Ebook: Health Continuum and Data Exchange in Belgium and in the Netherlands

This book is the second to appear in the IOS Press “Studies in Health Technology and Informatics” in order to describe a follow up of research projects and the development of standards for “e-Health in Belgium and in the Netherlands”.

F.H. Roger France, A. Hasman, E. De Clercq, G. De Moor, E-Health in Belgium and in the Netherlands, IOS Press, 2002, 93

It is first based on the Belgo-Dutch Medical Informatics Congress (Medische Informatica Congres), MIC 04. Its Proceedings are published in the first part of this book. MICs started in Rotterdam, the Netherlands, in 1978 and in Antwerp in 1979, in Belgium. For its 22nd edition, it is held in Brussels on 25-26 November 2004.

The collection of papers covers timely areas such as nursing and care process, the electronic patient record and knowledge bases, as well as ICT assessment. Applications are described by short abstracts.

The second part of the book is devoted to the description of the development of standards by the Belgian Commission “Norms for Telematics in the Health Care Sector”. It is a written support to the “Telematics@health.be 5th Symposium” held jointly with MIC04 in Brussels. A general introduction to the work of this Federal Commission in Belgium has been published in 2002.

F.H. Roger France and M. Bangels, Norms for Telematics in Health Care : Priorities in Belgium, (in E-Health in Belgium and in the Netherlands, IOS 2002, 93, 179-183)

These two Conferences share new trends in health informatics and present many timely ideas and practical proposals. They are directed to health care professionals who are leading the transformation of health care by using information and knowledge.

MIC04 is organised by the two national societies for Medical Informatics : MIM (Medische Informatica, Informatique Médicale) in Belgium and VMBI (Vereniging voor informatie verwerking in de zorg) in the Netherlands.

Telematics@health.be is an annual symposium managed by the Public Federal Service of Public Health.

We wish to thank all authors, as well as reviewers of the papers, and translators of recommendations. We express also our gratitude to Mrs Chris De Hollander and Mrs Dominique Pironet for the follow up and the technical editing, as well as of Mrs Dominique Dieng from INFOPOLE for her support.

F.H. Roger France, E. De Clercq, G. De Moor, J. van der Lei, Editors

This paper will demonstrate the added value of a Process Oriented Hospital Information System based on the current trends and changes in the organisation of patient care in hospitals. To support the integrated patient care with IT, basic functionalities will be described.

Background: Clinical pathways are commonly developed for homogenous patient groups. We were wondering if the traditional patient classification systems could be used for classifying clinical pathways.

Methodology: To examine the utility of patient classification systems for clinical pathways, a sample of 13 clinical pathways was analyzed, involving a total of 412 patients. Three classification systems were tested: International Classification of Diseases, Ninth Revision (ICD9-CM), Clinical Coding System (CCS) data and All-Patient Redefined Diagnosis Related Groups (APR-DRG).

Results: Categorization with ICD9-CM and CCS shows rather wide variation. However, when restricting for the principal codes, CCS classification shows an almost homogeneous relationship with clinical pathways. APR-DRG's are already corrected for secondary procedures and are difficult to assess. Categorization with the Risk Of Mortality (ROM) is more homogeneous than with the Severity Of Illness (SOI).

Conclusion: Patient groups in clinical pathways are rather heterogeneous. When restricting for the principal procedures, the strongest relationship seems to exist between clinical pathways and CCS. Further research is needed to refine this relationship.

For years electronic care plans have been touted as an important tool to provide better patient care. Until recently however, most efforts were hampered by design gaps in available Electronic Patient Record (EPR) systems and the difficulties involved in extending continuous care to the bedside. The growth in wireless LAN solutions, and the emerging maturity of EPR systems have finally made practical implementations possible. An extensive analysis, development and preparation phase followed by a pilot on the department of traumatology in the University hospital of Gent has proven the possibilities and validity of multidisciplinary electronic care plans as an integral part of the EPR. Wireless consultation, observation and charting enables bedside management of patient care. Roll-out on 5 more departments is planned in the coming year.

This paper describes the process of revising the Belgian Nursing Minimum Data Set (NMDS). The study started in 2000. Implementation is planned from 2006. The project is divided in 4 major phases. The first phase (June – October 2002) implied the development of the conceptual framework based on literature review and secondary data-analysis. The Nursing Interventions Classification (NIC) was selected as framework for the revision of the NMDS. The second phase focused on the language development (November 2002 – September 2003) with panels of clinical experts (N=75) for six care programs. They indicated hospital financing, nurse staffing allocation and assessment of the appropriateness of hospitalization as priorities of a revised B-NMDS. A draft instrument with 84 variables, using NIC, was developed during this period. This leads to an alpha version of a revised NMDS. The third phase (October 2003 – December 2004) focused on the data collection and validation of the new tool. The new NMDS was tested on 158 nursing wards in 66 Belgian hospitals from December 2003 until March 2004. This test generated data for some 95.000 inpatient days. The interrater-reliability of the revised NMDS is tested. The criterion-related validity of the revised NMDS is compared with the actual NMDS. The discriminative power of the revised NMDS is tested to select the most relevant items for data collection. This will result in a beta version of revised NMDS in December 2004. The records of the revised NMDS are linked with the hospital discharge dataset and other mandatory datasets to integrate the revised NMDS in the broader health care management. The fourth phase (January – December 2005) will focus on information management.

The goal of this paper is to contribute to the improvement of the quality of care. For physicians, it is a problem that they are often not aware of gaps in their knowledge and the corresponding information needs. Our research aim is to resolve this problem by formulating information needs automatically. Based on these information needs, patient-specific literature can be retrieved. As a first step, we investigate how to model a physician's information needs. Thereafter, we design and analyse an approach to instantiate the model with patient data, resulting in information-need templates that are able to represent patient-specific information needs. Our experiments show that a physician's information needs can be modelled adequately and can be substantiated into patient-specific information needs. Since the number of formulated information needs is rather high, future research will focus on methods that restrict the set of automatically formulated information needs to a more specialized set.

The paper tackles the topic of collecting data from home visits using the electronic patient record (EPR) of general practitioners (GPs), in a context with a high proportion of home visits in primary care. Since data from home visits, representing about 40% of GPs' consultations in Belgium, are rather scarcely recorded in the EPR, we wanted to study the impact of not taking into account home visits for quality assessment in primary care. Five quality indicators, which measured the accordance of the delivered care with guidelines on the management of osteoarthritis, were compared between a pooled database (consultations and home visits) and a restricted database (after removal of home visits). Our findings suggest that removing home visits from a database collected from primary care may provide a slight modification of the estimate of the quality of care, whereas conclusions on quality improvement remain relatively stable. Quality of care assessment with the EPR of GPs seems not to be dramatically hampered by the poor recording rate of home visits in the EPR.

Introduction: The Electronic Medical Records (EMR), used every day for primary health care may constitute an instrument for gathering locally usable data to improve the quality of care and, on a larger scale, be a basis of epidemiological data. In spite of a policy of promotion of the EMR made by the Federation of French-speaking Belgian “Medical Houses”, its use remains very marginal.

Methods: Eight Medical Houses, motivated by computerization of medical records have been met. Quantitative indicators of use of the EMR have been assessed. A qualitative assessment of the resistances to computerization, and solutions which can be brought, has been realized through the technique of the nominal group.

Results: The use of the EMR remains slight, allowing for exceptions. The proposed solutions could be put together in 5 categories : ethics, training, search for sense, practice and interdisciplinarity.

Discussion: The practitioners are willing to computerize if they get immediate advantages (knowledge of their patients and their team operating). They expressed the need of having a tool easy to use, that doesn't make them lose time and that has respect for their specificity of work and organization (interdisciplinary and self-managed teams). They expressed the need of an external support, under the form of adapted training and supervision for the data management. Ethical concerns (security, data transfer, place of the computer in the relationship with the patient) are surprisingly not present enough.

The PropeR project studies a genric combination of an electronic health record (EHR) and decision support software (DSS). This study comprises different medical domains. GOAL – develop a distributed EHR system that is flexible enough to be used in different domains without major modifications. METHODS – use of standards and standardized specification and available open source components to develop an EHR system that meets the goals. RESULT – PropeRWeb is a generic webbased EHR system that is flexible enough to easily accommodate different domains. DISCUSSION – discussion of some of the problems encountered in the development of the EHR system.

Medical decision support systems will only be accepted by the medical community if properly evaluated. However, little attention has been given in the scientific literature to the topic of how to incorporate evaluation issues into the design of a decision-support system. In this paper, we describe work in developing a decision-support system that is intended to support the management (diagnosis and treatment selection) of ventilator-associated pneumonia in patients. From the beginning of the development of this system, we have taken care to incorporate evaluation issues into the design of the system. In the paper, we analyse the problems that need be taken into account when evaluating a system. Next, we describe the consequences for the functionality of the system.

Operating Room (OR) information systems should manage the OR time, assigned to every surgeon, thereby minimizing the sum of costs of unused OR time and minimizing the costs of elective cases performed outside normal allocated OR time (excess OR-time). The aim of this paper is to illustrate how the introduction of an OR information system influenced daily OR activity performance.

Since January 2001, we introduced an OR information system with a visual, airport-like, screen as central part, displaying all scheduled OR activity linked in real-time activity with all OR theatres. For the aim of this paper, we compared all data of OR activity for elective abdominal surgery (EAS) for the first half of 2000 compared to the first half of 2001, after the introduction of our information system.

In 2000, 764 elective cases were performed, compared to 815 cases in 2001. For both periods, the total OR time allocated to EAS for this 6 months period was 805 h. For 2000, the total duration of OR activity for EAS was 1044h50min (implicating 239h50min over-time), compared to 1127h35min (implicating 322h35min over-time) for 2001. For 2000, we recorded 147h20min excess time (=exceeding the time limits of OR activity and inducing extra costs) and 46h45min unused OR time. For 2001, we recorded 123h04min excess time and 35h21min unused time.

In conclusion, in 2001 we recorded an increase in total OR activity for elective abdominal surgery by 7% in number of procedures and by 8% in total duration. However, in 2001 we recorded a decrease in excess time by 16% (123h04min vs 147h20min), which was for a large part due to a 23% decrease in unused OR time in 2001 compared to 2000 (35h21min vs 46h45min). Therefore, the introduction of an OR information system, with a real-time visual display of ongoing OR activity, resulted in a increased performance of OR activity, with more OR procedures performed despite less excess time and less extra costs.

In 2003 a workshop was held in Innsbruck, Austria, on the topic of evaluation of ICT applications in Health Care. A result of that workshop was the “Declaration of Innsbruck”. In the current paper we will further elaborate on this declaration and discuss some of the activities that are currently undertaken as supportive measures to enable the realization of the vision expressed in the declaration.

Purpose: The ISO IS 18104 is intended for helping the nursing profession to integrate their terminologies into computer systems and into larger health care reference terminologies. One purpose of the standard is to map between different terminologies.

Method: This mapping was tested, using three terminologies that are relevant for nursing in the Netherlands. Concepts and terms where selected, and their equivalence was determined by experts, and next these were dissected.

Results: The dissection revealed that several concepts can easily be interchanged among the three example terminologies, while others cannot, or only for specific purposes.

Conclusions: The ISO IS 18104 fulfills this purpose very well and can be considered the gold standard for mapping of nursing terminologies.

The Belgian Breast Cancer Screening program has been launched in 2002 according to the recommendations and quality assurance guidelines of the European Union. Women in the age range 50–69 years are invited to pass a mammography which is read by two independent radiologists. In case of discrepancy, a third reading is requested. Each reading is documented in detail. In the absence of a nationwide central support computer system, a novel Web-based computer system was designed and developed to support the program. The Web site is hosted on a Web server running Windows Server 2003 with Internet Information Server 6.0 and uses ASP technology from Microsoft. Patient data and readings results are entered from the Web site and are stored in an SQL Server database. The support system developed bears all the advantages of Internet-based facilities (e.g., low cost, remote data entry, flexibility, work comfort, ubiquitous access, user friendliness and advanced technology). Difficulties related to graphical data entry on Web pages were smartly resolved. A comprehensive algorithm for comparing mammography readings has been implemented in the system, enhancing the quality of the screening program. The application has been tested and implemented in the Province of Luxemburg, a widespread rural region particularly suited for Internet solutions in preventive medicine. More recently and with little efforts, the application was extended to the Province of Namur. The Web-based system provides management facilities, ubiquitous online statistics, and builds up a reservoir for official statistics and scientific research. As the application is concerned with sensitive medical data, special attention has been paid to provide a maximum of security. Administrative and medical personnel have expressed their total adherence to the system, while local health authorities have used it to justify their involvement in the screening program. Currently, the database for the Province of Luxemburg contains 25,321 women with a mean age of 59.5 ±6.1 years (range: 50–70 years). The participation rate amounts 17.2%, about twice as much as in the other provinces. After the first mammography reading, 20.4% of the women were found to be positive, but this figure dropped to 10.2% after the second mammography reading. The overall disagreement rate between the first and second readings currently amounts 19.7%. It follows that a third reading is required in about 20% of the cases. Statistical analyses have shown that Cohen's Kappa agreement coefficients between radiologists range between 0.37 and 0.70. The application has been running for two years with success to the satisfaction of managerial and medical personnel as well as of provincial public health authorities.

The Minimum Medical Record for Practitioners on Duty (DMMG) is a share and consultation platform containing all patient's essential medical data required in emergency cases. This prototype is now developed in the area of Verviers and in Eastern Belgium. The project is carried out by the Meditel non-profit-making organization and Professional Computing Solutions (PCSol).

The objective is to give to practitioners on duty, emergency services and mobile intervention teams a quick access to critical information about the patient, according to the duty lists. By this way, DMMG wants to improve the quality of care provided to the patients with respect to their rights. The aim is also to position the usual treating practitioner at the center of the healthcare process and to meet the new social challenges of emergency services.

The method used is a portal located on Internet with a high level of security. With the agreement of the patient, the treating practitioner transmits in a secure way to a central server all medical data that is considered as relevant in order to set up a minimum data file for the duty roles. Under the supervision of ASBL MEDITEL, access rights to the server are managed based on the active duty roles (GP and emergency practitioners).

DMMG data file is then available for all General Practitioners on duty, emergency practitioners and medical intervention vehicles (VIM). Remote reception of data (out of the hospital) is done on a laptop or PDA via GSM (GPRS) connection. In case of intervention, service on duty has access to DMMG. Every consultation or added information is transmitted to the Treating Practitioner in order to ensure healthcare continuity.

Results for the patient is the availability of reliable data about his health condition (responsibility of the patient for his health). He also avoids wasting time giving approximative medical explanations in difficult or emergency situations. The communication with the medical world is improved.

For the treating practitioner, DMMG optimizes medical data flows management and enables a prompt and precise diagnosis by others physicians even for patients at home. The physician is ensured of the healthcare continuity even during his absence. He stays in the middle of the healthcare process and he has a trust relationship with his patients and others colleagues.

Concerning the emergency services, DMMG allows an optimal management of this department by avoiding double examinations and speeding up patients handling.

Objectives : The recent legislation regarding “Well-being on the workplace” sealed a paradigm shift for nearly 100 Belgian external prevention services, leading to an important re-grouping movement – to 22 services at date – which has not yet found its final equilibrium. In the early nineties it became clear that new services requirements, multidisciplinary teams, higher quality standards – such as, recently, ISO 9001 – and the implementation of a medical “numerus fixus” at the universities would soon necessitate structural changes and the development of innovative instruments to meet future prevention needs.

The group IDEWE-IBEVE has played an active role in the genesis of the new legislation and the shift of traditional occupational health & safety prevention practices towards risk assessment, medical and environmental surveillance and psycho-social counselling at work, securing this revolution by the development of a modern software infrastructure to support its mobile prevention experts in a changing landscape.

Methods : The JaWS project is the largest effort in this novel support infrastructure. It centres around knowledge engineering: capturing and formalizing the wealth of expertise of a large multidisciplinary group of professionals, and applying it as building blocks in an auditing and reporting instrument suited to experts and novices alike.

The JaWS toolset is constructed to function as an automated refinery of expert knowledge, funnelling user-applied changes to a reviewing committee and re-distributing useful improvements to all mobile prevention advisors.

Stochastic methods are applied to detect and research possible relationships between observations belonging to distinct prevention domain ontologies (industrial sectors, professions, hazards, health and safety problems, medical investigations...) and to guide preventive measures tackling surfacing trouble spots.

Results : Hundreds of mobile prevention advisors have been using JaWS for two years now, generating standardized and tailored advisory reports. A team of epidemiologists is developing feed-back procedures based on harvested observations, and ICT-experts are shaping the JaWS mobile application generator to make maximum use of future mobile computing platforms.

The JaWS project is gathering momentum, regularly integrating expansion modules into the auditing platform. JaWS symbolizes the fact that IDEWE is sinking its teeth in the delicate task of re-inventing its role in a changing industrial and legal landscape, on the never-ending quest of making prevention work.

Objectives : In the actual context of rapide changes in the health care environment, the need for efficient communications of medical data between the care providers became critical. Therefore, hospitals, general and specialised practitionners started dicussions throughout Belgium. These initiatives led to the constitution of non profit medical telematics associations (ASBL/VZW) which goals remain similar : the elaboration of medical networks after analysis of the needs and the implementation of exchange procedures. These associations will keep these medical networks under the responsibility and management of physicians who must assess the identification, authentication and certification of the potential users and guarantee the respect of the patients rights and privacy. The same discussions have started in Brussels. The goal is the implementation of a Brussels Medical Telematics Association. The name “ABruMeT” has been choosen to respect the utilisation of 3 languages : French (Association Bruxelloise Médicale de Télématique), Dutch (Associatie of Brusselse Medische Telematica), and English (Association of Brussels Medical Telematics).

Method : In 2003, delegates of general practitionners and hospitals started discussions. They defined what they want to do together and how, and summarised their willing in three issues. The first one is to get together, as far as possible, all the recognised associations of general pratitionners and all the hospitals situated in the Brussels area, and to avoid commercial or financial interests. Therefore, the ASBL/VZW formula was choosen. It implies the redaction of a juridical agreement, the implementation of a specific structure, and the respect of each members'sensibility. The second issue is the need for an active collaboration with the Telematics Commission of the Federal Ministry of Public Health. Finally, the third issue concerns the medodology which included three aspects detailled in the results: which informations do the health care providers need? Which are the technical needs and the available tools? How to work in accordance with the law defining the patients rights and privacy?

Results : The ASBL/VZW juridical agreement has been written, discussed and submitted to a lawyer. Some members participating to the working cessions of the Federal Telematics Commission, its projects and realisations have been immediatly integrated into the task list. The task list detailed the three aspects mentionned in the methodology. The needed informations have been described in the collaboration chart and include bilateral secured messages, protected access to a synthetised health care record for both partners, the bilateral alert concept and the access from outside to the inhospital patient record. Besides a minimal computer equipment and optimal securisation procedures for the data for both partners, we need secured channels and standardised codification and structure. Such standardisation is going on with the homologation of electronical health care records for general practitionners and the developpement of a common language : the KMEHR. Finally, the procedures must be implemented to permit the integration of the patients rights into a system with as final goal the quality and the continuity of care.

This paper aims to propose an action plan for the deployment of the use of digital signatures in Belgian healthcare.

This action plan is the result of a number of technical, legal and organisational requirements. It starts by establishing the functional components that are needed to set up a framework for the deployment of digital signatures. The main components should implement an infrastructure for:

– the creation of digital signatures;

– the verification of digital signatures;

– the certification of signature keys;

– the certification of attributes;

– the handling of revocation.

The tasks in the action plan are the logical consequence of all the functions that need to be addressed.

The objective of this report is to list what has to be done and how it can be done in the context of healthcare, rather to state who will perform the functions required.