Ebook: Exploring Complexity in Health: An Interdisciplinary Systems Approach

The European Federation for Medical Informatics (EFMI) Association is the leading organisation in medical informatics in Europe as a federation of national societies of 30 countries. EFMI is organized as a non-profit organization concerned with the theory and practice of information science and technology within health and health science in a European context. The objectives of the EFMI are:

• To advance international co-operation and dissemination of information in medical informatics at the European level;

• To promote high standards in the application of medical informatics;

• To promote research and development in medical informatics;

• To encourage high standards in education in medical informatics;

• To function as the autonomous European Regional Council of IMIA.

This year is a special year for EFMI as it celebrates its 40th anniversary; the Federation was founded in 1976. Therefore, different special events have been organized including several conferences, work shops special issues in journals. In view of this special year for EFMI also the Medical Informatics Europe (MIE) conference, one of EFMI's top conferences, is organized in a special way.

Considering the complexity and interrelation of the health domain and as a sign of the long-lasting collaboration of major societies in the field a special joint conference was set up that unities the conferences of the German Association for Medical Informatics, Biometry and Epidemiology (GMDS), the German Society for Epidemiology (DGEpi), the International Epidemiological Association – European Region and the European Federation for Medical Informatics (EFMI). The societies involved have longstanding experience in integrating the disciplines of medical informatics, biometry, epidemiology and health data management. The collaboration will not only offer a unique opportunity for integration but also strengthen each of the disciplines involved both on a national and international level.

The event is organized under the common umbrella of HEC2016 by the motto of ‘Health – Exploring Complexity: An Interdisciplinary Systems Approach’, which took place in the city of Munich in Germany from August 28th to September 2nd.

The title points to the joint effort of all societies involved to rethink their approaches and to signal the need to move on from silo thinking by exploring the complexity of health together although from different perspectives. Complex systems often involve heterogeneous objects and multifaceted interactions. The health domain is recognised to be particularly complex; hence, we need to identify models that are able to integrate all the various aspects. We need to find new ways for collaboration of different scientific disciplines as well as for establishing comprehensive methodological approaches. The HEC2016 conference is a step forward.

The current volume supports this effort by documenting the results of this event. The HEC2016 received 833 contributions from 47 countries.

We would also like to take the opportunity to express our gratitude to all who contributed to this proceeding as well as to the success of this important event by submitting their contributions, reviewing them and by sharing their expertise and time.

Alexander Hörbst

Werner Hackl

Nicolette de Keizer

Hans-Ulrich Prokosch

Mira Hercigonja-Szekeres

Simon de Lusignan

We investigated the shortening or abolishing shift report as the effect of implementing electronic nursing and medical records and its side effects at 10 Japanese hospitals. The majority of staff nurses accepted this change, but both directors and staff nurses recognized the risk of insufficient collection and communication of patient information, difficulties of understanding the risks and matters of patients not under care and an increase in time to collect information from the computer before starting patient care. Directors should carefully evaluate and reduce the negative influences associated with changing or eliminating the traditional shift report.

Previous research highlighted generation and age effects on the perceptions and uses of technology. The goal of this study was to examine the relationship between age and perceptions of a Clinical Information System (CIS) for the clinical staff (especially physicians, nurses, medical secretaries). A survey was conducted in September 2015 in a French Teaching Hospital, based on a questionnaire consisting of items on the Likert scale. As results, the impact of age has a strong impact on Perceived Ease of Use, anxiety and Self-Efficacy. The result related to Perceived Ease of Use is unexpected. Younger staff reported to be less comfortable with technology than older staff. This result is not consistent with literature. We propose an explanation consisting in the importance of clinical process and organization knowledge and skills while general technology skills of young generations may be less significant.

In France, medicalization of information systems program (PMSI) is an essential tool for the management planning and funding of health. The performance of encoding data inherent to hospital stays has become a major challenge for health institutions. Some studies have highlighted the impact of organizations set up on encoding quality and financial production. The aim of this study is to evaluate a computerized information system and new staff organization impact for treatment of the encoded information.

Clinical data is often captured in unstructured texts and scattered in different health information systems. This complicates the aggregation of information in the process of clinical decision making. However, having a quick overview and an efficient representation of relevant aspects of a patient's health status are crucial for this process. While accessing patient data and perusing clinical documents, relevant details need to be discovered quickly. In this paper, we introduce an approach to visualize relevant information from clinical documents by tag clouds. The conventional tag clouds visualize the content of a document using the terms they are containing shown in different sizes with the size calculated based on the term frequency. Important facts and diagnostic results with low occurrence in a text may be ignored by this naïve method. In this paper, we therefore adapt the conventional tag clouds by information extraction and a guidelines-based classification schema, so that the clinical concerns can be visualized more correctly. The aspects are extracted according to a classification schema developed by clinical experts. We evaluate the approach on a set of radiology reports for cervical spine treatment.

Health systems around the world are investing increasing effort in monitoring care quality and safety. Dashboards can support this process, providing summary data on processes and outcomes of care, making use of data visualization techniques such as graphs. As part of a study exploring development and use of dashboards in English hospitals, we interviewed senior managers across 15 healthcare providers. Findings revealed substantial variation in sophistication of the dashboards in place, largely presenting retrospective data items determined by national bodies and dependent on manual collation from a number of systems. Where real time systems were in place, they supported staff in proactively managing quality and safety.

This study assessed the feasibility of using MetaMap to identify medical concepts from clinical notes written in Italian. We performed two experiments: in “EXP 1”, we used MetaMap to annotate Italian texts using a knowledge source consisting of Italian UMLS sources only; in “EXP 2”, we used MetaMap to analyze an English unsupervised translated version of the original Italian texts. We considered medical concepts related to three semantic categories: “Disorders”, “Findings” and “Symptoms”. Average recall, precision and F-measure were equal to 0.53, 0.98 and 0.69 in “EXP 1”, and to 0.75, 0.95 and 0.83 in “EXP 2”. For both “EXP 1” and “EXP 2” MetaMap showed better performances for the “Disorders” than for “Findings” and “Symptoms”. In conclusion, when using MetaMap with the English translation of the Italian clinical notes, we obtained performances good enough to allow using MetaMap in clinical practice. Further investigation about the types of MetaMap's failures could be useful to understand how to improve performances even better.

Providing appropriate support for the most vulnerable individuals carries enormous societal significance and economic burden. Yet, finding the right balance between costs, estimated effectiveness and the experience of the care recipient is a daunting task that requires considering vast amount of information. We present a system that helps care teams choose the optimal combination of providers for a set of services. We draw from techniques in Open Data processing, semantic processing, faceted exploration, visual analytics, transportation analytics and multi-objective optimization. We present an implementation of the system using data from New York City and illustrate the feasibility these technologies to guide care workers in care planning.

Health care systems need to cope with continuous changes such as with the current trends towards pay-for-performance and value-based health care. In this context, the article aims at analysing the potentials of the integration and utilisation of quality indicators in clinical pathways. It comprises the first steps of a design-oriented research process, i.e. problem motivation and objective definition. Therefore, a conceptual framework for pathway-integrated quality indicators is proposed. Potentials of the approach are outlined in three use case scenarios. The analysis points out great potentials for quality management on institutional and network level and for bridging the gap between medical research and practice. Further research topics are derived and summarised in an agenda.

In Senegal, great amounts of data are daily generated by medical activities such as consultation, hospitalization, blood test, x-ray, birth, death, etc. These data are still recorded in register, printed images, audios and movies which are manually processed. However, some medical organizations have their own software for non-standardized patient record management, appointment, wages, etc. without any possibility of sharing these data or communicating with other medical structures. This leads to lots of limitations in reusing or sharing these data because of their possible structural and semantic heterogeneity. To overcome these problems we have proposed a National Medical Information System for Senegal (SIMENS). As an integrated platform, SIMENS provides an EHR system that supports healthcare activities, a mobile version and a web portal. The SIMENS architecture proposes also a data and application integration services for supporting interoperability and decision making.

Medical research and health care highly depend on the use of information technology. There is a wide range of application systems (patient administration system, laboratory information system, communication server etc.) and heterogeneous data types (administrative data, clinical data, laboratory data, image data, genomic data etc.). Students and researchers do not often have the possibility to use productive application systems of e.g. hospitals or medical practices to gain practical experiences or examine new components and technologies. Therefore, the aim of this project is to develop a dedicated laboratory environment for patient health care and clinical research. Essential application systems were identified and a suitable architecture was designed for this purpose. It is accompanied by a teaching plan that considers learning modules for bachelor and master degrees in medical informatics. We implemented the laboratory environment called MI-Lab with multiple free and open source software components. All components are installed on virtual machines and/or Docker containers. This modular architecture creates a flexible system which can be deployed in various scenarios. The preliminary evaluation results suggests that laboratory environments like MI-Lab work well in teaching practical aspects of medical informatics and are widely accepted by students.

Short-stay MSO (Medicine, Surgery, Obstetrics) hospitalization activities in public and private hospitals providing public services are funded through charges for the services provided (T2A in French). Coding must be well matched to the severity of the patient's condition, to ensure that appropriate funding is provided to the hospital. We propose the use of an autocompletion process and multidimensional matrix, to help physicians to improve the expression of information and to optimize clinical coding. With this approach, physicians without knowledge of the encoding rules begin from a rough concept, which is gradually refined through semantic proximity and uses information on the associated codes stemming of optimized knowledge bases of diagnosis code.

Background: In health care, exchange of data is becoming increasingly important. However, it is still unclear how to interpret measurements of the same parameter from diverse data sources. In clinical chemistry point-of-care testing (POCT), e.g. for blood glucose, complements the analytical spectrum of central laboratories. Available data from “central laboratory”, “professional POCT” and “non-professional” blood glucose measurements can be used to realistically simulate errors in different environments. The ability to classify the disease status or to detect a significant change based on these simulated measurements was assessed in several scenarios.

Methods: Patients were simulated with realistic “true values” of blood glucose and a “diseased” or “non-diseased” status. To further simulate a change of blood glucose values, a random difference was created and classified as “significant” or “non-significant”. Scientific literature was searched for accuracy and precision of blood glucose measurements in different environments. These values were used to calculate “measured values” from the “true values”. In scenarios where only measurements from the same environment were combined the area under the ROC curve (AUC) was used to express classifier performance. Balanced accuracy was used for scenarios with a combination of measurements from different environments. Situations with and without prior knowledge of the data source were simulated separately.

Results: AUC for the classification of disease status remained around 0.68 in all scenarios. Median AUCs for the detection of a significant change ranged between 0.89 in the central laboratory and 0.76 in the non-professional environment. For the combination of different measurement environments median balanced accuracies reached 0.63 for the classification of the disease status and differed little between scenarios. Median balanced accuracy to detect a significant change ranged from 0.81 to 0.72. When there was no prior knowledge about the additional data source it could not be used to determine an optimal decision boundary. In these cases, median balanced accuracy was approximately 0.02 lower.

Conclusion: These simulations highlight issues that are relevant beyond the combination of blood glucose values. Measurements conducted to help clarify one medical issue are often reused in other contexts. However not all data sources are equally suitable for all analyses. Therefore, when data from laboratory medicine is exchanged, accompanying information that helps to estimate reliability is critically important.

Introduction: The information system on the causes of death (ISCD), set up in Burkina Faso in January 2014 at the University Hospital Center Souro Sanon (UHCSS) of Bobo-Dioulasso, was evaluated to assess its completeness in terms of death statistics generation.

Method: The capture-recapture method was used to assess this quality control using the three-sources technique.

Results: The cross verification of the three data sources (mortuary, admission department, death certificate) gave the following estimations: number of deaths observed: 735, total estimated deaths: 852 [820–900], i.e. 86% of completeness achieved by the statistics generating system.

Discussion: The ISCD is functional and produces easy-to-cross-check quality data. It could be extended to the entire country for the generation of mortality statistics. Nevertheless, it needs to be improved before deploying across the country.

Decision support systems for alert drug-drug interactions have been shown as valid strategy to reduce medical error. Even so the use of these systems has not been as expected, probably due to the lack of a suitable design. This study compares two interfaces, one of them developed using participatory design techniques (based on user centered design processes). This work showed that the use of these techniques improves satisfaction, effectiveness and efficiency in an alert system for drug-drug interactions, a fact that was evident in specific situations such as the decrease of errors to meet the specified task, the time, the workload optimization and users overall satisfaction with the system.

Few studies have been performed within cross-language information retrieval (CLIR) in the field of psychology and psychotherapy. The aim of this paper is to to analyze and assess the quality of available query translation methods for CLIR on a health portal for psychology. A test base of 100 user queries, 50 Multi Word Units (WUs) and 50 Single WUs, was used. Swedish was the source language and English the target language. Query translation methods based on machine translation (MT) and dictionary look-up were utilized in order to submit query translations to two search engines: Google Site Search and Quick Ask. Standard IR evaluation measures and a qualitative analysis were utilized to assess the results. The lexicon extracted with word alignment of the portal's parallel corpus provided better statistical results among dictionary look-ups. Google Translate provided more linguistically correct translations overall and also delivered better retrieval results in MT.

The emergence of social media on the Internet allows patients to discuss about their chronic diseases within online communities sharing common interests. This allows patients to gather other patients' experience, and gain new knowledge that is usually not shared by healthcare professionals. In this context, further studies are required on the actual impact of the use of social networks on the quality of life of patients participating in these online communities, focusing on the evolving role and impact of Lay Crowdsourced expertise (LCE) in improving disease management and control. We present a study on a large number of posts from social networks of different online communities. This study allowed us to choose four pathologies, with distinctive characteristics relevant for our future analysis, and to define the themes that will be covered in future work by online questionnaires. The analysis of responses from patients, who volunteer to participate, will help us in exploring how interactions between patients, on these online communities, may help them to gain useful information for managing their conditions and improving their quality of life. Furthermore, we will identify new ethical issues that arise in the sharing of health data.

To increase patients' empowerment and involvement in their own health, several countries has decided to provide patients with electronic access to their health record. This paper reports on the main findings from sub-studies and pilots prior to the implementation of patients' access to their medical records in large-scale in the Northern Norway Region. The largest pilot included nearly 500 patients. Data for the participatory design process was collected through questionnaires and interviews. The results revealed that the service in general functioned as expected. The patients reported that they would continue to use the service, recommend it to others, and generally had no problems in understanding the content.

The paper presents the results of the development and implementation of an expert system that automatically generates doctors' letters based on the results of laboratory tests. Medical knowledge is expressed using a first order predicate logic based language. The system was implemented and evaluated in the Helix laboratory service.

Publishing clinical guidelines (GLs) on the web increases their accessibility. However, evaluating their usability and understanding how users interact with the websites has been neglected. In this study we used Tobii eye-tracker to analyse users' interaction with five commercial and public GL sites popular in Norway (four in Norwegian and one English of US origin (UpToDate)). We measured number of clicks and usage rate for search functions, task completion time, users' objective and perception of task success rate. We also measured learning effect for inexperienced users. We found a direct correlation between participant's satisfaction regarding website usability and the time spent, number of mouse clicks and use of search function to obtain the desired results. Our study showed that users' perceived success rate was not reliable and GL publishers should evaluate their website regarding presentation format, layout, navigation bar and search function.

Problem: According to the International Diabetes Federation (IDF), a quarter of the world's population has Metabolic Syndrome (MS).

Objective: To develop (and assess the users' degree of satisfaction of) an online social network for patients who suffer from Metabolic Syndrome, based on the recommendations and requirements of the Human-Centered Design.

Results: Following the recommendations of the ISO 9241-210 for Human-Centered Design (HCD), an online social network was designed to promote physical activity and healthy nutrition. In order to guarantee the active participation of the users during the development of the social network, a survey, an in-depth interview, a focal group, and usability tests were carried out with people suffering from MS.

Conclusions: The study demonstrated how the different activities, recommendations, and requirements of the ISO 9241-210 are integrated into a traditional software development process. Early usability tests demonstrated that the user's acceptance and the effectiveness and efficiency of the social network are satisfactory.

A patient portal with access to a personal cross-enterprise electronic health record (PEHR) had to be developed for the project “INFormation technology for PATient-oriented healthcare in the Rhine-Neckar metropolitan region” (INFOPAT). Liferay was chosen as the platform technology in previous researches. Multiple portlets for patients, study members, security officers and administrators had been developed in Java. In this paper all portlets are presented. For three portlets the communication between them, Liferay and the PEHR are described in detail. To communicate with the PEHR a façade called IHE Connector had been implemented too. Despite the broad functionality of the Liferay Core some workarounds had to be implemented. The lack of information in the provided documentation of Liferay lead to delays in development. The Liferay IDE and Liferay itself showed an unstable state.