Ebook: Seamless Care – Safe Care

This volume contains the proceedings of the Tenth EFMI Special Topic Conference that will be held in Reykjavik, Iceland, from 2–4 June 2010. The EFMI STC 2010 is Europe's leading forum for presenting results of current scientific work in health-informatics processes, systems, and technologies.

Achievements in this area will be introduced to an international audience. As a major event for science, medicine, and technology, the conference provides a comprehensive overview and in-depth, first hand information on new developments, advanced systems, technologies and applications.

The EFMI STC 2010 was organized by the European Federation for Medical Informatics (EFMI) in cooperation with Fókus – the Icelandic Health Informatics Society and the Icelandic Society of Information Processing. It follows previous conferences in Bucharest, Romania (2001), Nicosia, Cyprus (2002), Rome, Italy (2003), Munich, Germany (2004), Athens, Greece (2005), Timisoara, Romania (2006), Brijuni Island, Croatia (2007), London, UK (2008), and Antalya, Turkey (2009).

The EFMI STC 2010, entitled “Seamless Care – Safe Care: the Challenges of Interoperability and Patient Safety in Health Care”, is dedicated to different aspects of interoperability and its implications for patient safety. Traceability is an important facilitator for interoperability and safety. Those multiple aspects were the reason for a strong engagement of the EFMI Working Groups “Electronic Health Records”, “Security, Safety and Ethics” and “Traceability” in this conference.

These proceedings contain two invited keynotes from eminent scientists, one session keynote as well as 25 full papers. The papers have been selected by the Scientific Programme Committee (SPC) out of 61 submissions of papers, posters, panel and workshop proposals from experts from 23 countries. Each submission has been reviewed by three reviewers, which have been selected from a list of 486 internationally acknowledged domain experts from all continents. The SPC chair and vice-chair are especially thankful to all reviewers, which have been listed in the proceedings.

The scientific topics presented in the proceedings comprise Electronic Health Records and Personal Health Records; Traceability; Security, Privacy, Safety, and Quality; Interoperability and Standards; Patient Empowerment and Patient Satisfaction; Patient Safety and Continuity of Care; Device Integration; Process and Systems Evaluation; and Case Mix.

Most of the topics presented at EFMI STC 2010 are interdisciplinary in nature of interest to a variety of professionals: medical informatics, bioinformatics, and health informatics scientists, medical computing and technology specialists, public health, health insurance and health institutional administrators, physicians, nurses, and other allied health personnel, and representatives of industry and consultancy in the various health fields.

90 researchers, residing in 18 different countries from Europe, North and South America, Asia and Australia, have reported their results in this volume.

The EFMI STC 2010 has been completed through panels on special topics, plenary poster sessions, and workshops such as the HL7/GS1 Joint Workshop, a Joint Workshop organized by the European eHealth Project epSOS and the European Thematic Network for eHealth Interoperability (CALLIOPE), but also the Joint Workshop of the EU 7FP Projects PSIP, EU-ADR and debugIT. Further 41 experts will present their poster, panel and workshop submissions to the conference, extending the number of actively representing countries to 20.

The editors would like to thank all the authors for their excellent work as well as the reviewers for lending their expertise to the conference, thereby contributing to the final achievements. Furthermore, they are indebted to HL7 International and GS1 Europe for sponsoring the print of the proceedings, but also the Ministry of Health and the University of Iceland for their inevitable support.

Bernd Blobel, Ebba Þóra Hvannberg, Valgerður Gunnarsdótir (Editors)

The vision of a seamless care environment enabled through the use of health information technology opens the door to exciting possibilities. The first is the creation of a patient-centric Electronic Health Record that would contain all health-related data about a patient from all sources. That EHR would contribute to highest quality, safe, efficient, and low cost care. That same data would be used for multiple purposes, and, by integrating all requirements at the beginning, would meet all those multiple needs. Key to obtaining seamless care is the creation of a global master registry of data elements with attributes that would provide not only interoperability throughout seamless health care but also permit the coupling of knowledge with data. To accomplish this lofty vision will require making critical decisions, staying to the course, eliminating siloed approaches, and adopting universal, cooperative solutions to the use of HIT.

Clinicians involved in clinical care generate daily volumes of important data. This data is important for continuity of care, referrals to specialists and back to the patient's medical home. The same data can be used to generate alerts to improve the practice and to generate care activities to ensure that all appropriate care services are provided for the patient given their known medical histories using electronic quality (eQuality) monitoring. For many years we have used patient records as a data source for human abstraction of clinical research data. With the advent of electronic health record (EHR) data we can now make use of computable EHR data that can perform retrospective research studies more rapidly and lower the activation energy necessary to ask the next important question using electronic studies (eStudies). Barriers to these eStudies include: the lack of interoperable data between and among practices, the lack of computable definitions of measures, the lack of training of health professionals to use Ontology based Informatics tools that allow the execution of this type of logic, common methods need to be developed to distribute computable best practice rules to ensure rapid dissemination of evidence, better translating research into practice.

Turning from organization-centric to process-controlled or even to personalized approaches, advanced healthcare settings have to meet special interoperability challenges. eHealth and pHealth solutions must assure interoperability between actors cooperating to achieve common business objectives. Hereby, the interoperability chain also includes individually tailored technical systems, but also sensors and actuators. For enabling corresponding pervasive computing and even autonomic computing, individualized systems have to be based on an architecture framework covering many domains, scientifically managed by specialized disciplines using their specific ontologies in a formalized way. Therefore, interoperability has to advance from a communication protocol to an architecture-centric approach mastering ontology coordination challenges.

Giving patients power over their personal health record is an unavoidable evolution in all industrialized countries which will reflect their active participation in the management of their own health. This would lead to patients sharing management with health professionals, which would need traceability of the data provider to maintain trust and transparency. The systematic use of electronic signatures by medical practitioners will be essential to provide sufficient guarantees and to clearly determine who has added what in the PEHR.

This paper discusses how a tele-rehabilitation program using home tele-monitoring may empower patients with chronic obstructive pulmonary disease (COPD). The paper is based on preliminary findings from an ongoing research and innovation project, called “Tele-homecare, chronic patients and the integrated healthcare system” (the TELEKAT project) that employs triple interventions related to patients, professionals, and the organization of care. The ways COPD patients make use of home tele-monitoring in the TELEKAT project points to the relevance of a concept of empowerment rooted in ideologies of social action, and focusing on the improvement of both personal and social conditions at the intersection of individual, organizational and community development.

The sharing of clinical information between ehealth systems requires a common terminology, and SNOMED CT is seen as an acceptable solution for this task. Widespread adoption of SNOMED CT may mean that other terminologies, particularly those of citizens and patients, are sidelined or ignored. This paper considers the role of a citizen's “voice” in a connected ehealth world.

Introduction of electronic lab test ordering and reporting corresponding results between laboratories when exchanging special tests for analysis in service labs, instead of manual paper based workflow, have reduced the fault rate by a factor 10 and reduced reporting time by 2 days compared to the manual workflow. Retyping orders and results into different IT systems is not longer needed as all 9 different labsystems in more than 60 laboratories are using the same standards and procedures resulting in full interoperability. The solution, challenges, implementation process and outcome is described in the paper.

This article describes a comparative study within intensive care where possibilities for quality monitoring have been examined regarding the data input. The study compared the results of making quality statistics based on ICD10 and on SNOMED CT. The article describes the method deployed for defining the subset used in the study and how the data comparison has been established. The study shows that the use of a more granulated, precise and well defined terminology used in daily clinical work can help clinicians doing better quality monitoring and quality development and at the same time may reduce time and costs in quality management. The study shows further that the use of an international terminology can increase the possibilities of international benchmarking and research. The article ends up by drawing attention to some challenges which must be dealt with especially regarding reimbursement.

The paper describes the security concerns related to Electronic Health Records (EHR) both in registration of data and integration of systems. A description of the current state of EHR systems in Iceland is provided, along with the Ministry of Health's future vision and plans. New legislation provides the opportunity for increased integration of EHRs and further collaboration between institutions. Integration of systems, along with greater availability and access to EHR data, requires increased security awareness since additional risks are introduced. The paper describes the core principles of information security as it applies to EHR systems and data. The concepts of confidentiality, integrity, availability, accountability and traceability are introduced and described. The paper discusses the legal requirements and importance of performing risk assessment for EHR data. Risk assessment methodology according to the ISO/IEC 27001 information security standard is described with examples on how it is applied to EHR systems.

In the last few years, Electronic Health Record (EHR) systems have received a great attention in the literature, as well as in the industry. They are expected to lead to health care savings, increase health care quality and reduce medical errors. This interest has been accompanied by the development of different standards and frameworks to meet EHR challenges. One of the most important initiatives that was developed to solve problems of EHR is IHE (Integrating the Healthcare Enterprise), which adapts the distributed approach to store and manage healthcare data. IHE aims at standardizing the way healthcare systems exchange information in distributed environments. For this purpose it defines several so called Integration Profiles that specify the interactions and the interfaces (Transactions) between various healthcare systems (Actors) or entities. Security was considered also in few profiles that tackled the main security requirements, mainly authentication and audit trails. The security profiles of IHE currently suffer two drawbacks. First, they apply end point security methodology, which has been proven recently to be insufficient and cumbersome in distributed and heterogeneous environment. Second, the current security profiles for more complex security requirements are oversimplified, vague and do not consider architectural design. This recently changed to some extend e.g., with the introduction of newly published white papers regarding privacy [5] and access control [9]. In order to solve the first problem we utilize results of previous studies conducted in the area of security-aware IHE-based systems and the state-of-the-art Security-as-a-Service approach as a convenient methodology to group domain-wide security needs and overcome the end point security shortcomings.

Patient care is a complex process with different providers located in various institutions co-operating within an integrated health environment. In spite of technical improvements in medical care, patient information is usually exchanged by paper. Digital and timely communication between regional care providers can improve the exchange of information. Different systems and missing data standards are challenges that have to be met. ByMedConnect, a project sponsored by the Bavarian State Ministry of the Environment and Public Health, develops and demonstrates a communication solution based on the EN 13606 standard. In a first step the dataset, which will be exchanged by the care providers, is defined. ByMedConnect develops the dataset in cooperation with practicing clinicians and converts it via modeling tools into archetypes that provide the base for reliable cross-sector communication. Existing heterogeneous systems are integrated via a dedicated module that transforms legacy data into a normalized representation. Information provided in a standardized form thereby enables semantic interoperability between different systems and allows medical add-on applications to connect. A secure digital communication network guarantees easy and direct data sharing. ByMedConnect aims to evaluate the achieved theoretical preliminary work in practice and to draft approaches, which can be applied beyond the pilot application.

The objective of this study is to design and implement a common-gateway oriented mediator to solve the health data interoperability problems that exist among heterogeneous health information systems. The proposed mediator has three main components: (1) a Synonym Dictionary (SD) that stores a set of global metadata and terminologies to serve as the mapping intermediary, (2) a Semantic Mapping Engine (SME) that can be used to map metadata and instance semantics, and (3) a DB-to-XML module that translates source health data stored in a database into XML format and back. A routine admission notification data exchange scenario is used to test the efficiency and feasibility of the proposed mediator. The study results show that the proposed mediator can make health information exchange more efficient.

Sharing information and knowledge among heterogeneous health information systems requires semantic interoperability. Most integration projects address semantic interoperability by implementing HL7 version 3 standard interfaces. However, it is challenging to achieve computable semantic interoperability with HL7 because of i) the complexity of the standard, requiring HL7 experts in the interface implementation process ii) inconsistencies and overlapping of the different HL7 information models (RIM, D-MIMs, R-MIMs, C-METs), and iii) instability of the different HL7 version 3 models. In this paper, an ontology-based service for health systems´ semantic interoperability is proposed. This service includes three main components: i) the conceptual model formalization component, responsible to represent the conceptual information models of the applications to be integrated as formal application ontologies; ii) the ontology mapper component; responsible to realize the semantic mapping between the formal application ontologies using a domain ontology, therefore solving inconsistencies found in the source application ontologies; (iii) the automatic interface generator, responsible to create and to maintain HL7 version 3 interfaces. The service presented in this paper is primary focused on the implementation of HL7 interfaces to integrate legacy systems. However being supported in an ontology-based mapping of HL7 information models, it can also support semantic interoperability among healthcare services and applications.

Working interoperability not only requires harmonized system's architectures, but also the same interpretation of technical specifications in order to guide the development process. This paper analyzes the commonly used terms to introduce different kinds of coded concepts by an alignment with the Generic Component Model (GCM).

The paper describes several classification systems that could improve patient safety through semantic interoperability among contemporary electronic health record systems (EHR-Ss) with support of the HL7 v3 standard. We describe a proposal and a pilot implementation of a semantic interoperability platform (SIP) interconnecting current EHR-Ss by using HL7 v3 messages and concepts mappings on most widely used classification systems. The increasing number of classification systems and nomenclatures requires designing of various conversion tools for transfer between main classification systems. We present the so-called LIM filler module and the HL7 broker, which are parts of the SIP, playing the role of such conversion tools. The analysis of suitability and usability of individual terminological thesauri has been started by mapping of clinical contents of the Minimal Data Model for Cardiology (MDMC) to various terminological classification systems. A national-wide implementation of the SIP would include adopting and translating international coding systems and nomenclatures, and developing implementation guidelines facilitating the migration from national standards to international ones. Our research showed that creation of such a platform is feasible; however, it will require a huge effort to adapt fully the Czech healthcare system to the European environment.

In this paper, we present the ResearchEHR project. It focuses on the usability of Electronic Health Record (EHR) sources and EHR standards for building advanced clinical systems. The aim is to support healthcare professional, institutions and authorities by providing a set of generic methods and tools for the capture, standardization, integration, description and dissemination of health related information. ResearchEHR combines several tools to manage EHR at two different levels. The internal level that deals with the normalization and semantic upgrading of exiting EHR by using archetypes and the external level that uses Semantic Web technologies to specify clinical archetypes for advanced EHR architectures and systems.

Since the approval of the CEN EN13606 norm for the electronic health record communication, a growing interest around the application of this specification has emerged. The main objective of the norm is to serve as a mechanism to achieve the semantic interoperability of clinical data. This will require an effort to use common terminologies, to normalise the clinical knowledge domain and to combine all these formalisations with the existing information systems. This paper presents a methodology and developed tools to reach the seamless semantic interoperability of health data in legacy systems and several study cases where the developed framework has been applied.

Background: The allure of interoperable systems is that they should improve patient safety and make health services more efficient. The UK's National Programme for IT has made great strides in achieving interoperability; through linkage to a national electronic spine. However, there has been criticism of the usability of the applications in the clinical environment. Method: Analysis of the procurement and assurance process to explore whether they predetermine usability. Results: Processes separate developers from users, and test products against theoretical assurance models of use rather than simulate or pilot in a clinical environment. The current process appears to be effective for back office systems and high risk applications, but too inflexible for developing applications for the clinical setting. Conclusions: For clinical applications agile techniques are more appropriate. Usability testing should become an integrated part of the contractual process and be introduced earlier in the development process.