Interoperability and system integration are central problems that limit the effective use of health information systems to improve efficiency and effectiveness of health service delivery. There is currently no proven technology that provides a general solution in low and middle income countries where the challenges are especially acute. Engineering health information systems in low resource environments have several challenges that include poor infrastructure, skills shortages, fragmented and piecemeal applications deployed and managed by multiple organisations as well as low levels of resourcing. An important element of modern solutions to these problems is a health information exchange that enable disparate systems to share health information.
It is a challenging task to develop systems as complex as health information exchanges that will have wide applicability in low and middle income countries. This work takes a case study approach and uses the development of a health information exchange in Rwanda as the case study. This research reports on the design, implementation and analysis of an architecture, the Health Information Mediator, that is a central component of a health information exchange. While such architectures have been used successfully in high income countries their efficacy has not been demonstrated in low and middle income countries. The Rwandan case study was used to understand and identify the challenges and requirements for health information exchange in low and middle income countries. These requirements were used to derive a set of key concerns for the architecture that were then used to drive its design. Novel features of the architecture include: the ability to mediate messages at both the service provider and service consumer interfaces; support for multiple internal representations of messages to facilitate the adoption of new and evolving standards; and the provision of a general method for mediating health information exchange transactions agnostic of the type of transactions.
The architecture is shown to satisfy the key concerns and was validated by implementing and deploying a reference application, the OpenHIM, within the Rwandan health information exchange. The architecture is also analysed using the Architecture Trade-off Analysis Method. It has also been successfully implemented in other low and middle income countries with relatively minor configuration changes which demonstrates the architectures generalizability.