The Nursing Specialist Group Information Technology in Nursing

The Nursing Specialist Group
Information Technology in Nursing
Volume 9 1997
MIE'97 The fourteenth Medical lnformatics Europe Congress
Denise E Barnett
Conference report.
The seat allocation system at Heathrow managed to crash on the Saturday of a Bank
Holiday weekend, just as the UK party were in the queue for seats on the plane to
Thessalonika. Then there was a four-hour delay for a plane to come from Greece, so
it was close to midnight (UK time) before the coach journey to the conference resort
got underway. Then the hotel had only six rooms left so the luggage had to be
reloaded for transfer to a second hotel. Those attending a conference abroad tend to
be the envy of their colleagues so complaints about such trials and tribulations elicit
little sympathy. More of a problem was the unannounced switching of two days in
the programme so that the day for education was delayed from Tuesday to Thursday
leaving some speakers unable to present their papers and others to miss the main
session of interest to them. "It's all Greek to me' took on a new meaning.
The opening ceremony emphasised the conference was being held in the cradle of
Greek civilisation not far from Mount Athos. The modern Apollo Theatre cum
cinema was open to the sky like an amphitheatre. The conference was blessed by a
priest in flowing robes who just happened to be a PhD informatics student.
Professor JC Healy gave the opening lecture using fractals as his analogy for the
structure of informatics in society. He suggested numbers were to be found in the
structure of organic and inorganic substances. For computing the basis was the
number two. As in tennis two participants exchanged a particle (the ball) back and
forth in a defined space (the tennis court). Such an exchange of energy was mirrored
at a sub-atomic level where a lepton or boson might be exchanged in the nucleus. At
an atomic level it was the electron or photon that was exchanged. In biology the
particle might be a hormone between cells or emotions such as affection between two
humans. In the global information society the particles of information might generate
stable or unstable structures, but no one knows what they may be. There may be new
structures, not just the sum of the components.
Professor Healy suggested that in health information those who had access to
information systems would be at a competitive advantage over those people with no
access. He predicted that Individualised information and feedback could influence
lifestyles, and on-line advice could bring enormous benefits perhaps adding a new
dimension to Darwinian natural selection. Will survival of the fittest in the future
depend on access to information technology?
The first practical example occurred later in the evening with the reception around the
hotel pool. The international exchanges of information such as names, informatics
projects and interests being well lubricated with alcohol and 1960s music from an
energetic duo.
New congress structure
This year the structure of the Congress was different. The first three days were each
devoted to a single topic and the last day covered two. The style was intended as a
compromise between a summer school and a working conference. However many of
the workshops were little more than a series of mini-presentations and the room
layout made discussion difficult.
Each session was introduced through a keynote presentation in the main hall. This
was followed by four or five parallel sessions covering related themes introduced by a
chair's lecture, with oral presentations followed by brief poster presentations.
Although movement between the thematic sessions was possible there were less
general movement than at earlier MIEs and thus less time wasted waiting for the
audience to change rooms. The location for the Congress was about two hours drive
from the nearest city so there were fewer participants attending just for a day. The
small open-air exhibition area saw a steady decline in contacts as knapsacks were
loaded with leaflets early in the week. The BJHC stand had to wait for customs to
clear its leaflets and suffered from its poorly signed location.
When there are 199 presentations and 34 workshops from which to choose a report
from one person can only be selective. Therefore the keynotes will be given in some
detail and a flavour of some of the other sessions must suffice. One heartening thread
for non-medical, non-computer engineers, was the overt recognition that the users
must be much more involved and that there were other needs beyond those of doctors.
Even the doctors asked for less concentration on diagnosis, and more on the
management of patient care and the other aspects of building and using clinical
knowledge.
Exchanging data
Patrice Degoulet MD from Broussais Hospital in Paris explored some of the issues
around the exchange of data which relied on words. These included the variation in
the words used by the different health care professions for the same area of care and
the range of meanings the same word might carry for different professions. Medical
knowledge was also constantly changing. These semantic problems were a key issue
for the open architecture in technology. He gave examples such as exact matching of
words for the transfer of electronic health records, the need for connectivity to allow
queries to be made or data to be mined. Then there was the appropriateness required
for coupling knowledge banks and the control of medical activities.
As an example he explained that, where there were words with opposite meanings,
such as hard and soft, it was possible to construct a continuum and estimate how far
other words were from these two ends. Semantic matching of messages was important
where two applications for the same subject, such as a patient care record, used
different forms of words. Date of birth in one application might be 'Birthday' in the
second one. Units of measurement might also be different, for example the blood urea
nitrogen in one application being in mmoll and in the second the blood urea being in
mg/dl.
The informatics engineers had to design tools based on concepts and relationships,
select an appropriate representation of the real world and then apply rules. Dr
Degoulet contrasted the relativistic approach with the holistic one. He suggested it
was more helpful to include interaction with the environment so that the context, in
which the rules should be applied, was also defined. This would add flexibility as it
could take account of the professional background of the person looking at the
record. A doctor might draw a different meaning from a word than would a nurse or
physiotherapist. Different situations could also be taken into account such as a
primary care setting or a hospital department. In addition the different goals could be
considered such as preventative health activities in primary care and diagnosis or cure
in a hospital ward. He used a model by Rosenthal to illustrate this with a planner,
describer and mapper and a communication interface to receive the different
messages. The describer would deal with syntax, encryption and refer to a
vocabulary, the mapper would deal with exact or partial matching of terms and the
planner would optimise the conversion, for example giving the order of approach of
these other steps.
To help engineers to build such applications it would be necessary to identify
descriptors and state their source, date, user and so on. Using common concepts the
system could be independent of the database.
In the question and answer session that followed Dr Degoulet's presentation he made
it clear that he believed that diversity should be valued, not lost. He gave as an
example the Internet which had not made English the only language as some had
predicted. Greek, French and other languages were used.
Health care information day
As an introduction to the parallel sessions on health care information Dr Degoulet
identified three challenges:
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to improve access;
to improve the quality of health care and,
to contain costs.
He suggested that for most people there were several episodes of care and the
information from these needed to be integrated. There were increasing numbers of
people involved in care, both as generalises and as specialists, with the patient playing
an increasing role. As costs increased there was pressure for less in-patient care and
more participation by the patient and the general practitioner. The concept of the
virtual enterprise using interconnected networks could be used to cope with these
pressures. Electronic referrals and encounters (such as telemedicine) allowed staff
from distant locations to be involved. The patient could be guided by the computer in
what dosage of medication to take, for example in the control of hypertension. The
applications and systems used for the World Wide Web could be applied to health.
Security
Starting with security of the electronic health record FH Roger France from Belgium
explained how it should go beyond the medical record to include complementary
therapies. He suggested it would become the collective memory of a variety of health
care professionals and with ubiquitous access could also service various objectives
such as research and resource management. He suggested that for costs and legal
reasons there should only be a single record without duplicates. Thus to go electronic
was a high level decision by the hospital board. To protect security the board then
had to establish a hospital informatics board and employ both a security officer and a
physician to take overall responsibility for the content of the patient record. Thus it
appeared he was proposing that the hospital take control of a record which might have
to be kept for 30 years or longer for its laboratory components. Also reactivating the
old chestnut of a consultant doctor being responsible for all the entries made by other
health care disciplines. There seems to be a risk that continental attitudes towards the
role of nurses and PAMs might become embedded in the UK through default.
Using one hospital as an example Dr Roger France suggested there might be a
temporary record which could be encrypted and accessed only by those with an
identity card including an electronic chip. On discharge from hospital the record
could then be securely archived after billing the patient or insurance company and
need not be encrypted. This might help get around potential problems from the long
period of storage such as changes in encryption methods and the need to keep old
keys and applications, changes in the technology and problems of compacting data.
He indicated that the current automated storage on cassettes had resulted in the
location of the data being unknown!
To protect the workstation Dr Roger France said his hospital had chosen the ID card
with a chip. The user could choose which record headings to use according to the
specially. The contents of their electronic health record included a section for the
patient's personal notes such as a pain chart or home record of blood pressure
readings. However later in his talk it became clear that any access by the patient to
this record was through the physician. The emphasis seemed to be on the 'postmortem' approach, examining the record after an incident rather than active risk
management of the clinical care.
The next speaker, FA Allaert had a medical, pharmacological and legal background
and an interest in telemedicine. He explained how the initial plan was to export
knowledge to the third world but it quickly became apparent that with decreasing
funds and fewer pathologists France also needed to exchange data for diagnostic
interpretation. The surgeon could send macroscopic or microscopic images of a
frozen section from the operating theatre to the pathologist.
The focus of Dr Allaerts presentation was again on confidentiality with a protective
zone around the computer, anti-intrusion detectors and sealed doors. Computer
security included smart card readers and 'fire walls'.
The data once entered could not be erased. Modifications to the system could only
made by habitual users with an electronic signature. All messages carried the date
and time. However he admitted that the data users were the main source of problems.
In France misuse, even if involuntary, could result in 5 years in jail or a fine of two
million francs. The staff culture he suggested was the main defence.
M Khair from the Lebanon in a joint paper with Greek authors described ten levels of
constraint built into a prototype application for patient records. The patient's name
was considered top secret, with the disease considered secret if it was HIV/AIDS. In
those circumstances a 'cover story' was created and the true diagnosis known only to
the primary nurse and the medical team. The possibility that the secret classification
would indicate to other staff the true diagnosis was denied by the presenter. The
record was available on-line to the patient but s/he was not allowed a hard copy.
An entertaining presentation by Dr P Ladas on the Greek perspectives of involvement
in the MERMAID project raised some of the problems of telemedicine at sea.
Everyday there are nearly 25 000 vessels at sea. The project is exploring ways to
provide a multi-lingual medical emergency service using satellite and terrestrial
communications. He pointed out that the EU Council's Data Protection Directive did
not mention telemedicine.
'The personal health information to be carried by the ship is limited to name and
allergies. Privacy is protected yet the patient may have to communicate with the
shore-based doctor through another member of the crew.
The legal implications were mind-blowing as the risk of error is high when the
languages spoken by the three people involved may all be different. The doctor may
risk being sued in a country he has never visited. The licence to practice medicine has
also proved a legal minefield, particularly with ships sailing under flags of
convenience.
The one saving grace was the strong belief that it was unlucky for the ship if someone
on it died at sea! However efforts at concealment were not uncommon.
HealthCare policies
The afternoon session was a mixture of papers that did not fit into the other sessions.
Thomas Biirkle, from Giej3en Hospital in Germany, described the use of the
Therapeutic Intervention Scoring System (TISS) devised in 1974 for intensive care. It
was heavily pushed for legal requirements but there were still problems in getting the
electronic charting integrated into the nurse's daily work.
Mrs Mazzoleni from Italy described experiences in achieving details of the subjective
experiences of the staff using the hospital information system in a 175 bed hospital.
The simple six-item questionnaire seemed a little light weight for the task.
Computer Based Patient Records
The plenary session on the second day was an off-the-cuff talk by Ilias Iakovidis
which over-ran and left the CEN working group trying to feedback the
recommendations of their pre-congress meeting in small chunks through the day.
The talk started with the statement that there were 24 combinations of words used to
describe the record. The suggestion was to focus on the electronic health record
(EHR), life-long and for shared care. The future included shared care and an
increasing emphasis on continuity, quality and access, as well as the current focus on
efficiency and cost containment. The speaker used various models to guide his talk,
suggesting that there were several levels of development from using existing word
processors more efficiently, such as putting the forms on the screen and disseminating
data electronically, through using technology to re-engineer work, such as
telemedicine, to using knowledge within the tools for evidence-based medicine.
Ilias Lakovidis suggested the main obstacles were that the EHR needs the
organisation and the local culture to support sharing and the development of trust
between professionals so assessments are not repeated. In some countries the primary
care service was not well developed so the focus was on hospitals. National and
regional policies for integration were slow to develop, the UK was one identified as
taking a lead. The other main issue was the technology. He suggested that user
acceptance would only be achieved if use could be intuitive and where the
applications did not change the work but allowed the staff to gradually make the
changes based on the personal benefits from the computer. This might only be
achieved when the system offered speed and a high quality of interaction. He
suggested a lot more research was needed on the subject. So it looks as if the UK is
on the right track with some of the projects that are being planned.
The need for terminology and coding to preserve meaning was emphasised, not only
for the EHR but for access to knowledge-based systems. Terminology had to link
health care to the outside world as well as between computers with massaging,
EDIFACT and object dictionaries. The security issues were aired, with reference to
the European Community Directive and the fear that control by national Data
Protection Authorities will interfere with daily clinical practice.
The industrial and market issues were covered briefly. He said it was a fragmented
market with limited collaboration, for example there were 72 companies in Belgium
claiming to be working on the electronic health record. The future would require
systems to support people in the prevention of ill health while providing human
interaction in the process. This should include on-line information and services at
home. It was suggested that 25 per cent of the queries lodged on the Internet were
health related. The Californian trend to keep personal health notes to monitor chronic
illness, diet and sports/exercise was set to spread to Europe. The North American
companies were working on these areas and sharing ideas was one solution to meeting
these new requirements.
EPR and Knowledge Systems
The session on the electronic based record included one presented by Dr Jeremy
Rogers from the University of Manchester on how the GRAIL classification had been
put into use. A surgical procedure entry tool had first to be devised as surgeons could
not author in GRAIL. Lots of drop-down lists had been used for speed, with
templates to capture the data. The system then did the work to map the descriptors
and then to map the links.
The experiences from Holland in building more flexible records were related by RP
Van der Lubbe. Internet technology was being used to link different hard and
software systems. This seems to be creating the anarchic system described by John
Bryden at the NSG Conference in 1995. The work on the patient data viewer had
involved nurses, this had resulted in the system supporting the user in jumping
through the record and lots of graphics and images. One advantage of the Internet
technology was that many of the users were now familiar with the navigation
programs through use of their home computers.
Computer-aided prescribing to support newly qualified doctors was developed for
Greece where there were 5 000 new commercial products each year. To help identify
which product the patient was taking, pictures of the tablet for each dose had been
included, supplied by the pharmaceutical companies. Updating was by CD-ROM
from the Greek Pharmaceutical Organisation. It was tested for primary care of
seamen's families and this had proved a difficult experience. The current method of
prescribing was by a multi-page form, so the computer system had printed selfadhesive details. The doctors had liked the system but the Seaman's Fund, which was
financing the trial, were concerned that it might introduce a ‘big brother' approach.
EU/CEN Workshop on Terminology
The workshops were held in the large auditorium so the presentations were formal
and the discussion limited. Alan Rector from Manchester University introduced the
findings and emphasised that although GALEN was seen as an academic project it
was intended to support clinical care by enabling information to be provided when
and where it was wanted and in the desired language. The aim was for "coherence
without uniformity'. He suggested there were now three generations of systems: from
the simple hierarchies such as ICD and Read version 1, to the second generation of
compositional systems such as LOINC and Read version 3 with the third generation
being part of the software as in GALENA and the Convergent Terms Project.
It was accepted that there was a need for terminologies to support the different health
care professions and that the current ones were very doctor dominated.
P Zanstra presented the brief report from the EU/CEN Workshop and reinforced the
points made earlier in the plenary session and by Professor Rector. The preliminary
analysis of headings had been done. It had been shown that patients do cross national
borders for health care. Multiprofessional terminology was needed but it had to be
sensitive to differences in meaning and vocabulary and to abstractions. One example
of this was the word ‘constipation', to the nurse it indicated a problem in elimination
but to the doctor it was a disorder in bowel function. This led on to their different
perspective of the action needed.
A common source of all the concepts would help developers. Practical links between
decision support systems and clinical records were also required. The action to be
taken included saving information, testing for correctness and planning for its use in
software. For legal and other reasons it was wise to retain the record in the format
seen by the clinician and not store it as standard codes.
The afternoon plenary session built on the earlier workshop presentations and
suggested some action. The main messages were for much greater collaboration to
contribute to convergence and the support of clinical care. This applied to the
architecture of the systems, with terminology as the glue to hold together
communication, security and links to knowledge. Standards had to be devised along
with the tools. One problem was that clinicians like to obtain information but they
were less keen to put it into systems. Quality assurance of the knowledge being
accumulated was also considered important.
It was suggested that the HealthCare professions were ambivalent about whether they
wanted a paper-less record or just less paper in the record and rapid access in an
emergency.
The plenary session on the Wednesday was about images and picture archiving and
communication systems including ultrasound and angiography. It was attended by the
few enthusiasts present who could make sense of the intricate computing involved.
This reporter was not one of them.
Nursing Workshop
The workshop organised by the EFMI working group on nursing (WG5) explored the
developments in nursing informatics education. Professor John Mantas from Athens
described some of the work of the NIGHTINGALE Project. This European funded
project is being undertaken by a consortium of educators from across Europe. Its
main focus is on achieving the effective use of information. The plan is to provide a
curriculum through consensus from a multidisciplinary background and using
demonstration sites.
The survey of existing nursing informatics education had been completed in 1996.
User workshops had been held and the results published. A database on a CD ROM
will be available this year. In 1998 there should be a textbook available. Four
courses were testing the material. Details of the November conference can be found
in the AD-IT section of 1TIN.
Patrick Weber, the new Chair of WG5, outlined the results of a survey of informatics
education in Switzerland. Of 63 sites only 27 had replied: 74% German- speaking
and 26% French-speaking areas. There were no courses specifically for nurses and
few of the teachers were educated in informatics.
Computers were mainly available for personal use by teachers and these were mainly
PCs (67%) with some Apple Macintosh (26%). The software was mainly for word
processing with a few having databases or graphics. The LANs were used mainly for
administrative purposes with only 13% having access to the Internet. Only 36% of
teachers claimed to have a good knowledge of English.
In Switzerland the informatics courses were optional and ranged in length from one
hour to forty hours. The Swiss Society of Medical Informatics and the Swiss Medical
Foundation were now working on the general problem of informatics education. The
medical course would be open to non-physician students. Patrick summarised the
situation as having a baseline from which to assess progress.
In the discussion which followed it became apparent that in other countries, such as
Italy and Romania, informatics was also given a low priority by the curriculum
developers even though the nursing students were keen to receive more about it. In
Italy the hospital wards will have more computers over the next few years so their aim
was now to include the topic in the first year rather than focus on post-qualification
courses. In Romania the change in education had to go first to the Ministry of Health
and then to the Ministry of Education. The difficulty lay in helping those involved to
understand there was a difference between informatics in general and its application
in nursing. Ioana Moisil expressed her thanks to members of the BCS Nursing
Specialist Group who had given up their own time to teach on informatics courses in
Romania. Some head nurses were now involved in the TELENURSE Project.
Ulla Gerdin reported that in Sweden the nursing schools had provided basic nursing
informatics, such as word processing, as part of the education programme. There
were also university courses for physicians, medical records officers and paramedical
groups. One full year was the current maximum, so if staff wanted to undertake a
Masters level course they had to travel to Denmark. This autumn the Swedish radio
will run a five week course in informatics in health. This would be free. The large
number of nurses needing informatics education meant that traditional routes would
take far too long to cover everyone so new routes had to be found.
On behalf of Working Group 5 Patrick Weber said one of its objectives would be to
disseminate information about nursing informatics via the Internet/World Wide Web
and by providing speakers for courses and conferences. Nursing informatics activities
needed to be reported in the local language as well as in English so the information
was accessible by all nurses.
Decision Support Systems
A combined workshop involving knowledge-based systems and neural networks with
decision support systems was chaired by Rory O'Moore. He suggested the current
state of development was to provide clinical information in a passive or active form
(where data about the situation has to be put in) to advise or focus attention on
relevant issues. It was possible to create systems to interpret, assist, critique, diagnose
or manage care.
He suggested that at the moment clinicians seem to like the passive computer aided
approach more than the active one. Examples of successful decision support systems
included links to the clinical laboratory systems and antibiotic surveillance in
pharmacy systems. If the two were linked then guidelines could be embedded to help
reduce the risk of resistance to antibiotics and thus the cost of treatment.
Systems for GPs now included information on drug interactions, automated patientrisk profiles and alerts for due dates for tests such as cervical smears. Alerts could
also be triggered for lipid levels, liver function tests and anticoagulant dosages.
The human aspects of technology assessment were seen as important, especially when
assessing decision support systems. The user believes he/she is responsible for the
events, not the computer system. The designer of the computer system therefore reengineers the work of the user and rarely is the user able to make explicit his/her own
working procedures. Users are therefore wary of the potential effect on their daily
work and on the outcomes of the patient care for which they remain responsible.
The computer designers in the audience were advised to use a phased assessment to
cover the entire life-cycle of the system. Feedback loops from assessments integrated
throughout the development stage were helpful. This would help screen layouts to
follow the normal work flow. It was also important to be clear whether the system
was to help the novice or support the expert.
Education
The last day was allocated to education and technology assessment. The plenary
session was introduced by Jos Aarts of Working Group 9. This is the Group in which
the current chair of NSG, Graham Wright, is an active participant. They had invited
Professor Ina Wagner from the Technical University of Vienna to talk about research
on the interplay of information technology in various settings. This was a brave
attempt to introduce hard scientists familiar with the concrete world of chips and
wires to the softer science of the sociologist.
Professor Wagner started with references to the work of Strauss in the 1980s on how
hospital staff manage illness. Field work was used to ground the interpretation and
conclusions. It demonstrated how staff use time management and the dilemmas they
face in their work.
She described hospitals as spatially fragmented institutions where staff treating the
same patient may never meet face-to-face yet have to diagnose and provide
therapeutic action as part of a complex web of care. To do this they rely on
information and informal relationships.
According to Professor Wagner HealthCare was highly personal and resonant of an
image of care. It takes place in complex organisations yet is immediate and intuitive
while requiring constant co-ordination with unknown others. She also suggested that
because of the high cost of care it was a target for debate and controversy. There
were pressures to standardise and to use technology to provide networks to extend the
physical and cultural space between participants. Thus while IT could offer a way out
of some of the current dilemmas it could also sharpen them.
Some of the social practices built around technology in hospitals included
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supporting the crossing of boundaries;
supporting a more explicit focus on multiple exigencies;
supporting specific forms of words;
ensuring practices were distributed and in flux.
Boundaries
Boundary crossing, Professor Wager suggested, involved power. She used a
radiology department as an example of how this affected the professions involved.
The facilities were centralised and involved co-producers of the X-ray films involving
the knowledge of the radiographers and the radiologists. The receivers of the product
were the clinicians. The task shaped the physical layout of the department with a core
of rooms for the radiologists surrounded by the machine rooms and waiting areas for
the patients. There were clear divisions around these spaces: not everyone had
physical access to all these areas. In addition there were support staff such as
administrators and receptionists to book in the patients and typists to produce the
reports on the films.
Introducing information technology into this situation resulted in a change in practice
but not in boundary crossing and interactions between the producers and the
receivers. In this hospital X-ray requests still had to be sent in on paper forms.
Report production remained regionalised and the technically-possible connections
were not used. The report writing was not done electronically. The radiographers
provided a one-way distribution of images for reporting. They could access patient
data but in this hospital the hospital information system link was not exploited.
The decision to do it this way was political. The radiologists provided authorisation
for X-rays and their image was changed to being providers of a technical service.
Thus the clinicians were not allowed to be co-producers of the diagnosis. Power
relationships may be used to express a need for boundaries, to protect space from
users interests, to protect a monopoly, for cost containment or to protect a personal
vision of the world.
Multiple exigencies
The multiple exigencies identified by Professor Wagner included the time
management of surgical teams. She used as an example a hospital with two large
departments where the resources were distributed according to the specially.
Technology could offer "more sensible' ways to distribute resources. The senior
surgeons planned their own patient lists allowing them to consider explicit priorities
such as cardiac surgery and their own hidden priorities.
The manager's desire for more co-operative planning required a higher level of
transparency that the surgeons did not like. It also made them more aware of the
department's needs, not just their own desires. Electronic networks introduced a more
explicit view of the whole and the connection between individual decisions and the
effect on the whole department.
Terminology
Nursing information systems were used as the example to explore some of the issues
behind the influence of wording. They introduced a new language with which to
discuss patients and to order work. However nursing care was reactive to patient's
needs, not just set routines which could be held in the computer. Introducing a
computer station increased the distance to immediate care, it also required time to be
allocated to input data and thus the nurse was physically away from the patient. The
data was used to make the nurses more conscious of the time required for care.
Nurses were using it to legitimise what they did and to counter the lack of trust from
managers and the economic constraints placed upon their work.
However Professor Wagner suggested the main IT focus was still on management
criteria with computerised care plans, packages of care and time as a cost. Where
care could be systematically evaluated it could change work patterns to the benefit of
patients.
Electronic space
Technology could have a dramatic influence on the work environment according to
Professor Wagner. It could support rapid and fluid change, with parallel and
immediate action or a rapid succession of activities.
A medical diagnosis came from a pooling of test results and clinical knowledge. With
networked computers the need to synchronise activities was reduced and health care
workers could work more independently. This was what Anthony Gibbons had called
a disembedding mechanism. It reduced social interaction. Work was now embedded
in an abstract system. It also supported the on-going assessment of practice and
reduced bodily contact.
Professor Wagner suggested that informaticians needed to take all these factors
into consideration when designing computer support for hospitals. They had to be
clear about the context and the power relationships. They needed to share an
understanding of the problem and the action to be taken. The disembedding from
electronic systems undermined the context of place as well as social and cultural
space. This might be expressed as "losing touch with reality" The challenge was how
to communicate the context. At the 'moment many applications ignore it, they do not
support existing work practices and add a further layer of reporting. In future systems
should support, not get in the way of clinical skills.
Discussion
This presentation provoked quite a large response from the audience. One person
commented that in France it had taken 30 years for the radiology department to move
from being a photographic department to one controlled by doctors. On the question
of power he asked who was responsible for IT. Professor Wagner responded by
suggesting it should be a multi-disciplinary alliance between users and informaticians
A general practitioner suggested that there was a "diagnosis fetish' among
informaticians. General practice required common sense and the current computer
systems assumed everything could be reduced to explicit facts and order. In reality it
was less structured and chaotic. Professor Wagner agreed that systems emphasised
diagnosing, classifying and reporting and were not fuzzy enough for the real world so
they distracted clinicians from their daily work. She suggested that given the
enormous presence of IT it may be hard to preserve the other approach although this
was very necessary.
The lack of knowledge of informatics among doctors and nurses was cited by another
member of the audience as a reason why computers were used when another approach
would be more effective. Shared care did need the distribution of information but had
to avoid the imposition of standardised terms and care plans. To this Professor
Wagner responded that it was not a technical problem. The health care workers had
not been involved in the design of systems. As an example she claimed 30 nursing
information systems with not one really helping the daily work of the nurses. The
concept of designing a system to support the local context was as hard to grasp as it
was to technically create.
One person claimed that the systems which crossed boundaries between departments,
hospitals and outside to other agencies could not be made in the image of just one of
those places. In Professor Wagner's view data transmission was only one type of
boundary crossing. She suggested that inter-disciplinary co-operation was another
type, and one that might not benefit the power issues. She suggested technology
should not just be viewed as a tool but as a system which created its own dynamic.
One example was the nursing information system which gave more control by general
managers over the work of clinical nurses. It gave managers real power to socialise
nurses away from taking the time needed to provide care to an individual towards the
manager's time logic.
Other issues raised by the audience included whether concepts were clear cut, the
omission of time allocations for talking with patients and the subversive ways that
junior doctors used computer systems.
Communication standards
In this session Jytte Brender from Denmark identified three stages in development of
information technology as: the initial technical development; assessment of how it
performs in practice and then an assessment of the effect on clinical practice.
To this were added three issues: recognition that the user is responsible for the events
taking place in the organisation (although this may be unclear in some settings such as
intensive therapy units); the design of IT-based solutions which requires reengineering of the work processes into which it is to be integrated; and the fact that
expert users are generally not able to make explicit their knowledge.
In reviewing the current approaches to knowledge based systems she claimed that few
developers used more complex approaches beyond logging activity and questioning
the user afterwards to interpret those actions. This ignored the many human aspects.
Much greater attention needed to be paid to the user's concept of quality, not just to
technical validity. The published paper lists 45 references to back up the claim.
A usability measurement for clinical software was presented by Adriana Terazzi from
Italy. An action-research approach had been used including subjective assessments
by users. It was recognised that systems get out of date as care changes and that the
increased cost of evaluation interferes with the full scope. The Software Usability
Measurement Inventory, a world-wide validated questionnaire, was selected for the
project. The method requires groups of at least ten people, but small groups do affect
the generalisability of the findings. Questionnaires were given a unique identifier but
were treated as anonymous with later interviews of the "outliers'. As a result of the
findings remedial action was taken as users said the software reacted too slowly; the
user interfaced was redesigned and access to Medline was added. Interviews
confirmed the users' perceived a lack of control was related to unexpected program
faults during the initial test period. There was also a significant link between a user's
perception of usability and the level of experience.
Vissers and Talmon's paper, from Maastricht University, outlined the methods to be
used to assess the Multimedia Application for Clinical Research in Oncology project
(MACRO). Clinical trials require a large number of data collection forms. It was
hoped that electronic templates would reduce the work and allow reuse in other trials.
Some components could also be monitored electronically. They had used a scenario
approach for the testing stage. Success criteria had been defined, these included: the
time needed for design and implementation of trials; the use of resources including a
desired reduction in costs and effort in taking part in a trial; improvement in the
quality of the data collected and an increase in the number of people entered into a
trial.
Quality models
A different approach was used in the quality model developed in Italy. It was based
on the 1SO/IEC standard number 9126. The standard definition of ISO 8402 was:
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fitness for purpose;
conformance with specification;
degree of excellence.
The issues were complex where there were different expectations among users.
The Italian team had accepted that a quality model was only an abstract
representation. Factors had to be broken down into criteria which could be measured.
The ISO/IEC 9126 standard describes software quality as a function of six
characteristics: functionality, reliability, efficiency, usability, portability and
maintainability. Each being sub-divided, for example for usability into: learnability,
operability and understandability. The results being expressed as a quality profile.
The importance of each characteristic will vary with the type of system.
Five systems had been identified by the team: networking, archiving, scientific,
clinical and administration. The usability profile for clinical systems required each of
the three sub-components to achieve a very high rating. Such an approach would
allow a pass or fail mechanism to be adopted and administered by an independent,
external organisation.
The next paper reported on the application of an extended version of the ISO/IEC
9126 standard to the prototype multimedia workstation for cardiac care. The
Integration and Communication for Continuity of Cardiac Care (1 4C project) was
being undertaken jointly in The Netherlands and in Glasgow, Scotland. The QUality
in INformation Technology (QUINT) approach describes one or more indicators
together with their measurement protocols.
Compared with three ISO/IEC 9126 characteristics the QUINT for usability adds:
explicitness, customisability, attractivity, clarity, helpfulness, user-friendliness and
overview ability. It is hoped to have completed the testing by 1998. The report will
be written in the language of the users and not technical jargon.
The user requirements assessment will be done before the technology assessment.
This helps the developers to know when good is good enough. The demonstrator
system will then be evaluated in several European hospitals primarily for efficiency,
reliability and portability.
Quality control
The session resumed after a siesta with a general paper from Greece which suggested
a structure for quality control mechanisms across four lines of communication: the
quality assurance moderator, the author(s), reviewers and project manager.
This was followed by a paper from The Netherlands on the VAlidation of Telematies
Applications in Medicine (VATAM) project. Another project receiving EU funding,
it has three phases: inventory, dissemination; and experience in applying the
validation method. The inventory phase collected information on validation
approaches and was completed in 1996.
The resulting framework proposed for validation uses three axes: stakeholders; type
of use (medical, support or auxiliary) and phase in the life cycle. This structure has
been tested on eight projects and is considered feasible so dissemination is underway.
The current guidelines are available from http://www-vatam.unimasqs.nl
Dr Altmann from Germany described how the Methodology for the Development of
Health Care Messages' devised by CEN TC251 in 1995 had been applied in the
exchange of data about tumours. The aim was to embed the required registry data
within the patient care record system with the aim of automated transfer.
The message paths had been mapped. These included from the hospital cancer
registry to an epidemiological registry, or to an anonymous central data evaluation
system, to a tumour specific registry (such as for melanoma). Two-way flows might
include the physician's office system for follow-up management and information
requests, with the pharmacy system for chemotherapy data, or with another hospital
cancer registry. Information might also flow in from a laboratory system.
The structure of the message had been derived from the hierarchical general message
descriptions (such as message header, event type, patient identification) and a tumour
specific part for which no standardised definitions existed.
One of the problems from tumour registries is the need to import data from a wide
variety of sources. A master object index had to be implemented (including object
attributes like name, date of birth, sex or classification codes for tumours). Whenever
a critical object has to be imported the index is automatically searched, based on its
primary key attributes, to see if it already exists. If not the database is then searched
for similar objects, the data being carefully calibrated to reduce the risk of an
erroneous match. If no similar match is found then the new data is automatically
imported. Where a similar object is found which cannot be exactly matched it is
either discarded or a controlling user is asked to make the decision. The system is
intended to support clinicians by reducing the need for direct user control.
User satisfaction
An overview of research into user satisfaction with health care systems was presented
by C Ohmann from Germany. In order to describe the social and psychological
phenomena in the interaction of the user with the computer system the theoretical
constructs described in the literature were listed. The team then analysed them and
derived a general model. There factors were classed as dependent on the health care
system or independent of it. These independent factors include "attitude towards
computers'.
The system-dependent factors were then classed as satisfaction with the content, or
interface with the health care system and satisfaction with the organisation within
which the health care system is applied.
A survey was undertaken in December 1996 when doctor's usage of the system was
voluntary. Only 39 of the 110 questionnaires sent out on user interaction satisfaction
were returned. There were differences between clinical assistants and senior doctors.
It appears that they use the health care system for different purposes. The plan is to
reword some of the items and to retest now that system usage is mandatory.
Security
Barry Barber from the UK presented the work of Gilles Trouessin from France. It had
been stimulated by the heated debate in the UK which followed the BMA paper on
security prepared by Ross Anderson.
The broad concepts of a security policy were defined, then the HealthCare security
policy needs were teased out. There was a multiplicity of local HealthCare
information systems so there was a multiplicity of actors such as: the patient, family
and heirs; health professionals such as doctor, nurse, pharmacist and dentist;
HealthCare organisations such as public or private hospitals, laboratories, HealthCare
centres; and HealthCare institutions such as social security, mandatory, private or
optional insurance.
Add to this the multiplicity of types of systems and of access rights and types. These
were influenced by the multiplicity of national health information systems involving
desirable security properties such as availability and integrity. There were multiple
security policies, situations, responsibilities and national perspectives. In short the
national or local HealthCare information system security policy had to be flexible yet
robust.
The formal modelling approach was used to examine the value of available models
and mathematical approach. Different well known security models were considered
and found too restrictive for HealthCare needs, others were too confidentiality
orientated, including the Ross Anderson nine principles. Modal logic was suggested
as offering the desired flexible and robust approach.
Accreditation
Gdza Lakner from Hungary described how an evaluation system for software
applications had been developed. The new Accreditation Board had used the ISO/
IEC 9216 standard with special medical requirements as an additional domain. The
data is represented visually as a radar diagram of the seven requirements. The
evaluation criteria are made public. The product registry and assessors' expert reports
are now available on-line.
In one of the few single-author papers of the conference F Wiseman from The
Netherlands described his experiment to study the differences between users of the
Archimedes Network System (ANS) for document retrieval and a standard Boolean
query mechanism, WinSpirs. Both systems used the same document set for the
experiment.
ANS provides a visual browser system with part of the network displayed on screen
using light grey boxes for concepts and dark grey boxes for document nodes. The 24
subjects were asked to "Find documents about..." Half had relatively little knowledge
about the chosen domain being in their second year at medical school and half were in
their fourth year. Later a third group of 12 second year students was added to test a
modification of the ANS which allowed the combining of key terms.
There were three questions, each to be answered within 20 minutes. The time actually
taken was used as a measure of efficiency. Two domain experts were used to assess
the relevance of the documents found to the test questions. This was used as a
measure of effectively. The classic measures are recall, or fraction of the available
documents retrieved, and the precision, or fraction of those retrieved which were
judged as relevant. There were only two points of difference, for one question ANS
provided a higher recall. This was thought to be due to the filtering of the long list of
key terms so only the most relevant were displayed which made searching easier. The
fourth year students were familiar with the WinSpirs system and were faster when
using it.
Celebration
The Congress closed after the plenary workshop at 20.00 hrs. By then most of the UK
contingent had gathered on the beach to watch the sun go down and to assess the
height of the waves in the bay. For most of the day high winds and a very choppy sea
had stopped the half-hourly ferry service to the small town across the bay. But
coming from a nation of seafarers the hired ferry was duly filled and rolled and
bucked its way across in time for the farewell meal. There were moments when an
early demise of key members of the IMG seemed imminent but everyone made it
there and back. Greece did not live up to the image of sunny beaches assumed by
those who were not able to attend MIE97 but the informatics content and the contacts
were well up to standard. Next year will be Medinfo in Korea so there will be no
separate MIE. However provisional arrangements are already being made for
Ljubiana in 1999.
The full papers can be found in:
Pappas C, Maglaveras N, Scherrer J-R.
Medical Informatics Europe'97.
Studies in Technology and Informatics No 43.
IOS Press. ISBN 90 5199 343