Ebook: E-Health in Belgium and in the Netherlands

The MIC (Medische Informatica Congres, Médical Informaties Congress) has a long tradition in Belgium and in The Netherlands. It started in 1978 in Rotterdam and was foUowed in 1979 in Antwerp. For its 20^th edition, it is held in Brussels (5-7 December 2002).

MICs were organised since their beginning by two national societies for médical informaties: MIM in Belgium {Medische Informatica, Informatique Médicale) and VMBI in the Netherlands {Vereniging voo r informatie verwerking in de zorg). They attracted regularly up to 400 participants.

MIC 2002 is organised in association with the Telematics@health-care.be symposium of the Belgian Fédéral Ministry of Social Affairs and Public Health.

These two Conferences share new trends in health informaties, such as local standards for patient records and for hospital information Systems, messages exchanges and privacy protection, as well as on line health networks. This book deals also with more academie subjects like clinical research and e-learning, as well as with specific applications in relation to nursing, pharmacy and gênerai practice.

This collection of papers presents many timely new ideas and practical proposals.

We wish to acknowledge the work of all authors as well as of reviewers who selected the papers and made proposals to improve their quality. We thank also Mrs Dominique Dieng from INFOPOLE for her precious contribution in the support of the éditorial work, as well as Mrs Chris De Hollander and Mrs Dominique Pironet, for the technical editing.

We hope that these MIC 2002 proceedings will help to develop further collaboration in the field of health informaties in these two countries and in Europe.

F. H. Roger France

A. Hasman

E. De Clercq

G. De Moor

A standard is a set of agreements between all parties involved. Delivering healthcare is a matter of co-operation: healthcare can only be delivered in a responsible fashion when parties involved comply to standards. This becomes evident when a healthcare information infrastmcture is under development. The authors dehver a comprehensive introduction to standards which apply to the Electronic Healthcare Record (EHR) , describe work in progress of relevant standardisation committees and argue about future work of such committees in order to pursue a coherent healthcare information infrastmcture.

Computer based information Systems aim at improving knowledge, évaluation and management processes. Such tools are still developing in the non- profit sector. This paper aims at : a) reminding how to evolve from data to management information Systems b) describing how to build a population based health information System c) describing the concepts required for conceiving a retrieval System and a system for inserting data d) documenting the importance of conceiving the system not only from a user driven perspective, but also taking into account the requirements of an information management System.

The Dynamic Patient Simulator (DPS) is an interactive case-program. After solving the case, third year médical students filled in an anonymous questionnaire. In this study we tried to have insight in the students’ learning process and satisfaction. First results are presented. It seems that the Implementation of the case was experienced as positive. The time aspect should be scheduled better and students should have as much time as they want to solve the case.

To ensure the acceptance and routine use of information Systems in heathcare tight coupling is required between the work practices of potential end- users and the Systems functionalities and presentation of these functionalities via the user interface. The application of methods from cognitive engineering during requirement analysis may contribute to the support of healthcare work practice by computer Systems. We applied the think aloud method in combination with video analysis during the requirement analysis phase in designing a user interface for a patient information retrieval system. These methods provided a detailed insight in the infomiation needs of physicians and the way in which they search through this information in preparing a patient visit. Using these insights in end- users work practices in the early phase of user interface development may lead to a better fit between physicians’ work practices and the supporting computer System.

TENDO is a project conducted by the Department of Medical Informaties and Statistics of the Ghent University in the field of E-Leaming and more specificly E-Testing (Electronic, on line testing). At this stage, the main goal of Tendo is to measure the knowledge of (medical) students making use of the Internet. The on line Tendo E-Testing tooi has been used to examine students of the 4^th year studying Physical Therapy and Rehabilitation. The aim of this document is to give an overview of the features of E-Testing and more specificly of the Tendo product.

Background: Computerised decision support Systems (CDSS) can be categorised as either being inquisitive or non-inquisitive. The non-inquisitive System uses routinely entered electronic patient data, to generate patient specific feedback based on guidelines. The Dutch College of General Practitioners’ (DCGP) cholesterol guideline classifies patients into risk groups, eligible for screening. The availability of sufficient routinely recorded electronic patient data to classify patients according to the DCGP cholesterol guidehne is unknown.

Objective: To assess whether it is possible to classify patients according to the screening criteria of the DCGP cholesterol guideline, using data routinely recorded by general practitioners.

Methods: We analysed the DCGP cholesterol guideline to identify selection criteria for screening. These selection criteria were subsequently used to create a cohort of patient records eligible for screening in the Integrated Primary Care Information (IPCI) Database. We calculated incidence and prevalence of risk factors and selected patient records for active management according to the identified screening selection criteria.

Results: 145866 valid patient records were selected for classification. In the retrieved records 9741 (13.6%) males and 5756 (7.8%) females were identified for active management according to the selection criteria of the DCGP cholesterol guideline.

Conclusion: The classification of patients into risk groups, eligible for screening, according to the criteria of the DCGP cholesterol guideline using routinely recorded electronic patient data is feasible. Care should be taken when using only diagnostic codes, as it gives higher than expected incidence and prevalence of risk factors. Based on these findings we are currently building Cholgate, a non-inquisitive decision support system for cholesterol management.

In this paper we report on a study on the possible scenarios for the in- troduction of PACS that was conducted at the LUMC in 2002 by a workgroup. The results of this study should facilitate the decision on PACS to be taken by the management of the LUMC at a later stage. In this paper our main research question is to what extent the decisions to be made at the introduction of PACS can be derived from an information system architecture in place, and vice versa: how can these decisions help to refine an information system architecture that is still immature.

Of the information items that must be easily available to the different actors involved in the care process, radiological images are not the least important. While until recently it was not feasible to include these into the medical information system, this situation has changed. Still, emphasis in PACS (Picture Archiving and Communication Systems) is primarily on the technological aspects. In this paper, in contrast, we stress the importance of integration of images into the overall Workflow and into the overall medical record. We do so using illustrations from the PACS project of the University Hospitals Leuven. We briefly indicate that tight integration at the user interface level is needed, and that this requires more than standardized communication between Subsystems.

The study reported in this article examines the implementation of the same software in 3 emergency departments from different Belgian hospitals. It was experienced and perceived very differently as a failure or a success by the units’ staff. The software integrates different functionalities, which can be chosen and customized by some members of the units themselves. We will look at the three processes of inplementation to find out different plausible explanation for their ‘failure or success’. Our approach is developed through the qualitative methodology of case studies. The translation theory is presented as a renewal way of thinking the perceived ‘successful or failed’ implementation of a new information system and a guide for new project in emergency department.

Using the hospital’s drug prescription and distribution system as a guide, benefits and drawbacks of a medical activity management system that is tightly integrated with the supply chain management of a hospital will be discussed from the point of view of various participating healthcare actors.

The design and implementation of Clinical Information System architecture is presented. This architecture has been developed and implemented based on components following a streng underlying conceptual and technological model. Common Object Request Broker and n-tier technology featuring centralised and departmental clinical information Systems as the back-end store for all clinical data are used. Servers located in the “middle” tier apply the clinical (business) model and application rules. The main characteristics are the focus on modelling and reuse of both data and business logic. Scalability as well as adaptability to constantly changing requirements via component driven Computing are the main reasons for that approach.

VIZI and its successor NICTIZ (National ICT Institute for Healthcare) carried out a study to assess the status of ICT use in hospitals. The statutory obligation for the retention of care records and instructions was highlighted by the professional nursing institutions. Literature was studied to find out more about the contribution of nursing records to the care provided. Nursing records are kept in all hospitals, and keeping a good record is essential to the care. Nevertheless not much evidence was found to support the idea that the traditional way of keeping of keeping a nursing record has substantial positive effect on the care provided. It became clear however that Clinical Pathways does indeed seem to be promising as a protocol for treating patients and putting demands on registration, and to provide a clear method by which the electronic nursing record could be built up as a part of the integrated electronic patient record. By means of two questionnaires, one applied to suppliers and one applied to hospitals, the status of ICT in hospitals was addressed. It transpired that several suppliers are active in this area, but usually with general EPR Systems which have little dedicated functionality for nurses. The number of nurses in hospitals who are using computers on a regular basis is on the increase. It also transpired that most of the functions that are being used by nurses are general functions such as recording demographie patient data, roster planning, etc. Finally we asked the hospitals to send us information about their own projects. Some 20 projects where submitted, 10 of which were regarded as being significant. The best application was rewarded with a prize.

The Belgium Nursing Minimum Data Set (BNMDS) started nationally in 1988. It has to be updated to reflect the current évolution of health care. This document describes the firamework and methodology for this updating project. The main preoccupation of the research project is to update the existing instrument while avoiding an overload of additional items. A wide range and in-depth analysis of the existing data sets (BNMDS and related data sets) is prerequisite with a view to the development of relevant and effective nursing care indicators. New items and their registration are only acceptable when existing data are insufficient for the required indicators. Indicators relate to clinical nursing care as well as the management of nursing care, e.g. nursing care, nurse Staffing, variability of nursing care in view of hospitalization types. While the current indicators make the nursing care process visible only, the updated BNMDS and its indicators should pilot the appropriateness of hospital admissions and their modus, e.g. in-patient versus one-day, and length of stay, the quality of nursing care and the adequacy of nurse Staffing.

The project focuses on six care programs or clinical pathways: care of the elderly, intensive care, chronic care, pediatrics, cardiology and oncology. A first work package includes the development of new indicators and updating of existing ones, based on secondary data analysis of the existing BNMDS and related data sets. The second work package involves the establishment of Workgroups for each care program. The Workgroups wil l review, evaluate and fine-tune the proposals of the researchers. Finally, in work package three, the updated BNMDS wil l be tested in the hospital setting.

Specific aspects of the Belgian health care policy may have a direct or indirect effect on the way hospitals should develop their information system. This article illustrâtes three important aspects of this policy and their effects on the conceptual choices of a Hospital Information System.

Our Structured Data Entry application makes use of a domain specific data model. The principles governing the modeling of this data model, are similar to the requirements of the criteria underlying taxonomie Systems. Using the DSM-IV as reference source to create a data model for psychiatry, revealed a number of flaws in the criteria of this system, which potentially influence the reliability and validity of this taxonomie system. We conclude that the modeling process provides us with a powerful tool which can be used during the revision process of such Systems.

The focus of this study was to determine requirements for a general; pain EPR (electronic patient record), design this EPR and develop a prototype for demo purposes in pain clinics in the Netherlands. The specifications for this EPR were derived from the ‘Nijmegen Classification of Pain’, analysis of patient paper records and in-depth interviews with six anaesthesiologists, three physiotherapists and two psychologists. For development a generic configuration tool was used.

The actual EPR consisted of five components (two for the anaesthesiologists, one for the physiotherapist, one for the psychologist and one for the whole team). The five components comprised of numerous dialogues. The medical care process directed these dialogues.

Conclusions: The different organisational settings and the variability in provided patient care compromised the development of an EPR for all pain clinics. Defining the granularity of the dialogues was influenced mainly by the factors mentioned previously. However, most respondents agreed on the importance of the following functional demands: registration speed, security, flexibility and supporting of communication between the care providers.

Routinely collected patient data are often recorded as unstructured and ambiguous free text by physicians. These data are, however, also of interest to clinical researchers, for whom they must be clearly defined and preferably coded. We have developed an application to support physicians in recording patient data in a structured, yet expressive manner. The flexible domain-independent data representation and storage approach underlying the application made data extraction for research purposes very complex. The changes that we made to the representation and storage approach to facilitate extraction, without reducing expressiveness for data entry, are presented in this paper, together with the underlying principles of the data extraction tool that we created to enable data extraction for clinical research.

Since 1987 several painclinics in the Netherlands have started with some kind of computer-assisted recording of data, mainly for purposes of quality control. However, this has not yet led to routinely generated reports about the quality of these clinics because a consensus on how to assess quality in pain-treatment is missing.

Using classical system-development methods a global specification for an information System for quality assessment was defined on which a prototype application was based. Various changes were adopted into this prototype, which ultimately resulted in explicit requirements stating: 1. Which data to record, 2. What organisational prerequisites to fulfil for such a system, 3. The user-interface, and 4. Interactions with other information Systems.

The final application was implemented in a number of pain clinics where its usefulness in quality control is currently assessed.

Healthcare networks fonction as a structural synergy serving the various healthcare actors, including the patient, who is the beneficiary. Medically speaking, they meet the need of healthcare professionals for targeted information sharing with regard to the medical record. Economically speaking, they may represent an added value and/or a diminution of costs, thus contributing to quality of care. The adoption of the same standards for ail concerned servers is an absolute prerequisite if multidisciplinary applications are to be generated, as well as related services of an informational and educational nature.

We set up Web-access to the central electronic medical record of the University Hospitals Leuven. Purpose was to enable extemal physicians to more actively participate in the care process as full members of the multidisciplinary treatment team. They get a view on the complete care process in the hospital, and can access results as these become available instead of being provided summary information post factum. This complements traditional electronic exchange between healthcare records. We report on technical setup and results from an extended pilot. We believe that this approach can enrich the discussion on how to provide the “global medical record”.

Communication makes up a very important part of the daily practice of health professionals. Current trends in health care indicate that this will even increase. However, the explicit application of Information and Communication Technologies (ICT) in order to support communication is relatively rare. This leaves a great potential of ICT in health care unused. The clinical informaties group at the Leiden University Medical Centre has established a research program which aims at eliciting, analysing, and specifying requirements for communication supporting ICT-applications in health care. Several research projects are part of this program already. Two of these, that focus on supporting a specific kind of health professional/client communication, are discussed in this paper against the background of the research program.

The paper describes the experiences with a Belgian Primary Care data Network from 1999 till 2002. Three cycles of data collection have been performed. The network involves about 300 general practitioners (GPs) and up to 8 different software packages. This network is semi-anonymous, semi-automatic and mixed (paper and electronic with various software’s). For the coming next years, efforts should be focused on solving some frequently occurring problems with the data collection through the EPR, such as a considerable number of data lacking and the fact that GPs do not always use the problem oriented structure of the EPR (Electronic Patient Record). Afterwards, more promising usage could be considered and developed such as repeated data collection using a same GPs ‘ sample, long term recording studies, usage of larger GPs’ samples, etc.

PRIDEH (Privacy Enhancement in Data Management in e-Health) is a project that runs for two years and is partly funded by the European Commission. The focus of PRIDEH is on the Stimulation of the take-up of privacy enhancing technologies within the health domain. Privacy enhancing technologies build upon available cryptographic and communication technologies. The concept of privacy enhancing services delivery through the use of intermediary trusted third parties has already been described in literature but rarely tumed into practice. A number of limited PET (Privacy Enhancing Technologies) applications exist in closed domains. The very few existing solutions are not based on an independent TTP (Trusted Third Party) concept which renders their trustworthiness questionable. PRIDEH wants to enhance the take-up of PET delivery based on sound TTP principles in the domain of healthcare.

A Commission has been established by Royal Decree in order to make recommendations to Ministers of Social Affairs and Public Health in matters related to standards in telematics for the health care sector in Belgium. The present strategic plan has three priorities: (1) To obtain coherent information Systems allowing uniform data transfer between hospital and ambulatory care, using quality labels supported financially and taking in account long term archiving. (2) To develop secure and standardised communication Systems using electronic signature and standard messages in XML. The implementation of health professionals and patient identifiers is in progress. (3) To reinforce collaboration between health care services by using a health network prototype linked both to general practitioners and hospital institutions.