Ebook: Medical Informatics in a United and Healthy Europe

This volume contains the proceedings of the Twenty-second International Conference on Medical Informatics Europe MIE 2009, that will be held in Sarajevo, Bosnia and Herzegovina, from 30 August to 2 September 2009. The MIE 2009 is the European's leading forum for presenting the 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 and technologies, and current and future applications.

The MIE 2009 conference was organized by the European Federation for Medical Informatics (EFMI) in cooperation with the Society for Medical Informatics of Bosnia and Herzegovina (BHSMI). It follows the previous conferences in Cambridge (1978), Berlin (1979), Toulouse (1981), Dublin (1982), Brussels (1984), Helsinki (1985), Rome (1987), Oslo (1988), Glasgow (1990), Vienna (1991), Jerusalem (1993), Lisbon (1994), Copenhagen (1996), Porto Carras (1997), Ljubljana (1999), Hannover (2000), Budapest (2002), Saint Malo (2003), Geneva (2005), Maastricht (2006), and the conference 2008 in Gothenburg.

The proceedings contain 213 contributions to the MIE 2009 conference. They cover all presentations which are part of the scientific program of MIE 2009, among them 150 full paper presentations with five pages each, 21 student paper presentations with one page each (which was quite difficult for our students!), 21 presentations that will be presented as posters but received five pages each in the proceedings, and 14 workshop descriptions with again five pages each. Furthermore, seven keynote addresses from eminent scientists coming from Europe and overseas are also included into this proceedings. The papers included were selected by an International Scientific Programme Committee (SPC) out of 324 submissions after careful review by three international reviewers for every single submission. The SPC chair and his two co-chairs (K.-P. Adlassnig, B. Blobel, and J. Mantas) are especially thankful to all their reviewers whose efforts are highly estimated. As a specific token of appreciation and to recognize their work not only anonymously, the MIE 2009 reviewers' names are listed in the proceedings. The – often extended – recommendations of the reviewers were incorporated in the final texts, and careful language revision was carried out to achieve a high quality of presentation.

The scientific topics present in this proceedings volume range from national and trans-national eHealth roadmaps, health information and electronic health record systems, systems interoperability and communication standards, medical terminology and ontology approaches, and social networks to Web, Web 2.0, and Semantic Web solutions for patients, health personnel, and researchers. Furthermore, they include quality assurance and usability of medical informatics systems, specific disease management and telemedicine systems, including a section on devices and sensors, drug safety, clinical decision support and medical expert systems, clinical practice guidelines and protocols, as well as issues on privacy and security. Moreover, bioinformatics, biomedical modeling and simulation, medical imaging and visualization and, last but not least, learning and education through medical informatics systems are parts of the included topics.

There are several trends and developments that can be recognized by carefully examining the single contributions to the various topics:

First, interoperability and data exchange standards become most important. Systems must and will be interconnected to each other: locally, nationally, and transnationally. Medical information and electronic health record systems will be the first to benefit.

Second, ontologies are being developed to an increasing extent. Medical data items and medical concepts (terms) are being represented, arranged, and interconnected in standardized collections of “the phenomena that exist” (=ontology) in medicine. By doing so, not only the medical vocabulary that is used in an application but also the semantics of applied items and terms are defined.

Third, Web applications allow to share medical information and knowledge by many users – researchers, staff, and patients – close or far. Web 2.0 applications deliberately involve the user, and the Semantic Web provides even knowledge inferences over remote knowledge places and allows to develop futuristic systems.

Fourth, clinical decision support systems in all possible manifestations are and will increasingly be demanded by physicians and patients equally – after patients' medical data from the many data sources are finally digitized and made available. They will provide huge impact on medical workflow and patient care to the benefit of the patient, the caring physician, and the financing healthcare bodies.

Most of the topics presented at MIE 2009 are interdisciplinary in nature and may be 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.

The MIE 2009 conference gathers participants all over the world, although mainly Europeans. This is reflected by the authors of the proceedings' contributions; altogether 931 researchers have reported their results in this volume (double author entries have not been eliminated). By considering the nationality of the authors, 38 different countries from Europe, North and South America, Asia, Africa, and Australia can be counted to have contributed to this volume.

The great variety of scientific topics and countries that will be present should guarantee both a highly interesting international Medical Informatics Europe MIE 2009 conference in Sarajevo in August/September and a fruitful study of the proceedings by those interested in Medical Informatics.

Acknowledgements. The editors are most grateful to Andrea Rappelsberger for her careful and extensive work in the preparation of this proceedings. We are thankful to Susanne Rom, whose many efforts are appreciated. (Both are with the SPC Office in Vienna, Austria.) Without their help it would not have been possible to produce such a valuable and comprehensive book.

Klaus-Peter Adlassnig, Vienna; Bern Blobel, Regensburg; Joh Mantas, Athens; Izet Masic, Sarajevo (Eds.) , July 2009

European medical informatics professionals traditionally gather at congresses of the European Federation for Medical Informatics (EFMI) named “Medical Informatics Europe – MIE”. After more than three decades of successive organization of these congresses, some important points of their history of are presented. As the MIE Congress in Sarajevo, organized by the Society for Medical Informatics of Bosnia and Herzegovina (BHSMI), is the third EFMI event in the western part of South-East Europe, a short review of the development of medical informatics in this part of Europe, together with important events in its history, will shortly be presented.

For much of the world, truly productive and functional Electronic Health Record Systems (EHRs) remain an elusive goal of the future. Opportunities abound from the visibility provided by the availability of Health Information Technology funding in the U.S. and other countries of the world. Now is the time to seize the initiative to move from the past to the future to design HIT systems that meet the specific needs of each nation of the world in a way that is obtainable and affordable, and that provides an immediate return on investment. We need to move from an electronic system based on the paper-system to an empowering system based on available technology. We need to recognize that the EHR is not just for data storage but needs to become an intelligent, active partner with the healthcare provider and the patient to enhance health. This paper describes the current state of EHRs and addresses challenges for moving into the future.

Our societies are changing worldwide. Life expectancy has increased in many societies and this increase is often related to an increase in the relative amount of elderly persons. Health-enabling technologies are information and communication technologies for creating sustainable conditions for self-sufficient and self-determined lifestyles. Sensor-enhanced health information systems play a major role in this context. The question is discussed, whether health-enabling technologies for pervasive health care can be regarded as a pivotal field for future medical informatics research and education.

Chronic diseases cause a major problem to the modern health care services world wide. Our work describes a new approach to tackle the problem of the chronically ill patients, by using information and communication technology (ICT) for patient's empowerment and managed their care. Our research, which is conducted with close cooperation with the health maintenance organizations and is still continuing, is based on a “bottom-up” approach and is also aimed at changing paradigms, well established in the western healthcare services.

Pressing needs of cost-effectiveness in healthcare and opportunities of emerging electronic health record technologies offer unprecedented chance for progress. Ongoing health care improvement and patient safety initiatives demand new information collection and communication technologies (e.g., Centers for Medicaid and Medicare Services, Joint Commission, National Patient Safety Foundation, public health surveillance). Particularly, desire for faster action and cost-effective health care drive unprecedented investments in electronic patient records worldwide. Recognizing these opportunities, many countries and the World Health Organization have launched several major health care improvement initiatives that are driven by new electronic record technologies. In the United States, historic $19 billion investment is provided through the American Recovery and Reinvestment Act of 2009. Models of sharing electronic patient data and citizen expectations for personal electronic health records will be reviewed. Regional health information networks and other information sharing initiatives depend on the interoperability of systems. Ultimately, the recent flood of health information standards needs to be balanced with actual interoperability opportunities. It is anticipated that the current policy discussions on the “meaningful use” of electronic health records will have major beneficial technical and also reimbursement implications.

Selected workflows combining computer-assisted teleplanning and navigation (including 3D-stereolithography) are presented. It is shown how interactive teleplanning of dental implants or optimization of a surgical treatment of large bone defects is done.

Clinical decision support (CDS) can impact the outcomes of care when used at the point of care in electronic medical records (EMR). CDS has been shown to increase quality and patient safety, improve adherence to guidelines for prevention and treatment, and avoid medication errors. Systematic reviews have shown that CDS can be useful across a variety of clinical purposes and topics. Despite broad national policy objectives to increase EMR adoption in the US, current adoption of advanced clinical decision support is limited due to a variety of reasons, including: limited implementation of EMR, CPOE, PHR, etc., difficulty developing clinical practice guidelines ready for implementation in EMR, lack of standards, absence of a central repository or knowledge resource, poor support for CDS in commercial EMRs, challenges in integrating CDS into the clinical workflow, and limited understanding of organizational and cultural issues relating to clinical decision support. To better understand and overcome these barriers, and accelerate the translation of clinical practice guideline knowledge into CDS in EMRs, the CDS Consortium is established to assess, define, demonstrate, and evaluate best practices for knowledge management and clinical decision support in healthcare information technology at scale – across multiple ambulatory care settings and EHR technology platforms.

A description of the newest Romanian eHealth project is presented. The SIUI project – Integrated Unique Information System of the National Health Insurance House was tested on three pilot units in 2007 and generalized in 2008, becoming mandatory for all healthcare units in 2009. The implementation process revealed some difficulties and the user acceptance is still low. A couple of supporting measures, including educational programs, are finally discussed.

Dedicated primary care research networks aim to gather and analyse data collected from general practioners' (GPs) electronic health records (EHRs). ResoPrim (2003–2008) was a Belgian multidisciplinary research project which was set up to provide recommendations for facilitating the organisation and management of these primary care research networks, assessing and improving opportunities for researchers working with available data from EHRs, and stimulating the involvement of GPs in such networks. This paper provides a short description of Resoprim's global methodology (which included 2 pilot phases involving 64 GPs and 6 different software systems), followed by the project's final recommendations.

Ten years have passed since the design of the Slovenian health insurance card system, which has been used daily in the entire Slovenian health sector for the last eight years. Eventually, however, a growing number of business and technical reasons arose for the gradual renovation of the system. Therefore, in 2006, on the basis of a study of feasible solutions, the Health Insurance Institute of Slovenia prepared a concept for renovation and began modernising several system components, including the new cards as the key security elements of the system. In September 2008, the first new professional cards were issued; in November 2008, the release of the new health insurance cards began.

In 2009 the Slovenian healthcare and health insurance sector is implementing a national system for the secure on-line exchange of administrative and medical data. All general practitioners, hospitals, pharmacies and other healthcare providers will connect their information systems to this electronic service. Solutions have been built upon, as well as the renovation of the existing well recognized national Health Insurance Card System. Using the On-line System, health professionals directly access centrally stored patient medical data (data on prescriptions issued, on medical technical aids, pregnancy, etc), and a comprehensive set of administrative data. The on-line system is a solid infrastructure for the further development of applications for direct data exchange between the information systems of healthcare providers. It has significant benefits for patients, healthcare professionals and health administration.

Sweden has as part of its national eHealth strategy decided to develop a generic National Information Structure. It is based on three models: The Generic Process, Concepts and Information model. The models are intended to be specialised for various forms of care including social and community care. The importance of interacting models developed in an iterative approach with user involvement is emphasised.

Currently documentation processes for routine patient care and clinical research are kept separate (dual source). Due to overlaps between routine and research documentation, a single source approach provides opportunities to improve efficiency of medical documentation given the large workload of physicians related to documentation. Organisational, technical and regulatory conditions need to be considered for the design of single source systems. We present a single source architecture for clinical studies and provide results from pilot implementations.

There is understandable concern about low uptake and sub-optimal use of health informatics systems, which is often caused by a lack of shared objectives and values by the different stakeholders. Moreover, all parties work to different ethical codes. For future success, all need to work to the same values and objectives, measured by agreed outcomes data, creating robust evidence. The Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI), by being recently endorsed by IMIA, EFMI and the EQUATOR Network, may therefore provide a generic objectives framework to help achieve common goals.

This paper describes the design and definitions of an information system (SIGLIC) to support a new integrated management program (SIGA) to improve the access to surgery in Portugal. SIGIC, the Ministry of Health's agency responsible for access to surgery management, started re-thinking the system in 2005 by re-defining key processes and workflows. The designed information system SIGLIC integrates all hospitals with surgery with every other hospital, where it picks the data to help manage optimal solutions for each patient. The results since 2005 are very interesting and show the importance of an integrated information system to overcome the bureaucracy in the system: it was noticed a 50% improvement in scheduled surgical episodes and a 49% reduction in waiting time.

This paper addresses the role of IT Governance in a Hospital Information System (HIS) management. ITIL is introduced as a best practice for supporting HIS development. Since IT Governance is extensive, we focused our study on an ITIL Assessment. The assessment was centred on IT Service Management, and which, according to our findings, is being carried inefficiently in Hospital São Sebastião. Although the literature quotes the many benefits brought by ITIL to the organizations, they all depend on how good the planning and implementing processes are. The implementation process itself is very complex and we focused our study on the assessment step. The ITIL assessment was crucial to identify IT Governance weakness; and it is a way for the organization to become consciousness about IT improvement priorities. The results were used to rethink HIS strategy in order to properly address the next challenges.

The Ministry of Health of Slovenia decided to support the introduction of two new organised screening programmes for cancer, one for breast and the other for colon cancer in 2005. This was an addition to the first, already running, programme for cervical cancer. Two of them are entrusted to the Institute of Oncology while the National CINDI programme takes care of the third one. Besides connection to some external public databases, cancer screening programmes require national Cancer Registry data. High quality and user friendly information support for citizens and medical professionals following doctrinal requirements and possible changes is a must.

Cancer is the second leading cause of death worldwide and in focus of epidemiological research. In Germany the cancer registration law stipulates an electronic report to the population-based cancer registry (PBCR). In this context the Comprehensive Cancer Centre Münster (CCCM) required a new concept to support the obligation to register cancer diseases. We analysed Hospital Information System (HIS) data structures related to cancer documentation and PBCR documents. Our main idea was to export available data items from the HIS and to convert them into the import format of the PBCR. We analysed HIS data and developed an XML-based converter to support an electronic reporting procedure. Using available HIS data can avoid redundant data entry and supports information workflow within the CCCM. HIS data can provide a secondary use beyond clinical routine in form of reporting, quality assurance and clinical research.

To assess the performance of vital status determination by record linkage between a hospital database and the French national mortality database with anonymised data in order to adhere to French legislation. Hospital database of the Institut Gustave Roussy (IGR), the largest cancer centre in France, and the French mortality databases from 1998–2004 were used for this record linkage. A phonetic code adapted to French language was first applied to identifiers. The last name, maiden name, all first names and the date of birth were then each rendered anonymous using irreversible hash coding. Record linkage, using the probabilistic method developed by Jaro, was based on four fields: the last name, first given name, date of birth and code of birth place. Other variables were used for further automatic and manual validation. Linkage results were very satisfactory for the 10,089 patients included: sensitivity was 94.8% and specificity 99.5%. The positive and negative likelihood ratios were respectively 190 and 0.05. The main causes of discordances were erroneous or incomplete information such as unrecorded maiden name in the hospital database. Results were improved by adding manual validation to electronic matching: sensitivity rose to 97.2% and specificity to 99.4%. Record linkage using anonymised data applied to large scale hospital data is possible and has good validity. This method offers new prospects for large prognostic studies based on hospital data provided that the diagnosis date is systematically recorded in the hospital database.

International cross-border private hospital chains need to apply the standards for foreign currency translation in order to consolidate the balance sheet and income statements. This not only exposes such chains to exchange rate fluctuations in different ways, but also creates added requirements for enterprise-level IT systems especially when they produce parameters which are used to measure the financial and operational performance of the foreign subsidiary or the parent hospital. Such systems would need to come to terms with the complexities involved in such currency-related translations in order to provide the correct data for performance benchmarking.

For research projects in preventive medicine a flexible information management is needed that offers a free planning and documentation of project specific examinations. The system should allow a simple, preferably automated data acquisition from several distributed sources (e.g., mobile sensors, stationary diagnostic systems, questionnaires, manual inputs) as well as an effective data management, data use and analysis. An information system fulfilling these requirements has been developed at the Center for Life Science Automation (celisca). This system combines data of multiple investigations and multiple devices and displays them on a single screen. The integration of mobile sensor systems for comfortable, location-independent capture of time-based physiological parameter and the possibility of observation of these measurements directly by this system allow new scenarios. The web-based information system presented in this paper is configurable by user interfaces. It covers medical process descriptions, operative process data visualizations, a user-friendly process data processing, modern online interfaces (data bases, web services, XML) as well as a comfortable support of extended data analysis with third-party applications.