The Design of Flexible Front End Framework for Accessing Patient Health Records Through Short Message Service M.K. Abd Ghani1, R.K. Bali1, R.N.G. Naguib1, I.M. Marshall1 , A.S. Shibghatullah2 1
Biomedical Computing and Engineering Technologies Applied Research Group (BIOCORE) Faculty of Engineering and Computing, Coventry University, CV1 5FB, UK. 2 Fakulti Teknologi Maklumat dan Komunikasi, Universiti Teknikal Malaysia Melaka, Ayer Keroh, 75450 Melaka, Malaysia.
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Abstract – Seamless access to a patient’s lifetime health records is crucial for helping doctors in making decision for providing accurate treatment and continuous care. It is equally crucial in the situation where patients freely visit any healthcare facility for the same medical problem, and can be referred to the appropriate hospital anywhere in the country. Without seamless and continuous capability, the patient health records cannot be accessed timely, accurately and completely. Patients may have to perform repetitive tests and exams even though they may have historically suffered from the same disease. This paper proposes flexible front-end framework to upkeep a patient’s health records continuously and seamlessly using portable devices such as laptops and mobile phones and the Global System for Mobile and Short Message Service. Keywords: Patient Health Record, Portable Devices, Short Message Service.
1
Introduction
Prompt access to a patient’s electronic medical history or lifetime health record (LHR) is fundamental for providing seamless and continuous care. This can be achieved through the convergence of ICT, medical content and health knowledge. Through this convergence, the patient’s medical history can be shared among healthcare professionals and across healthcare facilities regardless where the previous visit was made. However, the fragmented and paper-based medical records have significant limitations such as illegibility, unavailability, sheer physical volume (over time), difficult transferability and integration between providers and institutions, and the necessity to record the same data many times (duplication) on different documents [1,2,3]. These problems become worse when patients are able to freely visit any healthcare facilities for the same medical problem, and where the patients can be referred to an appropriate hospital anywhere in the country. This scenario currently occurs in healthcare facilities (hospitals and clinics) where the majority of the medical records are individually kept in different health premises, the Hospital Information System (HIS) is set up in a fragmented fashion, and the landline telecommunication infrastructure to retrieve patients’ health records across healthcare facilities is inconsistent and inadequate. This paper proposes
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flexible front-end framework (FFeF) to upkeep a patient’s health records continuously and seamlessly. The framework utilizes portable devices such as laptops and mobile phones to access and store a summary of patient’s health records through the Global System for Mobile (GSM) digital cellular network and Short Message Service (SMS) [4]. Before describing FFeF, this paper presents some of the problems that are related to healthcare systems. Then, the issues that highlight the need for a FFeF are discussed. Thereafter, the components of FFeF are defined and described in details. Finally, the conclusion and suggestions for further research are dealt with.
2 2.1
Medical records and channels of delivery Portable devices
As previously noted, medical records have traditionally been written and stored on paper and medical record offices have long been associated with dusty shelves stacked high with assorted reams of paper files making retrievability a very precarious endeavour indeed. With the emergence of ICT and healthcare practices, there is now a variety of daily used items upon which medical records can be written and displayed [5]. These include items such as PDAs, mobile phones, smart cards [6,7] and laptops which are in the possesion of individuals, and are therefore readily available at all times [8]. These devices are important for continuity of care purposes such as storage of health records and viewer and clinical decision support at the point of care. Portable devices and wireless technology applications in healthcare can be recognised as both emerging and enabling technologies that have been applied in various countries for improving patient care services. For example, a variety of wireless technologies such as mobile computing, wireless networks and global positioning systems (GPS) have been applied to ambulance care in Sweden [9] and emergency trauma care in the Netherlands [8].
2.2
SMS applications
The SMS [10], often called text messaging, is a means of sending short messages to and from portable devices that support GSM service such as mobile phones or personal digital assistant (PDA). Harper A. et al. (2006) demonstrated that the use of SMS technology in healthcare increases efficiency and decreases cost in delivering healthcare services [11]. For example, there is a potential saving of between £240-370 million a year to the NHS in England alone by the introduction of SMS appointment reminders to patients and potential cost savings of up to £1.9 million per 1000 patients if a SMS support system is introduced into treatment programmes for TB patients. The SMS support system also leads to a reduction in deaths and brings health benefits to public [11]. Looking at these facts, the SMS application could be utilized to improve patient care services and provide a cheaper solution to problems than the landline telecommunication infrastructure across healthcare facilities. In Malaysia, the network infrastructure may not be consistent across the country and among healthcare facilities. For example, the average Internet penetration in Malaysia in 2005 was around 14%, while the penetration in cities, such as Kuala Lumpur, is higher at around 50% [12]. SMS could be a better and cost effective solution to mitigate the inadequacy and inconsistancy of a landline telecommunication infrastructure across healthcare facilities nationwide. Based on the survey conducted by MCMC [13] on mobile phone penetration as at December 2005, there were 19.6 million mobile phone users in the country and the population of Malaysia at that time was 26 million. The survey also reported that a significant 84.9% of the users subscribed to SMS in the subscriber base [12]. Given this penetration mobile phones have great potential as an access device for lifetime health records of patients in Malaysia.
3
Patient health records: Problems and context
Today there are many barriers that prevent seamless electronic data communication with remote systems and services that the healthcare professionals want to access at a certain time and place [4]. This is especially the case in healthcare facilities (hospitals or clinics) where the telecommunication needs are very complex and context dependent, and where the availability of the infrastructure is inconsistent across healthcare facilities. The major problems caused by the inadequacy and inconsistency of the telecommunication infrastructure have consequences for the patients health records.
3.1
Incompleteness of the contents of patient health records
If the electronic medical record (EMR) is not stored correctly or is lost when the system is down then the health record is incomplete. Manual data entry brings issues of reliability and validity of medical records normally captured by non-clinical staff. This is supported by many studies that questioned the variable quality of existing patient records [14]. There are also criticisms that the patient medical records are often missing, illegible or inaccurate [15].
3.2
Issues in accessing of, availability to and retrieving of patient health records
Reverting to manual procedures is a normal backup plan for ICT services when a system disaster happens. It has been demonstrated on many occasions that access to paper records is generally problematic and resource intensive [16]. According to a study done by the General Accounting Office in the United States, one hospital could not find the medical records 30% of the time and the physicians found great difficulty in accessing patient records at the right time [17,18].
3.3
Issues on linkages and integration
The EMR is normally stored in database system such as a relational database management system (RDBMS) which has linkages between information and record-specific data types that are kept in columns and rows called ‘tables’. In the case of downtime during updating of the linkages, some of the saved data will be incomplete and data integrity will be an issue that requires data maintenance. Incompleteness at the micro level of medical data affect the integration and seamlessness of LHR. This hampers optimal use of LHR in providing patient care in the distributed environment of healthcare facilities.
4
The FFeF architecture framework
This section proposes a FFeF framework to mitigate the problems associated with accessing patients health records during any unavailability of the telecommunication network. This section starts with the description of the design approach and continues with the description of the components of the architectural framework.
4.1
Design approach
The architectural approach for FFeF is based on the Rational Unified Process Methodology (RUP) [19]. The FFeF architectural solution uses the system layer to organize the view of the framework structure. The selected views are as follows:
• •
•
4.2
Use case view describes the functional requirements of a system and interactions between users and the system itself. Decomposition view serves to break a large system down into smaller, more manageable systems within the context of the larger system as a whole. Deployment view exposes the FFeF deployment diagram functionality in the extensibility interface.
The FFeF use case view
Patient
Doctors
Retrieve Health Record
View Health Condition
Mobile Devices
Capture and Save Health Records
Figure 1: FFeF use case view
The use cases were identified to support the system implementation and to mitigate those issues described in the previous section. Patient, doctor and mobile devices are the actors of the use cases. The patient and doctors are the main users interacting with the system. •
•
•
Use case views health condition. The use case is meant to view the health condition and medical history of the patients. It is crucial for a doctor to know the patient’s condition to help them diagnose the problem and providing accurate treatment. In the case of follow-up patients, his/her previous health records such as symptoms and medication can be copied to create a new episode of the visit. This will avoid any errors in providing medication and medical treatment to the patient. Use case retrieves health records. The use case is meant to retrieve the five latest episodes of patient health records from the LHR repository at a central system. In the absence of a landline telecommunication network, the mobile device (mobile phone) through SMS is used to retrieve the data. The mobile phone attached to the PC transmits the data to the computer and is displayed on the computer screen. Use case captures/saves health records. The use case is meant to save and send the captured health records to the LHR repository at the central
4.3
system. The data is compressed, encrypted and sent to the central system through SMS using a GSM phone.
Application layer
This section provides a discussion of decomposition balanced against the unifying principles of the architecture in support of the targeted functionality.
Overview The FFeF system has two contracts between DisasterManager and ClientController. DisasterManager is a software program responsible for monitor network availability within the PC. It sends an appropriate message to ClientController to alert the ClientController that the system is off-line or on-line. Once ClientController receives an ‘off-line’ message, it sends a message to ClientStorageManager for retrieving patient health records from the available portable storage device (mobile phone). The patient health records are requested by typing the patient identification number and sending the SMS request through the GSM network to the central backend system. The ClientStorageManager receives the messages and sends it to the ClientController to forward to UI Manager to display the health records. The doctor is able to view the patient’s health records and perform necessary data entry for the visit. Once the doctor saves the data and discharges the patient, the ClientController sends the data to the ClientTxnManager for data formating. The formatted data is passed to the ClientStorageManager for sending to the central back-end system through SMS using GSM. The data is also stored on local data storage in a journal file for auditing purposes and backup. When the system is restored, the RescueManager identifies any pending transactions from the journal file and transmits to central back-end system either via landline telecommunication or SMS. Figure 2 depicts the inter-relationship of FFeF’s components.
The FFeF system decomposition view Front-end system Validation Manager
disasterManager
UI Manager
clientStorage Manager
clientController
Mobile phone PDA
rescueManager
clientTxn Manager
Journal File
Local patient health records
Figure 2: The FFeF component diagram
Back-end System
Decomposition is really the central process of architecture [20]. It serves to breakdown a large system into smaller, more manageable systems each with its own local context that is independent of, but not inconsistent with, the context of the larger system as a whole. Figure 2 above depicts the major FFeF components and classes and serves both to provide a view of the system partitioning, and to ensure that dependencies embodied in the system are sensible. ClientController This component is meant to control the overall FFeF framework. This class is the facade [21] between the user interface (UI) and the rest of the subsystem/component. By having this facade, it shields the UI from the implementation details and promotes UI independence. Therefore, we can implement the UI using any UI toolkit (such as Java AWT and Swing or MS SDK) that talks to this class. This makes FFeF scalable enough for the implementation and enhancement of clinical information systems (CIS) in future. DisasterManager This component is meant to monitor the system disaster event (downtime of telecommunication network) and dispatch the signal to the ClientController for further action. This class handles the attempts to save health records data remotely when the first attempt fails. This component is a real-time application service. RescueManager This component is meant to transmit the off-line transaction to the back-end system. It acts and operates as a service and allows the user to manually view and submit the pending transaction (clinical episodes of the patient) for updating to the central LHR repository at the central back-end system. ClientStorageManager This class manages and determines the available storage device medium dynamically. If more than one medium is available it will alert the user whether to write to all media or write to only one medium. Only one storage medium can be used to retrieve patient health data even though multiple storage media are available to write to. The user should give an option to retrieve the patient health data from the preferred medium. An example is to retrieve data from local hard disk or portable device such as a mobile phone or smart card (in this research, the data will retrieve only from a mobile phone or PC/laptop hard disk). ClientTxnManager
This component is meant to keep the transaction data as an audit trail. The transaction will be kept on the local data storage in a journal file. ValidationManager This component is meant to manage the validation of the data format and rules entered by the users. An example is to validate the formula to calculate the body mass index (BMI), date, blood type range etc.
4.4
The system deployment view
The deployment view describes and illustrates the software, firmware, hardware and communications to be installed and executed in the user’s actual environment.
Figure 3: FFeF deployment view
The FFeF framework component is installed on all doctors’ PCs at health centres. The GSM mobile phones are attached to all PCs to enable the sending and receiving of data (health records summary) between doctors at the health centre and central back end system. This is located at the Ministry of Health office (MOH) (e.g. Telehealth data centre). The retrieving and storing of the patients health records would use the SMS applications as a transport for data transmission. In order to ensure the captured clinical finding is not lost during system downtime, the local data storage is also provided by the FFeF. The FFeF can also be used by the mobile paramedic to retrieve a patient’s health history while providing emergency treatment to the patient. The SMS server located at the back-end system is a gateway to send (and receive) SMS messages from a doctor’s computer to the health record management system. Finally, the back-end system located at MOH office is linked to mobile network operator using either wireless or internet protocol (IP) connection.
5
Conclusions
This paper has described the issues relating to accessing patient health records during patient-doctor encounters in healthcare services. It was noted that the patients’ health records are still in a fragmented fashion and disparate across healthcare facilities. The telecommunication network is a fundamental
infrastructure for enabling the capability to continuous and seamlessly access patients’ health records. The use of GSM and SMS technologies in healthcare services provide potential benefits in term of efficiency and cost reduction in providing healthcare services to patients. This research proposes a FFeF to deal with those problems where the front-end computing (such as mobile phones and laptops) and SMS technology are used to make sure the patients’ health records can be retrieved and stored safely and continuously. Our plans for further development include the design and research of the integration component that investigates the interoperability capability of FFeF with other hospital information systems and telemedicine systems [22,23]
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