11

Towards standards for management Towards standards for management and transmission of medical data in and transmission of medical data in

web technologyweb technology

Francesco SicurelloFrancesco SicurelloPresident of @ITIM, Italian Association on Telemedicine and President of @ITIM, Italian Association on Telemedicine and

Medical Informatics;Medical Informatics; National Research Council-Institute of Biomedical Technologies, National Research Council-Institute of Biomedical Technologies,

Milan; Milan; Health Directorate, Lombardia Region;Health Directorate, Lombardia Region;

22

Medicine challengesMedicine challenges Increase of elderly people

Cronical diseases Cardiovascular diseases Cancer Neuropathologies

Infectious diseases Genetic causes of diseases Diseases prevention (epidemiology) Rehabilitation Home care assistance Citizens/patients ask for more information

33

Needs of health assistance and Needs of health assistance and biomedical researchbiomedical research

Circulation of knowledge, information and data with the aim of achieving productivity management control and of maintaining high standards of healthcare;

Population ageing with leads to demand for continuous treatment and care improving quality;

Globalization of health, seems as market and demands of ever more qualified health services.

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FocusFocus Medical recordMedical record

Electronic patient recordElectronic patient record Patient data cardPatient data card …………..• Record linkageRecord linkage- Integration of health databaseIntegration of health database- EpidemiologyEpidemiology- Evaluation of care and structures qualityEvaluation of care and structures quality- Clinical researchClinical research• NetworkingNetworking- Telemedicine (teleconsulting/telediagnosis)Telemedicine (teleconsulting/telediagnosis)- Teleassistance/telemonitoringTeleassistance/telemonitoring- Internet in health careInternet in health care- Medical wwwMedical www

55

Medical recordMedical record (BLOIS 1984) (BLOIS 1984)

Set of patient information useful to diagnosis and Set of patient information useful to diagnosis and care at different level:care at different level:

- outpatient clinic- outpatient clinic- hospital- hospital- emergency- emergency- GPs- GPs- ……..- ……..

Clinical databaseClinical databaseSet of medical records of different patients, useful Set of medical records of different patients, useful for clinical research and epidemiological studies.for clinical research and epidemiological studies.

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MULTIMEDIA MEDICAL RECORD

The Electronic Medical Record (EMR) must be complete as possible, containing also biomedical signals and images, video, etc.

This constitutes

the Multimedia Medical Record (MMR).

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MULTIMEDIA MEDICAL RECORDMMR contains :

anagraphycal and administrative data

clinical data

anamnestic data

lab tests

diagnostic referrals ( ECG, EEG, X-Ray, TC, MRI, ECO, …)

MMR improve:

information availability,

a fast data access and analysis

a better control of patients workflow

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COMPUTERISATION OF MR IS:COMPUTERISATION OF MR IS: A VERY IMPORTANT TECHNOLOGY FOR A VERY IMPORTANT TECHNOLOGY FOR

HEALTH CARE.HEALTH CARE.

OFFERS:OFFERS: BETTER AND FASTER MANAGEMENT OF BETTER AND FASTER MANAGEMENT OF

PATIENT PATIENT DATA FOR CLINICAL RESEARCH DATA FOR CLINICAL RESEARCH

AND EPIDEMIOLOGICAL STUDIES.AND EPIDEMIOLOGICAL STUDIES.

99

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MEDICAL RECORDMEDICAL RECORD

  

THE THE MR MR IS THE COLLECTION OF PATIENT IS THE COLLECTION OF PATIENT DATA USEFUL TO DIAGNOSIS AND CARE.DATA USEFUL TO DIAGNOSIS AND CARE.

MR CAN BE:MR CAN BE: HEALTH BOOKLETHEALTH BOOKLET

   OUTPATIENT CLINIC CARDOUTPATIENT CLINIC CARD

CLINICAL CHARTCLINICAL CHART

1111

Clinical record

Anagraphic chartAnamnesis

Transfer and discharge

Diary

Parameters

Diary

Therapy

Refertation

Familiar Physiological

Remote pathology Near pathology

Objectivity

Particular

General

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MEDICAL RECORD

Percorso del medico

Percorso del paziente

Servizio Infermieri

Laboratori e servizi diagnostici

Farmacia

Servizi Amministrativi

Direzione Sanitaria

Ambulatori

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Health/Clinical Health/Clinical Information SystemInformation System

ADTADT Wards Wards Outpatient clinicOutpatient clinic Diagnostics/therapeutical divisions;Diagnostics/therapeutical divisions; Emergency care.Emergency care.

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Clinical Information SystemClinical Information System

Support patient activity of care Support patient activity of care (diagnosis/therapy)(diagnosis/therapy)

Maintain hystorical databasesMaintain hystorical databasesAre not CIS:Are not CIS:- patient monitoring ssystem (not hystorical patient monitoring ssystem (not hystorical

D.B.)D.B.)- Research protocol and clinical trials (does not Research protocol and clinical trials (does not

support care activity)support care activity)

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Information SystemInformation System- P- Procedures for management of information flow in an organized rocedures for management of information flow in an organized

structure useful to decision and programming activities.structure useful to decision and programming activities.

- Data management: collection, archiving, exchange, processing, - Data management: collection, archiving, exchange, processing, retrieval, communication of data.retrieval, communication of data.

Elements of I.S. :Elements of I.S. :- DataData- Management procedures (SW)Management procedures (SW)- Human activitiesHuman activitiesFeatures of I.S.:Features of I.S.:- InteractiveInteractive- Depending by organization Depending by organization - Open processOpen process- Changement suitableChangement suitable

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Area Clinico- Sanitaria Area Amministrativa

Anagrafica Pazienti

Program- mazione operativa

Attività operativa

Fatturazione e incassi

Controllo direzionale

Simulazioni

Reporting

Budget

ContabilitàGenerale

edAnalitica

Prestazioni Interne e Reparti

Altri sottosistemiFarmacia

Sistemi di supporto Clinico

Servizi tecnico Sanitari

Scheme of HIS Information flow

Hospital Information System Main components:•Administrative information sub-system•Health/Clinical information sub-system

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Clinical and AdministrativeInformation Systems

Clinical Orientation- Focus on patient care- A tool for care providers- Timely and accurate- Administrative data a by product

Administrative Orientation- Part Institution’s infrastructure- Motivated by productivity and cost concerns- The institutional’ view dominates

Some tensions:- Who are the users?- Do clinicians see it as their system?- Who makes the purchase decisions?

1818Radiological System

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EDIS-Emergency Department EDIS-Emergency Department Information SystemInformation System

- Hospital Sub-System for delivery services to Hospital Sub-System for delivery services to respond immediatly to emergency care 24 respond immediatly to emergency care 24 hours/24hours/24

- Services involvedServices involved AdministrativeAdministrative Diagnostic departmentDiagnostic department WardsWards ………………

2020

•Information flow about•Admission/discharge•Clinical info•Injury surveillance•Triage data•Patient expects•Patient alerts•Waiting list overview•Daily list•Transfer details

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Medical record/electronic patient recordMedical record/electronic patient record- center of health information system useful for: center of health information system useful for: - clinical practiceclinical practice- medical educationmedical educationMR/EPRMR/EPRIs present in:Is present in:- Patient registration/booking services- Patient registration/booking services- ADT hospital systems- ADT hospital systems- Clinical laboratories- Clinical laboratories- Radiological diagnostics- Radiological diagnostics- Outpatient clinicOutpatient clinic- ………………

Record linkageRecord linkage- - Integration of medical record into ISIntegration of medical record into IS- Data base in health care is main component of Health - Data base in health care is main component of Health

Information Systems.Information Systems.

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Integration of HIS -Intranet

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MEDICAL RECORD AND PATIENT DATA CARDMEDICAL RECORD AND PATIENT DATA CARD    

A MINIMUM BASIC DATA SET CAN BE EXTRACTED A MINIMUM BASIC DATA SET CAN BE EXTRACTED FROM THE MR FROM THE MR AND STORED INTO A PDC.AND STORED INTO A PDC.

     PDC IS:PDC IS:  

- A PORTABLE MEDICAL RECORD- A PORTABLE MEDICAL RECORD  

- RECORD LINKAGE AND COMMUNICATION TOOL- RECORD LINKAGE AND COMMUNICATION TOOL  

PDC CAN BE USED AS:PDC CAN BE USED AS:  

- DATA-LINKAGE AND STORAGE DEVICES- DATA-LINKAGE AND STORAGE DEVICES  

- ACCESS KEY TO DB OF MEDICAL INFORMATION - ACCESS KEY TO DB OF MEDICAL INFORMATION SYSTEM AND HEALTH NETWORKINGSYSTEM AND HEALTH NETWORKING

  - INTEROPERABILITY SYSTEMS BETWEEN HEALTH - INTEROPERABILITY SYSTEMS BETWEEN HEALTH

SERVICESSERVICES

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2525

Smart Card for Alzheimer patientsSmart Card for Alzheimer patients

Bull chip da 8 Kb

2626

Hybrid card for neurological patientsHybrid card for neurological patients

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Personal dataPersonal data

Electronic signatureElectronic signature

Emergency Emergency health datahealth data

Administrative health dataAdministrative health data

Crypt abilityCrypt ability

REGIONAL SERVICE CARD

PrescriptionsPrescriptions

Any other data is on the network

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Madison Wisconsin Smart Health Card TestMadison Wisconsin Smart Health Card Test

Emergency room

Personal data insurance data clinic data

Personal data insurance data clinic data

Personal data insurance data clinic data

Personal data insurance data clinic data

AdmissionPhysician

Pharmacy

Smart health card central system card issuance communication management security management electronic billing medical research tracking

Smart card and Services NetworkSmart card and Services Network

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TelemedicineTelemedicine uses telecommunications to deliver uses telecommunications to deliver health health care, often over great distances, with the possibility of cost care, often over great distances, with the possibility of cost savings particularly in remote and rural areas. savings particularly in remote and rural areas.

Telemedicine means, literally, 'medicine at a distance'. There Telemedicine means, literally, 'medicine at a distance'. There are several different definitions, but: are several different definitions, but: the definition of telemedicine adopted by an international the definition of telemedicine adopted by an international consultation group convened by the WHO in Geneva in consultation group convened by the WHO in Geneva in December 1997 says:December 1997 says:

“ “Telemedicine is the delivery of health-care services, where Telemedicine is the delivery of health-care services, where distance is a critical factor, by health-care professionals distance is a critical factor, by health-care professionals using information and communication technologies for the using information and communication technologies for the exchange of valid information far diagnosis, treatment and exchange of valid information far diagnosis, treatment and prevention of disease and injuries, and for the continuing prevention of disease and injuries, and for the continuing education of health-care providers as well as research and education of health-care providers as well as research and evaluation, all in the interests of advancing the health of evaluation, all in the interests of advancing the health of individuals and their communities.”individuals and their communities.”

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Benefits associated with ICT and Benefits associated with ICT and introduction of Telemedicineintroduction of Telemedicine

Health education of people and population; Employment opportunities for technicians and paramedics at a

peripheral level; Diffusion of medical knowledge; Availability of normal (or on demand) health treatments, in

distant areas to prevent diseases; Improvement of health indicators used by WHO and by national

government structures; Telemedicine could help some countries to cut health costs. (A

study carried out in the United States at the end of the last century has estimated that a figure of between 35 and 40 billion dollars could be saved by the health structures by using telecommunication and telemedicine technologies more efficiently).

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Telemedicine fields:Telemedicine fields:

Teleconsulting (clinicians clinicians) Telediagnosis (clinicians phisicians) Telemonitoring (clinical centers patients) Telesurveillance [i.e. home telecare] (health

structure patients) Tele-emergency (first aid centers health

operators ambulances patients)

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Telemedicine and emergencyTelemedicine and emergency

Data transmission from ambulances to ED:Data transmission from ambulances to ED: Patient vital signs/ECG (portable monitor cum defibbrillator)Patient vital signs/ECG (portable monitor cum defibbrillator) Blood pressureBlood pressure Heart rate and pulse oximetryHeart rate and pulse oximetry Other information communicated by paramedics in Other information communicated by paramedics in

ambulances (collected in notebook), ex: ambulances (collected in notebook), ex: - respiratory rate, objective evidence, patient mental - respiratory rate, objective evidence, patient mental state (Glasgow Coma Scale).state (Glasgow Coma Scale).(SW system can compute trauma score).(SW system can compute trauma score).- transmission of data, before leaving site, to - transmission of data, before leaving site, to

receiving receiving hospital ED ad initial pre-arrival information.hospital ED ad initial pre-arrival information.ED staff can prepare therapeutical procedures, useful drugs, etc.ED staff can prepare therapeutical procedures, useful drugs, etc.

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TeleradiologyTeleradiology

A teleradiological platform for A teleradiological platform for Teconsulting/Telediagnosis can be composed by: Teconsulting/Telediagnosis can be composed by:

personal computer of recent generation; personal computer of recent generation; connection in geographic net between the connection in geographic net between the

headmasters, realized through the introduction of headmasters, realized through the introduction of suitable net apparatuses; suitable net apparatuses;

software for elaboration and acquisition of the images software for elaboration and acquisition of the images with registration functionality according to the with registration functionality according to the DICOM3 standard;DICOM3 standard;

monitor for the reporting with 2 Mpixel resolution.monitor for the reporting with 2 Mpixel resolution.

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TELECARDIOLOGY

A TeleCardiological system is set of :

peripheral equipment of survey of the data and clinical parameters

telecommunication net that allows the connection of the equipment

operating platform of receipt, treatment and reports of the data

operating protocol

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Telecardiological systemTelecardiological system

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TelepathologyTelepathology

Telepathology is a practical activity of the Telepathology is a practical activity of the pathology to distance, able to have the images pathology to distance, able to have the images of the slides seen on a screen instead than of the slides seen on a screen instead than through the microscope.through the microscope.

The transmitted images can be used for The transmitted images can be used for primary diagnoses, second opinion, check of primary diagnoses, second opinion, check of quality control, ability tests and widening at quality control, ability tests and widening at distance.distance.

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TelepathologyTelepathology

▀ Telepathology platform Telepathology platform is constituted by: is constituted by: microscope,telecamera, microscope,telecamera, PC, communication PC, communication network, architecture network, architecture client/server, relational client/server, relational DBMS, SW Firewall, DBMS, SW Firewall, SW of compression of SW of compression of the images (i.e. Jpeg).the images (i.e. Jpeg).

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Telemedicine Project ITALY (Palermo) -EGYPT (Cairo)

3939

Internet in MedicineInternet in Medicine

Diffusion of Internet services in healthcare; Building of web sites and portals in medical fields; To share and to access to clinical information

(protocols of care, guidelines, etc.); Teleconsulting and telediagnosis in peripherical

health structures and also at home; Costs reducing.

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Example:Example: Milan Network for Neuro Radiological Teleconsulting

Service Provider

PPP Server

www server

INN Besta

Cancer Institute xxx Hospital

Niguarda Hospital

Sacco Hospital

ISDN 128Kbps

ISDN 128Kbps

4141

WEB TECHNOLOGY:WEB TECHNOLOGY:PORTAL IN MEDICINEPORTAL IN MEDICINE

Web Portal to access clinical database and for Web Portal to access clinical database and for teleconsulting/telediagnosis.teleconsulting/telediagnosis.

Creation of Medical Network, in order to Creation of Medical Network, in order to improve healthcare information dissemination, to improve healthcare information dissemination, to facilitate the access to clinical data base and facilitate the access to clinical data base and therapeutical diagnostic protocols and to permit therapeutical diagnostic protocols and to permit teleconsultation and telediagnosis; it is based on teleconsultation and telediagnosis; it is based on a multifuctional platform integrated with clinical a multifuctional platform integrated with clinical and diagnostic services, located in large hospitals and diagnostic services, located in large hospitals and Medical Research Institutes.and Medical Research Institutes.

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The The MED PORTALMED PORTAL project can provide integration project can provide integration among services aready available to the local among services aready available to the local communities or extended to a wider geographical communities or extended to a wider geographical area. area.

It can favorite the access to clinical information and It can favorite the access to clinical information and processing in the health services for clinical activity processing in the health services for clinical activity to users (doctors, radiologists, etc.) and the clinical to users (doctors, radiologists, etc.) and the clinical activity of teleconsulting and telediagnosis. activity of teleconsulting and telediagnosis.

It can also offer the opportunity to integrate and co-It can also offer the opportunity to integrate and co-ordinate methods of care and ordinate methods of care and diagnostic/therapeutical protocols).diagnostic/therapeutical protocols).

2nd opinion.2nd opinion.

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MED PORTAL:MED PORTAL:

- - Based on a multifuctional platform integrated with clinical and diagnostic services, located in large hospitals and Medical Research Institutes.

- Aimed to integrate several hospitals database imed to integrate several hospitals database developed by RDBMS, using XML as a glue developed by RDBMS, using XML as a glue language to improve users accessibility and language to improve users accessibility and information distribution in a standard WEB information distribution in a standard WEB enviroment.enviroment.

Standards: HL7, DICOM, CORBAMED,….Standards: HL7, DICOM, CORBAMED,…. GRIDGRID

4444

INTR

@M

ED

2

DB

HOSPITAL DB

HOSPITALWEB SERVER

FI

RE

W AL

L

INTR@MED2

PORTAL

LAN

INTR

@M

ED

2

DB

4545

From INTERNET to GRID technologyFrom INTERNET to GRID technology As the net evolues, all machines and people will

become nodes on one network. Rapid improvements in communications technologies

are leading many to consider more decentralized approaches to the problem of computing power.

In the world there are about 500 million of PC. Internet computing and GRID technologies promise

to change the way we tackle complex problems. They will enable large scale aggregation and sharing

of computational data and other resources across institutional boundaries.

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LIFE in the GRID 2000-2010LIFE in the GRID 2000-2010GRID technology opens perspective of large

computational power and easy accessibility to heterogeneous data services.

GRID was coined in 1995 to denote a proposed distributed computing infrastructure for advanced science and engineering.

Health GRID would provide framework for sharing, computing and storaging resources, promoting standards and fostering synergy between Bio-Informatics and Medical Informatics.

Integrating genetic data into medical record. Researching individualized health care.

4747

GRID: Networking and intelligent processing Computational and data GRID are new frontier in

development of a world wide distributed computing model..

GRID uses all computing and archieves resources spread out in its test bed and makes them available in a secure way to whoever is authorized to utilize them.

Virtual Organization in the world needs: Interoperability Portability Code sharing Standard protocols

4848

GRID Projects: DATAGRID CROSSGRID EUROGRID BIOGRID MAMMOGRID GEMSS

GRID and medical simulation services. Distributed medical support system for drug therapy of HIV

infection. Diseases prevention, GRID for public health promotion. E-Heart GRID

GRID concept and technology are in the R&D projects of EC.

4949

GRID in BIO-MEDICINEGRID in BIO-MEDICINE BIOGRIDBIOGRID MAMMOGRIDMAMMOGRID TUMORI RARITUMORI RARI CARDIOLOGIA (E-HEART GRID)CARDIOLOGIA (E-HEART GRID) SIMULATIN WITH BIOMEDICAL IMAGES SIMULATIN WITH BIOMEDICAL IMAGES

GEMMSGEMMS NEUROSCIENCESNEUROSCIENCES EPIDEMIOLOGYEPIDEMIOLOGY

MULTIDISCIPLINARY NEEDS OF COLLABORATION BETWEEN OPERATORS INTERNET SERVICES (E-MAIL, SITI WEB, ECC.) PERMIT TO

COOPERATE CONNECTION BETWEEN COMPUTERS, DATA AND

RESOURCES

5050

Standards used for data/images management are different and include:

EDIFACT

DICOM

X-12

HL7

XML

Standardization in medical Standardization in medical informaticsinformatics

5151

MEDICAL RECORD MEDICAL RECORD StandardizationStandardization

Phases of medical record standardization process:

1. structure analysis of medical records;

2. random retrieval and review of records of cases;

3. comparison of the results among the different records;

4. recording of data from new cases using a common record format.

5252

Record Format Analysis

Locating of main modules (personal data, follow up, laboratori, etc.) Variables Classification

Selection of a retrospective sample of records

Chiose of common parameters in the different centres

Descriptive analysis of variables

Comparison and interpretation of results

Estimate of parameters and prediction of illness evolution

Definition of common set of parameters to find

Data gathering of new cases

Data analysis and results interpretation

Comparison of present results with the precedine one

Evaluation of answer, mistakes, missing cases,…

New definition and standardization of record

5353

Medical Record in XML

From EDI messages to Internet Technology, using a “structured clinical message” in XML language.

5454

Meta-language: universal language developed by the World Meta-language: universal language developed by the World Wide Web Consortium (W3C) in 1998 Wide Web Consortium (W3C) in 1998

Permits to Internet applications to “understand each other” and to Permits to Internet applications to “understand each other” and to control the communication between these one and the traditional control the communication between these one and the traditional software.software.

ExtensibilityExtensibility Another important aspect: it is possible to re-use the typologies Another important aspect: it is possible to re-use the typologies

of XML documents, simply extending them with new tagsof XML documents, simply extending them with new tags

XML : eXtensible Markup Language

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Use of XML in MMR (Multimedia Medical Use of XML in MMR (Multimedia Medical Record) realizationRecord) realization

eXtensible Markup Language

Structure of Database :

DTD (Document Type Definition) realization

Multimedia data (images, viedeo) are considered in .jpeg and .mpeg format.

5656

DTD (Document Type Definition)DTD (Document Type Definition)

eXtensible Markup Language

<?xml version="1.0" encoding="UTF-8"?><!ELEMENT MD.table (MDATA)+ > <!ELEMENT MDATA (CodMD, PesoPaz, AltezzaPaz, Voltaggio, RitmoAtr, FrqVentr, PrSist, Prdiast, PrGiug, Tracciato, Eco, RxTorace, CodPaz) ><!ELEMENT CodMD (#PCDATA) ><!ATTLIST CodMD

Type CDATA "number"Size CDATA "4">

<!ELEMENT PesoPaz (#PCDATA) ><!ATTLIST PesoPaz

Type CDATA "number"Size CDATA "2">

…….......…………

<?xml version="1.0" encoding="UTF-8"?><!ELEMENT Esami.table (Esami)+ > <!ELEMENT Esami (CodESAM, Emoglobina, Ematocrito, Globuli_bianchi, Piastrine, TLinfociti, Urea, Creatinina, Livello_CSA, CodPaz) ><!ELEMENT CodESAM (#PCDATA) ><!ATTLIST CodESAM

Type CDATA "number"Size CDATA "4">

<!ELEMENT Emoglobina (#PCDATA) ><!ATTLIST Emoglobina

Type CDATA "number"Size CDATA "2">

………….………….

5757

XML documentsXML documents

eXtensible Markup Language