DISTRIBUTED ARCHITECTURE FOR ELECTRONIC HEALTH REFERRAL SYSTEM UTILIZING COMPUTATIONAL INTELLIGENCE FOR CLINICAL DECISION SUPPORT

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5 DISTRIBUTED ARCHITECTURE FOR ELECTRONIC HEALTH REFERRAL SYSTEM UTILIZING COMPUTATIONAL INTELLIGENCE FOR CLINICAL DECISION SUPPORT By Majd Misbah Al-Zghoul Supervisor Dr. Majid Al-Taee, Prof. This Thesis was Submitted in Partial Fulfillment of the Requirements for the Master s Degree of Science in Computer Engineering and Networks Faculty of Graduate Studies The University of Jordan Aug, 2012

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7 iii Dedication I dedicate this work to my father who is always pushing me to achieve the best; also I dedicate this work to my Grandparents, my special Mother and fiancé.

8 iv Acknowledgement It gives me great pleasure in acknowledging the support and help of my supervisor Professor Majid Al-Taee. I consider it an honor to be supervised by him, he always have the vision and was always helpful and pushing towards doing the best in this work. Also I would like to acknowledge and thank the Jordanian University Hospital staff for their help and support in completing this work, especially Computer Bureau and Medical Records departments. A special thanks for Mr.Ibraheem Alshogran, Mr.Adi Batayneh, Eng.Musab Alqudah, Mr. Emad Raja, Dr.Ali ALqurneh and Mr. Rami Ali as they provided the required data and feedback for this work. Finally I would like to thank and acknowledge the Jordanian University Computer department members and staff for their cooperation and help.

9 v Table of Contents Dedication...iii Acknowledgement... iv Table of Contents... v List of Acronyms and Abbreviations... vii Abstract...viii Chapter 1 Introduction Background Problem statement Research objectives Thesis organization... 7 Chapter 2 Literature Review on Distributed EHR Systems Introduction EHR architectures Data standardization Security, privacy and responsibilities Development methodologies Decision support in EHR context Development platforms of EHR systems Overview of the proposed EHR system Chapter 3 Development Methodology and System Requirements Introduction Data gathering methods Rapid prototyping and COMET System requirements Chapter 4 System Architecture and Design Models Introduction System architecture Static design models... 47

10 vi 4.4 Dynamic design modules Decision support modules Database schema Chapter 5 System Implementation and Test Introduction Overview of development environment Presentation tier Business logic implementation Data tier implementation Security and privacy System deployment and test scenarios Conclusions and Future Work Conclusions Future work References Appendices A1. Functional Requirements Use Case Models A2. Activity Diagrams A3. Class Diagrams A4. Sequence Diagrams Abstract in Arabic

11 vii List of Acronyms and Abbreviations ADEs Adverse Drug Events. ADR Adverse Drug Reactions. AJAX Asynchronous JavaScript And XML. ASP Active Server Page. CLR Common Language Runtime. CDS Clinical Decision Support. CDSS Clinical Decision Support System. CDA Clinical Document Architecture. DICOM Digital Imaging and Communications in Medicine. EGADSS Electronic Guideline and Decision Support System. EHR Electronic Health Record. EMR Electronic Medical Record. HL7 Health Level 7. ICD International Classification for Diseases. IIS Internet Information Services. IPD In Patient Department. J2EE Java Enterprise Edition. JUH Jordan University Hospital. OPD Out Patient Department. PHP Hypertext Preprocessor. PHRs Personal health records. PSO Patient Summary Ontology. SNOMED CT Systematized Nomenclature of Medicine-Clinical Terms. UML Unified Modeling Language. VS2010 Visual Studio 2010.

12 viii DISTRIBUTED ARCHITECTURE FOR ELECTRONIC HEALTH REFERRAL SYSTEM UTILIZING COMPUTATIONAL INTELLIGENCE FOR DECISION SUPPORT By Majd M. K. AlZghoul Supervisor Majid Al-Taee Abstract Electronic Health Record (EHR) systems have been a key enhancement objective in the Jordanian health sector over the past several years. This is reflected by the emergence of several projects, of these, HAKEEM project is the most outstanding. Employing different vendors and standards causes interoperability and compatibility issues. Thus, medical records sharing and exchange requires performing complex integration and standardization processes for the implemented solutions. The decision making in Jordanian health sector relied on knowledge and experience of physicians. This work proposed a national EHR system architecture that resolves interoperability and compatibility issues. The proposed architecture enables medical records sharing and exchange between different healthcare providers through a centralized EHR database. A contextual approach for medical and personal data separation in the database is proposed to enable the data usage by decision makers and researchers, without affecting privacy. Adoption of general CDS components in the EHR system was proposed to enrich the current decision making process. The work proposed adding CDS components like medical summaries and medication prescription. These components are used by most of healthcare providers, and can help physicians to make informed decisions. Developing a distributed EHR system based on a centralized national database is suggested to resolve the standing interoperability problem between the existing local EHR systems. The proposed system avoids complexities and costs of integrating existing local EHR system, and offers improved interoperability, scalability, security and modularity. Availability and portability are of main importance for EHR system usage as they simplify the system access for different healthcare providers, thus encourage complete documentation of healthcare services given to patients. The integration of common CDS modules in EHR system benefits healthcare professionals, as it provides them with summary of the most important medical history information, and possible drugdrug interactions, in addition to past medication usage feedback.

13 1 Chapter 1 Introduction 1.1 Background Traditional medical records consists of file folder, that contains papers documenting the patient health state and care provided (Roukema et al, 2006). Medical records mainly support patients care delivery, serve as a legal report of medical actions and help in healthcare management (Van Bemmel, 1997). The accumulated medical records form a valuable data store for researchers (Stakic and Teodosijevic, 2010). Medical records can be used to find trends and relations between symptoms, diagnosis and medications or other chosen factor (Van Bemmel, 1997). Electronic Health Records (EHR) appeared to replace traditional paper based medical records systems as the later suffered many weaknesses that can be summarized as follow (Roukema et al, 2005) (Steinfeld and Keyes, 2011). Limited availability of paper based medical records is among the most important weakness points. Physicians can often find the manual records unavailable or incomplete. This results difficulties in care coordination, increases the possibility of medical errors and may lead to duplicate lab tests and images orders. In emergency cases medical record unavailability increases the possibility of medical errors as the patient is unaware to be asked about anything such as allergies he may have. Physicians bad handwriting which is often eligible or unclear limits the medical records readability and usability. The medical records file folders become bulky with time, requiring larger stores and secondary storage areas for inactive file folders.

14 2 Inefficiency in terms of infrastructure. The cost of using and maintaining manual referral systems is very high. Traditional referral systems occupy large stores and needs well-conditioning. Also the store should be capable of fighting fire and inaccessible by unauthorized people. The traditional system requires large number of employees (depends on the healthcare provider size) to manage, store and retrieve medical records, and to file medical documents to corresponding file folder. Traditional systems have high cost in terms of time. As the time needed to transfer a medical record from the store to a certain department remains high. The data in medical records is valuable for researchers but the traditional form of these records limits their research usage compared to mining an electronic database for the same information. EHR impacts healthcare delivery by reducing medical errors, improving healthcare efficiency, cutting cost and improving health outcomes (Steinfeld and Keyes, 2011). In contrast to paper based health record systems EHR offers several benefits (Poissant et al, 2005) (Thakkar and Davis, 2006) (MacKinnon & Wasserman, 2009) (Hillestad et al, 2005): Availability and easy accessibility. EHR is accessible and available to healthcare provider anytime. Compared to traditional file folders being locked in a certain hospital store or in a physician's office. Enables sharing medical records between healthcare professionals and between healthcare providers. Reduces unnecessary tests and treatment by listing existing lab tests and medical images orders and results.

15 3 Reduces the probability of medical errors, because it contains cautionary information such as the patient's allergies. Increases quality of care provided to patients through providing precise knowledge about patients and increasing physician patient interaction time. Properly implemented EHR system is expected to reduce cost of healthcare service. For example, in USA if 90 percent of hospitals and physicians adopted nationwide electronic medical records, the estimated annual cost savings is more than US$81 billion dollars, coming from improved efficiency and reduced medication errors and side effects. The ranking of EHR deployment expected benefits is shown in Table 1 ( Thakkar and Davis, 2006). Table 1. Benefits of using an EHR system (Thakkar and Davis, 2006). Benefit Rank Interoperability (exchanging patient information electronically) with other departments within the facility 7.33 Quality of care 6.84 Clinical workflow 6.25 Medical staff's work efficiency and time management 5.76 Patient safety 5.66 Interoperability outside the facility, but still within the entire healthcare system 5.35 Patient privacy and confidentiality 4.87 Business processes (strategic and operations) 4.72 Patient-physician relationship 4.38 Cost of care 3.95 Majority of healthcare providers in Jordan use traditional paper based medical records. And often keep lab tests, medical images and clinical documents in separate stores. This

16 127 Doctor get list of patients patients list Patient selection Patient:Patient find admitted patients patients list select patient initialize patient object order past operations and procedures history retrieve past opeartions and procedures history order Operation/Procedure Operations and procedures orders find past operation or procedures history retrieve the past operations and procedures history store procedure /operation order successful order view past operations notes Operation Notes find past operations notes retrieve past operations notes order add operation notes retrieve the full notes of operations store Operation notes Order patient O.P.D history successful O.P.D History order O.P.D past h retrieve full O.P.D history retrieve O.P.D past h Figure 62. IPD physciansequence diagram

17 128 Nurse get list of patients patients list Patient selection Patient:Patient find admitted patients patients list select patient initialize patient object view outstanding and past doctor orders View and perform Doctor orders find list of orders and thier status list of past and outstanding doctor orders sign performing an order retrieved the list of doctor orders for the patient and t update order status successful find past observation profile Observation Profile find past observation profile shee list of observation profiles save new observation profile sheet retrieve past observation profile store observation profile sheet find past intake output balance sheet successful intake output balance find past intake out retrieved intake output balance sheets save new intake output balance sheet retrieve past intake o store intake output b successful Figure 63. IPD nurse sequence diagram

18 129 Nurse get list of patients Patient selection Patient:Patient find admitted patients patients list patients list select patient initialize patient object Daily Assessment View past daily assessment sheets past daily assessment sheets Update discharge plan order retrieve of past daily assessment sheets retrieved past daily assessment sheets store assessment sheet successful find past Discharge plan Discharge plan find last entered discharge plan view past discharge plan Update discharge plan retrieve last saved discharge plan store updated discharge plan successful Figure 64. IPD nurse sequence diagram.