Ebook: MEDINFO 2007

Playing an active role in the 12th World Congress on Medical Informatics has been an honour and a privilege for the Editorial Committee. We closely cooperated with our colleagues and friends of the Scientific Program Committee (SPC) and the Organizing Committee (OC).

Out of 638 submissions, 292 high quality papers were selected for publication in these proceedings by the SPC. Out of 218 poster submissions, 21 posters were nominated for a best poster award; they are included as 1 page contributions in these proceedings. While high quality contributions have been selected by the SPC, the Editorial Committee has focussed on providing proceedings with a high quality of format and presentation which made additional editing necessary. The proceedings are also appearing on CD-ROM. All accepted poster contributions are published on an additional CD-ROM.

The MEDINFO 2007 Proceedings present an excellent overview of a dynamic and quickly growing field, demonstrating methodical and practical progress from around the world. Information science and, specifically, (Bio-) Medical Informatics have become core pillars of foundational and clinical research, of medical care, and of prevention. MEDINFO 2007 in Brisbane will be the leading conference of the year, bringing a worldwide community together.

We have organized the proceedings into twelve chapters, covering topics such as eHealth, Decision Support, Improving Quality, Usability, Sustainability, Genomics, Biomedical Image and Signal Processing, and Education and Training. Within each chapter, the articles are organized according to the conference sessions; the session titles are shown in the table of contents.

The assistance of HISA has been invaluable in all editorial steps, including communication with authors, language editing, and formatting of manuscripts. We owe specific thanks to Joan Edgecumbe, Dale Proposch and Tom Morgan.

The Editorial Committee

Klaus A. Kuhn, Germany; James R. Warren, New Zealand; Tze Yun Leong, Singapore

Chronic diseases are increasing rapidly and this phenomenon is becoming a major burden to the health delivery system around the world. A new health care paradigm with focus on chronic treatment and care will actualize the need for interoperable standards based services due to the complexity of care where different health levels and professions are involved. Given the complexity of the domain, we argue the need for a systematic and formal approach to the development of interoperable information systems if there shall be any real support of the cooperating actors. We describe our work on technical interoperability done in the Linkcare project addressing new models of care and technology to support them in the domain of the chronically ill using concrete results from an architecture built using the MAFIIA architecture framework and the UML 2.0 profile for software services, and argue that building formal architectural descriptions on the basis of shared interface descriptions and profiles are an important part of achieving continuity of care based on sustainable health systems.

Despite the abundance of past home care projects and the maturity of the technologies used, there is no widespread dissemination as yet. The absence of accepted standards and thus interoperability and the inadequate integration into transinstitutional health information systems (tHIS) are perceived as key factors. Based on the respective literature and previous experiences in home care projects we propose an architectural model for home care as part of a transinstitutional health information system using the HL7 clinical document architecture (CDA) as well as the HL7 Arden Syntax for Medical Logic Systems. In two short case studies we describe the practical realization of the architecture as well as first experiences. Our work can be regarded as a first step towards an interoperable – and in our view sustainable – home care architecture based on a prominent document standard from the health information system domain.

Clinically relevant family history information is frequently missing or not readily available in electronic health records. Improving the availability of family history information is important for optimum care of many patients. Family history information on five conditions was collected in a survey from 163 primary care patients. Overall, 53% of patients had no family history information in the electronic health record (EHR) either on the patient's problem list or within a templated family history note. New information provided by patients resulted in an increase in the patient's risk level for 32% of patients with a positive family history of breast cancer, 40% for coronary artery disease, 50% for colon cancer, 74% for diabetes, and 95% each for osteoporosis and glaucoma. Informing physicians of new family history information outside of a clinic visit through an electronic clinical message and note in the EHR was not sufficient to achieve recommended follow-up care. Better tools need to be developed to facilitate the collection of family history information and to support clinical decision-making and action.

Surveys of patients consistently demonstrate a very strong interest in having secure electronic access to their own laboratory test results. In recent years, a number of health care providers and lab service centers have offered this capability, which now extends to millions of patients in the United States. Yet, little has been published on the methods of making lab results available. This case report identifies the objectives, methods, and results of a feasibility pilot conducted at Partners Healthcare from May to September, 2006. A candidate set of results were identified, approved for release, programmed into Patient Gateway, Partners' secure patient portal, and studied. Patient and practice feedback was positive. No noticeable rise in patient concerns was observed by practice staff or through patient surveys. One-half of patients who viewed results accessed reference information linked to a result. Organizational and practice-level issues necessary to support continued rollout are described.

Healthcare planning seems beset with problems at all hierarchical levels. These are caused by the ‘soft’ nature of many of the issues present in healthcare planning and the high levels of complexity inherent in healthcare services. There has, in recent years, been a move to utilize systems thinking ideas in an effort to gain a better understanding of the forces at work within the healthcare environment and these have had some success. This paper argues that systems-based methodologies can be further enhanced by metrication and modeling which assist in exploring the changed emergent behavior of a system resulting from management intervention. The paper describes the Holon Framework as an evolving systems-based approach that has been used to help clients understand complex systems (in the education domain) that would have application in the analysis of healthcare problems.

Modeling is used increasingly in healthcare to increase shared knowledge, to improve the processes, and to document the requirements of the solutions related to health information systems (HIS). There are numerous modeling approaches which aim to support these aims, but a careful assessment of their strengths, weaknesses and deficiencies is needed. In this paper, we compare three model-centric approaches in the context of HIS development: the Model-Driven Architecture, Business Process Modeling with BPMN and BPEL and the HL7 Development Framework. The comparison reveals that all these approaches are viable candidates for the development of HIS. However, they have distinct strengths and abstraction levels, they require local and project-specific adaptation and offer varying levels of automation. In addition, illustration of the solutions to the end users must be improved.

São Paulo is the largest city in Brazil and one of the largest cities in the world. In 2004, São Paulo City Department of Health decided to implement a Healthcare Information System to support managing healthcare services and provide an ambulatory health record. The resulting information system is one of the largest public healthcare information systems ever built, with more than 2 million lines of code. Although statistics shows that most software projects fail, and the risks for the São Paulo initiative were enormous, the information system was completed on-time and on-budget. In this paper, we discuss the software engineering principles adopted that allowed to accomplish that project's goals, hoping that sharing the experience of this project will help other healthcare information systems initiatives to succeed.

In order to estimate the impact of an innovation on a segment of the health care system under certain assumptions such as different possible regulatory or financing schemes (scenarios) prior to its diffusion, one must understand the dynamic behavior of the entire system with its essential control loops. Aim of this feasibility study was to explore the potential of System Dynamics (SD) modeling for this purpose. First, a UML-based modeling of an Innovative Care for Elderly (ICE) system for provision of integrated social and health care services to elderly living at home was done. Then monetary and quality of life aspects of the social and health care system were described by two coarse SD models. On these models the impact of the introduction of the ICE system under certain assumption (scenarios) was studied, based on data from the German Health Expenditure and German Federal Statistics Office. The simulations show plausible behavior, however, are not yet detailed enough for a final conclusion. A major problem is missing data for setting model parameters: estimates had to be made. In conclusion, SD modeling might be a useful method for studying impacts of the diffusion of an innovation in the health for elderly sector, but more research is needed.

To ensure that quality is ‘engineered in’ a holistic, integrated and quality approach is required, and Total Quality Management (TQM) principles are the obvious foundations for this. This paper describes a novel approach to viewing the operations of a healthcare provider where electronic means could be used to distribute information (including electronic fund settlements), building around the Full Service Provider core. Specifically, an approach called the “triple pair flow” model is used to provide a view of healthcare delivery that is integrated, yet detailed, and that combines the strategic enterprise view with a business process view.

Faulty exchange and impaired access to clinical information is a major contributing factor to the incidence of medical error and occurrence of adverse events. Tradtional methods utilized for systems analysis and information technology design fail to capture the nature of information use in highly dynamic healthcare environments. This paper describes a study designed to identify information task components in a cardiovascular intensive care unit and the development of an observational data collection tool to characterize the use of information in this environment. Direct observation can be a time-consuming process and without easy to use, reliable and valid methods of documentation, may not be reproducible across observers or settings. The following attributes were found to be necessary components for the characterization of information tasks in this setting: purpose, action, role, target, mode, and duration. The identified information task components were incorporated into the design of an electronic data collection tool to allow coding of information tasks. The reliability and validity of this tool in practice is discussed and an illustration of observational data output is provided.

e-Health Networks require cost-effective approaches for routine operation to achieve long-lasting sustainability. By using a model to represent (i) the network's enterprise functions, (ii) the applications used and (iii) the physical implementations, the tasks of management, adapting to changes and providing continued maintenance can be effectively supported. The paper discusses approaches for modeling, assesses their usefulness for the above tasks and decides on the use of the 3LGM meta model. Based on this concept, three ways for modeling the specific properties of an e-Health network are presented, leading to the decision to represent the hospitals involved in only one layer. As a result the model derived is presented, assessed and proved to support strategic management, day-to-day maintenance and documentation.

The openEHR foundation has developed an innovative design for interoperable and future-proof Electronic Health Record (EHR) systems based on a dual model approach with a stable reference information model complemented by archetypes for specific clinical purposes.

A team from Sweden has implemented all the stable specifications in the Java programming language and donated the source code to the openEHR foundation. It was adopted as the openEHR Java Reference Implementation in March 2005 and released under open source licenses. This encourages early EHR implementation projects around the world and a number of groups have already started to use this code.

The early Java implementation experience has also led to the publication of the openEHR Java Implementation Technology Specification. A number of design changes to the specifications and important minor corrections have been directly initiated by the implementation project over the last two years. The Java Implementation has been important for the validation and improvement of the openEHR design specifications and provides building blocks for future EHR systems.

The aim of this project is to contribute to limiting the risk of CHIS (computerised hospital information system) failure by identifying factors which are associated with the successful implementation of CHISs in district and regional hospitals in South Africa (SA). Case studies were conducted in four regional hospitals in the Western Cape province of SA to obtain data about user perceptions of the success or lack of success of the CHISs in use. A conceptual model of CHIS use has been developed based on the results of the case studies, in order to assist in the interpretation of the differing experiences across the hospitals. Key factors in the conceptual model are perception of usefulness of the CHIS and management commitment to ensuring CHIS success, which in turn are related to effective use of CHIS and/or CHIS outputs, and allocation of resources for CHIS further development. Further development of the model will be influenced by the next phase of this project: a survey of district and regional hospitals in two SA provinces.

Problem-oriented functions have been implemented in almost all Belgian GPs' software systems since 2003. We therefore investigated whether some of them – especially the explicit linking procedure between treatments or referrals and the relevant problems – can be used by GPs in their current daily practice.

In 2005, within the Belgian ResoPrim project, we organized data collection, mainly around the theme of “hypertension and cardiovascular risk factors”, by 26 volunteer GPs' practices using three different software systems. Data were collected prospectively over six weeks in early 2005, and retrospectively for 2004. In this paper we report only on the part of the study that aimed to assess the linking procedure. For all patients and hypertensive patients alike, the key indicators used were the percentage of (problem-) linked drugs among the drugs extracted, the percentage of anti-hypertensive (problem-) linked drugs among anti-hypertensive drugs extracted, and the percentage of (problem-) linked referrals among the number of referrals extracted.

For all patients, the data collected relate to 10 914 contacts (7 831 patients) in 2005, and to 74 878 contacts (16 813 patients) in 2004. Large variations were observed per software system and GP, and also over time. The percentage of linked drugs rose from 2% (2004, two GPs) to 36% (2005, fourteen GPs). For linked referrals the percentage was 65% in 2004 vs. 75% in 2005.

Our study shows that some functions related to the problem-oriented patient record were spontaneously used by GPs in daily practice. This use increased during collaboration with the primary care research network. This increase was not restricted to the theme of data collection (i.e. not restricted to hypertensive patients, to anti-hypertensive drugs or to links with cardiovascular problems).

At the University Children's Hospital Heidelberg the concept of ‘Developmental, Family-Centred, Individual Care of Premature Infants and Newborns’ was introduced to support optimal growth of premature infants. This interdisciplinary concept requires cooperation of different specialists. A well operating communication is a precondition for such cooperation.

As a patient's record is not only used for storing information but also for exchanging information, the question was if a complete electronic patient record (EPR), in contrast to the existing patient's record, could sensibly support this new concept of care. To answer this question the whole communication of the staff in the infants ward was analysed using different observation methods. These observations delivered several issues which showed that an EPR could improve communication and workflow. Therefore an EPR for the neonatology at the University Children's Hospital Heidelberg can now be designed on the basis of our communication concept.

Multiple detection modalities have increasingly gained attention in population-based screening. However, the disease natural history and its efficacy have been barely addressed. We reviewed a series of articles addressing multiple detection modalities including mammography, ultrasound and magnetic resonance image between 1995 and 2005. A stochastic model was developed to estimate transition parameters pertaining to the disease natural history defined by multiple detection modalities. The effectiveness of the combination of ultrasound or magnetic resonance image (MRI) with mammography was projected using a series of computer simulation models.

The results indicated that multiple detection modalities may lead to reduced mortality. However, the benefit and the selection of detection modalities are affected by biological factors including age, breast tissue type and histological type. In addition, other social factors may also affect the utilization of multiple detection modalities.

The Norwegian Centre for Telemedicine (NST) has, over the past two decades, contributed to the development and implementation of telemedicine and ehealth services in Norway. From 2002, NST has been a WHO Collaboration Center for telemedicine. In August 1996, Norway became the first country to implement an official telemedicine fee schedule making telemedicine services reimbursable by the national health insurer. Telemedicine is widely used in Northern Norway. Since the late 1980's, the University Hospital of North-Norway has experience in the following areas: teleradiology, telepathology, teledermatology, teleotorhinolaryngology (remote endoscopy), remote gastroscopy, tele-echocardiography, remote transmission of ECGs, telepsychiatry, teleophthalmology, teledialysis, teleemergency medicine, teleoncology, telecare, telegeriatric, teledentistry, maritime telemedicine, referrals and discharge letters, electronic delivery of laboratory results and distant teaching for healthcare personnel and patients. Based on the result achieved, the health authority in North-Norway plans to implement several large-scale telemedicine services: Teleradiology (incl. solutions for neurosurgery, orthopedic, different kinds of surgery, nuclear medicine, acute traumatic and oncology), digital communication and integration of patient data, and distant education. In addition, the following services will also be considered for large-scale implementation: teledialysis, prehospital thrombolysis, telepsychiatry, teledermatology. Last in line for implementation are: pediatric, district medical center (DMS), teleophthalmology and ear-nose-throat (ENT).

The risk of epidemics and emerging or re-emerging diseases such as avian flu, tuberculosis, malaria and other vector-borne diseases, is rising. These risks can be contained with prevention, early warning, and prompt management. Despite progress in information technology, communication is still a bottleneck for health early warning and response systems in post-disaster situations. This paper presents Satellites for Epidemiology (SAFE), a component-based interoperable architecture for health early warning that employs satellite, radio, and wireless networks, geographic information systems, integration technology, and data mining to promptly identify and respond to a disease outbreak. In a post-disaster situation, a mobile health emergency coordination center is established and integrated to public health services for health monitoring. The added-value of SAFE for post-disaster health management will be demonstrated as part of an earthquake readiness exercise regarding a typhoid fever epidemic, in the island of Crete. Advanced communication and data mining techniques in SAFE offer new tools to the “Epidemic Intelligence” and contribute to advanced preparedness and prompt response by lifting communication barriers, promoting collaboration, and reducing the isolation of affected areas.

Stroke is a serious neurological accident which accounts for a wide fraction of the healthcare costs in industrialized societies. Recovery from stroke and other neurological accidents usually include motor rehabilitation, maintained for several months, and logopedic training for the recovery of cognitive and speech abilities. The MyHeart consortium is addressing several aspects of cardiovascular diseases' management by combining clothes with embedded biomedical sensors and information technologies. One of the application areas is especially devoted to supporting Neurological Rehabilitation (NR). This article describes how MyHeart's Concept NR is structured and how technologies are leveraged to support both motor rehabilitation and speech/cognitive training. Information technology and garment-embedded sensors, combined, permit assisted training both at the clinic and at home, after discharge from the intensive care unit.

A gap exists in cardiac care between known best practices and the actual level of care administered. To help bridge this gap, a proof of concept interface for a PDA-based decision support system (DSS) was designed for cardiac care nurses engaged in teletriage. This interface was developed through a user-centered design process. Quality of assessment, quality of recommendations, and number of questions asked were measured. Cardiac floor nurses' assessment quality performance, but not their recommendation quality performance, improved with the DSS. Nurses asked more questions with the DSS than without it, and these additional questions were predominantly classifiable as essential or beneficial to a good assessment. The average participant satisfaction score with the DSS was above neutral.