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

2. © 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 general practitioner assi stent 4500 pharmacy phar macist assi stent 2500 hospital medical specialist assi stant 150 other healthcare provider healthcare professional assi stant 10 000 patient / client

3. © Logica 2010. All rights reserved 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 other healthcare provider hospital pharmacy GP practice PhIS xISLIS healthcare professional assi stant phar macist assi stent GpIS general practitioner assi stent HIS medical specialist assi stant

4. © Logica 2010. All rights reserved Enable queries across boundaries, with minimum impact for healthcare providers and their XIS-suppliers Nationwide EHR other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS Nictiz NSP HIB Health Information Broker VPN healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

5. © Logica 2010. All rights reserved Registering health records other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS Nictiz NSP HIB VPN REC record locator PhISGpISHIS healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

6. © Logica 2010. All rights reserved Querying patient data other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS Nictiz NSP HIB VPN REC query access point PhIS GpIS HIS Q QQQ QRY healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

7. © Logica 2010. All rights reserved Collecting patient data other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS Nictiz NSP HIB VPN REC query access point PhIS GpIS HIS QRY A2A3A1 healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

8. © Logica 2010. All rights reserved Returning patient data other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS Nictiz NSP HIB VPN REC query access point PhIS GpIS HIS QRY A2 A3 A1 healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

9. © Logica 2010. All rights reserved Protecting patient data other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS Nictiz NSP HIB VPN PKI PKI smartcards AUTLOGI&A identification & authentication authorisation protocol patient consent access log REC QRY healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

10. © Logica 2010. All rights reserved Nationwide EHR Advantages : uniform solution for whole of the Netherlands for all patients and all medical applications qualification enforces compliance patient rights have been established security transparant security enforced by HIB Disadvantages : government project gets full attention of press: stubborn misunderstandings public and political resistance solid but expensive solution new legislation needed… Nictiz HIB AUTLOGI&A REC ZABQRY

11. HIS GP GpIS PhIS HIBxIS Pharmacist Specialist other register record query patient data return patient data update record locator update log update record locator consult record locator authorise query

12. © Logica 2010. All rights reserved 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

13. © Logica 2010. All rights reserved Registering health record other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS NSP REC service VPN PhISGpISHIS AUT service LOG service healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

14. © Logica 2010. All rights reserved Requesting authorisation ticket other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS NSP VPN REC service PhIS GpIS HIS T R LOG service healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant AUT service

15. © Logica 2010. All rights reserved Finding records with relevant patient data other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS NSP VPN PhIS GpIS HIS REC service PhIS GpIS HIS QT AUT service LOG service healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

16. © Logica 2010. All rights reserved Querying patient data other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS NSP VPN REC service PhIS GpIS HIS QB QT AUT service LOG service healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

17. © Logica 2010. All rights reserved Collecting patient data other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS NSP VPN REC service PhIS GpIS HIS A3A2A1 AUT service LOG service healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

18. © Logica 2010. All rights reserved Logging the access to patient data other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS NSP VPN REC service PhIS GpIS HIS LOG service L3L2L1 AUT service healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

19. © Logica 2010. All rights reserved Security other healthcare provider hospital pharmacy GP practice PhIS xISLIS GpIS HIS NSP REC service VPN AUT service LOG service PKI I&A Identification & Authentication I&A healthcare professional assi stant phar macist assi stent general practitioner assi stent medical specialist assi stant

20. HIS GP GpIS PhIS RecxIS Pharmacist Specialist other register record return record locations AutLog get record locations issue ticket request ticket query patient data log acces return patient data

21. © Logica 2010. All rights reserved Which is better? Capacity Scalability Flexibility Reusability Simplicity Security Modifiability Compliance Service level Scope 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

22. © Logica 2010. All rights reserved 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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24. © Logica 2010. All rights reserved Centralised Services Distributed Services xis HIB recaut qry log i&a xis recaut log