JOURNAL OF COMPUTER SCIENCE AND ENGINEERING, VOLUME 13, ISSUE 2, JUNE 2012 16

Hospital Information Systems: A partial Integration

E. Mourtou

Abstract— In this paper, we explore the additional issues that stand-alone applications present for managing patient information, as well as our concerns about the problems associated with the clarity of data expression, as well as the interoperability with the Hospital Information System (HIS). While proper medical treatment depends among others on timely access to laboratory results, we have implement-ed a partial data integration between the HIS and the Laboratory Information System (LIS), through the use of link-based methods and map-ping techniques. Based on the patient unique registration number (RN), and due to the presence of a large number of patient data into the LIS, we first applied a deterministic linking method into the two databases, and then we exploited barcode technology for patient identification, succeeding so the development of new communications tools that are less expensive than a full integration of HIS and LIS in the context of the Greek financial crisis. Although we have not provided a full integration of both systems, partial integration can profitably be used not only to reduce the large amount of patient duplicates, but also to give the hospital a control mechanism of medical orders that arrive at the LIS, providing so savings from reduced tests expenses.

Index Terms—Barcode, HIS, Integration, LIS

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1 INTRODUCTIONN today’s world there is high demand for improving both the quality of healthcare and the overall health status of individuals. It is not surprising that national

healthcare systems are facing a number of challenges in the coming years and pose great opportunities to IT pro-fessionals. However, the diversity and complexity of e-health information systems combined with the fact that the data requested by different organisations is variable and subject to change over time, places great importance on the flexibility of information systems. According to the national eHealth roadmap for Greece that was launched by the Ministry of Health and Social Solidarity, new poli-cies in specific health applications and infrastructural is-sues are encompassing [1]. As patient medical data are often complex, healthcare professionals are faced with the challenge of information integration from heterogeneous data sources. Unfortu-nately, there are many gaps in the implementation of IT in public sector and they vary by institutional size and accreditation status. Almost 90 percent of Greek hospitals, for example, reported that they use HIS for administra-tion transactions across a number of departments, but not in the area of clinical process and activity-based analysis. Nearly 4, 87 percent of hospitals use electronic medical records and a 46, 34 percent partly uses electronic lab re-sults [2]. On the same subject we have to point out that very few public health professionals have received any training in informatics, while many of them still fear that

new technology could trace them. In addition, a number of considerations are raised in electronic healthcare envi-ronment, like confidentiality, privacy and ethic issues that must be properly faced. Many healthcare professionals still believe that the entering the patient data into the EMR would reduce their time with each patient. Also the high cost of EMR in conjunction with the low Greek budget has acted as a major stumbling block for integra-tion in electronic health applications in public hospitals. According to WHO, the Greek budget pays retrospective-ly for all hospital expenses incurred and so “the system is open-ended and demand-led, containing no incentives whatsoever to encourage cost-containment or efficient practices” [3]. However, some hospital medical depart-ments in order to improve the quality of patient care have implemented stand alone applications, in an effort to gain complete and accurate information about their patients. Although these applications are implementing modern ways to bring useful medical information to physicians, and to patients, they are not interoperable and hence are characterized as local systems. These systems partially overlap in their areas of concern and within those over-lapping areas heterogeneity arises at the following issues: Different data structures, Disparate sets of data, Different procedures codes for the same medical tests, Differences in query structure, and Manual handling of data between different information systems. Nevertheless, during the last two years and under the Memoranda of Economic and Financial Policies, a number of initiatives have been undertaken by the Ministry of Health to insure preserva-tion of digital information. These among others include hospital data collection in an on-line environment – called ESYNET platform, e-procurement, and e-prescription, as well as many activities relating to reducing health care

———————————————— • E. Mourtou is with the the School of Social Science of Hellenic Open Uni-

versity’s, Patras, GreeceBoulder.

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costs. For instance, the implementation of the Diagnosis-Related Group (DRG) into the Greek National Health Sys-tem as a refunding methodology, poses many challenges that surround the need to develop tools that permit the health professionals to manipulate the patient data from diverse sources in an integrated schema. Although inte-gration tools are not enough developed and applied in health informatics and despite the fact that public hospi-tals have not undertaken such large scale projects in the past, hospital information systems should take simple steps to address these issues radically and effectively enough. Before the development of complex and expen-sive strategies for complete data integration among all the heterogeneous isolated hospital databases, we could simply try to combine some –not all- types of data and learning knowledge from them in a single framework or algorithm [4]. As Tarczhy-Hornoth and Minie pointed out, “Intelligent parsing of queries, frequently involving natural language processing of both queries and sources, is becoming a key component of information access and retrieval” [5]. There is no need yet for an all inclusive Hospital Information System, while legacy information systems must not be easy to by-pass or render non-operational. Where appro-priate, it is essential to incorporate such systems into the workflow of a reliable HIS, instead of dropping them away. In this paper we first provide a broad overview of the HIS, the Local Clinical Information Systems (LCIS), and the Laboratory Information System (LIS) and their use in a Greek public Hospital. We also explore the addi-tional issues that stand-alone applications present for managing patient information and our concerns about the problems associated with the clarity of data expression, as well as the interoperability with HIS. Then we analyze a module that provide a partly data integration between the HIS and the LIS, through the use of link-based meth-ods and mapping techniques. We conclude the paper with discussion of medical data integration and future work of relevance.

2 AN OVERVIEW OF THE HOSPITAL DATABASES

In St. Andrew hospital (Patras, Greece), three main types of information system are implemented: a HIS, a number of LCIS and a LIS. The details of them are outlined below. 2.1 The Hospital Information System St Andrew Hospital in Patras, Greece, a 450-bedded hos-pital that serves a population of 200.000, in collaboration with the Computer Centre of Social Security Services (IDIKA SA), has implemented a Hospital Information System (HIS) that is based on the SCO-Unix operating system and Ingres II Enterprise Edition, providing so transparent access for application development, connec-tivity, and open information access across the Database Management System (DBMS). However, the HIS does not incorporate the specific workflow of medical depart-ments to over-come specific issues, like pacing details of pacemaker patients, endoscopy and lab reports, and input signs and symptoms associated with the diagnosis. We

could say that the HIS is mostly a database designed for patient registration and billing, rather than for medical information. For example, the HIS includes patient de-mographic data and medication, first-listed diagnosis and final diagnosis in ICD-10 codes, as well as physician iden-tification number, and total charges by DRGs, but it does not contain information about the clinical diagnosis (e.g.: diagnosis based on signs, symptoms, and laboratory find-ings), the differential diagnosis (e.g.: the determination of which one of several diseases may be producing the symptoms), as well as the physical diagnosis (e.g.: diag-nosis based on information obtained by inspection, palpa-tion, percussion, and auscultation) [6]. In addition, the HIS does not provide the physicians the opportunity to write details about their patients, like systolic blood pres-sure, or, physical examination, and known allergies to some class of medication that patients are being pre-scribed. Even textual medical information is not permit-ted by the system architecture and so patient medical da-ta are often missing from the EMR. In other words, there is no way to represent inside the HIS concepts such as “the disease progression during or following treatment with some medication” or “failure to achieve a satisfacto-ry response after some days of treatment”. Based on the above described limitations and to face the new challeng-es of modern information management to health data, we have extended the HIS to provide barcode technology for patient identification that has been shown to be feasible in several countries and associated with improvements in efficiency and patient benefits. Next we describe the pathway that barcode labels are created by the HIS dur-ing patient admission. When a patient is admitted to the hospital for the first time, a unique registration number (RN) is automatically generated by the HIS by the admission services. At the same time and by the same service at least forty Patient Barcode Identification (PBI) self-sticking labels are print-ed in order to be send to the ward that the patient is being admitted to, while in case that a patient changes ward, another set of barcode identification labels is printed with the new ward’s ID as well as the date of transfer. Barcode labels are also produced for out-patients. When a medical test is ordered for a patient, a barcode label is applied to the relevant specimen tube and the specimen is sent to the laboratory, where it is scanned eliminating so the manual-ly data entry of patients demographics into the LIS. Thus this comprises a solution guidance in how to perform better data retrieval that not only saves personnel time but also greatly reduces the risk of errors since the error rate for barcode data entry is less than one error per three million scans [7]. Figure 1 is a graphical view of the pa-tient information pathway from the moment of the pa-tient admission where barcode labels are created, to the laboratory where tests are provided.

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One core problem is illustrated in Figure 1, which is the dotted curve between the Emergency-patient and the HIS; meaning that these patients are not registered by the ad-mission office and thus no RN is assigned to them. The up-down arrow between the HIS and the LIS emphasizes the need for integration of both systems and although this process can be sound simple, indeed it is complex enough to implement and it will be analyzed in next sections.

2.2 The Local Clinical Information Systems Because of the absence of records about many levels

of patient hospitalization detail, and in order to provide a more detailed and useful medical information for patient, several hospital departments has developed LCIS, in co-operation with the Hospital Informatics Department (HID) and other vendors. In fact, these LCIS are designed as standalone applications mostly in Ms-Access environ-ment, not only because it is relatively easy to be imple-mented by non-expert users, but also because Ms-Access enables a good level of functionality for applications that would not be otherwise possible. However, it is very im-portant to realize, that there are many health-related con-cerns about the use of the LCIS: For instance, if a physiccian wants to study the relationship between the pacing details and the differential diagnosis, the names of both entities need to be correctly identified, while the unique patient identifier should be the same with the rel-evant identifier in the HIS, in order to integrate medical information gathered by both systems.

For these reasons, applications that were designed by the HID were configured with at least one unique prima-ry key in patient and staff demographics data tables that were exactly the same with the relevant tables of the HIS, taking into consideration a future integration of patient medical data with the HIS. Nevertheless, several LCIS developed by other vendors did not take account of all relevant considerations and possible constrains, including unique identification numbers, since the interconnections between the HIS and LCIS were not yet be envisioned. Many IT vendors created stand-alone systems provided with clinical documentation templates, and patient lists, but these systems require a great deal of customization in

order to function in a particular integrated hospital envi-ronment. It should be noted that many of these systems are not properly designed, and maintained, meaning that in many cases they did not take into account the range of possible queries that might be made of them, and they are not functioning as a whole, but as “isolated islands” of patient data [8].

2.3 The Laboratory Information System On the other hand, patient specimen processing is han-dled through the hospital’s LIS that has been applied suc-cessfully in many clinical laboratories including Hema-tology, Clinical Chemistry, Microbiology, and Serolo-gy/Immunology department. However, the LIS is not yet integrated with the HIS, and thus physicians have no on-line access to lab reports of their patients; they are waiting for papers reports and this is not only impractical for the time-sensitive medical information, but also it might be critical for patient. Similarly medical test orders are still handwritten and so there is no controlled mechanism to manage the necessity of them; stated another way, in some cases medical orders may arrive at the LIS for hos-pital visitors and not for in-patients, thus resulting nega-tive consequences in terms of additional hospital costs, and the provision of State funding to cover such costs would not constitute an economic advantage. In addition, the LIS involves considerable complexity since it consists of different data structures than the HIS, and it is con-nected to medical devices (e.g., chemical and electrolyte analyzers). Despite the complexity and to enable data interoperability, the LIS supports the Health Level 7 (HL7) protocol since it is the dominant messaging stand-ard for transfer of clinical information. Unfortunately not all LCIS exchange HL7 messages and the HIS has not adopted yet the HL7 standard as well [9]. In order to overcome the limitation of HL7 missing, the first step is to apply a number of mapping techniques to the minimum amount of information necessary, namely to a number of patient demographics and identifiers between the LIS and the HIS, which are outlined in the following section.

3 Building Integration Techniques The basic idea of the integration is that when a blood sample arrives at the LIS, the user of the LIS at first should connect to the HIS through a barcode reader, to search and find the patient RN, instead of manual writing it. Then all the patient relevant information (e.g.: de-mographics) is transferred into the LIS, and this is the critical part to successful linking of both systems: Alt-hough patient digital information is moved through two different databases, this particular linkage provides the opportunity to develop new communications tools that are less expensive than a full integration of HIS with LIS in the context of the Greek financial crisis. To enable the LIS applications (in MSSQL) to access the HIS (Ingres II) data through Structured Query Language (SQL), a number of techniques has been successfully ap-

© 2012 JCSE www.journalcse.co.uk

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plied, in collaboration with the IDIKA SA and the LIS vendor, and according to Ingres Administrator’s Guide. Foe example, the appropriate ODBC drivers and gate-ways to the host have been installed, as well as a virtual node on Ingres database was created and defined. Since we have focused on the concept of mapping techniques, the details of installation and creation are not thoroughly discussed in this paper. Also, integration process that is the core of the method is not a simple task, because a large number of patient data is already present into the LIS and so this process brings with it the danger of dupli-cates. Therefore, the fundamental basis of the integration of HIS with the LIS during the barcode reading is to apply a deterministic linking method in order to establish an association between patient files into the two databases by searching for an exact match against a given set of search keys or specific criteria [10]. At this point we have to mention that in a previous work, to make the HIS more suitable for integration, we applied a combination of de-terministic and probabilistic search methods to decrease the duplicates [11]. In addition, similar processes have taken place into the LIS and a great number of finding duplicates have been merged. First we have to specify the two basic tables that include patient data information from both tables of HIS (pat_h) and of LIS (pat_l), namely the data fields, their data type, and their attributes based on both DBMS requirements (Yes or No), and they are described in table 1.

As seen in Table1, both tables have similar structure, but pat_l table instead of containing the RN as the required patient identifier that is of great importance to the linking approach, and to the utilization of the barcode reading mechanism, it encompasses the specimen record number. Next step is the identification of a threshold above which pairs will be taken as linking, namely, to obtain a list of the necessary data elements that may determine the pos-sible duplicates. This means that we have to establish the specific criteria about which patient data need to mach exactly, according to the deterministic linking [12], in or-der to consolidate and maintain all the data fields for both datasets. To alleviate potential computational perfor-mance problems associated with this approach, we have identified a core set of criteria based on which queries will be performed frequently. The selected criteria for the deterministic linking were decided to be Last name, First Name, Middle Name and sex. Then a cross tab query is being designed that intends to find all patients from the pat_l table and their RN from the basic table pat_h, according to the following algo-rithm, where letters h and l represent the source tables (e.g. letter h indicates the pat_h table and letter l indicates the pat_l table): select h.RN, l.last_name, l.first_name, l.middle_name , l.sex, from pat_h h, pat_l l where h. last_name = l. last_name and h. first_name = l. first_name and h. middle_name = l. middle_name and h.sex = l.sex

order by last_name, first_name, middle_name, sex, RN commit; The results of the above query showed 30.000 patients exactly under the same four criteria fields, and for fast retrieval they were stored in the temporary “patient_l_h” table with a heap structure [13], and five columns in an alternative location “loc_temp”. However, among the number of 32.500 patients of LIS, 2.500 patients of the LIS have not been identified by our analysis, and thus deci-sions had to be taken by the Administrative Hospital Board whether to approve, edit, or reject this data infor-mation for the integration schema. The main reason to explain why these patients are not included into the HIS is that in case of emergency patients were not registered by the admission office during the time interval 23:00- 07:00, and before to apply the barcode label technique, and this means that no RN was assigned for them, yet medical tests were ordered and taken place by the LIS. To explain why this occurred, consider the following scenar-io: a patient has visited or transferred to the hospital emergency room, with signs of gastrointestinal symptoms including nausea, vomiting, and abdominal pain. Since the medical tests have shown that he has not a serious health problem, just suffering from a simple viral infec-tion, he is given then the first aid and medical advice, and goes home. Although this patient is recorded into the LIS database, on a contrary he is not registered into the HIS, and this constitutes an example of some reasons on the gaping hole in the Greek hospital budgets. In order to

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maintain an accurate picture of the overall hospital pa-tient information, the Administrative Hospital Board de-cided that the unregistered 2.500 patients of the LIS should be imported to the HIS database, and this task was rather easily done by the hospital Department of Infor-matics, based on the assumption that all of these patients were outpatients and they occur as data independently of medical department (e.g. cancelled appointments). At this time, the basic pat_h table was successfully updat-ed and the HIS was prepared for accessing the barcode reading mechanism, through the following plan: First the barcode reader scans the PBI from the specimen, opens the link for connection with the HIS, and through an ap-propriate procedure “proc_1” it opens the pat_h table, finds the RN of the patient, reads the respective fields and insert them via the link for LIS connection into the pat_l table by calling a second procedure “proc_2”. In case that a field in pat_h table has changed (e.g. phone number), then the respective field in pat_l table is updated. In case that no change exists, then there is no update in pat_l ta-ble. In both cases, since the patient is authenticated, the medical order process proceeds as usual for the collected sample at the LIS. However, in case that the RN of the patient has not been found in the pat_h table, then the LIS user receives an error message, like that: Error 99; the pa-tient is not found. Then the LIS user has a number of op-tions including the scanning repeat, asking to search for the patient name directly from the LIS DBMS, asking for hospitals admission office to authenticate the patient through the RN, or entering the patient data directly to the LIS. At this point we have to remember that on the patient barcode identification self-sticking labels are writ-ten besides the patient RN, and the unique PBI, also the patient’s first and last name. At the moment, all of the above options exist, due to the technical and hospital pol-icy challenges facing the development and deployment of the partial linking of LIS with HIS.

4 CONCLUSION AND DISCUSSION Our implementation of the barcode-based linking method consists of an authentication search of a basic patient data table on the HIS followed by inserting the authenticated patient data into a relevant patient data table on the LIS. Although our linkage method does not provide a full integration of both systems, it can profitably be used not only to reduce the large amount of patient duplicates, but also to give the hospital a control mechanism of medical orders that arrive at the LIS: Only tests order for authenticated hospital pa-tients are provided and, also savings from reduced tests expenses are provided. However, the process of partial integration of both sys-tems has shown the existence of many organizational problems that directly effect the linking implementa-tion. One serious problem is that out-patients that visit the hospital emergency room during the night are still not registered by the admission office, and thus they are not assigned by a RN, in order to be recognized by the HIS. No one denies that for these patients medical

tests must be provided, and this is the main reason that we have allowed the forth option to the LIS users, namely to enter the patient data directly to the LIS. Unfortunately, the hospital admission office is staffed only during normal working hours and it is not man-datory to be staffed during the night. Before the partial integration of LIS with HIS, patient data for medical tests provided for this-case patients, were not entered into the HIS, but this has stopped after the testing pro-cess: Every morning the Admission office enters all patient data into the HIS, not only for inpatients but also for the afore mentioned cases. Another problem that frequently arises is errors during the barcode reading, which depends on quality as-sessments coming from the manufacture of the bar-code reader, and the quality of the scanned barcode label. To address these problems, barcode devices must meet the basic quality standards, while the prop-er environmental lighting and conditions must be fac-tored into the relevant applications and inside the hos-pital laboratories [14]. An additional problem is that in order to maintain the validity of the links between the relevant tables of both DBMS, some modification of their structure is required. For example, it is possible conflicts to occur, because each client manages its own connection to each accessed file, and this could lead to an inconsistent database state. That is the reason that we used the ISAM structure, which as Ciardulli noted “is ideally suited to static or slowly growing tables with a static range of key values where range or partial key searches are required” [15]. Further, the proper fill factor should be set to 80% not only to leave space for more additions, but mostly because the tables are go-ing to be updated on a periodic basis [16]. One of the major concerns of the implementation of the integration is the definition of users and roles within the HIS and LIS for access, and the validation of users who are granted access to both systems, especially when the access has terminated. From a technical per-spective, it is essential to be sure that specified classes of security events are properly recorded in audit files for later analysis, and it is critically important to be able to define and implement a plurality of user-defined rules that contain security constraints for se-cure accessing of the medical information and receiv-ing a request at a user interface. Although we have managed to partly integrate the HIS with the LIS based on the patient unique registration number, many steps are required in order to cover all stages of the laboratory procedure, from the specimen receipt up to the final result delivery. Since proper medical treatment depends on timely access to accu-rate patient laboratory orders and results, full system integration should include automated orders receiv-ing, automated work list, automated procedures and validations during all phases of laboratory procedure, and appropriate distribution of the results to the de-mand points. Apart from the high cost of the full inte-gration, a number of important challenges are faced in order to facilitate the secure and accurate data among

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hospital departments. For example, medical procedure codes into the LIS should be first converted to a more properly demanded terminology, such as ICP, or to a mandatory standard coding system. In order to ad-dress a number of relevant considerations, including administrative, organizational, and operational measures, the Greek Ministry of Health and Welfare has recently established the Greek nomenclature and coding of the medical procedures as mandatory in eve-ry hospital medical processes. If criticism is to be made, it should be of Administrative Hospital Board who insists on keeping rock solid in terms of the re-form of hospital budget, cutting the cost from ICT that could solve integration tasks, and could also create structured resources that can be accessed by other hospital informatics applications. Having partial integrated LIS and HIS, our future re-search direction focuses on consolidating or integrat-ing all the hospital Local Clinical Information Systems as well as the regional health centers that belong to the hospital, improving so the transparency and the ex-change of sensitive medical information.

ACKNOWLEDGMENT The authors wish to thank Triantafyllos Samartzis who is involved in development of hospital information systems for IDIKA SA, for providing valuable insights about the integration method.

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E. Mourtou List of degrees: 1. PhD: Department of Business Administration, University of Patras, Greece (2005 - 2008) 2. First MSc degree: Mathematics of Computers and Decision Mak-ing, Department of Computer Engineering and Informatics, co-operating with the Department of Mathematics of the University of Patras, Greece (1999-2001) 3. Second MSc degree: Health Care Management, School of Social Science of Hellenic Open University (2002-2004) 4. Third MSc degree: Management of National Health Care System Services, School of Social Science of Hellenic Open University (2003-2004) 5. First Diploma degree: Department of Mathematics, University of Patras, Greece (1977-1981) 6. Second Diploma degree: Department of Biology, University of Patras, Greece (1984 – 1987) Employment: Current position (1987 - today): Head of Informatics Department of St. Andrew General Hospital, Patras, Greece, Current position (2008 - today): Tutor of the Hellenic Open University, School of Social Sci-ence in the Postgraduate Course of Health Care Management, and Tutor the Technological Educational Institute (TEI) of Patras, School of sciences of health & care, Department of Nursing Publication information

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27 papers, Chapter 2: “Modeling access control in healthcare organ-izations” in the book “Certification and Security in Health-Related web applications: Concepts and Solutions”, pp. 23-44, 2011, Pub-lished in the United States of America by Medical Information Sci-ence Reference (an imprint of IGI Global), ISBN 978-1-61692-895-7 (hardcover), ISBN 978-1-61692-897-1 (ebook), and Chapter 25: “Health Information Systems: Access levels and vulnerabilities”, in the book: “Collaborative Internet and Society”, Series: Society and Informatics, pp. 955-1000, edited by J. Apostolakis, Published in Greece by Papazisis house, ISBN 978-960-02-2565-5. Current research interests: Research in Logistics and Financial Ap-plications for the hospitals’ administration service, Statistical evalua-tion of hospital Medication and Supplies purchase, Development of WEB access for the Medicine and Nursing Service of the hospital, Statistical evaluation of hospital’s chemotherapy expenditure, Devel-opment of codification of the hospital’s Medical and Supplies and Surgical Equipment, Research in hospital’s upgraded cabling infra-structure to support local network and databases with new genera-tions of copper and fiber.