Networking Aspects of the Electronic Health Records: Hypertext Transfer Protocol Version 2 (HTTP/2) vs HTTP/3.

The rapid development of the digital healthcare and the electronic health records (EHR) requires smooth networking infrastructure to access data using Hypertext Transfer Protocol (HTTP)-based applications. The new HTTP/3 standard should provide performance and security improvements over HTTP/2. The goal of our work was to test the performance of HTTP/2 and HTTP/3 in the context of the EHRs. We used 45,000 test FHIR Patient resources downloaded and uploaded using 20, 50, 100 and 200 resources per Bundle, which resulted in 2251, 901, 451 and 226 HTTP GET and POST requests respectively. The first test downloading 20 resources per Bundle showed that HTTP/3 outperformed HTTP/2 in the local (mean request time 16.57 ms ± 7.2 standard deviation [SD]) and in the remote network (71.45 ms ± 43.5 SD) which is almost 3 times faster. In the 50 and 100 resources per Bundle test the HTTP/3 protocol demonstrated again more than two times gain in downloading performance for remote requests with mean request time 91.13 ms ± 34.54 SD and 88.09 ms ± 21.66 SD respectively. Furthermore, HTTP/3 outperformed HTTP/2 in the constructed clinical dataset remote transfer. In the upload tests HTTP/3 showed only a slight gain in performance merely in the remote network. The HTTP/3 protocol is a relatively new development and a major improvement for the worldwide web. This new technology is still missing in the digital health and EHRs. Its use could offer a major performance gain in situations where data is gathered from multiple remote locations.

Capture of real-time data from electronic health records: scenarios and solutions.

Background: The integration of real-time data (RTD) in the electronic health records (EHRs) is transforming the healthcare of tomorrow. In this work, the common scenarios of capturing RTD in the healthcare from EHRs are studied and the approaches and tools to implement real-time solutions are investigated. Methods: Delivering RTD by representational state transfer (REST) application programming interfaces (APIs) is usually accomplished through a Publish-Subscribe approach. Common technologies and protocols used for implementing subscriptions are REST hooks and WebSockets. Polling is a straightforward mechanism for obtaining updates; nevertheless, it may not be the most efficient or scalable solution. In such cases, other approaches are often preferred. Database triggers and reverse proxies can be useful in RTD scenarios; however, they should be designed carefully to avoid performance bottlenecks and potential issues. Results: The implementation of subscriptions through REST hooks and WebSocket notifications using a Fast Healthcare Interoperability Resources (FHIR) REST API, as well as the design of a reverse proxy and database triggers is described. Reference implementations of the solutions are provided in a GitHub repository. For the reverse proxy implementation, the Go language (Golang) was used, which is specialized for the development of server-side networking applications. For FHIR servers a python script is provided to create a sample Subscription resource to send RTD when a new Observation resource for specific patient id is created. The sample WebSocket client is written using the "websocket-client" python library. The sample RTD endpoint is created using the "Flask" framework. For database triggers a sample structured query language (SQL) query for Postgres to create a trigger when an INSERT or UPDATE operation is executed on the FHIR resource table is available. Furthermore, a use case clinical example, where the main actors are the healthcare providers (hospitals, physician private practices, general practitioners and medical laboratories), health information networks and the patient are drawn. The RTD flow and exchange is shown in detail and how it could improve healthcare. Conclusions: Capturing RTD is undoubtedly vital for health professionals and successful digital healthcare. The topic remains unexplored especially in the context of EHRs. In our work for the first time the common scenarios and problems are investigated. Furthermore, solutions and reference implementations are provided which could support and contribute to the development of real-time applications.

Comparison of the Performance of the Fast Healthcare Interoperability Resources (FHIR) Subscription Channels.

BACKGROUND: The Fast Health Interoperability Resources (FHIR) standard was proposed and released to solve the interoperability problems of the electronic health records. The FHIR Subscription resources are used to establish real-time event notifications from the FHIR server to another system. There are several communication channels such as rest-hook and websocket. The objective of our work is to compare the performance of the FHIR subscription using the rest-hook and websocket channels. METHODS: HAPI FHIR server, python websocket clients and HTTP endpoints were used to measure the processor and memory usage of the two subscription channels. Tests were performed with 5, 10, 15, 20, 30, 40, 50, 60, 70 and 80 clients. The performance was logged using windows performance monitor. RESULTS: The rest-hook subscription showed near six-fold increase in resource utilization when increasing the clients from 5 to 80. On the contrary, the websocket subscription channel did not reach a two-fold increase. CONCLUSION: The type of the subscription channel should be carefully selected and load distribution should be considered when the number of clients grows.

Comparison of WebSocket and Hypertext Transfer Protocol for Transfer of Electronic Health Records.

BACKGROUND: Electronic health records (EHR) emerged as a digital record of the data that is generated in the healthcare. OBJECTIVES: In this paper the transfer times of EHRs using the Hypertext Transfer Protocol and WebSocket in both local network and wide area network (WAN) are compared. METHODS: A python web application to serve Fast Health Interoperability Resources (FHIR) records is created and the transfer times of the EHRs over both HTTP and WebSocket connection are measured. 45000 test Patient resources in 20, 50, 100 and 200 resources per Bundle transfers are used. RESULTS: WebSocket showed much better transfer times of large amount of data. These were 18 s shorter in the local network and 342 s shorter in WAN for the 20 resource per Bundle transfer. CONCLUSION: RESTful APIs are a convenient way to implement EHR servers; on the other hand, HTTP becomes a bottleneck when transferring large amount of data. WebSocket shows better transfer times and thus its superiority in such situations. The problem can be addressed by developing a new communication protocol or by using network tunneling to handle large data transfer of EHRs.

A Case Showing a New Diagnostic Aspect of the Application of Radiofrequency Echographic Multi-Spectrometry (REMS).

Radiofrequency echographic multi-spectrometry (REMS) is an ultrasound technique that has been recently introduced in the medical field to detect osteoporosis and fracture risk at axial sites. The use of sonography to visualize the region of interest (ROI) of the hip neck provides the opportunity to identify occult fractures. A 91-year-old woman with persistent right leg pain was referred to rheumatologist due to a known history of arthritis and osteoporosis. She was able to walk using a crutch, although experiencing an antalgic gait. The patient had recently fallen on her right side from standing height. During the visualization of the ROI of the right femoral neck using REMS, an abrupt break of the femoral cortex suspected to be a fracture was seen; therefore, the measurement of the femoral neck was performed on the left side. The T-score had value of -2.9 SD and the fragility score was 86.7. Due to unclear signs of a fracture after an X-ray of the hip, a computed tomography (CT) exam of the hip was performed, which revealed a femoral neck fracture. Occult fractures of the femoral neck are challenging to diagnose and require numerous radiologic exams. The use of ultrasound as a method to measure bone density allows the simultaneous diagnosis of osteoporosis and detection of fractures.

Effect of the body mass index, basal metabolic rate, and body fat on the radiofrequency echographic multi-spectrometry (REMS)-based bone mineral density and fracture risk: a cross-sectional study.

Radiofrequency echographic multi-spectrometry (REMS) is a method to assess bone mineral density (BMD) of the axial skeleton, fragility score (FS), body mass index (BMI), basal metabolic rate (BMR), and body fat (BF) in %. The aim of the study was to investigate the influence of the BMI, BMR, and BF on the BMD and fracture risk with REMS. We conducted a cross-sectional study among 313 women, aged 20-90 years who underwent a screening for osteoporosis with REMS. Kruskal-Wallis was used to analyze the differences in BMI, BMR, and BF between the groups according to the BMD: normal BMD, osteopenia and osteoporosis and differences in the FS, fracture risk assessment (FRAX) for major osteoporotic fractures and for hip fractures (HF) according to the BMI groups: underweight, normal weight, overweight, obese, and extreme obese. Linear regression was used to assess the correlations BMI-BMD, BMR-BMD, and BF-BMD. BMI, BMR, and BF differed significantly between the groups according to the BMD (p < 0.001, p = 0.028, and p < 0.001, respectively). BMR showed high positive correlation to BMD (R = 0.765) with 95% confidence interval (CI) [0.715, 0.807] and significance of p < 0.001. BMI correlated significantly to BMD (p < 0.001), the correlation was low positive (R = 0.362) with 95% CI [0.262, 0.455]. In the BMI groups, there was significant difference in FRAX for HF and FS with p value 0.014 and < 0.001, respectively. Subjects with low BMI, BMR, and BF are at high risk for osteoporosis. Underweight women show significantly high fracture risk, assessed with FRAX and FS.

An observational study of the radiofrequency echographic multi-spectrometry (REMS)-based fragility score of the lumbar spine and total fracture risk at 5 years in women.

A novel fragility score (FS) parameter, obtained during radiofrequency echographic multi-spectrometry (REMS), was developed to estimate the ultrasound-based skeletal fragility. The aim of our study is to assess the REMS-based FS of the lumbar spine (LS) among the Bulgarian women and to compare their characteristics acquired with REMS between fracture risk classes corresponding to a total fracture risk at 5 years for major osteoporotic fractures (MOF). A total of 100 Bulgarian women, who underwent a screening for osteoporotic fracture risk using the REMS technology, were included in a prospective observational study. The mean age was 60 years (years) ± 13.9 standard deviations. We assessed the FS of the LS and for each subject. The fracture risk class (R1-R7) was identified using a table combining measured REMS T score and FS values. The mean FS was 36.9 ± 17.4 SD (range: 18.5-84.3). Twelve subjects (12%) were classified into the R6 group, twenty-three (23%) into the R5, sixty-one (61%) into R4, and four (4%) into R3. Statistical analysis showed significant difference in age, height, BMD, T score, Z score, age of menopause, FRAX for MOF, and FRAX for hip fractures between the risk class groups. This is the first study which showed the REMS-based FS of the lumbar spine among the Bulgarian women. T score alone is not a good predictor of fractures. Our study showed that its use in combination with the fragility score obtained during REMS offers a robust assessment of the fracture risk at 5 years for MOF.

Prevalence of low bone mineral density at axial sites and fracture risk in Bulgarian population.

Background: Osteoporosis is a common chronic disease characterized by low bone mineral density (BMD) and microarchitectural deterioration of the bone, which are associated with increased risk of fragility fractures. Currently the most popular tool is the fracture risk assessment model FRAX to calculate the 10-year probability of major osteoporotic fractures (MOF) and hip fractures (HF). Objective: To investigate the prevalence of low BMD at axial sites and fracture risk in Bulgarian population. Methods: We retrospectively analyzed dual energy X-ray absorptiometry (DXA) scan results of 12 478 subjects. Scan results included BMD and T-score assessments of lumbar spine and femoral neck. FRAX major osteoprotic fracture (MOF) and FRAX hip fracture (HF) were assessed in subjects between 40 and 90 years using BMD values. Results: Of total 12478 subjects, 12119 were women and 359 were men. The mean age of the subjects was 61 years (yrs.) ± 10 yrs. The overall prevalence of low BMD at the lumbar spine was 6084/9336 subjects (65.2%). 3502/9336 subjects (37.5%) were considered as osteopenic and 2582/9336 subjects (27.7%) were considered as osteoporotic. The overall prevalence of low BMD at the femoral neck was 2036/3140 (64.8%). 1641/3140 subjects (52.3%) were classified as osteopenic and 395/3 140 subjects (12.6%) were classified as osteoporotic. The mean values of FRAX MOF and FRAX HF increased significantly with increasing the age interval. Conclusion: This study is the largest epidemiological research in Bulgaria up to date about the prevalence of low BMD at axial sites.

Effect of the lumbar scoliosis on the results of dual-energy X-ray absorptiometry.

One of the most common causes of lumbar scoliosis in adults is the decreased bone mineral density (BMD). The scoliosis in the lumbar spine has a known effect over the dual-energy X-ray absorptiometry (DXA) scan results. The objective of this study is to assess the influence of the lumbar scoliosis on the results of the DXA scan of the lumbar spine. 1019 women aged ≥40 years underwent a DXA scan of the spine. Age, weight, height, total BMD, total Tscore of the lumbar spine were recorded. The angle of the lumbar scoliosis (Cobb's angle) was measured from the DXA scan image using a DICOM software. The incidence of lumbar scoliosis in the current study accounts to 12.3%. Women with scoliosis showed significantly higher incidence of discrepancy in BMD T-scores between the adjacent vertebrae by more than 1 SD compared to women without scoliosis, (p=0.046). DXA results of subjects with scoliosis require more detailed evaluation of the T-scores of each vertebra to make a prompt decision about the final diagnosis.