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Integration of a medical documentation and image

1. 4 2 4 3 4 4 4 5 Authentication WebEx provides a custom form Web page for users to enter their credentials Then a user credential token is stored in a cookie Nonrepudiation Accountability I suppose you mean how I handle the authorization which addresses the question What can you do WebEx has different authorization levels stored together with each user registration on the web server Integrity Control How I can guarantee that data is protected from accidental or deliberate malicious modification Like privacy integrity is a key concern particularly for data passed across networks WebEx uses 128 bit encryption and immediate expiry of webpages s plus no temporary client storage If you want to download loops and so on on request user dependent functionality the content is always zipped and password protected In which kind of environment is your system running e g local Intranet Intranet with remote users Internet It is designed for both the local intranet and the internet Which web browsers do you support The aspx sites is converted to XHTML 1 0EN witch means that the content is supported by all common web browsers Its tested on Netscape Internet Explorer Opera and on different platforms and operating systems like MAC LINUX and handheld devices Which adjustments modifications has the user to make to the default browser configuration like turning JavaScript on or installing plug ins like
2. QUIOJMAIA 143119 aA11eN yun a31n1as JEUOIIDUNY 40 SDYd PUB S a NPO N S31151181S a npoyy Bulnpayos quale a npoyy Iuswa eueyy uad s say ewojd p siy 0 JUBA9 94 JOU d4 Ad se pajjapow u q you aey sad 1 quad sadA Hess w sul UOIJEIIUNLULUOD y Jo speq A Appendix 126 Remote Location Workstation running VP Web client Figure A 4 Physical tool layer of the 3LGM system ospital PMS z B Workstation running VP Web client Functional Diagnostic Unit al ViewPoint Server Workstation running VP Web client DICOM US machine Workstation running VP Native Client US device without DICOM support model showing the future degree of integration of ViewPoint within the hospital information Features of a web based interface to ViewPoint Version 3 Minimal Version to have as soon as possible product which is ready for the market high importance 2 Next Version with new important features medium importance 1 Third Version offering all intended features low importance 0 not needed Purpose This questionnaire should help to determine the importance of each here listed feature of the web based user interface of ViewPoint Most likely the web server will be developed stepwise Please specify in the yellow marked column in which version the referring feature should be implemented Thanks a lot
3. RDC Requirements concerning hardware fulfilled fulfilled fulfilled hardware control possible According to the preceding comparison of the Web client and the Terminal client both solutions have their advantages and disadvantages From the current point of view it cannot be clearly determined which of them should be preferred Terminal client By picking the Terminal client it would be possible to guarantee access integration while offering all of the functions of the Native VP client This would also comprise the access and control of hardware which is for example required for the mea surement data transfer Unstable networks would also be supported by this solution as a sudden connection loss would have no influence on the data already entered Further more by utilising the RDWC it would be possible to provide a Web based UI without any remarkable design and implementation efforts like they are required for the Web client Moreover the RDWC needs no additional Plug ins Disadvantages of this solution are that the supported Web browsers are restricted to Microsoft Internet Explorer and Microsoft Windows Moreover the Terminal server utilises 6 3 Terminal Client as Alternative to a Web client 103 a non standard network port which might be blocked by the hospital s firewall In respect to the Web client a comparatively high bandwidth connection is required to allow an adequate viewing of image data Furthermore the Terminal clie
4. VP supports most of the common protocols used for communicating medical and adminis trative text data between the previously mentioned application components HL7 HCM clinicom BDT Open DataBase Connectivity ODBC and SAP RFC Some of the listed protocols are not directly supported by VP In order to enable their support a so called gateway software is used The software product utilised as gateway is Cloverleaf During import received messages of a not supported protocol are transformed by the gateway to a VP internal format which is then further processed in VP The export works vice versa For comparing the different protocols a distinction between messaging standard and com munication technique was drawn Although in their broadest sense both are protocols according to Holzmann s definition of a protocol Hol91 With the term messaging stan dard a protocol whose main purpose is to communicate complex medical or administrative information independent of the actual transport medium or transport protocol is denoted Communication technique denotes a protocol whose main purpose is to communicate data through different types of communication links independent of the actual information which is represented by the data Supported protocols and the thereby communicated data types are listed subsequently The third column specifies if VP communicates directly VP or indirectly via the gateway Cloverleaf CL Offered functions are
5. The analysis showed that all products stand out with some special functions which might at first glance seem difficult to be implemented by a Web based UI Still these functions were realised and so it appears to be adequate and realistic to demand that nearly all features of the Native client of VP should be implemented by the Web client as specified by FST Furthermore the capability of supporting Microsoft Windows and Microsoft Internet Ex plorer can be found in all products although every product makes its own choice of the additionally supported Platforms OS versions and Web browsers E3 is quite restrictive by only supporting Microsoft technology They can assume however that only due to the special contract of the NHS with Microsoft all of their potential customers utilize Microsoft technology Thus they have no need to support any alternative Platforms OS versions or Web browsers As VP and its future Web client is intended to be deployed worldwide it is essential to also support alternative technology as demanded by RS 2 1 and RS 2 2 so that a maximum of possible workstation configurations can be served by the Web client of VP Concerning RS 2 3 there is no analysed product which does not require any type of Web browser extensions It therefore seems adequate to utilise Web browser extensions Their number should be kept to a minimum though All analysed products also require changes of their Web browser s default config
6. WebEx has two ways for handling image data If image data is only to be reviewed the WebEx server converts it to standard Internet media formats like JPEG or MPEG 4 and shows it embedded in the related Web page If it is for example to be post processed in real time by EchoPAC it is compressed in an ZIP file on the server and can be downloaded to the workstation Concerning the networks supported by WebEx and their quality WebEx actually requires no minimum bandwidth Still constraints on the required bandwidth are set by the time which is seen as acceptable to load the image data from the server For example loading a full screen image loop over an Integrated Services Digital Network ISDN line would take around 2 minutes Thus completely loading an examination record would take at least eleven minutes assuming that usual examination records comprise image data of the size of five or more full screen image loops Unstable networks are not supported If the connection is lost the default warning message for offline status of the Web browser is displayed to the user Ifthe connection loss occurred during a download process the download can be resumed in case it was only a temporary interruption As WebEx is also designed for Internet usage security is assured by a number of tech nologies Authorisation and authentication are supported with the help of usernames and passwords The HPC may be supported in future depending on its impleme
7. 03 2003 AZEVEDO MARQUES P M de CARITA E C BENEDICTO A A SANCHES P R Integrating RIS PACS The Web based Solution at Uni versity Hospital of Ribeirao Preto Brazil In Journal of Digital Imaging 17 2004 Nr 3 S 226 233 BALZERT H Lehrbuch der Software Technik Software Management Software Qualitaetssicherung Unternehmensmodellierung Spektrum Akademischer Verlag 1998 ISBN 3827400651 BUNSE C KNETHEN A von Vorgehensmodelle kompakt Spektrum Akademischer Verlag 2002 ISBN 382741203X Davis A M Hs a P Giving Voice to Requirements Specification In IEEE Software 1994 S 12 16 ENGELMANN U MUNCH H SCHROETER A MEINZER H P CHILI Web Klinikweite Bildverarbeitung aus der elektronischen Patien tenakte heraus In Telemedizinf hrer Deutschland 2004 2004 ENGELMANN U SCHROETER A MUNCH H SCHWEITZER T BRAUN V MEINZER H P Von der bilateralen Teleradiologie zur Vernetzung von Regionen der CHILI Ansatz In Telemedizinf hrer Deutschland 2005 2005 S 261 265 GIESECKE amp DEVRIENT GMBH The Health Professional Card HPC Version 2006 http www gi de com portal page _pageid 42 55030 amp _dad portal amp _schema PORTAL Last checked 2 May 2006 HAUX R AMMENWERTH A IT Projektmanagement in Krankenhaus und Gesundheitswesen 3794524160 2005 ISBN 3794524160 Haux R AMMENWERTH E WINTER A BRIGL B Strategic In formation Ma
8. Offer means for telemedical purposes like e g Y lt 3 2 gt 3 fe 3 N o lt Ea fo S E gt o oO lt D lt o o e o Mm Mm o N oj o olol f pr ojoj jujo upport web browsers running on Linux upport web browsers running on Mac upport web browsers running on Solaris upport Mozilla Firefox Browser upport Internet Explorer Complete replacement of classical VP client by web based Ul vs Add on upport automatic testing of the web based Ul 0 lolol 0 N n wo ao o o o N wo Short Overview Product Analysis Author Vendor Euroking Product Name ES Product Category Web based documentation system for obstetrical departements Goals Supporting in real time the workflow Field of Application Obstrical departement Underlying techniques Web server MS Internet Information Server Database Intersystems Cach www intersystems com Other Java Virtual Machine Supported Browser Internet Explorer 5 5 or above with JVM activated Server Platform X Windows Linux Unix Solaris Product Type self tailored unique X of the shelf License Type open source X closed source Software Status alpha beta X stable URL www euroking com Contact amp eMail John Stapleton Questionnaire In case you use Apache Why did you choose Apache a
9. Moreover if the connection has a low bandwidth or long response time it will take some time until the refreshed Web page is transfered to the client and displayed to the user This handicap can be eliminated by using Web browser Plug ins As described in section Plug ins can access and alter the current Web page as they are executed within the Web browser s process Thereby means are offered to respond to user interactions without transferring any data between client and server In reference to the given example this means that the syntax of the entered data is checked immediately by the Plug in responsible at the client side The most popular Plug in used for these purposes is Java Script 5 2 5 Interaction with Other Application Components In IRD 6 1 RD 6 2 RD 6 3 and RD 6 3 it was postulated that the Web client should offer means to switch between itself and other application components without having to reenter login information or patient identification information to preserve the context The task resulting from this requirements is to identify means to preserve the patient context while switching between different application components and to offer SSO capa bilities In general the CCOW CMA as described in section 2 8 is the preferable solution to fulfil RD 6 3Jand RD 6 3 CCOW was intended right from the start to support context integration in healthcare and thus addresses most of the issues in this field In additio
10. Offered functions are e Every function from the examination module see section for details which does not modify any data e History view which displays a chronological list of all modification done to a certain patient record e Ability to view which user made these modifications and when they have been made 3 2 8 Examination Module The examination module is the core of VP Every function provided by the submodules listed here can be accessed through it 3 2 8 1 Case and Examination Management Submodule The case and examination management submodule is meant to offer the user the ability to manage the cases and related examination data of a patient A case can be for example a pregnancy Examinations are in this case all examinations and other procedures performed and documented within the scope of a pregnancy So logically multiple examinations are 38 3 Requirements Analysis ed Simplified Data Model Figure 3 3 Simplified UML data model of ViewPoint related to one case multiple cases are related to one patient A simplified data model of VP is shown in figure representing this relationship Furthermore the case and examination management submodule offers functions to lock examinations so that it is impossible to modify locked examination records This is crucial to guarantee data integrity when examination data of patient records has been exported For example this feature is essential for the German pe
11. Prenatal Reporting screenshot details Use cases of the report handling are shown in figure Archiving Process User admin CAP NUM OVA of the biometry submask The user can archive the currently recorded examination findings and image data by pressing the archive button in VP Although this step looks easy from the user level several complex functions are executed at the system level Some of these functions should be highlighted here Use cases of the archiving process are shown in figure 3 7 Executed functions are e Store all data of findings and references to image data in the local database Offer user the possibility to lock examinations after archiving e Archive image data to local archive or if connected send it via DICOM interface see section 3 3 1 2 for details to a PACS As archiving paths local directories as well as network shares which are handled like local archives are supported e Export billing data of the current examination like coded diagnoses and procedures to PMS 3 2 Current Functionality of the Native ViewPoint Client 41 PIA Fetal Database 4 Doreen Donald 09 01 2002 o E iej xj File Modul i view Report ioj xi P er ue eeel fa Fetal Anomaly see NT in week 13 Followup GK Lox Cancel atea History Maternal age 33 years pre pregnancy weight 58 0 kg height 165 0 cm BMI 21 3 blood group B Rh D Rh ve Menstrual cycle re
12. RD 6 4 The Web client shall offer means to switch from another appli cation components running on the same workstation to itself without having to reenter patient identification information to preserve the patient context Rationale Elimination of WP _14 and Requirements concerning the UI RD 7 1 RD 7 2 RD 7 3 RD 7 4 RD 7 5 The UI of the Web client shall be based on the existing masks definition if possible and feasible see 3 2 8 2 for details If not possible and feasible the Web client shall utilise a standardised UI definition language so that the UI of the Native client and the UI of the Web client can be created from a single definition Rationale Elimination of and The Web client shall offer a UI which resembles the one of the Native client in appearance and is controlled similarly Rationale Elimination of WP 12 The UI of the Web client shall offer more similarity to the UI of Trium CTG Online than the UI of the Native client and should thereby point out the close association between both products Rationale Elimination of WP_ 13 The Web client shall offer a UI which is compatible to automatic testing Rationale Elimination of WP 31 The Web client shall preserve the quality and integrity of all image data provided to the user via the Web based UI Rationale Elimination of WP 30 Requirements concerning hardware RD 8 1 RD 8 2 The Web client shall keep its hardware requirements
13. Video sequences can only be viewed adequately by means of a high bandwidth connection Otherwise the playback of sequences will no longer be smooth corresponds to RS 7 5 In a network performance test it appeared that working with VP is possible if a bandwidth of at least 64 kbit s is offered Data entry is possible although the operation of VP is not smooth The reviewing of image data is impossible though as it is too slow A broadband connection of 1 Mbit s and above is sufficient to review still pictures At least 2 Mbit s are needed for video sequence replay corresponds to RS 3 1land RS 3 3 Sudden connection loss as it occurs in unstable networks is not a problem for VP in case it is provided by the examined Terminal server The started Terminal session and therefore the data entered in VP will be kept on the server until the user reconnects or the session expires Also an IP address change is no problem as only the Terminal server has to cope with it and it does not affect VP in any way corresponds to and 6 The user has to login via the examined Terminal client on the Terminal server like a normal user sitting in front of the computer Thereby the means for authorisation and authentication of MsTS2003 are used corresponds to RS 4 1 and IRS 4 2 Moreover as the Native client of VP is used its means for authorisation authentication and accountability are applied corresponds to IRS 4 3 In contrast this is a fairl
14. nection by a rotating foetus in the right upper corner of the Web client If the connection is lost the foetus will no longer rotate and a warning message will be displayed to the user Security of Trium CTG Online is assured with the help of a set of technologies Authorisa tion and authentication is supported with the help of usernames and passwords The HPC may be supported in future Accountability is assured by logging user activities Thus it is possible to track which users have been logged in at the time an alarm indicating an abnormal CTG occurred Integrity control is assured by using the HTTPS protocol with 128 bit encryption CCOW or other means for context integration will not be supported in the near future If Trium Analysis Online GmbH had the chance to reimplement their Web client from scratch they would use a professional DBMS and build on the latest version of their application server 6 2 4 Definition of Comparison Criteria The products introduced in the preceding sections are compared in detail in table Comparison criteria have been defined according to the requirement specification set up in section 5 3 They are meant to show how other manufacturers realised certain requirements or issues linked to the requirements Other criteria covered by the comparison are issues which are or may be relevant for the implementation of the Web client The information used in this table was assessed with the questionnaire Product
15. 1 4 e Scanner USB port as described in section as described in section 3 3 1 9 Ultrasound device serial port for measurement data transfer as described in section 3 2 8 2 and 3 3 1 5 WP 32 Means to control access hardware required 62 3 Requirements Analysis 4 Definition of Requirements 4 1 Outline In the preceding chapter the current functions and the current degree of integration of the Native client have been analysed Furthermore weak points of the Native client and potential weak points of the future Web client have been identified The aim of this chapter is to create a general requirement definition It will be derived from the previously identified weak points in section Based on this definition the future degree of integration will be modelled in section The succeeding chapter will then specify the generally defined requirements in more detail 4 2 Requirement Definition I General requirements RD 1 1 RD 1 2 RD 1 3 VP shall provide a Web client Rationale Elimination of The Web client shall provide all functions of a Native client as specified by the requirements specification If this is not possible or feasible at once it shall be implemented in an incremental approach or it shall provide at least the functions which are demanded by the customers In case the incremental approach is chosen features should be prioritised according to their importance to the customer and added st
16. 7 4 Prospect 111 layer while figure on page 58 shows the physical tool layer During the identification of the weak points of VP in respect to integration the model has been used In section 4 3 the future degree of integration of VP was modelled Figure 4 1 shows the related logical tool layer figure 4 2 shows the physical tool layer The aim was to illustrate to what extend the future Web client would increase the degree of integration of VP 7 4 Prospect In summary the Web client turned out to be an adequate approach for integrating the medical documentation and image archiving system VP within the HIS Apart from the interfaces for data integration already offered by VP the Web client is the preferable solution to provide the missing means for access integration and contextual integration If the Terminal client could be an alternative to this approach has to be researched in more detail As far as it can be judged from the point of view of this thesis the Terminal client solution and its Web based UI could be utilised to bridge the time gap until the Web client is implemented and officially released 112 7 Conclusion Bibliography A1b03 AMCBS04 Bal98 BK02 DH94 EMSM04 ESM 05 Gie06 HA05 HAWBOA HBABW05 ALBRECHT C C A Comparison of Distributed Groupware Implementation Environments In 36th Annual Hawaii International Conference on System Sciences HICSS
17. Apart from modelling an additional intention while creating the 3LGM Meta model was to define a precise terminology for designating the components to prevent communication problems The layers were created to distinguish between different levels of abstraction The domain layer concentrates on the enterprise functions of a hospital the logical tool layer empha sises on application components whereas the physical tool layer focuses on physical data processing components The layers will later be described in more details The 3LGM Meta model will be used for requirements analysis because it offers the best means to visualise the differences between the current state of integration of VP in the HIS and the future state Modelling these two states with the 3LGM Meta model will greatly contribute to the goal of creating a well founded understanding of the problem domain 2 3 Requirements Engineering 17 Table 2 1 3LGM meta model graphical representation of elements at the domain layer Element Graphical represen tation enterprise function rectangle entity type oval using information arrow from entity type to function updating information arrow from function to entity type 2 3 2 2 Layers and Their Relationship Domain Layer The domain layer describes a hospital independent of its implementation as a set of enterprise functions These functions need information of a certain type about p
18. E http 192 168 131 65 tsweb YiewPoint Licensed to Fetal Database Demonstration 100 Patients max Press F1 for help User pia CAP NUM OVA start 3 ViewPoint Licensed be 17 18 2 Done PET 8 Internet start B f Manage Your Server J Configure Your Server Wea e Application Server E Remote Desktop Web Fu 17 18 Figure 6 7 Screenshot of ViewPoint s Native client running in the Microsoft Remote Desk top Web Connection 3A Terminal server implementation of Citrix which supports CCOW also exists It was not considered though as it would go beyond the scope of this thesis For more information please refer to for example 6 3 Terminal Client as Alternative to a Web client 101 With the Microsoft Remote Desktop Web Connection RDWC it is even possible to offer a Web based access to VP This means that a Web browser can be started and a Web page which contains an embedded Terminal client similar to RDC can be opened Until now this is restricted to Microsoft Internet Explorer only With this client a connection to the Terminal server on which VP runs can be established A screenshot of the RDWC with VP running in it is shown in figure The RDWC is an ActiveX control and can be hosted by any Web server Limitations of the RDWC are that it does not support full colour depth and as it is an ActiveX control can only be used by workstations running Microsoft Windo
19. Intel 186 hardware architecture Specification of Details See section 5 2 3 for details RS 2 2 The Web client shall support Firefox on Microsoft Windows and Linux and Microsoft Internet Explorer on Microsoft Windows Specification of Details See section 5 2 3 for details The Electronic Patient Record is a complete or partial patient record stored on an electronic storage medium HAWBO04 5 3 Requirement Specification 79 III IV RS 2 3 The Web client shall utilise Web browser extensions to support the display of image data and to fulfil RS 3 1 and RS 3 3 The chosen Web browser extensions have to fulfil RS 2 1 RS 2 2land RS 3 4 Specification of RD 2 3 Details See for details Requirements concerning quality of supported networks RS 3 1 RS 3 2 RS 3 3 RS 3 4 The Web client shall keep the needed bandwidth as low as pos sible Specification of Details The need of a low bandwidth can be achieved by using Plug ins They can carry out certain computation for example user interaction on the client side without requiring any client server communication See section for details The Web client shall also support unstable networks Specification of Details Unstable networks can be supported by offering sufficient means against connection losses and changes of the IP address of the client For example if the connection is lost while the user is entering data afte
20. Java or Macromedia Flash I m not using any plug ins so you don t need to download any extra components from the web server or to co figurate your browser The only requirement is to accept pop ups Since I support full screen viewing and dual screen solutions Are there any limitations concerning the platform on which the browser runs No but the platform must be able to display Windows Media or MPEG or MPEG4 loops It can be executed outside of the browser so the browser does not need to handle this kind of data within the browser it self In case there is a firewall between server and client which ports have to be open e g is it sufficient to have only port 81 for http open Or in other words which protocols do you use Port 80 https or http local intranet only Which is the minimum bandwidth required for client server communication up download No minimum bandwidth The loops will be buffered in memory on the client side The size of each loop depends on the frame rate and so on but its around 1Mb in most cases So the limitation must be set against how log time its acceptable to wait for a loop like this The other functionalities within WebEx requires less bandwidth 4 6 5 6 7 8 9 10 To which version of XHTML HTML JavaScript etc is the web interface conform XHTML 1 0 and in some cases 1 1 Which kind of data is distributed via the web sever Text images videos e
21. Trium CTG Online Patienten bersicht Mozilla Firefox E 10 xj File Edit View Go Bookmarks Tools Help A SCHWANGERE BENUTZER CTG ARCHIV UNVERKN PFTE CTGS Marianne Maler eE Archivierte CTG Aufzeichnungen tafel letzte Eintr ge Heute Gestern Woche Monat Suchen Reset Zar Datum a Name Geburtsdatum Aufn Nr SSW Para Archivdaten e 28 04 2005 16 09 Betula Bettina 7 07 1977 1 39 4 Ea pe 28 04 2005 15 55 Pinus Pia 6 06 1986 3 37 4 ua a Kommentar sr For 7 i 28 04 2005 15 33 Betula Bettina 7 07 1977 1 39 4 FA Optionen 2 28 04 2005 14 02 Betula Bettina 7 07 1977 39 4 Ze Pr 28 04 2005 14 02 Pinus Pia 8 06 1986 37 4 eh 28 04 2005 11 17 Fagus Fabula 1 08 1988 3945 Pr 28 04 2005 11 17 Betula Bettina 7 07 1977 39 4 9 28 04 2005 09 49 Pinus Pia 8 06 1986 37 4 pel 28 04 2005 09 49 Fagus Fabula 8 08 1988 39 5 gel 28 04 2005 08 41 Betula Bettina 7 07 1977 39 4 gel 28 04 2005 07 29 Pinus Pia 6 06 1986 37 4 gel 28 04 2005 07 29 Fagus Fabula 8 08 1988 39 5 gg 28 04 2005 07 29 Betula Bettina 7 07 1977 39 4 booed bd AN Figure 6 6 Screenshot showing the archive screen of Trium CTG Online 6 2 Product Analysis and Comparison 93 6 2 3 2 Technical Aspects Trium Analysis Online GmbH chose Apache as Web server as it is the market leader It offers several extensions and is from their point of view more secure than most other Web server
22. Web based technologies Task 5 2 Comparison of the different concepts incl Terminal Server Thin Client technology Task 5 3 Identification of the concept which suits best Result technology comparison recommendation of the concept with best benefits Aspired completion 06 03 2006 Question 6 Is the chosen concept adequate to fulfil the given requirements Task 6 1 Determine the requirements which cannot be fulfilled by the chosen con cept Result basis for further considerations Aspired completion 31 03 2006 1 6 Stakeholders This section is intended to clearly state the stakeholders of this diploma thesis and their interests in it ViewPoint Bildverarbeitung Gmbh GE Healthcare Their interest on this diploma the sis is to obtain a requirements specification of a Web based Ul to VP Furthermore they want to gain an overview of which technology is used by other vendors and which technology is the most suitable one for their purposes ViewPoint Bildverarbeitung GmbH GE Healthcare Technologies Argelsrieder Feld 12 D 82234 Wessling http www gehealthcare com viewpoint Institute for Medical Informatics Statistics and Epidemiology Their interest is to ob tain an impression on how a Web based interface can change the degree of integration of a medical documentation and image archiving system Institut fiir Medizinische Informatik Statistik und Epidemiologie Universitat Leipzig H rtelstra e 16 18 D 0410
23. able to understand the requirements specification without the need to familiarise with spe cial specification techniques Furthermore the centre of interest of this thesis is not only the creation of a require ments specification but also the analysis of similar products which already offer a Web based UI and the analysis of the Terminal client server architecture as an al ternative Therefore not every requirement will be specified in detail as it would go beyond the scope of thesis 2 3 1 Unified Modelling Language UML is an object modelling and specification language used in software engineering It is officially defined by the Object Management Group The following two views will be used for the creation of models during requirements analysis in section e Use Case View The use case view models the functionality of the system as per ceived by outside users called actors A use case is a coherent unit of functionality expressed as a transaction among actors and the system The purpose of the use case view is to list the actors and use cases and show which actors participate in each use case RJB99 16 2 Basic Principles The use case view will be used in section to illustrate the functions and the involved actors during the analysis of the current functions e Static view The static view captures object structure An objected oriented sys tem unifies data structure and behavioural features into a single object str
24. analysis is the process of deriving the system requirements through various methods Som95 e Core part of this stage is to understand the problem domain to develop a sound knowledge of it e Requirement analysis may involve the development of system models In order to fully understand the problem domain the functions of the current VP version will be presented in section and the current state of integration will be analysed in section Based on these information the current weak points with 14 2 Basic Principles Feasibility Requirements study A mut Feasibility report definition System models Requirements specification Requirements fr Specification of document requirements Figure 2 2 Requirements engineering process according to Som95 Definition of requirements prospect to integration will be identified in section 3 4 and the requirements will be derived from them In order to illustrate complex functions and the involved actors Universal Modelling Language UML Use Case Meta model will be used In order to analyse the state of integration the 3LGM Meta model will be applied 3 Requirements definition according to Som 95l e Requirements definition is the activity of translating the information gathered during the analysis activity into a document that defines a set of requirements Som95 e It should be written in an abstraction level that can be underst
25. as the person delivering mail paper based physical tools such as printed forms telephones books paper based patient record administrative stickers or computer systems such as terminals servers personal computers switches routers They are physically connected via so called data transmission connections for example data wires The constellation of these con nections leads to physical networks which are based on network protocols Note that physical as well as logical networks can be represented on the physical tool layer The graphical representations of the described elements can be found in the docu mentation of the 3LGM modelling tool Physical data processing components can be illustrated by custom symbols to emphasise their type Inter Layer Relationships A variety of dependencies called interlayer relationships ex 18 2 Basic Principles Table 2 2 3LGM meta model graphical representation of elements at the logical tool layer Element Graphical represen tation application component rectangle with rounded corners database system docu cylinder ment collection component interface oval user interface communication link arrow pointing it the direction in which the data flows ist among components of different layers Relationships exist between classes of the domain layer and the logical tool layer and between classes of the logical tool layer and the phy
26. can be used as model patterns to assist with deriving more specific models from it and to directly compare models concerning their completeness The domain layer of the 3LGM models which will be created in this thesis will be derived from the reference model of Htibner Bloder et al Until now only a German version of this model exists 2 4 Methods of Information Procurement 19 2 3 2 4 3LGM Modelling Tool Apart from the 3LGM Meta model IMISE also develops a software tool called 3LGM Tool to create and analyse 3LGM models It can be downloaded from http www 31gm2 de This tool will be used to create the 3LGM models in this thesis It still has beta status 2 4 Methods of Information Procurement Each method which has been used for information knowledge procurement will be sub sequently listed In the beginning a general description of each methods will be given followed by statements for which purposes they have been used For details on the meth ods and their pros and cons please refer to HA05 2 4 1 Interview An interview is a conversation between two or more people where questions are asked to obtain information from the interviewee Wik06 Interviews are appropriate to examine complex issues and offer a maximum of interactivity between the interviewer and inter viewee for example to eliminate ambiguities A disadvantage is that this method is time consuming y This method has been used to gather info
27. care regions adequately 1 2 3 Motivation The listed problems can be eliminated or at least reduced to a minimum by a Web based Ul to the VP system With the utilisation of a Web based Ul the user is able to access VP by using a standard Web browser The functional range which is made available via the Web based UI has yet to be determined Irrespective of the functionality this access method results in a set of significant advantages Data access via Web browser is platform independent as some Web browsers are available for nearly every OS for example Firefox The only precondition is that the accessing workstation needs to be networked with the VP server Considering those two points and the aspect that nearly every workstation within the hospital is interconnected via the hospital s Intranet a Web based UI enables access in tegration for VP The degree of access integration will be determined by the functionality which is offered by the Web based UI Today the usage of a Web browser is familiar to almost everybody as the distribution of the Internet has reached nearly every household So no special training is needed to learn the basic usage of Web based UI Presentation integration is certainly not guaranteed by this solution but as more and more vendors offer Web based UI for their software product and the handling of a Web browser is at least uniform it is one step in the right direction to presentation integration The
28. e Measurement data transfer by the utilisation of the following protocols connection types Serial cable connection Parallel cable connection 3 3 Current State of Integration 53 DICOM SR see section 3 3 1 2 for details Microsoft Windows network share e Customisation of the transfered values for example when the labels of the sent values differ on account of country specific firmware versions of the US device 3 3 1 6 Trium CTG Online Monitoring computer based Trium CTG Online Monitoring is a Web based cardiotocograph monitoring system VP offers an interface to export patient case information to this specific CTG monitoring system via a proprietary interface see section for more details 3 3 1 7 Chip Card Reader computer based VP offers an interface to import patient demographics and health insurance information from the German health insurance card Different chip card readers are supported con nected via a serial cable or integrated in a keyboard 3 3 1 8 Printing and Faxing Interface paper based As described in section 3 2 8 4 VP offers functions to print out or fax different variations of the VP Report and other information 3 3 1 9 Scanning Interface paper based As described in section 3 2 8 3 it is also possible to digitise paper based documents with the help of a TWAIN scanner 3 3 1 10 Other German Perinatal Inquiry computer based As mentioned above this interf
29. ee Sige el eae A gdh ah hg 69 5 2 1 Quantification of the Features Offered by the Native Client 69 5 2 2 Identification of Application Components where VP is Needed 71 pala e ARA A ee re 72 EnEn 74 5 2 5 Interaction with Other Application Components 77 do llo es eka eB oe Pe le a 78 85 61 Outline o 4 243 se Pade de eke ee be Ae Se ee bee PS 85 fae ed ceo dae ea ee eee 85 6 2 Eur king E3 sese scruta Ea rusa a ee 85 6 2 1 1 General Description 2 200 85 6 2 1 2 Technical Aspects ooo ee 86 i ipads See ei a Beas 2 88 6 2 2 1 General Description 2 2 2 2 222mm nennen 89 6 2 2 2 Technical Aspects 2 2 2 2 n nn 90 DR ck are ea ad da e Be rich ee a 91 6 2 3 1 General Description 2 208 92 6 2 3 2 Technical Aspects 2 22 o ee ee 93 A E A E oe 93 ee ee 95 oh Dace ace NR Gee 2 96 6 3 Terminal Client as Alternative to a Web client 98 6 3 1 Terminal Server and VPl o e 98 6 3 2 Web Client vs Terminal Client 101 105 AAA 105 pai aa Od PRE E da Boba 105 AA AR A 106 Gade Objective J oe ss asa ea eee 2a a a es Gs 106 1 3 2 Objective 2 sadoga a a 0 nn 107 Contents ix 1 33 OBJECIIVE 3 ca so 8 00 sa a a E oe wes 110 T A PTOSPDECH sh 2k a a A a e e ta Geek doe e et 111 113 116 121 139 Contents List of Figures 2 1 Spiral model o
30. efforts on each workstation In other words the control and access of hardware by the Web client is contradictory to the original idea of a Web client and should not be supported Consequently the Web client should be an alternative Ul to but no replacement for the Native client Still printers are indirectly supported by the Web client As every Web browser offers means to print out Web pages the Web client can indirectly interface with printers al though this is not one of its functions Nevertheless the quantification of the features should be further discussed before starting with the actual implementation Especially on account of that the demand for a certain feature is only one aspect The contrary aspect are the connected implementation efforts and constraints set by other requirements which in the worst case may completely change the priority 5 2 2 Identification of Application Components where VP is Needed In RD 1 3 1t was postulated that the Web client should provide access to VP from all application components where access to VP is required The task resulting from this requirement is to identify all application components where access to VP is actually needed As already mentioned in the introduction there are several application components where access to VP is needed The following list gives a detailed overview of these application components also including the ones where up until now data of VP is provided on a p
31. executed before the Native client is ready for usage First it should be checked if the client meets the criteria of the minimum software and hardware requirements Then the VP software client needs to be installed and configured properly During this step a valid license string has to be assigned If the client s functions were tested successfully VP is ready for productive usage on this workstation If an update for VP is issued it has to be installed on the VP server The next time the VP clients are started they automatically retrieve all updated files from the server High bandwidth is required for proper updating of the client as the size of the transfered files is usually 50 MBytes or more 3 2 3 General Description VP offers functions of a MDS and of a PACS and can be seen as a combination of both It is a PACS as it offers extensive functions for image data editing communication and archiving For more details please refer to 3 2 8 3 Concerning the types of MDSs it can be clearly assigned to the following classes defined in LGH 03 e Class I1 documentation with primary clinical information factual knowledge e Class P1 documentation for a primary patient related reporting e Class 53 mostly standardised documentation e Class Ul primary vertical documentation few data objects with many attributes e Class D2 primary direct documentation and e Class R1 computer based documentation While offering functions of
32. for your efforts Holger Schmuhl Respondents BEH FS KP WG Patient Management Patient Scheduling History Order Management Ability to search for existing patient records 3 3 3 3 3 Ability to manage create alter delete patient records 1 2 2 Ability to view the change history of a patient record and all its data Ability to view orders 3 1 2 1 3 Ability to manage create alter delete orders 1 1 2 1 2 Case and Examination Management Ability to view the F5 text 3 3 3 2 3 Ability to view previously printed reports 3 1 3 2 3 Ability to view exam data finding data in the Structured Finding Masks Findings System Image Review Capabilities Acquiring Image Data Export a case to the cardiotocograph monitoring system Trium CTG Online Display Charts 2 3 3 3 3 Receive and record Ultrasound US measurement data 0 0 2 2 2 Ability to review Single Frame Images 3 3 3 3 3 Ability to review Multi Frame Images Clips 2 3 3 3 3 Ability to review Raw Data Voluson or TruAccess 1 0 3 2 3 1 2 2 2 3 Perform measurements on images e g distances on a US image mport image data via DICOM interface 0 0 1 1 2 Digitize image data with the help of a Framegrabber 0 0 1 1 2 Digitize image data with the help of a TWAIN Export Image Data Export Image data via DICOM interface 0 1 2 1 2 Export Image data to file system 1 2 2 2 2 Printing and Faxing Ability to prin
33. in a hospital WebEx can in general connect to any type of database by means of ODBC At the moment it only supports the database structure of EchoPAC Done FI off Trusted sites R 100 Figure 6 4 Screenshot showing the image gallery screen of WebEx 90 6 Technology Comparison 6 2 2 2 Technical Aspects IIS was chosen as Web server due to GE Vingmed Ultrasound s choice of Microsoft Vi sual Studio NET as Integrated Development Environment IDE Therefore a Microsoft product was also chosen as Web server The Web based UI is conform to the Extensible HyperText Markup Language XHTML standard In general every common Platform and Web browser should be supported WebEx was successfully tested with Microsoft Internet Explorer Netscape and Opera running on Microsoft Windows Linux and Apple Macintosh The default configuration of the Web browser has to be modified to allow Pop Ups In addition a media player has to be installed which is capable of viewing Microsoft Windows Media MPEG 1 or MPEG 4 The player is not required to have an interface to the Web browser as videos are downloaded onto the workstation and can than be opened from the file system Additionally a ZIP compatible packing programme needs to be installed to be able to unpack downloaded videos In case that updates or security patches are issued for the Web server IIS the Microsoft Windows Automatic Update functionality is used to keep the server up to date
34. in general by searching the Internet Here statistics have been found although they varied greatly As example statistics taken from and statistics taken from are compared in table The figures are only shown for OS versions and Web browsers which were listed in both statistics the observation period is March 2006 The figures of W3S06 have been rounded to integers for a better comparability Table 5 2 Comparison of statistics taken from www TheCounter com The06 and www W3Schools com W3S06 in march 2006 W3S06 Web browsers Microsoft Internet Explorer 6 88 59 Firefox 7 25 Microsoft Internet Explorer 5 2 5 Opera 1 2 OSs Microsoft Windows XP 82 73 Microsoft Windows 2000 7 12 Microsoft Windows 98 5 2 Apple Macintosh 2 4 Microsoft Windows NT 0 0 Linux 0 3 Sample size of visitors 227 Mio 5 Mio One may now start to wonder what reasons there are for such big differences As this would be off the scope of this thesis 1t will not be discussed further For more information please refer to Ups06 for example Apart from an overview of different Web browser statistics this Web site also offers an analysis of bias sources On account of the significant differences in the cited statistics it was decided to take them just as guideline Both statistics suggest that Microsoft still has the majority of market shares of OSs and Web browsers while Firefox in the fi
35. ins are additionally Web browser dependent Require target platform testing and related optimisation Alb03 e Distributed The Client architecture was originally designed for a distributed environment Clients do not have to be installed as Web browsers are available on all Plat forms by default HTML protocol is thin and transfers quickly over low bandwidth connections This point does not apply on highly interactive applications which require frequent refreshing of the page to achieve interactivity and potentially cause significant server load and redundant data transmission A1b03 User data and control data markup and formatting information is exchanged between the server and the client e Interactive Web pages are essentially static once they leave the server Screen updates are not shown immediately and require a periodic client initiated refresh A1b03 26 2 Basic Principles Web browser extensions offer means to improve interactivity e Rich Interface Components UI components are severely limited A1b03 Web browser extensions are required to offer full featured Ul 2 6 3 Comparison In table 2 3 a brief comparison of both client architectures is given stating which type of client has poor or extensive support of the related criterion Table 2 3 Comparison of Native client and Web client architectures Architecture Native c
36. integration WP 14 No means for contextual integration provided WP 15 CCOW not popular Only few manufacturers implemented it 3 4 3 Weak Points of a Web Client 3 4 3 1 Weak Points of a Web Client in General With the utilisation of a Web interface everyone connected to the Web server has access or can at least try to gain access to the information provided thereby The chances of unauthorised access are higher in such an environment as the only tool needed to access the Web based Ul is a Web browser So compared to a Native client in which special software has to be installed to gain access to the information stored within the system a Web based Ul offers even to novices a noticeable chance to break into the system In the LAN of the hospital it can be assumed that all participants of the network are authorised or will at least not attempt to break into the system As soon as the Web based Ul is made accessible via the Internet unauthorised access attempts or other types of attacks on the security of the system must be assumed WP 16 High risk of security threats The operation of Web based clients or in general of Web pages tend to be slow compared to Native clients see section for details WP 17 Limited performance High chance of data loss if connection is interrupted network cable accidentally un plugged A Native client offers better means to protect against data loss in case of network interruptions WP 18
37. is changed in the course of transcription 160 for example when an internal report is printed out at the diagnostic service unit to have patient data available at the ward or when a CD ROM is burned for the assigning general practitioner so that she he The term patient demographics denotes data which describes basic properties of a patient It stays in the course of time stable Patient demographics means in the context of this thesis patients name address assigning physician and health insurance information It is also called demographic patient data 4 1 Introduction has the image data in high quality and with the ability to post process it at her his practice Beside the duplication of data which causes the commonly known problems of data redundancy media cracks may also lead to the inaccessibility of data as the reading device will not be available in future or is not available at all places where the media should be read Speaking in the context of an integrated health care region where remote sites are inte grated in the HIS as if they are situated within the hospital integration criteria have to be realised under circumstances which are inflicted by the special characteristics of Wide Area Network WAN connections VP system is not originally designed for teleconsult ing purposes as the client needs a permanent high bandwidth connection to access the VP server Therefore VP is not able to support the integration of health
38. its integration potentials In the second part of this section all weak points of the future solution will be identified Web based technology also comes with certain disadvantages or critical issues which have to be considered carefully during requirement specification and the later implementation stage They will be identified in subsection Moreover certain constraints are set by VP and its special characteristics They will have to be preserved by the future Web client A description of these constraints can be found in subsection Until now only a German version of this model exists 3 4 Weak Point Identification 55 3 4 1 Weak Points of the Native VP Client The points given here are derived from the description of VP given in section 3 2 As only Microsoft Windows 2000 XP or 2003 Server with certain Service Packs are sup ported see section for details VP cannot run on older Microsoft Windows versions or versions with different non supported Service Packs Neither can it run on other Platforms like Linux or Apple Macintosh which may also be present in an clinical infras tructure WP 1 Incompatibility with other Platforms and Microsoft Windows versions with different Service Packs VP requires certain software and hardware equipment see section for details Al though not the most recent technology is needed still the requirements of VP usually lead to the need of upgrading the workstation as most computer systems
39. level of data integration will not be changed by a Web based UI as it will not offer any new interfaces for electronic data exchange with other application components The Web based UI will just be an add on for the VP server which is responsible for electronic data exchange For context integration a Web based solution may be the ideal solution The exact real isation of context integration is at this point still in question Beside implementing the CCOW standard which is also available for Web based application components it is also conceivable to open a certain patient record and to send the required login information via a specific Uniform Resource Locator URL like on certain sites on the Internet Furthermore a Web browser compared to a VP client needs a minimum of soft and 1 3 Problems 5 hardware equipment and is a built in application component of nearly every OS these days In case it is not it can be simply installed without causing any compatibility problems with other software components As already mentioned the Web based Ul is accessible from every workstation which is connected to the VP server So with the utilisation of the Internet or a dedicated dial in network connection data access is also possible from a remote site as it may be the case that a physician wants to complete her his work from home or that an assigning physician wants to review the results of a requested examination By using standard WWW tech
40. offering the Web based view of DICOM image data is given subsequently They are all Java Applets offering DICOM viewing capabilities As a Java Applets runs as a separate process it can be classified as Helper Application see section 2 6 DICOM Viewer DICOM Viewer is Open Source and developed by the Nagoya Institute of Technology Iwata laboratory Japan It can be found at http mars elcom nitech ac jp dicom index e html It was for example used by Azevedo Marques et al in their approach of Web based RIS PACS Integration at the University Hospital of Ribeir o Preto AMCBS04 EViewBox EViewBox is Open Source and can be found at http eviewbox sourceforge net 76 5 Specification of Requirements CHILI Web Viewer CHILI Web Viewer is commercially available from the Chili GmbH http www chili radiology com It was originally developed at the German Cancer Research Centre Heidelberg with the intention to distribute radiological images from PACS to EHR Web based MEAMO3 EMSMO04 ESM 05 RemoteEye RemoteEye is commercially available from NeoLogica s r l http eng neologica it Sample screenshot is shown in figure A RemotEye Web DICOM Viewer by NeoLogica Microsoft Internet Explorer laj xj File Modifica Visualizza Preferiti Strumenti a Q maero 5 x Bie Cerca 5 7 Preferki og E44 JA 3 Indirizzo 2 http Jjserver01 RemotEyejtestIinstaliWindows htm 4 Muli S
41. perform the tasks For example the first part of Question 3 How is VP integrated within the HIS at the moment had to be answered before being able to answer Question 1 Which requirements should be fulfilled by the Web based UI Furthermore question 5 and 6 had to be shortened as it was impossible to set up different concepts for a Web client in the given period of time It was agreed with VP GE and IMISE to only compare the features of a Web client to those of a Terminal client and to determine to which extend they fulfil the requirement specification set up in this thesis 106 7 Conclusion Still during creation of this thesis the question and task definition has been used as an orientation As the thesis subject and scope are officially defined by the objectives the conclusion will be drawn based on these objectives In the succeeding section it will be reasoned why these objectives have been successfully achieved In general it emerged in the course of this thesis that it would have been more ap propriate to start from another point of view by defining the objectives and the general subject of this thesis in a more abstract way One of the main reasons for hospitals to demand for a Web client is to have an application component which enables access inte gration and generally offers adequate integration capabilities Thus it would have been more appropriate to name the topic of the corresponding thesis something lik
42. section 108 7 Conclusion Table 7 1 Short Overview of the requirements for a Web Client Requirement General requirements VP shall provide a Web client The Web client shall provide all functions of a Native client apart from the control and access of hardware RS 1 3 The Web client shall provide access to VP from local and remote locations Requirements concerning supported Platforms Web browsers and required Web browser exteni ons RS 2 1 The Web client shall support Microsoft Windows XP Microsoft Windows 2000 and Linux on the Intel 286 hardware architecture The Web client shall support Firefox and Microsoft Internet Explorer The Web client shall utilise Web browser extensions to support the display of image data and to fulfil RS 3 1 and RS 3 3 concerning quality of supported networks The Web client shall keep the bandwidth utilisation as low as possible The Web client shall also support unstable networks The Web client shall perform and respond in such a manner that the user is not hindered in doing her his actual work The Web client shall utilise only standard ports like HTTP port 80 or HTTPS port 443 concerning data security The Web client shall assure secrecy and confidentiality by offering sufficient means for authorisation T
43. sound support Server Platform X Windows Linux Unix Solaris Product Type self tailored unique X of the shelf License Type open source X closed source Software Status alpha beta X stable URL www trium de Contact amp eMail Christian Harb ck Questionnaire In case you use Apache Why did you choose Apache and not a closed source server e g like MS Internet 1 1 Information Server or self tailored server Apache is used as the basic communication server We chose apache because of it is the market leader offers several extensions modules and is more secure than lots of other web servers However we added functionality using the ColdFusion application server which runs on top of apache 1 2 How do you handle Critical Security Updates from apache org If updates are issued it is in the responsibility of the hospital to install them In case you use another web server 1 1 1 2 1 3 Why did you not choose Apache instead of your current web server How do you handle Critical security Updates for your web server How do you assure that your web server is safe With which techniques do you assure 2 1 2 2 2 3 2 4 3 4 1 4 2 4 3 4 4 4 5 4 6 5 6 Secrecy Confidentiality SSL certificates Authentication Username password Nonrepudiation Accountability for alarms user accounts Int
44. to a min imum Rationale Elimination of If possible the Web client shall offer means to control to VP connectable hardware devices Rationale Elimination of WP 32 4 3 Future State of Integration The future degree of integration of VP within the HIS has been modelled by using the 3LGM Meta model see section for details The model of the future degree of integration VP is based on the following assumptions e The Web client is realised based on the requirements defined in section 4 2 e RD 6 1 RD 6 2 RD 6 3 and RD 6 4lare realised by the utilisation of CCOW 4 3 Future State of Integration 67 e The Web client is utilised wherever access to data stored in VP is needed and was provided on a paper based basis e The Web client is an alternative UI to the Native client but no replacement for it Details of the communication links message types event types have not been modelled as they are not relevant to this diploma thesis Video signal Measurement data Patient and User context Image Data Image Data Patient demographics Findings Findings ADT Information ADT Information Figure 4 1 Logical tool layer of the 3LGM model showing the future degree of integration of ViewPoint within the hospital information system In figure 1 for full page view please see figure A 3 in the appendix the logical tool layer of the model is shown The newly add
45. which other modalities or PACS request image data from VP are not supported The received or acquired image data is stored in the VP archive using the DICOM file format VP can act as a long term storage archive in which image data is stored as long as it has to be kept according to legal regulations shown as alternative A in figure 8 11 If the hospital has a central PACS for long term storage VP stores the image data only temporarily for reviewing and post processing purposes in its archive and forwards all image data immediately after reception acquisition via DICOM to the central archive shown as alternative B in figure 8 11 In this case image data is deleted from the VP archive after a specific amount of time but can be retrieved later on from the central archive via DICOM DICOM image data VP offers functions to handle DICOM image data Speaking in the context of DICOM image data comprise still images so called single frame and video 3 3 Current State of Integration 51 Iternative A Iternative B Logical Tool Layer ViewPoint Server a ol ViewPoint Server PACS Server Physical Tool Layer Figure 3 11 Logical and physical tool layer of the 3LGM model showing the two alter natives of the DICOM storage concept of ViewPoint sequences so called multi frames One special characteristic of DICOM is that all image data of an examination of a certain patient is collected in a virtu
46. 2 16 20 24 28 32 36 40 12 16 20 24 28 32 36 40 weeks weeks weeks Sonographer Samantha Jones Physician Dr Moore Page 2 of report date 07 12 2005 Ms Sally Jones DOB 11 29 1967 Figure 3 10 Printing and Faxing Submodule Second side of an obstetrical ultrasound report 3 3 Current State of Integration 49 3 3 Current State of Integration 3 3 1 Identification of Available Interfaces As already stated in the introduction see section for details VP offers different interfaces to other application components or information processing devices to enable data integration Following the available interfaces will be listed 3 3 1 1 HL7 HCM Clinicom BDT and Other computer based In the terminology of VP GE the interface which will be described in this paragraph is called HIS interface What is actually meant by this term is that it is the interface to communicate with the PMS CDMS or any other application component which is process ing with VP redundant data types In the typical scenario patient demographics are imported from the PMS while billing information like coded diagnoses and procedures are exported to the PMS The report text is exported to CDMS In short the PMS holds the administrative data hospital wide meanwhile the CDMS holds the medical data hospital wide As this is the most common configuration interfaces to other application components using the protocols stated here will not be considered
47. 4A For a start a description of the scenario in which VP is used will be given to clarify the subject of this thesis The application of VP is initiated by the placement of an order at the general practitioners office ward or outpatient unit At this point an examination in a diagnostic service unit is requested by the physician responsible The order is sent in electronic or paper form to the executing department There a new patient record is created or if he she was already at the department the existing patient record is selected in VP All data emerging in the course of examination is recorded in VP This comprises findings which are entered in structured findings masks In these findings masks the user can choose from predefined clauses or enter free text The structured findings are based upon By reasons of simplicity single images also called still pictures and multi frames also called video sequences or loops will be denoted by the term image data if no further distinction is required 2 1 Introduction guidelines issued by the respective professional societies Beside findings VP offers also functionality to record image data like single images or sequences from modalities like ultrasound machines or endoscopy devices Based on the findings the physician can enter diagnoses and therapeutic recommendations in VP At the end of the examination and assessment process the health care professional can print out diff
48. 51 3 12 Logical tool layer of the 3LGM model showing the current integration degree of ViewPoint within the hospital information system 57 xii List of Figures 3 13 Physical tool layer of the 3LGM model showing the current integration degree of ViewPoint within the hospital information system 58 4 1 Logical tool layer of the 3LGM model showing the future degree of inte gration of ViewPoint within the hospital information system 67 4 2 Physical tool layer of the 3LGM model showing the future degree of inte gration of ViewPoint within the hospital information system 68 5 1 Sample screenshot of Java Applet RemoteEye of NeoLogica s r l taken from 6 1 Screenshot showing the patient selection screen of E3 86 6 2 Screenshot showing the pregnancy summary of E3 87 6 3 Screenshot showing the search screen of WebEx 4 88 6 4 Screenshot showing the image gallery screen of WebEx 89 6 5 Screenshot showing the overview screen of Trium CTG Online 91 6 6 Screenshot showing the archive screen of Trium CTG Online 92 6 7 Screenshot of ViewPoint s Native client running in the Microsoft Remote Desktop Web Connection 2 0 mn 100 A 1 Logical tool layer of the 3LGM model showing the current integration degree of ViewPoint within the hospital information system 123 A 2 Physical tool layer of the 3LG
49. 56 3 Requirements Analysis As stated in section 3 2 3 the findings and image data stored within VP only have medical significance in combination So considering the rich and detailed documentation features the broad connectivity to diagnostic devices and the handling of image data in a patient case examination oriented way VP is the preferred application component at the functional diagnostic unit WP 7 Dependency on VP VP has and requires a user management of its own Each user who wants to access VP has to log in assuming she he has a valid user account in VP and did not yet login during the current session WP 8 No smooth switching between Native client and other application com ponents on a workstation As the sales team reported in most tenderings a Web client is demanded VP does not offer a Web based UI Therefore major orders may be lost due to this missing feature WP 9 No Web client offered for VP 3 4 2 Weak Points in Respect to Integration Potentials of the Native VP Client The points given here are derived from the integration analysis of VP given in section 3 3 and the description of VP given in section They are classified by type of integration 3 4 2 1 Data Integration To a high degree VP does already support data integration see section for details For example patient demographics are imported from the PMS coded diagnoses and procedures are exported to the PMS VP Reports are exported to the C
50. 7 80 PDF PDMS Physical Tool Layer Picture Archiving and Communication Sys tem 1 E2 E E E ES EN E Platform 95 23 25 FORT 88 07 99 106 107 Plug in 25 25 160 6 74 77 79 BO 100 PMS B PNG 44 Pop Up Portable Document Format Qt 23 RAM RDC RDP RDWC Remote Desktop Protocol RemoteEye SAP IS H med SAP Remote Function Call SAP RFC Secure Socket Layer Service Pack Simple Object Access Protocol Single Sign On SOAP Software product Sparx Systems Pty Ltd SPSS SSL sso Sun Solaris Sybase SQL TCP IP Terminal Client Terminal server 6 TIF Trium Analysis Online GmbH Trium CTG Online TWAIN I fend JML Jniform Resource Locator B1 Ed 92 5 Jniversal Modelling Language IRL S Jser Interface 9 cada E coca ViewPoint Bildverarbeitung GmbH GE Health care Technologies 113 16 19 20122 129158660 62 90 96 ViewPoint Report ro Vivid Voluson 4D View VP VP GE VP Report VPAdmin WAN Web browser 4 5 15 TOT oso Web Client Web server WebEx Wide Area Network Wireless Local Area Network ES S 59 83 P1 164 92 03 E N BE m Index 119 WLAN X Windows System XAML XHTML XML XUL ZIP 88 B9 53 120 Index A Appendix Table A 1 Enterprise functions originating from the reference model of th
51. 7 Leipzig http www imise uni leipzig de 8 1 Introduction Holger Schmuhl He is the author of this thesis His interest is to successfully complete it by meeting the expectations of both parties eMail holger schmuhl Qweb de 2 Basic Principles 2 1 Outline In the preceding chapter a general introduction to the topic of this diploma thesis has been given The aim of this chapter is to give a sound description of principles which form the basis of this thesis The reader should thereby gain accurate knowledge of the used terms methods and technology so that she he is able to follow the course of the thesis First a disambiguation will be given in section 2 2 to prevent misunderstandings Section 2 3 will focus on requirements engineering which is one central objective of this thesis Section 2 4 will show the methods which have been used to gather the required information Following in section 2 5 the general idea behind product analysis will be highlighted Afterwards in section 2 6 the concepts behind a Native and a Web client will be introduced and compared to each other Furthermore the concept of a Terminal client will be generally introduced in section This chapter ends with giving an overview of CCOW in section The succeeding chapter will then start to deal with the actual subject of this thesis by analysing the requirements for a Web based UI 2 2 Disambiguation The intention of this paragraph is to clea
52. 7673 E Notes Gest LMP 3145 E X Pathway o gt Pregnancy META 2 Antenatal Care C Booking J Medical History J Obstetric History gt Current Pregnancy C Observations amp Christine s Observations Contacts Testing Clinical Development E Lunch Menu C Delivery Overview Category of Risk Working EDD Smoking Alcohol Screening Comments Gestation 31 5 Y Mother s Views Care Professionals Babies Open Close Pregnancy EDD by Scan J LMP Date 02 09 2005 EDDbyLMP 09 06 2006 J BMI at Booking nohe Latest no he tcs Booking Date 07 11 2005 id Delivery Date CS Date Intended to Deliver This hospital v AN Care Booked v Received Midwifery led care Reason for Change Clinical reason during labour Jan Feb 7 Mar Apr Today May BE t Calendar Mi Studio ALF 3 Internet O Documents Figure 6 2 Screenshot showing the pregnancy summary of E3 In case that updates or security patches are issued for the Web server IIS it is the responsibility of the customer to apply them For the E3 Web client it is recommended to have a network connection to the server with a bandwidth of at least 100 Mbit s Some hospitals run E3 on a 10 Mbit s LAN in a satisfying quality Unstable networks are not supported An unexpected connection los
53. A by current scan GA by previous scan Assigned GA Placenta anterior fundal Placenta Grade Grade 0 Structure normal Anatomy Scan Biometry Biparietal Diameter Head Circumference Abdominal Circumference Femur Humerus Estimated Fetal Weight Growth Percentile Fetal Anatomy Visualized with normal appearance head brain face spine 19w0d 21w6d 21w0d 21w6d Hadlock Hadlock Hadlock Hadlock Romero Hadlock BPD HC AC FL BPD 550 mm 22w5d HC 200 0 mm 22w1d AC 175 0 mm 22w3d FL 35 0 mm 21w0d HUM 33 0 mm 21w0d EFW 9 458 g EFW lbs oz 1 Ibs 0 ozs GP 45 21w5d tract kidneys bladder extremities skeleton Genitalia normal imagination at work port Hadlock neck skin chest heart abdominal wall gastrointestinal GE Healthcare Waukesha WI U S A 888 202 5528 www gehealthcare com Figure 3 9 Printing and Faxing Submodule First side of an obstetrical ultrasound re 48 3 Requirements Analysis Maternal Structures Cervix normal Cervical length 3 mm Left Ovary normal Right Ovary normal Report Summary Impression Growth and anatomy survey appears normal Recommendations We recommend evaluation in 8 weeks Biparietal diameter Femur length Abdominal circumference 110 90 450 100 80 400 li 70 350 80 70 60 300 60 50 250 mm so mm y mM 290 apl 30 150 30 20 20 100 10 10 50 0 o o 12 16 20 24 28 32 36 40 1
54. Analysis Questionnaire as described in section 2 4 2 2 94 6 Technology Comparison The used criteria for comparison will be subsequently defined together with the related requirement s they aim at Criteria which are to give a general overview of the product Manufacturer Name of the company Product Name Name under which the product is sold Product Category Category to which the product belongs to as defined by HAWBO4 89 100 Goals Main goal of the product Networks Network types the Web client was designed for Aims partly at RS 1 3 Web page for further information URL where further information on the product and its manufacturer can be found Criteria which are to give an overview of the Web server and its characteristics Web server Type of Web server used to host the Web based access Database Type of DBMS used Web server extensions Web server extensions which are used like scripting languages etc Criteria which are to give an overview of the Web client characteristics and some details on its implementation Supported platforms Aims at RS 2 1 Supported Web browsers Aims at RS 2 2 Required Web browser extensions Extensions which are required to be installed on the workstation to be able to run the Web client Also comprises required changes at the default configuration of the Web browser Aims at RS 2 3 RS 5 1Jand RS 5 2 Distributed media Media types and data file types which are di
55. COM protocol US measurement values are exchanged between the imaging modality and VP like image data Measurement data is processed as described in 3 3 1 5 3 3 1 3 CORBA computer based Since Version 5 VP is based on the Common Object Request Broker Architecture CORBA architecture At the moment the by such a kind of architecture offered features are only available to VP clients and servers The access of external application components to CORBA based services is not supported yet 3 3 1 4 Analog Image Video Capture computer based In order to capture images or video sequences from imaging modalities which offer analog video output only a Framegrabber card is used With the help of this special hardware VP converts analog video signals into digital ones which can then be processed like standard DICOM data The capturing process can be initiated by the utilisation of a switch which has to be connected to the capturing workstation 3 3 1 5 US Measurement Data computer based In the common work flow of an US examination all biometric measurements are performed directly at the US device and therefore stored on it In order to prevent duplicate data entry additional work connected to it and error probability electronic transfer of most measurement values from the US device to VP is supported The transfered values are automatically inserted into the findings masks of the currently opened patient record Offered functions are
56. CTG Online than the UI of the Native client and should thereby point out the close association between both products Specification of Details Trium CTG Online will be analysed in section 6 2 3 In general 1t is more desirable to demand Trium Analysis Online GmbH to modify their product s layout and handling so that it becomes similar to VP The modification of Trium CTG Online would cause much less effort and would not contradict RS 7 2 The Web client shall offer a UI which supports automatic test ing Specification of Details The tools for automatic testing used at VP GE should be ade quately supported by the Web client The Web client shall preserve the quality and integrity of all image data provided to the user through the Web based UI Specification of Details This requirement has been addressed in section It must be carefully determined that the chosen Web browser extension s for displaying the image data fulfil s this requirement Requirements concerning hardware RS 8 1 RS 8 2 The Web client shall keep its hardware requirements to a mini mum Specification of RD 8 1 Details The hardware requirements of the Web client result from the hardware requirements of the Web browsers and Web browser extensions used The Web client shall offer no means to control hardware devices connectable to VP Specification of RD 8 2 5 3 Requirement Specification 83 Details The original definition of t
57. D 6 4 Details See RS 6 3 VII Requirements concerning the UI RS 7 1 The UI of the Web client shall be based on the existing masks definition see section for details if possible and feasi ble If not possible and feasible the Web client shall utilise a standardised UI definition language so that the UI of the Native client and the UI of the Web client can be created from a single definition Specification of RD 7 1 82 5 Specification of Requirements VIII RS 7 2 RS 7 3 RS 7 4 RS 7 5 Details A detailed analysis of available UI definition languages would go beyond the scope of this thesis An overview of for example XML Markup languages for definition of UIs can be found at http xml coverpages org userInterfaceXML html Representatives of this class of user interface definition languages are for example the Extensible User Interface Language XUL of the Mozilla Foundation or Extensible Application Markup Language XAML of Microsoft There certainly are other classes of Ul definition languages but as XML is the most widespread and best known markup language it should be the preferred one The Web client shall offer a UT which resembles the one of the Native client in appearance and is controlled similarly Specification of RD 7 2 Details The look and feel should be as close to the Native client as possible The UI of the Web client shall offer more similarity to the UI of Trium
58. DMS image data is exported to the PACS and biometric measurement data is transfered from medical devices to VP These interfaces along with other application components are illustrated in figure A weak point concerning data integration is that no direct referencing between VP Reports and image data is possible as soon as they are exported to other application components That means that in case an exported VP Report is reviewed in CDMS no direct access to the related image data is possible as the VP Report does not contain any references links to those image data stored in the PACS So if the user also wants to view the image data she he has to access the PACS and search for the related image data by specifying the patient identity WP 10 No full data integration guaranteed as links references between VP Report and image data are not exported Other weak points concerning data integration are that data transfer from to certain diagnostic devices or other application components is not adequately supported As the 3 4 Weak Point Identification 57 Details of the communication links message types event types have not been modelled as they are not relevant to this diploma thesis Video signal Measurement data Image Data ee Patient demographics Findings Findings ADT Information ADT Information Figure 3 12 Logical tool layer of the 3LGM model showing the current int
59. Health Professional Card HPC Plshould also be carefully considered while implementing this requirement although the respondents of the questionnaire Features of Web based interface to VP valuated that supporting the HPC has only low signifi cance RS 4 3 The Web client shall offer sufficient means for non repudiation and accountability Specification of RD 4 3 Details RS 4 4 The Web client shall offer sufficient means for integrity control Specification of RD 4 4 Details RS 4 5 The technology chosen to address RS 4 1 RS 4 2 RS 4 3 and RS 4 4 shall fulfil all legal regulations of the countries where the Web client is to be employed Specification of new Details A detailed specification of the legal regulations would go be yond the scope of this thesis and should be done by the implementor In Germany these are for example Bundesdatenschutzgesetz BDSG Informations und Kommunikationsdienste Gesetz luKDG Teledienstege setz TDG Teledienstedatenschutzgesetz TDDSG Telekommunikation sgesetz TKG Signaturgesetz SiG etc An example for the USA would be HIPAA RS 4 6 The Web client shall offer means to protect against data loss Specification of Details Data loss in case of connection loss during data entry is addressed by RS 3 2 Data may also be lost if the Web browser quits unexpectedly or the workstations locks up unexpectedly during data entry Here the data already ente
60. Higher risk of data loss Not every required function may be realisable through a standard Web page see section for details 60 3 Requirements Analysis WP 19 Limited functionality A variety of Web browsers is available on the market only few of which are popular Although Web browsers like Microsoft Internet Explorer or Firefox state that they support many Internet standards the actual recognition and implementation of the corresponding standard is Web browser dependent and may even depend on the Platform on which the Web browser is used see section for details WP 20 Web browser specific implementation of the Web standards The default functions offered by a Web browser are usually not sufficient Plug ins or Helper Applications are required to realise the missing functions Most of the Web browser extensions are Platform or even Web browser dependent and therefore destroy the ad vantage of the Web client to be Platform and Web browser independent see section 2 6 2 for details WP 21 Plug ins or Helper Applications are Platform and Web browser specific Plug ins or Helper Applications need to be installed on the workstation see section 2 6 2 for details New versions are also issued for Plug ins or Helper Applications so once installed they also have to be maintained to support the version which is required by the Web client WP 22 Manual installation required to use Plug ins or Helper Applications on a w
61. Informatics Statistics and Epidemiology IMISE Terminal server technology should also be examined as an alternative technique to the Web based access to VP Objective 3 The degree of integration of VP in the HIS should be analysed and modelled by using the 3LGM meta model The current integration degree with the Native 6 1 Introduction client and the future integration degree with the additional Web client should be examined 1 5 Question and Taskdefinition Question 1 Which requirements should be fulfilled by the Web based UI Task 1 1 Identification of the available functions at a VP client Task 1 2 Determination of missing functions and additional functions which should be made available especially enabled by the special characteristics of the Web environment for example remote access etc Task 1 3 Weighting quantisation of listed functions to have a sound idea of which functions are essential to be adopted by the Web based interface and which are optional Weighting quantisation is based upon the input from the sales service and development departments of VP GE Result system requirement specification Aspired completion 1 12 2005 Question 2 How are certain Web based UI of medical documentation systems which are available at the market realised Task 2 1 Identification of other application components already offering a Web based UI Task 2 2 Analysis and evaluation of the application components foun
62. M model showing the current integration degree of ViewPoint within the hospital information system 124 A 3 Logical tool layer of the 3LGM model showing the future degree of inte gration of ViewPoint within the hospital information system 125 A 4 Physical tool layer of the 3LGM model showing the future degree of inte gration of ViewPoint within the hospital information system 126 List of Tables 2 1 3LGM meta model graphical representation of elements at the domain 2 2 3LGM meta model graphical representation of elements at the logical AE s sc soe ca 4 wu a Ewa a a ew AEG Gee wa ae i 18 2 3 Comparison of Native client and Web client architectures 26 3 1 Overview of the interfaces of ViewPoint to CDMS and PMS 50 5 1 Quantification of features which are offered by the Native client and shall be offered by the Web client 2 22 2 2 CE nn nn nn 70 5 3 Significance of supporting referring OS and Web browser 74 5 4 Web browser and OSs which should be supported by the Web client 74 6 1 Comparison of E3 WebEx and Trium CTG Online 2 2 22 22 95 6 2 Comparison of Web Client vs Terminal Client 101 7 1 Short Overview of the requirements for a Web Client 108 A 1 Enterprise functions originating from the reference model of the domain layer proposed by H bner Bloder et al HBABWO5 which are suppor
63. MMERVILLE I Software Engineering 5 Addison Wesley 1995 ISBN 0201427656 TANENBAUM Andrew S Computer Networks 4 Pearson Education Inc 2003 ISBN 0130384887 THECOUNTER COM Main Stats Version 2006 com stats 2006 March Last checked 4 April 2006 UPSDELL C A Browser News Statistics Version 2006 upsdell con BrowserNews stat htm Last checked 4 April 2006 W3SCHOOLS COM Browser statistics Version 2006 http www w3schools com browsers browsers_stats asp Last checked 4 April 2006 WINTER A BRIGL B WENDT T Modeling Hospital Information Sys tems Part 1 The Revised Three layer Graph based Meta Model 3LGM In Methods Inf Med 42 2003 S 544 51 WENDT T HABER A BRIGL B WINTER A Modeling Hospital Information Systems Part 2 Using the 3LGM Tool for Modeling Patient Record Management In Methods Inf Med 43 2004 S 256 67 WIKIPEDIA THE FREE ENCYCLOPEDIA Interview Wikipedia the free encyclopedia Version 2006 http en wikipedia org wiki Interview Last checked 1 April 2006 WILLIAMS T N Proposal for CCOW Specification Version 0 1 2003 Index 3LGM a a Data Processing Component Configuration NET Database Management System ActiveX 92 Adobe Acrobat Reader dBASE Apache DBMS Apple Macintosh 53 3 F B9 03 68 DICOM B B 10 EI B3 68 Hy 44 60 53 application component 70 76 49 DICOM Viewer 63 67 71 Digital Imag
64. OIJEIIUNLUILWOD y Jo speq A Appendix 124 Figure A 2 Physical tool layer of the 3LGM model showing the current integration degree of ViewPoint within the hospital information system 125 UOTJVULIOFUL eyidsogy oy UYM 2 H S waisAs juawabeuey Ned m pau H SI wa sts uawa eueyy pue uolye1uauundog jedu tuays s JUIOJM9IA JO UOTFRIBOYUT JO 99139P 9 MFNJ oY SULMOYS opow WHITE OY JO Jose 009 e130 Ey Smart uone wozuj 1aY uone W40JU LOW s6ulpul4 sBulpuly saiydesbowap quaied suuO 919 Uni 1 lua1s s Bunoyluoy Ydesbod0j0Ipse gt eq abewj ejeg abewj Jeue xa1u0 MOID qusuodwos uonesiddy 1x3JU02 4 SN pue JUSITEg ea 19n0 Aeman sanas uoles1uNnWWo gt QUIOJMAIA 1anas uun 891185 jeuolauny 104 SDYd PUB SAN d33y Quiog yun 83 1135 jeuolduny 104 SDYd PUB SAW VEaHJOD es MSN anpoyy uolealsiulupy Wa1s s a npowqns Bunay 3 ny 5 a npowans Bulxey pue Hunund ajnpowgns M jjeD L w wua1s s sBuIpuly jnpowqns yua w eue y uoneurwexg pue asep a npoyy uolyeulwexy jnpow 3AYIA Y UIOJMAIA 18119 qem Jun SALAS BUOIDUNY 104 SDYd pue elep JUaWainseay jeuBis oap A a sawd 181 61p Aujepow Bu beuu Boyeue uyepoyy Bupe wy MN
65. UNIVERSITY OF LEIPZIG Faculty of Medicine Institute for Medical Informatics Statistics and Epidemiology IMISE Integration of a Medical Documentation and Image Archiving System within Hospital Information Systems with the Utilisation of a Web Based User Interface Diploma Thesis Leipzig 23rd May 2006 written by Hans Holger Schmuhl DOB 24th February 1980 Instructor Prof Dr Alfred Winter IMISE Tutors Dr Thomas Wendt IMISE Bernd Nuber ViewPoint Bernhard Hornung ViewPoint ii 111 Acknowledgement To this diploma thesis contributed quite a lot of people First of all I like to thank my parents to whom I owe that I got so far at all They supported me wherever they could and especially encouraged my interest in sciences Then I like to thank ViewPoint in general Not only for offering me this thesis and supporting me in writing it They are the ones who finally brought me to study Medical Informatics In special I like to thank Bernhard Hornung and Bernd Nuber who looked after me during this thesis Furthermore I like to thank all my colleagues at ViewPoint who instantly and willingly answered my questions in detail Moreover I like to thank Dr Thomas Wendt and Prof Dr Alfred Winter at IMISE for enabling the cooperation with ViewPoint and especially for supporting me in writing this thesis In addition I like to thank Svein Fimreite John Stepleton and Christian Harb ck for providing me a compreh
66. a email e Christian Harb ck of Trium Analysis Online GmbH He is developer of Trium CTG Online He was chosen as he has a sound knowledge of it and its implementation The questionnaire has been answered in writing by C Harb ck Ambiguities in the answers have been clarified via phone and email A questionnaire with free text answers was chosen as it was seen as crucial to take as much information from the answers as possible At the time the questionnaire was cre ated the requirements had not yet been fully developed So it was important to allow free text answers because thereby aspects yet unknown could also be considered Neverthe less it turned out that all important issues had already been covered by the requirement specification draft The questionnaires in its original form together with the individual answers of the respon dents can be found in the 2 4 3 Analysis of Existing Data The analysis of existing data was extensively used throughout this thesis Apart from liter ature research in which books and papers were consulted also manuals and other technical 22 2 Basic Principles documentations at VP GE were accessed For additional and more up to date information the Internet was consulted The related resource are specified in the bibliography of this thesis 2 5 Product Analysis In case a new application component is needed in a business a requirement specification is set up According to this specificati
67. ace is only employed in the German perinatal reporting module Within the scope of the German perinatal inquiry data of all births in Germany is collected by central quality insurance institutions As VP is also an application component with which births can be documented it offers an interface to support this inquiry adequately Offered functions are e Export birth data in the respective coding for example ICD 10 etc to be send to the quality assurance institutions After the export the exported examinations will be locked e Configure the hospitals identification data which is included in the exported birth data to uniquely identify the origin of the data e For more functions please refer to section 3 2 8 5 as the rule checking submodule works closely related to the interface for the German perinatal inquiry 54 3 Requirements Analysis Fetal Medicine Foundation London computer based and paper based Since decades the FMF is specialised in assessing the risk of chromosomal abnormalities which are the major cause of perinatal death and childhood handicap The risk is determined by statis tical analysis of biochemical and ultrasound markers acquired during screening tests In order to improve the accuracy of the screening tests the FMF collects data of all performed screening tests in which the risk of chromosomal abnormalities was assessed as well as their outcome In order to support FMF in their work VP offers an interfa
68. al container called study In case VP receives or sends DICOM data over the network it utilises this container In other words if VP for example receives image data from an imaging modality it maps the DICOM study containing all image data to a VP examination so that it is accessible via the image gallery submodule see section for details Offered functions are e Receive image data and give the user the opportunity to handle it adequately via an UI for example assign a study to an examination record Send image data e Archive image data in VP for short term storage Archive image data by sending it for example to PACS for long term storage Handle multiple DICOM sources and destinations DICOM Worklist With the utilisation of DICOM worklists it is possible to receive patient demographics at the US device from VP This procedure works as follows A patient record is opened or created in VP The sonographer initiates the retrieval at the 52 3 Requirements Analysis US device which sends a request to the workstation on which VP runs VP answers this request by sending the related patient demographics to the US device Offered functions are e Ability to configure one of the following sources for creating a worklist Current patient Appointments Orders e Ability to map one order from the PMS to exactly one worklist entry DICOM SR DICOM SR is a way to send US measurement data by using the DI
69. al s patient ID versus an application component specific ID the mapping agents offer means to map between the different context subject identifiers so that an application component only needs to know the identifiers of its own to establish the context e Annotation agents which supply ancillary data about an identity subject Ancillary data could be for example patient demographics if the identity subject is the patient Each hospital defines the data sources for its annotation agents and so assures data integrity They have been added in CCOW version 1 3 e Action agents are proposed to be added to the CMA They should be enabled to provide non repudiation of document content and irrefutable evidentiary status of an individual s identity and professional credentials to enable digital signatures Yet this is only a proposal specified by W11031 It is vital to note that the CCOW CMA does define the roles and responsibilities for each of the listed components Moreover it precisely describes the interfaces that enable them to communicate It does not though define the implementation of any component ANNOTATION AGENTS Figure 2 6 Overview of the components of the CCOW CMA taken from Sel01 In order to illustrate how CCOW works in detail all steps which are required to synchronise the context between different application components are subsequently listed in their order of execution This listing is a literal citation taken fro
70. ance efforts are required Still these efforts should be kept to a minimum Requirements concerning interaction with other application components RS 6 1 RS 6 2 RS 6 3 RS 6 4 The Web client shall offer means to switch from itself to an other application component running on the same workstation without having to reenter login information Specification of RD 6 1 Details CCOW should be the preferred standard to address this re quirement Other technologies like SSO should also be considered This requirement is also related to RS 4 1 See section for details The Web client shall offer means to switch from another ap plication component running on the same workstation to itself without having to reenter login information Specification of RD 6 2 Details See RS 6 1 The Web client shall offer means to switch from itself to an other application component running on the same workstation without having to reenter patient identification information to preserve the patient context Specification of Details CCOW should be the preferred standard to address this require ment Alternatively the patient context can also be passed via specific URLs See section 5 2 5 for details The Web client shall offer means to switch from another ap plication component running on the same workstation to itself without having to reenter patient identification information to preserve the patient context Specification of R
71. anced security features so that it can also be accessed on the Internet and utilise techniques like the HPC or CCOW As VP is sold worldwide it has to fulfil all legal regulations like demanded by RS 4 5 when assuring data security The access of application components from remote places does not only come along with demands for advanced security The requirements to support low bandwidth and unstable network connections are also a big issue in this context Although especially WebEx and Trium CTG Online specify that they need a minimum bandwidth from a realistic point of view they require at least a bandwidth which is characteristic of LANs 10 100 Mbit s to not hinder the user in her his work So it is substantial to address the coherence between low bandwidth utilisation and not interfering the user s work in two separate requirements like it was done by and RS 3 3 WebEx and E3 see a sudden network interruption like it is common for unstable networks as a major problem while applying the online monitoring tool Trium CTG Online in unstable networks is irrelevant So it should be considered from the initial implementation of a Web client to offer means to also cope with unstable connections like it was specified by E3 is the only product which offers means against data loss by the auto saving functionality So the fulfilment of RS 4 6 is also essential when implementing a Web client although a 100 percent prevention of data loss will not be po
72. ankenhausleitung 5 Forschung und Lehre 6 Sonstige Aufgaben 123 tuays s UOLFBULIOJUL TOyIdsoy oY UTM JUIOGMaIA JO 99139P UOTFBIZOJUL JUOIINO oY SULMOYS TOPO WOTE I JO I9 RT 004 perso Ty Omar Z uonewozuj 1aY H SI tua1s s yua w eue y 1431184 uone wozuj 1aY a pau H SI wiayshs Juawe eueyy supu pue uorezua wnq edIUID sbulpul4 ssa yde bowap uae uuo OLD wnu uue1s s eeg ape wj Bunoyuopw yde1b030101p 1e eq abewj e1ep WaWainseay jes 130 Aemaye5 1anas uolediunuwo gt JUIOgMa IA lanas yun amas euoiuny 40 SDYd pue SAW UI0JMAIA yun adiAlas BUOIIDUNY 104 SDYd PUE SAW 3 npo yy Uolyesysiulupy WaIS S a npowans Bunay a ny jnpowqns Buixey pue Bululld ajnpowgns M jjeD abeu wusa1s s sBuIpuly jnpowqns 1uewebeuey uopeurwexg pue ase waua a npo y uoneuiwexg T a Npow SAY Y 9 NPO N SINSIIS QUIOgMa ua 9A11eN yun 3311135 JBUOIIDUNY 104 SDYd pue S jeu is oap ajnpoy Bul npayos quale jnpow 1uawabeuey 1431184 GQ OF E SDYd e1161p Auyepoyy Bube wj Bo eue Ay jepoyy Bupe wj s s y ewojdip siy 0 uenaja1 JOU 2e ADU se p jjapow u q you aney sad 1u 4 s d abessaul syu U
73. ans of integration The referencing between the components is realised by using unique HTML links A conceivable alternative to offer SSO capabilities would be to utilise functions offered by the OSs like for example Microsoft Enterprise SSO Service 5 3 Requirement Specification An overview of the following requirement specification can be found in table 7 1 on page 108 I General requirements RS 1 1 VP shall provide a Web client Specification of RD 1 1 Details RS 1 2 The Web client shall provide all functions of a Native client as specified by the requirements specification Seh05 The only functions which are excluded are features which require the con trol and access of hardware see WP 32 for details Specification of Details In case the Web client is implemented in an incremental ap proach features should be added based on their significance given in ta ble For every feature the significance should be weighed up against lts actual implementation efforts before the decision in which version the feature should be released is made See section 5 2 1 for details RS 1 3 The Web client shall provide access to VP from local and remote locations Specification of RD 1 3 Details See section for details II Requirements concerning supported Platforms Web browsers and re quired Web browser extenions RS 2 1 The Web client shall support Microsoft Windows XP Microsoft Windows 2000 and Linux on the
74. aper based basis In this context paper based means that the VP Report is printed out and transfered to a person or institution by mail Figures 3 13 and 4 2 illustrate this issue 72 5 Specification of Requirements e In the functional diagnostic unit In examination rooms for documentation At receptions for patient identification and examination planning At doctor s offices or nurses stations for completing or reviewing the find ing In conference rooms for reviewing daily examinations e In the hospital In other functional diagnostic units that patients are assigned to for further diagnostics or have been assigned from At wards where inpatients are accommodated and require adequate care and therapy At lecture rooms for reviewing findings for educational purposes e Outside the hospital At other branches of the hospital for example those located at another site which can comprise other functional diagnostic units or wards At other healthcare institutions that the patients are assigned to for further treatment or have been assigned from for example the general practitioner s office At specialised healthcare institutions to gather a second opinion and as sistance At the medicating doctor s or staff s home to complete or review the findings The sites listed here can be classified into two groups Local sites in the hospital and remote sites ou
75. ar as was specified in Furthermore Trium CTG Online already made some approaches to adjust their programme design to the one of VP still must also hold for future versions of both products RS 7 4 to support automatic testing of the Web client was not considered in the product comparison Still it is indisputable that this is a reasonable requirement The proper operation of WebEx is also audited with the help of testing tools included in Microsoft Visual Studio NET Handling image data carefully so that its medical significance and integrity is assured like specified by RS 7 5 has also proven to be a crucial issue WebEx addressed this issue by offering two ways of distributing image data by means of the Web client On one hand image data is converted to Internet media formats for simple reviewing purposes On the other hand the original image data as acquired by the imaging modalities is provided for post processing purposes RS 8 1 to keep the hardware requirements as simple as possible was not considered in the product comparison Still it is clear that this is a significant requirement to fulfil in order to have a real advantage over the Native client The analysed products did not connect directly to any hardware device So it seems adequate to exclude any direct interfacing with hardware as proposed by RS 8 2 6 3 Terminal Client as Alternative to a Web client 6 3 1 Terminal Server and VP In section 2 7 the Terminal clie
76. ased application component that sup ports documentation and management tasks clinic wide Medical Documentation System MDS The Medical Documentation System is a computer based application component that supports specific documentation tasks like patient history report writing etc in different medical fields like obstetrics gynaecology internal medicine etc N Picture Archiving and Communication System PACS The Picture Archiving and Com munication System is a computer based application component that supports the storage management and presentation of digital Image Data Moreover it offers means for transferring the Image Data from the storage media to the attached work stations It may offer additional functions for image processing HAWB04 Patient Data Management System PDMS The Patient Data Management System is a computer based application component that is specialised in automatically moni toring storage and presentation of patient related clinical data HAWB04 Patient Management System PMS The Patient Management System is a computer based application component that supports patient admission discharge and trans fer HAWBO4 12 2 Basic Principles Radiology Information System RIS The Radiology Information System is a computer based application component that offers functions for appointment scheduling or ganisation of examinations and staff provision of patient data and examinatio
77. at hospitals are out dated This is caused by the comparatively long lifespan of computer systems at hospitals which are not replaced by newer better systems due to budget limitations and organisational constraints WP 2 Comparatively high hardware requirements VP has a high bandwidth utilisation see section for details and due to CORBA see section for details requires a stable network connection These network character istics are in most cases only fulfilled in the wired LAN of a hospital So the usage of the Native client is not possible from sites like remote places which only have low bandwidth connections to the VP server In addition usage of the Native client over unstable net works like Wireless Local Area Network WLAN inside the hospital is critical as the IP address of a client might change during roaming inside the WLAN Also sudden network interruption may occur WP 3 High bandwidth required Access from remote sides nearly impossible WP 4 Stable network connection required Usage over WLAN nearly impos sible In order to be able to access VP from a workstation manual installation and configuration of the Native client is required as described in section Moreover after setup each VP client has to be maintained during its lifespan in a hospital resulting in additional efforts WP 5 Manual installation and configuration required to run VP on a work station WP 6 Maintenance efforts for each client
78. ative to the Web client This was further encouraged by the availability of a Web interface for the Terminal client RDWC An evaluation of the Terminal server client technology and its applicability to realise the requirements specification was performed in section In table 6 2 on page it was analysed to which extend it fulfils the requirements in comparison to the Web client It turned out that the Terminal client could be a serious alternative to the Web client especially when using the RDWC Outstanding advantages are that it could be used ad hoc without requiring any addi tional design or implementation efforts Moreover the access and control of hardware are supported by the examined Terminal client Still certain drawbacks are linked to its usage For example does RDWC only supports Microsoft Windows and Microsoft Internet Explorer Also the examined Terminal client does not offer any means to enable contextual integration See section 6 3 2 for details 7 3 3 Objective 3 The degree of integration of VP in the HIS should be analysed and modelled by using the 3LGM meta model The current integration degree with the Native client and the future integration degree with the additional Web client should be examined This objective was fully achieved In section 3 4 the current degree of integration of VP within the HIS was modelled by the utilisation of the 3LGM meta model Figure on page 57 shows the related logical tool
79. ave to be carefully analysed and evaluated in detail If this had been done for all requirements the connected efforts would have gone far beyond the scope of this thesis Still during requirement specifications wherever possible it was tried to give recommen dations which technologies could be used or at least which procedure should be preferred to fulfil the related requirement Outstanding recommendations which are not directly defined by the requirement specification for example that the Web client should support certain Platforms or Web browsers versions are e The most adequate Plug ins to enable viewing of image data through the Web client are Java Applets like introduced in See section for details e In order to reduce the network traffic and to enable immediate response to certain user activities a Plug in for example Java Script should be used to be able to edit the related Web page directly without requiring communication with the server See section for details e For authorisation and authentication purposes the potentials of SSO solutions should be considered e For authentication purposes the potentials of the HPC should be considered e In order to prevent data loss during data entry data entered already should be automatically saved on the server at regular intervals e In order to enable contextual integration CCOW should be the preferred standard It also offers means for authorisation and authentication See sec
80. based distribution and obstetrical department with PACS workstation designed archiving of cardiotocograph an easy to use interface to handle any type of readings in real time imaging modalities Networks Intranet Intranet and Internet Intranet Wb page for further information Web server IIS IIS Apache Database Intersystems Cache Microsoft SQL Server Microsoft Access Web server Microsoft Active Server Pages OpenSA Macromedia Cold extensions NET ASP NET Fusion G Web server Supported Microsoft Windows Microsoft Windows Apple Microsoft Windows platforms Macintosh Linux Supported Microsoft Internet Explorer Microsoft Internet Explorer Microsoft Internet Explorer Web Netscape Opera Firefox Mozilla browsers Required JVM has to be installed and Media player which is ca Macromedia Flash Adobe Web browser the usage of Java Script has pable of playing Microsoft Acrobat Reader JVM has extensions to be allowed Further appli Windows Media MPEG 1 or to be installed and the usage cations are required to open MPEG 4 ZIP tool to unpack of Java Script has to be al files managed by the file downloaded videos Allow lowed The SSL root CA cer management system of E3 use of Pop Ups tificate must be installed like Microsoft Word Adobe Acrobat Reader etc Distributed every data file type text images JPEG GIF text images Macromedia media v
81. can be divided into the following two types Plug in and Helper Application Both have in common that they are compiled for certain platforms and therefore are platform specific Client machine Client machine Browser Browser Helper Browser runs BaseN as a single code process Browser s interface used by plug in Plug in s interface__ Plug in Used by browser ae N Process Process 2 a l b Figure 2 4 Web browser plug In and helper application taken from Tan03 Plug ins are code modules which are executed within the Web browser s process they have access to the current Web page and can thus modify its appearance The interface between Web browser and Plug in is Web browser specific The Plug in has to be installed so that the Web browser is able to call it Examples for Plug ins would be Java Script or Macromedia Flash Helper Applications are complete programmes running as separate processes They have no interface with the Web browser and usually open a certain file specified by an URL The Helper Application has to be installed Tan03 Examples for Helper Applications would be Adobe Acrobat Reader or Java e Cross Platform Web pages can be displayed by a Web browser on all platforms Alb03 Browser incompatibilities cause problems Usage of Web browser extensions limit the cross platform support Plug ins and Helper Applications are platform dependent Plug
82. cation Seh05 according to the significance which each feature has to the customer The significance was assessed with the help of the questionnaire Features of a Web based Interface to VP as described in section Succeeding a table with the results is shown listing the general significance of each feature that is the mean of the assessed values expressed in degree of significance The original structure of the questionnaire has been changed to be conform to the module description given in 3 2 On account of the same reason the description of features and the used terminology have been modified in some Cases As already stated in section a 100 percent clear distinction between the modules cannot be made As the module partition at VP GE is slightly different from the one chosen in this thesis the question naire had to be structured differently 70 5 Specification of Requirements Table 5 1 Quantification of features which are offered by the Native client and shall be offered by the Web client Feature Significance Patient Management Module Ability to search for patient records High Ability to manage create alter delete patient records Medium Ability to view orders Medium Ability to manage create alter delete orders Low Patient Scheduling Module Ability to view appointments High Ability to manage appointments Medium Archive Module Ability to view the change history of a patient re
83. cation components see section for details like the CDMS Furthermore it can be saved as a file A sample screenshot of the VP Report is displayed in figure 3 6 Changes made in a VP Report can be traced in the Archive Module see section for 40 3 Requirements Analysis 2 PIA w Help Fetal Database 4 Doreen Donald 09 01 2002 218 xi Gestational age US BPD 49 0 mm OFD 64 0 mm HC 177 5 mm Vp imm Tep 21 0 mm CM mm Nuchal fold 1 0 mm Nasal bone mm TAD 48 0 mm APAD 49 0 mm AC 152 4 mm Femur 30 0 mm Humerus mm HC AC 1 165 HC FL 5 917 HC HL BPD OFD 0 766 EFW l SGA Fetus Cervix L mm IV Additional Biometry 20 w 3 D p lt gt a Hm BPD FL 1 633 Biparietal diamete sa a 70 a a a me a 10 o te I Calculate GA Heart action Fetal movements Presentation Placenta site Placenta grade Placenta structure Amniotic fluid Cord Head shape Brain Face Spine Neck Skin Thorax Heart Abdomen GIT Kidneys Genitalia Extremities Skeleton I Other findings present visible cephalic II Fundal Posterior Grannum Grade 0 normal normal 3 vessels normal normal normal normal normal normal normal normal normal normal normal m normal normal l Chromosomal markers Press any key to exit the graph Figure 3 4 Findings System
84. ce of each feature and also because many features are interconnected meaning that the implementation of one feature would go along with the implementation of another one The results of this part have been used in section 5 2 1 The other part of the questionnaire lists additional features which could be offered by the Web client The results of the second part have been used to answer certain issues in section The questionnaire in its original form together with the individual answers of the respon dents can be found in the 2 4 2 2 Questionnaire Product Analysis The aim of this questionnaire was to find out how the requirements which will be set up in this thesis are realised by several products Details which product has been chosen and reasons why can be found in section 2 5 The questionnaire has been sent by email to the following persons in agreement with B Hornung e John Stepleton of Euroking Miracle Ltd He is the development director at Euroking Miracle Ltd He was chosen as he has a sound knowledge of E3 and its implementa tion The questionnaire has been answered in the course of a phone interview with J Stepleton e Svein Fimreite of GE Vingmed Ultrasound He is the developer of WebEx and part of the development team of EchoPAC He was chosen as he has a sound knowledge of it and its implementation The questionnaire has been answered in writing by S Fimreite Ambiguities in the answers have been clarified vi
85. ce to easily gather and export the data to the FMF Offered functions are e Export FMF relevant data to file e Send FMF relevant data via email to the FMF e Display data which will be exported customise view depending on the examiner 3 3 2 Model of Current State of Integration The current integration degree of VP within the HIS has been modelled by using the 3LGM Meta model see section for details In figure page 57 for full page view please see figure A 1 in the appendix the logical tool layer and in figure page for full page view please see figure 4 2 in the appendix the physical tool layer of the model is shown The domain layer of the model was created based on the reference model proposed by Hiibner Bloder et al HBABW0O5 It is not shown as it is irrelevant to the objectives of this thesis By offering the Web client no changes in the enterprise functions which are supported by VP will occur Only the way how data stored in VP is accessed will alter Thereby the domain layer will not change Please refer to table on page for an overview of which enterprise functions are supported by vpi 3 4 Weak Point Identification In the first part of this section all weak points of the current solution will be identified Subsection 3 4 1 will focus on certain requirements and missing features which are weak nesses of the Native client Subsection 3 4 2 will concentrate on weak points of the Native client in respect to
86. cord and Medium all its data Examination Module In General Ability to view VP Report High Ability to view previously printed VP Reports Medium Ability to view Findings Masks Medium Ability to print VP Report for assigning doctor High Ability to alter the VP Report Medium Ability to alter content of the Findings Masks Medium Assign or unassign an order Medium Assign or unassign a DICOM study Medium Export a case to Trium CTG Online Medium Display Charts High Measurement data transfer from Ultrasound devices Low Examination Module Image Gallery Submodule Ability to view single frame images High Ability to view multi frame images High Ability to review raw data Voluson 4D View or LOGIQworks Medium FX Perform measurements on images Medium Import image data data via DICOM interface Low Digitise image data with the help of a Framegrabber Low Digitise image data with the help of a TWAIN compatible Low scanner device Import image data from file system Low Import image data from clipboard Low Export image data via DICOM interface Low Export image data to file system Medium Examination Module Printing and Faxing Submodule Ability to print High Ability to fax Medium Examination Module Rule Checking Submodule Ability to check plausibility of findings Low 5 2 Research of Open Issues 71 Comment The importance of the feature Ability to check plausibility of findings was calcula
87. d Task 2 3 Review and probable modification of the system requirement specification due to new ideas or concepts taken from other application components Results reviewed system requirement specification overview of the technology which is used by partners opponents to realise a Web based UI Aspired completion 31 01 2006 Question 3 How is VP integrated in the HIS at the moment What will change with the utilisation of a Web based UI Task 3 1 Analysis of the current state of integration without a Web based UI Task 3 2 Analysis of the future state of integration with a Web based UI Task 3 3 Modelling of both states using the 3LGM Meta model Result descriptions and models of the current and future state of integration Aspired completion 10 02 2006 Question 4 To what degree is Terminal server technology an alternative to the Web based UI of VP What are its advantages and disadvantages Task 4 1 Introduction to Terminal server technology Task 4 2 Examination of how Terminal server technology can support the integra tion of VP in the HIS 1 6 Stakeholders 7 Result brief idea of whether Terminal server technology can be a serious alternative to the Web based approach Aspired completion 24 02 2006 Question 5 What are the pros and cons of the different methods of resolution What methods should be chosen Task 5 1 Setup of different concepts realising the system requirements by Web based and alternative non
88. d Section will view a short prospect on the subject of this thesis 7 2 General Discussion When the task of Creating a Web client for VP came up at VP GE as potential topic for a diploma thesis it was clear that it would offer work for several diploma theses So the topic of this thesis was primarily limited to the development of a design concept for a Web client and the implementation of a prototype to demonstrate its viability These two objectives had originally been accepted by VP GE and IMISE as subject for this diploma thesis After creating the introduction and an initial literature research it turned out that these objectives have still been too wide to be adequately covered in the scope of a diploma thesis Furthermore it was later demanded by VP GE and IMISE that the Terminal client server architecture should also be partly covered by this diploma thesis as alternative technology to the Web client Finally VP GE and IMISE agreed to alter the original objectives in the way they are defined now see section 1 4 In order to achieve these objectives the author originally intended to answer the ques tions and to follow the related task definitions subsequently as specified in section As the question and task definition has however been created at the beginning when the author had not yet acquired a broad understanding of the problem domain and the connected efforts it soon turned out that it was obsolete to subsequently
89. d to implement a Web client With the Web client access to VP should be possible from every workstation which is networked with the VP server without any additional application components and by using a standard Web browser Limitations A selection of software products with a Web based UI should be examined and described to also consider existing solutions during the creation of the concept Selection is made in accordance with VP GE and IMISE Terminal server technology should also be examined as an alternative technique to the Web based access to VP This objective has been achieved with the limitation that the recommendation is left on a quite abstract level Requirement specification In order to be able to give a recommendation for technologies which should be used to implement a Web client first of all the Web client s characteristics and desired features had to be determined This was done by setting up a requirements specification Details of the approach used for requirements engineering can be found in section First a requirements analysis was performed in chapter 3 The resulting requirements were generally defined in chapter 4 The specification of requirements was realised in chapter Following the created requirements specification will be shown Certain requirements have been shortened indicated by for the purpose of enabling a quick overview The complete requirements and details on them can be found in
90. deline for conducting all required activities in the right order and to the right extend Thus after gaining a general idea of the process families and certain representatives like the spiral model of Boehm or the Rational Unified Process KK03 it came up that following a specific process model would not substantially contribute to the goal of this thesis It would rather complicate the general procedure without offering any compensatory benefits In most process models activities of the software specification are closely related to activ ities of other phases like implementation or validation This is for example characteristic for iterative process models in which the phases are manifoldly passed through Moreover the results produced and experiences made in other phases have a strong influence on the further development and successful completion of the software specification As the other phases will not however be passed through in this thesis and would therefore not give any input to the specification phase it was seen as more reasonable to refer to literature which is describing requirements engineering and its methodology in a more general way According to Davis et al requirements engineering applies proven principles techniques languages and tools to help analysts understand a problem or describe a potential prod uct s external behaviour DH94 2 3 Requirements Engineering 13 Evaluate alternatives ide
91. e Improve the degree of integration of a medical documentation and image archiving system within hospital information systems Furthermore a potential objective would be something like Establish a recommendation for what technology should be used to enable access integration So the Terminal client server technology could have been equally evaluated Also further technologies or methods as alternatives to the Web based access could have been considered However this is not the case Many hospitals expressly demand for a Web client in their tenderings VP GE wants to serve them and thereby needs adequate means to provide Web based access VP GE offered this thesis with the intention to gain ideas and concepts about how to implement a Web client So right from the start it was clear that a potential Web client is the focus of interest in this thesis no matter if it is the best technique to offer adequate integration capabilities or not 7 3 Achievement of Objectives In section the objectives which should be covered by this diploma thesis have been defined Following it will be verified if these objectives have been achieved in the course of the thesis 7 3 1 Objective 1 Determine which requirements are not met by the Native client of VP and the VP system in general for an adequate integration within the HIS This objective has been fully achieved In section it was examined to what degree VP and its Native client support t
92. e Ability to search for and transfer patient demographics of a certain patient from the CDMS to VP via a UI e Ability to automatically insert and update all patient demographics which are stored in the CDMS into VP 50 3 Requirements Analysis Table 3 1 Overview of the interfaces of ViewPoint to CDMS and PMS Messag Standard Comm technique Comm Import Export partner HL7 file transfer CL 1 2 1 3 4 HL7 socket VP 1 2 1 3 4 HCM socket file transfer CL 1 2 1 3 4 clinicom socket file transfer CL 1 2 1 3 4 ODBC VP 1 SAP RFC VP 1 BDT file transfer VP 1 Legend CL Cloverleaf indirect communication VP ViewPoint direct communication 1 patient demographics 2 clinical orders 3 findings report 4 revenue codes like for example ICD 10 or OPS e Ability to process orders via a UI see section for details e Ability to automatically export coded diagnoses and procedures of an examination record when it is archived 3 3 1 2 DICOM computer based Many types of the DICOM standard are supported by VP They will be described sub sequently at an quite abstract level For details please refer to DICOM conformance statement of VP Rus06 General PACS Functionality Storage Concept In its function as PACS VP can send and receive image data via the DICOM standard and can store it in its archive Advanced functions like query and retrieve functions in
93. e corre sponding data is protected in such a way that only selected users who are legitimate can access it Authentication denotes the process in which it is verified that the actor party truly is the actor party she he it claims to be and not an imposter Terminal server In this thesis the term Terminal server denotes not only the server itself that provides certain services in a client server architecture In addition Terminal server denotes the technology in general which is used in a Terminal client server architecture 2 2 2 Integration Types Integration Integration is a union of parts making a whole which as opposed to its parts displays a new quality An integrated HIS is a union that represents more than just a set of independent components HAWB04 Data Integration Data integration is guaranteed in a hospital information system when data that have been recorded are available wherever they are needed without having to be reentered Thus each data item needs to be recorded changed deleted or otherwise edited just once even if it is used in several application components Data integration is a prerequisite for the multiple use of data HAWBO4 Access Integration Access integration is guaranteed when the application components needed for the completion of a certain task can be used where they are needed HAWBO04 Presentation Integration Presentation integration is guaranteed when different applica tion compon
94. e domain layer proposed by H bner Bloder et al HBABWO5 which are supported by the corresponding modules of ViewPoint Enterprise Function VP Module 1 Patientenbehand 1 1 Patientenaufnahme 1 1 1 amp 2 2 1 Vormerkung und lung Einbestellung von Patienten 1 1 2 amp 3 1 2 Identifikation und Patient Manage Pr fung auf Wiederkehrer ment Module 1 1 3 amp 3 1 1 Administrative Patient Manage Aufnahme ment Module 1 1 4 rztliche Aufnahme Patient Manage ment Module Case and Examination Management Submodule 1 1 5 Pflegerische Aufnahme 1 1 6 amp 3 1 3 Patientenauskunft und Informationsdienste 1 2 Entscheidungsfindung Behandlungsplanung und organisation 1 3 Leistungsanforderung 1 3 1 Erstellung eines Auftrages Examination f r eine Massnahme Module 1 3 2 Terminanforderung 1 4 Diagnostische ther 1 4 1 Diagnostische amp Examination apeutische oder pflegerische therapeutische Massnahmen Module Ma nahmendurchf hrung durchf hrung 1 4 2 Pflegerische Massnahmen durchf hrung 1 5 Leistungsdokumentation 1 5 1 Diagnosen Klassierung Examination Module 1 5 2 Massnahmen Klassierung Examination Module 1 6 Entlassung und Weiter 1 6 1 amp 3 1 4 Administrative Ent leitung an eine andere Einrich lassung und Leistungsabrechnung tung 1 6 2 rztliche Entlassung und Examination Arzbriefschreibung Module 1 6 3 Pflegerische Entlassung amp Erstellung des Pflegeabschluss berichtes continu
95. e moment VP offers various interfaces for the electronic exchange of orders patient demographics diagnoses procedures findings and image data like Health Level 7 HL7 BDT and DICOM Access Integration in short means that the related application component is available wherever it is needed 128 In case of VP it is common to only install the system in the diagnostic service unit which examines the patient and acquires the data for example internal medicine or general ultrasound Normally no client is available at the ward or other assigning departments which are probably also interested in the data For physicians or other health care professionals this circumstance implies that they have to find a workstation on which the VP client is installed or to print out the relevant data to access the needed information at their place However this fact contradicts with the original idea of a paperless and integrated HIS and leads to media cracks In order to guarantee Presentation Integration data and the User Interface UI of different application components should be represented in unified ways 128 At present this scenario is far from reality Even if application components are produced by the same manufacturer they mostly come with different UI and data representations as there exist quite different and partly controversial opinions on software ergonomics This fact also applies to VP Contextual Integration means that the context is preserved
96. eX controls in Firefox They were not RS 2 1 fulfilled fulfilled RS 2 2 fulfilled naturally only Microsoft Internet Ex plorer on Microsoft Windows is sup ported RS 2 3 fulfilled fulfilled no extensions required Requirements concerning quality of supported networks RS 3 1 fulfilled fulfilled continued on next page considered though as it would go beyond the scope of this thesis 102 6 Technology Comparison Requirement Web Client Terminal Client partly fulfilled fulfilled fulfilled fulfilled fulfilled RDP utilises port 3389 by default Requirements concerning data security fulfilled fulfilled fulfilled fulfilled fulfilled fulfilled fulfilled fulfilled not examined in detail not examined in detail partly fulfilled fulfilled Requirements concerning installation and maintenance fulfilled fulfilled fulfilled fulfilled Requirements concerning interaction with other application components fulfilled not fulfilled fulfilled not fulfilled fulfilled not fulfilled fulfilled not fulfilled Requirements concerning the UI fulfilled irrelevant fulfilled irrelevant fulfilled irrelevant fulfilled irrelevant fulfilled not fulfilled when using low bandwidth connection or RDWC fulfilled when using high bandwidth connection and
97. ed elements are labelled with bold letters The difference to the model of the current degree of integration as shown in figure is that VP now also offers a Web client which communicates with the VP server via HTTP Moreover the Web client provides a CCOW interface with which it is possible to synchro nise patient and user context with other application components via a CCOW context manager The component denoted as application component is a placeholder for any application component s which support s CCOW and run s on the same workstation as the Web client of VP It is vital to note that no other interface is affected by the Web client In figure for full page view please see figure in the appendix the physical tool layer of the model is shown The newly added elements are labelled with bold letters The difference to the model of the current degree of integration as shown in figure 3 13 is that now access to data stored in VP is provided via physical data processing components from every location Paper based distribution of the required data is no longer needed The domain layer of the model was created based on the reference model proposed by Hiibner Bloder et al HBABWOD5 It is not shown as it is irrelevant to the objectives of this thesis By offering the Web client no changes in the enterprise functions which are supported by VP will occur Only the way how data stored in VP is accessed will alter Thereby the domaine layer wi
98. ed on next page 122 A Appendix Enterprise Function VP Module 2 Versorgungsmanage ment Ressourcenpla nung und Arbeitsor ganisation 2 1 Ver amp Entsorgungsmanagement 2 2 Termin und Ressourcenplanung 2 3 Personalwesen 1 1 1 amp 2 2 1 Vormerkung und Einbestellung von Patienten 2 2 2 Termin und Ressourcenplanung mit dem medizinischen Dienstleister 2 2 3 Termin und Ressourcenpla nung mit dem Patiententransport dienst Patient Schedul ing Module 3 Krankenhausverwal tung 3 1 Patientenverwaltung 3 2 Archivierung von Patien teninformationen 3 3 Qualit tsmanagement 3 4 Betriebssteuerung Controlling 3 5 Kosten und Leistungsrechnung 3 6 Finanzbuchhaltung 3 7 Geb ude und Fl chenmanage ment 3 8 Informationsmanagement 3 1 1 amp 1 1 3 Administrative Aufnahme 3 1 2 amp 1 1 2 Identifikation und Pr fung auf Wiederkehrer 3 1 3 amp 1 1 6 Patientenauskunft und Informationsdienste 3 1 4 amp 1 6 1 Administrative Ent lassung und Leistungsabrechnung 3 2 1 Anlegen der Patiente nakte 3 2 2 Verwaltung und Bereit stellung der Patientenakten 3 3 1 Internes Qualit tsman agement 3 3 2 Erf llung gesetzlicher Meldepflichten Patient Manage ment Module Patient Manage ment Module Archive Module Examination Module Archive Module Examination Module Statistics Module Statistics Module Checking Submodule Rule 4 Kr
99. egration degree of ViewPoint within the hospital information system extension of an existing or the creation of a new data transfer interface is not within the scope of this thesis it will not be analysed in detail and no requirements will be derived from it 3 4 2 2 Access Integration As described above it is common that VP is only installed on the functional diagnostic unit At the ward at other departments or from remote sites like the assigned physician s practice or the consulted specialist s hospital where information stored in VP is consulted direct access to VP is at the moment not possible There are many reasons for this circumstance Most of them have been covered in section to already limit the number of potential workstations on which the Native client could and would be installed Further limitations are set by organisational constraints For example locations outside the functional diagnostic unit may belong to other organisational units which have a separate budget and a different set of priorities Thus instead of adding a the Native client of VP to their IT infrastructure they might prefer to invest in things from which they could gain more of a direct benefit It can be summarised that the Native client is inadequate to provide access to VP wherever it is needed and no other means for this purpose are offered by VP for example a Web client WP 9 So to provide the information needed at locations where access
100. egrity Control In which kind of environment is your system running e g local Intranet Intranet with remote users Internet customer dependant normally local intranet but there are also customers using it remotely Which web browsers do you support See supported web browsers Which adjustments modifications has the user to make to the default browser configuration like turning JavaScript on or installing plug ins like Java or Macromedia Flash SSL root CA certificate must be installed IE requires additional configuration of security zones Optional plugins may be installed Adobe Reader Macromedia Flash Are there any limitations concerning the platform on which the browser runs Only windows platforms are tested In case there is a firewall between server and client which ports have to be open e g is it sufficient to have only port 81 for http open Or in other words which protocols do you use HTTPS 443 8080 for interprocess communication Which is the minimum bandwidth required for client server communication up download 9600 Bauds To which version of XHTML HTML JavaScript etc is the web interface conform HTML 4 01 Javascript 1 2 Which kind of data is distributed via the web sever Text images videos etc Text Images Flash PDF What happens if the network is congested or the connection lost We use an rotating foetus an indicator for network availability If the foetus won t rotate the net
101. eld of Web browsers also holds a considerable amount of market shares In order to figure out if support of other Platforms is also required their values of significance were acquired with the help of the questionnaire Features of a Web based Interface to VP as described in section Furthermore the significance to also support Firefox the second most spread Web browser on the market in contrast of supporting Microsoft Internet Explorer was assessed Note www TheCounter com is a commercial Web site offering so called counters which can be installed on Web sites and are used to gain information about the numbers and characteristics of Web page visitors The statistics shown here are based on data assessed from all of their counters on the Internet 3 Note www W3Schools com is a Web site offering freely available tutorials about Web technologies Statistics shown here are based on data assessed from visitors of their Web site 74 5 Specification of Requirements The following significance as shown in table 5 3 has been assessed Table 5 3 Significance of supporting referring OS and Web browser Feature Significance Support Web browsers running on Linux Medium Support Web browsers running on Apple Macintosh Low Support Web browsers running on Sun Solaris Not needed Support Firefox Medium Support Microsoft Internet Explorer Medium Comment Firefox and Microsoft Internet Explorer have been valuated by the
102. ensive insight in their products and thoughts Furthermore I like to thank Ike Biedermann for the proofreading of my English Finally I like to thank Susann for her everlasting patience and support Holger Schmuhl May 2006 iv Contents ontents v List of Figures xi xiii 1 Tek Outline s 00 s a ee nn aoe BORE Ae ate ee eee Be a a a i 1 So eG ee de SR EGS POS ee Oe we ee 4 a 1 1 2 1 Subject ac a4 2 2 eee ee ea a ee eR ele HO 1 ee A a a ee 2 A Te oh ee Bee eo ek e at 4 1 3 Problems sa s soc aaaea a be 84 Ha de Re ee Eda ae a 5 goke ke OS ER A RA ea ee Be ee A 5 fe Page de ea Sew at a a 6 1 6 5takeholders ic x s 2a ee ee ee ba dow Gee e e le 7 9 21 Outline cios 24 oe bese bb eG eee ae Ee a a 9 bch Be a a ee age fat Be owe a bse TE dee we a 9 2 2 1 General Terms me 9 A e eee 10 E oe eG 10 BIT Relevant Application Components in Hospital Information Systems 11 2 3 Requirements Engineering 2 2 nn 12 Fa BAe he ey eae e amp Be 15 232 SION Meta Model codi dara 16 2 3 2 1 Introduction emi al Sara ce ewe a 16 vi Contents 2 3 2 2 Layers and Their Relationship 17 2 3 2 3 Reference Model for the Domain Layer of HIS 18 2 3 2 4 3LGM Modelling Tool 19 2 4 Methods of Information Procurement 2 2 22 2m nn 19 24 1 Interview ic e poies n boe A A A 19 2 4 2 Questionnaire s ooa 19 2 4 2 1 Questi
103. ent 43 ud Write to Archiwes ViewPoint Save archiving Write archiving Objects in PIA Objects to PACS F PACS x E j Er include include n awe Archiving Objects to Archive Destination RAK me f include Write archiving Objects to Create H Network Share include Examination Network Share 7 TR User Health Care include H include Professional Modify x Examination ie a Ze ai include include coms x y 3 Export Coded Diagnoses and Procedures Lock Examination Figure 3 7 Findings System Archiving Process UML use case model modified version of the model taken from Seh05 e Display a report Extended Functions e Receive and record Ultrasound US measurement data as described in 3 3 1 5 e Manage user defined entries e Modify masks with the help of a UI 3 2 8 3 Image Gallery Submodule The image gallery of VP is also patient oriented and can be accessed via the examination module It gives the user extended functions to handle image data Each examination has a separate set of image data accessible via the image gallery If image data should be captured from an analog device for example an endoscopy device with RGB or S VHS output special hardware called Framegrabber is required 44 3 Requirements Analysis ud Manage Images ViewPoint Acquire Image Data Find Examination Framegrabb
104. entor with ideas of how the Web client could be realised Details on why especially these products have been chosen can be found in section 6 2 1 Euroking E3 The information given here has been acquired with the help of the questionnaire Product Analysis see section 2 4 2 2 for details Further information was taken from the Web page of Euroking Miracle Ltd 6 2 1 1 General Description Euroking Miracle Ltd is a partner of GE Healthcare Apart from distributing VP they also sell their own product E3 in the UK and Ireland E3 is a Maternity Information System and belongs to the class of MDS and Patient Data Management System PDMS It offers a wide range of functions to optimally support the work flow at an obstetrical department 86 6 Technology Comparison A http 192 168 0 4 csp userfwab bodyframe csp Microsoft Internet Explorer provided by Euroking Miracle Ltd BAE NHS Number Surname Forenames Gest Search 876 345 1239 Acom Arabella 3145 12 10 1980 02370P Hospital Number nn JANUARY NINTENTH 39 4 D 10 10 1966 ai Tomato Bobette 23 3 15 05 1987 umber Forename s Sumame DoB ddimmiyyyy 18 05 2005 Address Postcode save Bist Delete Calendar Mi Studio ALF Z Euroking Mir B http 192 1 RE 12 08 Figure 6 1 Screenshot showing the patient selection screen of E3 E3 stores data in a patient oriented way It supports the management of care pathway
105. ents represent data as well as user interfaces in a unified way HAWBO4 Contextual Integration Contextual integration means that the context is preserved when the application component is changed HAWBO04 2 2 3 Relevant Communication Standards in Health Care Health Insurance Portability and Accountability Act HIPAA The Health Insurance Porta bility and Accountability Act is a national standardisation approach for electronic health care transactions and national identifiers for providers health plans and em ployers in the USA It also addresses the security and privacy of health data It is issued by the United States Department of Health and Human Services Offi cial Web sites http www hhs gov ocr hipaa and http www cms hhs gov HIPAAGenInfo BDT The term BDT short form of the German term Behandlungsdatentrager denotes a standard which is used at general practitioner s practices to exchange administra tive and medical information between different electronic practice management sys tems The standard is issued by the Zentralinstitut ftir die kassenarztliche Versorgung Bundesrepublik Deutschland Official Web site 2 2 Disambiguation 11 Clinical Context Object Workgroup CCOW The term Clinical Context Object Work group denotes a standard used to automatically synchronise the patient and user context between different application components It is issued by the Clinical Con text Object Workgro
106. epwise in each new version release Rationale The Web client should be an equivalent alternative to the Native client of VP Implementation of all features may not be possible or feasible at once due to lack of resources like money time and man power The Web client shall provide access to VP from all locations where access to VP is required Rationale Elimination of and WP 7 VP is the preferred solution to access VP Report and the related image data at once The fulfilment of this requirement is also a suitable workaround for as the data can be directly accessed through VP and does not have to be exported to other application components to be available 64 4 Definition of Requirements II Requirements concerning supported Platforms Web browsers and re quired Web browser extenions III RD 2 1 RD 2 2 RD 2 3 The Web client shall support as few Platforms and OS versions like different Service Packs as are needed to fulfil Rationale Elimination of WP 24 and WP 25 By keeping the number of supported Platforms and OS versions as low as possible while still supporting all required Platforms and OS versions the testing and optimisation efforts can be kept to a minimum This will also increase the number of applicable Web browser extensions The Web client shall support as few Web browsers as are needed to fulfil Rationale Elimination of and By keeping the number of supported Web browsers as low as possible w
107. er T A Measure in Image HD Data Retrieve Image x Data T S e N r include F H al Delete Image Data i vinclude __ fe includes Data Acquisition Modality Professional 5 N h on A Le Al x Find Image User Health Care 7 a at i pl ea z r gt einelude LE gt s Tf Post process e i include Meza EEE x Rost Processing Host LOGIQworks Scan Image Data eextends i e include e i 2 i A View Image Data i N Import Image Data i Windows Clipboard ji Export Image Data File System Scanner Figure 3 8 Image Gallery Submodule UML use cases of image data handling modified version of the model taken from Seh05 Use cases of the image gallery submodule are shown in figure Offered functions are e View image data e Retrieve image data via DICOM interface see section 3 3 1 2 for details e Digitise image data with the help of a Framegrabber Still pictures and video se quences can be acquired from analog image sources see section 3 3 1 4 for details e Import image data via file import supported formats are JPEG PNG TIF and BMP AVI for video sequences e Import image data via Microsoft Windows clipboard e Import image data via TWAIN compatible scanner devices e Export image data via file export supported formats are JPEG PNG TIF and BMP AVI for video sequences and DICOM e Perform measurements on images for example dista
108. erent types of forms like for example a referral or discharge letter an internal report etc and also include images or graphs Moreover the examination data can be communicated electronically for billing purposes The report text is automatically created from the content of the masks However the health care professional has the possibility to modify this text Beside that VP offers functions for patient scheduling execution of basic statistical queries and image post processing The application of VP ends when the report about the examination is sent to the requesting physician or unit and further treatment of the patient is based on these results From a technical point of view the system is based on the client server architecture The server stores the central database and image archive Furthermore it offers functions for electronic data exchange and backup The clients differ in their functionality depending on the license purchased Minimal functionality offer so called viewing stations with which findings and image data can only be viewed without modifying capabilities Maximal functionality offer so called image acquisition stations with which the capturing analog modalities reception from DICOM modalities editing and archiving of image data is feasible in addition to the possibility to enter and modify findings Apart from medical practices the system is mainly utilised in hospitals There it is part of the Hospital Informa
109. eries Mode Load amp Fina Export E Hide Side Panel s Online Help About RemotEye General Into Image Displaying amp Processing gt Currently loaded 8 Frame Control Series Num 101 MR ABDOSCAN ements Current frame 5 7 ra Current zoom 141 4 Display Preferences Measurements Esad X Create annotation Bix x2 X Show on screen meas BB 2x2 88 3x3 Hii xa auto View ail _ Custom _ Display text overlays Display meas annotations m Measure j 2 Calibrate Area E Rectangle GP Ellipse Frame Control ab aa aa Current Image Info Angle Secret LES Sx Mode 1 gt Mode2 y Series Meta nto amp Patient Density EF DICOM Data Elements 7 EI Group Length A Density J D 27 9 CI File Meta Information Version string of bytes 9 Media Stor Class U Implementation Class 1 1 3 12 2 1107 5 9 20000 EI Implementation Version Nam 0 stemens_LEOVB304 El Applet RemotEye by NeoLogica started D i M intranet locale Figure 5 1 Sample screenshot of Java Applet RemoteEye of NeoLogica s r l taken from Neo06 Only Java Applets offering DICOM view capabilities have been listed because other Web browser extensions found did not fulfil RS 2 1land RS 2 2 A useful overview of Web based DICOM viewers and other DICOM tools can be fo
110. esentation Integration The Uls of software products being employed in the clinical environment differ greatly Even products of the same manufacturer have quite often a different UI As no attempts to standardise the Uls of software products in the clinical environment exist it is impossible to create a common Ul layout and operation Within the VP family presentation integration is guaranteed as every reporting module has the same UI So a user who is familiar with one reporting module can handle operate another reporting module intuitively WP 12 User expects the same appearance of all products within the VP prod uct family At obstetrical departments VP is often sold in combination with Trium CTG Online as an all in one solution Trium Analysis Online GmbH is a cooperate partner of VP GE As Trium CTG Online is Web based and was not originally designed to be sold as an enhancement to VP its Ul is quite different to the one of VP WP 13 No presentation integration between VP and Trium CTG Online 3 4 Weak Point Identification 59 3 4 2 4 Contextual Integration VP offers no means to synchronise e user information like login and password and e patient identification information like name or hospital ID with other application components running on one workstation Although a standard CCOW and various methods like integrated Microsoft Windows login exist VP supports non of them and thus does not guarantee contextual
111. esign and reimplement your product from scratch what would you change Using an enterprise grade database Replacing application server with latest version Received via eMail 02 01 2006 Holger Schmuhl 138 A Appendix B Declaration Hereby I affirm that I created this thesis on my own and that I used only the listed resources Ich versichere dass ich die vorliegende Arbeit selbstandig und nur unter Verwendung der angegebenen Quellen und Hilfsmittel angefertigt habe Place and date Ort und Datum Signature Unterschrift
112. f Boehm taken from 2 2 Requirements engineering process according to Som95 2 3 Client server architecture taken from 2 4 Web browser plug In and helper application taken from Tan03 version of a figure taken from Mat04 N 6 Overview of the components of the CCOW CMA taken from Sel01 29 3 1 Patient Management Module UML use case model of the management of patient records modified version of the model taken from Seh05l 34 3 2 Patient Scheduling Module UML use case model of the management of appointments modified version of the model taken from Seh05 36 3 3 Simplified UML data model of ViewPoint 24 38 3 4 Findings System Prenatal Reporting screenshot of the biometry submask 40 3 5 Findings System ViewPoint Report screenshot of the report modification Peer A Poe ac Pee ee 41 3 6 Findings System ViewPoint Report UML use case model of the report handling modified version of the model taken from Seh05 version of the model taken from Seh05 3 9 Printing and Faxing Submodule First side of an obstetrical ultrasound Pece ae Nae See a oe eo dae dh ee ed er ee ee 47 3 10 Printing and Faxing Submodule Second side of an obstetrical ultrasound Maik ee Oe eee ee e Vee ea a ae Ba me 48 3 11 Logical and physical tool layer of the 3LGM model showing the two alter natives of the DICOM storage concept of ViewPoint
113. f the computation needed for creating the Ul and realising the business logic is performed on the server side The only data transfered during startup and runtime is control data For forwarding the input and output actions only a minimum of hardware equipment is needed On the one hand a Terminal client could only be software Here the Terminal client is a standard programme executed on a workstation which has its own OS and other application components running On the other hand a Terminal client could be hardware and software with the only purpose to act as Terminal client In contrast the Terminal server has high hardware requirements as it has to support multiple users at once Each of the connected user may execute different programmes at once So a fast Central Processing Unit CPU and much of RAM is required During the old times of mainframe computers the Ul provided to the Terminal client was just a console text based non graphical UT Nowadays Terminal servers offer a fully functional graphical UI to their clients Representatives of these systems are the Microsoft Windows Server 2003 Terminal Services or the X Windows System system of Linux These Terminal server solutions do not only support the forwarding of standard input output devices like screen mouse and keyboard but also enable the forwarding of advanced interfaces like serial ports or sound output 28 2 Basic Principles 2 8 Clinical Context Management Most o
114. f the information which will be given in this section are taken from Sel01 and For more information on CCOW please refer to HL7 Australia CCOW Resources Page at http www h17 org au CCOW htm CCOW can be described as a standard aimed at offering proper means for contextual integration at the point of use It is issued by the Clinical Context Object Workgroup of the HL7 Committee which is already well known for the HL7 standard for clinical communication With the utilisation of CCOW the user has the experience of interacting with a single system when in fact he or she may be using multiple independent application components each via its native Ul By synchronising and coordinating application components so that they automatically fol low the user s context for example displaying data of same patient in every application component running on the workstation CCOW serves as the basis for ensuring secure and consistent access to patient information from heterogeneous sources Generally speaking CCOW offers means to synchronise user and patient data from different application com ponents By synchronising user data CCOW also offers means for Single Sign On SSO solutions Benefits of CCOW are that e it is easier to use e it offers increased utilisation of electronical information e it facilitates an increase in patient safety e and offers means for secure context management like it has been addressed by Health Insurance Portabi
115. fied version of the model taken from Seh05 3 2 Current Functionality of the Native ViewPoint Client 35 Offered functions for the management of patient records are e Create a new patient record e Find and view a patient record e Find and modify a patient record e Find and delete a patient record e Find and merge a patient record e Find and comment on a patient record e VP can import patient demographics from other application components like PMS if the corresponding interface is set up see section 3 3 1 1 for details to find or create a patient record Variants are User initiated import by pressing import button Automatic retrieval like reception of a clinical order orders are sent to VP and user can choose from a list which order to process e In case a DICOM interface see section 3 3 1 2 for details is used VP can receive studies and find or create a patient record from the included patient demographics e In case a chip card reader interface see section 3 3 1 7 for details is used VP can read patient demographics from an health insurance card and find or create a patient record from it Offered functions for the management of the list of the assigning physicians are e Create assigning physician entry e Modify assigning physician entry e Merge assigning physician entry e Deletion of assigning physician entry e Create or modify assigning physician entry from patient demographic
116. fore starting with the actual description of each module the basic requirements of a VP client will be mentioned as already addressed in the introduction On the software side the VP client and server are designed to run only on Microsoft Windows versions 2000 XP and 2003 Server Not all Service Packs of the related Microsoft Windows versions are supported In order to display videos VP needs at least Microsoft DirectX 8 1 The only supported Database Management System DBMS is Sybase SQL 32 3 Requirements Analysis version 9 0 On the hardware side the workstation on which VP should be installed needs to fulfil a set of minimum hardware requirements For example when the client is intended to record video sequences at least a computer with a 2 5 Ghz CPU 512 MB RAM 40 GB Hard Disk Drive HDD 100 MBit s TCP IP network connection free serial ports and a full length Bus Master PCI Slot is required It should be noted that in general a 100 MBit s TCP IP network connection should be preferred However clients can already operate on a 2 MBit s line resulting in a loss of performance These relatively high bandwidth requirements are due to the fact that VP was originally designed for application in LANs only For detail information on the requirements of VP version 5 please refer to the system requirements sheet A 3 2 2 Installation Procedure In general if VP should be installed on a workstation the following steps have to be
117. gular LMP unsure Obstetric History Living children gt 37W 1 1998 E Export Last period 22 August 2001 EDD by ultrasound 26 May 2002 EDD by LMP 29 May 2002 Gestational age 20 weeks 3 days Gestational age by dates 20 W 0 D Anomaly Scan transabdominal US with GE Logiq 700 Ultrasound view good Fetal Measurements plotted in relation to the normal mean and 5th to 95th centile Biparietal diameter BPD 490 mm Occipitofrontal diameter OFD 640 mm Head circumference HC 1775 mm Transcerebellar diameter TCD 210 mm Nuchal fold thickness 10 mm _ Abdominal circumference AC 152 4 mm 1 Thorax circumference TC 150 8 mm Cardiac circumference CC 456 mm Femur Length FL 30 0 mm dl Heart action present Fetal movements visible Presentation cephalic II Amniotic fluid normal Cord 3 vessels Placenta Fundal Posterior Grannum Grade 0 structure normal Fetal anatomy The following were visualised and appear normal head brain face spine neck and skin chest four chamber view and great vessels abdominal wall gastro intestinal tract kidneys and bladder extremities skeleton Echocardiography Operator Dr Jenkins Indication for Fetal Echo Increased nuchal translucency Image quality Good Situs Normal Position of stomach Left sided Heart size Normal I Press F12 to save and archive Press Esc to cancel User admin CAP NUM OvA Figure 3 5 Finding
118. he different types of integration within the HIS e Data integration is supported to a high degree by VP The only weak point is that a linkage between VP Reports and the corresponding image data is not supported once they have been exported to other application components WP 10 See section 3 4 2 2 for details e Access integration is not guaranteed by VP This is due to the special characteristics of the Native client which cannot be installed wherever access to VP is needed WP 7 3 Achievement of Objectives 10 1 to WP 6 Furthermore VP does not offer any other means to provide location independent access like a Web based UI WP 9 See section 3 4 2 2 for details e Presentation integration between VP and other application components is not possi ble This is because no common guidelines or standards which define the layout and handling of the Ul in a unique way exist Presentation integration within the different reporting modules of VP is guaranteed WPD Presentation integration is not guaranteed between VP and Trium CTG Online which are sold together to obstetrical departments as an all in on solution WP 13 See section 3 4 2 3 for details e Contextual integration is not supported by VP as it offers no means to synchronise patient or user context with other application components WP 14 See section 3 4 2 4 for details 7 3 2 Objective 2 Establish a recommendation for what technology should be use
119. he Web client shall offer sufficient means for authentication The Web client shall offer sufficient means for non repudiation and account ability The Web client shall offer sufficient means for integrity control The technologies chosen to address RS 4 1 RS 4 2 RS 4 3 and RS 4 4 shall fulfil all legal regulations The Web client shall offer means to protect against data loss concerning installation and maintenance The Web client shall require no or at least a minimum of installation and configuration efforts The Web client shall require no or at least a minimum of maintenance efforts a Q E 5 O B O u concerning interaction with other application components RS 6 The Web client shall offer means to switch from itself to another application component without having to reenter login information fzo fzo fzo un un un D n or N N The Web client shall offer means to switch from another application compo nent to itself without having to reenter login information Ps un gt w The Web client shall offer means to switch from itself to another application component without having to reenter patient identification information to preserve the patient context E un The Web client shall offer means to switch from another application compo nent to itself withou
120. hile still supporting all required Web browsers the testing and optimisation efforts can be kept to a minimum This will also increase the number of applicable Web browser extensions The Web client shall utilise as few Plug ins or Helper Applica tions as are needed to fulfil RD 1 2 Rationale Elimination of WP 19 WP 22 and WP 21 By keeping the number of utilised Plug ins or Helper Applications to a minimum the corresponding installation efforts are reduced Requirements concerning quality of supported networks RD 3 1 RD 3 2 RD 3 3 RD 3 4 The Web client shall support low bandwidth connections to fulfil Rationale Elimination of Clients which are connected to the server of VP via a low bandwidth for example at remote places should be supported The Web client shall also support unstable networks to fulfil RD 1 3 Rationale Elimination of Clients which are connected to the server of VP via an unstable network like WLAN devices should be sup ported The Web client shall perform and respond in such a manner that the user is not hindered in doing her his actual work Rationale Elimination of WP 17 The operation of a Web client is gener ally slower than the operation of a Native client Still with optimisation a sufficient performance could be achieved while fulfilling RD 3 1Jand RD The Web client shall utilise only HTTP port 80 or Hypertext Transfer Protocol Secure HTTPS port 443 Rationale Elimina
121. his requirement RD 8 2 has been dis proved in section The Web browser itself offers features to connect to printers which can also be utilised by the Web client 84 5 Specification of Requirements 6 Technology Comparison 6 1 Outline In the preceding chapter the requirements of a Web client have been specified in detail The aim of this chapter is to analyse and compare certain products which offer a Web based Ul Furthermore the Terminal client server architecture should be considered as an alternative technology to the Web client In sections to the products will be described and analysed In section the products will be compared to each other based on the requirements specification set up in section Section will try to evaluate the requirements specification based on the information gathered by the product analysis and comparison Section will describe which means are offered by the Terminal client server architecture to fulfil the requirements specification Section 6 3 2 will examine to which extent the Terminal server solution fulfils the requirement specification in comparison to the Web client The succeeding chapter will draw the conclusion of this thesis 6 2 Product Analysis and Comparison As described in section 2 5 product analysis was carried out to determine how other man ufacturers realised the requirement specification defined in section The product analysis and comparison is meant to provide the implem
122. hts and a digital signature for secure data transmission In general it could be used for authorization and authentication of the application user Sounds like there won t be a common standard in the UK and the card and its content and technique will be hospital specific also inside the NHS their strategy is that the authorization and authentication responsibility is at Windows they will just retrieve the user identification from Windows and thereby determine if the user is authorized to access E3 perhaps via ActiveX Is 1t possible to work offline and to reconnect No until now the old version had a special software client not web based with which offline data entry is possible for midwifes It synchronizes data as soon as the client has a network connection If you would redesign and reimplement your product from scratch what would you change Different DB they are satisfied with the current one and only would do it because of popularity reasons NET increase performance better integration concentrate more on supporting access from anywhere in the world Interviewed via Telephone 16 12 2005 Holger Schmuhl Short Overview Product Analysis Author Vendor GE Vingmed Healthcare Product Name WebEx EchoPAC Product Category PACS Goals High secured web architected PACS workstation designed to handle all types of modalities Field of Application Cardiology and other functional diagnostic unit
123. hysical or virtual entities of the hospital These types of information are represented as entity types The access of a function to an entity type can be using or updating information The graphical representations of the described elements can be found in 2 1 Logical Tool Layer At the logical tool layer application components are the centre of interest application components support enterprise functions Computer based ap plication components are controlled by application programmes which are adapted software products off the shelf products paper based application components are controlled by conventional working plans that describe how people use paper based data processing components application components are responsible for the storage and for the communication of data about entities of a certain type Computer based application components may have a local enterprise function to store data and paper based application components may file their documents in a document collection Communication interfaces ensure the communication among application components component interfaces but also between an application component and a user UI For communication among application components communication links can be defined The graphical representations of the described elements can be found in 2 2 Physical Tool Layer The physical tool layer is a set of physical data processing compo nents They can be human actors such
124. ideos MPEG 4 MPEG 1 Flash Portable Document Format PDF HTML HTML as supported by Mi XHTML 1 0 in some cases HTML 4 01 version crosoft Internet Explorer XHTML 1 1 Used ports HTTP or HTTPS HTTP or HTTPS HTTPS and port 8080 continued on next page 96 6 Technology Comparison E3 WebEx Trium CTG Online Required 100 Mbit s are recom No minimum bandwidth de 9600 Bit s 100 Mbit s rec network mended There are hospitals pends on how fast image ommended bandwidth operating with 10 Mbit s data is to be loaded Support of Not supported Offer peri unstable odical auto saving functions networks to prevent data loss Authoriza Login with username Login with username Login with username tion Authenti Password Password Password cation Account Logging of user activities Logging of user activities ability Integrity SSL SSL SSL Control Support of CCOW 6 2 6 Justification of Requirements In this section the validity and practicability of the requirements specified in section will be judged by means of the information gathered during the preceding product analysis and comparison A Web client has been a requirement in many tenderings Thus it is out of question to offer a Web client for VP as specified by RS 1 1 The major motivation of providing a Web client is to offer access to VP from all places where access is needed as appointed by
125. ing only additions relevant for context integration of Web based application components will be listed e Since version 1 2 CCOW also supports Web based application components Web based application components and mapping agents can for example send and re ceive URL encoded HyperText Transfer Protocol HTTP messages to the con text manager This version also comes with the capability to deploy over private and public networks for example the utilisation of the Secure Socket Layer SSL for communication over public networks e In version 1 5 CCOW is proposed to support Simple Object Access Protocol SOAP In general SOAP can be used for exchanging Extensible Markup Language XML based messages over a computer network usually by using HTTP According to the author s knowledge CCOW version 1 5 still has draft status and CCOW version 1 4 is the last official version As stated above CCOW is still an emerging standard In spite of extensive literature research no useful reports have been found which aimed at analysing or evaluating the practicability of CCOW 3 Requirements Analysis 3 1 Outline In the preceding chapter the basic principles have been described The aim of this chapter is to provide a detailed understanding and knowledge of the problem domain First of all the current functions of VP will be described in section 3 2 Then the current integration state of VP within the HIS will be analysed in section The
126. ing and Communications in Medicine 77108 81 6187 90 5 104 100 a en 2 Be EchoPAC ASCH Enterprise Architect ADP NET Enterprise function AVI Entity types BDT a cal Ltd BMP EViewBox Extensible Application Markup Language Cardiotocography CCOW Extensible HyperText Markup Language CDMS 9 Central Processing Unit Extensible Markup Language CHILI Web Viewer 107 Citrix Extensible User Interface Language Clinical Context Object Workgroup 9 u 87 By 67 77 79 Fetal Medicine Foundation London 37 189 91 03H95 97 99 107 Firefox 4 24 59 73 75 78 91 93 99 06 Clinical Documentation and Management Sys Firewall tem P 59 FT 29 50 72 75 87 0 PMF 87 Clinicom Framegrabber clinicom G Web server Cloverleaf ES R Broker Archi GE Healthcare 83 87 90 ommon Ject Request Broker Architec GE Vingmed Ultrasoun a 21 ture 108 Cookies GIF CORBA CPU Hard Disk Drive CTG HCM Index 117 HDD LAN Health Insurance Portability and Account Linux 88 ability Act Local Area Network 23 32 55 59 85 Health Level 7 Logical Tool Layer LOGIQworks FX Health Level Seven Health Professional Card Macromedia ColdFusion on Flash Helper Application 25 60 64 74 75 MDS 1 HIPAA Medical Documentation System HIS HLT Hospital Information System 9 HPC 79 HTML HTTP HTTPS Hypertext Markup Language HyperTe
127. ion 20 2 Basic Principles 2 4 2 1 Questionnaire Features of a Web based Interface to VP The aim of this questionnaire was to find out which functions should be offered by the Web client After a consultation with B Hornung it was decided not to contact customers directly This would have been connected with too much effort whereas most of the required information are already at hand of VP GE The following employees of VP GE have been chosen for answering the questionnaire as they all coincided with the demands for a Web client e Wilson Gottschield WG He is head of the American sales team and therefore extremely close to the customers and their demands He was chosen to represent the demands of the American customers e Michael Nilles MN He is representative of the German sales team He was chosen to represent the demands of the German customers e Franz St lzle FS He is the product manager of VP Among other things his business is to collect and quantify feature requests for future versions and to develop the marketing strategy He was chosen as he has a holistic view of VP itself and its further development e Bernhard Hornung BH He is head of the development department He was chosen as he has sound knowledge of the implementation efforts of most features and of how realistic it is to offer them through a Web client e Konrad Pscheidl KP He is head of the customer service He was chosen as he has disti
128. ionnaire see section 2 4 2 2 for details Further information was taken from the Web page of the Trium Analysis Online GmbH E TRIE F Figure 6 5 Screenshot showing the overview screen of Trium CTG Online 92 6 Technology Comparison 6 2 3 1 General Description Trium Analysis Online GmbH is a partner of GE Healthcare They are specialised in providing online Web based solutions for Telemedicine and Clinical Trials Trium CTG Online is sold internationally and also marketed by VP GE as an extension to VP Trium CTG Online is a PDMS It is used for centrally monitoring Cardiotocography CTG s at obstetrical departments All active CTG monitors send their measurement to the Trium CTG Online server where the data is received and recorded Visualisation is performed by the Web client It offers some special features like visual or acoustic alarms for abnormal CTGs Furthermore the Web client can also be utilised via mobile devices although the common area of application of Trium CTG Online is on workstations connected to the Intranet of a hospital The visualisation of CTGs is delivery room oriented The recorded data can be accessed in an patient oriented way Trium CTG Online interfaces with PMS CDMS and similar application components through the HL7 standard It has a special interface to VP from which patient demographics and certain details about the current pregnancy are imported http wsnt175
129. lient Web based client Low bandwidth utilisation Control hardware Cross platform z Distributed Interactive Rich interface components 2 7 Terminal Server The so called Terminal server technology is a third type of client server architecture which is articulately different to the two architectures described before In order to recall their main characteristics In case of a Native client all of the compu tation needed for creating the Ul and realizing the business logic behind it is performed on the client side During startup mostly control data is transfered between the client and server during runtime mostly user data is exchanged In case of the Web client most of the computation needed for creating the Ul and realizing the business logic is done on the server side During startup and runtime control and user data are exchanged Still certain computation is performed at the client side to display the Web page through the Web browser possibly by the utilisation of certain Web browser extensions A Terminal client works quite different to these approaches In a Terminal client server architecture multiple users are given the possibility to remotely work by using Terminal clients on a certain computer the Terminal server Each of the connected users is provided with her his own UI which is giving them the experience of sitting in front of the server and interacting directly with it This is due to
130. lient and the related features and inter faces have already been excluded from the required functions of the Web client in section and will not be discussed further Features requiring extensions The core function of the image gallery submodule see section for details is to view image data As the functions of the image gallery submodule should also be offered via the Web client it should if possible also be realised without using Web browser extensions In this context the first approach which might come up into mind could be to convert the image data from DICOM the storage format of VP for details see section 3 3 1 2 to standard Internet media formats like JPEG JPEG pictures and other Internet media formats can be displayed by all Web browsers without requiring any extensions However by converting DICOM image data to common Internet media formats additional information stored in DICOM files for example patient demographics scale overlay etc would not be transfered and therefore be omitted Furthermore in Internet media formats a higher compression as common to DICOM files is aspired This would lower the quality of the image data and thereby contradict with RS 7 5 Thus the preferred method should be to display DICOM image data directly through the Web client As DICOM is no common Internet media format and is thus not supported by Web browsers in general the usage of Web browser extensions is required A sample of extensions
131. lity and Accountability Act HIPAA requirements CCOW s Context Management Architecture CMA is composed of the following compo nents e application components for example VP or SAP IS H med e Context manager which coordinates and synchronises application components It is founded on the principle that common context can be established across applications by identifying things for example a patient or concepts for example a clinical encounter Plin a manner that different applications can nevertheless recognise them e Mapping agents which represent various synonymous real world identifier used to identify clinical patients users or other subjects As application components may 1SSO denotes a technique with which the user has to log on just once to be authorised for using different application components running on the workstation In the context of data modelling a thing for example a patient would be an entity type 3In the context of data modelling a concept for example a clinical encounter would be an attribute type of an entity type In the context of CCOW objects on whose basis the context is synchronised from different application components are denoted as subject A variety of subject types are available for example user identity patient identity encounter identity observation request identity DICOM study identity etc 2 8 Clinical Context Management 29 use different identifiers for example the hospit
132. ll not change Please refer to table A I on page 121 for an overview of which enterprise functions are supported by vpi Until now only a German version of this model exists 68 4 Definition of Requirements Figure 4 2 Physical tool layer of the 3LGM model showing the future degree of integra tion of ViewPoint within the hospital information system 5 Specification of Requirements 5 1 Outline In the preceding chapter the requirements for a Web client have been defined in general The aim of this chapter is to define these requirements in more detail wherever possible In section 5 2 issues which are yet unknown and need to be researched to be able to specify certain requirements in more detail will be discussed The actual requirement specification will be set up in section 5 3 The succeeding chapter will analyse and compare different products and an Terminal server as alternative technology to the Web based UI on basis of the requirement specification 5 2 Research of Open Issues 5 2 1 Quantification of the Features Offered by the Native Client In RD 1 2 1t was postulated that the Web client of VP should offer all functions of the Native client If this is not possible or feasible at once it should be implement in an incremental approach or offer only functions which are demanded by the customers The task resulting from this requirement is to prioritise the features specified by the requirements specifi
133. m Sen00 1 User selects the patient of interest from any application on the clinical desktop 2 Application tells the context manager to start a context change transaction and sets the context data to indicate the newly selected patient 30 2 Basic Principles Context manager tells patient mapping agent that context change is occurring map ping agent supplies the context manager with other identifiers by which the patient is known Context manager tells demographics annotation agent that context change is oc curring annotation agent supplies context manager with authentic demographics data Context manager tells the other applications that a new patient context has been proposed The context manager surveys the applications to determine whether each can apply the new context Each application indicates whether or not it can apply the new context If one or more of the applications cannot or prefers not to apply the new context the user is asked to decided whether to continue or cancel Context manager tells each application to apply new context or that the transaction has been cancelled Each application applies the new context if instructed to do so by the context man ager Each application gets the new patient context from the context manager CCOW is still a young standard and has been severally revised since its original release With each revision new functions have been added Follow
134. meric value text etc and can contain predefined values for example predefined values of the examination status of the heart normal conspicuous cannot be examined not examined as lists from which the user can choose one or more values when completing masks Depending on the entered input values other fields can be automatically hidden or be displayed during runtime for example if the examination status of the heart is not examined the link to the submask to enter details on the heart will be hidden to achieve more clarity In order to support the user in estimating the meaning of numerical values the findings module also offers functions to display graphs of the statistical distribution of most values The graph data originates from scientific publications A sample screenshot of a submask is shown in figure 3 4 The layout of masks submasks fields graphs and their behaviour and coherence is defined in configuration files which are interpreted during runtime ViewPoint Report A report is automatically generated from the content of the masks containing major information about the related examination Its generation is also defined in the configuration files It can be manually modified to the user s needs Following it will be designated as ViewPoint Report VP Report VP Report is utilised by the Printing and Faxing Submodule see section for details or when exporting medical data to other appli
135. mplement these features Furthermore the selected Web browser extensions according to RS 2 1 and RS 2 2 have to support Microsoft Internet Explorer on Microsoft Windows and Firefox on Microsoft Windows and Linux In this section only features of the Web client which require the use of Web browser extensions will be identified and possible Plug ins or Helper Applications will be given as 5 2 Research of Open Issues 75 example No specific Web browser extensions will be selected as this would go beyond the scope of this thesis and should be left to the implementor Features requiring no extensions The functions of the patient management module see section for details the patient scheduling module 3 2 5 the statistics module 3 2 6 the case and examination management submodule the findings system 3 2 8 2 and the rule checking submodule can be realised in Firefox or Microsoft Internet Explorer without requiring any Web browser extensions This is due to their utilisation of basic UI components like buttons fields and lists which can be realised by standard Web pages and Web browser functions The DICOM interface the faxing functionality and interfaces to PMS CDMS and similar application components do also not require any Web browser extensions This is because they are implemented on the server side and the server itself is the communication partner to the outside world The control and access of hardware by the Web c
136. n it is an open and freely available standard One disadvantage of CCOW is that it is quite young and not as popular and well known as HL7 for example In the questionnaire Features of Web based Interface to VP the respondents valuated the significance of the Web client to support CCOW as low It was noticeable that the European respondents have not been even aware of CCOW which ac tually implies that no customer demanded for it in Europe This impression was confirmed while completing the product analysis in section 6 2 in which none of the respondents have been familiar with CCOW Moreover during literature research no sufficient field reports about CCOW have been found Due to the lack of popularity of CCOW one should also consider alternatives while imple menting the Web client One conceivable alternative to preserve the context when switching from another appli cation to the Web client of VP would be to offer functions for opening a certain patient record via a specific URL The URL for example http viewpoint myhospital de open patid 12345 will open the patient record identified by the patient ID 12345 in the 78 5 Specification of Requirements Web based Ul of VP This feature is especially useful in case of a Web based distributed Electronic Patient Record EPR where non redundant data of a certain patient is stored in different application components The application components form a virtual single EPR by me
137. n parameters and the creation of reports HAWBOA 2 3 Requirements Engineering As already stated in the introduction the aim of this thesis is not to develop a running system but to create a concept or more precisely a recommendation of what technology should be used From a project perspective this thesis has some special characteristics compared to a stan dard software development project in which a software is created from scratch Following these will be listed e Subject is to develop a concept technical recommendation to enable Web based access to an already existing product leaving the actual functions of the product untouched e An requirements specification already exists defining the actual functions of the product It does not contain any requirements to address the demand for offering a Web client This implies that this project does not follow the course of a certain software develop ment process which starts from scratch and ends with the final product being released However according to the four fundamental process activities which are common to all soft ware processes software specification development validation and evolution described in Som95 it passes through the first phase in which the functions of the software and constrains on its operation are defined Nevertheless it was initially intended to use parts of an existing well defined and described software process model to have a sound gui
138. nagement in Hospitals Springer 2004 Health Informatics ISBN 0387403566 HUBNER BLODER G AMMENWERTH E BRIGL B WINTER A Spec ification of a Reference Model for the Domain Layer of a Hospital Informa tion System In Studies in Health Technology and Informatics 116 2005 S 497 502 114 Bibliography Hol91 KK03 LGH 03 Mat04 MEAMO3 Ne006 Psc02 Rie05a Rie05b RJB99 Rus06 Sch06 Seh05 SelO1 Sen00 HOLZMANN G J Design and Validation of Computer Protocols Prentice Hall 1991 ISBN 0135399254 KROLL P KRUCHTEN P The Rational Unified Process Made Easy A Practitioner s Guide to the RUP Addison Wesley 2003 ISBN 0321166094 LEINER F Gaus W HAux R KNAUP GREGORI P PFEIFFER K P Medizinische Dokumentation Schattauer 2003 ISBN 3794522656 MATHERS T W Windows Server 2003 2000 Terminal Server Solutions 4 Addison Wesley Professional 2004 ISBN 1578702763 MUNCH H ENGELMANN U A SCHROETER MEINZER H P Web based distribution of radiological images from PACS to EPR In International Congress Series 1256 2003 S 873 879 NEOLOGICA S R L RemotEye_big_1 jpg Version 2006 eng neologica it prodotti remoteye images RemotEye_big_1 jpg Last checked 7 April 2006 PSCHEIDL K VIEWPOINT BILDVERARBEITUNG GMBH GE HEALTH CARE Hrsg PIA 3 31 Specification 0 3 Wessling ViewPoin
139. nces on a US image 3 2 Current Functionality of the Native ViewPoint Client 45 e Post process image data with Internal functions like zooming taking snapshots commenting and assigning search terms for classification External functions offered by the LOGIQworks FX and Voluson 4D ViewPlug ins for processing raw data of the supported ultrasound devices Comment With the help of these Plug ins image editing functions from the related US scanner are made available at the workstation To a greater or lesser extent they are separate software packages which are too complex to be described here and would exceed the scope of this thesis 3 2 8 4 Printing and Faxing Submodule The Printing and Faxing Submodule offers functions to print out or to fax a variety of print forms The print forms range from informal and comprehensive mostly for internal use for example internal report for the ward to official and dedicated mostly for external use for example letter to assigning doctor The core of nearly every print form is the VP Report generated by the findings system see section 3 2 8 2 for details Beside informal and formal reports also special print forms are available for example labels or a partogram As example an Obstetrical Ultrasound Report is shown in figure page and page 48 Printers can be connected locally or via the network Fax functions are provided by the Microsoft Windows Fax Server to which VP con
140. nctive experience of the usage of VP in a hospital in everyday life A questionnaire with standardised answers was chosen as it was seen as crucial to assess the opinion of multiple respondents in an equivalent way and to create out of it an overview with an universally valid conclusion from it The respondents could valuate each listed feature with integers between 0 and 3 e 3 denotes highest significance meaning that in case of an incremental stepwise ap proach with 3 version releases it should be implemented in the first version of the Web client e 2 denotes medium significance meaning that it should be implemented in the second version e 1 denotes minor significance meaning that is should be implemented in the final version offering all functions which the Web client is intended to have e 0 denotes that this features is not needed and should thus not be implemented by the Web client By calculating the integral rounded arithmetic means of the values given by the different respondents to one feature the over all importance of the related feature was assessed One part of the questionnaire lists features offered by the Native client These features are a summary of all features specified by the requirements specification Seh05 and described 2 4 Methods of Information Procurement 21 in section Certain features have been pooled into one single feature This was done since it would take too much time to judge the importan
141. nd not a closed source server e g like MS Internet 1 1 Information Server or self tailored server 1 2 How do you handle Critical Security Updates from apache org In case you use another web server 1 1 1 2 1 3 Why did you not choose Apache instead of your current web server How do you handle Critical security Updates for your web server How do you assure that your web server is safe There was no big discussion as the NHS has a special cooperation contract with Microsoft and throughout the NHS Trusts only MS software is used IIS was chosen and the updating securing responsibility is in the hands of the hospitals With which techniques do you assure 2 1 Secrecy Confidentiality 2 2 Authentication 2 3 Nonrepudiation Accountability 2 4 Integrity Control Server is protected by firewall user has to get on the network until now simple login with username amp password in E3 in the future usage of an integrated login single login for all applications on a workstation actual login procedure is carried out by MS Windows applications just check the user name for authorization technique will be implemented NHS wide 3 4 1 4 2 4 3 4 4 4 5 4 6 5 6 7 In which kind of environment is your system running e g local Intranet Intranet with remote users Internet Intranet should be possible to connect clients via dial in or VPN Which web browsers do you s
142. nects Use cases of the Printing Mailing and Faxing Submodule are shown in figure Offered functions are e Different print forms can be chosen for printing e Different print forms can be chosen for mailing e Different print forms can be chosen for faxing e Availability of print forms can be made dependant on certain conditions for example specific mask fields have to be completed e Assigning doctor is made the standard recipient of the external report called letter to doctor e Ability to add graphs to print forms e Ability to add other recipients to print forms e Ability to add pictures to print forms 3 2 8 5 Rule Checking Submodule The rule checking submodule is a highly specific submodule which is only employed in the German perinatal reporting module Here every birth record has to be exported to the 46 3 Requirements Analysis state s quality assurance institutions within the scope of the German perinatal inquiry at least once per year see section for details In order to assure data integrity the institutions also issue rules to reveal integrity errors and to additionally categorise these errors into non correct but acceptable so called soft errors and non correct and unacceptable so called hard errors The rule checking submodule validates all recorded births and provides the user with a list of all hard and soft errors found within a birth record Offered functions are e Display a list
143. niques the connection has not to be of permanent type and can also be of lower bandwidth Although the Web based Ul might at first glance seem like an ideal solution to most listed problems also Terminal server technology should also be briefly examined as an alternative as it offers similar advantages 1 3 Problems Problem 1 Until now the access from many workstations to the VP system is highly complex Problem 2 VP is a highly specific medical documentation system so that the means of for example HL7 are not sufficient to adequately integrate VP within the HIS Problem 3 Until now no Web based UI for VP exists Problem 4 Until now at VP GE no sound knowledge of the requirements and expecta tions of a Web based UI exists 1 4 Objectives Objective 1 Determine which requirements are not met by the Native client of VP and the VP system in general for an adequate integration within the HIS Objective 2 Establish a recommendation for what technology should be used to imple ment a Web client With the Web client access to VP should be possible from every workstation which is networked with the VP server without any additional application components and by using a standard Web browser Limitations A selection of software products with a Web based UI should be examined and described to also consider existing solutions during the creation of the concept Selection is made in accordance with VP GE and Institute for Medical
144. not a maliciously modified one 722 The Web client shall offer means to protect against data loss Rationale Elimination of In case of malfunction of the work station on which the Web client is running or in case of an interruption or congestion of the network connection to the server it must be assured that no data entered or modified via the Web client is lost Requirements concerning installation and maintenance The Web client shall require no or at least a minimum of in stallation and configuration efforts Coherence with RD 2 3 Rationale Elimination of WP 5 WP 26land WP 22 The Web client shall require no or at least a minimum of main tenance efforts Coherence with RD 2 3 Rationale Elimination of and WP 23 Requirements concerning interaction with other application components RD 6 1 RD 6 2 RD 6 3 The Web client shall offer means to switch from itself to an other application components running on the same workstation without having to reenter login information The Web client shall offer means to switch from another appli cation components running on the same workstation to itself without having to reenter login information The Web client shall offer means to switch from itself to an other application components running on the same workstation without having to reenter patient identification information to preserve the patient context 66 4 Definition of Requirements VII VIII
145. not contribute to the goal of this diploma thesis as the functions of VPAdmin are too complex to be described here Please refer to Seh05 or the user manual Rie05b for more details Vital functions of the VPAdmin to note are the administration of the VP specific user management and the configuration and monitoring of the system s interfaces The question of whether the functions of VPAdmin should also be adapted by the Web based Ul will not be answered as this goes beyond the scope of this diploma thesis 3 2 Current Functionality of the Native ViewPoint Client GE Healthcare Obstetrical Ultrasound Report Patient Referring physician Indication Anatomy survey Sally Jones DOB 11 29 1967 age 37 years ViewPoint Image Archiving amp Reporting System Our reference no 8 Date 07 12 2005 Dr Ronald White Upland Hospital 64 High Ledge Avenue Boston MA 02110 Age 37 years Maternal age at EDC 37 years Gravida 2 Para 1 Last menstrual period 03 01 2005 History Dating LMP 03 01 2005 EDC Current Scan on 07 12 2005 EDC Based on BPD HC AC FL and HUM Previous Scan on 04 27 2005 EDC Assignment on 07 12 2005 EDC 12 06 2005 11 16 2005 11 22 2005 11 16 2005 The assignment was made on 07 12 2005 based on the ultrasound examination General Evaluation Presentation breech left Heart action present FHR 140 bpm Fetal movements visible Cord normal GA by LMP G
146. nt does not offer any means to enable contextual integration Web client By choosing the Web client naturally all of the requirements set up in section would be fulfilled as it would be created on its basis For example contextual integration would be fully supported Additionally the Web client could also be used over connections with a low bandwidth Furthermore the Web client would also utilise standard network ports only The main disadvantage of the Web client is that it does not yet exist and a great amount of design and implementation work would be required to put the requirement specification into reality Moreover the functions it offers would be limited compared to those of the Terminal client as it is not possible to control hardware via a Web based UI Furthermore the support of unstable networks is a major issue and cannot be fully resolved by the Web client Farther it is inevitable that the Web client will utilise certain Web browser extensions 104 6 Technology Comparison 7 Conclusion 7 1 Outline In the preceding chapter several products offering Web based Uls have been analysed and compared Furthermore the Terminal client server architecture has been examined as an alternative to the Web client The aim of this chapter is to draw the conclusion of this thesis In section 7 3 the thesis will be discussed in general Section 7 3 will focus on examining to which extend the defined objectives have been achieve
147. nt server architecture has been generally introduced as an alternative to a Native client or a Web client At first glance one might think that a Terminal server could also be an equal solution to the issues addressed by the Web client The motivation for considering a Terminal server in this thesis is based on the following idea A Web client for VP cannot be offered ad hoc A considerable amount of design and implementation work has to be done to create it In contrast by utilising the Terminal server as an alternative to the Web based UI no additional efforts are required The Native client can be installed as it is on the Terminal server Access to it is provided by the connected Terminal clients Following it will be briefly described which experiences have been made in running the Native client of VP on Microsoft Server 2003 Terminal Services MsTS2003 For details on VP provided by a Terminal server please consult the related manuals or test protocols The Native client of VP has been tested extensively on the Terminal server MsTS2003 by VP GE There have not been any serious drawbacks although certain limitations emerged As Terminal client only the latest Microsoft Remote Desktop Connection Client RDC run ning on Microsoft Windows has been tested There is also an official version for Apple 6 3 Terminal Client as Alternative to a Web client 99 Macintosh issued by Microsoft available Furthermore there are various implementa
148. ntation efforts and the significance it has to the customer The logged in users are automatically logged off after a certain period of inactivity Accountability is assured by logging user activity Integrity control is guaranteed by using the HTTPS protocol with 128 bit encryption The Web pages of the Web based UI expire immediately If they have to be reloaded they will be directly transfered from the server So a potential attacker does not have a chance to maliciously modify a temporarily stored copy of a Web site Furthermore integrity of image data downloaded at the client is assured by compressing A full screen image loop has a size of about 1 MBytes For example this could be one heart cycle recorded with a frame rate of 40 60 fps and a resolution of 1024 x 768 pixels An ISDN line has a bandwidth of 64 kbit s This implies that the corresponding transfer time of one full screen image loop is at least 1x22 0x8 Bit n Sule gt 4000 Bis gt 1315 2 2 min 6 2 Product Analysis and Comparison 91 it in a password protected ZIP file The use of CCOW or other means for contextual integration have not yet been evaluated for WebEx At the moment GE Vingmed Ultrasound is content with the technology chosen for WebEx and would not change anything if they had the chance to reimplement it from scratch 6 2 3 Trium CTG Online The information given here has been acquired with the help of the questionnaire Product Analysis Quest
149. ntification of Available Interfaces 2 22 2 2 49 3 3 1 1 HL7 HCM Clinicom BDT and Other computer based 49 3 3 1 2 DICOM computer based 2 2 2222 00 50 3 3 1 3 CORBA computer based 52 3 3 1 4 Analog Image Video Capture computer based 52 3 3 1 5 US Measurement Data computer based 52 3 3 1 6 Trium CTG Online Monitoring computer based 53 3 3 1 7 Chip Card Reader computer based 53 3 3 1 8 Printing and Faxing Interface paper based 53 3 3 1 9 Scanning Interface paper based 53 AAA e 3 gos ce ose a Dei a ee Ge ee Bk ae Be ee 53 o a l 54 pig heise AI 54 3 4 1 Weak Points of the Native VP Client 55 pido dada a A AA ee ee ee A 56 3 4 2 1 Data Integration o e e 56 3 4 2 2 Access Integration ooa 0220 57 3 4 2 3 Presentation Integration 24 58 pee BA oe ae lel eee a ae 59 3 4 3 Weak Points of a Web Client 2 o o 59 3 4 3 1 Weak Points of a Web Client in General 59 3 4 3 2 Points to Be Considered for a Web Client as an Alternative EEN A Oe ee 61 4 Definition of Requirements 63 A ie Yor ae SE OE ae Be a a A A 63 E me Beat 63 wa ae da EE ek ade ee ee De 66 5 Specification of Requirements 69 5 8 COUGHING i agers we BY a ae ae he Be ee oe Se Be a ee ok 69 Vili Contents ROW GE we E SG
150. ntify resolve risks Determine objectives alternatives constraints Risk analysis Opera tional protoype Prototype 2 Risk analysis Requirements plan Life cycle plan Simulations models benchmarks Concept of Operation Detailed design Requirement validatior Development plan Code Unit test Integration test Plan next phase ii Acceptance test Develop verify next level product Service Figure 2 1 Spiral model of Boehm taken from Som95 In general was taken as reference and guideline to come up with a requirements specification Sommerville described the requirements engineering process as a process consisting of four principle stages which will subsequently be outlined in short In addition it will be referenced how and where it was realised in this thesis 1 Feasibility study according to Som95 The intention of this stage is to estimate whether the user needs may be satisfied using current software and hardware technologies The focus is on economical aspects like cost effectiveness and budgetary constrains The completion of this stage should result in a feasibility report In this thesis a feasibility study will be completely omitted as economical analysis is not subject of this thesis and the decision of the actual implementation is at the hands of VP GE 2 Requirements analysis according to Som95l e Requirement
151. o Euroking Miracle Ltd but they doubt that it will become so popular that they will also have to support it Their doubts are mainly caused by the assump tion that third party providers will not agree to allow other applications to control their products For SSO functionality they rely on the Integrated Login as describe above For providing patient context based access to E3 they will offer a URL based solution in the near future By specifying a certain URL containing the patient identifier other application components can open the related patient record directly in E3 If Euroking Miracle Ltd had the chance to redesign E3 from scratch they would use another DBMS They are content with their current DBMS Intersystems Cache but would choose a different one on account of popularity reasons Furthermore they would utilise NET to increase the performance and offer better means for integration Additionally they would focus on offering access to E3 from anywhere 6 2 2 GE Vingmed Ultrasound WebEx The information given here has been acquired with the help of the questionnaire Product Analysis Questionnaire see section 2 4 2 2 for details Further information was taken from the Web page of the GE Vingmed Ultrasound Local Media DVD I Bookmarked patients Done Ir of Trusted sites A 100 Figure 6 3 Screenshot showing the search screen of WebEx 6 2 Product Analysis and Comparison 89 6 2 2 1 Gene
152. of all erroneous documented births with the number of errors It can be configured whether soft and or hard errors shall be shown e Define which birth records are shown in the list Birth records can be selected by specifying a time span birth number or quarter of a year e Start checking all birth records of the list or only the currently selected birth record e Open examination module of the currently selected birth record to correct errors e Open rule checking submodule in examination module to validate the currently recorded examination 3 2 9 System Administration Module VPAdmin In order to customise VP to the user s needs and to the site s characteristics it comes with a special administration programme It is used to setup VP on the server and workstations and to maintain it afterwards Part of the configuration is applied to the VP system as a whole valid for all workstations and part of the configuration is workstation specific In order to configure each workstation of a VP network VPAdmin offers a list view of all installed VP clients together with the workstation specific configuration parameters For the general setup of the system a separate configuration mask is available The common procedure is to set all parameters in the general configuration mask and only if a client needs a different or dedicated parameter adjustment modifications are made workstation specific Emphasising on the functions in detail would
153. ofessionals This card is used to assign read and or write access to specific data fields on the patient card The chip stores the doctor s ID read and or write access rights and a digital signature for secure data transmission In general it could be used for authorization and authentification of the application user I suppose this will require a separate program plug in on each client I m not sure if I m going to support HPC it depends on the requests and how easily and flexible it can be implemented Is 1t possible to work offline and to reconnect No If you would redesign and reimplement your product from scratch what would you change Nothing its perfect seen from my point of view Received via eMail 23 12 2005 Holger Schmuhl Short Overview Product Analysis Author Vendor Trium Analysis Online GmbH Product Name Trium CTG Online Product Category CTG online monitoring system Goals Enable web based CTG monitoring Field of Application mainly obstetrical departement Underlying techniques Web server Apache Database MS Access Other OpenSA 1 0 4 web server including Apache SSL module and apache proxy module Macromedia ColdFusion 4 5 Express National Instruments VISA Adobe Acrobat Reader Macromedia Flash Gweb server Supported Browser Firefox 1 0 Mozilla 1 7 Microsoft Internet Explorer 5 5 with JavaScript enabled Macromedia Flash Plug In for
154. on products at the market are analysed in respect to their compliance Market analysis should be performed by utilising a data entry form which could be a brief summary of the requirement specification By using a data entry form a maximum of comparability is achieved during product analysis The results may help to refine or revise the original requirements specification In this thesis only an analysis of certain predefined products was carried out The products to be analysed have been defined by VP GE Namely they are e E3 of Euroking Miracle Ltd e WebEx of GE Vingmed Ultrasound and e Trium CTG Online of Trium Analysis Online GmbH Selection criteria have been that the product characteristics are similar to VP and that the manufacturers would cooperate in providing the required information Product analysis will not be performed with the intention to pick a certain product It will be done to obtain a detailed idea of how other companies coped with certain issues of the requirement specification and where they saw opportunities or problems in offering a Web client Information has been gathered in form of a questionnaire see section 2 4 2 2 for details The results will be given in section 6 2 2 6 Native Client versus Web Client In oder to highlight the differences between a Native client and a Web client a short characterisation of each client architecture will be given In this context the term client designates a software com
155. onnaire Features of a Web based Interface to VP 20 2 4 2 2 Questionnaire Product Analysis 21 na Beis a he eh ee or 21 a Be a tS ee teak a GN ee ee A ee te O 22 2 6 Native Client versus Web Client o o e 00 22 2 6 1 Native Cliemtl e 23 2 6 2 Web Clienth e 24 2 6 3 Comparison acs swa gp aa cnaig a aa ee 26 2 7 Terminal Server ee 26 2 8 Clinical Context Management aoe ao a e 28 Requirements Analysis 31 31 Outline s coe sa a ee ee 31 3 2 Current Functionality of the Native ViewPoint Client 31 3 2 1 Hardware and Software Requirements of a Client 31 heat is PEER eee betta 32 3 2 3 General Description 2 22 22 Co on 32 3 2 4 Patient Management Module 2 2 2 2 nn nn nennen 33 3 2 5 Patient Scheduling Module 2 2 2 2 nn nn 35 A doe ae daw ee a A ya 36 3 2 7 Archive Modulel 4 4 cea 0 ra A rel 37 Das ee 37 3 2 8 1 Case and Examination Management Submodule 37 3 2 8 2 Findings System 0 000002 ee eee 39 3 2 8 3 Image Gallery Submodule 43 3 2 8 4 Printing and Faxing Submodulel 45 3 2 8 5 Rule Checking Submodule 45 Contents vil 3 2 9 System Administration Module VPAdmin 46 3 3 Current State of Integrati0M o e e 49 3 3 1 Ide
156. ood by an end user and the system customer Som95 Sommerville distinguished between two types of requirements Functional require ments statements on services the system should provide and Non Functional re quirements constraints on the services or functions offered by the system This distinction will not be made in this thesis as it is seen as more significant to arrange the requirements topically The requirements definition will be given in section Additionally Sommerville defined different types of major problems of requirements definitions They will be subsequently listed in conjunction with which was done to cope with them e Lack of clarity It is very difficult to use language in a precise and unambiguous way without making the document wordy and difficult to read Som95 In order to achieve as much clarity as possible it will be focused on making simple clear and unambiguous statements without using fill words or other stylistic means to make the text read smoother 2 3 Requirements Engineering 15 e Requirements confusion Functional requirements non functional requirements system goals and design information may not be clearly distinguished Som95 As stated above it will purposely not be distinguished between the different types of requirements in this thesis It is seen as more crucial to group the re quirements according to the general topic they aim at like data security quality of supported network
157. orkstation WP 23 Maintenance efforts for installed Plug ins or Helper Applications on a workstation On account of the Web browser and Platform dependency it is indispensable to test the Web client for each Web browser and on each Platform which should be supported In case of malfunction or insufficient performance the Web client has to be optimised for each Web browser an Platform WP 24 Testing and optimisation efforts required to support different Web browsers on different Platforms WP 25 Efforts increase with the number of Web browsers and Platforms which are supposed to be supported Every Web browser offers means to limit its features in order to protect it against security threats Those features are for example acceptance of Cookies allowance of Pop Ups allowance of execution of Java Script etc Thus the default configuration of a Web browser may prevent the usage of features utilised by the Web client The default configuration has to be modified to be able to use the Web client 3 4 Weak Point Identification 61 WP 26 Modification of the default Web browser configuration required Moreover certain Web browser extensions may utilise other network ports than the stan dard HTTP port If the client and the server are separated by a Firewall additionally needed ports have to be activated This is especially relevant for access to VP from remote sites WP 27 Non standard ports required by Web browser extension ma
158. ponent programme with a separate Ul used to access and display data which is managed and stored by a central server The clients run on separate workstations and communicate with the server over the network This kind of architecture is known as the client server architecture Clients and server together form a system which is designated as software product Data which is exchanged between client and server will be distinguished into user data and control data for an easier understanding User data designates the actual data which is relevant and meaningful to the user for example patient information Control data designates data which is used for providing the UI for example layout definition of the UI underlying business logic Albrecht et al proposed in AIb03 the following criteria for comparing different client architectures 2 6 Native Client versus Web Client 23 Client Figure 2 3 Client server architecture taken from Tan03 Cross Platform Aims to examine to which extend the client architecture supports different Platforms Distributed Aims to examine to which extend the client architecture supports dis tributed usage Interactive Aims to examine the degree of interactivity between the user and the system Rich Interface Components Aims to examine the functional range of the Ul which could be provided by the related client Afte
159. r giving a general description these requirements will be used to achieve a good level of comparability while characterising the Native and Web client 2 6 1 Native Client A Native client is a Ul provided by a dedicated programme The programme is compiled for a certain Platform It can utilise all OS functions and so also control the local hardware of the workstation for example serial interfaces or 3D hardware acceleration In most cases the UI s layout and the underlying business logic is defined and processed at the client side All or at least a set of files needed for the execution of the Native client control data is transfered from the server every time the client is started When the client is running mainly user data is transfered between the client and the server e Cross Platform Clients are typically targeted at single Platforms and therefore easier to use and faster to implement AIb03 Most clients are restricted to a certain Platform but can be ported to other Platforms with the utilisation of cross Platform libraries like Qt A1b03 e Distributed Native clients are characteristic for traditional group ware systems Those sys tems are designed for Local Area Network LAN usage and thus have high bandwidth utilisation A1b03 24 2 Basic Principles Clients require to be installed on each workstation Complex settings for each workstation have to be configured properly A1b03 If a ne
160. r the connection has been reestablished the user should have the possibility to continue entering data instead of restarting The Web client shall perform and respond in such a manner that the user is not hindered in doing her his actual work Specification of RD 3 3 Details This requirement is in large part dependent on RS 3 1 and can be achieved by using Plug ins as described in section The Web client shall utilise only standard ports like HTTP port 80 or HTTPS port 443 Specification of RD 3 4 Details This requirement is in large part dependent on RS 2 3 Requirements concerning data security Comment The requirements concerning data security cannot be specified in more detail without knowing the actual technology used The selection of that technology should be left to the implementor Furthermore analysis and comparison of theses technologies would go beyond the scope of this thesis Still some advice should be given RS 4 1 The Web client shall assure secrecy and confidentiality by offer ing sufficient means for authorisation Specification of RD 4 1 Details Potentials and constraints of SSO technology should also be carefully considered while implementing this requirement CCOW also enables deploying of highly secure SSO solutions 80 5 Specification of Requirements RS 4 2 The Web client shall offer sufficient means for authentication Specification of Details Potentials and constraints of the
161. ral Description GE Vingmed Ultrasound is a GE Healthcare company and the manufacturer of EchoPAC EchoPAC is sold worldwide EchoPAC is as the name already suggests a PACS for image data originating from US devices It stores data in a patient oriented way Its functional range includes classical PACS functionality as well as features for advanced analysis of image data and report generation Especially raw image data acquired by Vivid US devices is extensively sup ported by these advanced analysis tools EchoPAC is marketed as part of the Vivid product family As Vivid scanners are popular in cardiology EchoPAC s main area of application are cardiological departments at hospitals EchoPAC interfaces with PMS CDMS and similar application components by means of the HL7 standard WebEx is supposed to be the future Web client to EchoPAC offering similar functions It is reusing shared components of EchoPAC Until now it was developed by S Fimreite in his spare time and has not yet reached official status meaning that it is not yet sold to the customer and still in the evaluation and testing phase Specialities of WebEx are that viewing on mobile devices is also supported and that it offers full screen view capabilities and can be displayed on systems with two screens attached Moreover WebEx offers predefined texts for report generation and the performance of measurements on image data It aims at supporting any type of DICOM imaging modalities
162. red could for example automatically be sent to the server at regular intervals to prevent the loss of all data in case of failure Still it is clear that no full protection against data loss can be guaranteed by a Web client V Requirements concerning installation and maintenance RS 5 1 The Web client shall require no or at least a minimum of instal lation and configuration efforts Specification of Details In reference to section at least some Web browser extensions are required They are linked to installation efforts In order to enable its The Health Professional Card is an individually programmed access card for health care professionals The HPC is used to assign read and or write access to specific data fields on the patient card The chip of the card stores the doctor s ID read and or write access rights and a digital signature for secure data transmission Gie06 There are country specific standardisation attempts For more information on for example the German approach please refer to http www bundesaerztekammer de 30 eArztausweis 5 3 Requirement Specification 81 VI RS 5 2 usage changes at the default configuration of the Web browser will also be inevitable Still these efforts should be kept to a minimum The Web client shall require no or at least a minimum of main tenance efforts Specification of Details In reference to at least some Web browser extensions which are linked to mainten
163. refore the interfaces offered by VP will be identified and the current state of integration will subsequently be modelled This chapter will end with identifying weak points of the current solution the Native client of VP and weak points which are connected to the future solution the Web client of VP in section The succeeding chapter will define out of the discovered weak points a requirement defi nition for the future Web client 3 2 Current Functionality of the Native ViewPoint Client This section is meant to give the reader a well founded idea of the functions offered by the Native client of VP The purpose is not to give a complete and detailed requirements specification or system description of the Native client and the VP system in general In order to give an example At this point it is of importance that the client offers a DICOM interface but it is negligible how the import is performed in detail for example what happens if the received DICOM object already exists in VP For a detailed description of each feature its usage and its related behaviour please refer to the original requirements specification Seh05 or the user manual Rie05b In order to gain a more general idea of what VP is please refer to chapter 1 For a detailed description of how VP is integrated in the HIS please refer to section The analysed version is VP 5 which is the latest version 3 2 1 Hardware and Software Requirements of a Client Be
164. related 3 2 4 Patient Management Module VP from its purpose is a vertical documentation and stores data in a patient oriented way Therefore a module is needed to manage and store medical findings and all related information patient specifically The Patient Management Module fulfils these requirements and also supports the management of patient demographics In order to support the work flow of a functional diagnostic unit or doctor s practice in an appropriate way patient management is offered by a separate module This was done be cause there may be dedicated personnel to record and manage patient demographics Since in a hospital several patients may have the same assigning physician a list of all assigning physicians is maintained patient overlapping One or more entries can be connected to a certain patient record Use cases of the management of patient records are shown in figure 3 1 34 3 Requirements Analysis cd Manage Patients ViewPoint Import Patient from Chip Card Reader View Patient Chip Card Reader bort Patient Acquisition Modality in clu de Acquisition Modality 1 1 1 1 1 Retrieve Patient Find Patient Import Patient from PMS Create Patient x include e include Modify Patient User Health Care Professional Merge Patients Delete Patient Figure 3 1 Patient Management Module UML use case model of the management of patient records modi
165. respondents with equal significance This implies that both Web browsers should be supported by the Web client and not only one of both Based on these results and RD 2 1 and RD 2 2 it was decided to support the following OSs and Web browsers as shown in table 5 4Jon the Intel 286 hardware architecture Table 5 4 Web browser and OSs which should be supported by the Web client Web browser OS Microsoft Internet Explorer Microsoft Windows XP Microsoft Windows 2000 Firefox Microsoft Windows XP Microsoft Windows 2000 Linux No specific Service Pack version and no specific Web browser version was defined to achieve a maximum of compatibility Furthermore Microsoft Internet Explorer 7 is about to be released It is yet unknown how fast it will spread If a restriction to certain Service Packs or Web browser versions occurs due to implementation issues they have to be specified by the implementor 5 2 4 Identification of Required Web Browser Extensions In it was postulated that the Web client shall utilise as few Plug ins or Helper Applications as are needed to fulfil In addition the utilised Plug ins or Helper Applications have to support the Platforms OS versions and Web browsers defined by RD and The task resulting from this requirement is to identify Web browser extensions which are required to implement certain features as defined by RS 1 2 as a Web browser does not offer sufficient functions to i
166. rinatal inquiry or other third party application components where no way to instantly update the exported data exists if modifications in the patient record are made after the export process Offered functions for case management are Create new case record Find and view case record Find and modify case record Find and lock unlock case record Find and delete case record Export case data to the cardiotocograph monitoring system Trium CTG Online Process patient demographics as described in Offered functions for examination management are Create a new examination record Specify the type of the examination Depending on the chosen type one of the findings masks listed under 3 2 8 2 is being displayed Find and view an examination record Find and modify an examination record Find and merge an examinations record Find and lock unlock an examination record Find an examination record and assign unassign a study and its image data re ceived via DICOM to it see section 3 3 1 2 for details Find an examination record and assign unassign a clinical order received from an other application component to it see section 3 3 1 1 for details Find and delete examination record 3 2 Current Functionality of the Native ViewPoint Client 39 3 2 8 2 Findings System The Findings System offers all functions needed for recording displaying and processing medical findings in VP As the findings system is qui
167. rly state and highlight the meaning of certain terms Thereby misunderstandings should be prevented as there are quite different ter minologies in use In general the terminology proposed by IMISE will be used Most parts have been published in and have been defined while creating the 3LGM Meta model see section for details 2 2 1 General Terms Hospital Information System HIS By the term Hospital Information System most peo ple mean what is actually denoted in the terminology by PMS or sometimes Clinical Documentation and Management System CDMS Correctly a HIS is the socio technical subsystem of a hospital that comprises all information processing functions and the human or technical actors in their information processing role Image Data The term image data denotes single images also called still pictures and multi frames also called video sequences or loops if no further distinction is required Platform There are different definitions of the term Platform In this thesis the term Platform denotes a hardware architecture like the Intel x86 hardware architecture together with the used Operating System OS like Microsoft Windows 10 2 Basic Principles Web client versus Web based UI In this thesis the terms Web client and Web based UI are synonymously used Authorisation versus Authentication Authorisation denotes the process in which an ac tor party like for example an user is granted access to certain data Th
168. rmation about single issues For these issues it was already known that clear requirements exist In addition an interview was used in case that no adequate information sources have been found As the diploma thesis is performed on behalf of VP GE the author had access to the knowledge of the employees at VP GE Furthermore the thesis is performed in close cooperation with IMISE and the author also had access to the knowledge of the staff there 2 4 2 Questionnaire A questionnaire is a set of written questions which have normally to be answered in writ ing by more than one person Possible answers can be standardised so that the persons completing the questionnaire can only choose from predefined answers Thereby a fast evaluation is possible and a maximum of comparability is achieved HA05 Disadvan tages of standardised answers are that the respondents may not clearly understand the question or available answers and will therefore give a wrong statement on the issue In case of free text answers the respondents is given a maximum of freedom to answer the question adequately while significantly increasing the evaluation efforts Without offering predefined answers a maximum of information can be taken from the questionnaire if answered thoroughly Standardised answers may not consider certain aspects which are also relevant to the related issue The following two questionnaires have been used in the course of this thesis to assess informat
169. s Trium CTG Online utilises the OpenSA server suit which comes with Apache 1 X In order to provide additional functionality Macromedia ColdFusion is used as application server The Web based UI conforms to HTML 4 01 As Web browsers Microsoft Internet Explorer Mozilla and Firefox running on Microsoft Windows are supported The JVM needs to be installed on the client workstation and the usage of Java Script has to be allowed by the Web browser In order to enable acoustic alarms the installation of Macromedia Flash is required although usage of Trium CTG Online is possible without it Moreover Adobe Acrobat Reader needs to be installed to be able to view archived CTG printings A JPEG based viewing of archived CTG printings is also available Before using the Web client on a workstation for the first time the SSL root CA certificate has to be installed to enable encrypted data transfer In case updates or security patches are issued for the Web server Apache OpenSA it is the responsibility of the customer to install them Concerning the networks supported by Trium CTG Online and their quality Trium CTG Online requires at least a bandwidth of 9600 Bit s In the hardware recommendations for Trium CTG Online 100 Mbit s are defined Unstable networks are not supported as this would contradict the principle of the online monitoring system which needs to have a constant connection to the server The user is informed about an established server con
170. s risk management acquisition and storage of partograms real time data entry In addition it can utilise Microsoft Word for report generation One core feature of E3 is a document management system with which any type of data files like Microsoft Word or Adobe Acrobat Reader documents can be managed The creation of statistical reports is also supported E3 utilises the HL7 standard ODBC and XML to interface with other application components It does not support the DICOM standard although DICOM files can be handled by the document management system of E3 6 2 1 2 Technical Aspects As the National Health Service NHS has a special contract with Microsoft it could be assumed that all potential customers run only Microsoft technology So Microsoft Internet Information Service IIS was chosen as Web server to build on Microsoft Internet Explorer is the only Web browser and Microsoft Windows is the only OS supported by the Web client The Java Virtual Machine JVM needs to be installed on the workstation to be able to use the Web client The default configuration of Microsoft Internet Explorer has to be modified so that the execution of Java Script is allowed Applications to view or edit the file types managed by E3 have to be installed on the workstation which runs the Web client 6 2 Product Analysis and Comparison 87 a Pregnancy Summary form Microsoft Internet Explorer provided by Euroking Miracle Ltd ii Acorn Arabella 4384
171. s Underlying techniques Web server IIS Database Microsoft SOL Server Other ASP NET Media Player which is capable of playing Windows media Supported Browser Internet Explorer Netscape Opera Server Platform X Windows Linux Unix Solaris Product Type X self tailored unique of the shelf License Type open source X closed source Software Status alpha X beta stable URL Contact amp eMail Svein Fimreite Questionnaire In case you use Apache Why did you choose Apache and not a closed source server e g like MS Internet 1 1 Information Server or self tailored server 1 2 How do you handle Critical Security Updates from apache org I m not using the Apache server In case you use another web server 1 1 Why did you not choose Apache instead of your current web server I prefer the ITS server since I m using the latest Visual Studio 1 2 How do you handle Critical security Updates for your web server I m using the Windows Update functionality supported by Microsoft 1 3 How do you assure that your web server is safe I m using the test tool in Visual Studio NET designed for testers With which techniques do you assure 2 1 Secrecy Confidentiality Form security https 128 bit encryption WebEx also supports auto logoff functionality and audit logging 20 2 3 2 4 3 4 1
172. s Web pages are created dynamically by the server at the moment they are requested from the client The main advantages of this procedure are an easier maintainability of the server and better customisation to the user needs The Web browser fetches the Web page and displays it to the user Interactivity is achieved by the usage of links Each click of the user on a linked object inside the Web page causes the Web browser to send a request with the related URL to the server The server normally answers this request by sending an updated or new Web page to the Web browser depending on the URL clicked Due to these constraints it is clear that the performance of this client architectures relys strongly on the quality of the network connection The core part of a Web browser is the layout engine It creates a well formatted UI from a Web page which contains user data and markup information like Hypertext Markup Language HTML on the basis of formatting information like style sheets The recogni tion and interpretation of markup is dependent on the Web browser Even if the Web page conforms to certain standards it may occur that Firefox for example is able to display the page and Microsoft Internet Explorer cannot display it In order to be able to display and process also more advanced content certain techniques have been created to extend the limited functionality of a Web browser These extensions 2 6 Native Client versus Web Client 25
173. s is a major problem for E3 Still they offer means to prevent the complete loss of all data entered in a session One of it is a periodical auto saving function by which the entered data is saved on the server after a fixed period of time Another one is that after the completion of a mask or a set of entry fields the entered data is also committed to the server At the moment they have no capabilities to work offline The security policy of E3 is based on the following assumption All users of the LAN are authorised It is the hospital s responsibility to prevent unauthorised access to the network So there is no potential danger that packets are viciously modified and integrity control is required In future an Integrated Login SSO will be supported for authorisation purposes This Integrated Login is Microsoft Windows based and is supposed to be introduced NHS wide Authentication is performed by Microsoft Windows All other application components ln a former version of E3 a Native client was also offered with which offline work was possible It was made for midwives who could synchronise data after their home visits 88 6 Technology Comparison retrieve the username from Microsoft Windows In addition to the Integrated Login the HPC could be used although from the point of view of Euroking Miracle Ltd it looks that there will not evolve a common standard for the HPC in the UK in the near future CCOW is known t
174. s System ViewPoint Report screenshot of the report modification mask e Export medical data of the current examination for example the VP Report to CDMS e During data entry the current examination is saved periodically Available Findings Masks e General Reporting e Prenatal Reporting e Perinatal Reporting e Gynaecology Reporting e Mammogram Reporting e Ultrasound Reporting e Endoscopy Reporting e Echocardiographic Reporting 42 3 Requirements Analysis ud Manage Reports ViewPoint Create Report Export Report include includes User Health Gare Professional include ae a include 7 E 3 al File System Printing Mailing and Faxing Submodule View Report History Figure 3 6 Findings System ViewPoint Report UML use case model of the report handling modified version of the model taken from Seh05 Basic Functions e Predefined entries in input fields e User defined entries in input fields e Definition of default values for input fields which are automatically selected if the corresponding mask is opened e Definition of mandatory input fields which have to be completed to be able to close the related mask and archive the findings e Dynamic display of fields depending on the value of other fields for example for hiding fields which are not needed e Display graphs e Generate a report 3 2 Current Functionality of the Native ViewPoint Cli
175. s included in a clinical order 3 2 5 Patient Scheduling Module VP has an integrated customisable schedule for planning examinations dependent on the availability of physicians and resources The schedule is used to manage appointments for examinations An appointment can be made for a resource and a physician and be linked with a patient record Resources can be rooms or medical devices Use cases of the Patient Scheduling Module are shown in figure 3 2 Offered functions are e Find appointment 36 3 Requirements Analysis ud Manage Appointments WiewPoint Create Patient Find Order N include User Health Care y Professional a Create include Appointment Retriewe Patient from PMS Modify Appointment include Retrieve Order from PMS 7 Print Schedule Delete Export Worklist Appointment Acquisition Modality Figure 3 2 Patient Scheduling Module UML use case model of the management of appointments modified version of the model taken from Seh05 e Create appointment Appointments can also be created from orders e Modify appointment e Delete appointment e Print schedule 3 2 6 Statistics Module The statistics module is meant to offer the health care professional a way to vertically LGH 03 analyse the recorded data It offers a patient overlapping view of the recorded findings and is therefore able to answer questions concerning clinical issues adequately A
176. s medical data is entered in structured masks which consist of data fields stored in a relational database nearly every attribute of a patient can be accessed via this module by executing queries on this database 3 2 Current Functionality of the Native ViewPoint Client 37 The statistics module does not offer any professional statistic analysis functions as the name might suggest It only offers functions to gather densify and export recorded data so that it can be statistically evaluated by an external application component like SPSS for example Offered functions are e Menu based definition and editing of new or existing queries e Predefined statistic queries for special purposes for example standard statistics of certain health care regions or for certain institutions for example Fetal Medicine Foundation London FMF London see section 3 3 1 10 for details e Definition and modification of queries on a database language basis e Copy and export import query definitions to from the file system e Specification of filters depending on attribute types e Execute queries and display their results print them out or export them as a file ASCII dBASE and Microsoft Excel formats are available e Search image data depending on its comments or search terms 3 2 7 Archive Module The purpose of the archive module is to offer read only access to patient records and to enable tracing modifications made in them in the past
177. s or Platform OS version and Web browser constrains e Requirements amalgamation Several different requirements may be expressed together as a single requirement Som95 During requirement definition it was tried to densify the requirements as much as possible 4 Requirements specification according to Som95 e Requirements specification is a detailed and precise description of the system requirements Som95 On account of the following reasons Sommerville et al warned of using natural language for requirements specification Natural language understanding is reader and writer dependent which may lead to misunderstandings Furthermore natural language specification is over flexible so that the same thing can be expressed in different ways This may lead to problems in finding out whether different require ments are actually the same or distinct Moreover requirements are not effectively partitioned by the language itself and it is thus difficult to find related requirements Still the use of natural language is seen as more appropriate in this thesis to specify the requirements Other forms like graphical notations mathematical specifications or requirements specification languages have not been chosen as the requirements which are dealt with have a more general character While using natural language it will be focused on creating a clear and easily un derstandable requirement specification Every potential reader should be
178. sical tool layer HAWB04 Application Component Configuration Relationships between the domain layer and the logical tool layer are represented by the so called application component con figuration It states which enterprise function is supported by which application component It is possible that a function is supported by several application components by a single application component or by combinations of both Thereby the application component configuration may give hints about redun dancies enterprise function is alternatively supported by several application components or weaknesses one or several application components are jointly necessary to support an enterprise function in the domain layer HAWB04 Data Processing Component Configuration Relationships between the logical tool layer and physical tool layer are represented by the so called data processing component configuration It states which application component is installed on which physical data processing component It is possible that an application component is installed on several for example client server based system on one stand alone system or in combinations of both physical data processing components 2 3 2 3 Reference Model for the Domain Layer of HIS In Hiibner Bloder et al proposed a reference model for the domain layer of the HIS It was created from the need to save a considerable amount of effort needed when modelling specific HIS Moreover it
179. ssible Concerning the utilised network ports Apart from Trium CTG Online all products only communicate via standard ports which are most probably forwarded by the hospital s firewall This is crucial to be also adopted by the Web client of VP as specified in RS 3 4 From the current point of view no analysed product does support CCOW or will do so in future Before implementing CCOW it should be carefully determined which benefits can be taken from it Especially the question what advantages supporting CCOW have for VP when no other product can interface with it Perhaps it is sufficient to support the integrated login as describe for E3 and to offer some kind of URL based access to specific patient records In any case certain means for contextual integration must be provided by the Web client as demanded by RS 6 1 RS 6 2 RS 6 3land RS 6 4 to strongly facilitate the health care professionals in doing their actual work The requirement RS 7 1 has not been addressed by the product comparison Still the idea of code reusage was reported by S Fimreite WebEx also reuses components of the code 98 6 Technology Comparison basis of EchoPAC although this code is most probably not connected to Ul definition but fulfils the underlying functions The screenshots of the analysed products showed again that every company has another opinion on UI design Thus it is vital to focus on keeping the interface within the VP family simil
180. stributed via the Web client and which may need Web browser extensions to be viewed Aims at RS 2 3 HTML version HTML version to which the Web based UI is conform Aims at RS 2 2 Used ports Network ports utilised by the Web client Aims at RS 3 4 Required network bandwidth The minimum bandwidth required to run the Web client Aims at RS 3 1 Support of unstable networks If and how unstable networks are supported Also in cludes means against data loss Aims at RS 3 2 and RS 4 6 Authorization Means used for authorisation purposes Aims at RS 4 1 Authentication Means used for authentication purposes Aims at RS 4 2 6 2 Product Analysis and Comparison 95 Accountability Means used to guarantee non repudiation and accountability Aims at RS 4 3 Integrity Control Means used for integrity control purposes Aims at RS 4 4 Support of CCOW CCOW or other means supported to guarantee contextual integra tion Aims at RS 6 1 RS 62 RS 6 3 ana R56 6 2 5 Product Comparison In table 6 1 the analysed products are compared by the criteria as defined in section Table 6 1 Comparison of E3 WebEx and Trium CTG Online E3 WebEx Trium CTG Online Manufacturer Euroking Miracle Ltd GE Vingmed Ultrasound Trium Analysis Online GmbH Product E3 WebEx Trium CTG Online Name Product MDS and PDMS PACS PDMS Category Goals Support the workflow in an High secured Web based Web
181. t 3 3 2 3 3 Ability to fax 1 3 2 3 3 Rule checking for perinatal findings Ability to check plausibility of findings Additional features Access from Internet URL e g http viewpoint myhospital de open patid 12345 Support the Clinical Context Work Group CCOW standard to enable contextual integration CCOW enables contextual integration that means when you open patient XY in application A patient XY is automatically opened also in application B on the same workstation CCOW additionally offers functionality to exchange login information between different applications so that the user needs to login only once Support HPC Healthcare professional card is an individually programmed access card for health care professionals This card is used to assign read and or write access rights to specific data fields on the patient card The chip stores the doctor s ID read and or write access rights and a digital signature for secure data transmission In general it could be used for authorization and authentification Enable access to knowledge servers As major hospitals establish knowledge servers to distribute medical knowledge and guidelines hospital wide it is conceivable that the web based UI references to such information sources Meaning e g that in case certain diagnose is selected in a patient record a link to the referring medication and further treatment recommendations on the knowledge server will be displayed
182. t Bildverar beitung GmbH GE Healthcare 02 2002 RIEGER G VIEWPOINT BILDVERARBEITUNG GMBH GE HEALTHCARE Hrsg System Requirements for ViewPoint 5 0 3 0 Wessling ViewPoint Bildverarbeitung GmbH GE Healthcare 09 2005 RIEGER G VIEWPOINT BILDVERARBEITUNG GMBH GE HEALTHCARE Hrsg ViewPoint Basic User Manual 1 0 Wessling ViewPoint Bildver arbeitung GmbH GE Healthcare 09 2005 RUMBAUGH J JACOBSON I BOOCH G The Unified Modeling Language Reference Manual Addison Wesley 1999 ISBN 020130998X RUSAK A ViewPoint 5 01 DICOM Conformance Statement 0 1 Wessling 01 2006 SCHMUHL H H VIEWPOINT BILDVERARBEITUNG GMBH GE HEALTH CARE Hrsg Terminal Server Performance Test 1 0 Wessling ViewPoint Bildverarbeitung GmbH GE Healthcare 03 2006 SEHARSCH A VIEWPOINT BILDVERARBEITUNG GMBH GE HEALTH CARE Hrsg SRS ViewPoint 5 0 Core and Application Requirements 1 0 Wessling ViewPoint Bildverarbeitung GmbH GE Healthcare 09 2005 SELIGER R Overview of HL7 s CCOW Standard Version 2001 www h17 org library committees sigvi ccow_overview_2001 doc Last checked 17 May 2006 SENTILLION CCOW Tutorial Version 2000 http www icis ca cihiweb en downloads infostand_hl7ehealth_may01_e_Sentillion_ ccow pdf Last checked 17 May 2006 Bibliography 115 Som95 Tan03 The06 Ups06 W3S06 WBW03 WHBW04 Wik06 Wi103 SO
183. t having to reenter patient identification information to preserve the patient context Requirements concerning the UI continued on next page 7 3 Achievement of Objectives 109 Requirement RS 7 The Ul of the Web client shall be based on the existing masks definition if possible and feasible If not possible and feasible the Web client shall utilise a standardised UI definition language Ps un N 3 N The Web client shall offer a UI which resembles the Native client in its ap pearance and is controlled similarly The UI of the Web client shall offer similarity to the UI of Trium CTG Online The Web client shall offer a UI which supports automatic testing E un w Aya nin e al ES The Web client shall preserve the quality and integrity of all image data provided to the user via the Web based Ul Requirements concerning hardware es un 00 The Web client shall keep its hardware requirements to a minimum E un 00 iw The Web client shall offer no means to control hardware devices connectable to VP Technology recommendation During requirement specification it already turned out that it would be impossible to give a detailed technology recommendation for the imple mentation of the Web client For a serious recommendation the available technologies for the realisation of each requirement would h
184. t technique to prevent data loss Their current procedure is to save archive entered data stepwise e g when another mask is opened or a field was completed and to offer periodical auto saving functionality Which importance do you measure to CCOW Will you implement it in your application CCOW is a standard issued by the HL7 Workgroup CCOW enables contextual integration that means when you open patient XY in application A patient XY is automatically opened also in application B on the same workstation CCOW additionally offers functionality to exchange login information between different applications so that the user needs to login only once They heard about CCOW but they doubt that it will evolve as especially 3rd party providers will not agree that other applications control or access their program Login functionality will be covered by the integrated login single login for all applications on a workstation 8 9 10 Context integration has to be done another way e g by passing patient identification via a URL which is not yet implemented Which importance do you measure to the HealthCare Professional Card HPC Will you support it in a future version of your application HPC is an individually programmed access card for healthcare professionals This card is used to assign read and or write access to specific data fields on the patient card The chip stores the doctor s ID read and or write access rig
185. tc Text images jpeg gif video wmv MPEG4 M1V zip pdf user manual will be converted to html What happens if the network is congested or the connection lost Since the web sites expires immediately you will get the message that its not possible to view this site in offline mode If its in a middle of a zip download process and the lost connection was only temporary the downloading process will continue Which importance do you measure to CCOW Will you implement it in your application CCOW is a standard issued by the HL7 Workgroup CCOW enables contextual integration that means when you open patient XY in application A patient XY is automatically opened also in application B on the same workstation CCOW additionally offers functionality to exchange login information between different applications so that the user needs to login only once I ve not looked into this one I know that Microsoft supports a physician digital dashboard but I ve not evaluated the benefits by supporting this functionality I suppose it must be supported on both sides for instance both on the EchoPAC workstation or ViewPoint and on the web client I also suppose that this functionality will require an additional plug in on the client browser Which importance do you measure to the Health Care Professional Card HPC Will you support it in a future version of your application HPC is an individually programmed access card for healthcare pr
186. te complex a simple listing of the available functions is not seen as sufficient So first a general description of the architecture will be given followed by information about the report generated by the findings system Afterwards the archive process will be characterised and the available findings masks for different areas of medical reporting will be listed At the end a list of the available functions will be given differentiated by basic and extended functions Basic functions are part of the findings system Extended functions are connected to the Findings system but play a more supporting role in it In order to guarantee that the list is complete functions already mentioned in the architectural description will be repeated Architecture The findings are entered in structured masks Their structure and content is defined by guidelines published by respective professional societies or created in close cooperation with health care professionals In order to enable highest clarity more detailed data on specific medical objects is represented in submasks which are accessible through the main masks for example general findings on the heart would be entered in the main mask more specific information about the heart valves would be entered in a submask The content of the masks and submasks is composed of fields for different purposes for example label input field link to submask etc Input fields are of different type for example date nu
187. ted by the corresponding modules of ViewPoint 22 22 222220 121 xiv List of Tables 1 Introduction 1 1 Outline The aim of this chapter is to give a general description of the subject of this thesis Furthermore it will give reasons for why it is relevant to deal with this topic Both will be described in section 1 2 Section 1 3 will list problems which additionally motivate this thesis Section 1 4 will define clear objectives which should be achieved in the course of this thesis Additionally Section 1 5 will give a question and task definition to define a rough framework to successfully complete the thesis Finally the stakeholders of this thesis will be listed in section 1 6 to highlight their interests in it The succeeding chapter will give a description of basic principles which form the basis of this thesis 1 2 Subject and Motivation 1 2 1 Subject The ViewPoint VP image archiving and reporting system enables digital acquisition communication and archiving of single image and multi frame date and the recording of structured findings in areas of gynaecology obstetrics internal medicine and general ultrasound VP is made and supported by ViewPoint Bildverarbeitung GmbH GE Healthcare Technologies VP GE Concerning the offered functionality it can be seen as Medical Documentation System MDS and Picture Archiving and Communication System PACS inside the classes of application components HAWBO
188. ted from four instead of five votes as this feature is not available in the USA Thus the vote of WG was not counted In general no feature has been valuated with not needed meaning that at least the final version of the Web client should offer all features of the Native client This is consistent with the answers given to the question of whether the Web client should be a replacement of and no alternative to the Native client Here the majority of the respondents three out of five see the Web client as a replacement for the Native client although they valuated this feature with low significance There is one crucial limitation to the requirement that the Web client should offer nearly all functions of the Native client and could be a complete replacement of it The Web client will never be able to control and access hardware adequately as demanded by also see for details This can be reasoned by the following consideration In order to control and access hardware adequately the Web client needs to make extensive use of Web browser extensions If available at all those Web browser extensions need to use OS functions to be able to access and control hardware Thereby the Web client has a strong dependence on the supported Platforms and Web browsers Moreover only a limited number of Platforms and Web browsers could be adequately supported Apart from that there are many other disadvantages like considerable installation and configuration
189. the separation of input keyboard mouse and output devices screen from the actual computer A Terminal client retrieves and displays the screen from the Terminal server and forwards the related input actions key strokes mouse movements to it All computation like programme execution is performed on the Terminal server Each connected client is given an equal part of the server resources to do so As the server resources are partitioned to the connected users multiple users can work on the same server without interfering with each other By using the Terminal 2 7 Terminal Server 27 client the users can access the same functions offered by a workstation meaning that they can interact with the OS and execute any application component which is installed on the Terminal server for example the Native client of VP Desktop PC Desktop PC Interactively logged on user Console User Terminal Server 2 Figure 2 5 Terminal server with one local and three remotely connected users modified version of a figure taken from f In figure a Terminal server to which three users are remotely connected via Terminal clients is shown The clients are running on the three workstations which are denoted as Desktop PCs One user is directly accessing the Terminal server via its UI The UI is denoted as Console In order to continue the characterisation of the different client types as started before In case of the Terminal client all o
190. tion System HIS and tightly coupled with the Patient Management System PMS In the scope of this diploma thesis only the case in which VP is deployed inside a hospital will be considered As more and more hospitals change to a paperless HIS it is indispensable to facilitate access to image data and findings in the VP system from every workstation at every time At the moment this is only possible if a VP client is installed on the accessing workstation 1 2 2 Problem Definition The fact that VP needs to be installed on a workstation to be able to view data archived in the VP system may cause some unpleasant concomitants As the main aim of nearly every hospital is to come as close as possible to an integrated HIS the installation of a VP client on an existing workstation and the introduction of a new application component in general implies a tight coupling with other application components to realise as much integration types 127 129 as possible To start with Data Integration in short means data has to be recorded modified or deleted just once and is available wherever it is needed HAWB04 127 As VP also handles data which is redundantly stored in other application components for example 1 2 Subject and Motivation 3 patient demographics diagnoses procedures findings and image data it is inescapable to offer interfaces for electronic data exchange with other application components to enable data integration At th
191. tion for details e In order to enable the creation of different UIs from one definition like required for the Native and Web client XML based Markup languages for UI definition can be potential candidates See RS 7 1 for details 110 7 Conclusion Product analysis In order to determine how other manufacturers have realised a Web based Ul and if compared to their solutions the requirement specification set up in this thesis is adequate an analysis and comparison of several products was performed The product comparison is intended to be used as decision support for the later implementation of the requirement specification It covers nearly every requirement and is structured in a similar way see 6 2 4 for details on the comparison criteria The following products have been examined e E3 of Euroking Miracle Ltd See section for details e WebEx of GE Vingmed Ultrasound See section for details e Trium CTG Online of Trium Analysis Online GmbH See section for details The comparison of these products can be found in table 6 1 on page 95 It turned out that the requirement specification set up is adequate and should be used to implement the Web client Details on the justification of this statement on the basis of the product comparison can be found in section Terminal server As VP is already provided through a Terminal server at some customer sites the Terminal client server architecture was considered as possible altern
192. tion of WP 27 Utilisation of the Web client should also be possible if the server is protected by a Firewall HTTP and HTTPS ports are the standard ports and commonly forwarded by a Firewall Due to a restrictive security policy of the hospital it may be impossible to activate other ports 4 2 Requirement Definition 65 IV Requirements concerning data security VI RD 4 1 RD 4 2 RD 4 3 RD 4 4 RD 4 5 RD 5 1 RD 5 2 The Web client shall assure secrecy and confidentiality Rationale Elimination of WP_16 Access via the Web client to the data stored within VP must only be available to authorised users and must be protected against unauthorised access 722 The Web client shall offer sufficient means for authentication Rationale Elimination of It must be assured that each user logged into the Web client is in fact the user she he claims to be 722 The Web client shall offer sufficient means for non repudiation and accountability Rationale Elimination of It must be assured that it can be unambiguously tracked which user made which modifications of data via the Web client 722 Additionally even read only access via the Web client must be tracked The Web client shall offer sufficient means for integrity control Rationale Elimination of WP 16 It must be assured that during com munication between VP server and Web client only the original message as sent by the source is received by the destination and
193. tions of Terminal clients on Linux available which can connect to MsTS2003 corresponds to RS 21 In general it can be stated that the Native client supports MsTS2003 All of the Native client s functions are provided to the connected Terminal clients corresponds to RS 1 2 The following sites for example successfully access VP provided by MsTS2003 in everyday life e Maine Medical Center Portland Maine USA e St Vincent Hospital Indianapolis Indiana USA e Frauenklinik Kreiskrankenhaus Trostberg Trostberg Germany e Krankenh user Siegmaringen Pfullendorf und Saulgau Germany Queensland Ultrasound for Womens Brisbane Australia MsTS2003 can even connect to local hardware interfaces of the workstation running the RDC Thereby the measurement data transfer from US devices is supported Moreover the utilisation of locally connected Chip card readers scanners and printers is supported by the Native client of VP running in the RDC corresponds to RS 8 2 The only critical part when providing access to VP by the examined Terminal server is the viewing of image data especially of video sequences In general the displayed colour depth of the examined Terminal client can be reduced to accelerate the performance via a low bandwidth connection If this is done image data reviewed at the corresponding Terminal client is displayed with a lower colour depth and thus looses its medical significance This may lead to wrong decisions
194. to VP is not possible the VP Report and related image data have to be printed out see section for details and transfered According to 160 this is a transcription of data and leads to so called media cracks Apart from the typical problems which go along with the duplication of data like data inconsistency this procedure is also quite time consuming 58 3 Requirements Analysis Time consuming in so far as the transfer of the printouts via mail is concerned internal or external dependent on where the receiver is which takes considerably longer than electronic transfer Transfer via mail takes considerably longer than electronic transfer This weak point is illustrated by figure WP 11 No access integration guaranteed causing transcription of data and media cracks Remote Location Hos pital Functional Diagnostic Unit q A al PMS z B ISxH COMB 2 8 Pacs E Server a ia Server Server AN Simar i l aan I IS Sees m DICOM US et machine Workstation gt lt E n 7 rynning VP w __ AR pa Be feo pte i ative Client ie Outbox a le A Outbox u IE Printer A YA 3 E u ae a A Mail HA EA 3 US device without qo A e Mail e ps E rm In DICOM Inbox Inbox Scanner support uy Figure 3 13 Physical tool layer of the 3LGM model showing the current integration degree of ViewPoint within the hospital information system 3 4 2 3 Pr
195. tside the hospital 5 2 3 Identification of Platforms and Browsers which Should Be Supported by the Web Client In RD 2 1 and RD 2 2 it was postulated that the Web client should support as few Platforms OS versions and Web browsers as are needed to allow access from all application components where access to VP is required The task resulting from this requirement is to identify all Platforms OS versions and Web browsers which are used at application components where access to VP is needed Application components where access to VP is needed have been identified in section 5 2 2 It is clear that for accessing VP a computer is required at the local or remote site Normally most of the sites are already equipped with computers which are required to run other application components like PMS or CDMS The questions at hand are which type of Platform is each computer and which OS version and Web browser is installed First it was tried to find convenient statistics about the market shares of Platforms OS versions and Web browsers used in the healthcare sector Several sources were consulted 5 2 Research of Open Issues 73 like the Federal Statistical Office Germany the German Institute of Medical Documen tation and Information PubMed and the IEEE Computer Society Digital Library but nothing useful was found In the second attempt it was tried to find out what market shares the Platforms OS versions and Web browsers have
196. two application component types it is crucial to note that in case of VP the diagnose is created from the acquired image data and thus only findings 3 2 Current Functionality of the Native ViewPoint Client 33 and image data in combination have medical significance So for the user it is most preferable to have access to both data types findings and image data at once and through one application component In order to now describe the actual functions of a VP client the different modules of VP will be analysed Their availability to the user is controlled by licensing client specific license defines which modules are available to the client or by rights guaranteed to the currently logged in user user specific rights define which modules and functions are available to the user VP has its separate user management All listed modules are accessible via the main programme and will open in the same window except for the system administration module VPAdmin which is a separate programme As the functions and usage of each modules and submodules are closely related a 100 percent clear distinction cannot be made The partitioning given here is mostly based upon the original requirements specification of VP version 5 0 and the former requirements specification of VP version 3 31 Psc02 Special emphasis was placed on making a novice acquainted with the different features offered by each module and with how the modules and features are inter
197. ucture The static view includes all the traditional data structure concerns as well as the organisation of the operations on the data The static view will be utilised in section 3 2 8 1 to give a simplified model of the database structure of VP The tool Enterprise Architect 6 1 of Sparx Systems Pty Ltd has been used to create the UML models It was used as it is the product of choice at VP GE for the creation of any kind of UML model 2 3 2 3LGM Meta Model The following subsections are a summary of several papers and book extracts which should be consulted for further reading If appropri ate the descriptions are literal citations taken from the documents Otherwise the actual text was shortened or paraphrased still reproducing the ideas and opinions of the authors 2 3 2 1 Introduction A HIS is composed of heterogeneous paper and computer based subsystems and thus highly complex Before the 3LGM was created no sufficient means to model a HIS as a whole and to show the dependencies between the subsystems existed Especially for reasons of planning directing and supervising a blueprint or model of the HIS is indispensable WBWO3 On account of these needs the Three Layer Graph Based Meta model 3LGM was created by the IMISE to model HIS adequately The Meta model is based on the UML and aims to support the systematic management of a HIS as well as the quality assessment of information processing in hospitals HAWB04
198. und at http www sph sc edu comd rorden dicom html links or at http dicom online fr fr dicomlinks htm LOGIQworks FX and Voluson 4D View which are utilised by the image gallery submodule are also candidates which require Web browser extensions As stated above due to their complexity they will not be discussed in this thesis In RD 3 1 it was postulated that the Web client should keep the needed bandwidth as low as possible In RD 3 3 it was postulated that the Web client should perform and respond in such a manner that the user is not hindered in doing her his actual work These two requirements can also be fulfilled by using Web browser extensions to reduce the data 5 2 Research of Open Issues 77 which is exchanged between client and server to react to user interactions It should for instance be checked if the data entered in a Web page by the user is in the right syntax By using standard Web browser functionality data entered by the user at the client is sent to the server in a so called commit activity There it is validated and if the syntax is wrong the related Web page is sent back to the user containing the original data and some kind of warning message This behaviour is common for banking or shopping Web sites on the Internet So for the simple purpose of syntax checking the data entered by the user is sent to the server and the complete Web page is retransmitted to the client causing actual dispensable network traffic
199. up of the HL7 Committee The Clinical Context Object Workgroup is sometimes also denoted by the term CCOW See section for details Official Web site http www h17 org au CCOW htm Digital Imaging and Communications in Medicine DICOM The term Digital Imag ing and Communications in Medicine denotes a standard used to handle transfer and store medical images and related information It is issued by the National Electri cal Manufacturers Association NEMA Official Web site http medical nema org Health Level Seven HL7 The term HL7 denotes a set of standards for information interchange in health care The standards are issued by the Health Level Seven Inc which is also called HL7 Committee Official Web site http www h17 org HCM HCM is a proprietary standard of SAP AG for information interchange in health care Official Web site for more information http www sap com Clinicom Clinicom is a proprietary standard of Siemens Medical Solutions for information interchange in health care Official Web site for more information http www SAP Remote Function Call SAP RFC SAP Remote Function Call is a proprietary standard of SAP AG for information interchange in general Official Web site for more information http www sap com 2 2 4 Relevant Application Components in Hospital Information Systems Clinical Documentation and Management System CDMS The Clinical Documenta tion and Management System is a computer b
200. upport Internet Browser 5 5 or above gt NHS Microsoft coop Which adjustments modifications has the user to make to the default browser configuration like turning JavaScript on or installing plug ins like Java or Macromedia Flash Install Activate Java Virtual Machine nothing else Are there any limitations concerning the platform on which the browser runs Only MS Windows gt NHS Microsoft coop In case there is a firewall between server and client which ports have to be open e g is it sufficient to have only port 81 for http open Or in other words which protocols do you use http or https port Which is the minimum bandwidth required for client server communication up download They advise the customers to have 100 Mbps for optimal performance and real time data entry lower connections should be possible they also have houses working with 10 Mbps but as soon as the network is busy performance problems occur one customer even got a working connection with GPRS To which version of XHTML HTML JavaScript etc is the web interface conform Did not know the exact Version standard HTML like supported by IE Which kind of data is distributed via the web sever Text images videos etc Every file type can be linked in a patient record file management system no DICOM functionality What happens if the network is congested or the connection lost Major issue as E3 is completely web based they have no sufficien
201. uration This implies that VP s Web client might also need some modifications Still it is essential to keep the connected efforts for setup and maintenance of the Web client as low as possible as demanded by RS 5 1 and RS 5 2 6 2 Product Analysis and Comparison 97 Otherwise the Web client would not offer any outstanding advantages to the Native client The applicability of the analysed products is mostly limited to the Intranet of a hospital Only WebEx explicitly states that it is also designed for Internet usage Still the other products can be accessed from remote places as well The corresponding approach is to offer dial in facilities for remote users so that they can connect to the Intranet and thereby have access to the related application component Here the responsibility of preventing unauthorised access is in the hands of the hospital and the manufacturer does not need to secure its product for Internet usage On the Intranet all products utilise simple user credentials like username and password for authorisation and authentication purposes In order to guarantee accountability WebEx and Trium CTG Online are logging the user s activities The standard technology to assure the integrity of the transmitted data is to use SSL encrypted network connections The requirements specified by RS 4 1 RS 4 2 RS 4 3 and RS 4 4 have been acknowledged by the analysed products The Web client of VP should however offer more adv
202. w version of the software product is issued the clients have to be rein stalled or updated Once installed in most cases user data is the only type of data which is ex changed between the client and the server e Interactive Clients are most responsive as the logic responsible for the Ul is controlled and executed on the client side Only parts of the Ul can be updated quickly based upon user interactions In general application screens are dynamical and predictable A1b03 e Rich Interface Components Clients offer access to all components of the Platform as they are native A1b03 Users feel at home as the client s interface works like those of other applications on their OSs A1b03 2 6 2 Web Client A Web client is a UI which is Web based and displayed by a Web browser Web browsers are available for all platforms They utilise only few OS functions like accessing the local file system and offer no means to control the local hardware of a workstation In most cases the UI s layout and underlying business logic of the UI is defined created and processed on the server side and made available in form of a so called Web page to the client During startup and runtime of the Web client Web pages containing user and control data are exchanged between the client and server Originally only static Web pages have been stored on the server called Web server With the utilisation of scripting language
203. while switching between appli cation components on one workstation 128 Although a standard for context integration published by the Clinical Context Object Workgroup CCOW exists it is implemented by very few manufacturers and not yet supported by VP Now to focus on a more technical view VP needs an adequate soft and hardware equip ment to enable a smooth trouble free and user friendly programme execution Although the installation and maintenance of a VP client is comparatively simple every extra client is connected with additional expenses Especially when implementing an integrated HIS the number of potential clients will compulsorily increase For the IT department that means that every extra client is a new software component and in case the client is installed on a new computer also a new hardware component which is placed in their area of responsibility The client has to be maintained and its users have to be adequately supported If the hard and or software equipment is not sufficient it has to be upgraded which beside extra costs may cause compatibility problems with other application components Furthermore it is clear that with a growing number of workstations running VP the probability for inevitable hard or software errors will also increase accordingly As already mentioned in the section above about access integration the non existence of access integration compulsorily leads to media cracks in which the storage media
204. work connection may be lost Additionally there is a JavaScript popup window guiding the user to fix the error 7 8 9 10 Which importance do you measure to CCOW Will you implement it in your application CCOW is a standard issued by the HL7 Workgroup CCOW enables contextual integration that means when you open patient XY in application A patient XY is automatically opened also in application B on the same workstation CCOW additionally offers functionality to exchange login information between different applications so that the user needs to login only once I haven t heard about this standard before There are currently no integration plans Which importance do you measure to the Health Care Professional Card HPC Will you support it in a future version of your application HPC is an individually programmed access card for healthcare professionals This card is used to assign read and or write access to specific data fields on the patient card The chip stores the doctor s ID read and or write access rights and a digital signature for secure data transmission In general it could be used for authorization and authentication of the application user Starting with the German Heilberufeausweis this technique may get an enormous distribution Future versions may support HPC Is it possible to work offline and to reconnect No Wouldn t make much sense because of the type of application If you would red
205. ws and Microsoft Internet Explorer The description given here is only meant to give a brief idea of VP running on the Terminal server MsTS2003 Additionally it will be presented to which extend this solution fulfils the requirements specification set up in section A detailed analysis and evaluation would go beyond the scope of this thesis As mentioned above the company Citrix offers also Terminal server solutions They pro vide more sophisticated functionality like the support of CCOW or an optimised protocol for low bandwidth connections Citrix s solutions should also be examined as alternative Terminal server However they were not considered in this thesis 6 3 2 Web Client vs Terminal Client Following the future Web client implemented on the basis of the given requirements specification will be compared to the Terminal client server solution described in section The considered Terminal server is MsTS2003 Both solutions will be compared on the basis of the specified requirements Table 6 2 Comparison of Web Client vs Terminal Client Requirement Web Client Terminal Client General requir ements fulfilled fulfilled via RDWC fulfilled fulfilled fulfilled fulfilled browser exteni ons Requirements concerning supported Platforms We b browsers and required Web There are also Plug ins available which enable the use of Activ
206. xt Transfer Protocol E Hypertext Transfer Protocol Secure IDE IIS image data 118 0 62 B 57 65 80 55 65 63160 70 4 90 7 IMISE Institute for Medical Informatics Statistics and Epidemiology p Integrated Development Environment Integrated Services Digital Network Intel Inter Layer Relationships Internet A 59 60 73 75 EI 53105 Do Intersystems Cache Intranet ISDN Java Java Applet Java Script Java Virtual Machine JPEG 23 75 59 BT 3 JVM ER E Microsoft Microsoft Access Microsoft Active Server Pages NET Microsoft DirectX Microsoft Excel Microsoft Internet Explorer 75 78 84 88 91 93 94 PSHT 106 Microsoft Internet Information Service Microsoft Remote Desktop Connection Client 98 Microsoft Remote Desktop Web Connection Microsoft Server 2003 Terminal Services 99 Microsoft SQL Server Microsoft Visual Studio NET Microsoft Windows 9 73 74 78 841186 83 91 93 94 96 9S 100 106 108 Microsoft Windows Fax Server Microsoft Word Mozilla Mozilla Foundation MPEG 1 MPEG 4 MsTS2003 National Health Service Native Client Netscape NHS ODBC Open DataBase Connectivity Open Source OpenSA Opera 118 Index Operating System 94 74 OS 9 PACS Patient Data Management System patient demographics E Patient Management System 9 Z9 152160 7217518
207. y be dis abled by a Firewall 3 4 3 2 Points to Be Considered for a Web Client as an Alternative Ul to VP The Ul of a Web client for VP has to be defined The Ul definition of the Native client is in proprietary language see section for details and cannot be used instantly to define the Web based UI So in the worst case two UI definitions exist which keep redundant data and have to be maintained if changes in their content occur WP 28 High risk of inconsistency if the UIs of the Native client and the Web client are defined separately WP 29 Additional maintenance efforts required if the UIs of the Native client and the Web client are defined separately VP owns image data whose quality integrity and medical significance have to be preserved WP 30 Critical image data to be handled appropriately VP GE quality assurance and fast version release rely strongly on automatic testing Before the official version is released most tests are performed automatically by test tools WP 31 UI of VP is tested automatically by scripts and other testing tools The Native client of VP interacts with a variety of hardware devices The following listing shows the corresponding devices and the used hardware interface to control and access it e Printer parallel or USB port as described in section 3 2 8 4 Chip card reader serial or USB port as described in section and 3 3 1 8 Framegrabber PCI slot as described in section 3 2 8 3 and 3 3
208. y complicated procedure in which the user has to perform multiple logins until she he is able to use VP corresponds to RS 6 1 and RS 6 2 Additionally MsTS2003 RDC and the Native client of VP do 100 6 Technology Comparison not offer any means to synchronise the patient context apart from supporting CCOW corresponds to RS 6 3 and RS 6 4 Since MsTS2003 SP1 the RDC can connect to the server over an SSL encrypted connection So means for Integrity control are also offered corresponds to RS 4 4 The protocol which is used for communication between MsTS2003 and RDC is called Remote Desktop Protocol RDP It utilises port 3389 by default which is not a standard port corresponds to RS 3 4 The Terminal client RDC is by default included in Microsoft Windows XP On other Mi crosoft Windows versions it can be added It is a single executable file which does not have to be installed In case a new version of RDC is issued it can be exchanged So the Terminal client demands a minimum of installation and maintenance efforts apart from the setting up and administrating VP on the MsTS2003 corresponds to RS 5 1 and 52 As the Native client is provided by the Terminal server no new UI will be created Thus RS 7 1 RS 7 2 RS 7 3 and RS 7 4 are irrelevant 3 Remote Desktop Web Connection Microsoft Internet Explorer File Edit view Favorites Tools Help Q Back a search Se Favorites e Media or Ei Address

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