eHealth Turning Points as Forced by the Covid-19 Dramatic Experience.

In this ongoing fall of the year 2021, many disciplines are frightened by the Covid-19 situation. A generalized sense of Scientific and administrative impotence, - in keeping the pandemic under real control, - is felt widely in Society. In this Invited Lecture the author reminds us of the blows suffered, recalls pertinent elements present in our social organization, browses selected eHealth experiences and proposes an open agenda of actions to allow the eHealth to help the population segments better, and individuals as well.

The ALFA4Hearing Model (At-a-Glance Labeling for Features of Apps for Hearing Health Care) to Characterize Mobile Apps for Hearing Health Care.

PURPOSE: The aim of the study was to analyze, by using the ALFA4Hearing model (At-a-Glance Labeling for Features of Apps for Hearing Health Care), a sample of apps over a wide range of services in the hearing health care (HHC) domain in order to take a first picture of the current scenario of apps for HHC. METHOD: We tested 120 apps, and we characterized them by using the ALFA4Hearing model, which includes 29 features in 5 components (Promoters, Services, Implementation, Users, and Descriptive Information). We analyzed (a) the distribution of the 29 features in the sample, (b) the relationship between the Implementation features and the Services provided by the apps, and (c) the distribution of the 29 features in apps for professional use. RESULTS: The analysis of our sample of apps by means of the ALFA4Hearing model highlighted interesting trends and emerging challenges. Also, results suggested many potential opportunities for research and clinical practice, such as greater involvement of stakeholders, improved evidence base, higher technical quality, and usability. CONCLUSIONS: The ALFA4Hearing model is able to represent, at a glance, a large amount of information about apps for HHC, highlighting trends and challenges. It might be useful to HHC professionals as a basis for app characterization and informed decision making.

Attempting to Use MetaMap in Clinical Practice: A Feasibility Study on the Identification of Medical Concepts from Italian Clinical Notes.

This study assessed the feasibility of using MetaMap to identify medical concepts from clinical notes written in Italian. We performed two experiments: in "EXP 1", we used MetaMap to annotate Italian texts using a knowledge source consisting of Italian UMLS sources only; in "EXP 2", we used MetaMap to analyze an English unsupervised translated version of the original Italian texts. We considered medical concepts related to three semantic categories: "Disorders", "Findings" and "Symptoms". Average recall, precision and F-measure were equal to 0.53, 0.98 and 0.69 in "EXP 1", and to 0.75, 0.95 and 0.83 in "EXP 2". For both "EXP 1" and "EXP 2" MetaMap showed better performances for the "Disorders" than for "Findings" and "Symptoms". In conclusion, when using MetaMap with the English translation of the Italian clinical notes, we obtained performances good enough to allow using MetaMap in clinical practice. Further investigation about the types of MetaMap's failures could be useful to understand how to improve performances even better.

Use of "off-the-shelf" information extraction algorithms in clinical informatics: A feasibility study of MetaMap annotation of Italian medical notes.

Information extraction from narrative clinical notes is useful for patient care, as well as for secondary use of medical data, for research or clinical purposes. Many studies focused on information extraction from English clinical texts, but less dealt with clinical notes in languages other than English. This study tested the feasibility of using "off the shelf" information extraction algorithms to identify medical concepts from Italian clinical notes. Among all the available and well-established information extraction algorithms, we used MetaMap to map medical concepts to the Unified Medical Language System (UMLS). The study addressed two questions: (Q1) to understand if it would be possible to properly map medical terms found in clinical notes and related to the semantic group of "Disorders" to the Italian UMLS resources; (Q2) to investigate if it would be feasible to use MetaMap as it is to extract these medical concepts from Italian clinical notes. We performed three experiments: in EXP1, we investigated how many medical concepts of the "Disorders" semantic group found in a set of clinical notes written in Italian could be mapped to the UMLS Italian medical sources; in EXP2 we assessed how the different processing steps used by MetaMap, which are English dependent, could be used in Italian texts to map the original clinical notes on the Italian UMLS sources; in EXP3 we automatically translated the clinical notes from Italian to English using Google Translator, and then we used MetaMap to map the translated texts. Results in EXP1 showed that the Italian UMLS Metathesaurus sources covered 91% of the medical terms of the "Disorders" semantic group, as found in the studied dataset. We observed that even if MetaMap was built to analyze texts written in English, most of its processing steps worked properly also with texts written in Italian. MetaMap identified correctly about half of the concepts in the Italian clinical notes. Using MetaMap's annotation on Italian clinical notes instead of a simple text search improved our results of about 15 percentage points. MetaMap's annotation of Italian clinical notes showed recall, precision and F-measure equal to 0.53, 0.98 and 0.69, respectively. Most of the failures were due to the impossibility for MetaMap to generate meaningful variants for the Italian language, suggesting that modifying MetaMap to allow generating Italian variants could improve the performance. MetaMap's performance in annotating automatically translated English clinical notes was in line with findings in the literature, with similar recall (0.75), F-measure (0.83) and even higher precision (0.95). Most of the failures were due to a bad Italian to English translation of medical terms, suggesting that using an automatic translation tool specialized in translating medical concepts might be useful to obtain better performances. In conclusion, performances obtained using MetaMap on the fully automatic translation of the Italian text are good enough to allow to use MetaMap "as it is" in clinical practice.

Domains of Health IT and Tailoring of Evaluation: Practicing Process Modeling for Multi-Stakeholder Benefits.

This contribution focuses on the heterogeneity and complexity of health information technology services and systems in a multi-stakeholder environment. We propose the perspective of process modeling as a method to break out complexity, represent heterogeneity, and provide tailored evaluation and optimization of health IT systems and services. Two case studies are presented to show how process modeling is needed to fully understand the information flow, thus identifying requirements and specifications for information system re-engineering and interoperability; detect process weaknesses thus designing corrective measures; define metrics as a mean to evaluate and ensure system quality; and optimize the use of resources.

A Design Methodology for Medical Processes.

BACKGROUND: Healthcare processes, especially those belonging to the clinical domain, are acknowledged as complex and characterized by the dynamic nature of the diagnosis, the variability of the decisions made by experts driven by their experiences, the local constraints, the patient's needs, the uncertainty of the patient's response, and the indeterminacy of patient's compliance to treatment. Also, the multiple actors involved in patient's care need clear and transparent communication to ensure care coordination. OBJECTIVES: In this paper, we propose a methodology to model healthcare processes in order to break out complexity and provide transparency. METHODS: The model is grounded on a set of requirements that make the healthcare domain unique with respect to other knowledge domains. The modeling methodology is based on three main phases: the study of the environmental context, the conceptual modeling, and the logical modeling. RESULTS: The proposed methodology was validated by applying it to the case study of the rehabilitation process of stroke patients in the specific setting of a specialized rehabilitation center. The resulting model was used to define the specifications of a software artifact for the digital administration and collection of assessment tests that was also implemented. CONCLUSIONS: Despite being only an example, our case study showed the ability of process modeling to answer the actual needs in healthcare practices. Independently from the medical domain in which the modeling effort is done, the proposed methodology is useful to create high-quality models, and to detect and take into account relevant and tricky situations that can occur during process execution.

Advising patients on selecting trustful apps for diabetes self-care.

BACKGROUND: There has been a dramatic increase in mobile apps for diabetes self-care. However, their quality is not guaranteed and patients do not have the appropriate tools for careful evaluation. OBJECTIVE: This work aims to propose a tool to help patients with diabetes select an appropriate app for self-care. METHODS: After identifying the conceptual framework of diabetes self-care, we searched Apple US app store and reviewed diabetes self-care apps, considering both generic and diabetes-specific features. Based on an existing tool for representing the benefits and weaknesses of medical apps, we created the pictorial identification schema/Diabetes Self-care tool, which specifically identified medical apps in the diabetes domain. RESULTS: Of the 952 apps retrieved, 67 were for diabetes self-care, while 26 were excluded because they were not updated in the last 12 months. Of the remaining 41, none cost more than 15 USD, and 36 implemented manual data entry. Basic features (data logging, data representation, and data delivery) were implemented in almost all apps, whereas advanced features (e.g., insulin calculator) were implemented in a small percentage of apps. The pictorial identification schema for diabetes was completed by one patient and one software developer for 13 apps. Both users highlighted weaknesses related to the functionalities offered and to their interface, but the patient focused on usability, whereas the software developer focused on technical implementation. CONCLUSIONS: The Pictorial Identification Schema/Diabetes Self-care is a promising graphical tool for perceiving the weaknesses and benefits of a diabetes self-care app that includes multiple user profile perspectives.

Apps for Hearing Science and Care.

PURPOSE: Our research aims at the identification and assessment of applications (referred to as apps) in the hearing health care domain. This research forum article presents an overview of the current availability, affordability, and variety of hearing-related apps. METHOD: The available apps were reviewed by searching on the leading platforms (iOS, Android, Windows Phone stores) using the keywords hearing, audiology, audio, auditory, speech, language, tinnitus, hearing loss, hearing aid, hearing sys tem, cochlear implant, implantable device, auditory training, hearing rehabilitation, and assistive technology/tool/device. O n the bas is of the offered services, apps were classified into 4 application domains: (a) screening and assessment, (b) intervention and rehabilitation, (c) education and information, and (d) assistive tools. CONCLUSIONS: A large variety of apps are available in the hearing health care domain. These cover a wide range of services for people with hearing or communication problems as well as for hearing professionals, families, or informal caregivers. This evolution can potentially bring along considerable advantages and improved outcomes in the field of hearing health care. Nevertheless, potential risks and threats (e.g., safety, quality, effectiveness, privacy, and regulation) should not be overlooked. Significant research­particularly in terms of assessment and guidance­is still needed for the informed, aware, and safe adoption of hearing-related apps by patients and professionals.

A connecting system for cardiological lexicons.

The purpose of this paper is to present the approach and the development of a software application ("lexicons connecting" system) to correlate effectively and unambiguously the correspondence between the specialist medical vocabulary and the familiar medical vocabulary for the cardiovascular domain. To investigate the question, the idea, the design, and the implementation of such system will be described. To this end, firstly, a number of research methodologies will be examined including domain ontologies development, database design and implementation. Then, the following implementation methodology and its results are presented. Finally, an example of the application use will be depicted and future work will be briefly described.

Apps for hearing healthcare.

The hearing healthcare scenario is rapidly evolving due to the pervasive use of m-Health solutions, in particular mobile apps. This brings along significant advantages and opportunities (e.g., accessibility, affordability, personalized healthcare, patient empowerment) as well as significant potential risks and threats (e.g., safety, misuse, quality issues, privacy). Our research aims at the identification and assessment of apps in the hearing healthcare domain. In this article we present an overview of the current availability, variety, and penetration of hearing-related apps.

Web-based telemonitoring and delivery of caregiver support for patients with Parkinson disease after deep brain stimulation: protocol.

BACKGROUND: The increasing number of patients, the high costs of management, and the chronic progress of the disease that prevents patients from performing even simple daily activities make Parkinson disease (PD) a complex pathology with a high impact on society. In particular, patients implanted with deep brain stimulation (DBS) electrodes face a highly fragile stabilization period, requiring specific support at home. However, DBS patients are followed usually by untrained personnel (caregivers or family), without specific care pathways and supporting systems. OBJECTIVE: This projects aims to (1) create a reference consensus guideline and a shared requirements set for the homecare and monitoring of DBS patients, (2) define a set of biomarkers that provides alarms to caregivers for continuous home monitoring, and (3) implement an information system architecture allowing communication between health care professionals and caregivers and improving the quality of care for DBS patients. METHODS: The definitions of the consensus care pathway and of caregiver needs will be obtained by analyzing the current practices for patient follow-up through focus groups and structured interviews involving health care professionals, patients, and caregivers. The results of this analysis will be represented in a formal graphical model of the process of DBS patient care at home. To define the neurophysiological biomarkers to be used to raise alarms during the monitoring process, neurosignals will be acquired from DBS electrodes through a new experimental system that records while DBS is turned ON and transmits signals by radiofrequency. Motor, cognitive, and behavioral protocols will be used to study possible feedback/alarms to be provided by the system. Finally, a set of mobile apps to support the caregiver at home in managing and monitoring the patient will be developed and tested in the community of caregivers that participated in the focus groups. The set of developed apps will be connected to the already existing WebBioBank Web-based platform allowing health care professionals to manage patient electronic health records and neurophysiological signals. New modules in the WebBioBank platform will be implemented to allow integration and data exchange with mobile health apps. RESULTS: The results of this project will provide a novel approach to long-term evaluation of patients with chronic, severe conditions in the homecare environment, based on caregiver empowerment and tailored applications developed according to consensus care pathways established by clinicians. CONCLUSIONS: The creation of a direct communication channel between health care professionals and caregivers can benefit large communities of patients and would represent a scalable experience in integrating data and information coming from a clinical setting to those in home monitoring.

Implementing the lifelong personal health record in a regionalised health information system: the case of Lombardy, Italy.

BACKGROUND: The use of personal health records (PHRs) can help people make better health decisions and improves the quality of care by allowing access to and use of the information needed to communicate effectively with others concerning their health care. OBJECTIVE: This work presents the lifelong PHR system of the Lombardy region as an example of the implementation of an e-health solution that is capable of providing personal clinical documents from a lifelong perspective, integrating different healthcare providers over a large territory. METHODS: The lifelong PHR is embedded in the regional healthcare information system of Lombardy, which is characterised by a large and heterogeneous territory, a large number of different healthcare providers and organisations, and a significant population. RESULTS: The lifelong PHR makes clinical documents available to healthcare professionals and citizens when needed, and it is automatically updated with all of the documents regarding a clinical event regardless of which healthcare provider is currently taking care of the patient. Present statistics show that the lifelong PHR has experienced a wide diffusion in a short period of time, and at the end of 2010, it was active for more than five million Lombardy citizens. Digital reports and e-prescription transactions have almost doubled since 2007 and have reached a coverage of almost 100%. CONCLUSIONS: The qualified and exhaustive collection of patient clinical data and documents should impact daily medical practice, as well as the care pathways and services provided to patients, and should help in the renewal of health assistance and the simplification of patients' access to care.

Towards a decision support system for hand dermatology.

The complexity of the medical diagnosis is faced by practitioners relying mainly on their experiences. This can be acquired during daily practices and on-the-job training. Given the complexity and extensiveness of the subject, supporting tools that include knowledge extracted by highly specialized practitioners can be valuable. In the present work, a Decision Support System (DSS) for hand dermatology was developed based on data coming from a Visit Report Form (VRF). Using a Bayesian approach and factors significance difference over the population average for the case, we demonstrated the potentiality of creating an enhanced VRF that include a diagnoses distribution probability based on the DSS rules applied for the specific patient situation.

[Information and Communication Technology in medicine in Italy: problems and perspectives. A document by the "e-cardio" area of the Italian Association of Hospital Cardiologists (ANMCO)]. / Il problema della corretta implementazione dell'Information and Communication Technology in medicina nel nostro Paese: documento dell'Area "e-cardio" dell'Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO).

In Italy, health protection is an individual right protected by the article 32 of the Constitution, granted to everyone since 1978 by the foundation of the National Health Service. However, regionalization of the healthcare system has caused noticeable discrepancies among the different areas of the country. The use of the Information and Communication Technology (ICT) may be useful to solve them. The purpose of this document is to analyze the implementation of ICT in Italy, on the basis of the suggestions given by the Italian Association of Hospital Cardiologists (ANMCO). In 2010, the Italian government introduced the electronic health record (EHR), which includes a minimum core of essential documents that should be created and updated by general practitioners. The obvious limitations of this methodology become clear in the urgency-emergency clinical setting, where the availability of particular clinical data may influence both patient prognosis and cost reduction. Also the privacy rules, currently very restrictive, cause a drawback in reliability of the data reported in the EHR, thus arising the need for a balance shift from privacy to health rights at the level of both the individual and the community. A minimum core of mandatory clinical data to be included in the EHR should be defined. No formal indications for filling out the medical records are available and most few experiences concern "bureaucratic documents" on the diagnostic and therapeutic process. Conversely, we believe that medical records should become a diagnostic and therapeutic tool that makes health rights uniform across the country. Each medical record form should include the following features: a simple interface, a mandatory association of clinical findings and reports, data portability and accessibility, and adherence of the information to a minimal dataset. Additionally, medical records data should merge into a modified EHR available at any time and place through network access points with adequate connection speed. In this respect, inhomogeneous availability of broadband in Italy is at present a major challenging issue. Finally, current training programs in medicine do not allow for widespread application of ICT among young physicians. Some essential topics should be covered by university formative credits. It is crucial to address different needs: the patient needs, making data on "biological heritage" always available; the physician needs, providing them with professional tools able to improve their daily quality of work; the managers' and public decision makers' needs, helping to optimize costs of the healthcare system.

Modeling stroke rehabilitation processes using the Unified Modeling Language (UML).

In organising and providing rehabilitation procedures for stroke patients, the usual need for many refinements makes it inappropriate to attempt rigid standardisation, but greater detail is required concerning workflow. The aim of this study was to build a model of the post-stroke rehabilitation process. The model, implemented in the Unified Modeling Language, was grounded on international guidelines and refined following the clinical pathway adopted at local level by a specialized rehabilitation centre. The model describes the organisation of the rehabilitation delivery and it facilitates the monitoring of recovery during the process. Indeed, a system software was developed and tested to support clinicians in the digital administration of clinical scales. The model flexibility assures easy updating after process evolution.

Challenges of the e-Health curricular education in bio-medical engineering and in medicine.

Curricular recommendations coming from highly respectable associations are highly useful. Nevertheless, they show fatigue in keeping the pace of any fast evolution, as in the ICT happens. So we do the attempt to disclose the emerging challenges affecting e-Health curricular education.

Implementing standards for the interoperability among healthcare providers in the public regionalized Healthcare Information System of the Lombardy Region.

Information technologies (ITs) have now entered the everyday workflow in a variety of healthcare providers with a certain degree of independence. This independence may be the cause of difficulty in interoperability between information systems and it can be overcome through the implementation and adoption of standards. Here we present the case of the Lombardy Region, in Italy, that has been able, in the last 10 years, to set up the Regional Social and Healthcare Information System, connecting all the healthcare providers within the region, and providing full access to clinical and health-related documents independently from the healthcare organization that generated the document itself. This goal, in a region with almost 10 millions citizens, was achieved through a twofold approach: first, the political and operative push towards the adoption of the Health Level 7 (HL7) standard within single hospitals and, second, providing a technological infrastructure for data sharing based on interoperability specifications recognized at the regional level for messages transmitted from healthcare providers to the central domain. The adoption of such regional interoperability specifications enabled the communication among heterogeneous systems placed in different hospitals in Lombardy. Integrating the Healthcare Enterprise (IHE) integration profiles which refer to HL7 standards are adopted within hospitals for message exchange and for the definition of integration scenarios. The IHE patient administration management (PAM) profile with its different workflows is adopted for patient management, whereas the Scheduled Workflow (SWF), the Laboratory Testing Workflow (LTW), and the Ambulatory Testing Workflow (ATW) are adopted for order management. At present, the system manages 4,700,000 pharmacological e-prescriptions, and 1,700,000 e-prescriptions for laboratory exams per month. It produces, monthly, 490,000 laboratory medical reports, 180,000 radiology medical reports, 180,000 first aid medical reports, and 58,000 discharge summaries. Hence, despite there being still work in progress, the Lombardy Region healthcare system is a fully interoperable social healthcare system connecting patients, healthcare providers, healthcare organizations, and healthcare professionals in a large and heterogeneous territory through the implementation of international health standards.

Telemedicine and e-health.

We begin this article with the celebration of the 20th anniversary mentioning some activity lines in the area of telemedicine and e-health currently underway not only at the bioengineering department but also at other departments of the Politecnico di Milano.