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PubMed2002

Sharing clinical information. principles and task-oriented solutions.

Increasing cooperation among health professionals--within and across organizations--require a suitable sharing of clinical information from heterogeneous (electronic) documentation. Information originates from healthcare activities and may be organized within record systems in relation to health issues, episodes of care, episodes of illness, etc. Implementation of record systems depends on tasks and attitudes within each particular healthcare environment, that determine (i) the balance among functions of the record system, e.g. supporting human memory and decision making, supporting workflow management, recording circumstances about stored data, (ii) the particular organization of a record, (iii) the details of clinical statements that should be explicit or understood. In this paper we present a set of features of record systems and of their context that affect sharing of clinical information.

Confidentiality↗

PubMed2002

An augmented reality system for ultrasound guided needle biopsies.

We have developed an augmented reality visualization system that helps the physician perform ultrasound guided needle biopsies. For a needle biopsy, the needle has to be inserted into an anatomical target to remove a tissue sample. Ultrasound guidance is routinely used e.g. for breast needle biopsies. The real-time ultrasound images allow the physician to locate the target and to monitor the needle position. Our system uses a combination of an optical laser guide and a virtual guide in the augmented image to provide intuitive guidance for the needle placement. There is no need to track the needle, i.e. there is no need to instrument the needle for tracking. In phantom tests, users have performed well with the system without prior training. This paper describes special features of our system and the workflow for the needle placement procedure.

Biopsy, Needle↗

PubMed2002

Time stamp services for trustworthy health communications.

Trustworthy communication and co-operation requires in general static TTP services describing status and relation of communicating principals as well as their corresponding keys and attributes. Additional TTP services are needed to provide trustworthy information about dynamic issues of communication and cooperation such as message identifier, time and location of processes, workflow relations and system behaviour. Certified time stamps are important notary's functions dealing with the services mentioned above. Within the European RESHEN project, the ONCONET regional health network for improving cancer care has been moving from system-related to certified time stamps using a local secure time stamp server or deploying remote time stamp services provided by an accredited CA. After implementing such services at the beginning of 2002, an evaluation of the operation modes will be performed during 2002 to derive recommendations for optimisation of these important services in national and international health networks.

Communication↗

PubMed2002

Representing clinical guidelines in UMl: a comparative study.

Clinical guidelines can be represented using models, such as GLIF, specifically designed for healthcare guidelines. This paper demonstrates that they can also be modelled using a mainstream business modelling language such as UML. The paper presents a guideline in GLIF and as UML activity diagrams, and then presents a mapping of GLIF primitives to UML. The potential benefits of using a mainstream modelling language are outlined. These include availability of advanced modelling tools, transfer between modelling tools, and automation via business workflow technology.

Diabetes Mellitus↗

PubMedDate not supplied

Case study: improving efficiency in a large hospital laboratory.

Saint Francis Health System (SFHS) consists of three hospitals and one clinic: Saint Francis Hospital (SFH); Broken Arrow Medical Center; Laureate Psychiatric Hospital; and Warren Clinic. SFHS has 670 physicians on staff and serves medical (oncology, orthopedic, neurology, and renal), surgical, cardiac, women and infant, pediatric, transplant, and trauma patients in Tulsa County, Oklahoma, which has a population of 660,000. SFH incorporates 706 staffed beds, including 126 pediatric beds and 119 critical care beds. Each year, the health system averages 38,000 admissions, 70,000 emergency department visits, 25,000 surgeries, and 3,500 births. Saint Francis Laboratory is located within the main hospital facility (SFH) and functions as a core lab for the health system. The lab also coordinates lab services with Saint Francis Heart Hospital, a physician-system joint venture. The Optimal Equipment Configuration (OEC) Project was designed by the Clinical Laboratory Services division of Premier, a group purchasing organization, with the goal of determining whether laboratories could improve efficiency and decrease unit cost by using a single-source vendor. Participants included seven business partners (Abbott, Bayer, Beckman/Coulter, Dade/Behring, J&J/ Ortho, Olympus, and Roche) and 21 laboratory sites (a small, mid-sized, and large site for each vendor). SFH laboratory staff embraced Premier's concept and viewed the OEC project as an opportunity to "energize" laboratory operations. SFH partnered with Abbott, their primary equipment vendor, for the project. Using resources and tools made available through the project, the laboratory was re-engineered to simplify workflow, increase productivity, and decrease costs by adding automation and changing to centralized specimen processing. Abbott and SFH shared a common vision for the project and enhanced their partnership through increased communication and problem solving. Abbott's area representatives provided for third-party design expertise and quarterly metric reporting through Argent Consulting. Abbott incorporated lessons learned from the SFH OEC project with organizational changes to improve the way they work with customers. Following is a step-by-step description of the OEC project to allow others to benefit from the experience (Figure 1).

Efficiency, Organizational↗

PubMed2004

Digital image storage.

Film has long been considered the gold standard for displaying and storing clinical images. But that may be changing. Digital technology--specifically digital imaging and storage technology--has advanced to the point where it can now deliver on the promises envisioned years ago. That is, the ability to provide any image, virtually anywhere, at any time--a goal that could never be achieved with film. Achieving this goal, however, requires a properly implemented digital infrastructure, including effective digital image storage. As early adopters will attest, digital image storage can be difficult to implement. It requires the careful selection and implementation of storage technologies and the continuous management of storage operations. In this Guidance Article, we address many of the issues facing the healthcare professionals charged with managing this process: We introduce the topic of medical digital storage, discussing how it is accomplished and why storing images is not that different from storing other forms of data. We review the available storage alternatives, from fast-access hard drives and RAIDs to long-term magnetic tape and optical disc storage. We delve into the issue of image compression, describing what compression is and how much can be used without affecting patient care. And we review the pertinent legal, regulatory, and management issues. When committing to a digital image workflow, it is essential that a healthcare facility give careful consideration to data storage issues, since poor choices can lead to significant long-term costs for the facility.

Computer Storage Devices↗

PubMedDate not supplied

Considerations for planning and implementation.

Installing Picture Archiving and Communication System (PACS) has very wide implications on the radiology department and the hospital as a whole. PACS is an entire hospital investment, which will change many professionals' working practices. Its selection and implementation must involve all the groups it will affect and this demands an appropriate approach. Developing processes that establish the needs of the users, support strategic initiatives, and address risk management is not a minor undertaking. The development of a plan that provides PACS selection committees with a step-by-step roadmap to seek and procure PACS best suited to their workflow is a valuable tool. This review considers the process of planning and implementation for PACS.

Computer User Training↗

PubMedDate not supplied

Patient safety: getting there from here--quality management is the best patient safety program.

Historical management activities such as quality control (QC) and quality assurance (QA) have not prevented medical errors or patient safety problems related to the laboratory. Reports of laboratory quality assurance activities provide evidence of the need for significant improvement in the total laboratory path of workflow when measured on the Six Sigma scale. The old paradigm has been: people are the cause of medical errors and the solution is to name, blame, and shame them. This bias is being replaced by a new awareness that system failures cause medical errors and that a systematic process management approach to improving patient safety can prevent these hazards.

Humans↗

PubMedDate not supplied

The cost of patient safety.

To ensure patient safety, it costs an organization time, money, and commitment. The clinical laboratory may promote patient safety or may contribute to medical error. Laboratory errors put a patient at risk at any point along the path of workflow. The cost of an initiative in patient safety may be considered from four perspectives: compliance, feasibility, present risk, and financial. Three examples are offered to illustrate the use of these approaches. Most patient-safety strategies in laboratory medicine are not expensive. They are affordable with a structured outlay of existing resources and a willingness to follow defined work practices without exception. More extensive projects, especially those that cross jurisdictional lines within an organization, do require comprehensive project management. Management ofboth kinds of initiatives is addressed by NCCLS' documents on quality practice.

Cost-Benefit Analysis↗

PubMedDate not supplied

Picture archiving and communication system: the impact of filmless and distance radiology.

The progressive spread of Picture Archiving and Communication System (PACS) in medical imaging constitutes some of the major changes in the radiology and hospital environment during the past decade. The major benefit of PACS resides in its ability to communicate images and reports to referring physicians in a timely and reliable fashion. Filmless radiology offers the opportunity to redesign departmental and enterprise-wide workflow with increase in efficiencies of technologists, clerical staff and radiologists. PACS may improve patient care by providing real-time radiology and by enabling teleradiology. These technologies and the changing environment in radiology may force the radiologists to become more directly involved in the triage and management decisions for the patient. Occasional consultations, regularly scheduled consultation services, and multidisciplinary clinical discussions including a radiologist may help directing physicians to the best sequence of examinations to resolve a clinical problem.

Humans↗

PubMed2004

Knowledge and process management in health care organizations.

OBJECTIVE: Medical knowledge management and care process management have become to be considered as valuable strategic assets that can lead to sustained increase in Health Care Organization (HCO) performance. Thus, it is essential to investigate which are the enablers for promoting knowledge-based organizations (people, organization, process, and system perspectives). Although they are essential for a HCO to manage knowledge effectively, it is still unclear how to employ them in more principled fashion. This requires innovative management strategies to determine effective ways of utilizing knowledge resources and capabilities available both within and outside the organization. METHOD: This paper reviews knowledge and process management theories, methods, and technologies that are potentially effective in building high performance HCOs. They come from a variety of fields behind computer science and medical informatics, e.g. from business and organization sciences to psychological and cognitive sciences, from epistemology to sociology. However, the success in developing future Health Information Systems (HIS) requires their incorporation into a new conceptual framework after recognizing how peculiar are the characteristics of HCOs with respect to other organizations. Investigating the nature of knowledge, in general, and of medical knowledge, in particular, is essential to define which services the future HIS should provide to foster collaboration between patients and health professionals. The knowledge creation process is then described in order to emphasize its dynamic and social characteristics. The potential of workflow technology for building innovative HISs is analyzed together with several basic research issues which are very challenging for researchers in the field. RESULT: A framework for augmenting the conceptual analysis of theories, methods, tools and effects of knowledge management in building high performance HCOs.

Health Facility Administration↗

PubMed2004

North Karelia regional chain of care: Finnish experiences.

Information--and communication technology is one of the most important cornerstones in more and more data and knowledge intensive health care sector. However these factors don't create financial gains and productivity benefits spontaneously. They need organisational and social innovations and new business models. The growth of productivity is connected to the process and organisational innovations and not to the number of computers and the growth of using ICT. One of the problems prohibiting health care profession to move to real e-work environment is the lack of the reliable measures and on these measures based performance measurement and strategic management. Health care can be improved by utilizing ICT and tools like performance measuring are key weapons in the arsenal of new e-work environment and measuring based new strategic management. Neither public sector nor not-for-profit hospitals look for financial rewards as their ultimate proof of success. Instead, they seek to achieve ambitious missions aimed at improving the health standards and wellbeing of the citizens. ICT- based new way of managing in the public sector is just beginning to gain a critical level of digitalization and will most likely come to its own in the coming years. Therefore, it is essential to research on how the health care sector can be moved towards new regional models and clinical workflow using intelligent standard based strategic management and performance measurement. If the breakthrough of the eight-hour working day and shortening of working time are evaluated afterwards, it can be stated that they have made the society more anthropocentric and humane. During one century the annual working time has shortened from 3000 hours to 1700 hours in the European Union countries. These foundations of a more humane society--eight-hour working day and shortening of regular working time--are however disappearing in the post-industrialized information society. There are various grounds for the eight-hour working day. These grounds relate to quality of life, occupational safety and health and productivity of work. It is worth asking if the nature of work has changed in a way that the truths of an industrialized society do not hold true or has the development of working time in health care sector become uncontrolled in some new way?

Computer Communication Networks↗

PubMed2004

UUMA. Regional eHealth services in the hospital district of Helsinki and Uusimaa (HUS).

The UUMA approach is based on a stepwise implementation of integrated regional healthcare services to create a virtually borderless healthcare organisation--a patient centred virtual workspace. In the virtual workspace multi-professional teams and patients collaborate and share information regardless of time and place. Presently the regional ehealth network is comprised of four different integrated services between primary, secondary and tertiary care within the county of Uusimaa. The strategic healthcare modules consist of an (1) ereferral and econsultation network, (2) a knowledge-based disease management platform, (3) PACS system and (4) a universal model for integrated regional services between professionals and patients by a link directory service. The ereferral between primary and secondary care not only speeds up the transfer, but also offers an option for communication in the form of econsultation between general practitioners and hospital specialists. By sharing information and knowledge remote econsultations create a new working environment for integrated delivery of eServices between the health care providers. Last year over 60,000 eReferrals were transferred between health care providers. When associated with viewing of patient data through the link directory, interactive econsultations enable supervised care leading to the reduction of outpatient visits and more timely appointments. The link directory service extends the dimensions of networking between organizations by combining legacy systems within regional primary and secondary care. The link directory is an interface to diverse patient information systems, like HUSpacs, containing links pointing to the actual patient data located in remote information systems. The original data including images can be viewed with a web browser, but data can be accessed only with the patient's informed consent. The chronic disease management system is disease specific: information is utilised in parallel to viewing other relevant medical data through the link directory. We aim to create a new working environment for professionals by incorporation of innovative information and communication technology, new organisation of work and re-engineering of workflows. The citizen has an active role in deciding on the use of his medical information, participating in decisions on his care, carrying out guided self-care and taking steps of pro-active prevention.

Computer Communication Networks↗

PubMed2004

New developments in digital pathology: from telepathology to virtual pathology laboratory.

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.

Artificial Intelligence↗

PubMed2004

Body area network--a key infrastructure element for patient-centered telemedicine.

The Body Area Network (BAN) extends the range of existing wireless network technologies by an ultra-low range, ultra-low power network solution optimised for long-term or continuous healthcare applications. It enables wireless radio communication between several miniaturised, intelligent Body Sensor (or actor) Units (BSU) and a single Body Central Unit (BCU) worn at the human body. A separate wireless transmission link from the BCU to a network access point--using different technology--provides for online access to BAN components via usual network infrastructure. The BAN network protocol maintains dynamic ad-hoc network configuration scenarios and co-existence of multiple networks.BAN is expected to become a basic infrastructure element for electronic health services: By integrating patient-attached sensors and mobile actor units, distributed information and data processing systems, the range of medical workflow can be extended to include applications like wireless multi-parameter patient monitoring and therapy support. Beyond clinical use and professional disease management environments, private personal health assistance scenarios (without financial reimbursement by health agencies / insurance companies) enable a wide range of applications and services in future pervasive computing and networking environments.

Artificial Intelligence↗

PubMed2004

MET system: a new approach to m-health in emergency triage.

The MET (Mobile Emergency Triage) system is an m-health application that supports emergency triage of various types of acute pain at the point of care. The system is designed for use in the Emergency Department (ED) of a hospital and to aid physicians in disposition decisions. Given patient's condition, MET recommends a triage by consulting decision rules stored in the system's knowledge base. The rules have been created using a data mining method (based on rough set methodology) applied to data collected during a retrospective chart study and verified by the clinicians. MET is designed following the extended client-server architecture, suited for weak-connectivity conditions, where stable connection between clients and a server cannot be provided. The MET server interacts with the hospital's patient information system in order to retrieve information about patients admitted to the ED. It also stores current patients' demographic and clinical data to be exchanged with mobile clients. The MET mobile client, running on a Personal Digital Assistant (PDA), is used for collecting clinical data and supporting triage decisions. The support function runs solely on the client side, thus it can be invoked anytime and anywhere, even if there is no communication link with the server (e.g., there is no wireless network available in the ED). Due to implementation on PDAs and working in weak-connectivity conditions, the MET system is very well suited for use in the ED and fits seamlessly into the regular clinical workflow without introducing any hindrances or disruptions that are often reported when using stationary (i.e., working on desktop computers) clinical systems. The system facilitates patient-centered service and timely, high quality patient management. It provides recommendations using a limited amount of clinical data, normally available at the point of care. Furthermore, it provides a possibility for the structured evaluation of this data by an attending physician.

Acute Disease↗

PubMed2004

Security infrastructure services for electronic archives and electronic health records.

Communication and co-operation in the domain of healthcare and welfare require a well-defined set of security services based on a Public Key Infrastructure and provided by a Trusted Third Party (TTP). These services describe both status and relation of communicating principals, corresponding keys and attributes, and the access rights to applications and data. Additional services are needed to provide trustworthy information about dynamic issues of communication and co-operation such as time and location of processes, workflow relations, and system behaviour. Legal, social, behavioural and ethical requirements demand securely stored patient information and well-established access tools and tokens. Electronic (and more specifically digital) signatures--as important means for securing the integrity of a message or file--along with certified time stamps or time signatures are especially important for purposes of data storage in electronic archives and electronic health records (EHR). While just mentioning technical storage problems (e.g. lifetime of the storage devices, interoperability of retrieval and presentation software), this paper identifies mechanisms of securing data items, files, messages, sets of archived items or documents, electronic archive structures, and life-long electronic health records. Other workshop contributions will demonstrate related aspects of policies, patient privacy, and privilege management.

Access to Information↗

PubMed2005

Design and development of a mobile system for supporting emergency triage.

OBJECTIVES: Our objective was to design and develop a mobile clinical decision support system for emergency triage of different acute pain presentations. The system should interact with existing hospital information systems, run on mobile computing devices (handheld computers) and be suitable for operation in weak-connectivity conditions (with unstable connections between mobile clients and a server). METHODS: The MET (Mobile Emergency Triage) system was designed following an extended client-server architecture. The client component, responsible for triage decision support, is built as a knowledge-based system, with domain ontology separated from generic problem solving methods and used for the automatic creation of a user interface. RESULTS: The MET system is well suited for operation in the Emergency Department of a hospital. The system's external interactions are managed by the server, while the MET clients, running on handheld computers are used by clinicians for collecting clinical data and supporting triage at the bedside. The functionality of the MET client is distributed into specialized modules, responsible for triaging specific types of acute pain presentations. The modules are stored on the server, and on request they can be transferred and executed on the mobile clients. The modular design provides for easy extension of the system's functionality. A clinical trial of the MET system validated the appropriateness of the system's design, and proved the usefulness and acceptance of the system in clinical practice. CONCLUSIONS: The MET system captures the necessary hospital data, allows for entry of patient information, and provides triage support. By operating on handheld computers, it fits into the regular emergency department workflow without introducing any hindrances or disruptions. It supports triage anytime and anywhere, directly at the point of care, and also can be used as an electronic patient chart, facilitating structured data collection.

Acute Disease↗