Ebook: MEDINFO '98

Every three years since 1974, the MEDINFO world congresses of the International Medical Informatics Association (IMIA) represent a unique opportunity to gather specialists from all over the world and present the state-of-the art of health informatics from a scientific, research and application perspective.

The general theme of the 1998 Seoul congress is entitled “Global Health Networking: a Vision for the next Millennium”. With the year 2000 approaching, this concept of a global health networked society is progressively becoming a reality. Technology barriers of connectivity, storage, and interface are fading. Planet wide networks are rapidly developing. Multimedia information, such as that generated from digital imaging or signal processing is progressively integrated to the electronic patient record. The explosion of health information, such as the one produced by the unlocking of the human genetic code, can be counter-balanced by the availability of distributed knowledge banks. Decision support systems that require simultaneous access to patient information and filtered knowledge are progressively moving from the research to the production domain. As the same time, the need for continuous patient care as well as economic pressures, push the various health actors to collaborate to find optimal solution.

Papers from 47 different countries have been submitted for presentation to the scientific program committee. This high participation reflects the considerable impact and the large audience of Medical Informatics that emerges as a new, scientific, medical discipline.

Each submitted paper has been carefully reviewed by at least three reviewers from different countries. The Organizing, Editorial and Scientific Program Committee have been working diligently for the past couple of years to make the Congress a truly memorable professional and personal experience for all participants. We would like to thank all their members for all the energy devoted to the cause of medical informatics, as well as the previous organizers who allow IMIA to be a living and renewing world family.

MedInfo'80 Scientific Program Cochairmen

Charles Safran

Patrice Degoulet

At the Department of Cardiology of the Technical University of Munich and the Deutsches Herzzentrum München cardiac disease patients are treated in close co-operation. In order to support the collaborative treatment as well as cardiological studies a distributed medical record (DMR) has been implemented on the basis of a Holter-ECG archiving and analysis system. Architecture, experiences and major benefits of the solution are reported in the paper. Between January 1995 and December 1997 6500 Holter-ECGs have been archived and analysed. The DMR is in routine operation since January 1996 for all heart catheter patients.

A research project was undertaken to design an electronic medical record system which will cater for the specific needs of South African general practitioners and their unique requirements. The project was launched by sending out a questionnaire to general practitioners in the Free State, trying to determine their specific requirements and to gain insight into their attitudes and opinions regarding the use of computers, especially the computer-based patient record, in a general practice setting. The results indicated that there was a need to replace the current manual patient record with an electronic version, and that the attitudes of the general practitioners in South Africa were generally favourable regarding implementing and using such a system. Given these results, we can proceed to design a computer-based patient record system, specifically addressing the needs and requirements of the South African general practitioner.

A provider of mental health services on multiple sites experienced major problems of availability with traditional paper records and commenced development of an electronic patient record (EPR) and clinical information system in order to provide integrated, real time patient based information. The development process, including clinical and technical considerata is described in order to draw conclusions about the ways in which EPR’s can be a vehicle for change from traditional practice to the multidisciplinary, community based practise developments of recent years. The system can generate information for continuous quality improvement, service planning, and philosophies of care. The key requirements of good record systems are established and the inability of paper records to meet them. In contrast the electronic record has demonstrated ability to guarantee personalised, quality, mental health care.

This paper will outline the tasks involved, completed and not achieved over an eight year period involving the implementation of the Johns Hopkins Oncology Center Information System (OCIS) in an oncology department of a secondary / tertiary care hospital in Australia.

The Virtual Patient Record (VPR), the union of all collections of health relevant data that accumidates over a person’s lifetime in any institution that person has contact with, is a technical possibility in the age of networked computers[1]. This paper investigates, under what conditions the VPR may be useful and manageable. Quantitative considerations of the VPR for a population of 10 M people form the basis. Dynamic aspects of updating and decay in value for treatment decisions are also taken into account. The role of centralized and distributed data stores are compared and the need for indexing is identified.

This paper presents a vision of the future in which standards exist at all levels necessary to accomplish true interoperability. The infrastructure has been established to support connectivity among all healthcare-related institutions as well as the population at large. Provider and patient are integrated in the process of an individual's care.

This paper presents an outline of the Slovenian national project of introduction of the health insurance card system: the background, the grounds for its launching and benefits anticipated, system design, project phases, and interoperability with international healthcard systems.

The system promises to simplify appreciably the administrative procedures currently required in the patient’s daily encounters with the health care system, to benefit both the patient, the health care professionals and the insurance providers; as well as to provide the health care professionals with a new tool of accessing the networked information technology resources. In addition, the system cost-benefit analyses indicate significant economic benefits, which is a significant contribution to the containment of health care service.

In the present environment of trans-border mobility, the significance of international interoperability of any social service system is equally significant as its internal efficiency. Consequently, the issues of compliance to international technology and interoperability standards have been assigned the same high priority as the issues of technological features of the proposed solution in the system design and implementation phase.

With the advent of Integrated Healthcare Delivery Systems, medical records are increasingly distributed across multiple institutions. Timely access to these medical records is a critical need for healthcare providers. The CareWeb^™ project provides an architecture for World Wide Web-based retrieval of electronic medical records from heterogeneous data sources. Using Health Level 7 (HL7), web technologies and readily available software components, we consolidated the electronic records of Boston's Beth Israel and Deaconess Hospitals. We report on the creation of CareWeb^™ (freya.bidmc.harvard.edu/careweb.htm) and propose it as a means to electronically link Integrated Health Care Delivery Systems and geographically distant information resources.

The creation of portable decision support systems (DSSs) remains an important goal in medical informatics. The Adrenal Test Retrieval and Analysis System (ATRAS) has been developed as an example of a simple yet highly effective decision support application which runs in a system-independent way. It is the first implementation of a decision support application layered on the World Wide Web Electronic Medical Record System (W3-EMRS) architecture, which allows for unified access to remote heterogeneous electronic medical record system (EMRS) databases.

One of every four children in the USA is underimmunized. Surveys of children in New York City have documented rates of appropriate immunization as low as 37% in certain populations in northern Manhattan. In response to this, government and private agencies have undertaken efforts to improve immunization rates. As part of one such multiinstitution effort in northern Manhattan, we have begun implementation of a computer-based immunization registry. Key features of this registry system include adaptation of legacy software in order to perform initial capture of data in electronic format; design of a user interface using a World Wide Web server that provides data review and capture functions with appropriate security, implementation of a registry database with links to the server, communication links between hospital registration systems, a Master Patient Index, community providers and the central registry; and integration of decision support in the form of Medical Logic Modules encoded in the Arden Syntax. We discuss our design of this multi-institution immunization registry and implementation efforts to date.

This article presents a new way to manage computerized medical records, based on a totally-hypermedia system. As a matter of fact, the classical use of a database limits the necessary variability of the medical record, in function of both the patient profile and the care practitioner habits. The system we propose is based on a hospital Intranet, and on the XML language. This language allows the definition of semantic tags in hyperdocuments, and thus information retrieval is ensured through semantic tags indexation.

This article is based on a major empirical study of the state of adoption of Computerised Medical Records (CMRs) among General Practitioners (GPs) in Australia and Sweden. Responses were gained from a mail out questionnaire to random samples of GPs in both countries (n=600/country). This paper will report on the main findings gained emphasising some of the various similarities and differences between the two sample groups. This comparative study adds to the existing body of CMR literature by way of providing a cross cultural perspective on GP adoption states. As a result, some concluding comments are offered for understanding high and low diffusion rates of CMRs among GPs and the implications for health policy and technology adoption strategies.

Since 1989, Beth Israel Hospital has been deploying an extensive online patient record (the OMR), which augmented a heavily used integrated hospital information system. Initially begun in a large primary care practice, the system is now used to share patient records among 36 practices on three campuses. Although the system was intended to eliminate the need for paper, we have found that it has, in the short term, increased the amount of paper produced. Elimination of paper record in ambulatory care has saved us $56,000, but we have yet to realize the savings of an additional $200,000 per year. We explore the factors that contribute to this “paper paradox” and discuss the costs associated with increased paper production, areas in which we have reduced paper handling, and strategies for reducing our reliance on paper.

Prior to the implementation of a computer-based patient record, it is necessary to outline the requirements of the medical personnel. The paper is an account of a survey on information needs and demands on computer-based patient records. The study was conducted among physicians, nursing staff and therapists in two Dutch hospitals^*. In order to conduct the study, a measuring-instrument in form of a questionnaire was developed. Based on the results, it may be concluded, that health service staff does not only require improved inputand consultation uses with regard to the hard copy, but is also in need of additional functions. The developed measuring instrument appeared to be a proficient aid in outlining the information needs and demands of the health service staff. Through the developed questionnaire, the staff was able to obtain an idea of the possibilities of the computer-based patient record and state their own interest in same.

The World Health Organisation (WHO) Radiation Emergency Medical Preparedness (REMPAN) centres have built up the International Computer Database for Radiation Accident Case Histories (ICDREC) to document the treatment of acute radiation syndrome (ARS) patients.

Radiation induced skin lesions may cause severe late effects in radiation accident patients. Dermatological multimedia documentation is included into the ICDREC. In particular, retrieval and display of digitised skin photographs and medical reports serves to improve patient care, medical education, and scientific analysis concerning the cutaneous radiation syndrome (CRS).

The database has been built up as a client/server system. A particular focus has been set on using commercial off-the-shelf software components. The medical data including the multimedia data are stored in a relational database system. The database can be accessed by inexpensive personal computers in the dermatologist’s workplace. Authorised institutions can access the database via the Internet. Retrieval of one skin photograph via local area network (LAN) requires approximately 3 seconds.

The current state of the application is illustrated with the skin lesion treatment of a Chernobyl patient. An example is given on how to access the ICDREC from a dermatologist's desktop personal computer.

The discussion focuses on the advantages of storing the textual and pictorial data in one central database to be accessed from different care centres and how the results can be generalised for medical multimedia information systems.

The core of the health information system in the hospitals lies in the medical records, which contain all the data concerning diseases and practices. Then questions arise whether the medical records contain all the data needed in the reliable, complete and timely manners while meeting standards for confidentiality. In this study, we reviewed medical records of 11 general tertiary care hospitals in Seoul, Korea, according to the criteria we made based on the JCAHO's hospital accreditation manual. The focus of review was whether the medical records contain the valuable information fully and in timely manners. But the result was no better than our expectations. More caution should be given for the EPR software engineers to catch up all the information needed from the medical records. We also examine the cause of variation among hospitals and want to give basic information concerning the medical records for implementing the standardized EPR and suggest the method for keeping complete health information

Our first generation hospital information system is in routine use since 1989. The patient data are used for multiple clinical purposes: operation scheduling, reminder for patient care, case retrieval for research and education, and so on. The computerbased patient record was complemented by a flexible PC-based query and report facility for quality management. A regular export of patient data from the host is translated into a relational database model and assessed via the standard of Open Database Connectivity (ODBC) by a statistical analysis tool. Herewith, descriptive and analytical statistics become available to support the clinical departments in patient care. Concerning the migration of first generation systems to modern architectures the presented approach has to be compared with strategies of replacement and capsulation. A decision on the strategy applied should take into account local resources and opportunities.

Electronic patient record is expected to have edit, data analysis, and decision supporting functions. To realize these functions, the entered data should be structured. We made a template based data entry system with some devices. We defined a template for each describing unit, i.e., symptom, physical finding and examination report. Template is composed of several describing elements (a pair of property and value), which form tree structure in general. When a template is selected, the top layers of the elements are displayed at once allowing data entry. When the data qualified by other elements is entered then system presents the second layer about this data at once. This enables users to skip entering some unnecessary items. Users can constitute a form by combining some templates frequently used in a situation. Furthermore, at the second patient visit, the system can present the templates used in the former patient visit to check the different point. These templates and forms can be made easily by editing the master data using template master maintenance program. The entered patient data are presented in progress note and flow sheet. In progress note, the entered data are translated into natural language. In the flow sheet, representative data of each template are present in the cell of the matrix whose line indicates the describing unit and column indicates date. If the cell is clicked, then the details are presented. Using this system, we made templates and forms for cardiovascular field and entered the data about an actual patient with angina pectoris. The time taken by inputting data is shorter than that by handwriting and the content is enough for a patient record. This system is practical for structured data entry in electrical patient record.

At the Heidelberg University Hospital the conventional paperbased medical record is currently being replaced by a “unique” electronic patient record (EPR). This paper describes the stepwise integration of an EPR based on digital-optical archiving and multi-purpose health professional workstations. It focuses on the potentials of digital optical archiving as an integral part of hospital information systems. So far, the EPR has been introduced in the central archive of the “head clinic”, the Neurosurgical Clinic and the inpatient archive, the endoscopy and sonography section of the Department of Internal Medicine.

Data collection via Internet is usually performed with an HTML/CGI combination, which has a lot of disadvantages, most important the lack of security features. We therefore have developed a system written entirely in Java, which implements a true client/server application based on TCP/IP. The documents are created using a multi-lingual data dictionary, and the used GUI components are able to perform plausibility checks, which improves quality of the data. The system is designed to be easily extensible so that it can be used in almost any kind of clinical trials. It is based on a three-tier model where client requests are handled and monitored by an application server. We will describe this system and it's implementation and compare it to the HTML/CGI approach. Of special interest are security features, which are possible through the use of Java.

The process of creating a clinical referral for a patient and the transfer of information from the primary care physician to the specialist and back again is a key component in the struggle to deliver less costly and more effective clinical care. We have created a computer-based clinical referral application which facilitates 1) identifying an appropriate specialist; 2) collecting the clinical, demographic, and financial data required to generate a referral; and 3) transferring the information between the specialist and the primary care physician. Preliminary results indicate that the new computer-based process is faster.

In this paper the conception of the federated healthcare record server to support shared diabetes care is described. Business process modelling is applied to describe the shared care for diabetes patients. Typical dialogues between the different users (patient, internist, GPs, and diabetic nurses) are analysed and described in terms of use cases. Next to this modelling three incremental steps are defined to realise the record server based upon results of standardisation. It proves to be successful to design and build this record server on modern technologies like CORBA and JAVA.