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

 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 -

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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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