An objective method for bed capacity planning in a hospital department - a comparison with target ratio methods.

OBJECTIVES: To propose an objective approach in order to determine the number of beds required for a hospital department by considering how recruitment fluctuates over time. To compare this approach with classical bed capacity planning techniques. METHODS: A simulated data-based evaluation of the impact that the variability in hospital department activity produces upon the performance of methods used for determining the number of beds required. The evaluation criteria included productive efficiency measured by the bed occupancy rate, accessibility measured by the transfer rate of patients due to lack of available beds and a proxy of clinical effectiveness, by the proportion of days during which there is no possibility for unscheduled admission. RESULTS: When the variability of the number of daily patients increases, the Target Occupancy Rate favors productive efficiency at the expense of accessibility and proxy clinical effectiveness. On the contrary, when the variability of the department activity is marginal, the Target Activity Rate penalizes the proxy of clinical effectiveness, and the Target Occupancy Rate underoptimizes productive efficiency. The method we propose led to a superior performance in terms of accessibility and proxy of clinical effectiveness at the expense of productive efficiency. Such a situation is suitable for intensive care units. In the case of other departments, a weighting procedure should be used to improve productive efficiency. CONCLUSIONS: This approach could be considered as the first step of a family of methods for quantitative healthcare planning.

Monitoring incident report in the healthcare process to improve quality in hospitals.

Healthcare organizations are facing growing pressures to adopt intelligent technology to promote quality and safety care in public and private hospitals. In 2000, the Institute of Medicine report also indicated that an estimated 44,000 to 98,000 Americans die annually as a result of preventable medical errors and it appears that information management in hospitals can help the organization to improve the quality level. This paper aims to present an experience in the management of events not compliant with the best practice by monitoring these events in a hospital. We used ISO standard to implement general quality process and quality management. This project consists in proposing the possibility of declaring different dysfunctions and incidents by a simple form integrated into the intranet services of the hospital for the medical, nursing and administrative staff. This should lead to quality management of the medical units.

Managing educational resource in medicine: system design and integration.

The objective of this paper is to describe our experience in developing a tool based on web technologies, for storing, managing and providing medical courses written by professors in the medical university of Rennes. The increasing number of documents sent by professors leaded us to build a specific resource management system. We created a relational database, containing all meta information about each available document. Professors provide their courses in various formats. We use natural language parsing techniques to extract information from the text, and provide a proper semantic indexation which will be used by a medical-specific search engine. Then the content of our database is dynamically displayed on a web interface. A user's directory identifies teachers and students, controls the access, tracks the students' navigation and allows an on-line discussion forum. This portal contains 524 courses and we had more than 3,000,000 connections on it last year. We are now integrating its content using the semantic web approach in a larger project: the French Virtual Medical University.

A simple method to optimize hospital beds capacity.

OBJECTIVE: The number of acute hospital beds is determined by health authorities using methods based on ratios and/or target bed occupancy rates. These methods fail to consider the variability in hospitalization demands over time. On the other hand, the implementation of sophisticated models requires the decision concerning the number of beds to be made by an expert. Our aim is to develop a new method that is as simple to use as the ratio method while minimizing the roundabout approaches of these methods. METHOD: A score was constructed with three parameters: number of transfers due to lack of space, number of days with no possibility for S unscheduled admissions and number of days with at least a threshold of U unoccupied beds. The optimal number of beds is the number for which both the mean and the standard deviation of the score reach their minimum. We applied this method to two internal medicine departments and one urological surgery department and we compared the solutions proposed by this method with those put forward by the ratio method. RESULTS: The solutions proposed by this method were intermediate to those calculated by the local and national length of Stays ratio methods. Simulating an unusual increase in admission requests had no consequence on the bed number selected, indicating that the method was robust. CONCLUSION: Our tool represents a real alternative to the ratio methods. A software has been developed and is now available for use.

Evaluation of the Unified Medical Language System as a medical knowledge source.

OBJECTIVE: The authors evaluated the use of the Unified Medical Language System (UMLS) as a medical knowledge source for the representation of medical procedures in the MAOUSSC system. DESIGN: MAOUSSC, a multiaxial coding system, was used for the representation of 1500 procedures from 15 clinical specialties, using UMLS concepts (augmented by full sources for three new vocabularies being added to the UMLS) and relationships whenever possible. Evaluation criteria for the UMLS included (1) completeness of representation of concepts and of inter-concept relationships, (2) consistency in the categorization of both concepts and inter-concept relationships, and (3) usability, including adaptability of the UMLS to a foreign language (French), its suitability to a geographic region with different medical practices than the USA, and issues relative to the annual update changes in the test vocabularies. RESULTS: During the MAOUSSC trial, the number of missing concepts or relationships identified in the augmented UMLS sources was deemed to be inconsequential relative to overall project goals. "Missing" UMLS inter-concept relationships were identified, although they were small in number. Some inconsistencies in the UMLS were noted, especially in the area of hierarchic relationships. CONCLUSION: After UMLS was used for five years as a knowledge source for representing 1500 complex medical procedures in MAOUSSC, its value is considered significant. Future editions of the UMLS are expected to improve representation of inter-concept relationships and global consistency.

A Web terminology server using UMLS for the description of medical procedures.

The Model for Assistance in the Orientation of a User within Coding Systems (MAOUSSC) project has been designed to provide a representation for medical and surgical procedures that allows several applications to be developed from several viewpoints. It is based on a conceptual model, a controlled set of terms, and Web server development. The design includes the UMLS knowledge sources associated with additional knowledge about medico-surgical procedures. The model was implemented using a relational database. The authors developed a complete interface for the Web presentation, with the intermediary layer being written in PERL. The server has been used for the representation of medico-surgical procedures that occur in the discharge summaries of the national survey of hospital activities that is performed by the French Health Statistics Agency in order to produce inpatient profiles. The authors describe the current status of the MAOUSSC server and discuss their interest in using such a server to assist in the coordination of terminology tasks and in the sharing of controlled terminologies.

A computer-assisted drug prescription system: the model and its implementation in the ATM knowledge base.

Informatisation of drug prescription is an important topic in medical informatics. For several years now, computerized drug databases have been implemented. Usually only a small part of the prescriptions can be stored in prescription systems because of the format of the included information; prescriptions contain essentially free text without any structure and homogeneity of the used vocabulary. In this article a model is presented for knowledge representation in a computerized drug prescription system. The model should be applicable to clinical practice and be didactic for medical students. The problem of standardization of terminology had to be solved. A computer-assisted drug prescription program has been developed. The next step is its validation by clinicians. The program can also be used in a consultation mode.

An intelligent Computer-Assisted Instruction system for clinical case teaching.

The use of computers in the field of medical education is common. Our purpose is to present a Computer-Assisted Instruction system which has been developed over ten years at the University of Compiègne and the University of Rennes Medical School. This system can be used to help the student to solve clinical cases by analyzing and critiquing their answers and by using a knowledge base which has been previously structured in a rule network. It is an intelligent Computer-Assisted Instruction system comprising an author module, a pedagogical module and a student module. The CAI system can be used as a simulation model for any type of diagnostic or therapeutic problem. In this paper we present the author and pedagogical module which have been built using our previous work on intelligent computer-assisted instruction systems.

Automated coding of patient discharge summaries using conceptual graphs.

In medicine, as in other domains, indexing and classification is a natural human task which is used for information retrieval and representation. In the medical field, encoding of patient discharge summaries is still a manual time-consuming task. This paper describes an automated coding system of patient discharge summaries from the field of coronary diseases into the ICD-9-CM classification. The system is developed in the context of the European AIM MENELAS project, a natural-language understanding system which uses the conceptual-graph formalism. Indexing is performed by using a two-step processing scheme; a first recognition stage is implemented by a matching procedure and a secondary selection stage is made according to the coding priorities. We show the general features of the necessary translation of the classification terms in the conceptual-graph model, and for the coding rules compliance. An advantage of the system is to provide an objective evaluation and assessment procedure for natural-language understanding.

Computer assisted medical diagnosis using the Web.

The ADM (Aide au diagnostic Medical) project was started 15 years ago and was the first telematic project for physicians in France using the MINITEL terminal. The knowledge base contains information on more than 10000 diseases from all pathological fields, using more than 100000 signs or symptoms. The ADM system has two main functionalities for physicians: consultation of diseases descriptions and list of diseases containing one or more symptoms. The ADM knowledge base is supported by a relational database management system (DBMS ORACLE) and we developed a Web interface using the Perl language to produce HTML pages for the web server. We will describe our experience on redesigning a large existing medical knowledge base for diffusion on the web Internet.

CARDIOMEDIA: a communicable multimedia medical record on Intranet and digital optical memory card.

As part of French health reform, French physicians were computerised by the end of 1998. A specific Intranet network will be used to communicate medical data between the health professionals. The objectives of the CARDIOMEDIA project were to develop and evaluate the feasibility of a coronary multimedia data record stored on an optical card and communicable on Intranet within the hospital. Patients treated by angioplasty at the University Hospital of Rennes participated in the experiment. In general, patients are treated in the University Hospital and are followed up by another health care provider closer to their home. The patient leaves the University Hospital with his card, which is directly available elsewhere for emergency or for consultation. This approach is assumed to reduce the number of examinations and to offer a better patient follow-up. The CARDIOMEDIA card is a specialised record including various data types: text, images, image sequences of coronarography and ECG signals. For this purpose an optical card with its large memory is very convenient. We used the DICOM format for image exchange and management. It is combined with CARDIOMEDIA specific compressing software. For the multimedia record the HTML format and web Intranet method are chosen. This provides an intuitive interface which can combine various data types and helper applications like a DICOM image viewer.

A network of web multimedia medical information servers for a medical school and university hospital.

Modern medicine requires a rapid access to information including clinical data from medical records, bibliographic databases, knowledge bases and nomenclature databases. This is especially true for University Hospitals and Medical Schools for training as well as for fundamental and clinical research for diagnosis and therapeutic purposes. This implies the development of local, national and international cooperation which can be enhanced via the use and access to computer networks such as Internet. The development of professional cooperative networks goes with the development of the telecommunication and computer networks and our project is to make these new tools and technologies accessible to the medical students both during the teaching time in Medical School and during the training periods at the University Hospital. We have developed a local area network which communicates between the School of Medicine and the Hospital which takes advantage of the new Web client-server technology both internally (Intranet) and externally by access to the National Research Network (RENATER in France) connected to the Internet network. The address of our public web server is http:(/)/www.med.univ-rennesl.fr.

[Value of automated medical indexing of an image database and a digital radiological library]. / Intérêt de l'indexation médicale automatique d'une iconothèque et d'une bibliothèque radiologiques numériques.

We indexed the contents of a radiology server on the web to facilitate access to research documents and to link reference texts to images contained in radiology databases. Indexation also allows case reports to be transformed with no supplementary work into formats compatible with computer-assisted training. Indexation was performed automatically by ADM-Index, the aim being to identify the medical concepts expressed within each medical text. Two types of texts were indexed: medical imaging reference books (Edicerf) and case reports with illustrations and captions (Iconocerf). These documents are now available on a web server with HTML format for Edicerf and on an Oracle database for Iconocerf. When the user consults a chapter of a book or a case report, the indexed terms are displayed in the heading; all reference texts and case reports containing the indexed terms can then be called up instantaneously. The user can express his search in natural language. Indexation follows the same process allowing instantaneous recall of all reference texts and case reports where the same concept appears in the diagnosis or clinical context. By using the context of the case reports as the search index, all case reports involving a common medical concept can be found. The context is interpreted as a question. When the user responds to this question, ADM-Index compares this response with the answer furnished by the reference texts and case reports. Correct or erroneous responses can thus be identified, converting the system into a computer-assisted training tool.

[The virtual university in medicine. Context, concepts, specifications, users' manual]. / Université virtuelle en médecine. Contexte, concept, cahier des charges, mode d'emploi.

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.

[Image data bases and multimedia works on server and CD-ROM in medical imaging. A French experience]. / Iconothèques et ouvrages multimédia sur serveur et CD-ROM en imagerie médicale. Expérience Française.

The CD-ROM technology allows the production of multimedia works which costs far less than books do. The creation of Internet and the servers World Wide Web has the advantage of distributing those works world wide, without the difficulties and the delays related to books and magazines distribution. The Teachers' Council of Radiology of France (CERF) and the French Society of Radiology (SFR) have opted to use these new media and these information highways to spread a part of their radiology teaching work. Iconocerf is a software program which allows to create, store, read and to exchange digitized radiological cases. It's available free of charge, within the CERF and SFR. The CD-ROMs Iconocerf-Medimag contain 3,500 radiological files with 15,000 images, previously on the videodisc Medimag. The Server of the French Radiology is a W3 server which includes: the CERF directory, a guide for the teachers, the research workers and the students in Radiology and Medical Imaging. It also contains the teaching works on Radiology, and some Iconocerf clinical cases translated onto HTML. The aim of this project is to create an evaluation system for radiology. By using key words, this system allows to consult: radiological clinical cases, located on the server or on CD-ROMs; reference texts; and to have access to the experts' addresses to be able to send them eventually a difficult case through electronic mail.

[Web radiology servers: advices for users, their development and evaluation of the quality of sites]. / Les serveurs web de radiologie: conseils pour leur consultation, leur réalisation et mesure de la qualité des sites.

Sites available on the Internet are constantly increasing and over 15,000 medical websites covering all medical sub-specialties are now available. Finding relevant information on the web may be time consuming and difficult. We suggest that new users begin by accessing servers where lists of available sites are grouped under headings such as medical sub-specialties. We will list a selection of useful radiological websites providing image databases, case reports, radiological anatomy and continuing medical education. While surfing on the web, an evaluation of the quality of the websites is necessary. We used the quality criteria proposed by Darmoni to rate the quality of ten websites. The overall quality was good, but the lack of help options and external links were the main pitfalls that we noted. All webmasters should pay attention to quality criteria and show the Darmoni criteria on their homepage. In order to evaluate which internet options should be developed, we evaluated our own website and submitted a questionnaire to our users. Clinical cases were the most requested feature, they could be used for continuing medical education.

[Analysis of medical catalog terms using the MAOUSSC model: application to Gyncecology-Obstetrics]. / Analyse des libellés des actes du catalogue des actes médicaux à l'aide du modèle MAOUSSC: application à la Gynècologie-Obstétrique.

BACKGROUND: The Model of Assistance and Orientation of a User within a System of Coding (MAOUSSC) used to describe activity in human medicine was used to analyse French medical nomenclature in Gynecology and Obstetrics. METHODS: French medical nomenclature for gynecology and obstetrics was translated with the multiaxial model (MAOUSSC) to allow critical analysis. RESULTS: All the 119 medical acts in the French nomenclature involving the female genital tract and obstetrics could be translated with the model. 24% of the acts were imprecise, ambiguous or implicit: the nature of the procedure was not explicit in 7 cases, the surgical route was not given in 86 and the surgical instrumentation not named in 75. Activities involving numerous medical specialties and ambulatory activity can be described with the MOUSSC model. CONCLUSION: The MAOUSSC model is still in the experimental stage. It is however easy to implement, has a high potential for describing various medical acts and is suitable for the description of gynecological and obstetrical activity both in terms of economical and medical efficacy.

ADM-INDEX: an automated system for indexing and retrieval of medical texts.

ADM-INDEX is a system for indexing and retrieval of Patients Discharge Summaries (PDSs) by using linguistic methods (morphologic, syntaxic and semantic processing). The ADM-INDEX knowledge base is a restructuring of a diagnostic aid knowledge base (ADM) in order to allow the linguistic analysis of medical texts. The ADM system is a comprehensive medical knowledge base which has been developed since 1972 at the University Hospital of Rennes and which has been the first professional videotex medical diagnostic aid in France. After linguistic analysis, ADM-INDEX build the index table with thesaurus wording, medical words, concepts and phrases, unknown words contained in each PDS. The benefit of using those different elements is to improve information retrieval. Although our system is constructed with the ADM dictionary, it can be easily applied to other medical nomenclature or thesaurus. In this paper, we present on the one hand the ADM-INDEX knowledge base which is constituted by rules, a dictionary and a thesaurus, and on the other hand, the process of indexing and retrieval information.

A new Object Request Broker architecture in implementing a medical picture retrieval system.

This paper describes the approach we used to implement the world wide web user interface of MediPict, a medical picture retrieval system. The best software architecture seemed to be the three-tier client/server architecture using Objects Request Brokers (ORB) which appears to have many benefits. Although CORBA appears to be the standard ORB, we found it more adequate to develop a different approach. This new ORB resolves many of CORBA's weaknesses (non coherent types, need of a static IDL, maintenance difficulties) by using the same language on the top and middleware tiers.

A virtual university Web system for a medical school.

This paper describes a Virtual Medical University Web Server. This project started in 1994 by the development of the French Radiology Server. The main objective of our Medical Virtual University is to offer not only an initial training (for students) but also the Continuing Professional Education (for practitioners). Our system is based on electronic textbooks, clinical cases (around 4000) and a medical knowledge base called A.D.M. ("Aide au Diagnostic Medical"). We have indexed all electronic textbooks and clinical cases according to the ADM base in order to facilitate the navigation on the system. This system base is supported by a relational database management system. The Virtual Medical University, available on the Web Internet, is presently in the process of external evaluations.