Ebook: MEDINFO 2013

MedInfo 2013 continues a 39-year tradition of bringing together world leaders, policy makers, researchers, practitioners, educators, and students to exchange ideas and contribute to the latest developments, innovations, and global trends in this rapidly advancing, multidisciplinary field.

Recent natural disasters, emerging epidemics, changing demographics, volatile economics, and dwindling resources have called for collective and collaborative efforts to address the new and evolving challenges in health care and biomedicine. Echoing the conference theme, integrative innovations that converge multidisciplinary technologies, rigorous scientific investigations that explicate the nature of complex phenomena, and human-centered designs that connect people are crucial for realizing the immense potential of information and communication technologies to improve health care processes and patient outcomes.

MedInfo 2013 features a pre-congress offering of an extensive tutorial program by leading experts and a student paper competition that draws the best young talent from all over the world. The main program includes keynote talks, papers, posters, panels, workshops, and scientific demonstrations that span a broad range of topics from emerging methodologies that contribute to the conceptual and scientific foundations of biomedical and health informatics, to successful implementations of innovative application, integration, and evaluation of eHealth systems and solutions. The United Nations/World Health Organization strategies and efforts, as well as other initiatives to improve health outcomes in populations with varying resources in the world are featured in the program.

The conference program includes 186 paper presentations, 310 poster abstract presentations, 29 panels, 18 workshops and 8 scientific demonstrations. There are also two presentation categories new to the MedInfo program this year:

The “Care for the World” mini-symposia, which include four sessions, each featuring a set of global, regional, and national eHealth initiatives and programs that highlights the visions, challenges, and opportunities for government and industry collaboration, and innovations for improving health care and the quality of life for every world citizen. Follow-on discussions and activities are encouraged after the symposia.

The vision papers include eight presentations that highlight well-thought and well-argued concepts and proposals on special ideas and future directions in health and biomedicine. These papers serve to inspire and stimulate discussions on the relevant topics for further exploration and development.

The contributions and presentations included in the program are carefully selected through a rigorous review process from a large number of submissions from all over the world. The Scientific Program Committee is grateful to all the reviewers who have contributed to the process, and thanks all the people involved in putting the program together.

The conference participants come to Copenhagen from all continents and 60 different countries. We hope that you will enjoy the program!

Sincerely,

Dominik Aronsky, MD, PhD, FACMI and Tze-Yun Leong, PhD, FACMI

Co-Chairs, MedInfo 2013 Scientific Program Committee

European countries are world-leading in the development and implementation of e-Health. In Sweden, all primary healthcare centres and most hospitals use digital records. Some regions use the same software which allows for clinical information to be shared (regionally shared EHRs), but there is a movement towards making all EHRs inter-operable to allow for a National Patient Summary (NPS). The aim of this study was to explore the opinions of Swedish consumers and health professionals about shared EHRs and the NPS. Semi-structered phone interviews were conducted with consumers and health professionals. The majority of interviewed health professionals were currently using regionally shared EHRs. In their experience, having access to regionally shared EHRs facilitated a holistic patient approach, assisted in patient follow-up, and reduced inappropriate (over)prescribing. Consumers had a poor level of knowledge about shared EHRs and the NPS. Unlike health professionals, consumers perceived a NPS to be of great value. The findings indicate that there was a discrepancy between health professionals and consumers' knowledge of, and the perceived need for, a NPS.

Objective: To reach consensus among prescribers of different specialties and experience on the usefulness of computerised alerts and strategies for reducing low-value alerts within a commercial electronic prescribing system.

Method: We conducted a Delphi technique where participants were sent a 10-question survey in rounds 1 and 2 to rate the usefulness of existing alert types and to indicate if 1) therapeutic duplication alerts should be adjusted so that they fired only when both medication orders were active; 2) local messages should be changed to hyperlinks rather than alerts. Forty-seven prescribers completed round 1 and 21 round 2.

Results and discussion: Prescribers varied in their views on alerts of little value but agreed allergy and intolerance alerts should be retained. Most prescribers indicated that the proposed strategies for reducing local messages and duplication alerts would not compromise patient safety. Involving users in customization of alerts proved to be a successful approach.

Most providers have experienced increased documentation demands with the use of electronic health records (EHRs). We sought to identify efficiency strategies that providers use to complete clinical documentation tasks in ambulatory care. Two observers performed ethnographic observations and interviews with 22 ambulatory care providers in a U.S. Veterans Affairs Medical Center. Observation notes and interview transcripts were coded for recurrent strategies relating to completion of the EHR progress notes. Findings included: the use of paper artifacts for handwritten notations; electronic templates for automation of certain parts of the note; use of shorthand and phrases rather than narrative writing; copying and pasting from previous EHR notes; directly entering information into the EHR note during the patient encounter; reliance on memory; and pre-populating an EHR note prior to seeing the patient. We discuss the findings in the context of distributed cognition to understand how clinical information is propagated and represented toward completion of a progress note. The study findings have important implications for improving and streamlining clinical documentation related to human factors workload management strategies.

Consumer health informatics technologies have the potential to enhance shared decision-making and communication between older adults, health care providers, and other stakeholders. The objective of this study was to characterize the information needs of these stakeholders to inform the design of informatics tools that support wellness in older adults. We conducted four focus groups with 31 older adults and three focus groups with 10 health care providers to explore information needs, goals, and preferences for information sharing. Analysis of focus group transcripts was performed to identify and compare themes for different stakeholders. We identified four themes related to information activities: perceived goals of others, perceived information needs of others, information sharing by older adults, and role of family members. Older adults, family members and health care providers differ in their information needs. We provide recommendations to facilitate design and adoption of informatics tools that connect these stakeholders. Larger studies are needed to characterize different stakeholder goals, information needs and preferences.

Family-centered care is becoming the new standard for Neonatal Intensive Care Unit (NICU) patients. In support of this, we developed the Physician PArent Decision Support System (PPADS), which provides clinical updates and predictions of clinical outcomes for infants in the NICU to the neonatologists, and provides an aid to parents for making difficult decisions on the direction of care of their infant with the health care team. The tool may lead to earlier intervention, better allocation of resources, and reduction of the negative outcomes. The tool underwent a usability study with 8 parents whose infant survived the NICU stay and 5 neonatologists. Both parents and physicians thought the tool was easy to use, useful, and would help improve team communication. The next usability study will be with parents whose infant died while in the NICU, and then conduct a randomized prospective study with parents who have a sick infant admitted to the NICU.

Across the globe, healthcare delivery is being transformed by electronic sharing of health information. Such large scale health projects with a national focus are a challenge to design and implement. Delivering clinical outcomes in the context of policy, technical, and design environments represents a particular challenge. On July 1, 2012, Australia delivered the first stage of a personally controlled electronic health record – a national program for sharing a variety of health information between health professionals and between health professionals and consumers. As build of the system commenced, deficiencies of the traditional stakeholder consultation model were identified and replaced by a more structured approach, called clinical functional assurance. Utilising clinical scenarios linked to detailed design requirements, a team of clinicians certified clinical utility at implementation and release points.

Picture Archiving and Communication System (PACS) has been the main paradigm in supporting medical imaging workflows during the last decades. Despite its consolidation, the appearance of Cross-Enterprise Document Sharing for imaging (XDS-I), within IHE initiative, constitutes a great opportunity to readapt PACS workflow for inter-institutional data exchange. XDS-I provides a centralized discovery of medical imaging and associated reports. However, the centralized XDS-I actors (document registry and repository) must be deployed in a trustworthy node in order to safeguard patient privacy, data confidentiality and integrity. This paper presents XDS for Protected Imaging (XDS-p), a new approach to XDS-I that is capable of being outsourced (e.g. Cloud Computing) while maintaining privacy, confidentiality, integrity and legal concerns about patients' medical information.

Continuous glucose monitoring (CGM) is a new technology with the potential to detect hypoglycemia in people with Type 1 diabetes. However, the inaccuracy of the device in the hypoglycemic range is unfortunately too large. The aim of this study was to develop an information and communication technology system for improving hypoglycemia detection in CGM. The system was developed as an Android application with a build-in pattern classification algorithm. The algorithm processes features from CGM and typed in data from the patient, then warns the patient about incoming hypoglycemia. The system improved the detection of hypoglycemic events by 29%, with only one 1 false alert compared to CGM alone. Furthermore, the algorithm increased the average lead-time by 14 minutes. These findings indicate that it is possible to improve the hypoglycemia detection with an information and communication technology system, but that the system must be validated on a larger dataset.

VCM (Visualization of Concept in Medicine) is an iconic language for representing key medical concepts by icons. However, the use of this language with reference terminologies, such as SNOMED CT, will require the mapping of its icons to the terms of these terminologies. Here, we present and evaluate a semi-automatic semantic method for the mapping of SNOMED CT concepts to VCM icons. Both SNOMED CT and VCM are compositional in nature; SNOMED CT is expressed in description logic and VCM semantics are formalized in an OWL ontology. The proposed method involves the manual mapping of a limited number of underlying concepts from the VCM ontology, followed by automatic generation of the rest of the mapping. We applied this method to the clinical findings of the SNOMED CT CORE subset, and 100 randomly-selected mappings were evaluated by three experts. The results obtained were promising, with 82 of the SNOMED CT concepts correctly linked to VCM icons according to the experts. Most of the errors were easy to fix.

The objective of this study is to evaluate to approaches assisting the translation of SNOMED CT into French. Two types of approaches were combined: a concept-based one, which relies on conceptual information of the UMLS Metathesaurus and a lexical-based one, which relieson NLP techniques. In addition to the French terminologies (whether included in UMLS or not). Using the concept-based approach, a set of 156,157 (39.4%) SNOMED CT terms were translated to at least one French term from UMLS. Expanded to the French terms from UMLS terminologies translated by CISMeF, 2,548 (+0.7%) additional SNOMED CT terms were translated to at least one French term. Using the lexical-based approach, a set of 145,737 (36.8%) SNOMED CT terms were translated to at least one French term from HeTOP. The qualitative evaluation showed that 44% of the translations were rated as “relevant”. Overall, the two approaches have provided the translation of 168,750 (42.6%) SNOMED CT terms into French using different bilingual terminological sources included in UMLS or in HeTOP.

Medical care data is a valuable resource that can be used for many purposes including managing and planning for future health needs as well as clinical research. However, the heterogeneity and complexity of medical data can be an obstacle in applying data mining techniques. Much of the potential value of this data therefore goes untapped. In this paper we have developed a methodology that reduces the dimensionality of primary care data, in order to make it more amenable to visualisation, mining and clustering. The methodology involves employing a combination of ontology-based semantic similarity and principal component analysis (PCA) to map the data into an appropriate and informative low dimensional space. Throughout the study, we had access to anonymised patient data from primary care in Salford, UK. The results of our application of this methodology show that diagnosis codes in primary care data can be used to map patients into an informative low dimensional space, which in turn provides the opportunity to support further data exploration and medical hypothesis formulation.

Smartphones have become increasingly popular among every segment of the population. Caregivers do not want to miss out on this evolution and express interest in using mobile devices to perform their everyday care. This tendency has been well understood by many software providers who have produced many medical applications for smartphones. Before going a step further and developing tools to manage Clinical Information System data on handheld devices, it is wise to ask ourselves whether these new tools are well adapted to the healthcare environment. Indeed, some studies have raised concerns regarding the efficiency of these handheld devices to input medical data, especially with the induced errors. In this paper, we look to adopt a rigorous approach to acquire evidence about these concerns through a prospective study. In order to get this evidence, the study compares several input interfaces in the context of recording vital signs on mobile devices. We would like to discover not only which interface is the most efficient, but also which one is the least prone to errors.

Cytotoxic treatments for cancer remain highly toxic, expensive, and variably efficacious. Many chemotherapy regimens are never directly compared in randomized clinical trials (RCTs); as a result, the vast majority of guideline recommendations are ultimately derived from human expert opinion. We introduce an automated network meta-analytic approach to this clinical problem, with nodes representing regimens and edges direct comparison via RCT(s). A chemotherapy regimen network is visualized for the primary treatment of chronic myelogenous leukemia (CML). Node and edge color, size, and opacity are all utilized to provide additional information about the quality and strength of the depicted evidence. Historical versions of the network are also created. With this approach, we were able to compactly compare the results of 17 CML regimens involving RCTs of 9700 patients, representing the accumulation of 45 years of evidence. Our results closely parallel the recommendations issued by a professional guidelines organization, the National Comprehensive Cancer Network (NCCN). This approach offers a novel method for interpreting complex clinical data, with potential implications for future objective guideline development.

The typical radiology reporting workflow involves the radiologist first looking at one or more relevant prior studies before interpreting the current study. To improve workflow efficiency, PACS systems can display relevant prior imaging studies, typically based on a study's anatomy as indicated in the Body Part Examined field of the DICOM header. The content of the Body Part Examined field can be very generic. For instance, an imaging study to exclude pancreatitis and another one to exclude renal stones will both have “abdomen” in their body part field, making it difficult to differentiate them. To improve prior study matching and support better study filtering, in this paper, we present a rule-based approach to determine specific body parts contained in the free-text DICOM Study Description field. Algorithms were trained using a production dataset of 1200 randomly selected unique study descriptions and validated against a test dataset of 404 study descriptions. Our validation resulted in 99.94% accuracy. The proposed technique suggests that a rule-based approach can be used for domain specific body part extraction from DICOM headers.

The possibility of post-coordination of SNOMED CT concepts, especially by clinical users, is both an asset and a challenge for SNOMED CT implementation. To get insight in the applicability of post-coordination, we analyzed scenarios for user-directed coordination that are described in the documentation of SNOMED CT. The analyses were based on experiences from previous and ongoing research and implementation work, including national mapping projects, and investigations on collection of data for multiple uses. These scenarios show various usability and representation problems: high number of relationships for refinement and qualification, improper options for refinement, incorrect formal definitions, and lack of support for applying editorial rules. Improved user-directed coordination in SNOMED CT in real practice requires advanced sanctioning, increased consistency of definitions of concepts in SNOMED CT, and real-time analysis of the post-coordinate expression.

Personally controlled health management systems (PCHMS) often consist of multiple design features. Yet, they currently lack empirical evidence on how consumers use and engage with a PCHMS. An online prospective study was designed to investigate how 709 consumers used a web-based PCHMS to manage their physical and emotional wellbeing over five months. The web-based PCHMS, Healthy.me, was developed at UNSW and incorporates an untethered personal health record, consumer care pathways, forums, polls, diaries, and messaging links with healthcare professionals. The two PCHMS features that consumers used most frequently, found most useful, and engaging were the social features, i.e. forum and poll. Compared to participants who did not use any PCHMS social feature, those who used either the poll or the forum were 12.3% more likely to visit a healthcare professional (P=0.001) during the study. Social network analysis of forums revealed a spectrum of social interaction patterns – from question-and-answer structures to community discussions. This study provides a basis for understanding how a PCHMS can be used as a socially-driven intervention to influence consumers' health behaviours.

Accurately segmenting tumors in digital mammography images is a hard task. However, quality of segmentation is important to avoid misdiagnosis. In this work, the GrowCut technique, which is based on cellular automaton, was used to segment tumor regions of digitized mammograms available in the Mini-Mias database. A set of images was submitted to GrowCut technique and segmented images were compared with ground truth in terms of metrics of area, perimeter, Feret's distance, form factor, and solidity. For segmenting tumors, low user interaction is required. Results showed that GrowCut segmentation images obtained similar properties and shape of the ground-truth images, with an average estimated error close to zero, for all metrics analyzed.

The purpose of this literature review is to find out how incidents related to unintended consequences in caring processes are reported by patients or their families, and the status of patient reporting systems globally. The focus of the study is on patient self-reporting systems, and patient centrism. For that purpose, this scoping review examines studies that summarize the current position of patient self-reporting in health care. Scopus, PubMed including MEDLINE, and Cochrane retrievals, and hand search revealed in 50 articles for further analysis. The results showed that patient-reported incidents are still ifrequently researched. Patient reporting systems were implemented to some extent, but not worldwide in spite of the existence of several report systems. More research is obviously needed, especially within organizations where patient self-reporting systems are in use.

The past decade has witnessed an increased interest in what are called “medically unexplained syndromes” (MUS). We address the question of whether structuring the domain knowledge for MUS can be achieved by applying the principles of Ontological Realism in light of criticisms about their usefulness in areas where science has not yet led to insights univocally endorsed by the relevant communities. We analyzed whether the different perspectives held by MUS researchers can be represented without taking any particular stance and whether existing ontologies based on Ontological Realism can be further built upon. We did not find refutation of the applicability of the principles. We found the Ontology of General Medical Science and Information Artifact Ontology to provide useful frameworks for analyzing certain MUS controversies, although leaving other questions open.

Objective: to measure the effect of training with a virtual patient (VP) simulation system on clinical skills of healthcare professionals in Africa.

Methods: A randomized controlled intervention was carried out at Yaounde Central Hospital (Cameroon). The intervention consisted of two groups training on one of the two clinical vignettes implemented in the VP simulator. Four actors were trained to play standardized patient (SP) roles. The clinical skills (performance score) of participants were assessed on both clinical vignettes using these SPs.

Results: Twenty medical students from FMSB were recruited. The difference in overall score was observed between participants who received training from the VP system (higher average) and those who did not receive the training (lower average). This difference is statistically significant, especially when the focus is on participants' scores in the relevant items for proper management of the case.

Conclusion: This study suggests that the training with a medical consultation VP simulator can develop the operational clinical skills of the user.

Background: Investment in research, including clinical research, has positive effects both on health of a population and economic growth of a country. Several factors have been suggested as being related to the performance of clinical research. The goal of this work was to develop and perform initial validation of a survey that measures both current research involvement of physicians, as well as previously noted factors and additional informatics factors affecting this involvement. The survey was developed in both English and Spanish with the goal of its use in Latin America.

Methods: The initial survey was developed primarily from experience with other validated surveys developed for similar purposes. It was validated in three stages with modification or elimination of questions as indicated by this testing.

Results: The final survey contains 33 questions in the categories of research experience, education in research, environmental factors, computer experience, and collaboration.

Follow-up calls after ambulatory visits are not routinely done, yet they can potentially detect and mitigate unresolved problems. Automated calls via an Interactive Voice Response System (IVRS) are an innovative way to conduct follow-up, but patients' attitudes toward follow-up calls are unknown. This study assessed 1) patient perceptions about follow-up calls after visits; 2) differences in perceptions between human and IVRS calls; and 3) association between follow-up calls and patient satisfaction with care. Post-visit follow-up calls in two ambulatory care setting were done in two phases. Phase 1 used a human caller and phase 2 used IVRS. Patient satisfaction questionnaires were completed after each phase. Results showed that 88% of patients favor the idea of the calls and those receiving them found them helpful. There were no differences in attitudes between patients receiving calls from clinic staff or from an IVRS. Patients receiving calls had higher patient satisfaction scores than those not called.

Conclusion: Patients value follow-up calls and they are associated with patient satisfaction with care. IVRS is an innovative way to conduct post-visit follow-up.