Ebook: eHealth2014 – Health Informatics Meets eHealth

Successful Health-IT – Just the use of information and communication technology (ICT) in healthcare?

Recently the Austrian government has agreed on the nationwide implementation of an Electronic Health Record (ELGA) in Austria. Although the Electronic Health Record is the second great leap after the introduction of the e-card system in Austria, to provide healthcare with means for a trans-institutional infrastructure to securely share a patient's health data, it raised the awareness for eHealth respectively the use of ICT in healthcare to a new peak in public.

Compared with other sectors such as the service domain, healthcare is still far behind regarding the widespread use of information and communication technology, but is rapidly catching up. Considering the developments in medicine such as the increasing specialization and intense use of medical technology in diagnostics and therapy the future direction seems obvious. Apparently information and communication technology has the potential to support a high quality, high-tech medicine respectively allows extending the scope beyond current possibilities, and so does eHealth.

On the other hand new options always go together with new challenges, threads and indeed fears. The widespread use of ICT in healthcare allows for whole new processes, a whole new way of thinking. Eysenbach has already payed tribute to this in the year 2001 by defining eHealth in a holistic way not only as a “…technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care…”. Existing dogmas such as the relation between the doctor and patient are no longer axiomatic and can be questioned in either way. eHealth may in future empower a patient to question a doctor's opinion, provide medical data, supervise medical data usage or even partially substitute a doctor by technology. Contrary it is also possible that technology supersedes frequent or direct contact with a doctor, automatically monitors a patient or gives advice.

Looking back on the history of health informatics or even broader on informatics as a whole we know that the list of failures is at least the same size as the list of accomplishments when technology found its way out of the laboratories into practice. So there is the central question what makes the difference? Long before the concept of eHealth was published we have already learned that a sound technical implementation is necessary but not sufficient, does not guarantee success. Multiple projects in the domain of eHealth have also demonstrated this simple rule.

In order to successfully transfer scientific results/concepts to practice it is necessary to step back from an exclusive scientific claim of perfection to a more practical, holistic approach to quality, which also considers the needs, fears and context of potential users and parties concerned. This does not imply a mutual exclusion or any contradiction per se or that a scientific approach can't consider these dimensions right from the start but when moving out of the laboratory priorities may need to be rethought or certain dimensions added.

It is beyond all doubt that without the use of ICT the current direction set in healthcare can't be effectively persuaded. The ideas and concepts from the domain of eHealth are an integral part of current and future healthcare, acting as enabling technologies. But it is necessary to carefully consider the effect of such technologies on the healthcare system as a whole but more important on the individuals concerned. True success can only be achieved when the final product or service is technically and organizationally sound and creates a noticeable benefit for the individual user that exceeds its cost.

The 8th scientific eHealth conference (http://www.ehealth2014.at), which takes place in the context of the eHealth Summit Austria (http://www.ehealthsummit.at) from the 22nd to the 23rd of April 2014 in Vienna, picks up on the strained connection of a constant extension of the use of ICT in healthcare and the need to achieve benefits from it in order to make it a success. In consequence this year's theme is set to “Outcomes Research: The Benefit of Health-IT”.

Univ.-Doz. Dr. Alexander Hörbst

Dr. Dieter Hayn

Univ.-Doz. Dr. Günter Schreier

Univ.-Prof. Dr. Elske Ammenwerth

Hall in Tyrol and Graz, 9th of April 2014

In the daily routine of hospitals, which work with paper based medical records, the staff has to find the appropriate patient file if it needs information about the patient. With the introduction of ELGA the Austrian hospitals have to use specific standards for their clinical documentation. These structured documents can be used to feed an e-Ink reader with information about every patient in a hospital. Combined with RFID and security measures, the clinical staff is supported during the patient file searching process. The developed experimental setup of the Bedside Patient Data Viewer demonstrates a prototype of such a system. An Amazon Kindle Paperwhite is used to display processed data, supplied by a Raspberry Pi with an attached RFID module for identification purposes. Results show that such a system can be implemented, however a lot of organizational and technical issues remain to be solved.

Various applications using near field communication (NFC) have been developed for the medical sector. As a method of short-range wireless contact-driven data transfer, NFC is a useful tool in medicine. It can be used to transfer data such as blood pressure, control adherence to medication, or transmit in vivo data. The first proposed general framework uses NFC as a mechanism for indoor geo-localization in hospitals. NFC geo-localization is economical compared to classical concepts using indoor GPS or WLAN triangulation, and the granularity of location retrieval can be defined at a tag level. Using this framework, we facilitate the development of medical applications that require exact indoor geo-localization. Multi-user Android systems are addressed in the second framework. Using private NFC tags, users are able to carry on their personal settings for enabled applications. This eliminates the need for multiple user accounts on common Android devices, improves usability, and eases technical administration. Based on the prototypes presented here, we show a novel concept of using NFC-enabled Android devices in hospital environments.

Heart failure (HF) is a growing public health problem. The management of HF is usually multi-disciplinary and should comprise the cooperation of all groups of individuals involved in the care like clinicians, cardiologists, general practitioners, internists, nurses, relatives and patients. There is an ongoing debate with regard to monitoring and the optimal level and intensity of care for which kind of patients. Based on our experience with the recently established HF network HerzMobil Tirol, we developed a concept how to combine mHealth-based telemonitoring and disease management programs. The collaborative HF management concept timely and efficiently closes the feedback loop between patients and care providers and allows for continuity of care. The aim is to gradually adjust intensity of care according to the patients' level of disease severity and risk of readmission after hospital discharge along the overall trajectory of illness. Next steps will be to investigate how to define shared decision making, rights, duties, responsibilities and liabilities of the individual stakeholders as well as to analyze business models for reimbursement.

The availability of pharmacogenomic data of individual patients can significantly improve physicians' prescribing behavior, lead to a reduced incidence of adverse drug events and an improvement of effectiveness of treatment. The Medicine Safety Code (MSC) initiative is an effort to improve the ability of clinicians and patients to share pharmacogenomic data and to use it at the point of care. The MSC is a standardized two-dimensional barcode that captures individual pharmacogenomic data. The system is backed by a web service that allows the decoding and interpretation of anonymous MSCs without requiring the installation of dedicated software. The system is based on a curated, ontology-based knowledge base representing pharmacogenomic definitions and clinical guidelines. The MSC system performed well in preliminary tests. To evaluate the system in realistic health care settings and to translate it into practical applications, the future participation of stakeholders in clinical institutions, medical researchers, pharmaceutical companies, genetic testing providers, health IT companies and health insurance organizations will be essential.

To facilitate use of patient-centered health IT applications in everyday life, a high degree of usability is required. Based on the example of a patient-centered web application, we propose a usability study design enabling developers and researchers to assess usability of patient-centered health IT applications and derive implications for their improvement. Our study design integrates tasks that subjects have to process, an associated questionnaire based on Perceived Ease of Use, Perceived Usefulness, Attitude Toward Using, and Behavioral Intention to Use, a System Usability Scale questionnaire, and focus groups. Application of the usability study design demonstrates its feasibility and provides insights for assessment of usability in related projects in research and practice.

Objective: Reusing EPR data for secondary purposes often requires mapping to classifications and vocabularies such as ICD, LOINC or NCI thesaurus. We aimed for a common architecture which supports the use of different vocabularies and mapping tools.

Methods: We integrated the components clinical data warehouse, vocabulary resources and mapping tools with the EPR and client applications.

Results: In two projects we used this architecture to map laboratory parameters from the LIS to LOINC, and to map clinical data elements from the Soarian EPR to the cancer registry system using the NCI-Thesaurus®.

Conclusion: The approach was successful in both projects. The reference architecture does not resolve the mapping task, but provides reusable integration links between the different components and thus facilitates further mapping activities.

For patients suffering from rare diseases it is often hard to find an expert clinician. Existing registries rely on manual registration procedures and cannot easily be kept up to date. A prototype data collection system for discovering experts on rare diseases using MEDLINE has been successfully deployed. Initial manual analyses demonstrate proof of concept and deliver promising results. Examining the associations between authors, diseases and MeSH-Terms is expected to open up a variety of possibilities beyond expert discovery.

The advances in internet and mobile technologies and their increased use in healthcare led to the development of a new research field: health web science. Many research questions are addressed in that field, starting from analysing social-media data, to recruiting participants for clinical studies and monitoring the public health status. The information provided through this channel is unique in a sense that there is no other written source of experiences from patients and health carers. The increased usage and analysis of health web data poses questions on privacy, and ethics. Through a literature review, the current awareness on ethical issues in the context of public health monitoring and research using medical social media data is determined. Further, considerations on the topic were collected from members of the IMIA Social Media Working group.

This paper presents the methodology suitable for creation of a performance related remuneration system in healthcare sector, which would meet requirements for efficiency and sustainable quality of healthcare services. Methodology for performance indicators selection, ranking and a posteriori evaluation has been proposed and discussed. Priority Distribution Method is applied for unbiased performance criteria weighting. Data mining methods are proposed to monitor and evaluate the results of motivation system.We developed a method for healthcare specific criteria selection consisting of 8 steps; proposed and demonstrated application of Priority Distribution Method for the selected criteria weighting. Moreover, a set of data mining methods for evaluation of the motivational system outcomes was proposed. The described methodology for calculating performance related payment needs practical approbation. We plan to develop semi-automated tools for institutional and personal performance indicators monitoring. The final step would be approbation of the methodology in a healthcare facility.

Expectations and requirements concerning the identification and surveillance of healthcare-associated infections (HAIs) are increasing, calling for differentiated automated approaches. In an attempt to bridge the “definition swamp” of these infections and serve the needs of different users, we improved the monitoring of nosocomial infections (MONI) software to create better surveillance reports according to consented national and international definitions, as well as produce infection overviews on complex clinical matters including alerts for the clinician's ward and bedside work. MONI contains and processes surveillance definitions for intensive-care-unit-acquired infections from the European Centre for Disease Prevention and Control, Sweden, as well as the Centers for Disease Control and Prevention, USA. The latest release of MONI also includes KISS criteria of the German National Reference Center for Surveillance of Nosocomial Infections. In addition to these “classic” surveillance criteria, clinical alert criteria—which are similar but not identical to the surveillance criteria—were established together with intensivists. This is an important step to support both infection control and clinical personnel; and—last but not least—to foster co-evolution of the two groups of definitions: surveillance and alerts.

The outcome of the EU-funded project ElBik has been the lung simulator ‘iLung’, which imitates an actively breathing human lung with a porcine lung. In order to keep the explanted lung in a nearly physiological state during transportation from the slaughterhouse to the ventilation laboratory the tissue needs to be nourished and temperature controlled. The Project AlveoPic designs a mobile transport vehicle implementing an ISO/IEEE 11073-20601 compliant communication interface for the exchange of the physical parameters, alert messages and setpoint-values. An appropriate 11073 domain information model is designed and limitations of the defined services and attributes are identified. For monitoring purposes the Android App LUMOR is implemented providing a user with an easy-to-handle GUI. It was found, that alert capabilities and remote set features are not well supported in ISO/IEEE 11073-20601 at the moment and possible workarounds are discussed.

One of the outcomes of a training concept for physicians and nurses concerning pediatric emergencies at the Heidelberg University Hospital was that the work and procedures in childhood emergencies could be simplified by replacing the existing paper-based guidelines with a smartphone app. Since the project funds for this were already used up, a group of students from the master program “Medical Informatics” of Heidelberg and Heilbronn Universities took over the development of the app. Particular attention was given to the need for compatibility with the variety of devices (device size and screen resolution) and platform independence. The guidelines themselves were scripted in HTML5, JavaScript and CSS (responsive web design); managed by a container programmed in Sencha Touch. Even though the app is not yet available in the App-Store due to the limited timeframe, the students gained a great deal of valuable experience in developing platform independent software for mobile devices.

To increase the patient's acceptance of electronic health records and understanding for their laboratory findings a web application was developed which presents all parameters and possible deviations of standard values in a clear way and visualizes the time based trend of all recorded parameters graphically. Documents corresponding to the Clinical document architecture (CDA) R2 laboratory reports standard and a rapid prototyping framework called Groovy on Grails were used. This work shows, that it is possible to create a useful, standards based tool for patients and physicians with comparatively few resources – an application that could be in similar form a part of an electronic Health Record (EHR) system like the Austrian electronic Health Record (ELGA).

The goal of this study was to examine whether Schematron schemas can be generated from archetypes. The openEHR Java reference API was used to transform an archetype into an object model, which was then extended with context elements. The model was processed and the constraints were transformed into corresponding Schematron assertions. A prototype of the generator for the reference model HL7 v3 CDA R2 was developed and successfully tested. Preconditions for its reusability with other reference models were set. Our results indicate that an automated generation of Schematron schemas is possible with some limitations.

Dispatching ambulances is a demanding and stressful task for dispatchers. This is especially true in case of mass-casualty incidents. Therefore, the aim of this work was to investigate if and to what extent the dispatch operation of the Red Cross Salzburg can be optimized on such occasions with a computerized system. The basic problem of a dynamic multi-vehicle Dial-a-Ride Problem with time windows was enhanced according to the requirements of the Red Cross Salzburg. The general objective was to minimize the total mileage covered by ambulances and the waiting time of patients. Furthermore, in case of emergencies suitable adaptions to a plan should be carried out automatically. Consequently, the problem is solved by using the Adaptive Large Neighborhood Search. Evaluation results indicate that the system outperforms a human dispatcher by between 2.5% and 36% within 1 minute of runtime concerning total costs. Moreover, the system's response time in case that a plan has to be updated is less than 1 minute on average.

Due to the emerging evidence of health IT as opportunity and risk for clinical workflows, health IT must undergo a continuous measurement of its efficacy and efficiency. IT-benchmarks are a proven means for providing this information. The aim of this study was to enhance the methodology of an existing benchmarking procedure by including, in particular, new indicators of clinical workflows and by proposing new types of visualisation. Drawing on the concept of information logistics, we propose four workflow descriptors that were applied to four clinical processes. General and specific indicators were derived from these descriptors and processes. 199 chief information officers (CIOs) took part in the benchmarking. These hospitals were assigned to reference groups of a similar size and ownership from a total of 259 hospitals. Stepwise and comprehensive feedback was given to the CIOs. Most participants who evaluated the benchmark rated the procedure as very good, good, or rather good (98.4%). Benchmark information was used by CIOs for getting a general overview, advancing IT, preparing negotiations with board members, and arguing for a new IT project.

Medicine is evolving at a very fast pace. The overwhelming quantity of new data compels the practician to be consistently informed about the most recent scientific advances. While medical guidelines have proven to be an acceptable tool for bringing new medical knowledge into clinical practice and also support medical personnel, reading them may be rather time-consuming. Clinical decision support systems have been developed to simplify this process. However, the implementation or adaptation of such systems for individual guidelines involves substantial effort. This paper introduces a clinical decision support platform that uses Arden Syntax to implement medical guidelines using client-server architecture. It provides a means of implementing different guidelines without the need for adapting the system's source code. To implement a prototype, three Lyme borreliosis guidelines were aggregated and a knowledge base created. The prototype employs transfer objects to represent any text-based medical guideline. As part of the implementation, we show how Fuzzy Arden Syntax can improve the overall usability of a clinical decision support system.

Data from cancer registries can be used to track the epidemiology of cancer and can potentially serve to guide individual diagnostic and treatment decisions. Even though some cancer registry datasets have been made publicly available for scientific and clinical use, few applications have so far provided direct access to these data from within the patient context of an electronic patient record. The goal of this project was to implement a proof-of-concept integration of the public SEER (Surveillance, Epidemiology and End Results) cancer registry dataset with a digital breast cancer tumor board at a German university hospital and to determine its utility in the clinical settings. The integration was successfully established, using data from routine documentation to provide dynamic visualizations of cohort composition and Kaplan-Meier survival plots. Evaluation feedback was favorable regarding the concept and implementation, but highlighted that important data elements, e.g. receptor status data, were missing in the SEER dataset, limiting clinical value of the system.

Assessments deliver information about the knowledge level of a student. Formative assessments' main purposes are to identify student's weaknesses and strengths, and support educators in the planning process of their instruction. In this paper a graphical user interface concept is presented to provide feedback with the aid of the editing results of medical students, who train with Virtual Patient, which is a computer-based simulation of patient care.

Our ontology-based benchmarking infrastructure for hospitals, we presented on the eHealth 2012, has meanwhile proven useful. Besides, we gathered manifold experience in supporting knowledge discovery in medicine. This also led to further functions and plans with our software. We could confirm and extent our experience by a literature review on the knowledge discovery process in medicine, visual analytics and data mining and drafted an according approach for extending our software. We validated our approach by exemplarily implementing a parallel-coordinate data visualization into our software and plan to integrate further algorithms for visual analytics and machine learning to support knowledge discovery in medicine in diverse ways. This is very promising but can also fail due to technical or organizational details.

Significant improvements in the field of diagnostic methods and therapeutic options achieved during the last decade allow the early diagnosis, accurate follow-up and individual indication for the treatment with highly efficacious therapeutic agents in a wide range of ophthalmological pathologies. The burden on health care systems is extremely high, as treatment and diagnostic follow up has to be repeated in a regular manner. Whereas the treatment can only be applied in tertiary care centers (eye clinics), follow-up and management mainly depends on the OCT technology, which is becoming available at many field ophthalmologists' practices. This article describes the OphthalNet project, a network which optimizes collaboration between eye clinics and field ophthalmologists based on medical guidelines, workflow support and the future use of electronic infrastructure.

The skills of the workforce are a core factor for the quality of healthcare systems. On top of the basic education, postgraduate training is an important factor for continuously maintaining as well as improving the workforce qualification level. Advanced training often provides certification of the acquired skills. This paper analyses the status quo of international certification programs in the sector of eHealth (EU, US, Global). It uses available literature and observations from international educational expert's workgroups. It identifies gaps regarding certifications in eHealth and suggests steps for solutions. Despite little attention to legal and financial eHealth related content in certification programs in the EU as well as a low degree of harmonization of international certifications in general, there are strong activities especially in the international scope towards personal certification programs in eHealth. Major changes are to be expected within the coming years.

eHealth is not only a growing market, but also an important factor for new healthcare systems. National and European initiatives implicitly demand a higher level of knowledge in the areas of healthcare, engineering and management. As part of the eLearning4eHealth project an initial web based study was performed concentrating on European and global eHealth related educational programs. The results show that eHealth related courses do not evenly exist for the identified professions. 43% of the offered programs are focused on the engineering sector, whereas only 21% are available for the management sector. In order to offer compatible and comparable state of knowledge in the identified fields of profession and knowledge, further educational programs may be necessary. Despite the found shortcomings, results have shown that international activities have started in order to close the gaps and improve the quality of knowledge in the interdisciplinary field of eHealth.

The article describes an analysis of the use of e-learning to improve the learning transfer to practice in continuing education. Therefore an e-learning offer has been developed as a part between two attendance periods of a training course in the field of Ambient Assisted Living (AAL). All participants of the course were free to use the e-learning offer. After the end of the e-learning part we compared the e-learning users to the other participants. Using an online questionnaire we explored if there are differences in the activities in the field AAL after the training course. The results show that e-learning is beneficial especially for communication processes. Due to the fact that the possibility to talk about the learning content is an essential factor for the learning transfer, e-learning can improve the learning success.