The need to know the history of the use of digital patient data, in particular the EHR

The purpose of this article is to explore the need for the possibility to reconstruct electronic medical data, in particular the electronic health record (EHR) as they have been or could have been presented to a specified health care professional at a specified moment in the past. The approach taken is that first the need for such functionality is discussed with attention to the differences between electronic records and paper records in this respect. Next the architectural and technical consequences of the implementation of the functionality are considered. The article concludes that such functionality is needed for medical audit, self assessment and handling of complaints. It further concludes that it is far from easy to implement the functionality. If the health care community underwrites the need for such functionality this will have a significant impact on the architecture of medical information systems and the (distributed) EHR. It is recommended that the professional associations and the governments, in collaboration with WHO, take a position on the need to be able to reconstruct the contents of the EHR. IMIA could take the lead in that process.

Integration of information systems: assessing its quality

Due to organizational and technological changes the need for integrating information systems within healthcare institutions, has increased enormously. Although the technical means for systems integration have definitely matured, integration methodologies are still in their infancy. Two important questions regarding systems integration are hardly ever addressed in a systematic way: how to derive integration requirements, and how to check whether the requirements are met in a given integrated system. These two questions must be answered if we want to assess or improve the quality of integration of a given set of systems. In this article we present a nine-step method for deriving integration requirements from a business process model, and we assess the quality of integration of a given integrated system against these requirements. The method is demonstrated by elaborating two case studies from the health care domain.

Evolution of an integrated HIS in The Netherlands

This article considers the 26 years history of an integrated hospital information system (HIS). The system emerged from an experimental government sponsored project in the Leiden University Hospital and is now the leading HIS in The Netherlands. The evolution during these 26 years is presented and discussed in this article with an emphasis on the organisational setting and financing besides the aspects functionality, technology/architecture and evaluation aspects. Recently HISCOM was acquired by the BAAN-group completing the evolution and bringing the HIS to the international health care IT market.

Constructing an enterprise viewpoint: evaluation of four business modelling techniques

Business process modelling is presented as an important first step in the process of designing a distributed system by integrating pre-existing components. The elements describing a business process are derived from the ODP-enterprise viewpoint language. One of the viewpoints distinguished in the Open Distributed Processing standard is the enterprise viewpoint. This viewpoint describes the organizational context in which the distributed system to be constructed will be used. In this paper we will review four business modelling techniques and their suitability for expressing the enterprise viewpoint is evaluated.

Integrating information systems in medicine: a reference model for middleware

This paper addresses the problem of integrating healthcare information systems, from a technological viewpoint. We propose to take the concept of an ¿integration service' as an elementary concept in discussing the problem of integration. We then propose a taxonomy for grouping integration services according to their functionality and their domain specificity. The use of this taxonomy for decomposing an integration problem into (less complex) sub-problems is demonstrated. Finally, a sequence of steps to be taken in solving an integration problem is discussed.

The complexity of transactions: a means for assessing interoperability

Interoperability seems to be a major focal point of the activities within the Informatics Society in general, and the Medical Informatics society in particular. In both Europe and the USA standardization efforts are pursued in order to enable interoperability. However, even if the technical requirements are met, interoperability is sometimes not feasible because the message exchange needed is too complex. This complexity is influenced by at least three factors: the volume of the data to be exchanged, the functionality of the information exchange, and the communication standard adopted.

Guidelines for secure system development and secure implementation

In this paper the present state of development of the guidelines for both secure system development and secure implementation, as being drafted within the scope of the SEISMED project, are briefly described. For system development there is a lot of literature how to cope with security requirements. For secure implementation of systems within an organization hardly any literature was found. By consequence there is a significant difference in maturity of the two sets of guidelines.

Evaluation of automated information systems in health care: an approach to classifying evaluative studies

In this paper we discuss an approach to classifying evaluative studies of automated information systems in health care. Selected literature (76 studies) is classified according to the type of automated information system (based on relationship to the care process), the study design used, the data collection methods used, the effect(s) measured and the type of evaluation (e.g. cost-benefit analysis). First results show that certain types of automated information systems have not been evaluated much, going by the number of studies selected. Furthermore, it is observed that certain study designs (time-series design), data collection methods (modelling and simulation) and effect measures (job satisfaction) are hardly to be found in the literature. Only 10 of 76 selected studies used a type of evaluation for which both consequences and costs are considered. Detailed investigation of the literature may provide information for the development of a general framework for the evaluation of different types of automated information systems.

Protection of confidentiality in the computer-based patient record

To evaluate the confidentiality of the patients' data in the electronic patient records designed by members of the Center for Clinical Computing in Boston, we examined the accessibility of the computer-stored medical records of two groups of patients at Boston's Beth Israel Hospital: celebrities, hospital employees, and their relatives (VIPs) and other patients (non-VIPs). We studied how often authorized clinicians gained access to computer-stored data on the two types of patients and whether look-up patterns differed if the data concerned a VIP. Our results suggest that the measures used to maintain data confidentiality at Beth Israel Hospital are adequate.

Assessment of effects and costs of information systems

Insight into the effects and costs of information systems is becoming increasingly important. A key problem is to provide evidence which is transportable among sites. Transportability demands agreement on how to carry out assessment of information systems. In the VISTA study, three Dutch hospitals developed together an evaluation protocol for the assessment of the effects and costs of the nursing information system VISION. This protocol is based on a quasy-experimental study design allowing filtering for non-VISION influences. The protocol also included a uniform cost model. Based on a cost calculation for the three hospitals, the costs for hospital-wide implementation of VISION in a 445- and 800-bed hospital were extrapolated. VISTA is considered as a trial for application of one evaluation protocol at various sites. It is recommended to extend this national trial to a multi-national one, for instance by applying the cost model more broadly.

Setting the scene for the IMIA Working Group 10 working conference expanding HIS: fading boundaries

This article contains the text that was sent to all invited speakers as a general introduction to the working conference. Besides this general introduction, each invited speaker received a short description of the intended interpretation of the subject assigned to him.

Effects measured in the evaluation of automated information systems

The results of a literature search show that most of the evaluation studies of automated information systems are dealing with structure measures. Only 15 of 91 studies investigated effects on the outcome of the care process. Probably one of the reasons for this lack of investigated "outcome" measures is the fact that many of the evaluated systems were not in routine use at the moment of evaluation. It is, however, possible to obtain indicators of outcome measures by investigating the relationship between process measures and outcome measures. In the context of many developments, such as the trend of increasing attention to the evaluation of outcomes of the care process and the increasing costs of health care, the effect of automated information systems on the outcome of the health care process becomes more and more important. In the attempts to develop guidelines for the evaluation of automated information systems, it is therefore important to pay attention to the relationship between process and outcome.

ATIM, accompanying measure on the assessment of information technology in medicine

ATIM is an Accompanying Measure under the AIM programme which aims at developing consensus on methods and criteria for assessment of Information Technologies applied in health care and at the application of these methods in two AIM project lines: (a) Knowledge Based and Decision Support Systems and (b) Medical Multimedia Workstations and Images. ATIM builds on, and coordinates assessments and evaluations which are planned in current AIM projects. It consists of workshops, meetings and the coordination of assessments in the two project lines. Networking is an essential element. The main goal of ATIM is to demonstrate the value of assessment to the various actors in this field. One of the end-products of ATIM will be a handbook on how to assess information technologies in medicine, with practical examples from AIM projects.

PACER: a software tool for PACS decision makers

This paper describes the development of the software package PACER as it evolved from a cost model to a software package for PACS decision making. PACER was developed as part of the TEASS topic from the EurIPACS project. EurIPACS is an EU subsidized project covering a wide area of PACS related research. The TEASS topic concerns the evaluation of prototype PACSystems in three European hospitals. PACER allows the user to evaluate costs of various PACS implementation scenarios and compare them to the costs of the current film based situation. Its cost calculation is based on a straight forward description of costs of a film based radiology department and of PACS. The PACER cost analysis can consider stepwise introduction of PACS and a corresponding stepwise disappearance of the film environment. This analysis includes effects of price developments. PACER calculates costs and expenses for a number of years in succession. The calculated results can be analysed using graphs, tables and sensitivity analysis tools. Preliminary tests in three hospitals indicate that PACER can indeed be a useful tool in the decision process concerning PACS.

Presentation of electronic patient data and medical audit

With the increasing use of computers to store patient data and to use these data as an electronic patient record to support the direct patient care these data now play an essential role in the care process. Such a role can be expected to expand in the years to come. It is widely recognised that such use of data for direct support of patient care increases the need for security (in particular integrity and availability). However, until now little attention has been paid to the requirements for the system from the point of view of medical audit. If the data retrieved may play an important role in the care process it is important to be able to judge whether the health care professional has acted properly in view of the electronic information that was (or could have been) at his disposal. During one of the IMIA working conferences this issue was identified. In this paper the issue is explored further. Both requirements and technical consequences are discussed.

Security in Medical Information Systems

This review article addresses security in medical information systems. First, it is discussed why special attention is necessary for security in this field. Next, the history is considered, together with the role of IMIA. Current research issues are presented. The ongoing activities in the AIM SEISMED project are briefly described, followed by a consideration of standardization. The article concludes with an appeal to pay more attention to the security aspects of information systems.

Challenges and opportunities for technology assessment in medical informatics. Case study: PACS

In this paper the basic steps of cost-effectiveness analysis (CEA) are applied in the evaluation of picture archiving and communication systems (PACS). The exercise demonstrates that evaluations of PACS have been technology-orientated, rather than problem-orientated. Moreover, many of the potential benefits of the system have been insufficiently investigated. Assessment based on the analysis of the bottlenecks in the film-based system alone appears to be quite inaccurate, as shown by the diverging outcomes of early assessment results. The development of PACS has reached a state in which the first clinical experiences are being collected. This provides an opportunity to test postulated costs and benefits. Moreover it may provide a better insight into the future potential of the technology. Experimenting with PACS is expensive. Hence, we should work together in evaluation, in order to benefit as much as possible from each other's experiences.

Security in Medical Information Systems

This review article addresses security in medical information systems. First, it is discussed why special attention is necessary for security in this field. Next, the history is considered, together with the role of IMIA. Current research issues are presented. The ongoing activities in the AIM SEISMED project are briefly described, followed by a consideration of standardization. The article concludes with an appeal to pay more attention to the security aspects of information systems.

Access to Medical Databases; Theory and Practice

Response to: Pangalos GJ: Medical database security policies. Meth Inform Med 1993; 32: 349-56.

Workshop aims, outline of the program

This workshop on the Technology Assessment of PACS has been organized as a rounding off of the Technology Assessment activities which were initiated within the Dutch PACS Project (1986-1989). It is made possible by a funding from the Dutch Ministry of Health Care (WVC). We hope it will be not only a rounding off, but will contribute to more intensive cooperations in this area. In the scope of the Dutch PACS project, the software package CAPACITY for cost analyses of PACS has been developed, to stimulate the dialogue and exchange of data. During the workshop, the data which were collected with CAPACITY are used as a framework for discussions. This paper presents the outline of the workshop, its background, its aims and the program.

HIS, RIS, and PACS

In this paper the historical background of the concepts Hospital Information System, Radiology Information System, and Picture Archiving and Communication System (HIS, RIS, PACS) is presented. Next the present situation of the realization of the concepts is considered; the conceptual relation between the three is discussed. Accepting the existence of the three concepts, first the relation between HIS and RIS is analysed, next the relation between PACS and HIS/RIS is considered. It is concluded that such a relation is vital for the realization of a full-scale PACS. Moreover, it is concluded that not only data has to be exchanged but also information. The need for a generic description of an interface between the two is emphasized.

An analysis of the costs of a hospital-wide Picture Archiving and Communication System with the software package CAPACITY

Within the scope of the Dutch PACS project, the costs of a hospital wide PACS in the Utrecht University Hospital were estimated, with the help of the software package CAPACITY. The cost analysis was based on the most recent specifications of the costs of the equipment, on extrapolations, and on the experience acquired with a PACS prototype in the Utrecht University Hospital. Savings due to a possible reduction in the length of stay, or due to logistic improvements were not taken into account. The results indicate that the extra costs of a hospital wide PACS would amount to 3.2% of the total hospital budget. By taking into account the expected price movements, it is predicted that a hospital wide PACS may allow enough savings to pay itself back, when installed near the turn of the century. The result of this cost analysis depends on a large number of assumptions. Therefore two sensitivity analyses are carried out, i.e., concerning the number of workstations required and concerning the organizational impact of PACS.

Benefits and threats of new technologies

In this paper first the effect of new hardware and software technologies on threats to data integrity and usage integrity is considered. Next the potential is considered of new technical facilities for improving the protection. It is concluded that the increasing risks for data and usage integrity are not counter balanced at present by new protection measures. A concerted action is proposed to face this problem. Especially action is proposed to develop methods for quality assurance of software, for access control in networks and to improve data/usage integrity around PC's.

Picture archiving and communication system design issues: the importance of modelling and simulation

Picture archiving communication system (PACS) development turns out to be very complex. Due to both the vast amount of data and the complexity of hospital organizations, currently only small-scale systems have been realized. And although the experiences obtained with these systems are essential, there is a risk for underestimating the complexity and requirements inherent in hospital-wide PACS systems. In this paper, it is advocated that modelling and simulation be used as tools to obtain insight into the behavior and structure of future PACS systems. Modelling and simulation can also be used to actively support the design of PACS, especially its software. In order to capture the full complexity of PACS in a simulation model, and to take full advantage of simulation as a design tool, the development of a new modelling method has begun. This method is based on semantic data models and decision processes, and can be used for both system analysis and design. The first systems modelled with this method were imaging procedures in a hospital and a computer network. The resulting simulation models are a direct reflection of reality, and have a high degree of modularity. Consequently, in spite of the complexity of the systems, their models are easy to understand and maintain.

An integrated hospital information system in The Netherlands

The development of an experimental integrated hospital information system (HIS) at Leiden University Hospital was initiated by the Dutch government in 1972. As a result of this experiment, a sophisticated HIS is now used by 45 hospitals in the Netherlands, which together have more than 35% (22,000) of the acute care hospital beds in the country. Further development and maintenance of the system are in the hands of a nonprofit organization called BAZIS. This article describes the characteristics of the system and its functions. Special attention is given to technical issues, use of the system, costs, and the organizational structure overseeing multi-hospital participation.

A package for cost and critical analysis of picture archiving and communication indicating its true yield (CAPACITY)

The hospital-wide use of picture archiving and communication systems (PACS) promises a number of advantages in the future. These benefits will only be obtained at considerable costs, however. In view of the rapidly developing technology the costs of hardware can be expected to decrease. The ideas about the expected moment when the benefits will exceed the costs show wide variation. In order to get a better view on the cost comparison between PACS and the classical film-based system and also to stimulate discussions on this topic, a software package called CAPACITY (cost and critical analysis of picture archiving and communication indicating its true yield) has been developed by BAZIS within the scope of its IMAGIS (image information system) project. CAPACITY calculates the costs in the year of introduction for both situations, conventional and PACS, based on the consumption or use of the various resources (e.g. film, optical disks, manpower in the archive, operators, network, workstations etc.) needed for the production of the radiological department. These two costs are calculated for a series of years, thus giving an indication for the moment of breakeven. User-supplied data is interrelated and checked for plausibility against a number of expert given rules of thumb by CAPACITY's critique module. The first results and experiences acquired during a pilot study using a prototype version of the package will be discussed. The CAPACITY package is available for evaluation and trial (only distribution costs will be charged if experiences and results are returned).

Using hospital information systems for clinical epidemiological research

We address the question of how data collected during routine medical practice and stored in a hospital information system to support the various functions of the hospital can be used for clinical epidemiological research. The hospital information system HIS developed by BAZIS and implemented at the Leiden University Hospital is used as an example because the availability of data for clinical research is considered a potential benefit of the BAZIS-HIS. After a brief outline of the research area of clinical epidemiology and the BAZIS-HIS has been given, three different ways in which a hospital information system can be used in clinical epidemiology, are discussed: (1) as a sampling frame to select the study population; (2) to collect data from patients taking part in the study; (3) to register data specifically collected for the study. Whether or not the hospital information system is used in a particular study depends on the specific research question, the design of the study, the content of the database and the completeness and accuracy of the registration. We shall argue that retrieval facilities alone are not sufficient to support clinical research. To decide which items can best be used to select a study population, it is necessary to know how medical events take place in daily practice and how they are registered. Therefore when data stored in hospital information systems are used for epidemiological research, close collaboration is required between the clinical epidemiologists, the hospital administrative personnel and the data processing experts.

Automatic assignment of elliptical ROIs: first results in planar scintigrams of the left ventricle

Several algorithms for quantitative analysis of 201Tl scintigrams require operator assigned elliptical regions. Therefore these algorithms are hampered by inter- and intra-observer errors. In this paper we present a robust algorithm to determine automatically contours with elliptical shapes. The algorithm is based on the Hough transformation and can determine the parameters describing an ellipse even in low signal-to-noise ratio images and when the contour is only partially visualized such as in non-perfused regions of the left ventricular myocardium. As long as the number of parameters to describe the shape of the contour is not too large, the same kind of algorithm can also be used for differently shaped contours, and for 3D elliptical contours as in SPECT.

Prediction and analysis of PACS performance with the simulation tool MIRACLES

Since the construction of image information systems appears to be extremely difficult in practice, BAZIS has decided to use computer modelling and simulation as decision support tools. In order to support the construction of simulation models, the simulation package and modelling environment MIRACLES (Medical Image Representation, Archiving and Communication Learned from Extensive Simulation) has been developed by BAZIS. This paper describes modelling and simulation techniques in general, as well as the benefits of simulation within the scope of designing Picture Archiving and Communication Systems (PACS). In order to illustrate the theory, results of a concrete yet simple PACS, which has been simulated with MIRACLES, will be described and discussed.

Background of the demonstrated IMAGIS activities and future expectations

In The Netherlands a national PACS development programme has been started, supported by the Dutch Society of Radiology and funded by the Dutch Department of Health because of the national character of the project. Three main partners are cooperating in this development: the Utrecht University Hospital (AZU), BAZIS and Philips International (Product Division Medical Systems), with the Delft University of Technology as the main BAZIS subcontractor. The non-profit foundation BAZIS, developing and supporting the ZIS Hospital Information System (in use in some 30 Dutch hospitals, over 15,000 acute beds), initiated its current IMAGe Information System (IMAGIS) projects in 1984. The activities were later integrated into the Dutch PACS project started in 1986. The final goal of the project is to achieve a PACS which is fully integrated with already existing hospital information systems (HIS). The development and operation of a HIS-PACS include many aspects of technical and clinical. The current efforts of BAZIS are concentrated on three main issues: diagnostic image quality evaluation (e.g. effects of data compression); modelling, software simulation and technology assessment of a prototype PACS (both general and detailed aspects); and coupling and integration of PACS and HIS (e.g. the BAZIS ZIS). Philips, Hamburg, is supplying equipment, particularly prototype components. A systematic clinical evaluation will take place at the Utrecht University Hospital.2+ We outline the background of the intermediate results as demonstrated during the 6th EuroPACS Conference:the psychophysical software package for Feature Evaluation And System Inspection By Logged Experiments (FEASIBLE); the modelling and simulation software package for Medical Image Representation, Archiving and Communication, Learned by Extensive Simulation (MIRACLES); and first results of the coupling experiments.(ABSTRACT TRUNCATED AT 250 WORDS)

PACS costs: modelling and simulation

The advantages to be expected of full-scale PACS implementation are widely described in the literature. In the decision to introduce such systems, costs will also play an important part. The benefits to be achieved should at least outbalance the costs. In this paper the set-up of a software package for cost assessment is described. The configuration requirements have to be determined based on the workload of the radiology department and a PACS model using results of simulation studies. Of course additional user requirements are important input parameters (e.g. number of workstations, screen resolution, etc.). Data on costs of the various configuration components and the expected future trends in these costs will be used to estimate the costs of a specific PACS configuration as a function of time. Savings to be achieved in the various categories of resources will be input (again with their trends) to lead to an overview of the total savings to be expected. The package will result in a graph of the net annual costs as a function of the timing of PACS introduction. In the package a critique module is foreseen that checks whether the data fed into the system are of reasonable agreement with expert opinions.

HIS-PACS coupling: BAZIS/ZIS and Philips/MARCOM on speaking terms

Nowadays a growing number of experts in the PACS field agree on the necessity of having an integrated HIS-PACS combination available in modern hospitals in order to manage the enormous amounts of patient data, both textual, numerical and image information, in an effective way. Since 1986 BAZIS (the Development and Support Group of the Hospital Information System), Philips Medical Systems and the University Hospital of Utrecht (AZU) are partners in the so-called Dutch PACS Project in the development and evaluation of a fully integrated image information system. The first phase of the coupling (sub)project consists of establishing a communication link between the BAZIS/ZIS and the Philips/MARCOM system with the following restrictions: the only data sent concerns the inpatients of one ward; data will only flow one way, from BAZIS/ZIS to Philips/MARCOM. In the second phase two-way communication will be realized and more departments can be part of the experiment. In phase 3 a more general HIS-PACS interface will be developed, independent of the manufacturers of HIS and PACS. In this paper the technical solution chosen for the first phase coupling, the format of the messages being transferred, and the events which result in sending the messages, will be described. Also, reference is made to the demonstration of the working HIS-PACS link, given during the 6th EuroPACS meeting in Utrecht and Leiden on 25-26 April 1988.

EuroPACS: a catalyst for PACS in Europe

The EuroPACS organization and its intended role in PACS development in Europe is briefly described. EuroPACS was initiated at Braunlage FRG, August 1984. Its aim is to stimulate mutual contacts between various groups in Europe being active in the PACS field. Its main activities are: organization of EuroPACS conferences (once or twice per year), publication of a newsletter and organization of special sessions in larger congresses.

Delineating elliptical objects with an application to cardiac scintigrams

To delineate the myocardium in planar thallium-201 scintigrams of the left ventricle, a method, based on the Hough transformation, is presented. The method maps feature points (X, Y, Y')-where Y' reflects the direction of the tangent in edge point (X,Y)-into the two-dimensional space of the axis lengths of the ellipse. Within this space, a probability density function (pdf) can be estimated. When the center of the ellipse or its orientation are unknown, the 2-D pdf of the lengths of the axes is extended to a 5-D pdf of all parameters of the ellipse (lengths of the axes, coordinates of the center, and the orientation). It is shown that the variance of the edge-point-based estimates of the axis lengths increases when the location error of the center of the supposed ellipse or its orientation error increases. The likelihood of the estimates is expected to decrease with increasing variance. Therefore, local search algorithms can be applied to find the maximum likelihood estimate of the parameters of the ellipse. Curves describing the convergency of the algorithm are presented, as well as an example of the application of the algorithm to real scintigrams. The method is able to detect contours even if they are only partly visualized, as in thallium scintigrams of the myocardium of patients with ischemic heart disease. As long as the number of parameters describing the contour is relatively low, such an algorithm is also suitable for application to differently curved contours.

Hospital information systems

The intention of this paper is to give an overall view of. (a) The part a computer-based hospital information system (HIS) might play in a hospital. (b) The consequences of this part as to requirements for the contents (components, structure) of a hospital information system. This intention takes shape as follows: (1) Characteristics of data and their use in a hospital are considered including sensitivity, poor standardisation, high availability and long term storage required, incompleteness. (2) An outline is given of which part a HIS might play in this context and how a HIS can achieve this. Quantitative as well as qualitative improvements are described to be realised by checking the input, fast accessibility, improved standardisation, improved exchange of data, improvement of coordination of activities in the hospital. The concept of integration is shortly described. The logical structure of most HISs is introduced: a central databank with a huge storage capacity, accessible for authorised users by means of various application-packages (software) and a large number of terminals (hardware). (3) As an example of an operational HIS, the Leiden University Hospital HIS is described. The following subjects are covered: technical form (hardware, availability for the users), organisation, the applications, the use of the system, costs and benefits.(ABSTRACT TRUNCATED AT 250 WORDS)