cordis.europa.eucordis.europa.eu/docs/projects/cnect/3/620983/080/... · web viewusing a solution...

D4.1 Pilot Level Service Specification for CareWell ServicesWP4 INTEGRATED CARE ARCHITECTURE AND SERVICE SPECIFICATION

Version 0.11, date 18th February 2015

a

The CareWell project is co-funded by the European Commission within the ICT Policy Support Programme of the Competitiveness and Innovation Framework Programme (CIP). Grant Agreement No.: 620983

The information in this document is provided as is and no guarantee or warranty is given that the information is fit for any particular purpose. The user thereof uses the information at its sole risk and liability

D4.1 Pilot Level Service Specification for CareWell Services

DOCUMENT INFORMATIONORGANISATION RESPONSIBLE

Osakidetza

AUTHORSFaria, Angel (Osakidetza)Gonzalez, Nicolás (Osakidetza)Lewis, Leo (IRH)

CONTRIBUTING PARTNERSLast name, First name (Organisation)Last name, First name (Organisation)Last name, First name (Organisation)

DELIVERY DATE

DISSEMINATION LEVELP Public

VERSION HISTORYVersion Date Changes made By0.1 08/10/2014 Changes in Index Angel Faria0.2 20/11/2014 Structure of document Angel Faria0.25 15/12/2014 Updated Methodology Angel Faria0.3 19/01/2015 Sections 3.1, 3.2, and 4.1, 4.2 added Angel Faria,

Leo Lewis0.4 28/01/2015 Section 6, 1.4, 5.1 added; updates following

review by pilot sitesAngel Faria

0.9 12/02/2015 Further updates Leo Lewis0.10 13/02/2015 Section 1.4.2 moved to Appendix A, much of

section 5.2 moved to Appendix B; formatting standardised

John Oates

0.11 18/02/2015 Revised figures Ane Fullaondo

OUTSTANDING ISSUESFull quality review

FILENAMEdocument.docx

STATEMENT OF ORIGINALITYThis deliverable contains original unpublished work except where clearly indicated otherwise. Acknowledgement of previously published material and of the work of others has been made through appropriate citation, quotation or both.

v0.11 / 18th February 2015 of 103 Public


Executive SummaryThis deliverable defines the CareWell ICT-enabled service specification and IT architecture in terms of examining the current situation in relation to information and communication mechanisms and technologies, and those which will be implemented in each pilot site to support the implementation of the care pathways.In addition, it provides details of standards and other relevant technical guidance, together with information on the security and confidentiality processes followed by each of the pilot site.



Table of ContentsEXECUTIVE SUMMARY 3

TABLE OF CONTENTS 4

1. INTRODUCTION 81.1 Introduction to the project 81.2 Aims of this deliverable 81.3 Structure of the deliverable 81.4 Glossary 8

2. METHODOLOGY 11

3. CURRENT SERVICES AND TECHNOLOGICAL MODELS 163.1 Introduction 16

3.1.1 Current ICT-enabled service specification 173.1.2 Current IT architecture 18

3.2 Croatia 223.2.1 Current ICT-enabled service specification 223.2.2 Current IT architecture 23

3.3 Lower Silesia 253.3.1 Current ICT-enabled service specification 253.3.2 Current IT architecture 26

3.4 Veneto 283.4.1 Current ICT-enabled service specification 283.4.2 Current IT architecture 29

3.5 Puglia 303.5.1 Current ICT-enabled services specification 303.5.2 Current IT architecture 31

3.6 Wales 343.6.1 Current ICT-enabled service specification 343.6.2 Current IT architecture 35

3.7 Analysis of current service specification vs IT systems 38

4. CAREWELL ICT-ENABLED SERVICE SPECIFICATION AND IT ARCHITECTURES 40

4.1 Basque Country 404.1.1 CareWell service specification 404.1.2 CareWell IT architecture 41

4.2 Croatia 444.2.1 CareWell service specification 444.2.2 CareWell IT architecture 45



4.3 Lower Silesia 484.3.1 CareWell service specification 484.3.2 CareWell IT architecture 50

4.4 Veneto 514.4.1 CareWell service specification 514.4.2 CareWell IT architecture 52

4.5 Puglia 544.5.1 CareWell service specification 544.5.2 CareWell IT architecture 56

4.6 Wales 574.6.1 CareWell service specification 574.6.2 CareWell IT architecture 58

5. GUIDELINES TO ACHIEVE INTEROPERABLE AND EFFICIENT IT SYSTEMS 60

5.1 Guidelines for the development of interoperable systems 605.1.1 Levels and environments of interoperability 605.1.2 Standards 62

5.2 Interoperability Tools in CareWell pilots 645.2.1 Basque Country 645.2.2 Croatia 665.2.3 Lower Silesia 665.2.4 Veneto 665.2.5 Puglia 675.2.6 Wales 67

6. SECURITY AND CONFIDENTIALITY OF DATA 686.1 Basque country 686.2 Croatia 696.3 Lower Silesia 726.4 Veneto 736.5 Puglia 756.6 Wales 76

APPENDIX A: TECHNOLOGICAL TERMS 79

APPENDIX B: STANDARDS 102B.1 Communication Protocols (general applications) 103B.2 Syntax standards 103B.3 Format Specification 104B.4 Services Specification 104B.5 Process Specification 104



B.6 Communication Protocols (Health applications) 104B.7 Terminology and health nomenclature 105B.8 Clinical documentation 106B.9 Models of information 106B.10 Architecture of communication 106B.11 Knowledge models 107

LIST OF TABLESTable 1: Template - services vs applications 35Table 2: Current ICT-enabled services of Basque Country 42Table 3: Current ICT-enabled services of Croatia 48Table 4: Current ICT-enabled services of Lower Silesia 50Table 5: Current ICT-enabled services of Veneto 53Table 6: Current services of Puglia 55Table 7: Current ICT-enabled services of Wales 59Table 8: Services Evolution Basque Country 65Table 9: CareWell ICT-enabled services of Croatia 69Table 10: Evolution of ICT-enabled services in Lower Silesia 73Table 11: Evolution of ICT-enabled services in Veneto 76Table 12: Evolution of ICT-enabled services in Puglia 79Table 13: Evolution of ICT-enabled services in Wales 82Table 14: Basque Country standards used 94Table 15: Croatia standards used 95Table 16: Lower Silesia standards used 95Table 17: Veneto standards used 96Table 18: Puglia standards used 96Table 19: Wales standards used 96Table 20: Veneto kinds of secure access 104

LIST OF FIGURESFigure 1: Template Common CareWell Architecture 37Figure 2: Architecture of Basque Country Pre-CareWell 44Figure 3: Functional Architecture EHR in Primary Care (Osabide AP) 45Figure 4: Functional Architecture EHR in Secondary Care (Osabide Global) 46Figure 5: Architecture Basque e-Prescription system 47Figure 6: Architecture Multichannel services centre support in Basque Country 48Figure 7: Current IT architecture of Croatia 49Figure 8: Functional Structure G2 50Figure 9: Current Architecture of lower Silesia 52Figure 10: Current Architecture of Veneto 54Figure 11: Current Architecture of Puglia 57Figure 12: Architecture of Nardino 58



Figure 13: Current Architecture of Wales 60Figure 14: Communications channels of WCCG 62Figure 15: Welsh Clinical Portal (WCG) Integration architecture 62Figure 16: Wales: Level of development of ICT-enabled services 64Figure 17: CareWell Architecture of Basque Country 67Figure 18: New application modules 68Figure 19: Common features 68Figure 20: CareWell architecture Croatia 71Figure 21: EMH chronic disease management system 72Figure 22: FER Home Health Smart TV 73Figure 23: CareWell IT Architecture Lower Silesia 75Figure 24: CareWell IT architecture of Veneto 78Figure 25: Veneto Territorial Information System 79Figure 26: CareWell IT Architecture of Puglia 81Figure 27: Communication exchange and information flows 82Figure 28: CareWell IT Architecture of Wales 85Figure 29: Standards v. interoperability levels 89Figure 30: Interoperable platform 95Figure 31: Secure architecture for external communications 99Figure 32: PKI infrastructure e-health in Croatia 101Figure 33: Layers of security communication channels Croatia pilot 102Figure 34: Security architecture of data transmission channels in Lower Silesia 104Figure 35: Security architecture of data transmission channels in Veneto 107



1. Introduction1.1 Introduction to the projectFrail elderly patients are characterised as having complex health and social care needs, being at risk of hospital or residential care home admission and requiring a range of high level interventions due to their frailty and multiple chronic conditions. These patients typically demand an integrated care approach where all care practitioners working in the different levels of care have to be tightly coordinated and special emphasis is put on patient´s empowerment. CareWell aims to enable the delivery of integrated care for frail elderly patients supported by ICT-based technologies and platforms and associated new ways of working.

1.2 Aims of this deliverableThis deliverable describes the current and CareWell ICT (information, communication and technologies) enabled service model and technical infrastructure available in each of the pilot sites. The information has been obtained through onsite pilot site visits as well as completed questionnaires and workshops held as part of WP2 and WP3 work. In addition, the deliverable includes guidance on achieving interoperability between the different IT systems in use in the sites and security and confidentiality processes and considerations.

1.3 Structure of the deliverableThis deliverable has been structured as follows:This Introduction section is followed by Section 2 which describes the methodology that has been adopted to take forward the different tasks within WP4.Section 3 details the current service model available in each of the pilot sites including how communication takes place between the different members of the care team in the various care settings involved. Information contained in D2.2 and D3.1 includes the gap analysis detail for each sites’ CareWell implementation and this has not been duplicated within this deliverable. The deliverable also describes and illustrates the technical infrastructure currently available in each of the pilot sites including what IT systems are implemented in each of the care settingsSection 4 provides describes how the service model will be enhanced through the implementation of both new or improved ICT and associated new ways of working in each of the care settings. Diagrams illustrating the new technical infrastructure and IT systems are provided with descriptions of the new components where necessary.Section 5 details guidance on achieving interoperability between the different IT systems across the care settings and provides a high level illustration of the generic CareWell architecture.Section 6 concludes with a description of how each pilot site ensures the security and confidentiality of patient identifiable information within the IT systems and other methods of communication between the care team members.

1.4 GlossaryThe objective of this glossary is to help to reader of document to understanding it. See also Appendix A Technological TermsAReS Puglia Agenzia Regionale Sanitaria PuglieseBP Blood Pressure



BM Body MassCOPD Chronic Obstructive Pulmonary DiseaseCRM Customer Relationship Management service (see also Appendix A)DICOM Digital Imaging and Communication in Medicine (see also Appendix A)EC European CommissionECG ElectrocardiographyEHR Electronic Health Record (see also Appendix A)EU European UnionENT Ericsson Nikola Tesla D.D.FAQs Frequently asked questionsF.O.C. Free of chargeGP General PractitionerHIS Health Information System (see also Appendix A)ICCM Integrated Chronic Care ModelICCP Integrated Care Coordination PathwayICD Implantable Cardioverter-DefibrillatorICT Information Communication TechnologyIHR Individual Health RecordIKP Individual Patient Account (Lower Silesia)IMCR Intelligent Mobile Movement Sensor (Lower Silesia)INR International Normalised RatioIT Information TechnologyLHA Local Health AuthorityLIS Laboratory Information System (see also Appendix A)LSV Urzad Marszalkowski Wojewodztwa Dolnoslaskiego (Lower Silesia

Marshall's officePAS Patient Administration SystemPC Personal ComputerPDAs Personal Digital AssistantsPEHP Patient Empowerment and Home-care PathwayPHB Powys teaching Local Health BoardPHR Personal Health Record (see also Appendix A)PKI Public Key Infrastructure (see also Appendix A)RIS Radiology Information System (see also Appendix A)ULSS nr2 Unita Locale Socio-Sanitaria Number 2VPN Virtual Private Network (see also Appendix A)WiFi Wireless local area networkWoW Ways of WorkingWP Work Package



2. METHODOLOGYThe methodology adopted in this WP followed a ‘bottom up’ approach as illustrated below:

In order to describe the IT systems or applications involved, not only applications to be developed during CareWell, it is important to understand and document the applications or systems running before the commencement of CareWell which will have an impact on any new applications or services.The second stage involved the identification of the functionalities for each system/application: a summary of the features of each application and user roles.This was followed by the identification of services provided by each application: the outcome of this task is a table mapping ICT-enabled services and applications. Template below:



Table 1: Template - services vs applications

Services App1 App2 App3 App4EHRE-prescriptionTeleconference Professional –Professional (audio /movie)Teleconference Professional –Patient (audio /video)PHRCollaborative WebEducational WebTelecare serviceClinical interconsultationAnalysis and Exploitation of clinical and management data

The use cases developed in WP2 were then linked to the ICT-enabled services where one service could be included in more than one aspect of a use case.The information and communication flows were then mapped onto the pathways with the current use cases provided for each pilot. The outcome of this task was a first draft of the structure of pathways in each pilot site.In order to achieve the same global structure for each pilot site, a common template of architecture for every pilot site was prepared.

Figure 1: Template Common CareWell Architecture



The next step was to document the new or enhanced ICT-enabled services which would be provided in each pilot site. The technological challenge for pilots was to examine and document this aspect of the work package, following a common CareWell architecture, and the interoperability /security guidelines.The final step was to describe how the new or enhanced ICT-enabled services would impact on the service specification in each of the care settings in each pilot site. Common template for architecture picturesBelow is a description of each component included in the Common IT Architecture diagrams:

A. Pathway : The pathway element is identified by a rectangle. In CareWell there are two pathways. Rectangle orange – pathway ‘Integrated Care Coordination Services’

Rectangle Blue - pathway ‘Patient Empowerment And Home Support Services’

These elements form the basis for the introduction of the ICT-enabled services.B. Main Services :

EHR: green rectangle.

C. Level of care (primary, secondary/specialised)

D. Main applications



E. Secondary applications

F. Legacy Systems

G. Interoperability platform

Work package information collection The work package was taken forward using a number of different methods to elicit the necessary information to support the steps in the methodology described above.A. Questionnaires

During the WP two questionnaires were designed and administered for collecting information about the pilot sites:

o General Questionnaire: used to understand and document the current situation in each pilot site together with their proposed CareWell objectives. (Template in Annex 1)



o Security Questionnaire: used to collect information about the security elements used by pilots. (Template in Annex 2)

B. Study VisitsVisits to each pilot site were scheduled after the completion of the General Questionnaire. The aim of these visits was to:

Clarify information reported in the questionnaire Analyse the current technological situation for each pilot through discussions

with the technical team Observe the main applications which would be included in the CareWell

solution and analyse the main issues or improve guidelines Observe the performance and common user requirements of each applications Understand any current issues with existing systems in each site from a

technical perspective To understand the expectations and challenges in implementing the ICT-

enabled aspect of the CareWell project (service and IT point of view).C. Technical Telcos

Several telcos were scheduled both one to one telcos with each pilot site to clarify specific issues as well as general telcos to share the approach, generic issues and present new actions.

D. Technical WorkshopsTwo technical workshops were held: Barcelona: The main objectives of this workshop were:

To define the action plan and establish working groups To present the general questionnaire and approval of work plan

Palma de Mallorca: The objectives of this workshop were: To establish and analyse the IT diagrams Pre CareWell for each pilot



3. Current services and technological models

3.1 IntroductionThis chapter describes the current situation in each pilot site not only from a technological perspective but also functional where the service specification in each of the care settings is documented.The information is divided into two sub sections as follows:Current services provided: This information was captured using the table below. Each pilot site was asked to indicate whether or not their current service delivery was supported by each of the ICT-enabled services together with the implementation maturity level.

Pilot Site Name BeforeICT-enabled services Operational Maturity levele-PrescriptionMessaging clinician PatientsEHRInterconsultationCall CentreVirtual ConferencePHRNursing Information SystemEducational PlatformCollaborative PlatformTelemonitoringMultichannel Centre (Management Telecare Programs)

The maturity level was assessed using the following criteria: 0 = not implemented. 1 = service implemented and being tested. 2 = service 25% implemented. 3 = service 50% implemented. 4 = service 75% implemented. 5 = service 100% implemented, ie fully operational with all potential users and

CareWell patients involved.Current IT architecture: This section describes the current ICT tools deployed in each pilot site together with the communication channels and different care practitioners involved in the care settings within each pathway. Basque Country



3.1.1 Current ICT-enabled service specificationStable Patients – out of hospital careCurrently, the care of a ‘stable’ patient with complex needs is undertaken by the patient’s GP and GP practice nurse. Together, these care professionals assess the patient’s needs, draw up the care plan and medication regime, offer patient education, deliver any necessary interventions either in the GP practice or patient’s home, monitor, review and reassess the needs of the patient in a planned way as well as respond to any unplanned events or deterioration unless emergency services are sought through the eHealth centre. Information is shared between the care professionals and patient in face-to-face (F2F) contacts as well as by phone. Care professionals are able to share patient-related information through the EHR and e-Prescription and do have periodic multi-disciplinary team meetings F2F and by phone.Although the GP and GP practice nurse provide a case management service, the actual co-ordination of care is undertaken by the Telecare Centre as it acts as a hub for both health and social care practitioners. The Centre is able to activate additional services by following agreed protocols in response to telemonitoring alerts and alarms as well as emergency services if the situation is deemed to require such intervention.Unstable Patients – out of hospital careWhen a patient’s health status deteriorates, either the GP or the GP practice nurse will proactively case manage the patient in their own home and involve additional healthcare professionals to provide clinical interventions, including those from specialists, as necessary.Inpatient – hospital careIf a patient has an emergency admission to hospital, the reference internist takes responsibility for co-ordinating the care for the patient. This will include ordering tests and investigations, drawing up the care plan in consultation with other healthcare professionals, reviewing the medication regime and making adjustments as necessary, co-ordinating any additional specialist input into the patient’s care as well as communicating information on the hospital admission to the patient’s GP. The internists will also involve the hospital social care team if the patient requires a social care assessment with a view to requiring support at home post discharge. If the patient requires longer term hospitalisation to facilitate rehabilitation, for example, the internists will arrange the necessary referral.Inpatient – hospital discharge preparationThe hospital liaison nurse works closely with the reference internist to supervise the patient’s discharge from hospital. Information, such as the updated care plan and medication regime, is shared with the GP practice nurse in order for the intensive follow-up, including home visits when necessary, to monitor the patient’s recovery appropriately. A frailty assessment will be carried out and support from social care services activated if required. In addition, the patient is given information on their care plan and education on its content and medication regime.

Table 2: Current ICT-enabled services of Basque Country

Basque Country BeforeICT-enabled services Operational Maturity levele-Prescription YES 3Messaging clinician Patients YES 1EHR YES 3



Interconsultation YES 3Call Centre YES 2Virtual Conference NO 0PHR YES 3Nursing Information System YES 3Educational Platform NO 0Collaborative Platform NO 0Telemonitoring YES 2Multichannel Centre (Management Telecare Programs) YES 2

3.1.2 Current IT architecture Osakidetza has services in both the Integrated Care and Coordination and Patient Empowerment and Home-Support pathways and these services are provided by several systems. These systems are able to share information through the interoperability platform (Oracle business service). The figure below illustrates the current IT architecture.

Figure 2: Architecture of Basque Country Pre-CareWell

Integrated Care Coordination Services The Basque Country provides the EHR service through different systems depending on the health sector where the service is implemented (primary or secondary care). In primary care, Osabide AP is used, whereas in secondary care there are two systems deployed - Clinic and Osabide Global. This duplication is due to the Clinic system being an older viewer which receives clinic data from legacy systems for every hospital whereas the Osabide Global is a newer version with more functionalities which extend beyond view only.



Currently Osakidetza are performing a migration task to achieve a unique system to provide EHR service not only in secondary care but also in primary care.The e-Prescription service Presbide, is provided by a unique system in both care sectors. This system has been integrated as a module within the EHR systems (Osabide Global and Osabide AP).In addition, Osabide AP and Osabide Global provide the interconsultation functionality which enables care practitioners in primary and secondary care settings to share the most relevant clinical information. Patient Empowerment and Home-Support Services This pathway is composed of the PHR service provided through the Health Folder system, which is integrated within the Multichannel Services Centre (MSC). The MSC manages several health programs (stop smoking program, monitoring sedentary lifestyles etc) and collects data from questionnaires completed by patients in the PHF.In addition there are distinct telemonitoring programs that are not focused on frail elderly patients. These programs are not connected to the EHR systems nor MSC but use an external monitoring and management console.Relevant Systems / applications

E-Osabide: is the hospital information system deployed in all the hospitals to provide administrative information (e.g. appointments, demographic data) and clinical activity data.

Osabide AP: is used in primary care to provide the EHR service. It also has the Presbide module for providing the e-Prescription service. This system was developed in .net, has a client /server architecture and runs on a Citrix platform.

Osabide Global: is a secondary care application providing several services: EHR E-Prescription, implement specific module (Presbide) Interconsultation

It is developed in java following client/server architecture in high availability on rack oracle database.

Figure 3: Functional Architecture EHR in Primary Care (Osabide AP)



Both systems (Osabide Global and Osabide AP) are connected to legacy systems through the Intranet business service. Examples of legacy systems connected to the EHR are LIS, RIS, anatomic pathology, HIS etc.The following picture shows distinct connections between the EHR used in secondary care and the legacy systems. These connections are the same for the primary care sector systems.

Figure 4: Functional Architecture EHR in Secondary Care (Osabide Global) Presbide: is a module integrated in Osabide Global and Osabide Ap EHR systems

(secondary and primary care). It is developed in java on an Oracle database. The major difficulty of this tool was the construction because it requires the implementation of interoperability tools with internal systems as well as external systems. This complexity is due to the development and implementation of the e-Prescription being the responsibility of two organisations. The Basque health service (Osakidetza) has responsibility over the clinical aspect, ie the module for documenting the prescriptions and storage in a central database, and the Health Department having responsibility for the pharmacies and the dispensation process (dispensation module, erezeta) and Vademecun which is a set of services which offer information about medicines (products, posology, composition etc)

To date, the e-Prescription project provides interoperability not only in semantic and syntactic levels but in organisational and business process too between two different organisations (with different systems). The figure below illustrates this functional integration.



Figure 5: Architecture Basque e-Prescription system

Other elements of the figure: B38 VDM: Vademecun, Set of services which offering information about medicines

(products, posology, composition etc) A53 E-Osabide: is the HIS of Osakidetza with administrative, demographic data N12 SWAP: Catalogue of web services for integration with EHR of primary care

(Osabide AP) Zain: Corporate e-signature platform. B500 impression: Corporate printing system CSSM (Multichannel Services Centre Support): is composed of several applications

and modules and below describes the most important features included in CareWell:Health Folder: this app provides the PHR service. The patients access their health folder through the link deployed on the corporate Web site. The main functionalities of the health folder are:

Access to prescriptions (active and historical) Access to future clinical appointments Completed health questionnaires Access to health reports (secondary and primary care)

CRM: This module is used by clinicians for managing the chronic health programs and monitoring the health status of patients. Web Appointment: web used for managing appointments in primary care by patients.Health Council: set of nurses for attending doubts or questions of citizens. Using a solution based on OPA (Oracle Policy Automation) like decision making system.

Figure 6 below shows the functional structure of CSSM.



Figure 6: Architecture Multichannel services centre support in Basque Country

3.2 Croatia3.2.1 Current ICT-enabled service specificationStable Patients – out of hospital careOlder patients are cared for by primary care health professionals by either visiting their GP practice or having a home visit from a field nurse who is covering dedicated geographical areas, where she might have to cooperate with multiple GP practices. The patient’s GP will meet with the field nurse F2F from time to time as necessary and a patient’s care plan and medication regime will be adjusted accordingly. Field nurses will refer a patient for assessment by social care services if they are considered to have social needs. Currently, information on the care the field nurses deliver to patients is recorded in paper-based records and the information is shared with the patient’s GP on a need-to-know basis. The GP may choose to enter relevant information relating to the field nurse activities and care into their electronic record system.Unstable Patients – out of hospital careIf a patient becomes ‘unstable’, a patient can contact the field nurse in the healthcare centre (call centre) during a one-hour period first thing in the morning. The nurse will often increase their home visits or home visits will be initiated for a patient who was previously able to visit the GP in their practice. The GP will refer the patient for tests, investigations, and specialist consultations from hospital services where necessary and again, adjust the patient’s care plan and medication regime accordingly. There is no electronic exchange of information currently.Inpatient - hospital carePatients admitted to hospital are cared for by specialists and dedicated hospital nurses. If the GP refers the patient for admission, information is sent by paper with the patient. Inpatient – hospital discharge preparationDischarge information, including care plan and medication regime, is prepared from the hospital records by a dedicated nurse and a paper letter is given to the patient for them to give to their GP. When this information has been received by the GP, it will be entered into the GP electronic clinical record. The nurse will liaise by telephone with the field nursing using the call centre facility available each morning.



The table below summarises the current ICT-enabled service provision in the Croatian pilot site.

Table 3: Current ICT-enabled services of Croatia

Croatia BeforeICT-enabled services Operational Maturity levele-Prescription YES 5Messaging clinician Patients NO 0EHR NO 0Interconsultation NO 0Call Centre NO 0Virtual Conference NO 0PHR NO 0Nurse Information System (record of nursing care) NO 0Educational Platform NO 0Collaborative Platform NO 0Telemonitoring NO 0Multichannel Centre (Management Telecare Programs) NO 0

3.2.2 Current IT architecture The current IT architecture of the Croatian pilot is illustrated below:

Figure 7: Current IT architecture of Croatia



Integrated Care Coordination Services The architecture shows typical elements required to provide simple channels of communication between services of different health care sectors (primary, secondary and tertiary). Although there is not a global EHR service, the Croatian pilot has distinct GP systems containing health information (G2 or GP system) and a network for sharing some information between primary and secondary care (G1).Moreover, there are several legacy systems, such as LIS, HIS, RIS, in all hospitals. The information of these legacy systems can be visualized in secondary care through specific programs, which can differ from one hospital to another. Primary care professionals can access the information of legacy systems through VPN connection from G2 to G1.Patient Empowerment and Home-Support Services Currently, the Croatian pilot does not have any ICT-enabled system providing services oriented to patient empowerment and home-support pathway.Relevant Systems / applications Description of the principal systems in Croatia is detailed below:

G1 System: This application is also called the ‘Health networking information exchange system’. It is a central communication and processing platform used for communication between all stakeholders (IT systems) within the national healthcare system in Croatia. This application is running on a complex set of servers.

G2 application: This application is also known as the GP office application. It is used by GP and his assisting nurse, for managing patient data as well as business administration of GP office. There are many G2 applications supplied by various vendors that run on different platforms ranging from a PC as a client application that communicates with G1, up to those that have separate servers and clients where communication to G1 is executed from a local server.

Figure 8: Functional Structure G2 Hospital IT System: Integration Information system used for managing all aspects of

hospital operation (medical, administrative, financial, legal etc). There is a number of various vendors in Croatian market and therefore it is not possible to describe the overall IT infrastructure.



3.3 Lower Silesia3.3.1 Current ICT-enabled service specificationStable Patients – out of hospital careCo-ordination of care is currently undertaken by the GP and is reliant on the relevant information held in paper-based systems being shared by letter, fax or phone to inform decision-making. Unstable Patients – out of hospital careEnvironmental nurses visit patients at home at the request of GPs and they assess a patient’s needs and provide the necessary care. Again, information from paper-held records is shared with the relevant healthcare practitioners except for the electronic transmission of ECG to hospital by the emergency services. Patients and informal carers are reliant on signposting to support services as there is currently no ‘directory of services’ available to help people find appropriate care to meet their needs.Inpatient - hospital care A patient will be admitted to hospital if necessary, following an assessment in the emergency room. They will have their needs assessed by a multi-disciplinary team and this assessment includes frailty for older people. Information on the patient’s tests, investigations, care and treatment is recorded in a range of hospital IT systems and paper records and communication between the care practitioners is via these record systems and F2F. If the frailty assessment outcome indicates that the patient will require social care, home care, nursing care or long term care, the hospital social worker will make the necessary referrals.Inpatient – hospital discharge preparationA hospital discharge card containing information on recommendations for on-going care and support is prepared by a nurse on the hospital ward and given to the patient on discharge.The table below summarises the current ICT-enabled services available in Lower Silesia.

Table 4: Current ICT-enabled services of Lower Silesia

Lower Silesia BeforeICT-enabled services Operational Maturity levele-Prescription YES 2Messaging clinician Patients NO 0EHR YES 2Interconsultation NO 0Call Centre NO 0Virtual Conference NO 0PHR YES 2Nurse Information System (record of nursing care) NO 0Educational Platform NO 0Collaborative Platform NO 0Telemonitoring NO 0Multichannel Centre (Management Telecare Programs) NO 0



3.3.2 Current IT architecture The current IT architecture of Lower Silesia pilot is illustrated below:

Figure 9: Current Architecture of lower Silesia

Integrated Care Coordination ServicesIn Lower Silesia, the EHR Service/system is connected to legacy systems in all the hospitals by an internal Service bus. However, currently, it is not possible to exchange health information between hospitals electronically. In primary care, the clinical information is managed by GPs, who use different EHR applications with a local data store available.Patient Empowerment and Home Support- ServicesLower Silesia offers several web portals with information about the most common chronic diseases (diabetes, heart failure etc). On the contrary, no platforms are focused on patient/caregivers empowerment or targeted patient education.Relevant Systems / applications

HIS: Each hospital has its own HIS and it is not possible to access information held in other hospital HIS. The information stored in these systems is clinical and administrative. HIS is integrated with other hospital legacy systems through a service bus. The HIS provides the EHR and e-Prescription services.

GP system: There several applications providing GP systems in Lower Silesia. The EHR within the GP system is not shared with secondary care or other GP systems.



3.4 Veneto3.4.1 Current ICT-enabled service specificationStable Patients – out of hospital carePatients with complex needs are currently assessed by a multi-disciplinary team in the multidimensional assessment unit following a GP referral or referral following a hospital admission. From this assessment, which is informed by collecting information from the various care practitioners involved, a personalised care plan and medication regime is drawn up on paper and this is shared with the appropriate people. The GP and primary care territorial services co-ordinate the care of the patient. Some patients may have telecare services such as panic buttons or community alarms.Unstable Patients – out of hospital careIf a patient has previously had a multi-disciplinary assessment but their conditions are deteriorating, the GP or the other professionals can activates a new multi-disciplinary assessment. The new evaluation can lead to additional home care interventions and support through the territorial social workers, home-care nurses. The GP can also refer the patient for new tests, investigations or specialist consultation. The home care is co-ordinated by the Social and Health care District services, among which there is also the Territorial Operational Centre (TOC). A home-care nurse provides a case management service and delivers additional patient education to help the person self-care and self-manage. In the event that a telecare alarm has been activated, the response centre can arrange transportation to the hospital emergency room if considered necessary.The GP will refer the patient for the multi-dimensional assessment unit if their health and wellbeing has significantly deteriorated. As a result of the agreed care plan, the Social and Health care District (TOC) will co-ordinate the care of the interventions in the care plan and ensure communication takes places between the various care givers.The Client Resource Management (CRM) in the TOC collects and shares information between the different territorial health and social care services including the hospital laboratory and diagnostics, with communication between other services and care givers being by phone, email, paper/fax or F2F.Inpatient - hospital careWhilst a patient is in hospital, a patient is case managed by a hospital doctor with nurses delivering care, administering drugs, co-ordinating services and interventions. The doctor draws up a care plan, and the nurse makes arrangements for any home care interventions required. Information is recorded in the CRM with communications between the healthcare practitioners being undertaken F2F.Inpatient – hospital discharge preparationWhen a patient is ready for discharge, the hospital doctor and nurse liaise with the TOC or the Home care Nursing Service by phone and any necessary home-care services are scheduled. A referral to the multi-dimensional assessment unit can be made, a care plan is drawn up and information are given to the patient and any informal carers to help with self-care and self-management. The patient’s GP receives information on the care plan by phone and/or fax from the TOC or the hospital and, if required, visits to the patient at home are arranged.Below is the table summarising the current ICT-enabled services available in Veneto:

Table 5: Current ICT-enabled services of Veneto

Veneto BeforeICT-enabled services Operational Maturity level



e-Prescription YES 5Messaging clinician Patients NO 0EHR YES 1Interconsultation NO 0Call Centre NO 0Virtual Conference NO 0PHR NO 0Nurse Information System ( record of nursing care) NO 0Educational Platform NO 0Collaborative Platform NO 0Telemonitoring NO 0Multichannel Centre (Management Telecare Programs) YES 5

3.4.2 Current IT architecture Veneto has central databases for sharing information among clinical systems (prescriptions, demographic data and clinical reports).In addition, there are several interoperability platforms, such as the Mirth platform or Bus service, which uses HL7 to build the messages between systems (HL7, SOAP, DICOM etc).

Figure 10: Current Architecture of Veneto

Integrated Care Coordination Services The e-Prescription service is provided by same system in both care sectors (primary and secondary) and it has a central repository of prescriptions. The EHR is provided in primary care by the Territorial Information System. In secondary care the hospitals have a HIS with two modules, one for administrative management and another for documenting medical information – the e4cure module which is a proprietary EMR solution, together with the e-Prescription.



Patient Empowerment and Home Support-Services This pathway is supported by a web portal providing the PHR service and some educational materials together with the telecare service eg panic buttons and community alarms provided by the Regional Tele-emergency solution.Relevant Systems / applications The current application/systems running in Veneto have been developed following two types of architecture:

Three layers (Web applications): composed by presentation layer, business layer and persistence layer. This architecture comprises:

e-Prescription to provide the e-prescription support. Web site of LHA provides the PHR service. Regional Tele-emergency Solution provides telecare service. e4cure and Talete (EMR ) provides interconsultation service. Territorial Information System provides EHR service.

Client / Server application: This architecture comprises: GP systems: to provide EHR service. Pharmacy software: to provide an aspect of the e-Prescription.

3.5 Puglia3.5.1 Current ICT-enabled services specificationStable Patients – out of hospital carePatients are currently cared for by their GP in collaboration with nurses and specialists in outpatient clinics (not hospital outpatient clinics). Information is shared by phone and written documents. In addition, the integrated EHR is used to record and share information between the care manager and GPs. Specialists, to date, are not involved in sharing information through the EHR. Patient empowerment comes from the counselling given by the care manager.Unstable Patients – out of hospital carePatients with complex needs are case managed by in the outpatient clinic by a primary care specialist nurse (CM), GP and specialists. The care delivered to patients who are ‘unstable’ is the same although the frequency and intensity of some or all the care plan interventions would change. The GP and CM use the HER to share information about the patient but the specialists usually contact the team by phone. An integrated frailty assessment is undertaken and the patient follows their defined chronic care pathway and often referred to community and home care nursing services and/or any necessary social care service. All care and support is co-ordinated by the CM. Telemonitoring for patients is only in an emergency (when the A&E department is involved) and consists of the ambulance paramedic sharing information with the A&E doctors. Inpatient - hospital careWhen an ‘unstable’ patient is unable to be managed in the primary care setting, the GP or specialist refers them for hospital care. When admitted to hospital, the patient is assessed by a hospital specialist, using information from the GP if possible (communication is provided by phone, email and SMS). The hospital specialist arranges for any tests and investigations, draws up the care plan and associated medications. Day-to-day care is provided by the ward nurses supported by the family or informal care giver. Information on the hospital episode of care is recorded on a medical chart by the specialist and ward nurses and then synthesized into a discharge sheet, ICD9 CM codified, and uploaded into the regional health information system (Edotto). In turn this feeds the



national administrative database held by the Health Ministry and Economic Ministry. When a patient is deemed to be stable, the hospital specialists prepares a discharge letter summarizing the hospitalization event and shares this clinical information with the GP. Inpatient – hospital discharge preparationThe ‘stabilised’ patient is discharge from hospital back to their home. The hospital specialist transitions the patient to the territorial CM and gives them a discharge letter summarizing the hospitalization event to share the clinical information with their GP. The professionals only communicate via paper documentation.Below is the table of current ICT-enabled services available in Puglia:

Table 6: Current services of Puglia

Puglia BeforeICT-enabled services Operational Maturity levele-Prescription NO 0Messaging clinician Patients NO 0EHR YES 4Interconsultation NO 0Call Centre NO 0Virtual Conference NO 0PHR NO 0Nurse Information System ( record of nursing care) YES 5

Educational Platform NO 0Collaborative Platform NO 0Telemonitoring YES 3Multichannel Centre (Management Telecare Programs) YES 2

3.5.2 Current IT architecture The current IT architecture of Puglia pilot is illustrated below:



Figure 11: Current Architecture of PugliaIntegrated Care Coordination Services Puglia has an ICT architecture (Apulia WAN RUPAR) that provides connection services and brokering access with strong authentication to all operators of the Public Administration and in particular to the nodes of the health care system. Indeed, the Apulia RUPAR houses the Regional Health Information System named, Edotto which collects, informed by local Health Authorities, administrative and clinical data for the management, governance and epidemiological investigations in the field of health. Edotto summarizes data coming from different health domains (primary care, hospital discharges, outpatients clinics data, A&E flows, pharmaceutical consumptions, mental health, pathologic dependences etc.) both automatically into the system, or migrated from other information systems working on SPcoop standards (interoperability standards for public administrations). Many of data flows uploaded in Edotto feed the national administrative database of the Health Ministry and Economic Ministry.Patient Empowerment and Home Support-Services Patient empowerment and home-support services are currently provided by the CM through counselling the patient. Relevant Systems / applicationsIn cooperation with Edotto (from which extracts patients registry data), the Nardino information system, (Puglia Care program software) which provides the EHR for the primary care team. The Nardino Program is a web-based platform that provides management services to support the delivery of care for patients with chronic conditions. It is implemented on the WAN RUPAR directly or by a VPN enciphered connection. The information system, built with open source technology, manages the access profiles of all those involved in chronic patients’ care. Each team member has a specific operational profile, eg CM and GP. In particular, Care Puglia program software also implements a back office system for managing user profiles and information structure for displaying reports and indicators. The back office activities for the management of the user community are



delegated to specific users’ administrative access that can create new profiles or delete an existing one with the help of wizards and utilities automatic. The framework for reporting ensures the consultation of a list of approximately 150 indicators of process, outcome, and quality, processed and presented in real time. It also has a utility for downloading whole report in the CSV format.The system maintains a clinical framework that builds an information folder containing the patient's medical history, clinical evaluations and nursing, therapy, diaries notes, and a complex system for planning, co-ordination and follow-up of the typical activities of the CM. The Care Puglia program is also equipped with standard interfaces for Web services that use SOAP and SOA architecture with native support for HL7.Clinical information coming from Care Puglia program platform represents Electronic Health record (EHR), by which primary care health professionals (not the specialist) share information about a patient. The cardiac remote monitoring information collected in an emergency is not included in Edotto or Nardino. It is only seen by the hospital clinician in the A&E department.



Figure 12: Architecture of Nardino

3.6 Wales3.6.1 Current ICT-enabled service specification Stable Patients – out of hospital carePatients with complex needs are cared for by primary and community care services with the co-ordination usually undertaken by either a community district or specialist nurse. The patient’s GP or practice nurse undertake a scheduled review of their health and wellbeing on an annual basis and they may also be seen routinely in hospital outpatient appointments. Information on assessment, care plans and interventions is recorded in the GP clinical information system (EHR) and health board patient administration system as well as the nurses using some paper record keeping systems. Communication is by F2F, phone or email (patient identifiable information cannot currently be exchanged via email). Referrals to hospitals can be undertaken via the Welsh Clinical Communications Gateway (WCCG).Social care services can be accessed by the patient, family or informal carer by F2F communications or via the call centre. Healthcare professionals can also make a formal referral for an assessment by social care services.


Presentation Layer: Script CGI, WEB GUI (html, JS - Jquery)

Standard: DICOM, HL7, SOAP …

Persistent Layer: Logging, Environment variables, Crypt CBC …

Registry

Repository


Patients also have access to My Health Online which is a summary personal health record. Currently patients can order prescriptions, book GP practice appointments and view and update the demographic details of their PHR.Unstable Patients – out of hospital careIf a patient’s health and wellbeing deteriorates, additional community services can be accessed through the community resource team (CRT). This team will undertake a multi-disciplinary assessment, revise the care plan accordingly and monitor the recovery of the patient for a period of time. Most community nurses have access to information in the GP clinical information systems (EHR) but communication between the care team is usually F2F or phone.Inpatient - hospital careWithin Powys, patients can only be admitted to a community hospital and would go outside the area if their health needs were severe. The GP would arrange a community hospital admission, often involving the ambulance service for transport. Whilst in the hospital, they patients would be under the care of a GP and information entered into the Myrddin patient administration system. The GP assesses the patient, can order basic laboratory and radiology tests and adjust medication. Rehabilitation services are also available if required. Information from the GP clinical system is usually available to provide the medical history of the patient and the GP and hospital nurses use the health board’s patient administration system, Myrddin, and paper records to record the care delivered. Communication is mainly by phone between the GP practice and hospital.Inpatient – hospital discharge preparationA care transfer co-ordinator is responsible for making the necessary arrangements for hospital discharge and this will be recorded in the patient’s notes and patient administration system. This person will liaise by phone with the patient’s GP, community and/or specialist nurse, community therapy services if required, and reablement services. The Co-ordinator has F2F meetings with the hospital nurses and doctor to gain the necessary assessment and care planning information.The GP will refer the patient to a secondary care specialist via the WCCG if necessary. The GP will also enter information about the patient’s hospital admission into their EHR and prepare any e-Prescriptions as necessary.The table below summarises the current ICT-enabled services available in Wales:

Table 7: Current ICT-enabled services of Wales

Wales BeforeICT-enabled services Operational Maturity levele-Prescription YES 5Messaging clinician Patients NO 0EHR YES 5Interconsultation NO 0Call Centre YES N/AVirtual Conference NO 0PHR YES 4Nurse Information System (record of nursing care) NO 0Educational Platform YES 2Collaborative Platform YES 3Telemonitoring NO 0



Multichannel Centre (Management Telecare Programs) NO 0

3.6.2 Current IT architectureCurrently the Powys pilot has more IT architecture and ICT-enabled services to support the integrated care coordination pathway rather than the patient empowerment pathway.The current IT architecture of Powys pilot is illustrated below:

Figure 13: Current Architecture of WalesIntegrated Care Coordination ServicesThe integration care pathway is based on three elements (GP system, WCP, and WCCG).These three elements cover the most important services (EHR, e-Prescription, and inter-consultation). The EHR is provided through the WCP in secondary care and the GP system is the EHR in primary care. In addition, the WCCG provides the interoperability tool for sending referral information from primary care to secondary care. Currently, it is only is possible send electronic referrals to secondary care with the referral being populated automatically from the GP clinical system (EHR) together with free text. Patient Empowerment and Home Support- ServicesThe pathway for Patient Empowerment has three important applications / systems as follows:

My Health On line (MHOL): this app provides the PHR service. Myrddin: this system provides the district and specialist nurses with their home visit

schedule and activities.



Draig: This the current IT system to support the delivery of social care services in Powys. During CareWell this system will be replaced by an integrated social and health care administrative IT system (CCIS).

Relevant Systems / applications GP systems: this system is used in primary care for recording clinical information

and providing e-Prescription service. WCCG (Welsh Communications Gateway): this system allows GP System users to

execute electronic referrals to secondary care. The solution implemented is based on software developed by NHS Scotland. The user accesses the WCCG via a button or link within the GP System user interface. When the user ‘clicks’ on the button/link an external application is started, which is displayed in a browser on the user’s PC.

The WCCG will extract patient demographic and clinical data for inclusion in the referral from the GP System. The WCCG application is also able to write back data into the GP System via a GP System supplier specific (proprietary) interface.

The integration of WCCG and National Applications is under the ‘control’ of NWIS. There is a dependency on development resources with NHS Scotland but this is seen as a very low risk. This allows changes to the integration of applications between WCCG API and any other application in the future (as displayed in the above).

The illustration below shows the different connectors developed for the WCCG to achieve the interoperability between GP systems and systems used in secondary care. It also includes the specific module (GPs client) used by the GP system to connect with other secondary care systems facilitated through WCCG.

Figure 14: Communications channels of WCCG WCP (Welsh Clinical Portal): The WCP is a web application used in secondary care

for clinical communications with primary care and view individual patients records. Moreover WCP allows making prescriptions, reports, request etc.

Figure 15 below shows the several (internal and external) connectors developed to achieve interoperability with legacy systems within the hospitals and with external services through WCCG.



Figure 15: Welsh Clinical Portal (WCG) Integration architecture IHR (Individual Health Record): The IRH is a summary of the GP system EHR and is

derived and updated automatically each day. Currently, the IRH is used to support the GP out-of-hours service. Patients are able to ‘opt out’ of their GP EHR being used to create the IHR.

OOHS (Out-of-Hours Service): The IT system used by the Out-of-Hours GP is called Adastra and this enables access to the IHR on a view only basis.

eMPI (Electronic Master Patient Index): The eMPI is the national (all Wales) database of patient demographic details. IT systems in hospitals and GP practices can access the eMPI to read patient details and feed updated information back into the local IT system. Not all systems have full access to the eMPI but as new systems are implemented, the use of the eMPI is extended.

Myrddin (Patient Administration System): Myrddin is the name of the PAS used in secondary care (community hospitals) in Powys. It contains demographic, inpatient and outpatient contacts and activities for healthcare practitioners. The MPI within Myrddin provides demographic feeds to the eMPI and other clinical information systems.

3.7 Analysis of current service specification vs IT systems

The analysis of the current situation in relation to the level of service specification and ICT-enabled services and architecture available in each of the pilot sites indicates that the sites can be divided into two groups:

Pilot sites with many deployed systems that are an integral part of the CareWell solution, and therefore a level of integration or interoperability is required.

Pilot sites whose CareWell solution is less dependent of any existing deployed systems, and therefore the requirement for integration and interoperability is much less.

Below is a diagram illustrating the level of development of ICT-enabled services in CareWell:



e-pre

scrip

tion

Messa

ging

clinici

an ß

à Pati

ents

EHR

Interco

nsulta

tion

Call Cen

ter

Virt

ual Confer

ence

PHR

Nurs

e Info

rmati

on Syste

m

Educatio

nal Plat

form

Colab

orativ

e Plat

form

Telem

onitorin

g

Multi

chan

el Cen

ter0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

Series1

Figure 16: Wales: Level of development of ICT-enabled services



4. CareWell ICT-enabled service specification and IT architectures

This section describes the services, IT systems or IT architecture elements adapted within CareWell project.

4.1 Basque Country4.1.1 CareWell service specificationStable patients – out of hospital careThe current service model will be enhanced in a number of ways:

Wider deployment of the reference internist and hospital liaison nurse in to other hospitals in the region.

Developing and implementing procedures to provide messaging between patients and healthcare practitioners through the electronic Personal Health Folder.

Further develop the care pathways for frail older people to extend the eHealth Centre and Telecare Centre to provide improved telemonitoring and follow-up/response calls.

Provide symptom management questionnaires in the Personal Health Folder to further support self-care and self-management.

Rolling out the electronic prescription to additional healthcare professionals including pharmacists.

Provision of self-care and self-management educational material through the Personal Health Folder and Osakidetza web portal.

Unstable Patients – out of hospital careIn addition to the above service model enhancement for the ‘stable’ patient, healthcare professionals will have improved access to near-time information to assist with decision-making when a patient’s health status deteriorates. The enhanced role of the eHealth and Telecare Centres will enable easier continued follow-up of the patient during their recovery period thus reducing the need for F2F visits.Inpatient - hospital careHealthcare professionals in the hospitals will have richer information to understand the nature of a patient’s deterioration leading up to their emergency admission including telemonitoring information and symptom management questionnaire responses. It is likely that the acuity of patients requiring hospital admission will increase as more patients are able to be managed by telemonitoring and support in their own homes for minor exacerbations.Inpatient – hospital discharge preparationThe information entered into the CRM by the hospital liaison nurse will be able to be viewed by all healthcare practitioners involved in a patient’s care team and this will provide a much improved streamlined and safer service model.Tailoring telemonitoring and self-care and self-management information and education to the individual patient will be facilitated through defining the telemonitoring parameters and educational material provided to the patient and their family/informal care givers through the Personal Health Folder.



Table 8: Services Evolution Basque Country

Basque Country Before After

ICT-enabled service OperationalMaturity

level OperationalMaturity

level e-prescription YES 3 YES 5Messaging clinician Patients YES 1 YES 4EHR YES 3 YES 4Interconsultation YES 3 YES 4Call Centre YES 2 YES 2Virtual Conference No 0 NO 0PHR YES 3 YES 4Nurse Information System(record of nursing care) YES 3 YES 3Educational Platform No 0 YES 4Collaborative Platform No 0 NO 0Telemonitoring YES 2 YES 3Multichannel Centre (Management Telecare Programs) YES 2 YES 3

4.1.2 CareWell IT architecture As described in 4.1.1 above, the Basque Country is making a number of changes to improve their services:

Integration into the EHR data from the hospital pharmacy Integration of systems to provide EHR in unique system for both care sectors

(primary and secondary care) Messaging between patients (PHR) and clinicians (EHR) Integration of the clinical information from the CareWell chronic programs in EHR To improve the Business Intelligence to provide new functionalities for patients

stratification The development of an educational web platform for patients

The diagram below illustrates the CareWell architecture:



Figure 17: CareWell Architecture of Basque Country

The above technological improvements will result in new or enhanced applications and functionalities described below.New systems or new functionalitiesIntegration in EHR data of hospital pharmacy The e-Prescription service in secondary care will be extended to include primary care with a shared database. This will be achieved through the deployment of several web services designed to recover and upload data to the central e-Prescription database irrespective of whether the prescription request is made from the module in the primary or secondary care IT system. System integrated of both primary and secondary care EHRsThe interface of the application integrating both EHRs is equal to that used in secondary care. The major challenge, therefore, is the implementation of this application in primary care where practitioners can be reluctant to utilise new applications. In order to avoid this situation, a contingency measure has been established which defines a progressive functional adaptation for primary care users. This plan outlines how the functional modules only present in the primary care EHR can be gradually added to the new application, although the interface visualisation will be slightly different.The picture below shows the modules deployed in the new application during the first phase of the integration process.



Figure 18: New application modules

The following diagram shows the common features shared by primary care EHR and secondary care EHR.

Figure 19: Common features

Integration within the EHR of the clinical information collected from the telemonitoring platformMSC is the main element of the integration since it functions as a bridge between the EHR and the telemonitoring platform where the CareWell program is stored. The procedure consists of three steps: firstly, the clinical data is transmitted to the MSC; secondly, the MSC publishes a new web service; and thirdly, the EHR system requests the information from the patient’s CareWell program to the web service.Messaging between patients an cliniciansIn order to provide this service, new versions of both the EHR and PHR systems will be developed. The EHR system has its own system of messaging, which allows for messages



to be sent to the PHR through a service bus using a web service specifically created for this purpose.In addition, the PHR system will present a client which enables calling to web service and recovering the message from the EHR system. Additional minor changes have been incorporated into the graphical environment in order to define the user’s interface. The existing database will be adapted to store minimum historical messages. Development and standardization of the data collection to automate the risk stratification score calculationThe independent variables needed to calculate the risk stratification score developed in the Basque Country, come from several administrative and clinical database (hospitalization, emergency visits, consultation, prescription, diagnosis, prescription, demographic data, etc). All this data needs to be linked at patient level. During the CareWell project a Data Business Warehouse has been developed which allows data to be collected from several databases in a standardised way.Through this data collection process, the prediction risk algorithms is applied manually and the outcome of the risk stratification at patient level is uploaded into the EHR.The risk stratification score is used in the CareWell pathway to identify patients with high complex needs who are most likely to benefit from the CareWell pathways and services.Develop a new educational webNew educational materials and documentation has been added to the Basque Health Service’s web portal. There is a specific section in the portal called ‘Health School’ where distinct content aiming to foster patient/caregiver empowerment are described:

Actions in case patient health worsened. Healthy lifestyles. Information about your disease.

4.2 Croatia4.2.1 CareWell service specification Stable Patients – out of hospital careThe service model will predominantly be enhanced through the deployment of new ICT and resultant new ways of working between the GPs and field nurses, social workers and patients in the following ways:

Development and implementation of the EMH system for the field nurses to record the care they provide to patients. This information will be immediately available to the GP if necessary.

The implementation of the EMH system will enable GPs to review a patient’s care and provide advice or a change in a patient’s care plan or medication regime through the system rather than having to meet the nurse F2F.

Field nurses will be able to communicate with the social care workers through the EMH system.

Patient information to support self-care and self-management will be developed and made available through the EMH system for the nurses to pass on to the patient. This should ensure consistent quality of educational content and enable information to be updated easily within the system and new knowledge to be shared.



Unstable Patients – out of hospital careThe EMH system will facilitate the field nurses obtaining additional support and advice from the patient’s GP practice if they become ‘unstable’ and a patient’s care plan will be optimised to manage the ‘deterioration’ quicker that is the case currently. The nurses will also be able to provide the patient with additional educational material to help them self- care and self-manage their health and wellbeing during the period when they are considered ‘unstable’ and not requiring hospital admission.Inpatient - hospital careIf a patient does have to be admitted to hospital, the GP will be able to provide the hospital with up-to-date information to support the admission and medical history of the patient.Inpatient – hospital discharge preparationThe introduction of the EMH system will facilitate the discharge of patients as hospital healthcare professionals will be aware that patients can be more closely monitored in their own homes and be better supported to self-care and self-manage.Below is the table summarising the evolution of ICT-enabled services in CareWell.

Table 9: CareWell ICT-enabled services of Croatia

Croatia Before After



level e-prescription YES 5 YES 5Messaging clinician Patients NO 0 YES 1EHR NO 0 NO 0Interconsultation NO 0 NO 0Call Centre YES 3 YES 3Virtual Conference NO 0 NO 0PHR NO 0 YES 1Nurse Information System(record of nursing care) NO 0 NO 0Educational Platform NO 0 YES 1Collaborative Platform NO 0 NO 0Telemonitoring NO 0 YES 1Multichannel Centre (Management Telecare Programs) NO 0 NO 0

4.2.2 CareWell IT architecture The main challenge for Croatia pilot during CareWell is to develop and deploy the architecture required to deliver the Patient empowerment and home-support services pathway. The core of this architecture is Ericcson Mobile Health chronic disease management system.



Figure 20: CareWell architecture Croatia

For this activity, the EMH has several adapters and viewers that enable it to run on several platforms like Tablet, PC or TV (Smart TV).Main Technological Changes during CareWellThe Croatian pilot will focus on the following technological developments:

To adapt and deploy to a pilot population the Ericsson Mobile Health chronic disease management system (EMH), consisting of a number of modules to support chronic conditions management and the provision of digital educational tools for patients.

To integrate the telemonitoring data from the EMH into the GP patient record within the GP application (G2).

Develop and implement the Home Health Smart TV viewer to enable patients and informal caregivers to access the telemonitoring data collected by the field nurses using EMH.

Ericsson Mobile Health Chronic disease management systemThis is a Platform for providing remote health services, applicable for various use cases in healthcare, self-care and wellbeing, to be implemented for the purpose of CareWell project. EMH will receive input from physiological measurement devices and record the data into the PHR which will be viewable on the android application running on a tablet or Home Health Smart TV. This data will also be sent to G1. The roles able to use EMH will be GP/Nurse, Field Nurse, Social Care Worker, Caregiver, and Patient. In the scope of the project, there are novel features for Smart TV-based information and warning system will be developed by FER. Details of the functionality of the EMH and home health Smart TV is given below.



Figure 21: EMH chronic disease management system

FER Home Health Smart TVFER Home Health Smart TV will provide easy access to the valuable EMH data to patients. FER Home Health Smart TV is deployed on Android 4.2 Set Top Box which enables the execution of the application on any type of TV device. The system consists of 2 main components:

FER Home Health TV application Adapter service

Using the carefully designed application, patients and their caregivers can access and view their medical data such as medical measurements, warnings and messages and educational materials provided by medical experts. For the purpose of Croatia pilot FER Home Health TV will enable only 1 role – patient. In order to improve the interoperability of FER Home Health TV system, the adapter service is designed and integrated. Using the adapter service, internal application methods are adapted to the application



programming interface of appropriate eHealth service provider which enables the integration of FER Home Health TV system in different environments and eHealth systems. Adapter service in the scope of CareWell project, communicates with EMH Technical node REST API using HTTPS protocol.The advantage of adapter service is that it would be easily installed in other CareWell pilot sites if there was interest.The diagram bellows shows the ‘track and trend’ view of a patient’s physiological measurements within the Home Health Smart TV application.

Figure 22: FER Home Health Smart TV

4.3 Lower Silesia4.3.1 CareWell service specificationStable Patients – out of hospital careThe implementation of the CareWell integrated pathway will enable to following developments to the service model:

Better understanding of the roles and responsibilities of the different care practitioners involved in delivering services and interventions within the care pathway.

Integrating the hospitalisation of those patients who require it as part of the care pathway to provide better patient care transition experiences across the different sectors and professionals.

Introduction of telemonitoring for patients who require this service. Easier access to healthcare response service for patients through the platform. ECR will provide an improved communication mechanism through the email box and

thus enhance the co-ordination of a patient’s care. The platform will provide a directory of services for patients, family members and

informal care givers, as well as professionals, to search for appropriate quality assured health and wellbeing services that are available.

Patients will be able to access the e-Prescription and choose their dispensing pharmacy.



Unstable Patients – out of hospital careThe above enhancement for the ‘stable’ patient will also be relevant for the ‘unstable’ patient. In addition, virtual consultations will be able to be activated, if necessary, between the hospital specialists, nurses and GPs via the email box when a patient’s health and wellbeing deteriorates.Inpatient - hospital careThe hospital information system (HIS) will be integrated into the ECR and the healthcare professionals will have access to the information (anonymised) in the platform if a patient gets admitted. Selected doctors involved in CareWell will have access not only to the information in the HIS but also to the LSV CareWell platform. If the doctor is interested in the information uploaded by the patient, they will ask permission from the patient to look at this data. This should provide improved information on the patient’s medical history and the events and care leading up to the hospital admission.The educational platform in this phase of the project is not targeted at hospital doctors but they will be able to access the information in the platform if they are interested in it.Inpatient – hospital discharge preparationThe hospital will be able to refer the patient for telemonitoring if they are not already receiving the intervention according to the defined CareWell criteria, determine their physiological parameters and frequency accordingly. Furthermore, the patient will be signposted to appropriate patient empowerment services and educational content through the platform.For patients who were receiving telemonitoring prior to their admission, it is expected that they will return to receive the telemonitoring service upon discharge from the hospital.

Table 10: Evolution of ICT-enabled services in Lower Silesia

Lower Silesia Before After



level e-prescription YES 1 YES 2Messaging clinician Patients NO 0 YES 3EHR YES 1 YES 3Interconsultation NO 0 YES 4Call Centre NO 0 YES 3Virtual Conference NO 0 YES 4PHR YES 1 YES 3Nurse Information System(record of nursing care) NO 0 YES 2Educational Platform NO 0 YES 3Collaborative Platform NO 0 YES 3Telemonitoring NO 0 YES 4Multichannel Centre (Management Telecare Programs) NO 0 YES 3



4.3.2 CareWell IT architectureAs Lower Silesia currently does not have many IT systems implemented to support the delivery of care or share information, both CareWell pathways will be significantly improved with the proposed ICT-enabled services and functionality.The development of a platform to provide interoperability between the different IT systems used in primary and secondary care will enable information to be shared between the different care practitioners and patients.Work will also be undertaken to implement an e-Prescription system for primary and secondary care.

Figure 23: CareWell IT Architecture Lower Silesia

New systems or new functionalities Registration patient referrals for home care telemedicine (TOP). This is the first task

in the process of LSV teleCare. Logged user access in Information Portal to Integration Platform. Patients Registry Update Service in HIS by Integration Platform. Service of research results transfer by HIS Patient Portal to Integration Platform. Registration of performed by the patient results in HIS Portal. GP access to EHR and its own tasks supporting the process of LSV teleCare

procedure. Nurses access to the EHR, and their task of process that supports the LSV teleCare

procedure. Patient access to PHR own tasks and supports the process of LSV teleCare

procedure. Implementation e-Prescription in SIM (P1) during the LSV teleCare procedure.



Call Centre staff access to their own tasks supporting the LSV teleCare procedure process. Receive e-mail and SMS alerts.

Doctor, Nurse and Patient Access to the Information and Education Portal. Call Centre staff access to the Information and Education Portal.

Some of the developments and changes will revolve around the new interoperability platform Integratis.

4.4 Veneto4.4.1 CareWell service specification Stable Patients – out of hospital careThe service model underpinning the multi-disciplinary care pathways already implemented in Veneto will be further enhanced in the following ways through CareWell:

An online patient’s ‘dashboard’ will be created be bringing together the relevant information from health and social care records, home-care service records and hospital records. This ‘dashboard’ will be accessible to all care practitioners involved in a patient’s care through a role-based access model.

The care pathway data collection that informs the multi-dimensional assessment will be enhanced through the automatic feed from the patient ‘dashboard’.

Home-care nurses will provide a monitoring service to patients and the information will be shared with relevant healthcare practitioners via the Territorial ICT system.

The home-care nurses will provide a telemonitoring service responding to patients entering their physiological measurements and symptom management question answers into the system.

The home-care nurses’ monitoring systems will include educational material to assist the patient to self-care and self-manage.

In addition to the educational material available in the monitoring system, web-based material will be available through the ULSS 2 authority website.

Patients will be able to access the My Health Portal within the ULSS 2 website where they will be able to enter information about their health and wellbeing, search for some information in their health record and download results of tests and investigations and book appointments.

The Territorial ICT system will facilitate the sharing of information, care plans, patient monitoring measurements and self-management materials with all those in the care team.

Unstable Patients – out of hospital careAll the above functionality and enhancement to the service model will be available for the ‘unstable’ patient. Any deterioration in the patient’s condition should be able to be responded to more appropriately as there will be much greater near-time information available to the relevant care practitioners. In addition, the telemonitoring will allow patients, assisted by a nurse, to receive a teleconsultation with the specialist if necessary.Inpatient - hospital careHospital healthcare professionals will have access to the patient ‘dashboard’ and should improve the information supporting decision-making in assessing and drawing up the care plan for the patient.



Inpatient – hospital discharge preparationThe availability of the home-care nurses monitoring and telemonitoring services will facilitate the hospital discharge of a patient. In addition, the continuity of care across the different care sectors will be improved through the implementation of the patient ‘dashboard’ and consistency in education material to support the patient to self-care and self-manage.

Table 11: Evolution of ICT-enabled services in Veneto

Veneto Before After



level e-prescription YES 5 YES 5Messaging clinician Patients NO 0 NO 0EHR YES 1 YES 4Interconsultation NO 0 YES 4Call Centre NO 0 YES 4Virtual Conference NO 0 YES 4PHR NO 0 YES 3Nurse Information System(record of nursing care) NO 0 NO 0Educational Platform NO 0 YES 4Collaborative Platform NO 0 NO 0Telemonitoring NO 0 YES 4Multichannel Centre (Management Telecare Programs) YES 5 YES 5

4.4.2 CareWell IT architectureThe most important challenge for Veneto pilot during CareWell is the integration the EHR in primary and secondary care. This integration is possible thanks to extend the use of Territorial Information System to secondary care.This challenge is not only represent the number of users, this challenge represent others problems to resolve like:

To implement data to storage and typology of the data To implement new roles of users To develop new interoperability connections Major risk of data duplicity and incremental cost of support and management



Figure 24: CareWell IT architecture of Veneto

The Patient empowerment and home-support services pathway will include the following IT architecture developments:

Develop a personal health folder. To develop a Teleconference system. To develop the educational web site.

In order to achieve the integration of the Territorial Information System at all clinical levels, the Veneto Pilot will use Mirth Connect, a cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications and it allows interoperability between health systems. In addition, there are some applications that use ESB (Enterprise Service Bus), that is an open source solution, but it has been customized by the providers and thus it is proprietary software.



Figure 25: Veneto Territorial Information System

4.5 Puglia4.5.1 CareWell service specificationCareWell will facilitate the development and implementation of additional care pathways for chronic diseases.Stable Patients – out of hospital careCareWell will facilitate the development and implementation of additional services for chronic diseases. Therapeutic recall to improve adherence will be provided together with educational services that can be accessed by patient from a web based platform (Nardino enhancement). Patients will be cared for in a more integrated way by their GP in collaboration with nurses and specialists in outpatient clinics who can share information through the EHR. Specialists indeed, will be involved in sharing information by EHR and to consult and update patient's information in EHR. Messaging and picture sending service (8 a.m. – 8 p.m.) between informal care giver and Care Manager will be put in place according to a protocol. This can be useful to support the patient in self-care and self-management particularly in relation to recognizing symptom deterioration or improvement, clarification on medications etc as well as, for instance monitoring wound healing, e.g. a diabetic ulcer.



Unstable Patients – out of hospital careAs with the stable patient, a patient considered to be ‘unstable’ will be cared for by the same team and will benefit from the same new services mentioned above, with an increased frequency of delivery, needing additional monitoring and assessments, frequent adjustments of therapy, or additional counselling. Furthermore, additional services specified below will be implemented:

Each health professional involved in delivering the care and support of the care plan, thanks to his own log in profile, can join a virtual ‘community of health professionals’ using the online platform to discuss specific clinical problems of their patients.

Each professional engaged in a patient’s clinical management will participate in periodic and planned briefings via videoconference to assess the general clinical status of patients, according to a specific protocol agreed with the quality team.

Home monitoring will be introduced to measure blood pressure, weight, oxygen and glucose in blood, from devices used by the patients in their homes, interfaced to the Nardino software. All clinical measurements will be uploaded to the EHR.

Additional consultations/advice through the EHR will be provided according to a defined protocol in response to alerts generated from the telemonitoring technologies.

Inpatient - hospital careWhen an ‘unstable’ patient is unable to be managed at home through the integrated care pathway in primary care, the GP or Specialist will refer the patient to the hospital for an admission. When a patient is admitted to a reference hospital, the EHR information will be available to the healthcare practitioners involved in CareWell and this should improve decision making and inform the assessment and care planning process. The integrated care pathway will be enhanced with a more active specialist participation (even the hospital Specialist). They will be able to refer a patient who has been admitted to hospital inappropriately to the primary care team suggesting home telemonitoring as this has the potential to increase the patient’s confidence to self-care and self-manage and provide the primary care team with additional information for decision support in the event of a patient reporting deteriorating symptoms.Inpatient – hospital discharge preparationThe stabilized patient is discharged from hospital back to his home. Hospital specialist entrust the patient to territorial Care Manager and clinical information for the territorial care team is provided by EHR. Services for stable patient as above will be provided.Below is the summary of ICT-enabled services which will be implemented within CareWell:

Table 12: Evolution of ICT-enabled services in Puglia

Puglia Before After



levelMessaging clinician Patients NO 0 YES 4EHR YES 3 YES 4Interconsultation NO 0 YES 4Call Centre NO 0 NO 0Virtual Conference NO 0 YES 3PHR NO 0 NO 0Nurse Information System YES 4 YES 5



Puglia Before After



level(record of nursing care)Educational Platform NO 0 YES 4 Collaborative Platform YES 3 YES 4Telemonitoring YES 2 YES 4Multichannel Centre NO 0 NO 0

4.5.2 CareWell IT architecture Below we have attached the CareWell IT architecture of Puglia illustrating the communication exchange and information flows:

Figure 26: CareWell IT Architecture of Puglia

New systems or new functionalitiesDuring the CareWell implementation the CARE Puglia Program platform will be enhanced to support new service delivery and will undergo many technical adaptations.A new clinical profile will be created to allow Specialists to access the EHR and share information with the Care manager and GP. A new user role will be defined giving them the possibility to update information on patients and consult information uploaded from other members of the care plan. The platform is fully compliant with DICOM 3.0 standard, so CARE Puglia software will integrate a PACS for management of all forms of diagnostic



imaging to implement specific work flow or process a second opinion, or in general, to support specialized activities. Technological adaptation will be provided to create an interface between the telemonitoring device hub software (at patient’s home) and Care Puglia software and to create conditions for platform to receive clinical parameters from home monitoring; platform adaptation are also necessary, and they will be provided, to send therapeutic recalls toward HUB; Furthermore, it will be enhanced to support the release of educational tools for patients and their informal caregiver (by their own PC) and to upload images coming from messaging service between patients and Care Manager. Moreover technical interventions both on platform and Hub software will be set to create warning on the platform from extra range clinical parameters revealed by home devices.

4.6 Wales4.6.1 CareWell service specification Stable Patients – out of hospital careThe care pathway and service model for ‘stable’ patients living with complex needs will be enhanced through the following ICT functionality and associated new ways of working:

MSDi case finding tool to target to CareWell service at patients most likely to benefit.

Access to the Individual Health Record (IHR) for community nursing and therapy staff through TotalMobile.

Video conferencing communication within the community nursing team through Microsoft Lync.

Community nursing team able to access the GP EHR to record contacts, measurements taken and care given.

Comprehensive directory of health and wellbeing services available for patients in Powys through the Info Engine.

Community nursing team will provide a telemonitoring service in response to patiens taking and uploading their own physiological measurements at home.

GP practice websites to include chronic conditions management educational content to support patients to self-care and self-manage.

Patients will have access to My Health Online where they will be able to view a subset of their GP EHR, book GP practice consultations, order repeat prescriptions, and update their demographic details if necessary.

Unstable Patients – out of hospital careAll of the above functionality will be available to support improved team working and response services for patients who experience a deterioration in their health and wellbeing.Inpatient - hospital careHealthcare professionals in the community hospitals will have richer information to understand the nature of a patient’s deterioration leading up to their emergency admission including telemonitoring information and any symptom management questionnaire responses. It is likely that the acuity of patients requiring hospital admission will increase as more patients are able to be managed by telemonitoring and support in their own homes for minor exacerbations.The use of TotalMobile and Microsoft Lync by the community nursing team will facilitate improved communication between the team and community hospital staff.



Inpatient – hospital discharge preparationThe availability of the community nursing team’s telemonitoring service will facilitate the hospital discharge of a patient. In addition, the patient will be signposted to the relevant chronic conditions management educational content on the GP practice website and any additional support services available from searching the Info Engine.Below is the table of CareWell ICT-enabled services:

Table 13: Evolution of ICT-enabled services in Wales

Wales Before After



levele-Prescription YES 5 YES 5Messaging clinician Patients NO 0 YES 5EHR YES 5 YES 5Interconsultation NO 0 YES 2Call Centre YES 2 YES 2Virtual Conference NO 0 YES 5PHR YES 4 YES 5

Nurse Information System (record of nursing care) YES 2 YES 2

Educational Platform YES 2 YES 4Collaborative Platform YES 3 YES 5

Telemonitoring NO 0 YES 4Multichannel Centre

(Management Telecare Programs) NO 0 NO 0

The use of TotalMobile and Microsoft Lync by the community nursing team will facilitate improved communication between the team and community hospital staff.

4.6.2 CareWell IT architecture The most significant changes in the IT architecture will be those to deliver the Patient empowerment and home-support services pathway. Changes or new systems (pathway empowerment and home support):

Access mobile to EHR app, The current and new developed systems will be adapted for running on mobile devices such as Smartphones and tablets for the district and specialist nurses to use when the make visits to patients’ homes.

To implement a telemonitoring service. To develop a unique database with social and clinical information for community

services which is currently undergoing a national procurement. Educational materials and information available on GP practice websites.

Below is an illustration of the CareWell IT architecture to be implemented in Powys:



Figure 27: CareWell IT Architecture of Wales

The integrated and coordination services pathway will be enhanced in the following ways: Implement Interconsultation message (referrals) through EHR between clinicians. Implement live communication tool between community nurses and GP. Implement Videoconference.



5. Guidelines to achieve interoperable and efficient IT systems

5.1 Guidelines for the development of interoperable systems

In order to effectively provide integrated care services, it is necessary to be able to share information between the various stakeholders. Over many years, the healthcare organisations in the CareWell pilot sites have implemented a variety of IT systems to provide business and clinical care functionality in the different care settings but the extent to which data and information stored in these systems is shared with other systems and users is variable. There are two distinct terms used to describe ways of sharing information electronically:

Systems Integration. Systems interoperability: The IEEE defines interoperability as the ability of two or

more systems or components to exchange information and to use the information that has been exchanged.

Systems integration is the common solution when two or more systems are not interoperable. Below describes several cases to implement this solution

Legacy systems which your database technology don’t allow to access of data for sharing with other applications.

Legacy systems which is not possible develop process for using data from others applications.

In cases of develop new systems, the normal guidelines is addressed to include the major number of functionalities and services in the same application .(services provided at the moment by others applications).

In any of the three cases and especially in the last, the trend is the creation of the integrated system needed and the provision of the technology required to turn it into an interoperable system and therefore able to share information to provide benefits such as:

Easier functional scalability. Unique storage for data (avoiding data duplicity). Decrease of systems maintenance costs. To improve the performance of applications due to interoperable systems displaying

information in a more structured and easily readable way. To re-use resources. Standardisation of new developments (reducing costs).

5.1.1 Levels and environments of interoperabilityTo achieve the strong interoperability among systems we should to achieve an optimum level of three interoperability levels (Syntactic, Semantic and Organisational).

5.1.1.1 Syntactic interoperabilityIf two or more systems are capable of communicating and exchanging data, they are exhibiting syntactic interoperability. Specified data formats, communication protocols and the like are fundamental. XML or SQL standards are among the tools of syntactic interoperability. This is also true for lower-level data formats, such as ensuring



alphabetical characters are stored in a same variation of ASCII or a Unicode format (for English or international text) in all the communicating systems.Syntactical interoperability is a necessary condition for further interoperability.

5.1.1.2 Semantic interoperabilityBeyond the ability of two or more computer systems to exchange information, semantic interoperability is the ability to automatically interpret the information exchanged meaningfully and accurately in order to produce useful results, as defined by the end users of both systems. To achieve semantic interoperability, both sides must use a common information exchange reference model. The content of the information exchanged must be unambiguously defined: what is sent is the same as what is understood.In the field of health information, achieving semantic interoperability is even more important and difficult. Semantic interoperability has two subparts:

Overall semantic interoperability implies the ability to communicate with other systems and interpret correctly information from these. This is possible thanks to the application of standards to define concepts (content) and logical rules.

Distributed processing is the most common form of semantic interoperability. This implies that systems are implemented to meet standards to communicate and interpret information that are not able to make logical deductions. These systems implement a rigid set of standards for information exchange which cover, by prior arrangement, what information is exchanged, how and in what format, among others. The name refers to distributed processing of the information generated in a system that communicates with another to generate some kind of result value. Changes in the exchanged messages often require changes to software, which is clearly not desirable.

The main objective is to achieve semantic interoperability because it has a direct impact on the daily work of health professionals and citizens; this interoperability makes it possible to exchange and use information. This interoperability has two levels:1. Semantic interoperability for viewing: The viewing of information is the most common

need of health information systems because often the information held in one system needs to be viewed in another. For example, the results of laboratory tests need to be viewed in an EHR system.For the correct interpretation of information displayed in a different system, there are three main aspects to consider: How to display the information. How the user is accustomed to see the information. What device is used to view the information?

2. Semantic interoperability for processing. The automatic processing of information is one of main principles of IT, and one of processes that improves the value of health IT. The objectives of automatic processing of information include: Quality assessment: correction and completeness of information. To calculate indicators, percentages, durations, etc. To look for information of patient: bibliography resources, etc. Derivation: analysis to find new information from the current system. Decisions support, validations secure card, rules evaluation, alarms, etc. Processing, consolidation, communication and storage.



To achieve automatic processing of information, this information should be correctly structured.

5.1.1.3 Organisational or business interoperability To achieve such interoperability, business processes rules must be specified together with actors involved. Defining business rules requires analysis of various areas within an organisation (emergency, inpatient, outpatient, laboratories, pharmacies and others), their needs, their structure, their responsibilities and their products. The only way to have a clear vision of the entire organisation, is through formal definition of its components and the information they generate and consume. The same concept can be applied to the health system as a whole, with its components (actors), rules (laws), goals (welfare, trainers, research and regulators) and the interdependencies between them.

5.1.2 StandardsThe need for interoperable systems is evident in every part of health sector organizations as effective delivery of healthcare requires a constant exchange of information among health professionals, including service institutions, insurers and government, between medical staff and patients, between auxiliary imaging systems and laboratories, with electronic medical records systems and between public health systems, just to mention some interactions.Consequently, effective communication between these actors requires that a common framework that allows interaction and coordination of care sharing. Framework provided by the standards, which provide uniformity in the name of the components of the health system whether diagnoses, people, procedures, interventions and how it is transmitted, to ensure that data in one part of the system health are available and have meaning not only through the variety of clinical settings and public health but also administratively.In the Figure 28 we have a map with the most common standards and protocols (grouped by areas); these standards can be considered as an infrastructure of every IT system which has interchanged data with other systems.

Figure 28: Standards v. interoperability levels



The importance of this schema is to visualize that the use of a single standard is not enough to achieve the different types of interoperability and it is necessary to look for additional standards and with different foci which together enable communication and utilization of information.Effective use of information through a set of information systems is not achieved only with the pact that the systems can communicate; this is not possible even if the same standard of communications used. This problem is inherent in the information itself as well as the way it is obtained, processed and stored.Therefore, for effective interpretation and processing of information it is necessary to apply standards that allow representation of the context of information. Below is a brief description of the standards presented in the map in picture 17, which are organized by foci or areas of application, its aims and relations it performs.Communication infrastructure: In this area are the standards and protocols that enable physical and logical communication between computers and networks.Protocols that underlie the Internet are listed (Interoperability Toolkit (ITK) of the National Health System (NHS) in the UK).

Ethernet is a protocol link layer (layer 2 Open System Interconnection model or OSI) that allows two devices connected via a link (cable) data exchange higher layer protocols.

TCP / IP protocols are most used in the world. TCP is a transport protocol (layer 4 of the OSI model) that allows you to create logical connections over an IP network between two physically distant computers. IP is a network layer protocol (layer 3 of the OSI model). These protocols enabled the implementation of Internet.

The following topics related to standards are discussed in more detail in Appendix B: Communication Protocols (general applications). Syntax standards. Format Specification. Services Specification. Process Specification. Communication Protocols (Health applications). Terminology and health nomenclature. Clinical documentation. Models of information. Architecture of communication. Knowledge models.

5.2 Interoperability Tools in CareWell pilotsWe explain at the level of implementation the interoperable tools in CareWell pilot, focusing on two points:

What interoperable platform is used by the pilot? What standards are used in the CareWell systems?



5.2.1 Basque CountryInteroperable platformBasque Country has addressed our interoperability policy to SOA (Service Oriented Architecture). In the central of this architecture had deployed a commercial bus service (oracle Service Bus). Currently the Basque Country has deployed around 300 web services for share clinical, demographic and administrative information among corporative systems. The main applications to provide web services are:

E-Osabide : Hospital Information System (Administrative Tool). SAP: Commercial tool for management of financial and RRHH. CRM: Web services for Telecare and telemonitoring. Presbide: e-Prescription system.

Figure 29: Interoperable platform

Standards Used in CareWell systemBelow is a table which describes the standards used in the Basque Country pilot site.

Table 14: Basque Country standards used

Application Semantic standards

Syntactic Standards Organisational Interoperability

e-Prescription LOINC, ICD 9/10 HL7, xml, http, https, SOAP CDA1,Osabide AP ICD 9/10 DICOM, html, http, https, CDA1



XML, FTPOsabide Global ICD 9/10 HL7, DICOM, xml, http,

https, ftpCRM LOINC, ICD 9/10 xml, pdf, Cades, DICOM,

HL7, SOAPPHR https, PDF, HL7 CDA1Educational Web

5.2.2 CroatiaInteroperable platformCroatia pilot have not deployed any interoperability platform. The unique system for interconnecting systems or providing access to clinical data in secondary care from primary care IT systems is a VPN connection.Standards Used in CareWell systemBelow is a table which describes the standards in use in the Croatia pilot site:

Table 15: Croatia standards used


Syntactic Standards Organisational Interoperability

EMH LOINC, ICD 9/10 HL7v3, HL7v2, XML, SOAP, HTTPS

CDA1, Digital Signature

5.2.3 Lower SilesiaInteroperable platformWroclaw pilot has a bus service in every hospital used for interoperability legacy systems with HIS.Standards Used in CareWell systemBelow is the table containing the standards used in the Lower Silesia pilot site:

Table 16: Lower Silesia standards used


Syntactic Standards

Organisational Interoperability

Mobile ICD9/ICD10 XML / HTML Dictionaries, HL7Web ICD9/ICD10 XML / HTML Dictionaries, HL7 not yet

implementedClient/Server ICD9/ICD10 XML / HTML Dictionaries, HL7 not yet

implementedCommunicator Not referred Not referred Not referred

5.2.4 VenetoInteroperable platformIn the Local Health Authority is used Mirth Connect, a cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications and it allows interoperability between health systems. In addition, there are some



applications that use ESB (Enterprise Service Bus), that is an open source solution, but it has been customized by the providers and thus it is proprietary software.Standards Used in CareWell systemBelow is the table containing information on the standards used in the Veneto pilot site:

Table 17: Veneto standards used


Syntactic Standards


e-Prescription/ GP and Pharmacy’s software

LOINC, ICD 9/10 HL7, xml, http, https, SOAP

CDA2, IHE

web site html, http, httpsRegional Tele-emergency Solution

HL7, DICOM, xml, http, https, ftp

e4cure and Talete LOINC, ICD 9/10 xml, pdf, Cades, DICOM, HL7, SOAP

IHE

5.2.5 PugliaInteroperable platformPuglia has Open source interoperability platformStandards Used in CareWell systemBelow is the table containing information on the standards used in the Puglia pilot site:

Table 18: Puglia standards used


Syntactic Standards


CARE Puglia Program SOAP WSDL XML ebBPSS

5.2.6 WalesInteroperable platformPowys (Wales) has an internal interoperability platform (WCCG)Standards Used in CareWell system

Table 19: Wales standards used


Syntactic Standards




6. Security and confidentiality of data The main goal of this section is to describe the elements, tools and processes required for data security management. For this purpose, three principal aspects are considered:

1. Identification, authentication and authorization of persons and devices: this aspect ensures that all system users, not matter what device they use are able to be identified and given the appropriate level of access to only the information that is relevant for that defined role.

2. Security of stored and exchanged data: all information shared electronically and stored in IT systems must comply with legal and ethical legislation and guidance. The level of security varies for example, according to who the exchange is between, whether the information exchange is person identifiable, contains any sensitive information, encryption regulations and patient consent.

3. Establishment of guidelines, standards and best practices to ensure effective management of risks and threats: in order to ensure the security of health information systems and communications, appropriate audit processes should be implemented regularly and immediate steps taken to rectify any threats and breaches together with remedial action to minimise future breaches in security and confidentiality of patient-held data.

The next sub-section details a description of how the above three key aspects of security and confidentiality of data are approached in each pilot site.

6.1 Basque countryIdentification, authentication and authorization of persons and devices The Basque Health Service is gradually adopting a policy-based user management identity management and access through SSO (single sign on), so that once the user is authenticated in the OS of their computer, the system operative in charge of passing credentials match your identity to each application that is incorporated in the system. This process is underpinned by role-based access protocols.To support this, Osakidetza has a centralized system and an active user directory system (not only professionals but other staff with access to the system).The e-Prescription and the PHR systems in Osakidetza use an electronic personal certificate with the e-Prescription also including a secure electronic signature for prescriptions through the PKI architecture. Security of stored and exchanged dataIn Osakidetza there are two levels of security implemented depending on whether the data is being exchanged between internal or external systems If the exchange includes external systems, all communication of data is secure through the use of HTTPS (HTTP over SSL or HTTP Secure). Information and data exchanged between internal systems is secured through the individual and role-based identification and authentication process. In addition, Osakidetza has other tools implemented to protect their communications such as the demilitarized zone (DMZ).The diagram below shows the secure architecture for external communications:



Figure 30: Secure architecture for external communications

To ensure secure storage, security protocols for Osakidetza demand making incremental backups every day. These backup copies are stored in a different location to cpd. Actions for effective management of risks and threats

Preventive Actions (Audit systems): An audit system is implemented as a preventive action. In the Basque health service the systems which manage data of high level of security implements audit systems supported by a basic server log that has information on user actions and activities – user, role, and time of access. In addition, Osakidetza uses ORACLE databases that can allow auditing of the activities, depending on the edition of the database.

Reactive Actions: There is a system to monitor the network against external attacks in operation every day. There is also a document with all necessary protocols and processes to execute in case of external attack.

6.2 CroatiaIdentification, authentication and authorization of persons and devices UsersCareWell systems implemented are:

G1: Different levels of security including physical access control, private networks, network data encryption, as well as smart card authorization allowing access of G2 applications to central system.

G2: Smart card authorization for each user, https, private networks (there are several G2 market app).



Ericsson Mobile Health: This system is protected with user name / password secure access for each user on web application and Android device.

Devices used and their connections with back-ends The communication between the Android devices and the back-end system uses HTTPS protocol and encrypted communication channel by SSL.Security of stored and exchanged dataAll clinical reports providing clinical data, which are reported to G1, are digitally signed. Digital signature is provided with the same smart card used for secure access using the e-health national PKI infrastructure.The system is shown in the figure below.

Figure 31: PKI infrastructure e-health in Croatia

Regarding stored data, data is stored in two separate databases on the back-end system; one includes a patient´s demographic information and the other contains anonymous clinical data and measurements. Once the authorized user signs in with username/password, a patient´s name is related to a specific set of medical data (measurements, questionnaire etc.). Security data backups are made on a regular basis to protect data from being lost. In addition a redundant EMH server is used to secure the service delivery continuity.In addition, system data transmission channels in Ericsson Mobile Health is protected on four levels in Ericsson Mobile Health:

Medical Sensors -> Gateway Standard Bluetooth authentication (PIN based)

Gateway -> Back-end Server HTTPS protocol

Back-end server Physical separation of data Session and Role-based security

Back-end server -> Web application HTTPS protocol



Figure 32: Layers of security communication channels Croatia pilot

Actions for effective management of risks and threats Preventive Actions (Audit systems): An audit system is implemented as a preventive

action. In Croatia the EMH system has a basic server log that has information on user actions and activities – user, role, and time of access. Furthermore, the EMH uses MySQL database that can allow auditing of the activities, depending on the edition of the database (Enterprise edition has auditing features). For the CareWell project, MySQL Standard edition will be used which does not allow for auditing.

Reactive Actions: A monitoring system against external attacks is deployed and tested in both provider and client environments. The system is secured in the intranet, and entry is protected by a firewall. The back-end system only accepts connections from registered devices on particular ports. In addition, the restoration of the database is initiated when a corruption is identified (for this action, MySQL workbench tool is used).

6.3 Lower SilesiaIdentification, Authentication and authorization of people and devices UsersThe Managing Access to the application in the CareWell monitoring system (LSV) will be based on User / Password.



Devices used and its connections with Back-ends Devices are using the Bluetooth connectivity protocol.Security of stored and exchanged dataThe sensitive data will be stored on the server in the organization that owns the data (hospital) and for databases containing sensitive data, secure backup copies will made every day.In the data centre backup copies are made in full: –daily, incremental –weekly and monthly scheduled.Lower Silesia ensures the data transmission channels by SSL (https). The diagram below illustrates the security channels architecture. In the data centre, the data transmission channels are protected by SSL certificate, moreover the access to resources is carried out also by VPN.

Figure 33: Security architecture of data transmission channels in Lower Silesia

Actions for effective management of risks and threats Preventive Actions (Audit systems): The Lower Silesia Integration platform, which

implements the procedure for telemedicine and telecare services, will keep a log file in a database recording the following data on the operations performed on the system: - who?, when? and what kind of operation was performed ? (this will include the login to the application).



Reactive Actions: In the data centre there is a full system backup, which allows data to be restored after a loss or malfunction. The CareWell monitoring system integrator will develop a procedure for restoring databases after a crash.

In relation to monitoring systems against external attacks, the hospital policy is based on: Accessing the WAN (Internet) is possible for staff only; patients do not have access

to internet. Local area network is protected against intrusion from the network (wide) external

using hardware firewall on the main Router -model VIGOR 2910G. Firewall allows to filter packets (SPI), call filter, data filter, protection against DoS /

DDoS filter, IM / P2P filter, URL content filter and Web content filter. In order to reduce the possibility of infecting computers in the local network by

viruses and protect against unauthorized access, minimized risk by using professional software firewall (firewall) and a professional anti-virus program on each computer and a server at the Hospital has ESET Smart Security Software.

The data centre has a Cisco IPS and IronPort system.

6.4 VenetoIdentification, authentication and authorization of people and devices

Table 20: Veneto kinds of secure access

App Secure access Kind of secure accessePrescription/ GP and Pharmacy’s software

Yes user/password

web site Only for some services like reports download

user/password

Regional Telemergency Solution Yes user/passwordTerritorial Information System Yes user/passworde4cure and Talete Yes user/passwordACG and Qlickview Yes user/passwordApp7 Yes User/password

UsersReferring to CareWell systems the services that are already implemented, are:

ePrescriptionThe prescribing physicians authenticate themselves on a security infrastructure created at regional level. The architecture uses a federated authentication. All actors authenticate themselves to service through a system of identity management, located in all local health authorities of Veneto region. The system of access is declined in two levels. The authentication in the system takes place through username, password and software’s certificates; as a result of this authentication process, is issued a token that allows the accessibility to service and delivers all useful information. This token has a period of validity.

TelecarePatients have an emergency button to communicate through E.R. Social assistants of Local Health Authority have username and password to access to database in which there is all information about patients who have this service (https protocol).

Medical interconsultation



This service allows the consultation between specialists. Physicians access the software through username and password and can see clinical reports and patient data carried by other specialist according with Italian privacy law. The information sharing is within the LAN of the Local Health Authority so data are protected from external attacks.

Devices used and their connections with back-ends The CareWell system devices that will be used by nurses when delivering services at the patient home are: portable ECG, oximeter, portable glycosylated haemoglobin device, portable spirometer, and portable blood gas analyser, Tablet/PC, webcam digital camera. The connection for the import of data from devices to ICT system will use bluetooth, wifi or USB protocol depending on the technical features of the specific device. For the telecare service, patients have an emergency button which communicates with E.R. through the PSTN (Public Switched Telephone Network).Security of stored and exchanged dataIn Veneto the following reports are signed: emergency reports, hospital discharge’s reports, anatomic pathology reports, and radiology and laboratory analysis reports, discharge summaries.Systems of Veneto pilot do not store sensitive data in devices; this data is stored only in the server of local health authority of ULSS N.2 and the data backups are collected every day.The Local Health Authority has different procedures to protect data transmission. The transmission in the LAN is protected by external attacks through firewall, proxy and antivirus. Therefore, there are dedicated transmission channels in which operators’ access through specific tools like VPN and https protocol.

Figure 34: Security architecture of data transmission channels in Veneto



Actions for effective management of risks and threats Preventive Actions (Audit systems): There is an appliance that records all access

system administrators to various servers. Each application has its own log of the activities (log in dates, log out dates). Therefore, for ePrescription service, the system records authentication logs (user name, ID software, log in dates).

Reactive Actions: In case corruption or fail in database the backup systems allow to the recovery of the clinical data and reports. This process of backup/restore is made by a system provider. Moreover for protect the systems against external attacks, there are an Intrusion Prevention System (IPS) and an Intrusion Detection System (IDS) which highlight and store anomalies in network traffic on the firewall. In addition there is an active control on the availability of the systems that forwards alarms if the systems are not available.

6.5 PugliaIdentification, authentication and authorization of people and devicesUsersIn Puglia the applications use user/password authentication, while some systems use CNS via digital certificates.Devices used and their connections with back-ends Clinical data will flow from wireless medical devices (weight scale, blood pressure and glucose monitor, pulse oximeter) to a HUB via bluetooth connection; data will flow from the Hub to the web platform via 3G (mobile network) or land line phone connection.Security of stored and exchanged dataIn the Puglia pilot, the data will be stored on a central server. Care Managers, General practitioners and authorized data manager (DBA – data base administrator) have access to it. All the access is controlled by ID and Password from Care Managers and DBA (weak authentication), by CNS (strong authentication via digital certificate) from General Practitioners. To guarantee the data stored on the central server, IT Puglia make two kinds of data backup:

Weekly backup (complete backup) Daily backup (incremental backup)

In relation to the security of the data exchange channels in Puglia, the access to data takes place from workstations connected to RUPAR, the public administrations network of Apulia region or, from mobile stations, by encrypted VPN. Access to data is controlled by ID and password or digital certificates on smart cards. National certification and registration Authorities guarantee for traceability and legal non-repudiation of access (for strong authentication). Encrypted data will be transferred to authorized partners for processing and analysis; communication of results will be anonymous and macro aggregated.Actions for effective management of risks and threats

Preventive Actions (Audit systems): In Puglia the systems for auditing access are available. A database register of access tracks what, when, from which client is undertaken.

Reactive Actions: In case of corruption, data will be taken from the daily and weekly backup. Fault tolerance procedures (redundant storage and redundant disks) are available. Moreover, The IT architecture has a CISCO CCNA certification in each procedure.



6.6 WalesIdentification, Authentication and authorization of people and devicesUsersUsers of CareWell systems use user/password to access to systems.Devices used and its connections with Back-ends The devices use wifi or LAN connections to transfer the data to the back-endSecurity of stored and exchanged dataFile storage

Network storage on Microsoft domain Password protection using active directory SQL servers, firebird servers and oracle servers

Transmission of data WAN/LAN networks NWIS secure file sharing portal NHS.net MS Lync VPN

Database backup is assured through a number of measures to safeguard information stored in systems on Health Board networks. Where data is stored in remote locations, such data will be replicated back to a central data store. Shadow copy functionality is enabled on file stores to enable easy end user recovery of their data. Access to such information will be accessed via DFS shares to enable easy switch over to alternative physical storage with minimal interruption to service. Data is backed up from replicated data storage to backup to disc storage. Those backups will also have offsite data stores and physical tape storage for weekly backups. Backup processes will also enable the complete virtualized servers to new hosting hardware where deemed appropriate.Regarding protection of data transmission channels, the Network hardware will be housed in suitably secure environments. On hospital sites these may be restricted access locations with a locked data cabinet housing the equipment.Critical systems will be held in secure hosting environments. These rooms will be secured against unauthorised access with appropriate entry controls and intruder detection systems where necessary. They will also have a number of environmental controls covering fire suppression, power, and air conditioning as necessary.UPS devices will be provided following an assessment to ensure equipment is powered during switchover to generator cover.For authentication in, the network will use RSA SecurID tokens. Authorised users will be supplied with a unique user ID, a PIN and the token. The PIN and number displayed on the SecurID token forms a one use only password (The SecurID Token number will change very minute). The user account will be disabled after three failed attempts.Actions for effective management of risks and threatsPreventive Actions (Audit systems)The IT Operations Department will manage the Health Board’s information assets to minimize risks to data and systems.



Computer systems will be configured with protection software and standard policies. These will be designed to restrict access to systems and to monitor for unauthorized access.Systems will be maintained to the latest approved standards to protect against software bugs that could be used for unauthorized access.A number of network management systems will be used to proactive monitor and manage the data networks to identify risks or unauthorized access.Audit processes will be undertake to ensure user access is appropriate to need and removed when no longer required.Reactive ActionsAbout active reactions in case failure database or system. The provision of multiple proxy servers with failover provision to support access to internet resources. A number of domain controllers to facilitate rapid authentication of users onto the network. Major sites are provided with file servers that provide local file storage, computer address provision, printing services. DFS (Distributed File System) is used both as a virtual access point to data and as a method of replicating data between data stores Use of national or regional data centres are used whenever possible to host applications to reduce dependencies on local data storage (generally the service provision from such locations will be of an enhance nature including power provision / security / failover. Applications will be hosted, wherever possible, on virtualized systems to facilitate rapid changeover to new hosts. Spare network equipment is maintain for emergency swap out. Standard deployment is used wherever possible to enable users to log into any computer and to be able to access their applications. Processes are in place to support rapid deployment of applications.Regarding protecting systems against external attacks, the Powys pilot site uses a number of applications to monitor networks and end user devices to ensure compliance with standards, identify issues before they cause major incidents, to enable remote support and application deployment.The systems used will include:

Microsoft System Centre to maintain software and hardware asset inventories and to monitor asset compliance with standards. There is a further role to support the deployment of applications or updates.

Microsoft Update Services which is used to manage the deployment of security updates to end user devices across the network.

Solarwinds to monitor network performance and to identify performance issues. Wireless security and monitoring systems ePO to manage the security of devices and protect networks from malicious

software Safend Management Console to manage removable media McAfee Endpoint Encryption to protect data storage from unauthorized access Mailmarshal to control email service Webmarshal to control and manage access to internet resources Controls through active directory are used to determine what can be installed and

used on computers to increase the security of the networkManagement systems are used to monitor computer systems and to protect them from malware. The management system will provide updates, configuration changes from a central location.Operating System protection such as local firewalls is used to reduce the risks to devices.



Standard policies are applied to computers to restrict the ability to install, run applications and restrict access to operating system files as appropriate.The Webmarshal application is used to monitor and control internet access to minimise exposure to compromised websites.The Mailmarshal service is used to protect email from messages containing viruses or other risks.



Appendix A: Technological Terms.NetNET is an integral part of many applications running on Windows and provides common functionality for those applications to run. This download is for people who need .NET to run an application on their computer. For developers, the .NET Framework provides a comprehensive and consistent programming model for building applications that have visually stunning user experiences and seamless and secure communication.AppletAn applet is a component of an application running in the context of another program, for example in a web browser. The applet must run in a container, which provides a host program, through a plugin, 1 or applications such as mobile phones supporting programming model ‘applets’ Unlike a program, an applet cannot run independently, provides graphical information and sometimes interacts with the user, typically lacks session and have restricted security privileges. An applet normally takes within a very specific function that lacks independent use. The term was introduced in 1993 in AppleScript Common examples of applets are Java applets and Flash animations. Another example is the Windows Media Player used to display video files embedded in browsers like Internet Explorer. Other plugins allow you to display 3D models that work with an applet.A Java applet is a Java code that lacks a main method, so it is mainly used for work sites, since it is a small program that is used in a HTML page represented by a small graphic display within it.Moreover, the difference between a JAVA applet and application is how to run. To load an application JAVA interpreter (pcGRASP of Auburn University, Visual J ++ from Microsoft, Sun Forte Visual Café) is used. Instead, an applet can be loaded and run from any browser that supports Java (Internet Explorer, Mozilla Firefox, Google Chrome, Netscape etc).Call CentreThis is the office where a group of specifically trained people is responsible for providing some care or telephone service. Importantly, the call centre can be operated by the company itself or outsourced to an external company. There are companies that are dedicated to establishing call centres (with the necessary infrastructure and trained personnel) and market such provision. There are essentially two ways you can organize a call centre: dedicating one or more physical spaces (offices) of their activities, earmarking a box to each of its employees; hiring people to perform work remotely. The latter is increasingly common, thanks to the amenities offered by Internet, allowing to constantly monitor via instant messaging systems and send documents containing relevant information to employees without any delay.



The main advantage of a call centre to a company is that centralizes attention. If you do not have a call centre, all calls arrive at different offices and be more difficult to decide how they are channeled and recorded. The call centre, however, is intended solely to facilitate communication. Operators are trained to resolve issues on their own and newly derived the call to an executive in exceptional casesClient / server applicationA client/server application is a piece of software that runs on a client computer and makes requests to a remote server. Many such applications are written in high-level visual programming languages where UI, forms, and most business logic reside in the client application. Often such applications are database applications that make database queries to a remote central database server (this can, however, get much more complicated than that and involve other communication methods).

This screen shot shows an example of a client /server application running locally on a computer. This is the same application shown running remotely in some of the Terminal Server and Citrix screen shots in the previous section. A client / server application can be cross platform if it is written in a cross platform language, or it can be platform specific. In the case of a cross platform language there is an advantage that the application can potentially provide a user interface that is native in appearance to the OS or platform environment it is running under. An issue of client/server is that the application must be installed on each user’s computer. Depending on the complexity of the program, the environment it is written in, and the care the developer took to package the program, this can be as easy as creating a shortcut to an executable on a shared network drive or it can be as hard as spending hours installing and configuring runtime software and components on each client computer.



Client / server applications, either run locally on a client computer or through something like Terminal Server, Citrix, or VNC, can work closely with the underlying OS to provide a rich, powerful, robust, easy to use interface. By running locally on a client computer applications can also work with other local hardware such as scanners, bar code readers, modems, removable media, accelerated video for multimedia, or 3d video acceleration.CRM Customer relationship management (CRM) entails all aspects of interaction that a company has with its customers, whether it is sales or service-related. While the phrase customer relationship management is most commonly used to describe a business-customer relationship (B2C), CRM systems are also used to manage business to business to business (B2B) relationships. Information tracked in a CRM system includes contacts, clients, contract wins and sales leads and more.

DICOMDICOM (Digital Imaging and Communication in Medicine) is world renowned for the exchange of medical tests, designed for handling, display, storage, printing and transmission standard. Includes defining a file format and a network communication protocol. The communication protocol is an application protocol that uses TCP / IP to communicate between systems. The DICOM files can be exchanged between two entities that are able to receive images and patient data in DICOM format.DICOM enables the integration of scanners, servers, workstations, printers and network hardware from multiple vendors within a storage system and image communication. The different machines, servers and workstations have a DICOM Conformance Statement (conformance statements) which clearly establishes the DICOM classes they support. DICOM has been widely adopted by hospitals and is making foray into small office application dentists and doctors.



Digital SignatureA digital signature (not to be confused with a digital certificate) is a mathematical technique used to validate the authenticity and integrity of a message, software or digital document.The digital equivalent of a handwritten signature or stamped seal, but offering far more inherent security, a digital signature is intended to solve the problem of tampering and impersonation in digital communications. Digital signatures can provide the added assurances of evidence to origin, identity and status of an electronic document, transaction or message, as well as acknowledging informed consent by the signer.In many countries, including the United States, digital signatures have the same legal significance as the more traditional forms of signed documents. The United States Government Printing Office publishes electronic versions of the budget, public and private laws, and congressional bills with digital signatures.Digital signatures are based on public key cryptography, also known as asymmetric cryptography. Using a public key algorithm such as RSA, one can generate two keys that are mathematically linked: one private and one public. To create a digital signature, signing software (such as an email program) creates a one-way hash of the electronic data to be signed. The private key is then used to encrypt the hash. The encrypted hash -- along with other information, such as the hashing algorithm -- is the digital signature. The reason for encrypting the hash instead of the entire message or document is that a hash function can convert an arbitrary input into a fixed length value, which is usually much shorter. This saves time since hashing is much faster than signing.The value of the hash is unique to the hashed data. Any change in the data, even changing or deleting a single character, results in a different value. This attribute enables others to validate the integrity of the data by using the signer's public key to decrypt the hash. If the decrypted hash matches a second computed hash of the same data, it proves that the data hasn't changed since it was signed. If the two hashes don't match, the data has either been tampered with in some way (integrity) or the signature was created with a private key that doesn't correspond to the public key presented by the signer (authentication).A digital signature can be used with any kind of message -- whether it is encrypted or not -- simply so the receiver can be sure of the sender's identity and that the message arrived intact. Digital signatures make it difficult for the signer to deny having signed something (non-repudiation) -- assuming their private key has not been compromised -- as the digital signature is unique to both the document and the signer, and it binds them together. A digital certificate, an electronic document that contains the digital signature of the certificate-issuing authority, binds together a public key with an identity and can be used to verify a public key belongs to a particular person or entity.



Most modern email programs support the use of digital signatures and digital certificates, making it easy to sign any outgoing emails and validate digitally signed incoming messages. Digital signatures are also used extensively to provide proof of authenticity, data integrity and non-repudiation of communications and transactions conducted over the Internet.Electronic Health RecordAn electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centred records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can:

Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results

Allow access to evidence-based tools that providers can use to make decisions about a patient’s care

Automate and streamline provider workflowOne of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.



EncryptionEncryption is the conversion of electronic data into another form, called ciphertext, which cannot be easily understood by anyone except authorized parties. The primary purpose of encryption is to protect the confidentiality of digital data stored on computer systems or transmitted via the Internet or other computer networks. Modern encryption algorithms play a vital role in the security assurance of IT systems and communications as they can provide not only confidentiality, but also the following key elements of security:

Authentication: the origin of a message can be verified. Integrity: proof that the contents of a message have not been changed since it was

sent. Non-repudiation: the sender of a message cannot deny sending the message

ePrescriptionEPS allows prescribers - such as doctors and practice nurses - to send prescriptions electronically to a dispenser (as a pharmacy) patient choice. This makes the process of prescribing and more efficient and convenient for patients and staff dispensation.


http://whatis.techtarget.com/definition/algorithm

http://searchnetworking.techtarget.com/definition/network

http://searchwindevelopment.techtarget.com/definition/Internet


Functionalities In information technology, functionality is the sum or any aspect of what a product, such as a software application or computing device, can do for a user.A product's functionality is used by marketers to identify product features and enables a user to have a set of capabilities. Functionality may or may not be easy to use.HL7HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information. These standards define how information is packaged and communicated from one party to another, setting the language, structure and data types required for seamless integration between systems. HL7 standards support clinical practice and the management, delivery, and evaluation of health services, and are recognized as the most commonly used in the world. HL7 standards are grouped into reference categories:

Section 1: Primary Standards - Primary standards are considered the most popular standards integral for system integrations, inter-operability and compliance. Our most frequently used and in-demand standards are in this category.

Section 2: Foundational Standards - Foundational standards define the fundamental tools and building blocks used to build the standards, and the technology infrastructure that implementers of HL7 standards must manage.

Section 3: Clinical and Administrative Domains - Messaging and document standards for clinical specialties and groups are found in this section. These standards are usually implemented once primary standards for the organization are in place.

Section 4: EHR Profiles - These standards provide functional models and profiles that enable the constructs for management of electronic health records.

Section 5: Implementation Guides - This section is for implementation guides and/or support documents created to be used in conjunction with an existing standard. All documents in this section serve as supplemental material for a parent standard.

Section 6: Rules and References - Technical specifications, programming structures and guidelines for software and standards development.

Section 7: Education & Awareness - Find HL7's Draft Standards for Trial Use (DSTUs) and current projects here, as well as helpful resources and tools to further supplement understanding and adoption of HL7 standards.

All HL7 Standards can also be located by other classifications such as ANSI/ISO/HITSP approval and various search variables in our Master Grid.HL7 encompasses the complete life cycle of a standards specification including the development, adoption, market recognition, utilization, and adherence. Please refer to our IP Policy for more information about how members and non-members can use the standards.Hospital Information System (HIS)A hospital information system is defined as the socio-technical subsystem of a hospital, which comprises all information processing as well as the associated human or technical actors involved in their respective information processing rolesTypical HIS components are:

Enterprise functions (i.e. hospital functions), Business processes, Application components,



physical data processing systemsThe goal of a hospital information system is to sufficiently enable the adequate execution of hospital functions for patient care, including patient administration, taking into account economic hospital management as well as legal (e.g. data protection or reimbursement aspects) and other requirementsHospital information systems have to consider various areas of a hospital, such as:

Wards and outpatient units Service units: diagnostic (e.g., laboratory department, radiology department),

therapeutic (e.g., operation room) and others (e.g., pharmacy, patient records archive, library, blood bank)

Hospital administration areas (e.g., patient administration department, patient record archive, department of quality management, financial and controlling department, department of facility management, information management department, general administration department, human resources department)

Offices and writing services for (clinical) report writingHTTPSHTTPS stands for HyperText Transfer Protocol over SSL (Secure Socket Layer). It is a TCP/IP protocol used by Web servers to transfer and display Web content securely. The data transferred is encrypted so that it cannot be read by anyone except the recipient. HTTPS is used by any Web site that is collecting sensitive customer data such as banking information or purchasing information. If you are making a transaction online, you should make sure that it is done over HTTPS so that the data remains secure. IHEIHE created and operates a process through which interoperability of health care IT systems can be improved. The group gathers case requirements, identifies available standards, and develops technical guidelines which manufacturers can implement. IHE also stages ‘connectathons’ and ‘interoperability showcases’ in which vendors assemble to demonstrate the interoperability of their products.

IHE integration profiles describe a clinical information need or workflow scenario and document how to use established standards to accomplish it. A group of systems that implement the same integration profile address the need/scenario in a mutually compatible way.For example, the Digital Imaging and Communications in Medicine (DICOM) standards specify many different formats for image data. A given set of images that might comply with some optional parts of the standards might still not be accepted by an application in use by a particular radiologist. Profiles reduce the chances of these incompatibilities. The Logical Observation Identifiers Names and Codes (LOINC) standard codes for use in databases are often used in IHE profiles. A model for cross-enterprise document sharing called XDS allows hospitals to share electronic records that use the Health Level 7 (HL7) standards and LOINC codes. The United States Department of Veterans Affairs revised its plans in 1999 to adopt IHE recommendations. IHE integration statements are prepared and published by a vendor to list the IHE profiles supported by a specific release of a specific product.IHE technical frameworks are detailed documents which specify the integration profiles and associated actors (systems) and transactions. For example, one specification is for a common way of binding identification numbers to patients.



IHE connectathons are annual events where equipment vendors bring products with IHE profiles and test them with other vendors. The term ‘connectathon’ was coined in the 1980s by Sun Microsystems for similar vendor-neutral interoperability testing of the Network File System protocols and related technologies. The events are held in Europe as well as the US. In 2008, an agreement was announced for cooperation with the Continua Health Alliance. In 2012, a guide was published on access to health data from mobile devices. Although in 2004 an estimate was that complete interoperability could be completed in ten years, by 2013 results were still mixed. In 2013, co-chairs were David Mendelson, director of clinical informatics at Mount Sinai Medical Centre and Elliot B. Sloane of the Centre for Healthcare Information Research and Policy and research professor at Drexel University.InterconsultationA consultation is communication between two medical professionals with different areas of expertise in which the applicant requires the review pathology of the patient to a consultant who gives its opinion on the case. Interconsultation usually occurs without the presence of the patient by any communication system. The medical seeks advice regarding a specific problem of a patient, either by complexity, severity, specialization. The ‘expert’ medical responds to the applicant issuing the judgment and recommendations on the care and treatment to be consulted about the problem. We distinguish the following types:

Conventional Interconsultations. These are made based on a preprinted form where the petitioner records data concerning the case and answerable to the interconsultation advice on treatment criteria or tests to be performed to the patient.

Interconsultation of pre-application assessment appointment. Some specialties have established a system of prior assessment of patients before requesting a quote from initial consultations. In these cases the MAP, forwards the assessment form and the specialist responds by making express reference to the desirability of quoting the patient in consultation and priority A&E appointment .

Interconsultation images. They are made by a computer system in which images or electronic records to conventional data is attached. Serve to support telemedicine systems.

We addressing the scope, differences can those in the hospital setting (inpatient, emergency room or served in queries) differentiated between levels: primary care and specialized care.Generally the consults are performed asynchronously between the applicant and the consultant, having a delay time previously agreed response. Maximum time is generally agreed in based on the priority of the case and the circumstances of the patient (admitted in emergencies, etc.)The process of consults, like any healthcare process, from the point of view of information systems, should be part of the EHR. All data recorded on a consultation, they have to be part of the patient's history and therefore must be stored in a structured repository of the HCE.The valuation (report) as part of the same care act should be part of the data warehouse EHR, and be available to professionals in both the specialized care setting as primary careInteroperability platformIn computing, cross-platform, or multi-platform, is an attribute conferred to computer software or computing methods and concepts that are implemented and inter-operate on



multiple computer platforms. The software and methods are also said to be platform independent. Cross-platform software may be divided into two types; one requires individual building or compilation for each platform that it supports, and the other one can be directly run on any platform without special preparation, e.g., software written in an interpreted language or pre-compiled portable bytecode for which the interpreters or run-time packages are common or standard components of all platforms. JAVAJava is a programming language expressly designed for use in the distributed environment of the Internet. It was designed to have the ‘look and feel’ of the C++ language, but it is simpler to use than C++ and enforces an object-oriented programming model. Java can be used to create complete applications that may run on a single computer or be distributed among servers and clients in a network. It can also be used to build a small application module or applet for use as part of a Web page. Applets make it possible for a Web page user to interact with the page.The major characteristics of Java are:

The programs you create are portable in a network. (See portability.) Your source program is compiled into what Java calls bytecode, which can be run anywhere in a network on a server or client that has a Java virtual machine. The Java virtual machine interprets the bytecode into code that will run on the real computer hardware. This means that individual computer platform differences such as instruction lengths can be recognized and accommodated locally just as the program is being executed. Platform-specific versions of your program are no longer needed.

The code is robust, here meaning that, unlike programs written in C++ and perhaps some other languages, the Java objects can contain no references to data external to themselves or other known objects. This ensures that an instruction cannot contain the address of data storage in another application or in the operating system itself, either of which would cause the program and perhaps the operating system itself to terminate or ‘crash.’ The Java virtual machine makes a number of checks on each object to ensure integrity.

Java is object-oriented, which means that, among other characteristics, an object can take advantage of being part of a class of objects and inherit code that is common to the class. Objects are thought of as ‘nouns’ that a user might relate to rather than the traditional procedural ‘verbs.’ A method can be thought of as one of the object's capabilities or behaviours.

In addition to being executed at the client rather than the server, a Java applet has other characteristics designed to make it run fast.

Relative to C++, Java is easier to learn. Java was introduced by Sun Microsystems in 1995 and instantly created a new sense of the interactive possibilities of the Web. Both of the major Web browsers include a Java virtual machine. Almost all major operating system developers (IBM, Microsoft, and others) have added Java compilers as part of their product offerings.The Java virtual machine includes an optional just-in-time compiler that dynamically compiles bytecode into executable code as an alternative to interpreting one bytecode instruction at a time. In many cases, the dynamic JIT compilation is faster than the virtual machine interpretation.JavaScript should not be confused with Java. JavaScript, which originated at Netscape, is interpreted at a higher level, is easier to learn than Java, but lacks some of the portability of Java and the speed of bytecode. Because Java applets will run on almost any operating system without requiring recompilation and because Java has no operating system-unique extensions or variations, Java is generally regarded as the most strategic language in which to develop applications for the Web. (However, JavaScript can be useful for very small applications that run on the Web client or server.)


http://searchcio-midmarket.techtarget.com/definition/method


Legacy SystemA legacy system, in the context of computing, refers to outdated computer systems, programming languages or application software that are used instead of available upgraded versions.LISA laboratory information system (LIS) is a class of software that receives, processes, and stores information generated by medical laboratory processes. These systems often must interface with instruments and other information systems such as hospital information systems (HIS). A LIS is a highly configurable application which is customized to facilitate a wide variety of laboratory workflow models. Deciding on an LIS vendor is a major undertaking for all labs. Vendor selection typically takes months of research and planning. Installation takes from a few months to a few years depending on the complexity of the organization. There are as many variations of LIS as there are types of lab work. Some vendors offer a full-service solution capable of handling a large hospital lab's needs; others specialize in specific modules. Disciplines of laboratory science supported by LIS include haematology, chemistry, immunology, blood bank (Donor and Transfusion Management), surgical pathology, anatomical pathology, flow cytometry and microbiology. This article covers clinical lab which encompasses haematology, chemistry and immunology.LIS can be used by doctors to track every part of a patient's visit to them. They can be used to manage patient check-ins, order and manage different tests, processing, order and result entries, patient demographics, etc. All of the information from a patient's visit will be stored in the database for future reference and will update with every future visit.



Medical DeviceA medical device is an instrument, apparatus, implant, in vitro reagent, or similar or related article that is used to diagnose, prevent, or treat disease or other conditions, and does not achieve its purposes through chemical action within or on the body (which would make it a drug). Whereas medicinal products (also called pharmaceuticals) achieve their principal action by pharmacological, metabolic or immunological means, medical devices act by other means like physical, mechanical, or thermal means.Medical devices vary greatly in complexity and application. Examples range from simple devices such as tongue depressors, medical thermometers, and disposable gloves to advanced devices such as computers which assist in the conduct of medical testing, implants, and prostheses. The design of medical devices constitutes a major segment of the field of biomedical engineering.Medical Health Record (MHR)MHR are a digital version of the paper charts in the clinician’s office. An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to:

Track data over time. Easily identify which patients are due for preventive screenings or checkups. Check how their patients are doing on certain parameters—such as blood pressure

readings or vaccinations. Monitor and improve overall quality of care within the practice.

But the information in EMRs does not travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record.MirthMirth Connect is a cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications over multiple transports available under the Mozilla Public License (MPL) 1.1 license. On September 9th, 2013 Mirth Corporation announced they were acquired by Quality Systems. Mirth Connect uses a channel-based architecture to connect HIT systems and allow messages to be filtered, transformed, and routed based on user-defined rules. Channels consist of connectors (both inbound and outbound), filters, and transformers. Multiple filters and a chain of transformers can be associated with a channel.Endpoints are used to configure connections and their protocol details. Source connectors are used to designate the type of listener to use for incoming messages, such as TCP/IP or a web service. Destination connectors are used to designate the destination of outgoing messages, such as an application server, a JMS queue, or a database. All messages and transactions are optionally logged to an internal database. Mirth Connect can be also configured to auto-generate an HL7 acknowledgement response (ACK).Mirth Connect supports sending and receiving healthcare messages over a variety of protocols:

TCP/MLLP. Database (MySQL, PostgreSQL, Oracle, Microsoft SQL Server, ODBC). File (local file system and network shares). PDF and RTF documents. JMS.



FTP/SFTP. HTTP. SMTP. SOAP (over HTTP).

An open architecture allows for the easy addition of custom and legacy interfaces.The Certification Commission for Healthcare Information Technology (CCHIT), in a push to ensure interoperability standards between electronic health records, has adopted Laika, an open source standards software program. At the 2009 Annual HIMSS Conference, Mirth was selected as one of the testing tools for the coming interoperability tests.PACSA PACS is a system of digital storage, transmission and download of radiological images. The PACS systems consist of software and hardware parts, which directly communicate with modalities and get pictures of them. The images are transferred to a workstation (workstation) for viewing and issuing radiological reports. The PACS viewer is a software that is installed on the workstation that uses the radiologist to receive and display radiological images. The images are then archived in the PACS server for later download to workstations.Architecture PACS: The basic components of a PACS system are:

Server Central PACS: It consists of the main system hardware. Work Station PACS: Allows radiologists visualization and analysis of digital images. Database System: Responsible for managing the store all the information and

pictures of PACS. DICOM Server: Responsible for all communication with DICOM imaging modalities

(such as CT or MRI), other PACS DICOM workstations and servers. Storage System: The hardware required to store DICOM images from PACS system. Interfaces to RIS / HIS: Consolidate all patient information from different sources,

allowing a flow of qualified labour. Web Server for Remote Access: Essential for teleradiology. Using the Web Access,

images and information stored in the PACS server can be accessed via a web browser such as Internet Explorer, Mozilla Firefox, Safari, etc.



Personal Health Record (PHR)The PHR is a tool that you can use to collect, track and share past and current information about your health or the health of someone in your care. Sometimes this information can save you the money and inconvenience of repeating routine medical tests. Even when routine procedures do need to be repeated, your PHR can give medical care providers more insight into your personal health story.Remember, you are ultimately responsible for making decisions about your health. A PHR can help you accomplish that.Important points to know about a Personal Health Record:

You should always have access to your complete health information. Information in your PHR should be accurate, reliable, and complete. You should have control over how your health information is accessed, used, and

disclosed. A PHR may be separate from and does not normally replace the legal medical

record of any provider.Medical records and your personal health record (PHR) are not the same thing. Medical records contain information about your health compiled and maintained by each of your healthcare providers. A PHR is information about your health compiled and maintained by you. The difference is in how you use your PHR to improve the quality of your healthcare.Take an active role in monitoring your health and healthcare by creating your own PHR. PHRs are an inevitable and critical step in the evolution of health information management (HIM). The book ‘The Personal Health Record’ assists new users of PHRs in getting started, addressing current PHR trends and processes.



PKI ArchitectureA public key infrastructure (PKI) is a set of hardware, software, people, policies, and procedures needed to create, manage, distribute, use, store, and revoke digital certificates. In cryptography, a PKI is an arrangement that binds public keys with respective user identities by means of a certificate authority (CA). The user identity must be unique within each CA domain. The third-party validation authority (VA) can provide this information on behalf of the CA. The binding is established through the registration and issuance process, which, depending on the assurance level of the binding, may be carried out by software at a CA or under human supervision. The PKI role that assures this binding is called the registration authority (RA), which ensures that the public key is bound to the individual to which it is assigned in a way that ensures non-repudiation.Public key cryptography is a cryptographic technique that enables users to securely communicate on an insecure public network, and reliably verify the identity of a user via digital signatures. A public key infrastructure (PKI) is a system for the creation, storage, and distribution of digital certificates which are used to verify that a particular public key belongs to a certain entity. The PKI creates digital certificates which map public keys to entities, securely stores these certificates in a central repository and revokes them if needed. A PKI consists of:

A certificate authority (CA) that both issues and verifies the digital certificates. A registration authority which verifies the identity of users requesting information

from the CA. A central directory—i.e., a secure location in which to store and index keys. A certificate management system. A certificate policy.



ProtocolIn information technology, a protocol is the special set of rules that end points in a telecommunication connection use when they communicate. Protocols specify interactions between the communicating entities. Protocols exist at several levels in a telecommunication connection. For example, there are protocols for the data interchange at the hardware device level and protocols for data interchange at the application program level. In the standard model known as Open Systems Interconnection (OSI), there are one or more protocols at each layer in the telecommunication exchange that both ends of the exchange must recognize and observe. Protocols are often described in an industry or international standard.The TCP/IP Internet protocols, a common example, consist of:

Transmission Control Protocol (TCP), which uses a set of rules to exchange messages with other Internet points at the information packet level.

Internet Protocol (IP), which uses a set of rules to send and receive messages at the Internet address level.

Additional protocols that include the Hypertext Transfer Protocol (HTTP) and File Transfer Protocol (FTP), each with defined sets of rules to use with corresponding programs elsewhere on the Internet.

There are many other Internet protocols, such as the Border Gateway Protocol (BGP) and the Dynamic Host Configuration Protocol (DHCP).

RISA radiology information system (RIS) is a networked software suite for managing medical imagery and associated data. An RIS is especially useful for managing radiological records and associated data in a multiple locations and is often used in conjunction with a picture archiving and communication system (PACS) to manage work flow and billing.An RIS has several basic functions:

Patient management: An RIS can track a patient’s entire workflow within the radiology department; images and reports can be added to and retrieved from electronic medical records (EMRs) and viewed by authorized radiology staff.

Scheduling: Appointments can be made for both in- and out-patients with specific radiology staff.

Patient tracking: A patient’s entire radiology history can be tracked from admission to discharge. The history can be coordinated with past, present and future appointments.

Results reporting: An RIS can generate statistical reports for a single patient, group of patients or particular procedure.

Film tracking: An RIS can track individual films and their associate data. Billing: An RIS facilitates detailed financial record-keeping, electronic payments and

automated claims submission.RPM SystemRPM Package Manager (RPM) (originally Red Hat Package Manager; now a recursive initialism) is a package management system. The name RPM variously refers to the .rpm file format, files in this format, software packaged in such files, and the package manager itself. RPM was intended primarily for Linux distributions; the file format is the baseline package format of the Linux Standard Base.Even though it was created for use in Red Hat Linux, RPM is now used in many GNU/Linux distributions. It has also been ported to some other operating systems, such as Novell NetWare (as of version 6.5 SP3) and IBM's AIX (as of version 4).



An RPM package can contain an arbitrary set of files. The larger part of RPM files encountered are ‘binary RPMs’ (or BRPMs) containing the compiled version of some software. RPM files however may also contain the source code, then called ‘source RPMs’ (or SRPMs) used to produce a package. SRPMs have an appropriate tag in the file header that distinguishes them from normal (B)RPMs, causing them to be extracted to /usr/src on installation. SRPMs also customarily carry the file extension ‘.src.rpm’ (.spm on file systems limited to 3 extension characters, i.e. old DOS FAT).Service BusAn enterprise service bus (ESB) is software architecture for middleware that provides fundamental services for more complex architectures. For example, an ESB incorporates the features required to implement a service-oriented architecture (SOA). In a general sense, an ESB can be thought of as a mechanism that manages access to applications and services (especially legacy versions) to present a single, simple, and consistent interface to end-users via Web- or forms-based client-side front ends.In essence, ESB does for distributed heterogeneous back end services and applications and distributed heterogeneous front-end users and information consumers what middleware is really supposed to do: hide complexity, simplify access, allow developers to use generic, canonical forms of query, access and interaction, handling the complex details in the background. The key to ESB's appeal, and possibly also its future success, lies in its ability to support incremental service and application integration as driven by business requirements, not as governed by available technology.One of the major vendors of ESB, IBM, promotes it as a way to meet the challenges of integrating applications and provide a single, unified architecture —- built around IBM WebSphere —- that can:

Distribute information across an enterprise quickly and easily. Mask differences among underlying platforms, software architectures, and network

protocols. Ensure information delivery even when some systems or networks may go off-line

from time to time. Re-route, log, and enrich information without requiring applications to be rewritten. Provide incremental solution implementations so all enterprise services and

applications need not change immediately or all at once.According to IBM, ‘ESB is not a new software product – it's a new way of looking at how to integrate applications, coordinate resources, and manipulate informationSmartphoneA smartphone combines cellular telephone, Internet access for e-mail and Web, music and movie player, camera and camcorder, GPS navigation system and a voice search for asking a question about anything (see personal assistant). A smartphone is much more personal than a personal computer, because it is with you all the time when traveling and nearby if you use it as your main phone.SMART TVA smart TV, sometimes referred to as connected TV or hybrid TV, (not to be confused with IPTV, Internet TV, or with Web TV) is a television set or set-top box with integrated Internet and Web 2.0 features, and is an example of technological convergence between computers and television sets and set-top boxes. Besides the traditional functions of television sets and set-top boxes provided through traditional broadcasting media, these devices can also provide online interactive media, Internet TV, over-the-top content, as well as on-demand streaming media, and home networking access. The software that runs smart TVs can be preloaded into the device, or updated or installed on demand via an app store or app marketplace, in a similar manner to how the



Internet, Web widgets, and software applications (in this context commonly just referred to as ‘apps’) are integrated in modern smartphones.SOA (Service Oriented Architecture)Service-oriented architecture (SOA) is a design pattern based on distinct pieces of software providing application functionality as services to other applications via a protocol. This is known as service-orientation. It is independent of any vendor, product or technology. A service is a self-contained unit of functionality, such as retrieving an online bank statement. Services can be combined by other software applications to provide the complete functionality of a large software application. SOA makes it easy for computers connected over a network to cooperate. Every computer can run an arbitrary number of services, and each service is built in a way that ensures that the service can exchange information with any other service in the network without human interaction and without the need to make changes to the underlying program itself.

SSSLSSL (pronounced as separate letters) is short for Secure Sockets Layer, a protocol developed by Netscape for transmitting private documents via the Internet. SSL uses a cryptographic system that uses two keys to encrypt data − a public key known to everyone and a private or secret key known only to the recipient of the message. Both Netscape Navigator and Internet Explorer support SSL, and many Web sites use the protocol to obtain confidential user information, such as credit card numbers. By convention, URLs that require an SSL connection start with https: instead of http:.Another protocol for transmitting data securely over the World Wide Web is Secure HTTP (S-HTTP). Whereas SSL creates a secure connection between a client and a server, over which any amount of data can be sent securely, S-HTTP is designed to transmit individual messages securely. SSL and S-HTTP, therefore, can be seen as complementary rather than competing technologies. Both protocols have been approved by the Internet Engineering Task Force (IETF) as a standard.



StandardA document, established by consensus and approved by a recognized body that provides for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of interoperability between information systems. Standards are necessary for interworking, portability, and reusability. They may be de facto standards for various communities, or officially recognised nationally or internationally.TelecareTelecare is the continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living.TelemonitoringIt is a medical practice that involves remotely monitoring patients who are not at the same location as the health care provider. In general, a patient will have a number of monitoring devices at home, and the results of these devices will be transmitted via telephone to the health care provider. Telemonitoring is a convenient way for patients to avoid travel and to perform some of the more basic work of healthcare for themselves.In addition to objective technological monitoring, most telemonitoring programs include subjective questioning regarding the patient's health and comfort. This questioning can take place automatically over the phone, or telemonitoring software can help keep the patient in touch with the health care provider. The provider can then make decisions about the patient's treatment based on a combination of subjective and objective information similar to what would be revealed during an on-site appointment.Some of the more common things that telemonitoring devices keep track of include blood pressure, heart rate, weight, blood glucose, and hemoglobin. Telemonitoring is capable of providing information about any vital signs, as long as the patient has the necessary monitoring equipment at his or her location. Depending on the severity of the patient's condition, the provider may check these statistics on a daily or weekly basis to determine the best course of treatment.Telemonitoring is common for patients with diabetes or hypertension. These patients can take advantage of regular vital sign monitoring and regular provider feedback without having to commute to the health care provider. Telemonitoring is particularly effective for people with diabetes and hypertension, because it is extremely important for the vital statistics of such patients to be consistently observed.There are a number of advantages of telemonitoring for both the patient and the health care provider. For the health care provider, telemonitoring is an efficient way to gather necessary patient information without a great time commitment. This efficient means of gathering information is also relevant to disease-based research, because a large amount of information can be gathered and recorded with little effort. Telemonitoring is useful to patients because they can receive health care provider feedback on their vital statistics much more often than they otherwise might. Also, because the patient is more involved in his or her own treatment, the patient will become more aware of his or her vital statistics and possibly gain a better sense of what affects these statistics and how the statistics in turn affect how he or she feels.Three-tier architectureA Three-tier architecture is a client-server architecture in which the functional process logic, data access, computer data storage and user interface are developed and maintained as independent modules on separate platforms. Three-tier architecture is a software design pattern and a well-established software architecture.



Three-tier architecture allows any one of the three tiers to be upgraded or replaced independently. The user interface is implemented on a desktop PC and uses a standard graphical user interface with different modules running on the application server. The relational database management system on the database server contains the computer data storage logic. The middle tiers are usually multi-tiered.The three tiers in a three-tier architecture are:

Presentation Tier: Occupies the top level and displays information related to services available on a website. This tier communicates with other tiers by sending results to the browser and other tiers in the network.

Application Tier: Also called the middle tier, logic tier, business logic or logic tier, this tier is pulled from the presentation tier. It controls application functionality by performing detailed processing.

Data Tier: Houses database servers where information is stored and retrieved. Data in this tier is kept independent of application servers or business logic.

A 3-tier application is an application program that is organized into three major parts, each of which is distributed to a different place or places in a network. The three parts are:

The workstation or presentation interface. The business logic. The database and programming related to managing it.

In a typical 3-tier application, the application user's workstation contains the programming that provides the graphical user interface (GUI) and application-specific entry forms or interactive windows. (Some data that is local or unique for the workstation user is also kept on the local hard disk.)Business logic is located on a local area network (LAN) server or other shared computer. The business logic acts as the server for client requests from workstations. In turn, it determines what data is needed (and where it is located) and acts as a client in relation to a third tier of programming that might be located on a mainframe computer.The third tier includes the database and a program to manage read and write access to it. While the organization of an application can be more complicated than this, the 3-tier view is a convenient way to think about the parts in a large-scale program.A 3-tier application uses the client/server computing model. With three tiers or parts, each part can be developed concurrently by different team of programmers coding in different languages from the other tier developers. Because the programming for a tier can be changed or relocated without affecting the other tiers, the 3-tier model makes it easier for an enterprise or software packager to continually evolve an application as new needs and opportunities arise. Existing applications or critical parts can be permanently or temporarily retained and encapsulated within the new tier of which it becomes a component.VPNA virtual private network, VPN, or VPN stands for Virtual Private Network, is a networking technology that allows a secure extension of the local network (LAN) over a public or uncontrolled network such as the Internet. Allows the computer on the network to send and receive data on shared or public networks like a private network with full functionality, security and management policies of a private network. This is done by establishing a virtual point-to- point by use of dedicated connections, encryption or a combination of both methods.Common examples are the ability to connect two or more branches of a company using as Internet connection, allowing team members support the connection from home to



data centre, or a user can access their home computer from a remote site such as a hotel, all using the Internet infrastructure.The VPN connection via Internet is technically a union wide area network (WAN) between the sites but the user does seem like a private- link from there the ‘virtual private network’ designation.WDSLWSDL is an XML format for describing network services as a set of endpoints operating on messages containing either document-oriented or procedure-oriented information. The operations and messages are described abstractly, and then bound to a concrete network protocol and message format to define an endpoint. Related concrete endpoints are combined into abstract endpoints (services). WSDL is extensible to allow description of endpoints and their messages regardless of what message formats or network protocols are used to communicate, however, the only bindings described in this document describe how to use WSDL in conjunction with SOAP 1.1, HTTP GET/POST, and MIME.Web applicationA Web application (Web app) is an application program that is stored on a remote server and delivered over the Internet through a browser interface.Web services are Web apps by definition and many, although not all, websites contain Web apps.Within the mobile computing sector, Web apps are sometimes contrasted with native apps, which are applications that are developed specifically for a particular platform or device and installed on that device. However, the two are not mutually exclusive because many applications contain elements of both native and Web apps. Programs that combine the two approaches are sometimes referred to as hybrid application.Web ServiceWeb services are client and server applications that communicate over the World Wide Web’s (WWW) HyperText Transfer Protocol (HTTP). As described by the World Wide Web Consortium (W3C), web services provide a standard means of interoperating between software applications running on a variety of platforms and frameworks. Web services are characterized by their great interoperability and extensibility, as well as their machine-processable descriptions, thanks to the use of XML. Web services can be combined in a loosely coupled way to achieve complex operations. Programs providing simple services can interact with each other to deliver sophisticated added-value services.

WSSLThe Secure Sockets Layer (SSL) is a computer networking protocol that manages server authentication, client authentication and encrypted communication between servers and clients.



SSL uses a combination of public-key and symmetric-key encryption to secure a connection between two machines, typically a Web or mail server and a client machine, communicating over the Internet or an internal network.Using the OSI reference model as context, SSL runs above the TCP/IP protocol, which is responsible for the transport and routing of data over a network, and below higher-level protocols such as HTTP and IMAP, encrypting the data of network connections in the application layer of the Internet Protocol suite. The ‘sockets’ part of the term refers to the sockets method of passing data back and forth between a client and a server program in a network, or between program layers in the same computer.The Transport Layer Security (TLS) protocol evolved from SSL and has largely superseded it, although the terms SSL or SSL/TLS are still commonly used; SSL is often used to refer to what is actually TLS. The combination of SSL/TLS is the most widely deployed security protocol used today and is found in applications such as Web browsers, email and basically any situation where data needs to be securely exchanged over a network, like file transfers, VPN connections, instant messaging and voice over IP.The SSL protocol includes two sub-protocols: the record protocol and the ‘handshake’ protocol. These protocols allow a client to authenticate a server and establish an encrypted SSL connection. In what's referred to as the ‘initial handshake process,’ a server that supports SSL presents its digital certificate to the client to authenticate the server's identity. Server certificates follow the X.509 certificate format that is defined by the Public-Key Cryptography Standards (PKCS). The authentication process uses public-key encryption to validate the digital certificate and confirm that a server is in fact the server it claims to be.Once the server has been authenticated, the client and server establish cipher settings and a shared key to encrypt the information they exchange during the remainder of the session. This provides data confidentiality and integrity. This whole process is invisible to the user. For example, if a webpage requires an SSL connection, the URL will change from HTTP to HTTPS and a padlock icon appears in the browser once the server has been authenticated.The handshake also allows the client to authenticate itself to the server. In this case, after server authentication is successfully completed, the client must present its certificate to the server to authenticate the client's identity before the encrypted SSL session can be established.



Appendix B: StandardsThe need for interoperable systems is evident in every part of health sector organizations as effective delivery of healthcare requires a constant exchange of information among health professionals, including service institutions, insurers and government, between medical staff and patients, between auxiliary imaging systems and laboratories, with electronic medical records systems and between public health systems, just to mention some interactions.Consequently, effective communication between these actors requires that a common framework that allows interaction and coordination of care sharing. Framework provided by the standards, which provide uniformity in the name of the components of the health system whether diagnoses, people, procedures, interventions and how it is transmitted, to ensure that data in one part of the system health are available and have meaning not only through the variety of clinical settings and public health but also administratively.In the figure below we have a map with the most common standards and protocols (grouped by areas); these standards can be considered as an infrastructure of every IT system which has interchanged data with other systems.

Figure 35: Standards v. interoperability levels

The importance of this schema is to visualize that the use of a single standard is not enough to achieve the different types of interoperability and it is necessary to look for additional standards and with different foci which together enable communication and utilization of information.Effective use of information through a set of information systems is not achieved only with the pact that the systems can communicate; this is not possible even if the same standard of communications used. This problem is inherent in the information itself as well as the way it is obtained, processed and stored.Therefore, for effective interpretation and processing of information it is necessary to apply standards that allow representation of the context of information. Below is a brief



description of the standards presented in the map in picture 17, which are organized by foci or areas of application, its aims and relations it performs.Communication infrastructure: In this area are the standards and protocols that enable physical and logical communication between computers and networks.Protocols that underlie the Internet are listed (Interoperability Toolkit (ITK) of the National Health System (NHS) in the UK).

Ethernet is a protocol link layer (layer 2 Open System Interconnection model or OSI) that allows two devices connected via a link (cable) data exchange higher layer protocols.

TCP / IP protocols are most used in the world. TCP is a transport protocol (layer 4 of the OSI model) that allows you to create logical connections over an IP network between two physically distant computers. IP is a network layer protocol (layer 3 of the OSI model). These protocols enabled the implementation of Internet.

B.1 Communication Protocols (general applications) Simple Mail Transfer Protocol (SMTP). It is based on plain text messages to send

emails protocol. Allowed the implementation of large-scale email. File Transfer Protocol (FTP). It is the protocol par excellence to transferring files

between computers connected over a TCP network (such as the Internet). It is designed to obtain maximum connection speed because the files represent large amounts of data.

Simple Mail Transfer Protocol (SMTP). It is based on plain text messages to email protocol. It allowed the implementation of large-scale email.

Hypertext Transfer Protocol (HTTP). This protocol allows the transfer of resources (files, text, images, videos, sounds, etc.) on the Internet. It is based on the request / response model where each request made by a client computer to a server, it sends a message in response which may include the requested resources.

Simple Objet Access Protocol (SOAP): A protocol that accepts objects in different systems to communicate with each other by exchanging XML messages over HTTP. It is one of the protocols that allow implementing web services.

B.2 Syntax standards Hypertext Markup Language (HTML) of World Wide Web Consortium (W3C):

Multimedia format documents on the Internet. It is based on labels that can be read by a human form. These labels are used to organize the content of the documents and give them a format. Attaches different types of multimedia content through references (URLs), and also link documents together. The last families of HTML and XHTML documents (HTML1-1991, HTML5-201X) are also XML documents.

Electronic Data Interchange (EDI) of American National standards Institute (ANSI 1979): It is the format for exchanging electronic documents between computer systems. It aims to represent electronic documentation replacing the paper.

JavaScript Object Notation (JSON) of internet Engineering Task Force (IETF): It is a very popular format on the Internet to represent structured objects. The main rationale for using JSON instead of XML is that to represent a single structure is much lighter (which is a necessity in networks with low bandwidth).

eXtensible Markup Language (XML) of World Wide Web Consortium (W3C): Extensible meta tags based on plaintext used to represent structured data. XML does not define a particular format, it is rather a way of defining formats (eg SOAP is based on XML). In turn, these individuals serve as syntax formats for the exchange of information between applications generally run on different computers.



Yet another Markup Language (YAML), For representing structured information that enables computer processing time and is friendly format for reading by humans.

B.3 Format Specification XML Schema, It is a language used to define XML structures and restrictions on the

data that will contain; also defines particular uses of XML format. Web Service Definition Language (WSDL) uses it to define formats of web services and items that are exchanged via SOAP.

B.4 Services Specification Web Service Definition Language (WSDL): The format eXtensible Markup Language

(XML) to describe Web services as a set of interfaces that operate on messages containing document-oriented or process information.

B.5 Process SpecificationBoth Guides clinical practice as clinical protocols are implementable way of computing processes using the standards for the specification process. Analogously, administrative and managerial processes can also be implemented with these standards. One feature of the processes in health are interdependent, so its informatics Formal definition allows better communication and management of the entire system, making visible processes and controlling their execution by quality parameters.

Business Process Execution Language (BPEL). A standard of the Organization for the Advancement of Structured Information Standards (OASIS) of a language that can be implemented and used to specify actions within the business processes of organizations through web services. Specify integrated processes between the services provided by different information systems.

Business Process Definition Metamodel (BPMD. It is a standard of the Object Management Group (OMG) with the ability to represent and model business processes, regardless of the notation or methodology. To achieve a metamodel, which is kind of vocabulary processes with well-defined connections between terms and concepts used? XML notation used to represent processes.

ebXML Business Process Specification Schema (ebBPSS). An OASIS standard that establishes a set of nominal elements and specifications necessary to establish a collaboration between business partners and provide configuration parameters for systems at runtime to achieve collaboration among a set of systems.

B.6 Communication Protocols (Health applications) HL7 v2: is a messaging standard based on the EDI format for the exchange of

messages between computerized information systems in health. The latest versions include messaging in XML format.

X12, is a US communication protocol for communication applied in different areas of government and industry, including health. These protocols use EDI and XML messaging and are based on the definition of sets formed by electronic messages with predefined formats transactions.

National Council for Prescription Drug Program (NCPDP), is an American standard that provides transactions involving prescription, dispensing and billing of drugs.

DICOM is an open standard managed by the National Electrical Manufacturers Association (NEMA) and created by industry, consumers and others stakeholders to allow the standardization of digital imaging records and communication between systems.



HL7 v3, is a messaging standard based on the HL7 Reference Model (Informative Reference Model or RIM) and XML format. HL7 v3 messages are divided into domains such as accounting and billing, healthcare, claims and reimbursement for clinical decision support, clinical document architecture, clinical genomics, clinical claims, laboratory orders and reports of public health, among others.

CEN/ISO 13606 is the standard CEN / ISO for communication of digital clinical documents between EHR systems or between them and centralized repositories of clinical information. The standard is divided into five parts: model reference exchange archetypes, vocabularies and terminology, safety and specification of interfaces.

B.7 Terminology and health nomenclatureThere are different types of health terminologies and nomenclatures. His organization, structure and granularity depends on your purpose. For example, the rankings have statistical purposes, while controlled vocabularies or thesauri seek to standardize the clinical record. In any case, the objective is the normalization, which enables interoperability (American Health Information Management Association, 2008; Merabti and others, 2009; Kranthammer, s / f; Powell and Willis, 2005).

Radiology Lexicon (RadLex) of the Radiology Society of North America (RSNA), Terminology for radiology that serves to organize and find images, radiological and clinical reports related records. It contains a lexicon to assist in natural language processing. It complements other terminologies as Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) and DICOM.

Unified Medical Language System (UMLS) Of the National Library of Medicine of United States. It is a medical terminology consists of three sources of knowledge: meta-thesaurus (database with a vocabulary), a semantic network (which categorizes and related terms vocabulary) and the SPECIALIST lexicon that contains information to assist the natural language processing. Includes data sources such as Medical Subject Headings (MeSH), Current Procedural Terminology (CPT) of the American Medical Association (AMA), International Classification of Diseases (ICD), Logical Observation Identifiers Names and Codes (LOINC) and SNOMED CT.

Medical Subject Headings (MeSH) of the National Library of Medicine (NLM) of United States. Terminology reduced with preferred by NLM cataloguing books and library materials and index items to include in databases related to health, such as MEDLINE terms.

International Classification of Disease (CIE) of World Health Organization (WHO). It is a statistical classification of clinical terms as diseases, signs, symptoms, findings, complaints, social circumstances and external causes of injury or disease. The version 9 Amendments Clinics (ICD 9 CM) contains a list of terms for diagnostic, surgical and therapeutic procedures. The version 10 with Modifications Clinics (ICD 10 CM) contains, in addition, codes that combine diagnosis and symptom codes needed to reduce expressing a given condition.

International Classification of Primary Care (CIAP2) of the World Organization of Family Doctors (WONCA). Sort and encoding processes as well as signs and symptoms, infections, tumours, injuries, congenital anomalies and other diagnoses, all classified by (digestive, ear, circulatory, etc.).

Current Procedural Terminology (CPT) of AMA, Classification with codes and descriptions for reporting medical services and procedures performed by physicians.

Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) of the International Health Terminology Standards Development Organization (IHTSDO). Terminology controlled clinical multi-language exhaustive and covers diseases, clinical findings, etiologies, procedures, living organisms and clinical information used to record results. The content is based on relationships between concepts,



their attributes and context information for expressing each concept to a fine granular level, enabling consistent record level between different health professionals.

Logical Observation Identifiers Names and Codes (LOINC) of the Regenstrief Institute. Facilitates the exchange and sharing of results of para-clinical studies, both for medical assistance and for the management or research results. Includes terms for laboratory, microbiology, toxicology, radiology, haemodynamics and other clinical observations.

B.8 Clinical documentation Continuity of Care Record (CCR), ASTM standard for the representation of

documents summarizing the healthcare Starring in order to ensure continuity of care while the patient is treated at various centres.

ISO 13606-1, Specifies a model of clinical information that structure documents for communication between systems with the ability to communicate extracts complete records residing in electronic medical record systems.

Data Elements for Emergency Department Systems (DEEDS), Standard of the National Centre for Injury Prevention and Control (NPC) for the standardized registration information in emergency departments, in order to reuse the information for other purposes such as public health and education.

Clinical Document Architecture (CDA), HL7 standard to represent any kind of clinical documentation through its reference model and then express them in XML format for communication.

B.9 Models of information HL7 RIM is a model reference information HL7 v3. Its aim is to provide a basis for

consistent definition of HL7 v3 messages for communication of clinical, administrative and accounting information.

OMG COAS (Clinical Observation Access Service), It is an OMG standard that specifies a detailed clinical observations useful for the definition of services and communication of information on these comments model, including diagnoses, vital signs, para-clinical studies, etc.

OpenEHR RM, is a reference model of open systems standard electronic medical history. openEHR defines a generic model based on a process of resolution of clinical problems that can model any type of medical attention completely with its context and semantics.

B.10 Architecture of communication Integrating the Healthcare Enterprise (IHE), It is an initiative by healthcare

professionals and industry in order to improve computer systems in healthcare share information. IHE defines a set of technicians to implement communication between systems in diverse areas such as laboratory, radiology, cardiology and coordination of patient care among other profiles.

National Health System Interoperability Toolkit (ITK), This toolkit aims to connect existing systems rather than replacing them. This consists of a set of standards and interoperability frameworks covering transactional and analytical services to accelerate the provision of health services.



B.11 Knowledge models Archetypes allow you to specify structures about a generic model information.

These specifications can be shared, translated and integrated with international terminologies and coding systems for interagency agreements specify semantics, structure and content of information to be exchanged. The openEHR and ISO 13606 standards archetypes used as a mechanism to specify and share clinical concepts between institutions. openEHR proposes Agent Definition Language (ADL) such as computer-readable format for the definition of archetypes.

The ontologies are ways of organizing the elements of reality comprehensible and accurate manner, generating a semantic base capable of being processed by computers. By defining ontologies for basics that make health systems, such as people, users, professionals, institutions, services and facilities, it is possible to construct a semantic basis consistent for the entire health system from which to generate information and services capable of Global business semantics and interoperability. The standard Web Ontology Language (OWL) of the World Wide Web Consortium (W3C) allows the expression of ontologies in computer runnable format. The ontologies defined in OWL, in combination with inference tools are able to derive logical reasoning to find new rules and information based on them and current information.

Resource Definition Framework (RDF) is a simple model for the representation of metadata. The purpose of RDF is to add semantic processing capacity to identify and define allowing web properties on the resources of this (documents, images, videos, etc.). By treating the clinical documentation as a resource, the application of RDF for semantic processing of information in the area of health is promising. Some of their specific applications refer to the integration of metadata (different vocabularies / schemes), greater accuracy in the search of information (ability to categorize and organize resources) and establishing a basis for reasoning (induction) of new information, among others.


cordis.europa.eucordis.europa.eu/docs/projects/cnect/3/620983/080/... · web viewusing a solution...

Documents