Ebook: Transformation of Healthcare with Information Technologies

The final phase of the PRO-ACCESS project coincides with the accession of ten new member states to the European Union. This exciting moment in European history brings great opportunities for the entrant countries, but it also means they will have to face new challenges.

The accession process demands considerable effort on the part of new member states, aimed at developing common policies and strategies. Over the last two years we have tried to encourage the community of medical informatics professionals and researchers from Central and Eastern European countries to undertake these challenges and join European activities in the field of e-health. We are aware of the fact that only common standards and procedures will enable full integration of this region with the main stream of Information Society developments, currently accelerating all over Europe.

The PRO-ACCESS project aims at carrying modern e-health perspectives to new EU member states. We are proud that a considerable number of papers presented in this book have been prepared by authors from these countries. This should prove encouraging for all those who believe in the great potential of this European region. This book also reports on the results of cooperation between researchers and centres representing both new EU entrants and those countries, that have been part of the Community for a long time.

The European Commission has consistently fostered the strategy of e-health development over the past decades. Yet, the economic transformation underway in Central and Eastern European countries does not favour rapid development in this domain. Healthcare systems all over the region are being transformed in search of more effective mechanisms of financing. Even though the e-health environment brings many opportunities related to improved resource management and better quality of care, its potential cannot currently be fully explored, due to the difficult economic situation and the lack of a welldeveloped information infrastructure.

One of the main motivations for publishing this book was the editors' conviction that only continuous effort to trigger activities, exchange ideas and share experience can speed up e-health services development in Central and Eastern countries. Transfer of knowledge and technology is surely one of the key mechanisms through which these new EU member states can integrate themselves with the Community. Such transfer brings a chance of achieving synergy during the expansion process and bodes well for the increased competitiveness of the enlarged European Union.

We would like to express our thanks to all authors, colleagues and partners from the PRO-ACCESS project, who supported our efforts to prepare this Book.

Mariusz Duplaga, Krzysztof Zieliński

Web systems present executives with a new variant of an old problem: determining “What am I getting out of this communication technology implementation?” The creation of a set of value criteria is vital. The main aim of the paper is to modify the approach suggested by Kaplan‐Norton, emphasizing the value chain processes and other development aspects important for e‐healthcare (patient satisfaction, finance, knowledge and technology). The paper contains the definition of the value generated in an e‐healthcare system. The paper develops M. Porter's value chain approach and contains a model value chain for an e‐healthcare organisation. This approach explains the activities behind the generation of value.

E‐health is an emerging field on the intersection of medical information technologies, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. Portal technology, allowing services to be accessible over the Internet is a perfect tool for providing e‐health services. The use of portal technologies has had deep influence on the architecture of the whole e‐health system, both regarding new subsystems and older ones which we want to integrate with the portal. Portals provide new possibilities for creating novel types of e‐health applications as well.

In this paper we provide a brief overview of e‐health systems and portal technologies, and present many technical aspects of portal technology application for e‐health systems such as the architecture of portal‐based e‐health systems, graphical user interfaces, access to various e‐health systems' resources, personalization, security and privacy.

Before 1997, the Internet was strongly associated with universities and higher education, including medical research. There were only small virtual communities at that time, but all their members had equal access to the entire body of information placed on the net. Each networking participant was able not only to retrieve but also to create and distribute medical information. This state was a symmetry, of sorts, between passive and active Internet usage. Since that time, however, significant commercialization of the Internet (including the medical domain) has been increasing its asymmetry.

We currently observe a division into providers, serving and distributing medical information on the net, and consumers, who receive pre‐prepared “products”. This brings new challenges for both academic and practicing e‐health physicians. First, while all large‐scale initiatives to certify medical portals have so far failed, the public must be educated to chose valuable, high quality medical information themselves. Secondly, this imbalance favors abusive commercial behavior, such as spam, spreading viruses and advertising without content‐related information. Stimulating a restoration of the previous idea of the Internet for non‐profit activities seems to be best way to avoid the continuation of Internet “degeneration”. Manuel Castells has defined future industrial and postindustrial progress of humanity as activity in global virtual communities, interchanging ideas, knowledge and information. The role of medical professionals seems to be to educate patients and their families on how to search for quality medical information and to stimulate other medical professionals, researchers as well as patients' supportive groups to be active themselves. Reducing the medical information asymmetry will provide a positive influence on the progress of e‐health in the future. Open source software may help reduce costs by creating adequate resources.

The purpose of this study was the development of a Web‐based e‐health service for comprehensive assistance and clinical decision support. The service structure consists of a Web server, a PHP‐based Web interface linked to a clinical SQL database, Java applets for interactive manipulation and visualization of signals and a Matlab server linked with signal and data processing algorithms implemented by Matlab programs. The service ensures diagnostic signal‐ and image analysis‐sbased clinical decision support. By using the discussed methodology, a pilot service for pathology specialists for automatic calculation of the proliferation index has been developed. Physicians use a simple Web interface for uploading the pictures under investigation to the server; subsequently a Java applet interface is used for outlining the region of interest and, after processing on the server, the requested proliferation index value is calculated. There is also an “expert corner”, where experts can submit their index estimates and comments on particular images, which is especially important for system developers. These expert evaluations are used for optimization and verification of automatic analysis algorithms. Decision support trials have been conducted for ECG and ophthalmology ultrasonic investigations of intraocular tumor differentiation. Data mining algorithms have been applied and decision support trees constructed. These services are under implementation by a Web‐based system too.

The study has shown that the Web‐based structure ensures more effective, flexible and accessible services compared with standalone programs and is very convenient for biomedical engineers and physicians, especially in the development phase.

Access to information and communication systems for PwD (Persons with Disabilities) is a priority both for the EU and candidate countries. This paper presents some results of the Romanian project called “InHand – Information Center for Persons with Disabilities)“. The main goal of the project is to contribute to improving the quality of life and health status of this group of people. Our emphasis is on the benefits of universal design. By eliminating barriers that prevent people with disabilities from using Web sites, it is possible to make each site more useful for all visitors, not to mention ease of maintenance and cost‐effectiveness.

Cancer registration has developed in Europe over the last 50 years, and in the last decade intensive joint activities between the European Cancer Registries, in response to the need of pan‐European harmonization of registration practices, have taken place. The Hungarian Paediatric Cancer Registry has been functioning as the database of the Hungarian Paediatric Oncology Network since 1971, aiming to follow the incidence and the treatment efficacy of malignant diseases.

The goals of this globally unique open source information system are the following: 1) to raise the quality of the registration system to the European level by developing an Internet‐based registration and communication system, modernizing the database, establishing automatic statistical analyses and adding an Internet website, 2) to support clinical epidemiological studies that we conduct with international collaborators on detailed analyses of the characteristics of patients and their diseases, evaluation of new diagnostic and therapeutic methods, prevention programs, and long‐term quality of life and side effects.

The benefits of the development of the Internet‐based registration and communication system are as follows: a) introduction of an Internet‐based case reporting system, b) modernization of the registry database according to international recommendations, c) automatic statistical summaries, encrypted mail systems, document repository, d) application of data security and privacy standards, e) establishment of a website and compilation of educational materials.

The overall objective of this scientific project is to contribute towards the improvement of cancer prevention and cancer care for the benefit of the public in general and of cancer patients in particular.

The creation of a complex telemedical system oriented towards childhood Hodgkin's disease has been undertaken at the Department of Bioinformatics and Telemedicine of the Jagiellonian University Medical College in cooperation with the Department of Oncology and Pediatric Hematology of the Polish‐American Institute of Pediatrics, JU MC. Data collecting, data processing and data transmission is aimed to aid and/or supervise surgical and drug treatment.

The Tele‐Database of Childhood Hodgkin's Disease (TDCHD) is not a simple Internet database project. A few hundred data items are presented in each patient's record, covering the complete medical treatment period. Efficient management and proper data protection are necessary for a medical database. Therefore, the interface for entering data has been divided into several parts. Each part is subjected to separate editing and transfer. A double‐layer debugging system has been applied in the program: the first pass occurs on the client side (programmed in JavaScript and XML), the second ‐ on the server side (programmed in PHP). Strict authorization is requested for all participants. Clinical data collected according to management standards and information governance (data quality, security and confidentiality) is organized in a way that facilitates practical and scientific use.

Aims: To analyse the present status and future development of computerized diagnostic pathology in terms of work‐flow integrative telepathology and virtual laboratory.

Present status: Telepathology has left its childhood. The technical development of telepathology is mature, in contrast to that of virtual pathology. Two kinds of virtual pathology laboratories are emerging: a) those with distributed pathologists and distributed (>=1) laboratories associated to individual biopsy stations/surgical theatres, and b) distributed pathologists working in a centralized laboratory. Both are under technical development. Telepathology can be used for e‐learning and e‐training in pathology, as exemplarily demonstrated on Digital Lung Pathology Pathology (www.pathology‐online.org).

Features of virtual pathology: A virtual pathology institution (mode a) accepts a complete case with the patient's history, clinical findings, and (pre‐selected) images for first diagnosis. The diagnostic responsibility is that of a conventional institution. The internet serves as platform for information transfer, and an open server such as the iPATH (http://telepath.patho.unibas.ch) for coordination and performance of the diagnostic procedure. The size of images has to be limited, and usual different magnifications have to be used. A group of pathologists is “on duty”, or selects one member for a predefined duty period. The diagnostic statement of the pathologist(s) on duty is retransmitted to the sender with full responsibility. First experiences of a virtual pathology institution group working with the iPATH server (Dr. L. Banach, Dr. G. Haroske, Dr. I. Hurwitz, Dr. K. Kayser, Dr. K.D. Kunze, Dr. M. Oberholzer,) working with a small hospital of the Salomon islands are promising. A centralized virtual pathology institution (mode b) depends upon the digitalisation of a complete slide, and the transfer of large sized images to different pathologists working in one institution. The technical performance of complete slide digitalisation is still under development and does not completely fulfil the requirements of a conventional pathology institution at present.

Virtual pathology and e‐learning: At present, e‐learning systems are “stand‐alone” solutions distributed on CD or via internet. A characteristic example is the Digital Lung Pathology CD (www.pathology‐online.org), which includes about 60 different rare and common lung diseases and internet access to scientific library systems (PubMed), distant measurement servers (EuroQuant), or electronic journals (Elec J Pathol Histol). A new and complete data base based upon this CD will combine e‐learning and e‐teaching with the actual workflow in a virtual pathology institution (mode a). The technological problems are solved and do not depend upon technical constraints such as slide scanning systems

Perspectives: Telepathology serves as promotor for a new landscape in diagnostic pathology, the so‐called virtual pathology institution. Industrial and scientific efforts will probably allow an implementation of this technique within the next two years.

The rapid growth and development of information technologies over recent years, in the areas of mobile and wireless technologies is shaping a new technological scenario of telemedicine in diabetes. This telemedicine scenario can play an important role for further acceptance by diabetic patients of the existing continuous glucose monitoring systems and insulin pumps with the final goal of improving current therapeutic procedures. This paper describes a Personal Smart Assistant integrated in a multi‐access telemedicine architecture for the implementation of a mobile telemedicine closed‐loop system for diabetes management. The system is being evaluated within the European Union project named INCA (“Intelligent Control Assistant for Diabetes”).

Many existing medical systems are good candidates for improvement via incremental migration. Incremental software improvement is, however, much more difficult if the system consists of independent functional modules built with different technologies. The goal of this paper is to present architecture migration aspects of contemporary telemedical systems. The paper discusses two approaches: the Software Architecture Analysis Method, and the Architecture Tradeoff Analysis Method in the context of migration of the medical teleconsultation system Konsul. The system, designed and implemented under KCT activity, is being successfully employed in day‐to‐day activities at the John Paul II Hospital in Krakow despite many existing drawbacks in its internal architecture.

The paper presents the SAAM method of analysis of legacy systems. Two architectures are proposed as a result of this analysis – one based on the migration of the existing architecture, the other built according to the state‐of‐the‐art Service Oriented Architecture.

Konsul II, implementing the migration approach, has already been developed whereas Konsul III is in the design phase. The paper concludes with remarks about migration of telemedical systems.

Teleconsultation services at referential centres are an important area of telemedicine development. The implementation of such scenarios brings high‐level competencies to peripheral hospitals through telecommunication links. Pulmonary teleconsultations were one of the key aspects of Krakow Centre of Telemedicine (KCT) activities conducted in 2002‐2003. The role of the referential centre for respiratory medicine was played by the Division of Interventional Pulmonology, Jagiellonian University Medical College. Peripheral centres were pulmonary wards situated in local hospitals or policlinics located 20‐80 km from Krakow. These hospitals were equipped with PC‐based telemedical workstations and ISDN lines (256 kbps). Dedicated software (Telenegatoscope) was used for real‐time discussions among physicians on medical images (X‐rays, CTs) sent from peripheral centres to the referential centre. Images inserted in light boxes were cropped at peripheral centres with a high‐resolution digital camera.

During the pilot phase, about 40 pulmonary patients were referred via telemedical links to the University Hospital. The frequency of soliciting a second opinion at the referential centre was analyzed for each main type of disease. Top positions are currently occupied by diagnoses of lung cancer, pleural fluid of unknown origin, asbestosis and tuberculosis. About 70% of the patients referred for virtual consultation were admitted for further diagnostics and treatment in an ambulatory or inpatient mode at the Division of Interventional Pulmonology. The review of teleconsultations results indicates that teleconferencing contacts, even if conducted through relatively limited bandwidth, may bring considerable benefits to patients requiring complex diagnostic and sophisticated, procedures available at the referential university hospital.

Cardiovascular diseases and, in particular, diseases related to arrhythmias are a problem that affects a significant percentage of the population, being one of the major causes of death in Europe. New advances in the fields of PDAs, mobile phones, wireless communications and vital parameter sensors have permitted the development of revolutionary medical monitoring systems, which strikingly improve the lifestyle of patients. However, not all those monitoring systems provide patients with real assistance – anywhere and at any time. We have developed a system that goes a step further than the previous approaches, being designed to capture, record and, as a distinctive feature, locally analyze the ECG signals in a PDA carried by the patient. In that sense, the system has a decision support module based on decision tree methods that can detect, with high precision, any arrhythmias that the user may be suffering. Alarms can then be activated in time to alert a medical center in order to provide the proper medical assistance. One of our aims when building the system has been to optimize limited and expensive resources like PDA memory size and wireless communication costs. Moreover, accessibility is also an important feature of the system that has been achieved by the development of web services to query the data computed in the PDA. In this way, authorized personnel (physicians and relatives) can easily obtain access to that data.

The current techniques used to diagnose cardiac arrhythmias such as Holter, Rtest and telemetry systems are partially efficient because they are limited either in time or in space. In this paper, a platform dedicated to the real‐time remote continuous cardiac arrhythmias detection and monitoring is proposed. Such a platform allows to improve the accuracy and the efficiency of the diagnostic of ventricular tachycardia among the high‐risk patients and enables the implantation of ICD to prevent sudden death. The new method allows the patient to lead a normal life while being remotely monitored in real‐time by an ambulatory wireless ECG sensor. When a cardiac arrhythmia is detected a message including a sequence of ECG signals and the patient's images (indoors only) is sent to a remote surveillance server. According to the gravity of the symptom, the cardiologist can intervene in real time or later. The system has been evaluated on some ten patients with regard to heartbeat and cardiac rhythm disturbance. The real‐time results are similar to those offered by HP telemetry systems.

The paper presents the development results of teleconsultative cardiology systems and their application in rehabilitation and sport medicine. The first teleconsultative cardiology (TELECARD) system was developed for outpatient departments in the city of Kaunas, using Internet links. It was based on the CompCardioSignal terminal. One branch of the TELECARD system with a mobile CompCardioSignal terminal was used for functional state evaluation of Lithuanian sportsmen during the 2000 Sydney Olympic Games. The examined results have shown that every sportsman responded differently to acclimatization and the TELECARD system provided support to physicians and coaches for making optimal decisions regarding the sportsmen's adaptation and other situations. The final telemetry system was used for rower monitoring. It was based on the new CompCardioSignal terminal with three EASI ECG leads and synchronously recorded motion signals for evaluation of human reaction to physical load. The developed telemonitoring systems were a useful tool for evaluation of human reaction to physical load in rehabilitation and sports activities.

Cardiovascular diseases remain the main cause of morbidity and mortality in Lithuania, and early detection of those diseases is one of opportunities to reduce this problem. Usage of information technologies including clinical decision support systems, telemedicine networks and computer analysis of cardiac signals, can serve this purpose. Therefore, the presented paper deals with development of a system for the analysis of 12‐lead electrocardiograms (ECG), impedance cardiograms (ICG) and seismocardiograms (SCG) in the aim to use it in a wider cardiologic teleconsultative system. Such a complex set of signals makes it possible to monitor the electric (ECG), hemodynamic (ICG) and mechanical (SCG) properties of cardiac activity. The hardware for synchronous recording of 12‐lead ECG, ICG and SCG as well as the software containing programs for signal input, recognition, measurement, analysis and data transmission has been developed.

The ultimate end‐point of healthcare and health‐related life sciences, more or less as regulatory idea, is the prevention and cure of diseases, considering the fate of individual patients as well as the challenge of providing sufficient care for all. However, all undertakings stand under the “proviso of rightness of action”. The movement of evidence‐based medicine has triggered a renaissance of systematic self‐assurance of best practise.

The systematic utilization of healthcare records and research study recordings in an inter‐linked manner provides a better enabling environment to improve evidence. Good e‐health must contribute to accumulate inter‐generation clinical experience. Qualified research should ensure methodological strictness via gold standards like controlled, randomised and masked trials.

Building information systems for e‐health as well as for e‐science bears as a special focus the mutual cross‐fertilization of these application domains. Analysing a variety of building blocks shows that both areas can benefit from generic solution pattern, keeping in mind that each domain has distinguished knowledge realms. Generic patterns as well as distinguished special features are illustrated by analysing state of the art solutions plus some experimental approaches, as there are: the generic part of the HL7 V3 RIM, the RCRIM work, laboratory information handling, vital sign standardization efforts, like ECG information models.

Finally, the precision of the usage of the ubiquitous term “metadata” is taken as example of an open issue.

Clinical guidelines have been used for diagnostic and treatment purposes, and lately much of this information has become available in electronic formats. In Norway a medical electronic handbook has been developed [1] to give support for the physician, deciding upon diagnoses and treatment. This electronic handbook is now widely used, but not in a systematic fashion – due to lack of user‐friendliness. The lack of integration with EPR systems and, more importantly, the lack of integration with the working process, are additional obstacles.

In order to improve the usability of the electronic handbook, we have developed a prototype where the commercially‐available handbook is tightly integrated with the EPR system and where the EPR system is based on a problem‐based approach. The prototype is focused on providing support to the diagnostic process, treatment planning, documentation and pointers to extended knowledge support. The integration of knowledge support and the EPR system was based on a semantic model representation in the middleware and an XML‐based representation of the knowledge content within a SQL database. In addition to clinical guidelines, the ICPC‐2[2] codes and their inclusion and exclusion criteria are used to support the diagnostic task.

Free‐text forms of medical guidelines that are used in medical care are often cumbersome and difficult to memorize. Therefore a system that is able to present guidelines in a user‐friendly manner has been designed. Guidelines are at first formalized by means of the popular GLIF3 model. Subsequently, the GLIF3 model is coded in XML. The system uses patient data and an XML‐coded GLIF3 model graph evaluating the conditions of decision steps. If some conditions cannot be evaluated, (due to the unavailability of required data items), the system stops and highlights a branch from the root of the decision tree to the final step. Then, the user can input missing data into the system so that the system can continue to provide visualization. Thus, the presentation of guidelines is data‐driven, making its use easier. The visualization system and the Electronic Health Record can be integrated in a system that can, during examination of a patient, suggest subsequent medical actions according to medical guidelines. Such a system has been designed and is now under development.

There is a worldwide consensus for using the diagnosis related groups (DRG) when considering hospital activity. This tool leads to the production of tables of numbers (case mix), the interpretation of which is difficult. Therefore, methods aimed at facilitating this interpretation are needed.

One of such methods is the case view, i.e. a graphical representation of the case mix. It reduces, in a way, each DRG to a “pixel”, the set of the DRGs being an image (the case view). The reference set should be organized according to three criteria: medical/surgical, nosological and economic. This method can be used to answer theoretical questions or to visualize activity at the level of a hospital or at the level of a department.

The purpose of this paper is to present important principles inherent in this graphic representation, both at the level of the method and at the level of the user.

Several hospital management tools are currently used by the DRG financial system. Each case is classified into a DRG group, so it is necessary to know the distribution of hospital or departmental cases into DRG groups, and to follow the variances of this distribution. The DRG's properties include the income and expenses related to each case. There are differences in the profitability of the cases, depending on their DRG. It is important to know own expenses and the recuperated costs for every case.

There are several systems for data collecting and analysis in hospitals, depending on existing hospital information systems and management. We can, however, be sure, that a DRG data collection system works in every department, because it is the basis of assessing income. The tool, which is shown in this article, facilitates an overview of the DRG, presenting the hospital's or other healthcare provider's own data. These services are supported by a platform‐independent, accessible Internet application.

One of the important research tasks of the European Centre for Medical Informatics, Statistics and Epidemiology – Cardio (EuroMISE Centre – Cardio) is the applied research in the field of electronic health record design including electronic medical guidelines and intelligent systems for data mining and decision support. The research in the field of data storage and data acquisition was inspired by several European projects and standards, mostly by the I4C and TripleC projects. Based on experience gathered during cooperation in the TripleC project we have proposed a description of a flexible information storage model. The motivation for this effort was the large variability of the set of collected features in different departments ‐ including temporal variability. Therefore, a dynamically extensible and modifiable structure of items is needed. In our model we use two basic structures called the knowledge base and data files. The main function of the knowledge base is to express the hierarchy of collectable features – medical concepts, their characteristics and relations among them. The data files structure is used to store the patient's data itself. These two structures can be described using graph theory expressions. Based on this model, a three‐layer system architecture named “Multimedia Distributed Record” (MUDR) has been proposed and implemented. During the implementation, modern technologies such as Web Services, SOAP and XML were used.

For the practical usage of EHR MUDR, an intelligent application called MUDRc (MUDR Client) was created. It enables physicians to use EHR MUDR in a flexible way. During the development process, maximum emphasis was placed on user‐friendliness and comfortable usage of this application. Several methods of data entry can be used: pre‐defined forms, direct entry into the tree data structure of the EHR MUDR, or automatic unstructured free‐text report parsing and data retrieval. The system enables fast and simple importing and exporting of data as well. The system integrates modern multimedia formats (X‐ray photos, sonography and other pictures, video‐sequences, audio records) as well as progressive methods of decision support systems realized by medical guidelines and other modules.