A security architecture for interconnecting health information systems

Several hereditary and other chronic diseases necessitate continuous and complicated health care procedures, typically offered in different, often distant, health care units. Inevitably, the medical records of patients suffering from such diseases become complex, grow in size very fast and are scattered all over the units involved in the care process, hindering communication of information between health care professionals. Web-based electronic medical records have been recently proposed as the solution to the above problem, facilitating the interconnection of the health care units in the sense that health care professionals can now access the complete medical record of the patient, even if it is distributed in several remote units. However, by allowing users to access information from virtually anywhere, the universe of ineligible people who may attempt to harm the system is dramatically expanded, thus severely complicating the design and implementation of a secure environment.This paper presents a security architecture that has been mainly designed for providing authentication and authorization services in web-based distributed systems. The architecture has been based on a role-based access scheme and on the implementation of an intelligent security agent per site (i.e. health care unit). This intelligent security agent: (a) authenticates the users, local or remote, that can access the local resources; (b) assigns, through temporary certificates, access privileges to the authenticated users in accordance to their role; and (c) communicates to other sites (through the respective security agents) information about the local users that may need to access information stored in other sites, as well as about local resources that can be accessed remotely.     

Antibiotic resistant pathogenic bacteria and their resistance genes in bacterial biofilms

Biofilm-forming bacteria are ubiquitous in the environment and also include biofilm-forming pathogens. Environmental biofilms may form a reservoir for risk genes and may act as a challenge for human health. Examples of the health relevance of biofilms are the increase in antibiotic resistant bacteria hosted in biofilms in hospital and environment and consequently the interaction of these bacteria with human cells, e.g. in the immune system. Although data concerning the occurrence and spread of resistant bacteria within hospital care units are available, the fate of these bacteria in the environment and especially in the aquatic environment has barely been investigated. Once antibiotic resistant bacteria have entered the environment, a back coupling by ingestion or other possible entry into the host has to be prevented. Therefore a strategy to investigate paths of entry, accumulation and spread of resistant bacteria in environmental compartments has been developed using quantitative determination of genetic resistance determinants. Additionally a bacterial bioassay assessed bioeffectivity thresholds of low antibiotic concentrations. This approach enables an evaluation of the potential of contaminated waters to exert a selection pressure on bacterial communities and thus promote the persistence of resistant organisms. Completed with an indicator system for the identification of sources of multiresistant bacteria a concept for monitoring and evaluation of environmental compartments with respect to their potential of antibiotic resistance dissemination is suggested.     

Should we screen for colonization to control the spread of multidrug resistant bacteria?

Should we screen for colonization to control the spread of multidrug-resistant bacteria? A multidrug-resistant bacteria surveillance program was performed in 1999 at La?nnec Hospital (Nantes, France). After a 3-year period, the results permit us to determine the strategy to strengthen their spread. In 2001, Staphylococcus aureus resistant to methicillin represented 45% of the 202 multidrug-resistant bacteria isolated. The global incidence rate per 100 admissions remained stable between 1999 and 2001 (0.42%), but those of infections acquired in our institution decreased significantly from 0.27% in 1999 to 0.18% in 2001 (P < 0.05), particularly in medical care units (P < 0.04). In spite of this surveillance program and hygiene trainings, the global incidence remained stable during the study period, even if our action contributed to decrease the incidence of S. aureus resistant to methicillin acquired in our institution. Isolation precautions and screening for colonization policy in intensive care units are not sufficient to control the spread of MRB at hospital level. They should be strengthened by procedures for the transfer of infected or colonized patients and by antibiotic use control.     

Monitoring the standard of deputizing services.

The standard of medical care provided by deputizing services is important for patients receiving care and for doctors using the service. The monitoring of these standards is discussed here in terms of what should be measured, how this should be done, and who should carry out this monitoring. The features to be taken into account include professional values, accessibility, clinical competence, and ability to communicate. Various bodies, such as the deputizing services, family health services authorities, and individual doctors and patients will usefully be involved in assessing standards. The future might hold radical solutions to the management of out-of-hours calls. These solutions could involve patients, general practitioners and the deputizing services. The result must be that patients receive the best possible care.     

Health information systems - past, present, future

In 1984, Peter Reichertz gave a lecture on the past, present and future of hospital information systems. In the meantime, there has been a tremendous progress in medicine as well as in informatics. One important benefit of this progress is that our life expectancy is nowadays significantly higher than it would have been even some few decades ago. This progress, leading to aging societies, is of influence to the organization of health care and to the future development of its information systems. Twenty years later, referring to Peter Reichertz' lecture, but now considering health information systems (HIS), two questions are discussed: which were lines of development in health information systems from the past until today? What are consequences for health information systems in the future? The following lines of development for HIS were considered as important: (1) the shift from paper-based to computer-based processing and storage, as well as the increase of data in health care settings; (2) the shift from institution-centered departmental and, later, hospital information systems towards regional and global HIS; (3) the inclusion of patients and health consumers as HIS users, besides health care professionals and administrators; (4) the use of HIS data not only for patient care and administrative purposes, but also for health care planning as well as clinical and epidemiological research; (5) the shift from focusing mainly on technical HIS problems to those of change management as well as of strategic information management; (6) the shift from mainly alpha-numeric data in HIS to images and now also to data on the molecular level; (7) the steady increase of new technologies to be included, now starting to include ubiquitous computing environments and sensor-based technologies for health monitoring. As consequences for HIS in the future, first the need for institutional and (inter-) national HIS-strategies is seen, second the need to explore new (transinstitutional) HIS architectural styles, third the need for education in health informatics and/or biomedical informatics, including appropriate knowledge and skills on HIS. As these new HIS are urgently needed for reorganizing health care in an aging society, as last consequence the need for research around HIS is seen. Research should include the development and investigation of appropriate transinstitutional information system architectures, of adequate methods for strategic information management, of methods for modeling and evaluating HIS, the development and investigation of comprehensive electronic patient records, providing appropriate access for health care professionals as well as for patients, in the broad sense as described here, e.g. including home care and health monitoring facilities. Comparing the world in 1984 and in 2004, we have to recognize that we imperceptibly, stepwise arrived at a new world. HIS have become one of the most challenging and promising fields of research, education and practice for medical informatics, with significant benefits to medicine and health care in general.     

Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine

Chronic insomnia is the most common sleep complaint which health care practitioners must confront. Most insomnia patients are not, however, seen by sleep physicians but rather by a variety of primary care physicians. There is little agreement concerning methods for effective assessment and subsequent differential diagnosis of this pervasive problem. The most common basis for diagnosis and subsequent treatment has been the practitioner's clinical impression from an unstructured interview. No systematic, evidence-based guidelines for diagnosis exist for chronic insomnia. This practice parameter paper presents recommendations for the evaluation of chronic insomnia based on the evidence in the accompanying review paper. We recommend use of these parameters by the sleep community, but even more importantly, hope the large number of primary care physicians providing this care can benefit from their use. Conclusions reached in these practice parameters include the following recommendations for the evaluation of chronic insomnia. Since the complaint of insomnia is so widespread and since patients may overlook the impact of poor sleep quality on daily functioning, the health care practitioner should screen for a history of sleep difficulty. This evaluation should include a sleep history focused on common sleep disorders to identify primary and secondary insomnias. Polysomnography, and the Multiple Sleep Latency Test (MSLT) should not be routinely used to screen or diagnose patients with insomnia complaints. However, the complaint of insomnia does not preclude the appropriate use of these tests for diagnosis of specific sleep disorders such as obstructive sleep apnea, periodic limb movement disorder, and narcolepsy that may be present in patients with insomnia. There is insufficient evidence to suggest whether portable sleep studies, actigraphy, or other alternative assessment measures including static charge beds are effective in the evaluation of insomnia complaints. Instruments such as sleep logs, self-administered questionnaires, symptom checklist, or psychological screening tests may be of benefit to discriminate insomnia patients from normals, but these instruments have not been shown to differentiate subtypes of insomnia complaints.     

Infection control in cystic fibrosis

Over the past 20 years there has been a greater interest in infection control in cystic fibrosis (CF) as patient-to-patient transmission of pathogens has been increasingly demonstrated in this unique patient population. The CF Foundation sponsored a consensus conference to craft recommendations for infection control practices for CF care providers. This review provides a summary of the literature addressing infection control in CF. Burkholderia cepacia complex, Pseudomonas aeruginosa, and Staphylococcus aureus have all been shown to spread between patients with CF. Standard precautions, transmission-based precautions including contact and droplet precautions, appropriate hand hygiene for health care workers, patients, and their families, and care of respiratory tract equipment to prevent the transmission of infectious agents serve as the foundations of infection control and prevent the acquisition of potential pathogens by patients with CF. The respiratory secretions of all CF patients potentially harbor clinically and epidemiologically important microorganisms, even if they have not yet been detected in cultures from the respiratory tract. CF patients should be educated to contain their secretions and maintain a distance of >3 ft from other CF patients to avoid the transmission of potential pathogens, even if culture results are unavailable or negative. To prevent the acquisition of pathogens from respiratory therapy equipment used in health care settings as well as in the home, such equipment should be cleaned and disinfected. It will be critical to measure the dissemination, implementation, and potential impact of these guidelines to monitor changes in practice and reduction in infections.     

Combining diagnosis and treatment using ASBRU

Traditionally, diagnosis and treatment have been seen as two distinct tasks. Consequently, most approaches to computer supported health care focus on one of the two-mostly on diagnosis or rather on the interpretation of measurements which is much better understood and formalised. However, in practice diagnosis and treatment overlap and influence each other in many ways. Combinations range from repeatedly going through the diagnosis-treatment loop over a period of time to permanent monitoring of the patients' health condition as it is done in intensive care units. In this article we describe how to model these combinations using the clinical protocol-representation language ASBRU. It implements treatment steps in a hierarchy of skeletal, time-oriented plans. Diagnosis can either be described in a declarative way in the conditions, under which treatment steps are taken or it can be modelled explicitly as plans of their own right. We demonstrate our approach using examples taken from the American Association of Paediatricians' guideline for the treatment of hyperbilirubinemia in the new-born.     

Evidence Based Medicine and Shared Decision Making: The challenge of getting both evidence and preferences into health care

Evidence Based Medicine (EBM) and Shared Medical Decision Making (SDM) are changing the nature of health care decisions. It is broadly accepted that health care decisions require the integration of research evidence and individual preferences. These approaches are justified on both efficacy grounds (that evidence based practice and Shared Decision Making should lead to better health outcomes and may lead to a more cost-effective use of health care resources) and ethical grounds (patients’ autonomy should be respected in health care). However, despite endorsement by physicians and consumers of these approaches, implementation remains limited in practice, particularly outside academic and tertiary health care centres. There are practical problems of implementation, which include training, access to research, and development of and access to tools to display evidence and support decision making. There may also be philosophical difficulties, and some have even suggested that the two approaches (evidence based practice and Shared Decision Making) are fundamentally incompatible. This paper look at the achievements of EBM and SDM so far, the potential tensions between them, and how things might progress in the future.     

Primary care mental health workers: models of working and evidence of effectiveness.

The NHS Plan proposed the creation of a new role in primary care to assist with the management of common mental health problems: the primary care mental health worker (PCMHW). However, it is not clear how PCMHWs should be employed to be most effective. Current literature concerning different models of mental health care is reviewed. This suggests that four key dimensions are of relevance: the types of patients that PCMHWs will manage; the degree to which PCMHWs will work autonomously, or as part of a system of care; at what stage in patients' illness trajectory they will intervene; and whether the role of PCMHWs will be related to clinical interventions, or whether they will have a wider, non-clinical role in the organisation and monitoring of care. Finally, published data concerning relevant interventions are presented. Experimental studies reporting the empirical outcomes associated with these models are reviewed in relation to four different outcomes: clinical effectiveness, cost effectiveness, patient satisfaction, and access to care. The data suggest that problem-solving therapy, group psycho-education, self-help, and some models of 'collaborative care' may be highly relevant to PCMHWs. Each model provides different advantages and disadvantages in terms of the four dimensions of outcome.     

Characteristics, epidemiology and clinical importance of emerging strains of Gram-negative bacilli producing extended-spectrum beta-lactamases

Beta-lactam antimicrobial agents represent the most common treatment for bacterial infections and continue to be the leading cause of resistance to beta-lactam antibiotics among Gram-negative bacteria worldwide. The persistent exposure of bacterial strains to a multitude of beta-lactams has induced dynamic and continuous production and mutation of beta-lactamases in these bacteria, expanding their activity even against the newly developed beta-lactam antibiotics. These enzymes are known as extended-spectrum beta-lactamases (ESBLs). The majority of ESBLs are derived from the widespread broad-spectrum beta-lactamases TEM-1 and SHV-1. There are also new families of ESBLs, including the CTX-M and OXA-type enzymes as well as novel unrelated beta-lactamases. In recent years, there has been an increased incidence and prevalence of ESBLs. ESBLs are mainly found in strains of Escherichia coli and Klebsiella pneumoniae but have also been reported in other Enterobacteriaceae strains and Pseudomonas aeruginosa. Infections with ESBL-producing bacterial strains are encountered singly or in outbreaks, especially in critical care units in hospitals, resulting in increasing cost of treatment and prolonged hospital stays. Not only may nursing home patients be an important reservoir of ESBL-containing multiple antibiotic-resistant organisms, but ambulatory patients with chronic conditions may also harbor ESBL-producing organisms.     

Medical comorbidity in psychiatric inpatients: relation to clinical outcomes and hospital length of stay

Medical comorbidity is common in psychiatric inpatients and may be associated with substantial impairment and mortality. Few studies have examined the relation between this comorbidity and psychiatric outcomes. A series of 950 admissions to the Johns Hopkins Hospital Phipps Psychiatric Service were rated by attending psychiatrists at admission and discharge on symptom and functional measures. A subset was also evaluated on the General Medical Health Rating, a valid and reliable measure of seriousness of medical comorbidity. Attending psychiatrists were also asked at discharge whether medical comorbidity had been a focus of care during the hospitalization; medical comorbidity had been a focus of care in about 20% of the patients. Serious active medical comorbidity was present in 15% of patients on admission and 12% at discharge. Medical comorbidity was associated with a 10%-15% increase in psychiatric symptoms and functional impairment at discharge, even after adjustment for admission clinical status. In addition, when comorbidity had been a focus of care during the hospitalization, length of stay was prolonged by 3.25 days on average. Medical comorbidity has measurable effects on the psychiatric outcomes of psychiatric inpatients and in some cases prolongs hospital stay. Psychiatrists should redouble their efforts to detect and treat this comorbidity and should consider whether special inpatient units might be needed to care for psychiatric patients with complex medical comorbidity.     

Natural Protection of Spring and Well Drinking Water Against Surface Microbial Contamination. II. Indicators and Monitoring. Parameters for Parasites

Abstract

Recent outbreaks of cryptosporidiosis and reports of other newly described para-sitic diseases associated with drinking water transmission prompted a reevaluation of source water monitoring criteria for public health protection. The field of microbial indicators was reviewed and each candidate sentinel evaluated in terms of its sensitivity, specificity, and technical feasibility. In addition, a clear distinction was made between source water monitoring and monitoring in the distribution system. Of all potential candidate microbial sentinels, Escherichia coli is deemed the most efficacious for public health protection. Based on a conservative estimate of its half-life in groundwater for 8 d. it is recommended that at least two samples be obtained during this half-life. In addition to E. coli, two water quality indicator sentinels, which are not necessarily direct public health threats, should also be monitored at the same frequency. These are the total coliform group and the enterococci. If E. coli is present in any source water sample, the borehole and any directly connected borehole should be embargoed. If either total coliforms or enterococci are detected, only that individual borehole should be taken off line and not used until the situation is remediated and the cause of the fecal contamination eliminated. Clostridium perfrigens spores serve as a useful long-lived indicator. However, their perseverance in a sample should not be considered a direct public health threat because spores may far outlive pathogens. As a parasite indicator, C. perfringens should have the same importance as a positive colifom or enterococcus analysis. Coliphages do not yet fulfill enough of the criteria to be routinely employed. Biological monitoring should be coupled with physicochemical monitoring to establish a long-term history of the source. Because all natural waters vary in the amounts of heterotrophic plate count bacteria, test methods should be employed that are refractory to them. A combination of rigorous source protection plus extraordinary source monitoring serve as sufficient multiple barriers for parasite protection.     

Maîtrise du risque fongique environnemental dans les établissements de santé

In the attempt of chemoprophylaxis that has been proved to be effective, prevention of hospital-acquired fungal infection is currently based on air-control measures with monitoring of environmental fungal contamination. It is the most important way to significantly reduce the incidence of nosocomial aspergillosis in particular. High-risk patients should thus benefit from air treatment such as high-efficiency particulate air (HEPA) filtration, laminar airflow systems, and high rates of room-air changes, positive pressure, and well-sealed rooms. Prevention strategies should also fight contamination from the many other sources of spore transmission, food, water etc. Monitoring of environmental fungal contamination detects increases in conidia density and assesses the efficiency of air filtration. Monitoring of air and surface fungal loads is highly recommended (i) in hospital units, which benefit from air control measures, and (ii) during specific investigations in the case of Aspergillus infection. We describe the current French regulatory procedures on hospital environmental surveillance. The French Afnor recommendation (NF S 90 351) specifies different tests to evaluate the effectiveness of protective measures during installation of the system and once it is up and running. These tests include specific biocontamination controls. The French hospital guidelines specify that each hospital is responsible for the air and the water they provide to the patient, and that air-control efficiency must be monitored. Optimal environmental monitoring requires efficient and specific methodologies to detect fungal spores in addition to bacteria.     

Prevalence of colonisation with third-generation cephalosporin-resistant Enterobacteriaceae in ICU patients of Heidelberg University Hospitals

The aim of this study was to assess colonisation and transmission of third-generation cephalosporin-resistant Enterobacteriaceae (CRE) from patients in 16 intensive care units. A prospective, repetitive point prevalence survey was performed over 6 months, involving samples from 1851 patients. CRE were isolated from 186 (10%) patients, with Enterobacter spp. being the most common. Mean point prevalence rates were significantly higher for paediatric wards (22.5%) compared to surgical (8.1%) and medical (5.5%) units. All CRE isolates were typed by pulsed-field gel electrophoresis. Non-outbreak nosocomial transmission rates of these pathogens were calculated as 12.8% for paediatric patients, compared to 6.8% for adult patients, which may reflect differences in sensitivity to overgrowth with resistant bacteria and contact with health care workers.     

The Performance of mHealth in Cancer Supportive Care: A Research Agenda

Background

Since the advent of smartphones, mHealth has risen to the attention of the health care system as something that could radically change the way health care has been viewed, managed, and delivered to date. This is particularly relevant for cancer, as one of the leading causes of death worldwide, and for cancer supportive care, since patients and caregivers have key roles in managing side effects. Given adequate knowledge, they are able to expect appropriate assessments and interventions. In this scenario, mHealth has great potential for linking patients, caregivers, and health care professionals; for enabling early detection and intervention; for lowering costs; and achieving better quality of life. Given its great potential, it is important to evaluate the performance of mHealth. This can be considered from several perspectives, of which organizational performance is particularly relevant, since mHealth may increase the productivity of health care providers and as a result even the productivity of health care systems.

Objective

This paper aims to review studies on the evaluation of the performance of mHealth, with particular focus on cancer care and cancer supportive care processes, concentrating on its contribution to organizational performance, as well as identifying some indications for a further research agenda.

Methods

We carried out a review of literature, aimed at identifying studies related to the performance of mHealth in general or focusing on cancer care and cancer supportive care.

Results

Our analysis revealed that studies are almost always based on a single dimension of performance. Any evaluations of the performance of mHealth are based on very different methods and measures, with a prevailing focus on issues linked to efficiency. This fails to consider the real contribution that mHealth can offer for improving the performance of health care providers, health care systems, and the quality of life in general.

Conclusions

Further research should start by stating and explaining what is meant by the evaluation of mHealth’s performance and then conduct more in-depth analysis in order to create shared frameworks to specifically identify the different dimensions of mHealth’s performance.     

Tracking bacterial DNA patterns in septic progression using 16s rRNA gene amplicon sequencing analysis

Bloodstream infections remain prevalent in intensive care units, leading to a public health challenge worldwide. Routine diagnosis is mainly based on blood culture, but the technique is limited by its time-consuming process and relatively low sensitivity. Emerging molecular diagnostic tools, such as 16S metagenomics, have been developed for detecting bacteria in the blood samples of septic patients. Using a collection of 168 blood samples from 96 septic patients, 16S metagenomics method followed by bioinformatics were applied to study bacterial alterations during the pathogenesis of sepsis. Significant taxonomic variations were found between the two survival groups at different therapeutic time points through sequential 16S metagenomics research. The results on the third day during the treatment course were notably distinct among the studied groups. 16S metagenomics approach can bring novel genetic insight about microbiological fluctuations during septic progression, which may be utilized as a complementary prognostic application. Further etiologic and pathophysiologic explorations are needed to fully explain the linkage between clinical outcomes and genetic changes.     

Chronic disease or physical disability? The role of the general practitioner.

There has been a lack of discussion and consensus as to what the role of the general practitioner should be in the care of patients with chronic diseases. Should general practitioners concentrate on the disease or should their remit include the resultant disability and handicap? General practitioners have tended to concentrate on the disease, but this may be inappropriate. For many disabled people, their general practitioner is their only source of health care and is the gatekeeper to other services. Greater knowledge among doctors of the functional and social aspects of disease would therefore improve the quality of care for patients, and should be assessed through clinical audit. Ways are described in which general practitioners, working together with their patients with chronic diseases and with other health professionals, can improve aspects of the care of these patients.     

Big ticket health technology: is rational utilization possible?

Medical technologies that have high initial and operating costs are commonly labeled 'Big Ticket Technologies'. However, technologies with lower initial and operating costs, but which are utilized extensively in patient care, should be considered Big Ticket as well. Some of these technologies are product innovations, because they represent a new product or service. Others are process innovations because they provide an alternative way of delivering health care. Radiology and radiation oncology offer many examples of Big Ticket technologies in medicine, including CT scanners, MRI units and linear accelerators. Other examples include extracorporeal shock wave lithotripsy and resuscitation and intensive care technologies. Differences in the availability of these technologies in various countries reflects financial incentives and disincentives at work in the countries, expectation levels for health care in the countries, and the degree to which the diffusion and use of medical technologies are regulated. Evidence of the cost-effectiveness of medical technologies, and the impact of their use on health outcomes, is rapidly being added as an additional criterion for evaluation of the usefulness of medical technologies in health care.