Ebook: The New Navigators: from Professionals to Patients

Medical Informatics today

In a developing information society, the members of the European Federation for Medical Informatics are keen to develop the dissemination of health information to the public at large.

Health Care should be safe, effective, efficient and patient-centred. Moreover, the health system should be more transparent. It should make information available to patients and their families that allows them to make informed decisions when choosing among alternative treatments or clinical practices. Information technology must play a central role in the redesign of building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, and clinical education.

Information and Communication Technology (ICT) is now accessible to the public in developed countries. The development of wireless and portable technologies also makes this access possible in developing countries. The extensive use of the web by patients and laymen for health information challenges us to build information services that are easily accessible and trustworthy. The evolution toward a semantic web is one of the topics that are addressed in this book.

Papers on the state of the art of more classical topics covering all the fields of biomedical informatics have been selected and presented in this book. In order to promote the links between medical informatics and bio-informatics, thanks are expressed to the authors of different papers, posters, keynote presentations and tutorials, which are specifically dedicated to this aspect. This conference and the ones following insist on this necessary synergy.

The selection process for MIE 2003

The Scientific Programme Committee (SPC) for Medical Informatics Europe 2003 in Saint Malo, France, quickly decided to work towards and contribute to the enhancement of the quality of the conference and the proceedings, from a scientific point of view. But it rapidly appeared that such a policy would negatively impact on the participation of young and new scientists, who may experience difficulty in having their contribution selected. Any kind of elitism would be a strategic error, against the wishes of the Council of the European Federation for Medical Informatics. Therefore, it was necessary to navigate between these two constraints.

The first step was the call for papers. Any selection process is strongly dependent on the number of submitted contributions. In coordination with the Local Organising Committee, the call for papers was intensive, and hopefully very successful. No less than 300 contributions were submitted, not always within the specified deadlines. This is a considerable increase compared with the last conference in 2002. The immediate consequence was that no more than one paper out of two could be selected for full presentation, on the basis of a four track conference during three days.

The second step was the reviewing process. An ideal review of any paper would be to obtain comments from three reviewers from different countries working in a related field. This means 900 reviews. In fact, we got 175 reviewers from all around the world, but the majority from Europe and this was not enough for the above-mentioned target. Indeed, some papers have been reviewed only twice, and some very late reports were orally given during the last working session of the SPC. This point should be improved in the next event, on the condition of finding more reviewers. A better “European quality” in Medical Informatics could be reached by a continuous teaching process, where the reviewers take the time to comment and to guide new authors whose papers are not yet at the top level. Such an effort will certainly show positive results in the long term.

The third step was the preparation of the conference proceedings, where the style of presentation is just another aspect of quality. The SPC, supported by the EFMI Council, is in favour of a printed book with a strict set of instructions for authors in order to guarantee some uniformity to the reader: such a target is definitely not easy to reach. The maximum size of a contribution was defined as 6 pages with a l2pt font on an A4 format. This source format was reduced in the final hard cover book edited by IOS Press.

The last step is clearly to gain as large a participation as possible during the conference: the bigger the audience, the more economic freedom for the organizer, the more interesting for authors to attend this conference, the better the submissions for future events.

MIE, a peer-reviewed scientific conference

All the full papers presented at the conference are present in the proceedings and will be indexed by Medline. The strict reviewing policy is a necessary condition for that. The SPC is confident that this system is a strong guarantee for future scientific developments in Europe.

In order to provide a tribune and an audience for more contributions, the SPC has decided on two specific actions. First, some 50 papers were invited for a short oral presentation of five minutes, intermixed with the full papers with 20 minute presentations. Second, some 90 other contributions have been transformed into poster presentations, and their authors were invited to display their contributions at the conference site, where two “walking” poster sessions were organized. The short oral presentations can also be presented as posters. All these contributions are published on the conference CD-ROM to be distributed to all participants. These opportunities should make close contact between participants easy to achieve. All contributions at all levels are clearly visible, and one expects that the best authors will be an example for future authors. This is a pedagogical and pragmatic approach to the art of scientific publications.

Medical Informatics provides an opportunity for different events throughout Europe and the professionals in this domain may sometimes find it difficult to select the event which best corresponds to their needs and interests. A short guide in a few lines may be of help. There are two kinds of conferences: scientific and commercial. Though they look quite similar, there is an essential difference: peer reviewing of contributions and selection of authors is the condition for the label scientific conference. This is not to say that commercial conferences are not useful: indeed, they are a vector of communication and a way to stay “up-to-date” in a world of galloping technology. On the basis of these two kinds of conference, another criterion is certainly the size of the conference and the scope of relevant subjects. MIE is typically a large-scope conference, where all domains of medical informatics are present. On the other hand, a number of specialized conferences or workshops are flourishing elsewhere, generally dedicated to a single topic.

To conclude this point, let us say that MIE is a universal conference of Medical Informatics, scientifically oriented, and the main event of this kind in Europe. MIE is the focal point of 26 member countries of Europe for two conferences every three years.

In the cardiovascular system, altered flow conditions — such as separation, flow reversal, and low or oscillatory shear stress areas — are recognized as important factors in the development of arterial disease. A detailed understanding of the local hemodynamics, of the effects of vascular wall modification on flow patterns, and of longterm adaptation of the system to surgical procedures can have useful clinical applications. In this context, the availability of effective and accurate numerical simulation tools could be a real breakthrough.

The two-dimensional flow over a square-step can be regarded as a two-dimensional stenosis model from witch some information on the properties at arterial stenoses can be obtained

The target of this study was the development of mathematical models that best describe the behaviour of respiratory parameters.

First of all, we studied lung volume in relation to time both for normal and maximal inspiration/expiration by developing mathematical models. For the construction of these equations the exponential model was used Then we tried to study the flowvolume of a typical spirometer curve by dividing it into two parts: the first part reaches the Peak Expiratory Flow (PEF) point and the second follows until the volume reaches Vital Capacity (VC). For the first part we built an exponential equation; for the second part a number of existing prediction equations for the flow in various points of VC were used For the volume pressure diagram, we built exponential equations that describe the volume pressure relation below Vo (Vo: lung volume where pressure is zero). The equations were coupled for expiration and inspiration.

The modeling of respiratory mechanics led us to the conclusion that the developed models could offer new potentials in the description of other respiratory parameters as well.

We describe in this paper a smart multisensor kernel, given the shape of a wriststrap and able to characterise a current physiological state among a number of ones resulting from a previous analysis, and to transmit those results using a radio link. The main advantage of this product is its adaptability. As examples, we describe two applications which are the remote monitoring of elderly people and the sleep staging.

A new method for ECG signal enhancement is presented, based on “matched” timefrequency filtering in the Wigner representation. Performance analysis shows that the method is particularly useful for noise removal in clinical ECG.

In view of an increasing use of breast MRI supplementing X-ray mammography, the purpose of this study was the development of a method for fast and efficient analysis of dynamic MR image series of the female breast.. The dynamic image data sets were analyzed by tracer kinetic modeling in order to describe the physiological processes underlying the contrast enhancement in mathematical terms and thus to enable the estimation of functional tissue specific parameters, reflecting the status of microcirculation. To display morphological and functional tissue information simultaneously, a multidimensional real-time visualization system (using 3D-texture mapping) was developed, which enables a practical and intuitive human-computer interface in virtual reality.

Segmentation of positron emission tomography (PET) images is a difficult task. In this study, we propose a new method for delineation of brain structures according to the tracer uptake. The method is based on a new deformable model which is particularly designed for extracting surfaces automatically from noisy images. The automation is achieved by using a global optimization algorithm for minimizing the energy of the deformable model. As an example, the coarse cortical structure was extracted from FDG PET brain images by delineating first the brain surface and then the white matter surface. We have tested the method with the image of the brain phantom and images from a small number (N=17) of FDG brain studies. The cortical structure was automatically and reliably found from all the images. The proposed method provides new opportunities for automatic and repeatable structure extraction applicable for regional quantification of the tracer uptake.

The heart disease is caused by the alterations in the biological tissue of its muscles. The myocardium alterations have been analysed and evaluated on echocardiographic images. The statistical parameters of the heart texture on the defined region of interest present information about the state of myocardium. There are hundreds of the texture parameters, which could be used to evaluate the heart tissue structure. The goal was to choose the most informative ones by applying the statistical analysis techniques. The Fisher statistics has been applied for hypothesis testing to define the most informative texture parameters. The data for the certain position of a transducer has been compiled for sound and heart patients. Two kinds of echocardiographic images (native and harmonic ones) have been used for analysis. The most informative texture parameters on evaluating changes in myocardium structure proved to be: local mean intensity, the form of local histogram, local variance and run-length nonuniformity. The statistical analysis was limited to the measurements of the most informative position of the transducer from the compiled database.

The paper describes the results obtained for differential diagnostics of substantially complex disorders in the acid-base status. Since the first attempts of applying the genetic programming to this problem, presented by the authors at MIE 2000, proved promising, the investigation has been continued. The goal of the present study is to create computer genetic programs which, while taking into account a set of laboratory gasometric and electrolyte measurments, would be able to assist the diagnostics of acid-base disorders. Seven (7) single acid-base disorders, eleven (11) double acid-base disorders and six (6) triple complicated disorders with accompanying anion gap alterations are approached in the study. A set of simulated laboratory measurements has been prepared, providing 250 results for the evaluation of the fitness function of the designed genetic computer programs, plus some additional results for testing. The final results are presented in the form of a confusion matrix for the testing data, which shows that the developed system may be helpful in clinical practice.

Improvement of image guided surgery systems requires a better anticipation of the surgical procedure. This anticipation may be provided by a better understanding of surgical procedures and/or the use of information models related to neurosurgical procedures. We are introducing a generic model of surgical procedures in the context of multimodal image-guided craniotomies. The basic principle of the model is to break down the surgical procedure into a sequence of steps defining the surgical script. Each step is defined by an action; the model assigns to each surgical step a list of image entities extracted from multimodal preoperative images (anatomical and/or functional images) which are relevant to the performance of that particular step. The model has been built in two phases: creation and consolidation. Besides, a planning software prototype based on the generic model has been built. The resulting generic model is described by an UML class diagram and textual description. Some initial benefits of this approach can already be outlined: improvement of multimodal information management, enhancement of the preparation and the guidance of the surgical act.

Inverse electrocardiography has been developed for several years. By coupling electrocardiographic mapping and 3D-time anatomical data, the electrical excitation sequence can be imaged completely non-invasively in the human heart. In this study, a bidomain theory based surface heart model activation time imaging approach was applied to single beat data of atrial and ventricular depolarization. For sinus and paced rhythms, the sites of early activation and the areas with late activation were estimated with sufficient accuracy. In particular for focal arrhythmias, this model-based imaging approach might allow the guidance and evaluation of antiarrhythmic interventions, for instance, in case of catheter ablation or drug therapy.

Integration of disparate biomedical terminologies is becoming increasingly important as links between biological science and clinical medicine grow. Mapping concepts in the Gene OntologyTM(GO) to the UMLS may help further this integration and allow for more efficient information exchange among researchers. Using a gold standard of GO term — UMLS concept mappings provided by the NCI, we examined the performance of various published and combined mapping techniques, in order to maximize precision and recall. We found that for the previously published techniques precision varied between (0.61-0.95), and recall varied from (0.65-0.90), whereas for the hybrid techniques, precision varied between (0.66-0.97), and recall from (0.59-0.93). Our study reveals the benefits of using mapping techniques that incorporate domain knowledge, and provides a basis for future approaches to mapping between distinct biomedical vocabularies.

We present an interactive literature based biomedical discovery support system (BITOLA). The goal of the system is to discover new, potentially meaningful relations between a given starting concept of interest and other concepts, by mining the bibliographic database Medline. To make the system more suitable for disease candidate gene discovery and to decrease the number of candidate relations, we integrate background knowledge about the chromosomal location of the starting disease as well as the chromosomal location of the candidate genes from resources such as LocusLink, HUGO and OMIM. The BITOLA system can be also used as an alternative way of searching the Medline database. The system is available at http://www.mfuni-lj.si/bitola/

IMGT, the international ImMunoGeneTics information system® (http://imgt.cines.fr), is a high quality integrated information system specializing in immunoglobulins (IG), T cell receptors (TR), major histocompatibility complex (MHC) and related proteins of the immune system of human and other vertebrates, created in 1989, by the Laboratoire d’ImmunoGénétique Moléculaire (LIGM), at the Université Montpellier II, CNRS, Montpellier, France. IMGT is the global reference in immunogenetics and immunoinformatics and provides a common access to standardized data which include nucleotide and protein sequences, oligonucleotide primers, gene maps, genetic polymorphisms, specificities, 2D and 3D structures. IMGT includes three sequence databases (IMGT/LIGM-DB, IMGT/MHC-DB hosted at EBI, IMGT/PRIMER-DB), one genome database (IMGT/GENE-DB), one 3D structure database (IMGT/3Dstructure-DB), Web resources comprising 8000 HTML pages (“IMGT Marie-Paule page”) and interactive tools for sequence (IMGT/V-QUEST, IMGT/JunctionAnalysis, IMGT/Allele-Align, IMGT/PhyloGene) and genome (IMGT/GeneSearch, IMGT/Gene View, IMGT/Locus View) analysis. IMGT data are expertly annotated according to the rules of the IMGT Scientific chart, based on the IMGT-ONTOLOGY concepts. IMGT tools are particularly useful for the analysis of the IG and TR repertoires in physiological normal and pathological situations. IMGT has important applications in medical research (repertoire analysis in autoimmune diseases, AIDS, leukemias, lymphomas, myelomas), biotechnology related to antibody engineering (phage displays, combinatorial libraries) and therapeutic approaches (graft, immunotherapy). IMGT is freely available at http://imgt.cines.fr.

Semantic interoperability between knowledge bases in medicine, and knowledge base in genomics and molecular biology will lead to advances in fundamental research as well as to improved patient care. DNA chips strategy is used for transcriptome analysis in order to identi deregulated genes in physio-pathological conditions. The objective of the BioMedical Knowledge Extraction project (BioMeKe) is to develop a knowledge warehouse in the context of transcriptome analysis during liver diseases. Knowledge sources include ontologies, related terminologies and annotations linked towards public databases (e.g., SWISSPROT). BioMeKe has been developed to have access to information using systematic investigation upon a concept, gene, gene products, pathology, or any target keyword, and is based on the combination of several relevant resources: UMLS, GeneOntology, MeSH supplementary terms, GOA, and HUGO. Current efforts are focusing on exploiting this ontology-based Knowledge Extractor, to enrich the expression data on genes delivered by a liver specific DNA microarray for better assistance of analysis.

Objectives: To model and implement a medical web portal providing access to well qualified and high-quality information. Material and methods: The Unified Medical Language System (UMLS) knowledge sources of the U.S. National Library of Medicine and an Information Sources Catalog (ISC) resulting from the ARIANE project are described The XML technology that allows files transformations by the means of XSLT is briefly presented Results: The design and implementation of software modules that exploit knowledge sources, operate the translation of a user’s query to selected information sources, and wrap obtained results are detailed Discussion: Current implementation and wrapping perspectives are discussed in terms of integration and interoperability of health information resources.

A Multi-Source Information System (MSIS) has been designed for the Renal Epidemiology and Information Network (REIN) dedicated to End-Stage Renal Disease. Interoperability has been considered at 4 levels: semantics, network, formats and contents. An n-tier architecture has been chosen at the network level. It is made out ofa universal client, a dynamic Web server connected to a production database and to a data warehouse. The MSIS is patient-oriented, based on a regional organization. Its implementation in the context of a regional experimentation is presented with insights on the design and underlying technologies. The n-tier architecture is a robust model and flexible enough to aggregate multiple information sources and integrate modular developments. The data warehouse is dedicated to support health care decision-making.

The increase of population mobility has been promoting a crescent dispersion of patient clinical records in Healthcare Information Systems. In this scenario, it is mandatory that new services will be available for healthcare practitioners, namely web-based interfaces with strong control access mechanisms providing effective authentication and identification of persons, and the establishment of new access models to the disperse patient information.

This paper proposes and describes a Healthcare Access Model that integrates a new set of functionalities coping with patient mobility and implements an innovative concept of a virtual unique Electronic Patient Record - EPR.

Proprietary systems for dermoscopy images analysis are available to improve the diagnosis and follow-up of the pigmented skin lesions. Their performance seems comparable with that of a human expert. Progress in computer-aided classification of melanocytic lesions depends notably on judicious choices of the algorithms dedicated to the extraction of signs from the dermoscopy images and of the method which combines these signs to classes the lesions.

To allow the researcher’s community to benefit from their large set of elementary algorithms already available for dermoscopy, we set up a system accessible through the Internet which:

- allows the engineers to register their algorithms while preserving their secrecy: their programs run on their own server;

- lets a user to define its own sequence of image analysis and to apply it to its images: the system automatically calls the appropriate remote programs;

- makes possible and stimulates the synergy of worldwide researchers in order to validate algorithms of images analysis best suited to achieve the correct diagnosis and to track the malignant melanoma;

- makes these techniques available to the greatest number of users through the Web and thus to support a mass screening;

- reduces the maintenance of the system to the minimum: it requires users only an Internet browser and engineers to follow a simple widespread standardised interface for distributed programs.

Various problems should be addressed:

- the lack of standardisation of images acquisition: algorithms based on relative colours are best suited to this system;

- the copyrights on images and algorithms;

- charging the use of remote computer resources.

This system allows for an international collaborative work in the fight against the malignant melanoma by offering a conceptual and technical platform of teledermoscopy. It is intended to support synergy between the engineers and the users implied in the diagnosis and teaching of dermoscopy.

Organizing the Homecare with new information technologies is nowadays an important challenge. Indeed, some medical evolutions as the improvement of the duration of life, the number of chronic diseases and some social evolutions, such as the quality of patient life, or economic evolutions, such as the reduction of hospitalisation costs, could benefit from homecare. In this paper, we present the problem of the communication of information in the homecare context. Some main phases have been described that compose the two homecare processes: a logistic process and a care process. The communication of information during homecare depends on the concerned phases: first, some exchanges of information from existing Information System to the Homecare Information System; then, some exchanges between the homecare system and the mobile health care actors; and then, some mails during the outcome phase. Coordination architecture is briefly described, and two different implementations for the communication of information during homecare are presented: one is using XML messages to exchange information between Information Systems; the other is using mobile tools for communicating with mobile actors.

In western countries, heart disease is the main cause of premature death. Most of cardiac deaths occur out of hospital. Because of a continuously growing elderly population, the number of heart attacks is steadily increasing. Symptoms are often interpreted incorrectly. Victims do not survive long enough to benefit from inhospital treatments. To reduce the time before treatment, the only useful diagnostic tool to assess the presence of a cardiac event is the electrocardiogram (ECG). Event and transtelephonic ECG recorders are used to improve decision-making but require setting up new infrastructures. The pervasive solution proposed by the European EPI-MEDICS project is an intelligent Personal ECG Monitor for the early detection of cardiac events. It includes part of the patient electronic health record (EHR), embeds a web server and decision-making techniques, generates different alarm levels and forwards alarm messages to the relevant care providers by means of new generation wireless communication. It is cost saving, involving care providers only if necessary, without requiring to set-up specific infrastructures. Healthcare becomes personalized, wearable and ubiquitous.

This paper presents the main differences existing in the elaboration process of law and standard and analyses their potential conflicts. It also describes the respective force of law and standards in three main areas : legal threat versus financial threat, conflict versus cooperation and finally their respective position faced to oligarchic power.

Due to actual equalization of qualified electronic signatures with handwritten signatures and the legal acknowledgment of the electronic form, the opportunity to use electronic patient records instead of classic paper-based ones is given. The archiving of medical records over a period of 10 to 30 years represents an important factor in medical documentation which has to be assured for electronically signed documents as well. The ArchiSig project deduces principles on long-term conservation of electronically signed documents and corresponding technical components to be realized by the means of multi professional analyses.