Ebook: eHealth: Combining Health Telematics, Telemedicine, Biomedical Engineering and Bioinformatics to the Edge

Current demographic, economic and social conditions which developed countries are faced with require a paradigm change for delivering high quality and efficient health services. In that context healthcare systems have to turn from organisation-centred to process-oriented and finally towards individualised patient care, also called personal care, based on eHealth platform services. Interoperability requirements for ubiquitous personalised health services reach beyond current concepts of health information integration among professional stakeholders and related Electronic Patient Records. Future personal health platforms have particularly to maintain semantic interoperability among systems using different modalities and technologies, different knowledge representation and domain experts' languages as well as different coding schemes and terminologies to include home care as well as personal and mobile systems. This development is not restricted to regions or countries, but appears globally, requiring a comprehensive international collaboration.

From December 2nd to 5th, 2007, the eHealth Competence Center (eHCC) supported by the International Center for Telemedicine (ICT) at the University of Regensburg Medical Center and several other organisations such as IMIA, EFMI, ISfTeH and the Czech Society of Biomedical Engineering and Medical Informatics, organised an International Conference on eHealth thereby aiming at uniquely combining Health Telematics, Telemedicine, Biomedical Engineering and Bioinformatics to the edge. This Global Experts Summit Textbook within the Series “Studies in Health Technology and Informatics” at IOS Press presents invited speeches from internationally leading experts representing all domains involved in eHealth. The International Conference has been completed through specific seminars, workshops and symposia addressing collaboration and potential projects between Europe and Latin America (ELAN), analysing cross-border activities between Germany, Austria, the Czech Republic, and Switzerland, promoting current eHealth achievements of MEDTEL (Prague, CZ), and presenting poster submissions to the conference concerning telematics and telemedical applications. Those results have been jointly published at IOS Press, Amsterdam, and Akademische Verlagsgesellschaft Aka GmbH, Berlin.

The editors would like to thank all the invited authors for their excellent contributions. Furthermore, they thank the Gold Sponsors Siemens AG Medical Solutions, InterComponentWare AG and InterSystems GmbH, and also HL7 Germany, AGFA HealthCare GmbH, ID-Berlin GmbH, ManaThea GmbH and SAP AG for their inevitable support.

Bernd Blobel, Regensburg, December 2007

For improving quality and efficiency of health delivery under the wellknown burdens, the health service paradigm has to change from organizationcentered over process-controlled to personal health. Established in connection to the already existing International Center for Telemedicine, the eHealth Competence Center in Regensburg has been dedicated to advance research, development, education and administration of comprehensive eHealth. In cooperation with internal and external partners, the Personal Health paradigm comprising of health telematics, telemedicine, biomedical engineering, bioinformatics and genomics is pushed ahead. The paper introduces the underlying paradigms, requirements, architectural framework and development processes for comprehensive service-oriented Personal Health interoperability chains.

The International Medical Informatics Association (IMIA) is the only organization in health and biomedical informatics which is fully international in scope, bridging the academic, health practice, education, and health industry worlds through conferences, working groups, special interest groups and publications. Authored by the IMIA Interim Vice President for Strategic Planning Implementation and co-authored by the current IMIA President and the IMIA Past-President, the intention of this paper is to introduce IMIA's current strategic planning process and to set this process in relation to 'eHealth: Combining Health Telematics, Telemedicine, Biomedical Engineering and Bioinformatics to the Edge', the theme of this conference. From the viewpoint of an international organization such as IMIA, an eHealth strategy needs to be considered in a comprehensive way, including broadly stimulating high-quality health and biomedical informatics research and education, as well as providing support to bridging outcomes towards a new practice of health care in a changing world.

This paper tries to make an inventory and classification of several possible barriers, which can lead to unfulfillment in Health Information Systems implementation. The reports are compared and discussed within this context.

The long-term effect of education in the field of biomedical informatics and eHealth on efficiency and quality of healthcare is discussed. Selected educational methods and tools are presented and their applications are shown.

With personal health records (PHRs) acting much like ATM cards, increasingly wired consumers can “bank on health”, accessing their own personal health information and a wide array of services. Consumer-owned, the PHR is dependent upon the existence of the legal electronic medical record (EMR) and interoperability. Working PHRs are in place in Veterans Health Administration, private health care institutions, and in the commercial sector. By allowing consumers to become involved in their own care, the PHR creates new roles and relationships. New tools change the clinician's workflow and thought flow, and pose new challenges for consumers. Key components of the PHR include the EMR and regional health information organizations (RHIOs); key strategies focus on human factors in successful project management. Online resources provided by the National Library of Medicine and Health On the Net help address consumer needs for information that is reliable and understandable. The growth of self-management tools adds to the challenge and the promise of PHRs for clinicians and consumers alike.

This information was first presented at the 2006 Annual HIMSS Conference and Exhibition in San Diego, Calif. Reprinted with permission from the Healthcare Information and Management Systems Society (HIMSS).

A new perspective for personalized care which genomics and bioinformatics cooperatively open was described, with emphasis on promising possibilities which “genome/omics-based personalized care” is thought to bring about. In doing so, we took it into consideration that, along the rapid progress of the genome/omics and bioinformatics, the contents of “genome/omics-based personalized care” have evolved, mainly through three generations. The first generation is personalized care based on (1) the polymorphism of the “germline” genome sequences, such as personalized medication depending on the individual genetic differences concerning the pharmacodynamics/phamarcokinetics or estimation of genotype relative risk for individual's disease occurrence, the second generation is that based on (2) the information pattern of vast amount of omics data of diseased “somatic” cell, which brings about detailed classification, early diagnosis and prognosis of the disease, and the third generation is that based on (3) the system level understanding of complex diseases which enables wholistic comprehension of the mechanism of diseases, with special reference to disease pathway.

For meeting the requirements for high quality and safe of care as well as efficiency and productivity of health systems, latter have to move towards job sharing, communicating and cooperating structures. This paradigm change must be supported through sustainable and semantically interoperable architectures for health information systems, especially for Electronic Health Record (EHR) systems as the core application in any eHealth environment. Advanced system architectures are characterized as being highly distributed, component-oriented, model-based, service-oriented, knowledge-based, user-friendly, lawful and trustworthy, based on a unified development process, a harmonized ontology and reference terminologies. Existing and emerging approaches for EHR systems are to be compared using the Generic Component Model (GCM) as architectural reference. Any system can be assessed according to GCM dimensions: transparent domain representation, composition/decomposition behavior and reflection of the systems' viewpoints as well as their components' interoperability level. All those aspects have to be interrelated for real systems analysis, design, implementation, and deployment by that way enabling the migration of different EHR approaches on the basis of GCM.

The shift in health care to an aggregate corporate and distributed model dominated by electronic methods of diagnosis, record-keeping and communication spanning jurisdictional boundaries raises technical, social and paradigmatic issues. The technical issues concern the material natures of the tools, devices, procedures and protocols; the social issues gravitate around abstract matters like individual rights and models of responsibility within a corporate setting and accountability in inter-jurisdictional contexts; the paradigmatic issues centre in the question of how the rights and duties of traditional and direct health care translate into the mediated context of the globally expanded corporate model of eHealth and telemedicine. The present discussion presents a brief overview of the issues and sketches some of their implications for the evolution of contemporary health care.

The phenomenon of an aging society is frequently raised in scientific, public and political discussions in the developed world. It is well known that a number of challenges related to the demographic, economic and societal development will lead to increasing demands for health and social care. To cope with these challenges, effective delivery of health and social care will be more dependent on different technological solutions. The objective of this paper is to identify emerging technological solutions and to relate them to the expected changes occurring in an aging society. Results from an analysis of existing literature show that ubiquitous care in aging societies is merely a social than a technical challenge as it will require a redesign of today's healthcare processes. Supportive technologies have to be adapted to older people's needs, self-care processes and coping strategies, and to support new ways of healthcare delivery under close surveillance of patient safety, legal and ethical issues.

Personal health settings establishing health service chains lead to new legal challenges. The safe harbor principle of doctor-patient relationships has to be extended for including multilateral relations and other parties by reconciling a broad variety of legal regulations with detailed contractual agreements. Beyond security and privacy, also liability, risk management and reimbursement have to be ruled.

The health care sector is quickly exploiting Information and Communication Technologies towards the provision of e-health services. According to recent surveys, one of the most severe restraining factors for the proliferation of e-health is the (lack of) security measures required to assure both service providers and patients that their relationship and transactions will be carried out in privacy, correctly, and timely. A large number of individuals are not willing to engage in e-health (or are only participating at a reduced level) simply because they do not trust the e-health service providers' sites and the underlying information and communication technologies to be secure enough. This paper considers privacy and security issues and challenges for e-health applications.

Medical technology without coordination and without the right information available anywhere, any time, can only lead to results, that are inefficient, costly, and sometimes the wrong care for the patient. The most important lever to alter this situation is the use of healthcare information technology across the whole healthcare continuum: interoperable electronic records, electronic prescribing, clinical decision support, rules engines, workflow-based systems as well as a secure technical infrastructure. They are all a critical part of the solution and have the power to realize ubiquitous care. Together with the progress in medical technology, which provides for an earlier diagnosis and intervention, medical IT for process optimization will be the prerequisite to further improve the quality of care while reducing its costs.

Nanomanipulation is a technology to manipulate a small object sized in nanometer to submicron scale. Optical tweezers is one of nanomanipulation techniques, which can investigate pico-newton to femto-newton force exerted on microscopic objects. We have developed a cell palpation system by use of optical tweezers and performed palpation experiments on cells. With the cell palpation system, an operator manipulates a probe particle to touch a certain location of a cell and feels the strength of the cell by hand through a haptic device, which displays force calculated and generated by a computer. We expect this technique can be used in diagnostic purpose and utilized not only in research field but also in daily medicine.

The Danubian Biobank Consortium (www.danubianbiobank.de) was initiated in 2005 as a network of Danube Universities and associated partner universities between Ulm and Budapest, with a major focus on case/control studies of aging disorders like vascular and metabolic diseases, Type2-diabetes, and neurodegenerative diseases. Beyond case/control studies some centers also directly participate in longitudinal population based studies and population isolate studies or provide enabling technologies for these studies. The mission of the Danubian Biobank Consortium is to directly integrate biobanking into local and regional healthcare along the Danube through E-health portal structures and IT-based strategies. Biobanking as an integral part of the workflow of the healthcare process is considered as key element to generate qualified long term patient databases and health records. The major objective of the project is to generate a common central encrypted patient and sample information database to facilitate international research interactions, combined with local and regional biobanking facilities under common Good Practice (GP) and Standard Operating Procedure (SOP) conditions to move existing healthcare systems towards personalized healthcare. This process will be driven by local E-health portal implementation to network healthcare providers, industry, insurance companies, medical research and public healthcare in a Private Public Partnership (PPP) model to cover jointly the expenses. All information including patient recruitment, blood withdrawal and storage place of the samples will be saved in phase I as standardized processing procedures (SPP) to implement a central IT-based databank in phase II, which can be used in encrypted form for scientific project planning and investigations. In the local E-health portals the actionable health information will be also accessible for direct medical care for the authorized practitioner. In addition to local centers three regional DNA, plasma, and tissue banks in Regensburg, Vienna, and Budapest store samples and encrypted patient data for scientific purposes.

It is now 20 years that the European Union supports research and development of information and communication technologies based tools for healthcare (eHealth). From 1989 till today, funding has continually been increased, initiating new research, complementing Member State initiatives, strengthening European industrial competitiveness, and tackling new health and social problems related to the free movement of people in the EU. By now, many of the earlier visions and dreams have been realised or are close to wider implementation. Accordingly, the European Commission is now providing strong support also for market validation and implementation of eHealth solutions and services, and at the health policy level. Examples are the recent eHealth Action Plan, annual High Level Ministerial Conferences, an upcoming Recommendation on European eHealth Interoperability, or the Member States-led Large Scale Pilot on a pan-European core patient summary and ePrescribing. This will be complemented by a Lead Market Initiative identifying eHealth as a core future innovation field. Growing cooperation with counterparts in the USA and elsewhere underline that eHealth is becoming a global reality. A more than 40 year old vision is now closer to global reality for the better of all citizens.

Reducing risks and improving benefits to the patients are requirements health professionals are faced with in their daily work. Furthermore, cuts in health funds and the competition for budgets require to enhancing efficacy and efficiency of health services. For meeting both challenges, adequate information and knowledge is needed, which can be gathered from documentation systems such as Electronic Health Records or Personal Health Records (PHRs), but also by performing dedicated clinical studies such as randomized controlled trials (RCTs) or cohort studies. Based on a literature analysis, quality of, and benefits from, RCTs have been analyzed. The benefits from connecting public health and PHRs are discussed in some details.

The ICW eHealth Framework (eHF) is a powerful infrastructure and platform for the development of service-oriented solutions in the health care business. It is the culmination of many years of experience of ICW in the development and use of in-house health care solutions and represents the foundation of ICW product developments based on the Java Enterprise Edition (Java EE). The ICW eHealth Framework has been leveraged to allow development by external partners – enabling adopters a straightforward integration into ICW solutions. The ICW eHealth Framework consists of reusable software components, development tools, architectural guidelines and conventions defining a full software-development and product lifecycle. From the perspective of a partner, the framework provides services and infrastructure capabilities for integrating applications within an eHF-based solution. This article introduces the ICW eHealth Framework's basic architectural concepts and technologies. It provides an overview of its module and component model, describes the development platform that supports the complete software development lifecycle of health care applications and outlines technological aspects, mainly focusing on application development frameworks and open standards.