Throughout the 1990s, technological advances brought about many changes in medical informatics, and by the second half of the decade the discipline was in the process of major changes.
This book presents the proceedings of the Medical Informatics Europe congresses, MIE 96, held in Copenhagen, Denmark, in August 1996. The congress was one of a sequence of international conferences organized by the European Federation for Medical Informatics and alternating with the MEDINFO congresses organized by the International Medical Informatics Association, and the book reflects the impact of the European Commission's Third and Fourth Framework Programmes in health telematics, which is well documented in the large number of papers based on or derived from research projects conducted under these research and development programs included here.
The proceedings contain 224 peer-reviewed papers, selected from 309 submissions, which are grouped according to a number of topics, including: networking and telemedicine; medical concepts and language; quality and IT systems; handling patient data; and education and training.
There is a growing recognition of the need for enterprise-wide integration of information management. Technically this is becoming much easier, with growing numbers of data sets defined and exchanged as messages to meet the various business requirements, largely independent of computing platforms, architectures or standards in use by the communicating systems. However there is still only one national health information system in operation world-wide, in New Zealand, despite efforts to move in that direction in various other countries.
A number of key success factors in the implementation of such systems have been identified: these must be adequately addressed for any chance of a successful outcome. This paper outlines some of the principal factors that have been identified and outlines the experience gained from this New Zealand project [1,2] of how these can be managed successfully.
Health authorities, at local, regional, or national levels have over the last few years expressed an increasing interest in and need for international health data comparison in pursuance of policy making and monitoring. To promote health and prevent diseases, administrations need high-quality, policy-oriented health information; information that will allow them to monitor the impact of health programs and policies and provide a means for comparison between countries as well as comparison at European Community level. This task would be greatly facilitated by the development of an EU-wide Health Information System. Such a system should consist not only of a series of indicators covering the areas of interest, but also of a telematic system for the collection and dissemination of this data and indicators. However, the development of an EU-wide Health Information System will be a difficult task - politically and technically. A number of issues have to bevery carefully considered when planning, developing and implementing such a telematic system. The principles for the design and development of the system are the subject of this article.
Knut Bernstein, Henrik Bjerregaard Jensen, Ib Johansen, Tove Lehrmann
13 - 17
Denmark is close to implementation of a National Health Care Network. The first, small projects started in 1989. The large scale National programme, MedCom, is running in 1995 and 1996. MedCom implements structured messaging, based on European EDIFACT's. We have experienced that most of the technical problems now are solved, and the new focus is on human facets. MedCom and it's pilot project is now focused i.e. at user involvement, organizational changes, personal networking and dissemination of the technology.
Knut Bernstein, Henrik Bjerregaard Jensen, Ib Johansen, Giorgio Orsi
18 - 22
This paper emphasizes the electronic communication as a means for fulfilling new requirements for the Health Care: the demand for continuity and coordination in the provided services. Regional Health Care Networks can interconnect different computer systems for health care, and support cross sectorial communication. The barriers for implementation of such networks are discussed. A European project - CoCo - which aims at reducing the barriers and improvingthe continuity and coordination of health care and social services, is presented.
Ib Johansen, Tove Lehrmann, Henrik Bjerregaard Jensen, Knut Bernstein
23 - 26
A successful implementation of a health care data network is dependent of a number of different - non technical - factors. The implementations of one of the largest Regional HC Network in Europe, FynCom, have been very fruitful. The experience obtained within this field has led to a set of 10 commandments. The main focus has been the collaboration among the different partners and the role of human aspects in the development, implementation and dissemination of the project.
Constantin Ionescu-Tirgoviste, Sergiu Bejan, Emilia Stanciu, Gheorghe Rachiteanu, Tania Roman, Simion Pruna, Iulian Mincu
27 - 31
In order to provide the material support required by the BlackSeaDiab Action Project, possible solutions for the creation of a regional informational network covering the countries surrounding the Black Sea have been studied. The solution sought had to facilitate an extension of the network from a minimal level up to a top level, with the smallest costs. A two stage solution has been adopted. In a first stage, an INTERNET compatible network (protocols, application interfaces) will be realised using existent physical communication channels, with limited INTERNET access. In the second stage, the network will be developed to use high speed communication channels, with total INTERNET access from any point of the network.
The scope of the project ranges from routine diabetes care to diabetes research. A wide range of software applications will be developed such as: patient monitoring, programs for the assistance of the research regarding various aspects of diabetes mellitus, epidemiology. education and treatment, statistical analysis of information recorded in data bases, etc.
Wolfgang Schoner, Karl P. Pfeiffer, Joerg Glasauer, Gerhard Raudaschl
32 - 35
Regional Health Information Networks (HIN) that structure information about local health services and make it available to both professional people and patients are to be developed within the next years in many regions. The main goals of HINs are both to support professionalist by reducing their administrative workload and to give people the chance to take better care of themselves. A conceptual framework based upon the experiences with the Tyrolean HIN is presented in this paper.
The premise of star$\openstar$ is that if the medical record is region-wide then the care that is delivered to the patient will be seamless. A number of sites across Europe will soon be demonstrating heterogeneous information systems intenworking in real-time, enabling the delivery of seamless care to patients.
Steen Mariboe, Henrik Bjerregaard Jensen, Tove Lehrmann, Knut Bernstein
41 - 43
This paper describes the Danish approach to developing and implementing solutions to create a coherent Health Care Data Network
Three Danish Project-groups, situated on Funen and sharing facilities and expertise, are researching, initiating and coordinating pilote projects municipally, county- and nationwide. Also the largest European research and development project in the Health Telematics Applications area under the 4th framework programme is sharing the facilities and expertise.
The approaches to fulfill the needs for continuity and coordination in health care and the extended support for the projects by public and private organisations are described.
E. Contini, G.P. Costantino, R. Harti, F. Quarello, G. Sancipriano, N.H. Selwood
44 - 48
This paper briefly describes a possible structure for a complete dialysis monitoring system currently being developed at CSELT with the aim of eventually satisfying the needs of nephrology for telemonitoring.
Of importance is the subsystem related to data acquisition and follow-up of patients undergoing domiciliary Chronic Ambulatory Peritoneal Dialysis (C.A.P.D.) which allows patients themselves to forward, from their home, essential treatment data. Symptoms, accidents or consumption of drugs unrelated to therapy can also be monitored. Additional services, such as mailing and remote changing of therapy by the physician, are facilitated. The choice of a suitably programmed smart-phone as the home platform, has demonstrated its potential for telemedicine applications, with a simplification of the patient/user interface.
A trial of this sub-system, called TELEDIAL, is in progress at the G. Bosco hospital in Turin (I).
Uwe Engelmann, Andre Schröter, Ulrike Baur, Antje Schroeder, Oliver Werner, Kerstin Wolsiffer, Hans-Jürgen Baur, Frank Saurbier, Bengt Göransson, Eric Borälv, Hans-Peter Meinzer
49 - 53
This paper gives an introduction to the teleradiology system MEDICUS which has been developed at the Deutsches Krebsforschungszentrum (German Cancer Research Center) in Heidelberg, Germany. The system is designed to work on ISDN lines as well as in a local area network. The global software architecture is explained in the article. Special attention has been given to the design of the user interface and data security, integrity and authentication. The software has been evaluated in a field test in Germany at 15 radiology departments in university clinics, small hospitals, private practices, and research institutes. First experiences show that the system is easy to use and can save time, patient transports and reduce film costs. It is well suited for remote consultation or for sharing resources, such as expensive equipments or radiologists.
The aim with this paper is to explain the IT-solutions in a centrally organised mammography screening project in Norway. All of the major participants in the project are connected together in the same network (ISDN). Sending and receiving data is automatically taken care of with a replication server. In this way very sensitive medical data are being transferred via telecommunications among each participant. To secure the information that are being transferred an encryption/decryption unit is being used.
Enrique J. GóMez, M. Elena Hernando, Francisco del Pozo
58 - 62
This paper presents the DIABTel Telemedicine Service to support daily care of diabetic patients. The telemedicine system relies on three basic telemedicine services: telemonitoring, telecare, and teleeducation of patients. The system architecture is comprised by two main components: a Medical Workstation to be used by physicians at a hospital diabetes day center unit, and a Patient Unit, to be used during the patients daily living. The main features of the new approach to diabetes care provided by the DIABTel service are: 1) to provide both patients and doctors an integrated service to manage and improve several areas of daily diabetes care; 2) the continuous analysis of incoming patients monitoring data, based on the telemonitoring service 24-hour call center, providing patients with what we called a “supervised autonomy” during their ambulatory monitoring process; 3) the remote assistance of patients on treatment modification; 4) the decrease of the time response therapy adjustment, enhancing the patient’s self-management and education; 5) the improvement of the quality and quantity of patient’s monitoring data, facilitating the follow-up of an increased number of patients without decreasing their quality of care; and 6) the optimization of the number of patient’s visits to the hospital, but providing them, at the same time, a better access to clinical and monitoring data. A discussion of practical problems, limitations and critical implementation issues of the Telemedicine service are also presented.
Young Moon Chae, Hae Jong Lee, Jaegoog Jo, Hyung Sik Choi
67 - 71
Telemedicine can increase accessibility to advanced medical technology at the university hospital for community residents living in a remote area. This paper focused on the economic evaluation of telemedicine to identify important factors influencing costs and benefits and to understand how these factors can be changed to improve economic performance of the telemedicine. When the telemedicine project currently operating in Korea was evaluated based on the traditional cost-benefit analysis, the results showed a heavy net loss with a B/C ratio of 0.17. As several values were added to the analysis based on Information Economics approach, B/C ratios steadly increased. When the saving of medical expenses from the early detection of diseases was taken into consideration, the ratio exceeded the break-even point. From the sensitivity analysis, a number of patients and the cost for equipment and communication were found to be the key factors for influencing economic performance of telemedicine.
The phenomenon of Teleambulance is becoming increasingly popular. This awakening technological development is enhancing the quality of healthcare delivery by providing possibilities for remotely assisting the emergency treatment of patients at the scene of incidence or during transportation in the ambulance before their arrival in the hospital wards. Both the mobile (ambulance) and the host (hospital) workstations communicate by sending messages, conveyed through the air by radio frequency (RF) signals. Transmitted data include. the emergency forms, monitored patient physiological measurements, textual remarks and images. The server/host resident software incorporates both a display and a database units for archiving the incoming patients records of incidence.
This paper aims at bringing to the limelight the state of the art in the developing world of Teleambulance. It presents the new GSM-based Teleambulance workstation which was designed and developed by the Laboratory For Biomedical Informatics (LBMI), to replace her previous radiomodem installation. The spectacular inclusions in this newly designed GSM-based configuration are the possibilities of combining the speech, the data and the fax communications in only one channel. More still, the system eliminates the thick-wall hospital screening effect and in no way whatsoever introduces radio frequency interference with the hospital electronic instrumentations. While the installation cost is almost only confined to the mobile station, the modularity of this new configuration boosts the cost effectiveness of a running Teleambulance service.
Council Directives 92/29 and 93/103 establish the “use of long distance medical consultation” for the protection of the safety and health of maritime workers and distant or isolated populations of the EU. In response to these needs, MERMAID will set up an integrated 24-hour multilingual, telematic, around-theworld, medical emergency service that will transfer medical expertise via satellite and ground based ISDN networks when and where necessary. Since, (a) voice medical teleconsultation is obsolete, (b) videotele-phony has introduced “face-toface” medical teleconsultation and remote visual inspection and (c) telemedical interventions, (which are critically dependent on local paramedic skills), can now receive multimedia support on medical procedure, MERMAID will develop: (1) A locally $\underline(resident \ multimedia \ medical \ guide \ for \ ships)$ to serve both for training and as a reference during emergencies. (2) $\underline(A \ system \ of \ INMARSAT-A \ (ship \ to \ shore) \ links)$ (for transfering images, sounds, text / patient anamnesis and signals), $\underline(which \ is \ feeding \ into \ an \ ISDN \ network \ that links \ together \ the \ MERMAID \ health \ service \ providers)$. (3) $\underline(The \ telematic \ means \ for \ the \ medical \ teleconsultant \ to \ remotely \ interact \ with \ the \ local \ multimedia \ medical \ guide)$ and efficiently demonstrate health care procedures to local paramedics. Requests for help, broadcast over MERMAID INMARSAT-A links will be routed to one or more specialists depending on type of help needed, language(s) required for efficient communication, proximity to the site of emergency etc. Thus MERMAID, relying on telepresence and combining locally stored multimedia reference material with remote consultation, it proposes a viable solution to the problem of missing medical expertise for isolated populations. It is significant that the MERMAID pilot users represent 1% of the world merchant marine, a size that guarantees the validity of its outcome and is a good start for disseminating the MERMAID results.
European Union (EU) Council Regulation 2847/93 sets rules on the use of fishing resources. In its framework a number of pilot applications of telematic services for fishing fleet management have been implemented. They are based on continuous tracking of the exact position of fishing vessels is effected through satellites while messages (structured or unstructured) can be exchanged with other vessels and land or sea-based control centers. The EU fishing population is spread thin, not reaching the critical mass that would make it meaningful for health care systems to provide good and inexpensive medical coverage. In addition, fishing is an activity that takes place in rough environments: Boats stay at sea for several days, sometimes isolated from the core of a fishing fleet, often in bad weather conditions. Generally they are small in size and are manned by minimal crews. Under these conditions medical emergencies can easily evolve into critical situations, managed by inexperienced fellow mates. The severity of the fishermen working conditions was recognised by Council Directive 92/29 which goes on to state that “the use of long distance medical consultation methods constitutes an efficient way of contributing to the protection of the safety and health of workers”. Against this background a consortium to “Transfer Medical Teleconsultation and Emergency Aid Services to European Fishing Vessels” (TRATA) has been set up that envisages to provide an integrated medical emergency service by utilising the telematic infrastructure set up under Council Regulation 2847/93. The present paper is a presentation of the TRATA telematics application in the context of the services it proposes to offer and the issues involved.
This paper describes the functional specifications of a telemedicine system prototype, devoted to the Management of Insulin Dependent Diabetes Mellitus. This work is part of the Telematics Application project T-IDDM, funded by the European Commission.
Daniel Karlsson, Christer Ekdahl, Nosrat Shahsavar, Hans Gill, Urban Forsum, Ove Wigertz
93 - 97
We have designed and developed a knowledge-based decision support system using World Wide Web technology. The system uses both rule-based and hypertext knowledge to give support in clinical medicine. We use Arden Syntax for representing rule-based knowledge and HTML for representing hypertext documents. The two representations are integrated to provide extended explanation to the advice produced by the Arden Syntax rules and to find hypertext documents relevant to a specific question and to a specific patient. This way we believe that the usability of decision-support systems can be enhanced.
The paper considers the continuing need for information security and associated awareness methods within modern European Healthcare Establishments (HCEs). It presents details of a novel security information dissemination service that will soon be offered as part of the new European Union ISHTAR (Implementing Secure Health Telematics Applications in Europe) project. The objective of the project is to increase the awareness of both the public and healthcare personnel on issues related to health data protection, by way of seminars and worldwide dissemination. The selected means of achieving the latter is to promote healthcare security issues over the Internet, utilising a dedicated server on the World-Wide Web.
The paper examines the way in which the service will be implemented, the features that it will offer and the advantages that the approach provides. The principal point here is considered to be the easier availability of consistent security advice to a wide audience.
JJ Sancho, NC Oliveri, G. Faba, M Campos, F Sanz, FT De Dombal
103 - 107
The morbidity and mortality of unusual clinical cases ranges from five to sixfold times those of usual clinical cases. Noneless, there is an acute lack of structured information sources on the best managing practices for those cases. The general objective of ELCANO is to build and exploit a multilingual Virtual Library of outstanding clinical guidelines to manage unusual cases. This Virtual Library will be distributed across The Internet from the partners servers and accessed by specialists and specialists in training. Gastroenterology will be the initial area of the clinical practice to be addressed. The unique and innovative aspects of ELCANO are its orientation toward unusual cases, the framework embracing countries from Europe and Latin-America, the structured pre-validation of the cases and its multilingual contents as well as their indexing and codification using internationally accepted standards. An immediate benefit from ELCANO will be the availability of critical clinical information in places where there is a lack of experience coming from places where this experience is commonplace. ELCANO is to be regarded as a exploratory measure, to test the implementation of North-South and South-North collaboration in telecommunication of clinical information. When successful, a broader range of medical specialities and more countries in both regions as well as new regions are foreseen to be involved.
Georges De Moor, Maria Laires, Mike McCurry, Christine Thayer
108 - 112
The purpose of the EUROPEAN HEALTH TELEMATICS OBSERVATORY (EHTO) is to collect, analyse and make available in a coherent and user-friendly form a wide range of information on developments in the field of health telematics. The Observatory by virtue of its multi-faceted approach to health telematics, will rapidly constitute a European pole of information and activity and a starting point for health telematics deployment. Diffusion of the information collected is the raison d'être of the Observatory
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