1. The electronic prescription of medication inside hospitals (ePrescription) General overview1

2. Electronic prescription inside hospitals
Medical prescriptions are subject to several conditions concerning shape and content
essential: each prescription has to be signed and dated by the prescriber
Inside hospitals a deviation is possible:
Usage of electronic document
Without electronic signature of prescriber
But with timestamp and guarantee of integrity of the prescription by a mandated body, eg. the eHealth-platform

3. Functionalities Needed functionalities for eletronic prescribing:
authentication of the prescriber and verification of his quality as a prescriber
Timestamping of the prescription within a reasonable time-frame after its creation
Guarantee that the prescription cannot be changed after time-stamping,
guarantee of integrity
Possibility to verify the content of the prescription and guarantee that it has not been changed afterwards

4. Conditions for the electronic prescription
Today only medication prescription by doctor or dentist inside the hospital, so for internal use with the hospital pharmacy
In each hospital an agreement has to be signed by the hospital and each prescriber about::
The authentication procedure of the prescriber
Done locally inside hospital
Can be usernemae/password; eID; certificate;…
The procedure of electronic timestamping and guarantee of integrity
Procedure/protocol approved by RIZIV/INAMI

5. Overview Hospital eHealth-platform prescription A prescrition B1 6
prescription A
prescrition B
archive
hashing 2
hashcode A
hashcode B 5
electronic
signature 3
timestamp bag 4
elektronic
timestamp 6
archive

6. ePrescription in a hospital Technical info and procedures6

7. Design overview

8. Design Overview

9. Time stamping individual journal / TS bags

10. Information in a Timestamp
based on RFC-3161
More specifically:
The hash code of the TSBag
The date and time of the timestamp, generated by the time stamp server
The sequence number as generated by the time stamp server
The digital signature of all these data, generated by the time stamp server

11. Handling multiple clinical systems in one hospital

12. Handling multiple clinical systems in one hospital

13. Protocol overview

14. Protocol between timestamp client & server
Oasis-DSS protocol with the time stamp profile
(see )
Features of the Timestamp services
Accessible through internet
Only registered IP-address are authorized
(preventing DOS-attack)
Protected by a WS-Policy v1.2
Sign Timestamp
Sign body
Sign BinarySecurityToken (BST)
Identification based on the identification certificate (BST)

15. Requirements of the archive
The hospitals and eHealth-platform will need to set up an archive that guarantees that the hospital journal, the TSBags and the timestamps are stored safely and completely unchanged for as long as the hospital journal is to be kept.
To accessing the archives the same keys are used (easy to match both archive upon inspection)
unique identification of the Timestamp client
Date and time of the timestamp
Sequence number of the timestamp
Archiving period
Journal entries, TSBags and timestamps should be archived for 30 years.

16. Technical Requirements of the archive
Goal: store information secure until 2030
How:
The timestamp service MUST sign with a key length of at least 2048 bits
Minimum SHA-224 MUST be used to hash the prescriptions
Recommendation of (Prof.Quisquater)
SHA-256 is used in the reference implementation

17. eHealth Trusted Timestamp archive
Principles of the eHealth-archive
The TSA-service stores all requests & replies in the archive.
The archive will be kept for the period 30 years.
Only for the last 5 years is online consultation possible.

18. Illustration of both archives

19. Timestamp Visualizer

20. Functionality of the time stamp visualizer
The doctors in the hospital are legally responsible for the information in the hospital journal. It is likely that the doctors have access to the timestamp visualizer.
When the internal staff uses the visualizer, hospital confidentiality rules must be respected e.g. person X has no access to information Y via the operational IT-system, info is not available through the visualizer either.

21. Architecture of the visualiser
User interface in different languages
Implementation of a local cache
Using XSLT to visualize a prescription
Possible to add additional features
Plug-ins available for the moment
Document viewer
Document inspector

22. Functionality of the time stamp visualizer

23. Functionality of the time stamp visualizer

24. Use of the reference implementation

25. Technical Requirements
Two Timestamp service client programs
Timestamp Authority Client:
TTS Client
archive consistency check
incl. debugging tools (show bag, show serialNumbers,…)
incl. java runtime environment
Timestamp Viewer
Java 1.6 as programming language
Batch-scripts available for Windows
Microsoft SQL server 2005 as database system
Distributed under Apache 2.0 license

26. Structure of the TTSClient archive
bin batch-scripts to execute
conf configuration-files
certificates certification of the timestamp server
sql sql-statements to create the database
doc documentation
java java v1.6 runtime environments
lib needed jar-files
logging contains the different logfiles
openssl
opensslconf configuration files for openssl
sources sources of the programs

27. How to install the Timestamp client
Installation steps:
Create the buffer database
Create the hospital archive database
Configuration of the Timestamp client
Install the trusted time stamp client as a service
Testing the program
Installing the archive consistency checker
Incident report registration program

28. Configuration of the Timestamp client
The configuration file (/conf/configuration.txt)
Connection to the buffer and archive database
Document inspectors
Configuration of the classes for the plug-ins
Configuration for security and proxy
Location of directory where certificates time stamp server are installed
URLs of the eHealth-platform trusted time stamp service

29. Structure of the TS visualizer archive
certs certificates needed by the visualizer
conf configuration-files
I18n language-files
jre java v1.6 runtime environments
lib needed jar-files
plugins available plug-ins for the visualizer
xsl XSLT to visualize the prescription

30. How to install the Timestamp visualizer
Installation steps:
Add user to the hospital archive database
Config of the visualizer (/configuration.txt)
Configuration for security / proxy settings
URLs of the trusted time stamp service

31. eHealth procedures

32. Contact
The organization contacts eHealth )
In reply eHealth sends an with:
Explication of the whole test procedure
Documents necessary to obtain a certificate
Installation guide and binaries of the reference implementation
Further questions:

33. Test procedure Obtaining an eHealth-certificate
Installation of the certificate in the 'hospital' environment
Period of the testing and validation in acceptation
Obtaining an eHealth-certificate for production (optional)
Period of testing and validation in production
The 'hospital' system obtains the authorization to use the time stamping in production mode.

34. eHealth-Certificates: specifications
x509v3 certificate
Issued by GovernmentCA (fedict)
Current Subject specifications
CN = Logical name of the certificate
O = Official name of the organization
OU = Type of identification no. e.g. CBE / NIHII / …
SerialNumber = Identification no. of the organization

35. eHealth-Certificates: procedure ( 1 / 2 )
The Certificate responsible of the organization creates a Certificate Signing Request (CSR)
The legal representative of the organization fills in the proxy form
The representative sends the proxy form to Smals
Regular mail Smals - Rue du Prince Royal Bruxelles
subject: eHealth – identification certificate proxy
Fax: 02/ (Barbara Meyers / Sara Vander Meeren)

36. eHealth-Certificates: procedure ( 2 / 2 )
The Certificate responsible sends an with the generated CSR as attachment subject: eHealth – identification certificate CSR
As reply on his , he obtains the public key of the certificate.

37. Thank you for your attention! Questions?