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Web and Internet based technology is used to create a community health information network called the Medical Web. The techniques used are presented and the general applicability of the model is discussed.
In recent years healthcare organizations and providers have formed increasingly complex relationships in order to successfully compete and survive. As a result, information systems have had to evolve in order to support these new administrative and management networks. This has happened despite a lack of standards for sharing health-related information.
Healthcare enterprises have become virtual enterprises defined by relationships between organizations, care providers, and resources1. Even in the absence of a formal healthcare enterprise, entities in a given community with referral relationships can be viewed as a loosely defined virtual enterprise. Traditionally, each of the groups that make up this loosely defined virtual enterprise uses different information systems designed to meet the needs of that group. Cost, politics, and functionality are all barriers to integrating the virtual enterprise into one seamless information system.
From the above it becomes clear that individual information systems will have to interface with one another in order to meet the need of the virtual enterprise. However, without the emergence of a set of standards this goal will remain elusive. Within a single "wholly-owned" enterprise, wide area networks (WAN) have been built to help individuals gain access to each of the systems from which they need to access information. While this may lighten the load of phone calls, it poses a serious training and security issue. In a community based virtual enterprise, there is little or no networking to interconnect systems, so traditionally burdensome methods of phone calls and mailing are still used to communicate.
The goal of sharing information has two major obstacles: infrastructure and system integration. First, infrastructure needs to be in place to even attempt system integration. It is impossible to link disparate systems without a network in place to allow the systems and individuals to interface at will.
The Medical Web is a concept with two concurrent approaches to achieving an information system capable of supporting virtual health care enterprises. The first approach is to build an infrastructure throughout the community that is suitable for exchanging all formats of information while remaining scalable in accordance to the needs of the individual member organizations. The second approach is to create a migratory information system that can be accessed from most any kind of operating system and hardware platform that may be in use in the community or enterprise.
For a network of this type to work where providers competition is an issue, a third approach must be taken to insure growth. In a community with no dominating healthcare enterprise, typically two or more enterprises struggle to build competing physical networks. Neither organization will participate with the other's network. The Medical Web Project calls for independent management of the physical network in such situation. In the case of the Northeast Indiana Medical Web, there is one single network with two major players participating and competing to provide services on the network instead of competing to build their own network. Because there is a single network, entities that work with both enterprises are not burdened with the costs of participating in two networks. Furthermore, each of the enterprises can invest in information systems instead of telecommunications equipment and focus on providing healthcare services instead of network support.
The Northeast Indiana Medical Web (Med-Web NI) is the one of the first to marry the three approaches described above in order to achieve a true Community Health Information Network (CHIN)2. The Med-Web NI will be used throughout this paper to illustrate methods used to integrate disparate information systems.
The Internet is changing the world communications concepts, helping networks to become common place. It is important to note that the Internet is not synonymous with the World Wide Web (WWW). The Internet is the physical network that interconnects many different networks and computers over the world. The Internet allows different types of information to be exchanged. The World Wide Web is an interface to the Internet resources.
Scope
Due to the popularity of the Internet and the explosion
in Local Area Networking (LAN), telecommunications
hardware and connectivity have become more
affordable. It is only recently that a small office has
become able to afford the technology to connect to a
Wide Area Network without the need to invest tens of
thousands of dollars and an information systems staff to
maintain it. It is important that even the smallest
offices be able to connect to the network and share
information. The full potential of the Med-Web concept
could not otherwise be reached.
Architecture
The Northeast Indiana Medical Web is deploying
dedicated Frame Relay connections out to every
participant in the project. These are dedicated
connections in order to eliminate difficulties other
technologies such as modems and ISDN may engender.
Busy signals, dialing time, connection problems are all
delays that can make the network more burdensome
than telephone calls and mailing. Frame relay
technology is scalable allowing a spectrum from very
inexpensive low-bandwidth uses all the way up to more
expensive very high-speed uses. Low speed usage
might include claims transmission, remote host access,
eligibility, transcription, etc. High-speed needs might
include real-time video, voice, teleradiology, and
medical record storage. The Med-Web is modeled after
the Internet in that TCP/IP is used primarily throughout
the network. The network however is constructed in
such a way as to allow any transport protocol to be used.
To this point, we have emphasized the infrastructure that is necessary for successful system integration. However, building an infrastructure is easier compared to the effort of integrating the numerous information systems that one might find in any given community.
Obstacles to Information Exchange
There are several obstacles to sharing information both
within an enterprise and within a community. The first
obstacle, which has already been addressed, is that of
infrastructure. Other obstacles that need be addressed
in order to share information efficiently are presented in
what follows.
Platform Dependence
When an IS staff looks at the task of sharing
information with many different groups, typically the
groups that use common platforms and hardware get
access to the data more easily. As an example, there is
currently a push to move applications to Microsoft
Windows based environments due to their rich content
and user-friendly interface. This approach however
leads to some major pitfalls. Many groups have
decided not to widely deploy Microsoft products for a
combination of reasons. It is unrealistic to believe
things are going to change in a short period of time,
and organizations that do not address other platforms
may be limiting their audience. For and IS department
to "cross develop" an application takes a lot of time
and expertise that may or may not be readily available.
Security
As information systems are deployed security is often
setup, but rarely maintained. A simple
username/password scheme is usually a good start, but
this paradigm usually ceases to work when there are
multiple systems each with a different username
/password combination. Users begin to forget their
passwords, and calling a help desk to ask for it
becomes common place. Alternatively, users begin
posting their passwords on their desks or work areas
for anyone to see. In some cases, doctors give their
personal passwords to their staff and the passwords are
never changed. All of these events lead to the erosion
of security throughout the system.
Training
As information systems are developed very few use
common user interfaces. Users of these systems invest
large amounts of time to learn how to use them. As
discussed earlier, if many systems are utilized users
must become proficient in each.
The healthcare industry is not the first to face the obstacles of sharing information. The Internet has been a proving ground for system integration and has by far the most varied types of hardware, operating systems, and applications. Until the creation of the WWW, the Internet had many different interfaces and cumbersome methods of accessing information. The WWW is not so much an application as it is an interface to an application. Many of the same protocols that were in use on the Internet 20 years ago are still in use, but the way people use these protocols is via the browser instead of using individual programs to access the information. For example, before the advent of the WWW, one may have used a gopher program to find out information about a file on the Internet, a telnet program to access an "archie" server to find out where the file is stored, and then an FTP program to transfer the file. Each was its own application, and none of the applications shared information. As a consequence, only technically oriented individuals used the Internet to any significant extent.
The WWW is centered around the "browser," an application that can speak to a Web Server, and is able to speak to some other types of servers such and a FTP (File Transfer Protocol) server. Uniform Resource Locators (URL) organize information on the WWW. These tell the browser:
a) the type of protocol to use
b) the server to access
c) the resource to retrieve.
The URL can also identify a username to use when accessing the information. The information typically retrieved is in Hypertext format, a standard method of specifying how information should appear. After the information is retrieved, it is up to the browser to display it to the user as best as possible given the capabilities of the hardware.
Advantages of Web Based Technology
There are many advantages to using Web based
technology as user interfaces for information systems.
Ease of Use
Hypertext is a very intuitive interface, which makes it
easy to use. The "point and click" interface to
information lends itself to touch screen technology. As
an example, one OB/GYN clinic that is participating in
the Northeast Indiana Medical Web is using
touch-screens to make it easy access information within
the practice. Another benefit to using web-based
technology is that the Internet is preparing everyone for
this technology. It is impossible to turn on a television
without seeing a URL. With companies integrating the
browser into televisions, phones, and automobiles,
employees are eager to learn. As a consequence,
training may require less time than other
methodologies.
Portability
Because browsers have been designed for nearly every
operating system and hardware platform, Web based
technology is ideal for sharing information where it is
critical to share it with the most number of people.
Figure 1 is shows an insurance eligibility application
that is accessed via a Windows-based system and how
that same application looks using a text-based system.
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Security
With new web technology there comes new methods of
user authentication that can be used to build a very
flexible yet secure network of information. It is
possible to protect every resource with user
authentication and because the browser asks the user
once, and uses the information repeatedly, the user is
not burdened with having to re-enter the information
every time it is requested. This blessing can also be a
problem if not addressed properly as discussed later.
Use of "certificates" allow a trusted third party to
authenticate a user on the network to all parties on the
network. This allows a user to keep track of a single
password, and gives the user the ability to change the
password once, instead of many times on several
different hosts.
Using browser technology, a developer can make multiple systems appear to and end-user as one single system. For example, it is possible to integrate an X-ray image of a patient stored on an imaging system with admission information stored on a hospital information system. The technique involves the use of URLs to point to information instead of actually integrating it on one system. Using this technique, one system must know the URL format for the others and point the browser to that location.
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The example in Figure 2 shows a dedicated "Index Server" that would know where to retrieve information from other servers. Building this model would require that the other servers update the Index Server with timely information so that the Index Server may collate it. This model is very similar to the way a user might search for information on the Internet using a search engine. The user points the browser to a search engine, makes a query, and the server returns the best URLs for that query.
Even in cases where information is not collated by some central Index Server, making the information available in Hypertext can be more convenient for an end-user. A user can manually point their browser to the server and retrieve information. While this is less than ideal, it is much better than somehow getting physical access to the system, logging in, and then retrieving the information though some other means.
Just as web based technology is powerful, it is dangerous. If systems are not designed and managed properly from the start, they may get wildly out of hand quickly. Standards must be set so that information is not bound to network architecture. URLs can decay as host names change, or network topology evolves3.
Security can be made to be very flexible, but usually flexibility means a compromise in security. For example, it is possible to configure a browser to remember a username/password combination indefinitely, which may be fine if the machine is located in a secure area and is used by only one individual; however, if the machine is available for others to use, it is not wise to setup security in this fashion.
Developers must also be careful in developing Web- based applications so that special features of one browser are not used and consequently eliminate the possibility of allowing users of other browsers access.
Web and Internet based technology may be used to implement powerful and user-friendly health information systems if done carefully. The flexibility of the technology make it a good choice, especially in cases where there are loosely defined virtual enterprises with many kinds of systems in use. Until standards for transmitting medical information are widely used, web-based technology can serve to bridge disparate information systems, and may prove to be the user-interface of the future.