Saturday, March 28, 2009

Case for a Collaborative Health-Support Software System - Part 3 of 3

Introducing the ReAsure HealthNode™ Software Technology

In my previous two post (click here for the 1st in the series), I (a) presented a case for using collaborative health-support software systems in loosely-coupled networks of healthcare professionals and consumers and (b) explained how to implement such systems and networks in a way that increases value to the consumer. In this post I introduce a next-generation software system we've been developing for quite some time, called the ReAsure HealthNode™ software technology, which is designed to help these networks transform our current low-value, fragmented, healthcare industry into a high-value one by enabling people in widely scattered localities to:

  • Collaborate around personalized health-support software
  • Evolve those programs
  • Use the programs to help prevent, treat, and manage health problems efficiently and effectively …
Resulting in:
  • Better care coordination
  • Greater consumer-centered cognitive support
  • superior shared decision-making
  • More competent self-maintenance (self-care).
The system utilizes innovative methods and the patented CP Split™ technology[1] to deliver a unique set of benefits and advantages, which follows.

Benefits and Advantages #1:
A Simple, Flexible, Low-Cost Way to Exchange Health-Support Software and Data Files

The ReAsure HealthNode™ software apps provide a simple, flexible, low-cost way to exchange health-support software and data files rapidly and securely via peer-to-peer mesh networks. These networks operate in a node-based[2] communications architecture in which each computerized device loaded with a ReAsure HealthNode™ software module and a health-support software program becomes a node connected to other nodes in the network. Each node, furthermore, has publisher-subscriber functionality,[3] which means certain nodes serve as publishers and other as subscribers. The publisher nodes send the files and the subscriber nodes receive them. The system uses a "desktop-to-desktop" (application-to-application) architecture and exchanges the files via FTP (file transfer protocol), e-mail attachments, or other methods of file transfer through Internet connections.

At one end of the connection, the node serving as the publisher must authorize the transfer of a health-support software file and/or data file by authenticating that each subscriber node is allowed to receive them. At the other end of the connection, the subscribing nodes must allow the publisher node to deposit any necessary file(s) into the subscriber's computer.

Exchanging Health-Support Software Files

The health-support software files designed for the ReAsure HealthNode™ apps consist of particular types of software templates. These templates are electronic files that run (execute) the health-support software by applying particular rules (algorithms) consisting of mathematical formulas, logic, text functions, and formatting instructions (which reflect the software's underlying model). The software templates have two basic functions:
  • Create Data Files (also called "content files") for distribution, which is a publisher function
  • Consume (extract data from) the content file and render it in reports or enable new data to be input, which is a subscriber function.
The health-support software template files are sent from the publisher node to its subscribers when the initial connections are made, and again if the templates have been modified. The files are also exchanged when network collaborators want to compare and examine the different software programs, discuss their findings, debate the pros and cons of competing programs, modify the programs, build new programs, etc. This process is crucial for the software's evolution (continuous improvement) and can be facilitated by giving the nodes access to knowledge management software containing a virtual forum.[4] The oil & gas industry, for example, has used a node-based virtual forum, which enable participants to share lessons learned, best practices, after action reviews, drilling reports, and health & safety alerts on deep water drilling rigs around the globe.[5] Such a program can be applied to healthcare to help collaborators evolve the health-support software.

Exchanging the Data that the Software Uses

In addition to exchanging health-support software files, the ReAsure HealthNode™ Network system uses node networks to exchange and transform data files containing consumers' health information. Figure 1 (below) describes the basic components and processes of its node-based data file exchange method, which are explained following the figure.

Click image to enlarge

Starting on the left of Figure 1, the Software Template File box depicts the health-support software template file and the arrow through it depicts the publisher node sending the file to the subscriber nodes as discussed above. Note that ReAsure HealthNode™ apps can also interface with other software programs via application programming interfaces APIs[6] (which is not depicted in the Figure 1).

The Node as Publisher box in Figure 1 depicts a node that:
  • Uses a health-support software template to:
    • Acquire data and information (content) from specified sources, as depicted by the arrow from the Data Input to Data/Information Sources box, which is a template input function. The content may include numbers and text, as well as links to electronic documents, images, and web sites.
    • Process (manipulate, transform, and organize) the content as defined by the template's algorithms and then package that content in encrypted, delimited (e.g., comma separated value)[7] content file (Data File). Since the content file do not contain any formatting instructions or "markup tags,"[8] they are very small to transmit and efficient to use. These template output functions are depicted by the arrow to the Content File box.
  • Uses its publisher module to transmit the content file to its subscribers via e-mail or any other methods, as depicted by the arrow to the Node as Subscriber box, which is a publisher node transmission function.
The Node as Subscriber box depicts a node that:
  • Uses its subscriber module to retrieve the data & information from the content file, which is a subscriber node input function, as depicted by the arrow coming out of the Content Files box.
  • Uses a health-support software template to:
    • Format the content and displays it in interactive reports, which is a template output function, as depicted by the arrow to the Report Display box.
    • Enable a person to enter new and modified content through its user interface, as depicted by the arrow to the Data Input box, which is template input function. Note that his added or changed content may be used to update the existing content file stored locally in the person's computer, as depicted by the arrow to the Existing Local content file box, or the content may be exported to any databases or other data sources, as depicted by the arrow back to the Data Input to Data/Information Sources box; both of which are template input functions.
Since the content files are typically much smaller than the software template files, transmitting the content files as encrypted e-mail attachments has several advantages:
  • It provides a convenient and transparent automated method that accommodates everyone's needs—from people with continuous broadband to those connected to the Internet only occasionally, as well as those using low speed dial-up services
  • It saves money by eliminating the need for expensive hardware, high-speed networks, costly IT support, and complex software systems.
Figure 2 (below) depicts how a network of nodes operates to exchange information.

Click image to enlarge

Following is a description of the six steps shown in Figure 2.

Step 1: Line #1 depicts the node at the top retrieving content from databases (including EMR/EHRs, laboratory systems, etc.), as well as from electronic files and other sources, and then processing that content to create a content file using node functions defined in its health-support software file.

Step 2: The solid blue arrows of line #2 show the node at the top using the publisher functions to send content files via encrypted e-mail attachments to the node at the upper right, the nodes on the left, and the node at the bottom.

Step 3: This dashed arrow (line #3) shows the top node, after sending content files to the node on it left, subsequently receives the content file from that same node and retrieves it via its subscriber functionality. This means both these nodes invoke their publisher and subscriber functionality.

Step 4: These two nodes receive and retrieve content files; only their subscriber functionality is invoked.

Step 5: These dotted arrows show content files being passed sequentially from one node to the next, with each node adding to or modifying the files it receives, before sending extended content files to the next node; their provider and subscriber functions are invoked.

Step 6: The bottom node receives content files from two other nodes via its subscriber functionality. After forming a composite content file from the accumulated content, as defined by its health-support software templates, it sends the composite content file back to the node at the top using its publisher functionality.
Thus, based on Figures 1 and 2, networks of nodes using publisher subscriber modules and health-support software can:
  • Exchange and evaluate software template files
  • Create and share content files
  • Generate personalized, interactive reports
  • Modify the contents file and then reuse it to generate updated reports or export it to other data stores.
Following is a practical example of a collaborative health-support software system in action.

A Practical Example

Imagine a consumer having the ReAsure HealthNode™ modules in his computer, along with a health-support software program. When he installed the node modules, he went through a registration process during which he sent requests, as a publisher, to the nodes of people to whom he wants to send certain of his health information. He also sent requests, a subscriber, to people from whom he wanted to receive information. In addition, he received requests from others who want to receive his health data (i.e., they subscribed to him). The nodes used e-mail to transmit the content files, so the e-mail addresses of the corresponding nodes were stored during registration. As each request was approved by the appropriate parties, the transfer of software template files and content file began.

Now, whenever he wants to sends particular data to the healthcare providers he authorized as his subscribers, he click his mouse to initiates certain publisher node functions, which instruct his node to:
  • Retrieve and decrypt his content file
  • Extract from his content file the particular data authorized for each provider; these authorizations are based on the provider's "role" (e.g., the provider's area of specialty)[9] Pack the extracted data into other content files and encrypts them
  • Attach the content file to e-mails and sends them to the appropriate providers.
Upon receipt of the e-mails by his providers, each of their subscriber nodes:
  • Retrieves the content file from the e-mail
  • Decrypts the content file
  • Extract the data from the content file
  • Exports the data to the provider's electronic medical record system.
All these steps taken by the publisher and subscriber nodes are done automatically.

In a similar manner, the consumer may want to obtain data from a provider or lab, that is, he may want to be one of their subscribers. If the provider (or lab) has a ReAsure HealthNode™ and the registration process is completed, the consumer would send a request to their nodes for a content file containing certain information. In this scenario, the consumer's node uses its subscriber functionality, and the provider (or lab) node serves as the publisher.

Once the consumer's node receives the e-mail with the content file attached, it automatically retrieves and decrypts the content file, extracts its contents, and merges the new data into his own (locally stored) content file. Depending on the software rules, the data may replace (i.e., overwrite) existing data in his content file or it may be added to the existing data. His content file can then be accessed, formatted, and presented by any appropriate health-support software program, such as the Personal Health Profiler™.[10]

In yet another scenario, a provider may request particular data from the consumer, or certain rules the guide in the consumer's node might be executed on behalf of the provider (e.g., if the consumer has diabetes, a rule might tell his node to send his glucose readings to his primary care physicians, endocrinologists and wellness coach once a week). In this case, the consumer's node is once again the publisher, which automatically extracts those data from his content file and sends it to the subscriber's (i.e., providers') nodes.

Data Transformation and Translation

Transmitting content files between nodes and rendering them as reports is only part of the process. What happens when a publisher node sends a content file to subscriber nodes utilized by people who use different terminologies, speak different languages, or have different data storage and presentation requirements? How are the contents of the content file transformed and translated to meet the diverse needs of everyone in such loosely-coupled networks?

Transforming Data

Data often has to be transformed when being sent from one database to another. This happens when, for example, the databases have different table field[11] names (e.g., "birth_date" and "dob") or data formats/syntax (e.g., whether or not dashes should be included in a phone number). What is required, therefore, is either to force everyone to use the same data standard, such as transforming everything to XML[12] using a common "schema" (data structure). Another is to transform the original data names and formats so the data are received in the proper configurations.

XML data standards can be used in the node network to transform data, and the content files can be constructed of data transmitted in XML files. But simpler and most efficient ways include having rules included in the node functionality that instruct:
  • The publisher node to do the necessary data transformations prior to packing the data into the content file before sending it to its subscribers
  • The subscriber nodes to do the transformation upon receipt of the content file
  • Intermediate nodes make the transformations as the content file passes through them.
Note that these transformation methods require that the publisher and subscriber nodes be notified in advance as to the required transformations. This notification process can happen during the registration or upon a subscriber node's request for data from the publisher.

Translating Information

When people in loosely-coupled networks share information there is often the need for it to be translated. In addition to language translation (e.g., English to Spanish), the issue of terminology translation must be addressed. This refers to the problem that occurs when different people use different terms (their local standards) to refer to the same concept.

One common strategy used to avoid such problems is to force everyone to adopt the same global terminology standards[13] by agreeing on one set of terms (semantics). While setting arbitrary global standards for health-related terms is a way to foster widespread communications between people from different regions, organizations and healthcare cultures/communities, there's also a downside to eliminating the local standards people rely upon, i.e., they lose information due to reduced semantic precision and nuance.

Take, for example, the term "high blood pressure;" there are 126 different terms referring to this concept of elevated blood pressure levels. These terms include "malignant hypertension," which refers to very high blood pressure with swelling of the optic nerve behind the eye; it's a condition usually accompanied by other organ damage such as heart failure, kidney failure, and hypertensive encephalopathy. "Pregnancy-induced hypertension," on the other hand, is when blood pressure rises during pregnancy (also called toxemia or preeclampsia). These are very different types of hypertension. So, while referring to a person's condition using a global standard term such as "hypertension" clearly conveys that the person has high blood pressure, the standardized term loses important details found in the more detailed local standard terms. These lost details, in turn, could very well affect treatment decisions and outcomes. So, there is a good reason to have multiple terms for a health-related concept.

Furthermore, relying on global standards are problematic because, as standards evolve, it can be very difficult and costly to change the global standards Consider, for example, the clamor over by switching to the new ICD-10 global standard of diagnostic terms (codes), which have evolved from the ICD-9 standard.[14]

It would be much better, therefore, to keep local standards, support their evolution, and use the data translation described above to ensure everyone gets the information needed using the terms they need and understand. In a node network, this can be accomplished in a similar way data transformation occurs, but instead of transforming the data, the terms that the subscriber node requires either replace, or are added to, the terms in the original content file.

Composite Reporting 

In addition to modifying a content file data through transformations and translations through node networks, the nodes support composite reporting. Composite reports consist of information sent from multiple publisher nodes to a single subscriber node. The subscriber node takes all that information and combines it into a single integrated content file, which is then used to generate composite reports containing information from multiple sources.

For example, let's say a primary care physician (PCP) wants to keep track of the treatment a patient is receiving from several provider specialists. The PCP's node, which serves as the subscriber, would send a request for certain data from all the patient's specialists. Upon receipt of the data request, the specialists' nodes, which serve as the publishers, retrieve the requested data from their different electronic health record databases and send the data automatically to the PCP's node. The PCP's node then incorporates the data into a composite report tailored to the PCP's needs and preferences, and then presents the report on screen for the PCP to view. The PCP's subscriber node could also be instructed to request data from the publisher node connected to the patient's personal health record and, upon receipt (and as authorized by the patient), add the data into the same report as authorized by the patient. Likewise, a consumer using the Personal Health Profiler™ software can create composite reports in a similar manner from data sent by multiple provider nodes.

Protecting Personal Health Information

With all this personal health data being sent around, a powerful method is needed to protect people's privacy. While encryption and authentication handles security issues (e.g., making it safe to send content file by e-mail), it doesn't deal with privacy issues (i.e., who is allowed to receive a person's health information). Instead, protecting the privacy of information sent by consumers' nodes requires strategies such as transmitting "limited data sets" and enabling "granular level" of control. That is, consumers should be able to implement one-time authorization to share certain parts of their content files with specific types of providers. They should also have granular control over whom, if anyone, gets to see their information by authorizing particular types of providers to receive particular pieces of information. Warnings and alerts inform the consumer if certain information not being authorized ought to be shared with certain providers who need those data to help make diagnostic and treatment decisions.[15] The Personal Health Profiler™, for example, deploys these privacy safeguards.

Benefits & Advantages #2:
An Elegant Way to Maintain a Complete and Evolving Data Set 

A second set of benefits and advantages of the ReAsure HealthNode™ Network system is its ability to maintain a complete and evolving data set that excludes nothing. That is, every possible piece of health information—about one's health status, risks, conditions, treatments received, the clinical outcomes (results) and costs of the treatments, etc.—can be collected, stored and used over a person's entire lifetime. It does it using an indexing and categorizing method similar to the Dewey Decimal classification system libraries use to organize books and magazines.

This all-encompassing method enables rich, detailed health-support software to be built. And it also permits development of holistic (mind-body-environment) health-support software that improve care value by promoting greater understanding of a consumer's health problems, threats, and needs. The holistic approach provides feedback, guidance, and instruction about people's:
  • Signs & symptoms[16] and their possible relationship to medications side-effects treatment procedures, including complementary and alternative medicine[17]
  • Psychological (emotional, cognitive, and behavioral) health and its relationship to biomedical conditions (e.g., the effect of mental stress of blood glucose control in diabetic persons)[18]
  • Genetic markers and the associated health risk factors[19]
  • Health trends based on health status changes and lab test results over time
  • Methods for coping with and solving personal problems.

Benefits & Advantages #3:
A Way to Increase Care Value to Consumers while Protecting Populations

And a third set of benefits and advantages refers to the ReAsure HealthNode™ Network system's ability to support evidence-based research across all healthcare disciplines focused on improving healthcare value to consumers, and to protect populations through surveillance and support of emergency personnel.

Increasing Care Value to Consumers through Evidence-Based Research

Increasing and sustaining care value to consumers requires a simple, flexible, low-cost way to exchange health-support software; a convenient, secure, economical way to exchange the data used by the software; and an effective, efficient way to maintain a complete and evolving data set. By adding the system's ability to de-identify consumers' health data[20] to these previously discussed advantages and benefits, it becomes apparent that the ReAsure HealthNode™ Network system is ideal for researchers involved in creating, studying, and evolving high-value evidence-based guidelines across all healthcare disciplines (both sick-care and well-care, as well as conventional and complementary & alternative care[21]).

This kind of research is essential for development of evidence-based healthcare decision support systems utilizing quality metrics, practice guidelines, knowledge services and tools, and continuous quality improvement feedback loops.[22]

Protecting Populations

  • The ReAsure HealthNode™ Network system also addresses the need to protect populations through:
    Comprehensive biosurveillance and post-market drug & medical device surveillance[23]
  • Support for first-responder and trauma center staff during disasters[24][25]
  • Has no "single point of failure,", which leaves centralized systems vulnerable in disaster situations.[26][27]

Summary and Conclusion

Collaboration among loosely-coupled networks of healthcare providers, researchers, and consumers using health-support software is an essential strategy for increasing healthcare value. ReAsure HealthNode™ Network system demonstrates how to enable efforts to bring consumers high value care.

We welcome any feedback and opportunities for collaboration.

References and Notes

[2] A node is an electronic device (e.g., a PC, laptop, cell phone, and hand-help device) attached to a network, which contains a software module enabling it to send, receive, or forward information across that network.
[4] A virtual forum enables people share information over the Internet, online or offline, through “threaded” discussions in messages on the same topic are grouped together for easy retrieval and reading.
[9] Each provider’s role is established during the registration process and used by the node thereafter.
[20] The ReAsure HealthNode™ system de-identifies consumers’ health data by “decompositing” their content files and extracting the data without identifying to whom it belongs. See

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