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Informatics methodologies for evaluation research in the practice setting.

A continuing challenge in health informatics and health evaluation is to enable access to the practice of health care so that the determinants of successful care and good health outcomes can be measured, evaluated and analysed. Furthermore the results of the analysis should be available to the health care practitioner or to the patient as might be appropriate, so that he or she can use this information for continual improvement of practice and optimisation of outcomes. In this paper we review two experiences, one in primary care, the FAMUS project, and the other in hospital care, the Autocontrol project. Each project demonstrates an informatics approach for evaluation research in the clinical setting and indicates ways in which useful information can be obtained which with appropriate feed-back and education can be used towards the achievement of better health. Emphasis is given to data collection methods compatible with practice and to high quality information feedback, particularly in the team context, to enable the formulation of strategies for practice improvement.

Cross-Sectional Studies↗

[The virtual university in medicine. Context, concepts, specifications, users' manual].

The widespread use of Web servers, with the emergence of interactive functions and the possibility of credit card payment via Internet, together with the requirement for continuing education and the subsequent need for a computer to link into the health care network have incited the development of a virtual university scheme on Internet. The Virtual University of Radiology is not only a computer-assisted teaching tool with a set of attractive features, but also a powerful engine allowing the organization, distribution and control of medical knowledge available in the www.server. The scheme provides patient access to general information, a secretary's office for enrollment and the Virtual University itself, with its library, image database, a forum for subspecialties and clinical case reports, an evaluation module and various guides and help tools for diagnosis, prescription and indexing. Currently the Virtual University of Radiology offers diagnostic imaging, but can also be used by other specialties and for general practice.

Computer-Assisted Instruction↗

Prognosis: wired. Why Internet technology is the next medical breakthrough.

One observer calls it "e-mail on steroids." Whizzing along the Internet and encrypted against hacking, clinical messaging lets doctors consult on tough cases, speed up test results, even chat with their patients. So why aren't these systems widely used? Blame politics, not the technology.

Attitude of Health Personnel↗

Interface design for health care environments: the role of cognitive science.

An important challenge in the development of computer-based health care environments is the design of effective user interfaces. In this paper we consider a number of aspects of interface design related to the study of human-computer interaction from a cognitive perspective. It is argued that user interfaces must be designed with consideration of the information requirements, cognitive capabilities and limitations of the end users. Greater concern for fundamental research in design of user interfaces is also needed to complement short-term goals and approaches to improving user interfaces. Towards these objectives, several emerging trends are beginning to have an important impact in the design of health care interfaces. This includes the recognition of the need for iterative design and evaluation of user interfaces, applying theoretical frameworks and methods from cognitive science. An understanding of distributed as well as individual cognition will also become critical in the development of effective user interfaces as access to health care systems becomes increasingly widespread.

Cognition↗

Information technology and general practice. A survey of general practitioner attitudes towards computerisation.

AIM: General practitioners in the central Sydney area were surveyed to quantify the extent of, and attitudes towards, computerisation in Australian general practice. METHOD: Two surveys were mailed to all GPs in the central Sydney area, first in 1994, and again in 1996. The majority of questions in both surveys were identical. The results were collated and descriptive and comparative statistics calculated. RESULTS: There was an increase in the use of computers for clinical tasks and, GPs' attitudes towards computerised prescribing systems became more positive. There was a persistent negative attitude towards the actual costs of computerisation. CONCLUSION: Methods are now required to transform the increased use of computers by GPs into improved outcomes for them and their patients.

Attitude to Computers↗

Hickam 2000: the maturation of, and linkages between, medical informatics and bioinformatics.

I have always been infatuated with computers and convinced of their potential for solving problems in biologic research and clinical care. In the 1960s I thought we could use the computer to predict the shape of macromolecules from their chemical formulas and fundamental physical chemical principles. However, with the computers of the 1960s that was a fantasy. So I focused on the use of computers to manage medical record content and to assist with clinical care. The Electronic Medical Record (EMR) we began developing in 1972 with 33 diabetes patients now carries nearly 300 million separate results for more than 3 million patients. The data include lab and other diagnostic studies, dictated notes, orders, encounter records, radiology images, electrocardiograph tracings, and motion cardiac echoes, and the care provider at Indiana University and Wishard Hospital is accessed 10 million times per year. We have also agitated for standards to make the collection of these data easier. This work has become part of a field called medical informatics. In the meantime, the application of computers to biology has rapidly matured into a field called bioinformatics, and researchers in this field now provide annotated databases for many categories of molecules, programs for "matching" newly discovered genomic sequences with previously studied sequences, and systems for storing and processing massive amounts of genomic and molemic data. They have developed sophisticated methods for predicting the shape of biologic macromolecules and other important insights about biology and evolution. Medical informatics and bioinformatics intersect at many points. The most important intersection is between electronic medical records and the human specimen databases that can link genotype to the phenotype, as needed, to unravel polygenetic disease causality. The National Cancer Institute is embarking on an intriguing effort to use EMRs (phenotype) to link to paraffin blocks (genotype) in pathology laboratories where opportunities for cancer genomic discovery are open. We will participate in this effort and look forward to bending the EMR we developed for clinical use to bioinformatics uses as well.

Clinical Medicine↗

Human factors engineering for clinical applications.

This position paper advocates the necessity for promoting a Human Factors Engineering (HFE) approach to new clinical applications in the medical informatics domain. We first describe the negative consequences of NOT using HFE methods for such sensitive applications as medication Computerized Physicians Order Entry systems. We then describe rapidly the HF technology and how it would apply to the healthcare domain. The specific and complex problem of the necessary re-engineering of existing applications is then addressed. We conclude on the mandatory cooperative characteristic of any practical HFE project for designing or re-engineering safety-sensitive clinical applications.

Ergonomics↗

A strategic vision for telemedicine and medical informatics in space flight.

This Workshop was designed to assist in the ongoing development and application of telemedicine and medical informatics to support extended space flight. Participants included specialists in telemedicine and medical/health informatics (terrestrial and space) medicine from NASA, federal agencies, academic centers, and research and development institutions located in the United States and several other countries. The participants in the working groups developed vision statements, requirements, approaches, and recommendations pertaining to developing and implementing a strategy pertaining to telemedicine and medical informatics. Although some of the conclusions and recommendations reflect ongoing work at NASA, others provided new insight and direction that may require a reprioritization of current NASA efforts in telemedicine and medical informatics. This, however, was the goal of the Workshop. NASA is seeking other perspectives and views from leading practitioners in the fields of telemedicine and medical informatics to invigorate an essential and high-priority component of the International Space Station and future extended exploration missions. Subsequent workshops will further define and refine the general findings and recommendations achieved here. NASA's ultimate aim is to build a sound telemedicine and medical informatics operational system to provide the best medical care available for astronauts going to Mars and beyond.

Aerospace Medicine↗

Medical informatics: once more towards systematization.

Commenting on a paper by Van Bemmel (Medical Informatics, Art or Science? [1]), the following questions are raised: What is the meaning of medical informatics?, How to systematize medical informatics?, is medical informatics an art, a science or a technology?. It is argued that medical informatics is concerned with the systematic processing of data, information and knowledge in medicine and health care, and that medical informatics is not just the application of computers in these fields. Three classifications for medical informatics research and education are presented. It is concluded that medical informatics is a scientific medical discipline, similar to surgery, internal medicine, epidemiology, or microbiology; and that medical informatics has a strong relationship with the health sciences concerning its field of application, and to informatics concerning its methods and tools. It is a cross-sectional discipline, with relevance for virtually all other specialties of medicine and the health sciences. This is the reason for its impact on research and education in these specialties. It also causes that the quality of the processing of data, information and knowledge has a direct and considerable effect upon the quality of health care in practically all these specialties.

Delivery of Health Care↗

Medical informatics in population health: building Wisconsin's strategic framework for health information technology.

Medicine is increasingly practiced through the application of information sciences. Medical informatics deals with optimal information use within bioinformatics, imaging, clinical, and population health domains. Population health informatics plays an important role in that it critically informs practice in each of the other domains. Proper functioning of health care systems requires an advanced health information network that supports clinical care, personal health management, population health, and research. But this infrastructure does not yet exist in the United States. A number of federal initiatives are underway to address this problem, including the development of a framework for a national health information network and funding for implementation. This network will be facilitated by federal leadership, but public and private partnerships, and state, regional, and local implementation and policy development will play a critical role. In this article, we describe several Wisconsin initiatives that are keys to developing a strategic framework and building the state's electronic health information infrastructure.

Biomedical Technology↗

Medical informatics as a market for IS/IT.

Medical informatics is "the application of information science and information technology to the theoretical and practical problems of biomedical research, clinical practice, and medical education." A key difference between the two streams lies in their perspectives of "What Is Important in MI to Me?" MI may be seen as the marketplace where biomedicine consumes products and services provided by information science and information technology.

Bibliometrics↗

Bridging theory and practice: cognitive science and medical informatics.

Medical informatics has experienced dramatic growth, both as an applied and as a research discipline in recent years. In this paper, we argue that there is a need to expand the research base to characterize the cognitive dimension of informatics. Theories and methods from cognitive science can provide an effective counterpart to traditional medical informatics in addressing issues of usability of the systems, the processing of information, and the training of physicians. In the first part of the paper, we address the problems inherent in applying basic theories to practice and suggest some potential solutions. The second section deals with epistemological issues that are fundamental to cognitive science research and medical informatics. We then discuss two areas of application of cognitive scientific theories and methods to medical informatics: cognitive evaluation of human computer interface and intelligent medical decision support systems. The paper addresses the progress that has been made thus far and discusses how future cognitive research can facilitate further growth in the development of these applications.

Artificial Intelligence↗

Telemedicine at the top of the world: the 1998 and 1999 Everest extreme expeditions.

The National Aeronautics and Space Administration (NASA) initially established a Commercial Space Center (CSC) in the Department of Surgery at Yale University School of Medicine to further develop and evaluate technologies in information systems, telecommunications applied to medicine, and physiologic sensors. The CSC is known as the Medical Informatics and Technology Applications Consortium (MITAC). The overall purpose for this NASA program is to leverage technology, innovation, and resources from industry and academia through collaborative partnerships. The Yale-NASA CSC/MITAC organized the Everest Extreme Expeditions (E3) for the spring Himalayan climbing seasons in the years 1998 and 1999. The primary mission was to deliver advanced medical support with global telemedicine capabilities to one of the world's most remote and hostile settings--Mount Everest. The purpose was both humanitarian (providing medical support) and scientific (conducting medical and technology research). The Yale team provided medical care for the Everest Base Camp community; conducted validation experiments for several types of advanced medical technologies in this remote, hostile environment; and performed real-time monitoring of selected climbers, while also assessing the basic science of altitude physiology. Additionally, the teams conducted outreach medical care to the citizens of Nepal and provided several educational forums for a variety of medical and nonmedical personnel--including school-age children. As part of the project's mission, the E3 medical teams at both Nepal and New Haven were on a 24-hour emergency call system to deliver medical care in the event of a crisis. Unlike most of the teams at Everest, the mission of E3 was not to climb the 29,028-foot mountain the Nepalese call Sagarmatha ("Sky Head"). The mountain served as an extreme testing ground for telemedicine. The lessons learned from this testbed are reviewed here and further clarify the abilities to provide better health care in remote and extreme environments--which for some may even be their home environment during/after a medical illness.

Altitude Sickness↗

The role of low-bandwidth telemedicine in surgical prescreening.

PURPOSE: Low-bandwidth, Internet-based telemedicine is an inexpensive technology that could help deliver heath care in medically underserved areas. The purpose of this study was to evaluate the usefulness of low-bandwidth telemedicine in remote surgical evaluation. METHODS: A group of surgeons and nurses traveled to Mombasa, Kenya to provide surgical assistance at the Coast Province General Hospital (CPGH). Before the visit of the surgical team, surgeons evaluated patients via low-bandwidth telemedicine. Prescreening was performed through use of an Internet-based desktop computer system that was supported technically by the Virginia Commonwealth University (VCU) Medical Informatics and Technology Applications Consortium (MITAC) telemedicine laboratory. Surgical patients were evaluated remotely regarding appropriateness of surgical intervention by reviewing e-mails that included the patient's age, history, physical examination, digital images of the patient, and digital images of pertinent radiographs. RESULTS: Fifty-one patients, including 7 pediatric patients, were prescreened. Thirty-three of the 51 patients (65%) were deemed inappropriate for surgery before this trip because of advanced disease or absence of necessary local medical resources. Of the 18 patients determined to be appropriate candidates for surgery by remote prescreening, 18 (100%) were operated on successfully during the relief effort. Sixty patients including 9 (15%) pediatric patients underwent surgery over the course of 5 days in CPGH. Pediatric cases included various laparoscopic, oncologic, and soft tissue reconstruction. CONCLUSIONS: Low-bandwidth, Internet-based telemedicine is a cost-effective technology that can efficiently and effectively prescreen surgical patients in remote areas.

Adult↗

Evolution of a cardiovascular information system.

The competitive nature of our evolving health care system mandates a concomitant increase in the level of sophistication of the cardiovascular information system. The new paradigms in health care also mandate a re-engineering of the process of data collection and analysis. This paper deals with a variety of hardware, software, and human issues encountered at our institution. Topics covered include implementation of service line management, utilization of an interdisciplinary medical informatics model, database conversion, and application development. Special attention will be paid to the development of a system which is a comprehensive information system for clinical and financial management of the cardiovascular patient, not just a quality-of-care database.

Cardiology Service, Hospital↗

François Grémy and the birth of IMIA. 1st IMIA/UMIT Medical Informatics Award of Excellence given to Professor Grémy.

In 2001 the International Medical Informatics Association (IMIA) approved the establishment of a Medical Informatics Award of Excellence to be given every three years to an individual, whose personal commitment and dedication to medical informatics has made a lasting contribution to medicine and healthcare through her or his achievements in research, education, development or applications in the field of medical informatics. The first award was given in 2004 to Prof. François Grémy, Uzes, France. As the first chairman and moderator of TC4, François Grémy is considered to be the first President of its renamed and refocused successor, the International Medical Informatics Association. The role of IFIP-TC4 in bringing together early health informaticians cannot be underestimated. Although TC4 was composed in large part of computer professionals interested in medical applications, Grémy recruited the first generation of IMIA officers and members from the medical and healthcare communities. Intellectually as well as organizationally, IFIP-TC4 was the true predecessor of IMIA.

Awards and Prizes↗

Telemedicine in extreme environments: analogs for space flight.

The integration of telecommunications and information systems into health care delivery in human space flight operations is not new. It has been an integral tool for over 45 years. During these past decades, numerous efforts have been conducted to further develop and promulgate telemedicine. The National Aeronautics and Space Administration (NASA) established a commercial space center in 1997, known as the Medical Informatics and Technology Applications Consortium (MITAC). MITAC has developed and conducted a variety of test beds in several international settings, including Russia, Ecuador and other extreme and remote environments. These test beds have been designed to evaluate and validate technologies and techniques that have application in the delivery and support of health care in unique environments. The characteristics of these test beds are analogous to what might be observed or experienced in low earth orbit or on space-based platform. These include intermittent communications, low bandwidth, level of competency of the front line health worker, etc. These test beds have led to new approaches for the delivery of health care as well as enhanced education. These experiences have been beneficial in the promulgation of telemedicine as an effective tool and have provided new ideals for space exploration as well terrestrial medicine. This paper will highlight MITAC's test beds and their relationship to space exploration.

Animals↗