6th International Policy and Research Conference on Social Security

Emerging trends in times of instability: New challenges and opportunities for social security

Luxembourg, 29.9–1.10.2010

Towards an e-health integration platform to support social security services Laura González, Guzmán Llambías, Pablo Pazos Universidad de la República del Uruguay Uruguay

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The International Social Security Association (ISSA) is the world's leading international organization bringing together national social security administrations and agencies. The ISSA provides information, research, expert advice and platforms for members to build and promote dynamic social security systems and policy worldwide.

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© International Social Security Association, 2010.

Towards an e-health Integration Platform to Support Social Security Services

Laura González, Guzmán Llambías, Pablo Pazos

Laboratorio de Integración de Sistemas, Instituto de Computación, Facultad de Ingeniería, Universidad de la República del Uruguay. Julio Herrera y Reissig 565, CP 11300,

Montevideo, Uruguay.

{lauragon, gllambi}@fing.edu.uy, pablo.swp@gmail.com

Abstract Nowadays, health services are increasingly related to social security systems. In many countries, either health benefits are part of social security programmes or they are associated to the rights of certain population (e.g. workers and their families). Such relations generate interactions between the health and social security implementations, especially when they are based on Information and Communication Technology (ICT) systems.

The automation of these interactions presents various benefits like the possibility to share and combine facilities and information, in order to provide value added social security services. Various standards have been proposed to support these interactions in an interoperable way, while leveraging the ICT assets within the interacting organizations.

However, health actors usually adopt specific information representation standards (e.g. HL7), which normally differs from the ones used by social security organizations. Moreover, standards constantly evolve which present various challenges in terms of flexibility, adaptability and interoperability.

This paper analyzes these issues and proposes solution approaches based on middleware and semantic technologies. The paper focuses on interoperability issues and how the facilities provided by advanced middleware and semantic technologies, like Enterprise Service Bus and Semantic Web Services respectively, can assist in resolving them. The solutions were analyzed, implemented and evaluated in the context of a reference architecture based on service oriented principles. The work presented in this paper constitute a starting point towards building an e-health integration platform, in which social security organizations can leverage to interact with heterogeneous health actors.

1. Introduction Nowadays, there is a strong trend to coordinate the development of health insurance programmes with social security programmes. This also involves the coordination of welfare benefits with other social plans.

Additionally, health organizations are increasingly required to interact with each other, in the context of various coordination initiatives that are being driven in many countries. These coordination initiatives mainly seek to balance two strategies: expanding universal coverage of risk and strengthening public health care provisions. [1]

In Uruguay, for example, a unified National Integrated Health System (Sistema Nacional Integrado de Salud, SNIS) was implemented. This system constitutes a framework through which public and private health organizations deliver health services to the population. Broadly speaking, the SNIS aims at allowing the population to have health services of the best possible quality, accessible in the most effective way and

implemented in the most rational way, trying to leverage the existing or future assets in the involved organizations. [2]

One of the requirements to support these coordination initiatives is to have a fluent and systematic integration among the ICT systems of the organizations. However, these systems are usually very heterogeneous regarding technological platforms, capabilities, terminologies and data models, among others, which prevent them from being interoperable. Moreover, this heterogeneity can even occur in an intra-organizational scheme.

The development of standards has been a key issue in achieving interoperability at various levels. However, standards are not always adopted by health organizations, an even if they are adopted, they present some issues which might cause difficulties to achieve end-to-end interoperability [3]. Indeed, the “lack of commonly defined and consistently implemented standards” has been identified as one of the main barriers that prevent countries from achieving efficiency improvement through ICTs [4].

In this context, it is evident the need for an integration platform which addresses and solves interoperability issues. This paper first describes concepts, technologies and approaches regarding building interoperable information systems and analyzes some examples of how they are being applied within the health domain. Additionally, it proposes solution approaches, combining advanced middleware (i.e. Web Services and Enterprise Services Bus) and semantic technologies, for building an e-health integration platform which facilitates the integration of the involved organizations.

This work mainly originates from joint activities [6][7][8] with the Banco de Previsión Social (BPS) [5], which is the main social security organization in Uruguay, and other governmental Uruguayan organizations. The topics presented in this paper are being addressed by the academic group Laboratorio de Integración de Sistemas (LInS) [9].

The remaining of this paper is organized as follows. Section 2 describes concepts, technologies and approaches regarding building interoperable information systems and provides examples of how they are being applied in the health domain. Section 3 proposes solution approaches, combining advanced middleware and semantic technologies, to build a service-oriented e-health integration platform. Finally, section 4 presents conclusions and future work.

2. Interoperable Health Information Systems This section presents various concepts, technologies and approaches for building interoperable information systems and describes initiatives, products and tools which leverage them in the health domain.

2.1 Interoperability Achieving interoperability has become an essential requirement in almost every domain, like the public and business sectors. Interoperability has been defined as the ability of ICT systems, and of the business processes they support, to exchange data and to enable the sharing of information and knowledge [10].

According to the European Interoperability Framework [10], interoperability can be considered at three different dimensions: technical, semantic and organizational. Technical Interoperability covers the technical issues of linking computer systems and services. Semantic Interoperability is concerned with ensuring that the precise meaning of exchanged information is understandable by any other application that was not initially developed for this purpose. Organizational Interoperability is concerned with defining business goals, modeling business processes and motivating the collaboration

of organizations that wish to exchange information and may have different internal structures and processes.

The development of standards has been a key issue in achieving interoperability. For example, Web Services [11] standards constitute nowadays the main mechanism to achieve technical interoperability in a heterogeneous ICT environment. Moreover, the Web Services-Interoperability (WS-I) [12] organization is an industry consortium that seeks to enhance interoperability among Web Services implementations by publishing implementation guidelines (e.g. WS-I Basic Profile 1.0) with the goal of enhancing interoperability. Additionally, Semantic Web standards [13] provide mechanisms to support semantic interoperability.

In the health domain, interoperability is also an essential issue. The Office of the National Coordinator for Health Information Technology (ONC) [14] consider that interoperable health IT can improve individual patient care in numerous ways like providing complete, accurate and searchable health information, a more efficient and convenient delivery of care, earlier diagnosis and characterization of diseases and increased efficiencies in administrative tasks, among others. Additionally, the US Federal Health Information Technology Strategic Plan states that “to effectively exchange health information, health IT systems and products must use consistent, specific data and technical standards” [15].

2.2 Health Standards During the last decades, many health standards have been developed and are currently being adopted by various health actors. For example, various international standards have emerged to standardize the way clinical information is represented and structured.

The open standard OpenEHR [16] defines a generic reference model of clinical information that is based on an ontological analysis of the healthcare domain. It only represents the minimum most important semantic clinical concepts and its archetypes constraint this model by defining specific clinical concepts. For example, the OpenEHR reference model deals with generic clinical observations, but it does not include the blood pressure, which is a particular observation.

As well, the Health Level Seven (HL7) [17] organization develops standards for exchanging, managing and integrating health information. It also has a reference model, but it is aimed to model the information to be exchanged among systems, unlike the OpenEHR that models the internal architecture of medical record systems. HL7 information model contains clinical, demographic and accounting concepts, as it is an emerging standard in the USA where the health system is closely linked to insurance companies, so that accounting transactions were considered within the model. HL7 includes the CDA (Clinical Document Architecture), a standard that seeks to represent any kind of electronic medical document for interchange.

Another standard of interest in the health domain is the CEN/ISO 13606, which is a model for information exchange compatible with the OpenEHR model. Also, the ASTM CCR (Continuity of Care Record) information model seeks to model medical summaries to communicate them among different health services. OMG COAS (Clinical Observation Access Service Model) provides an information model for communicating clinical observations on a given patient. Finally, the International Healthcare Technology Standards Developing Organization is rapidly promoting SNOMED CT as the preferred terminology in healthcare.

2.3 Service Oriented Architecture Service Oriented Architecture (SOA) is a logical way of designing a software system to provide services in a network, via published and discoverable interfaces. SOA enables

interoperability and flexibility by converting monolithic and static systems into modular and flexible components, represented as services, which can be requested via technology standards. [18]

A SOA facilitates many of the tasks of developing enterprise applications, like their integration, the development of business processes and leveraging legacy systems. Additionally, a SOA provides the flexibility and agility that business users require, allowing them to define coarse grained services which can be combined and reused to address current and future business requirements. [18]

Healthcare organizations manage a large amount of software systems, which usually need to integrate with each other, and must address evolving clinical requirements. As well, organizations increasingly need to interact with other organizations. In this context, SOA can provide healthcare organizations the mechanisms to support reuse and sharing of system resources in an intra or inter-organizational scheme. [19]

There are currently many projects and initiatives in the health area which are taking this direction.

In Denmark, for example, a service-oriented architecture based on Web Services was built to support the online exchange of health care data among the various heterogeneous IT systems in the health sector. The architecture forms a federation of Web Services and enables secure and reliable authentication of end-users and systems. As well, the architecture is based on national and international standards and specifications. [20]

Additionally, the Healthcare Services Specification Project (HSSP) [21] is a collaborative initiative, between HL7 and the Object Management Group (OMG), which sees the need to specify services to support the information technologies in the health area. In the context of this project, a practical guide to SOA in healthcare [22] has been elaborated.

2.4 Web Services A Web service is a software system identified by a URI, whose public interfaces and bindings are defined and described using XML, and whose definition can be discovered by other software systems. These software systems may then interact with the Web Service in a manner prescribed by its definition and using XML based messages conveyed by Internet protocols. [23]

The Web Service technology is based on three fundamental standards: Simple Object Access Protocol (SOAP), Web Service Description Language (WSDL) and Universal Description Discovery and Integration (UDDI). Additionally, many others standards, know as WS-*, have emerged to address advanced requirements like security and transactions, among others.

Web Services are the most common way to provide technical interoperability among heterogeneous software systems. Additionally, given their characteristics, Web Services are the preferred technology to implement services in a SOA. In healthcare, Web Services are also being used to achieve these goals. Indeed, many efforts are being made to provide guidelines in using health specific standards with Web Services standards.

For example, the Web Services profile for HL7 (HL7WSP) [24] has the goal of providing implementation best practices to promote the interoperability among applications which exchange HL7 (version 3) messages, using Web Services. The profile considers recommendations of other organizations, like the Web Services Interoperability (WS-I), to leverage previous performed efforts to promote interoperability.

Additionally, Integrating the Health Enterprise (IHE) [25] is an initiative driven by healthcare professionals and industry actors, with the goal of improving the way in which computer systems in healthcare share information. To this end, a set of guidelines have been elaborated to promote the coordinated use of established standards such as DICOM and HL7, and their use with Web Services standards.

2.5 Enterprise Service Bus An Enterprise Service Bus (ESB) is a standards-based integration platform that combines messaging, Web Services, data transformation, and intelligent routing to reliably connect and coordinate the interaction among heterogeneous applications. [26]

Even thought Web Services constitute a solid base to implement SOAs, their point-to-point nature might affect maintainability and scalability of the solutions implemented with this technology. In this context, the ESB provides a middle integration layer, with reusable integration and communication logic, to enable the interaction between clients and services in a SOA. The ESB accept requests in the form of messages, over which it can perform different mediation operations (e.g. message transformation, validation and enrichment), to solve heterogeneities between clients and services. The ESB promotes loosely couple interactions between clients and services, and allows separating the integration and communication logic from the business logic implemented by the services.

Most ESBs provide capabilities to support transport protocol conversion, message transformation, message routing and reliable messaging, among others.

ESBs can be leveraged in many ways to address interoperability issues and to implement SOAs in healthcare organizations. Indeed, various ESB-like products are incorporating health specific features.

Microsoft, for example, provides an Accelerator for HL7 [27] to extend Biztalk Server capabilities by delivering a comprehensive HL7 messaging solution that enables sharing of patient information within and between healthcare organizations. Additionally, Mirth [28] is an open source healthcare messaging integration engine, which was built on top of Mule (an open source Java ESB). Mirth allows message filtering, transformation and routing, and provides an integration server that supports a variety of messaging standards protocols for connecting to external systems, and numerous databases for storing message data.

2.6 Metadata and Semantic Technologies Metadata is structured information that describes, explains, locates, or otherwise makes it easier to retrieve, use, or manage an information resource. Metadata is often called data about data or information about information [29]. Describing resources with metadata might facilitate interoperability.

Metadata schemes are sets of metadata elements designed for a specific purpose, such as describing information resources of a specific domain. The definition or meaning of the elements is known as the semantics of the scheme. [29]

Even though, there is not a unique language to express metadata in a digital way, during the last years a set of standard specifications have been developed (e.g. XML, RDF and OWL) in the context of the Semantic Web [31][32] Activity of the World Wide Web Consortium (W3C). Figure 1 illustrates the stack of standards of the W3C, putting on its bottom, the less semantic technologies and standards and on top, the most expressive and rich ones.

Figure 1 - Semantic Web Standard Stack [34]

The eXtensible Markup Language (XML) constitutes a syntactic base for the rest of the standards. The Resource Description Framework (RDF) is a data model based in triples object-attribute-value. Additionally, formal ontology has recently emerged as a knowledge representation infrastructure for the provision of shared semantics to metadata [33]. An ontology is an explicit specification of a conceptualization, where a conceptualization is an abstract, simplified view of the world that we wish to represent for some purpose [30]. An ontology can be defined using the Web Ontology Language (OWL).

In a Web Service context, OWL and RDF are two semantic standards too broad and general to express the semantics of a Web Service. Therefore, standards like OWL-S [35], WSDL-S [36] and WSMO [37] have emerged, expanding the possibilities to achieve this challenge in a more specific and effective way. Web Services built using Semantic Web technologies are commonly known in the literature as Semantic Web Services and are becoming a very useful resource to address the semantic interoperability problem.

In an e-health environment, the Artemis [38] and Miuras [39] projects are two examples of the application of semantic technologies to solve this challenge.

The Artemis project addresses the interoperability problem during the exchange of messages between client and Web Services that use different health standards. They use the domain knowledge exposed by the existing healthcare informatics standards to define a Service Functionality and a Service Message ontology. The Service Functionality ontology is used to specify the operational meanings of Web services and it is based on HL7. The Service Message ontology is used to specify the semantics of Web service messages and is developed through electronic healthcare record based standards such as ENV 13606 and GEHR [40].

On the other hand, the Miuras project is developing a semantic integration engine that simplifies the exchange of information between health applications and health information systems of a hospital. The engine simplifies the integration of heterogeneous systems using the HL7 and ISO 13606 health standards.

3. Towards an e-health Integration Platform This section presents solution approaches towards building an integration platform, which leverages the facilities provided by middleware and semantic technologies to address interoperability issues within an e-health domain.

The integration platform is proposed in the context of a SOA and integrates the capabilities of ESBs, ontologies and Semantic Web Services.

3.1 General Description The proposed solution [8] addresses the problem presented in Figure 2, where various health organizations, that need to collaborate, support different version of standards to interact with other organizations (e.g. HL7 v2 and v3). Moreover, some organizations might not support any standard.

Figure 2 - Organizations supporting and not supporting standards

In this context, if an organization needs to interact with the rest of the organizations, it has to know how to deal with the different standards or proprietary mechanisms they manage. This might be a suitable solution when the number of organizations is small, but as this number grows this solution becomes harder to implement and maintain.

Figure 3 presents an alternative solution which consists of an integration platform that, leveraging enterprise service bus and semantic mechanisms, addresses these matters. Within this platform, health organizations publish the services they provide to allow other organizations to discover and consume them.

Figure 3 - e-health Integration Platform

The solution proposes using an Enterprise Service Bus (ESB) and extending it with health specific capabilities. For example, the extended ESB incorporate components to perform health standards related transformations. As well, it includes components to invoke Semantic Web Services.

In order to consume the services published in the platform, clients send XML messages to the extended ESB. This allows decoupling clients and services in terms of the communication protocols and the health standards they used. It also provides location transparency, that is, clients do not need to know the real location of the services in order to consume them.

Additionally, the solution requires the definition of a global ontology, defined in OWL, which includes the identified health domain concepts (e.g. Patient, Doctor, etc). Each interacting organization has to map their communication data model to the concepts defined within the global ontology. This might be performed by an expert user in charge of administrating the platform.

Organizations have to publish their services, implemented as Web Services, in a Semantic Web Services directory. These services have to be described using OWL-S and the concepts within the global ontology. For example, an organization might specify that a Web Service receives as an input parameter a Doctor and return as a response the list of Patients associated with this Doctor. Both Patient and Doctor are concepts defined in the global ontology.

When the ESB receives an XML request, it uses the defined mappings to transform this input in an instance of the global ontology. This allows querying the Semantic Web Services Directory in order to find a suitable service to fulfill the request, for example, based on the specified input parameter. Once a service is found, it is invoked and the response is transformed back to the communication format used by the client. In this way, clients and services can interact without having to agree in the standards they use.

3.2 Implementation Details The proposed solution was prototyped focusing in HL7 v2.x and HL7 v3 standards. The prototype was built with JBoss ESB [41] which is the ESB product provided by JBoss.

Additionally, various technologies were used to assist in performing the required transformation, discovery and invocation tasks. HAPI (HL7 Application Programming Interface) [42], for example, is an open-source, object-oriented HL7 2.x parser for Java. It was used to parse HL7 messages and be able to manipulate them as Java objects, which simplifies this task. On the other side, Jena [43] is a Java framework for building Semantic Web applications. It provides a programmatic environment for RDF, RDFS and OWL, among others. Finally, OWL-S API [44] provides a Java API for programmatic access to create, read, write, and execute OWL-S described atomic as well as composite services.

4. Conclusions and Future Work Throughout this paper, solution approaches to build an e-health integration platform were analyzed. Concretely, various technologies for building interoperable information systems were described, along with their application in an e-health domain. SOA, for example, can provide healthcare organizations the mechanisms to support reuse and sharing of system resources. ESBs allow decoupling clients and services at different levels (e.g. communication protocol, supported health standards, etc). As well, semantic technologies, in particular semantic Web Services, provide suitable mechanisms to achieve semantic interoperability.

Based on this analysis, solution approaches were proposed in order to integrate advanced middleware and semantic technologies in a consolidated platform. Concretely, an integration platform, based on an ESB, a global ontology and semantic Web Services, was specified and prototyped, as a first step towards building an e-health integration platform. This platform allows publishing and consuming semantically described e-health services, and leverages ESB capabilities to transform and route requests and responses in order to resolve heterogeneities between clients and services.

Despite of the fact that integrating semantic and ESB technologies in a consolidated platform allows taking advantage of the capacities of both technologies, there are many issues that still remain open. For example, although standards are a key element for achieving interoperability, current standards present some problems which prevent them from guaranteeing end-to-end interoperability [3]. Additionally, most middleware technologies (e.g. ESBs) do not specifically address issues related with the health domain. Therefore, an interesting work in this direction is to enrich current middleware platforms to explicitly address and support health standards and solve domain specific problems. Finally, given the mediation role of the ESB, it becomes a suitable place to perform runtime adaptation tasks (e.g. replace service, use cache, etc) in order to maintain the quality of service of the provided services.

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