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A Patient Referral and Counter-Referral Management System for Hospitals

Conference Paper · October 2011

DOI: 10.1007/978-3-642-24352-3_20

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Hospital system for management of patient

Reference-Counter Reference process
Javier F. Díaz – Laura A. Fava – Jorge Rosso – Pablo Iuliano– Diego Viches
Informatics Faculty, La Plata National University
50 and 120, 2nd floor, La Plata, Buenos Aires, Argentina.
{jdiaz, lfava, jrosso, piuliano, dvilches}@info.unlp.edu.ar

Maria Terzaghi
Medical Sciences Faculty, La Plata National University
60 and 120, La Plata, Buenos Aires, Argentina.
mterzaghi@sbarra.ms.gba.gov.ar


Abstract
The continuous and increasing population demand for good
medical care, in addition to the low and deficient resource
endowment in many of our country´s health institutions has
made the patient reference and counter reference an
important administrative care process. This process begins
with a reference or patient derivation from a lower resolution
capacity establishment towards one with more complex
assistance, diagnosis or therapeutic complementing, and it
ends with a counter-reference or patient transfer to the
establishment he came from, accompanied with a concrete
diagnosis, information on the services provided and with
answers and indications for the assistance demands.
In consequence, this article presents an informatics system
developed with Free/Libre Open Source Software (FLOSS)
[Ref. 1] technology to promote a proper and efficient use of
the Specialized Hospital ―Dr. Noel H. Sbarra‖ [Ref. 2], to
improve the interaction among pofessionals who belong to the
health ¨network¨ described, in order to increase the primary
care resolution capacity and this way avoid unnecessary
transfers of children and youngsters. It is important to
highlight that students from a Chair in the last year of the
Degree careers of the Faculty of Informatics in the La Plata
National University have been in charge of the system [Ref.
3].
Index Terms— Reference - Counter Reference, Medical
Record, Free/Libre Open Source Software (FLOSS), Java EE.
I. INTRODUCTION
In Argentina, certain public hospitals at a provincial and
national level count with very good specialist professionals
and with medium and high complexity technology that
distinguishes from the rest of the health institutions. It is
important to clarify that the health system has been designed
in increasing complexity levels to optimize the use of
resources. That is, as a diseases prevention and prevalence of
different pathologies, there is a greater supply of primary care
in the pyramid base, and as you progress in technological
sophistication and professional expertise, the offer is reduced,
therefore, it is concentrate4d in the reference centers
mentioned before. The absence of some technical and human
resources in small towns and in the interior responds, thus, to
the pyramidal logic with which the health system was
conceived [Ref. 4].
This is why they receive patient consultation and derivations
which mainly come from polyvalent hospitals, health centers,
educational and social development institutions, where the
lack of resources and specialist professionals many times
complicate the access to an adequate diagnosis or treatment.
The use of human and material resources provoked by the
derivations or transfers for consultation mentioned above
could diminish through the use of informatics systems –
currently scarce- for they would enable Web interaction to
obtain an efficient professional assessment and avoid and
¨unjustified¨ transfers, reduce problem resolution times and
costs. For this reason, during the year 2009, after various
meetings with medical professionals from the Neurology area
of the pediatric hospital ―Dr. Noel H. Sbarra‖, a system
prototype of the patient reference-counter reference process
was implemented with students from the course ¨Software
production technology workshop¨ [Ref. 3] for that institution.
Basically, this development pursuits the optimization of the
resources of the busy pediatric hospital ―Dr. Noel H. Sbarra‖,

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stimulating the resolution capacity of professionals in primary
care, to improve this way the service quality in all care levels.
The informatization of clinic histories, currently hand
written, is also one of our objectives. This accomplishment
will rank dramatically, for multiple reasons, this essential and
imprescindible document that records medical practices.
The application applies the technique known as Reference
and Counter Reference. When the child needs a specific
therapeutic, the small institution asks for a transfer to ―Noel
H. Sbarra‖ hospital. This is a Reference Process. Before
transferring the patient, the doctors of both institutions
interact through the system. In some cases, this interaction
avoids to transfer the patient and it’s a very important result.
On the other hand, when the patient transferring is
imperative, ―Noel H. Sbarra‖ hospital can apply the Counter
reference Process. Basically it means to return the patient to
the small hospital when it is possible, that is, when the
critical pathology has been resolved and the small hospital
can continue the specific treatments.
This web application is the first approach to the concept of
bringing medicine to the point of care. This means to bring
near the more suitable tools to the doctors in the point of
primary care (inside the hospital, health clinics, health
centers). The first source of information is to give advices
about therapeutic methods, diagnosis tests, protocols,
experiences and, when it is necessary, to transfer patients to
the most complex and specialized hospital. Additionally, the
possibility to return patients to smaller hospitals improves the
administration of resources of specialized hospitals avoiding
unnecessary costs. From the point of view of the child
patient, to stay close to his/her family and friends improves
the quality of his/her evolution.
From the student point of view, the development of this
system was a challenge because of the use of open
technologies related with Java as well as for the deploy in a
local pediatric hospital, where they didn´t use –it´s important
to mention it- informatics systems for this specific objective.
The methodology used for the system deployment consisted
on asking the students to form groups of no more than 3 team
members and invite each group to develop a system module,
applying the technologies taught during the course (Java
Servlets, JavaServerPages, Hibernate, Struts 2, SubVersion,
etc.).
In addition to the system encoding and the strictly informatics
aspects, the students participated in the meeting with the
hospital´s professionals committee –a multidisciplinary team
of professionals: doctors, psychologists, etc.-, who transmitted
their needs for the reference and counter reference process.
The prototype we describe in this article will be extended and
improved by two of the students in the course, who will be
chosen for the abilities shown during the course development.
The prototype we describe in this article will be extended and
improved by two students from the course mentioned before,
chosen for the skills demonstrated during the course.
2
II. SETTING
The Specialized Zone Hospital ―Dr. Noel H. Sbarra‖ is one of
the most qualified health centres for children and youngster
care in La Plata city. It receive patients from different parts of
the Buenos Aires province, the province with the highest
population in Argentina. The patients –and their families-
from far away places need to travel many kilometers to reach
the institution and have access to specialized attention and to
complex equipments, because the hospitals ans health centers
they are transferred from are generally general purpose
hospitals with scarce pediatrician specialists.
On the other hand, unnecessary or late patient transfers are
not infrequent and this obviously generates undesirable
consequences.
A system to facilitate interaction among professionals from
the Dr. Sbarra hospital (internal doctors) and professionals
from local and zone hospitals (external doctors) would
eliminate the frustration these consequences bring. This
interaction would facilitate: (i) internal professional
assessment –doctors, psychologists, speech therapists, etc.- or
external professionals related to therapeutic methods,
diagnosis tests, protocols, etc.; (ii) to avoid transfers, with
adequate information (iii) propitiate urgent transfers. There
are extemporaneous patient transfers with irreversible clinical
situations, and in those cases, frustration is inescapable.
An informatics system would enable a fluid communication
among professionals, in consequence, external professionals
could consult and receive assessment on the treatments to
apply in the place of primary care before requesting patient
transfer. From the patient point of view, to be surrounded by
ones affections –family, friends- favours evolution; and from
the point of view of the specialized hospital, human resource
management would be improved –which means more
availability for children who really need it – and hospital
resources as well –more availability of complex equipments
for those situations that require them.
The system would also mean the first significant step towards
the generation of a case knowledge base. This could help, in
the future, to solve similar cases as well as to observe, with
efficient, adequate and updated medical information, the
evolution of different treatments. This case base, evidently,
could be used by external professionals for similar
pathologies.
The following is a description of the Reference and Counter
Reference techniques and the Distance Communication
model applied to medicine.
III. REFERENCE, COUNTER_REFERENCE TECHNIQUES AND
DISTANCE COMMUNICATION MODEL
As it was previously mentioned, the Counter Reference
Technique is a process that allows to transfer or to return a
patient to a smaller hospital. The patient continues his/her
treatment in this hospital (generally close to his/her home).
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At least two doctors are in charge of the patient, one of them facilitate data updating, for example, while visiting a patient
belongs to ―Dr. Noel H. Sbarra‖ hospital and the other to the in a hospital floor [Ref. 6].
smaller one. The interaction between them enables to keep a
register of the patient evolution. This information is useful Below is a detail of functionalities associated with the three
for Sbarra hospital to better manage their resources and user profiles in the system.
medical services. This system also allows Sbarra hospital
doctors to track the status of their patients, even if he/she is Internal Doctor Profile
not yet there, and this is another good result of the process. An Internal Doctor is a professional who belongs to the
On the other hand, the Reference Technique is a similar Sbarra hospital, and is basically allowed to receive and
process to Counter Reference but seen from the point of view answer consultations and generate counter reference of those
of the smaller hospitals or institutions. In this case there is a inpatients in the Sbarra.
smaller institution that requests a patient transfer to ―Dr. Noel A user that enters the system as an internal doctor can do the
H. Sbarra‖ hospital. The smaller hospital or institution does following actions:
not have the resources, the experience and the knowledge to  Interconsulations: enables to interact with external and
do the correct diagnosis test neither to perform the internal doctors through a message system. The system
therapeutic treatment. In some cases, transferring a patient is displays a menu that allows to create an interconsultation
not as easy as it should be. The distance between both access inbox para to read and answer assistance support
institutions is huge and for a patient and his/her family it is requests and access sent box to verify ans sent answers.
hard to face the feeling of family uprooting and also to afford
such expenses.
Distance communication or inter-consulting is a
process/mechanism that enables interaction among
professionals form Sbarra hospital and professionals from
other institutions. Communicacion begins with a consultation
from a professional in a smaller hospital or institution, who is
responsible for a patient, with the objective of obtaining
orientation on a conduct to follow with a patient, without the
Sbarra professionals assuming direct responsibility over the
patient.
Usually, an external professional makes various consultations
to arrive to a precise diagnosis to indicate the adequate
therapy, if not, he could ask for a reference of his patient.
The information registered along the time about patients such
as Referenced Patients, Counter Referenced Patients and all
questions and answers from the Distance Communication
system allow in the future to compare different medical cases
treated in the hospital and to solve current patient cases.
These techniques applied all together are an approach to
bringing medicine to the point of care [Ref. 5]. Hospitals have Figure 1: Consultations received from external doctors
a useful base of medical cases and from them it is possible to
make a diagnosis to resolve cases if it is possible and avoid • Redirect the inter-consult to an internal service: When the
transferring the patient to the specialized hospital in order to internal doctors receive a consult from an external doctor,
let him/her stay in the hospital near his/her home and receive the system provides a screen to forward the consult to an
the therapeutic treatments there. internal specialized in the Sbarra hospital.
• Register the reception of a referenced patient: the system
requests a date and time to register the income of the patient
IV. SYSTEM FUNCTIONALITIES to the specialized hospital. From that moment on the
practices can be entered in the patient´s basic medical
Access to the system requires a computer with Internet access, record.
a web browser and an account (user, password) with access to • Make a Counter Reference: the system provides the
one of the user system profiles. With these minimum complete forms that the internal doctor must complete to
requirements, it is highly probable for doctors to be able to make the counter reference. This information is very useful
access the system from the hospital, from their office or even to continue the treatment in the primary care hospital.
from their home. Among future work planned for this year, • Follow the health state of the counter referenced patients:
we have considered accessing the system through pda's, this option enables the internal doctor to periodically
handhelds and other mobile technologies, which would

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consult the evolution of the counter referenced patient and
eventually make a suggestion to the head doctor.
Figure 2: Reference list directed to an internal doctor.
• Search by key word: the reference information
(presumptive diagnosis, requested tests, social condition of
the patient, etc.) and the counter reference information
(practices carried out, final diagnosis, etc.) is entered with
hey words in the Database to facilitate the search of similar
case pathologies.
External Doctor Profile
An external doctor is a professional who is responsible of
one of the external entities to the Sbarra hospital. Basically he
is able to send distance consultation and make references to
the specialized hospital.
A user that enters the system as an external doctor can carry
out the following actions:
• Inter-consultation: enables to interact with specialized
pediatrician doctors from the Sbarra hospital to ask for
suggestions regarding their patients with complicated
pathologies. The system displays a menu with the same
options as the internal doctor.
• Make a reference: the system provides a form (shown in
Figure 3) with data from a ―primary‖ medical record (the
presumptive diagnosis, the applied treatments, the requested
tests) and specially the social condition of the references
patient. This information is used by the internal doctors to
know the health state of the patient.
• Distance consulting of the health state of the referenced
patients: the system enables to access the medical record of
the patient to know the practices he is receiving and the
evolution of his health state.
• Search by key word: provides the same functionality as the
internal doctors, but in this case it may be more useful for it
may help solve cases in primary care spots and avoid a
transfer.
4
Figure 3: Loading reference request for a patient.
Manager Profile
It is an informatics professional responsible for maintaining
the consistency of the system data, creating users, enabling
permissions and carrying out all the tasks related with the
data and the correct system functioning.
V. APPLIED TECHNOLOGIES
The course "Workshop on Software Production Technologies"
aims to introduce students in a context of realistic software
production to the standards of art, using Java and free
software. Over the course they will deepen on the various
libraries that are part of the standard Java platform for
distributed application development, known as Java EE or
Java Platform, Enterprise Edition [Ref 7].
Java EE is a standard developed and maintained under the
Java Community Process or JCP1. It includes several API
specifications, such as Servlets, JavaServer Pages, Enterprise
JavaBeans, Portlets and various web services technologies,
that we analyze and use in deliverable practical jobs, in order
for students to become familiar with the various Java
technologies. It also trains students in the use of free software
tools such as Web containers, Java EE container, database
engines, development environments and frameworks for java.
In the following section we synthesize the selected tools for
the development of this counter-Reference System-SRC.
1
Software development community led by SUN. The URL with
specifications is http://es.wikipedia.org/wiki/Java_Community_Process

1569289547
A. Java Technologies
Servlets and JavaServer Pages (JSP Pages)
Java Servlet technology and JavaServer Pages (JSP pages) are
server-side technologies that have dominated the server-side
Java technology market; they've become the standard way to
develop web applications.
Both the servlet and JSP pages are web components that
dynamically process requests and responses could be built
based on those requirements. They need a web container to
run and integrating them with a Model 2 architecture is a
good practice. In this mode, JSP pages are used for the
presentation layer, and servlets for processing tasks. The
servlet acts as a controller responsible for processing requests,
creating any beans needed by the JSP page and for deciding
which JSP page to forward the request. The JSP page
retrieves objects created by the servlet and extracts dynamic
content for insertion within a template. This model promotes
the use of the Model View Controller (MVC) design pattern
architectural style. During the course students get to know
these good practices by manipulating these technologies, and
then we teach them the Apache Struts framework 2, which is
an implementation of MVC pattern. This framework is best
used for complex applications where a single request or form
submission can result in substantially different-looking
results.
Persistence
For data persistence we used Java Persistence API or JPA, the
standard management interface for persistente and
object/relational mapping of Java Enterprise Edition 5.0 (JEE
5) platform. JPA is part of the EJB 3.0 specification [Ref 6, 7]
and is supported by most providers of Java EE containers. To
access the database, we also implemented a layer of data
access, commonly known as DAO-Data Access Object,
essential in any application architecture. This layer provides a
separation regarding the persistence of objects and the logic
of access to data, any persistence mechanism or particular
API, allowing flexibility to change the persistence mechanism
without changes in the application logic that interacts with
the DAO. Currently the persistency is being implemented
with JPA with annotations, but could be changed to use JDBC
or other APIs without major changes.
B. Open Technologies
For the SRC implementation we have used some open source
software Duch as Apache, Tomcat, MySQL, Mantis,
SubVersion and Struts 2.
Apache HTTP Server
5
The Apache HTTP Server is a project of the Apache Software
Foundation [Ref. 11]. The goal of this project is to provide a
secure, efficient and extensible server that provides HTTP
services in sync with the current HTTP standards. Apache is
an open-source HTTP Server and has been the most popular
web server on the Internet since April 1996.
Although Tomcat is also a web Server, we use Apache
because it allows us to configure security aspects, to install a
load balancer in case of a posible and inminent growth of the
health network. In Fac., the SRC was programmed
anticipating this growth and the installation of a cluster of
web servers to maintain a good response time.
Tomcat Web Server
Tomcat is a Java Servlet and JSP container and web server
from the Jakarta project of the Apache Software Foundation
[Ref. ]. A web server dishes out web pages in response to
requests from a user sitting at a web browser. But web servers
are not limited to serving up static HTML pages; they can
also run programs in response to user requests and return the
dynamic results to the user browsers. Tomcat is very good at
this because it provides both Java Servlet and JSP
technologies (in addition to traditional static pages). The
result is that Tomcat is good choice to use as a web server for
many applications; also if you want a free servlet and JSP
engine. It can be used standalone or used behind traditional
web servers such as Apache HTTP Server, with the
traditional server serving static pages and Tomcat serving
dynamic servlet and JSP requests.
Currently we are using Tomcat 5.5 which is the
implementation for the Servlet 2.4 and JSP 2.0 specifications.
Eclipse IDE
Eclipse is an open source integrated development
environment or IDE [Ref. 12] that started as a tool for
developments with Java, but its plug-ins architecture enabled
its expansion to other languages, including C/C++, PHP,
Python/Jython, Ruby, JavaScript, etc. This versatility is
particularly attractive when the software development
requires working in several languages. For example, a Java
development often requires access to tools that support
HTML, XML, Javascript, SQL, and an installation of Eclipse
may be enhanced by plug-ins to support all these
technologies.
Version control system
To synchronize the software versions developed by different
programmers, we used the version control system Subversion
or SVN [Ref 13]. This tool is an evolution of the first
concurrent version manager -CVS or Concurrent Versions
System with the following optimizations: efficient use of
bandwidth at the time of the information transfers over the
network, improves the creation of branches and labels,
optimized management of binary files, etc. Subversion is a
project of the Apache Software Foundation group, that uses

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an Apache license, making it an open source project. The
most important operations used in version control are:
• Checkout: allows to obtain a local copy of the repository in
the client´s.
• Commit: facilitates sending the changes the client has made
to the repository and optionally enables to add a brief
description of it.
• Update: Sends changes from the repository to the local
copy. Gets the changes that another client has made another
in the version stored in the repository and stores them in the
local version.
• Merge: Applies the differences between two same versions.
When conflicts are detected between the local copy and the
version on the server, such conflicts are resolved by a
mixture of the local version and the server one, monitored
by the client. Currently, there are several graphical
interfaces that are used as front-end for Subversion, these
being, individual programs or plugins applicable to
development IDEs. As for the IDE that we use, Eclipse,
there are two plugins that let you manage the code
versioning in a simple and intuitive way, both Subclipse and
Subversive software released under Eclipse Public License
(EPL). We are currently using Subversive.
Mantis
Mantis is a free web-based bugtracking system [Ref 14] that
provides traceability and resolution of bugs throughout the
software development, thus contributing to improving
software quality and collaboration of the various components
of a project. They are necessary when working in teams with
different functions and working in a distributed manner as in
the case of this project.
Mantis is a software released under the terms of the GNU
General Public License (GPL) widely used in the software
development community. It allows not only to make a follow
up on the resolution of errors, but also to centralize the new
functionalities to be implemented by distributing them among
the different development groups involved in the project, to
know the progress of each new functionality, etc. Mantis is
used by most of the skills assigned to the project as Project
Leader, Tester, Developer, End Users, etc.
MySQL
For information storing we decided to use MySQL [Ref. 15],
a data base engine that won popularity in the open source
community This engine is available under both the GPL and
commercial licenses. The use of Java technology JPA allows
independence between the application and the database
engine used for persistence, facilitating the migration to any
other Relational Data Base Management System (RDBMS).
Thus, it is possible to adapt the system to the economic
availability and volume of information acquired by other
health agencies.
6
The framework Struts 2
Using a framework for developing a web application not only
speeds the development process but also promotes best
practices for implementation. Considering the course students
skills, we decided to teach Struts 2 [Ref 16, 17], a framework
for developing Web applications that implements the design
pattern MVC (Model-View-Controller) and also is compatible
with the Java EE platform that is deepened during the course.
This framework is based on actions, not on events or
components-and we believe is most appropriate for the level
of the students. It is a mature framework, with an important
community of developers and users. Applications can be
developed in two ways: using XML-based configuration or
using the annotations provided by the new Java platform. It
provides user interface components with AJAX allowing a
better interactivity with the system users and also allows
multiple viewing options.
The Reference-Counter reference system (SRC) is a
multitiers web application where all the technologies
described above are applied. In the scheme of implementation
shown in Figure 4, two modalities for the client layer can be
seen, one using desktop technologies and another using
mobile technologies. Then in the middle layer we have as a
front-end a web server-Apache-to avoid most of the security
problems, followed by a Tomcat web-container-to support the
execution of Servlets and JSP Pages and also disposes of JPA
engine to access the database engine using object / relational
mapping.
Figure 4: Implementation Outline
VI. CONCLUSIONS
In this article we present the experience of a university
outreach activity for public hospitals. As a result of this, the
children´s hospital ―Dr. Noel H. Sbarra‖ and its contact
network will have a modern web based system to manage the
process of patient reference- counter reference and distant
interconsulting among doctors. The system, as already stated,

1569289547
uses free technologies, so that any medical professional with
Internet access may dispose of the system services. We hope
the use of the SRC increases the resolution capacity in
primary care and avoids unnecessary transfers of children and
youngsters.
On the other hand, we observed that students were highly
motivated with the development of a system that would later
be used by a hospital in our city. In addition to the
development of a system with social impact, the students were
also able to experiment with open technologies and interact
with real users of a system before their graduation.
Following this university outreach activity channeled through
the Informatics Faculty of La Plata University, where help is
provided to a hospital in the same city with the development
of a specific software, the idea of presenting a project for the
2010 call of University Outreach Activities [Ref. 18], to
improve and extend this Reference- Counter Reference and
Distant Consulting system. So far we have been notified that
the project has been accredited and subsidized for this
objective. In the following section we give details on the
project´s future objectives.
VII. FUTURE WORK
The future work will mainly focus on two aspects:
Improved management of medical record information
In a first version of the system we intend to discriminate and
structure the data of the medical record from both the primary
institution as the medical reports generated during the patient
stay in the bypass institution. This will allow quick access to a
correct diagnosis, therapeutic and prognostic decision and
eventually collect data for statistics and epidemiological
studies.
Another important aspect to take into account,
technologically speaking, is the use of digital signature to
carry out the provisions of the recent Law 26.529 [Ref. 19] in
relation to the informatized medical record, which states to
ensure ―integrity, authenticity, age resistance, durability and
recoverability of the data contained therein in a timely
manner‖ , art. 13 of the quoted Law.
Creation of a version for PDAs
The fast evolution of mobile devices and their recent
availability in our country, added to the documented results –
in developed and developing countries- that reveal that
mobile technology improves efficiency in sanitary care [Ref.
20], we´ve decided to extend the SRC implementing a new
system version for mobile phones, smart phones, PDAs, etc.
This access alternative will provide health professionals more
freedom to focus on their daily job, for counting with a
portable, practical and agile tool which will enable access to
precise information wherever he/she needs it. This system
7
version will be very useful to access the medical reports and
the results of the previous studies done to the patients.
Similarly it will be very useful to update and add any new
information that emerges from its exam. Also, in case of an
urgent transfer, an external doctor could load during the trip,
using a PDA with Internet access (with a 3G technology such
as HSDPA), all the information he considers relevant for the
internal doctor to make a fast evaluation of the case and
organize the resources for an effective intervention.
VIII. REFERENCES
[1] Why Open Source Software/Free Software (OSS/FS,
FLOSS, or FOSS)? Look at the Numbers!, The URL is
http://www.dwheeler.com/oss_fs_why.html
[2] Specialized Regional Hospital "Dr. Noel H. Sbarra", from
Buenos Aires province, Argentina. The URL is
http://www.hospitalsbarra.com.ar
[3] Workshop on Software Production Technologies, a 3rd
year course from the University Analyst Programmer,
Informatics Faculty, La Plata Nacional University,
https://catedras.linti.unlp.edu.ar/login/index.php.
[4] Stategic Health Plan, conceptual and tactical-operational
guidelines, http://www.buenosaires.gov.ar/areas/salud/pes/
plan_estrategico_salud.ppt
[5] Bringing Evidence to the Point of Care,
http://www.cebm.utoronto.ca/projects/
[6] Mobile Technologies in Libraries, how the academic
library is using pda's, handhelds and other mobile
technologies http://web.simmons.edu/~fox/pda/
[7] Java EE at a Glance, http://java.sun.com/javaee/
[8] Head First Servlets & JSP, Bryan Basham, Kathy Sierra,
Bert Bates. O'Reilly
[9] EJB 3.0 JPA Specification, http://jcp.org/aboutJava/
communityprocess/final/jsr220/index.html
[10] Hibernate in Action, Christian Bauer and Gavin King.
ISBN: 193239415X
[11] Apache, HTTP Server Project, http://httpd.apache.org/
[12] Eclipse Open Source Software, http://www.eclipse.org/
[13] Subversion, http://subversion.tigris.org/
[14] Mantis Bug Tracker, www.mantisbt.org/
[15] MyQSL, http://www.mysql.com/
[16]Apache Struts 2, http://struts.apache.org/2.1.6/index.html
[17] Struts 2 in Action, Donald Brown, Chad Michael Davis,
and Scott Stanlick. ISBN: 193398807X
[18] The UNLP deepens its extensión policy.
http://www.unlp.edu.ar/articulo/2009/12/21/proyectos_extensi
on_subsidio_2009
[19] Law on Patient`s rights, Medical Record and Informed
Consent http://infoleg.mecon.gov.ar/
infolegInternet/anexos/160000-164999/160432/norma.htm.
[20] m-Health for development, http://www.unfoundation
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