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Multilevel Interdisciplinary Intelligent Systems in Medicine

  • Visoka tehnička škola strukovnih studija, Serbia, Subotica
  • Subotica Tech - College of Applied Sciences Subotica

Abstract and Figures

Intelligent systems often show incompatibility between healthcare levels. The work of medical professionals on each stage is often individual; multilevel interdisciplinary consultations, consilia, diagnostic and a coordinated approach is limited by existing differences. The aim of this work is to point out potential benefits of integrating healthcare levels on the basis of intelligent systems.
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Multilevel Interdisciplinary Intelligent Systems in
Andor Sagi*, Anita Sabo**, Bojan Kuljić***, Tibor Szakáll****
* General Hospital Subotica, Subotica, Serbia
**, ***, **** Subotica Tech, Subotica, Serbia
*, **, ***, ****
Abstract— Intelligent systems often show incompatibility
between healthcare levels. The work of medical
professionals on each stage is often individual; multilevel
interdisciplinary consultations, consilia, diagnostic and a
coordinated approach is limited by existing differences. The
aim of this work is to point out potential benefits of
integrating healthcare levels on the basis of intelligent
In Serbia healthcare functions on primary, secondary,
tertiary level and institutions which encompass the
previous 3 levels. Patients receive GP, pediatric,
gynecological, EM, home treatment, medical transport,
laboratory, imaging, specialist, nursing or other services.
Primary contact itself is therefore divided into various
seemingly different activities tied with a common goal.
Integration is therefore needs to start on this first level
before moving to other healthcare types. This is partly
achieved so far, for example by electronic data exchange
between laboratory diagnostics and GP ordinations. A
patient may use in a short time many of these levels;
therefore proper coordination is a must in order to
evaluate current and planned states and procedures. Many
relations will arise and therefore this problem is separately
treated in the next section. Secondary healthcare is often,
but not always continues patient evaluation and treatment.
It is often devastating for an emergency specialist to find
no previous healthcare information about a patient before
performing time consuming, risky or costly diagnostics,
which would hinder time efficiency in urgent situations,
posing unnecessary risks for the patient itself (radiation,
time loss, etc.). Above all, treatment cannot be optimal
without proper insight into previous medical data, which
may result in suboptimal or even poor prognosis. Further
consultative and interdisciplinary collaboration may also
be misdirected without proper multilevel, interdisciplinary
intelligent system integration and as a result
hospitalization [1]. This introduction to the problems on
the level of secondary healthcare by no means represents
even a broad overview on the subject and will therefore be
separately discussed in this work. Tertiary healthcare
presents somewhat similar, but far more complex
relations, with often the addition of academic approach.
Needless to say institutions working on all levels of
healthcare could function most efficiently after integrating
each levels separately and then on a multilevel basis.
Statistical data and further large scale (national and
international) decisions may depend on this subject. After
giving a broad outline to this vast and important subject
level based considerations will be discussed.
Primary healthcare usually provides primary patient
contact. However not all parts of this level may represent
this, some providing a stage after initial evaluation. Initial
evaluation may start, for example on the stage of general
practice, pediatric care, gynecological ordination, EM
(which may be further divided into ordination based or
field emergency care, pediatric and adult medicine).
Further services and evaluation may be any of these stages
also one or more from the following: home treatment,
medical transport, laboratory, imaging, specialist, nursing
or other services.
This order be also complicated if one of the secondary
stages indicates primary contact (for example a specialist
may indicate evaluation for a patient without a referral).
Any secondary stage may also send the patient back to the
primary contact after diagnostic and consultative
procedures. Often a patient is referred to the next
healthcare level after evaluation on 3 or more stages.
The referral, a medical document itself which makes
this possible, cannot contain all necessary medical data.
Referrals may aim at hospitalization when it seems
indicated or examination, furthermore they may be urgent
or scheduled. Each of these four types (which are printed
on 2 different forms) contain not more than the diagnosis
and its ICD classification, or sometimes crucial but brief
medical information.
All other medical documentation is presented separately
and therefore – as seen in practice – not presented. The
reason of this may be patient or medical professional
related. Even when it is presented in its entirety, insight
into earlier GP and other primary care records will still not
be available for the attending healthcare professional. This
would only be possible by an integrated, multilevel,
interdisciplinary intelligent system [5].
The Figure 1 graphically represents the possible both
way relations between significant parts of primary level
healthcare system from the angle of bidirectional patient
Figure 1. Possible both way relations between
significant parts of primary level healthcare system, encompassed
by bidirectional patient transport (white arrow)
Following typical, practical examples of patient
evaluation may provide an insight into the practical
significance of integration. Often patients are evaluated at
a GP ordination. Main symptoms, status praesens,
systemic anamnesis, anamnesis vitae et familiae,
infectious disease related anamnesis, clinical findings and
all collected documentation provide lengthy patient
information which may be stored in physical, electronic
form or in both. When it is required to store data in both
forms, examination time naturally increases. Recording
and keeping patient history must not reduce the time and
attention dedicated to the patient. From this follows that
by fixed daily working hours and constant high quality
healthcare, general practitioners are sometimes forced to
reduce the number of checkups. This must, of course,
never be on the expense of medical emergencies or patient
health. Information collected by a medical technician is
also of vital importance and may form part of complete
patient records. This information is already collected
according to standards and partly integrated, more open
availability to authorized personnel may prove beneficial
enabling interdisciplinary, multilevel consultations.
Such a system would prevent the need and cost of
unnecessary transportation to other institutions, which
beside economical reasons would prove a more patient
friendly approach. Certain laboratory values
(prothrombin time, international normalized ratio, etc)
are often under control of a specialist, electronic
availability of these in the absence of the need of physical
examination may reduce a transportation need or risk (for
example immune compromised patients during influenza
epidemic, elder or terminal cancer patients, etc.).
General practitioners are timely informed about the
conditions under which drugs are prescribed to patients.
These conditions often change, and require diagnosis and
indications determined by a specialist in order to enable
government funding, full or partial. These must be done
periodically. Having proper documentation available by
an integrated, interdisciplinary, multilevel compatible
intelligent system a specialist would be able to approve
further medication. Such a multilevel cooperation would
accordingly benefit both levels of healthcare (no need for
classic referrals, less time for administration, reducing
waiting line, enabling more checkups, etc.) and most
importantly the patient (no need for checkup,
transportation, time and convenience friendly). In case of
immobilized patients transportation services and costs
might be spared.
Conditions for all forms of government funding
(medication, rehabilitation, medical devices, etc.) in GP
practice may be available real time for the attending
doctor. Printing and transportation costs of these
materials would be eliminated.
Integrated intelligent systems provide the function of
checking laboratory, X-ray or specialist findings
momentarily after their competition, eliminating the need,
cost and time needed to pick them up. This would also
enable timely reaction in case of urgency, before their
physical arrival.
Using similar systems would open the possibility of
multilevel, interdisciplinary medical consultations in
order to provide a more precise approach to any condition
[3]. This could reduce the numbers of unnecessary
examinations in hospitals, or provide a timely specialist
consultation in medical emergency even before arriving
at a hospital. In certain cases such an approach might
have an effect on timely prehospital diagnosis, treatment
and patient prognosis. This could be directly beneficial
for most of the branches of primary healthcare, not just
for emergency services.
When a patient is referred to a radiologist, full
medical documentation and patient history would enable
this specialist to focus on certain examinations or even
order further diagnostics. Using an integrated system
constructive communication between the doctor who
indicated the examination and the radiologist would lead
to a more detailed and precise diagnostic process.
Besides those already mentioned, there are numerous
mutual benefits of adequate interdisciplinary multilevel
communication between the primary and other levels of
healthcare. Since proper patient care should be done in
the spirit of this collaboration, these benefits are often
ascribed to both sides. Therefore discussing the benefits
of multilevel interdisciplinary intelligent system
integration on other levels of healthcare means often
benefit on the level of the primary contact [6].
Disregarding solitary cases when a specialist working
in secondary and tertiary healthcare indicates
hospitalization, a patient must be sent to these institutions
with all available medical documentation and a referral.
Part of the hospitalization is taking place in the
Emergency Department and part in polyclinic
ordinations. Indicating hospitalization is a complex
process based on anamnesis, heteroanamnesis, clinical,
radiology and laboratory findings, patient history and
other factors. In practice often only printed medical
documentation is available, which is often incomplete or
absent. There are numerous reasons why otherwise
available, useful medical information won’t reach
secondary healthcare. Common reasons include a medical
condition (for example vitally compromised,
nonresponsive, unconscious or psychotic patient,
accidents on field, etc.),panic and rush in case of a
medical emergency, lack of motivation or health related
inability for adequate record keeping or storing all
medical information in primary care patient archives
(which are accessible only during working hours,
indirectly). A multilevel interdisciplinary intelligent
system would provide solution to all aforementioned
problems. Access to patient history is of vital importance.
In case of existing drug allergy, lack of patient data is a
risk of potentially fatal anaphylactic reaction. Access to
chronic medications and earlier medical conditions may
influence therapy choice in serious conditions (for
example antiarrhytmic choice in a patient suffering from
bronchial asthma, treating pulmonary edema in dialysis
patient, etc.). Multilevel systems sometimes provide
crucial information which is otherwise unavailable or
unattainable in a hospital ward [2]. Such information is
the insight if a medical condition is newly developed or
chronic – which influences not just evaluation, diagnostic
or treatment but the decision about hospitalization or
patient discharge. Often the duration of a trial fibrillation
or distinguishing a new left bundle branch block from a
chronic condition is of utmost importance to the attending
medical professional. Realizing the significance of
interdisciplinary consultative intelligent systems is today
a reality in our country. Figure 2 illustrates a possible
emergency ward work algorithm showing
multidirectional data flow between administrative, main
and supportive care units and common possible
Information about previous medical examinations by
other ward, polyclinical ordination laboratory or
radiology findings may prove insight into the complexity
of patient history. All interdisciplinary medical findings
may be put on discharge documentation providing
primary care insight into all conducted and planned
examinations, established diagnoses, intra hospital and
home medication, planned control checkups and
diagnostics. Such a system, regardless its efficiency does
not provide electronic feedback to primary care. Any
reason which results in failure of back up acquired
information in its entirety is flawed – not providing
insight into all important data. The failure may be on
patient side, or even if discharge documents reach
primary care practically cannot form part of its intelligent
system due to lack of compatibility, due to the lack of a
multilevel interdisciplinary approach. Copies of discharge
documents may form a physical part of patient achieves
at a general practitioner ordination, however it will most
likely be – in its fullness or in a part – inaccessible for
other participants of primary healthcare.
Figure 2. Possible emergency ward work algorithm illustrating
multidirectional data flow between administrative, main and supportive
care units and common possible outcomes.
Often emergency services therefore, despite the
existence of detailed patient history, cannot access any
information on duty or transportation. This opens the
question by which means this information may be
available to this team. A separate study is needed to
analyze benefits, risks, cost and potential of wireless
versus classical means of data access. Secondary level
healthcare may transport patients to tertiary level
institutions, for further evaluation and treatment.
The lack of a multilevel interdisciplinary intelligent
system results in similar difficulties, regardless of proper
discharge documentation. If the patient is having a life-
threatening or other serious condition transportation to
the next level healthcare institution is done by an
accompanying team of medical professionals. Access to
more detailed, well organized information during
transportation may prove beneficial.
After arrival tertiary healthcare will not have an
insight into full primary and secondary care
documentation, nor to electronically stored data
describing events during transport. Academic approach
which also exists in university centers will be limited by
the lack of complete patient history and statistical data
which will endanger the patient.
The need for precise, preferably real-time medical
information is present for institutions which cover all
three levels of healthcare. Therefore reciprocal
communication is an invaluable tool in this case also,
since the work and data collected and analyzed by them
may affect national or international level decision
making. A practical illustration and problem of this kind
is the duty to report determined infectious diseases to
these institutions. Without regular and precise reports
statistical data will lack the needed imperative precision
that the field of medicine requires. An intelligent system
could assist the medical professional forming a report
while electronic information would provide easier data
analysis for recipients [4]. Epidemiological or statistical
data would be available real-time for collecting, on the
other hand reciprocal information to all 3 levels of
healthcare could be sent in a cheap, fast, efficient and
controllable manner. Intrahospital infections, epidemics
could also be registered and followed in a real-time
environment. Statistical information about any disease or
medical condition should become traceable at once in
every healthcare institution of the country. Identifying
possibilities of multilevel interdisciplinary intelligent
system integration for institutions functioning on all three
levels of healthcare is also a voluminous and time
consuming task, which would require collaboration of
experts from different areas of healthcare. Similarly to
previous levels it is required to treat these possibilities in
not just a separate treatise, but numerous analyses and
further investigation is required by a experts of various
fields of medicine. The intention of the author was to
point out the need and potential benefit of investigations
in his field of medicine.
In the era, of economical crisis, limited resources,
strict control of medical funds establishes control over
expenses, tending to eliminate unnecessary, unequal or
unaffordable costs. Realizing rights covered by the fund
is according to numerous instructions. Failure to comply
results in covering the monetary value of the service in
question –by the healthcare institution or the medical
professional. Since often these mistakes are due to lack of
knowledge and not checking current (dynamically
changing) rules, it might prove beneficial that an
intelligent system would control the process on a
multilevel system. It may contain every change in real-
time, therefore practical application becomes at once a
possibility. A warning message would alert the
medical professional that requirements for providing a
certain service are not met, minimizing the possibility of
conflict between him and the fund. Same way it would
also alert a medical professional if these conditions are
met, and the patient should not cover the costs.
Information about the monthly medication quantity
covered by the fund would most likely reduce
unnecessary costs, even correct therapy and improve
prognosis [7].
The present work illustrates the need for multilevel
interdisciplinary integrated intelligent systems in
It has been shown that integration is imperative not
just on the level of primary, secondary, tertiary healthcare
and institutions that work on all three levels – but
bidirectional communication between them is necessary.
It is hoped that such a system would not just lower costs,
speed up healthcare services, provide accurate statistical
data, enable scientific interdisciplinary and multilevel
planning, provide more precise medical documentation or
help in making national healthcare decisions- but provide
the most valuable achievements of all – improving the
health and clinical prognosis of patients.
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[5] C. Pagliari “Design and Evaluation in e-Health: Challenges and
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