Exploitation of statistical tables: conceptual interaction with epidemiologic data.

Health-care applications need flexible data and interaction models capable of dealing with data of different natures coming from different sources. These applications are usually devoted to diverse user groups, often casual or novice. The user interface must help the user to understand the database information content in his or her querying process. The authors synthetically describe FLN, a system featuring an integrated interaction with epidemiologic data. In an integrated model the statistical aspects of data (macro data) are represented, together with the intensional and extensional views of the variables involved in statistical tables.

Patient records: from single events to elements for health planning.

Data collected in patient records are not only the kernel of a ward information system, but also the groundwork for planning and evaluating services in health care. The aim of this study was to analyze the problem of aggregate data generation starting from separate items in patient records. After describing the different uses of patient record data, we outline the process which generates aggregates data starting from individual records. This process leads to the definition of the "view on aggregation" as an intermediate step between patient records and aggregate data. A simplified schema is presented based on the Entity-Relationship model representing a conceptual model of the integration of aggregate data and patient record items. Finally, the role is discussed of automation in this process and the perspectives for its implementation.

Toward a general model for the description of multimedia clinical data.

The patient folder integrates information originating from heterogeneous sources. For this reason computerized tools for patient data management should exploit the advantages of multimediality and offer an integrated environment for data presentation, and image and biosignal visualization. Object-oriented modeling is the best approach for designing systems for multimedia patient folder management. We propose an object-oriented model, able to define the entities constituting the patient folder and their logical organization. This model has sufficient flexibility to adapt to the most varied clinical environments. It allows the physician to structure the information needed for his/her patient folder without employing a programming language.

ADAMS: Aggregate Data Management System for epidemiologists and health-care managers.

An effective health-care policy is supported by the availability of data in the form of statistical tables for epidemiologists and health-care managers. Creation, analysis and exploitation of these data strongly support the monitoring of trends in mortality and morbidity phenomena and the evaluation of offered health services. This might imply the transformation of statistical tables to more suitable formats. A successful management, manipulation and querying of a statistical table is a complex activity requiring a considerable knowledge of statistical problems. Computerised support can be precious in this task and this led to the development of several data management systems. In this paper we sketch out the features of ADAMS (Aggregate Data Management System), a system conceived to allow an easy interaction with statistical tables, reshaping and browsing of their descriptive part. ADAMS aims at simplifying the problem of extracting information from a statistical database and performing statistical table manipulation. The following functionalities are provided: definition of a statistical database at descriptive level; storage of data in the database; manipulation of data according to the summarisation and reclassification operators; browsing between data and their descriptive part. It also supports different manipulation styles according to different user profiles.

Context trees: representing co-operative healthcare activities in IREP.

The IREP Project is based on the concept of 'rehabilitation programme' (LLP--Life Long Programme). It consists in a global vision of the patient's therapeutic-rehabilitative path, that is realised by the description, selection, adaptation and evaluation of generalised protocols. This paper discusses the issues arising in the definition of multidisciplinary rehabilitation programmes involving the co-operation of independent teams. A methodology to formalise and collect descriptions of programmes is presented. A programme is considered as a set of interconnected activities, represented as a graph of Activity Modules, organised in Context Trees; the resulting structured representation is the framework to implement timely and effective communication services in a global information system on rehabilitation. Based on this experience, a set of possible requirements for software tools to formalise and manage programmes have been suggested; it was the basis for the realisation of a first prototype under field test in a rehabilitation environment by other partners of the IREP Project.

A survey of telemedicine in Italy.

Italy has a tradition of experimental telemedicine which dates back to the early 1970s. However, despite promising experience, widespread diffusion of telemedicine services has not occurred. The Ministry of Research recognized the potential of telemedicine for improving the quality of health care and reducing costs, and has launched a national plan for financing research and training. The plan is expected to have a major impact on the organization of telemedicine research in Italy. In this paper we describe the current situation, outline the structure of the national plan, and survey various applications in different fields, such as teleconsulting, teleradiology and telemonitoring.

Telematic evolution of day-hospital in oncology.

The telematic evolution of the Day-Hospital can be considered as the virtual hospitalization, implementing the integration between hospital care and home care and predefining an hospital system which "goes to the patient home". In this paper the authors describe tools, characteristics, and advantages of this proposal, as well as the interaction model. Then the medical problem is illustrated: the first model implemented in oncology involves the liver tumors, which are the more frequent malignant neoplasms, and, in particular, the hepatocellular carcinomas (HCC),. The Organization Model, the Information System, the Tools and the Modalities of Telemonitoring for Hepatocellular Carcinoma in telematic day-hospital are still illustrated and a brief conclusion is given.

A hypermedia tool to support the interaction between radiologists and clinicians.

In this work we discuss problems related to the radiological reporting process and attempt to identify the ones which emerge during clinician-radiologist communication. We propose a hyper-reporting system, which allows the clinician to share the knowledge and critical factors that prompt the radiologist's diagnostic hypothesis during the discussion of results. This is possible by creating hypermedia links among different elements: reporting text, images, comments and the graphic models library. These elements make radiological knowledge explicit and clarify to the clinician the logical-diagnostic path traveled by the radiologist. A questionnaire, a survey of clinicians' and radiologists' needs allowed us to define some aspects of a hypermedia demo interface. Finally, we describe an example of a working session with the use of a few explanatory cards.

Hepatocellular carcinoma: the virtual hospitalization in day-hospital.

The virtual hospitalization can be considered as the telematic evolution of the Day-Hospital, implementing the integration between hospital care and home care and predefining an hospital system which "goes to the patient home". In this paper the authors describe characteristics, motivations and advantages of this proposal, as well as the interaction model. Then the medical problem is illustrated: the liver tumors, which are the more frequent malignant neoplasms, and, in particular, the hepatocellular carcinomas, which represent about the 50% of these tumors. The Organization Model, the Information System and the Modalities of Telemonitoring for Hepatocellular Carcinoma are still illustrated and a brief conclusion is given.

Extending the standard architecture for healthcare units: the guideline server.

The main topic of our research is health care unit (HCU) reengineering. To this aim, a guideline oriented conceptual model of HCUs was developed. In order to map this conceptual model into an information system with a client-server architecture, a guideline server is needed. The guideline concept and its life cycle are introduced and the main functions of the guideline server are presented.

A system for the description of healthcare guidelines.

Contained costs and quality of treatment are two elements which have to be considered when planning and controlling both clinical and managerial activities of healthcare structures (HCSs). Each structure has to be marked by a high level of quality of treatment and by specific professional competencies and skills of its operators. It is therefore fundamental to provide a system which supports the management of processes and of guidelines which characterise an healthcare structure. In this paper we present a system able to describe processes of an HCS and in particular clinical guidelines. This system is based on a workflow conceptual model, able to represent clinical and managerial activities carried out in HCSs (the Atreus model).

A model for the structured description of healthcare activities and related data.

Rehabilitation involves long-term, interdisciplinary processes. A model was developed, for the structured description of typical healthcare activities. Telematic services based on this model can support accurate data acquisition and communication among healthcare teams. Presentation of data within their context and according to the specific user's view is envisaged, based on deviations from the typical behaviours. Benefits are also expected in better understanding of the care processes themselves, easier comparison of different approaches, and diffusion of consensus-based knowledge.

A conceptual representation of clinical and managerial guidelines: the ATREUS workflow model.

In this paper we propose a workflow conceptual model able to represent clinical and managerial activities within healthcare structures, the ATREUS model. This model uses: a) a graphical representation which models the activities and the events that activate them; b) a textual representation of information related to: a set of conditions used for the control of activity execution; the actors who undertake the activity; the resources and tools necessary for its enactment, the clinical and managerial data generated by the activity execution; c) a state diagram which allows the control of the activity execution. The model allows modularity, activity nesting and temporal flexibility using a top-down refinement of processes. This model, unlike others, makes it possible to highlight the different types of decision involved in the performance of an activity.

Relevance of mandates, notifications and threads in the management of continuity of care.

Availability of electronic healthcare records (EHCR) and geographical networks allows nowadays to realise a set of functionalities to support continuity of care. Actual exchange of complete clinical information, common centralised records, common decisions within an agreed protocols are not mandatory. Sub-optimal alternatives, involving easier management, are possible. In fact, the crucial challenge for continuity of care is the mutual awareness of the multiple perspectives by the actors contributing to patient's care. The various actors should timely know changes in the status of: mandates, i.e. who is involved in the care provision and thus is responsible for a "local" record. knowledge about the patient, i.e. active and inactive problems, impressions, relevant findings. provision of healthcare activities, i.e. plans, orders and performed activities. The decisions on the actual implementation depend on the healthcare context, as implemented within the information system. For example, the mechanism for notifications involves decisions on the quality and quantity of information that must be exchanged, as well as on the modalities for the exchange, regulated by individual user's profiles. Each notification could be sent as a message to a central repository, and then each authorized user could select within the repository the pertaining messages. Or a notification could be sent directly to the list of professionals involved in the care of a patient, that asked for it in their profile. Mandates may be used to regulate the access of the users to the patient's information. This approach was embedded in a European standard under development in CEN/TC251 (CONTSYS--"System of concepts to support continuity of care").

Is workflow technology suitable to represent and manage clinical trials?

The clinical trial has to be rigidly followed because it identifies a uniform clinical behaviour, which has to be adopted by the different physicians carrying out the test. The life cycle of the clinical trial is therefore based on a planning and definition phase, a next experimental phase connected with its diffusion to the involved centres and finally an evaluation phase of the results. An information system, which supports the users in the different phases of the clinical trial life cycle, has to take into account the different characteristics of each phase. The aim of this paper is to illustrate the role of WF technology as a component of an information system which supports the life cycle of a clinical trial also on the basis of the experience of the Italian Group for Haematological Disease of Adults (GIMEMA).

A hypermedia radiological reporting system.

Report is the main phase of a diagnostic process by images. The product of the process is the diagnostic report. We are proposing an hypermedia structure of diagnostic report in radiology, in order to facilitate exchange between radiologist and clinician (specialist in internal medicine or surgeon) on a clinical case, without anymore charge on the side of the radiologist but with an 'off-line' consultation. An hypermedia radiological report software will produce further advantages in many aspects: radiologist and clinician could access patient's data directly from DB on patients; radiologist could check DB on exemplary cases real-time; clinician could read preliminary and final reports available in network and make requests online. The proposed hyper-report system is modular. Starting from the 'report text' writing, edited by the radiologist on the basis of most significative images, it is possible to insert comments in text, drawing and 'external' images form.

Virtual hospitalization: reality or utopia?

In this paper the problem regarding the way in which the increasing capacity and facilities of the telemedicine to link points of care, supporting services and health care sectors, is described. The virtual hospitalization is discussed, as well as its insertion in a new health care system, whose services will provide everyone with effective health care in their homes or in isolated places or in their working places or in emergencies, and which will permit remote consultations between professionals in specialized centers, hospitals and other peripheral points of care.

An object-oriented tool for the generation and management of multimedia patient folders.

Computer-based patient folders are evolving from the simple reproduction of traditional paper documents toward active tools, able to support the whole diagnostic and therapeutic process. The advent of multimediality has given emphasys to the idea of computerized folder, i.e. a collection of heterogeneous kinds of documents pertaining different media. In this paper we present a tool implementing generation and management of multimedia patient folders showing its architecture and functionalities and the innovative interaction paradigms adopted. The tool realized allows medical users to choose the concepts desired in their target application and generates a customized patient folder management system by means of a friendly interface and without the need of a programming language. The system automatically created can be effectively employed for reporting and storing clinical cases.

Evaluation stages and design steps for knowledge-based systems in medicine.

After the early experiments in artificial intelligence a methodology is emerging around advanced systems for the management of medical knowledge. The stress is moving away from the implementation of prototypes to the evaluation. It is possible to adapt and to apply this to field evaluation techniques already developed in similar contexts of knowledge management (books, drugs, epidemiology, consultants, etc.). The time is ready for a further step: to envisage a methodology for the design of real systems that cope with the 'knowledge environment' of the user. Every stage of the evaluation process is re-examined here, and considered as a framework to define goals and criteria about a step of design: (1) the impact of the system on the progress of health care provision (priorities, cost-benefit analysis, share of tasks among different media); (2) effectiveness in the end-user's environment and long-term effects on his behaviour (changes in people's role and responsibilities, improvements in the quality of data, acceptance of the system); (3) the intrinsic efficiency of the system apart from the operational context (correctness of the knowledge base, appropriateness of the reasoning). The need to differentiate the test sample into three classes (obvious, typical, atypical) is emphasized, discussing the influence on both evaluation and design. In particular the difficulty of having 'gold standards' on atypical cases, due to the disagreement among the experts, leads to the definition of two alternative attitudes: the 'standardization mode' and the 'brain-storming mode'.

Intelligent management of epidemiologic data.

In the lifecycle of epidemiologic data three steps can be identified: production, interpretation and exploitation for decision. Computerized support can be precious, if not indispensable, at any of the three levels, therefore several epidemiologic data management systems were developed. In this paper we focus on intelligent management of epidemiologic data, where intelligence is needed in order to analyze trends or to compare observed with reference value and possibly detect abnormalities. After having outlined the problems involved in such a task, we show the features of ADAMS, a system realized to manage aggregated data and implemented in a personal computer environment.