Enhancing the many-to-many relations across IHE Document Sharing Communities

Transcription

1 Enhancing the many-to-many relations across IHE Document Sharing Communities Luís S. Ribeiro, Carlos Costa and José Luís Oliveira Universidade de Aveiro IEETA, Aveiro, Portugal Abstract. The Integrating Healthcare Enterprise (IHE) initiative is an ongoing project aiming to enable true inter-site interoperability in the health IT field. IHE is a work in progress and many challenges need to be overcome before the healthcare Institutions may share patient clinical records transparently and effortless. Configuring, deploying and testing an IHE document sharing community requires a significant effort to plan and maintain the supporting IT infrastructure. With the new paradigm of cloud computing is now possible to launch software devices on demand and paying accordantly to the usage. This paper presents a framework designed with purpose of expediting the creation of IHE document sharing communities. It provides semi-ready templates of sharing communities that will be customized according the community needs. The framework is a meeting point of the healthcare institutions, creating a favourable environment that might converge in new inter-institutional professional relationships and eventually the creation of new Affinity Domains. Keywords. IHE, XCA, XDS, ATNA, cloud computing, patient centric document sharing Introduction Document sharing communities also known as affinity domains allow the exchange of patient health information across several organizations, providing the clinicians with more information about the patient s health, aiding the delivery of well informed diagnosis, and ultimately improving the healthcare service itself [1]. However, the implementation of such communities faces many barriers, such as inter-site interoperability, heterogeneity of information, legal and ethical issues, initial economical investment and maintenance of the IT infrastructure, turning the deployment of such solutions in a difficult and longstanding process[2]. Since 1998, IHE has been developing integration profiles that address the lack of interoperability among the computer systems serving the healthcare institutions. IHE aims to achieve true inter-site interoperability defining the standards to be used at each step of the joint care workflow. Through integration profiles[3], IHE defines the guidelines to enable interoperability inside the affinity domains in several dimensions: Cross-Enterprise Document Sharing (XDS): it enables centralized discovery, publishment and retrieval of documents from distributed document repositories through well defined transactions. XDS is the major building block of a document sharing community. It aggregates several stakeholders in the same

2 integrated sharing domain, implicitly obligating the participants to normalize, among others, access and privacy policies, patient identifiers, document formats, and share the same IT infrastructure. Cross Community Access (XCA): it allows the access to documents by authorized entities that do not belong to the affinity domain. Furthermore, it is the encouraged method to communicate between federations of XDS affinity domains. Patient Identity Cross-Reference (PIX): XDS affinity domains require a patient identifier domain, where the patient identifiers are global and unique within the community. PIX supplies the means to map the local identifiers of the organizations with the global identifier of the affinity domain. Audit Trail and Node Authentication (ATNA): it controls the access to patient s documents. All the interactions and attempts are recorded for audit purposes, establishing security measures that provide patient information confidentiality, data integrity and user accountability. For instance, it enables user audit when break-the-glass is triggered. Basic Patient Privacy Consent (BPPC): it adds the possibility of defining privacy policies within the affinity domain and records the patient consent to such policies. All these integration profiles provide the building blocks to create interoperable document sharing communities. However, the healthcare environment is highly heterogeneous and complex, therefore the integration profiles tend to be flexible and extensible. On the one hand, this covers more domains of the healthcare workflow and allows freedom for implementations to add an extra value to their solutions. On the other hand, it turns the orchestration and configuration of the several integration profiles more complex, hampering itself the instantiation of new document sharing domains. To overcome this difficult balance, we designed a framework that allows the instantiation of affinity domains. The framework offers several templates of affinity domains, where the community administrator(s) may choose from as a starting point to build the new affinity domain. After the launching step, all the IHE actors composing the community may be tuned according to the specific needs of the community. Our framework allows the administrator to launch, configure, test and manage the access to the community through a web browser. Therefore, the platform is a meeting point of the healthcare institutions and professionals that want to interact with the affinity domain(s). This paper describes how we modelled our framework to expedite the creation of new affinity domains and to enhance the many-to-many relations between the practitioners. Despite our solution is heavily based on cloud infrastructure, the challenges of deploying document sharing communities (e.g. patient privacy, legal issues) over the cloud is out of the purpose of this paper. The discussion surrounding these issues may be accessed in [4-5]. Nevertheless, the final deliverable of our framework is(are) the virtual machine(s) of the ready to use affinity domain, that are capable of running on IaaS cloud, private cloud or local machines with OS virtualization layer (e.g. VMware).

3 1. Methods Our framework relies on a set of core web routines, accessed through a web browser, that interact with the Amazon EC2 web service API. One snapshot of a pre-configured operating system embedding a web server container (Tomcat) and the IHE actors with provider role (e.g. XDS document registry, repository, ATNA audit repository) is used to create virtual machines within the chosen IaaS cloud. Figure 1 illustrates the concept. When a user triggers the launching of a new affinity domain, the system through the cloud s API clones the snapshot and initializes the virtual machine keeping the original snapshot unchanged. After this the user may configure the IHE actors, manage admissions (add/remove participants of the community), manage certificates, define privacy policies (BPPC based), check the audit logs, among others. After the configurations, the affinity domain actors and transactions may be tested and retested till they reach the administrator s requirements. Finally, the newly created snapshot of the affinity s virtual machine may be downloaded and launched on the user s own IaaS cloud account or within a private cloud. Web-browser Framework of Services Cloud s data storage (1) - Launch Affinity Domain (2) - Init Affinity Domain Template Virtual Machine On the cloud Affinity Domain Administrator Cloud s Web Service API (3) - Deploy, Configure, Test (4) - Download ready to use Figure 1. Simplified workflow of an affinity domain administrator deploying, configuring and testing a new document sharing community on the cloud Enhancing the many-to-many relations Any healthcare institution or professional may create an account in our framework even if does not belong yet to any affinity domain. By doing so, our platform acts as a meeting point of healthcare institutions. The system was modeled to reduce the initial inertia to join such platform, enhance the relationships between entities and, at the same time, preserve privacy and control of the users over their resources. The main entities of our framework are: user, administrator, founder, healthcare professional, affinity domain, and accreditation authority. The user may be seen as the starting point in the framework. After the account activation a user may follow into several paths, by creating his own network of professional relationships. A user may search for other registered healthcare professionals, invite them to join his private group of colleagues or apply to the healthcare institutions he desires. Besides the private group of colleagues, a user may also create special groups of entities, more precisely, institutions or affinity domains. The institution and affinity domain classes are trust communities designed to mimic the real world institutions interactions. The user that creates one of these trust communities becomes automatically its founder. The founder is at the same time owner and administrator of the trust community, however, he may appoint other registered users for the administration of the community. The

4 administrator has the responsibility of managing the community, by accepting or inviting entities to join the trust community. If the user belongs to an institution it becomes automatically a healthcare professional of that institution. Analogously, when an institution joins an affinity domain it has access to the XDS Document Registry of that affinity domain. The new institution may also add its own data sources (e.g. XDS Repositories or XDS-I Imaging Document Sources) to the Affinity Domain. However, the adding of new document sources must have the approval of one affinity domain administrator. The affinity administrators may perform the following activities: (i) add or remove institutions to the affinity domain; (ii) access the usage logs of the affinity domain; (iii) view activity statistics; (iv) add or remove IHE actors; (v) configure the affinity s Patient Identity Source; (vi) launch the affinity domain on the cloud provider (this task may only be performed once per affinity); (vii) define the BPPC privacy policies. Furthermore, there is the accreditation authority class that is responsible to certify the entities present in the framework. For instance, nothing prevents one or more users to found a trust community claiming that is one specific institution or affinity domain. The accreditation authority solves this problem by verifying the validity of the account and if it concludes that the entity is actually the claimed entity it may certify the account as the official. 2. Results Our framework is an ongoing large project and currently we are already able to launch semi-configured IHE actors in the cloud: XDS Document Registry, XDS Document Repository, XCA Initiating Gateway, XCA Responding Gateway, ATNA audit repository and Consistent Time. All the actors were developed with the OpenXDS toolkit [6]. By conjugating centralized integration profiles (e.g. XDS, PIX) with federated profiles (e.g. XCA, XCPD) it is possible to organize the communities with several architectures: (i) one institution, one affinity domain; (ii) multiple institutions, one affinity domain (e.g. [7]); (iii) external entities accessing one affinity domain; (iv) federations of affinity domains connected through XCA (e.g. [8]). Enabled by IHE, the deployed document sharing communities may vary according to size, nature and scope. However, one of the challenges of the document sharing communities not addressed by IHE is the identification and discovery of sharing partners [9]. Our framework keeps track of the relationships between partners, and authenticated users may easily discover affinity domains, institutions and professionals, check to which trust communities the entity belongs, and confirm if the entity is accredit by the accreditation authorities. 3. Discussion and Conclusion E-health and telemedicine are rapidly evolving from point-to-point to many-to-many relationships. In addition, the medical expertise around the patient is more widely distributed and the care service is more and more frequently performed within heterogeneous teams of experts. This scenario magnifies the need to share patient medical information across workplaces and institutions [10]. The healthcare environment is heterogeneous, extensive, and extremely complex. Therefore, IHE defines flexible integration profiles that will adapt to the healthcare wide broad of requirements. Our system facilitates the process of configuring and testing the affinity

5 domains before their deployment in a real scenario. Our framework uses the public cloud infrastructure as the production line affinity domains, delivering at the end the virtual machines ready to be deployed at any machine with an OS virtualization layer. By using our system, multiple and isolated document sharing communities will eventually flourish. IHE, through the cross-community profiles, defines the means to securely exchange documents between those future communities, while our framework will promote the communication and accreditation of the participant partners. Interinstitutional patient information exchange is more than data transmission from a site to another. By following the IHE integration profiles our framework assimilates knowhow gathered from years of clinic, industrial, and academic experience. Based on profiles, it is possible to create interoperable document sharing communities that respect the security, privacy and legal demands of the healthcare domain. Our framework enables the creation of multiple affinity domains with associated professionals and institutions. In our opinion, having a framework that launches semiconfigured IHE actors, required to achieve interoperable document sharing communities, expedites by itself the creation of such communities. Moreover, by keeping the relations between entities, it imprints higher levels of trust when new institutions want to join one affinity domain or when new cross-community interactions need to be established (e.g. through XCA). Our framework involves accredited participants in a network of trust, enabling transmission of reputation within the federation of peers and, as a consequence, enhancing the many-to-many relationships which may lead to the establishment of new interactions between health partners. 4. Acknowledgements The research leading to these results has received funding from Fundação para a Ciência e Tecnologia (FCT) under grant agreement PTDC/EIA-EIA/104428/2008. References [1] Paul G. Shekelle, S.C.M., Emmett B. Keeler, Costs and Benefits of Health Information Technology 2006, Agency for Healthcare Research and Quality U.S. Department of Health and Human Services. p [2] W. Dorda, G. Duftschmid, L. Gerhold, W. Gall, J. Gambal, Austria s Path Toward Nationwide Electronic Health Records. Methods of Information in Medicine, (2): p [3] IHE, Infrastructure Technical Framework (Aug. 19). Integration profiles Revision Final Text p [4] Luís S. Ribeiro, C.C.a.J.L.s.O., Current Trends in Archiving and Transmission of Medical Images, in Medical Imaging, O.F. Erondu, Editor. 2011, InTech. [5] Kuo, M.-H., A. Kushniruk, and E. Borycki. Can Cloud Computing Benefit Health Services? A SWOT Analysis. in XXIII International Conference of the European Federation for Medical Informatics Oslo, Norway. [6] Tools, O.H. and M.O.S. Solutions, OpenXDS [7] Lautenbach, M. and T.d. Bruin, Success Story: Medical Centre Leeuwarden. 2010: Friesland, the Netherlands. p [8] Saccavini, C., Success Story: Health Optimum. 2011: Veneto, Italy. p [9] Witting, K. and J. Moehrke, Health Information Exchange: Enabling Document Sharing using IHE profiles (Draft in preparation for public comment). 2012, IHE International, Inc. p Huang, H.K., PACS and Imaging Informatics: Basic Principles and Applications. 2010: John Wiley & Sons.