International Journal of Hybrid Information Technology
Vol.8, No.4 (2015), pp. 201-212
http://dx.doi.org/10.14257/ijhit.2015.8.4.23
CloudeMR: A Cloud Based Electronic Medical Record System
Olutayo Boyinbode and Gbenga Toriola
Department of Computer Science,
Federal University of Technology, Akure, Nigeria
[email protected]
Abstract
The utilization of modern information technology in the delivery of healthcare is to
enhance the availability and reliability of improved healthcare services to patients at a
reduced cost. The alternative in this context is to outsource the computing storage
resources with the help of cloud infrastructure. The drastic reduction in the cost of
healthcare services, utilization of resources, maintainability and the adoption of new
technologies are some of the benefits that healthcare centers in rural areas can get from
cloud-based medical information system. Also, new prospects such as easy and everpresent access to medical records and the chances to make use of services of physicians
that are not readily available in the rural areas are some of the opportunities offered by a
cloud-based medical information system. This paper proposes and implements a cloudbased electronic medical record (CloudeMR) system to improve the delivery of healthcare
system in the rural communities of Nigeria.
Keywords: Cloud computing, Electronic medical record, HealthCare Information
Systems, ICT
1. Introduction
The healthcare industry in Nigeria has not been able to tap into the full potential of
modern information technology to improve on healthcare delivery [7]. Accesses to
patients’ longitudinal records are often times difficult and cumbersome. The lack of
proper access has cost the healthcare industry a huge fortune every year due to duplication
and waste [7]. This is just one of the many challenges facing the healthcare industry.
Cloud computing technology has received tremendous attention in recent years. In
simplest terms, cloud computing can be defined as a form of computing where shared
resources, software, infrastructures and information are delivered to computers and other
devices through network or an internet. The accesses to information or network shared
resources are not limited by the user’s physical location. Therefore, vital resources and
people are connected irrespective of where they are around the world, provided there is
network connectivity [3, 4].
The ability of cloud computing to facilitate the exchange of medical information
between the healthcare stakeholders such as the pharmacist, doctors and all other
healthcare institutions that are geographically isolated can help to modernize healthcare
services [9]. Privacy, confidentiality, security and regulation problems have however
curtailed the immediate adoption and implementation of cloud computing in the
management of healthcare system. One of the reasons for the slow adoption rate is the
inability to guarantee if the data are fully secured. Kuo [9] and Malin [10] stated that
societal stigmatization and isolation may for instance cause some HIV and mental health
patients to want their medical information to be strictly confidential.
Healthcare industry has recorded a significant improvement in the last two decades
through advancement in information technology. Despite all success recorded, there are
still concerns in many areas that affect almost every individual in the industry, and
ISSN: 1738-9968 IJHIT
Copyright ⓒ 2015 SERSC
International Journal of Hybrid Information Technology
Vol. 8, No. 4 (2015)
especially the patients who are direct beneficiary of all the successes also bear the brunt of
lapses in the system. Some of the problems can be classified as lack of access to patient’s
medical records [7], limited medical personals in rural areas, high mortality rate [1]. The
goal of this paper is to design and implement a cloud-based electronic medical record
system that can be used to effectively manage the sharing of medical information.
2. Related Works
The utilization of modern information technology in the delivery of healthcare is to
enhance the availability and reliability of improved healthcare services to patients at a
reduced cost. There exists a handful of published research that uses the adoption of cloud
computing as a dependent variable to explore healthcare industry characteristics that are
associated with the implementation of these technologies.
Padhy, et al. [14] designed and presented the implementation of a cloud-based
healthcare information system model for rural communities; this system makes use of a
cloud central server that accepts virtual machines as tenants. The tenants are secure
facilities that store information in different healthcare centers. The configuration and
connectivity of the system is based on the cloud data center location and the policy of the
service provider. The internet is the main link of communication between the rural
healthcare center and the service provider. It also maintains the network traffic between
the physical resources and the cloud. The authentication server uses the authentication and
authorization mechanisms. The system can be used by other applications and across
various devices to share information in near real-time situation effortlessly. However,
there is no fail-safe mechanism in the model to ensure system reliability and availability.
Also, small hospitals and private physicians do not have the IT requirements to support
the technologies deployed in the system.
Saif, Wani, & Khan [17] proposed a system of engineering network solution for data
sharing solution across healthcare providers for protecting patients’ health information in
an Electronic Health Record (HER) system. This system was implemented on a rolebased and signature-based delegation. The signature-based delegation provides a secure
avenue for basic delegation and revocation, while the role based delegation yields
dynamics in the face of delegates’ status, availability and change. In addition to this, basic
access control based on public key encryption techniques was also implemented. This
ensures the sharing of data and also that the privacy of patients’ data is protected across
all collaborating healthcare centers but the introduction of proxy sign-in in the system
exposes it to another high security risk.
An approach based on utility computing and Wireless Sensor Networks (WSN) was
proposed by [16]. Wireless Sensor Networks (WSN) uses sensors that can be worn to
gather vital indications that enable the easy collection and distribution of information to
and from any mobile device. These two computing features were combined to develop a
system that automates the collection, input and analyses patients’ critical information
through network of sensors connected to installed medical devices, which in turn deliver
the records to the health center’s cloud for storage, processing, and distribution. Medical
specialists can use the information collected to monitor and observe patients anywhere
through the internet (on a computer or mobile devices). The system makes use of micro
controllers to evaluate data collected. However, there was no provision made for the
confidentiality, integrity and privacy of patient data in this system. Also, the design has a
complex architecture which may be difficult to implement in developing societies due to
lack of infrastructural facilities.
Another mechanism designed to ensure a trusted communication between different
health information systems was presented by [15]. This system uses an advanced cross
platform model which incorporates national and regional security domains via an interdomain zone. Interoperability service and a common security service are offered by this
202
Copyright ⓒ 2015 SERSC
International Journal of Hybrid Information Technology
Vol.8, No.4 (2015)
zone to all the connected domains. The function of the platform is to provide security
services that are centrally managed for a cross-organizational predefined communication.
The fundamental security services of this cross-platform domain are to bridge security
policies, identification and authentication of users crossing the domain, certification
services, auditing services and management of static privileges. Public Key Infrastructure
(PKI) services were used on the platform to enable external users from the public to gain
access to any of the EHRs inside the connected domains. However, this mechanism lacks
harmonized legal and ethical framework, common security standards and trans-border
communication security services.
However, all these previous researches either lack legal, security and privacy of
patient’s data or the system is too complex to implement. Also the reliability and
availability of the system cannot be guaranteed. This study differs to every other works
considered by taking into account all the lapses to design a robust, yet simple and
effective electronic medical record (EMR) system that will ensure security, privacy,
reliability and availability of patient’s records. This system can easily be implemented in
small hospitals and by private physicians, without running afoul of the existing healthcare
legislation and regulations.
3. Healthcare Information System (HIS) – A Nigerian Case Study
Advancements in technology made in the world especially in the last two decades have
altered the entire scenario in every sector of the economy. As the healthcare sector
continues to be one of the most expensive and crucial sectors in the economy, Health care
system in Nigeria is currently in a comatose state, there is a high rate of preventable and
curable diseases such as maternal mortality, diabetes, high blood pressure and other
controllable diseases. The Nigerian government is yet to improve the health care delivery
through the use of technology [1, 2].
According to Okeke [12], a lot of Nigerian patients seeking medical treatments are
being forced to patronize the traditional medical practitioners and patent dealers of
medicine due to the lack of access and high cost of modern healthcare facilities. The rich
and wealthy in the society rather embark on medical tourism abroad to get medical
services, because of scarcity of experienced medical personnel [11].
Ayeni, et al. [1], also pointed out that there is Zero level of significance in EMR based
hospitals because only less than 10% of Nigerians can afford it and most of these EMRs
are remotely located in hospital’s infrastructure rather than moving it to the cloud. There
is need for (EMR) Electronic Medical Records to be moved to the cloud to allow
Nigerians have easy access to health care delivery.
4. Benefits of Healthcare Information Systems (HIS)
The workflow among the various healthcare entities is improved upon by the
healthcare information system and also, patient’s access to healthcare increases [13, 19].
The communication between organizations and stakeholders is facilitated by the
application information and communication technologies. ICT helps to improve on the
seamless workflow among people and the organization; effective processes can also be
achieved through efficient and effective interactions [21]. Weiner [23] stated that network
effectively among themselves with the use of electronic health technology, by allowing
the review of patient’s treatment online and to accurately prescribe the necessary drugs.
Keenan et al. [8] discovers that the care given to patients is enhanced and also the daily
work of the physician has improved: (a) the turn-around times of medication fell from
5:28 hours to 1:51 hours; (b) the procedure completion times of radiology fell from 7:37
hours to 4:21 hours; and (c) the reporting times of lab results fell from 31:3 minutes to
23:4 minutes. In the same study, errors in orders due to transcription declined, and the
length of stay in hospital decreased. The online monitoring of vital signs, improved
Copyright ⓒ 2015 SERSC
203
International Journal of Hybrid Information Technology
Vol. 8, No. 4 (2015)
physicians’ collaboration in patient care and multi-site review of patients records are the
other benefits of electronic medical records systems. EMR speed up the access to
medication administration records easily, and the ease by which consultation reports are
shared, the decreased time taken to transmit test results are parts of the benefits of
healthcare information system [8].
The errors recorded in diagnosis and the administration of drugs decline with the
introduction of electronic healthcare information system. Fuji and Galt [5] opined that in
the United States, over 1.5 million residents suffer injuries that are related to error in
prescription and other medical complacencies yearly, the authors suggested that the
figure could as well be a fraction of the total patients that suffers adverse medical errors,
especially when patient’s own mix-up is considered. They deduced that some parts of the
healthcare information systems increase participation of patients in the care process,
thereby reducing all forms of medical and prescription errors.
Healthcare facilities are accessed between the urban and the rural communities with
great disparity due to the heterogeneous nature of the Nigerian society. The introduction
of healthcare information system can help to bridge the gap [13]. Also, the clinical data
captured by clinical information system helps to improve on the clinical decision making
of the physician on patients care [22, 24]. Policy makers in healthcare that seeks ways to
improve the quality of healthcare at some reduced cost can also leverage on the healthcare
information system to deliver the inexpensive healthcare [18, 20].
Woodside [25] agrees that electronic exchange of patient’s records between physician
and pharmacist can help to protect the patient by detecting the prescription of drugs
combinations that are not compactible, stating potential allergens to patients. One very
important benefit of the electronic exchange is Insurance verification. Lots of healthcare
providers do not have means of verifying insurance claims by patients; some just provide
care without getting assurance from the patient’s insurance company. All these issues are
solved with the use of electronic exchange between the healthcare entities. Delays in
approval process and healthcare services are reduced.
Clinical time optimization as a result of effective communication and also the
increased level of compliance with guidelines are some of the other benefits of healthcare
information system [6]. Medical students and resident doctors can benefits from the
effective educational tools provided by the EMR system, the healthcare information
technology also offers a very strong potential in clinical protocols and research
development [8].
5. System Design and Implementation
5.1. Design Methodology
This section introduces the design methodology of the cloud based electronic medical
record system.
Design Considerations
i. Cloud-based EMR: To pool different healthcare IT resources into large clouds so as
to be able to share records easily.
ii. Authentication: Security is achieved through the use of username and passwords.
5.2. Architecture of the System
The architecture of the cloud-based electronic medical record system is presented in
Figure 1. The system consists of two major components which are: the cloud-based
system and the e-health web portal.
204
Copyright ⓒ 2015 SERSC
International Journal of Hybrid Information Technology
Vol.8, No.4 (2015)
Figure 1. Architecture of a Cloud-based Electronic Medical Records System
5.3. The Cloud-Based System
This system consists of (a) a Central Database Server, (b) a Unifier Interface
Middleware (UIM) and (c) an Authentication Server.
(a) The Central Database Server
This server acts as the unifying data repository for all the collaborating hospitals. The
cloud datacenter holds the central database server as the information bank which stores
electronic medical records and also retrieves patient information. The data is stored in a
unified standard layout which can be retrieved from the collaborating hospitals’ Web
Portal system through the Unifier Interface Middleware (UIM).
(b) Middleware
This part of the cloud provides a common platform for all the EMR systems of the
collaborating hospitals. The middleware has an interface that covers the heterogeneity of
all the collaborating hospitals EMR standards, to ease the communication process
between the Central Database and hospitals’ systems. The middleware remains in the
cloud and recognizes any type of EMR standard it interacts with. It communicates with
each collaborating hospitals via network connections. Therefore, each hospital does not
need to have its own separate interface mask in order to benefit from the cloud; all it
needs is just an interface.
(c) Authentication Server
This part of the system handles authentication and authorization. The authentication
verifies if an entity using the system has the right to perform the intended action such as
(updating, retrieving, transferring, etc.) on the medical information provided. It grants
access to authorized users and denies unauthorized users access to the records or
resources on the system. The system generates usernames and passwords for doctors (or
other members of staff) of the sharing hospitals that will serve as part of the admin. All
Copyright ⓒ 2015 SERSC
205
International Journal of Hybrid Information Technology
Vol. 8, No. 4 (2015)
the members of the admin are expected to log in to the system with their username and
password. The system compares the username and password with those in the local
database and grants access to the user if they match, otherwise, the user is denied access.
5.4. The E-Health Web Portal
The e-health web portal is the front end of the whole cloud system, and the part of the
cloud (top layer) that provides the application - Software as a service (SaaS) for the EMR
system. The proposed cloud system presents a web portal configured for end users
(authorized doctors, clinicians and the hospitals administrators who serves as the cloud
administrator) to navigate through the central database and the whole EMR system. The
web portal communicates by sending messages and receiving response messages between
the middleware and the hospital system. For each sharing hospital in the cloud, the web
portal provides the user two ways to access the database, one for accessing the hospital’s
local EMR system, and the other for joining the cloud central database.
Every authorized user (cloud administrator) can retrieve, update and receive medical
information from the cloud’s central database through this web page with some degree of
restrictions which depends on the end user’s privileges. The web portal also shows where
the information of a particular patient from a specific hospital resides, whether in the
cloud or on the target hospital system and can decide to view medical information about
the patient or even copy the information into its local database from the collaborating
hospitals connected to the cloud.
Each collaborating hospitals allow its administrator and doctors to have different view
of the patient’s record in the database. The administrator can see the number of doctors
and patients in the hospital and can also view their details. Only the bio-data of the
patients will be displayed to the administrator and not the result of the different diagnosis
and doctor’s report, this will ensure some level of privacy to the patients. Such
information can be viewed only by the doctors.
The application was developed with macromedia Dreamweaver and Wamp server
technology, HTML, JavaScript, PHP and CSS and MySQL for data storage.
6. Implementation and Results
The implementation and testing of the system was carried out using five personal
computers and one server with internet facilities meeting the minimum software and
hardware requirements. The five computers represent five different hospitals
collaborating on the use of resources and sharing information. When the application is
launched by the administrator, the administrator login page or authorization interface
comes on. The hospital’s administrator seeking authorization enters his username and
password in their respective columns in order to gain access into the system; it compares
the details with those of the administrator in the database and the system grants access to
administrator, the login interface is shown in Figure 2.
206
Copyright ⓒ 2015 SERSC
International Journal of Hybrid Information Technology
Vol.8, No.4 (2015)
Figure 2. Login Interface for Administrator
If access is granted for an authorized user (administrator), it leads to another interface
that displays the summary of doctors and patients in the hospital as shown in figure 3, the
administrator also have the option of adding a new patient to the database or to add a new
doctor, to view details (bio-data) of existing patients and doctors.
Figure 3. Login Access Interface for an Authorized Administrator
However, if an unauthorized user attempt to gain access into the system by entering
incorrect details (i.e. incorrect username and password); the system denies such user the
access as shown in Figure 4.
Figure 4. Unauthorized User Denied Access
A cloud administrator can also copy records of patients not in the local database from
the cloud into their system. Patients find themselves in different hospitals at any time for
Copyright ⓒ 2015 SERSC
207
International Journal of Hybrid Information Technology
Vol. 8, No. 4 (2015)
different reasons, they can tell the administrator to get a copy of their record that resides
in database of their last or former hospital from the cloud. Figures 5 and 6 shows the
interface where the cloud administrator copies record from the former hospital.
Figure 5. Cloud Administrator Interface to Copy Patients Record
Figure 6. Patients Record Transfer Section Interface
When the application is launched by the doctor, the doctor’s login or authorization
interface comes on. The doctor seeking authorization enters his username and password in
their respective columns in order to gain access into the system; it compares the details
with those of the doctor in the database and the system grants access to doctor, the login
interface is shown in Figure 7.
Figure 7. Login Interface for Doctors
208
Copyright ⓒ 2015 SERSC
International Journal of Hybrid Information Technology
Vol.8, No.4 (2015)
If access is granted to the authorized user (doctor), it leads to another interface that
welcomes the doctor and provides tab to view patients in the hospital’s record as shown in
figure 8, if the doctor clicks on the “view patient” tab, a page comes on that displays the
list of all the existing patients in hospital’s database. Against each patient’s name are two
tabs; “diagnose patient” and “view full details”. The “view full details” tab allow doctors
the view of only the bio-data of the patient, however, the “diagnose patient” tab displays
both the bio-data and the result of previous diagnosis of the patient. Also, there are
columns where laboratory, radiology and pharmacy information can be entered to
generate a new diagnosis report as shown in Figures 10 and 11.
Figure 8. Home Page Interface That Welcomes the Doctor
Figure 9. Interface Showing the List of Existing Patients
Figure 10. Diagnose Patient Interface
Copyright ⓒ 2015 SERSC
209
International Journal of Hybrid Information Technology
Vol. 8, No. 4 (2015)
Figure 11. Diagnose Patient Interface
7. Conclusion
In this paper, a complete, robust and efficient cloud-based EMR system has been
designed and implemented. Cloud computing has been identified generally as the next big
deal in computing infrastructure and it offers some benefits by allowing the use
infrastructures like networks, storages, and servers, software such as application programs
and platforms like operating systems and middleware services. Adapting the cloud
technology to medical record management, reduces the cost of healthcare delivery
through reduce administrative bottlenecks. The convenience this kind of system will give
to physicians, patients and hospital administrator especially in developing world cannot
be quantified. With time, it is hoped that hospitals, health care regulatory bodies and the
Health ministries in Nigeria will take advantage of innovations that are becoming
available through internet solutions to improve healthcare system. It is also hoped that
synergy among health care stakeholders will produce results expected from health care
organizations.
References
[1] E. Ayeni and O. Oladoyinbo, “Overcoming barriers of electronic health records and effective health
care delivery system in Nigeria using socialized medicine”, (2014).
[2] A. Benson, “Hospital Information Systems in Nigeria: A Review of Literature,” The Journal of Global
Health Care Systems, vol. 1, no. 3, (2011).
[3] R. Buyya, C. S. Yeo and S. Venugopal, “Market-Oriented Cloud Computing: Market Oriented Cloud
Computing: Vision, Hype, and Reality for Delivering IT Services as Computing Utilities,” Proceedings
of the 10th IEEE International Conference on High Performance Computing and Communications. Los
Alamitos (2008).
[4] G. Fernández, I.T. Díez and J. Rodrigues,” Analysis of the cloud computing paradigm on mobile health
records system,” Proceeding of the 6th international conference on innovative mobile and internet
services in ubiquitous computing, July 2012, Palermo, Italy. ISBN: 978-1-4673-1328-5, (2012), pp. 927932.
[5] K. T. Fuji and K. A. Galt, “Pharmacists and health information technology: Emerging issues in patient
safety,” HEC Forum, vol. 20, no. 3, (2008), pp. 259–275. doi:10.1007 /s10730-008-9075-4.
[6] A. Georgiou, J. I. Westbrook, J. Braithwaite and R.A. Iedema,” Multiple perspectives on the impact of
electronic ordering on hospital organizational and communication processes,” Health Information
Management Journal, vol. 34, no. 4, (2009), pp. 130-135.
[7] Hitachi Data Systems, “How To Improve Healthcare With Cloud Computing,” WP-429-A DG (2012),
May.
[8] C. R. Keenan, H. H. Nguyen and M. Srinivasan, “Electronic medical records and their impact on
residents and medical student education,” Academic Psychiatry, vol. 30, no. 6, (2006), pp. 522-527
doi:10.1176/appi.ap.30.6.522.
[9] M. H Kuo, “Opportunities and Challenges of Cloud Computing to Improve Health Care Services,” J Med
Internet Res;13(3):e67-Hankel type involving products of Bessel functions,” Phil. Trans. Roy. Soc.
London, vol. A247, (2011), pp. 529–551
210
Copyright ⓒ 2015 SERSC
International Journal of Hybrid Information Technology
Vol.8, No.4 (2015)
[10] A. B. Malin, E. K. Emam and C. M. O'Keefe, “Biomedical data privacy: Problems, perspectives, and
recent advances,” Journal of the American medical informatics association, vol. 20, no. 1, (2013), pp. 26.
[11] L. C. Okafor-Dike, “The effect of leadership on economic development: A case study of Nigeria,”
(Doctoral dissertation).
[12] J. O. Okeke, “Shortage of health professionals: A study of recruitment and retention factors that impact
rural hospitals in Lagos state, Nigeria,” (Doctoral dissertation).
[13] S. Ouma and M. E. Herselman, “E-health in rural areas: Case of developing countries,” International
Journal of Biological and Life Sciences, vol. 4, no. 4, pp. 194-200,
[14] R. Padhy, M. Patra and S. Satapathy, “Design and Implementation of a Cloud based Rural Healthcare
Information System Model,” UNIASCIT, vol. 2, no. 1, (2012), pp. 149-157.
[15] R. Pekka,” A Cross Platform Model for Secure Electronic Health Record Communication,” International
Journal of Medical Informatics, pp. 291–295.
[16] C. Rolim, F. Koch and C. Westphall, “A Cloud Computing Solution for Patient’s Data Collection in
Health Care Institutions,” Network and Management Laboratory, (2010).
[17] S. Saif, S. Wani, and S. Khan, “A Network Engineering Solution for Data Sharing Across Healthcare
Providers and Protecting Patients,” Health Data Privacy Using EHR System, Journal of Global Research
in Computer Science, vol. 2, no. 8, (2010).
[18] D. Sammon, K.A. O’Connor, and J. Leo, “The patient data analysis information system: Addressing data
and information quality issues,” The Electronic Journal Information Systems Evaluation, vol. 12, no. 1,
pp. 95-108
[19] P. G. Shekelle, S. C. Morton and E. B. Keeler “Costs and benefits of health information technology,”
Evidence Report Technology Assessment, vol. 132, pp. 1-71.
[20] S. R. Simon, M. L. McCarthy, R. Kaushal, R. Jenter, C. A. Volk, L. A. and E.G. Poon, “Electronic
health records: Which practices have them, and how are clinicians using them?,” Journal of Evaluation in
Clinical Practice, vol. 14, no. 1, (2008), pp. 43-47. doi:10.1111/j.1365-2753.2007.00787.
[21] L. C. Sisniega, “Barriers to electronic government use as perceived by citizens at the municipal level in
Mexico,” (Doctoral dissertation).
[22] M. M. Ward M. Jaana, J. A. Bahensky, S. Vartak and D. S. Wakefield, “Clinical information system
availability and use in urban and rural hospitals,” Journal of Medical Systems, vol. 30, no. 6, (2006), pp.
429–438, doi: 10.1007/s10916-006-9014-3.
[23] C. Weimar, “Electronic health care advances, physician frustration grows Physician Executive,” vol. 35,
no. 2, pp. 8-15.
[24] F. William, S.A. Boren, “The role of electronic medical record in care delivery in developing countries,”
International Journal of Information Management, vol. 28, no. 6, (2008), pp. 503-507,
doi:10.1016/j.ijinfomgt.2008.01.016.
[25] J. M. Woodside, “A real-time framework for healthcare data exchange”, Journal of Medical Systems,
vol. 31, no. 3, (2007), pp. 178-184. doi:10.1007/s10916-007-9053-4.
Authors
Olutayo Boyinbode, PhD, she is a Senior Lecturer in the Computer Science
Department at the Federal University of Technology, Akure, Nigeria. Her research
interests are in Mobile Learning, Ubiquitous Learning, Cloud Computing and Mobile
Networks. She is a professional member of ACM and IEEE
.
Gbemga Toriola, is a Postgraduate student in the Computer Science Department at the
Federal University of Technology, Akure, Nigeria.
Copyright ⓒ 2015 SERSC
211
International Journal of Hybrid Information Technology
Vol. 8, No. 4 (2015)
212
Copyright ⓒ 2015 SERSC