A SURVEY OF INTEROPERABILITY IN E-HEALTH SYSTEMS
The European Approach
Marcos Da Silveira, Nicolas Guelfi
Laboratory for Advanced Software Systems, University of Luxembourg, 6, rue Coudenhove-Kalergi, L-1359 Luxembourg
Jerry-David Baldacchino, Pierre Plumer, Marc Seil, Anke Wienecke
Centre de Recherche Public Henri Tudor 2A, rue Kalchesbrück, L-1852 Luxembourg
Keywords: Interoperability, standards, e-health, information technology.
Abstract: The interoperability is often associated with the capacity of exchanging information that belongs to different
workflows in a distributed environment. In e-health, the implementation of interoperable systems has a
direct impact on the access of medical services, the costs and the quality of those services. This paper
summarizes the efforts of standardization done by a selected group of Europeans researchers in the
healthcare domain. The assessment of this standardization effort is made through a study of its impact in 20
FP5 and FP6 European projects that address the healthcare domain. The objectives are identify the new
trends on interoperability technologies and to point out the importance of approximate industrials and
research institutes.
1 INTRODUCTION
During the last century advances in medicine have
significantly contributed to the reduction of the
mortality rates. New medical practices, healthcare
supporting tools (equipments, methods, medications,
etc.), and the more participative role of the patients
and their families in the treatments allow many
patients to surpass physical and mental illnesses. But
these practices are frequently isolated and
information exchanges are done later when good
results are obtained. The next challenge for
healthcare domain is to implement collaborative
works in a comprehensive environment where
information exchanged between physicians are
simple, fast and reliable. Consequently, this
environment can contribute to reduce or to avoid
misuse of new medicine practices, to improve the
quality of healthcare services and to facility (and
control) the medical information’s access.
According to the lessons learned from Canada,
Denmark and New Zeland (GAO, 2005), the
standards’ definition, the free access of national
classification from all stakeholders, the education,
the founding for implementation, and the proactive
position of the government to solve privacy
protection problems are important topics to be
considered during the definition of national e-health
programs. It has been obtained by means of a
common effort of industries and public institutions
to define and to diffuse standards like HL7 (HL7,
2007), Cen/TC 251 (CEN/TC, 2007) and DICOM
(DICOM, 2003) in order to improve the
interoperability between healthcare systems. The
aim of this paper is to verify if these in facto
standards have been taking into account in
researches funded by the European community.
The next section we present the impact that a set
of standards has in a selected set of Framework
Projects (FP5 and FP6).
2 STANDARDS IN RESEARCH
PROJECTS
According to (IEEE, 1990), interoperability is the
ability of two or more systems or components to
exchange information and to use the information
that has been exchanged. The scope of this paper
covers only the interoperability between e-health IT
systems. The importance of interoperability in the e-
health market has increased with the rising number
of healthcare professionals that use computers and
172
Da Silveira M., Guelfi N., Baldacchino J., Plumer P., Seil M. and Wienecke A. (2008).
A SURVEY OF INTEROPERABILITY IN E-HEALTH SYSTEMS - The European Approach.
In Proceedings of the First International Conference on Health Informatics, pages 172-175
Copyright
c
 SciTePress

electronic devices to improve their services.
Proprietary solutions have gradually been substituted
by standard-based technologies. However, the
implementation of these products has still facing a
large number of barriers as well as unclear
legislation, high implementation costs, physicians’
reluctance (to adopt those technologies) and
disorganization within healthcare structure.
According to the Department of Health and Human
Service of USA (HHS), healthcare is the largest
sector of the economy that has not fully embraced
information technology. The Medical Group
Management Association and the Healthcare
Information and Management Systems Society
(GAO, 2005) reported that only 31% of physician
group and only 19% of hospitals practices use fully
operational Electronic Health Records (EHRs). This
reality is often the result of adopting equipments and
IT solutions that were not developed to interoperate
with other systems. Changing these technologies is
very expensive and takes time. The healthcare
system is not ready to invest money without any
guarantee of world interoperability and the market is
not mature enough to give this guarantee.
This work contributes to analyze the European
market trends based on the information took from a
selected number of research projects in the e-health
domain. We also point out if the interoperability
challenge has really been attacked by scientist and
industrials. During our researches, we evaluated two
distinct levels of standards: One coming to integrate
medical equipment (named physical level standards)
and the other used to integrate customers’
applications (named application level). In the first
level, the selected standards are: CAN, I2C,
Bluetooth, Zigbee, USB, FireWire, RS232, IEEE
1284, Ethernet, GSM/GPRS, UMTS and IEEE
802.11x. In the second level the following standards
are addressed: HL7, DICOM, ebXML and VITAL.
The analyze procedure starts by looking for
references of this set of standards in the homepage
of European projects (and in open source
documents) available in the internet. In a second
phase, we searched for partners of these projects that
also participate on the specification of the selected
group of standards. In the next section, the projects
considered in our researches are presented.
2.1 Looking for Projects
In the previous sections we showed that the
association of informatics with healthcare domains
brings up many advantages and that the Healthcare
industry is positioned to beneficiate of the
advancements in technology and connectivity. High
technological devices and software are available for
healthcare services’ providers and are adapted to the
patient needs (patient-centered systems) (LAU et al.,
2002). Customers of these technologies can expect
to achieve greater performance, to reduce costs and
to improve patient care. Consequently, they are
expanding marketshare and pushing the transition to
a digital era of e-Health. An example of the
Table 1: The selected list of European projects and the standards adopted.
# Project Area/objective Supported Standards
1 C-CARE EHR XML, HL7, CEN, ISO
2 CHS Home monitoring of Diabetes, heart failure, post trauma patients UMTS, GPRS
3 HEALTHMATE Telecare, Tele-consultation XML, Bluetooth, GPRS, UMTS
4 HUMAN Telemedicine, domotic UMTS, GPRS
5 IDEAS Multimedia architecture for e-health
XML, Bluetooth,
GPRS, DICOM,
6 MOBIDEV Secure access of medical database Bluetooth, UMTS
7 MOBIHEALTH Telemedicine, remote assistance GPRS, UMTS
8 TOPCARE Telecommunication support to Telecare ---
9 WIDENET European EHRs interconnectivity ---
10 ARTEMIS Semantic Web-Services ---
11 AUBADE Neurology, psychology. Recognition of emotional state of the patient Bleutooth, GPRS, UMTS
12 BIOPATTERN Identification of European bioprofile ---
13 CLINICIP Automatic injection of Insulin in ICU ---
14 COCOON Healthcare risk management ---
15 DICOEMS Integrated medical environment and database for critical situations GPRS
16 INTREPID Phobias’ monitoring and treatment. ---
17 MYHEART Intelligent clothes for heart failures prevention Bleutooth, GPRS
18 NOESIS Diagnosis supporting tools and Web-services ---
19 SEMANTICMINING Data mining of medical information ---
20 PIPS Generic medical database ---
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Table 2: Synergy between standards and European projects FP5 & FP6.
PROJECT STANDARD STANDARD
DEVELOPERS’ MEMBER
INDUSTRIAL PARTNERS
C-CARE XML, HL7,
CEN, ISO
NO HEALTH INFORMATION MANAGEMENT,
STACKS CONSUTION E INGENIERIA EN
SOFTWARE, OLIVETTI SANITA, MEDIGRIDGE,
PROGEA, DATASOFT, INTRASOFT
CHS UMTS, GPRS YES (I2C, BLUETOOTH,
ZIGBEE, FIREWIRE, USB,
802.11, HL7, DICOM)
PHILIPS, PAULADIS, AMERICAN MEDICAL
DEVELOPMENT, CARD-GUARD
HEALTHMATE XML,
BLEUTOOTH,
GPRS, UMTS
YES (CAN, I2C,
BLUETOOTH, ZIGBEE,
USB, 802.11, HL7, DICOM)
AIRTEL, BULL, SIEMENS, APLITEC, KNOSOS
HUMAN UMTS, GPRS NO SYNAPSIS, SEMA, EUTAELSAT, MBI
IDEAS XML,
BLEUTOOTH,
GPRS, DICOM,
NO APLITEC
MOBIDEV BLEUTOOTH,
UMTS
NO AIRTEL, ARAKNE, INTERCEM, RELATIONAL
TECHNOLOGY
MOBIHEALTH GPRS, UMTS YES (I2C, BLUETOOTH,
ZIGBEE, FIREWIRE, USB,
802.11, HL7, DICOM)
PHILIPS, TELEFONICA, LOGICAM,
TELIASONERA, HP, YUCAT, GESUNDHEITSCOUT
TOPCARE --- NO CALEA, GMD, DATAMED, DRAGER
WIDENET --- NO SADIEL, PROREC
ARTEMIS --- NO ALTEC, TEPE
AUBADE BLEUTOOTH,
GPRS, UMTS
YES (CAN, I2C,
BLUETOOTH, ZIGBEE,
USB, 802.11, HL7, DICOM)
ANCO, MARSERATI, SIEMENS
BIOPATTERN --- NO DAEDALUS, GAP, HELLENIC, HOEGSKOLAN,
NEOVENTOR, SYNAPSIS
CLINICIP --- NO BRAUN, CARMEDA SISETRONIC, GAMBRO,
SENSLAB
COCOON --- YES (USB, FIREWIRE,
802.11, HL7)
AQUITAINE, CEFRIEL, ELYROS, ENPHASIS,
MICROSOFT, ICSF, IDS, LOGICOM
DICOEMS GPRS NO SYNERGIA 2000 , SSM
INTREPID --- NO AURELIA, ELYROS, INOCUS, PALLADION
MYHEART BLEUTOOTH,
GPRS
YES (I2C, BLUETOOTH,
ZIGBEE, FIREWIRE, USB,
802.11, HL7, DICOM)
CSEM, HEIN, LINEAPIU, MANIFATURE,
MEDGATE, MEDTRONIC, NOKIA, NYLSTAR,
PHILLIPS
NOESIS --- YES (CAN, I2C,
BLUETOOTH, ZIGBEE,
USB, 802.11, HL7, DICOM)
AIRAL, SIEMENS
SEMANTIC-
MINING
--- NO KITHAS, MERALL-ROSS
PIPS --- YES (HL7) ASTRAZENECA, ATENA, ATOS,
GLAXOSMITHKLINE, MEDIC4ALL
increasing interest on e-health solutions are the
quantity of research projects supported by the
European Union, in particular in the Framework
Project 5 (FP5) and 6 (FP6).
The work presented on this section summarizes
the main area/objectives of a selected list of e-health
projects founded by FP5 and FP6. The objective is
to verify how interoperability was considered in
those works.
The selection procedure had started with a list of
80 projects and finished with 20 projects (after
applying the filter). This filter consists on verify if
the keywords e-services, standard, platform,
telemonitoring, telemedicine, protocols, e-services,
security and devices were present in the context of
the research projects. Table 1 shows the selected
projects’ name, their main area/objective and the
standards that were explicitly indicated in their
homepages. The evaluation methodology consists on
the identification of industrial partners of each
European project and cross it with the members’ list
of each emerging standard. The expected results are:
Verification that European projects take into account
emerging standards; Identification of new trends on
the e-health domain; Point out the importance of
industrial partners for those projects.
Table 2 presents the firsts results of these researches.
The colon “standards developers’ members”
indicates that at least one of the partners belongs to
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at least one of the standard members’ list. The
considered standards are: USB; CAN; ZIGBEE;
Bluetooth; I2C (internet research with the keywords:
company name + I2C); HL7; DICOM; FIREWIRE;
IEEE 802.11; ebXML (the considered websites are
in the references).
3 CONCLUSIONS
A list of interoperability standards used in healthcare
systems was compared in this paper with a selected
set of projects of framework programs 5 and 6. It is
important to highlight that some projects have an
incomplete/out-of-date website and the access to
their technical reports were sometimes impossible.
The available information led us to conclude that the
international standards have not been taken into
account by the majority of the considered FP
projects. It identifies a gap between the industrial
perspectives, the governmental efforts and the
research trends. Lessons learned from New Zealand
experiences (GAO, 2005) show that educating
stakeholders about the value of developing health IT
and using standards is very important to the success
of a national plan. Diffusing the successes is also an
important tool. This analysis allows us to highlight
some weaknesses in the European research trends
and can be useful to define new research strategies,
in particular giving priority to projects that include
international standards’ promoters and participants
(users, providers and developers). The participation
of more research institutes in these committees can
also contribute to the education of stakeholders.
REFERENCES
CEN/TC 251, European Standardization of Health
Informatics. Retrieved June 10, 2007, from
http://www.centc251.org
DICOM - Part 1 (2003). Introduction and Overview.
Retrieved June 10, 2007, from
http://medical.nema.org/dicom/2003/03_01PU.PDF
GAO - United States Government Accountability Office.
Health information technology: HHS is taking steps to
develop a national strategy. Report to the Chairman,
Committee on the Budget, House of Representatives,
May, 2005. Retrieved June 10, 2007, from
http://www.gao.gov/new.items/d05628.pdf
HL7 - Health Level Seven. Retrieved June 10, 2007, from
http://www.hl7.org
IEEE - Institute of Electrical and Electronics Engineers.
IEEE Standard Computer Dictionary: A Compilation
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The websites of standards members’ lists are:
http://www.usb.org/members_landing/directory/complex_
search_companies_form/process
http://www.can-cia.org/cia/member-
list/index.php?m=2&ss=&sa=Search&sl=100
http://www.zigbee.org/en/about/members.asp
https://programs.bluetooth.org/apps/directory/default.aspx
http://www.hl7.org/about/benefactors.htm
http://medical.nema.org/members.pdf
http://www.1394ta.org/About/Members/
http://www.ieee802.org/11/Voters/votingmembers.htm
http://www.oasis-
open.org/about/foundational_sponsors.php
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