IT@2009- NOMINEES

1. An Interoperability Platform for Telemedicine Services in the Veneto Region

Claudio Saccavini

Telemedicine applications in Veneto Region Health Service were in some cases fragmented and scarcely interoperable among the 23 Local Health Authorities (LHAs) spread over the regional territory. Arsenàl.IT, Veneto’s Research Centre for eHealth Innovation worked giving technical advice in the European Telemedicine Project called HEALTH OPTIMUM and released implementation guidelines (on the basis of IHE Integration Profiles) to set up Telecounselling Service for Neurosurgery, Telelaboratory and experiment with other new services (e.g. Stroke Management and Oral Anticoagulation Therapy).

These guidelines were designed adopting in a coordinate way the most advanced IHE Integration Profiles (e.g. XDS, XDS-I, XCA, etc…) and the most authoritative e-health standards (e.g. ebXML, XML CDA2, DICOM, PKCS#7, etc.). This facilitated interoperability between the 23 LHAs divided in 7 different provinces, through a federal approach where each province is independent and where it is possible to share digitally signed Reports (XML-CDA2 documents) and DICOM CT Images.

The greater challenge taken up by Arsenàl.IT is to switch-on a Regional Telemedicine platform composed by 7 heterogeneous Domains that have adopted both open standards and legacy solutions.

Taking advantage of this cooperation platform, a Governance System of Telemedicine Services is being developed with the purpose to check and monitor all systems and applications, provide the semantic interoperability (thanks to the adoption of a common coding system), the correct pricing of the service and the ability to carry out statistical analysis.

The key purpose of these applications is to avoid useless patient transfers, guarantee the continuity of care provision in all regional territory (about 5 million inhabitants spread over 18.000 km2), tearing down the economic and organisational costs. In addition, the use of open standards provides the necessary flexibility to extend the telemedicine services also to other clinical fields of use (e.g. Cardiology, Gastroenterology, etc…).

2. Integral Healthcare Information System Of Montenegro

Denis Reković, Ružica Milutinović

The Integral Information System for primary healthcare is implemented at a very high technological level. It is integrated with the Health Insurance Fund, the pharmaceutical sector, with all providers of health services at primary level and completely open for connection with higher levels of healthcare and other participants of the system. The entire population of the state is included.

One of the goals of health system reform is for the insured person be at the centre of the system and that the money follows insured person.

This implies standardisation and support of the process "end-to-end" (end2end) from notarisation of the medical insurance card by choice of a medical practitioner as gatekeeper of the system, to sending to the laboratory, prescribing medicines and their dispensing at the pharmacy.

Encryption methodology for drugs is introduced by ATC, for services ICPC2 for ICD10 diagnosis, etc

Taking advantage of this project solution is completely off multipleentering the same information in different parts of the system. This means that once data is entered into the system, it becomes available to all segments of the system with respect to the rules of access and authority. Registration data, for example of the insured in the Fund insured persons database, becomes available to the whole system without the need for writing and possibility of making mistakes.

The implemented solution allows forming of: HER and Financial electronic card of the patient (costs - contributions).

Our experience has shown that ICT can bring many advantages, but only if they are closely related with the organisational characteristics of the company. One particular advantage is the savings by the use of IS in the pharmaceutical sector, they considerably exceed the cost of investment in the system.

3. The Successful Roll-Out of PACS in England –and Moving Forward with Image Sharing Between Hospital Trusts

Robert Hammond, Mary Barber,

By December 2007 all hospital trusts in England were using the digital imaging technology known as Picture Archiving & Communication Systems (PACS). This was as the result of a national roll-out encompassing 127 separate hospital trusts over a three year period.

Now, PACS is enabling clinicians to view diagnostic images at multiple locations within their hospital trusts, leading to speedier and more accurate diagnoses and treatment.

The national PACS programme – a collaborative effort between a central programme team at NHS Connecting for Health, strategic health authorities, hospital trusts, professional bodies, IT service providers and other stakeholders – is now working on ways to improve the sharing of images (and reports) across hospital trusts so that even more benefits can be realised.

The programme is taking a creative, pragmatic and cost conscious approach, meeting the large majority of clinicians' image sharing requirements by supporting the adoption of solutions such as web view and image routing technology that are available now.

4. Shared Electronic Medical Record in Catalonia (HC3)

Manuel Sanromà

The Shared Electronic Medical Record (HC3) is the back bone of our efforts in ICT in the e-health field. Its main objective is the improvement of citizens’ healthcare service by using a tool to facilitate physicians’ tasks, by allowing them the shared use of patients’ available information from the Catalonian care centres. The HC3 facilitates and potentiates the continuity of care avoiding the repetition of diagnostic explorations or procedures.

This initiative piloted by Manuel Sanromà, CIO from the Santa Tecla Hospital, has increased the cost-benefit ratio by proving that with only a small financial investment, great benefits in quality of care for the patient, in the health professionals’ way of working and overall efficiencies such as greater diagnosis speed.

The HC3 contents are structured in two big blocks. Firstly, the care centre’s information, with the primary and specialised healthcare as well as the diagnosis procedures and, secondly the information provided by the Health Department, which contains the Hospital Minimum Data Set from the Discharge report, the dispensed medical treatment and the medical evaluations. All of this information is accessible through the high security Catalan Health network.

The HC3 is unique and outstanding because it is designed to respect that each provider chooses and implements their own system interoperable through the HC3. This uniqueness is reflected with our model of proven interoperability and standards rather than a centralised system, and it is the feature due to which only a reduced financial investment was needed.

The challenge in implementing this non-centralised model was the standards adoption. The success is due to enthusiastic CIOs like Manuel Sanromà who promoted unconditionally its benefits. And it has only been possible through the leadership of the Health Department in setting and promoting the use of standards, the enrollment and the implementation.

5. Telestroke Programme

Oscar Ezinmo, Carmen Jiménez

A stroke is an acute vascular event that is associated with bleeding into the brain or decreased blood flow to part of the brain. Both hemorrhagic and ischemic strokes may be treatable. Hemorrhagic strokes may be amenable to surgery (i.e. to remove blood clots or to clamp bleeding vessels). Ischemic strokes (approximately 85% of all cases) occur when there is decreased blood flow to a part of the brain and consequent cell death.

During a stroke every minute counts and access to neurological care makes the difference between life and death.

The successful treatment of stroke requires the prompt identification of the cause and its characterisation by a stroke expert (neurologist). Reviews of the clinical evidence show that favorable outcomes are achieved if thrombolysis with tissue plasminogen activator (tPA) is administered within 90 minutes of the onset of symptoms and that positive benefits can still be achieved up to 270 minutes after the onset of symptoms.

The geographic divide between islands, combined with the shortage of available skilled neurologists makes the specialised evaluation and the use of tPA difficult. Stroke is one of the leading causes of mortality in the Balearic Islands. With only one hospital (the University Hospital Son Dureta located in Palma, Mallorca) specialised in stroke treatment, patients' access to timely care is the region’s major predicament.

This led Ib-Salut, the health authorities in the Balearic Islands, to explore innovative strategies to deliver timely treatment. These strategies include the development of designated stroke centres, emergency services and hospitalary diagnosis and treatment protocols, and telehealth applications or “telestroke.”

6. Florence, Clinical Information Integrated System and its Tool Florence Mobile

Luis Barcia Albacar, Miguel Ortiz Garcia, Bernardo Vila Roig, Alfonso Perez Cervello

The Torrevieja Hospital pursues a high efficiency management of its recourses, as well as the maximum level of services offered to its patients. And here “Florence” plays the key role. Florence is a clinical information and management integrated system, it assures communication between managers, doctors and patients. Florence allows access to necessary information in real time and from any place, in order to be able to make right clinical and management decisions. Consequently this improves efficiency, facilitates and speeds up administrative and clinical processes, improves assistance quality, makes the recourses profitable, foresees different situations, reduce incidents and increase users satisfaction.

For our doctors, the most useful and innovative tool is definitely “Florence Mobile”. It allows accessing the EMR in real time by means of mobile phone. Thanks to Florence Mobile, they can see laboratory and radiology test results, receive and respond to the referrals of other doctors and work on the EMR of hospitalised patients from any place with no need of a PC.

Florence Mobile allows receiving alerts by SMS about results of urgent tests when they are available in the EMR; also it offers an access to worklists of emergency departments, hospitalisation, etc.

The monitoring of use of Florence Mobile has confirmed that “benefits” are mainly focussed on speeding up the work of doctors by offering them important clinical information at any moment and place using mobile phones.

7. Shared Web-Based Electronic Patient Record for Hospital, General Practitioner and Patient

Peeter Ross, Kelli Podoshvilev

Much attention has been paid to the development of the functionality and user friendliness of the electronic patient record (EPR) inside healthcare institutions. However, secure distribution of medical data outside the organisation still remains an issue. Besides of the development of universal EPR the aim of our hospital was to enable the retrieval of medical data through the single entry from outside the hospital. We used SSL link and Estonian nation-wide data exchange platform called x-road to secure the access to EPR from outside of the hospital. Identification of the person accessing EPR was based on the compulsory ID-card issued by the state.

The EPR enables work in different modules: Ambulatory care, stationary care, diagnostic and administrative module. For medical image viewing there is full integration with picture archiving and communication system (PACS). There are two modules for users from outside the hospital: e-health record for general practitioners (GP), and iPatient for patient access. GPs and patients can use their module to book an appointment at the hospital, retrieve his/her patients´ or own medical data, and view images. The challenging aim of EPR development is to enable secure access to patient’s health data and medical images from any location by both healthcare professionals and patients; this was successfully fulfilled. Our EPR is also connected to Estonian country-wide Health Information System.

8. Paper Free Patient Care

Raymond Rooijakkers

Like many hospitals, Ammerland-Klinik, located in Westerstede, Germany, has been moving toward implementing electronic medical records (EMR) for several years. In 1997, the 356-bed hospital opted for a hospital information system. In 2007, the decision was made to also upgrade the hospital’s entire inventory of cardiopulmonary diagnostic equipment.

The aim was to make the hospital as paper free as possible, integrating ECGs into the electronic health records. All processes are digital and traceable; test results are available immediately. The project is in its early stages but progress has been made.

9.Biofeedback and Virtual Reality: The INTREPID Project

Alessandra Gorini, Claudia Repetto, Federica Pallavicini, Giuseppe Riva

Generalised anxiety disorder (GAD) is a psychiatric disorder characterised by a constant and unspecific anxiety that interferes with daily-life activities. Its high prevalence in general population and the severe limitations it causes, point out the necessity to find new efficient strategies to treat it. Together with the cognitive-behavioural treatments, relaxation represents a useful approach for the treatment of GAD, but it has the limitation that it is hard to be learned.

The INTREPID project is aimed to implement a new instrument to treat anxiety-related disorders and to test its clinical efficacy in reducing anxiety-related symptoms. The innovation of this approach is the combination of virtual reality and biofeedback, so that the first is directly modified by the output of the second. In this way, the patient is made aware of his or her reactions through the modification of some features of the VR environment in real time. Using mental exercises, the patient learns to control these physiological parameters and using the feedback provided by the virtual environment, is able to gauge his or her success.

The supplemental use of portable devices, such as PDA or smart-phones, allows the patient to perform at home, individually and autonomously, the same exercises experienced in therapist's office. The goal is to anchor the learned protocol in a real life context, so enhancing the patients' ability to deal with their symptoms. The expected result is a better and faster learning of relaxation techniques, and thus an increased effectiveness of the treatment and reduced treatment costs if compared with traditional clinical approaches.

10.  Computerised Surveillance and Alerting of Nosocomial Infections, Antimicrobial Resistance and Antibiotic Consumption in the Intensive Care Unit

Kristof Lamont, Kristof Taveirne, Kirsten Colpaert

Hospital acquired or nosocomial infections are associated with unfavourable clinical and economic outcomes, and are especially alarming in the intensive care unit (ICU).  Since ICU patients have the highest incidence rate and develop the most severe nosocomial infections, the ICU is clearly the epicentre of the problem.

The decrease in occurrence of nosocomial infections and antibiotic resistance can only be achieved by an efficient infection surveillance system.  However, manual collection of data, gathered for this purpose, is retrospective, incomplete and very labour-intensive and therefore costly.

The COSARA software was developed by a consortium consisting of the Department of Information Technology of the Ghent University and the ICU of Ghent University Hospital, a large 56 bed mixed tertiary ICU, with the aim to completely automate the surveillance of nosocomial infections. The product consists of two parts, namely a bedside client with patient level details and a management console with details on the ICU level.

The bedside client visualises all necessary data regarding the infections, thereby supporting the physician in his daily workflow. Unique is the linking information between nosocomial infections, antibiotic therapy and microbial data. The COSARA management console informs ICU staff of alarming trends in the incidence of nosocomial infections, multi-resistant microorganisms and overuse of antimicrobial drugs.

This results in optimal antimicrobial therapy on multiple levels:  patient level, ICU-wide level and, if implemented nation-wide, the aggregated ICU data can provide clear information for policy support.

11. Orthopedic Web-Based Fracture Healing Telediagnostic Decision Support System

Wojciech MichalGlinkowski, Adam Karpowicz, Piotr Orlowski, Andrzej Górecki

Fracture healing assessment is both a clinically relevant and frequently used outcome measure in orthopaedics. A lack of consensus with regard to the definition of fracture healing in the current orthopaedic literature is well known. Manual manoeuvre and radiographic image subjective evaluation remain commonly used methods in bone union assessment clinically. Web-based Computer Aided Diagnostic (CAD) system, that has been designed for fracture union assessment, combines EHR with Orthopaedic Analysis System for Fracture healing monitoring. The digital image analysis method based on open system Internet technology provide an alternative to supplement the traditional approach for a quantitative, accurate and cost-effective assessment of fracture healing.

The described system was developed and implemented as Web application that utilises single server and Web Browser for Internet communication. Networked functions including web access, database access, and graphical analyser of digitised radiographic image are based on the client-server model. The system can be complemented with existing picture archiving and communication system (PACS), as well as recent advances in Internet technology. A relational image database system is used to organise fracture images, their extracted quantitative features and patient data. The Adobe Flash-based Web user interface allows users to interact with the series fracture radiograms database.

12.The BioSig Project - Getting a Grip on Biosignals

Alois Schlögl, Hubert Leitner

Biomedical signals like electrocardiogram (ECG), electroencephalogram (EEG), electromyogram (EMG), etc. are (like medical images and clinical laboratory results) an important part of the patient health record. Biosignals are stored in a variety of different data formats. The specifications of about 20 different data formats are available in public. However, every vendor is using its own data format. A rough estimate yield at least 80 different data formats for biomedical signals. Standardisation efforts were so far only partially successful in some specialised areas like in short-term ECG recordings.

BioSig - the free and open source software library for biomedical signal processing (http://biosig.sf.net) provides a software library with a common interface to a variety of data formats. Currently, more than 40 data formats can be read, and over 10 can be written. According to our knowledge, this is more than any other software package in this area. Biosig provides a converter between various data formats, a viewing and scoring tool (SigViewer), and software interfaces to C/C++, Octave/Matlab and Python. These tools are in production use in various research projects. Moreover, a proof-of-concept for a client-server-based archiving system for biomedical signal data is available, too. BioSig is platform-neutral, i.e. it runs on Windows, Linux and MacOSX.

The Biosig tools have been very useful in extracting data from large routine EEG and polysomnographic databases of epileptic patients and neonates (ICU at paediatric department). This enabled the application of new data analysis methods, which were impossible with the original software provided by the vendor. In summary, the common software interface to different data formats ease the handling (exchange and archiving) of biosignal data from different equipment vendors.

13. Videoconferencing application to Improve the Quality of Service Given to Cancer Patients

Marc Monballieu, Donald Claeys

When a doctor diagnoses cancer, a “Multidisciplinary Oncological Consultation” is recommended and in some cases obligatory, in accordance with the oncological care programmes in Belgium. This entails a consultation between all the doctors concerned in the diagnosis. The AZ Maria Middelares hospital declares and treats some 1000 new cases of cancer every year.

In this consultation, the active involvement of the general practitioner (GP) is of crucial importance. Not only is he aware of the physical, psychical and social situation of the patient, he also plays a vital role in the communication with the patients and their family. However, recent figures from the National Institute for Health and Invalidity Insurance (INAMI/RIZIV) show that the GP is present in only 3.5% of the cases. The most important reason for this is that the GP loses a lot of precious time travelling to and from the hospital.

As a close cooperation with the GP is explicitly mentioned in the mission statement of AZ Maria Middelares, they have launched a project to allow GPs to participate in the Multidisciplinary Oncological Consultation via videoconferencing.

Belgacom, the solution provider, installed a Tandberg 3000 MXP videoconferencing solution in a meeting room at the hospital, using a 42” monitor and a high definition camera. At the GP's end, no additional investment or operational cost is required as he can run the Tandberg software on his PC with a broadband connection. During the encrypted connection, the GP can, not only conference with the team in the hospital, but also consult the medical file of the patient, including Imaging.

14. Lifetime Dental Cross

Tatjana Dostalova, Jana Zvarova, Karel Zvara, Michaela Seydlova, Karel Chleborad, Vaclav Kaspar

The Lifetime Dental Cross is an application that uses structured electronic health record to gather and store clinical information about the patient. It is based on a model that has been created during scientific project No. 1ET200300413 supported by the Academy of Sciences of the Czech Republic. This software is a complex tool that allows for fast, effective, voice controllable data collection in the field of paediatric and adult dental care. Collected data are further used in decision support systems for dental care that are under development with support of the project 1M06014 MSMT CR.

This voice module is fully automated and it is being routinely used at the Department of Paediatric Stomatology at the University Hospital Motol in Prague. The programme, in cooperation of the project contractor and the Institute of Computer Sciences AS CR, has been translated to English and it has become a commercial product for the area of the Czech Republic and English speaking countries.

15. Senolog, an Innovative Medical Database on Mammographic Practices

Aïssa Khelifa, Stéphane Thiroux, Jean-Philippe Masson

French regulations for breast cancer screening have allowed for the coexistence of both an organised and an individual screening. The Health Insurance has comprehensive financial data on both practices, but with very poor medical information. On the contrary, the breast screening programme owns highly-medicalised information, but limited to the organised screening activity.

To cope with the lack of information on a highly strategic activity, Senolog has thus been designed by FNMR (French Private-Practice Radiologist Union) as a comprehensive database on both senologic practices.

Designed in 2003, with the cooperation of RIS editors, who have implemented several versions of the module and agreed to quality assurance testing and certification, Senolog extracts from the RIS a large set of data, including limited patient information. The overall project has been performed with a grant by National Health Insurance. In 2008, 2400 radiologists have sent 3.8 million procedures to Senolog, accounting for 70 % of total senologic activity.