Health care in the information society. A prognosis for the year 2013

Our society is increasingly influenced by modern information and communication technology (ICT). Health care has profited greatly by this development. How could health care provision look in the near future, in 10 years, or more precisely, in the year 2013? What measures must be undertaken by political and self-governing health institutions, and by medical informatics research, to ensure an efficient, medically advanced and yet affordable future health care system? Three factors will greatly influence the further development of information processing in health care within the near future: the development of the population, medical advances, and advances in informatics. These factors have motivated us to set up 30 theses for health care provision in the year 2013. The theses cover areas of health care, such as its people, its information systems, and its ICT tools. Three major goals requiring achievement have been identified: patient-centered recording and use of medical data for cooperative care, process-integrated decision support through current medical knowledge, comprehensive use of patient data for research and health care reporting. In consequence, political institutions should provide a framework for networked, patient-centered health care. They are called on to regulate the storage and exchange of health care data and of appropriate information system architectures. Finally, the health care institutions themselves must emphasize professional information management more strongly. Relevant research topics in medical informatics are: comprehensive electronic patient records, modern health information system architectures, architectures for medical knowledge centers, specific data processing methods ('medical data mining'), and multi-functional, mobile ICT tools.     

Electronic patient records and the impact of the Internet

The term electronic patient record (EPR) means the electronic collection of clinical narrative and diagnostic reports specific to an individual patient. A true EPR should allow physicians and nurses to practice in a paperless fashion. The wide adoption of Internet technologies should allow truly distributed sharing of patient data across traditional organizational barriers. Hence, the meaning of an EPR, as a representation of documents, should be transformed into a collaborative environment that supports workflow, enables new care models and allows secure access to distributed health data. This paper reviews the current realization of EPRs in the context of paper-based medical records. The Internet architecture that Boston-based medical informatics researchers refer to as W3-EMRS is described in the context of a successful implementation of CareWeb at the Beth Israel Deaconess Medical center. Finally, we describe how this Internet-based approach can be extended beyond the boundaries of traditional care settings to help evolve new collaborative models of eHealth.     

Data security and protection in cross-institutional electronic patient records

This paper aims at identifying the specific legal requirements concerning data security and data protection of patient health data that apply to a cross-institutional electronic patient record (EPR) and describes possible solutions for meeting these requirements. In Germany, the legal framework for such records provide that disclosure of patient health information to physicians of third-party institutions is only allowed in case that it is necessary for the joint treatment of the patient, i.e. in case of a “treatment connection”. As a first step, the functionality of a remote-access architecture was proven allowing a one-way connection between the EPR systems of two health institutions in Germany, which jointly treat tumor patients. Besides, a signature system model for ensuring the integrity and authenticity of medical documents was developed and implemented in the existing information system architecture of the University Medical Center of Heidelberg. Especially in Germany, the legal framework for cross-institutional EPRs is very complex and has a considerable influence on the development and implementation of cross-institutional EPRs. However, its introduction is thought to be valuable, since a cross-institutional EPR will improve communication within shared care processes, and thus improve the quality of patient care.     

The contextual nature of medical information

Successful design of information systems in health care starts with a thorough understanding of the practices in which the systems are to function. In this paper, we discuss the nature of 'medical information' from a sociological perspective. We focus on the (im)possibilities of the utilization of primary health care data for secondary purposes such as research and administration. In much of the literature on EPRs, this secondary utilization is only seen to depend on the question whether the IT connections are in place. It is then simply a matter of selecting which information to transport and to where. In this article, we argue that this view of medical information is mistaken. Information should be conceptualized as always entangled with the context of its production. The disentangling of information from its production context is possible, but that entails work. We propose the following 'law of medical information': the further information has to be able to circulate (i.e. the more diverse contexts it has to be usable in), the more work is required to disentangle the information from the context of its production. The question that then becomes pertinent is; who has to do this work, and who reaps the benefits?     

Patients and professionals in the information society: what might keep us awake in 2013

This commentary of Haux' prognosis of the state of affairs in health care and information technology in the year 2013 argues the importance of standing up against the many high-tech, utopian dreams that are often associated with ICT in health care. Discussing many of the themes that Haux brings up, three issues are particularly focused upon: the importance of 'patient-centered' care, the changing position of the professional in current health care, and the nature of health care information. In all these issues, cliches threaten to hide several real and possibly painful issues, which, if unaddressed, will hamper any real progress. In all these issues, moreover, medical informatics plays an important role, and is a core actor in the future shaping of our health care systems. This responsibility should not be taken lightly.     

Information and communication technology in health care: do we need feedback?

Applying information and communication technology (ICT) to a given medical domain is not merely adding a new technique. When applied to a medical domain, ICT has the potential to radically change processes in that domain. In their paper 'Health care in the information society: a prognosis for the year 2013' Haux and co-workers provide us with a set of predictions based on progress in three main areas: (1). patient-centred recording and use of medical data for collaborative care; (2). process-integrated decision support; and (3). comprehensive use of patient data for research and health care reporting. We complement their theses by predicting some of the feedback mechanisms that will develop as ICT is shaping health care. Feedback is return to the input of a part of the output of a mechanism; this part of the input constituting information that reports discrepancies between intended and actual operation and leads to a self-correcting action that can be utilised. We discuss feedback in the areas Haux identifies: the patient record, decision support, and the use of data for research and health care reporting. For each of these domains, we will discuss the output that serves as input, the discrepancies discovered, and the self-correction that will or should follow.     

The evolution of medical informatics in China: A retrospective study and lessons learned

BackgroundIn contrast to China’s giant health information technology (HIT) market and tremendous investments in hospital information systems the contributions of Chinese scholars in medical informatics to the global community are very limited. China would like to have a more important position in the global medical informatics community.ObjectiveA better understanding of the differences between medical informatics research and education in China and the discipline that emerged abroad will better inform Chinese scholars to develop right strategies to advance the field in China and help identify an appropriate means to collaborate more closely with medical informatics scholars globally.MethodFor the first time, this paper divides the evolution of medical informatics in China into four stages based on changes in the core content of research, the educational orientation and other developmental characteristics. The four stages are infancy, incubation, primary establishment and formal establishment. This paper summarizes and reviews major supporting journals and publications, as well as major organizations. Finally, we analyze the main problems that exist in the current disciplinary development in China related to medical informatics research and education and offer suggestions for future improvement.ConclusionsThe evolution of medical informatics shows a strong and traditional concentration on medical library/bibliographic information rather than medical (hospital information or patient information) information. Misdirected-concentration, a lack of formal medical informatics trained teaching staff and mistakenly positioning medical informatics as an undergraduate discipline are some of the problems inhibiting the development of medical informatics in China. These lessons should be shared and learned for the global community.     

Modeling a medical environment: an ontology for integrated medical informatics design

Modern medical environments have seen an increase in technological complexity and pressures of handling more patients with fewer resources, resulting in higher demands on medical practitioners. Medical informatics designers will have to focus on the problem of organizing medical information more effectively to enable practitioners to cope with these challenges. This article addresses this research problem for the particular area of medical problem solving in patient care. First, we describe a traditional modeling approach for medical reasoning used as a basis for developing some decision support systems. We argue these models may be faithful to what is known about biomedical knowledge, but they have limitations for human problem solving, especially in unanticipated situations. Second, we present an ontological framework, known as the abstraction hierarchy (Rasmussen, IEEE Trans. Man. Cybernetics 15 (1985) 234-243), for integrating patient representations that are faithful to existing biomedical knowledge and that are consistent with what is known about human problem solving. Through an example of a critical event in the operating room, we reveal how this framework can support medical problem solving in unanticipated situations. Third, we show how to use these representations as a frame of reference for mapping medical roles, responsibilities, sensors, and controls in an operating room context. Finally, we provide some insight for medical informatics designers in using this framework to design novel training programs and human-computer displays.     

National questionnaire study on clinical ICT systems proofs: physicians suffer from poor usability

Objective

In the health informatics field, usability studies typically focus on evaluating a single information system and involve a rather small group of end-users. However, little is known about the usability of clinical information and communication technology (ICT) environment in which healthcare professionals work daily. This paper aims at contributing to usability research and user-oriented development of healthcare technologies with three objectives: inform researchers and practitioners about the current state of usability of clinical ICT systems, increase the understanding of usability aspects specific for clinical context, and encourage a more holistic approach on studying usability issues in health informatics field.

Methods

A national web questionnaire study was conducted in Finland in spring 2010 with 3929 physicians actively working in patient care. For the purposes of the study, we described three dimensions of clinical ICT system usability that reflect the physicians’ viewpoint on system usage: (1) compatibility between clinical ICT systems and physicians’ tasks, (2) ICT support for information exchange, communication and collaboration in clinical work, and (3) interoperability and reliability. The dimensions derive from the definitions of usability and clinical context of use analysis, and reflect the ability of ICT systems to have a positive impact on patient care by supporting physicians in achieving their goals with a pleasant user experience. The research data incorporated 32 statements with a five-point Likert-scale on physicians’ experiences on usability of their currently used ICT systems and a summative question about school grade given to electronic health record (EHR) systems.

Results

Physicians’ estimates of their EHR systems were very critical. With the rating scale from 4 or fail to 10 or excellent, the average of the grades varied from 6.1 to 8.4 dependent on the kind of facility the physician is working. Questionnaire results indicated several usability problems and deficiencies which considerably hindered the efficiency of clinical ICT use and physician's routine work. Systems lacked the appropriate features to support typical clinical tasks, such as decision making, prevention of medical errors, and review of a patient's treatment chart. The systems also required physicians to perform fixed sequences of steps and tasks, and poorly supported the documentation and retrieval of patient data. The findings on ICT support for collaboration showed mainly negative results, aside from collaboration between co-located physicians. In addition, the study results pointed out physicians suffering from system failures and a lack of integration between the systems.

Conclusions

The described study and related results are unique in several ways. A national usability study with nearly 4000 respondents had not been conducted in other countries in which healthcare technologies are widely adopted. The questionnaire study provided a generalized picture about the usability problems, however, it should be noted that there were significant differences between legacy systems in use. Previously, researchers had not approached contextual aspects of usability the context of clinical work, where numerous systems are in use. The described usability dimensions and the presented study results can be considered as the first step towards conceptualizing ICT usability in the unique setting of clinical work.     

Advanced tool kits for EPR security

Responding to the challenge for efficient and high quality health care, the shared care paradigm must be established in health. In that context, information systems such as electronic patient records (EPR) have to meet this paradigm supporting communication and interoperation between the health care establishments (HCE) and health professionals (HP) involved. Due to the sensitivity of personal medical information, this co-operation must be provided in a trustworthy way. To enable different views of HCE and HP ranging from management, doctors, nurses up to systems administrators and IT professionals, a set of models for analysis, design and implementation of secure distributed EPR has been developed and introduced. The approach is based on the popular UML methodology and the component paradigm for open, interoperable systems. Easy to use tool kits deal with both application security services and communication security services but also with the security infrastructure needed. Regarding the requirements for distributed multi-user EPRs, modelling and implementation of policy agreements, authorisation and access control are especially considered. Current developments for a security infrastructure in health care based on cryptographic algorithms as health professional cards (HPC), security services employing digital signatures, and health-related TTP services are discussed. CEN and ISO initiatives for health informatics standards in the context of secure and communicable EPR are especially mentioned.     

Teaching the fundamentals of information systems management in health care. Lecture and practical training for students of medical informatics

For the management of information systems in health care, it is important that projects are systematically planned and carried out. This is a major task for medical informatics professionals which should be taught in a medical informatics curriculum. In the respective lecture in the Heidelberg/Heilbronn medical informatics curriculum, we teach fundamentals of the management of information systems and of projects. The examples of the lecture are taken from hospital information systems. Furthermore, we have developed a 5-step method for the systematic, goal-oriented planning of projects. The lecture is complemented by a comprehensive practical training, so that the methods taught can be applied to a particular, relevant problem of the Heidelberg University Hospital.     

Virtual biomedical universities and e-learning

In this special issue on virtual biomedical universities and e-learning we will make a survey on the principal existing teaching applications of ICT used in medical Schools around the world. In the following we identify five types of research and experiments in this field of medical e-learning and virtual medical universities. The topics of this special issue goes from educational computer program to create and simulate virtual patients with a wide variety of medical conditions in different clinical settings and over different time frames to using distance learning in developed and developing countries program training medical informatics of clinicians. We also present the necessity of good indexing and research tools for training resources together with workflows to manage the multiple source content of virtual campus or universities and the virtual digital video resources. A special attention is given to training new generations of clinicians in ICT tools and methods to be used in clinical settings as well as in medical schools.     

Improving clinical decisions and outcomes with information: a review

The clinical information available to clinicians is expanding rapidly. It can enhance clinical decision-making, but it can also confuse the process. To be most useful, information should be available at the time and place it is needed and be specific to the task at hand. In the new paradigm of medicine, one based on continuous quality improvement, useful information must be relevant to both the processes and outcomes of care. Clinical practice guidelines have become increasingly popular for improving the quality of health care. The field of medical informatics can bring cogent information to the point where decisions are being made to augment quality improvement activities in general, and practice guidelines in particular. However, such innovations are dependent on the type, quantity, and quality of information available. This article discusses when guidelines can enhance the quality and outcomes of care and how medical informatics can help achieve these goals. In particular, the barriers to the broad implementation of electronic medical records in a variety of health care settings are explored.     

The role of methodologies to improve efficiency and effectiveness of care delivery processes for the year 2013

This paper aims at further expanding the vision of future health care delivery systems presented by Haux et al. (2002). Starting from the observation that information and communication technology (ICT) is deeply transforming the shape of organizations as expected, we argue that the coordination of work activities is a fundamental need for any organization. This is even more important for health care organizations since there is an increasing pressure to increase quality of care they deliver without further increasing its costs. However ICT by itself will not cause the desired changes without rethining the way of managing best practice biomedical knowledge and care delivery processes. Thus the paper focuses on the need of developing intense research efforts in the fields of knowledge management and workflow modelling, which have been identified as fundamental to provide suitable solutions to the problems of designing and building innovative health care information systems. Moreover, the paper discusses the role of mobile communication systems. Moreover, the paper discusses the role of mobile communication and speech understanding technologies to support a satisfactory user-system interaction in daily work.     

Modeling in biomedical informatics: an exploratory analysis part 2

OBJECTIVE: Modeling is a significant part of research, education and practice in biomedical and health informatics. Our objective was to explore which types of models of processes are used in current biomedical/health informatics research, as reflected in publications of scientific journals in this field. Also, the implications for medical informatics curricula were investigated. METHODS: Retrospective, prolective observational study on recent publications of the two official journals of the International Medical Informatics Association (IMIA), the International Journal of Medical Informatics (IJMI) and Methods of Information in Medicine (MIM). All publications of the years 2004 and 2005 from these journals were indexed according to a given list of model types. Random samples out of these publications were analysed in more depth. RESULTS: Three hundred and eighty-four publications have been analysed, 190 of IJMI and 194 of MIM. For publications in special issues (121 in IJMI) and special topics (132 in MIM) we found differences between theme-centered and conference-centered special issues/special topics (SIT) publications. In particular, we could observe a high variation between modeling in publications of theme-centered SITs. It became obvious that often sound formal knowledge as well as a strong engineering background is needed for carrying out this type of research. Usually, this knowledge and the related skills can be best provided in consecutive B.Sc. and M.Sc. programs in medical informatics (respectively, health informatics, biomedical informatics). If the focus should be primarily on health information systems and evaluation this can be offered in a M.Sc. program in medical informatics. CONCLUSIONS: In analysing the 384 publications it became obvious that modeling continues to be a major task in research, education and practice in biomedical and health informatics. Knowledge and skills on a broad range of model types are needed in biomedical/health informatics.     

Role of medical technologists in the infection control team

The infection control team (ICT) plays important roles in many different aspects of infection control. They include (1) surveillance for hospital-acquired infection, (2) developing the infection control manual, (3) checking that the manual is followed correctly, (4) giving information about the isolation of microorganisms in the hospital, (5) educating and instructing medical staff, etc. Many data have been accumulated on a database in the microbiology laboratory. Bacterial samples are also examined in the microbiological laboratory therefore medical technologists will be the first to notice hospital-acquired infection. Offering prompt information, obtained by surveillance or routine work, greatly contributes to infection control. Furthermore, a 24hr system for the microbiological laboratory may prevent occupational infection of health care workers. The role of the medical technologist in ICT is thus important. To prevent outbreaks of infection, the regional network is also important for the collection of information about the pathogen and the susceptibility of antimicrobial agents in the region. The medical technologist should participate in and communicate with this network. As mentioned above, the inclusion of medical technologists in infection control practice is essential. To participate in the ICT, medical technologists need to have communication skills, and be recognized by other team members as an essential member.     

Preparing the ground for the 'paperless hospital': a case study of medical records management in a UK outpatient services department

PurposeThe purpose of the study was to understand the preparations for the introduction of electronic patient record systems (EPRs) within the outpatient services department of a large acute hospital based in the UK. In particular, one of the main aims of the study was to examine in detail the likely impact of EPRs on the working practices of healthcare workers, their expectations regarding the impact of EPRs within the department and other sociotechnical aspects of the management of patient information.MethodsTwenty-seven semi-structured interviews were undertaken with staff in a variety of roles that deal with the management of medical records. The interviews focused on the organisation of the medical records department and current problems (e.g., missing records). In addition, the interviews contained questions about the specific role of medical records supervisors in the administration of records, as well as pathways and expectations about EPRs more generally. The data from the interviews was analysed using a mixture of thematic and template analysis and coded using constructs from a sociotechnical model of information system implementation and adoption.ResultsThe findings show that despite severe delays to the nationally led (NPfIT) roll-out of EPRs and associated IT infrastructure within the UK, staff attitudes within the department were broadly positive about the potential of future EPRs to deliver efficiencies (e.g., improved workflow within the department, reduced reliance on paper-based systems). One of the main influences on attitudes towards the type of EPRs that should exist within outpatients was prompted by negative reactions to the way in which NPfIT systems had been managed and attempted to be introduced in the past. A strong commitment to end-user involvement in EPRs design, together with a rejection of NPfIT, appears to have shaped attitudes towards future expectations of the adoption of new EPRs within the department. In addition, staff do not believe that a rapid change to ‘paperless’ working is likely to be possible.ConclusionsOur findings provide further evidence that there is a need to treat the implementation of EPRs not simply as an exercise in technical system delivery, but as a larger process of sociotechnical systems change. We conclude the paper with some guidelines, the aim of which is to provide guidance regarding EPRs implementation and adoption informed by sociotechnical principles and ideas.     

Education and training of medical informatics in the medical curriculum

The teaching of medical informatics is of importance for students in medicine and health care, realizing that they will be the health professionals of the future. Training in medical informatics is also of value for practicing clinicians who are overwhelmed by the avalanche of systems that are available on the market. Some examples of operational systems are presented here to indicate that health care has changed dramatically over the last decades. This paper intends to contribute to the drafting of IMIA guidelines for teaching medical informatics by (1) reporting on the experience at the Faculty of Medicine and Health Sciences of the Erasmus University Rotterdam as part of the curriculum, (2) reporting on the implementation of guidelines for teaching medical informatics in The Netherlands since these guidelines were drafted in 1986, and (3) by introducing the teaching material contained in the new Handbook of Medical Informatics and on its Web site.     

The Ontology of Clinical Research (OCRe): An informatics foundation for the science of clinical research

To date, the scientific process for generating, interpreting, and applying knowledge has received less informatics attention than operational processes for conducting clinical studies. The activities of these scientific processes – the science of clinical research – are centered on the study protocol, which is the abstract representation of the scientific design of a clinical study. The Ontology of Clinical Research (OCRe) is an OWL 2 model of the entities and relationships of study design protocols for the purpose of computationally supporting the design and analysis of human studies. OCRe’s modeling is independent of any specific study design or clinical domain. It includes a study design typology and a specialized module called ERGO Annotation for capturing the meaning of eligibility criteria. In this paper, we describe the key informatics use cases of each phase of a study’s scientific lifecycle, present OCRe and the principles behind its modeling, and describe applications of OCRe and associated technologies to a range of clinical research use cases. OCRe captures the central semantics that underlies the scientific processes of clinical research and can serve as an informatics foundation for supporting the entire range of knowledge activities that constitute the science of clinical research.     

Ethical and legal challenges for health telematics in a global world: telehealth and the technological imperative

Telehealth is one of the more recent applications of ICT to health care. It promises to be both cost-effective and efficient. However, there lies a danger that focusing mainly on pragmatic considerations will ignore fundamental ethical issues with legal implications that could undermine its success. Implicated here are, among others, changes in the nature of the health care professional patient relationship and informed consent, etc. The position of health informatics professionals as well as hard- and software providers is also affected. A further complicating factor is outsourcing. This paper identifies relevant issues and outlines some of their implications.