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National Integrated Information Healthcare System of the Republic of Uzbekistan Main

30 мая 2018

National Integrated Information Healthcare System of the Republic of Uzbekistan

1. Introduction

Information Technologies become integral feature of the present-day reality. Medical information science has a rapid growth all over the world. Leading european experts think the implementation and usage of automated information systems in medical institutions will be the main task among new technologies to be implemented in nearest future. Only «application of polymerase chain reaction at genetic deseases can be comparable to this issue» (W. Guder, J.Beutner, 1998)

Increasing dependence of well-developed countries on information sources at the end of 80th resulted to the new «national information resource» idea formation, which is a major indicator of technological advantage between conutries having such sources and others. Not for nothing the future postindustrial society of XXI century can be visible as an information society, having the information resource as preferable from other resources.

The driving force of society development will be not material products, but informational and intellectual products manufacturing. The most of working people will take collection, production, accumulation, storage, processing, distribution, sale and consumption of the information and first of all of the knowledge as the highest form of information. Collection of new knowledge and its application to sciences and practices is the ground of further development of scientific and technological progress and of society in general.

The material and technical and technological basis of information society will be various automated information technologies and systems. Everyone will get access to the reliable information source at any time at any place.

Thus raising of the information value as the source of new knowledge and the basis of the decision-making processes makes information resource the major strategic resource of XXI century.

Information resource represents aggregate of knowledge, received and collected through the development of sciences, human practical works and functioning of various devices recorded on media, which provide their transmission to the consumers to solve the management, production and scientific tasks.

Information is intellectual resource, e.g. it is the result of collective creative work, not only mental performance. While it stands out as a society driving force only together with other resources, otherwise it has only potential value.

Within last decades the drastic increase of information volume and number of information sources are observed and all areas of social life. Collection and accumulation of scientific information, including the medical knowledge, is going on geometric series. At the beginning of XX century the volume of scientific information doubled within 40 years, and since the end of century it takes only 5 years. For the present time the volume of the medical publications comes to more than 2 mln articles per year and has the trend to be increased. Situation of contradiction between limited human capacity to perceive and process information and intensive collection of knowledge is named asinformation explosion or information crisis .

Under conditions of informaton explosion the activity of doctors, pharmacists and healthcare managers cannot be possible without wide-applied modern information communication technologies (ICT).

However for the time being there is realistic contradiction between information demand to support the healthcare managers in decsision-making processes and existed level of healthcare managers' computer literacy and information culture. This is the deterrent to use the modern ITC for further optimization and efficacy of medical business and education and medical resources management as well. As a matter of fact, the usage of capability of modern ITC is very limited in day-to-day activity of medical professionals.

This causes that one of the public priority tasks is the informatization of society, of all areas of life, including the healthcare.

2. Criteria for Improving the Quality of Healthcare Delivery in Uzbekistan

2.1 Facts and Figures

2.1.1. Background

Before 1991 Uzbekistan’s healthcare system was under strict centralized USSR govern. After proclamation of Uzbekistan sovereignty, healthcare process, as well as all other government driven processes, needed to be reorganized within a newly formed independent state. Healthcare reorganization was very painful process, and it is still ongoing. The difficulty was powered due to Uzbekistan’s geographic (very large country with specific geographic specificities) and demographic facts (clear distinction between rurally populated and urban populated regions). Moreover, the Republic of Uzbekistan has the highest density of population and by this criterion takes the first place in Central Asia. Organization, controlling and provision of quality healthcare in such circumstances were very difficult. This can be especially perceived in rural parts of the country that suffers from lack of qualified healthcare personnel.

Originally healthcare was provided free of charge at base principle that all should be able to access healthcare services (“Everyone shall have the right to receive skilled medical care”, Uzbekistan Constitution, 1992.). Ministry of Health was appointed body for administration of the complete healthcare process, supervising technical units of care, epidemiology care centers, professionals training etc. Services were financed by public revenue, with budget allocation defined centrally. This shows that resources and healthcare provisioning was not locally adapted and oriented, which was a must, due to early-explained reasons.

2.1.2. Uzbekistan Health Indicators

Uzbekistan has some clear health indicators that should be targeted in order to provide better, more efficient and high quality healthcare service. Several problems raise the alert and should be addressed. Full and quality monitoring and pursuance is furthermore difficult due to large spread rural areas.

Health sector was one of the areas most severely affected by the post-independence economic recession. Main source of complete healthcare budget are still taxes revenues and public financing. Public expenditure on healthcare is maintained at about 3.5% of GDP. The government plan is to maintain healthcare budget at approximately 10% of state budget. Some of the healthcare expenditures are covered by direct consumer payment (about 7% of overall healthcare budget), After 1993, with waves of privatization, some of services are provided in private sector, which are believed to be better equipped with better medical care. This has unveiled additional problem concerning serious lack of state control over the quality of health care provided, as well as fact that private practitioners do not have to maintain statistics on the outcome of the patients treated, nor they have to provide financial accounts.

One of key health problems anguishing population, especially in rural areas, is a large number of different diseases. Great burden carry infectious diseases (TBC, pertussis, measles, viral hepatitis and other communicable diseases). For example, TBC incident rate increased nearly 50% in late nineties, in some rural areas reaching as high as 0.2% of all population infected with TBC. Outbreaks of such diseases are also pretty common. To help stop spread and sustain these outbreaks, it is a must to define mechanisms and processes for adequate and fast detection, reliable reporting and recording. Also, complete vaccination process monitoring, both per-person, locally in institute that delivers vaccination (preferably from birth) and per-geographical area in epidemiological institutes, can reduce outbreaks and even extinct some types of communicable diseases. As a conclusion, sanitary-epidemiological services must be organized at the highest level with complete necessary data collected from all country areas and information at disposal for quality and opportune decision-making process and timely response. Reform of Sanitary Services shall provide the better quality of monitoring and fast response to infectious diseases in accordance with fixed criteria and indicators.

Additional problems carry non-communicable diseases such as cardiovascular diseases, endocrinological (pancreatic diabetes), oncologic, endemic disease, etc. These are maybe even harder medical problems to fight against. Adequate access to health services with quality medical personnel in remote areas can help dealing with those diseases. Telemedicine is also one recognized way of prevailing those problems in distant rural centers lacking qualified medical personnel.

Prenatal, postnatal child and maternity care is another great health issue. Problem again lies in spread medical institutes and medical services. Centrally accessible data about complete medical history for both mother and child could bring information to healthcare personnel on top of which they could give evidence based advice and treatments that will help bringing better medical care. This is also applicable for health care in general for whole population.

Shortage of ambulatory and primary healthcare posts, as a first line of contact in treating patients, leads to heavy exploitation of hospitals. Hospital sector receives roughly 80% of total healthcare budget, so, there are little funds left for outpatient and primary health care in polyclinics. Decentralization of medical treatments should be a key goal of medical service restructuring. Focusing on better outpatient healthcare service in rural areas could lead to lower costs, faster patient admission and treating health problem, which eventually brings better and more quality service for the end user – patient.

Uzbekistan has a relative excess of physicians. Furthermore, most of trained personnel operate in urban areas, so there is serious lack of medical know-how in rural areas. Propagation of quality services, medical knowledge and proficiency towards rural areas should be of great concern. Nowadays, modern technology provides ways of sharing knowledge, which can lead to lowering training costs and bringing “best-in-class” service to even most remotely rural part of the country through telemedicine concepts.

Along side these critical health related problems, there are also a lot of other aspects (process management, financial flow control, education provisioning and others), that can help to increase the quality of healthcare services for population.

2.2 Key Requirements for National Integrated Information Healthcare System (NIIHS)

Having in mind crucial characteristics and detected problems in the Uzbekistan’s healthcare system and delivery processes, of which most influential and sensitive ones have been noted above, a strategy framework has been created for deploying National Integrated Information Healthcare System (NIIHS) that is targeting these issues right in the centre of the problem. In addition to that, but not less important, this strategy takes an integrative and visionary approach, with the goal to introduce additional quality improvements that are time proof and a potential stepping stone for new advancements and services. The actions proposed in the strategy will be targeting many stakeholders in the healthcare system, where we envision additional advancements in the services delivery.

Expected benefits of healthcare system improvement envisioned by the strategy are multifold and potentially extremely large. All the stakeholders that are, in one way or the other, included in care delivery processes, can and should experience these benefits, where the strategy that comes at the start is crucial. Taking into account current situation in Uzbekistan’s healthcare system, but also having a long-term vision in mind, in order to provide health care delivery on the highest level, NIHS should fulfill following requirements:

- Healthcare delivery and provisioning should be safe, in sense of avoiding injuries to patients from the care that is intended to help them. This targets all the levels of care, where the system should be helping healthcare professionals in reaching the most appropriate decision, based on the accurate information about the patient;

- Healthcare delivery should be effective, in sense of avoiding both overuse and underuse of healthcare resources. The healthcare system should give it’s best effort to provide care to patients that is based on proven evidence, that is based on the most recent medical knowledge available;

- Health care should be patient-centered, where the practice should respect individual patients needs, values and preferences, which can heavily influence the effectiveness of the cure process;

- Health care should be as timely as possible, in sense of avoiding waits and delays that can be potentially very harmful for person that is receiving care;

- Health care needs to strive to highest level of efficiency, in sense of avoiding waste of limited resources available;

- Healthcare system should give all effort to try to reach highest level of equity and fairness, where the care provided to patients should not vary due to personal characteristics such as gender, geographic location, socio-economic status etc.

3. NationalIntegratedInformationHealthcareSystem(NIIHS) of Uzbekistan

Following chapter will describe a comprehensive framework for National Integrated Information Healthcare System (NIIHS) that is envisioned as the base ICT solution for Uzbekistan’s healthcare system. The framework will address key success factors and include organizational structure proposal that adopts NIHS solution. At the end, it will enumerate proposed standards, security mechanisms and other requirements that will provide complete healthcare system solution.

3.1. Healthcare Organization Management

NIIHS is a system that has six aims presented in the previous section as it's fundamental qualities; i.e. the care provisioning based on NIHS should be safe, timely, patient-centered, efficient, effective and equitable. NIHS is envisioned as an advanced and transparent health system that serves as the cornerstone of better health services delivery to the entire population of Uzbekistan, and does so by putting the patient right in the focus of the system.

NIHS takes the advantage of iterative and integral approach, which is represented with a set of small and distinctive steps. Every step represents a specific service that targets most important problems representing the biggest burden to the care delivery process. Furthermore, NIHS services share the same common ground, where the parts of them can and should be reused in the next steps taken in the approach, in which way the vision ensures longevity, cost optimization and highest quality services delivery.

depicts most important quality criteria that represent the basis for all the services included in the vision. By taking the integral approach, NIHS takes advantage of one quality parameter representing the input for the other. Here the wholeness and the integrity of approach are the cornerstones for making the system more transparent, efficient and patient oriented.

Healthcare Delivery System Critical Quality Parameters

Figure 1. Healthcare Delivery System Critical Quality Parameters.

Current Uzbekistan’s healthcare system can be divided into rural and urban healthcare provisioning. Before restructure, it had too many different layers of care, such as feldsher-midwifery posts, polyclinics, community hospitals, district hospitals and regional hospitals as highest level of health care provisioning. Government has planned to restructure healthcare, reducing the count of health provisioning access points (feldsher-midwifery posts, rural medical centers, central district hospitals, polyclinics and regional hospitals). Restructuring also covers clear distinction between posts for primary healthcare provisioning and more specialized care.

Current tendency is to aggregate primary healthcare medical provisioning into polyclinics and medical centers as a first point of entry. More specialized health care is provisioned in rural medical centers, district and regional hospitals. Moving first point of care towards patients is very important in terms of providing better and more cost efficient healthcare.

Figure 2 presents the restructuring of healthcare system:

Healthcare delivery reform

Figure 2. Healthcare delivery reform

In accordance with reform the most of rural hospitals and feldsher-midwifery posts will be closed or re-organized, but some will most likely remain in remote areas such as mountains and semi-deserts regions.

Due to low rate of infrastructure coverage (telecommunications and computer area networks), proposed National Integrated Information Healthcare System (NIIHS) solution have to adapt to given situation and provide mechanism that will overcome the problem. Architecture solution should provide services to the most distant patients, but at the same time be prepared to interconnect with central system as soon as interconnection prerequisites are fulfilled. Due to that reason, medical centers must be able to work in autonomous mode, independent of central communication integration system, but with complete and uncrippled functionality. This can be achieved with powerful thick clients with complete set of functionality replication (local data management and repository, implemented certain security mechanisms etc.) and be developed according to approved medical and communication standards adopted as official standards in Uzbekistan healthcare. After fulfilling connection prerequisites, data and information collected over time within autonomous systems, will be feasible and reusable throughout complete integrated system regardless of access point. It would be beneficial if application clients could have possibility to connect to central system periodically, optimally utilizing infrastructure resources, e.g. wireless or mobile networks. In more distant areas, infrastructure resources could be used from time to time, in order to fetch data from other systems connected to integration platform, to send data to repositories within system or to utilize systems features such are telemedicine, medical portal, electronic medical library etc.

Using this implementation proposal, the main goal can be reached: Healthcare professionals in different healthcare provisioning centers, using adequate external healthcare applications and systems, are connected to healthcare integration platform making Uzbekistan’s National Integrated Information Healthcare System (NIIHS) powerful healthcare delivery system that provides first class health care to patients without any type of segregation.

Figure 3 presents the solution for NIIHS of Uzbekistan.

the solution for NIIHS of Uzbekistan

Figure 3. National Integrated Information Healthcare System (NIIHS)of Uzbekistan.

3.2. Key Success Factors

3.2.1. Open Standards and Recommendations

National Integrated Information Healthcare System (NIIHS) should completely rely on standards and generally approved recommendations due to several facts:

- System openness – following standards system opens its interfaces toward easier integration with other products, vendors and third party software suppliers by that receiving powerful feature of adaptation to any healthcare process. Furthermore, conformance tests and certification of legacy systems is much easier with well defined standards as pattern for certifications;

- Best practice approach – Implementing standards, system indirectly implements solutions for all problems that may occur in projects that have already implemented and validated standards. Following them, we avoid all technical and logical problems that we might not have foreseen in non-standard implementation path;

- Focus shift – Using standards, business and development resources are shifted from “how” to “what”, meaning it more focuses on important problems on more global perspective rather on some technical issues;

- Internationalization – Inter-country cooperation becomes very important part of political and economy life. Communication between healthcare systems over the political borders becomes feasible only if both systems use standard approach. And healthcare domain is one of domains that can gain a lot from connecting to different systems outside political country borders.

As a conclusion, by implementing standards we achieve high level of safety, quality and consistency of the product and processes.

National Integrated Information Healthcare System (NIIHS) should be based on the standards that deal with medical document exchange, medical entity communication, format and norms of clinical data sets, security mechanisms etc.

- CEN - The European Committee for Standardization, founded in 1961. By the national standards bodies in the European Economic Community and EFTA countries. One of the areas dealt by CEN is the area of health informatics. The Technical Committee 251 was formed to address these issues. The scope of activities of TC 251 is the standardization in the field of health information and communications technology (ICT) to achieve compatibility and interoperability of independent systems and to enable modularity. This includes requirements on health information structure to support clinical and administrative procedures, technical methods to support interoperable systems, as well as requirements regarding safety, security and quality. Especially interesting are ENV 13606 series of recommendation documents defining electronic patient record architecture, term lists, security distribution rules and messaging for exchange electronic medical data.

- HL7 is one of several ANSI-accredited Standards Developing Organizations (SDOs) focusing on the health care area. Most standards medical exchange standards for different health care domains, such as clinical data, pharmacy, medical devices or insurance transactions. Health Level Seven's domain is clinical and administrative data. HL7's mission is to provide standards for the exchange, management and integration of

data that supports clinical patient care and the management, delivery and evaluation of health care services. Specifically, to create flexible, cost effective approaches, standards, guidelines, methodologies, and related services for interoperability between health care information systems.

When answering the question which version of HL7 standard to use, one has to take into account current situation of the whole HealthCare System of the Republic of Uzbekistan. Having the creation of new system and strategy on a national-level, it is highly recommended to go directly to HL7v3 due to following main reasons:

- HL7v3 based solutions are time proof;

- HL7v3 provides high level of interoperability of solutions in local, regional, national and trans-national environments;

- Conformance profiles are well defined, where solutions are tested to comply to specifications.

As a conclusion, HL7v3 should be used as widely accepted and standardized clinical messaging and as a foundation for future proof, interoperable system.

3.2.2. National Integrated Information Healthcare System (NIIHS) Process Management

Healthcare management is a process constituted of several very complex factors including financial management, public health management, healthcare provisioning and other logistic management processes. Separating lines of responsibilities, but at the same time having in mind implicit connections between them, is a key success factor in managing complete and complex healthcare process. Separation of roles and responsibilities will provide clear communication lines between subsystems that can help bringing decisions based on correct, newest and relevant data collected within system in several points, regardless of time or geographical factor. Using comprehensive data collection and processing, one can make decisions about care of patients and healthcare process management, based on explicit and judicious facts and figures.

One especially critical point should be a clear distinction line between financial flows and decision-making process. Besides lowering healthcare costs, by monitoring and channeling funds where appropriate, this is a right step towards modern healthcare system with any number of public or private healthcare insurance companies.

Separation line between primary and secondary healthcare provisioning is another line that must be clear and visible. This distinction can bring substantial benefits to all stakeholders within healthcare process: patients can receive better care and healthcare process will become timelier and financially efficient.

All this premises cannot be realized without powerful National Integrated Information Healthcare System (NIIHS) that could provide management of healthcare procedures.

As a summary, healthcare system informatization, connecting complete healthcare processes and resources into a unique entity and completely transparent system, will bring several key benefits, such as:

- Improvement of quality of health service;

- Better administration of healthcare bodies and processes;

- Cost management and cash flow channeling with rationalizing the system (less pressure on hospitals by giving more authority to primary healthcare services);

- Cost effectiveness control, especially in rural areas in primary healthcare provisioning;

- Strengthen financing and management of overall healthcare system;

- Improvement of sanitary-epidemiological service;

- Decentralizing healthcare system without degrading quality of service in rural parts (telemedicine);

- Evidence-based medicine;

- Continual professional medical education, including the trainings based on distance-learning methods.

3.2.3. Fundamental Parts of National Integrated Information Healthcare System (NIIHS)

National Integrated Information Healthcare System (NIIHS) can be divided in two constitute parts, supporting each other: First one is Healthcare Integrated Platform (HIP), being common communication and integration infrastructure; and second is external healthcare applications and systems that provide interface towards stakeholders.

3.2.3.1. Healthcare Integrated Platform (HIP)

Healthcare integration platform should be backbone of complete system. It should be built component-wise, mutually connecting all entities into powerful common infrastructure. This approach also allows components addition or subtraction as appropriate and needed.

Common components that should be integral part of such integration platform are:

- Electronic Healthcare Record Management System (EHR) - a clinical data repository and management system. It should be comprehensive high performance storage and patient data management sub-system using advanced information and communication technology build upon open healthcare standards, offering easy integration with other components. It is intended as a central point of healthcare IT system. This component brings benefits to several key stakeholders:

- Patient – Patent data is safely stored in one secure place and available virtually anywhere within National Integrated Information Healthcare System (NIIHS). This improves quality of healthcare service provided to patient no matter where the care is needed and provided;

- Ministry of Health – With data reporting on EHR database, it is possible to improve the quality of health care, identify priorities for medical research, monitor population health, etc.;

- The Department of Sanitary-Epidemiological Inspection – Defining special triggers on the EHR repository, system can easily provide overall control and monitoring over the sanitation status of the republic and control of infectious diseases including supervising all sanitary-epidemiological institutions. It also provides tracing health trends, monitoring of vaccination process and status

- The Department for the Protection of Maternal and Child Health – Defining special criteria and indicators on the EHR can help supervision and improvement of healthcare for children and woman at fertilization age provisioning;

- Educational Institutions – Data collected and centrally stored in one repository can be unfailing well of information that can be used in educational purposes and training of health personnel, as well as forecasting the requirements for health personnel and human resources planning.

- Electronic Population Register (EPR) – Central population register that can be used in both clinical and administrative environment. By creating link between electronic healthcare record and population register storage, we get complete information storage system open to exchange data with any possible systems via common infrastructure and standardized interfaces. As stated, complete population information can be registered uniquely in such a system, so it can provide numerous advantages to other stakeholders that can benefit from population register, using it in other administrative purposes (i.e. voting body administration, population statistic activities etc.)

- Health Resource Register (HRR) - provides advanced management of a wide range of healthcare resources information that are available in healthcare system. HRR contains information about devices (CT device, X-ray device, etc), healthcare professionals (gastroenterologists, neurosurgeon, etc) and physical resources (hospital beds, operation rooms, etc). Availability of that information through standardized interface can significantly improve the patient care in general.

- Terminology Service - provides repository of various medical notation standards, complete with their codes and descriptions (ICD, ICPC) used in health systems. Terminology Service provides additional functions to healthcare systems such as translation between different medical notation and validation of medical notations.

- NIHS Portal - provides centralized web portal used by both healthcare professionals and patients to access various medical information. Furthermore healthcare professionals can use NIHS Portal as help in medical decision process (to get information about medical procedures; to access knowledge database; etc). It’s on-line collaboration and conference functionality provides basis for telemedicine and e-Learning (one-to-one healthcare professional consultancy, on-line seminars and classrooms, etc.)

- Service integration component – complete integrated information and communication infrastructure providing data integrity and consistency, communication between stakeholders, information access and security mechanisms. It defines common infrastructure for interconnecting enumerated system parts, creating powerful and unique information system and, at the same time, it is open and ready to integrate with any newly defined system part or service. Ultimate objective is a connection of all elements within healthcare system with goal of providing optimal healthcare service.

All the NIIHS registers and repositories are standalone products with well-defined use. Integration of these into one complex system will provide powerful tool that will enable free data exchange, superior information management and optimal healthcare service. Openness and standard pursuance of the system also enables interconnection of any other kind of register or repository system that service healthcare process requires. Furthermore, central system management reduces healthcare process administrative costs.

Complete and integrated system now gets even more stakeholders and brings several key benefits, such as:

- Easier health care legislation and regulation;

- Easy development and monitoring curricula for the training of health professionals;

- Issue licenses and certifies health care providers;

- Reliable demographic and statistical data.

3.2.3.2. External Healthcare Provisioning Applications and Systems

Through common platform described in previous chapter, different care provisioning centers can be connected to Healthcare Integration Platform (HIP) creating powerful National Integrated Information Healthcare System (NIIHS).

Healthcare provisioning centers using this applications and systems can be:

- Healthcare service providers:

- Feldsher-midwifery posts;

- Rural medical centers;

- Polyclinics;

- Central district hospitals;

- Regional hospitals;

- Emergency centers;

- Municipal clinical hospitals;

- Biochemical laboratories, etc.

- Scientific research institutes and laboratories;

- Educational institution (Tashkent Institute of Advanced Medical Education; institutes of higher medical education, colleges, lyceums, etc);

- Drugstores;

- The Department of Sanitary-Epidemiological Inspection and its services;

- Different administrative centers,

- Related organizations: Ministry of Internal Affairs, State Statistics Committee, Ministry of Justice, etc.

Any number of different external healthcare provisioning applications and systems, can seamlessly be connected to National Integrated Information Healthcare System (NIIHS), if are built on adopted standards, already summarized in chapter 3.2.1. Different healthcare centers can use different healthcare applications and systems, certified by adopted Uz standards, such as:

- General Practitioner application;

- Laboratory Information System;

- Pharmacy application;

- Dentistry application;

- Hospital Information System (HIS);

- Specialized GIS systems, etc.

It is important that government has complete control of independent vendor’s various systems that are to be connected to National Integrated Information Healthcare System (NIIHS). Body for quality labeling, licensing and certification authority must be established, that will, on national level, define rules, formal reasons and prerequisites that have to be met, it order that certain product is allowed to be used in NIHS. This will help keep healthcare process consistent and transparent, in completely controlled environment.

3.2.4. Architecture description of National Integrated Information Healthcare System (NIIHS)

National Integrated Information Healthcare System (NIIHS) should represent a comprehensive solution for healthcare delivery systems, based on open integration-communication platform, common middleware services and health care specific application components, adjusted to specific needs. Combining and scaling system components, the solution can be applied to a wide range of healthcare service integration needs. Such a solution connects users and stakeholders from different health care provisioning system parts.

Integration platform system should have multi-tier, open architecture design with all its constitutive parts. Architecture can be divided into several layers. Lowest is communication layer, responsible for communication between components. It should reside on common technologies such as IP network for interoperability and virtual private network (VPN) concept that provides security mechanism on transport layer. Transport layer provides reliable communication and transactional platform for exchanging clinical, financial or any other possible data. This layer ensures secure and reliable data delivery.

Between communication layer and application layer (external provisioning healthcare applications and services) there is a system/middleware layer with purpose to facilitate aspects of cooperative processing. This middleware component provides upper layer applications with common services. Directly on top of communication layer lays middleware’s common healthcare generic components layer. It is constituted of components providing services such as authentication, authorization, logging, encryption and so forth. Basically, it provides common services that upper layers application and components can easily utilize in their processing. Above it, there is one more specialized set of services, which is more healthcare oriented, but still provides common services to upper layer applications. These can include data and information management, healthcare portal functionality etc. Also, this layer assures collection, processing and data storing for high efficiency quality information control.

Again, it is important to stress that one of the main drivers for such architecture is scalability. Because of that National Integrated Information Healthcare System (NIIHS) must be adjustable and customizable to any of the healthcare process on any level desired, but at the same time adaptable to any already defined healthcare process.

Multi-layer architecture

Figure 4. Multi-layer architecture

3.2.5. Security

Security is a very important quality parameter and is one of the key factors to provide highest quality health care throughout the entire system. Healthcare integration platform architecture must provide acceptable trade off between security, usability and overall system price. System architecture must allow implementation of security mechanisms gradually, adding a new security feature with every step taken. It is essential that this architecture make a clear distinction between medical and administrative data management, providing the basis for adoption of advanced security mechanisms, when applicable and needed. Furthermore, infrastructure and components must be built in that way so they allow and promote security mechanism upgrades whenever prerequisites are fulfilled (law regulatory, financial availability, standardization approvals on national level, data and communication formats regulated etc.)

National Integrated Information Healthcare System (NIIHS) should be able to implement five core security features extended with two optional security features recommended for system higher security performance:

Security features

Figure 5. Security features

The core security features are:

- Authentication - process of reliably identifying security subjects by securely associating an identifier and its authenticator

- Authorization - policy allowing access to a system, or privilege to perform some task in a system

- Non-repudiation - the property, that the author or owner or caretaker of asset cannot deny that they are associated with it

- Confidentiality - the property that information is not made available or disclosed to unauthorized individuals, entities or processes

- Integrity - the property that data has not been altered or destroyed in unauthorized manner

Additional security features are:

- Auditing - process of reliably storing the handled assets for future lookup

- Availability - property of being accessible and usable upon demand by authorized entity

Leak of any core security feature will automatically harm or disable some other feature. For example, if we don’t have integrity, we cannot guarantee non-repudiation or confidentiality of data and data cannot be used for auditing.

Loss or leak of patient medical data can be considered as low direct cost, but since patient privacy is harmed, cost can be considered as very high in case of lawsuit or some other

patient troubles caused by data loss or leek. Therefore, patent medical and administrative data have to be secured in best way.

Strong user authentication and authorization is a must for keeping patient data confidential. It is recommended to implement private key infrastructure (PKI) with system user certificates and private keys stored on smart card for user authentication on NIHS system and digital signature of electronic documents. Smart-card technologies used in Uzbekistan provides the capabilities to support the security certificates for various applications (banking, heakthcare, etc.) in case the banks allow additional application usage, bank’s smart cards can be also used in healthcare domain. Physical security and operational instructions have to ensure that only authorized user can access patient medical and administrative data. Solution architecture has to ensure system high availability and protection of data losses.

Implementation of all five core security features and two additional on highest possible level, keeping in mind that security is as strong as the weakest link, is curtail for patient data protection

Architecture should allow security to be modular, applicable on all levels of communication and data exchange:

- Physical and data level

- Network level (Virtual private networks, VPN’s)

- Transport level (secure protocols, HTTPS, SSL)

- Session level (identification, authentication, authorization)

- Presentation (digital signatures)

- Application

Figure 6 shows layered implementation of security implemented on all levels of communication and data processing.

shows layered implementation of security implemented on all levels of communication and data processing

All of those mechanisms are independent and can be implemented apart. Applied security mechanisms can be very advanced, e.g. smartcards for healthcare providers with digital keys for authorization, authentication, signing or retrieving data from the system.

4. Pilot Project

In order to prove values of proposed National Integrated Information Healthcare System (NIIHS) of Uzbekistan, it is highly recommended the establishment of Pilot project that will run for two months. In the scope of the pilot, the usage of Healthcare Integration Platform with certain number GP doctor applications and Radiology Information Systems assumed. It is a must to have at least few GP doctors involved because GP’s are the first level of medical care on which health care reform is based. If there are no GP’s in EMC we propose to involve nearest urban polyclinic with their GP’s. System could be hosted in Emergency Medical Center.

In order to demonstrate what kind of information can be provided to the other stakeholders of National Integrated Information Healthcare System (NIIHS) a few simulators with sanitary-epidemiological, national public health and healthcare insurance related information shall be provided.

Pilot proposal for National Integrated Information Healthcare System of Uzbekistan

Figure 7. Pilot proposal for National Integrated Information Healthcare System of Uzbekistan

Terms and abbreviation definition

ANSI - American National Standards Institute

CEN - The European Committee for Standardization

EHR – Electronic Healthcare Record

EPR – Electronic Population Register

GP – General Practitioner

HIP – Healthcare Integration Platform, communication and integration platform, serves as core entity in complete NIHS

HIS – Hospital Information System, enterprise system used in complex hospitals healthcare provisioning centers

NIIHS – National Integrated Information Healthcare System, complete ICT solution for Uzbekistan’s healthcare delivery system. System is component designed, with parts such as Healthcare Integration Platform and external healthcare provisioning applications and systems

HL7 – Health Level 7

HRR – Healthcare Resource Register

HTTPS – The HyperText Transport Protocol (Secure), the standard encrypted communication mechanism on the World Wide Web

ICD - The International Statistical Classification of Diseases and Related Health Problems

ICT – Information and Communication Technology

ICPC – International Classification for Primary Care

RIS – Radiology Information System

SSL - Secured Sockets Layer is a protocol that transmits communications over the Internet in an encrypted form. SSL ensures that the information is sent, unchanged, only to the server intended to send it to

TBC – Tuberculosis

VPN – Virtual Private Network