Los Alamos National Laboratory

Contact:
Los Alamos National Laboratory
Los Alamos, NM 87544
http://www.acl.lanl.gov/TeleMed

Tools Used
CORBA, Java, Web browser

Benefits/Problem Solved:
Healthcare providers and payers have long realized the benefits computer-based patient records could provide. Virtual patient records provide a user with virtual access to data possibly scattered around the world. On August 21, 1996, the U.S. enacted into law a process that will govern the adoption of national standards for health-related electronic commerce.

One of the most basic standardization issues for international health care transactions involves how to handle the many different person identifiers existing in disparate medical record systems. Even within a single hospital, different departments may have separate electronic records for the same person, each with a different identification number for that person. Historically, health care providers dealt with this issue by creating a Master Patient Index (MPI) that used a limited set of demographic data (for example, name, gender, date of birth, and so on) to help retrieve the disparate elements of a patient's records. Originally, MPIs were manual and were primarily used to link patient episodes for continuous care. Maintaining the continuity of patient care is still the most important role of automated MPIs. However, existing MPI software applications typically rely on proprietary solutions, involving a centralized approach that uses a new indexing number to cross-reference multiple disparate records, rather than taking a distributed nonproprietary approach to solving the problem.

Viability of a virtual patient record collaboratory will depend heavily on the ability to quickly and securely identify a patient and his or her respective health care providers and payers. Different indexing schemes used in different nations, as well as privacy and confidentiality concerns, currently preclude a centralized approach to the MPI problem at the international level.

A MPI can be summarized as a secure directory of uniquely identifiable patients together with pointers to locations where the respective medically related information about each patient resides. A MPI does not record any clinical data; it merely points to where clinical data is located, whether in electronic form or possibly on paper. By relying on proprietary or domain specific MPI applications for functionality, a nonproprietary standard interface to MPIs could facilitate the process of accessing information across the continuum of care. A standard MPI interface could grant access to pointers that provide authorized and secure access paths to records from disparate health care organizations, even when distributed at an international level.

Working in collaboration with physicians at the National Jewish Medical and Research Center (NJC) in Denver, CO, TeleMed was developed, that is, the early prototype for a virtual patient record. TeleMed uses a media-rich patient record to allow multiple physicians, possibly located remotely across a wide-area network, to consult on a patient record. Consolations can take place interactively in realtime, or offline using textual or audio annotations combined with graphical markers in the record.

The original prototype demonstrated the feasibility of virtual patient records, but it did not reach the stage of full functionality with actual patient records on a day-to-day basis. Los Alamos National Laboratory plans to deploy a more functional version of TeleMed in some of the small clinics and hospitals of northern New Mexico. The Northern New Mexico Rural Telemedicine Project (NNMRTP), led by the Northern New Mexico Community College, aims to develop the information infrastructure required to support telemedicine services in nine countries. This project will provide an important testbed for a collaboratory based on the TeleMed prototype.

TeleMed dynamically assembles a chronologically oriented graphical patient record using data gathered from several different remote locations. It assigns icons and other graphical features as placeholders in the chronological record to mark the onset and duration of events it finds recorded in the data. The assigned graphic icons then become user interface components for selections about which information to retrieve for more detailed viewing. Analogous to hyperlinks on a Web page, these icons provide access to information on demand. Object Request Brokers (ORBs) then mediate the interactive access linking the icons in the graphical patient record to the distributed databases that provide the persistent object storage for the multimedia data. The physicians using TeleMed interact with a seamless longitudinal record that gives no indication that multiple databases were used.

The latest version of TeleMed supports real-time interactive collaborations between multiple users. Multiple physicians at remote locations can simultaneously view, edit, and annotate the patient data. Furthermore, each physician can see the data another physician has entered as well as monitor some of the other physician's interactions with various user interface windows. This allows physicians to engage in collaboratory electronic discussions so that referrals and consultations can occur in a natural manner. This is the concept which underlies the design of TeleMed.

In this most recent implementation, Java-based ORBs embedded in Web browsers now use the much more robust Internet Inter-ORB Protocol (IIOP), for the communication channel. This enables the support of full transaction processing necessary to support multiple users interacting with the patient record simultaneously. Such a capability enables the same architecture to be used for real-time consultations as well for offline sessions in which the physician is seeking a second opinion. The user begins a TeleMed session by launching the TeleMed application for a Web Browser. This initiates a sequence of events that downloads the ORB interfaces to the user's desktop. After the ORB has downloaded, a login window appears adjacent to the Web browser window and requests the user to enter a login name and password. The Java-based implementation and environment enables the same TeleMed client to run independent of the underlying operating systems or hardware due to the fact that Java provides cross-platform application development and compatibility.

Authorized users will next see the initial TeleMed interface window that allows them to select a database site to serve as the current site for the session transactions. Once a database has been selected, a CORBA-based transaction vends the relevant patient record objects from the selected site to the requesting client. Textual data from the retrieved patient objects is then used to populate a list of patient names.

When the user selects one of the names in the list, that patient's Graphical Patient Record (GPR) window appears. TeleMed's chronological GPR is dynamically assembled by CORBA-based transactions that merge all of the relevant data from multiple databases to form the seamless view presented to the user. The fact the user selected a current database serves only to isolate the preferred site for storing current transactions.

An international collaboratory based on virtual patient records can eventually include a wide assortment of health practitioners and their patients to work together more naturally and more effectively and, thereby, deliver a higher quality care to a more extended population in a cost-effective manner. The timing is right to invest now during a time of transition to develop a new information infrastructure for health care.

More information about TeleMed can be found at http://www.acl.lanl.gov/TeleMed.

D. Kilman & D. Forslund, Communications of the ACM - August 1997, p. 111-117