Contextualized Access to Electronic Health Records

Application to Hospital Interoperability

Bel´en Prados-Su´arez

, Carlos Molina

, Miguel Prados de Reyes

and Carmen Pe˜na-Ya˜nez

Department of Software Engineering, University of Granada, Granada, Spain

Department of Computer Sciences, University of Ja´en, Ja´en, Spain

Computer Science Department, San Cecilio Hospital, Granada, Spain

Keywords:

Contextualized Access, Interoperability, EHR, Electronic Health Records.

Abstract:

Everyday more hospitals develop their own Electronic Health Record (EHR) Systems to improve the accessi-

bility to the information on it. There are some standards and proposals to homogenize the structure of these

EHR, but they use to be so generic, that the ﬁnal EHR structure has so many particularities that is different

in each hospital. This situation has created a huge problem of interoperability, since Hospital Information

Systems (HIS) are not capable of communicating nor understanding each other. At this point it seems very

difﬁcult that all the Hospital Information Systems change their EHR structures into a common one, to get this

communication capability. Proposals to solve this issue require to create a common EHR or to translate all

the existing EHR structures into a common one, and both cases seem to be unapproachable. This is why we

propose a different approach based on the contextualized access to the information. The underlying idea is that

the assistance acts, i.e. situations or contexts, where the information is acceded, as well as the data required

for each, i.e pertinent information, is almost the same independently of the hospital where you are. Hence, it

is not necessary to establish a correspondence between the EHRs, we only need to identify the context of the

extern access and retrieve and send the information pertinent to it. In addition, our proposal also allows the

adaptation to the needs of information of each medical doctor in each Hospital, as well as solves the problem

of EHR fragmentation.

1 INTRODUCTION

Everyday more hospitals join to the digitalization

of the medical records, which is giving room for a

wide variety of proposals to structure the information

into the Electronical Health Records (EHR). Some

of them are speciﬁc for concrete medical specialities

(Karahoca et al., 2010) or for the sanitary system of

a given country (Stan et al., 2011). This variety of

proposals has shown up the necessity of standardiza-

tion, and this is where the standards HL7, Open EHR,

SNOMED-CT, DICOM and the proposal of the Euro-

pean Committee for Standardization, the ISO 13606

regulation, come into play.

However these proposals are so generic, ﬂexible

and abstract, to allow the versatility of the informa-

tion to be stored into the EHR, that the concrete im-

plementations in each hospital end up being quite dis-

similar. Is has made arise serious interoperability is-

sues: on the one hand several venues of the same hos-

pital can’t access the EHR stored at the other; on the

other hand there are no good connections between the

part of the EHRs stored in the primary attention cen-

ters and the hospital EHR; and in addition, when a

patient moves from one hospital (with its own EHR

structure) to a different one (with a different EHR im-

plementation) there is no way to access the from one

of them the information generated in the other one,

generating the EHR fragmentation problem.

Up to the moment the interoperability issue has

been faced in the literature from different points of

view:

• At the machine or communication protocol level,

viewing the problem as the integration into an

EHR structure the information produced from

the different medical equipments and devices like

PACs (Liu et al., 2011; Hu et al., 2011).

• From the security point of view, remarking the

need of authentication methods and identity man-

agement when the different Hospital Information

Systems (HIS) try to communicate (Campos et al.,

2011).

272

Prados-Suárez B., Molina C., Prados De Reyes M. and Peña Yañez C..

Contextualized Access to Electronic Health Records - Application to Hospital Interoperability.

DOI: 10.5220/0004453602720279

In Proceedings of the 15th International Conference on Enterprise Information Systems (ICEIS-2013), pages 272-279

ISBN: 978-989-8565-59-4

 2013 SCITEPRESS (Science and Technology Publications, Lda.)

• As the need of knowledge mobilization, to be able

to access only the relevant parts of the EHR for

the emergency situations where mobile devices

are used (DePalo and Song, 2011).

• The problem of EHR fragmentation (Vergari

et al., 2011) and the need of making the EHR

more “person centric” by using cloud storage and

computing (Van Gorp and Comuzzi, 2012) or in-

tegrated databases (de la Torre-Diez et al., 2013),

but with the inconveniences of the personal data

protection and database matching issues respec-

tively.

• It is also essential to deal with the issue of the

semantic understanding between different HIS,

which has been approached in two different ways:

as the construction of an Ontology to share the

information (Arch-Int and Arch-int, 2011), or by

means to the transformation of the OpenEHR

archetypes into ISO EN 13606 and vice versa

by combining Semantic Web and Model-driven

Engineering technologies (Martinez-Costa et al.,

2010). However, although these proposals allow

logical and structured access to the information,

they don’t describe how to exploit the Ontology

nor the Archetypes to get interoperability between

systems, nor they avoid the uncomfortable se-

lections steps and the successive screen-shots to

reach the desired information (Miguel Prados de

Reyes and Su´arez, 2006).

Only a few proposals are capable of facing some

(not all) of these problems at once, and they are

mainly based of the use of frameworks that work as

intermediaries between HIS, working in two stages

as Halevy suggests in (Halevy, 2011). His proposal

is to ﬁrst translate all possible clinical terminologies

and deﬁnitions of all the EHR to communicate into a

common format that will be used as local EHR. Then,

in the second stage, the interoperability system will

semantically organize the information to ensure that

its meaning stays true in whatever environment the

record is used. This is a theoretical proposal similar to

the previous one of Sunil Kumar (Sunil Kumar et al.,

2010), consisting on the creation of their own EHR

structure, and the translation of every EHR of the HIS

to communicate into their EHR proposal. Once done

it, they have developed a healthcare information ex-

change software based on a proposed adaptable stan-

dard. This way they create a complete EHR of patient

which is interoperable in healthcare systems accord-

ing to their information exchange standard. Never-

theless these proposals have two main drawbacks: the

need to translate each EHR of each different HIS into

the local or proprietary one, and the above mentioned

problem of the limited agreement on the standards to

be used in the second communication stage.

In addition, none of the existing proposals face the

problem as a whole, considering simultaneously all of

the above mentioned implications and supplying an

integrated solution, which doesn’t require the change

or translation of different EHR structures. This is pre-

cisely our aim here. In (Prados-Su´arez et al., 2012;

Prados-Suarez et al., 2012) we proposed to improve

the accessibility of the information based on the iden-

tiﬁcation of the context of the access and the informa-

tion pertinent to it, that we have developed in collab-

oration with the University Hospital San Cecilio from

Granada. Here we extend this proposal to solve the

problem of the interoperability.

In section 2 we summarize the characteristics of

the system that we take as example and reference, so

it can be seen that it is common to the majority of

the HIS, and hence our proposal is easily applicable.

Then, in section 3, we show our proposal to access

the information based on the contextualization of the

situation from which it is required, and how to de-

terminate the pertinent information for each context.

In section 4 we propose how to exploit this contex-

tualized access to solve the interoperability problem.

Finally, in section 5, we summarize our conclusions.

2 BACKGROUND AND SYSTEM

DESCRIPTION

Next we brieﬂy describe the ISO 13606 standard and

the main characteristics of the HIS that we have taken

as reference.

2.1 CEN/ISO ISO 13606

The ISO 13606 (ISO-13606, 2008) proposes a dual

model. The ﬁrst one is the reference model and estab-

lishes a basic structure for the data using an object-

oriented paradigm deﬁning the main classes with the

characteristics to store for each one. The second

model sets the Archetypes as a way to deﬁne the clin-

ical concepts or sets of clinical information items,

managed by the systems and with a concrete clini-

cal meaning (from the pregnancy protocol to the bio-

chemistry information or HDL-cholesterol item in-

side an analysis).

2.2 EHR Information System

The HIS of the San Cecilio Hospital stores around

800.000 EHR, containing more than 50 millions doc-

uments, and it is having a fast increase in size due

to the inclusion of new types of documents from two

ContextualizedAccesstoElectronicHealthRecords-ApplicationtoHospitalInteroperability

273

sources: old documents that still have not been dig-

italized (scanned images, MRI, etc.) and new doc-

uments generated from newly acquired devices and

equipments like PACs.

This HIS gives service, not only to the Hospital

itself, but also to several venues disperse in the city of

Granada, including primary attention centers.

In Figure 1 we show the structure of the system.

Figure 1: Structure of the system.

This system, as legally demanded, stores each ac-

cess to the EHR and the data acceded, including the

staff member acceding and the assistance situation

(called “controlled assistance situation”) in which

the access occurs. In case of modiﬁcation, it also

stores the modiﬁed data. From now on, we will call

this access data base as Retrospective Access Data

Base (RADB). The number of records stored in the

RADB is in the order of hundreds of millions. Our

proposal is based on the analysis of the registers of

this RADB since, it allows us to know which infor-

mation has been acceded and the related context.

2.2.1 Electronic Health Records Structure

As given by the ISO13606 Reference Model the EHR

structure is organized according to an Ontology with a

class structure with the classes Folder, Section, Entry,

Cluster and Element.

The EHR gathers all the documents of any type

generated in each assistance act of a patient, follo-

wing the structure shown in Figure 2). In (Prados-

Su´arez et al., 2008), can be found the properties used

to characterize each document in the EHR, which are

organized according to assistance episodes and classi-

ﬁed considering 1500 different documents classes in

the system.

Items inside the documents can be grouped into

data groups: small logical units related under a clini-

cal point of view. Each data group has its own speciﬁc

properties, but also inherits the general properties of

the document where it is contained. The “special”

data group with the EHR’s and patient’s identiﬁca-

Figure 2: Logical Organization of the EHRs.

tion, common to all the documents is discarded from

the processes explained later.

3 CONTEXT-BASED ACCESS TO

EHRS

In this section we brieﬂy show the context-based

mechanism of access, but in (Prados-Su´arez et al.,

2012; Prados-Suarez et al., 2012) can be found a more

detailed explanation of this system.

Deﬁnition 3.1. We call Context to a situation in

the doctor-patient relationship inside an assistance

act, requiring an access to the information previously

stored in the EHR.

We set three criteria according to which it is ob-

jectively reasonable to identify the set of contexts:

pathological process, medical specialty and kind of

assistance.

To automatically detect the situation or context

where a medical doctor accesses an EHR we consider

the following variables: type of medical staff (spe-

cialty and position), type of the medical workstation

(type of terminal, medical unit associated and physi-

cal location) and type of the present and last patient’s

appointments.

To identify the data groups for each context we

introduce the concept of pertinence:

Deﬁnition 3.2. We deﬁne the pertinence of a concrete

data group for a given context as its relevance: the

more needed or interesting the data group is for the

context, the higher its pertinence to the context is.

This pertinence is calculated considering a the fo-

llowing factors:

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Figure 3: Scheme of the contextualized query process.

• The regulations about each clinical process: P

• The opinion of the concrete doctor: P

• The data groups with a great and especial impor-

tance for a given patient: P

• The aging of the information (loose of validity as

the time passes) or time pertinence: P

(D).

• The access patterns or restrospective pertinence,

obtained according to the accesses stored in the

RADB database: P

(X)

Next deﬁnition aggregates this information:

Deﬁnition 3.3. Let X be a group of data in a docu-

ment D, and C a context, we deﬁne the global perti-

nence of X to C as

(X) = (P

(X)⊕P

(X))⊗P

(D)

(1)

All the pertinences are in [0, 1] and we have cho-

sen the maximum and the minimum as t-conorm and

t-norm because of their simplicity, and therefore, ef-

ﬁcient and fast calculation as well as they are quite

extended.

This way a data group is relevant if the number of

accesses to it is high in comparison to the total num-

ber of accesses allowing, the update of the pertinence

according to the decreasing relevance due to the ag-

ing of the access and to automatically adapt to new

accesses patterns and future needs.

An scheme of the access process in shown in Fig-

ure 3. With this scheme we never loose the access

to the whole EHR, but we get the information in it

according its relevance for the present act. More in-

formation about the interface once logged, the process

to get a concrete data item and a comparison with the

context based access can be found in (Prados-Su´arez

et al., 2012; Prados-Suarez et al., 2012).

The update of the system is performed on each

access by the update of the retrospective pertinence

Figure 4: Scheme for pertinence’s update process.

when the access is logged in the RADB. A scheme

summarizing of the process is shown in Figure 4.

4 CONTEXT-BASED

INTEROPERABILITY

As previously seen proposals made so far lies in fo-

cusing their attention in the interoperability between

system structures, forgetting the real users of the sys-

tem. We change the approach and face it in a more

practical way, giving more importance to the users

and to satisfy their needs of information.

In a real situation, the medical staff does not need

to access the complete EHR of the patient but only

the portion of it related to the act in process. In other

words, in every hospital what a medical doctor needs

is the portion of information pertinent to the context

he/she is involved in. In addition, the contexts in most

of the hospitals are almost the same due to the medical

praxis is very similar in most of the institutions.

Considering these two premises, the main idea is

to apply the context-based access to the communica-

tion between systems such that given two hospital H1

and H2 with a context-based interface (Figure 5):

• A staff member inside a given context in H1 needs

information from H2.

• H1 sends to H2 the identiﬁcation of the context.

• H2 retrieves the information deﬁned as pertinent

for that context, stores the record of the access

performed and returns it as response to H1.

• H1 shows the received blocks of information to

the staff member in the usual interface of H1.

• If the information required is not in the received

block the communication process is repeated till

the desired data items are retrieved.

Based on the two premises above, in most of the

cases the information needed will be found in the ﬁrst

blocks. Let us remark that each user works with the

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275

Figure 5: Scheme for an extern access.

usual interface of his/her hospital. Since the commu-

nication is made at the level of archetypes it is only

necessary that both systems support the archetype lan-

guage and that the user interfaces are context-based.

Even if H1 doesn’t have a context-based interface,

H1 could send the information that H2 needs to iden-

tify the context and H2 would perform the context

identiﬁcation and return the information in any of the

standard formats for medical documents, like DICOM

for images and PDF or XML for textual information.

4.1 Archetype-based Contexts

As mentioned above, the CEN/ISO 13606 only de-

ﬁnes a general structure for EHR system interfaces

but not for the internal structure of the system. It is

ﬁgured out to establish the interoperability at the level

of archetypes because otherwise it would be neces-

sary to perform the translation of data and structures

between systems. Our proposal here is to deﬁne the

contexts as archetypes in such a way that the commu-

nication between institutions will be reduced to send

the identiﬁcation of the context and get the informa-

tion pertinent to it in the archetype language.

4.1.1 Context Deﬁnition

To deﬁne the contexts as archetypes we need that their

deﬁnition is made as standard as possible. In addition,

the resulting set of contexts must be complete enough

to consider the widest set of possible contexts so all

usual access situations from hospital and institutions

are taken into account. Here we propose to deﬁne the

contexts based on the three criteria indicated above

but ﬁlling them with standard sources instead of per-

sonalizing them for a concrete hospital. Then the set

of contexts will be obtained from:

• Pathological Process. Each HIS must register all

the diseases deﬁned by the World Health Organi-

zation (WHO) in the ICD, International Statisti-

cal Classiﬁcation of Diseases and Related Health

Problems, even though they are unusual. Hence

a context for each will be created. The same pro-

cess can also be performed with the ICF (Inter-

national Classiﬁcation of Functioning, Disability

and Health) and ICHI (International Classiﬁcation

of Health Interventions).

• Medical Specialty. There are several standards

and correspondencesbetween medical specialities

in different countries, that can be used to create

the contexts. This is the case of the regulation of

the European Union related to the medical spe-

cialities that are automatically recognized in all

the EU plus Norway, Iceland and Liechtenstein or

the American or Australian listings.

• Kind of Assistance. This source has more variety

since it is more related to the internal work-ﬂow

of the sanitary systems, but there are also some at-

tempts of standardization like the one in the Clin-

ical Care Classiﬁcation (CCC) System or ICF.

In the ICD, ICF and ICHI the WHO has coded the

information (each disease, intervention, etc. has an

unique code), so it isn’t necessary to establish a cor-

respondence. Only in the case of the contexts deﬁned

by medical speciality may be necessary to create a ta-

ble that stores the correspondences between different

sanitary systems. But, as can be seen, this is a very

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276

simple and small table that, in addition, the system

can automatically complete with the use.

With it the spectrum of contexts covered is wide

enough to ensure a ﬂuent communication and in-

teroperability in most of the usual cases, and only

very special and rare situations might not be covered.

However, even in these cases the access could be per-

formed, it will only require the more queries till the

desired information is found.

4.1.2 Context Identiﬁcation

The local system at H1, prior to ask for the data, iden-

tiﬁes the context of the access. The system sends it to

the extern hospital H2 when asking for the EHR using

an standard language for medical data like HL7. The

system at H2 looks for that context on its database.

If H2 ﬁnds the context, then looks for the pertinent

data groups and sends them back to H1. If the con-

text is not found, the H2 system uses the specialty of

the medical staff member at H1 to send back a list

of contexts related to that specialty. The medical staff

member at H1 selects then the more appropriated con-

text and H1’s system sends the choice to H2’s system.

Then the list of pertinent data groups is created and

sent back to H1. If the person at H1 selects one of

these data groups to see it, then H2 system makes a

correspondence between the required context and the

one selected from the list so in future accesses the sys-

tem can identify it, and send back the pertinent infor-

mation without this previous negotiation.

At this point let us remind that once acceded any

context it is always possible to access the whole his-

tory if necessary, so entering through a wrong context

only would mean that it will be necessary more mouse

clicks to reach the desired information.

4.1.3 Context Adaptation: Extern Pertinence

At this point arise questions like:

• How to obtain information that is pertinent in the

context of the hospital querying, but is not for the

same context of the other hospital.

• How the content of the context can reﬂect the

changes in the needs of information.

The response in all the cases is the same as in the

local system. To adapt the system to the peculiarities

of the accesses from each hospital or institution, we

introduce an extern pertinence This pertinence will be

learnt with the consecutive accesses in the same way

as explained above for the local system. To calculate

this pertinence the acceded data groups are stored in

a table like the RADB. Then, when a new access is

performed, this new pertinence (P

) is introduced in

the calculation of the global pertinence as follows:

(X) =



(X) ⊕ P

(X)

⊕P

(X) ⊕ P

(X)



⊗ P

(D)

Hence, as seen in ﬁgure 6, in the case of extern ac-

cesses both the local dynamic pertinence and the ex-

tern pertinence are considered. Tanking into account

only the extern pertinence would make the system un-

able to adapt to new needs in the case of few accesses,

due to the lack of information to update the perti-

nence. On the other hand, considering only the local

dynamic pertinence the system would never adapt to

the needs of the extern hospitals requirements, since

the extern accesses would never have enough weight

regarding the local number of accesses.

The ﬁrst time the EHR is acceded for the extern

hospital, the P

is 0 for all the data groups and con-

texts, so the local information determinate the perti-

nent information. This access updates the extern per-

tinence and is stored for future accesses (increasing

the P

for some data groups). If the interaction con-

tinues the system will be adapted to the extern hos-

pital needs. This is specially useful, as an example,

when patients are derived from the primary attention

to hospitals with medical specialties, or when a hospi-

tal frequently send patients to a special unit in another

hospital (i.e. emergency or maternity centers).

Regarding implementation issues, the system only

requires to store the pertinence of the acceded data

groups in a table similar to the dynamic pertinence

one, adding the identiﬁcation of the extern hospital.

4.2 Final Remarks

In this section we indicate the requirements to imple-

ment this proposal, as well as how the problems men-

tioned in the introduction are tackled.

4.2.1 System Requirements

First of all it must be noted that in most of the coun-

tries laws obligate to store the information about the

medical staff accesses to the information in the EHR.

In other words, all the hospitals must have a database

similar to the above mentioned RADB. To implement

this proposal in addition to this RADB are only nec-

essary:

• A context-based user interface.

• Support for an archetype based language or for

any other standard of communication like HL7.

• A table to store the correspondencesbetween con-

texts of different institutions.

• A table to store the extern pertinence.

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277

Figure 6: Scheme for an extern access with Extern pertinence and access record.

4.2.2 EHR Defragmentation

The fragmentation of the EHR for a given patient

is also solved in the following way: When an ex-

tern hospital H1 attends a patient and access his/her

EHR, this access is stored in the RADB of the hospital

queried H2 as mentioned above. When that patient re-

turns to his/her usual hospital H2, all the contexts re-

lated to the context from which the extern access was

performed will reﬂect the extern access. If the med-

ical doctor consider that extern act as relevant, they

can make an extern consultation to H1 to retrieve the

part of the EHR generated in that extern assistance

act. Otherwise, this information will lose relevance

with the time and stop being pertinent, but a record of

it will remain stored in the EHR.

4.2.3 Communication between Systems

The solution to transfer the information depends on

the systems that interact: if both systems support an

archetype language, then the information can be sent

using this language. In other cases, standard formats

for medical documents can be used like DICOM for

images and PDF or XML for textual information.

4.2.4 Security and Authentication

The problems of security and authentication are eas-

ily to solve in this proposal since each hospital and in-

stitution is responsible of authenticating the members

its staff when they access the local system. The au-

thentication problem then is transferred to the authen-

tication between institutions, in such a way that when

a hospital receives a query from another one they are

sure of the identity of each other. This problem in fact

is also solved since most of the institutions use digital

certiﬁes, and if not, any of the available mechanisms

to this purpose can be used.

5 CONCLUSIONS

In this paper we have presented an approach to pro-

vide the HIS with interoperability capabilities by the

use of a context-based interface. In addition our pro-

posal improves the accessibility of the information ,

since the medical staff can reach the desired informa-

tion easier and faster (in less steps), also the mobiliza-

tion of the knowledge since speciﬁc contexts for the

mobile devices can be created. Even more the system

is able to adapt to the speciﬁc requirements of infor-

mation of each staff member or patient in a hospital,

as well as to the requirements performed from any

other extern institution. Moreover it also adapts to the

changes in the patterns of access over time and it all

is done in an automatic an efﬁcient way.

The problem of the EHR fragmentation is also

solved trough a mechanism to register and localize all

the disperse parts of it, regardless where it is or the

format it is stored in, and avoiding the saturation of

the medical doctors with too much information.

There are no problems of security, since the identi-

ﬁcation between institutions is done as usual, and ev-

ery hospital is responsible of the staff identiﬁcation.

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278

Finally, this proposal is easy and not costly to im-

plement, and doesn’t require to modify the structure

of the EHR of the hospitals to communicate nor per-

form the translations between these structures. In ad-

dition it is not dependent on the underlying technol-

ogy, and it complies with the ISO 13606 standard but

is also valid for any other protocol of communication

solving the problem of the lack of agreement in the

standard to use.

ACKNOWLEDGEMENTS

The research reported in this paper was partially

supported by the Andalusian Government (Junta

de Andaluc´ıa) under project P07-TIC03175 ”Repre-

sentaci´on y Manipulaci´on de Objetos Imperfectos en

Problemas de Integraci´on de Datos: Una Aplicaci´on

a los Almacenes de Objetos de Aprendizaje”, by the

Spanish Government (Science and Innovation De-

partment) under project TIN2009-08296, and also by

project UJA11/12/56. We would also like to thank

their collaboration to the medical personnel that is

participating in the development of the system.

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