1. Study on Electronic Health Record for use by Private Emergency Medical Service (EMS) in Indonesia - A case study of EHR in developing countries - Yunan Mahastra Satria Graduate School of Global Information and Telecommunication Studies (GITS) Waseda University Tokyo, Japan ysatria@gmail.com Kano Sadahiko Graduate School of Asia Pacific Studies (GSAPS) Waseda University Tokyo, Japan kanos@waseda.jp Abstract – This paper studies the use of free open-souce software technology based on openEHR in order to develop an affordable electronic health record (EHR) in developing countries for the use in private emergency medical service (EMS). The resulting EHR system was tested successfully by the actual private EMS provider in Jakarta, Indonesia. The feedback from the actual EMS team was mostly very positive with some modifications at the human interface level. The availability of EHR system will change how EMS will run its operation in developing countries expected to be more efficient and effective with the help from technology. Keywords – EHR, EMS, open-source, openEHR, java, developing countries I.INTRODUCTION The objective of this paper is to find the most appropriate solution for Electronic Health Record (EHR) to be utilized for private Emergency Medical Service (EMS) in Indonesia in order to replace the current paper based health record. Due to the fact that paper based health record may not be reliable to support medical expertise for future EMS operation, therefore, EHR can be considered here as a solution in order to solve the current issue of sharing health information among different experts involved in emergency medical service more efficiently and less time consuming. We considered that developing a web based free open source EHR software will provide much better supportive tools for the EMS Communication Center (Call Center) and Paramedics that can be used to access patient’s health information more effectively before and during medical emergency cases. Figure 1 shows the flow of operation in EMS where each expertise can easily share health information necessary to assist each of their own specialized work and responsibility so that mission of saving lives can be supported with the right information tools. What we used to support this study were 1) openEHR health standard information tool and 2) Java programming language and its development supporting tools, both of which are free open-source software. The reason why free open-source software technology has been chosen to develop EHR in this study is due to the fact that buying proprietary EHR software is not financially affordable in a developing country such as Indonesia. During this study, we have also accomplished to develop a prototype of EHR application which focuses on web technology so that sharing of health information among different medical experts on the field can be accomplished more efficiently and effectively. The completed solution was put to experimental use in Jakarta (capital city of Indonesia) over the internet network to test its usefulness by the emergency medical team. Figure 1: Sharing of health information among different experts in EMS operation The web based EHR consists of central server hardware and mobile hand-held terminal offering remote user access and they were evaluated by EMS doctor and paramedics in Jakarta, Indonesia to support their current operational needs. The essence of this study is to prove that EHR can be completely developed fully from open source software in order to solve the lack of financial resources, while enabling effective health information sharing in developing countries. II.CURRENT SITUATION OF HEALTHCARE IN DEVELOPING COUNTRIES In developing countries such as Indonesia, the condition of health services in public sector (government) can be considered as below average as compared to health services in developed countries, such as Japan or United States. This is happening due to several reasons starting from the fact that most developing countries suffer the lack of financial resources and knowledge resources regarding standard health services. Welfare of one nation can easily be determined from the point of view of its healthcare services. In developing countries like Indonesia, there is still so much room that needs to be improved when it comes to healthcare services especially of public sector. III.CURRENT CONDITION OF EMERGENCY MEDICAL SERVICE IN INDONESIA There are many challenges to this large, diverse, and developing nation, not least the difficulties presented by an unstable political situation and unsteady economy. Organizing a pre-hospital care system in major cities in Indonesia is hard enough but when you look at the vast area of Indonesia it seems almost impossible to accomplish. The government has promised some pre-hospital resources in the future, but given the current political/economical situation, it is quite difficult to say how much of that can be expected to happen in the near future. The funny misperception in Indonesia is that there is a culture of accepting accidents of death as a fate and often there is no real impetus to improve the state of pre-hospital emergency care accordingly. Linked to this can be the attitude and ignorance of the public about the role of the paramedic, the ambulance service, as well as other emergency services. There is rarely any effort by ordinary drivers to pull over or give way to ambulances (possibly because ambulances were previously used mainly to transport those already dead!). Adding to this, Jakarta people accept poor response time of ambulance services knowing the huge volume and chaotic nature of Jakarta traffic as well as the massive area to be covered by only few ambulances. Emergency Medical Service (EMS) is a program providing pre-hospital or out of hospital acute care and transport to definitive care, to patients with illnesses and injuries, which the patient believes constitutes a medical emergency. The most common and recognized EMS type is an ambulance organization. In more advanced countries, an EMS organization may also be called a first aid squad, emergency squad, rescue squad, ambulance service or life squad. The major aim of EMS is to provide treatment to those in need of urgent medical care, with the goal of either satisfactorily treating the malady and/or arranging for timely removal of the patient to the next point of definitive care. EMS also exists to fulfill the basic principles of first aid, which are to preserve life, prevent further injury and promote recovery. Commonly used system includes: 1) Early Detection, 2) Early Reporting, 3) Early Response, 4) Good On Scene Care, 5) Care in Transit and 6) Transfer to Definitive Care. The important key of EMS is a medical communication center which connects all critical members of the qualified medical team while dealing with emergency situation. Medical communication system is a critical area in the pre-hospital emergency medical services chain of care, and is actually completely neglected area in Indonesia healthcare system. The “health” of many EMS systems cannot be gauged only by the appropriateness of training, protocols, involvement of pre-hospital EMS physicians, instruction of dispatchers, response time, etc, but also of equal importance is how sophisticated the communication center system is in order to support and control all the EMS operational activities smoothly. IV.STUDY APPROACH AND SOLUTION Developing EHR software application can be achieved using different kinds of software development technology; however, the issue remains on whether the software technology that we use to develop EHR is clinically standard, accessible, readable, interoperable and last but not least is affordable to other entities that will use the same health information. The first approach is toward the free open source software that will help to solve the affordability issue. Generally speaking, free open source software has been around for years and has been used quite intensively as an alternative solution toward expensive proprietary software. The openEHR standardization is an open source software standard that was developed to aim at enabling standardization of health information to be interoperable among different institutions. Due to the arising need and interest of semantic interoperability in healthcare system, it has come to the attention of building logical standard health record specifications that could provide a critical sustainable solution for this matter. In addition, openEHR has also been standardized based on ISO 13606 standard, which was approved quite recently by ISO in 2008. The basic structure of openEHR specification relies on fixed schema and service layer for all data, and it consists of maximum set of clinical health information needed in the form of “Archetype” that have been gathered and used by medical professionals internationally. This will ensure the interoperability of not only the programming syntax, but also the semantic medical terminologies that are globally shared. Therefore, developing standard EHR based on openEHR seems to be more practical to achieve with decreased start up work (not totally starting from scratch), by using standard health parameters, shared health components and rules provided by openEHR approach. Most important of all is that the integration of various data structures and format on various platforms can be resolved with openEHR specification. This feature is what makes the openEHR to be quite interesting source to develop our own EHR because it provides enough flexibility for software developers to design EHR according to each of their own use case requirements. Figure 2 below clearly describes how openEHR archetype architecture can be used with flexibility as the basic blocks in building the health templates for HER system in accordance with each of its health or medical use case needs. The final product of the EHR system will consist of the openEHR archetypes that will be used for each of patient’s use case health templates and other medical requirements. openEHR Architecture explanatory diagram (1/2)- from Archetypes to Templates -Demo-graphyName, Age,Gender,...HeightWeightLipidsGlucoseLiverFunctionBlood PressureECG(Cardiogram)CT ScanImage・・Archetypes・・DiagnosisMedicationBlood Test Results(Reusable Common Clinical Concepts)[Total: some 200]** Proposed additions/changes have to be approved by openEHRforum board members.Medical Knowledge DomainContributor: Medical domain specialists Policy domain specialistsTool: Archetype Editor(add/change archetypes)Building blocks to construct
Templates
Lipids GlucoseMetabolicSyndrome TestLiverdisease Kidneyfunction(Cre, BUN) Urianalysis ECG CT scan iimage Liver function(ALT, AST)CT scan image・・KidneydiseaseTemplatesHeart disease Lipids Glucose Urianalysis Diagnosis Advices Laboratory OrderDischargeSummaryTool: Template Designer(Creates a specific template, by collecting appropriatearchetypes and editing them properly.) (Clinical documentationscenario for each diseasecase or medical action) Lipids Glucose UrianalysisLaboratory ResultTo be used by: Practicing medical doctor for each disease casePrepared by: programmers (Ocean Informatics)Prepared by: programmers (Ocean Informatics)Copyright: Kano Lab, Waseda Univ, Tokyo, 17 March 2009, Version 2To be used ｂｙ： Medical domain specialistsInsurancePolicyHealth InsuranceCountry Specific Info.Height, Weight , Blood Pressure,......,Specific Diseasedependent templatesHeight, Weight, Blood pressure, Basic blood test results,.....Basic templatecommon to alldisease typesDemography, Insurance policyDiagnosis, ....＊＊ country specific openEHR Architecture explanatory diagram (2/2)- from Templates to Website view EHRs for individual patients-Templates(Clinical documentationscenario for each diseasecase or medical action)Patient A1Basic TemplateMetabolic Syndrome Test LaboratoryOrder LaboratoryResultWebsite viewEHRsfor individual PatientsPatient A2 Basic templateMetabolic Syndrome Test LaboratoryOrder LaboratoryResult・・EHRs for Metabolic Syndrome PatientsEHRs for Liver Patients・・Patient B1 Basic templateLiver Function LaboratoryOrder LaboratoryResultPatient B2 Basic templateLiver Function LaboratoryOrder LaboratoryResultPatient CBasic templateKidney function Liver Function LaboratoryOrder LaboratoryResultEHRs for Kidney and Liver PatientPatient DBasic templateHeart Disease LaboratoryOrder LaboratoryResult DischargeSummarhyEHRs for Heart disease Patient, who was dischargedTool:Website view EHR Editor(Creates a specific Website view EHRs for individualpatients, by collecting appropriate templatesand editing them properly.To be used: by practicing doctor for each specific patientTo be prepared: by programmers(under study by Kano Lab at Waseda Univ.)Note: Currently this is done by programmersusing C# or PHP programming language)Copyright: Kano Lab, Waseda Univ, Tokyo, 17 March 2009, Version 2 Lipids GlucoseMetabolicSyndrome TestLiverdisease Kidneyfunction(Cre, BUN) Urianalysis ECG CT scan iimage Liver function(ALT, AST)CT scan image・・KidneydiseaseHeart disease Lipids Glucose Urianalysis Diagnosis Advices Laboratory OrderDischargeSummary Lipids Glucose UrianalysisLaboratory ResultHeight, Weight , Blood Pressure,......,Specific Diseasedependent templatesHeight, Weight, Blood pressure, Basic blood test results,.....Basic templatecommon to all diseasesDemography, Insurance policyDiagnosis, .... Figure 2. The openEHR archetype building blocks V.THE OPENEHR DEVELOPMENT TOOLS The challenge of developing EHR software application based on openEHR architecture model is to understand the whole data structures and follow its standard data compositions that have already been pre-defined in order to build the complete EHR system with all of its standardized components. The “Archetype Editor” tool has been provided in order to understand all the components within each archetype. Basically it shows what each block of archetype is made of. The archetype itself is actually written in ADL language which is not quite popular; however, the archetype editor enables the conversion of this ADL language format to a more commonly used XML data format. Furthermore, the archetype editor has another function which will help software developer to see and understand the components of archetype in the form of interface view that clearly enables the archetype contents and structures to be more easily understood as to how the archetype is constructed. As a matter of fact you can actually use the archetype editor to build your own archetype with all the components according to your requirements although it is not recommended because the archetype you have built may not be the standardized archetypes. The interface view is quite handy in order to see how the archetype data will look like as a template later on, and each of the archetype components are described on a display so that when we construct the health template, we should be able to have a picture in our mind how we can build our templates. Figure 3 shows an example of interface display view of some of the components inside the archetype to help us understand. Figure 3. Interface view of openEHR-EHR-Observation.blood_match archetype components Each of the components in the archetype is medically defined and explained with this tool; therefore, understanding each component explanation from the medical point of view is made easier. In addition, each archetype has been examined by medical expertise around the world and is approved by the Archetype Review Board of the openEHR Foundation. In addition, openEHR also provides what is called the “Knowledge Manager” tool, which is basically a web application supportive software that allows software developers to search and download the right archetypes necessary for each of their own use case implementation. There are currently more than 200 archetypes available that have been standardized by ISO 13606. Figure 4 shows how the openEHR web based Knowledge Manager tool looks like from the browser. Figure 4. The openEHR Knowledge Manager tool The use of Java development tool to design archetype based EHR is also important. One of the main reasons that Java development has been chosen is because it can be implemented over independent platform due to the existence of Java Virtual Machine (JVM). Therefore, it is a free platform programming language that can offer flexibility and compatibility in different computer and server environment platform starting from Unix, Linux, Windows and etc. In a sense, Java is designed to be sophisticated development software because of its community based programming language software; therefore it is stronger in community wise and quite promising in development and providing better interoperability for long term future. In terms of use case, Java has applied object oriented programming which is one of very popular and effective methods now in use in programming world. The general idea here is how openEHR data structures can be extracted and used as a basic foundation to develop the program on top of Java development environment. Then, web browser based information template which includes demographic and health information can be developed for data entry and data retrieve where the final data will be saved in the database format. Figure 4 basically shows the architecture and flow process of Java MVC (Manage, View and Control) based software technology so that important demographic and health data entry and retrieve can be achieved with the help from web technology, and how we can take advantage of our internet cloud computing today. Figure 4. Java MVC Architecture for Web Based EHR VI.RESULT OF THE STUDY EXPERIMENTATION The final challenge of this study was to experiment the developed EHR software directly by the users (EMS doctor and paramedics in Jakarta, Indonesia with the existing hardware (PC user and Mobile user) over different network platform (Internet and Mobile network) as previously described in Java MVC model in Figure 4. This would prove whether the aim of this project is achieved or not, which is to share health information among different expertise described in Figure 1. The first experiment was done from a Tomcat apache server that contains the developed EHR software application hosted over the internet network using DynDNS (Dynamic Hosting Services) and HSDPA wireless broadband network in Japan. The remote user will access the web based EHR software through Wi-Fi internet network with another pc and iPod touch PDA. Initially intended remote users were remote EMS doctors and paramedics. Figure 5.1 shows how the interface looks like on the iPod Touch PDA. The remote user will initially need to login as a registered/authorized user in our MySQL database to be able to use this service. Figure 5.1. Login Screenshot View of EHR Application over Ipod Touch PDA Interface Once the remote user succeeds through the login authorization screen, it will go to the profile page which consists of several options of activity that can be done by EMS doctor or paramedics in relation to health record service. This will include inputting new patient health information and/or retrieving the existing patient health information from the database. However, in this experiment, EHR service will be limited only to patient’s demographic information and patient’s physical health examination needed for EMS use case only. This is shown in Figures 5.2 and 5.3 below. The health data structures and components shown below are taken from the openEHR archetype repository. Figure 5.2. Profile Page Screenshot of EHR Application Figure 5.3. Patient’s Physical Health Examination Template of EHR Application The second experiment was conducted for remote users in Jakarta, Indonesia, to access the Java MVC server architecture in Tokyo, Japan. The remote users are now accessing the EHR service provided by this server architecture in Tokyo from a GSM-GPRS mobile network in Jakarta, Indonesia for mobility purpose. Since Indonesia is still using GSM-GPRS network for its mobile network therefore the data speed was actually slower to access the internet network compared to mobile network in Japan. Figure 6 below shows how the second experiment was implemented for the EMS doctor and paramedics in Indonesia. Figure 6. Web Based EHR Service over HSDPA and GSM-GPRS Mobile Network The remote user also accesses the EHR service with different mobile device interface, such as a Blackberry mobile phone via GSM-GPRS network. Therefore the quality and interactivity of the internet based computing may not be as good as in Japan using the IPod Touch PDA interface. In addition, due to a slow speed of GSM-GPRS mobile network, there might be some errors caused by loss in network signal. Figure 7 shows the screenshot of how the EHR application service looks like with a Blackberry mobile interface. The health information was able to be sent from client’s mobile interface in Indonesia to EHR server in Japan taking advantage of internet network so that the EHR software application is accessible anywhere and anytime. Figure 7. Web Based EHR Service over Blackberry Mobile Interface As a result of this simulation, the EHR software application had also been examined directly by both EMS doctor (Dyah Gustinar Savitri, EMS director and doctor in charge) and paramedics team leader (Jim Crouch, an experienced and licensed EMS paramedics) for its usefulness. Their responses were that information provided by the software is practical, relevant and frequently used by doctors or paramedics on EMS and Clinics. The ability to update and retrieve medical information anytime and anywhere is very helpful for doctor, nurses or paramedics taking care of you or even saving life in emergency situation. They have also realized the completeness of openEHR archetype based EHR application in fulfilling medical parameters needed for the use in EMS operation. VII.STUDY EVALUTION The most important benefit that we experienced was the fact that open source technology has given more exposures and alternative options in software technology development that can be applied in various computing environment. The main objective of this study is to find a good solution of technology for developing countries to develop EHR in order to replace the existing paper based health record. The open source based technology has helped us to achieve most efficient and affordable solution for providing a better health information sharing and documentation. Having a web based EHR application taking advantage of today’s internet network has shown that Emergency Medical Service team can run its operation more efficiently and effectively thanks to the capability of sharing health information among different expertises in the team. Web based EHR will not only eliminate the inefficiency of paper based health record that is more time consuming in sharing important health information, but also solve compatibility issues across different device interface platforms compared with more traditional client software interface. There will be less administrative work being done compared to paper based health record; therefore, additional financial savings in work operation can also be achieved. Finally, the development of EHR based on the openEHR standard has given added values toward the health service itself due to the structure of health information which is compatible with the world standardization which can be shared among medical doctors and experts internationally. Most important of all is that the end users, EMS team, has felt the practicality of using this web based EHR application from their device both computer and mobile handheld in order to support each of their field of expertise. The main essence of the openEHR archetype data model has enable the sharing of the same health information to different expertise although the way it is presented may differ depending on each use case requirement. A standard syntax and semantic health data from the openEHR will enable different medical experts to share important health information in a timely manner not just for their own requirements, but also for a wider range of healthcare services beyond Emergency Medical Service. ACKNOWLEDGMENT We are deeply thankful to God that we are able to complete this study in Waseda University fulfilling our roles in the community. We wish to thank all other members of Kano laboratory as well for all the experiences together as a team. We are grateful as well for the people in Jakarta, Indonesia whom we are not able to mention the names one by one. These people have been one of major reasons for the ambition and completion of this study in Waseda University, Japan. REFERENCES 1. Professor Sadahiko Kano, “Introduction to openEHR”, Segaia Meeting. May 15, 2009 in Okinawa. 2. Ocean Informatics Archetype Editor Website https://projects.oceaninformatics.com/ confluence/display/TTL/Archetype+Editor. 3. The openEHR Knowledge Manager Website http://www.openehr.org/knowledge 4. Ocean Informatics, Clinical Modeling Tools https://projects.oceaninformatics.com/ confluence/display/TTL/Clinical+Modelling +Tools 5. The openEHR, Java Reference Implementation http://www.openehr.org/wiki/display/ projects/Java+Reference+Implementation 6. Object Oriented Analysis and Design Understanding System Development with UML 2.0, Mike O’docherty. Wiley-India 2005 7. Head First Java, Kathy Sierra and Bert Bates, O’Reilly 8. Head First Servlets and JSP, Passing the Sun Certified Web Component Developer Exam, Bryan Basham, Kathy Sierra and Bert Bates, O’Reilly 9. Emergency Triage Kevin Mackway-Jones, Janet Maresden, Jill Windle, Manchester Triage Group, Wiley- Blackwell, 2006