Evolving large scale healthcare applications using open standards

Highlights

• Development of standard based clinical application.

• Dynamic adaptation of developed clinical application for any regional language without any prior knowledge of the clinical data being processed.

• Creation of new / modification of existing archetype for developing countries such as India.

• A generic persistence capable to acquire any new information without any schema changes.

• Support for internationalization and localization.

Abstract

Electronic Health Records (EHRs) are becoming more prevalent in health care. Worldwide exchange of healthcare data demands adherence to semantic interoperable standards to overcome the language and platform barriers. Various healthcare organizations in developing countries such as, India adopt their own independent information systems without adhering to standard guidelines. Thus, this tends to sacrifice interoperability. This affects permanent persistence of longitudinal health records for future reference and research purpose. Current research implements a standard based clinical application to be used for healthcare domain in India. The study has been done for enhancing the data quality through standardization. It aims at providing a generic permanent persistence to track life-long interoperable health records of patients. This is the first effort for exploring its adoption for various regional languages in India. The user interfaces have been generated for various Indian languages for testing on a sample set of archetypes. The clinical application deployed in ‘Hindi’ language can be easily deployed for other people in ‘Tamil’ language, while maintaining semantic interoperability. The persistence will also be maintained, with the same meaning (of data) for both the regions. Implementing these standard based healthcare applications helps in reducing the costs while enhancing patient care. Thus, this study aims to build a standard based, and platform independent healthcare application to provide support for interoperability, usability and generic persistence.

Introduction

Healthcare applications provide a medium for storing and retrieving the information of one or more patients. An application includes items such as, information about blood tests, retrieving billing details, and analysing records of patients suffering from a specified disease. Current health record systems are maintained as Electronic Medical Records (EMRs). These are diverse and heterogeneous. An EMR's applicability is restricted to local clinics. According to National Alliance for Health IT, Electronic Health Record (EHR) data “can be created, managed and consulted by authorized clinicians and staff across more than one healthcare organization.” [1].

In the healthcare domain, there is a major evolution to bring all the systems to some standardized format. Various organizations are replacing the manual record keeping systems with a standardized computer based system which gives better access to data, thus enhancing effective care, interoperability, and usability. ‘Semantic interoperability’ is the goal when it comes to EHRs and the perceived means by which medical informatics can improve today's shared healthcare environment [42]. Standards development organizations, open source communities, research groups, and early implementers in different countries (usually funded by their governments) are putting considerable effort to make this vision a reality. Current research focus on three major issues related to EHRs, i.e., interoperability, usability and knowledge evolution.

Medical domain constitutes thousands of clinical concepts containing ambiguous terms. This ambiguity results in different interpretations to different medical persons involved. Interoperability aids in resolving ambiguity by providing a common picture of data. Moreover, interoperability reduces the cost of care. If a patient admitted in one hospital needs to be referred to some other hospital, all records related to that patient has to be transferred to the other hospital. The records may or may not be as per the semantics understood by other hospital. Interoperability resolves such issues efficiently. To achieve semantic interoperability, adoption of a standard is required. Exchange of data among healthcare organizations (i.e. semantic interoperability) is trivial, until they all commit to follow a common standard with capability of unambiguously translating the dataset in desired regional language.

Database of EHRs is an ocean of information. Usability of large size database is dependent upon its interface. The semantics of data can be well understood through a User Interface (UI) [3]. If a medical expert is unable to convey to the EHR system about his requirements from database, then even the richest data store fails to provide any value. A Graphical User Interface (GUI) requires filling a simple form with desired parameters. Efficient UI helps medical experts to access data in a reasonable time hiding technicalities of EHRs. Further, UI should provide multi-language abilities.

In different countries, different religions and languages coexist. Due to the language barrier, healthcare workers in developing countries, such as India are not able to take full advantage of technology in rural and urban areas. Considering the medical terms, the problem is tightly coupled with local areas and culture. Thus, user interface capable of supporting multiple languages and switching functionality from one language to another is highly demanded for worldwide adaptability of an application. Hence, one of the major aspects to achieve high usability is the requirement of crossing language boundaries. The interfaces which are in practice, mostly support English language. For large scale healthcare applications, there is a need to develop UI in regional language of developing countries, like India. Authors agree on the fact that the problem of standardization is much deeper than multi-language support alone, but every effort done for standardization has no worth until it can be used by any person anywhere irrespective of communicating language.

As technology is growing exponentially, evolution of knowledge is frequent in healthcare domain. As new concept arises, the knowledge evolved needs to be incorporated in database and application built on that database. Extending relational model with the newly evolved knowledge (in terms of attribute/columns) incurs computation cost and demands changes in application as well. Moreover, RDBMS restricts the number of columns that a relational table can accommodate. Thus, there is requirement of generic storage which can add any number of attributes to handle knowledge evolution without making changes in existing schema and application.

Primary aim of current research is to develop a healthcare application using open standards which will handle the issues of interoperability, usability and knowledge evolution.

Lack of interoperability limits the utility of healthcare application. Exchange of information should be unambiguous to avoid any hazards to patient. Dual model approach proposed by openEHR standard is adopted to have a maximal definition of any concept with linkage to standard terminologies, such as SNOMED-CT [13] and LOINC [14]. Key contributions of current research for achieving interoperability are: Creation of new / modification of existing archetypes for developing countries such as, India.

• Support for internationalization and localization.

• Achieving semantic interoperability as a supplement of adopting standard (openEHR).

The success of any application is dependent upon the ease of use provided by it. A major factor to the utility of an application is the language support provided by it. Thus, this research aims to provide an application with multi-lingual support through following:

• Developing standard based clinical application adaptable for any regional language without any prior knowledge of the clinical data being processed, such as vital signs, diagnoses or orders.

• An Application Programming Interface (API) independent of operating system and browser used.

• Database is augmented to provide storage of data in any language.

Frequently evolving knowledge needs to be handled at two levels, i.e., application level and database level. Application should be scalable in terms of capturing any new concept without rebuilding existing implementation code. Also, evolution of knowledge in database should be transparent to application layer. Thus, this research aims to provide knowledge evolution at both levels (application and database) by providing following.

• A generic persistence capable to acquire any new information without any schema changes.

• An application that supports dynamic generation of form as new medical concept is introduced.

The rest of the paper is organized as follows. Section 2 explores state-of-the-art. Section 3 presents the developing process of proposed standard based healthcare application. Case study of various openEHR based projects in India and rationale of current research is detailed in Section 4. Section 5 highlights related work. Finally, Section 6 provides summary and conclusions.