HEALTHCARE INFORMATION SYSTEMS IN A NETWORK

ENVIRONMENT

An Interoperability Model and a Real Case in a Pathology Network

Emanuele Baj, Paolo Locatelli, Ilaria Marzolla, Nicola Restifo

Fondazione Politecnico di Milano, Via Garofalo, 39, 20133 Milan, Italy

Silvia Bragagia, Gianni Origgi

A.O. Ospedale Niguarda Ca’ Granda – S.C. ICT, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy

Keywords: eHealth, Healthcare Management Systems, Electronic Health Record, Semantic and Syntactic

Interoperability, Pathology Networks.

Abstract: Interoperability between Healthcare Management Systems is a fundamental requirement to improve the

quality of care, to assure patients continuous assistance and to improve clinical research. Pathology

Networks create a common virtual environment which allows to overcome single HIS’ borders, by

connecting different healthcare organizations adopting common formats to share clinical data and,

consequently, knowledge. Syntactic and semantic standards are paramount to enable interoperability in this

context, since common document formats ensure efficient communication, while internationally known

vocabularies allow the unambiguous interpretation of contents. This paper has the purpose to show a real

experience of participation to a Pathology Network, providing a model based on open standards which

could be taken as a reference model for similar initiatives in other healthcare environments. Benefits

resulting from such an initiative will be presented, in terms of improvement for clinical research and quality

of patients’ care. The real case we describe is an example of how Pathology Networks can provide scientific

features to Electronic Health Records, by adding information not usually reported on standard clinical

sheets, but necessary to perform new analysis with the purpose of improving clinical research.

1 INTRODUCTION

Interoperability between clinical information

systems represents one among the major

opportunities of health informatics. The spreading

of many solutions in the field of Electronic Health

Records provides a great amount of digital data

about patients, potentially available to feed scientific

research in order to improve the efficiency of

clinical processes (Chauldry et al., 2006). An

interoperable infrastructure to enable data sharing is

paramount to best exploit the potential represented

by digital information: daily activities performed by

physicians and nurses are sources of a great amount

of data, whose value in terms of clinical and

scientific research could be enhanced if handled and

stored in a standard formats. In order to allow this

interoperability, it is necessary that syntactic and

semantic standards are provided: the former are

needed in order to assure a common representation

to the data which are transferred, while the latter are

required to assure unambiguous interpretation of

their meaning.

This direction is being followed by initiatives

known as “Pathology Networks”, whose aim is

creating a cross-organizational virtual database for

patients affected by a same disease.

This paper analyzes the concept of Pathology

Networks, their features and purposes, also by

presenting a reference model which could be taken

as a basis for such initiatives in different healthcare

contexts. The case study we describe is the solution

implemented at “Fondazione IRCCS Istituto

Neurologico Carlo Besta”.

461

Baj E., Restifo N., Marzolla I., Restifo N., Bragagia S. and Origgi G. (2010).

HEALTHCARE INFORMATION SYSTEMS IN A NETWORK ENVIRONMENT - An Interoperability Model and a Real Case in a Pathology Network.

In Proceedings of the Third International Conference on Health Informatics, pages 461-464

DOI: 10.5220/0002744404610464

 SciTePress

2 A REAL CASE: EPINETWORK,

THE EPILEPSY NETWORK OF

LOMBARDY REGION

In line with interoperability objectives fixed by

Italian Ministry of Health, the Region of Lombardy

has laid the foundations for the creation of four

Pathology Networks, concerning Rare Diseases,

Epilepsy, Haematology and Oncology. These

networks enhance contact among clinical and

research centres working on the same pathologies,

provide a coordinated assistance to patients, helping

to ensure the delivery of high quality care processes,

empowering clinical research and spreading the

outcomes among the different actors.

Among the various initiatives, adherence to

Epinetwork, the Epilepsy Regional Network, is

being analyzed at Fondazione IRCCS Istituto

Neurologico Carlo Besta in a research supported by

the Italian Ministry of Health within the project

“Web Integrated Information System for the

management of clinical and research activities in the

field of the neuroscience and the implementation of

individual electronic health record”, coordinated by

the Institute and with the participation of A.O.

Ospedale Niguarda Ca’ Granda and Fondazione

Politecnico di Milano. Istituto Besta is an

internationally renowned centre of excellence in the

care of neurological diseases and, among them,

Epilepsy: physicians and researchers of the Institute

worked in a team of experts coordinated by the

Region of Lombardy in order to define semantic

standards needed to identify an epileptic patient and

to provide all information required to follow his care

process. A.O. Ospedale Niguarda, together with

Fondazione Politecnico di Milano, a research and

innovation partner connected to the Politecnico di

Milano technical university, is working at a

technical solution for the Institute, by exploiting the

methodology already followed during previous

experiences in the development of a reference

solution for the Hematologic and Oncologic

Regional Networks.

The solution will exploit the features provided to

the Electronic Health Record (EHR) which the three

partners are already realizing for the Institute

(Locatelli et al., 2009) ; each feature was analyzed

and developed trying to produce as much structured

data as possible, with the purpose of creating an

operative tool aiming at supporting ordinary

activities in a complex system able to provide useful

information to feed scientific research. Among

Besta’s scientific pipeline, Epilepsy represents an

opportunity to create a structured methodology to

collect data, which overcomes the Institute’s

borders, thanks to Epinetwork regional initiative.

3 A REFERENCE MODEL FOR

PATHOLOGY NETWORKS

A Pathology Network is the concretization of an

“inter-corporate virtual department” in which

operators involved in the same pathologic treatment

can profitably contribute to the process of diagnosis

and care, even if operating at different geographical

sites. This way of cooperation envisages, within a

wide domain, that highly specialized medical hubs,

qualified for high complexity treatments – as

intensive chemotherapy, stem cells transplant and

haemorrhage emergency management - and smaller

peripheral institutions could not only share and

exchange knowledge and opinions but, above all,

publish on the Pathology Network all medical

reports produced after patient’s treatment.

By following well known international standards,

it will be possible to study homogeneous data

collections, i.e. to analyze a wide range of disease

cases monitoring the results of new clinical

experimentations, or to compare different treatment

schemes with the purpose of defining common care

pathways for specific diseases and establishing

prevention practices (Tang et al., 1994).

The keystone in a Pathology Network is

represented by the implementation of a

technological platform linking clinical databases of

all hospitals involved in the network and enabling

the exchange of clinical data (e.g. patient cases,

scientific knowledge, etc.). This platform should be

carried out in a flexible way, in order to interconnect

the heterogeneous clinical data repository of each

nodes, realized with different technologies, various

information systems and data management tools.

Data sharing for each clinical episode takes

place only at a logical level, not at a physical one:

this means that clinical reports are not sent to or

received from hospitals but what is really shared is

the logical link by means of which each document

can be univocally retrieved by a HIS at its physical

location.

Italian Region of Lombardy is bringing forward

initiatives in this sense, with a centralized structure

represented by the extranet SISS (Italian acronym

for Social Healthcare Information System) and a

central domain embodied by an EHR called FSE, a

database collecting data related to the whole clinical

history of a citizen registered to the National

Healthcare Service (SSN). The cooperative logic

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characterizing the FSE structure lets each subject

involved in the network act both as supplier and user

of clinical documents, at the same time.

FSE database feeding is achieved by publishing

clinical electronic documents (called DCE) produced

by qualified healthcare organization as PDF files to

which physicians’ digital signature is applied. In

order to give legal value to digitally signed reports,

the repository keeps a clear reference of the

versioning of the document collected.

Various DCE documents exist, concerning

outpatients’ examination results, specialized

radiology or laboratory reports, accidents and

emergency reports, inpatients’ discharge letters,

evaluation notes, patients’ summaries, phone contact

reports and tele-consulting results.

Figure 1: Interoperability model for Pathology Networks.

Based on these assumptions, the Pathology

Network database is fed with a DCE subset, made

up of predefined sets of data, codified into XML

tags, suitable to collect various data formats.

Epinetwork solution is based on a syntactical

structure defined inside a XML CDA2 (Clinical

Document Architecture Rel.2) standard. This

standard, besides being the reference solution for

exchanging healthcare information at international

level, helps us adding efficiency to interoperability:

persistence and human-readability assure that all

different recipients of the information are able to

receive and properly interpret stored information;

moreover, CDA specification is so rich and flexible

that doesn’t place any limitation to future definition

of new document typologies (Dolin et al., 2001).

The XML document allows physicians to fill in

specific pathology-related fields, such as diagnosis,

codified with the international classifications ICD 9

and ILAE (International League Against Epilepsy)

(OREp, 1996), causal factor and assessment over

Epilepsy’s severity, both semantically codified.

Other information are required, especially

concerning drugs, EEGs and other exams or

demanded performances.

Pathology Networks imply some specific needs

in terms of privacy respect and data security: in

order to ensure that only authorized subjects can

access data, some fundamental concepts regarding

report’s publication have been introduced, which are

DAO, GAN and “consolidated CDA”. A DAO -

Italian acronym for “Authorization and Obfuscation

Document” - defines if the DCE is authorized, i.e.

freely and autonomously consultable by the patient

and if it must be obfuscated, i.e. not visible by

healthcare operators due to a voluntary patient’s

deny or in case of special legal cases (HIV,

voluntary termination of pregnancy, drug addiction,

abuse), except in case of emergency assistance.

GAN document - whose acronym stands for

“Authorization and Designation Management” -

compiled by the patient at his first contact with the

hospital and then digitally signed by a clinical

responsible, specifies who inside the Pathology

Network is authorized to consult the DCE, with the

understanding that access to patient’s data are

restricted to clinical information correlated to the

specific pathology treated.

A “consolidated CDA”, the real entity shared by

healthcare organizations, is made up of the digitally

signed DCE (P7M format), the clinical report in

XML-CDA2 format, and the XSL file containing

presentation rules; this set is then compressed into a

ZIP archive, encoded with Base64 system and

finally inserted as a field of an HL7 message, which

will then be shipped over the network through a

manager.

The procedure applied for feeding the Pathology

Network is carried out in a semi-automatic way from

structured clinical documents contained in the

Health Information System’s local repository,

following the guidelines “Integration Profile”

defined by IHE (IHE International, 2003).

When requesting storage of a Pathology Network

document, such as an Epilepsy report, a form is

opened soliciting the physician's digital signature,

realized with a card identifying the user as an

operator enabled to publish documents over the SISS

platform: signature enables the creation of the

Epilepsy structured report. Then, a first transaction

“Provide & Register Document Set” takes place

towards the clinical organization’s repository

producing the document; due to platform’s

constraints in terms of control over documents’

formal correctness, an employee owning a SISS card

HEALTHCARE INFORMATION SYSTEMS IN A NETWORK ENVIRONMENT - An Interoperability Model and a Real

Case in a Pathology Network

463

with super-user rights is assigned to collect all

reports stored into local database and not yet

published, control that related DAO documents are

authorized and not obfuscated, and finally mark

them with a timestamp. At this point, the “Register

Document Set Document Registry” transaction can

be processed, which effectively publishes the report

into FSE database.

Figure 2: Feeding and retrieval process of a Pathology

Network.

In case an Epinetwork member asks for patient’s

clinical documents consultation, a Query Registry is

invoked over FSE Document Registry: services

offered by SISS infrastructure control if requester is

allowed by the GAN and, if so, generate a Retrieve

Document transaction to show the epilepsy report to

the final user through his local visualization tool.

4 DISCUSSION

The aim of this paper is to show a real solution

adopted to participate in a pathology network and to

show the positive effects it could have inside a

healthcare environment. The solution realized at

Besta represents a particular implementation of a

general model already applied to the Hematologic,

Oncologic and Epileptic Pathology Networks in the

Region of Lombardy, and it could be taken as a

reference methodology for similar initiatives in

different environments. Generality and reusability of

the solution are ensured by technological choices:

first of all, the interoperable platform is supplied by

a unique provider (in this case the Region), which

takes care of all aspects concerning data security and

communication between repositories; moreover, the

adoption of international syntactic standards ensures

correct interpretation of all data published by various

participating systems.

Advantages experienced in taking part in a

Pathology Network can be felt both at clinical and

scientific level, since clinical researchers are

provided with a great amount of high reliable data,

on which more efficient analysis can be performed,

contributing to support clinical decisions, providing

a general improvement in diseases’ care processes

and a better service level to patients.

Pathology Networks could be seen as a

revolutionary concept in healthcare, since it moves

the focus from Health Information Systems to Web

integrated Healthcare Information Systems.

Networks allow to overcome single organizations’

borders, enabling extended co-operation via Web

between healthcare professionals working in

different structures: this represents an opportunity to

share experiences and to join together different

approaches towards the care of diseases, with

undeniable benefits for scientific progress and the

quality of assistance delivered to patients.

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