The Complexity of a Clinical History.

The paper describes a new metrics for measuring the structural complexity of clinical history (modelled by a HINe model) in order to compare different clinical histories and then assign it to the right types of learners.

Unusual case of enlarged choroidal vessels in neurofibromatosis type 1 observed with near-infrared reflectance and spectral domain optical coherence tomography.

ABSTRACT: The cardinal diagnostic signs of neurofibromatosis type 1 (NF1) are Lisch nodules of the iris and optic pathway gliomas. Retinal mi-crovascular alterations have been described but with uncertain signi-ficance. Choroidal nodules, detectable with near-infrared reflectance (NIR) imaging, are present in most cases and have been proposed as a new diagnostic criterion. Recently, a study reported the presence of unusual dilated choroidal vessels, visible through NIR examination. We report a case of a 65-year-old patient with NF1. Best-corrected visual acuity was 20/20 with a refractive error of +2.75 diopters in both eyes. Anterior segment examination revealed Lisch nodules in both eyes. At NIR imaging the patient presented typical choroidal alterations in both eyes. No retinal vessel anomalies were detected. The patient presented enlarged choroidal vessels in the left eye, first detected by NIR and then analyzed through enhanced depth imaging spectral domain optical coherence tomography (EDI-SDOCT). These vessels extended from the choroidal-scleral junction to the outer border of the retinal pigment epithelium/Bruch's layer. The choriocapillaris layer was absent above the dilated vessels. The presence of enlarged choroidal vessels may be considered as a novel distinctive ophthalmologic aspect of NF1, but further studies are necessary.

A system of concepts to support the integration of Health and social care and assistive domotics services: the Health@Home project.

The main objective of this work is to define a common shared conceptual model that describes the health care environment using the ContSys standard, harmonizing it with the social care and assistive domotics concepts. The development of this model supports the integration of services, the interoperability among systems and the continuity of care across domains.Starting from the identification and extraction of the portion of the ContSys model suitable for the healthcare part, the article provides the methodology adopted to extend it with social and home automation concepts and to integrate them in a unique framework that supports the continuity of care.The integrated model defined in this paper has been adopted in the design phase of an interoperable open platform, called Health@Home, that organizes the provision of a set of health, social and home automation integrated services provided at home.Our model is a starting point to analyze the various determinants of wellbeing able to guarantee a high-level individual's quality of life. At the moment the Health@Home system is at the implementation phase.

Extending Contsys Standard with Social Care Concepts: A Methodology Proposed by the UNINFO Working Group in Italy.

The increasing demand for territorial services requires the improvement of the coordination and cooperation among stakeholders in planning and delivery of integrated health and social services. In this scenario, to improve the communication among stakeholders there is a need of a formal conceptual model that facilitates the interoperability between organizations and professionals. This paper presents the methodology adopted by a UNINFO working group established in Italy to extend the ContSys standard with social care concepts to integrate health and social care contexts in a continuity of care perspective. An example of this extension is also provided considering the definition of patient's care plans.

Understanding Petri Nets in Health Sciences Education: The Health Issue Network Perspective.

Scarce literature exists as to the use of Petri Nets (PN) to model the dynamic evolution of health issues in a deterministic way. Starting from the HIN (Health Issue Network) approach, the paper aims at describing the suitability of PN in supporting the Case-Based Learning method for improving an educational simulation environment in which students can manage realistic clinical data related to the evolution of a patient's health state over time.

HIN - Health Issue Network as Means to Improve Case-Based Learning in Health Sciences Education.

HIN (Health Issue Network) is introduced as a peculiar approach to enhance Case-Based Learning (CBL) methodology for health sciences education, as well as innovative tool to query problem-oriented EHRs. In this paper HIN's Petri Nets-based formalism is described, and a first example of its twofold (lower and upper) representation level is proposed.

Sustainability of Endovenous Iron Deficiency Anaemia Treatment: Hospital-Based Health Technology Assessment in IBD Patients.

Iron deficiency anaemia (IDA) is the main extraintestinal manifestation affecting patients with inflammatory bowel disease (IBD). The Health Technology Assessment approach was applied to evaluate the sustainability of intravenous (IV) iron formulations in the Italian hospital setting, with particular focus on ferric carboxymaltose. Data on the epidemiology of IBD and associated IDA, in addition to the efficacy and safety of IV iron formulations currently used in Italy, were retrieved from scientific literature. A hospital-based cost-analysis of the outpatient delivery of IV iron treatments was performed. Organizational and ethical implications were discussed. IDA prevalence in IBD patients varies markedly from 9 to 73%. IV iron preparations were proven to have good efficacy and safety profiles, and ferric carboxymaltose provided a fast correction of haemoglobin and serum ferritin levels in iron-deficient patients. Despite a higher price, ferric carboxymaltose would confer a beneficial effect to the hospital, in terms of reduced cost related to individual patient management and additionally to the patient by reducing the number of infusions and admissions to healthcare facilities. Ethically, the evaluation is appropriate due to its efficacy and compliance. This assessment supports the introduction of ferric carboxymaltose in the Italian outpatient setting.

Case-Based Learning: A Formal Approach to Generate Health Case Studies from Electronic Healthcare Records.

There is an increasing social pressure to train medical students with a level of competency sufficient to face clinical practice already at the end of their curriculum. The case-based learning (CBL) is an efficient teaching method to prepare students for clinical practice through the use of real or realistic clinical cases. In this regard, the Electronic Healthcare Record (EHR) could be a good source of real patient stories that can be transformed into educative cases. In this paper a formal approach to generate Health Case Studies from EHR is defined.

Intracameral epinephrine without the addition of intracameral lidocaine in the management of tamsulosin associated intraoperative floppy iris syndrome.

OBJECTIVE: Intracameral mydriatics using epinephrine associated with lidocaine have been reported as efficacious in reducing intraoperative floppy iris syndrome (IFIS) complications during cataract surgery. The aim of this study was to verify the efficacy of intracameral epinephrine without intracameral lidocaine as prophylaxis against IFIS in patients on tamsulosin. MATERIALS AND METHODS: This was a retrospective study on the results of cataract surgery in 18 patients on therapy with tamsulosin. Patients had undergone routine phacoemulsification in one eye. Successively, they underwent phacoemulsifcation in the fellow eye using non preserved intracameral epinephrine 1:4000 diluted with BSS. Intraoperative complications during cataract surgery had been documented and IFIS was graded based on iris billowing, miosis or iris prolapse. Follow-up was 3 months. RESULTS: Thirty-six eyes of 18 patients were included in the evaluation. The incidence of IFIS was significantly higher in the eyes where routine phacoemulsificaton had been performed (100%) with respect to eyes where phacoemulsification was carried out using intracameral epinephrine (33%) (Chi Square test =15.12, p<0.001). In routine phacoemulsification 16 eyes showed iris billowing, 14 eyes had some extent of miosis and 14 eyes had tendency to iris prolapse. In phacoemulsification with the use of intracameral epinephrine 5 eyes showed iris billowing, 4 eyes presented some extent of miosis and 2 eyes had tendency to iris prolapse. There were no serious intraoperative complications. CONCLUSIONS: Intracameral epinephrine without the addition of lidocaine was efficacious in the management of IFIS in patients on tamsulosin.

Data Warehouse Design from HL7 Clinical Document Architecture Schema.

This paper proposes a semi-automatic approach to extract clinical information structured in a HL7 Clinical Document Architecture (CDA) and transform it in a data warehouse dimensional model schema. It is based on a conceptual framework published in a previous work that maps the dimensional model primitives with CDA elements. Its feasibility is demonstrated providing a case study based on the analysis of vital signs gathered during laboratory tests.

Designing ETL Tools to Feed a Data Warehouse Based on Electronic Healthcare Record Infrastructure.

Aim of this paper is to propose a methodology to design Extract, Transform and Load (ETL) tools in a clinical data warehouse architecture based on the Electronic Healthcare Record (EHR). This approach takes advantages on the use of this infrastructure as one of the main source of information to feed the data warehouse, taking also into account that clinical documents produced by heterogeneous legacy systems are structured using the HL7 CDA standard. This paper describes the main activities to be performed to map the information collected in the different types of document with the dimensional model primitives.

A conceptual framework to design a dimensional model based on the HL7 Clinical Document Architecture.

This paper proposes a conceptual framework to design a dimensional model based on the HL7 Clinical Document Architecture (CDA) standard. The adoption of this framework can represent a possible solution to facilitate the integration of heterogeneous information systems in a clinical data warehouse. This can simplify the Extract, Transform and Load (ETL) procedures that are considered the most time-consuming and expensive part of the data warehouse development process. The paper describes the main activities to be carried out to design the dimensional model outlining the main advantages in the application of the proposed framework. The feasibility of our approach is also demonstrated providing a case study to define clinical indicators for quality assessment.

The use of a mathematical model in the adoption of an integrated EHR system.

The development of healthcare information systems is broadly considered a promising strategy to ensure, enhance and deliver of quality patient services, thus improving the healthcare economic sustainability [1]. However, their systematic evaluation needs to implement economic evaluation models that can help decision makers to determine a feasible and suitable analysis of the impact of an information system in the appropriate healthcare setting [2]. Aim of this paper is to define a mathematical model to provide an "ex-ante" measure of adequacy and significance in the adoption process of Electronic Healthcare Records (EHRs). In particular, the model establishes how different subjects (General Practitioners, GPs and patients) are involved in the testing process and how the resources provided can be invested to find out the most suitable intervention strategies.

Steps towards a digital health ecosystem.

In the paper an IT infrastructure for supporting the shift from organization-centric to patient-centric model of healthcare service delivery to facilitate collaborative, multidisciplinary and cross-organizational healthcare delivery processes is presented. The core of this infrastructure is an internet platform that provides e-services and promotes the interoperability by enabling not only inter-communication among authorized healthcare professionals, but also sharing the Virtual Healthcare Record, an authoritative, multi-dimensional view on the patient health state. The platform is implemented in the LuMiR project for Basilicata, an Italian region where integration of healthcare applications is required. The LUMIR approach, its origin and peculiarities are briefly presented. The project's final target is the regional health digital ecosystem that interacts with the healthcare system for better supporting it. The agent-oriented paradigm emerges as a promising approach to map the autonomic healthcare systems and their users in virtual entities, and to add values such as flexibility, adaptability, and reusability. over traditional object- or service-oriented approaches.

Response to medication dosing alerts for pediatric inpatients using a computerized provider order entry system.

OBJECTIVE: Medication dosing errors are of particular concern in hospitalized children. Avoidance of such errors is essential to quality improvement and patient safety. Computerized provider order entry (CPOE) systems with clinical decision support (CDS) have the potential to reduce medication errors. The objective of this study was to evaluate provider response to the dosing alerts in a CPOE system with CDS for pediatric inpatients and to identify differences in provider response based on clinician specialty. PATIENTS AND METHODS: We conducted a retrospective analysis of all medication dosing alerts over a 1-year period (January 1 through December 31, 2008) for all pediatric inpatients at Hospital for Special Surgery. Alerts were analyzed with respect to medication dosing, prescriber, and action taken by the prescriber after the alert was triggered (i.e., accepted suggested change, ignored recommendation/overrode, or cancelled the order). RESULTS: During the study period, 18,163 medication orders were placed and 1,024 dosing alerts were fired. Overdosing of medications accounted for 91% of the alerts and underdosing 9%. The pediatric-trained providers ignored more alerts and cancelled fewer orders than the non-pediatric-trained providers (p<0.001). Both groups changed the order similarly based on CDS recommendations. CONCLUSIONS: Differences in response to CDS were found between pediatric-trained and non-pediatric-trained providers caring for pediatric patients; however, both groups changed orders based on CDS similarly. CPOE with built-in CDS may be of particular value when providers with different specialties and types of training are caring for pediatric patients.

LuMiR: the region-wide EHR-S in Basilicata.

The Lucania-Medici in Rete (LuMiR) project aims to support the shift from organization-centric to patient-centric healthcare in Basilicata, a region in the southern Italy. Main objective of the project is to foster collaborative, multidisciplinary and cross-organizational healthcare processes by developing and stimulating the adoption of a region-wide, software infrastructure, the LuMiR system. It is a suite of e-services that facilitates the sharing of patient related clinical data among authorized professionals, by enabling the interoperability among Electronic Medical. In the paper the LuMiR project approach is discussed, pointing out the methodology adopted in the design and development of the LuMiR system, the peculiarities of the system architecture and interventions scheduled to mitigate the risks related to the large scale adoption of the LuMiR system itself.

A medical device domain analysis model based on HL7 RIM.

Clinical investigations (CIs) are carried out to demonstrate safety and efficacy of new Medical Devices (MDs). The presence of many stakeholders participating in CIs makes it necessary to develop a common standard language to achieve semantic interoperability among systems and organizations. In Italy the National Research Council is carrying out a project supported by Ministry of Health aiming to develop an information system (MEDIS) that manages MD clinical investigations. In order to develop a flexible and interoperable system, MEDIS design has been based on the application of HL7 (Health Level 7) v.3 standards. This paper presents the results of the MEDIS design: the MD DAM based on HL7 RIM.

A multi-agent approach to the design of an e-health system.

E-medicine covers the whole range of medical process and service. Multi-agent approach is suitable for the development of e-medicine systems. In this paper, firstly the requirements of e-medicine are analyzed and taxonomy is proposed for e-medicine systems. Secondly multi-agent approach is introduced for developing e-medicine systems, and the design of agents and the design of multi-agent structure are presented for e-medicine systems. Finally a case study is presented on a telemedicine for diabetes to illustrate the development of e-medicine systems. Then, our future work is to implement the proposed system.

E-DIMEM: an economic model to estimate the costs of e-disease management.

In order to estimate the cost of generic clinical guidelines based on telemedicine services for chronic patients, an economic model (E-DIMEM) has been defined. This model is designed to help health suppliers and managers to plan for the future. It is essentially a workflow composed by diagnosis and therapeutic activities. The cost of each workflow activity is related to healthcare providers (activity agents), drugs, instruments, telemedicine services, and type of specialized healthcare centers used (hospital, clinics, etc.). This model performs multidimensional analysis. A web service based on the E-DIMEM has been implemented.

Integrated multimedia medical data agent in E-health.

E-Health is producing a great impact in the field of information distribution of the health services to the intra-hospital and the public. Previous researches have addressed the development of system architectures in the aim of integrating the distributed and heterogeneous medical information systems. The easing of difficulties in the sharing and management of medical data and the timely accessibility to these data is a critical need for health care providers. We have proposed a client-server agent that allows a portal to the every permitted Information System of the Hospital that consists of PACS, RIS and HIS via the Intranet and the Internet. Our proposed agent enables remote access into the usually closed information system of the hospital and a server that indexes all the medical data which allows for in-depth and complex search queries for data retrieval.