An Approach to Cross-Hospital Emergency Medical Service Suppor

An Approach to Cross-Hospital Emergency Medical Service Support

Yen-Chun Lin ¹ , Albert Jeng* , and Chun-I Huang

[email protected], [email protected], [email protected]

Department of Computer Science and Information Engineering, National Taiwan University of Science and Technology

*Department of Information Management, Kao Yuen Institute of Technology

Abstract

Objective: It is a great challenge to collect the medical records fast enough for physicians to provide definitive care to save emergency department (ED) patients. This paper describes an approach to fast collection of ED patients’ medical records in Taiwan. ED patients’ survival rate can thus be increased.

Setting: Emergency care in Taiwan.

Methods: State-of-the-art information technologies and standards are useful in collecting ED patients’ medical records before they arrive at the hospital. Our approach considers preventing medical records from unauthorized disclosure or modification. The information technologies and infrastructures taken into account are as follows. Radio Frequency Identification systems can provide superior identity authentication of patients. With the implementation of General Packet Radio Service, Global System for Mobile Communications networks can connect to the Internet to transfer data. The Healthcare Institution Cards issued to hospitals by the Healthcare Certification Authority of Taiwan are used for mutual authentication between hospitals. The Health Level Seven protocol with Secure Sockets Layer can be used for secure exchange, management, and integration of clinical data to provide interoperability between healthcare information systems. The Health Information Network 2.0 can be the physical media to transmit information.

Result: A distributed architecture for rapid collection of medical records, especially those of ED patients’, is proposed. The architecture integrates existing healthcare resources in Taiwan. An ambulance can acquire the identification of a patient and transmits it to the hospital. An ED physician can then collect the patient’s medical records early enough, even before the patient arrives at the hospital.

Conclusion: The system helps reduce ED patients’ critical consultation time and is particularly beneficial to unconscious patients.

1. Introduction

The earlier we provide definitive care to critically ill and injured patients, the better progress they may have.

Since emergency department (ED) patients may have to go through the sickness/injury severity classification, medical records inquiry, and vital sign measurements, it may take a longer time than 15 minutes before the patients can be properly taken care of [1]. In general, it is a great challenge to collect the medical records fast enough for physicians to provide definitive care to save ED patients.

This paper proposes a fast medical record collection system, which reconciles with the fact that each hospital maintains its own patients’ medical records. State-of-the-art information technologies and standards are taken into account to collect patients’ medical information before they arrive at the hospital. ED patients’

survival rate can thus be increased.

1

Correspondence: Dr. Yen-Chun Lin, Professor of Department of Computer Science and Information

Engineering, National Taiwan University of Science and Technology. No. 43, Sec. 4, Keelung Rd., Taipei 106,

Taiwan.

2. Materials and Methods

We now briefly introduce technologies and standards that make a convenient, fast, and secure infrastructure for collection of patients’ medical records.

Radio Frequency Identification (RFID) systems [2] can provide superior identity authentication, especially for senior citizens and mentally disabled or retarded people. RFID has very useful properties. First, it can be used to identify a patient at a distance of several meters. Second, an RFID reader is able to read several hundred RFID tags per second. This is especially efficient in a catastrophic situation to identify a large number of people, each carrying an RFID tag. An RFID tags can be attached to a wrist watch, belt, necklace, or ring carried by a person.

Alternatively, in Taiwan, the National Health Insurance (NHI) IC Card can be used for patients’ identification.

However, it may not be easy to find a patient’s NHI IC Card when an accident happens.

The wireless network technology enables us to communicate with each other anytime and anywhere.

Although the Global System for Mobile Communications (GSM) technology carries mainly voice, with the implementation of General Packet Radio Service (GPRS), GSM networks can connect to the Internet to provide data transfers. This makes a convenient and fast communication environment to facilitate transmission of a patient’s information from the accident location to the emergency-care hospital.

The Taiwan government has established a Healthcare Certification Authority (HCA) in 2003 to provide cryptographic security for medical information transfer [3]. The HCA issues Healthcare Institution Cards (HICs) to hospitals for mutual authentication between hospitals.

To converge medical records from all the hospitals that one has ever visited into a unified emergency medical service (EMS) file, it is desirable to have a standard protocol for information exchange between hospitals. The Health Level Seven (HL7) standard includes a protocol for exchange, management, and integration of clinical data to provide interoperability between healthcare information systems [4]. It is a widely accepted international standard.

The Secure Sockets Layer (SSL) protocol is the de facto standard for providing secure connections between servers and clients over the Internet [5]. It can be used to connect healthcare institutions for medical information transmission, particularly for HL7 connections [6].

In 1987, the Department of Health of Taiwan government started to build infrastructures for Health Information Network (HIN). It carried healthcare-related information. This isolated network has been greatly improved to be HIN 2.0 [7].

3. Results

Considering the diverse medical information systems of hospitals, we propose a distributed architecture to serve ED patients. Figure 1 shows the overall architecture of the proposed cross-hospital emergency medical service support system (CHEMS3).

For each patient, hospital members of CHEMS3 are classified into three categories: home hospital (HH), emergency-care hospital (ECH), and visited hospital (VH). A person joins CHEMS3 as an individual member through his HH, where the person supposedly visits regularly when medical treatment is needed. The HH should have most of the individual member’s medical record, and therefore it serves as the primary source of medical information. The ECH refers to the hospital where an individual member checks in for EMS. A VH is a hospital member where the individual member has ever visited, other than the HH. It is the secondary source of medical records. Hospital members need to establish a trust circle through the architecture. These hospital members should sign a cooperation and collaboration agreement regulating rights and responsibilities.

When an individual member is being sent to the ECH in an ambulance, the ambulance acquires the

identification of the individual member, probably by RFID technique, and transmits it through the GPRS to the

ECH. An ED physician will issue a request to the trusted third party (TTP) to collect and compile the patient’s

medical information. The TTP asks other hospital members to transfer this individual member’s medical records

to the ECH.

Ambulance

Health Certification

Authority

Home Hospital

Visited Hospital

Visited Hospital HIN2.0

SSL

SSL

SSL SSL

SSL GPRS

Emergency-Care Hospital

HL7 Trusted

Third Party

SSL

...

Figure 1. CHEMS3 Architecture

The TTP is an independent organization for providing the following services: (1) It maintains all individual members’ HH and VHs. (2) When the ECH needs a patient’s HH and VHs to provide the patient’s medical records, the TTP can verify whether the patient is an individual member of the CHEMS3. (3) The TTP finds out the individual member’s HH and VHs, and tells the ECH what they are, from which the ECH expects to receive medical records. (4) It acts as a dispatcher on behalf of the ECH to inform the individual member’s HH and VHs to send medical records to the ECH.

The HIN 2.0 together with HL7 should be able to provide fast and secure information transmission for the CHEMS3. The isolation nature of HIN 2.0 and the secure interoperability of HL7 with SSL make them perfect for the CHEMS3. Since the amount of information transmission is limited, HIN 2.0 will not be overloaded.

4. Discussion

We have proposed an approach to integrating the existing healthcare resources in Taiwan to set up the CHEMS3 to help reduce patients’ critical consultation time, which is particularly beneficial to ED or unconscious patients. It makes the medical records of patients available rapidly, so that ED physicians can provide effective treatments to save patients. We based our architecture on the NHI IC Card, RFID technique, HIN 2.0, SSL, and the wireless communication services to collect an individual member’s medical records from HH and VHs without compromising any privacy. At the same time, it can also improve the overall EMS quality.

In our architecture, the TTP collaborates and cooperates with hospital members to compile patient’s medical records. If this is not the case and we allow each ECH to request a patient’s medical records directly from the other hospital members, then every hospital member has to store the information of all the other hospital members for identity and authorization authentication. Furthermore, when a new hospital member joins or an old hospital member leaves the CHEMS3, all the other hospital members have to update this. By establishing a TTP, the identity management service is provided through the TTP, and all the hospital members only need to trust the TTP to perform member identity authentication on their behalf. Thus, we can make the identity authentication and authorization check between hospital members easier.

When an individual member joins the CHEMS3, the person can optionally choose the RFID tag, as well as

the NHI IC Card, for identification. The HH should upload the new individual member’s personal information to

the TTP. After receiving the information, the TTP broadcasts it to all other hospital members and asks them

whether they have medical records of this new individual member. Thus, the TTP can maintain a list of HH and VHs for each individual member.

When an individual member visits a hospital member, the hospital should check whether it has the individual member’s medical record in its CHEMS3 database. If this is the first time the individual member visits the hospital, then the hospital will build a new medical record of the person in its database and notify the TTP to add itself to be a VH of the individual member.

In Taiwan, fire stations are under EMS authorities. An ambulance of a fire station is staffed by two paramedics, called emergency medical technicians, who are fire fighters having received at least 60 hours of training and passed the certification examination [8].

When an ambulance is taking an individual member to the ECH, the paramedic in the ambulance transmits the patient’s identification to the ECH via the wireless network. The ECH can then poll the TTP to inquire the list of HH and VHs. The TTP simultaneously instructs all the patient’s HH and VHs to send their respective copies of the patient’s medical record to the ECH. All that received by the ECH will be integrated for the ED physician’s use. After the individual member arrives at the ECH, the patient’s identification should be reconfirmed by the RFID tag or NHI IC Card before treatment.

The extent of medical records collection depends on its application. Unnecessary medical information will overburden the ED physicians with interpretation difficulties and consume precious time in retrieval and transmission. The European Emergency Cards defines a concise emergency medical record with 44 attributes [9].

These attributes should also prove useful for the CHEMS3. Each hospital member should extract relevant medical attributes from each individual member’s clinical records to update this patient’s medical record in the CHEMS3 database. In the EMS setting, the pre-edited and concise medical records facilitate quick retrieval and transmission.

In order to improve the efficiency of the EMS, the European Union has issued Emergency Cards [9]. The Cards provide patients’ medical records to assist physicians in making correct judgment of treatment. An Emergency Card is updated each time the cardholder visits a hospital. The physician who treats the patient should extract relevant medical information from the patient's clinical record, and store it in the Emergency Card.

Implementing the Emergency Cards in Taiwan will require a huge initial investment of money and time to build a gigantic hardware and software infrastructure, including issuing tens of millions of smart IC cards. Since the number of times for each person to receive the emergency care throughout lifetime is very few, it is more cost-effective to retrieve a patient's medical information from each hospital visited when necessary than to build a new emergency card system.

On the other hand, the NHI IC Card of Taiwan currently holds only limited personal information without useful medical record. Therefore, it alone is not useful for the EMS.

The Medical Information Exchange Centre (MIEC) project has provided an information exchange platform for electronic medical cases [10]. When a patient is referred to another hospital, this platform assists the transferred patient in receiving continuous quality medical care. Another subsequent project, a study on WWW-based trust centre of patient record, has planned to form a networked medical record trust centre [11]. Its purpose is to provide a centralized trust centre to have a custody of patients’ medical records.

5. Conclusion

We have proposed a system for fast and secure collection of medical records, which is particularly useful for ED or unconscious patients. The system takes into account current information technologies and medical information setting in Taiwan to achieve the goal. The ED physician can thus provide effective treatments as soon as possible. The EMS quality can be improved, and patients’ privacy can be protected.

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