Ebook: e-Health Across Borders Without Boundaries

This volume contains the proceedings of the 11-th EFMI Special Topic Conference that will be held in Laško, Slovenia on 14 and 15-th of April 2011. The EFMI STC 2011 is an important international forum for presenting results of current scientific work in health-informatics processes, systems, and technologies.

Achievements in this area will be introduced to a global 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 2011 was organized by the European Federation of Medical Informatics (EFMI) in cooperation with Slovenian Medical Informatics Society (SDMI). It follows previous conferences in Bucharest, Romania (2001), Nicosia, Cyprus (2002), Rome, Italy (2003), Munich, Germany (2004), Athens, Greece (2005), Timişoara, Romania (2006), Brijuni Island, Croatia (2007), London, UK (2008), Antalya, Turkey (2009) and Reykjavik, Iceland (2010).

The theme of the STC 2011 is “E-salus trans confinia sine finibus – e-Health across Borders without Boundaries”, addressing a range of important aspects of cross-border e-Health services, like Knowledge Representation, Patient Empowerment, Social Care, or Cross-border Interoperability. The EFMI Working Groups that are scientifically supporting the conference are “Healthcare Informatics for Interregional Cooperation”, “Primary Care Informatics”, “Electronic Health Records”, and “Security, Safety and Ethics”.

The objective of the conference, reflected in the contents of the present volume, was to highlight health-related communication and collaboration at regional, national, and international level. Achieving and maintaining cross-border interoperability of electronic health record systems implies managing the continuous process of change and adaptation of a multitude of elements within and across electronic infrastructures in neighboring countries.

The proceedings volume opens with excellent keynote and invited contributions covering cross-border e-Health from international perspective, p-Health interoperability, and education across borders. The volume contains 21 papers from specialists of the field and also PhD papers continuing the good EFMI tradition encouraging young scientists to participate and present valuable work. The papers have been selected by the Scientific Program Committee (SPC) out of 41 submissions of papers, posters, and workshop proposals sent by experts from 20 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-chairs are especially thankful to all reviewers listed in the proceedings.

The scientific topics presented in the proceedings comprise interregional health information systems and applications, cross-border e-Health projects, patient and cross-border e-Health systems, multi-language and cultural issues in e-Health system, international standardization, assessment of e-Health systems, safety and security aspects of interconnected e-Health systems, e-communications in a global community, and cross-border education in health informatics.

The topics presented at EFMI STC 2011 are interdisciplinary in nature and consequently 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, as well as representatives of industry and consultancy in the various health fields.

74 researchers, residing in 16 countries from Europe, North America, and Asia have reported their results in this volume. The EFMI STC 2011 has been completed through 9 posters presented in a special session, and 3 workshops.

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 Slovenian Ministry of Health and HL7 International for sponsoring the print of the proceedings.

Lăcrămioara Stoicu-Tivadar, Bernd Blobel, Tomaž Marčun, Andrej Orel

(Editors)

Acknowledgement. The editors are indebted to Ivan Eržen, SDMI President for hosting the conference, to Mojca Paulin, Danila Perhavec and Nina Dolenc for managing the conference Website, the registration process and extended communications. They thank Thomas Schabetsberger for facilitating the online congress management. Furthermore, they are grateful to Mihaela Vida from University “Politehnica” Timişoara for her careful work in formatting the proceedings on hand.

Establishing sustainable telemedicine has become a goal of many developing countries around the world. Yet, despite initiatives from a select few individuals and on occasion from various governments, often these initiatives never mature to become sustainable programs. The introduction of telemedicine and e-learning in the Balkans has been a pivotal step in advancing the quality and availability of medical services in a region whose infrastructure and resources have been decimated by wars, neglect, lack of funding, and poor management. The concept and establishment of the International Virtual e-Hospital (IVeH) has significantly impacted telemedicine and e-health services in Kosova. The success of the IVeH in Kosova has led to the development of similar programs in other Balkan countries and other developing countries in the hope of modernizing and improving their healthcare infrastructure. A comprehensive, four-pronged strategy developed by IVeH “Initiate-Build-Operate-Transfer” (IBOT), may be a useful approach in establishing telemedicine and e-health educational services not only in developing countries, but in developed countries. The development strategy, IBOT, used by the IVeH to establish and develop telemedicine programs is described. IBOT includes assessment of healthcare needs of each country, the development of a curriculum and education program, the establishment of a nationwide telemedicine network, and the integration of the telemedicine program into the very core of healthcare infrastructure. The end point is the transfer of a sustainable telehealth program to the nation involved. By applying IBOT, a sustainable telemedicine program of Kosova and Albania has been established as an effective prototype for telemedicine in the Balkans. Once fully matured, the program is transitioned to the Ministry of Health, which ensures the sustainability and ownership of the program. Similar programs are being established in Macedonia, Montenegro and other countries around the world. The IBOT model has been effective in creating sustainable telemedicine and e-health integrated programs in the Balkans and may be a good model for establishing such programs in developing countries.

Nowadays, eHealth and pHealth solutions have to meet advanced interoperability challenges. Enabling pervasive computing and even autonomic computing, pHealth system architectures cover many domains, scientifically managed by specialized disciplines using their specific ontologies. Therefore, semantic interoperability has to advance from a communication protocol to an ontology coordination challenge including semantic integration, bringing knowledge representation and artificial intelligence on the table. The resulting solutions comprehensively support multi-lingual and multi-jurisdictional environments.

With the overall growth of informatics, the medical education system should also provide programs at both graduate and post-graduate levels. While there is a wide consensus as to the importance of this urgent need, several factors slow down the construction and operation of effective education programs in medical and nursing schools. The increasing need for better and more comprehensive training in informatics is strongly limited by several factors including undefined output skills, tight time frame etc. An efficient development of partnerships within the health care system assumes that all professionals involved must possess strong informatics and interpersonal knowledge, and skills reaching beyond their own individual fields. There is an emerging need to define the basic skills and knowledge for each level of the health care education. Trans-border cooperation offers a unique opportunity for the establishment of common criteria for basic skills and knowledge, via joint discussions, collaborative thinking and concerted action.

The perception that an individual holds about his place in life, which depends upon his culture and values, defines this individual's Quality of Life (QoL). When applied in a health context this known as: Health-Related Quality of Life (HRQoL). The assessment of HRQoL is a Medical goal; it is used in clinical research, medical practice, health-related economic studies and in planning health management measures and strategies. Obtaining a patient self-assessment with QoL measuring instruments on the platform developed in this project, through user-friendly software, aids the study, promotes the creation of databases, and accelerates its statistical treatment. The possibility of graphically representing results that physician needs to analyze, immediately after the answer collection, makes this assessment a diagnosis instrument ready to be used routinely in clinical practice. Knowledge Management Systems (KMS) applied to this context enable knowledge creation and storage, and guide therapeutic decisions.

A study is presented for the detection of nicotine impact in different cigarette type, using recorded data and Computational Intelligence techniques. Recorded puffs are processed using Continuous Wavelet Transform and used to extract time-frequency features for normal and abnormal puffs conditions. The wavelet energy distributions are used as inputs to classifiers based on Adaptive Neuro-Fuzzy Inference Systems (ANFIS) and Genetic Algorithms (GAs). The number and the parameters of Membership Functions are used in ANFIS along with the features from wavelet energy distributionare selected using GAs, maximising the diagnosis success. GA with ANFIS (GANFIS) are trained with a subset of data with known nicotine conditions. The trained GANFIS are tested using the other set of data (testing data). A classical method by High-Performance Liquid Chromatography is also introduced to solve this problem, respectively. The results as well as the performances of these two approaches are compared. A combination of these two algorithms is also suggested to improve the efficiency of this solution procedure. Computational results show that this combined algorithm is promising.

Archetypes model individual EHR contents and build the basis of the dual-model approach used in the ISO/EN 13606 EHR architecture. We present an approach to create archetypes using an iterative development process. It includes automated generation of electronic case report forms from archetypes. We evaluated our approach by developing 128 archetypes which represent 446 clinical information items from the diabetes domain.

The paper presents a method connecting medical databases to a medical decision system, and describes a service created to extract the necessary information that is transferred based on standards. The medical decision can be improved based on many inputs from different medical locations. The developed solution is described for a concrete case concerning the management for chronic pelvic pain, based on the information retrieved from diverse healthcare databases.

This paper reports on the process of the Swiss national strategy to define and implement eHealth. Switzerland is a federal political organization with 26 cantons that are autonomous for the health legal framework. Switzerland must also provide support for four national languages. Thus, this experience addresses many challenges that are experienced at the European level in a much larger scale. Also, Switzerland benefits from the major projects ongoing in Europe, such as epSOS, to define its own strategy.

Patient portals provide patients with access to a provide-managed electronic health record (EHR). They may provide an interesting approach to increase patient empowerment. The objective of this paper is to provide a first overview of the state-of-the-art and the impact of patient portals. Based on a systematic literature search, we identified five evaluation studies on patient portals. These studies demonstrate only little effect of patient portals on patient empowerment.

Through this article, we point out the unavoidable empowerment of patients with regard to their personal health record and propose the mixed management of patients' medical records. This mixed management implies sharing responsibilities between the patient and the Medical Practitioner (MP) by making patients responsible for the validation of their administrative information, and MPs responsible for the validation of their patients' medical information. We propose a solution to gather and update patients' administrative and medical data in order to reconstitute patients' medical histories accurately. This method is based on two processes. The aim of the first process is to provide patients administrative data, in order to know where and when they received care (name of the health structure or health practitioner, type of care: outpatient or inpatient). The aim of the second process is to provide patients' medical information and to validate it under the responsibility of the MP with the help of patients if needed. During these two processes, the patients' privacy will be ensured through cryptographic hash functions like the Secure Hash Algorithm, which allows the pseudonymization of patients' identities. The Medical Record Search Engine we propose will be able to retrieve and to provide upon a request formulated by the MP all the available information concerning a patient who has received care in different health structures without divulging the patient's true identity. Associated with strong traceability of all access, modifications or deletions, our method can lead to improved efficiency of personal medical record management while reinforcing the empowerment of patients over their medical records.

Informatization has been bringing important, quick and extensive changes into the healthcare environment for years. Individual systems still represent isolated information islands; however, the need for interconnectivity and mutual accessibility has become more pronounced. On the one hand, integration of systems brings numerous, financially measurable advantages, and on the other hand, personal information in such systems becomes more vulnerable. Providing personal information protection is therefore the permanent task of informatisation and, with elimination of national borders and integration of national systems, it is becoming a challenge from the legal, organisational, technical and financial standpoints.

Machines that perform linguistic medical image interpretation are based on fuzzy algorithms. There are several frameworks that can edit and simulate fuzzy algorithms, but they are not compatible with most of the implemented applications. This paper suggests a representation for fuzzy algorithms in XML files, and using this XML as a cross-platform between the simulation framework and the software applications. The paper presents a parsing algorithm that can convert files created by simulation framework, and converts them dynamically into an XML file keeping the original logical structure of the files.

The Critical Home Care System – CHCS, we propose, achieves permanent advising, frequent control appointments and quick reaction to critical conditions by constant remote monitoring of patient's vital signs from the hospital, while staying at his home. Physicians react properly to the developing condition, contacting the patient or a member of the household, or sending an ambulance in an emergency. The CHCS additionally provides constant inspection of the patient's condition to the ambulance doctor in emergency situations and to the urgent centre staff to prepare better for accepting the patient, enabling a fully connected emergency intervention. In this paper we will concentrate on the data flow during the emergency intervention in this highly collaborative system.

A major obstacle in ensuring ubiquitous information is the utilization of heterogeneous systems in eHealth. The objective in this paper is to illustrate how an architecture for distributed eHealth databases can be designed without lacking the characteristic features of traditional sustainable databases. The approach is firstly to explain traditional architecture in central and homogeneous distributed database computing, followed by a possible approach to use an architectural framework to obtain sustainability across disparate systems i.e. heterogeneous databases, concluded with a discussion. It is seen that through a method of using relaxed ACID properties on a service-oriented architecture it is possible to achieve data consistency which is essential when ensuring sustainable interoperability.

With the remarkable advantages of thin-client computing (TCC) on security enhancement and cost reduction, the TCC architecture seemed appropriate for EPR utilization in cross-border e-health systems. The advantage in less consumed network bandwidth, however, still remains quantitatively unidentified at present. This study aimed to estimate the network traffic required in using EPR on WAN environments through the comparison of TCC and server-client (SC) models The results indicated that one of representative TCC applications required much less network bandwidth than the conventional SC model. Further studies will be focused on the verification of the adopted scenarios and a combination of applications that would affect the estimation of the network bandwidth.

This is Me is the largest youth counseling web portal in Slovenia, providing teens with a friendly, simple, fast, free, anonymous and efficient public access to expert information and problem-solving assistance. Network of web counselors includes 38 experts (medical specialists, psychologists, social pedagogues, social workers, and teachers), who are volunteers from 12 different institutions. In the course of ten years, experts have answered almost 21,000 questions about dilemmas and problems faced by teens. The program was created by the Institute of Public Health Celje. This is Me supports adolescents in their problem-solving efforts. The program focuses on development of positive mental health, with emphasis on self-image, social and life skills. The program responds to the adolescents needs and makes efficient use of web technology. Youth web portal is a response to the current teen lifestyle. Most users are between ages of 13 and 18.

The present study reports the results of the evaluation of an e-learning CME course in the field of Occupational Medicine. In particular the following aspects have been investigated: If and how the course contents have met the educational users' needs; The effectiveness of the course in terms of knowledge improvement; Users' behaviour. Attendance data and results of a sample of 1128 attendees have been analyzed via ad hoc developed tools for direct inspection of Moodle CMS database. The results document the effectiveness of the e-learning course, as regards meeting the educational needs of physicians and also the improvement in terms of knowledge and problem solving skill acquisition. Users' behaviour has revealed a certain tendency for passing the tests, more than for pursuing the best possible result. Interaction with the tutor is low.

This paper suggests a solution to acquire medical data from hospitals located in a region (addressing especially the DKMT Euroregion), and then perform data mining. The medical data from the hospital databases are exported in XML format, according to HL7 CDA standard. Afterwards, they are automatically centralized on a server in a database using web services calls. The data will be analyzed with the data mining tool WEKA. Data of interest are converted into ARFF format and loaded into WEKA. The next stage consists in preprocessing and analyzing the data based on the algorithms provided by WEKA, having as a goal several relevant medical conclusions. WEKA application interface has been improved to facilitate the process of performing predictions.

The use of integrated Hospital Information Systems is related with many benefits for the healthcare system, increasing the effectiveness of the provided services and assuring quality of care. Aim of this study is to investigate the types of Information Systems, the level of integration and the problems identified during the implementation phase, in three public hospitals. The above are expected to contribute to the understanding of the organizational, human resource and technical factors related with the successful implementation of a hospital IS. In order to investigate those elements, an assessment questionnaire was developed and completed by nine hospitals IT employees of the three hospitals. In addition, open interviews were organized with the same employees to further formulate an overall aspect, while in one hospital case, observation and discussion with four different categories of involved staff was undertaken. It was found that the implementation problems are mainly related with the underfunding, inadequate use of standards, lack of skilled IT experts, insufficiently trained personnel and users' reserve. The problems may be tackled with a supportive hospital administration committed to the successful implementation. The external contracting company working on its own, without any participation of the hospital IT department seems to be a failure recipe. It is evident that an active management support and skillful hospital IT employees, are expected to result to success stories during the implementation of integrated hospital information systems.

The central information system of primary health care of the Republic of Croatia is in an early stage of implementation which for now covers integration of all family doctors' offices into a single comprehensive eHealth network connecting their software solutions with the national payer institute and public health authority. Measuring the quality and efficiency of information systems at an early stage of development is a very difficult task. The main goal of this work is establishing the foundation for a formal methodology to measure and quantify the experience of family doctors in the current use of this system. A questionnaire has been created to support the work which, on one side carefully follows our assumptions for quality criteria, and on the other collects valuable input from the users of the technology and solutions implemented. Our work is closely aligned with worldwide accepted standards and recommendations carefully analyzed and localized to reflect the current environment and health policy. This paper presents some preliminary results based on the survey conducted with family doctors on the field.