A Privacy-Preserving Audit and Feedback System for the Antibiotic Prescribing of General Practitioners: Survey Study.

BACKGROUND: Antibiotic resistance is a worldwide public health problem that is accelerated by the misuse and overuse of antibiotics. Studies have shown that audits and feedback enable clinicians to compare their personal clinical performance with that of their peers and are effective in reducing the inappropriate prescribing of antibiotics. However, privacy concerns make audits and feedback hard to implement in clinical settings. To solve this problem, we developed a privacy-preserving audit and feedback (A&F) system. OBJECTIVE: This study aims to evaluate a privacy-preserving A&F system in clinical settings. METHODS: A privacy-preserving A&F system was deployed at three primary care practices in Norway to generate feedback for 20 general practitioners (GPs) on their prescribing of antibiotics for selected respiratory tract infections. The GPs were asked to participate in a survey shortly after using the system. RESULTS: A total of 14 GPs responded to the questionnaire, representing a 70% (14/20) response rate. The participants were generally satisfied with the usefulness of the feedback and the comparisons with peers, as well as the protection of privacy. The majority of the GPs (9/14, 64%) valued the protection of their own privacy as well as that of their patients. CONCLUSIONS: The system overcomes important privacy and scaling challenges that are commonly associated with the secondary use of electronic health record data and has the potential to improve antibiotic prescribing behavior; however, further study is required to assess its actual effect.

The Norwegian PraksisNett: a nationwide practice-based research network with a novel IT infrastructure.

PURPOSE: Clinical research in primary care is relatively scarce. Practice-based research networks (PBRNs) are research infrastructures to overcome hurdles associated with conducting studies in primary care. In Norway, almost all 5.4 million inhabitants have access to a general practitioner (GP) through a patient-list system. This gives opportunity for a PBRN with reliable information about the general population. The aim of the current paper is to describe the establishment, organization and function of PraksisNett (the Norwegian Primary Care Research Network). MATERIALS AND METHODS: We describe the development, funding and logistics of PraksisNett as a nationwide PBRN. RESULTS: PraksisNett received funding from the Research Council of Norway for an establishment period of five years (2018-2022). It is comprised of two parts; a human infrastructure (employees, including academic GPs) organized as four regional nodes and a coordinating node and an IT infrastructure comprised by the Snow system in conjunction with the Medrave M4 system. The core of the infrastructure is the 92 general practices that are contractually linked to PraksisNett. These include 492 GPs, serving almost 520,000 patients. Practices were recruited during 2019-2020 and comprise a representative mix of rural and urban settings spread throughout all regions of Norway. CONCLUSION: Norway has established a nationwide PBRN to reduce hurdles for conducting clinical studies in primary care. Improved infrastructure for clinical studies in primary care is expected to increase the attractiveness for studies on the management of disorders and diseases in primary care and facilitate international research collaboration. This will benefit both patients, GPs and society in terms of improved quality of care.Key pointsPractice-based research networks (PBRNs) are research infrastructures to overcome hurdles associated with conducting studies in primary careImproved infrastructure for clinical studies in primary care is expected to increase the attractiveness for studies on the management of disorders and diseases in primary care and facilitate international research collaborationWe describe PraksisNett, a Norwegian PBRN consisting of 92 general practices including 492 GPs, serving almost 520,000 patientsAn advanced and secure IT infrastructure connects the general practices to PraksisNett and makes it possible to identify and recruit patients in a novel way, as well as reuse clinical dataPraksisNett will benefit both patients, GPs and society in terms of improved quality of careThis paper may inform and inspire initiatives to establish PBRNs elsewhere.

User-Centred Design with a Remote Approach: Experiences from the Chronic Pain Project.

User-centred design involves end-users or user groups during all the parts of the development process. The research project Chronic Pain aims to develop a shared decision making application for patients and physicians, addressing individually adapted pain treatment. The project employs a user-centred design process, and in middle of it, Covid-19 pandemic social distancing restrictions were imposed. This paper presents how the user-centred design process together with a patient organisation was transformed to a digital approach and the experiences from performing a remote co-creation user workshop. The digital approximation had a satisfactory result and the main contribution lies in the sharing of recommendations for how to practically apply a remote user-centred design methodology.

User-Centred Design of a Mobile Application for Chronic Pain Management.

Chronic pain patients constitute a large and heterogeneous patient group and it is important to build tools and methods that can identify efficient treatment options for each individual patient. It is estimated that 20-30% of the population has suffered from chronic pain and this imposes enormous costs on society and the national welfare programs. The research project Chronic Pain addresses the problem of how to provide patients and physicians with relevant, valid and adapted decision alternatives in a shared decision making tool. This paper presents the results from co-creation workshops early in the user-centred design process of the chronic pain mobile application. The end-users contributed in mapping the user needs and requirements, and made paper prototyping of the user interface. The main contribution lies on how a user-centred design methodology can be applied in a clinical development context.

Privacy-preserving architecture for providing feedback to clinicians on their clinical performance.

BACKGROUND: Learning from routine healthcare data is important for the improvement of the quality of care. Providing feedback on clinicians' performance in comparison to their peers has been shown to be more efficient for quality improvements. However, the current methods for providing feedback do not fully address the privacy concerns of stakeholders. METHODS: The paper proposes a distributed architecture for providing feedback to clinicians on their clinical performances while protecting their privacy. The indicators for the clinical performance of a clinician are computed within a healthcare institution based on pseudonymized data extracted from the electronic health record (EHR) system. Group-level indicators of clinicians across healthcare institutions are computed using privacy-preserving distributed data-mining techniques. A clinician receives feedback reports that compare his or her personal indicators with the aggregated indicators of the individual's peers. Indicators aggregated across different geographical levels are the basis for monitoring changes in the quality of care. The architecture feasibility was practically evaluated in three general practitioner (GP) offices in Norway that consist of about 20,245 patients. The architecture was applied for providing feedback reports to 21 GPs on their antibiotic prescriptions for selected respiratory tract infections (RTIs). Each GP received one feedback report that covered antibiotic prescriptions between 2015 and 2018, stratified yearly. We assessed the privacy protection and computation time of the architecture. RESULTS: Our evaluation indicates that the proposed architecture is feasible for practical use and protects the privacy of the patients, clinicians, and healthcare institutions. The architecture also maintains the physical access control of healthcare institutions over the patient data. We sent a single feedback report to each of the 21 GPs. A total of 14,396 cases were diagnosed with the selected RTIs during the study period across the institutions. Of these cases, 2924 (20.3%) were treated with antibiotics, where 40.8% (1194) of the antibiotic prescriptions were narrow-spectrum antibiotics. CONCLUSIONS: It is feasible to provide feedback to clinicians on their clinical performance in comparison to peers across healthcare institutions while protecting privacy. The architecture also enables monitoring changes in the quality of care following interventions.

The Association Between Health Information Seeking on the Internet and Physician Visits (The Seventh Tromsø Study - Part 4): Population-Based Questionnaire Study.

BACKGROUND: The internet is being widely used for seeking health information. However, there is no consensus on the association between health information seeking on the internet and the use of health care services. OBJECTIVE: We examined the association between health information seeking via the internet and physician visits. In addition, we investigated the association between online health information seeking and the decisions to visit and not to visit a physician. METHODS: We used the cross-sectional electronic health (eHealth) data of 18,197 participants from the seventh survey of the Tromsø Study (Tromsø 7). The participants were aged ≥40 years and living in Tromsø, Norway. We used logistic regression models to examine the association between online health information seeking and physician visits, the decision to visit a physician, and the decision not to visit a physician, with adjustment for the demographic status, socioeconomic status, and health status of the participants. RESULTS: The use of Web search engines was associated with a physician visit. However, the association was moderated by age, and the OR decreased as age increased. The ORs for the use of Web search engines were 1.99 (95% CI 1.94-2.02) and 1.07 (95% CI 1.03-1.12) at ages 40 and 80 years, respectively. The decision to visit a physician was associated with the use of Web search engines (OR 2.95, 95% CI 2.03-4.46), video search engines (OR 1.43, 95% CI 1.21-1.70), and health apps (OR 1.26, 95% CI 1.13-1.42). The association between social media use and the decision to visit a physician was moderated by gender. Women who used social media had 1.42 (95% CI 1.31-1.55) times higher odds of deciding to visit a physician, whereas the decision to visit a physician was not different between men who used social media and those who did not use social media. Conversely, the decision not to visit a physician was associated with the use of Web search engines (OR 2.78, 95% CI 1.92-4.18), video search engines (OR 1.27, 95% CI 1.07-1.51), social media (OR 1.28, 95% CI 1.10-1.49), and health apps (OR 1.20, 95% CI 1.07-1.35). CONCLUSIONS: Health information found on the internet was positively associated with both the decision to visit a physician and the decision not to visit a physician. However, the association of health information seeking with the decision to visit a physician was slightly stronger than the association with the decision not to visit a physician. This could imply that the use of eHealth services is associated with a resultant increase in physician visits. In summary, our findings suggest that the internet serves as a supplement to health care services rather than as a replacement.

Impact of Illness on Electronic Health Use (The Seventh Tromsø Study - Part 2): Population-Based Questionnaire Study.

BACKGROUND: Patients who suffer from different diseases may use different electronic health (eHealth) resources. Thus, those who plan eHealth interventions should take into account which eHealth resources are used most frequently by patients that suffer from different diseases. OBJECTIVE: The aim of this study was to understand the associations between different groups of chronic diseases and the use of different eHealth resources. METHODS: Data from the seventh survey of the Tromsø Study (Tromsø 7) were analyzed to determine how different diseases influence the use of different eHealth resources. Specifically, the eHealth resources considered were use of apps, search engines, video services, and social media. The analysis contained data from 21,083 participants in the age group older than 40 years. A total of 15,585 (15,585/21,083; 73.92%) participants reported to have suffered some disease, 10,604 (10,604/21,083; 50.29%) participants reported to have used some kind of eHealth resource in the last year, and 7854 (7854/21,083; 37.25%) participants reported to have used some kind of eHealth resource in the last year and suffered (or had suffered) from some kind of specified disease. Logistic regression was used to determine which diseases significantly predicted the use of each eHealth resource. RESULTS: The use of apps was increased among those individuals that (had) suffered from psychological problems (odds ratio [OR] 1.39, 95% CI 1.23-1.56) and cardiovascular diseases (OR 1.12, 95% CI 1.01-1.24) and those part-time workers that (had) suffered from any of the diseases classified as others (OR 2.08, 95% CI 1.35-3.32). The use of search engines for accessing health information increased among individuals who suffered from psychological problems (OR 1.39, 95% CI 1.25-1.55), cancer (OR 1.26, 95% CI 1.11-1.44), or any of the diseases classified as other diseases (OR 1.27, 95% CI 1.13-1.42). Regarding video services, their use for accessing health information was more likely when the participant was a man (OR 1.31, 95% CI 1.13-1.53), (had) suffered from psychological problems (OR 1.70, 95% CI 1.43-2.01), or (had) suffered from other diseases (OR 1.43, 95% CI 1.20-1.71). The factors associated with an increase in the use of social media for accessing health information were as follows: (had) suffered from psychological problems (OR 1.65, 95% CI 1.42-1.91), working part time (OR 1.35, 95% CI 0.62-2.63), receiving disability benefits (OR 1.42, 95% CI 1.14-1.76), having received an upper secondary school education (OR 1.20, 95% CI 1.03-1.38), being a man with a high household income (OR 1.67, 95% CI 1.07-2.60), suffering from cardiovascular diseases and having a high household income (OR 3.39, 95% CI 1.62-8.16), and suffering from respiratory diseases while being retired (OR 1.95, 95% CI 1.28-2.97). CONCLUSIONS: Our findings show that different diseases are currently associated with the use of different eHealth resources. This knowledge is useful for those who plan eHealth interventions as they can take into account which type of eHealth resource may be used for gaining the attention of the different user groups.

Electronic Health Use in a Representative Sample of 18,497 Respondents in Norway (The Seventh Tromsø Study - Part 1): Population-Based Questionnaire Study.

BACKGROUND: Electronic health (eHealth) services may help people obtain information and manage their health, and they are gaining attention as technology improves, and as traditional health services are placed under increasing strain. We present findings from the first representative, large-scale, population-based study of eHealth use in Norway. OBJECTIVE: The objectives of this study were to examine the use of eHealth in a population above 40 years of age, the predictors of eHealth use, and the predictors of taking action following the use of these eHealth services. METHODS: Data were collected through a questionnaire given to participants in the seventh survey of the Tromsø Study (Tromsø 7). The study involved a representative sample of the Norwegian population aged above 40 years old. A subset of the more extensive questionnaire was explicitly related to eHealth use. Data were analyzed using logistic regression analyses. RESULTS: Approximately half (52.7%; 9752/18,497) of the respondents had used some form of eHealth services during the last year. About 58% (5624/9698) of the participants who had responded to a question about taking some type of action based on information gained from using eHealth services had done so. The variables of being a woman (OR 1.58; 95% CI 1.47-1.68), of younger age (40-49 year age group: OR 4.28, 95% CI 3.63-5.04), with a higher education (tertiary/long: OR 3.77, 95% CI 3.40-4.19), and a higher income (>1 million kr [US $100,000]: OR 2.19, 95% CI 1.77-2.70) all positively predicted the use of eHealth services. Not living with a spouse (OR 1.14, 95% CI 1.04-1.25), having seen a general practitioner (GP) in the last year (OR 1.66, 95% CI 1.53-1.80), and having had some disease (such as heart disease, cancer, asthma, etc; OR 1.29, 95% CI 1.18-1.41) also positively predicted eHealth use. Self-rated health status did not significantly influence eHealth use. Taking some action following eHealth use was predicted with the variables of being a woman (OR 1.16, 95% CI 1.07-1.27), being younger (40-49 year age group: OR 1.72, 95% CI 1.34-2.22), having a higher education (tertiary/long: OR 1.65, 95% CI 1.42-1.92), having seen a GP in the last year (OR 1.58, 95% CI 1.41-1.77), and having ever had a disease (such as heart disease, cancer or asthma; OR 1.26, 95% CI 1.14-1.39). CONCLUSIONS: eHealth appears to be an essential supplement to traditional health services for those aged above 40 years old, and especially so for the more resourceful. Being a woman, being younger, having higher education, having had a disease, and having seen a GP in the last year all positively predicted using the internet to get health information and taking some action based on this information.

Impact of the Use of Electronic Health Tools on the Psychological and Emotional Well-Being of Electronic Health Service Users (The Seventh Tromsø Study - Part 3): Population-Based Questionnaire Study.

BACKGROUND: Electronic health (eHealth) has been described as a silver bullet for addressing how challenges of the current health care system may be solved by technological solutions in future strategies and visions for modern health care. However, the evidence of its effects on service quality and cost effectiveness remains unclear. In addition, patients' psychological and emotional reactions to using eHealth tools are rarely addressed by the scientific literature. OBJECTIVE: This study aimed to assess how the psychological and emotional well-being of eHealth service users is affected by the use of eHealth tools. METHODS: We analyzed data from a population-based survey in Norway, conducted in the years 2015-2016 and representing 10,604 eHealth users aged over 40 years, to identify how the use of eHealth tools was associated with feeling anxious, confused, knowledgeable, or reassured. Associations between these four emotional outcomes and the use of four types of eHealth services (Web search engines, video search engines, health apps, and social media) were analyzed using logistic regression models. RESULTS: The use of eHealth tools made 72.41% (6740/9308) of the participants feel more knowledgeable and 47.49% (4421/9308) of the participants feel more reassured about their health status. However, 25.69% (2392/9308) reported feeling more anxious and 27.88% (2595/9308) reported feeling more confused using eHealth tools. A high level of education and not having a full-time job were associated with positive reactions and emotions (feeling more knowledgeable and reassured), whereas low self-reported health status and not having enough friends who could provide help and support predicted negative reactions and emotions (ie, feeling anxious and confused). Overall, the positive emotional effects of eHealth use (feeling knowledgeable and reassured) were relatively more prevalent among users aged over 40 years than the negative emotional effects (ie, feeling anxious and confused). About one-fourth of eHealth users reported being more confused and anxious after using eHealth services. CONCLUSIONS: The search for health information on the internet can be motivated by a range of factors and needs (not studied in this study), and people may experience a range of reactions and feelings following health information searching on the Web. Drawing on prior studies, we categorized reactions as positive and negative reactions. Some participants had negative reactions, which is challenging to resolve and should be taken into consideration by eHealth service providers when designing services (ie, including concrete information about how users can get more help and support). There is a need for more studies examining a greater range of reactions to online health information and factors that might predict negative reactions to health information on the Web.

Secure and scalable deduplication of horizontally partitioned health data for privacy-preserving distributed statistical computation.

BACKGROUND: Techniques have been developed to compute statistics on distributed datasets without revealing private information except the statistical results. However, duplicate records in a distributed dataset may lead to incorrect statistical results. Therefore, to increase the accuracy of the statistical analysis of a distributed dataset, secure deduplication is an important preprocessing step. METHODS: We designed a secure protocol for the deduplication of horizontally partitioned datasets with deterministic record linkage algorithms. We provided a formal security analysis of the protocol in the presence of semi-honest adversaries. The protocol was implemented and deployed across three microbiology laboratories located in Norway, and we ran experiments on the datasets in which the number of records for each laboratory varied. Experiments were also performed on simulated microbiology datasets and data custodians connected through a local area network. RESULTS: The security analysis demonstrated that the protocol protects the privacy of individuals and data custodians under a semi-honest adversarial model. More precisely, the protocol remains secure with the collusion of up to N - 2 corrupt data custodians. The total runtime for the protocol scales linearly with the addition of data custodians and records. One million simulated records distributed across 20 data custodians were deduplicated within 45 s. The experimental results showed that the protocol is more efficient and scalable than previous protocols for the same problem. CONCLUSIONS: The proposed deduplication protocol is efficient and scalable for practical uses while protecting the privacy of patients and data custodians.

The Learning Healthcare System: Where are we now? A systematic review.

BACKGROUND AND OBJECTIVE: The Learning Healthcare System paradigm has attracted the attention of researchers worldwide. The great potential originating from high-scale health data reuse and the inclusion of patient perspectives into care models promises personalized care, lower costs of health services and minimized consumption of resources. The aim of this review is to summarize the attempts to adopt the novel paradigm, putting emphasis on implementations and evaluating the impact on current medical practices. METHOD: PRISMA methodology was followed for structuring the review process. Three major research databases (PubMed, IEEE Xplore and ACM DL) were queried with the predefined search terms "learning healthcare" and "learning health". Publications containing specific theoretical or empirical results were considered. RESULTS: Three hundred and fifty-eight publications were identified; however, only 32 met the inclusion criteria. Nineteen papers were characterized as theoretical contributions, while the rest presented empirical achievements. Only one paper described the initial estimates of impact and economy. DISCUSSION: Individualistic communication of studies ignoring popular frameworks for assessing and reporting research achievements prevents the systematic generation of knowledge. Evaluating the impact of the Learning Healthcare System instances where it is implemented could work as a catalyst in reaching higher acceptance and adoption of the proposed ideas by healthcare worldwide; however, it mostly remains described in theory. CONCLUSIONS: The review demonstrated the interest of researchers in exploring the Learning Healthcare System ideas. However, it also revealed minimal focus on evaluating the impact of the novel paradigm on both healthcare service delivery and patient outcome.

Assessing the impact of telestration on surgical telementoring: A randomized controlled trial.

INTRODUCTION: Using graphical annotations in surgical telementoring promises vast improvements in both clinical and educational outcomes. However, these assumptions do not consider the potential patient safety risks resulting from this feature. Major differences in regulations regarding the implementation of telestration encourage an assessment of the utility of this feature on the outcomes of telementoring sessions. METHODS: Eight students participated in a randomized controlled trial, comparing verbal with annotation-supplemented telementoring via video conferencing. A remote mentor guided the participants through four localization exercises, identifying the features in a still laparoscopic surgery scene using a laparoscopic simulator. Clinical and educational outcomes were assessed; the time consumption and quality of mentoring were determined. RESULTS: The study revealed no significant difference in localizing the intervention between the studied methods, while educational outcomes favoured verbal mentoring. Telestration-supplemented guidance was considerably faster and resulted in fewer miscommunications between the mentor and mentee. DISCUSSION: The initial hypothesis of the major clinical and education benefits of telestration in telementoring was not supported. A potential 33% decrease in the duration of the mentored episodes is expected due to the ability to annotate live video content. However, the impact of time saving on the outcome of the procedure remains unclear. Regardless of the quantitative measures, most of the participants and the mentor agreed that graphical annotations provide advantages over verbal guidance.

Video Conferencing Services in Healthcare: One Communication Platform to Support All.

We present a novel approach to the design of video conferencing (VC) systems, taking advantage of recent technological achievements in web-based implementation. Delivering VC functionality as a service over the Internet opens new grounds for easier integration, support, and application in many scenarios, since hardware-agnostic ad-hoc VC connections are a feature of the proposed architecture. Validity is demonstrated through latency measures in surgical telementoring service and comparing them to reported thresholds.

Semantic Interoperability in Clinical Decision Support Systems: A Systematic Review.

The interoperability of Clinical Decision Support (CDS) systems with other health information systems has become one of the main limitations to their broad adoption. Semantic interoperability must be granted in order to share CDS modules across different health information systems. Currently, numerous standards for different purposes are available to enable the interoperability of CDS systems. We performed a literature review to identify and provide an overview of the available standards that enable CDS interoperability in the areas of clinical information, decision logic, terminology, and web service interfaces.

What device should be used for telementoring? Randomized controlled trial.

BACKGROUND AND OBJECTIVE: The paper analyzes behavioral patterns of mentors while using different mentoring devices to demonstrate the feasibility of multi-platform mentoring. The fundamental differences of devices supporting telementoring create threats for the perception and interpretation of the transmitted video, highlighting the necessity of exploring hardware usability aspects in a safety critical surgical mentoring scenario. MATERIALS AND METHODS: Three types of devices, based on the screen size, formed the arms for the randomized controlled trial. Streaming video recordings of a laparoscopic procedure to the mentors imitated the mentoring scenario. User preferences and response times were recorded while participating in a session performed on all devices. RESULTS: Median response to a mentoring request times were similar for mobile platforms; expected durations were considerably longer for stationary computer. Ability to perceive and identify anatomical structures was insignificantly lower on small sized devices. Stationary and tablet platforms were nearly equally preferred by the most of participants as default telementoring hardware. DISCUSSION: As a side effect, incompatibility of daily duties of the surgeons in the hospital and telementoring responsibilities while implementing systems locally was identified. Scaling up the use of the service in combination with the organizational changes of clinical staff looks like a promising solution. CONCLUSION: The trial demonstrated the feasibility of using all three types of devices for the purpose of mentoring, allowing users to choose the preferred platform. The paper provided initial results on the quality assurance of telementoring systems imposed by the regulatory documents.

Internet-based remote consultations - general practitioner experience and attitudes in Norway and Germany.

UNLABELLED: The objective of the study was to identify experiences and attitudes of German and Norwegian general practitioners (GPs) towards Internet-based remote consultation solutions supporting communication between GPs and patients in the context of the German and Norwegian healthcare systems. METHODS: Interviews with four German and five Norwegian GPs were conducted. The results were qualitatively analyzed. RESULTS: All interviewed GPs stated they would like to make use of Internet-based remote consultations in the future. Current experiences with remote consultations are existent to a limited degree. No GP reported to use a comprehensive remote consultation solution. The main features GPs would like to see in a remote consultation solution include asynchronous exchange of text messages, video conferencing with text chat, scheduling of remote consultation appointments, secure login and data transfer and the integration of the remote consultation solution into the GP's EHR system.

Privacy-preserving Statistical Query and Processing on Distributed OpenEHR Data.

UNLABELLED: Reuse of data from EHRs is essential for many purposes. The objective of the study was to explore how distributed electronic health record (EHR) data can be reused for privacy-preserving statistical query and processing. METHOD: We have designed and created a proof of concept prototype solution based on the OpenEHR specification to ensure interoperability and to query the EHRs. XMPP was used for communication between the distributed processing components. RESULTS: We have created a two-phased process where a distributed virtual dataset is first created and thereafter processed using distributed privacy-preserving statistical queries. CONCLUSION: Health authorities in Norway are currently defining the set of archetypes for the national interoperability program. This will create a common information schema enabling reuse of EHR data for statistical query and processing in a privacy-preserving manner. One benefit of the approach is that information transformation between information models for clinical use and statistical processing can be avoided.

The snow system: A decentralized medical data processing system.

Systems for large-scale reuse of electronic health record data is claimed to have the potential to transform the current health care delivery system. In principle three alternative solutions for reuse exist: centralized, data warehouse, and decentralized solutions. This chapter focuses on the decentralized system alternative. Decentralized systems may be categorized into approaches that move data to enable computations or move computations to the where data is located to enable computations. We describe a system that moves computations to where the data is located. Only this kind of decentralized solution has the capabilities to become ideal systems for reuse as the decentralized alternative enables computation and reuse of electronic health record data without moving or exposing the information to outsiders. This chapter describes the Snow system, which is a decentralized medical data processing system, its components and how it has been used. It also describes the requirements this kind of systems need to support to become sustainable and successful in recruiting voluntary participation from health institutions.

An evaluation framework for defining the contributions of telestration in surgical telementoring.

BACKGROUND: An increasing quantity of research in the domain of telemedicine show a growing popularity and acceptance of care over distance systems among both clinicians and patients. We focus on telementoring solutions, developed for providing remote guidance to less experienced surgeons. Telestration is often regarded as an extra functionality of some telementoring systems. However, we advocate that telestration must be viewed as a core feature of telementoring due to its advantages. OBJECTIVE: To analyze and define concepts, parameters, and measurement procedures to evaluate the impact of using telestration while telementoring. METHODS: A systematic review of research dealing with telestration during remote guidance sessions was performed by querying three major online research databases (MEDLINE, Association of Computing Machinery, and Institute of Electrical and Electronics Engineers) using a predefined set of keywords ("laparoscopy", "annotate", "telestrate", "telestration", "annotation", "minimally invasive", and "MIS"). RESULTS: The keyword-based search identified 117 papers. Following the guidelines for performing a systematic review, only 8 publications were considered relevant for the final study. Moreover, a gap in research defining the impacts of telestration during telementoring was identified. To fill this niche, a framework for analyzing, reporting, and measuring the impacts of telestration was proposed. CONCLUSIONS: The presented framework lays the basics for the structured analysis and reporting of telestration applied to telementoring systems. It is the first step toward building an evidence knowledge base documenting the advantages of live video content annotation and supporting the presented connections between the concepts.

Surgical telementoring in knowledge translation--clinical outcomes and educational benefits: a comprehensive review.

BACKGROUND: Surgical telementoring has been reported for decades. However, there exists limited evidence of clinical outcome and educational benefits. OBJECTIVE: To perform a comprehensive review of surgical telementoring surveys published in the past 2 decades. RESULTS: Of 624 primary identified articles, 34 articles were reviewed. A total of 433 surgical procedures were performed by 180 surgeons. Most common telementored procedures were laparoscopic cholecystectomy (57 cases, 13%), endovascular treatment of aortic aneurysm (48 cases, 11%), laparoscopic colectomy (32 cases, 7%), and nefrectomies (41 cases, 9%). In all, 167 (38%) cases had a laparoscopic approach, and 8 cases (5%) were converted to open surgery. Overall, 20 complications (5%) were reported (liver bleeding, trocar port bleeding, bile collection, postoperative ileus, wound infection, serosa tears, iliac artery rupture, conversion open surgery). Eight surveys (23%) have structured assessment of educational outcomes. Telementoring was combined with simulators (n = 2) and robotics (n = 3). Twelve surveys (35%) were intercontinental. Technology satisfaction was high among 83% of surgeons. CONCLUSION: Few surveys have a structured assessment of educational outcome. Telementoring has improved impact on surgical education. Reported complication rate was 5%.