Dutch nationwide Electronic Health Record why the centralised services architecture?

1. Dutch nationwideElectronic Health Recordwhy the centralised services architecture? Ir. Karel de Smet, principal IT architect WICSA 2011, June 23th Boulder CO, USA

2. patient / client Healthcare providers in the Netherlands Many, small sized, independent healthcare providers Each provider has to maintain a health record for each patient 4500 2500 150 10 000 hospital other healthcare provider GP practice pharmacy assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

3. Healthcare Information Systems 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 hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

4. Nationwide EHR Nictiz Enable queries across boundaries, with minimum impact for healthcare providers and their XIS-suppliers HIB Health Information Broker NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

5. Registering health records Nictiz HIB record locator REC NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS GpIS PhIS HIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

6. Querying patient data Nictiz HIB GpIS query access point REC QRY Q Q Q PhIS HIS NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS Q assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

7. Collecting patient data Nictiz HIB GpIS query access point REC QRY PhIS HIS NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy A1 A2 A3 GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

8. Returning patient data Nictiz HIB GpIS A1 query access point REC QRY PhIS A2 A3 HIS NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

9. Protecting patient data PKI PKI PKI PKI PKI PKI PKI PKI Nictiz identification & authentication HIB authorisation protocol REC QRY access log AUT I&A LOG NSP NSP patient consent VPN VPN PKI smartcards hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

10. PhIS HIS GpIS HIB xIS register record update record locator Pharmacist Specialist other GP register record update record locator register record update record locator query patient data authorise query consult record locator query patient data return patient data update log return patient data

11. 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

12. Registering health record REC service AUT service LOG service NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS GpIS PhIS HIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

13. Requesting authorisation ticket GpIS REC service AUT service LOG service PhIS T HIS NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS R assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

14. Finding records with relevant patient data GpIS PhIS HIS GpIS REC service AUT service LOG service PhIS HIS NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy GpIS PhIS HIS LIS xIS QT assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

15. Querying patient data GpIS REC service AUT service LOG service PhIS HIS NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy QT QB QB GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

16. Collecting patient data GpIS REC service AUT service LOG service PhIS HIS NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy A1 A2 A3 GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

17. Logging the access to patient data GpIS REC service AUT service LOG service PhIS HIS NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy L1 L2 L3 GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

18. Security PKI PKI PKI PKI PKI PKI PKI PKI Identification & Authentication REC service AUT service LOG service I&A I&A I&A NSP NSP VPN VPN hospital other healthcare provider GP practice pharmacy I&A I&A I&A I&A I&A GpIS PhIS HIS LIS xIS assi stent phar macist assi stent medical specialist assi stant healthcare professional assi stant general practitioner

19. PhIS HIS GpIS Rec Aut Log xIS register record Pharmacist Specialist other GP register record register record request ticket issue ticket get record locations return record locations query patient data return patient data log acces

20. Which is better? Capacity Scalability Flexibility Reusability Simplicity Security Modifiability Compliance Service level Scope control Centralised: • bottle-neckfor bulk • HIB scalable as a whole • fixed query pattern • requires HIB modification + XIS has 1 point of access + Securitysimpler + may bridge incompversions + control over community + easily monitored • compound query service easilyextended 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

21. 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

22. Questions? Logica xxx Visitor address Street Postcode City Country www.logica.com Contact: Name Function T: +XX (0) 000 00 000 000 F: +XX (0) 000 00 000 000 E: address@logica.com

23. Centralised Services Distributed Services xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis HIB i&a qry xis xis xis xis xis xis rec aut log xis xis rec aut log xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis xis