A Standardized Middleware as the core of a Telemonitoring European Project.

Abstract

In order to develop smart and innovative solutions which are able to realize the concept of care continuum, the use of a number of different multiple devices, based on heterogeneous technologies, is necessary. In this complex context it is important to study and design systems whose architecture ensure the interoperability between devices and service. A standardized middleware which is able to guarantee this important requirement within the European Project CHIRON, is presented in this article.

Full text

A Standardized Middleware as the core of a
Telemonitoring European Project
Fabio VERGARIb,1, Roberta GAZZARATAa, Francesco MORANDIb, Viola PARODIc,
Simone NASOc, Alessandra AREZZAc, Tulio SALMON CINOTTIb and Mauro
GIACOMINIa
a Department of Communication, Computer and System Sciences (DIST), University of
Genoa, Genoa, Italy
b Advanced Research Center on Electronic Systems for Information and
Communication Technologies E. De Castro (ARCES), University of Bologna, Bologna,
Italy
c Infinity Technology Solutions (ITS), Genoa, Italy
Abstract. In order to develop smart and innovative solutions which are able to
realize the concept of care continuum, the use of a number of different multiple
devices, based on heterogeneous technologies, is necessary. In this complex
context it is important to study and design systems whose architecture ensure the
interoperability between devices and service. A standardized middleware which is
able to guarantee this important requirement within the European Project CHIRON,
is presented in this article.
Keywords. Interoperability, HL7 v3 CDA R2, Smart Space.
Introduction
Over recent years demographic and socio-economic challenges have highlighted the
need for change in healthcare; the population is ageing, life expectancy is increasing,
the number of people with chronic diseases is growing and healthcare and social costs
are exploding [1-2]. In this complex context, ICT provides biomedical engineering
with the instruments to research, project and develop smart and innovative solutions
which are able to renovate healthcare practice. One category of these solutions is
represented by telemonitoring systems which can enlarge the boundaries of healthcare
and promote the concept of continuum care. For example HeartCycle [3], a 2008
European Project, was aimed at improving the quality of care of patients affected by
cardiac diseases by developing systems for health condition monitoring at home and
involving the patient in the daily management of their disease. Other systems are aimed
at compensating for the loss of physical and/or cognitive abilities by helping persons
with disabilities and aging citizens to augment their autonomy (EASY LINE+ [4],
IWARD [5]).
This introduction points out just some of the most recent projects but there is a
constant underlying common aspect present in all of them: the amount of multiple
different devices, based on heterogeneous technologies, and the necessity for
1 fvergari@arces.unibo.it
Quality of Life through Quality of Information
J. Mantas et al. (Eds.)
IOS Press, 2012
© 2012 European Federation for Medical Informatics and IOS Press. All rights reserved.
doi:10.3233/978-1-61499-101-4-497
497

integration according to the specific user and environmental needs. Therefore, the
main aim of the European Project CHIRON [6] is to design a reference architecture for
personal healthcare which will ensure the interoperability between heterogeneous
devices and services, a reliable and secure patient data management and a seamless
integration with the clinical workflow. Our work in this project consists in studying a
standardized solution to solve all the problems related to physic, syntactic and semantic
interoperability and then to design and develop a middleware based on the Health
Level Seven version 3 (HL7 v3) standard. The solution must allow a standardized
information transmission between the User and the Medical Plane and provide the
ability to reactively and automatically generate and communicate alarms conditions
when the patient health state is critical. The User Plane is concerned with the set of
devices and instruments used to monitor the patient and the local feedback; the Medical
Plane represents interactions by and with the doctors (assessment of clinical data,
diagnosis, treatment planning and execution, and feedback to the patient).
1. Methods
One of the main objectives of the CHIRON project is to define a standard based
framework to allow information transmission between the User and the Medical
Planes; this solution must be able to generate and communicate the alarm conditions
based on the personalized patient criteria by processing vital signals and context
(activity and environmental information) acquired from the heterogeneous devices.
Consequently, the first priority was to identify a common standard for medical
information exchange between the CHIRON architecture layers and a solution
providing interoperability with applications and devices used to monitor the patients.
Therefore, two different solutions were combined, which together allowed the
projection and development of a telemonitoring solution completely interoperable from
the physic, syntactic and semantic point of view.
The Smart Space (SS) solution, which was developed in SOFIA [7] project, was
adopted in order to ensure information interoperability concerning the collection of
sensor data between heterogeneous devices and instruments.
To solve syntactic and semantic interoperability in information transmission the
HL7 Version 3 Clinical Document Architecture (CDA) Release 2 (R2) was utilised.
1.1. Smart Space
The Smart Space solution guarantees information (or semantic) interoperability, that is
the shared understanding of information significance. The SS information is about
entities existing in the physical environment, that is, the users, the objects surrounding
them, the devices used, or about the environment itself. This multi domain solution in
CHIRON architecture could be the possible core of the User Plane. In this scenario
every patient has his personal Smart Space that manages information collected from
heterogeneous devices together with the user profile; thanks to its publish/subscribe
mechanism, the solution is responsible also for event/notification. SS architecture has
two main actors: the semantic information broker (SIB) and the knowledge processor
(KP). The SIB is a digital entity where relevant real-world information is stored and
kept up-to-date. The information model is a directed labeled graph corresponding to a
set of Resource Description Framework (RDF a basic semantic web standard) triples.
F. Vergari et al. / A Standardized Middleware as the Core of a Telemonitoring European Project498

The information semantics is specified by ontologies defined in OWL (Web Ontology
Language). The KPs are software components interacting with the SIB and producing
and/or consuming data. The legacy adapters are KPs that enable legacy SS-unaware
devices to exchange information with the SIB (Figure 1). A KP exchanges data through
a simple protocol named smart space access protocol (SSAP), an application layer
protocol based on XML (eXtensible Markup Language). The SSAP defines a simple
set of messages (join, insert, remove, update, query, subscribe, and leave) that can be
used over multiple connectivity mechanisms [8]. KPs uses SSAP API developed in
different programming languages (C#, C, Python, Java, PHP) while SS runs on a Linux
based system.
Figure 1. Smart Space
1.2. HL7 v3 Clinical Document Architecture Release 2
Clinical Document Architecture Release 2 is a document markup standard developed
by HL7, encoded in markup languages as XML or RDF, that specifies the structure and
semantics of a clinical document for the purpose of exchange. The HL7 CDA R2
provides an object model in order to represent a technical diagram of the CDA
specification and structure. The basic structure of the CDA Release 2 is formed by two
parts fully HL7 v3 RIM (Reference Information Model) derived: a header and a body.
The header’s purpose is to set the context for the document as a whole: to enable
clinical document exchange across and within institutions, to facilitate clinical
document management and to facilitate compilation of an individual patient’s clinical
documents into a lifetime electronic patient record. The other part, the body, contains
the clinical report and it can be either an unstructured blob or can be comprised of
structured markup. In the second case, the body is divided up into recursively nestable
document sections. Each section contains a single ‘‘narrative block’’, any number of
CDA entries and external references (such as some other image, procedure, or clinical
document). The ‘‘narrative block’’ represents content to be rendered, which is
expressed in human language. Every section can contain a clinical statement which is
one of the following: an observation, a substance administration, a supply or a
procedure. Each clinical statement in turn can relate to another one with a semantic
relationship (e.g., cause, component, reason).
Data types used in the CDA define the structural format of the data carried within
an attribute, and influences the set of allowable values an attribute may assume. Several
CDA components are designed to carry concepts drawn from the HL7-defined or HL7-
recognized coding systems such as LOINC (Logical Observation Identifiers Names and
Codes) or SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) [9].
F. Vergari et al. / A Standardized Middleware as the Core of a Telemonitoring European Project 499

2. Results
To design and develop an interoperable exchange of information between the User and
the Medical Plane, the two solutions explained previously were combined: Smart Space
and the HL7 v3 CDA. This combined solution benefits of the SS advantages
(publish/subscribe mechanism and information interoperability) adding to the HL7
standardization value. This prototype was realized through an ASP.NET Web Service
(WS) which provides a set of functionalities for the exchange of messages whose types
and formats are based on the adopted medical standard, HL7 v3 CDA R2. The WS has
the middleware role which allows a simple and standardized communication among
heterogeneous actors The functionalities exposed by the WS are; RegisterNewPatient,
SendPatientCDA, SendAlarm, UpdatePatientCDA. Here below are presented different
storyboards as implemented use cases, based on the previously explained solution
(Figure 2).
Figure 2. Storyboards
2.1. First storyboard – Settings of alarms safety thresholds: from the Medical Plane to
the User Plane
When a patient is discharged from the hospital, he/she will be monitored at home by
our SS system. The Medical Plane sends a new CDA document containing the new
patient data to the middleware. This one provides a service which is able to register a
new patient in the middleware repository: RegisterNewPatient. Another service
receives the Patient CDA from the Medical Plane and extracts observations with
thresholds values related to the Patient and sends them to the User Plane within a HL7
v3 message: SendPatientCDA.
2.2. Second storyboard – Alarms communications from User to Medical Plane
The User Plane monitors a patient at home. An alarm is automatically generated inside
the SS when the measured values are outside the allowed ranges. This alarm is sent by
the SS from the User Plane to the middleware in the form of a HL7 alarm message. The
middleware extracts the required information from the HL7 alarm message and sends
the new observation to the Medical Plane. These actions are realized by the SendAlarm
service.
F. Vergari et al. / A Standardized Middleware as the Core of a Telemonitoring European Project500

2.3. Third storyboard – Updating the CDA
The Medical Plane receives the alarm from the User Plane through the middleware. It
needs the old CDA in order to update it with new data. The Medical Plane sends a
notification via a HL7 message to the middleware through a Web Service:
UpdatePatientCDA. This service queries the old CDA from the repository, updates it
with new data and sends it back to the CDA to the Medical Plane.
3. Discussion
The CHIRON project intends to design a reference architecture for personal healthcare,
ensuring interoperability between heterogeneous devices and services, as well as a
reliable and secure patient data management and a seamless integration with the
clinical workflow. To ensure correct and complete communication between different
layers and devices, the Service Oriented Architecture (SOA) paradigm has been
adopted as support for the information communication. In this work we presented our
fully functional prototype (middleware) enabling the out of hospital monitoring of a
patient by the Medical Plane. This solution has been accepted as the middleware of the
CHIRON project thanks to its flexibility and its capability to react to an event. The
solution will be tested on the field during the project trial.
Acknowledgment
This work was developed within CHIRON and SOFIA projects of the European Joint
Undertaking on Embedded Systems ARTEMIS and are co-funded by the EU and by
National Authorities (CHIRON: GA n. 100228; SOFIA: GA n. 100017).
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