TGWS

should be revised to include individuals’

authentication. Security constraints in the

deployment of solutions create harsh conditions to

SMBs and long calendar time from idea to

production. Therefore the centralized access control

should be extended to decentralized access control.

It is interesting to analyze possible business and

organizational models that would best support

criteria’s for NHS and telemedicine.

ACKNOWLEDGEMENTS

Morten Kyng, Henrik Blunk, Michael Christensen,

Thomas Hohn, Klaus Hansen, Henrik Christensen,

NSI, Security group at AI, Lakeside, Trifork & Lars

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