Ebook: Open Systems in Medicine

Integration and communication of medical patient data are the principal aims of a long-term project set up at the Division of Cardiology at the German Heart Institute and the University Hospital Rudolf Virchow in close collaboration with the Functional and Logical Programming Group at the Technical University of Berlin. In order to achieve these aims, a project group has been established in which scientists and experts from various disciplines co-operate with other institutions on research and development. This project is mainly supported by the DeTeBerkom, Company for Research and Application in Telecommunication, which is funded by the German national telecommunications service TELEKOM. In addition the group has participated in several projects of the European Community: the TELEMED project (CEC RACE program), the AIMS project (CEC ESPRIT II program), and FEST project (CEC AIM program). It maintains cooperative links with companies and research and development groups in Germany, England, Greece, Italy, France, Spain and the Netherlands.

This book provides a snapshot describing intermediate results, steps for solutions and further directions of developments on the way to an integrated electronical medical record as a basis for complete fulfilment of all tasks in health care. It is obvious that an enterprise of such an extent has many cooperators and collaborations which cannot be completely cited. We wish to give our special thanks to all in the past and in the future who have helped in their individual context to bring about a functioning system, which will help for more rational access and handling to the problem of health care.

E. Fleck

Berlin, September 1994

The principles discussed below give guidance for broader development and exploitation of information and communication technology support in medicine. They are based on intensive work since 1988 in the Berlin project initiative in medicine informatics¹. and in European consortia in Telemedicine and Health Care Telematics². They summarize observations that have since been made and proven in practice.

Based on models of medical work, practice and patient care, and on concepts of data processing, these principles draw a picture of the engineering task of computer support in medicine. It is to be noted, that for brevity throughout this chapter, we often use the term computer support to mean the wider combination of both information and communication technology.

At the German Heart Institute Berlin the introduction of information technology to clinical practice went an unusual way. Instead of serving the administration exclusively, the first thing computerized was the patient admission, the medical documentation and text processing. This is important to note because it is the medical documentation that contains or causes almost all data, that will later on be used for administration purposes. Medical documentation however sets many more obstacles in the way to computerization than administrative applications. To overcome these problems the BAIK system is used. More than 2000 catheter and 3500 surgery procedures documented each year with BAIK prove the viability of the system for day-to-day operations. That it is still used, despite the fact that it was designed in the sixties, makes a review of the original design criteria a learning experience for new developments in computer applications for medical documentation.

Distribution, information management, and integration are central themes in BERMED. Before describing the realization of an open distributed management system, this chapter provides a clarification of certain terms and an overview of the architectural approach adopted. It clarifies the benefits and problems associated with distribution in computing systems, the prime aims of information management, and the meaning of the term open. The architectural approach follows that described in the draft international standard for open distributed processing [1]. One part of this architecture is the open distributed management system, another is the integrated medical application.

The BERMED open distributed management system provides the infrastructure on which to base the integrated medical application. In essence it can be seen to provide the transparency mechanisms that mask from the medical applications programmer the distribution and access methods. The descriptions used here correspond to the computational, and engineering viewpoints. The information and technology viewpoints of BERMED are described later in “Integrated Medical Application”.

In the implementation we utilize the Open Software Foundation’s Distributed Computing Environment to provide remote procedure communications, security and directory services. In the Heart Institute, which makes extensive use of MUMPS technology, a central patient directory has been implemented using the Veterans Administration’s FileMan database. In the Department of Radiology of the University Clinic, integration has been enabled using both the services of DCE and of an object-oriented database, Itasca. These implementations are discussed in a later chapter. The use of commercial products has allowed the rapid development of a reliable infrastructure, whilst at the same time allowing emphasis on the development of the medical application functionality. It is clear that most health professionals are far more interested in the end functionality than the elegance of the underlying object management infrastructure. To have any chance of acceptance the system must support their work.

The data used by the health professional in patient care is multimedia in the true sense of the word. For example, information required for diagnosis or planning of therapy may be derived from the images of a multitude of examination techniques, from reports, graphs, charts, reference books, hand written notes, film and video sequences, audio recordings, and conversations with the patient and colleagues. The data required is most often distributed. Although the true integration and processing of the multimedia information is performed by the physician, the modern computer workstation can provide significant help through the storage, integration, retrieval, processing, filtering, and presentation of much of the required data.

In patient care, there are several significant application areas for this technology. Hypermedia provides a suitable means for the structuring of compound medical documents cornposed of text, images, video and audio components. Object-oriented databases provide the means for the storage, querying, and retrieval of structured multimedia documents. Multimedia communications enables the computer based support for cooperation in medicine through the remote access of data or realtime conferencing.

In this chapter, we discuss some of these technologies, the relevant standards, and their use in BERMED, in particular for the logical integration of patient data to form the multimedia electronic medical record

Until now many applications of knowledge based systems in medicine are technologydriven: some new computational or representational techniques are applied to a particular medical domain. But to get a usable system for the daily clinical routine there is an urgent need for an integrating methodology for medical knowledge based systems construction processes. Such a methodology must consider the organization of the clinical environment where it should run and the tasks in this organization which can profit from the knowledge based systems. The other important part is the interaction with other agents, various types of users (physicians, nurses, other healthcare professionals) and other software systems [17].

The Integrated Medical Application (IMA) gives the physician access to medical services and functionality from a single graphical desktop. The desktop offers services for the local and remote access to electronic patient records of hospitals, specialist clinics, and general practitioners. The distributed patient records within a hospital or practice are logically combined by means of a meta-patient record. A meta-patient record provides information about the local multimedia patient documents. In addition to basic data such as document type, location, and creation date, the record provides information concerning the document structure (see chapter “Multimedia Documents”).The information supplied by the meta-record from each practice and hospital can be combined to form the complete, virtual patient record. The management and access to each record and each document is carried out by the Open Distributed Management System (see chapter “Realization of an Open Distributed Management System”). An object-oriented model has been used throughout. Each local implementation of the record may be different, depending on the facilities of the local environment, but each presents the same external interface to the outside. This mechanism enables the scalable integration over a wide area of all patient documents. At present, the two implemented meta-records provide information and access to all the multimedia documents of the German Heart Institute and the University Hospital Rudolf Virchow departments of cardiology and radiology.

The central components of the IMA provide functionality for the transparent access of local and remote documents obtained through selected meta-record services, the navigation in the patient record, the visualization of multimedia documents, and the processing of images. Other tools that have been integrated in the graphical desktop include advanced image processing capabilities e.g. for quantification of stenosis, communications services such as email, text processing, desktop conferencing, and access to external information sources such as the Internet World-Wide Web.

The IMA is presently being used locally in the campus of the German Heart Institute and the Rudolf Virchow Hospital in Berlin and in a field trial providing the remote access to documents for 9 practitioners and 5 external hospitals.

The experiences resulting from the development and extensive trials in BERMED of the open distributed management platform and the integrated medical application have shown the limits of existing approaches to integration, and have shown which obstacles must be overcome before real progress can be made. Most of these obstacles would, at first sight, appear to be trivial. The required technology often exists. The barriers are not only on a technical level. Commercial interests have in the past ensured that proprietary subsystems (particularly imaging modalities) remain closed. In addition, many barriers that affect the introduction and success of computer support can be on a sociological or organizational level. Although these issues must be addressed, they remain outside the scope of this chapter. The experiences in BERMED and the identification of the certain obstacles has led to the definition of a project to provide an infrastructure for the future medical workstation. Certain of these barriers can only be overcome through a concerted industry wide collaboration. The scope of the planned project is detailed in a later chapter (“A Support Platform for Medical Workstations”).