Health information provides the foundation for all decision making in healthcare whether clinical at the bed side, or at a national government level. This information is generally collected as part of systems which support administrative or clinical workflow and practice. This chapter describes the many and varied features of systems such as electronic health records (EHRs), how they fit with health information systems and how they collectively manage information flow. Systems engineering methods and tools are described together with their use to suit the health industry. This focuses on the need for suitable system architectures and semantic interoperability. These concepts and their relevance to the health industry are explained. The relationship and requirements for appropriate data governance in these systems is also considered.
In the CONQUEST Quality Management System, assessment and improvement of the quality of treatment process and outcome is done by introducing a Clinical Quality Management Support System. Initially the treatment of breast cancer was chosen to illustrate the potential benefits of introducing quality management in the treatment process. The main objective of the CONQUEST Quality Management System is to provide a flexible framework for supplying quality management of the treatment process and enable comparison of clinical results, despite differences in the local best clinical practice guidelines used in the participating treatment centres.
Second Life (SL) is emerging as a repository of health information. The purpose of this study was to determine the number of places and groups that offer specific health information in SL. A retrospective analysis of SL places and groups was conducted for cancer. Findings indicate that more cancer information is available from groups than specific places in SL. All current and future cancer information will need to be evaluated for reliability and efficacy.
This paper describes the role of simulation involving end-users in Health Informatics. Simulation has long been established as a widely accepted method in clinical skills training. During the last decade simulation has also gained a place in the development and evaluation of clinical information systems. Simulation is especially well suited for the evaluation of human factors and organizational aspects in relation to application of information systems. In full-scale simulation tests it is possible to evaluate socio-technical interaction. A near to real life experience can be achieved by creating high fidelity environments. The paper discusses how simulation may be used during the lifecycle of clinical information systems, and the requirements on simulation fidelity in various situations. We recommend that simulation should get a more prominent role in the design and evaluation of clinical information systems.
This paper is concerned with how the future information needs of the medical community should be met. The current dominant belief within medicine is that these information needs should be met from bespoke research studies. The necessity of this approach is far from certain. Health organisations worldwide are currently investing vast resources into centralising and amalgamating every day patient data. Is there a future for these Electronic Medical Records in informing medical decisions? This paper describes the challenges to be met in using both research studies and every day patient data to inform medical decisions. It then describes an ongoing practical project to evaluate these information sources' ability to meet the information needs of cancer care decision makers. Details of background, methodology and initial promising results are presented.
To support the ongoing development of software-based surgical simulation systems, work is underway to acquire the mechanical properties of living tissue. When such simulations include force feedback, visco-elastic properties must be evaluated over a range of frequencies relevant to human perception and motor control. A minimally invasive instrument has been developed which can perform normal indentation on solid organs, and apply and measure deformations over a frequency range from DC to approximately 100Hz. Measurement performance was validated on a series of objects and materials with known properties, and the device was subsequently used in in vivo tests on porcine liver. Results of these validation tests as well as the data extracted from the in vivo experiments are presented. Testing in ongoing, and will be expanded to more completely characterize liver, as well as porcine spleen and other solid organ tissues. While these animal tissue property tests are valuable in and of themselves, they pave the way for the development of instruments and experimental protocols suitable for the measurement of human tissue properties.
The Lyon school has proposed a preparation to brace wearing through an intensive mobilization in order to obtain a better reduction of the braced scoliotic curve. Our aim was to verify this hypothesis.
A prospective controlled study on consecutive patients having idiopathic scoliosis with brace management.
Results after 5 months of brace wearing were reviewed by radiographic examination without the brace.
SEAS Group exercises according to the protocol SEAS.02 (Scientific Exercises Approach to Scoliosis, version 2002); CONT Group various type of exercises. Population. 110 patients (34 females), 13.5+/-2.4 years, 31.1 degrees +/-11.1 degrees Cobb (degrees C), 14.4 degrees +/-6.0 degrees Bunnell (degrees B). All parameters improved at follow-up in both groups. SEAS had better results than CONT for degrees C. Clinical results (variations of at least 5 degrees C and 2 degrees B) were better in SEAS than CONT. This study proves the efficacy of SEAS.02 exercises preparatory for bracing. Bracing demonstrated its short term efficacy.
There is low evidence on the possible efficacy of exercises to treat idiopathic scoliosis, graded as C by the existing Italian Guidelines. Our aim was to verify if exercises quality has an effect on results.
Prospective controlled study on idiopathic scoliosis patients that performed only exercises to avoid progression.
SEAS Group make exercises according to the protocol SEAS.02 (Scientific Exercises Approach to Scoliosis, version 2002). The CONT Group performed exercises at a local structure according to different protocols preferred by the treating therapists. Population. SEAS: 48 patients (37 females), 12.5+/-2.2 years, 15.1 degrees +/-5.7 degrees Cobb (degrees C), 9.0 degrees +/-3.3 degrees Bunnell (degrees B). The difference in the number of braced patients within the first year has been almost statistically significant (P=0.07): 1 in SEAS vs. 5 in CONT. Cobb degrees improved with treatment (P<0.05) only in the SEAS group. Clinical results (variation of at least 5 degrees C or 2 degrees B) were better in SEAS than CONT. Not all exercises for scoliosis have the same efficacy: this study proves the short term efficacy of SEAS.02 when compared to usual care.
This paper tries to synthesize the discussion of a seminar on medical informatics educational tasks held in May 1998 in Sinaia, Romania, within the frame of the Tempus-Phare Project CME-02555-96 entitled "Know How Transfer from University to Industry" and coordinated by the University of Medicine and Pharmacy Timisoara, Romania. Special emphasis was paid to particular features of medical education requirements in East European countries, with particular reference to Romania.
The International Classification for Nursing Practice (ICNP) Programme focuses on terminology for nursing practice and acknowledges that nursing practice is not static but changing and dynamic. A number of major revisions were made to the Beta 2 to develop the ICNP Version 1.0. Although the Beta 2 Version functioned to compare and combine data from different sources, there were many recommendations for improvement. In this paper, we examined the ICNP Version 1.0 and identified the changes from the Beta 2 Version. A major change was the use of new technology for development of the ICNP Version 1.0 using description logics. Another change to the new version is the single classification structure that was refined into representation of a 7 Axis Model. The new coding system and new guidelines for composing statements that were developed using an International Organization for Standardization (ISO) Standard are also discussed.
The determination of the number of beds needed for a hospital department is a complex problem that try to take into account efficiency, forecasting of needs, appropriateness of stays. Health authority used methods based on ratios that do not take into account local specificities and use rather to support an economic decision. On the other side, the models developed are too specific to be applied to all type of hospital department. Moreover, all the solutions depend on the LoS (Length of Stay). We have developed a non parametric method to solve this problem. This modelisation was successfully tested in teaching and non teaching hospitals, for an Intensive Care Unit, two Internal Medicine and a surgical departments. A software easy to use was developed, working on Windows available on our website www.sante.univ-nantes.fr/med/stat/.
At MMVR 2007 we presented NeuroVR (http://www.neurovr.org) a free virtual reality platform based on open-source software. The software allows non-expert users to adapt the content of 14 pre-designed virtual environments to the specific needs of the clinical or experimental setting. Following the feedbacks of the 700 users who downloaded the first version, we developed a new version - NeuroVR 1.5 - that improves the possibility for the therapist to enhance the patient's feeling of familiarity and intimacy with the virtual scene, by using external sounds, photos or videos. Specifically, the new version now includes full sound support and the ability of triggering external sounds and videos using the keyboard. The outcomes of different trials made using NeuroVR will be presented and discussed.
NeuroVR 1.5 is a cost-free virtual reality platform based on open-source components, allowing professionals to easily modify a virtual world, to best suit the needs of the clinical setting. The goal of the present project is to extend the functionalities of this platform by allowing users to interact with the virtual environment by using gestures detected by a webcam. To this end, we used CamSpace Beta 7, a cost-free and user-friendly computer vision technology. We describe how this integrated approach can be used to implement cognitive and motor training programs, involving partial or full-body movements.
At CT 2007, we presented NeuroVR (http://www.neurovr.org), a free virtual reality platform based on open-source software. The software allows non-expert users to adapt the content of 14 pre-designed virtual environments to the specific needs of the clinical or experimental setting. Following the feedbacks of the 700 users who downloaded the first version, we developed a new version - NeuroVR 1.5 - that improves the possibility for the therapist to enhance the patient's feeling of familiarity and intimacy with the virtual scene, by using external sounds, photos or videos. The key characteristics that make NeuroVR suitable for most clinical applications are the high level of control of the interaction with the tool, and the enriched experience provided to the patient. Actually, NeuroVR is used in the assessment and treatment of Obesity, Alcohol Abuse, Anxiety Disorders, Generalized Anxiety Disorders, and Cognitive Rehabilitation.
The paper addresses the issue of device management system design for software agents compliant with IEEE 1073 device communication standard. Based on middleware architecture the device control layer represents a universal versatile object-oriented application-programming interface. The approach presented in the paper allows to implement plug-and-play integration and interoperability of medical acquisition devices within the medical device system be means of common middleware services. Adherence to Medical Data Information Base nomenclature, component part of IEEE 1073 communication standard, adds necessary consistency to presented component-based infrastructure.
Systems developed through informatics methods can be evaluated at different levels, depending on the purpose of the evaluation. A key class of measures useful in relating information systems to the quality of patient care is benefit or out-come measures, which reflect differences in the health or welfare of the patient that result from the system being utilized. A framework for describing evaluation measures is presented, definitions are discussed, and the results of a literature review are presented to indicate outcome measures used in medical informatics over several decades. The conclusion suggests that more attention should be given to the standardization of terminology and to outcome measures and methods.
The adaptation of the 10x10 certificate program in health information systems for a Puerto Rican audience is described. The 10x10 program was initially developed in the USA by the Oregon Health Sciences University (OHSU), then adapted to Latin America by Hospital Italiano de Buenos Aires. Puerto Rico is in the intersection of the United States and Latin America, in terms of government, health care system, culture and language. Therefore, it seemed reasonable to re-adapt the program back to the USA, in Spanish, taking into account these facts and the experience of the team in delivering blended learning adapted to local needs. Forty professionals from Puerto Rico are currently taking the first version of the course, supported by the Regional Extension Center for Puerto Rico and the US Virgin Islands, and endorsed by the American Medical Informatics Association (AMIA).
In order to support semantic interoperability in eHealth systems, domain terminologies need to be carefully designed. SNOMED CT and the upcoming ICD-11 represent a new generation of ontology-based terminologies and classifications. The proposed alignment of these two systems and, in consequence, the validity of their cross-utilisation requires a thorough analysis of the intended meaning of their representational units. We present the ICD11 SNOMED CT harmonization process including: a) the clarification of the interpretation of codes in both systems as representing situations rather than conditions, b) the principles proposed for aligning the two systems with the help of a common ontology, c) the high level design of this common ontology, and d) further ontology-driven issues that have arisen in the course of this work.
WG 11 is one of the Working Groups of the EDISANTE Association. First, his mission was to define message models with two parts: The envelope of the message, including a header, the characteristics of the transmitter, of the receiver, and of the patient concerned. The contents of the message, including medical data which could be exchanged between different middleware. This second part was halted by the " Réseau Santé Social", public network for all the healthcare professionals, who want to have a structured content for his "medical message format". The prupose of EDISANTE is essentially to promote the use of EDI in health care. In a second time, this association decide to include work about envelope in a larger domain concerning all exchanges in medical domains, so the GT 11 centred his action on content.
This paper describes the process and outcome of the efforts to develop a new standard for Personal Health Data (PHD) based on the existing 11,073 family of standards for medical devices. It identifies the requirements for a standard that is to be applied to small devices with limited resources of processor, memory and power and that will use short range wireless technology. It describes how existing components of 11,073, such the Domain Information Model and nomenclature have been used and adapted to create the new standard.
The aim of this survey was to examine health care professional's attitudes towards technology involving support from artificial intelligence (AI), robots and humanoids. Within 10-15 years, every third student has to choose occupation within the health care sector to obtain the current personal level, due to the aging population and retirement within the health service sector.
The preliminary investigation interviews presented a wide range of activities. These were nursing tasks, service tasks, monitoring/alarms, telemedicine and social communication. First, a five minutes presentation movie was presented. The movie demonstrated expected personal needs in the future and what robots and AI can do today and tomorrow. After this presentation, the 111 respondents, from different representative care institutions, replied on a questionnaire that dealt with selected areas identified above. The questions included different views of robots as supported aids in healthcare.
The respondents were overall negative using AI and robot technology related to caring activities. However, all groups were positive in using robots in service tasks, monitoring/alarms, telemedicine communication. Of 29 assertions, 18 were mostly positive and 13 of them were over 70 % positive. The frequency of positive and negative attitudes, were similar in the central areas. Within the caring area, a positive robot assisted task requires an interaction (collaboration): caregiver-robot-individual and subsequently, within the nursing area; robot assisted tasks must involve a certain degree of human caring.
Empirical medical research needs services for the maintenance of item collections. We evaluated the appropriateness of ISO/IEC 11179 "Information technology - Metadata Registries (MDR)" part 3 "Registry Metamodel and basic attributes" for a national MDR. In particular, possibilities of including classifications and terminologies (summarized as vocabularies) using the metamodel of this standard were assessed. The hierarchical structure of classifications and terminologies could be mapped easily to ISO's metamodel. The Classification Markup Language (ClaML) is attractive as interface standard for the import of classifications into the MDR. The correct linkage between data elements and vocabularies remained unclear however. An extension of the ISO 11179 metamodel might be necessary to satisfy the predefined needs of a national MDR.
In this work, we perform a comparison between the spatial normalization of [123I]FP-CIT SPECT brain images when a FP-CIT SPECT and a MRI template are used. A 12-parameters affine registration model is calculated by the optimization of a sum of squares cost function. When the images are registered to a FP-CIT template, the intersubject variation is found to be lower than when the MRI template is used, specially in the striatum, which is the most relevant part of the brain in FP-CIT SPECT brain images.
Clinically relevant family history information is frequently missing or not readily available in electronic health records. Improving the availability of family history information is important for optimum care of many patients. Family history information on five conditions was collected in a survey from 163 primary care patients. Overall, 53% of patients had no family history information in the electronic health record (EHR) either on the patient's problem list or within a templated family history note. New information provided by patients resulted in an increase in the patient's risk level for 32% of patients with a positive family history of breast cancer, 40% for coronary artery disease, 50% for colon cancer, 74% for diabetes, and 95% each for osteoporosis and glaucoma. Informing physicians of new family history information outside of a clinic visit through an electronic clinical message and note in the EHR was not sufficient to achieve recommended follow-up care. Better tools need to be developed to facilitate the collection of family history information and to support clinical decision-making and action.
Within the working programme of CEN/TC251 (Health Informatics), a standard for Security Categorisation and Protection for Healthcare Information Systems has been developed. This document was formally adopted in 1997 by CEN as pre-standard CEN ENV 12924. A demonstration and implementation effort, which was to be effected in principle at one location, was planned and executed as part of the MEDSEC project. The standard CEN ENV 12924 contains a security categorisation model for information systems in Healthcare, distinguishing six categories, plus some refinements. For each category it specifies the required protection measures. The project task consisted of demonstrating and implementing the standard (as far as possible within a limited period) in a real life situation, and providing feedback on these results to the CEN organisation. To this end, the categorisation scheme, as specified in the standard, was applied to a large part of the information (sub)-systems in the Leiden University Medical Centre. A set of ten sub-systems was then selected for a more detailed investigation. The actual protection status for each sub-system was evaluated on the basis of the recommended protection profiles specified in the standard. For each of the relevant recommendations in the standard, its status was recorded, and remarks were added on its relevance, feasibility, etc. These detailed data have been gathered in separate reports for each sub-system. These reports evidently are confidential, in view of protection of the hospital's information security. A similar, though more limited exercise has been done at Magdeburg University Hospital (UHM), in order to be able to allow for possible differences in local situations. A thorough comparison of results for different hospitals was beyond the scope of the project, however. From the overall picture we have tried to draw conclusions on the quality, completeness and applicability of the standard, as well as on the actual level of protection of the systems. As a by-product of the investigation, for all systems out of the small group, implementation plans have been specified to bring the protection in the various (sub)-systems on a higher level, where necessary. Subsequently, these plans have been realised to a large extent. To facilitate the bookkeeping of the results, we have used the SIDERO model, resulting from the SEISMED project. This model has been enhanced, for this purpose, with the recommendations from this standard. A brief description of this database model has been included in Appendix B. As an overall conclusion, we may state that the standard has proven to be a very useful instrument, providing a good basis for a security review of the types of Healthcare information systems which are encountered in a hospital environment. Some suggestions have been presented, for amending recommendations that were found too unpractical or too heavy in the circumstances considered. Also, we suggest to add one category to the set of six which is being used now. Furthermore, the use of a 'bookkeeping tool' (like e.g. SIDERO) is strongly recommended.
The US National Institutes of Health (NIH) includes 27 institutes and centers, many of which conduct clinical research. Previously, data collected in research trials has existed in multiple, disparate databases. This paper describes the design, implementation and experience to date with the Biomedical Translational Research Information System (BTRIS), being developed at NIH to consolidate clinical research data. BTRIS is intended to simplify data access and analysis of data from active clinical trials and to facilitate reuse of existing data to answer new questions. Unique aspects of the system includes a Research Entities Dictionary that unifies all controlled terminologies used by source systems and a hybrid data model that unifies parts of the source data models and include other data in entity-attribute value tables. BTRIS currently includes over 300 million rows of data, from three institutes, ranging from 1976 to present. Users are able to retrieve data on their own research subjects in identified form as well as deidentified data on all subjects.
In 1996 a national strategy for the development of electronic patient records (EPR) for the Danish hospitals and primary care was launched. An element in the strategy was to support a number of regional EPR development projects. The EPR-Observatory has in the two recent years collected data from the regional projects, dealing with the expectations in four areas: 1) Impact on organisational issues, 2) Benefits of EPR, 3) Integration of EPR with other information systems and 4) security aspects of EPR. Among the observations an increasing teamwork and im-proved knowledge about the patient was found. What was expected, but not found, was resistance to EPR, as a result of changes in skills and power. The most obvious benefits are increased data accessibility and improved decision ma-king. The most considerable disadvantage is an enormous growth in discontent with the systems performance and the fact, that all the projects are delayed. Many different types of integration solutions are chosen, because of a lack of a common model for integration. Generally the projects find, that EPJ yields increased security, but logistical problems arise in having the systems running 24 hours 7 days a week. Economical benefits cannot be documented. This relates to the fact, that the regional projects are stand-alone projects. The ongoing growth in discontent with the EPR-systems and the fact, that all the projects are delayed must be subject to further exploration.
Among the existing patterns of EHR interoperability, the ISO 13606 standard is an important consideration. It is believed that the use of this norm, in conjunction with semantic technologies, may aid in the construction of a robust architecture, keeping in mind the challenges of semantic interoperability. The objective of this paper is to present a proposal for an EHR architecture, based on ISO 13606 and on the utilization of semantic technologies, for a real EHR scenario. In order to accomplish that, a real EHR scenario is described, as well as its main interoperability requirements and a candidate architecture is proposed to solve the presented challenges of interoperability. The ability of the ISO 13606 EHR reference model to accommodate the scenario was highlighted, together with the support provided by the use of the ontology specification languages--RDF and OWL--in respect to the maintenance of a controlled vocabulary.
Semantic interoperability of clinical standards is a major challenge in eHealth across Europe. It would allow healthcare professionals to manage the complete electronic healthcare record of the patient regardless of which institution generated each clinical session. Clinical archetypes are fundamental for the consecution of semantic interoperability, but they are built for particular electronic healthcare record standards. Therefore, methods for transforming archetypes between standards are needed. In this work, a method for transforming archetypes between ISO 13606 and openEHR, based on Model-Driven Engineering and Semantic Web technologies, is presented.
The idea of two level modeling has been taken up in healthcare information systems development. There is ongoing debate which approach should be taken. From the premise that there is a lack of clinician's time available, and the need for semantic interoperability, harmonization efforts are important. The question this paper addresses is whether Detailed Clinical Models (DCM) can bridge the gap between existing approaches. As methodology, a bottom up approach in multilevel comparison of existing content and modeling is used. Results indicate that it is feasible to compare and reuse DCM with clinical content from one approach to the other, when specific limitations are taken into account and precise analysis of each data-item is carried out. In particular the HL7 templates, the ISO/CEN 13606 and OpenEHR archetypes reveal more commonalties than differences. The linkage of DCM to terminologies suggests that data-items can be linked to concepts present in multiple terminologies. This work concludes that it is feasible to model a multitude of precise items of clinical information in the format of DCM and that transformations between different approaches are possible without loss of meaning. However, a set of single or combined clinical items and assessment scales have been tested. Larger groupings of clinical information might bring up more challenges.
Archetypes model individual EHR contents and build the basis of the dual-model approach used in the ISO/EN 13606 EHR architecture. We present an approach to create archetypes using an iterative development process. It includes automated generation of electronic case report forms from archetypes. We evaluated our approach by developing 128 archetypes which represent 446 clinical information items from the diabetes domain.
To enable the efficient reuse of standard based medical data we propose to develop a higher-level information model that will complement the archetype model of ISO 13606. This model will make use of the relationships that are specified in UML to connect medical archetypes into a knowledge base within a repository. UML connectors were analysed for their ability to be applied in the implementation of a higher-level model that will establish relationships between archetypes. An information model was developed using XML Schema notation. The model allows linking different archetypes of one repository into a knowledge base. Presently it supports several relationships and will be advanced in future.
The comparison of the patient's current medication list with the medication being ordered when admitted to Hospital, identifying omissions, duplications, dosing errors, and potential interactions, constitutes the core process of medicines reconciliation. Access to the medication the patient is taking at home could be unfeasible as this information is frequently stored in various locations and in diverse proprietary formats. The lack of interoperability between those information systems, namely the Primary Care and the Specialized Electronic Health Records (EHRs), facilitates medication errors and endangers patient safety. Thus, the development of a Patient Summary that includes clinical data from different electronic systems will allow doctors access to relevant information enabling a safer and more efficient assistance. Such a collection of data from heterogeneous and distributed systems has been achieved in this Project through the construction of a federated view based on the ISO/CEN EN13606 Standard for architecture and communication of EHRs.
HL7 Templates and EN/ISO 13606 Archetypes are essential components for a semantically interoperable exchange of electronic health record (EHR) data. In this article the underlying models from which Templates and Archetypes are instantiated, namely the HL7 Template Model and the EN/ISO 13606 Archetype Object Model will be compared to identify discrepancies and analogies.
The EHR system ZK-ARCHE automatically generates forms from ISO/EN 13606 archetypes. For this purpose the archetypes are augmented with components of the reference model to achieve so-called "comprehensive archetypes". Data collected via the forms are stored in a list which associates each value with the path of the corresponding comprehensive archetype node coded as W3C XPath. From this list archetype-conformant EHR extracts can be created. The system is embedded with the IHE XDS profile to allow direct data exchange in an environment of distributed data storage.
Magnetic Resonance Imaging (MRI) has unmatched potential for planning, guiding, monitoring and controlling interventions. MR arthrography (MRA) is the imaging gold standard to assess small ligament and fibrocartilage injury in joints. In contemporary practice, MRA consists of two consecutive sessions: 1) an interventional session where a needle is driven to the joint space and gadolinium contrast is injected under fluoroscopy or CT guidance. 2) A diagnostic MRI imaging session to visualize the distribution of contrast inside the joint space and evaluate the condition of the joint. Our approach to MRA is to eliminate the separate radiologically guided needle insertion and contrast injection procedure by performing those tasks on conventional high-field closed MRI scanners. We propose a 2D augmented reality image overlay device to guide needle insertion procedures. This approach makes diagnostic high-field magnets available for interventions without a complex and expensive engineering entourage.