Blockchain Papers

Alex Roehrs, Cristiano André da Costa, Rodrigo da Rosa Righi, Valter Ferreira da Silva · 6 authors

No abstract is available for this record.

Ian Mitchell, Sukhvinder Hara

No abstract is available for this record.

Anuraag A Vazirani, Odhran O’Donoghue, David Brindley, Edward Meinert

BACKGROUND: The decentralized nature of sensitive health information can bring about situations where timely information is unavailable, worsening health outcomes. Furthermore, as patient involvement in health care increases, there is a growing need for patients to access and control their data. Blockchain is a secure, decentralized online ledger that could be used to manage electronic health records (EHRs) efficiently, therefore with the potential to improve health outcomes by creating a conduit for interoperability. OBJECTIVE: This study aimed to perform a systematic review to assess the feasibility of blockchain as a method of managing health care records efficiently. METHODS: Reviewers identified studies via systematic searches of databases including PubMed, MEDLINE, Scopus, EMBASE, ProQuest, and Cochrane Library. Suitability for inclusion of each was assessed independently. RESULTS: Of the 71 included studies, the majority discuss potential benefits and limitations without evaluation of their effectiveness, although some systems were tested on live data. CONCLUSIONS: Blockchain could create a mechanism to manage access to EHRs stored on the cloud. Using a blockchain can increase interoperability while maintaining privacy and security of data. It contains inherent integrity and conforms to strict legal regulations. Increased interoperability would be beneficial for health outcomes. Although this technology is currently unfamiliar to most, investments into creating a sufficiently user-friendly interface and educating users on how best to take advantage of it would lead to improved health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/10994.

Yu Rang Park, Eunsol Lee, Wonjun Na, Sung-Jun Park · 6 authors

BACKGROUND: There are many perspectives on the advantages of introducing blockchain in the medical field, but there are no published feasibility studies regarding the storage, propagation, and management of personal health records (PHRs) using blockchain technology. OBJECTIVE: The purpose of this study was to investigate the usefulness of blockchains in the medical field in relation to transactions with and propagation of PHRs in a private blockchain. METHODS: We constructed a private blockchain network using Ethereum version 1.8.4 and conducted verification using the de-identified PHRs of 300 patients. The private blockchain network consisted of one hospital node and 300 patient nodes. In order to verify the effectiveness of blockchain-based PHR management, PHRs at a time were loaded in a transaction between the hospital and patient nodes and propagated to the whole network. We obtained and analyzed the time and gas required for data transaction and propagation on the blockchain network. For reproducibility, these processes were repeated 100 times. RESULTS: Of 300 patient records, 74 (24.7%) were not loaded in the private blockchain due to the data block size of the transaction block. The remaining 226 individual health records were classified into groups A (80 patients with outpatient visit data less than 1 year old), B (84 patients with outpatient data from between 1 and 3 years before data collection), and C (62 patients with outpatient data 3 to 5 years old). With respect to mean transaction time in the blockchain, C (128.7 seconds) had the shortest time, followed by A (132.2 seconds) and then B (159.0 seconds). The mean propagation times for groups A, B, and C were 1494.2 seconds, 2138.9 seconds, and 4111.4 seconds, respectively; mean file sizes were 5.6 KB, 18.6 KB, and 45.38 KB, respectively. The mean gas consumption values were 1,900,767; 4,224,341; and 4,112,784 for groups A, B, and C, respectively. CONCLUSIONS: This study confirms that it is possible to exchange PHR data in a private blockchain network. However, to develop a blockchain-based PHR platform that can be used in practice, many improvements are required, including reductions in data size, improved personal information protection, and reduced operating costs.

David M. Maslove, Jacob Klein, M. Kathryn Brohman, Patrick Martin

BACKGROUND: Blockchain technology is emerging as an innovative tool in data and software security. OBJECTIVE: This study aims to explore the role of blockchain in supporting clinical trials data management and develop a proof-of-concept implementation of a patient-facing and researcher-facing system. METHODS: Blockchain-based Smart Contracts were built using the Ethereum platform. RESULTS: We described BlockTrial, a system that uses a Web-based interface to allow users to run trials-related Smart Contracts on an Ethereum network. Functions allow patients to grant researchers access to their data and allow researchers to submit queries for data that are stored off chain. As a type of distributed ledger, the system generates a durable and transparent log of these and other transactions. BlockTrial could be used to increase the trustworthiness of data collected during clinical research with benefits to researchers, regulators, and drug companies alike. In addition, the system could empower patients to become more active and fully informed partners in research. CONCLUSIONS: Blockchain technology presents an opportunity to address some of the common threats to the integrity of data collected in clinical trials and ensure that the analysis of these data comply with prespecified plans. Further technical work is needed to add additional functions. Policies must be developed to determine the optimal models for participation in the system by its various stakeholders.

Asoke K. Talukder, M. Chaitanya, David Arnold, Kouichi Sakurai

Studies suggest that a significant proportion of the diagnosis in non-communicable diseases (NCD) is erroneous, unwanted, or unnecessary. To reduce the disease burden and improve public health, algorithmic support is essential. To realize this, health data must be computer understandable, secured, ubiquitous, and interoperable. Medical and disease data entered into computers are unstructured natural language texts with medical jargons which a computer normally cannot understand. EMR (Electronic Medical Records) are data silos in the hospital and do not interoperate. In this paper we present Ethereum based future ready Proof of Disease (PoD) consensus protocol with a computer understandable single instance of truth. It will solve many challenges that electronic health records (EHR) or health information exchange (HIE) have failed to address. This medical system will help achieve all the complex needs of P6 (Participatory, Personalized, Proactive, Preventive, Predictive and Precision) medicine and finally reduce the disease burden.

Michael L. Gagnon, Grant Stephen

Associating the health-related records and transactions of patients with their numerous “identities” as they interact with different healthcare providers, payers, pharmacy benefit managers and other entities is an expensive and complex problem. With many years of experience addressing this issue in different healthcare systems and Health Information Exchanges (HIEs), it is apparent that there is now a compelling and relatively straightforward technical solution for this problem. Presented here is a broadly feasible and technically compelling argument for a blockchain-based approach to addressing these issues. At the same time, challenges ahead and potential strategies to address them are discussed. Keywords: Blockchain; Master Patient Index; MPI; Distributed Ledger; Patient Identity; HIE; HealthInformation Exchange

Leslie Mertz

Work is already underway to bring blockchain technology to the healthcare industry, and hospital administrators are trying to figure out what it can do for them, their clinicians, and their patients. That includes administrators at Beth Israel Deaconess Medical Center, a leading academic medical center located in Boston.

Mark Gaynor, Betsy Tuttle, Allison Roe

In this paper, we present the applications of blockchain technology in healthcare. Furthermore, we evaluate the choice and deployment of Blockchain technology in such applications, review the advantages and disadvantages of such an approach. We review the Estonian system, which is the first blockchain-based health system at the national level, in detail and discuss its ramifications to Turkey. This paper is one of the first papers in this domain and, to the best of authors' knowledge, the first in Turkish.

Katharine Gammon

No abstract is available for this record.

Patrick Mangesius, Johannes Bachmann, Thomas Healy, Samrend Saboor · 5 authors

INTRODUCTION: Interoperability of health information systems is one of the key challenges of modern healthcare systems. A weak spot in this technology stack of interoperability protocols as defined by HL7 and IHE is cross affinity domain exchange of access control information and policies. In several industries the Blockchain technology had a major breakthrough. The goal of this paper is to elaborate how to exchange cross affinity domain access information enhancing well established IHE networks with block chain technology. METHODS: Using literature analysis and research on current interoperability standards the state of the art of securely exchanging medical information was elaborated. We enhanced this system with the capabilities of the peer2peer based Blockchain network elaborating the workflows of exchanging the access control specific information. RESULTS: We extended an IHE based affinity domain by adding a block chain ledger to the deployment. This ledger is fed with XACML based policies which are propagated through the peer2peer based system. Using the Blockchain protocol other affinity domains are informed of the change and can retrieve the information. Acting as an additional source of policies and consents the policy decision point is capable of querying this network and building a decision based on the retrieved information.

Weiß Jan-Patrick, Tobias Welzel, Bernd J. Hartmann, Hübner Ursula · 5 authors

BACKGROUND: Diabetes mellitus is one of the most prominent examples of chronic conditions that requires an active patient self-management and a network of specialists. OBJECTIVES: The aim of this study was to analyze the user and legal requirements and develop a rough technology concept for a secure and patient-centered exchange platform. METHODS: To this end, 14 experts representing different stakeholders were interviewed and took part in group discussions at three workshops, the pertinent literature and legal texts were analyzed. RESULTS: The user requirements embraced a comprehensive set of use cases and the demand for "one platform for all" which is underlined by the right for data portability according to new regulations. In order to meet these requirements a distributed ledger technology was proposed. CONCLUSION: We will therefore focus on a patient-centered application that showcases self-management and exchange with health specialists.

Ming Chao Wong, Kwang Chien Yee, Christian Nøhr

Blockchain technology is often considered as the fourth industrial revolution that will change the world. The enthusiasm of the transformative nature of blockchain technology has infiltrated healthcare. Blockchain is often seen as the much needed and perfect technology for healthcare, addressing the difficult and complex issues of security and inter-operability. More importantly, the "value" and trust-based system can deliver automated action and response via its smart contract mechanism. Healthcare, however, is a complex system. Health information technology (HIT) so far, has not delivered its promise of transforming healthcare due to its complex socio-technical and context sensitive interaction. The introduction of blockchain technology will need to consider a whole range of socio-technical issues in order to improve the quality and safety of patient care. This paper presents a discussion on these socio-technical issues. More importantly, this paper argues that in order to achieve the best outcome from blockchain technology, there is a need to consider a clinical transformation from "information" to "value " and trust. This paper argues that urgent research is needed to address these socio-technical issues in order to facilitate best outcomes for blockchain in healthcare. These socio-technical issues must then be further evaluated by means of working prototypes in the medical domain in coming years.

Rui Guo, Huixian Shi, Qinglan Zhao, Dong Zheng

Electronic Health Records (EHRs) are entirely controlled by hospitals instead of patients, which complicates seeking medical advices from different hospitals. Patients face a critical need to focus on the details of their own healthcare and restore management of their own medical data. The rapid development of blockchain technology promotes population healthcare, including medical records as well as patient-related data. This technology provides patients with comprehensive, immutable records, and access to EHRs free from service providers and treatment websites. In this paper, to guarantee the validity of EHRs encapsulated in blockchain, we present an attribute-based signature scheme with multiple authorities, in which a patient endorses a message according to the attribute while disclosing no information other than the evidence that he has attested to it. Furthermore, there are multiple authorities without a trusted single or central one to generate and distribute public/private keys of the patient, which avoids the escrow problem and conforms to the mode of distributed data storage in the blockchain. By sharing the secret pseudorandom function seeds among authorities, this protocol resists collusion attack out of N from N -1 corrupted authorities. Under the assumption of the computational bilinear Diffie-Hellman, we also formally demonstrate that, in terms of the unforgeability and perfect privacy of the attribute-signer, this attribute-based signature scheme is secure in the random oracle model. The comparison shows the efficiency and properties between the proposed method and methods proposed in other studies.

Peng Zhang, Douglas C. Schmidt, Jules White, Gunther Lenz

No abstract is available for this record.

Peng Zhang, Jules White, Douglas C. Schmidt, Gunther Lenz · 5 authors

Secure and scalable data sharing is essential for collaborative clinical decision making. Conventional clinical data efforts are often siloed, however, which creates barriers to efficient information exchange and impedes effective treatment decision made for patients. This paper provides four contributions to the study of applying blockchain technology to clinical data sharing in the context of technical requirements defined in the “Shared Nationwide Interoperability Roadmap” from the Office of the National Coordinator for Health Information Technology (ONC). First, we analyze the ONC requirements and their implications for blockchain-based systems. Second, we present FHIRChain, which is a blockchain-based architecture designed to meet ONC requirements by encapsulating the HL7 Fast Healthcare Interoperability Resources (FHIR) standard for shared clinical data. Third, we demonstrate a FHIRChain-based decentralized app using digital health identities to authenticate participants in a case study of collaborative decision making for remote cancer care. Fourth, we highlight key lessons learned from our case study.

William J. Gordon, Christian Catalini

Interoperability in healthcare has traditionally been focused around data exchange between business entities, for example, different hospital systems. However, there has been a recent push towards patient-driven interoperability, in which health data exchange is patient-mediated and patient-driven. Patient-centered interoperability, however, brings with it new challenges and requirements around security and privacy, technology, incentives, and governance that must be addressed for this type of data sharing to succeed at scale. In this paper, we look at how blockchain technology might facilitate this transition through five mechanisms: (1) digital access rules, (2) data aggregation, (3) data liquidity, (4) patient identity, and (5) data immutability. We then look at barriers to blockchain-enabled patient-driven interoperability, specifically clinical data transaction volume, privacy and security, patient engagement, and incentives. We conclude by noting that while patient-driving interoperability is an exciting trend in healthcare, given these challenges, it remains to be seen whether blockchain can facilitate the transition from institution-centric to patient-centric data sharing.

Thomas F Heston

Blockchain technology is a system of creating an immutable, secure, distributed database of transactions. Blockchains were initially created to provide a distributed ledger of financial transactions that did not rely upon a central bank, credit company, or other financial institution. The technological breakthrough, however, has been extended to transactions involving legal matters, medical records, insurance billing, and smart contracts. One primary way that blockchain technology is important to healthcare professionals in that it can revolutionize medical database interoperability. This greater interoperability can help improve access to medical records, imaging archives, prescription databases. Given that a patient’s medical history is a primary cornerstone of good medicine, blockchain technology has the potential to dramatically improve medical care.

Warren S. Sandberg

Rarely in medicine does one observe the adoption of a new technology as it moves from infancy (and a domain of early adopters) into the realm of widespread, general use. Anesthesiologists may be an exception; they have long been in the vanguard of new technology adoption as a part of an ongoing quest for improved patient safety. More recently, however, technological developments in anesthesiology have involved information systems. These systems' potential to improve patient care is not so traditionally obvious as something such as a new physiologic monitor or a better anesthesia machine. Hence, the adoption of anesthesia information management systems (AIMS) has been slow, in part, because they are regarded as expensive, “optional” technology with little direct patient benefit. However, a new study by Halbeis et al. indicates a sharp uptick in the number of academic anesthesia departments that are either in the process of installing an AIMS, or have allocated resources to do so in the near future.1 The authors suggest that adoption of AIMS in academic departments is passing through a “tipping point,” as defined by Gladwell, wherein a new idea catches on and penetrates the culture widely.2 In other words, AIMS appear on the verge of completing the adoption lifecycle. Suddenly, anesthesia departments are finding themselves heavily involved in information systems (IS) either as clients or, in many cases, as the “business owners” of their own IS groups. Once installed, AIMS applications quickly become critical to the department's financial health and daily clinical activities. This focuses a sharp lens on the resources required to operate an AIMS. Limited IS funds and competition for priority are frequently cited reasons for delayed or deferred AIMS adoption in the Halbeis et al. study.1 This state of affairs commands attention from potential AIMS adopters, as every center with any substantial AIMS experience has learned that the acquisition and implementation costs are only part of the total cost of AIMS ownership. There is also a continuing requirement for application and system support that must be reliably met, so that the AIMS continues to meet changing clinical and administrative demands. What are the resources required to ensure initial and ongoing AIMS success? An AIMS requires dedicated personnel, not just for implementation, but also for ongoing support of the software, the associated hardware, maintenance and modifications of the user interface, and development and implementation of new functionalities. The specifics of how these resources are provided, which budget(s) they are supported by, and under whose jurisdiction they fall in the organizational chart differ widely, ranging from all support provided by hospital-wide IS departments to all AIMS activities being supported by the anesthesia department. Despite the disparate organizational features of the AIMS-dedicated IS resources, there are key roles that are common and easily identified in organizations with a successful AIMS. These roles must be anticipated and filled by departments considering an AIMS installation. First, there must be a competent, committed clinical champion—an individual familiar with the anesthesia workflow of the department who can both set up the AIMS interface and keep the interface up to date as the needs of the department change. This person must understand the capabilities and limitations of the AIMS well enough to know what can and cannot be accomplished when setting up the AIMS in order to match the operating room workflow. Almost always, this person is an anesthesiologist with facility in software, computer hardware, medical device interfaces, or database management. Given that none of these topics is addressed during anesthesia residency, such individuals are rare. The AIMS clinical champion should participate in product selection, so that their expertise regarding local anesthesia workflow, practices, and expectations may influence the selection of an AIMS whose capabilities most closely match the clinical setting. Here we encounter a Catch-22. How would the AIMS expertise required to make an informed selection develop in a department preparing to select its first AIMS? Frequently, a clinician with some prior interest and acknowledged ability in personal computing is nominated, and an informal consultation network with existing AIMS users is established. The process repeats for each new department selecting an AIMS; very few centers have been through the process more than once. Fundamental questions such as “How much of the clinician's time will selection and implementation require?” are negotiated anew each time. Given the financial and practice-impact issues at stake, AIMS selection is an area ripe for the development of capability and professionalism. The clinical champion must either be capable of maintaining the AIMS software and databases themselves, or be assisted by a software engineer, database administrator or programmer analyst with sufficient cross-training to work in all of the aforementioned specialties. For a multi-specialty anesthesia practice, this “AIMS engineer” role typically requires a full-time professional. Increasingly, hospital IS include electronic health records, provider order entry systems, and computerized lab result systems, all of which must interface with the AIMS. This increases the complexity of the programming/engineering services required, and potentially calls for more than one full-time equivalent person in the AIMS engineer role. The AIMS is literally and figuratively at the interface between medical devices and medical information systems. Thus, a successful AIMS requires constant attention from biomedical personnel (usually a biomedical engineer) who has sufficient IS background to set up, maintain and troubleshoot the physical connections and interfaces between the anesthesia equipment, intraoperative monitors, and the AIMS. Problems with these connections have resulted in medico-legal liability and losses that offset the value of the AIMS.3 Because this maintenance and troubleshooting capability must be available, or at least on call during all times the AIMS is in use, multiple individuals are typically required. Behind the scenes, perhaps the largest end-user of any AIMS is actually the anesthesia billing office. Because the AIMS functions required to support a successful billing operation are quite distinct from the clinical implementation, maintenance and development efforts, one or more separate, dedicated programmer analysts are often required to support the business functions. As mentioned above, no two organizations are alike in the exact configuration, governance, and funding of the resources supporting the AIMS. However, each of the half-dozen departments with established, successful AIMS implementations have either provided or secured personnel to fill these roles. For many early adopters, the resources were secured “on the fly,” as it became clear that the AIMS would founder without them. In successful programs the resources applied are not aberrations but, practically speaking, are quite homogeneous with respect to full-time equivalent clinicians, engineers, programmers and analysts across the various institutions. Every organization contemplating an AIMS installation should plan for these requirements or risk appearing ill-prepared when they must be urgently met. Installing an AIMS brings the anesthesia department into the world of operating room medical information systems demanding new personnel and capabilities, and ongoing resources to support this new operation. Can there be additional benefits, beyond the obvious (better charting) from the new expertise and expense? The Halbeis et al. study provides a hint: upcoming AIMS adopters strongly value improved data collection for clinical, quality assurance, and safety purposes, and to support clinical research as reasons for installing an AIMS.1 The early adopters have demonstrated the added benefits of having an AIMS, with examples such as easy retrospective searches for Quality Assurance/Quality Improvement purposes, easy reporting for “pay-for-performance” purposes, a platform for active quality management (including documentation quality related to billing, which justifies the cost), and a platform for managerial decision support.4–10 However, in virtually every case reported, the “out of the box” AIMS product was insufficient to provide the extra value. Instead, the considerable resources applied by the early adopters were used to modify or extend the capabilities of the AIMS. In some cases, AIMS vendors have incorporated new functionalities into their products in response to user examples or demands.3 However, the current offerings still do not perform all of the functions that a department will desire. The take-home message is that when planning for AIMS acquisition, anesthesia departments and hospitals must specify in their requests for proposals the additional personnel and list the additional functionalities to be developed, in addition to the capital and software acquisition and installations costs. Departments should develop their own requirements for additional AIMS functionalities, but should start by searching the medical literature. Almost without exception, what is known about AIMS modifications and additional functionalities has been published in peer-reviewed journals. In other words, the fundamental proof-of-concept reports about various additional functionalities and their operational and/or financial impacts are readily available. This is not to say that there is nothing more to be learned; the available reports merely scratch the surface, but the current body of knowledge is available and searchable. Thus, when developing additional requirements, the key reliance should be on the applicable scientific literature. In addition to the selected examples cited above, review of the AIMS-related literature indicates that AIMS-mediated improvements in anesthesia are related to the process of care (e.g., on-time antibiotics), billing, managerial decision-support, etc. In contrast to electronic health record systems in primary care settings, the time course of the data flow from (input) → AIMS → (output) is seconds to minutes as compared to hours to weeks. This compressed time frame may be a key differentiator between AIMS and other electronic medical record systems. A traditional medical informatics approach may not be ideally suited to advancing knowledge and capabilities. Instead, the early AIMS adopters are moving towards automated process monitoring and process control. The general form is as follows: Process modeling to create a reference process against which actual process progress can be compared, seeking noteworthy exceptions. Data integration of multiple electronic sources and different data types. Continuous process monitoring by recursive queries of the AIMS and other databases to identify process exceptions. Pushing data to key stakeholders, seeking to provide the right information to the person who needs it, at the time when it is most useful. The skills required to build these capabilities are closer to industrial engineering and scientific programming than to medical informatics. Anesthesia departments contemplating AIMS adoption must also think about how to get that expertise into their organizations. There is a significant risk to AIMS success that is still at hand, but little discussed. All of the successful AIMS implementations that have produced added value beyond simpler charting have been systems that were either developed by the implementers themselves, were products that the vendors modified in response to customer requests, were products that allowed additional software to be run on top of the AIMS, or some combination of these. Each of these AIMS products could be considered an anesthesiology-oriented product, and is frequently a standalone application. However, many hospital IS departments are seeking to cover all of the hospital's needs with one monolithic solution from a single vendor. Thus, there is a potential conflict among AIMS-users and AIMS-purchasers (i.e., the hospital) over a fundamental choice between vendors producing systems that serve anesthesia well (but are mute with respect to the rest of the hospital's needs), and vendors producing systems that cover more areas but may not perform the AIMS function very well. Depending on the hospital IS department's orientation, the larger software vendors' products may have a significant sales advantage. However, the AIMS adopters who have reported value-adding successes in the peer-reviewed literature have, to date, voted with their feet in favor of products over which they have the most control. Although AIMS adoption may have tipped in favor of implementation at academic centers, the technology as a whole is still vulnerable, perhaps more so because of the increased exposure to demanding users and high expectations for benefits that the out-of-the-box products do not provide. The potential for frustration and missed opportunities is high, as not all centers will succeed in selecting an optimal product, or in securing the resources to adapt the AIMS to best meet their needs. Hence, AIMS vendors would be well advised to attend to the users' needs themselves.

César Sánchez, Edwin Triana, Eduardo Romero

This article presents a web oriented telehealth platform adapted to the social and economic conditions of a developing country like Colombia. The platform aims to satisfy health care needs integrating modules for telemedicine, where medical processes are modelled following the HL7 Reference Information Model which has allowed easy inclusion of many specialities such as dermatology, radiology, cardiology, pathology and infection diseases, among others. The system implements many security mechanisms such as Digital Signature and Zero Knowledge Proof for authentication. A telecare real-time module measures patient's vital signs such as blood pressure, electrocardiogram, oxygen saturation and sends them over the network to monitor patient's health. After 19 months of service, the system processed 4.751 actual telemedicine cases from 31 remote stations with an average response time of 1, 3 days, showing flexibility, security and scalability.

Martin Thomas Ivers, George F. Timson, Hans von Blankensee, Gary Whitfield · 6 authors

The United States Veterans Administration provides a medical care delivery system comprising more than 170 hospitals, clinics and domicilliaries. Historically, these institutions have been relatively autonomous in their day-to-day operations and consequently efforts at computerization have been difficult to adequately coordinate. A recent undertaking of the VA has been to establish decentralized coordination of planning and implementation for hospital computer systems. This presents a unique opportunity to promote standard, portable and well-designed solutions to meet the widely variable needs of a large and diverse health care delivery organization. Although computer systems for each hospital will vary with the needs of the hospital, functional program packages can be delivered and maintained in a cost-effective and manpower-efficient manner. Additionally, because all systems will be based on a common data dictionary it will be possible to gracefully expand systems as needed and to study clinical care and delivery methodologies across many institutions.

Dimitrios G. Katehakis, Manolis Tsiknakis, Stelios C. Orphanoudakis

Healthcare is usually delivered within certain organizational boundaries and information produced at each site is managed by isolated autonomous clinical information systems. In some cases point-to-point communication is enabled, facilitating the exchange of information. In contrast, integrated regional health telematics; networks enable accessibility to information and services without visible organizational boundaries, to provide decentralized healthcare through integrated services for seamless and personalized information delivery. This has the advantage that enables informed citizens to have an impact on the healthcare system and to be more concerned and care for their own health. The current vision comprises affordable access to healthcare resources and services for all citizens, thus making medical expertise a shared resource wherever and whenever needed. Important areas in which information society technologies are likely to have a significant impact include those of pre-hospital health emergencies, remote monitoring of patients with chronic conditions, and medical collaboration through sharing of health-related information resources. Accessibility to these and other media-rich, user-oriented. services, in the context of the emerging global information society, will be supported by a healthcare information infrastructure, which can achieve effective horizontal integration of networked information sources.

K. Kwiatkowski, Patrícia Flatley Brennan, David L. DeMets, Karen Dahlen · 5 authors

The University of Wisconsin-Madison Health Sciences Schools are currently in the planning stage of developing an Integrated Advanced Information Management System (IAIMS). The planning phase of this project attends to the unique opportunities that are found at the flagship campus of a large state university system. Statewide teaching and research initiatives and accelerated campus-level capital development challenge the planners to create an IAIMS plan that anticipates an emerging health science environment. Additionally, UW-Madison has an organizational culture with a strong tradition of faculty governance, which provides a very desirable and flexible decision-making environment for a cross-discipline collaborative information management initiative. Development of a shared IAIMS vision conflicts with a governance model that most directly supports intradepartmental decision-making. The challenge presented here for an IAIMS initiative has less to do with hard wiring a technical infrastructure and more to do with increased stakeholder cooperation in a highly decentralized organization with autonomous information systems.

Gordon Db, Sam Marafioti, Michael Carter, Hans Kunov · 5 authors

Sunnybrook Health Science Center (Sunnybrook) is a multifacility academic teaching center. In May 1994, Sunnybrook struck an electronic patient record taskforce to develop a strategic plan for the implementation of a comprehensive, facility wide electronic patient record (EPR). The taskforce sought to create a conceptual framework which provides context and integrates decision-making related to the comprehensive electronic patient record. The EPR is very much broader in scope than the traditional paper-based record. It is not restricted to simply reporting individual patient data. By the Institute of Medicine's definition, the electronic patient record resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge, and other aids [1]. It is a comprehensive resource for patient care. The taskforce proposed a three domain model for determining how the EPR affects Sunnybrook. The EPR enables Sunnybrook to have a high performance team structure (domain 1), to function as an integrated organization (domain 2), and to reach out and develop new relationships with external organizations to become an extended enterprise (domain 3) [2]. Domain 1: Sunnybrook's high performance teams or patient service units' (PSUs) are decentralized, autonomous operating units that provide care to patients grouped by 'like' diagnosis and resource needs. The EPR must provide functions and applications which promote patient focused care, such as cross functional charting and care maps, group scheduling, clinical email, and a range of enabling technologies for multiskilled workers. Domain 2: In the integrated organization domain, the EPR should facilitate closer linkages between the arrangement of PSUs into clinical teams and with other facilities within the center in order to provide a longitudinal record that covers a continuum of care. Domain 3: In the inter-enterprise domain, the EPR must allow for patient information to be exchanged with external providers including referring doctors, laboratories, and other hospitals via community health information networks (CHINs). Sunnybrook will prioritize the development of first domain functionality within the corporate constraints imposed by the integrated organization domain. Inter-enterprise computing will be less of a priority until Sunnybrook has developed a critical mass of the electronic patient record internally. The three domain description is a useful model for describing the relationship between the electronic patient record enabling technologies and the Sunnybrook organizational structures. The taskforce has used this model to determine EPR development guidelines and implementation priorities.