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Interoperability in DALLAS. Interim version 1.0 Published: September 2011
- Chad Ross
- 3 years ago
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1 Interperability in DALLAS Interim versin 1.0 Published: September 2011 i
2 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 ii
3 Interperability fr DALLAS applicants and cmmunities Warning This dcument is nt an apprved Technlgy Strategy Bard, Health KTN, ICT KTN, ALIP r DALLAS dcument. This versin is an Interim White Paper. The Task Frce welcmes cmments and recmmendatins fr future iteratins.. The DALLAS Interperability Task Frce is a wrking grup chaired by the ICT KTN with a specific gal t investigate the interperability challenges f the DALLAS assisted living prgramme. The utput prduced is used t present at events, write psitining papers n interperability, identify innvatin pprtunities and act as the catalyst fr cllabrative activities supprting DALLAS. The pinins and views expressed within this psitining paper have been reviewed by the members f the DALLAS Interperability Task Frce. The views and pinins d nt necessarily reflect thse f the individual members f the task frce r the rganisatins that the members represent. The list f DALLAS Interperability Task Frce members is at Appendix G. iii
4 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 iv
5 Cntents Page Frewrd vii Summary ix 1 Intrductin 16 2 Scpe f White Paper 17 3 Visin 17 4 Establishing a DALLAS ecsystem 23 5 Guidelines fr interperability 'in the rund' 29 6 Data presentatin - applicatin f standards 30 7 Telecare and telehealth cmmunicatins example 32 8 NHS Interperability Tlkit 39 9 Cmmunicatins netwrks Vide and VIP fr DALLAS Cmmunities 46 Annex A Glssary 49 Annex B Architectures 53 Annex C Security 57 Annex D Quality f Service and Grade f Service Requirements 63 Annex E Spectrum cnsideratins 67 Annex F Changes in fixed telecmmunicatins prvisin 69 Annex G Interperability landscape and its evlutin 73 Annex H ITF Membership 79 References 81 v
6 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 vi
7 Technlgy Strategy Bard - White Paper Interperability fr DALLAS applicants and cmmunities Frewrd DALLAS - Delivering Assisted Living Lifestyles at Scale A ttal investment f up t 23 millin is being made in the UK-wide DALLAS prgramme Delivering Assisted Living Lifestyles at Scale. This cmprises an 18m investment by the Technlgy Strategy Bard and the Natinal Institute fr Health Research, with a further 5m cntributin frm the Scttish Gvernment, Highlands and Islands Enterprise and Scttish Enterprise. DALLAS will establish three t five cmmunities f 10,000 peple each r mre acrss the UK, f which ne will be in Sctland. These will shw hw assisted living technlgies and services can be used t prmte wellbeing, and prvide tp quality health 1 and care, enabling peple t live independently including a preventative apprach. We aim t unlck new markets in scial innvatin, service innvatin and wellness, enabled by technlgy, and shw that technlgies and services can be made available at a sufficient scale and cst t enable independent living. The cmpetitin will help t grw the assisted living sectr and psitin UK cmpanies t take advantage f increasing glbal demand fr assisted living gds and services. The absence f technical interperability has been seen as ne (f a number) f the barriers t uptake f assisted living services. DALLAS has prvided the pprtunity t address this challenge, bringing tgether the supply chain and the supplier industry wrking tgether t prvide statutry service prviders, private service prviders, 3rd sectr agencies and general public with interperable slutins. Technical interperability is expected t pen up the market t further innvatin in systems and services, which tgether have the ptential t enrich the lives f thse wh need assistance in life and manage mre effectively the burden f care. The DALLAS Interperability Task Frce has been established t prvide guidance as t hw this might be achieved. It brings tgether supplier and service prvider representatives, mstly drawn frm existing Assisted Living Innvatin Platfrm prjects, with standards experts. The Task Frce membership can be fund at Annex H. This dcument is intended fr use as a reference tl. It is extensive but it des nt claim t be exhaustive and there are relevant viewpints and challenges such as service re-design and regulatry issues that will be imprtant fr DALLAS, but are nt within the scpe f this paper. The scpe f the challenge is significant. It ranges frm interactive interfaces, sensr systems, wireless netwrks, data transmissin acrss mbile and bradband netwrks thrugh a wide array f desirable human cmmunicatins and interactins including the infrmatin and wrkflw t requirements f care prvisin and care recrds. It includes discussin f the relevant standards and standards bdies embracing telecare standards including BS8521, health devices under IEEE and the Cntinua Alliance and als includes wider, less traditinal, cmmunicatin cllabratin. It takes int accunt existing guidance and lks at emerging and future issues. Cnsideratins shuld nt be cnstrained t frmal systems r extant slutins and services, but shuld take int accunt the wider scpe f mainstream cmmunicatins, media and services and ther assistance that can be harnessed t supprt the target cmmunity. 1 State f cmplete physical, mental and scial well-being and nt merely the absence f disease r infirmity (WHO - fficial recrds f the Wrld Health Organisatin N 2, p100 7 April 1948) vii
8 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 viii
9 Technlgy Strategy Bard White Paper Interperability fr DALLAS applicants and cmmunities Summary DALLAS Lifestyles at Scale - Lifestyles and Interperability DALLAS is abut Lifestyles At Scale. It is abut delivering Cmmunities that prmte active and healthy lifestyles. It is abut changing the eths f hw independent living is perceived, cnceived and delivered. The Lifestyles Task Frce was set up t address lifestyle eths as a cmpnent t tward achieving independent lifestyles at scale. T address scalability the Interperability Task Frce was established as arguably interperability is the mst challenging technical barrier twards achieving scalability. The DALLAS prgramme is funded upn six key Lifestyle principles. The six C s frm the eths f the prgramme verall and thse f the DALLAS cmmunities within it. Each f these principles is relevant at bth a cnceptual and a practical level. Cllectively they guide imprtant cnsideratins n DALLAS intent and utcmes and the challenges psed by interperability. They are: Chice Fstering persnal chices (e.g. f what t d and hw t live, care and be cared fr, in ways, places and at times which are the mst apprpriate); Cnnectedness Being jined up (e.g. peple, places and knwledge, services, plicies and rganisatins); Cllabratin Enabling useful interactin (e.g. easy pprtunities fr cmmunicatin and human interchange, fr increased effectiveness and efficiency, reach and innvatin) Cntributin Enabling active participatin (e.g. scially and ecnmically, educatinally and in the care field, by helping t balance cmplex lives and t vercme cnstraints) Cmmunity Fstering cmmunity-wide living and engagement (e.g. living at hme, nt being cnfined t hme; prmting the wellbeing f individuals, cmmunities and the ecnmy) Cntrl Increasing pr-activeness (e.g. reducing care demand by increasing wellbeing thrugh stimulus and active living, r thrugh having better knwledge t trigger pre-emptive actin) Prviding fr Interperability prvides fr the plug and play services that are desired by the service prvider and by the user living independently. Interperability shuld lead t imprved ease f use, easier installatin, better human factr capability, greater chice, internatinal ecnmies f scale and market develpment, and hence lwer unit csts, but abve all imprved utcmes fr users. Interperability is abut infrmatin prvisin (nt data). It can facilitate integrated services, but services may need t be redesigned, requiring rganisatinal change. They will always need t be delivered in ways that are sensitive t the individual user s needs and preferences. Taking the 6C s as ur starting pint what des this imply fr Interperability? Chice Fstering persnal chices: interperability can, enable the best mix f independent living technlgies and services t be deplyed t meet a citizen's evlving needs. Cnnectedness Being jined up: interperability can, help ensure that the right infrmatin is available t the right peple at the right time. Cllabratin Enabling useful interactin: interperability can, facilitate persnal and rganisatinal interwrking t assist better integratin assistance with life. ix
10 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Cntributin Enabling active: interperability can, make it easier fr all citizens and carers t play their rles in independent living. Cmmunity Fstering cmmunity-wide living and engagement: interperability can, enable citizens t interact with friends, relatives and carers, regardless f lcatin. Cntrl Increasing pr-activeness: interperability can make it easier fr sme citizens t manage their daily activities, and fr thers t be assisted by timely actin. What d we mean by Interperability? Interperability has a very specific meaning, r cllectin f meanings. Earlier wrk 2, adpted by ALIP in its standards review, defined interperability as fllws: Interperability: where different applicatin functins are able t use shared infrmatin in a cnsistent way. This requires interwrking as a building blck as well as c-existence, and adds business rules, prcesses and security prvisins that enable applicatins t be jined tgether; e.g. a hme wireless security system being cntrlled and mnitred remtely using a separate web applicatin, sending alerts t the wners mbile phne r TV set. The benefit is that applicatins can interact with each ther and create greater efficiencies by sharing resurces acrss multiple systems. Interperability is, hwever, nt just abut technlgy. In the Eurpean Telecmmunicatins Standards Institute (ETSI) White Paper "Achieving Technical Interperability the ETSI Apprach" fur categries f interperability were identified 3 : i) technical usually assciated with hardware/sftware cmpnents, systems and platfrms that enable machine-t-machine cmmunicatin t take place; ii) syntactical usually assciated with data frmats; iii) semantic usually assciated with the meaning f cntent ; iv) rganisatinal the ability f rganisatins wrk tgether using shared semantic understanding. Why was Interperability specified in DALLAS? The ALIP team recgnised in frming DALLAS, that In rder t enable persnal chice, useful interactin, participatin and engagement, and the wider benefits f an assisted, independent living envirnment there is a requirement fr interperable services and equipment. The absence f technical interperability is a recgnised barrier t take up f assisted living technlgy and services. Its absence makes decisins n prcurement, particularly fr the public sectr harder; fr prviders f services it reduces flexibility, increases csts, and hampers service integratin. Its absence als delays the lngerterm establishment f a cnsumer market. Technical interperability extends frm the shared semantics f infrmatin passed between services in supprting the individual and the sensrs deplyed dwn t the physical intercnnectin f devices and usage f cmmunicatins. The scpe f the challenge is significant. It ranges frm interactive interfaces, sensr systems, wireless netwrks, and data transmissin acrss mbile and bradband netwrks thrugh a wide array f desirable human cmmunicatins and interactins including the infrmatin and wrkflw t requirements f care prvisin and care recrds. It includes discussin f the relevant standards and standards bdies embracing telecare standards including BS8521, health devices under IEEE and the Cntinua Alliance, and als includes wider, less traditinal, cmmunicatin cllabratin. It takes int accunt existing guidance and lks at emerging and future issues. Cnsideratins shuld nt be cnstrained t frmal systems r extant slutins and services, but shuld take int accunt the wider scpe f mainstream cmmunicatins, media and services and ther assistance that can be harnessed t supprt the target cmmunity Fr the alarm/mnitring cmmunicatins paradigm familiar in telecare and telehealth, the Cntinua Alliance 4 has made sme prgress, but nt yet t the extent that interperable 2 Frm TAHI The Applicatin Hme Initiative See 3 ETSI White Paper N. 3 Achieving Technical Interperability the ETSI Apprach. Octber See paragraph 7.3 f the White Paper and x
11 technlgy is easily available ff the shelf. Similarly, the IEEE and HL7 6 standards prvide an interperable framewrk but are nt yet widely supprted by prducts. Fr the NHS in England the Interperability Tl Kit 7 has been created t help the flw f infrmatin arund the NHS. Hwever, significant challenges have been identified, many f which are clsely related t the existing business mdels emplyed, e.g. integratin f legacy equipment particularly scial alarms/telecare. The different standards, including the scial alarm standards, are discussed in much mre detail in the DALLAS Interperability White Paper. The DALLAS requirement fr interperability presents an pprtunity t address these challenges in an pen and transparent prcess. The White Paper prvides the basis fr technlgy cmpanies t cme tgether, and t wrk with service prviders. It des nt describe a mandated requirement, and the ALIP team d nt expect nn-technical DALLAS applicants t understand the full picture. Rather, it is designed t help DALLAS applicants describe the ptins DALLAS Cmmunities need t cnsider in their applicatins. There is n ne slutin; DALLAS Cmmunities will need t make a judgement, frm their wn circumstances, n hw they can best achieve interperability. Interperability shuld thugh lead t imprved ease f use, easier installatin, better human factr capability, greater chice, internatinal ecnmies f scale and market develpment, and hence lwer unit csts, but abve all imprved utcmes fr users. The DALLAS Interperable Ec-System The DALLAS ec-system is unlikely t be established in a sterile envirnment devid f existing prvisin but is mre likely t be a hybrid and build upn evlutin f the existing prvisins f equipment, services and prcesses which explits existing assets and infrastructure but adds further innvatin. There is an installed base acrss the UK f telecare prvisin t mre than 1.5m clients but the verwhelming majrity f frmally prvisined services address a simple Alarm-Respnse service need. Hwever there is gd architectural verlap between the needs f Scial and Health mnitring and the verall landscape schematic shwn in Figure x can be applied t bth clinical and scial (telecare) health mnitring and related activity and is typical f hw telecare services are currently cnnected. Figure x: Interperability landscape NOTE: The term RMMS was first cined by IHE/HITSP in the US and helps describe a wide range f functinality which culd include: Device management, Respnse management, Recrd keeping, Cntent management / distributin, Custmer Relatinship Management (CRM) /cntact management, etc. The interperability architecture, current landscape and evlutin prpsal dealt with in the White Paper is in supprt f the wrkflw assciated with alarm and mnitring handling because it is a natural start pint frm which t migrate the existing deplyed base t that in supprt f assisted living in its widest sense. There are significant challenges in evlving the current envirnment which are discussed and detailed in Appendix G. These challenges include prviding a chice f devices thrugh plug and play integratin, and prviding care cmmunity-wide pen service integratin as a key enabler fr scale. 5 See paragraph HL7 is a nt-fr-prfit rganisatin respnsible fr the prductin and prmtin f the HL7 series f healthcare IT cmmunicatins standards in UK. See paragraph See belw and paragraph 8 xi
12 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 DALLAS prvides an pprtunity t create market demand fr standards-based prducts, but there is a widespread lack f interperability in existing equipment and limited availability f standards based cmpnents, as well as lcal variatins in services and prcesses. There are als significant gaps f ptential pprtunity t prvide care cmmunity-wide pen service integratin, and integratin f family, friends, 3 rd sectr, hme suppliers and service prviders. There is a significant challenge fr DALLAS t mve in the directin f a mre pen ec-system which allws fr evlutin, recnfiguratin, extensin and integratin f new and 3 rd party service prvisin; fr example, ensuring that interactive vide services fr cnsultatin r reassurance are capable f perating with the necessary quality f service. Similarly, supprt fr questin and answer prtcls, interactive incentives, and authenticated remte cntrl f clse-t-citizen systems (windw blinds, etc.) may be demnstrably useful capabilities. A Cmmissiners Perspective Cmmissiners f services strngly desire t be able t use peripheral devices such as sensrs frm any supplier with any hme device, in rder that they have a wider chice in selecting peripherals t meet client specific needs. This shuld make prvisin fr new technlgy sensrs t be intrduced int existing systems and installatins t be adapted with the change in assessment f client needs. Different services require different slutins as suggested in the layered apprach in figure y. Figure y: Layered service prvisin building upn self-managed care. There is als a desire t select a means f cmmunicatin with the service prviders: Smart Phne, Dedicated Hme Hub Device r ther means which nt nly meets their functinal needs but the envirnmental cnstraints f the installatin, and t ffer t the client chice in the lk and feel in the hme r pcket. Furthermre, the telecare/telehealth service tplgy shuld link the mnitring centre nt nly t the health recrd but als t the scial care recrd (and by implicatin enable a linkage f the tw t each ther). A key element fr the successful delivery f integrated health and scial care services is the grwth f psitive practices in inter-wrking. T achieve such inter-wrking requires technlgical interperability. One f the ambitins fr DALLAS shuld be t act as a catalyst fr the pening f thse recrds (health and scial care) bth ways. This wuld be a significant step, which ges beynd technical interperability int service re-design. xii
13 The DALLAS Interperability White Paper stps shrt f prviding advice n service re-design which is a substantial issue in itself, but it cvers elements f integratin with the NHS particularly in England. The Interperability Tl Kit and the telehealth messaging standard, are imprtant relatively new develpments which are highlighted here in the summary but cvered in greater detail in the White Paper. NHS Interperability Tlkit The Interperability Tlkit (ITK) has been created t help the flw f infrmatin arund the NHS in England. Its aims include: reducing the amunt f mney the NHS spends n lcal integratin by standardising technlgy and interperability specificatins. helping the NHS realise business benefits by speeding up the develpment f integrated services. prviding a framewrk fr innvative business slutins by defining a pervasive interperability specificatin. easing the develpment f lcal health cmmunity integrated systems. lwering the entry barrier t new systems develpers by prviding a cnsistent cde f cnnectin. Further infrmatin n the Tl Kit can be fund in the White Paper. Interfacing t NHS clinical systems DALLAS cmmunities shuld als nte wrk n interfacing t NHS clinical systems. The NHS Technlgy Office has been cllabrating n develpment f the HL7 telehealth messaging standard. This was develped as part f the Whle System Demnstratr 8 wrk at Newham. In rder t advance adptin and supprt imprvements, the Telehealth grup within Intellect (the UK IT Trade bdy) have started a prgramme t bring the health IT industry (GP systems, Telehealth Systems, Acute systems) tgether t accept this as the starting pint, and t wrk tgether t bring it t market. Future Services Services are the key elements that technlgy can enable and the successful design and implementatin f thse services may well be key t shaping the market and demand fr assisted living, just as services such as, fr example, iplayer, YuTube, Facebk, Flikr, Ggle, Skype and Twitter have helped t shape the use and f the internet and demands fr access and bandwidth. As the market matures, we expect sme assisted living functins t be embedded in cmmdity cnsumer prducts and be easily amenable t family- and self-prvisined care. Assisted living technlgies shuld als be intuitive t thse with sme level f physical and r mental impairment, and must nt require any technical knwledge t initiate, r maintain, and use. 8 The Whle System Demnstratr prgramme see e.g. xiii
14 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 xiv
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16 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Technlgy Strategy Bard - White Paper Interperability fr DALLAS applicants and cmmunities 1 Intrductin Assisted Living shuld enable and fster active, healthy living, and thus prmte mental and physical wellbeing, hence reducing demand n statutry services. This will help maximise ecnmic and scial engagement f all citizens, regardless f physical cnstraints; and thus be a key element benefitting emplyers and the UK ecnmy as a whle. In rder t enable persnal chice, useful interactin, participatin and engagement, and the wider benefits f an Assisted Living envirnment there is a requirement fr interperable services and equipment. The absence f technical interperability is a recgnised barrier t take up f assisted living technlgy and services. Its absence makes decisins n prcurement, particularly fr the public sectr, harder; it reduces flexibility, increases csts, and hampers service integratin. Its absence als delays the lnger-term establishment f a cnsumer market because f uncertainty abut the extent f prduct capability t meet anticipated needs. Technical interperability extends frm the shared semantics f infrmatin passed between services in supprting the individual and the sensrs deplyed dwn t the physical intercnnectin f devices and usage f cmmunicatins. The DALLAS requirement fr technical interperability presents an pprtunity t address these challenges in an pen and transparent prcess. This dcument prvides the basis fr technlgy cmpanies t cme tgether, and t wrk with service prviders. It des nt describe a mandated requirement, and there is n expectatin f nn-technical DALLAS applicants t understand the full technical picture. Rather, the paper is designed t help DALLAS applicants describe the ptins DALLAS Cmmunities need t cnsider in their applicatins. There is n cmplete and/r ff the shelf slutin; DALLAS Cmmunities will need t make a judgement, within their wn cntext and the wider market, n hw they can best achieve interperability. In sme cases, this will be by selecting lcal appraches; in thers by adpting widely agreed slutins, which culd send a strng signal t the supplier cmmunity t imprve availability f standards based slutins. Hwever, interperability shuld lead t imprved ease f use, easier installatin, better human factr capability, greater chice, internatinal ecnmies f scale and market develpment, and hence lwer unit csts; but abve all imprved utcmes fr all thse invlved.. The DALLAS evaluatin 9 will examine these expectatins. Fr the alarm/mnitring cmmunicatins paradigm familiar in telecare and telehealth, the Cntinua Alliance i was established t address sme f these issues and has made significant prgress, but nt t the extent that interperable technlgy is easily available ff the shelf. Similarly, the IEEE and HL7 11 standards prvide an interperable framewrk but are nt yet widely supprted by prducts. Fr the NHS in England the Interperability Tl Kit 12 has been created t help the flw f infrmatin arund the NHS. Hwever, significant challenges have been identified, many f which are clsely related t the existing business mdels emplyed, e.g. integratin f legacy equipment particularly scial alarms/telecare. 9 See 10 See See 7.10 and See 8 16
17 2 Scpe f White Paper 2.1 Cntext It is assumed that the reader is familiar with the DALLAS backgrund papers 13 This dcument is extensive but des nt claim t be exhaustive. 2.2 In scpe Whilst highlighting sme f the brader interperability issues, this dcument is cncerned primarily with enabling cmmunicatin by achieving technical, semantic and infrmatin interperability within the dmain f the individual and between the individual and assisted living services, whether they be infrmal, statutry, cntracted r 'third' sectr. 2.3 Out f scpe This dcument des nt address (thugh it mentins them in cntext) plicy, regulatin, prcurement and service design issues that affect infrmatin and cmmunicatin interperability f assisted living services whether they be infrmal, statutry, cntracted r 'third' sectr. Similarly, this dcument des nt, in general, g int detail abut particular use cases r lng-term cnditins thugh these are cited briefly as examples if apprpriate. It is hped that by remaining generic the pitfalls f service management issues will be avided whilst giving sufficient material t enable interperability principles t be applied. 3 Visin 3.1 Key values and principles The DALLAS prgramme is abut enabling and fstering independent assisted living. It is funded n six Lifestyle principles develped by the cmpanin DALLAS Lifestyles Task Frce, which characterise this intent; tgether they frm the eths f the prgramme verall, and the DALLAS Cmmunities within it. Each f these principles (referred t as the Six Cs ) is relevant at bth a cnceptual and a practical level. Cllectively they guide imprtant cnsideratins n prject intent and utcmes, as well as technlgy enablement and interperability. They are: Chice Fstering persnal chices (e.g. f what t d and hw t live, care and be cared fr, in ways, places and at times which are the mst apprpriate); Interperability can, fr example, help enable the best mix f assistive living technlgies and services t be deplyed t meet a citizen's evlving needs. Cnnectedness Being jined up (e.g. peple, places and knwledge, services, plicies and rganisatins); Interperability helps ensure that the right infrmatin and cmmunicatin is available t the right peple at the right time. Cllabratin Enabling useful interactin (e.g. easy pprtunities fr cmmunicatin and human interchange, fr increased effectiveness and efficiency, reach and innvatin) Interperability facilitates persnal and rganisatinal interwrking t assist better integratin f assistance with life. Cntributin Enabling active participatin (e.g. scially and ecnmically, educatinally and in the care field, by helping t balance cmplex lives and t vercme cnstraints) Interperability makes it easier fr citizens and carers t play their rles in cmmunities, the wrkplace and wider sciety. 13 See Articles and Dcuments at 17
18 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Cmmunity Fstering cmmunity-wide living and engagement (e.g. living at hme, nt being cnfined t hme; prmting the wellbeing f individuals, cmmunities and the ecnmy) Interperability helps enable citizens t interact with friends relatives and carers, regardless f lcatin. Cntrl Increasing pr-activeness (e.g. reducing care demand by increasing wellbeing thrugh stimulus and active living, r thrugh having better knwledge t trigger pre-emptive actin) Interperability makes it easier fr sme citizens t manage their daily activities, and fr thers t be assisted by timely actin. Develpments in technlgy t enable assisted living funded n the 6C Lifestyle principles shuld be designed with cnsideratin f the established, and/r aspired t, rganisatinal infrastructures within which they will be delivered and sensitive t the individual client needs and preferences. A 5-layer mdel f levels f Interperability is prvided (see Figure 2, page 21) as an illustratin f the challenge and pprtunity in ne specific envirnment. Within DALLAS Cmmunities, the achievement f Lifestyles utcmes shuld be enabled by Interperability withut users being aware f the technlgical means needed t achieve seamless and apprpriate assistance. 3.2 Develping the principles DALLAS cntributes t these principles thrugh innvatin in technlgy and services, prviding timely and relevant infrmatin, enabling useful cmmunicatin and cllabratin thrugh means that are accessible, affrdable, interperable and sustainable. Gd technical slutins are nes that are easily adpted because their benefits utweigh the csts and difficulties f installatin, custmisatin and peratin. Gd rganisatinal slutins are nes which fit with the values and aspiratins f established service prviders, which prvide a high added value and recgnise the available skill pl and training needs and prvide equity in the sharing f benefits acrss the value chain f supply and delivery. A key element f DALLAS needs t be the facilitatin and enablement f service change making best use f available infrmatin, sharing where apprpriate acrss rganisatinal bundaries, and crdinating actins and interventins t make the best pssible use f resurces. The lifestyle spectrum is very brad encmpassing bth yung and ld, and a wide range f assisted living supprt frm wellbeing and reassurance, thrugh supprting services, t emergency interventin. There is a wide range f peple wh have special needs but with the aid f assistance are capable f living as mre independent and fulfilled members f a cmmunity. DALLAS Cmmunities shuld lk t hw they can enable independent and fulfilling lives, t wider participatin in cmmunity life and less dependency n institutinal care. With predicted demgraphic changes in the ppulatin, there will be a significant increase in the numbers f elderly, and better medical care means that there are an increasing number f trauma victims and peple with disabilities wh have special needs. Lifestyle chices mean an increasing ppulatin suffering frm lng-term cnditins such as Type II Diabetes. In delivering independent assisted living at scale, DALLAS Cmmunities need t ensure that n specific grup is marginalised r disadvantaged further by emergent changes in services, prcesses r technlgy. This includes ensuring that all can participate actively in sciety and the ecnmy, regardless f cnstraint. Lng-term assisted living needs t transcend rganisatinal bundaries f scial care; primary, cmmunity and secndary care; and the vluntary sectr. Increasing numbers f peple, particularly lder peple, have mre than ne lng-term cnditin (LTC) yet face increasingly fragmented, specialised respnses. Withut significant actin, the number f peple with mre than ne cnditin will rapidly increase. Redesigning f disease-specific pathways isn t ging t be sufficient fr the future. Peple with lng term cnditins have t live with them 24 hurs a day 7 days a week and what they universally say is they wish t be treated as a whle persn, and that the caring services act as ne team. 18
19 Figure 1: Cmmunicatin flws fr assisted living enabled by interperability It is unrealistic t expect technlgy t fully cmpensate fr the scietal changes that have led t the dispersal f the family unit, and the dislcatin f tight-knit, self-supprting cmmunities, which prvided the infrastructure fr the supprt f mre vulnerable cmmunity members in past times. Hwever, we knw frm the small-scale examples where that happens nw that nt nly can technlgy help us engage and enable wider cllabrative supprt cmmunities, e.g. satisfy patients and carers better, but als that csts are less and that the utcmes are imprved. N statutry system, as currently cnfigured, fr lng term care is sustainable in the face f that grwing need. The DALLAS challenge therefre is t demnstrably transfrm the way we enable assisted living fr thse with lng term cnditins nt nly by additin f technlgy, but als by ensuring that apprpriate cmmunicatin happens at the right time s that apprpriate actin can be taken. In ding s, it will cntribute t the current imperative f financial savings but in ding s set UK industry, caring services and sciety itself in a better psitin t remain viable fr the future. There are cmmercial principles that will unavidably apply t the delivery f assisted living and, if nt managed, frustrate take-up and sustainability. These are thse f return n investment and/r risk and reward. Thse with a higher appetite fr risk will prbably lead initiatin f develpments in supprt, but even they risk failure if there is n perceived equity f return amngst stakehlders. Cperatin in the enabling f assisted living depends in a measure n the perceptins and clarity f what is ften called what's in it fr me. Withut these challenges being addressed, persistence f change is nt likely t ccur and the 'assistance prvisin' landscape will remain relatively unchanged. Again, technlgy alne cannt meet these challenges but apprpriate use f technlgy can enable delivery f better assistance in ways mre satisfying t all parties. Assisted living prvisin shuld be sensitive t persnal chice and preference, cultural, scial and religius requirements; avid stigmatising the client and extend the quality f life and perid f independent living f the recipient f services. It shuld enable and fster health and active living and supprt the free mvement f the individual. It shuld enable services that prtect the safety and dignity f the individual, and build cnfidence t interact with sciety prviding a level f assurance in the envirnment f cnnected media that matches the physical wrld. Assisted living shuld aspire t be desirable and an attractive alternative t institutinalised health and scial care with a perceived value that utweighs its cst. It shuld be as unbtrusive as pssible and inspire cnfidence in its use. 19
20 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 The requirements fr cmmunicatins emerging frm the Visin (see Figure 1) are t meet the purpses f safe, effective and efficient supprt f assisted living whether supprted by frmal, infrmal r selfcarers. Current wrk within the ALIP and ther TSB prgrammes n Trusted Services ii as well as Identity Assurance iii has prvided valuable insights n hw key aspects f this Visin culd becme a reality. 3.3 Understanding interperability Earlier TAHI wrk iv, adpted by ALIP in its standards review, defined interperability as fllws: Interperability: where different applicatin functins are able t use shared infrmatin in a cnsistent way. This requires interwrking as a building blck as well as c-existence, and adds business rules, prcesses and security prvisins that enable applicatins t be jined tgether; e.g. a hme wireless security system being cntrlled and mnitred remtely using a separate web applicatin, sending alerts t the wners mbile phne r TV set. The benefit is that applicatins can interact with each ther and create greater efficiencies by sharing resurces acrss multiple systems. Interperability shuld als lead t imprved ease f use, better human factr capability, greater chice, internatinal ecnmies f scale and hence lwer unit csts. Interperability is, hwever, nt just abut technlgy. In the White Paper "Achieving Technical Interperability the ETSI Apprach" v fur categries f interperability were identified by the Eurpean standards bdy frmally respnsible fr telecmmunicatins technlgies: i.technical usually assciated with hardware/sftware cmpnents, systems and platfrms that enable machine-t-machine cmmunicatin t take place; ii.syntactical usually assciated with data frmats; iii.semantic usually assciated with the meaning f cntent ; iv.rganisatinal the ability f rganisatins wrk tgether using shared semantic understanding. It is widely recgnised and discussed in sme detail in a study fr the Eurpean Cmmissin vi that the difficulty f achieving interperability increases dwn this list; with crss-cultural interperability being ntriusly tricky. The Eurpean Cmmissin ("Cmmunicatin n telemedicine fr the benefit f patients, healthcare systems and sciety" vii ) adpted a five layer apprach; i.e. plitical, rganisatinal, technical, semantic and educatinal layers. The wider literature viii frequently refers t the syntactic interperability listed in the ETSI reprt, a cncept that is f increasing value with the widespread use f XML, which is ften misleadingly described as self-describing ix. It is nt explicitly prpsed that DALLAS Cmmunities adpt these layered appraches. The value f the insights that they each bring t help fcus n the achievement f lifestyles utcmes enabled by interperability withut users being aware f the technlgical means needed t achieve seamless and apprpriate assistance acrss agencies is useful. The challenge fr full-scale technlgical interperability x is t devise a generalised apprach t representing every cnceivable kind f cntent in a cnsistent way. This needs t cater fr cntent arising frm any device, persn, prfessin, speciality r service, whilst recgnising that the data sets, value sets, templates etc. required by different care will be diverse, cmplex and will change frequently as practice and knwledge advance. 3.4 Interperability in DALLAS The previus sectin implies that there is nt ne universal and rigid slutin t the challenges psed by DALLAS. Such a develpment wuld imply a static and rigid implementatin resistant t change and evlutin. A gd slutin wuld be ne which is pen t new and innvative services, sensrs and cmpnent elements, cmmunicatin and human interactin and adaptable t meet individual citizen's needs. 20
21 Figure 2: Interperability in the cntext f different hme-riented dmains and functins related t telecare and telehealth Fr example, in the hme envirnment interperability can be cnceptually viewed as perating at 5 levels, which prvide significant challenges as illustrated in Figure 2. It is nt as simple as this implies either. The hme is nt either the bundary r the fcus f interperability because mbile services are prvided utside the hme, and fulfilment f the visin implies extending interperability much further int the area f service prvisin itself. Nr is it likely that, fr example, the need fr semantic interperability is restricted t the 'cnventinal' telecare and telehealth functins. The reasn fr bringing 'standards' int the interperability landscape fr DALLAS is that it is relatively easy t build a system, even a large ne, in which everything wrks tgether but which is nt scalable t include ther cmmunities, r saleable t ther markets with subtly different dynamics. By seeking t either adpt r adapt existing internatinal, Eurpean r British de jure r de fact standards the DALLAS investments shuld prvide a secure basis fr strng market grwth. 3.5 Cmmunicatins implied by the DALLAS visin The DALLAS visin implies a richer, mre cnnected flw f infrmatin and cmmunicatin between stakehlders t deliver the assistance services required. This is infrmed by earlier wrk in the ALIP prgramme and needs t supprt the breadth f use cases envisaged - which are illustrated by a few examples General cnsideratins Previus ALIP wrk in the Digital Access Prvisin Frum (DAP) has prduced valuable backgrund and frmative materials xi xii xiii that utline many f the requirements. Underpinning these examples are the principles f enabling 'care team' (including participant) c-peratin, whilst ensuring safe (and apprpriately secure) infrmatin sharing and cmmunicatin. Annex B, Architectures, deals with a number f architectural issues that need t be cnsidered by an 'enterprise' respnsible fr integrating the prvisin f care fr multiple citizens with ne r mre needs acrss at least as many specialist prvider functins Impact f use cases and related technical prvisin fr assisted living Starting with the cmmnly deplyed technlgies, we list in Table 1 sme examples f knwn use cases and related technlgies fr which sme interperability cnsideratins have been identified. The implicatins fr interperability are nt well understd fr a number f these and it is likely, even expected, that DALLAS Cmmunities will raise ther use cases t vercme cnstraints f lcatin r mbility nt shwn in these. DALLAS Cmmunities shuld design fr interperability wherever pssible and ensure implementatin is flexible t evlve during and/r after DALLAS, thereby addressing upgrade t a plug and play envirnment. 21
22 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Table 1: Example use cases, technlgy and interperability implicatins Use case Technlgy Interperability implicatins 1 Scial alarm call Prprietary telecare systems as deplyed t ~1.5M, mstly elderly, citizens 2 Sensr alarms / alerts fr, e.g. mvement, fld, gas, etc. 3 Mnitring activities f daily living fr, e.g. medicatin cmpliance, kettle use, dr pening, etc. 4 Mnitring health cnditins fr, e.g. medicatin cmpliance, health status, etc. 5 Clse mnitring f physilgical indicatrs fr, e.g. medicatin cmpliance, xygenatin, weight, etc. 6 Enterprise reprting f RMMS (see fig 3) activity and findings 7 Assistance with activities f daily living t citizens with physical disability 8 Remte cnsultatin fr scial, mental r acute health prblems (mstly in remte areas) 8 Mbile cnsultatin fr urgent, pprtunistic r reminder calls. 10 Incentivised gaming fr caching f teens and yung adults with, e.g. cystic fibrsis 11 Remte interactin, t enable wrk, vlunteering, mentring, scial participatin 12 Infrmatin Service Access, t amend visit schedules, knw transprt times, rder materials, etc. Extended telecare systems fr mre vulnerable sub-ppulatin f (1) Extended telecare systems fr mre vulnerable sub-ppulatin f (2) Prprietary telehealth systems as deplyed t a few thusand citizens with lng term health prblems. Prprietary telehealth systems as deplyed t a subset f (4) citizens with unstable lng term, r pst-acute, health cnditins. Trend, event r peridic reprts (accrding t service level agreement) supprting a range f structured and unstructured data types. Service rbtics and assistive adaptive cntrls deplyed withut wider interperability cnsideratins. Interactive videcnferencing chiefly using prprietary systems based n ITU standards. Peer t peer mbile phne cnsultatin. Caller's mbile acts as https server? Bespke, prprietary, applicatins Vide interactin via PC, TV r mbile device Interactive scheduling, timetables, e-shpping functinality Existing prvisin is cvered by EN and BS standards Existing prvisin is cvered by EN, IEEE and BS standards Existing prvisin is cvered by EN, IEEE and BS standards Sme aspects are cvered by HL7 standards. Mst aspects are cvered by IEEE and HL7 standards. Little used, but well cvered by IHTSDO and HL7 standards, as well as clinical prfessinal standards gverning cntent. Nt cnsidered in this dcument thugh sme requirements are cvered by EN and BS standards. Implicatins fr bradband QS (see 9.6), QS issues. Multiple platfrms nt cvered in this dcument. Nt cvered in this dcument Vide pen standards, Internet prtcl based (cmmunicatin device-independent). Cmmn Wrld Wide Web Cnsrtium (W3C) methds. In the instances where it is nted, "existing prvisin is cvered by EN and BS standards" this des nt imply that all further use implicatins are addressed. In reality, it is nt likely that all the example use 22
23 cases listed abve can be mutually interperable within the DALLAS timescale, r even much lnger even if it is necessary r desirable. It will therefre be necessary t seek best achievable interperability utcmes (i.e. reprducible mdels f supprt f jined-up service prvisin) cnsistent with the visin and principles f DALLAS. DALLAS Cmmunities will need t identify hw their use cases adhere t the interperability principles C-existence and verlaps with ther technlgy dmains Assistive technlgies, such as service rbtics and assistive adaptive cntrls straddle safety, security, in-hme cntrls etc. Safe physical c-existence has t be a minimum acceptable psitin as well as a strategic end gal. This implies, by extensin, that there has t be as much knwledge as is necessary t handle physical/transprt c-existence with ther material entering r leaving the apprpriate cmmunicatins envirnment. The security and safety dmain have much in cmmn with telecare, with many sensrs being cmmn. There can be peratinal interperability, sharing a cmmn prtcl fr sensrs and ut f hme cmmunicatin. Further dmains fr cnvergence are in-hme cntrl f energy (heating, lighting). There is ptential fr synergy at the level f functinal interperability. 4 Establishing a DALLAS ecsystem 4.1 Cntext It is imprtant that we understand where the envisined services have t start frm, s in the first part f this chapter we lk at the current landscape, fllwed by a lk at hw assisted living and assciated technical services might evlve frm that starting pint. The sectin then ges n t lk at interperability frm the perspective f the individual and their carers at the centre f the service prvisin, service prviders, clinical prviders and service cmmissiners; and finishes with an enterprise architect's view. There is ptential fr ambiguity and misunderstanding between the terms DALLAS Cmmunity and DALLAS Ecsystem used here. The DALLAS Ecsystem transcends a DALLAS Cmmunity, which will cntain its wn ecsystem. The intentin t f DALLAS is t ensure interperability between cmmunities, requiring crss-cmmunity discussins and agreement n interperability implementatin and cnvergence strategies. 4.2 Current landscape Within a DALLAS Cmmunity the ecsystem is unlikely t be established in a sterile envirnment devid f existing prvisin but is mre likely t be a hybrid and build upn evlutin f the existing prvisins f equipment, services and prcesses which explits existing assets and infrastructure but adds further innvatin. There is nw an installed base acrss the UK f telecare prvisin t mre than 1.5 millin clients but the verwhelming majrity f frmally prvisined services address a simple Alarm-Respnse service need. Figure 3: Interperability landscape 23
24 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 NOTE: The term RMMS was first cined by IHE/HITSP in the US and helps describe a wide range f functinality which culd include: Device management, Respnse management, Recrd keeping, Cntent management / distributin, Custmer Relatinship Management (CRM) /cntact management, etc. Hwever there is gd architectural verlap between the needs f scial and health mnitring and the verall landscape schematic shwn in Figure 3 is typical f hw telecare services are currently cnnected, and can be generalised t many assisted living cmmunicatins. Mre infrmal persn t persn cmmunicatins and interactins generally cntain the same general elements albeit with different 'actrs'. DALLAS shuld nt be cnstrained by current architectures and services. The future Ecsystem is expected t be pen t a much richer cnnectivity f stakehlders and services and tuch n aspects f the Internet f Things and service rbtics. The Internet f Things is cnceived as a much wider ecsystem f cmmunicating bjects, a system f systems wrld with wide ptential fr data access and cntrl althugh the fundamental cmmunicatins issues remain the same. The sensing that meters energy usage may give infrmatin abut activities f daily living and there may be further useful service infrmatin t be derived frm sensing and mnitring in the client envirnment that has utility in supprting the client. 4.3 Evlutin The interperability architecture, current landscape and evlutin prpsal dealt with in this sectin is in supprt f the wrkflw assciated with alarm and mnitring handling because it is the natural start pint frm which t migrate the existing telecare deplyed base t that in supprt f assisted living in its widest sense. There are significant challenges in evlving the current envirnment, which are discussed and detailed in Appendix G. These challenges include: prvide a chice f devices thrugh plug and play integratin; prvide care cmmunity-wide pen service integratin as a key enabler fr scale, particularly in health ecnmies seeking t encurage plurality f prvisin. Figure 4: Layered service prvisin building upn self-managed care. There are pprtunities, fr example, t create market demand fr standards-based prducts. The ptential scale f demand arising frm DALLAS culd have a psitive impact n the vendrs ecnmic case fr adapting slutins t use standards. Hwever, there are sme issues such as the widespread 24
25 lack f interperability in existing equipment and limited availability f standards based cmpnents, and the lcal variatins in services and prcesses. There are als significant gaps f ptential pprtunity e.g. t prvide care cmmunity-wide pen service integratin, Integratin f service agents (family, friends, 3 rd sectr, hme suppliers and service prviders). There is a significant challenge fr DALLAS t mve in the directin f a mre pen ecsystem that allws fr evlutin, recnfiguratin, extensin and integratin f new and 3 rd party service prvisin. The fllwing subsectins are written frm the perspective f the established base f scial alarm services as an illustrative example f the interperability challenges and pssible evlutinary pathways. This des nt imply that ther starting scenaris r evlutinary rutes are in any sense invalid, r utside the scpe f DALLAS. Fr example, ensuring that interactive vide services (fr, e.g., cnsultatin r reassurance) are capable f perating with the necessary quality f service is delivered is a valid requirement. Similarly, supprt fr questin and answer prtcls, interactive incentives, authenticated remte cntrl f clse-t-citizen systems (windw blinds, etc.) may be demnstrably useful assisted living capabilities. Sme f these brader issues are cnsidered in Annex B and Annex G. It is imprtant t recgnise that the example interperability architecture, current landscape and evlutin in supprt f the wrkflw assciated with alarm handling and mnitring cited in this dcument is just that an example. It is used because fr many cmmunities it will be the natural start pint frm which t evlve the substantial existing telecare deplyed base t supprt f assisted living in its wider sense. Services are the key elements that technlgy can enable and the successful design and implementatin f thse services may well be key t shaping the market and demand, just as services such as, fr example, iplayer, YuTube, Facebk, Flikr, Ggle, Skype and Twitter have helped t shape the use f the internet and t increase demands fr access and bandwidth. As the market matures, we might expect assisted living functins t be embedded in cmmdity cnsumer prducts and easily amenable t familyand self-prvisined care. What is already knwn t be essential is that assisted living technlgies be intuitive t thse with sme level f physical and r mental impairment, and that they must nt require any technical knwledge t initiate, r maintain, and use. Alternative starting pints fr cnsideratin might be fr example the mbile phne which, enabled by GSM (2G and 3G) in the 1990 s and enrmus market grwth, has evlved as the handbag lifeline fr a huge ppulatin and prduced a generatin f Smart Phnes with extensive integrated sensr, cmmunicatins, display and prcessing capability. The later sectins f this dcument (6 t 10) prvide mre detail abut hw it currently seems desirable that sme aspects f this evlutin ccur within DALLS Cmmunities Supplier perspective The key driver fr interperability is nt abut every part f every system being interperable, but rather that the infrmatin created by assistive living technlgies is interperable, and mre imprtantly that the infrmatin can be accessed by thse wh need it, and when they need it. End t end interperability is, abut infrmatin flws in supprt f human-t-human cmmunicatin, nt abut technical cnnectin. There is a feeling within the industry that lack f interperability and expensive telehealth is the reasn why adptin has been limited t date. Hwever, there are multiple factrs that have impacted adptin. Evidence f the benefits, and the scalability f benefits, has been seen as a significant bstacles, as has pr awareness f assisted living amng prfessinal cmmunities, and the lack f incentives t existing stakehlders t adpt change as s ften, benefits d nt necessarily accrue t thse asked t make the biggest changes t their ways f wrking. Current experience is that interperable peripherals cst typically three times as much as prprietary peripherals t acquire. Sme telehealth cmpanies have therefre interfaced the varius peripherals required by clinicians, in sme cases at n extra cst. This ad hc and n-demand service is feasible (at cst t the integratr) while the number f sensrs and market size remain limited. It is nt practical when the range f sensrs, with subtly different functinality 25
26 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 (e.g. pulse ximeters able t 'ignre' Parkinsnian tremr), and the range f cnditins addressed, increases. There is an unmet market demand fr plug and play cnnectivity f peripherals s cmmissiners can meet specific needs, service prviders cannt currently enable this wider chice with the existing deplyed equipment. This meeting f specific needs can at present nly be achieved with prprietary interfaces. A de fact mainstream interface, such as USB, may be a partial slutin t this prblem. The advantage t suppliers f making peripherals interperable lies in the pening up f the market and in the ptential fr the market t grw. The hme market has grwn slwly but is ne f the mre develped Eurpean markets in the take-up and delivery f services based upn telecare. Opening up peripheral interfaces enables innvatin in sensrs and services t be cnsidered with lwer entry barriers. Acceptance and cmpliance can als be addressed by interperability. Lack f chice and ability t custmise delivery is a barrier t take up. Allied t this is the lack f flexibility ffered by ff-the-shelf prducts designed fr persnal purchase and use. Fr the mst part these are still single mdality systems, resulting in a drawer-full f equipment and cables being required fr thse wishing t measure mre than ne parameter. Interperable peripherals wuld make self-purchase nt nly mre aesthetically and ergnmically attractive but imprve ease f use (standards cnfrmant designs are designed fr 'activate and use' simplicity) and drive dwn csts fr the clinical market. Trying t make sure every feature f every system at every level is interperable culd mean that innvative slutins cannt be develped and used as unique selling pints fr a cmpany s ffering. Innvatin cmes as rganisatins develp new ideas and features. If there are limiting standards between the different cmpnents then thse features cannt be intrduced as the standard cannt supprt it, and if intrduced it wuld make a system nn-cmpliant. Any interperability standard r guidance adpted has t be s clear abut its scpe and purpse that knwledgeable specifiers r purchasers can understand, and require, interperability apprpriate t the desired functin see 0. In an envirnment where peple have a wide range f assistive living technlgies, and a range f service prviders such as health and telecare alarm centres, the right infrmatin has t be available t the right peple. It may nt be desirable t allw cmmunity alarm staff t access and view clinical data, but it may be desirable t allw a cmmunity nurse t see if smene has had a fall, etc. The issues f cnsent and the definitin f rles in existing telecare prvisin may need t be re-examined t ensure that client privacy, and individual preferences are respected and that rganisatin and prcesses are matched t the envirnment. The guiding principle is that it shuld never, because f a lack f interperability between equipment, be necessary t duplicate functinally similar devices in rder t prvide the services required. Nr, fr the same reasn, shuld it be necessary t cmpletely remve existing, and reinstall new, equipment if needs change Clinical perspective 14 Much has been learnt already frm wrk in prjects that have lked at patient and prfessinal user requirements and frm earlier wrk n remte mnitring. A general practice may have between 14% and 18% f the patients n a chrnic disease register. Study f a randmised grup f patients frm the disease register shwed that 37% had clinical utcme measurements that lay utside the parameters quted by The Map f Medicine as thse levels at which patients gain their best clinical utcme. Fr Chrleywd Health Centre this wuld result in apprximately 400 patients needing clinical interventin and wuld prve untenable 6.4% f a practice ppulatin f 6,250 peple. Of the grup studied 10% required significant interventin and the care f these patients can be cnsidered later. It is the care f the 27% (360 patients) with lesser difficulties that needs t be addressed because if tls can be develped t supprt them, the caselad will be reduced. Fr example, in diabetes, many patients are 14 This sectin is abstracted and generalised frm " The Future fr the Hydra Prgramme" by Prf Russell Jnes f Chrleywd Health Centre. The full text, with an extensive use-case, can be fund at: 26
27 stable and well but thse wh may be in the 27% grup may need sme supprt t adjust their diet and levels f activity. NICE guidelines advise a review f medicatin and dsages alng with shifting the dietary balance away frm sugars tward starch and assessing levels f physical activity. It is prpsed that a lp-back algrithm and educatinal resurces t supprt patients in their wn effrts t achieve imprved care can achieve this. If successful, this will prmte a patient s self-care and reduce a wrklad prblem fr health care services that remte mnitring will create. The pint t be made is that fr remte mnitring t make an impact n healthcare services it must be used where there is an expected clinical gain fr the patient. By cmparisn, telecare is used t a far greater extent because perhaps the gain is mre straightfrward and the data mre easily interpreted. A frail elderly persn wh falls is at immediate risk f dying and the alarm is easily understd and services alerted. In telehealth, data are mre cmplex and nt always easily interpreted. Alarms are less likely and data d nt have the same immediacy as in telecare. A mre measured clinical respnse is called fr that is driven by a number f elements: the data itself, the clinical recrd and the assciated knwledge f the patient, integrated medical and nursing skill, and the explitatin f usual clinical services t supprt the apprpriateness f the respnse. T cnvince, the case fr the widespread remte mnitring f patients must highlight its ability t make a difference t clinical utcme and patient risk in additin t being affrdable and deliverable by present healthcare services. Remte mnitring data has been restricted t a specific scial prblem r clinical specialty. The chices reflect the interest f the spnsr and what prves t be pssible r affrdable. This des nt fit well with scial realities and illness. Fifteen per cent f us will have a lng-term cnditin and mst f us in that grup will d s because f ur ld age. We may suffer many illnesses and becme disrientated and cnfused and ever mre dependent. Fr much f the time it is manageable, life is relatively nrmal, and there will be little reasn fr cnstant and intense mnitring leading t active clinical r scial interventins. At any ne time, abut fifteen patients f the Chrleywd practice will need active and fcussed mnitring. This will need t cver all pssible areas f illness and persnal risk. The ld and ill will fall and average expectatin f life n falling and fracturing a hip is shrt. Hw this high risk and high demand grup is recgnised needs t be cnsidered. In Chrleywd s earlier wrk, they knew the members f the grup but had nt measured their frailty and vulnerability. The high-risk grup was nt recgnised within the chrnic disease register. The present Quality Outcmes Framewrk (QOF) system f care utcmes des nt recgnise the high-risk patient and wrks n the principle that driving greater attentin t the detail and prcess f a system f care will result in the imprvement f care. Sadly, recent evidence has shwn that the QOF apprach may nt have itself imprved health utcmes fr the chrnically ill patient. Remte mnitring gives a new pprtunity t address the issue. The intermittent use f mnitring with measures f risk culd recgnise the high-risk individual. The latter can then receive mnitring until clinical stability is regained r underg cntinuus mnitring with data being used t appraise either clinicians r scial wrkers, r indeed bth, f the levels f illness and safety leading t apprpriate and timely care. It shuld nt be frgtten that it is nt nly the elderly that make up the register f chrnic disease but als children and yung adults, althugh happily there are far fewer t cnsider. New advances mean that data can be cllected by standards driven sensrs that can be replaced r imprved upn withut the need t change the whle remte mnitring platfrm, patients shuld nt have t be cncerned abut technical reliability r functins. Cllecting and string infrmatin fr n gd reasn is at best flish and at wrst prurient. In healthcare, the cllecting and string f bdy parts and tissue withut cnsent prved unacceptable and the cllecting f health data, irrespective f its use, is little different. Implementatin must be ethically rbust and fllw usual practice f the invlved carer rganisatins. Data shuld becme part f the clinical r client recrd. The latter have cntrls and standards fr cnduct established and mnitred by prfessinal bdies and a data regulatry authrity. Infrmed cnsent with a full understanding f hw data will be mved, shared and used is f fundamental imprtance in making telecare/telehealth successful and acceptable. The remte mnitring platfrm needs cmmunicatin between the patient/client citizen and a principal prvider that can ffer and maintain a cntract f care. The principal prvider may be an individual carer r care institutin. Hw the latter is funded r gverned is f n matter t the citizen patient/client. It is the cntracted cmmitment that matters. The prvider may be any f the fllwing: a private cmpany, a nt-fr-prfit cmpany, a charity, a state funded care rganisatin, an insurance funded care rganisatin r a private individual. Whatever their designatin, the relatinship with the patient/client and the descriptin f their respnsibility must be stated in the cntract. This shuld be exchanged acrss the remte mnitring platfrm and infrmed cnsent held securely and it shuld be pssible t negtiate 27
28 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 variatins in respnse t patient/client need. There is the further cmplexity that will ccur where a review f carer cmpetence indicates a need t request advice and help frm ther individuals r rganisatin. The latter might then accept a sub-cntract frm the principal cntractr with the agreement f the patient/client. A family member r recgnised nminated carer culd manage the cntract n behalf f the patient/client where the latter has difficulty managing the cntract. In this way a netwrk f care rganisatins and services can be rganised t prvide remte mnitring and respnd t need in a disciplined manner that is similar t hw usual care services functin and allws an audit f services and csts. These last pints are crucial t the remte mnitring platfrm s perating design and prvide security fr the user and resurce management fr the service cmmissiners Cmmissining perspective 15 A fundamental principle fr a DALLAS prgramme is that the chice f peripherals shuld nt be cnstrained by the applicatin-hsting device r by the technlgy service prvider(s). Cmmissiners f Services strngly desire t be able t use peripheral devices such as sensrs frm any supplier with any hme device in rder that they have a wider chice in selecting peripherals t meet client-specific needs. This shuld allw new technlgy sensrs t be intrduced int existing systems and installatins t be evlved r adapted t suit changes in client needs. There is a further desire t select a means f cmmunicatin with the service prviders: Smart Phne, Dedicated Hme Hub Device r ther means which nt nly meets their functinal needs but the envirnmental cnstraints f the installatin and ffer t the client chice in the lk and feel in the hme r pcket. Furthermre, the telecare/telehealth service tplgy shuld link the mnitring centre nt nly t the health recrd but als t the scial care recrd (and by implicatin enable a linkage f the tw t each ther see Figure 1). A key element fr the successful delivery f integrated health and scial care services is the grwth f psitive practices in inter-wrking. T achieve such inter-wrking requires technlgical interperability. One f the ambitins fr the use f DALLAS shuld be t act as a catalyst fr the pening f thse recrds (health and scial care) bth ways. This needs a fresh apprach t infrmatin gvernance that bth enables the services required by the cnsumer but als prvides the essential safeguards t prtect their interests in additin t legal and regulatry cmpliance. The practices f prcurement need t be revisited t enable cmmissiners and suppliers t deliver best value fr mney slutins t their clients, and shift the paradigm away frm cmmditised lwest-cst appraches. This implies that innvative slutins t acquisitin may be a cntributin t enabling the necessary paradigm shift in care delivery Enterprise perspective It is clear that during the lifetime f DALLAS, and fr sme time t cme, there will remain a rump f legacy equipment and the challenge f hw t manage this. There are standards gaps where nly prprietary ptins currently exist and n clear migratin strategy has emerged. There are difficult chices between custmisatin and standardisatin, which may well impact n take-up and change. Hw shuld legacy be managed? Can the wrk f Cntinua Alliance be an effective stepping-stne twards meeting future needs? Hw can new and established cmmunicatins infrastructure been used t meet service requirements in an affrdable and reliable way? Fr the care service prvider and equipment supplier there are clearly trade-ffs between prducing and stcking a range f equipment that is tailred t the circumstances f each installatin r a mre limited range f equipment that can cver a wide range f hme situatins by aut-adaptin, cnfiguratin at installatin by specialist installer, prgramming r standards adptin. There will fr the freseeable future remain a chasm in dwnlad and backhaul capabilities between urban lcatins f high ppulatin density and mre remte rural areas f lw ppulatin density where the difficulties f transprt and service access arguably make imprved telecare a higher pririty. 15 This sectin is supplemented by a case study, "Gwent Frailty Prgramme - case study" by David Hartwell- Williams. The full text can be fund at: 28
29 There is expected t be a widening range f individual demands, which will vary accrding t needs and preferences. Chice is an imprtant cnsideratin bth in selecting equipment and selecting services. Services shuld nt be lcked-in by prviders and the prjects need t cnsider hw they will deal with transfer issues such as thse currently managed by the mbile phne and banking industries. 5 Guidelines fr interperability 'in the rund' Interperability shuld be seen as a just ne f a number f means twards the end gal f hlistic independent, assisted living, and is nt an end gal in itself. Within this sectin, we intrduce an example f interperability in supprt f infrmatin and cmmunicatin flw frm the individual, thrugh service t 'cmmissiners' (nt necessarily frmal r rganisatinal) r in the reverse directin, This infrmatin and cmmunicatin flw (green lines in Figure 5) is knwn, even in this extensive example based n the familiar telecare/telehealth mnitring scenari, t address nly sme f the ttal flw (yellw, amber and red lines) necessary t ensure jined-up delivery f prvisin in a single service use case and desn't even start t address crss-service flws. Figure 5: Illustrative infrmatin and cmmunicatin flws assciated with alarm and mnitring prvisin. The amunt and type f material presented t, fr example, GP cmmissiners needs t be carefully managed t ensure that they are nt verwhelmed by the ptentially large quantities f data being prduced by the devices.. A GP cmmissiner wuld reasnably expect that the service prvider will manage alarm events in an agreed manner, mnitr trends in data frm devices, and summarise that infrmatin int a perid, r exceptin, reprt that can be integrated with the health recrd held by the GP. In ther wrds, ne persn's infrmatin is anther's fld f meaningless data; the amunt f hard data tends t diminish frm left t right acrss the green flws Figure 5, whereas the amunt f interpreted infrmatin tends t increase in the same directin. On the yellw, amber and red flws, the infrmatin and cmmunicatin tends t be cndensed t the 'needed fr actin' cntent, with greatest reductins happening frm right t left. Whilst recgnising the impact f existing 'legacy' prvisin DALLAS Cmmunities need t weigh carefully the balance f initial equipment cst and technical practicality against enabling adaptable prvisin f the apprpriate assistive services in, and beynd, the duratin f the frmal DALLAS prgramme. It is mre 29
30 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 difficult t make this judgement fr citizen-purchased equipment and services, but a nn-interperable, quick buck, apprach is unlikely t result in cnsumer cnfidence and the desired market grwth. The guiding principle fr Cmmunity ecsystems remains: that it shuld never, because f pr interperability between equipment, be necessary t duplicate functinally similar devices t prvide the services required. Nr, fr the same reasn, shuld it be necessary t cmpletely replace equipment if a persn's needs change in either intensity r number. Similarly, care prvisin services that serve multiple DALLAS Cmmunities shuld nt have t deply mre than ne means f dealing with the same cmmunicatin they shuld be able t rely n interperability acrss the DALLAS Ecsystem as a whle. 6 Data presentatin - applicatin f standards Service delivery and semantic interperability are the main drivers fr standards. Standards help t develp markets by encuraging adptin but can, if prly drafted (r drafted t serve particular interests), be a barrier t innvatin and fulfilment f emerging requirements. Well-drafted infrmatinrelated standards define a cre set f cmmn requirements and prvide explicit mechanisms fr prprietary extensins that d nt 'break' interperability fr the cre set but allw 'added value' / USP functins t be handled within the cnfines f the prprietary envirnment. While prprietary appraches (de fact standards) may present gd shrt-term value they may limit lng-term adaptability and interperability, similarly de jure standards that have little industry backing may present unacceptable risk. DALLAS Cmmunities may wish t carefully cnsider the balance f these factrs in their wn ecsystems, in the DALLAS Ecsystem as a whle and in the light f glbal viability. Physical lng-term cnditins lend themselves t well researched, and tried care pathways but ther aspects f peple care are either less deterministic and well understd, r nt clearly supprted by existing evidence based appraches. In particular, the care needs f peple with mental health prblems and/r learning disabilities may vary widely. There are significant differences als, especially amngst the elderly, in the extent t which sensry impairment impacts upn their lifestyle and engagement in sciety. Assistive living technlgy that becmes available t prvide further supprt t these grups may nt be well r elegantly supprted in current standards but needs t be accmmdated. The needs fr prvisin in these areas g beynd established symptmatic and vital signs data cllectin and extends int mental state, behaviur, activity and respnse t stimulus; types f data cllectin currently acquired thrugh bservatinal study r cntrlled 'stimulus and respnse' testing. It culd be argued that there are sme issues and areas where departure frm standards is desirable and there can als be practical challenges f management and use f data. The fllwing is a discussin f sme f these issues specific t telehealth. 6.1 Health status cmmunicatin Handling f symptmatic data Very little vital sign data is captured and transferred by telehealth systems currently in use. Systems capture a range f indicatins t d with symptms, quality f life, security, patient experience, text and vide messages, peratinal, maintenance related, etc. These requirements can be split bradly int tw headings, namely data frm and abut the patient (patient data), and data fr managing the security, resilience and infrastructure f the telehealth system (peratinal data) Patient data The data that is cllected under this heading is nt prprietary t a supplier, but is frm questins that have been chsen and selected by clinical teams respnsible fr pathways f care. What is currently prprietary is the methd by which the questins are selected, stred, cmbined tgether, transferred t 30
31 the Persnal Hub and then presented back t the individual by that Hub16. There are hwever a number f validated questinnaires (PHQ-9, HSQ2.0, HRQL, HADS) in existence sme targeted at specific disease management. Typically when a patient is enrlled nt a system, the clinician will select a range f questins that they want the patient t answer, sme f which will be t cllect vital signs, such as bld pressure, etc, but the rest will be a cmbinatin f multi-chice, numeric, scale based questins that are abut symptms. Clinicians are mre likely t be interested in symptms than in vital sign measurement, and may nt actually cllect indicatrs f the latter. Typical questins may be: Hw breathless have yu been tday? fr which the answers culd be: Much Less than usual Less than usual As usual Mre than usual Much Mre than usual Assciated with the questin, is the reasn why the clinician wants t ask the questin, what is the intent f the questin, what am I trying t find ut? In additin, when it cmes t displaying the data in the server systems, yu will als need a Title (i.e. Daytime Breathlessness). Assciated with the answer will als be time f day the questin was answered. Language usage is nt static, it varies with time, lcatin, gender and scial grup and custmisatin may nt be avidable. Nested, branching lgic, questins are als needed, such that a certain answer t a questin will lead the system t ask an additinal questin. Fr example, if the answer Much mre than usual is answered then yu may ask if that was at rest r upn exertin. The questins and the answers are related and will need t be cnsidered tgether by the clinician. It is als imprtant t understand that every clinician will want t change the questin slightly (which is why yu may have a questin intent statement) Als needed may be Quality f Life and Patient experience questinnaires, which are typically a cllectin f questins that are asked as a set. Patients can let their clinician knw if they are ging away and the system autmatically knws when they return. Sme systems allw patients t type messages, recrd vide messages, and even in sme circumstances have a vide-cnference. Industry players may need t cnsider getting tgether t define (perhaps based n the existing HL7 standard) hw this data is packaged and interpreted. wrk Operatinal Data The majrity f existing Hubs are prprietary and even standardisatin f infrmatin flws assciated with patient care des nt necessarily imply standardisatin in the management f the link between Hub and back ffice abve the Transprt Level (see Annex F). The infrastructure f a safe and resilient telehealth system is nn-trivial. The Persnal Hubs are being enabled with mre functinality, there are infrmatin and cmmunicatin gvernance issues t cver, the servers need t knw if the Hubs are cnnecting each day, if the patients are entering data, hw t safely and reliably dwnlad and manage new questin sets, new sftware releases, encryptin and data prtectin issues, etc. All this is handled by each server/hub supplier cmbinatin, hwever if hardware is shared (fr example in the hme) then sme minimum interperability standards that can be relied upn t ensure adequate functinality shuld be supprted Display f cllected data The way data is displayed is prprietary, and is ne f the differentiatrs between systems. Fr example if single data pints (fr example weight values) were sent t a typical NHS system, it wuld nt be able t display the data apprpriately, and the full picture will nt be available fr the clinician. It is apprpriate 16 True fr vital sign questins as well, and is why a Persnal Hub needs t be clsely linked t a server with cmplementary capability see end f
32 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 t d intermediate cllatin and presentatin f relevant infrmatin, nt irrelevant data, int a frmat that can be cnsumed by a clinical system where it may easily be reviewed. Fr example, key values such as Bld Pressure r Weight, etc, might be presented, but nt all the symptmatic data. A tactical apprach t prviding data can be adpted when a full integratin is t cmplex; fr instance, prviding access t data in the telehealth system using URLs and Web Services. It may be cnsidered imprtant fr the purpses f cnsistency in training and patient safety that there are sme agreed and standard presentatins f data fr prfessinals t use. This des nt preclude prprietary extensin but shuld ensure that default presentatins are available t all 7 Telecare and telehealth cmmunicatins example 7.1 Overview In this sectin we return t the specific example f interperability in supprt f the wrkflw assciated with alarm handling and mnitring; which is used because fr many cmmunities it will be the natural start pint frm which t evlve the substantial existing telecare deplyed base t supprt f assisted living in its wider sense. 7.2 End t end interperability The need fr an ecsystem As illustrated in Figure 3 there are, in the current scpe, three main cmmunicatin 'hps' that have interperability requirements. They are in rder f infrmatin flw (as shwn in Figure 3): 1. Persnal health device cmmunicatin (Persnal and/r Lcal Area Netwrk); 2. Public netwrk cmmunicatin (Wide Area Netwrk); 3. Cmmunicatin fr wellness caching and care pathway integratin (varius netwrks). The aim is t develp a DALLAS Cmmunity ecsystem that is able t supprt (in agreed stages) end-tend interperability as shwn in Figure 3 and Figure 5 t satisfy the need fr semantic interperability as illustrated in Figure 2. In this architecture telecare and telehealth sensrs may be cnnected in the same platfrm and data transmitted thrugh a cmmn channel frm the hme t a WAN Receiver, which wuld direct t the apprpriate, and perhaps separate, service prvider. In mainstream, integrated, service prvisin a peridic reprt t service cmmissiner cmpletes the end-t-end infrmatin flw. Furthermre, the ecsystem shuld allw further sensrs t be added withut need t update firmware n the Applicatin Hsting Device (AHD). This culd be accmplished either because the AHD frwards the data t the system f the Service Prvider (which is able t act n the received infrmatin) r because the AHD culd (assuming the service existed frm the WAN receiver) cpe with a WAN-delivered upgrade f sftware including f new specialisatin capability. This capability requires adptin f standards designed and crdinated t supprt end-t-end transfer frm sensr thrugh t Service Prvider. The Applicatin Hsting Device (AHD) t Service prvider link shuld be able t perate ver available cmmunicatins infrastructure and t supprt business cntinuity. DALLAS will invlve peratins at a scale that will actually require this level f enterprise integratin / interperability, making this a key area fr ptential interventins. The balance between the 50,000 subscribers within DALLAS and the initial investment budget might, unless ther stakehlders jin the wrk f a DALLAS Cmmunity, restrict hardware acquisitin. This raises the issue f sweating the existing legacy assets t get best value. Enterprise integratin and interperability is ne way t d this (see 7.11), hwever the degree f lw-level interperability that can be achieved n the basis f existing deplyment is limited. We may need t demnstrate pathways t interperability and shw that it can be dne but it is nt intended t sweep ut a mass f existing 32
33 sensrs and 'carephnes' just t prve the pint. That wuld ignre sunk csts and existing stcks. The challenge is rather hw legacy equipment and systems can be integrated. See als paragraph Standards that have been designed t address the cmmunicatins need The Cntinua Healthcare Alliance has been wrking t cmpile guidelines t bring tgether, r spnsr develpment f, standards that supprt the end-t-end cmmunicatin requirements by linking the elements identified abve. The fcus f the Cntinua Alliance has been upn health care and wellness but until recently it has nt given much cnsideratin t established scial alarm services and established standards with their different infrmatin exchange requirements17. The materials described in this sectin are thse that frm the basis f the Cntinua Guidelines. The activity f the Cntinua Alliance is a cntinuing wrk in prgress, which has made significant headway and achieved a wide acceptance. Hwever, instantiatin at the level f available system cmpnents and their deplyment is as yet limited and there remain artificial price differentials that are at present deterring take-up. The Cntinua Alliance architecture is utlined as a reference pint. The anticipated aim, bjectives and derived benefits are then summarised. The issues f semantic and then transprt level interperability are further develped in the cntext f Health care delivery. This draws heavily upn the wrk f the Cntinua Alliance and HL7 grups. 7.4 Cntext The Cntinua Health Alliance has defined an end-t-end architecture that includes: Cmmn architecture and prtcl fr telecare sensrs and telehealth devices Object level definitin f sensrs (agents) that prvide plug and play interperability Flexible and extensible architecture Sensr independent Applicatin Hsting Device (AHD) (frward transmissin f data withut need t understand data requirements f the sensr) Wide area message and Enterprise dcument cmmunicatins in accrd with NHS requirements It shuld be nted that the AHD platfrm may als ffer lcalised r parallel services utside f the Cntinua interface cmpnent. 7.5 Aim In the cntext f expanded requirements f assisted living supprt and the DALLAS prgramme, interperability has as its aim: 17 Establish an interperable prtcl fr telecare systems that is flexible and extensible, and able t perate ver a variety f IP cnnectin media Accmmdate cnvergence trend twards a telecare and telehealth cmmn architecture, using pen standards and aligned with DH requirements. Reduce need fr reprgramming and upgrade in the field Gain field experience f installatin and service issues fr review and imprvement Give the market a better appreciatin f the benefits enabled by migratin frm existing services Althugh an IEEE standard (and nw a BS, ) fr an ADL hub t utput a range f standardised indicatrs as used in BS8521 has been in existence since 2008 it has received little attentin frm Cntinua perhaps because n new sensrs sales are implied. 33
34 White Paper - Interperability fr DALLAS applicants and cmmunities v Objectives The DALLAS Interperability prgramme has as bjectives fr telecare and telehealth (in n particular rder r pririty): At an infrmatin level, establish a cmmn prtcl t prvide interperability fr scial alarm systems and sensrs frm different manufacturers (near term) Prvide at least the same level f base functinality as existing systems, and nt preclude advanced functinality being prvided in future Prvide an extensible prtcl Supprt cnverging telecare and telehealth requirements Supprt newly emerging sensrs Data prtcls t be netwrk agnstic Architecture nt t require recnfiguratin f AHD when new sensr added Lss f cnnectin f sensrs t be detected and reprted Means t re-establish Sensr cnnectin t AHD if lst unexpectedly Prblems with sensrs t be detected and reprted Lss f cnnectin f AHD with MC t be detected Cnnectin between AHD and MC t be re-established if lst Alternative path fr cnnectin between AHD and MC t be explited if available RF level interperability as a future phase, thugh ne which shuld nt be precluded by decisins in current phase Establish an enterprise-level MD reprt frmat t the respnsible cmmissining persn r rganisatin 7.7 Benefits Adpting a cmplete, end-t-end, standards based architecture wuld bring the fllwing benefits: 34 End t end plug and play interperability Interperability between devices frm different manufacturers Integratin f telecare and telehealth and ther dmains Reduced cst t the cnsumer Market grwth Incremental grwth f systems new sensrs added quickly and easily Greater cnsumer cnfidence Reduced cst f manufacture OEM manufacture f mdular cmpnents (e.g. wireless mdules) Wider range f available devices Ability t supprt niche sensrs Simple set up prcedure fr new sensrs Upgrade f firmware t supprt new sensrs eliminated (An analgy being an IP ruter nt needed t be upgraded every time a new IP device is added, r a new service run n a device Reduced risk, in a regulatry cntext, f adptin and implementatin f new technlgies Enabling f new service cncepts Supprt fr mbility
35 7.8 Twards semantic interperability The main aim f the DALLAS apprach t interperability will be t wrk twards an architecture that adpts standards that prvide semantic interperability acrss several dmains (see Architecture). At a minimum this shuld supprt cnvergence f the telecare and telehealth dmains, prviding apprpriate semantic interperability. This is particularly imprtant fr data that riginates frm medical devices. Any sftware r hardware that mdifies medical data while in transit between endpints is, under current UK and US regulatry regimes, a medical device with a higher risk categrisatin than many simple riginatrs f data. Cnfrmance t a standard that establishes semantic equivalence lwers this regulatry hurdle. Within the cntext f the ISO/IEEE 11073xiv and HL7xv wrk there has been a specific activity t ensure that internatinal cnsensus is reached n the cmmn gld standard representatin f semantics apprpriate t the use dmain. Fr the Persnal Device Dmain t Netwrk Interperability Dmain the required semantic representatin uses When reprts are utput frm the Netwrk Interperability Dmain t the Care Pathway Integratin Dmain then SNOMED CT representatin is used. The safe transitin frm the device-riented terms f t the clinician-riented terms f SNOMED is managed by a cmmittee f experts under the auspices f a memrandum f understanding between IEEE and xvi IHTSDO (respnsible fr SNOMED). Under this arrangement, there is mutual listing f the equivalent terms within bth the IEEE and IHTSDO standards and a maintenance prcess managed by NIST in the USA. This detailed arrangement is imprtant fr implementers because it means that they are nt liable fr establishing the crrect relatinship f terms that liability is held by the standards bdies; a cnsensus arrangement respected by regulatrs as being state f the art. 7.9 Persnal health device dmain BS EN ISO/IEEE Overview The IEEE standards were riginally designed t allw cmmunicatin f, and between, medical devices used in acute care. They were, hwever, designed specifically t allw plug-and-play cnnectin that required n ther user interventin and they were deliberately specified in a way that allws very simple n-the-wire implementatin by pwer- and capability-cnstrained devices. Whilst retaining these characteristics, the Persnal Health Device standards were simplified as much as pssible t get rid f the cmplexities f devices typically nly seen in medical use. The IEEE Persnal Health Device standards are designed t prvide the fllwing: Semantic interperability (including with existing healthcare systems) by adpting standardized nmenclature and bject mdels Sensr interperability by defining standard device behaviur thrugh specializatins Functinal interperability by prviding standardized prtcls Device interperability by adpting standardized transprt layer prtcls have cmmn features It is imprtant t emphasise that the frmally mdelled cmmunicatin scheme this is slely fr the purpses f ensuring that the cmmunicatins are fully understd and d nt, when implemented, behave in unpredictable ways. State transitin mdel testing has been undertaken fr the same reasn. Implementatin des NOT require that the full extent f the mdelling needs t be understd, nr that cmmunicatins themselves are bject riented. Device interperability is accmplished by adpting a device cmmunicatin architecture with 3 layers, as shwn in Figure 6. 35
36 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Figure 6: ISO/IEEE Persnal Health Devices architecture Transprt layer prtcls IEEE defines that all transprt layers shall have cmmn basic characteristics f reliable, full-duplex transmissin. Specifics f cnnectin, physical implementatin are nt defined within IEEE , but are prfiled by Cntinua fr transprt layer technlgies adpted by Cntinua. Currently Bluetth, USB and Zigbee have Cntinua prfiles Exchange prtcls IEEE defines the exchange prtcl fr infrmatin between the agent (sensr device) and manager (AHD). IEEE has been described as an ptimized exchange prtcl, as it has been designed specifically fr small devices with very limited resurces f CPU, memry and battery capacity. Fr this reasn binary-data transfers are used. Hwever, IEEE is designed t be extensible and flexible, and plug and play. T accmplish this it uses bject descriptins f the device and data surces. The prtcl supprts self-descriptin f the bject mdel n assciatin f an agent with the related manager Presentatin frmat It is imprtant t understand that IEEE and the related device specializatins define a precise nmenclature and cntainment hierarchy which frm the basis f all semantic interperability thrughut the rest f the ecsystem. It therefre fllws that as sensrs fllwing IEEE self describe n assciatin, creating a prxy versin f the bject mdel in the AHD, and send all nmenclature terms in the LAN-IF r PAN-IF messages; then the AHD has all the infrmatin t create the PCD-01 message fr the WAN-IF withut further reference t any ther surce Netwrk interperability dmain: HL7 messaging (Cntinua WAN) Intrductin The IHE Patient Care Devices (PCD) wrking grup fcuses n the integratin f medical devices int the healthcare enterprise. As the cre f that effrt, they have cnstructed a set f prfiles that describe an interperable way t cmmunicate medical device data in near real-time. 36
37 One f the primary prfiles created by this grup is the Device Enterprise Cmmunicatins (DEC) prfile. Each IHE Prfile defines a set f actrs and a set f standard message exchanges called transactins. The primary transactin in the DEC prfile is PCD-01: Cmmunicate PCD Data. The HL7 (v2.6 ORU) messages defined by this transactin have been selected fr use n the Cntinua WAN interface in rder t enable the uplad f device bservatins t a WAN Receiver (ften at a mnitr centre (MC ur RMMS)) The purpse f this cmmunicatin, fr the mnitring and alarm use cases, is t send Device data t the RMMS. This cmmunicatin may be triggered in varius ways: n measurement, at predetermined time, n request frm RMMS, etc. The Device data is mediated by a physical, r lgical, Persnal Hub. The paylad prtin f the cmmunicatin is based n the IHE PCD-01 transactin f the Device Enterprise Cmmunicatin (DEC) prfile spnsred by IHE PCD. It uses HL7 V2.6 messaging and the IEEE nmenclatures, including the nmenclature extensins that supprt Persnal Health Devices (PHD) Device enterprise cmmunicatins (DEC) specificatin The PCD prfile is described in the PCD s Technical Framewrks dcuments Vlume 1 and Vlume 2. Figure3 describes the cre actrs and transactins. The cre actrs in this prfile are the Device Observatin Reprter (DOR) ur Persnal Hub and the Device Observatin Cnsumer (DOC). ur RMMS. The DOR is respnsible fr cnstructing an bservatin reprt and initiates the cre transactin. The DOC actr receives this reprt via the PCD-01 transactin. The DOF is an ptinal actr that can reside between the DOR and the DOC. The DOF receives the initial feed f data frm the DOR (via PCD-01) and can prvide filtered data (again via PCD-01) t the DOC. The cntrl/management f the DOF is dne via a pre-defined publish/subscribe type prtcl (PCD-02). Hwever, fr the current versin f the WAN-IF f the Cntinua Architecture, the DOF actr and the PCD-02 transactin are t be ignred. Figure 7: DEC Actrs and transactins IHE Mre detail n this tpic is in the papers IHE prfiles and Telecare Architecture v3.0 at 37
38 White Paper - Interperability fr DALLAS applicants and cmmunities v Care pathway integratin dmain (Cntinua Enterprise Reprt) Intrductin The purpse f this cmmunicatin is t send reprts frm the Remte Mnitring Management System (RMMS) t the persn r rganisatin respnsible fr cmmissining the RMMS. Where RMMS and cmmissiner are the same entity, the purpse is t recrd actins t a repsitry a case and/r health recrd system. This cmmunicatin, designed fr the mnitring and alarm use cases (see Visin fr wider / lnger-term needs), relates t a service level agreement abut respnse t trends, alarms r a default reprting perid. The paylad prtin f the cmmunicatin uses the HL7 Implementatin Guide fr CDA Release 2: Persnal Healthcare Mnitring Reprt - an extensin f HL7's Cntinuity f Care Dcument (CCD) specificatin HL7 Implementatin Guide fr CDA Release 2: Persnal Healthcare Mnitring Reprt The mst recent release is "HL7 Implementatin Guide fr CDA Release 2: Persnal Healthcare Mnitring Reprt (PHMR), (Internatinal Realm) Draft Standard fr Trial Use, Release 2; DSTU (July 2010)." The purpse f this dcument is t describe cnstraints n the CDA Header and Bdy elements fr Persnal Healthcare Mnitring Reprt (PHMR) dcuments which mstly cntain a cmbinatin f analysed and raw infrmatin abut data generated by persnal healthcare mnitring devices such as glucmeters, BP cuffs, thermmeters, weight scales. The PHMR is a dcument that carries persnal health mnitring infrmatin. The infrmatin is transmitted as ntes and as raw data. A remte mnitring management service may add ntes. The infrmatin in the dcument may have multiple characteristics, including: Representatin f measurements captured by devices. Representatin f ntes, summaries, and ther kinds f narrative infrmatin that may be added by caregivers r by individuals being mnitred themselves. Representatin f graphs that may be added by intermediary devices that represent trends f wellbeing. The Cntinua Health Alliance prvides an implementatin guide that includes guidelines fr IHE XDS based transprt f the dcument. Cntinua Health Alliance als ffers a certificatin prcess fr data surce cmpliance the interface. This will enable high interperability with the standard specificatin. An example implementatin was perfrmed fr IBM's WebSphere Sensr Events platfrm which cllects, prcesses, and rutes medical device and sensr data. IBM used the Persnal Healthcare Mnitring Reprt (PHMR) dcument frmat, in the cntext f Cntinua HRN interface, t achieve data exchange frm WebSphere Sensr Events t varius applicatins, fr example prducts fr chrnic disease management. IBM als used the HRN interface t achieve data exchange frm WebSphere Sensr Events int a health infrmatin exchange. In additin there were several prttypes develped within the Cntinua Health Alliance scpe by NHS (ITK candidate?), Rche, Phillips, Lamprey Netwrks and thers. Cntinua Health Alliance als implemented a test tl fr certificatin f cmpliance t the specificatin Interfacing t ther NHS clinical systems The Department f Health Infrmatin Directrate, DHID in England (frmerly CFH - Cnnecting fr Health) has been cllabrating n develpment f this HL7 standard t allw certain data sets and events 38
39 t be transmitted t a GP system (see 8.2.5). An English NHS prttype f this was develped as part f the WSD wrk at Newham. In rder t advance adptin and supprt imprvements, the Telehealth grup within Intellect (the UK IT Trade bdy) started a prgramme t bring the health IT industry (GP systems, Telehealth Systems, Acute systems) tgether t accept this as the starting pint and t wrk tgether t bring it t market, wrking with the ITK team at DHID, Infrming Healthcare, etc.. The Use Cases fr the telehealth messaging will be expanded t manage the symptmatic questins and the use f web resurces t make infrmatin and cmmunicatin available t individuals and care prviders (see 8.2.5). The gal result will be a standard that aims t allw any telehealth system t be able t transfer infrmatin int any NHS clinical system, and this interface aims t include the use f Web Services t enable transfers f URL s and subsequent data displays. There was early cnsensus in the DALLAS Interperability Task Frce that use f this Enterprise Reprt is recmmended at an early stage f prject planning by any supplier implementing this type f cmmunicatin within a DALLAS Cmmunity and the DALLAS Ecsystem as whle see Mre detail n this tpic is in the paper HL7 PHMR at 8 NHS Interperability Tlkit 8.1 Intrductin One significant stakehlder, the Department f Health in England, has been wrking t prduce the Interperability Tlkit (ITK), which has been created t help the flw f infrmatin and cmmunicatin between peratinal entities. Its aims include: reducing the amunt f mney the NHS spends n lcal integratin by standardising technlgy and interperability specificatins; helping the NHS realise business benefits by speeding up the develpment f integrated services; prviding a framewrk fr innvative business slutins by defining a pervasive interperability specificatin; easing the develpment f lcal health cmmunity integrated systems; lwering the entry barrier t new systems develpers by prviding a cnsistent cde f cnnectin. 8.2 The ITK structure Crrespndence Specificatins There are many dcument interperability standards develped fr crrespndence such as Hspital Discharge and Ambulance Reprting. These prvide cnfrmance specificatins fr the transmissin f certain types f crrespndence, using HL7's Clinical Data Architecture (CDA). There als exists a general CDA cnfrmance specificatin that allws ther frmatted dcuments (fr example a prtable dcument frmat (PDF)) t be embedded within a CDA dcument Interactin with English NHS Data Stres Fr example, services exist that allw interactin with the Persnal Demgraphic Services (PDS). These Spine Mini Services are available via middleware suppliers and prvide facilities t lk up and verify English NHS Numbers, as well as return patient demgraphic infrmatin. 39
40 White Paper - Interperability fr DALLAS applicants and cmmunities v Admissin, Discharge and Transfer Interactins Based n HL7's versin 2 ADT message specificatins these message definitins interact with Patient Administratin Systems (PAS) t prvide standardised interperability between PAS systems and ffer ther interfaces int PAS systems such as thrugh admissin bths ITK "Cre" Underpinning all these ITK standards is the ITK "Cre". The Cre prvides cmmn standard artefacts that are used by all the packs that g int making up the ITK specificatin. These Cre cmmn artefacts include: Cre service definitins - definitins f services which are applicable acrss the ITK. Distributin Envelpe - ITK paylads are wrapped in a "thin" wrapper called the Distributin Envelpe. The Envelpe cntains infrmatin fr ruting the transmissin and sme details abut its paylads. Acknwledgement framewrk - an verview f the acknwledgements apprpriate fr ITK implementatins Relevance t DALLAS The main pint f Telecare/Telehealth mnitring integratin with ther English NHS prcesses is at the Care Pathway Integratin Dmain. The reprt used in this cmmunicatin in Cntinua is already an HL7 CDA implementatin knwn as the Persnal Health Mnitring Reprt (PHMR). Because this Reprt was specified in large part by the English Department f Health Infrmatin Directrate (DHID) with knwledge f the WSD requirements, it is likely that althugh Assisted Living/ Telehealth has nt yet been authrised as a prject fr ITK R2.1 by the management grup, it is likely t be included. ITK 2.0 was released n July , and ITK R2.1 is being scped at the mment, with new prjects dependent n NHS pilts stepping frward, s DALLAS Cmmunities wrking with Trusts might have pprtunities in that wrk18. As part f the scping f the PHMR an analysis f the wrkflw in WSD wrk was undertaken and this wrk shuld be the fundatin f wrk undertaken t serve the needs f DALLAS Cmmunities in the cntext f the DALLAS Ecsystem see Cmmunicatins netwrks 9.1 Current telecare situatin This sectin prvides an verview f the established 3-Step mdel f infrmatin transfer in telecare cmmunicatins and the way in which current services are supprted. It then examines the knwn planned changes in the cmmunicatins envirnment during the lifetime f the DALLAS prjects and beynd. The general cnclusins are that there is cntinuus change anticipated sme f which cannt be ignred because it will inevitable impact upn service delivery if it is nt attended t. Hwever, the technlgies t prvide cmmunicatins d exist and fr the mst part hw it is prvisined and managed falls t a business decisin by the service prvider. A key challenge may be hw t package the unit linking the LAN and WAN cmpnents as it is evident that a universal slutin that meets all service cmmunicatin requirements may n lnger be feasible and lw cst. It is prbable in the Dallas timeframe that the majrity f IP cnnectins will be based n the current mst widely deplyed technlgies. There are particular issues with ADSL: Sme ISPs will nly prvide service t their wn CPE; Mst ADSL CPE is nt easily made EN50134 cmpliant; Sme ADSL CPE It is understd that DHID funding is expected t be available t enable implementatin prjects t be assisted with develpment f ITK cnfrmant cmmunicatins.
41 cannt be remtely reset; Mst ADSL equipment is subject t prblems f rate degradatin and t blcking in the event f IP address cntentin which requires manual interventin t recver. 9.2 Telecare devices and user terminals Telecare uses existing cmmunicatins wherever pssible as the mst cst effective prvisin ptin. That is t say, wherever present the end user fixed telephne line will be used as the WAN link t the call centre r back ffice. The nly ther widely available ecnmic alternative service prvisin is GSM r GPRS based equipment t prvide the WAN link between the hme and call centre (satellite, r fixed wireless access technlgies prviding equivalent services are nt used t any significant extent). Data is nt encrypted r prtected ver the land-line. Security is prvided by CLI and by unique equipment identifiers. Fr the small number f existing hme health mnitring applicatins currently deplyed prprietary appraches t infrmatin prtectin are used, and are believed t be based upn de-fact standards such as PGP and HTTPS Persnal Area Netwrk There are a limited range and number f persnally wrn devices that require Persnal Area Netwrk (PAN) cmmunicatins. PAN ptins currently available are limited, and standards such as Bluetth and Zigbee (de fact specificatins, als Zigbee uses IEEE ) and WiFi (IEEE standard ) are nt very mature in the healthcare applicatin area althugh multiple surces exist and sme have prven interperability as assured by Cntinua Alliance certificatin Lcal Area Netwrk Lcal Area Netwrk (LAN) ptins currently used, e.g. WiFi, are similar t PAN ptins and nt really differentiated frm PAN cmmunicatins ptins. The mst widely deplyed sensrs are persnal alarms. Increasingly fall detectrs, lcatin and cmmunicatin devices are wrn but these either cmmunicate with a Hme Hub r directly t a wide area cmmunicatins infrastructure. There is a significant standards gap in the current field f deplyed equipment. The majrity f devices that are nt hard wired int the hme hub are cnnected by pint t pint RF links. These in cmpliance with Eurpean Directives n Spectrum Usage and EN perate in allcated spectrum at 169MHz r 869MHz but there are n standards abve the physical layer fr these devices in cntrast t the mre cmplete stack f standards available fr use cases supprted and develped under the Cntinua Alliance. The mdulatin, medium access and infrmatin transprt frmat is prprietary in nature and believed t be rudimentary lacking mechanisms fr cnfirmatin f delivery r cntentin management in many cases Wide Area Netwrk / Telephny Fr Wide Area Netwrk (WAN) and Telephny there are apprpriate established and emerging standards that prvide fr end-t-end cmmunicatin ver a circuit-switched (and/r packet-switched) telecmmunicatins netwrk and these cver the lwer fur layers f the ISO 7 layer mdel (see Figure 12). They are based upn the requirements f established service prvisin and methds f wrking in the telecmmunicatins industry (manufacturers and peratrs) and take accunt f the QS characteristics f lng established telephny prvisin and electricity supply. These make requirements fr example fr identified cpper path circuits at the physical layer and fr significant hld up f service capability in the event f mains pwer failure. There is an almst insular separatin between systems intended t supprt Scial Alarms and thse intended fr medical data mnitring with nly limited verlapping r cmmn functinality, such as medicatin reminders. At the Sessin Layer and abve Telecare hme hubs are used t reprt an alarm situatin, which is subject t a triage prcess at the Alarm Receiving Centre with respnse times defined and mnitred by the Telecare Cde f Practice against which service prviders are audited. This prcess may invlve establishing duplex vice cmmunicatins fllwing receipt f the alarm data event. In the case f medical data, cmmunicatins are mstly structured as a data uplad peratin and an uncnnected brwser sessin fr end user interactin with stred and prcessed data. 41
42 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Telecare phnes with integral dial pads can duble as a huse phne giving the ccupants access t any available telephne service. Sme hme ccupants may have access t interactive hme services prvided by means f bradcast televisin r web based services that can be accessed thrugh hme entertainment prducts r hme cmputers if they are subscribers t bradband services. Sme end users may als have smart phnes that can enable a wide range f applets and services including lcatin, rientatin and web based services. In cnsidering Internet based cmmunicatins, pen, prprietary, and standards based appraches need careful cnsideratin at the service design stage as pririties and services differ between internet service prviders (ISPs). We recmmend clse cperatin with intended prviders. 9.3 The emerging envirnment Smart metering is due t be intrduced universally in the UK between 2011 and The exact details f the implementatin are still emerging but they will be sharing the envirnment with their wn demands fr Lcal wireless cmmunicatins and backhaul WAN cmmunicatins. This may prvide additinal infrastructure that can be explited, cmpetitin fr resurce r a cllabrative rute fr develpment and sharing resurces with significant ecnmies f scale? There are a significant number f changes that need t be cnsidered in designing telecare cmpnents prviding cverage, with clear interfaces, every level in the ISO 7 layer mdel stack s that they are interperable: Changes in fixed telecmmunicatins prvisin: A grwing diversity f deplyed media pathway types and cmbinatins: cpper, fibre and wireless t the hme. The path frm the last peratr switching pint t the terminatin in the hme may invlve mre than ne pathway, e.g. FTTC, r a fixed-wireless access lcal switch, with a cpper terminatin. Hwever, a single media type is mre cmmn: cpper is the mst prevalent, including single-pair telephne land-lines fr histrical reasns, and als cable; there is significant uptake f wireless bradband supplied via UMTS, which supprts use n the mve (see belw); fibre t the user premises (FTTH) is gradually increasing in vlume. We face a hetergeneus netwrk technlgies envirnment with small but significant variatins in parameters and QS between them. Detailed discussin f the changing telecmmunicatin envirnment is cntinued in Annex F, Changes in fixed telecmmunicatins prvisin Future Issues: During the DALLAS implementatin timescales, there will remain in the UK a rump f legacy equipment that may take almst 10 years t wrk thrugh the system unless there is a significant case t write ff existing stcks. There may be alternative appraches that allw existing assets t be effectively integrated int newer equipment, which enables mre extended care services. These may perhaps be relay devices which cnvert and retransmit n a standards basis the riginal sensr signals. There may even be advantages in this apprach by physically separating the LAN base frm the WAN base which allw imprved alarm reliability and ergnmic lcatin f the hme hub withut cmprmising the requirements f lcatin and access with thse fr RF cverage. There is a standards gap in the field f scial alarm SRDs. Significant wrk is in hand t develp a set f standards t supprt Health Data transprt t the Hme hub. The presentatin layer f IEEE11073, is a gd candidate t prvide a cmmn interperable standard fr bth scial alarm and health care and it can prbably be extended within the timeframe f the prject, but it is nt be the apprpriate apprach fr all infrmatin interchange. Lking at the brad range f ptential users fr assisted independent living, shuld cmmn equipment and standards be designed n the basis f a Paret like rule, which implies that they will meet a significant prprtin f needs? A lwest cmmn denminatr f needs, i.e. a limited set f cre 42
43 functins? Or shuld the bundaries be extended t encmpass as far as is pssible an extended and plausible set f use cases which reduces the barrier fr intrductin f new capabilities and services fr the individual and service prviders? Existing telecare equipment and standards are highly tuned twards scial alarm management within a quite narrw mdel f service prvisin. A significant element f simple health mnitring requirements culd be ptentially integrated int telecare equipment. Fr example daily patient weight, pulse and BP measurements culd be accmmdated withut significant effrt int existing scial alarm hme hubs taking advantage f the current infrastructure and practice. Is this an ecnmic and effective use f the existing stck f equipment, which shuld be cntemplated? Or des it blw ut f prprtin requirements fr traffic security and equipment regulatin? The Eurpean views n SRD spectrum management are evlving in ways that suggest current use is nt sustainable in the lng term, but there is in the UK a huge installed equipment base. If the limitatins are well understd, migrating t 2.4GHz is clearly satisfactry fr currently cnceived medical mnitring and health requirements and by its de-fact use fr hme WiFi can supprt web based interactive services but ADSL and WiFi reliability is nt gd. When the prspect f smebdy wh may be frail and the call ut csts t a service prvider f maintaining and testing system availability is factred in, is this a viable platfrm fr develpment; r is there a need fr a mre rbust and dedicated hme LAN slutin that meets cmbined health and scial care needs; r even a cmmn bus that carries all hme traffic with a degree f interperability that allws them t share bearers? Culd such a slutin be shared with smart metering, hme energy and security management in an interperable way that drives up vlume and drives dwn cst by appraching mainstreaming? Is there a candidate that culd be further develped within the Dallas timeframe? Future telecare needs will extend beynd the current levels f safety and independence management prvided by the majrity f telecare installatins and may require ther mdalities such as vide telephny. This is pssible with sme new generatin TVs which culd be used t cmpliment the care management. T what extent shuld ALIP explit emerging cmplementary technlgy, the rich dmestic picture r strive t be self-cntained t prvide fr these capabilities within telecare r be interperable with ther prvisins? The Cntinua mdel sees the hme cnnected t the WAN by an Applicatin hsting Device (AHD). At a minimum this repackages the received sensr data int a standardised frm that is digested by clinical infrmatin management systems (HL7). The current US, UK and Eurpean (except Sweden) view is simple repackaging f data des nt make the AHD a medical device. The current Telecare mdel by cntrast is always a stre and frward r shrt term buffer device with a well defined standards cmpliance regime. It is clearly nt a medical device and hlds n persnal data. Can these differences be recnciled int a cmmn hst mdel with a clear and cst effective fit t the market need? Telecare services currently use a cmmn vice grade channel fr bth data and vice cmmunicatins. Fr data there are clear advantages in mving t IP Transprt but suitable standards need t be adpted t cpe with the hetergeneity f requirements and available data links. Lcal sharing f infrastructure can easily lead t IP address cntentin, interperability and equipment failure frm which autmatic r remtely managed recvery is essential. Current ADSL services and ruters d nt have the perfrmance and reliability needed fr telecare. It is very unlikely that at all lcatins and at all times in the freseeable future that available cmmunicatins transprt will prvide fr demands fr data, vice and vide s strategies are needed which will recgnise the different circumstances that prevail with perhaps a minimum acceptable QS based upn assessment f need. 9.4 Spectrum issues Shrt range devices - wireless scial alarms Current nrmative requirements are that fr scial alarm equipment Class 1 receiver characteristics are applied. The majrity f the scial alarms used tday are cnnected via a shrt range RF link in the 169MHz r 869 MHz licensed-exempt bands. These are usually relayed thrugh a hub in the hme t call centres using fixed line r mbile cnnectins. Several ther shrt range technlgies are starting t be used in ther licensed-exempt bands using standards such as Bluetth, Wi-Fi and ZigBee. 43
44 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Regulatin f spectrum in the Eurpean regin is subject t plicy changes and sme reallcatin f existing spectrum t new uses. Tgether these create a changing envirnment where a lnger term strategy f spectrum use fr wireless scial alarms needs t be develped. Sme f the knwn issues are elabrated further in Annex C. 9.5 Security Current telecare systems and assciated rganisatinal barriers prvide adequate levels f prtectin against knwn threats and fr regulatry cmpliance. Hwever DALLAS is expected t change the service delivery mdel and by actins such as imprving cperatin between rganisatins and changing the flws f infrmatin may well intrduce a change f threats and imply a need t revise the applied security implementatin. Privacy is a cncern. It is an aspect f authrisatin (wh is allwed t see infrmatin), authenticatin (are they wh they say they are) and access cntrl (what can they d with it when they are authrised and authenticated). These three mechanisms are ften abbreviated t AAA. AAA is nt sufficient if the infrmatin is sent acrss a netwrk because its rules are first invked when smebdy tries t access the infrmatin. The infrmatin must als be encrypted t prevent a snper frm recrding it during transmissin in fact; it shuld be encrypted all the time because snpers can als read disks and memry. AAA data (usernames, passwrds, permissins) must als be prtected but, ultimately, there must be sme transfer, pssibly exchange, f infrmatin, r keys, between authrised parties t allw anything t be encrypted and decrypted crrectly. There is a perid f vulnerability during this phase that can be explited by intruders. In sme cases, if an intruder recrds these keys, then he can masquerade as an authrised user, especially if the keys becme the embdiment f AAA attributes. See Annex C fr a full cnsideratin f the issues. Sectin deals nly with identified assisted living specific issues What needs fixing t slve the prblem? Cmmunicatins security is usually characterised with fur basic parameters: Cnfidentiality: the cmmunicatins is delivered nly t the parties fr whm it is intended. Integrity: the cmmunicatin is received as it was sent unaltered by the recipient Availability: the cmmunicatin is cnveyed within bunds f acceptable delay Nn repudiatin: the recipient can be assured that the cmmunicatin was riginated by the party identified as the sender and the sender assured that the intended recipient has received it. All f these are high imprtance t telecare delivery. The understanding f infrmatin and cmmunicatins security is maturing in ther market sectrs and much f this experience and existing technlgy slutins can be explited in DALLAS. Whilst there may be sme unique requirements there is a rich seam f established practice and experience n which t draw t find slutins allwing effrts t be cncentrated in slving the prblems unique t the sectr. Current telecare takes advantage f Caller Line Identificatin, tgether with unique equipment identifiers t ensure that all alarm calls arising are prperly screened and secure. The nrmal prtectin f infrastructure, and in the case f mbile, the embedded security measures, prtect the cmmunicatins in transit. There is nthing t prevent incming calls t the client premises and n mnitring r screening f them by the scial alarm prvider althugh there is limited prtectin t prevent ver the air reprgramming f the user equipment by an intruder. The current assessed threat t telecare is mainly denial f service thrugh reliability, inadvertent r deliberate attack. The standard apprach t resilience is thrugh repeat autdialing with a priritised number list and in extreme cases rute diversity f cmmunicatins. 44
45 Mving clser twards mainstream brings with it the assciated burden f vulnerabilities enjyed by the internet cmmunity. The GSM mbile system has a sphisticated standards based apprach t security which is managed effectively thrugh the issue f SIM Cards. This is an extant and prven technlgy, albeit with sme limitatins, which is mainstream, and might be a viable ptin fr securing telehealth cmmunicatins fr the future. There are ther authenticatin appraches based upn widely used and established user accunts with existing internet services that can be used t enable transactins and authenticatin with service prviders. Sme f these, fr example PayPal and Ggle Payment, are effectively mainstream. The Cabinet Office is currently lking at the use f existing cmmercial identity prviders within the Identity Assurance Prgramme, part f the Gvernment Digital Services Prgramme19" ( The Identity Assurance Prgramme started in May and will run in parallel with the DALLAS prgramme. DALLAS Cmmunities shuld cnsider hw this service can prvide the cntext fr interperable identity services that will engender crss-rganisatinal wrking and cllabratin between frmal and infrmal (Internet) dmains. Fr further details see Annex C. Hwever, cmmunicatins security is nly ne aspect f fulfilling the regulatry requirements fr infrmatin prtectin and infrmatin security. Invcatin f mechanisms such as encryptin f traffic and databases carry a heavy cst in implementatin and peratin and in reality might ffer limited additinal prtectin against a minr risk at high cst. (Is it the 21st century equivalent f the ftman with a flag walking in frnt f the mtr car?) A ratinal apprach t system security design might be t examine the threats, risks, legislative and rganisatinal cnstraints and design an end-t-end security mdel which recgnises these but enables desired service utcmes. Questins therefre arise regarding hw best t assure apprpriate security: Is there a standard interperable security mdel that prevents prlngatin f the established set f sils and which meets the citizen's best interests withut undue risk t sciety? What prcess, audit trails and gvernance are required? Is there an interperable, standards-based apprach t this that can be mapped int training prvisins, wrk flw and supprting infrmatin and cmmunicatin systems? 9.6 Quality f Service (QS) and Class f Service (CS) requirements This sectin deals nly with identified assisted living specific issues. See Annex D fr a fuller discussin f this issue. The fixed, mbile and even the LAN envirnment is in a state f cnstant flux. It is mre hetergeneus nw than at any pint in the past, and there are plans fr further develpments. There is a questin whether the current telecare mdel is sustainable as mst implementatins are n the lwest phne tariff. Netwrk perfrmance is als very imprtant fr telecare services, which may have safety f life implicatins, and whse events can be classed with a range f qualities, such as safety-critical, safetyrelated r nn-safety. Hwever, they are highly technical and cmplex aspects f the netwrk s perfrmance, and ultimately its design, cnfiguratin and deplyment. Quality f service (QS), and grade f service are terms that are defined by the ITU-T and subject t ITUT recmmendatins, e.g. the E series fr fixed netwrk services and the P series fr wireless cmmunicatins. Class f service (CS) is a term that is assciated with specific prtcls and services. It is a mechanism fr telling the service that a particular piece f infrmatin and cmmunicatin is imprtant, r less s. 19 Gvernment Digital Services Prgramme, 45
46 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 These aspects f a netwrk s perfrmance are very imprtant fr telecare services, which may have safety f life implicatins, and whse events can be classed with a range f qualities, such as safetycritical, safety-related r nn-safety. Hwever, they are highly technical and cmplex aspects f the netwrk s perfrmance, and ultimately its design, cnfiguratin and deplyment. Currently all public access IP netwrks prvide cmmunicatins n a best effrts basis. Telephne netwrks have mre stringent grade f service bjectives. The implicatin f this is that when the netwrk is scaled t have significant excess capacity, all users get the highest quality f service available. When netwrks are cngested and there is cntentin fr access, this can result in transmissin delays and drpped packets fr the reasns indicated abve. Drpping r even delaying a safety alarm culd be a serius prblem whereas drpping the ccasinal packet f vide r vice may result in nly a minr degradatin in perceived quality. In the WAN envirnment it remains t be seen if netwrk capacity grwth can cntinue t utstrip demand r will class f service mechanisms need t be invked, especially where mbile access is cnsidered. Hw wuld such mechanisms be invked and administered? The cmmunicatins prvisins currently are t the subscriber and nt part f a telecare service prvisin. What frm shuld the relatinships take fr the future? Shuld the primary telecare service prvider be a virtual peratr and include the cmmunicatins infrastructure t the client as an element f the prvisin? There is sme uncertainty that current best effrts prvisin will supprt the mre stringent requirements f emerging telecare because demand fr bandwidth is beginning t vertake the infrastructure. Vice interactin is an established element f Telecare and there are real ptential requirements fr extending this t interactive vide freseen in health and scial care. Current ADSL is asymmetric supprting lwer rate uplad and dwnlad and is cntended fr bandwidth. Sme service prviders d implement CS but nt all currently d s. Are existing (vluntary) prvisins adequate r is there a case fr a specific CS fr Healthcare? There are significant variatins in the mechanisms used by different telecmmunicatins prviders and in the service packages that are n ffer. Current telecare explits existing client cntracted prvisins but need nt and there may be a service prvider rle in managing cnnectivity. Currently services are managed by a cmbinatin f data and interactive vice cmmunicatins; vide is mre demanding f bandwidth. Internet based implementatins such as Skype have prven t be very ppular and sme newer TVs are nw at least in part Skype enabled. Whilst fr clinical and prfessinal telecare purpses interactive vide may nt be seen as an essential cmpnent, des it frm the viewpint f wider client enablement becme a mre imprtant cmpnent with a cmpelling case fr cnsideratin? Whilst taking a wide-view f new pssibilities and slutins is desirable, there is a need t recgnise that frmal systems and extant slutins/services are influenced by perfrmance requirements and standards such as EN These play an essential rle in prtecting users by ensuring that critical services can be relied upn. They (r their successrs) will cntinue t prvide sme necessary bundaries fr telecare services, and may be applicable in part r whle t ther services. 10 Vide and VIP20 fr DALLAS Cmmunities 10.1 Cntext It is anticipated that many f the assisted living technlgies will be centred n real time cmmunicatin between individuals using bradband cnnectins. This shrt sectin therefre lks at sme available standards and technlgies and makes sme cncrete recmmendatins t DALLAS Cmmunities VOIP: Vice ver Internet prtcl.
47 10.2 Backgrund There are numerus vide cdec and transprt mechanisms being used t deliver n the internet tday, bth fr live pint-t-pint r pint-t-multipint calls, and fr n-demand delivery. At ne end f the spectrum, there are internatinal standards, such as the H.264 and H.263 vide cding standards, the RTP stream encapsulatin standard and the SIP call set-up standard. Other imprtant standards include µlaw, alaw, G.722, GSM and SPEEX fr audi cding; and the XMPP instant-messaging standard fr call set-up. There are als prprietary systems e.g. Skype, which has pen APIs. In terms f vice r vide calls ver the internet, it is systems, such as Skype, that are the mst-widely deplyed tday, althugh systems that are based mre n standards are nw available (e.g. Ggle Talk and Apple Facetime). The public internet des nt ffer any guaranteed quality f service (QS); traffic is delivered n a "best effrt" basis. The ability f the numerus technical slutins t vide streaming t cpe with changeable r pr quality f service is variable Interperability Guidelines A pragmatic apprach needs t be taken t interperability fr vide and VIP. Any decisin as t what technlgy t deply fr a vide streaming applicatin must take int accunt the end-user(s) and the likely QS f the internet cnnectin t them. If the applicatin is fr use by individual cnsumers n their existing persnal cmputer ver their dmestic internet cnnectin, then it may be mre suitable t use a widely-deplyed prprietary technlgy that the end-user may already be using fr ther purpses. If the applicatin is t cnnect prfessinal premises with a gd, high-speed internet cnnectin, then the lng-term interperability benefits f using a system t an internatinal standard may be cnsidered t utweigh any benefits f a prprietary slutin. Initial cnsideratins may include: Interperability with existing cnsumer equipment, if relevant; Interperability with existing prfessinal Vide Cnferencing equipment, if relevant; Interperability between B2B and B2C systems, if relevant; Suitability f technlgy chsen fr deplyment infrastructure; Interperability plan than avids single surce technical slutin; Interperability plan that decuples vide / VIP standards rute frm metadata, health recrds, and ther systems and wrkflw chices; In the future cnsideratins may include an interperability plan fr ptential cnvergence f main technlgy candidates, e.g. t allw cnslidated call centre fr multiple DALLAS Cmmunities using different technlgies. 47
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49 Annex A Glssary Abbreviatin Definitin 3G 3 Generatin Mbile AAA Authenticatin, Authrisatin and Accunting ADSL Asymmetric Digital Subscriber Line technlgy rd ADT Admissin, Discharge and Transfer AHD Applicatin Hsting Device alaw Telecmmunicatins cmpanding algrithm API Applicatin Prgramming Interface ARC Alarm Receiving Centre (see RMMS) B2B Business t business B2C Business t cnsumer BP Bld Pressure BSI British Standards Institute CCD Cntinuity f Care Dcument (HL7) CDA Clinical Dcument Architecture (HL7) CfH NHS Cnnecting fr Health (England) CLI Caller Line Identificatin CS Class f Service CPE Custmer Premise Equipment DEC Device Enterprise Cmmunicatins DH Department f Health (DH) DHID Department f Health Infrmatin Directrate DOC Device Observatin Cnsumer DOF Device Observatin Filter DOR Device Observatin Reprter DSTU Draft Standard fr Trial Use (HL7, BSI equivalent = Public Draft) EN Eur Nrme (ETSI), Electrmagnetic cmpatibility and Radi spectrum Matters ETSI Eurpean Telecmmunicatins Standards Institute FTTC Fibre T The Curb FTTH Fibre t the hme FTTP Fibre t the premises G722 Vice cdec ITU standard GP General Practitiner GPRS General Packet Radi Service GSM Glbal System fr Mbile cmmunicatins H264 Vide cmpressin standard (MPEG) HADS Hspital Anxiety and Depressin Scale HCP Health care prfessinal HITSP Healthcare Infrmatin Technlgy Standards Panel (f American Natinal Standards Institute, ANSI) 49
50 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Abbreviatin Definitin HL7 Health Level 7 HRN Health Recrd Netwrk (Cntinua) HRQL Health Related Quality f Life HSQ2.0 Health Status Questinnaire 2.0 HTTPS Hypertext Transfer Prtcl Secure IEEE Institute f Electrical and Electrnics Engineers IHE Integrating the Healthcare Enterprise IP Internet Prtcl ISO Internatinal Standards Organisatin ISP Internet service prvider ITU Internatinal Telecmmunicatin Unin ITU-T ITU Telecmmunicatin Standardizatin Sectr LAN Lcal Area Netwrk MC Management Centre MPEG Mving Picture Experts Grup MVNO Mbile Virutal Netwrk Operatr NHS Natinal Health Service NHS 24 Natinal Health Service 24 hur helpline (Sctland) NHS Direct Natinal Health Service 24 hur helpline (England) PAN Persnal Area Netwrk PCD Patient Care Devices PDF Prtable Dcument Frmat PDS Persnal Demgraphics Services (NHS England) PGP Pretty Gd Privacy PHMR Persnal Healthcare Mnitring Reprt PHQ-9 Patient Health Questinnaire OEM Original Equipment Manufacturer QS Quality f Service RF Radi Frequency RMMS Remte Management Mnitring Service RTP Real-time Transprt Prtcl SCP Scial Care Prfessinal SIM Subscriber Identificatin Mdule SIP Sessin Initiatin Prtcl SPEEX Speex is a patent-free audi cmpressin frmat SRD Shrt Range Device TSA Telecare Services Assciatin µlaw Telcmmunicatins cmpanding algrithm UMTS Universal Mbile Telecmmunicatins System URL Universal Resurce Lcatr USB Universal Serial Bus VIP Vice ver Internet Prtcl WAN Wide Area Netwrk WiFi Trademark f the Wi-Fi alliance. Wireless Lcal Area Netwrk technlgy (IEEE 50
51 Abbreviatin Definitin family f standards) WSD Whle System Demnstratr XDS Crss-Enterprise Dcument Sharing (IHE) XMPP Extensible Messaging and Presence Prtcl Zigbee Trademark f Zigbee alliance (Based upn the IEEE standard). 51
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53 Annex B Architectures B.1 Enterprise-level architecture perspective Given the nature f the current status f telecare and telehealth deplyments, there is a tendency fr the "Device Enterprise Cmmunicatins" (see 7) pint f view t dminate. Hwever, we need t build a strng enterprise-level architecture perspective (see Chapters 4 and 5 f the Digital Access Prvisin xi Frum paper "A Framewrk fr assisted living ") that puts the detailed issues "in their place", i.e. enables the natural fci f intense interest frm varius stakehlders t be given due weight withut drwning ut ther essential viewpints. There cexist differing strategies fr jining up citizen-centric infrmatin using different architectural appraches. These can be characterised as "Cnnect all" v " Single recrd" and are summarised in Figure 8. C-rdinatin thrugh a shared recrd will be a useful pattern generally at the cmmunity f care level in DALLAS, and cmmunities will als need t cmmunicate with entities that d nt have access t a shared recrd fr the service user. S, a hybrid f these tw generalised patterns is mst likely t be apprpriate, with a different balance between the tw patterns emerging in different DALLAS Cmmunities. This difference f architectural strategy raises specific issues in cmmunity brder regins where health and scial services bundaries nt aligned and even verlap n natinal brders, r where a 'cmmunity' spans different health and scial services with differing architectural mdels. It is expected that the frmal care aspects f infrmatin flw in these regins will be made interperable via 'brder' gateways. Figure 8: Different mdels f health recrd handling. Whatever the technical device slutin cnsidered (e.g. alarm handling, physilgical mnitring, lifestyle caching, incentivised gaming, etc) each needs balanced attentin as part f the ttal infrmatin and cmmunicatin mix; regardless f whether this relates t rganisatinal, semantic, syntactic r technical interperability. Table B.1 n the next page presents sme f the enterprise-level cnsideratins (largely frm a health enterprise perspective) n infrmatin interperability frm device cmmunicatin thrugh t recrd sharing in health and scial care. 53
54 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Table B.2: Enterprise-level architecture perspective n interperability Shrt name Frm T Purpse Standards Ntes Tele-X device cmmunicatins Devices Tele-X system Rutine data cmmunicatins Cntinua (IEEE 11073) standards with adptin grwing frm initial base f vendr supprt General vendr supprt fr these standards is a gal fr the end f DALLAS (and specifically nt a gatekeeper fr participatin). Ntificatins and Alerts Tele-X device r hub Specific SCP/HCPs and Patient recrd Initiate care respnse t change in mnitred situatin Existing telecare prvisin is cvered by EN and BS standards. Existing wrk is largely if nt exclusively within single systems and thin flat sil style pilt netwrks. Tele-X summary Tele-X hub Patient recrd (shared under gvernance acrss whle assisting team) Human readable, meaningful summary created frm the sea f data recrded and analysed by the Tele-X system There is an HL7 CDA prfile DSTU (ballted draft standard) designed fr this purpse. See nte belw regarding patient recrd architecture key differences in recrd sharing philsphy between Wales and England. DALLAS is exactly the kind f prgramme that can prvide useful trial use fr this very technically stable DSTU. Change management f standards is a necessity fr any beynd-pilt implementatin & needs t be in place as part f preparing fr the lng term. There will be a need t negtiate the gaps between this DSTU & UK-specific CDA prfile (wrk with HL7 UK & DHID/ITK) s we will need rbust methds fr cmbining standard and nn-standard cmmunicatins within a safe architecture there is expertise and technlgy available t help with this (in particular, see Need t negtiate the detailed gaps between internatinal and UK required data (wrk with DHID/ITK and IHE UK). HCP assessments HCP HCP and Patientheld recrd CAF and similar frmalities the cmmunicatins standards are likely t be useful als fr less frmalized assessment practices. DHID HSCI (Health and Scial Care Integratin) and HL7 CDA-based standards. Limited interperatin recently demnstrated between DHID HSCI standards and established ad-hc standards such as FACE. General care events and cmmunicatins As required As required Healthcare and ther cmmunicatins fllwing nn-dallas business prcesses DHID/ITK standards and thers (Scpe will emerge frm future wrk). A wide range f ther cmmunicatins and dcumentatin may be relevant, depending n the dimensins f assisted living that are in place fr this service user. It must be pssible t share such cmmunicatins within a citizen's assisted living team, and put in place alerts, ntificatins etc relating t them, within defined patterns f access and cnsent. 54
55 Shrt name Frm T Purpse Standards Ntes HCP recrd keeping HCP Patient recrd, Scial care recrd and Patientheld recrd Recrd keeping in accrdance with HCP prfessinal standards and practice Welsh standards are under develpment in NWIS, designed with an eye n safe cexistence with emerging DHID cmmunicatins standards in England (see nte). It wuld be sensible fr DALLAS as a whle t standardize n the simple generic CDA cmmunicatins defined in the ITK, which is likely t becme widely supprted within NHS Trusts in the life f the DALLAS prgramme. Scial care recrd, Patient recrd and Patientheld recrd Recrd keeping in accrdance with SCP prfessinal standards and practice There are sme, but much less mature than health in standards terms needs investigatin. Questin t what extent are Health and Scial Care recrds pen bth ways in a DALLAS cntext? suggest an assumptin fr nw that there will be specific dcument types and prtcls agreed fr shared access. Scial care recrd keeping SCP In Wales, NWIS is steering a middle grund, ensuring interperatin with English standards whilst managing-dwn the knwledge burden f standards adptin within NHS Wales t cntain csts. 55
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57 Annex C Security C.1 Security Privacy is ne cncern that has been viced cncerning ehealth and telecare. It is an aspect f authrisatin (wh is allwed t see infrmatin), authenticatin (are they wh they say they are) and access cntrl (what can they d with it when they are authrised and authenticated). These three mechanisms are ften abbreviated t AAA. AAA is nt sufficient if the infrmatin is sent acrss a netwrk because its rules are first invked when smebdy tries t access the infrmatin. The infrmatin must als be encrypted t prevent an intruder frm recrding it during transmissin in fact, all infrmatin shuld be encrypted all the time because intruders can als read disks and memry, lad perating systems, read prgrams and ptentially gain access t cause disruptin. AAA data (usernames, passwrds, permissins) must als be prtected but, ultimately, there must be sme transfer, pssibly exchange, f infrmatin, r keys, between authrised parties t allw anything t be encrypted and decrypted crrectly. There is a perid f vulnerability during this phase that can be explited by intruders. In sme cases, if an intruder recrds these keys, then he can masquerade as an authrised user, especially if the keys becme the embdiment f AAA attributes. It is necessary t minimise the duratin f the vulnerability, assess risks f it being breached, and have a prcess fr recvery when this happens. A separate channel can als be used, e.g. an encrypted using a different key. The advantage f integrating AAA attributes int a key is that it can be used fr each transactin, as it shuld be, s that every single access can be validated. T he key must be changed sufficiently ften that intruders can be frustrated e.g. fr WiFi, the WEP encryptin mechanism culd easily be brken in abut 10 minutes nce the key was acquired; the WPA mechanism is anyway mre secure and als updates the keys during an assciatin faster than the estimated time take t break ne key. The key shuld als be embedded in additinal authenticatin infrmatin accmpanying the transactin t verify the infrmatin in that transactin even if it is encrypted, it culd be captured, mdified in randm ways and replayed in the hpe f unlcking ther infrmatin in a system r disrupting its peratin. The HMAC prtcl use in IP security systems achieves this bjective. This can als be used t mitigate against repudiatin, i.e. the situatin where a transactin tk place but ne mre parties deny that it happened. A transactin may have a lng life, e.g. a web-brwsing sessin (prtected by HTTPS) r a TCP transfer encrypted using TLS r a secure VPN established at netwrk layer using IPSec, r it may be limited t a single piece f infrmatin, e.g. a bld pressure reading transprted in UDP, pssibly in a VPN but prtected in additin using HMAC. The lifetime f the keys may match the duratin f the transactin, and this culd be very lng. There are several questins cncerning keys and their vulnerabilities: where d they key cme frm, wh wns them, wh maintains them, wh has the authrity ver them? In additin, given the diversity f situatins in which they are created, distributed and used, hw can they be made interperable? Hw scalable are they in real use? The keys are generated by algrithms which use a cllectin f basic infrmatin, sme user-specified, sme btained at the time f generatin (machine ID, time f day), t generate a sequence f bits. This sequence is then applied t messages t encrypt and decrypt them at sender and receiver. This is already naïve: ne key is nt enugh. PGP, fr example, has fur per assciatin between sender and receiver. Each uses a pair: ne t encrypt messages it sends (which it never transmits the private key) and ne t decde messages received frm the ther party (fr which the ther party has sent its key the public key). Each party wns its public and private keys, and shares the public ne with thers that it want t cmmunicate with. Thus it has t stre a different pair fr every such relatinship. In fact, this kind f apprach wrks best if the keys are generated fr the transactin in which they are t be used and invalidated subsequently. 57
58 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 It is ften the case that the parties accessing a service d nt wn the key. The netwrk peratr, service prvider and manufacturer f the phne fr example, and in the mbile telephne, wn the identities and keys n a UMTS SIM. Tgether, they are used t assciate the subscriber with the phne and the netwrks t which access is allwed. The need t share, and stre, keys is supprted by a range f prtcls, e.g. ITU-T X.509, and services, such as The Directry, familiar t IT users via LDAP r the Active Directry. The IETF has defined an extensible prtcl, EAP, which is widely used. Sme aspects f healthcare fit naturally int an ICT mdel f security. Others are mre challenging, especially because there will be many simple devices that cannt engage in cntinual, r additinal verhead f, cmmunicatin dminated by security exchanges. Keys can be issued when the device is packaged fr delivery, r at manufacture, and exchanged when the device is cmmissined. This is nt ideal, given the discussin abve, but the cnstraints are such that cmprmises will have t be fund. It is ntewrthy that the security mechanisms discussed here allw a certain level f trust t be established between machines and peple wh use them t cmmunicate electrnically. They supprt, but d nt substitute, fr the ther necessary means f establishing trust in the infrmatin and sequences f its use at the service r rganisatinal level. It is evident that keys and infrmatin related t security prliferate very quickly and are different at different levels f a cmmunicatin system. They are als likely t be different between different rganisatins, which have a legitimate claim n their wnership. The differences can lead t interperability prblems and denial f access t legitimate users. The develpment f federatin mechanisms allws rganisatins t authrise the sharing f keys in such a way that their different plicies are acknwledged and implemented t allw access. Finally, security is a natinal issue and prviders f equipment that enfrces security, r claims t be secure, has t be certified. Organisatins such as CPNI and CESG have this respnsibility in the UK. C.1.1 Attacks Every netwrked distributed system will be attacked. Smetimes it will behave in ways that are crrect and within bunds but circumstances make the transient sequence f events appear as if an attack is in prgress, e.g. an excessive delay in exchange f messages that establish a secure assciatin. Repeated attempts t establish security assciatins that fail may be attacks, r just user incmpetence. Attacks can be crude, e.g. deliberate swamping f a target with bgus messages t deny access t legitimate users. If an adversary can insert snping equipment n a link, and replay traffic n the link, then mre sphisticated attacks can be made. Attacks can include theft f devices that have valid credentials that are then reused befre they can be invalidated. Authrities can be subverted t release keys. Security experts are familiar with attacks and the tls f frensic investigatin. Hwever, telecare enterprises, which have enjyed gd prtectin until nw, are being placed in a psitin that is ptentially mre expsed t attack n their ICT systems. Users, the public, have almst n idea abut security and the ptential fr attack especially n devices that they depend n. C.2 Cabinet Office Identity Assurance Prgramme As part f the Gvernment Digital Services (GDS) prgramme21 Cabinet Office has initiated a prject that is aimed at transfrming gvernment services thrugh the use f digital technlgies. The prgramme has a number f streams, ne f which is the GDS Identity Assurance Prgramme22, which fcuses n 21 Gvernment Digital Services prgramme details can be fund at 22 GDS Identity Assurance details can be fund at 58
59 the challenge f building greater trust in the use f the internet fr gvernment services. The Technlgy Strategy Bard is running a parallel prgramme Trusted Services, that is explring issues f human and digital trust as they apply t the use f the Internet fr sharing health infrmatin. DALLAS Cmmunities and technlgy prviders are invited t cnsider hw the utput f these tw prgrammes applies t their technlgy prpsals. C.2.1 Identity Assurance Prgramme Objectives The bjectives f the Gvernment Digital Services Identity Assurance Prgramme are t: Create a market f 'Identity Prviders' fr enabling access t digital public services Leveraging existing & evlving private sectr capabilities Under a cmmercially sustainable mdel Develp/enhance existing fraud detectin and preventin infrastructures Ensure persnal privacy is prtected. C.2.2 Principles f Identity Assurance The fllwing identity assurance principles are currently prpsed: Custmer fcus: an identity assurance slutin must be based arund the needs f the individual therwise it will nt be used r valued. Peple have different and changing needs. N ne big brther slutin will meet the needs f all custmers in all cntexts. Data minimisatin: the minimum amunt f persnal data shuld be requested in a transactin. The data shuld have relevance t the cntext f the transactin. N single identifier: in line with the Data Prtectin Actin, there shuld be n general identifier fr a custmer that can be used by an unauthrised party t piece tgether a persn s activities acrss multiple cntexts. Custmer cntrl: the use f a custmer s identity and persnal data shuld be fully transparent and cntrlled by the custmer. Decentralisatin: there shuld be n central stre f data (a recnstituted Natinal Identity Register) that culd act as a single pint f weakness if cmprmised. Cllabratin: with full transparency and cntrl fr the custmer, the slutin apprach shuld incentivise cllabratin between the custmer, public sectr and private sectr t bear dwn n the cmmn prblem f fraud. Standards based slutin: use f cmmercial ff-the-shelf prducts is attractive t bth the private sectr Identity Prvider and public sectr digital channel wner. C.2.3 Delivery Mechanism The Identity Assurance Prgramme aims t deliver an identity infrastructure and service thrugh existing initiatives as described in Figure 9. 59
60 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Figure 9: Identity Assurance Prgramme infrastructure, services and initiatives C.2.4 Identity Assurance Prgramme high level architecture The high level architecture f the prpsed Gvernment Digital Services Identity Assurance Prgramme is best understd by the fllwing walkthrugh, als shw diagrammatically in Figure 10: 1. A citizen requires access t a Gvernment Service by clicking a web link (URL). 2. At this stage the request is unauthrized (annymus) and is redirected t a plicy engine cntained in a central Federatin Hub. The plicy engine in the Hub determines the credential type, assurance level and claims that are required fr access t the service. 3. A SAML 2.0 (Security Assertin Markup Language see request can be sent t ne r mre identity prviders that can fully satisfy the request. At this pint, the user may be able t select frm a number f identity prviders (fr example PayPal, Pst Office, NHS r pssibly Facebk/Ggle/Windws Live/Yah! fr lw-assurance transactins) and may be asked t enter a username and passwrd r present at tken such as a smartcard. 4. If the request requires additinal attributes ver and abve the identity request (fr example prf f registratin with the General Medical Cuncil) then further attributes will be requested frm a gvernment f cmmercial Attribute Prvider. 5. The signed and encrypted SAML respnse is attached t the URL and sent t the Service Prvider and the user gains access t the service. 60
61 Figure 10: Identity Assurance Prgramme high level architecture 61
63 Annex D Quality f Service and Grade f Service Requirements D.1 General These aspects f a netwrk s perfrmance are very imprtant fr telecare services, which may have safety f life implicatins, and whse events can be classed with a range f qualities, such as safetycritical, safety-related r nn-safety. Hwever, they are highly technical and cmplex aspects f the netwrk s perfrmance, and ultimately its design, cnfiguratin and deplyment. Quality f service (QS), and grade f service are terms that are defined by the ITU-T and subject t ITUT recmmendatins, e.g. the E series fr fixed netwrk services and the P series fr wireless cmmunicatins. Class f service (CS) is a term that is assciated with specific prtcls and services. It is a mechanism fr telling the service that a particular piece f infrmatin and cmmunicatin is imprtant, r less s. D.1.1 Quality f service Quality f Service is used t state requirements by a user r applicatin f the service required t supprt assured peratin. There are sme well-knwn parameters: thrughput, residual errr rate, packet rate lss and delay (n a link, r als rund-trip); speech quality and intelligibility. The bserved perfrmance f a service is measured by the values achieved by the prvider (the peratr, the equipment, the end-tend path, and pssibly the cmmunicatins channel itself depending n hw the measurement is being made) fr the same parameters, and these bservatins are cllectively termed QS as well. D QS variatin QS varies because: Physical electrmagnetic prcesses, faults, and the dispsitin f the medium in the prpagatin envirnment perturb the prgress f a signal in a channel. All types f media are affected, sme, e.g. wireless, mre than thers. The perturbatins generally degrade the signal, causing errrs. Mst specificatins prvide prtectin f the bit stream s that these errrs can be detected, ften crrected. The mst cmmn, but nt universal (e.g. sme Classes f Service in UMTS see belw) actin in the event f an errr that cannt be crrected is t discard the faulty unit (frame, cdewrd r packet). This leads t lss. The lss may nt be detected until smetime later, r the entity that detects it may immediately request a retransmissin (e.g. WiFi des this but Ethernet des nt). This causes delay. The cmbinatin f lss and delay reduces thrughput, which ultimately affects ther metrics and end-t-end perfrmance; Frwarding elements (switches, ruters) have finite capacity and perfrmance. A link has a maximum capacity but the receiving interface may nt be able t prcess data at that capacity, especially if there is a wide variatin in packet sizes many big packets will ccupy mre space and take lnger t pass thrugh the frwarder. The receiving device may be able t blck the sender if it becmes t busy, s the sender then cannt flush its wn buffers. The sender s buffer space fills up s that it, t can n lnger receive n incming links. The cngestin is thus prpagated backwards twards traffic surces. The sender may be able t select an alternative link t divert the excess lad but this depends n the cnfiguratin and cnnectivity f the netwrk verall. 63
64 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 Prtcls in devices at the edge f the netwrk must be designed and implemented in such a way that they are resilient t errrs. Hwever, when they are ver-eager in retransmitting packets that they think are lst, they can, themselves, cntribute t verlad and make a bad situatin wrse. When they are slw t react, the applicatin may stp wrking (a Grade f Service prblem). It is inevitable that QS will vary and there is n tractable analysis tl that can explain hw it will vary, and thus hw t design and implement a netwrk that will guarantee QS. The effective crude mitigatins against the effects abve are t increase the data rates as much as pssible (ver-prvisin) and ensure that bit errr rates are minimised as far as pssible. Other measures are cntradictry in their effects: fr example, delivery f gd packets can be imprved by retransmissin but the cnsequent delivery delay may stp the applicatin wrking (e.g. fr vice). There are als many mre sphisticated mitigatin measures. Because QS varies, and because frwarders are relatively intelligent, there is the pssibility that they can mnitr flws f traffic. Knwing what is passing thrugh, they can use rules given t them by the peratr, the users and the applicatins, r infrmatin in the packets themselves, t give a defined service (thrughput, delay, jitter) t a flw r pssibly priritise flws relative t ne anther. These appraches are deceptively attractive t users but are difficult t implement in mst practical deplyments invlving multiple prviders. Anther side-effect is that they are intensive in prcessing and memry usage and thus reduce link utilisatin and thrughput, thereby causing exactly the effects that they were designed t prevent, In general, the lessn is that the means t enfrce differential priritised service must be built int the entire stack frm the physical layer up and cnfigured by management actin (autmated r human) accrding t the requirements f the applicatin ppulatin. D.2 Grade f service Grade f service cvers a wide range f parameters related t service perfrmance, as distinct frm QS which measures netwrk perfrmance. The parameters fr circuit-switched services such as vice r fax, fr example include the likelihd f call being blcked r drpped r wrngly cnnected etc. System level parameters include availability, serviceability, mean time t failure, mean time between failures. QS impacts n grade f service. The tw grups f parameters can be cllected tgether int a Service Level Specificatin (SLS) that is used by the user r applicatin prvider n behalf f a user t define expectatins f the service t the peratr r service prvider. Service Level Agreements, which are knwn t be difficult t define fr telecare applicatins, are the cntractual mechanism fr assciating SLS with service bjectives (SLOs). D.3 Class f service Class f Service is mre specifically applied t infrmatin cnveyed within the cmmunicatins traffic, ften at different layers in the stack, and which prvides t the cmmunicatins infrastructure infrmatin abut the traffic which can be used t assign it differential treatment. The Class f Service mechanisms exist in many specificatins at bearer level, at basic framing level, and in netwrk layer packets, including IP. Hwever, they are ften nt used. In the future they may need t be cnsidered fr example t prevent a streaming vide dwnlad frm blcking a scial alarm r real time health mnitring uplad in the LAN envirnment. Hwever, it is essential t take heed f the warnings given abve: it is difficult t d at all if the mechanisms at nt cnfigured crrectly and cnsistent frm the physical layer upwards and anyway prblematic because different peratrs in the end-t-end delivery chain may nt have the same SLAs r interpretatins f parameters. D.4 Implicatins fr telecare services Currently all public access IP netwrks prvide cmmunicatins n a best effrts basis. Telephne netwrks have mre stringent grade f service bjectives. The implicatin f this is that when the netwrk is scaled t have significant excess capacity, all users get the highest quality f service available. When 64
65 netwrks are cngested and there is cntentin fr access, this can result in transmissin delays and drpped packets fr the reasns indicated abve. Drpping r even delaying a safety alarm culd be a serius prblem whereas drpping the ccasinal packet f vide r vice may result in nly a minr degradatin in perceived quality. In the WAN envirnment it remains t be seen if netwrk capacity grwth can cntinue t utstrip demand r will class f service mechanisms need t be invked, especially where mbile access is cnsidered? Hw wuld such mechanisms be invked and administered? The cmmunicatins prvisins currently are t the subscriber and nt part f a telecare service prvisin. What frm shuld the relatinships take fr the future? Shuld the primary telecare service prvider be a virtual peratr and include the cmmunicatins infrastructure t the client as an element f the prvisin? 65
66 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 66
67 Annex E Spectrum cnsideratins E.1 Shrt range devices - Wireless Scial Alarms Current Nrmative requirements are that fr Scial alarm equipment Class 1 receiver characteristics are applied. The majrity f the scial alarms used tday are cnnected via a shrt range RF link in the 169MHz r 869 MHz licensed-exempt bands. These are usually relayed thrugh a hub in the hme t call centres using fixed line r mbile cnnectins. Several ther shrt range technlgies are starting t be used in ther licensed-exempt bands using standards such as Bluetth, Wi-Fi and ZigBee. Regulatin f Spectrum in the Eurpean regin is subject t plicy changes and sme reallcatin f existing spectrum t new uses. Tgether these create a changing envirnment where a lnger term strategy f spectrum use fr wireless scial alarms needs t be develped. Licensed-exempt devices are expected t perate in a nn-prtected interference envirnment and it highly recmmended that interference mitigatin techniques are incrprated such as very shrt duty cycles r listen befre transmit prtcls. In the case f cntinuus interference, blcking a scial alarm, the nly ther ptin wuld be t switch t anther band. The dwnside t this apprach wuld require the implementatin f tw radis. Future demands, and the increase in licensed-exempt spectrum usage, means that the design and implementatin fr scial alarms needs t take int accunt the likely increase f n channel usage (ptential interferers in the same band) and the c-existence f ptential adjacent channel interference, such as frm the new LTE services t be rlled ut in the upper cleared TV spectrum, 791MHz t 862MHz (800MHz Digital Dividend spectrum). E MHz band Shrt Range Devices (SRDs) The MHz band is allcated n a harmnised basis thrughut Eurpe fr use by licensedexempt Shrt Range Devices (SRDs). As this band lies just abve the prpsed new mbile transmit sub-band part f the 800 MHz digital dividend spectrum, there will be the ptential fr interference frm bth base statins and frm mbile terminals int SRDs in the adjacent band. The SRD band is subdivided int three applicatin-specific sub-bands, which are illustrated belw. The entire band may als be used by generic SRDs which may include cnventinal narrw band systems r wideband systems using spread spectrum technlgy. Figure 11: 863MHz t 870MHz Spectrum usage Existing standards and prprietary slutins reflect the current relatively benign adjacent band interference envirnment, with high pwer TV transmitters at fixed lcatins and a limited number f prfessinal micrphne deplyments. Operatin f base statins and mbile terminals in clse prximity t SRD receivers will lead t interference r blcking in sme scenaris, particularly at the lwer end f the SRD band. Ofcm has cmmissined tw studies, t ascertain the extent f SRD deplyment in the MHz band in the UK and t assess the immunity f SRDs t interference frm mbile terminals belw 862 MHz (but nt the fixed mbile variant r base statin). On the basis f these studies Ofcm cncluded that in general SRDs in this band are unlikely t suffer any significant increase in interference as a result f the 67
68 White Paper - Interperability fr DALLAS applicants and cmmunities v1.0 deplyment f mbile services in the MHz band, hwever interference des ccur and in the specific case f scial alarms, given the safety critical nature f these devices, Ofcm has cmmissined further wrk t ascertain whether specific mitigatin measures may be required. E.3 169MHz band Shrt Range Devices (SRDs) Accrding t EU rules, 169 MHz band can be used nt nly fr legacy paging systems, but als fr hearing aids, scial alarms, asset tracking r tracing systems and meter reading systems. The 169MHz band is currently the subject f a CEPT reviewxvii mandated by the EC. The intent is t maximize spectrum efficiency f use, and t cnsider accmmdate new services in this case ptentially including remte metering, and innvative lng range technlgies within the high-pwer sub-band. The utcme may have implicatins fr Scial Alarm usage. Extract frm cmmissin dcument, Review f Cmmissin Decisin 2005/928/EC (169 MHz Decisin) the way frward, published 9th March 2011 Due t technlgical evlutin in using the harmnised frequency range, a discussin abut a review f the 169 MHz Decisin is necessary because a shrtcming f the present channelling arrangements in sub-band B has been identified, which reduces the number f 25 khz channels fr exclusive use by "hearing aid" applicatins frm fur theretically freseen in the Decisin t three effectively. The handicap is caused by a partial verlap in the current channelling arrangement between the exclusive channels fr hearing aids and thse fr scial alarms. 68
69 Annex F Changes in fixed telecmmunicatins prvisin F.1 The emerging envirnment There are a significant number f changes that need t be cnsidered in designing telecare cmpnents at every level in the ISO 7 layer mdel stack s that they are interperable: Figure 12: The Seven layers f the Open Systems Intercnnectin (OSI) mdel A grwing diversity f deplyed media pathway types and cmbinatins: cpper, fibre and wireless t the hme. The path frm the last peratr switching pint t the terminatin in the hme may invlve mre than ne, e.g. FTTC, r a fixed-wireless access lcal switch, with a cpper terminatin; hwever a single media type is mre cmmn: cpper is the mst prevalent, including single-pair telephne land-lines fr histrical reasns, and als cable; there is significant uptake f wireless bradband supplied via UMTS, which supprts use n the mve (see belw); fibre t the user premises (FTTH) is gradually increasing in vlume; We face a hetergeneus netwrk technlgies envirnment with small but significant variatins in parameters and QS between them. Smart metering is due t be intrduced universally in the UK between 2011 and The exact details f the implementatin are still emerging but they will be sharing the envirnment with their wn demands fr Lcal wireless cmmunicatins and backhaul WAN cmmunicatins. This may prvide additinal infrastructure that can be explited, cmpetitin fr resurce r a cllabrative rute fr develpment and sharing resurces with significant ecnmies f scale? S, there is a substantial and accelerating increase in diversity f access mde and bearer services inside and utside the hme. There are many internatinal standards fr access and prvisin f basic bearers fr any f the media types mentined abve. The fllwing six sectins list typical examples and expected changes in the service envirnment. 69
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