dutch nationwide electronic health record why the centralised services architecture? ir. karel de...

Dutch nationwideElectronic Health Record

why the centralised services architecture?

Ir. Karel de Smet, principal IT architect WICSA 2011, June 23th Boulder CO, USA

© Logica 2010. All rights reserved

Many, small sized, independent healthcare providers

Each provider has to maintain a health record for each patient

Healthcare providers in the Netherlands

GP practice

generalpractitioner

assistent

4500

pharmacy

pharmacist

assistent

2500

hospital

medicalspecialist

assistant

150

otherhealthcare provider

healthcareprofessional

assistant

10 000

patient / client


GpIS = GP Information System

PhIS = Pharmacy Information System

HIS = Hospital Information System

LIS = Laboratory Information System

Each xIS contains a local EHR (electronic health record), which

cannot be queried across discipinary and organisational boundaries

Healthcare Information Systems

otherhealthcare providerhospitalpharmacy GP practice

PhIS xISLIShealthcareprofessional

assistant

pharmacist

assistent

GpISgeneralpractitioner

assistent

HISmedicalspecialist

assistant


Enable queries across boundaries,

with minimum impact for

healthcare providers

and their XIS-suppliers

Nationwide EHR


PhIS xISLISGpIS HIS

Nictiz

NSPNSP

HIBHealth

InformationBroker

VPNVPN


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Registering health records


PhIS xISLISGpIS HIS

Nictiz

NSPNSP

HIB

VPNVPN

RECrecord locator

PhISGpIS HIS


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Querying patient data


PhIS xISLISGpIS HIS

Nictiz

NSPNSP

HIB

VPNVPN

REC query access pointPhIS

GpIS

HIS

Q

QQQQRY


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Collecting patient data


PhIS xISLISGpIS HIS

Nictiz

NSPNSP

HIB

VPNVPN


GpIS

HIS

QRY

A2 A3A1


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Returning patient data


PhIS xISLISGpIS HIS

Nictiz

NSPNSP

HIB

VPNVPN


GpIS

HIS

QRYA2A3

A1


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Protecting patient data


PhIS xISLISGpIS HIS

Nictiz

NSPNSP

HIB

VPNVPN

PKI PKI PKI PKI PKI PKI PKI PKI

PKI smartcards

AUT LOGI&A

identification & authentication

authorisation protocol

patient consentaccess log

REC QRY


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant

HIS

GP

GpIS PhIS HIB xIS

Pharmacist

Specialist

other

register record

register record

register record

query patient data

query patient data

return patient data

return patient data

update record locator

update log



consult record locator

authorise query


Why the centralised services?

• Current centralised services architecture:• alle messages pass through HIB • more message-oriented• HIB allows for man-in-the-middle• HIB easily becomes monolytic• HIB may become bottle-neck

• Why not a distributed services architectuur?• all messages exchanged directly between endpoints • more service oriented (?)• separate record locator service• separate authorisation service• separate logging service


Registering health record


PhIS xISLISGpIS HIS

NSPNSP

RECservice

VPNVPN

PhISGpIS HIS

AUTservice

LOGservice


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Requesting authorisation ticket


PhIS xISLISGpIS HIS

NSPNSP VPNVPN

RECservice

PhIS

GpIS

HIST

R

LOGservice


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant

AUTservice


Finding records with relevant patient data


PhIS xISLISGpIS HIS

NSPNSP VPNVPN

PhISGpIS

HIS

RECservice

PhIS

GpIS

HIS

QT

AUTservice

LOGservice


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Querying patient data


PhIS xISLISGpIS HIS

NSPNSP VPNVPN

RECservice

PhIS

GpIS

HIS

QBQBQT

AUTservice

LOGservice


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Collecting patient data


PhIS xISLISGpIS HIS

NSPNSP VPNVPN

RECservice

PhIS

GpIS

HIS

A3A2A1

AUTservice

LOGservice


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Logging the access to patient data


PhIS xISLISGpIS HIS

NSPNSP VPNVPN

RECservice

PhIS

GpIS

HIS

LOGservice

L3L2L1

AUTservice


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant


Security


PhIS xISLISGpIS HIS

NSPNSP

RECservice

VPNVPN

AUTservice

LOGservice

PKI PKI PKI PKI PKI PKI PKI PKI

I&A

Identification & Authentication

I&AI&A

I&A I&A I&A I&A I&A


assistant

pharmacist

assistent

generalpractitioner

assistent

medicalspecialist

assistant

HIS

GP

GpIS PhIS Rec xIS

Pharmacist

Specialist

other

register record

register record

register record

return record locations

Aut Log

get record locations

issue ticket

request ticket

query patient data

log acces

return patient data


Which is better?

CapacityScalabilityFlexibilityReusability

SimplicitySecurityModifiability

ComplianceService levelScope control

Distributed:

+ no bottle-neck+ services separately scalable+ XIS may optimize pattern+ easier

– XIS has N points of access– Security more complex– no bridging

– risk for cartel formation– hard to monitor+ primitive services

Centralised:

– bottle-neck for bulk– HIB scalable as a whole– fixed query pattern– requires HIB modification

+ XIS has 1 point of access+ Security simpler+ may bridge incomp versions

+ control over community+ easily monitored– compound query service

easily extended


Conclusion

Centralised services architecture, with HIB:• good to start with• less complexity voor XIS’es

Distributed services architecture, separate services:• more room for innovation• more difficult to manage service levels and version compatibility

However, politics quit funding the Nationwide EHR:• computer illiterates perceive HIB as a big privacy threat • cost cuttings sought because of financial crises • Nictiz has to find another funder

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Questions?

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dutch nationwide electronic health record why the centralised services architecture? ir. karel de...

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