CloudeMR: A Cloud Based Electronic Medical Record System · cloud central server that accepts virtual machines as tenants. The tenants are secure facilities that store information

International Journal of Hybrid Information Technology

Vol.8, No.4 (2015), pp. 201-212

http://dx.doi.org/10.14257/ijhit.2015.8.4.23

ISSN: 1738-9968 IJHIT

Copyright ⓒ 2015 SERSC

CloudeMR: A Cloud Based Electronic Medical Record System

Olutayo Boyinbode and Gbenga Toriola

Department of Computer Science,

Federal University of Technology, Akure, Nigeria

[email protected]

Abstract

The utilization of modern information technology in the delivery of healthcare is to

enhance the availability and reliability of improved healthcare services to patients at a

reduced cost. The alternative in this context is to outsource the computing storage

resources with the help of cloud infrastructure. The drastic reduction in the cost of

healthcare services, utilization of resources, maintainability and the adoption of new

technologies are some of the benefits that healthcare centers in rural areas can get from

cloud-based medical information system. Also, new prospects such as easy and ever-

present access to medical records and the chances to make use of services of physicians

that are not readily available in the rural areas are some of the opportunities offered by a

cloud-based medical information system. This paper proposes and implements a cloud-

based electronic medical record (CloudeMR) system to improve the delivery of healthcare

system in the rural communities of Nigeria.

Keywords: Cloud computing, Electronic medical record, HealthCare Information

Systems, ICT

1. Introduction

The healthcare industry in Nigeria has not been able to tap into the full potential of

modern information technology to improve on healthcare delivery [7]. Accesses to

patients’ longitudinal records are often times difficult and cumbersome. The lack of

proper access has cost the healthcare industry a huge fortune every year due to duplication

and waste [7]. This is just one of the many challenges facing the healthcare industry.

Cloud computing technology has received tremendous attention in recent years. In

simplest terms, cloud computing can be defined as a form of computing where shared

resources, software, infrastructures and information are delivered to computers and other

devices through network or an internet. The accesses to information or network shared

resources are not limited by the user’s physical location. Therefore, vital resources and

people are connected irrespective of where they are around the world, provided there is

network connectivity [3, 4].

The ability of cloud computing to facilitate the exchange of medical information

between the healthcare stakeholders such as the pharmacist, doctors and all other

healthcare institutions that are geographically isolated can help to modernize healthcare

services [9]. Privacy, confidentiality, security and regulation problems have however

curtailed the immediate adoption and implementation of cloud computing in the

management of healthcare system. One of the reasons for the slow adoption rate is the

inability to guarantee if the data are fully secured. Kuo [9] and Malin [10] stated that

societal stigmatization and isolation may for instance cause some HIV and mental health

patients to want their medical information to be strictly confidential.

Healthcare industry has recorded a significant improvement in the last two decades

through advancement in information technology. Despite all success recorded, there are

still concerns in many areas that affect almost every individual in the industry, and


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202 Copyright ⓒ 2015 SERSC

especially the patients who are direct beneficiary of all the successes also bear the brunt of

lapses in the system. Some of the problems can be classified as lack of access to patient’s

medical records [7], limited medical personals in rural areas, high mortality rate [1]. The

goal of this paper is to design and implement a cloud-based electronic medical record

system that can be used to effectively manage the sharing of medical information.

2. Related Works

The utilization of modern information technology in the delivery of healthcare is to

enhance the availability and reliability of improved healthcare services to patients at a

reduced cost. There exists a handful of published research that uses the adoption of cloud

computing as a dependent variable to explore healthcare industry characteristics that are

associated with the implementation of these technologies.

Padhy, et al. [14] designed and presented the implementation of a cloud-based

healthcare information system model for rural communities; this system makes use of a

cloud central server that accepts virtual machines as tenants. The tenants are secure

facilities that store information in different healthcare centers. The configuration and

connectivity of the system is based on the cloud data center location and the policy of the

service provider. The internet is the main link of communication between the rural

healthcare center and the service provider. It also maintains the network traffic between

the physical resources and the cloud. The authentication server uses the authentication and

authorization mechanisms. The system can be used by other applications and across

various devices to share information in near real-time situation effortlessly. However,

there is no fail-safe mechanism in the model to ensure system reliability and availability.

Also, small hospitals and private physicians do not have the IT requirements to support

the technologies deployed in the system.

Saif, Wani, & Khan [17] proposed a system of engineering network solution for data

sharing solution across healthcare providers for protecting patients’ health information in

an Electronic Health Record (HER) system. This system was implemented on a role-

based and signature-based delegation. The signature-based delegation provides a secure

avenue for basic delegation and revocation, while the role based delegation yields

dynamics in the face of delegates’ status, availability and change. In addition to this, basic

access control based on public key encryption techniques was also implemented. This

ensures the sharing of data and also that the privacy of patients’ data is protected across

all collaborating healthcare centers but the introduction of proxy sign-in in the system

exposes it to another high security risk.

An approach based on utility computing and Wireless Sensor Networks (WSN) was

proposed by [16]. Wireless Sensor Networks (WSN) uses sensors that can be worn to

gather vital indications that enable the easy collection and distribution of information to

and from any mobile device. These two computing features were combined to develop a

system that automates the collection, input and analyses patients’ critical information

through network of sensors connected to installed medical devices, which in turn deliver

the records to the health center’s cloud for storage, processing, and distribution. Medical

specialists can use the information collected to monitor and observe patients anywhere

through the internet (on a computer or mobile devices). The system makes use of micro

controllers to evaluate data collected. However, there was no provision made for the

confidentiality, integrity and privacy of patient data in this system. Also, the design has a

complex architecture which may be difficult to implement in developing societies due to

lack of infrastructural facilities.

Another mechanism designed to ensure a trusted communication between different

health information systems was presented by [15]. This system uses an advanced cross

platform model which incorporates national and regional security domains via an inter-

domain zone. Interoperability service and a common security service are offered by this


Vol.8, No.4 (2015)

Copyright ⓒ 2015 SERSC 203

zone to all the connected domains. The function of the platform is to provide security

services that are centrally managed for a cross-organizational predefined communication.

The fundamental security services of this cross-platform domain are to bridge security

policies, identification and authentication of users crossing the domain, certification

services, auditing services and management of static privileges. Public Key Infrastructure

(PKI) services were used on the platform to enable external users from the public to gain

access to any of the EHRs inside the connected domains. However, this mechanism lacks

harmonized legal and ethical framework, common security standards and trans-border

communication security services.

However, all these previous researches either lack legal, security and privacy of

patient’s data or the system is too complex to implement. Also the reliability and

availability of the system cannot be guaranteed. This study differs to every other works

considered by taking into account all the lapses to design a robust, yet simple and

effective electronic medical record (EMR) system that will ensure security, privacy,

reliability and availability of patient’s records. This system can easily be implemented in

small hospitals and by private physicians, without running afoul of the existing healthcare

legislation and regulations.

3. Healthcare Information System (HIS) – A Nigerian Case Study

Advancements in technology made in the world especially in the last two decades have

altered the entire scenario in every sector of the economy. As the healthcare sector

continues to be one of the most expensive and crucial sectors in the economy, Health care

system in Nigeria is currently in a comatose state, there is a high rate of preventable and

curable diseases such as maternal mortality, diabetes, high blood pressure and other

controllable diseases. The Nigerian government is yet to improve the health care delivery

through the use of technology [1, 2].

According to Okeke [12], a lot of Nigerian patients seeking medical treatments are

being forced to patronize the traditional medical practitioners and patent dealers of

medicine due to the lack of access and high cost of modern healthcare facilities. The rich

and wealthy in the society rather embark on medical tourism abroad to get medical

services, because of scarcity of experienced medical personnel [11].

Ayeni, et al. [1], also pointed out that there is Zero level of significance in EMR based

hospitals because only less than 10% of Nigerians can afford it and most of these EMRs

are remotely located in hospital’s infrastructure rather than moving it to the cloud. There

is need for (EMR) Electronic Medical Records to be moved to the cloud to allow

Nigerians have easy access to health care delivery.

4. Benefits of Healthcare Information Systems (HIS)

The workflow among the various healthcare entities is improved upon by the

healthcare information system and also, patient’s access to healthcare increases [13, 19].

The communication between organizations and stakeholders is facilitated by the

application information and communication technologies. ICT helps to improve on the

seamless workflow among people and the organization; effective processes can also be

achieved through efficient and effective interactions [21]. Weiner [23] stated that network

effectively among themselves with the use of electronic health technology, by allowing

the review of patient’s treatment online and to accurately prescribe the necessary drugs.

Keenan et al. [8] discovers that the care given to patients is enhanced and also the daily

work of the physician has improved: (a) the turn-around times of medication fell from

5:28 hours to 1:51 hours; (b) the procedure completion times of radiology fell from 7:37

hours to 4:21 hours; and (c) the reporting times of lab results fell from 31:3 minutes to

23:4 minutes. In the same study, errors in orders due to transcription declined, and the

length of stay in hospital decreased. The online monitoring of vital signs, improved


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physicians’ collaboration in patient care and multi-site review of patients records are the

other benefits of electronic medical records systems. EMR speed up the access to

medication administration records easily, and the ease by which consultation reports are

shared, the decreased time taken to transmit test results are parts of the benefits of

healthcare information system [8].

The errors recorded in diagnosis and the administration of drugs decline with the

introduction of electronic healthcare information system. Fuji and Galt [5] opined that in

the United States, over 1.5 million residents suffer injuries that are related to error in

prescription and other medical complacencies yearly, the authors suggested that the

figure could as well be a fraction of the total patients that suffers adverse medical errors,

especially when patient’s own mix-up is considered. They deduced that some parts of the

healthcare information systems increase participation of patients in the care process,

thereby reducing all forms of medical and prescription errors.

Healthcare facilities are accessed between the urban and the rural communities with

great disparity due to the heterogeneous nature of the Nigerian society. The introduction

of healthcare information system can help to bridge the gap [13]. Also, the clinical data

captured by clinical information system helps to improve on the clinical decision making

of the physician on patients care [22, 24]. Policy makers in healthcare that seeks ways to

improve the quality of healthcare at some reduced cost can also leverage on the healthcare

information system to deliver the inexpensive healthcare [18, 20].

Woodside [25] agrees that electronic exchange of patient’s records between physician

and pharmacist can help to protect the patient by detecting the prescription of drugs

combinations that are not compactible, stating potential allergens to patients. One very

important benefit of the electronic exchange is Insurance verification. Lots of healthcare

providers do not have means of verifying insurance claims by patients; some just provide

care without getting assurance from the patient’s insurance company. All these issues are

solved with the use of electronic exchange between the healthcare entities. Delays in

approval process and healthcare services are reduced.

Clinical time optimization as a result of effective communication and also the

increased level of compliance with guidelines are some of the other benefits of healthcare

information system [6]. Medical students and resident doctors can benefits from the

effective educational tools provided by the EMR system, the healthcare information

technology also offers a very strong potential in clinical protocols and research

development [8].

5. System Design and Implementation

5.1. Design Methodology

This section introduces the design methodology of the cloud based electronic medical

record system.

Design Considerations

i. Cloud-based EMR: To pool different healthcare IT resources into large clouds so as

to be able to share records easily.

ii. Authentication: Security is achieved through the use of username and passwords.

5.2. Architecture of the System

The architecture of the cloud-based electronic medical record system is presented in

Figure 1. The system consists of two major components which are: the cloud-based

system and the e-health web portal.


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Figure 1. Architecture of a Cloud-based Electronic Medical Records System

5.3. The Cloud-Based System

This system consists of (a) a Central Database Server, (b) a Unifier Interface

Middleware (UIM) and (c) an Authentication Server.

(a) The Central Database Server

This server acts as the unifying data repository for all the collaborating hospitals. The

cloud datacenter holds the central database server as the information bank which stores

electronic medical records and also retrieves patient information. The data is stored in a

unified standard layout which can be retrieved from the collaborating hospitals’ Web

Portal system through the Unifier Interface Middleware (UIM).

(b) Middleware

This part of the cloud provides a common platform for all the EMR systems of the

collaborating hospitals. The middleware has an interface that covers the heterogeneity of

all the collaborating hospitals EMR standards, to ease the communication process

between the Central Database and hospitals’ systems. The middleware remains in the

cloud and recognizes any type of EMR standard it interacts with. It communicates with

each collaborating hospitals via network connections. Therefore, each hospital does not

need to have its own separate interface mask in order to benefit from the cloud; all it

needs is just an interface.

(c) Authentication Server

This part of the system handles authentication and authorization. The authentication

verifies if an entity using the system has the right to perform the intended action such as

(updating, retrieving, transferring, etc.) on the medical information provided. It grants

access to authorized users and denies unauthorized users access to the records or

resources on the system. The system generates usernames and passwords for doctors (or

other members of staff) of the sharing hospitals that will serve as part of the admin. All


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the members of the admin are expected to log in to the system with their username and

password. The system compares the username and password with those in the local

database and grants access to the user if they match, otherwise, the user is denied access.

5.4. The E-Health Web Portal

The e-health web portal is the front end of the whole cloud system, and the part of the

cloud (top layer) that provides the application - Software as a service (SaaS) for the EMR

system. The proposed cloud system presents a web portal configured for end users

(authorized doctors, clinicians and the hospitals administrators who serves as the cloud

administrator) to navigate through the central database and the whole EMR system. The

web portal communicates by sending messages and receiving response messages between

the middleware and the hospital system. For each sharing hospital in the cloud, the web

portal provides the user two ways to access the database, one for accessing the hospital’s

local EMR system, and the other for joining the cloud central database.

Every authorized user (cloud administrator) can retrieve, update and receive medical

information from the cloud’s central database through this web page with some degree of

restrictions which depends on the end user’s privileges. The web portal also shows where

the information of a particular patient from a specific hospital resides, whether in the

cloud or on the target hospital system and can decide to view medical information about

the patient or even copy the information into its local database from the collaborating

hospitals connected to the cloud.

Each collaborating hospitals allow its administrator and doctors to have different view

of the patient’s record in the database. The administrator can see the number of doctors

and patients in the hospital and can also view their details. Only the bio-data of the

patients will be displayed to the administrator and not the result of the different diagnosis

and doctor’s report, this will ensure some level of privacy to the patients. Such

information can be viewed only by the doctors.

The application was developed with macromedia Dreamweaver and Wamp server

technology, HTML, JavaScript, PHP and CSS and MySQL for data storage.

6. Implementation and Results

The implementation and testing of the system was carried out using five personal

computers and one server with internet facilities meeting the minimum software and

hardware requirements. The five computers represent five different hospitals

collaborating on the use of resources and sharing information. When the application is

launched by the administrator, the administrator login page or authorization interface

comes on. The hospital’s administrator seeking authorization enters his username and

password in their respective columns in order to gain access into the system; it compares

the details with those of the administrator in the database and the system grants access to

administrator, the login interface is shown in Figure 2.


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Figure 2. Login Interface for Administrator

If access is granted for an authorized user (administrator), it leads to another interface

that displays the summary of doctors and patients in the hospital as shown in figure 3, the

administrator also have the option of adding a new patient to the database or to add a new

doctor, to view details (bio-data) of existing patients and doctors.

Figure 3. Login Access Interface for an Authorized Administrator

However, if an unauthorized user attempt to gain access into the system by entering

incorrect details (i.e. incorrect username and password); the system denies such user the

access as shown in Figure 4.

Figure 4. Unauthorized User Denied Access

A cloud administrator can also copy records of patients not in the local database from

the cloud into their system. Patients find themselves in different hospitals at any time for


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different reasons, they can tell the administrator to get a copy of their record that resides

in database of their last or former hospital from the cloud. Figures 5 and 6 shows the

interface where the cloud administrator copies record from the former hospital.

Figure 5. Cloud Administrator Interface to Copy Patients Record

Figure 6. Patients Record Transfer Section Interface

When the application is launched by the doctor, the doctor’s login or authorization

interface comes on. The doctor seeking authorization enters his username and password in

their respective columns in order to gain access into the system; it compares the details

with those of the doctor in the database and the system grants access to doctor, the login

interface is shown in Figure 7.

Figure 7. Login Interface for Doctors


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If access is granted to the authorized user (doctor), it leads to another interface that

welcomes the doctor and provides tab to view patients in the hospital’s record as shown in

figure 8, if the doctor clicks on the “view patient” tab, a page comes on that displays the

list of all the existing patients in hospital’s database. Against each patient’s name are two

tabs; “diagnose patient” and “view full details”. The “view full details” tab allow doctors

the view of only the bio-data of the patient, however, the “diagnose patient” tab displays

both the bio-data and the result of previous diagnosis of the patient. Also, there are

columns where laboratory, radiology and pharmacy information can be entered to

generate a new diagnosis report as shown in Figures 10 and 11.

Figure 8. Home Page Interface That Welcomes the Doctor

Figure 9. Interface Showing the List of Existing Patients

Figure 10. Diagnose Patient Interface


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Figure 11. Diagnose Patient Interface

7. Conclusion

In this paper, a complete, robust and efficient cloud-based EMR system has been

designed and implemented. Cloud computing has been identified generally as the next big

deal in computing infrastructure and it offers some benefits by allowing the use

infrastructures like networks, storages, and servers, software such as application programs

and platforms like operating systems and middleware services. Adapting the cloud

technology to medical record management, reduces the cost of healthcare delivery

through reduce administrative bottlenecks. The convenience this kind of system will give

to physicians, patients and hospital administrator especially in developing world cannot

be quantified. With time, it is hoped that hospitals, health care regulatory bodies and the

Health ministries in Nigeria will take advantage of innovations that are becoming

available through internet solutions to improve healthcare system. It is also hoped that

synergy among health care stakeholders will produce results expected from health care

organizations.

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Authors

Olutayo Boyinbode, PhD, she is a Senior Lecturer in the Computer Science

Department at the Federal University of Technology, Akure, Nigeria. Her research

interests are in Mobile Learning, Ubiquitous Learning, Cloud Computing and Mobile

Networks. She is a professional member of ACM and IEEE

.

Gbemga Toriola, is a Postgraduate student in the Computer Science Department at the

Federal University of Technology, Akure, Nigeria.


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Documents

CloudeMR: A Cloud Based Electronic Medical Record System · cloud central server that accepts virtual machines as tenants. The tenants are secure facilities that store information