Handbook of Biomedical Informatics

Wikipedia Handbook of Biomedical Informatics
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Contents
Articles
General Overview
Health information technology Health informatics Clinical Informatics Cybermedicine eHealth Health 2.0 Public health informatics 1 1 6 14 22 23 26 30 33 33 35 35 40 42 42 47 48 54 57 81 85 86 86 101 106 116 117 117 118 120 121
Applications in Healthcare Management

Health Administration Informatics Medical integration environment Health information exchange Hospital information system Healthcare workflow Computer physician order entry ICU quality and management tools Laboratory information management system Laboratory information system mHealth Practice management software Clinical Quality Management System
Health Electronic Records

Electronic health record Electronic medical record Personal health record COmputer STored Ambulatory Record ProRec Health record trust Canadian EMR ClearHealth Laika
openEHR OpenEMR OpenMRS Kind Messages for Electronic Healthcare Record Summarized Electronic Health Record VistA VistA imaging VistA Web WorldVistA ZEPRS
123 125 131 134 135 136 146 149 151 153 158 158 166 170 172 172 173 176 177 178 179 181 183 184 187 189 200 200 203 204 207 208 214 216 221 221
Decision Support Applications

Clinical decision support system Computer-aided diagnosis Medical algorithm Medical logic module Arden syntax Concept Processing Guideline execution engine CADUCEUS DXplain Internist-I Mycin Physicians' Information and Education Resource RetroGuide Symptomat STD Wizard
Medical Imaging Applications

Digital radiography Imaging informatics Patient registration Radiology information system Picture archiving and communication system Analysis of Functional NeuroImages 3DSlicer Analyze CARET
CAVEman FreeSurfer ImageJ InVesalius ITK-SNAP Mango OsiriX
223 224 226 229 231 234 235 237 237 241 244 246 247 247 248 249 251 251 253 254 256 258 260 265 270 271 273 276 278 280 281 282 282 287 291
Medical and biological signal applications

Medical monitor Holter monitor Automated ECG interpretation Open ECG project MECIF Protocol SCP-ECG European Data Format OpenXDF
Databases, Digital Libraries and Literature Retrieval

Biological database Medical literature retrieval MEDLINE Entrez ETBLAST PMID PubMed GoPubMed Pubget PubMed Central UK PubMed Central TRIP Database Twease SciELO
Telehealth and Telemedicine

Connected Health Telehealth Telemedicine
Telecare Telephone triage Remote guidance Tele-epidemiology Telenursing Teledermatology Telemental Health Telepsychiatry Teleradiology Telerehabilitation Virtual reality in telerehabilitation Campus medicus Wireless Medical Telemetry Service
301 302 305 306 307 309 312 313 314 316 321 323 324 326 326 330 332 340 341 343 351 359 365 368 370 372 372 381 384 384 388 394 395 399 401
Computer-Aided Surgery, Medical Robotics and Virtual Reality

Computer assisted surgery Remote surgery Robotic surgery Surgical Segment Navigator Bone segment navigation Robotic prostatectomy Robot-assisted heart surgery Cyberknife da Vinci Surgical System NeuroArm Laboratory Unit for Computer Assisted Surgery
Legislation and Regulation

Health Insurance Portability and Accountability Act Certification Commission for Healthcare Information Technology
Software Systems
Medical software Dental software List of freeware health software List of open source healthcare software List of neuroimaging software Mirth
Mpro Open Dental Personal Health Application Texas Medication Algorithm Project
403 404 409 410 412 412 429 429 431 433 436 440 441 443 445 447 450 450 451 454 455 456 459 460 461 464 464 465 467 467 470 473 477 478 480
Languages and Development Platforms

MUMPS
Internet Projects
Bing Health Dossia E-Patient Google Health iMedicor Microsoft Amalga Microsoft HealthVault Patient portal Virtual patient
Clinical Research Informatics

Translational research informatics Clinical trial management Clinical data management system Case report form Clinical coder Clinical data acquisition Data clarification form Patient-reported outcome
Standards, Coding and Nomenclature

Diagnosis codes Procedure codes Bar Code Medication Administration Bidirectional Health Information Exchange Classification Commune des Actes Mdicaux Classification of Pharmaco-Therapeutic Referrals Clinical Context Object Workgroup Clinical Data Interchange Standards Consortium Clinical Document Architecture
Continuity of Care Document Clinical Document Architecture Continuity of Care Record COSTART Current Procedural Terminology Diagnosis-related group Digital Imaging and Communications in Medicine DOCLE Electronic Common Technical Document EUDRANET General Data Format for Biomedical Signals Health Level 7 Healthcare Common Procedure Coding System Healthcare Information Technology Standards Panel Health Informatics Service Architecture Healthcare Services Specification Project International Statistical Classification of Diseases and Related Health Problems ICD-10 ICD-10 Procedure Coding System International Classification of Diseases for Oncology International Classification of Functioning, Disability and Health International Classification of Health Interventions International Classification of Primary Care International Healthcare Terminology Standards Development Organisation ICPC-2 PLUS ISO 27799 ISO/IEEE 11073 ISO/TC 215 LOINC MEDCIN MedDRA Medical Subject Headings Minimum Data Set Multiscale Electrophysiology Format NANDA Nursing Interventions Classification Nursing Minimum Data Set Nursing Outcomes Classification
481 482 483 484 484 489 492 500 501 503 504 505 512 513 514 515 517 522 524 530 542 545 546 547 548 549 550 557 560 562 563 564 567 568 569 570 571 571
OpenGALEN SNOMED SNOMED CT Standard for Exchange of Non-clinical Data TC 251 WHOART
572 574 576 580 580 581 582 582 583 584 587 588 590 592 592 593 594 596 597 598 598 601 604 605 605 606 607 608 609 612 612 614 618 620 621 622
Healthcare Ontologies
Nosology Archetype OBO Foundry Ontology for Biomedical Investigations Open Biomedical Ontologies TIME-ITEM
Associations, Committees and Conferences

American Association for Medical Systems and Informatics American College of Medical Informatics American Health Information Management Association American Telemedicine Association Belgian Health Telematics Commission Belgian Medical Informatics Association Brazilian Society of Health Informatics Brazilian Congress on Health Informatics Center for Telehealth and E-Health Law Centre for e-Health European Federation for Medical Informatics European Health Telematics Association European Health Telematics Observatory European Institute for Health Records Health On the Net Foundation HISA Indian Association for Medical Informatics International Medical Informatics Association Medinfo National Resource Center for Health Information Technology Open Source Health Care Alliance The Continua Health Alliance
UNESCO Chair in Telemedicine World Health Imaging, Telemedicine, and Informatics Alliance
625 627 630 630 631 632 634 634 635 636 637 639 640 641 642 643 653 657 666 667 671 672 674 674 675 676 678 678 681 689 694 695 700 702 704
Publications
List of medical and health informatics journals Journal of Information Professionals in Health Journal of Medical Internet Research
National Projects
BeHealth Canada Health Infoway Distance Learning and Telemedicine Grant and Loan Program eHealth Ontario HealthConnect Health Information Systems Programme District Health Information System FLOW Health informatics in China NHS Direct NHS National Programme for IT Ontario Telemedicine Network Public Health Information Network SAPPHIRE SmartCare
International Projects
Building Europe-Africa Collaborative Network for Applying IST in Health Care Sector Global Infectious Disease Epidemiology Network Integrating the Healthcare Enterprise
Miscellanea
GIS and Public Health Neuroinformatics Healthcare Effectiveness Data and Information Set E-epidemiology Epi Info OpenEpi Living Human Project Stereolithography
Virtual Physiological Human Visible Human Project
705 712 715 715 719 721 725 726
People
Edward H. Shortliffe Don E. Detmer Homer R. Warner Robert Ledley Vimla L. Patel
References
Article Sources and Contributors Image Sources, Licenses and Contributors 729 735
Article Licenses
License 738
General Overview
Health information technology
Health information technology (HIT) provides the umbrella framework to describe the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, government and quality entities, and insurers. Health information technology (HIT) is in general increasingly viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system (Chaudhry et al., 2006). Broad and consistent utilization of HIT will: Improve health care quality; Prevent medical errors; Reduce health care costs; Increase administrative efficiencies Decrease paperwork; and
Expand access to affordable care. Interoperable HIT will improve individual patient care, but it will also bring many public health benefits including: Early detection of infectious disease outbreaks around the country; Improved tracking of chronic disease management; and Evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared.
Concepts and Definitions

Health information technology (HIT) is the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making (Brailer, & Thompson, 2004). Technology is a broad concept that deals with a species' usage and knowledge of tools and crafts, and how it affects a species' ability to control and adapt to its environment. However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques. For HIT, technology represents computers and communications attributes that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT. Informatics refers to the science of information, the practice of information processing, and the engineering of information systems. Informatics underlies the academic investigation and practitioner application of computing and communications technology to healthcare, health education, and biomedical research. Health informatics refers to the intersection of information science, computer science, and health care. Health informatics describes the use and sharing of information within the healthcare industry with contributions from computer science, mathematics, and psychology. It deals with the resources, devices, and methods required for optimizing the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. Medical informatics, nursing informatics, public health informatics, and pharmacy informatics are subdisciplines that inform health informatics from different disciplinary perspectives. The processes and people of concern or study are the main variables.
Implementation of HIT
The Institute of Medicines (2001) call for the use of electronic prescribing systems in all healthcare organizations by 2010 heightened the urgency to accelerate United States hospitals adoption of CPOE systems. In 2004, President Bush signed an Executive Order titled the Presidents Health Information Technology Plan, established a ten-year plan as this technology is essential to put the needs and the values of the patients first and gives patients information they need to make clinical and economic decisions. According to a study by RAND Health, the US healthcare system could save more than $81 billion annually, reduce adverse healthcare events and improve the quality of care if it were to widely adopt health information technology.[1] The most immediate barrier to widespread adoption of technology is cost: patients benefit from better health, and payers benefit from lower costs; however, hospitals pay in both higher costs for implementation and lower revenues due to reduced patient length of stay.
Types of technology
In a recent study about the adoption of technology in the United States, Furukawa, and colleagues (2008) classified applications for prescribing to include electronic medical records (EMR), clinical decision support (CDS), and computerized physician order entry (CPOE). They further defined applications for dispensing to include bar-coding at medication dispensing (BarD), robot for medication dispensing (ROBOT), and automated dispensing machines (ADM). And, they defined applications for administration to include electronic medication administration records (EMAR) and bar-coding at medication administration (BarA).
Electronic Health Record (EHR)

Although frequently cited in the literature the Electronic health record (EHR), previously known as the Electronic medical record (EMR), there is no consensus about the definition (Jha et al., 2008). However, there is consensus that EMRs can reduce several types of errors, including those related to prescription drugs, to preventive care, and to tests and procedures.[2] Recurring alerts remind clinicians of intervals for preventive care and track referrals and test results. Clinical guidelines for disease management have a demonstrated benefit when accessible within the electronic record during the process of treating the patient.[3] Advances in health informatics and widespread adoption of interoperable electronic health US medical groups' adoption of EHR (2005) records promise access to a patient's records at any health care site. A 2005 report noted that medical practices in the United States are encountering barriers to adopting an EHR system, such as training, costs and complexity, but the adoption rate continues to rise (see chart to right).[4] Since 2002, the National Health Service of the United Kingdom has placed emphasis on introducing computers into healthcare. As of 2005, one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT), the NHS component of which is known as the "Connecting for Health Programme".[5] However, recent surveys have shown physicians' deficiencies in understanding the patient safety features of the NPfIT-approved software.[6]
Clinical point of care technology

Computerized Provider (Physician) Order Entry (CPOE) Prescribing errors are the largest identified source of preventable errors in hospitals. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay.[7] Computerized provider order entry (CPOE), formerly called Computer physician order entry, can reduce total medication error rates by 80%, and adverse (serious with harm to patient) errors by 55%.[8] A 2004 survey by Leapfrog found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOE within 2 years.[9] In addition to electronic prescribing, a standardized bar code system for dispensing drugs could prevent a quarter of drug errors.[7] Consumer information about the risks of the drugs and improved drug packaging (clear labels, avoiding similar drug names and dosage reminders) are other error-proofing measures. Despite ample evidence of the potential to reduce medication errors, competing systems of barcoding and electronic prescribing have slowed adoption of this technology by doctors and hospitals in the United States, due to concern with interoperability and compliance with future national standards.[10] Such concerns are not inconsequential; standards for electronic prescribing for Medicare Part D conflict with regulations in many US states.[7]
Technological Innovations, Opportunities, and Challenges

Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to substantial errors and injuries, according to the Institute of Medicine (2000) report. The follow-up IOM (2004) report, Crossing the quality chasm: A new health system for the 21st century, advised rapid adoption of electronic patient records, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions.[11] However, many system implementations have experienced costly failures (Ammenwerth et al., 2006). Furthermore, there is evidence that CPOE may actually contribute to some types of adverse events and other medical errors.(Campbell et al., 2007) For example, the period immediately following CPOE implementation resulted in significant increases in reported adverse drug events in at least one study (Bradley, Steltenkamp, & Hite, 2006) and evidence of other errors have been reported.(Bates, 2005a; Bates, Leape, Cullen, & Laird, 1998; Bates; 2005b) Collectively, these reported adverse events describe phenomena related to the disruption of the complex adaptive system resulting from poorly implemented or inadequately planned technological innovation.
Technological Iatrogenesis
Technology may introduce new sources of error [12] [13] Technologically induced errors are significant and increasingly more evident in care delivery systems. Terms to describe this new area of error production include the label technological iatrogenesis [14] for the process and e-iatrogenic [15] for the individual error. The sources for these errors include: Prescriber and staff inexperience may lead to a false sense of security; that when technology suggests a course of action, errors are avoided. Shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses. CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia.[16] Irrelevant or frequent warnings can interrupt work flow.
References
[1] RAND Healthcare: Health Information Technology: Can HIT Lower Costs and Improve Quality? (http:/ / www. rand. org/ pubs/ research_briefs/ RB9136/ index1. html) Retrieved on July 8, 2006 [2] American College of Physicians Observer: How EMR software can help prevent medical mistakes (http:/ / www. acponline. org/ journals/ news/ sep04/ emr. htm) by Jerome H. Carter (September 2004) [3] Kensaku Kawamoto, fellow1, Caitlin A Houlihan, E Andrew Balas, David F Lobach (2005). "Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success" (http:/ / bmj. bmjjournals. com/ cgi/ content/ full/ 330/ 7494/ 765). British Medical Journal 330 (7494): 765768. doi:10.1136/bmj.38398.500764.8F. PMC555881. PMID15767266. . Retrieved 2006-06-29. [4] Gans D, Kralewski J, Hammons T, Dowd B (2005). "Medical groups' adoption of electronic health records and information systems" (http:/ / content. healthaffairs. org/ cgi/ content/ abstract/ 24/ 5/ 1323). Health affairs (Project Hope) 24 (5): 13231333. doi:10.1377/hlthaff.24.5.1323. PMID16162580. . Retrieved 2006-07-04. [5] NHS Connecting for Health: Delivering the National Programme for IT (http:/ / www. connectingforhealth. nhs. uk/ delivery/ ) Retrieved August 4, 2006 [6] C J Morris, B S P Savelyich, A J Avery, J A Cantrill and A Sheikh (2005). "Patient safety features of clinical computer systems: questionnaire survey of GP views" (http:/ / qhc. bmjjournals. com/ cgi/ content/ full/ 14/ 3/ 164). Quality and Safety in Health Care 14 (3): 164168. doi:10.1136/qshc.2004.011866. PMC1744017. PMID15933310. . Retrieved 2006-07-08. [7] The Institute of Medicine (2006). "Preventing Medication Errors" (http:/ / www. nap. edu/ catalog/ 11623. html). The National Academies Press. . Retrieved 2006-07-21. [8] David W. Bates, MD, et al. (1998). "Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors" (http:/ / jama. ama-assn. org/ cgi/ content/ abstract/ 280/ 15/ 1311). JAMA 280 (15): 13111316. doi:10.1001/jama.280.15.1311. PMID9794308. . Retrieved 2006-06-20. [9] "Hospital Quality & Safety Survey" (http:/ / www. leapfroggroup. org/ media/ file/ Leapfrog-Survey_Release-11-16-04. pdf) (PDF). The Leapfrog Group. 2004. . Retrieved 2006-07-08. [10] Kaufman, Marc (2005-07-21). "Medication Errors Harming Millions, Report Says. Extensive National Study Finds Widespread, Costly Mistakes in Giving and Taking Medicine" (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2006/ 07/ 20/ AR2006072000754. html). The Washington Post. pp.A08. . Retrieved 2006-07-21. [11] Institute of Medicine (2001). "Crossing the Quality Chasm: A New Health System for the 21st Century" (http:/ / www. nap. edu/ books/ 0309072808/ html). The National Academies Press. . Retrieved 2006-06-29. [12] Ross Koppel, PhD, et al. (2005). "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors" (http:/ / jama. ama-assn. org/ cgi/ content/ abstract/ 293/ 10/ 1197). JAMA 293 (10): 11971203. doi:10.1001/jama.293.10.1197. PMID15755942. . Retrieved 2006-06-28. [13] Lohr, Steve (2005-03-09). "Doctors' Journal Says Computing Is No Panacea" (http:/ / www. nytimes. com/ 2005/ 03/ 09/ technology/ 09compute. html?ei=5089& en=402b792e748d99a2& ex=1268110800& adxnnl=1& partner=rssyahoo& adxnnlx=1150474153-xVix1BcYkvTKJpuLyHStrQ). The New York Times. . Retrieved 2006-07-15. [14] Patrick Palmieri, et al. (2007). "Technological iatrogenesis: New risks force heightened management awareness" (http:/ / www. hom. ba. ttu. edu/ FordPub/ Palmieri_JHCRM_2008_Technological iatrogenesis. pdf). Journal of Healthcare Risk Management 27 (4): 1924. doi:10.1002/jhrm.5600270405. PMID20200891. . Retrieved 2008-07-02. [15] Weiner, et al.; Kfuri, T; Chan, K; Fowles, JB (2007). "e-Iatrogenesis: The most critical unintended consequence of CPOE and other HIT" (http:/ / www. jamia. org/ cgi/ reprint/ 14/ 3/ 387. pdf). Journal of the American Medical Informatics Association 14 (3): 387388. doi:10.1197/jamia.M2338. PMC2244888. PMID17329719. . Retrieved 2008-08-24. [16] Santell, John P (2004). "Computer Related Errors: What Every Pharmacist Should Know" (http:/ / www. usp. org/ pdf/ EN/ patientSafety/ slideShows2004-12-09. pdf) (PDF). United States Pharmacopia. . Retrieved 2006-06-20.
Further reading
Ammenwerth, E., Talmon, J., Ash, J. S., Bates, D. W., Beuscart-Zephir, M. C., Duhamel, A., Elkin, P. L., Gardner, R. M., & Geissbuhler, A. (2006). Impact of CPOE on mortality rates contradictory findings, important messages. Methods Inf Med, 45(6): 586-593. Ash, J. S., Sittig, D. F., Poon, E. G., Guappone, K., Campbell, E., & Dykstra, R. H. (2007). The extent and importance of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association, 14(4): 415-423. Bates, D. (2005a). Computerized Physician Order entry and medication errors: finding a balance. Journal of Biomedical Informatics, 38(4): 250-261. Bates, D.W. (2005b). Physicians and ambulatory electronic health records. Health Affairs, 24(5): 1180-1189.
Health information technology Bates, D. W., Leape, L. L., Cullen, D. J., & Laird, N. (1998). Effect of computerized physician order entry and a team intervention on prevention of serious medical errors. Journal of the American Medical Association, 280: 1311-1316. Bradley, V. M., Steltenkamp, C. L., & Hite, K. B. (2006). Evaluation of reported medication errors before and after implementation of computerized practitioner order entry. Journal Healthc Inf Manag, 20(4): 46-53. Brailer, D., & Thompson, T. (2004). Health IT strategic framework. Washington, DC: Department of Health and Human Services. Chaudhry, B. Wang , J., & Wu, S. et al., (2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care, Annals of Internal Medicine, 144(10), 742752. Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P., & Dykstra, R. H. (2007). In reply to: e-Iatrogenesis: The most critical consequence of CPOE and other HIT. Journal of the American Medical Informatics Association. Edmunds M, Peddicord D, Detmer DE, Shortliffe E. Health IT Policy and Politics: A Primer on Moving Policy Into Action. Featured Session, American Medical Informatics Association Annual Symposium (2009). Available as a webinar at https://www.amia.org/amia-policy-101. Furukawa, M. F., Raghu, T. S., Spaulding, T. J., & Vinze, A. (2008). Health Affairs, 27, (3), 865-875. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C: National Academies Press. Jha, A. K., Doolan, D., Grandt, D., Scott, T. & Bates, D. W. (2008). The use of health information technology in seven nations. International Journal of Medical Informatics, corrected proof in-press. Kawamoto, K. H., Caitlin, A., Balas, E. A., & Lobach, D. F. (2005). Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. British Journal of Medicine, 330(7494): 765-774. Sidrov, J. (2006). It aint necessarily so: The electronic health record and the unlikely prospect of reducing healthcare costs. Health Affairs, 25(4): 1079-1085.
External links
Health Resources and Services Administration (HRSA) (http://www.hrsa.gov/healthit/) Health Information Technology (http://www.hhs.gov/healthit/) at US Department of Health & Human Services Healthcare Information Technology (http://www.ansi.org/standards_activities/standards_boards_panels/hisb/ hitsp.aspx?menuid=3) from American National Standards Institute (ANSI) Certification Commission for Healthcare Information Technology (CCHIT) (http://www.cchit.org/) Health Information Technology Videos (http://www.ehrtv.com/) Health IT Discussion Forum (http://www.healthinformaticsforum.com/) Hospital Management Information System (http://www.cdacnoida.in/HIS/index.asp) from Center for Development of Advanced Computing (C-DAC) (http://www.cdacnoida.in/) American Society of Health Informatics Managers (http://www.ashim.org/) Patient Safety Initiatives in India Using Health IT (http://thepatient.in/safety/)
Health informatics
Health informatics
. Health informatics (also called health care informatics, healthcare informatics, medical informatics, nursing informatics, clinical informatics, or biomedical informatics) is a discipline at the intersection of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy, and (bio)medical research.
Electronic patient chart from a health information system
The international standards on the subject are covered by ICS 35.240.80[1] in which ISO 27799:2008 is one of the core components.[2] Molecular bioinformatics and clinical informatics have converged into the field of translational bioinformatics.
History
World wide use of technology in medicine began in the early 1950s with the rise of the computers.[3] In 1949, Gustav Wager established the first professional organization for informatics in Germany.[4] The prehistory, history, and future of medical information and health information technology are discussed in reference.[5] Specialized university departments and Informatics training programs began during the 1960s in France, Germany, Belgium and The Netherlands. Medical informatics research units began to appear during the 1970s in Poland and in the U.S.[4] Since then the development of high-quality health informatics research, education and infrastructure has been the goal of the U.S. and the European Union.[4] Early names for health informatics included medical computing, medical computer science, computer medicine, medical electronic data processing, medical automatic data processing, medical information processing, medical information science, medical software engineering, and medical computer technology. The health informatics community is still growing, it is by no means a mature profession, but work in the UK by the voluntary registration body, the UK Council of Health Informatics Professions [6] has suggested eight key constituencies within the domain - information management, knowledge management, portfolio/programme/project management, ICT, education and research, clinical informatics, health records(service and business-related), health informatics service management. These constituencies accommodate professionals in and for the NHS, in academia and commercial service and solution providers. Since the 1970s the most prominent international coordinating body has been the International Medical Informatics Association (IMIA).
Health informatics
Medical informatics in the United States

Even though the idea of using computers in medicine sprouted as technology advanced in the early twentieth century, it was not until the 1950s that informatics made a realistic impact in the United States.[3] The earliest use of computation for medicine was for dental projects in the 1950s at the United States National Bureau of Standards by Robert Ledley.[7] The next step in the mid 1950s were the development of expert systems such as MYCIN and Internist-I. In 1965, the National Library of Medicine started to use MEDLINE and MEDLARS. At this time, Neil Pappalardo, Curtis Marble, and Robert Greenes developed MUMPS (Massachusetts General Hospital Utility Multi-Programming System) in Octo Barnett's Laboratory of Computer Science [8] at Massachusetts General Hospital in Boston.[9] In the 1970s and 1980s it was the most commonly used programming language for clinical applications. The MUMPS operating system was used to support MUMPS language specifications. As of 2004, a descendent of this system is being used in the United States Veterans Affairs hospital system. The VA has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patients electronic medical record at any of the VA's over 1,000 health care facilities. In the 1970s a growing number of commercial vendors began to market practice management and electronic medical records systems. Although many products exist, only a small number of health practitioners use fully featured electronic health care records systems. Homer R. Warner, one of the fathers of medical informatics,[10] founded the Department of Medical Informatics at the University of Utah in 1968. The American Medical Informatics Association (AMIA) has an award named after him on application of informatics to medicine.
Current state of health informatics and policy initiatives

Americas
Argentina Since 1997, the Buenos Aires Biomedical Informatics Group, a nonprofit group, represents the interests of a broad range of clinical and non-clinical professionals working within the Health Informatics sphere. Its purposes are: Promote the implementation of the computer tool in the healthcare activity, scientific research, health administration and in all areas related to health sciences and biomedical research. Support, promote and disseminate content related activities with the management of health information and tools they used to do under the name of Biomedical informatics. Promote cooperation and exchange of actions generated in the field of biomedical informatics, both in the public and private, national and international level. Interact with all scientists, recognized academic stimulating the creation of new instances that have the same goal and be inspired by the same purpose. To promote, organize, sponsor and participate in events and activities for training in computer and information and disseminating developments in this area that might be useful for team members and health related activities. Health informatics (also called health care informatics, healthcare informatics, medical informatics, nursing informatics, clinical informatics, or biomedical informatics) is a discipline at the intersection of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy,
Health informatics and (bio)medical research. The international standards on the subject are covered by ICS 35.240.80[1] in which ISO 27799:2008 is one of the core components.[2] Molecular bioinformatics and clinical informatics have converged into the field of translational bioinformatics. The Argentinian health system is very heterogeneous, because of that the informatics developments shows an heterogeneous stage. Lot of private Health Care center have developed systems, as the German Hospital of Buenos Aires who was one of the first in develop the electronic health records system. Brazil The first applications of computers to medicine and healthcare in Brazil started around 1968, with the installation of the first mainframes in public university hospitals, and the use of programmable calculators in scientific research applications. Minicomputers, such as the IBM 1130 were installed in several universities, and the first applications were developed for them, such as the hospital census in the School of Medicine of Ribeiro Preto and patient master files, in the Hospital das Clnicas da Universidade de So Paulo, respectively at the cities of Ribeiro Preto and So Paulo campi of the University of So Paulo. In the 1970s, several Digital Corporation and Hewlett Packard minicomputers were acquired for public and Armed Forces hospitals, and more intensively used for intensive-care unit, cardiology diagnostics, patient monitoring amd other applications. In the early 1980s, with the arrival of cheaper microcomputers, a great upsurge of computer applications in health ensued, and in 1986 the Brazilian Society of Health Informatics was founded, the first Brazilian Congress of Health Informatics was held, and the first Brazilian Journal of Health Informatics was published. Canada Health Informatics projects in Canada are implemented provincially, with different provinces creating different systems. A national, federally-funded, not-for-profit organization called Canada Health Infoway was created in 2001 to foster the development and adoption of electronic health records across Canada. As of December 31, 2008 there were 276 EHR projects under way in Canadian hospitals, other health-care facilities, pharmacies and laboratories, with an investment value of $1.5-billion from Canada Health Infoway.[11] Provincial and territorial programmes include the following: eHealth Ontario was created as an Ontario provincial government agency in September 2008. It has been plagued by delays and its CEO was fired over a multimillion-dollar contracts scandal in 2009.[12] Alberta Netcare was created in 2003 by the Government of Alberta. Today the netCARE portal is used daily by thousands of clinicians. It provides access to demographic data, prescribed/dispensed drugs, known allergies/intolerances, immunizations, laboratory test results, diagnostic imaging reports, the diabetes registry and other medical reports. netCARE interface capabilities are being included in electronic medical record products which are being funded by the provincial government. United States In 2004 the U.S. Department of Health and Human Services (HHS) formed the Office of the National Coordinator for Health Information Technology (ONCHIT). The mission of this office is widespread adoption of interoperable electronic health records (EHRs) in the US within 10 years. See quality improvement organizations for more information on federal initiatives in this area. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards for electronic health records (EHR) and supporting networks, and certify vendors who meet them. In July, 2006 CCHIT released its first list of 22 certified ambulatory EHR products, in two different announcements.[13]
Health informatics
Europe
The European Union's Member States are committed to sharing their best practices and experiences to create a European eHealth Area, thereby improving access to and quality health care at the same time as stimulating growth in a promising new industrial sector. The European eHealth Action Plan plays a fundamental role in the European Union's strategy. Work on this initiative involves a collaborative approach among several parts of the Commission services.[14] [15] The European Institute for Health Records is involved in the promotion of high quality electronic health record systems in the European Union.[16]
UK
There are different models of health informatics delivery in each of the home countries (England, Scotland, Northern Ireland and Wales) but some bodies like UKCHIP (see below ) operate for those 'in and for' all the home countries and beyond.
England
The NHS in England has contracted out to several vendors for a national health informatics system 'NPFIT' that originally divided the country into five regions and is to be united by a central electronic medical record system nicknamed "the spine".[16] The project, in 2010, is seriously behind schedule and its scope and design are being revised in real time. In 2010 a wide consultation was launched as part of a wider Liberating the NHS plan. Many organisations and bodies (look on their own websites, as most have made their responses public in detail for information) responded to the consultation and a new strategy is expected in the second quarter of 2011. The degree of computerisation in NHS secondary care was quite high before NPfIT and that programme has had the unfortunate effect of largely stalling further development of the installed base. Almost all general practices in England and Wales are computerised and patients have relatively extensive computerised primary care clinical records. Computerisation is the responsibility of individual practices and there is no single, standardised GP system. Interoperation between primary and secondary care systems is rather primitive. A focus on interworking (for interfacing and integration) standards is hoped will stimulate synergy between primary and secondary care in sharing necessary information to support the care of individuals. Scotland has an approach to central connection under way which is more advanced than the English one in some ways. Scotland has the GPASS system whose source code is owned by the State, and controlled and developed by NHS Scotland. GPASS was accepted in 1984. It has been provided free to all GPs in Scotland but has developed poorly.[citation needed] Discussion of open sourcing it as a remedy is occurring. History The broad history of health informatics has been captured in the book UK Health Computing : Recollections and reflections, Hayes G, Barnett D (Eds.) [17], BCS (May 2008) by those active in the field, predominantly members of BCS Health and its constituent groups. The book describes the path taken as early development of health informatics was unorganized and idiosyncratic. In the early -1950s it was prompted by those involved in NHS finance and only in the early 1960s did solutions including those in pathology (1960), radiotherapy (1962), immunization (1963), and primary care (1968) emerge. Many of these solutions, even in the early 1970s were developed in-house by pioneers in the field to meet their own requirements. In part this was due to some areas of health services (for example the immunization and vaccination of children) still being provided by Local Authorities. Interesting, this is a situation which the coalition government propose broadly to return to in the 2010 strategy Equity and Excellence: Liberating the NHS (July 2010); stating: "We will put patients at the heart of the NHS, through an information revolution and greater choice and control with shared decision-making becoming the norm: no decision about me without me and patients having access to the information they want, to make choices about their care. They will have increased control over their own care records."
Health informatics These types of statements present a significant opportunity for health informaticians to come out of the back-office and take up a front-line role supporting clinical practice, and the business of care delivery. The UK health informatics community has long played a key role in international activity, joining TC4 of the International Federation of Information Processing (1969) which became IMIA [18] (1979). Under the aegis of BCS Health [17], Cambridge was the host for the first EFMI [19] Medical Informatics Europe (1974) conference and London was the location for IMIAs tenth global congress (MEDINFO2001). UK Council for Health Informatics Professions In 2002, the idea of a profession of health informatics across the UK was first mooted and by 2004 a voluntary open register was established. The UK Council for Health Informatics Professions (UKCHIP) [6] now has a formal Code of Professional Conduct, standards for expressing competences which are used for entry, confirmation of fitness to practice, re-grading and personal development. Consistent standards express competences of health informatics professionals in both domain-specific and generic informatics professional areas. The consistency is intended to apply in operational care delivery organizations, academia and the commercial service and solution providers. In 2011, self-assessment tools were introduced for use by any interested party. In addition, the principles and UKCHIP model are being considered internationally (as at 2011). UKCHIP certification is being considered for regulatory purposes. In conjunction with workforce development tools such as the NHS HI Career Framework it is possible for individuals to compare their skills against typical job roles, determine their professional level, and for employers to carry out detailed workforce analysis to meet the emerging requirements of the informatics strategies of all the home countries. Accreditation of the service organisations that provide health informatics support to NHS operational units involves an NHS Benchmarking Club.
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Emerging Direction (European R&D)

The European Commission's preference, as exemplified in the 5th Framework[20] as well as currently pursued pilot projects,[21] is for Free/Libre and Open Source Software (FLOSS) for healthcare.
Asia and Oceania

In Asia and Australia-New Zealand, the regional group called the Asia Pacific Association for Medical Informatics (APAMI)[22] was established in 1994 and now consists of more than 15 member regions in the Asia Pacific Region. Australia The Australasian College of Health Informatics (ACHI) is the professional association for health informatics in the Asia-Pacific region. It represents the interests of a broad range of clinical and non-clinical professionals working within the health informatics sphere through a commitment to quality, standards and ethical practice.[23] Founded in 2002, ACHI is increasingly valued[24] for its thought leadership, its trusted advisors and national and international experts in Health Informatics. ACHI is an academic institutional member of the International Medical Informatics Association (IMIA)[25] and a full member of the Australian Council of Professions.[26] ACHI is a sponsor of the "e-Journal for Health Informatics",[27] an indexed and peer-reviewed professional journal. ACHI has also supported the "Australian Health Informatics Education Council" (AHIEC) since its founding in 2009.[28] Although there are a number of health informatics organisations in Australia, the Health Informatics Society of Australia[29] (HISA) is regarded as the major umbrella group and is a member of the International Medical Informatics Association (IMIA). Nursing informaticians were the driving force behind the formation of HISA, which is now a company limited by guarantee of the members. The membership comes from across the informatics spectrum that is from students to corporate affiliates. HISA has a number of branches (Queensland, New South Wales, Victoria and Western Australia) as well as special interest groups such as nursing (NIA), pathology, aged and
Health informatics community care, industry and medical imaging (Conrick, 2006). Hong Kong In Hong Kong a computerized patient record system called the Clinical Management System (CMS) has been developed by the Hospital Authority since 1994. This system has been deployed at all the sites of the Authority (40 hospitals and 120 clinics), and is used by all 30,000 clinical staff on a daily basis, with a daily transaction of up to 2 millions. The comprehensive records of 7 million patients are available on-line in the Electronic Patient Record (ePR), with data integrated from all sites. Since 2004 radiology image viewing has been added to the ePR, with radiography images from any HA site being available as part of the ePR. The Hong Kong Hospital Authority placed particular attention to the governance of clinical systems development, with input from hundreds of clinicians being incorporated through a structured process. The Health Informatics Section in Hong Kong Hospital Authority[30] has close relationship with Information Technology Department and clinicians to develop healthcare systems for the organization to support the service to all public hospitals and clinics in the region. The Hong Kong Society of Medical Informatics (HKSMI) was established in 1987 to promote the use of information technology in healthcare. The eHealth Consortium has been formed to bring together clinicians from both the private and public sectors, medical informatics professionals and the IT industry to further promote IT in healthcare in Hong Kong.[31] New Zealand Health Informatics is taught at five New Zealand universities. The most mature and established is the Otago programme which has been offered for over a decade.[32] Health Informatics New Zealand (HINZ)(www.hinz.org.nz [33] ), is the national organisation that advocates for Health Informatics. HINZ organises a conference every year and also publishes an online journal- Healthcare Informatics Review Online www.hinz.org.nz/journal [34]. Saudi Arabia The Saudi Association for Health Information (SAHI) was established in 2006[35] to work under direct supervision of King Saud University for Health Sciences to practice public activities, develop theoretical and applicable knowledge, and provide scientific and applicable studies.[36]
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Health Informatics Law

Health informatics law deals with evolving and sometimes complex legal principles as they apply to information technology in health-related fields. It addresses the privacy, ethical and operational issues that invariably arise when electronic tools, information and media are used in health care delivery. Health Informatics Law also applies to all matters that involve information technology, health care and the interaction of information. It deals with the circumstances under which data and records are shared with other fields or areas that support and enhance patient care.
Clinical Informatics
Clinical Informatics is concerned with use information in health care by clinicians.[37] [38] Clinical informaticians transform health care by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve [patient] care, and strengthen the clinician-patient relationship. Clinical informaticians use their knowledge of patient care combined with their understanding of informatics concepts, methods, and health informatics tools to: assess information and knowledge needs of health care professionals and patients,
Health informatics characterize, evaluate, and refine clinical processes, develop, implement, and refine clinical decision support systems, and lead or participate in the procurement, customization, development, implementation, management, evaluation, and continuous improvement of clinical information systems. Clinicians collaborate with other health care and information technology professionals to develop health informatics tools which promote patient care that is safe, efficient, effective, timely, patient-centered, and equitable.
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Translational bioinformatics
With the completion of the human genome and the recent advent of high throughput sequencing and genome-wise association studies of single nucleotide polymorphisms, the fields of molecular bioinformatics, biostatistiques, statistical genetics and clinical informatics are converging into the emerging field of translational bioinformatics.[39]
[40] [41]
References
[1] "35.240.80: IT applications in health care technology" (http:/ / www. iso. org/ iso/ products/ standards/ catalogue_ics_browse. htm?ICS1=35& ICS2=240& ICS3=80& ). ISO. . Retrieved 2008-06-15. [2] Fraser, Ross. "ISO 27799: Security management in health using ISO/IEC 17799" (http:/ / sl. infoway-inforoute. ca/ downloads/ Ross_Fraser_-_ISO_27799. pdf). . Retrieved 2008-06-15. [3] "The History of Health Informatics" (http:/ / healthinformatics. uic. edu/ history-of-health-informatics). Health Informatics, Nursing Informatics and Health Information Management Degrees. University of Illinois at Chicago. . [4] "NYU Graduate Training Program in Biomedical Informatics (BMI): A Brief History of Biomedical Informatics as a Discipline" (http:/ / www. nyuinformatics. org/ education/ degree-programs). www.nyuinformatics.org. NYU Langone Medical Center. . Retrieved 11 November 2010. [5] Robson, B.; Baek, O. K. (2009). The engines of Hippocrates: From the Dawn of Medicine to Medical and Pharmaceutical Informatics. Hoboken, NJ: John Wiley & Sons. ISBN9780470289532. [6] http:/ / www. ukchip. org [7] Sittig DF, Ash JS, Ledley RS (2006). "The story behind the development of the first whole-body computerized tomography scanner as told by Robert S. Ledley". Journal of the American Medical Informatics Association 13 (5): 4659. doi:10.1197/jamia.M2127. PMC1561796. PMID16799115. [8] MGH - Laboratory of Computer Science (http:/ / www. lcs. mgh. harvard. edu/ ) [9] Edwin D. Reilly (2003). Milestones in Computer Science and Information Technology. Greenwood Press. pp.161. ISBN978-1573565219. [10] Patton GA, Gardner RM (1999). "Medical informatics education: the University of Utah experience". Journal of the American Medical Informatics Association 6 (6): 45765. PMC61389. PMID10579604. [11] Priest, Lisa (2008-02-18). "Your medical chart, just a mouse click away" (http:/ / www. theglobeandmail. com/ servlet/ story/ RTGAM. 20080218. wmychart18/ BNStory/ specialScienceandHealth/ ). The Globe and Mail (Toronto). . [12] "Head of eHealth Ontario is fired amid contracts scandal, gets big package" (http:/ / www. cbc. ca/ canada/ story/ 2009/ 06/ 07/ ehealth-kramer. html). CBC News. 2009-06-07. . Retrieved 2009-08-26. [13] Certification Commission for Healthcare Information Technology (July 18, 2006): CCHIT Announces First Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ First+ Certified+ Electronic+ Health+ Record+ Products. htm). Retrieved July 26, 2006. [14] European eHealth Action Plan (http:/ / ec. europa. eu/ information_society/ activities/ health/ policy_action_plan/ index_en. htm) [15] European eHealth Action Plan i2010 (http:/ / ec. europa. eu/ information_society/ eeurope/ i2010/ index_en. htm) [16] "Electronic Health Records for Europe" (http:/ / www. esa. int/ esaMI/ Telemedicine_Alliance/ SEMWC7SMD6E_0. html). European Space Agency. 2005. . Retrieved 2009-01-13. [17] http:/ / www. bcs. org/ health [18] http:/ / www. imia-medinfo. org [19] http:/ / www. efmi. org [20] Cordis FP5web (http:/ / cordis. europa. eu/ fp5/ ) [21] European Patient Smart Open Services (http:/ / www. epsos. eu) [22] "Asia Pacific Association of Medical Informatics" (http:/ / www. apami. org). . [23] "Australasian College of Health Informatics" (http:/ / www. ACHI. org. au). . Retrieved 3 May 2010.Australasian College of Health Informatics [24] University of Sydney (http:/ / www. fhs. usyd. edu. au/ health_informatics/ about/ index. shtml) Current Developments in Health Informatics
Health informatics
[25] "International Medical Informatics Association - Academic Institutional Members - Australia - Australian College of Health Informatics" (http:/ / www. imia. org/ members/ profiles/ academic. lasso?-Search=Action& -Table=CGI& -MaxRecords=1& -SkipRecords=2& -Database=organizations& -SortField=english_vers& -SortOrder=ascending& type=academic& approved=yes). 12 August 2009. . Retrieved 22 February 2010. [26] ACHI Memberships (http:/ / www. ACHI. org. au) ACHI memberships: Professions Australia [27] eJHI - electronic Journal of Health Informatics (http:/ / www. ejhi. net/ ojs/ index. php/ ejhi/ about/ journalSponsorship) (open access journal) [28] Australian Health Informatics Education Council (AHIEC) (http:/ / www. AHIEC. org. au) AHIEC Auspicing Organisations [29] "Health Informatics Society of Australia Ltd" (http:/ / www. hisa. org. au). . Retrieved 3 April 2010. [30] Health Informatics Section in Hong Kong Hospital Authority (http:/ / www. ha. org. hk/ hi/ Welcome. html) [31] eHealth Consortium (http:/ / www. iproa. org/ ProjectDetail. action?id=270) [32] Karolyn Kerr; Rowena Cullen, Jan Duke, Alec Holt, Ray Kirk, Peter Komisarczuk, Jim Warren and Shona Wilson (2006). "Health Informatics Capability Development In New Zealand - A Report to the Tertiary Education Commission" (http:/ / homepages. mcs. vuw. ac. nz/ ~peterk/ healthinformatics/ tec-hi-report-06. pdf). . Retrieved 2009-01-08. [33] http:/ / www. hinz. org. nz [34] http:/ / www. hinz. org. nz/ journal [35] "Medical Pharmaceutical Information Association (MedPharmInfo)" (http:/ / www. imia. org/ members/ profiles/ national. lasso?-Search=Action& -Table=CGI& -MaxRecords=1& -SkipRecords=27& -Database=organizations& -KeyField=Internal Record ID& -SortField=country& -SortOrder=ascending& -SortField=country& -SortOrder=ascending& type=national& type=national). Imia.org. 2008-05-18. . Retrieved 2010-07-29. [36] "Saudi Association for Health Informatics (SAHI)" (http:/ / www. sahi. org. sa/ objectives. php). www.sahi.org.sa/. . [37] Gardner RM, Overhage JM, Steen EB, et al. (2009). "Core content for the subspecialty of clinical informatics". Journal of the American Medical Informatics Association 16 (2): 1537. doi:10.1197/jamia.M3045. PMC2649328. PMID19074296. [38] Safran C, Shabot MM, Munger BS, et al. (2009). "Program requirements for fellowship education in the subspecialty of clinical informatics". Journal of the American Medical Informatics Association 16 (2): 15866. doi:10.1197/jamia.M3046. PMC2649323. PMID19074295. [39] Butte, AJ (2009). "Translational bioinformatics applications in genome medicine.". Genome medicine 1 (6): 64. doi:10.1186/gm64. PMC2703873. PMID19566916. [40] Kann, M. G. (2009). "Advances in translational bioinformatics: computational approaches for the hunting of disease genes". Briefings in Bioinformatics 11 (1): 96. doi:10.1093/bib/bbp048. PMC2810112. PMID20007728. [41] Lussier, YA; Butte, AJ; Hunter, L (2010). "Current methodologies for translational bioinformatics.". Journal of biomedical informatics 43 (3): 3557. doi:10.1016/j.jbi.2010.05.002. PMC2894568. PMID20470899.
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External links
Health informatics (http://www.dmoz.org/Health/Medicine/Informatics/) at the Open Directory Project Australasian College of Health Informatics (http://www.ACHI.org.au) e-Journal for Health Informatics (http://www.eJHI.net) Article about informatics (http://www.biomedcentral.com/1472-6947/9/24) UK Council for Health Informatics Professions, its principles, code and standards (http://www.ukchip.org) Healthcare Informatics Magazine (http://www.healthcare-informatics.com)
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. Health informatics (also called health care informatics, healthcare informatics, medical informatics, nursing informatics, clinical informatics, or biomedical informatics) is a discipline at the intersection of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy, and (bio)medical research.
Electronic patient chart from a health information system
The international standards on the subject are covered by ICS 35.240.80[1] in which ISO 27799:2008 is one of the core components.[2] Molecular bioinformatics and clinical informatics have converged into the field of translational bioinformatics.
History
World wide use of technology in medicine began in the early 1950s with the rise of the computers.[3] In 1949, Gustav Wager established the first professional organization for informatics in Germany.[4] The prehistory, history, and future of medical information and health information technology are discussed in reference.[5] Specialized university departments and Informatics training programs began during the 1960s in France, Germany, Belgium and The Netherlands. Medical informatics research units began to appear during the 1970s in Poland and in the U.S.[4] Since then the development of high-quality health informatics research, education and infrastructure has been the goal of the U.S. and the European Union.[4] Early names for health informatics included medical computing, medical computer science, computer medicine, medical electronic data processing, medical automatic data processing, medical information processing, medical information science, medical software engineering, and medical computer technology. The health informatics community is still growing, it is by no means a mature profession, but work in the UK by the voluntary registration body, the UK Council of Health Informatics Professions [6] has suggested eight key constituencies within the domain - information management, knowledge management, portfolio/programme/project management, ICT, education and research, clinical informatics, health records(service and business-related), health informatics service management. These constituencies accommodate professionals in and for the NHS, in academia and commercial service and solution providers. Since the 1970s the most prominent international coordinating body has been the International Medical Informatics Association (IMIA).
15
Medical informatics in the United States

Even though the idea of using computers in medicine sprouted as technology advanced in the early twentieth century, it was not until the 1950s that informatics made a realistic impact in the United States.[3] The earliest use of computation for medicine was for dental projects in the 1950s at the United States National Bureau of Standards by Robert Ledley.[6] The next step in the mid 1950s were the development of expert systems such as MYCIN and Internist-I. In 1965, the National Library of Medicine started to use MEDLINE and MEDLARS. At this time, Neil Pappalardo, Curtis Marble, and Robert Greenes developed MUMPS (Massachusetts General Hospital Utility Multi-Programming System) in Octo Barnett's Laboratory of Computer Science [7] at Massachusetts General Hospital in Boston.[8] In the 1970s and 1980s it was the most commonly used programming language for clinical applications. The MUMPS operating system was used to support MUMPS language specifications. As of 2004, a descendent of this system is being used in the United States Veterans Affairs hospital system. The VA has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patients electronic medical record at any of the VA's over 1,000 health care facilities. In the 1970s a growing number of commercial vendors began to market practice management and electronic medical records systems. Although many products exist, only a small number of health practitioners use fully featured electronic health care records systems. Homer R. Warner, one of the fathers of medical informatics,[9] founded the Department of Medical Informatics at the University of Utah in 1968. The American Medical Informatics Association (AMIA) has an award named after him on application of informatics to medicine.
Current state of health informatics and policy initiatives

Americas
Argentina Since 1997, the Buenos Aires Biomedical Informatics Group, a nonprofit group, represents the interests of a broad range of clinical and non-clinical professionals working within the Health Informatics sphere. Its purposes are: Promote the implementation of the computer tool in the healthcare activity, scientific research, health administration and in all areas related to health sciences and biomedical research. Support, promote and disseminate content related activities with the management of health information and tools they used to do under the name of Biomedical informatics. Promote cooperation and exchange of actions generated in the field of biomedical informatics, both in the public and private, national and international level. Interact with all scientists, recognized academic stimulating the creation of new instances that have the same goal and be inspired by the same purpose. To promote, organize, sponsor and participate in events and activities for training in computer and information and disseminating developments in this area that might be useful for team members and health related activities. Health informatics (also called health care informatics, healthcare informatics, medical informatics, nursing informatics, clinical informatics, or biomedical informatics) is a discipline at the intersection of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy,
Clinical Informatics and (bio)medical research. The international standards on the subject are covered by ICS 35.240.80[1] in which ISO 27799:2008 is one of the core components.[2] Molecular bioinformatics and clinical informatics have converged into the field of translational bioinformatics. The Argentinian health system is very heterogeneous, because of that the informatics developments shows an heterogeneous stage. Lot of private Health Care center have developed systems, as the German Hospital of Buenos Aires who was one of the first in develop the electronic health records system. Brazil The first applications of computers to medicine and healthcare in Brazil started around 1968, with the installation of the first mainframes in public university hospitals, and the use of programmable calculators in scientific research applications. Minicomputers, such as the IBM 1130 were installed in several universities, and the first applications were developed for them, such as the hospital census in the School of Medicine of Ribeiro Preto and patient master files, in the Hospital das Clnicas da Universidade de So Paulo, respectively at the cities of Ribeiro Preto and So Paulo campi of the University of So Paulo. In the 1970s, several Digital Corporation and Hewlett Packard minicomputers were acquired for public and Armed Forces hospitals, and more intensively used for intensive-care unit, cardiology diagnostics, patient monitoring amd other applications. In the early 1980s, with the arrival of cheaper microcomputers, a great upsurge of computer applications in health ensued, and in 1986 the Brazilian Society of Health Informatics was founded, the first Brazilian Congress of Health Informatics was held, and the first Brazilian Journal of Health Informatics was published. Canada Health Informatics projects in Canada are implemented provincially, with different provinces creating different systems. A national, federally-funded, not-for-profit organization called Canada Health Infoway was created in 2001 to foster the development and adoption of electronic health records across Canada. As of December 31, 2008 there were 276 EHR projects under way in Canadian hospitals, other health-care facilities, pharmacies and laboratories, with an investment value of $1.5-billion from Canada Health Infoway.[10] Provincial and territorial programmes include the following: eHealth Ontario was created as an Ontario provincial government agency in September 2008. It has been plagued by delays and its CEO was fired over a multimillion-dollar contracts scandal in 2009.[11] Alberta Netcare was created in 2003 by the Government of Alberta. Today the netCARE portal is used daily by thousands of clinicians. It provides access to demographic data, prescribed/dispensed drugs, known allergies/intolerances, immunizations, laboratory test results, diagnostic imaging reports, the diabetes registry and other medical reports. netCARE interface capabilities are being included in electronic medical record products which are being funded by the provincial government. United States In 2004 the U.S. Department of Health and Human Services (HHS) formed the Office of the National Coordinator for Health Information Technology (ONCHIT). The mission of this office is widespread adoption of interoperable electronic health records (EHRs) in the US within 10 years. See quality improvement organizations for more information on federal initiatives in this area. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards for electronic health records (EHR) and supporting networks, and certify vendors who meet them. In July, 2006 CCHIT released its first list of 22 certified ambulatory EHR products, in two different announcements.[12]
16
17
Europe
The European Union's Member States are committed to sharing their best practices and experiences to create a European eHealth Area, thereby improving access to and quality health care at the same time as stimulating growth in a promising new industrial sector. The European eHealth Action Plan plays a fundamental role in the European Union's strategy. Work on this initiative involves a collaborative approach among several parts of the Commission services.[13] [14] The European Institute for Health Records is involved in the promotion of high quality electronic health record systems in the European Union.[15]
UK
There are different models of health informatics delivery in each of the home countries (England, Scotland, Northern Ireland and Wales) but some bodies like UKCHIP (see below ) operate for those 'in and for' all the home countries and beyond.
England
The NHS in England has contracted out to several vendors for a national health informatics system 'NPFIT' that originally divided the country into five regions and is to be united by a central electronic medical record system nicknamed "the spine".[16] The project, in 2010, is seriously behind schedule and its scope and design are being revised in real time. In 2010 a wide consultation was launched as part of a wider Liberating the NHS plan. Many organisations and bodies (look on their own websites, as most have made their responses public in detail for information) responded to the consultation and a new strategy is expected in the second quarter of 2011. The degree of computerisation in NHS secondary care was quite high before NPfIT and that programme has had the unfortunate effect of largely stalling further development of the installed base. Almost all general practices in England and Wales are computerised and patients have relatively extensive computerised primary care clinical records. Computerisation is the responsibility of individual practices and there is no single, standardised GP system. Interoperation between primary and secondary care systems is rather primitive. A focus on interworking (for interfacing and integration) standards is hoped will stimulate synergy between primary and secondary care in sharing necessary information to support the care of individuals. Scotland has an approach to central connection under way which is more advanced than the English one in some ways. Scotland has the GPASS system whose source code is owned by the State, and controlled and developed by NHS Scotland. GPASS was accepted in 1984. It has been provided free to all GPs in Scotland but has developed poorly.[citation needed] Discussion of open sourcing it as a remedy is occurring. History The broad history of health informatics has been captured in the book UK Health Computing : Recollections and reflections, Hayes G, Barnett D (Eds.) [17], BCS (May 2008) by those active in the field, predominantly members of BCS Health and its constituent groups. The book describes the path taken as early development of health informatics was unorganized and idiosyncratic. In the early -1950s it was prompted by those involved in NHS finance and only in the early 1960s did solutions including those in pathology (1960), radiotherapy (1962), immunization (1963), and primary care (1968) emerge. Many of these solutions, even in the early 1970s were developed in-house by pioneers in the field to meet their own requirements. In part this was due to some areas of health services (for example the immunization and vaccination of children) still being provided by Local Authorities. Interesting, this is a situation which the coalition government propose broadly to return to in the 2010 strategy Equity and Excellence: Liberating the NHS (July 2010); stating: "We will put patients at the heart of the NHS, through an information revolution and greater choice and control with shared decision-making becoming the norm: no decision about me without me and patients having access to the information they want, to make choices about their care. They will have increased control over their own care records."
Clinical Informatics These types of statements present a significant opportunity for health informaticians to come out of the back-office and take up a front-line role supporting clinical practice, and the business of care delivery. The UK health informatics community has long played a key role in international activity, joining TC4 of the International Federation of Information Processing (1969) which became IMIA [18] (1979). Under the aegis of BCS Health [17], Cambridge was the host for the first EFMI [19] Medical Informatics Europe (1974) conference and London was the location for IMIAs tenth global congress (MEDINFO2001). UK Council for Health Informatics Professions In 2002, the idea of a profession of health informatics across the UK was first mooted and by 2004 a voluntary open register was established. The UK Council for Health Informatics Professions (UKCHIP) [6] now has a formal Code of Professional Conduct, standards for expressing competences which are used for entry, confirmation of fitness to practice, re-grading and personal development. Consistent standards express competences of health informatics professionals in both domain-specific and generic informatics professional areas. The consistency is intended to apply in operational care delivery organizations, academia and the commercial service and solution providers. In 2011, self-assessment tools were introduced for use by any interested party. In addition, the principles and UKCHIP model are being considered internationally (as at 2011). UKCHIP certification is being considered for regulatory purposes. In conjunction with workforce development tools such as the NHS HI Career Framework it is possible for individuals to compare their skills against typical job roles, determine their professional level, and for employers to carry out detailed workforce analysis to meet the emerging requirements of the informatics strategies of all the home countries. Accreditation of the service organisations that provide health informatics support to NHS operational units involves an NHS Benchmarking Club.
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Emerging Direction (European R&D)

The European Commission's preference, as exemplified in the 5th Framework[16] as well as currently pursued pilot projects,[17] is for Free/Libre and Open Source Software (FLOSS) for healthcare.
Asia and Oceania

In Asia and Australia-New Zealand, the regional group called the Asia Pacific Association for Medical Informatics (APAMI)[18] was established in 1994 and now consists of more than 15 member regions in the Asia Pacific Region. Australia The Australasian College of Health Informatics (ACHI) is the professional association for health informatics in the Asia-Pacific region. It represents the interests of a broad range of clinical and non-clinical professionals working within the health informatics sphere through a commitment to quality, standards and ethical practice.[19] Founded in 2002, ACHI is increasingly valued[20] for its thought leadership, its trusted advisors and national and international experts in Health Informatics. ACHI is an academic institutional member of the International Medical Informatics Association (IMIA)[21] and a full member of the Australian Council of Professions.[22] ACHI is a sponsor of the "e-Journal for Health Informatics",[23] an indexed and peer-reviewed professional journal. ACHI has also supported the "Australian Health Informatics Education Council" (AHIEC) since its founding in 2009.[24] Although there are a number of health informatics organisations in Australia, the Health Informatics Society of Australia[25] (HISA) is regarded as the major umbrella group and is a member of the International Medical Informatics Association (IMIA). Nursing informaticians were the driving force behind the formation of HISA, which is now a company limited by guarantee of the members. The membership comes from across the informatics spectrum that is from students to corporate affiliates. HISA has a number of branches (Queensland, New South Wales, Victoria and Western Australia) as well as special interest groups such as nursing (NIA), pathology, aged and
Clinical Informatics community care, industry and medical imaging (Conrick, 2006). Hong Kong In Hong Kong a computerized patient record system called the Clinical Management System (CMS) has been developed by the Hospital Authority since 1994. This system has been deployed at all the sites of the Authority (40 hospitals and 120 clinics), and is used by all 30,000 clinical staff on a daily basis, with a daily transaction of up to 2 millions. The comprehensive records of 7 million patients are available on-line in the Electronic Patient Record (ePR), with data integrated from all sites. Since 2004 radiology image viewing has been added to the ePR, with radiography images from any HA site being available as part of the ePR. The Hong Kong Hospital Authority placed particular attention to the governance of clinical systems development, with input from hundreds of clinicians being incorporated through a structured process. The Health Informatics Section in Hong Kong Hospital Authority[26] has close relationship with Information Technology Department and clinicians to develop healthcare systems for the organization to support the service to all public hospitals and clinics in the region. The Hong Kong Society of Medical Informatics (HKSMI) was established in 1987 to promote the use of information technology in healthcare. The eHealth Consortium has been formed to bring together clinicians from both the private and public sectors, medical informatics professionals and the IT industry to further promote IT in healthcare in Hong Kong.[27] New Zealand Health Informatics is taught at five New Zealand universities. The most mature and established is the Otago programme which has been offered for over a decade.[28] Health Informatics New Zealand (HINZ)(www.hinz.org.nz [33] ), is the national organisation that advocates for Health Informatics. HINZ organises a conference every year and also publishes an online journal- Healthcare Informatics Review Online www.hinz.org.nz/journal [34]. Saudi Arabia The Saudi Association for Health Information (SAHI) was established in 2006[29] to work under direct supervision of King Saud University for Health Sciences to practice public activities, develop theoretical and applicable knowledge, and provide scientific and applicable studies.[30]
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Health Informatics Law

Health informatics law deals with evolving and sometimes complex legal principles as they apply to information technology in health-related fields. It addresses the privacy, ethical and operational issues that invariably arise when electronic tools, information and media are used in health care delivery. Health Informatics Law also applies to all matters that involve information technology, health care and the interaction of information. It deals with the circumstances under which data and records are shared with other fields or areas that support and enhance patient care.
Clinical Informatics is concerned with use information in health care by clinicians.[31] [32] Clinical informaticians transform health care by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve [patient] care, and strengthen the clinician-patient relationship. Clinical informaticians use their knowledge of patient care combined with their understanding of informatics concepts, methods, and health informatics tools to: assess information and knowledge needs of health care professionals and patients,
Clinical Informatics characterize, evaluate, and refine clinical processes, develop, implement, and refine clinical decision support systems, and lead or participate in the procurement, customization, development, implementation, management, evaluation, and continuous improvement of clinical information systems. Clinicians collaborate with other health care and information technology professionals to develop health informatics tools which promote patient care that is safe, efficient, effective, timely, patient-centered, and equitable.
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Translational bioinformatics
With the completion of the human genome and the recent advent of high throughput sequencing and genome-wise association studies of single nucleotide polymorphisms, the fields of molecular bioinformatics, biostatistiques, statistical genetics and clinical informatics are converging into the emerging field of translational bioinformatics.[33]
[34] [35]
References
[1] "35.240.80: IT applications in health care technology" (http:/ / www. iso. org/ iso/ products/ standards/ catalogue_ics_browse. htm?ICS1=35& ICS2=240& ICS3=80& ). ISO. . Retrieved 2008-06-15. [2] Fraser, Ross. "ISO 27799: Security management in health using ISO/IEC 17799" (http:/ / sl. infoway-inforoute. ca/ downloads/ Ross_Fraser_-_ISO_27799. pdf). . Retrieved 2008-06-15. [3] "The History of Health Informatics" (http:/ / healthinformatics. uic. edu/ history-of-health-informatics). Health Informatics, Nursing Informatics and Health Information Management Degrees. University of Illinois at Chicago. . [4] "NYU Graduate Training Program in Biomedical Informatics (BMI): A Brief History of Biomedical Informatics as a Discipline" (http:/ / www. nyuinformatics. org/ education/ degree-programs). www.nyuinformatics.org. NYU Langone Medical Center. . Retrieved 11 November 2010. [5] Robson, B.; Baek, O. K. (2009). The engines of Hippocrates: From the Dawn of Medicine to Medical and Pharmaceutical Informatics. Hoboken, NJ: John Wiley & Sons. ISBN9780470289532. [6] Sittig DF, Ash JS, Ledley RS (2006). "The story behind the development of the first whole-body computerized tomography scanner as told by Robert S. Ledley". Journal of the American Medical Informatics Association 13 (5): 4659. doi:10.1197/jamia.M2127. PMC1561796. PMID16799115. [7] MGH - Laboratory of Computer Science (http:/ / www. lcs. mgh. harvard. edu/ ) [8] Edwin D. Reilly (2003). Milestones in Computer Science and Information Technology. Greenwood Press. pp.161. ISBN978-1573565219. [9] Patton GA, Gardner RM (1999). "Medical informatics education: the University of Utah experience". Journal of the American Medical Informatics Association 6 (6): 45765. PMC61389. PMID10579604. [10] Priest, Lisa (2008-02-18). "Your medical chart, just a mouse click away" (http:/ / www. theglobeandmail. com/ servlet/ story/ RTGAM. 20080218. wmychart18/ BNStory/ specialScienceandHealth/ ). The Globe and Mail (Toronto). . [11] "Head of eHealth Ontario is fired amid contracts scandal, gets big package" (http:/ / www. cbc. ca/ canada/ story/ 2009/ 06/ 07/ ehealth-kramer. html). CBC News. 2009-06-07. . Retrieved 2009-08-26. [12] Certification Commission for Healthcare Information Technology (July 18, 2006): CCHIT Announces First Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ First+ Certified+ Electronic+ Health+ Record+ Products. htm). Retrieved July 26, 2006. [13] European eHealth Action Plan (http:/ / ec. europa. eu/ information_society/ activities/ health/ policy_action_plan/ index_en. htm) [14] European eHealth Action Plan i2010 (http:/ / ec. europa. eu/ information_society/ eeurope/ i2010/ index_en. htm) [15] "Electronic Health Records for Europe" (http:/ / www. esa. int/ esaMI/ Telemedicine_Alliance/ SEMWC7SMD6E_0. html). European Space Agency. 2005. . Retrieved 2009-01-13. [16] Cordis FP5web (http:/ / cordis. europa. eu/ fp5/ ) [17] European Patient Smart Open Services (http:/ / www. epsos. eu) [18] "Asia Pacific Association of Medical Informatics" (http:/ / www. apami. org). . [19] "Australasian College of Health Informatics" (http:/ / www. ACHI. org. au). . Retrieved 3 May 2010.Australasian College of Health Informatics [20] University of Sydney (http:/ / www. fhs. usyd. edu. au/ health_informatics/ about/ index. shtml) Current Developments in Health Informatics [21] "International Medical Informatics Association - Academic Institutional Members - Australia - Australian College of Health Informatics" (http:/ / www. imia. org/ members/ profiles/ academic. lasso?-Search=Action& -Table=CGI& -MaxRecords=1& -SkipRecords=2& -Database=organizations& -SortField=english_vers& -SortOrder=ascending& type=academic& approved=yes). 12 August 2009. . Retrieved 22 February 2010. [22] ACHI Memberships (http:/ / www. ACHI. org. au) ACHI memberships: Professions Australia
[23] eJHI - electronic Journal of Health Informatics (http:/ / www. ejhi. net/ ojs/ index. php/ ejhi/ about/ journalSponsorship) (open access journal) [24] Australian Health Informatics Education Council (AHIEC) (http:/ / www. AHIEC. org. au) AHIEC Auspicing Organisations [25] "Health Informatics Society of Australia Ltd" (http:/ / www. hisa. org. au). . Retrieved 3 April 2010. [26] Health Informatics Section in Hong Kong Hospital Authority (http:/ / www. ha. org. hk/ hi/ Welcome. html) [27] eHealth Consortium (http:/ / www. iproa. org/ ProjectDetail. action?id=270) [28] Karolyn Kerr; Rowena Cullen, Jan Duke, Alec Holt, Ray Kirk, Peter Komisarczuk, Jim Warren and Shona Wilson (2006). "Health Informatics Capability Development In New Zealand - A Report to the Tertiary Education Commission" (http:/ / homepages. mcs. vuw. ac. nz/ ~peterk/ healthinformatics/ tec-hi-report-06. pdf). . Retrieved 2009-01-08. [29] "Medical Pharmaceutical Information Association (MedPharmInfo)" (http:/ / www. imia. org/ members/ profiles/ national. lasso?-Search=Action& -Table=CGI& -MaxRecords=1& -SkipRecords=27& -Database=organizations& -KeyField=Internal Record ID& -SortField=country& -SortOrder=ascending& -SortField=country& -SortOrder=ascending& type=national& type=national). Imia.org. 2008-05-18. . Retrieved 2010-07-29. [30] "Saudi Association for Health Informatics (SAHI)" (http:/ / www. sahi. org. sa/ objectives. php). www.sahi.org.sa/. . [31] Gardner RM, Overhage JM, Steen EB, et al. (2009). "Core content for the subspecialty of clinical informatics". Journal of the American Medical Informatics Association 16 (2): 1537. doi:10.1197/jamia.M3045. PMC2649328. PMID19074296. [32] Safran C, Shabot MM, Munger BS, et al. (2009). "Program requirements for fellowship education in the subspecialty of clinical informatics". Journal of the American Medical Informatics Association 16 (2): 15866. doi:10.1197/jamia.M3046. PMC2649323. PMID19074295. [33] Butte, AJ (2009). "Translational bioinformatics applications in genome medicine.". Genome medicine 1 (6): 64. doi:10.1186/gm64. PMC2703873. PMID19566916. [34] Kann, M. G. (2009). "Advances in translational bioinformatics: computational approaches for the hunting of disease genes". Briefings in Bioinformatics 11 (1): 96. doi:10.1093/bib/bbp048. PMC2810112. PMID20007728. [35] Lussier, YA; Butte, AJ; Hunter, L (2010). "Current methodologies for translational bioinformatics.". Journal of biomedical informatics 43 (3): 3557. doi:10.1016/j.jbi.2010.05.002. PMC2894568. PMID20470899.
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External links
Clinical Informatics (http://www.dmoz.org/Health/Medicine/Informatics/) at the Open Directory Project Australasian College of Health Informatics (http://www.ACHI.org.au) e-Journal for Health Informatics (http://www.eJHI.net) Article about informatics (http://www.biomedcentral.com/1472-6947/9/24) UK Council for Health Informatics Professions, its principles, code and standards (http://www.ukchip.org) Healthcare Informatics Magazine (http://www.healthcare-informatics.com)
Cybermedicine
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Cybermedicine
Cybermedicine is the use of the Internet to deliver medical services, such as medical consultations and drug prescriptions. It is the successor to telemedicine, wherein doctors would consult and treat patients remotely via telephone or fax. Cybermedicine is already being used in small projects where images are transmitted from a primary care setting to a medical specialist, who comments on the case and suggests which intervention might benefit the patient. A field that lends itself to this approach is dermatology, where images of an eruption are communicated to a hospital specialist who determines if referral is necessary. A Cyber Doctor,[1] known in the UK as a Cyber Physician,[2] is a medical professional who does consultation via the internet, treating virtual patients, who may never meet face to face. This is a new area of medicine which has been utilized by the armed forces and teaching hospitals offering online consultation to patients before making their decision to travel for unique medical treatment only offered at a particular medical facility.[3]
External links
The Medicalisation of Cyberspace, by Dr Andy Miah & Dr Emma Rich [4] Cybermedicine by Warner V. Slack, Jossey Bass publisher Second Edition [5]
References
[1] US term,http:/ / www. sfgate. com/ cgi-bin/ article. cgi?f=/ c/ a/ 2007/ 05/ 27/ BAGOKQ2IEQ1. DTL [2] UK term,http:/ / society. guardian. co. uk/ health/ story/ 0,,408225,00. html [3] Online visits a boon for far-off patients, Sfgate.com,http:/ / www. sfgate. com/ cgi-bin/ article. cgi?f=/ c/ a/ 2007/ 05/ 27/ BAGOKQ2IEQ1. DTL [4] http:/ / cybermedicine. blogspot. com [5] http:/ / www. amazon. com/ dp/ 0787956317
eHealth
23
eHealth
eHealth (also written e-health) is a relatively recent term for healthcare practice supported by electronic processes and communication, dating back to at least 1999.[1] Usage of the term varies: some would argue it is interchangeable with health informatics with a broad definition covering electronic/digital processes in health,[2] while others use it in the narrower sense of healthcare practice using the Internet.[3] [4] [5]
Forms of e-health
The term can encompass a range of services or systems that are at the edge of medicine/healthcare and information technology, including: Electronic health records: enabling the communication of patient data between different healthcare professionals (GPs, specialists etc.); Telemedicine: physical and psychological treatments at a distance; Consumer health informatics: use of electronic resources on medical topics by healthy individuals or patients; Health knowledge management: e.g. in an overview of latest medical journals, best practice guidelines or epidemiological tracking (examples include physician resources such as Medscape and MDLinx); Virtual healthcare teams: consisting of healthcare professionals who collaborate and share information on patients through digital equipment (for transmural care); mHealth or m-Health: includes the use of mobile devices in collecting aggregate and patient level health data, providing healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vitals, and direct provision of care (via mobile telemedicine); Medical research using Grids: powerful computing and data management capabilities to handle large amounts of heterogeneous data.[6] Healthcare Information Systems: also often refer to software solutions for appointment scheduling, patient data management, work schedule management and other administrative tasks surrounding health.
Contested definition
Several authors have noted the variable usage in the term, from being specific to the use of the Internet in healthcare to being generally around any use of computers in healthcare.[7] Various authors have considered the evolution of the term and its usage and how this maps to changes in health informatics and healthcare generally.[8] [9] [10] Oh et al., in a 2005 systematic review of the term's usage, offered the following definitions of eHealth:[11]
E-Health data exchange

One of the factors blocking the use of e-Health tools from widespread acceptance is the concern about privacy issues regarding patient records, most specifically the EPR (Electronic patient record). This main concern has to do with the confidentiality of the data. There is also concern about non-confidential data however. Each medical practise has its own jargon and diagnostic tools. To standardize the exchange of information, various coding schemes may used in combination with international medical standards. Of the forms of e-Health already mentioned, there are roughly two types; front-end data exchange and back-end exchange. Front-end exchange typically involves the patient, while back-end exchange does not. A common example of a rather simple front-end exchange is a patient sending a photo taken by mobile phone of a healing wound and sending it by email to the family doctor for control. Such an actions may avoid the cost of an expensive visit to the hospital. A common example of a back-end exchange is when a patient on vacation visits a doctor who then may request access to the patient's health records, such as medicine prescriptions, x-ray photographs, or blood test results. Such
eHealth an action may reveal allergies or other prior conditions that are relevant to the visit.
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Thesaurus
Successfull e-Health initiatives such as e-Diabetes have shown that for data exchange to be facilitated either at the front-end or the back-end, a common thesaurus is needed for terms of reference.[12] Various medical practises in chronic patient care (such as for diabetic patients) already have a well defined set of terms and actions, which makes standard communication exchange easier, whether the exchange is initiated by the patient or the caregiver. In general, explanatory diagnostic information (such as the standard ICD-10) may be exchanged insecurely, and private information (such as personal information from the patient) must be secured. E-health manages both flows of information, while ensuring the quality of the data exchange.
Early adapters
Chronic patients over time often acquire a high level of knowlegde about the processes involved in their own care, and often develop a routine in coping with their condition. For these types of routine patients, front-end e-Health solutions tend to be relatively easy to implement.
E Mental Health
E Mental Health refers to the delivery of mental health services via the internet through videoconferencing, chat, or email web applications. E Mental Health encompasses online talk therapy, online pharmaceutical therapy, online counseling, computer-based interventions, cyber mental health approaches, and online life coaching. This form of psychological intervention modality offers a series of benefits as well as challenges to providers and clients. Most notable of all challenges is online security.[13] E Mental Health has been gaining momentum in the academic research as well as practical arenas in a wide variety of disciplines such as psychology, clinical social work, family and marriage therapy, and mental health counseling. Testifying to this momentum, the E Mental Health movement has its own international organization, The International Society for Mental Health Online.[14] It also has its own academic peer review journals, such as the Journal of Medical Internet Research.[15] The efficacy and effectiveness of E Mental Health approaches are currently being studied by Universities around the world. For instance, University of California Davis has initiated a series of studies based on E Mental Health.[16] There are a number of E Mental Health Centers now operating around the world, particularly in the USA and Australia. These centers offer services to disabled populations, rural populations, weather inclement populations, as well as populations who are comfortable using the internet and world wide web.
References
[1] Della Mea V (2001). "What is e-Health (2): The death of telemedicine?" J Med Internet Res 2001;3(2):e22 (http:/ / www. jmir. org/ 2001/ 2/ e22/ ) [2] International Telecommunication Union (2008). "Implementing e-Health in Developing Countries: Guidance and Principles" (http:/ / www. itu. int/ ITU-D/ cyb/ app/ docs/ e-Health_prefinal_15092008. PDF) [3] "HIMSS SIG develops proposed e-health definition", HIMSS News, 13(7): 12 [4] Eysenbach G, Diepgen TL. The role of e-health and consumer health informatics for evidence-based patient choice in the 21st century. Clin Dermatol. 2001 Jan-Feb;19(1):11-7 [5] Ball MJ, Lillis J. E-health: transforming the physician/patient relationship. Int J Med Inform. 2001 Apr;61(1):1-10 [6] Jochen Fingberg, Marit Hansen et al.: Integrating Data Custodians in eHealth Grids Security and Privacy Aspects (http:/ / www. ccrl-nece. de/ publications/ paper/ public/ LR-06-262. pdf), NEC Lab Report, 2006 [7] Eysenbach G (2001). "What is e-health?" J Med Internet Res 2001;3(2):e20 (http:/ / www. jmir. org/ 2001/ 2/ e20/ ) [8] Della Mea V (2001). "What is e-Health (2): The death of telemedicine?" J Med Internet Res 2001;3(2):e22 (http:/ / www. jmir. org/ 2001/ 2/ e22/ )
eHealth
[9] Pagliari C, Sloan D, Gregor P, Sullivan F, Detmer D, Kahan JP, Oortwijn W, MacGillivray S. "What Is eHealth (4): A Scoping Exercise to Map the Field" J Med Internet Res 2005;7(1):e9 (http:/ / www. jmir. org/ 2005/ 1/ e9/ ) [10] Ahern DK, Kreslake JM, Phalen JM. "What Is eHealth (6): Perspectives on the Evolution of eHealth Research" J Med Internet Res 2006;8(1):e4 (http:/ / www. jmir. org/ 2006/ 1/ e4/ ) [11] Oh et al. "What Is eHealth: A Systematic Review of Published Definitions." J Med Internet Res 2005;7(1):e1 (http:/ / www. jmir. org/ 2005/ 1/ e1/ ) [12] e-Diabetes on the website of the Dutch Diabetes foundation (http:/ / www. diabetesfederatie. nl/ ndf/ e-diabetes. html) [13] Journal of Medical Internet Research (http:/ / www. jmir. org/ 2010/ 5/ e61/ ) [14] The International Society for Mental Health Online, (https:/ / www. ismho. org/ home. asp). [15] Journal of Medical Internet Research (http:/ / www. jmir. org/ ) [16] University of California Davis, http:/ / psy. psychiatryonline. org/ cgi/ content/ full/ 48/ 2/ 135
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Year Source (M = Medline, W = Wilson Business Abstracts, G = Google) Definition 1999 Mitchell (G) A new term needed to describe the combined use of electronic communication and information technology in the health sector. The use in the health sector of digital data transmitted, stored and retrieved electronically for clinical, educational and administrative purposes, both at the local site and at a distance. 2000 JHITA (G) Internet-related healthcare activities 2000 McLendon (M) Ehealth refers to all forms of electronic healthcare delivered over the Internet, ranging from informational, educational and commercial "products" to direct services offered by professionals, non-professionals, businesses or consumers themselves. Ehealth includes a wide variety of the clinical activities that have traditionally characterized telehealth, but delivered through the Internet. Simply stated, Ehealth is making healthcare more efficient, while allowing patients and professionals to do the previously impossible. 2000 DeLuca, Enmark - Frontiers of Medicine (W) (M) E-health is the embryonic convergence of wide-reaching technologies like the Internet, computer telephony/interactive voice response, wireless communications, and direct access to healthcare providers, care management, education, and wellness. 2000 Pretlow (G) E-health is the process of providing health care via electronic means, in particular over the Internet. It can include teaching, monitoring ( e.g. physiologic data), and interaction with health care providers, as well as interaction with other patients afflicted with the same conditions. 2001 Eysenbach (M) e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology 2001 Strategic Health Innovations (G) The use of information technology in the delivery of health care. 2001 Robert J Wood Foundation (G) EHealth is the use of emerging information and communication technology, especially the Internet, to improve or enable health and health care. 2001 Ontario Hospital eHealth Council (G) EHealth is a consumer-centred model of health care where stakeholders collaborate utilizing ICTs including Internet technologies to manage health, arrange, deliver, and account for care, and manage the health care system. 2003 COACH (G) The leveraging of the information and communication technology (ICT) to connect provider and patients and governments; to educate and inform health care professionals, managers and consumers; to stimulate innovation in care delivery and health system management; and, to improve our health care system. 2003 eEurope - eHealth2003 (G) The application of information and communication technologies (ICT) across the whole range of functions which one way or another, affect the health of citizens and patients. 2003 Regional Office for the Eastern Mediterranean - World Health Organization (G) E-health is a new term used to describe the combined use of electronic communication and information technology in the health sector OR is the use, in the health sector, of digital data-transmitted, stored and retrieved electronically-for clinical, educational and administrative purposes, both at the local site and at a distance
eHealth 2003 HMS Europe (G) The practice of leveraging the Internet to connect caregivers, healthcare systems and hospitals with consumers
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References
Health 2.0
Health 2.0 (as well as the closely related concept of Medicine 2.0[1] ) are terms representing the possibilities between health care, eHealth and Web 2.0, and has come into use after a recent spate of articles in newspapers, and by Physicians and Medical Librarians.[2] [3] A concise definition of Health 2.0 is the use of a specific set of Web tools (blogs, Podcasts, tagging, search, wikis, etc) by actors in health care including doctors, patients, and scientists, using principles of open source and generation of content by users, and the power of networks in order to personalize health care, collaborate, and promote health education.[4] A possible explanation for the reason that Health has generated its own "2.0" term are its applications across health care in general, and in particular it potential in public health promotion. One author describes the potential as "limitless."[5]
Definitions and Inclusions

As yet there is no common agreement amongst experts and participants, but from the Health 2.0 wiki (not the Wikipedia version), there are several competing & complementary definitions of Health 2.0. The "Traditional" definition focuses on technology as an enabler for care collaboration-"The use of social software and light-weight tools to promote collaboration between patients, their caregivers, medical professionals, and other stakeholders in health" [6] An expanded version of the traditional definition breaks this into components: 1. Personalized search that looks into the long tail, but cares about the user experience. 2. Communities that capture the accumulated knowledge of patients and caregivers; and cliniciansand explain it to the world, 3. Intelligent tools for content deliveryand transactions, and 4. Better integration of data with content. All with the result of patients increasingly guiding their own care[7] Scott Shreeve considers Health 2.0 as a wider system reform-"New concept of health care wherein all the constituents (patients, physicians, providers, and payers) focus on health care value (outcomes/price) and use competition at the medical condition level over the full cycle of care as the catalyst for improving the safety, efficiency, and quality of health care"[8] Then there's the concept of Health 2.0 as a participatory process between patient and clinician (with a couple of notable twists) -Health 2.0 defines the combination of health data and health information with (patient) experience through the use of ICT, enabling the citizen to become an active and responsible partner in his/her own health and care pathway.[9] Health 2.0 is participatory healthcare. Enabled by information, software, and community that we collect or create, we the patients can be effective partners in our own healthcare, and we the people can participate in reshaping the health system itself. [10] Definitions of Medicine 2.0 appear to be very similar but typically include more scientific and research aspectsMedicine 2.0: "Medicine 2.0 applications, services and tools are Web-based services for health care consumers, caregivers, patients, health professionals, and biomedical researchers, that use Web 2.0 technologies as well as semantic web and virtual reality tools, to enable and facilitate specifically social networking, participation, apomediation, collaboration, and openness within and between these user groups. [11] [12] Published in JMIR Tom Van de Belt, Lucien Engelen et al systematic review found 46 (!) unique definitions of health 2.0 [13]
Health 2.0 Health 2.0 is evolving fast as the technology landscape evolves. As does the desire by healthcare professionals and by patients to embrace new technology and new services. However, already there are signs of Health 3.0 emerging. Health 3.0 [14] is defined as delivery of healthcare which leverages the use of elements of Semantic Web such as location awareness, the emerging Internet of Things and embedded sensors. Doctors 2.0 [15] are also leveraging social media as a powerful tool. Dedicated social networking sites for doctors like Sermo, SocialMD, Ozmosis etc. are doctor-only social networks. Here the doctors get a chance to interact and share knowledge with other doctors. Doctors are entering into the field of blogging, where they share their experiences in the form of case studies, give insight about diseases, discuss common healthcare issues, and offer simple remedies for them.
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Overview
Health 2.0 refers to a number of related concepts including telemedicine, electronic medical records, mHealth, Connected Health , and the use of the internet by patients themselves such as through messageboards, blogs, and other more advanced systems. A key concept is that patients themselves should have greater insight and control into information generated about them. Traditional models of medicine had patient records (held on paper or a proprietary computer A model of Health 2.0 system) that could only be accessed by a physician or other medical professional. Physicians acted as gatekeepers to this information, telling patients test results when and if they deemed necessary. Such a model operates relatively well in situations such as acute care, where information about specific blood results would be of little use to a lay person, or in general practice where results were generally benign. However, in the case of complex chronic diseases, psychiatric disorders, or diseases of unknown etiology patients were at risk of being left without well-coordinated care because data about them was stored in a variety of disparate places and in some cases might contain the opinions of healthcare professionals which were not to be shared with the patient. Increasingly, medical ethics considers such actions to be medical paternalism and are discouraged in modern medicine. A hypothetical example demonstrates the increased engagement of a patient operating in a Health 2.0 setting: A patient goes to see their primary care physician with a presenting complaint, having first ensured his own medical record was up to date via the internet. The treating physician might make a diagnosis or send for tests, the results of which could be transmitted direct to the patient's electronic medical record. If a second appointment is needed the patient will have had time to research what the results might mean for them, what diagnoses may be likely, and may have communicated with other patients who have had a similar set of results in the past. On a second visit a referral might be made to a specialist. The patient might have the opportunity to search for the views of other patients on the best specialist to go to, and in combination with their primary care physician decides who to see. The specialist gives a diagnosis along with a prognosis and potential options for treatment. The patient has the opportunity to research these treatment options and take a more proactive role in coming to a joint decision with their healthcare provider. They can also choose to submit more data about themselves, such as through a personalized genomics service to identify any risk factors that might improve or worsen their prognosis. As treatment commences, the patient can track their health outcomes through a data-sharing patient community to determine whether the treatment is having an effect for them, and can stay up to date on research opportunities and clinical trials for their condition. They also have the social support of communicating with other patients diagnosed with the same condition throughout the world.
Health 2.0
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Level of use of Web 2.0 in Health Care

Partly due to weak definitions, the novelty of the endeavor, and as an entrepreneurial (rather than academic) movement, little empirical evidence exists to understand how much Web 2.0 is being used in general. While it has been estimated that nearly one-third of the 100m Americans who have looked for health information online say that they or people they know have been significantly helped by what they found.,[16] this study considers only the broader use of the Internet for health management. A study examining physician practice has suggested that a segment of 245,000 physicians in the U.S are using Web 2.0 for their practice, indicating that use is beyond the stage of the early adopter with regard to physicians and Web 2.0.[17]
Types of Web 2.0 technology in Health Care

Web 2.0 is commonly associated with technologies such as weblogs (blogs), social bookmarking, wikis, podcasts, RSS feeds (and other forms of many-to-many publishing), social software, and web application programming interfaces (APIs) (see main article Web 2.0).
Types of Web 2.0 use in Health Care

The following are examples of uses that have been documented in academic literature.
Purpose Description Case example in academic literature [18] RSS, Podcasts and search tools Users All (medical professionals and public) All (medical professionals and public)
Staying informed Used to stay informed of latest developments in a particular field
Medical education
Use for professional development for doctors, and public health promotion for by public health professionals and the general public Web 2.0 tools use in daily practice for medical professionals to find information and make decisions
How podcasts can be used on the move to increase total [19] available educational time or the many applications of [20] these tools to public health
Collaboration and practice
Google searches revealed the correct diagnosis in 15 out of 26 cases (58%, 95% confidence interval 38% to 77%) in a 2005 [21] study
Doctors, Nurses
Managing a Patients who use search tools to find out particular disease information about a particular condition
Shown that patients have different patterns of usage depending Public on if they are newly diagnosed or managing a severe long-term illness. Long-term patients are more likely to [22] connect to a community in Health 2.0 All (medical professionals and public)
Sharing data for research
Completing patient-reported outcomes and Disease specific communities for patients with rare conditions aggregating the data for personal and aggregate data on treatments, symptoms, and outcomes to scientific research improve their decision making ability and carry out scientific [23] research such as observational trials
Criticism of the use of Web 2.0 in health

Several criticism have been raised in the use of Web 2.0 in health. Firstly, the limitations for Medical Doctors (MDs) to use Google as a diagnostic tool, which may be more effective only for conditions with unique symptoms and signs that can easily be used as search term.[21] Secondly, long-held concerns exist about the effects of patients obtaining information online, such as the idea that patients may delay seeking medical advice.[24] Finally concerns exist about the quality of user generated content leading to misinformation, though one study has suggested that in certain support groups only 6% of information is factually wrong and that only 3% reported that online advice had caused serious harm.[25] Other venues of information are likely to be less useful to the general public.
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Tensions in Health 2.0

Hughes et al. (2009) argue there are four major tensions represent in the literature on Health/Medicine 2.0: these are over the lack of clear definitions; issues around the loss of control over information that doctors perceive; safety and the dangers of inaccurate information; and issues of ownership and privacy.[4]
References
[1] Eysenbach G Medicine 2.0: Social Networking, Collaboration, Participation, Apomediation, and Openness (http:/ / www. jmir. org/ 2008/ 3/ e22/ ). J Med Internet Res 2008;10(3):e22 [2] Economist, The. 2007. Health 2.0 : Technology and society: Is the outbreak of cancer videos, bulimia blogs and other forms of user generated medical information a healthy trend? The Economist, September 6: 73-74 [3] Giustini, D. 2006. How Web 2.0 is changing medicine: Editorial. British Medical Journal, 333:1283-1284 [4] Hughes B, Joshi I, Wareham J. Health 2.0 and Medicine 2.0: Tensions and Controversies in the Field (http:/ / www. jmir. org/ 2008/ 3/ e23/ ), Journal of Medical Internet Research, 10(3): e23 [5] Crespo, R. 2007. Virtual Community Health Promotion. Preventing Chronic Disease, 4(3) : 75 [6] Adapted from Jane Sarasohn-Kahn's "Wisdom of Patients" report, by Matthew Holt, Last updated June 6, 2008 [7] "Holt's evolving view of a moving target", by Matthew Holt, updated from original September 20, 2007 presentation at Health 2.0 Conference, October 22, 2008 [8] Last updated on May 25, 2007 Scott Shreeve, MD - January 24, 2007) [9] "Patient 2.0 Empowerment", Lodewijk Bos, Andy Marsh, Denis Carroll, Sanjeev Gupta, Mike Rees, Proceedings of the 2008 International Conference on Semantic Web & Web Services SWWS08, Hamid R. Arabnia, Andy Marsh (eds), pp.164167, 2008, http:/ / www. icmcc. org/ pdf/ ICMCCSWWS08. pdf [10] Ted Eytan MD, June 6, 2008, http:/ / www. tedeytan. com/ 2008/ 06/ 13/ 1089 [11] Eysenbach, Gunther. Medicine 2.0 Congress Website launched (and: Definition of Medicine 2.0 / Health 2.0) [12] Gunther Eysenbach's random research rants (Blog). URL: http:/ / gunther-eysenbach. blogspot. com/ 2008/ 03/ medicine-20-congress-website-launched. html. Accessed: 2008-03-07 [13] Van De Belt TH, Engelen LJ, Berben SAA, Schoonhoven L Definition of Health 2.0 and Medicine 2.0: A Systematic Review (J Med Internet Res 2010;12(2):e18)URL: http:/ / www. jmir. org/ 2010/ 2/ e18/ [14] http:/ / www. disruptivedemographics. com/ 2010/ 04/ health-30-new-data-on-aging-boomers. html [15] http:/ / www. socialf5. com/ blog/ 2011/ 05/ web-2-0-doctors/ [16] Levy, M. 2007. Online Health. Assessing the Risk and Opportunity of Social and One-to-One Media. Jupiter Research. Accessed at http:/ / www. jupiterresearch. com/ bin/ item. pl/ research:vision/ 103/ id=98795/ on 20/1/2008 [17] Manhattan Research, LLC. 2007. White Paper: Physicians and Web 2.0: 5 Things You Should Know about the Evolving Online Landscape for Physicians. Accessed at http:/ / www. manhattanresearch. com/ TTPWhitePaper. aspx on 20/1/2008 [18] Giustini, D. 2006. How Web 2.0 is changing medicine: Editorial. British Medical Journal, 333:1283-1284 [19] Sandars J, Haythornthwaite C. New horizons for e-learning in medical education: ecological and Web 2.0 perspectives. Med Teach. 2007 May;29(4):307-10. Review. PMID: 17786742 [20] Crespo R. Virtual community health promotion. Prev Chronic Dis. 2007 Jul;4(3):A75. PMID: 17572979 [21] Tan H, Ng JHK. Googling for a diagnosisuse of Google as a diagnostic aid: internet based study. BMJ 2006;333:1143-5. [22] Ferguson, T. ePatients white paper. www.e-patients.net. 2007. URL: http:/ / www. e-patients. net/ e-Patients_White_Paper. pdf on 22/1/08 [23] Frost JH, Massagli MP, Wicks P, Heywood J (2008) How the social web supports patient experimentation with a new therapy: The demand for patient-controlled and patient-centered informatics, AMIA Annu Symp Proc 6:217-21 [24] Ojalvo, H. E. (1996). Online advice: Good medicine or cyber-quackery? Retrieved September 22, 2007 from http:/ / www. acponline. org/ journals/ news/ dec96/ cybrquak. htm [25] Economist, The. 2007. Health 2.0 : Technology and society: Is the outbreak of cancer videos, bulimia blogs and other forms of user generated medical information a healthy trend? The Economist, September 6: 73-74
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External links
The term Health 2.0 (http://www.health2con.com/) is trademarked by this conference series A set of useful resource on the Health 2.0 Wiki (http://health20.org/wiki/Main_Page) including a list of Health 2.0 companies (http://health20.org/wiki/Health_2.0_Companies) A list of medical wiki websites (http://www.healthplusplus.com/wiki/Main_Page) including links to more than 40 medical wikis Medicine 2.0 Congress (http://www.medicine20congress.com/), which is similar or identical to the Health 2.0 concept, but also includes "Science 2.0" " Web Site Harnesses Power of Social Networks (http://www.washingtonpost.com/wp-dyn/content/article/ 2009/10/18/AR2009101801844.html)", The Washington Post, October 19, 2009
Health 2.0 Chapters

Health 2.0 Boston Chapter Health 2.0 Hawaii Chapter Health 2.0 Japan Chapter Health 2.0 NYC Chapter (http://health20nyc.org/)
Public health informatics

Public Health Informatics has been defined as the systematic application of information and computer science and technology to public health practice, research, and learning. It is one of the subdomains of Biomedical Informatics.
United States
In the United States, public health informatics is practiced by individuals in public health agencies at the federal and state levels and in the larger local health jurisdictions. Additionally, research and training in public health informatics takes place at a variety of academic institutions. At the federal Centers for Disease Control and Prevention in Atlanta, Georgia, the Public Health Informatics and Technology Program Office (PHITPO) [1] focuses on advancing the state of information science and applies digital information technologies to aid in the detection and management of diseases and syndromes in individuals and populations. The three sub-units within PHITPO include Informatics Practice, Policy and Coordination; Informatics Solutions and Operations; and Informatics Research and Development. The bulk of the work of public health informatics in the United States, as with public health generally, takes place at the state and local level, in the state departments of health and the county or parish departments of health. At a state health department the activities may include: collection and storage of vital statistics (birth and death records); collection of reports of communicable disease cases from doctors, hospitals, and laboratories, used for infectious disease surveillance; display of infectious disease statistics and trends; collection of child immunization and lead screening information; daily collection and analysis of emergency room data to detect early evidence of biological threats; collection of hospital capacity information to allow for planning of responses in case of emergencies. Each of these activities presents its own information processing challenge.
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Collection of public health data

Before the advent of the internet, public health data in the United States, like other healthcare and business data, were collected on paper forms and stored centrally at the relevant public health agency. If the data were to be computerized they required a distinct data entry process, were stored in the various file formats of the day and analyzed by mainframe computers using standard batch processing. (TODO: describe CDC-provided DOS/desktop-based systems like TIMSS (TB), STDMIS (Sexually transmitted diseases); Epi-Info for epidemiology investigations; and others ) Since the beginning of the World Wide Web, public health agencies with sufficient information technology resources have been transitioning to web-based collection of public health data, and, more recently, to automated messaging of the same information. In the years roughly 2000 to 2005 the Centers for Disease Control and Prevention, under its National Electronic Disease Surveillance System [2] (NEDSS), built and provided free to states a comprehensive web and message-based reporting system called the NEDSS Base System [2] (NBS). Due to the funding being limited and it not being wise to have fiefdom-based systems, only a few states and larger counties have built their own versions of electronic disease surveillance systems, such as Pennsylvania's PA-NEDSS [3]. These do not provide timely full intestate notification services causing an increase in disease rates versus the NEDSS federal product. To promote interoperability, the CDC has encouraged the adoption in public health data exchange of several standard vocabularies and messaging formats from the health care world. The most prominent of these are: the Health Level 7 (HL7) standards for health care messaging; the LOINC system for encoding laboratory test and result information; and the Systematized Nomenclature of Medicine (SNOMED) vocabulary of health care concepts. Since about 2005, the CDC has promoted the idea of the Public Health Information Network to facilitate the transmission of data from various partners in the health care industry and elsewhere (hospitals, clinical and environmental laboratories, doctors' practices, pharmacies) to local health agencies, then to state health agencies, and then to the CDC. At each stage the entity must be capable of receiving the data, storing it, aggregating it appropriately, and transmitting it to the next level. A typical example would be infectious disease data, which hospitals, labs, and doctors are legally required to report to local health agencies; local health agencies must report to their state public health department; and which the states must report in aggregate form to the CDC. Among other uses, the CDC publishes the Morbidity and Mortality Weekly Report (MMWR) based on these data acquired systematically from across the United States. Major issues in the collection of public health data are: awareness of the need to report data; lack of resources of either the reporter or collector; lack of interoperability of data interchange formats, which can be at the purely syntactic or at the semantic level; variation in reporting requirements across the states, territories, and localities.
Storage of public health data

Storage of public health data shares the same data management issues as other industries. And like other industries, the details of how these issues play out are affected by the nature of the data being managed. Due to the complexity and variability of public health data, like health care data generally, the issue of data modeling presents a particular challenge. While a generation ago flat data sets for statistical analysis were the norm, today's requirements of interoperability and integrated sets of data across the public health enterprise require more sophistication. The relational database is increasingly the norm in public health informatics. Designers and implementers of the many sets of data required for various public health purposes must find a workable balance between very complex and abstract data models such as HL7's Reference Information Model (RIM) or CDC's Public Health Logical Data Model [4], and simplistic, ad hoc models that untrained public health practitioners come up with and feel capable of working with. Due to the variability of the incoming data to public health jurisdictions, data quality assurance is also a major issue.
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Analysis of public health data

The need to extract usable public health information from the mass of data available requires the public health informaticist to become familiar with a range of analysis tools, ranging from business intelligence tools to produce routine or ad hoc reports, to sophisticated statistical analysis tools such as DAP/SAS and PSPP/SPSS, to Geographical Information Systems (GIS) to expose the geographical dimension of public health trends.
Applications in health surveillance and epidemiology

SAPPHIRE (Health care) or Situational Awareness and Preparedness for Public Health Incidences and Reasoning Engines is a semantics-based health information system capable of tracking and evaluating situations and occurrences that may affect public health.
References
[1] [2] [3] [4] http:/ / www. cdc. gov/ osels/ ph_informatics_technology/ index. html http:/ / www. cdc. gov/ nedss/ https:/ / www. nedss. state. pa. us/ nedss/ http:/ / www. cdc. gov/ phin/ library/ documents/ pdf/ PHIN_LDM_User_Guide_v1. 0. pdf
Public Health Informatics and Information Systems by D.A. Ross, A.R. Hinman, K. Saarlas, and W.H. Foege (Hardcover - Oct 16, 2002) ISBN 0-387-95474-0 A Vision for More Effective Public Health Information Technology (http://papers.ssrn.com/sol3/papers. cfm?abstract_id=962532) on SSRN Olmeda, Christopher J. (2000). Information Technology in Systems of Care. Delfin Press. ISBN 978-0-9821442-0-6 http://www.fda.gov/fdac/features/596_info.html on FDA Health Data Tools and Statistics (http://phpartners.org/health_stats.html) and make sure you dont get stabbed or raped
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Applications in Healthcare Management

Health Administration Informatics
The emerging field of Health administration informatics is concerned with the evaluation, acquisition, implementation and day to day operation of information technology systems in support of all administration and clinical functions within the health care industry. The closely-related field of biomedical informatics is primarily focused on the use of information systems for acquisition and application of patients' medical data, whereas nursing informatics deals with the delivery, administration and evaluation of patient care and disease prevention. What remains unclear, however, is how this emerging discipline should relate to the myriad of previously existing sub specializations within the broad umbrella of health informatics - including clinical informatics (which itself includes sub areas such as oncology informatics), bioinformatics and healthcare management informatics - particularly in light of the proposed "fundamental theorem" of biomedical informatics posed by Friedman in early 2009. The field of health administration informatics is emerging as attention continues to focus on the costly mistakes made by some health care organizations whilst implementing electronic medical records. [1]
Relevance within the health care industry

In a recent survey of health care CIOs and Information System (IS) directors, increasing patient safety and reducing medical errors was reported as among the top business issues. Two other key findings were that: two-thirds of respondents indicated that the number of FTEs in their IT department will increase in the next 12 months; and three-quarters of respondents indicated that their IT budgets would be increasing. The most likely staffing needs reported by the health care executives are network and architecture support (HIMMS, 2005). The government and private insurers are beginning to pay hospitals more for higher quality careand the only way to measure quality, and then improve it, is with more information technology. Hospital spending on such gear is expected to climb to $30.5 billion next year , from $25.8 billion in 2004, according to researcher Dorenfest Group (Mullaney and Weintraub, 2005). This fundamental change in health care (pay for performance) means that hospitals and other health care providers will need to develop, adapt and maintain all of the technology necessary to measure and improve on quality. Physicians have traditionally lagged behind in their use of technology (i.e., electronic patient records). Only 7% of physicians work for hospitals, and so the task of wooing them is an extremely delicate task (Mullaney and Weintraub, 2005).
Careers
The market demand for a specialized advanced degree that integrates Health Care Administration and Informatics is growing as the concept has gained support from the academic and professional communities. Recent articles in Health Management Technology cite the importance of integrating information technology with health care administration to meet the unique needs of the health care industry. The health care industry has been estimated to be around 10 years behind other industries in the application of technology and at least 10 to 15 years behind in leadership capability from the technology and perhaps the business perspective (Seliger, 2005; Thibault, 2005). This means there is quantifiable demand in the work force for health care administrators who are also prepared to lead in
Health Administration Informatics the field of health care administration informatics. In addition, the increasing costs and difficulties involved in evaluating the projected benefits from IT investments are requiring health care administrators to learn more about IT and how it affects business processes. The health care Chief Information Officer (CIO) must be able to build enterprise wide systems that will help reduce the administrative cost and streamline the automation of administrative processes and patient record keeping. Increasingly, the CIO is relied upon for specialized analytical and collaborative skills that will enable him/her to build systems that health care clinicians will use. A recent well-publicized debacle (shelving of a $34 million computer system after three months) at a top U. S. hospital underlines the need for leaders who understand the health care industry information technology requirements (Connolly, 2005). Several professional organizations have also addressed the need for academic preparation that integrates the two specializations addressed by UMUCs MSHCAI degree. In the collaborative response to the Office of the National Coordinator for Health Information Technology (ONCHIT) request for information regarding future IT needs, thirteen major health and technology organizations endorsed a Common Framework to support health information exchange in the United States, while protecting patient privacy. The response cited the need for continuing education of health information management professionals as a significant barrier to implementation of a National Health Information Network (NHIN) (The Collaborative Response, 2005).
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References
Connolly, C. (2005, March 21) Cedars-Sinai doctors cling to Pen and paper. The Washington Post. Health Informatics World Wide (2005, March). Health informatics index site. Retrieved March 30, 2005 from [2]. Healthcare Information and Management Systems Society (HIMSS) (2005, February). 16th annual HIMSS leadership survey sponsored by Superior Consultant Company. Retrieved 3/30/2005 from [3]. Mullaney, T. J., & Weintraub, A. (2005 March 28). The digital hospital. Business Week 3926, 76. Seliger, R. (2005). Healthcare IT tipping point. Health Management Technology 26(3), 48-49. The Collaborative Response to the Office of the National Coordinator for Health Information Technology Request for Information (2005, January). Retrieved March 30, 2005 from [4]. Thibault, B. (2005). Making beautiful music together. Behavioral Health 26(3), 28-29.
External links
University of Maryland University College [5] University of Alabama - Birmingham [6] University of Illinois at Chicago [7]
References
[1] [2] [3] [4] [5] [6] [7] (http:/ / www. healthcareitnews. com/ story. cms?id=9413) http:/ / www. hiww. org/ us. html http:/ / www. himss. org/ 2005survey/ docs/ Healthcare_CIO_finalreport. pdf http:/ / world. std. com/ ~goldberg/ collaborativeresponsenhin. pdf http:/ / umuc. edu/ programs/ grad/ mshai/ http:/ / main. uab. edu/ shrp/ default. aspx?pid=77369 http:/ / healthinformatics. uic. edu/
Medical integration environment
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Medical integration environment

Medical integration environment (MIE) are specialised tools to simplify the sharing a medical and related data between medical equipment and electronic health records. Technically it is similar to an Enterprise Service Bus but with several extra features allowing for legacy systems that do not use web services messaging. Typically they use Java Message Service most Enterprise Application Integration systems can be modified to be used as an MIE but may lack the crucial HL7 and Arden syntax for storing medical knowledge. The largest company working in the e-health integration market is SeeBeyond who was purchased by Sun Microsystems in 2005. Other companies include TIBCO and BEA Systems Raleigh Holdings International [1] claims to be the first company specialising in MIE with the Medi2 and Medi2-NG software packages.
References
[1] http:/ / www. raleighholdings. com
Health information exchange

Health information exchange (HIE) is defined as the mobilization of healthcare information electronically across organizations within a region, community or hospital system. HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care. HIE is also useful to Public Health authorities to assist in analyses of the health of the population. HIE systems facilitate physicians and clinicians meeting high standards of patient care through electronic participation in a patient's continuity of care with multiple providers. Secondary health care provider benefits include reduced expenses associated with: duplicate tests, time involved in recovering missing patient information, paper, ink and associated office machinery, manual printing, scanning and faxing of documents, the physical mailing of entire patient charts, and manual phone communication to verify delivery of traditional communications, referrals and test results. According to an internal study at Sushoo Health Information Exchange [1], a single-clinician practice spends $17,160/year associated with the current method of exchanging patients' health information. Formal organizations are now emerging to provide both form and function for health information exchange efforts, both on independent and governmental/regional levels. These organizations are, in many cases, enabled and supported financially by statewide health information exchange grants from the Office of the National Coordinator for Health Information Technology. These grants were legislated into the HITECH components of the American Reinvestment and Recovery Act in 2009.[2] The latter organizations (often called Regional Health Information Organizations, or RHIOs) are ordinarily geographically defined entities which develop and manage a set of contractual conventions and terms, arrange for the means of electronic exchange of information, and develop and maintain HIE standards.[3] In the United States, federal and state regulations regarding HIEs and HIT (health information technology) are still being defined. Federal regulations such as "Meaningful Use" legislation[4] as well as the implementation of some state governments of state-sponsored HIEs (such as the North Carolina HIE[5] ) in addition to fluctuating health care regulations among the states are rapidly changing the face of this relatively new industry. HIEs and RHIOs continue to struggle to achieve self-sustainability and the vast majority remain tied to Federal, State, or Independent grant funding in order to remain operational; with some exceptions such as the Indiana HIE.[6]
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Established HIE Communities

Chesapeake Regional Information System for our Patients (CRISP) [7]: Chesapeake Regional Information System for our Patients (CRISP) is a non-profit corporation that is implementing health information exchange in the state of Maryland. The organization also serves as the Health IT Extension Center for Maryland. CRISP was created by Johns Hopkins Medicine, MedStar Health, the University of Maryland Medical System and Erickson Retirement Communities.[8] Audacious Inquiry serves as program director and technical architect for the health information exchange while Dynamed Solutions provides project management and organizational support under CRISP. Northern Virginia Regional Health Information Organization (NoVA RHIO) [9]: NoVA RHIO serves as the health information exchange organization for northern Virginia. The NOVA RHIO organization recently began a pilot to ensure that electonic copies of patient medication histories are available from Pharmacies in the region's emergency departments.[10] e-Health Network of Long Island (EHNLI) [11]: e-Health Network of Long Island is a non-profit RHIO servicing eastern Nassau county and all of Suffolk County in Long Island, New York. Members of the EHNLI include Stony Brook University Medical Center, Winthrop-University Hospital, Southampton Hospital, and other various hospitals, adult long-term care facilities, and community physicians. HealthUnity is the primary technology provider. EHNLI's headquarters are located in Stony Brook, NY. Southern Tier HealthLink NY (STHL) [12]: STHL is a non-profit New York RHIO designed as a partnership which brings together health care providers and consumers in Central New York with technology that will improve health care quality, access, and safety while reducing costs. Sushoo Health Information Exchange [1]: Sushoo is an independent HIE operating on the community level in multiple states. OpenHRE Community [13]: The OpenHRE Community is a consortium of communities and organizations throughout the United States that are working together to achieve secure and sustainable health information exchange via utilization of the OpenHRE Toolkit, an open source software suite originally developed by Browsersoft, Inc. OpenHRE was used to deploy the Nation's first Multiple Health Market Health Information Exchange between Indianapolis, Boston and Mendocino CA. Health Monitoring Systems [14]: Health Monitoring Systems is a private firm that connects hundreds of hospitals to public health departments throughout the United States primarily for the sake of syndromic surveillance. Public health and hospital users are able to see regional emergency department activity. LIPIX - Long Island Patient Information Exchange [15]: An independent, not-for-profit corporation established to develop a Regional Health Information Organization (RHIO) for Nassau county in Long Island, NY. Headquartered in Manhasset, NY. Healthcare Access San Antonio (HASA) [16]: A health care consortium and OpenHRE Community Contributor serving the medically uninsured in Bexar County, TX. HASA participants include the seven major safety net hospitals, City of San Antonio Metropolitan Health District (Immunization Data) and a network of community FQHCs serving the uninsured of San Antonio. The SecureShare centralized community repository contains demographic and clinical records for over 500,000 uninsured patients.
Health information exchange CareSpark [17]: CareSpark is an innovative effort underway in the central Appalachian region that is working to improve health through the collaborative use of health information. The CareSpark region includes 17 counties in the Tri-Cities Tennessee and Virginia area with approximately 750,000 residents, 21 hospitals, and 1,200 physicians. Eastern Kern County Information Technology Association (EKCITA) [18]: A rural community based 501.c3 not-for-profit corporation and OpenHRE Contributor in Southern California. EKCITA has enabled sharing of electronic health files and clinical data for public health, patient care, and research purposes. The EKCITA deployment provides community caregivers access to over 32,000 local patient health profiles. Bayou Teche Community Health Network (ByNet, Franklin LA.) [19]: A non-profit, rural health network and OpenHRE Contributor comprising community health centers, local and regional hospitals and FQHCs, a social service agency, a tribal health clinic, a regional State of Louisiana Office of Public Health, and a coalition of over seventy St. Mary Parish organizations. The ByNet centralized repository contains demographic and clinical records that will exceed 100,000 patients. Medical Information Network - North Sound [20]: The Medical Information Network - North Sound is a Washington state-based HIE consisting of three members: Skagit Valley Hospital, Island Hospital, and United General Hospital. Kansas Health and Environment (KDHE) Diabetes Quality of Care Project [21]: The Kansas Diabetes Quality of Care Project involves over 68 funded organizations at 90 provider sites across the State of Kansas. This effort has electronically connected many of these sites to allow the collection and analysis of patient diabetes data by KDHE personnel for improving quality of care. Over 350 health professionals participate in this program with representation from over 50% of Kansas counties. KDHE is an OpenHRE Contributor. Big Bend RHIO [22]: The BBRHIO is a 501.c3 not for profit Florida Corporation that aims to deliver an enhanced level of patient centered care. Headquartered in Tallahassee, Florida. Idaho Health Data Exchange [23]:The Idaho Health Data Exchange, Inc., a 501(c)(6) non-profit corporation, was established to govern the development and implementation of a health information exchange in Idaho. We are governed by a Board of Directors which provides direction and oversight to our project. The Board includes representation from both the public and private sectors, including the health care delivery and financing systems, health care providers, Idaho Employer Coalition and consumers. The IHDE was created as a result of the efforts of the Health Quality Planning Commission. The Health Quality Planning Commission was created by the 2006 Legislature. The Commission was charged with promoting improved quality of care and health outcomes through investment in health information technology. HealthBridge [24]: Southwest Ohio, North Central Kentucky and South Eastern Indiana Regions. Indiana Health Information Exchange [25]: The Indiana Health Information Exchange (IHIE) provides several health information exchange services throughout the state of Indiana. IHIE provides a clinical messaging result delivery service and a clinical quality improvement services called Quality Health First(tm) [26] MA-SHARE: Massachusetts SHARE (Simplifying Healthcare Among Regional Entities) is a regional collaborative initiative operated by the Massachusetts Health Data Consortium. In June, 2009, MA-SHARE merged with the New England Healthcare Exchange Network. New England Healthcare Exchange Network (NEHEN) [27]:
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Health information exchange NEHEN, headquartered in Waltham, MA is a 501.c3 organization with more than thirty five member organizations and founded in 1998. Initially focused on payor/provider information exchange, after the merger with MA-SHARE, NEHEN now offers electronic prescribing support and clinical information exchange to its members as well as healthcare administrative transaction support. Redwood MedNet HIE [28]: Redwood MedNet, located in Mendocino County, California, is a community based nonprofit 501(c)(3) organization operating a clinical results delivery service in a thinly populated 5000-square-mile (13000km2) rural region on the north Pacific coast. The MidSouth eHealth Alliance [29]: The MidSouth eHealth Alliance is a community wide information system that helps health care providers in the treatment of patients. Providers are as doctors, nurses, healthcare workers, hospitals, and clinics. The MidSouth eHealth Alliance is based in Memphis, TN. Michiana Health Information Network [30]: The Michiana Health Information Network is a health information exchange that support institutions and health care providers and clinicians in northern Indiana and southwestern Michigan. University of Pittsburgh Medical Center [31]: UPMC is an integrated healthcare delivery network that provides healthcare services to a large portion of the population in Western Pennsylvania. Incorporating an HIE solution has enabled the integration of patient data across the enterprise in addition to the flexibility of the creation and rapid deployment of enterprise wide applications that leverage integrated patient data. Clalit Health Services / Rambam Medical Center / Sheba Medical Center [32]: Covering more than half of Israels population, this HIE has been operational since 2001. The HIE includes 16 hospitals (8100+ beds), 1300 primary and specialized clinics and 400 pharmacies, and collectively provides health services to close to over 5 million patients. Wisconsin Health Information Exchange [33] WHIN - Western Health Information Network [34]: WHIN - Western Health Information Network (formerly Long Beach Network for Health) Is an independent, community based not-for-profit corporation operating a regional Health Information Exchange for Southern California. Headquartered in Long Beach, CA. MedVirginia [35]: MedVirginia Solution is an HIE serving central Virginia. US Government Agencies - VA and DoD [36]: The U.S. Department of Veteran's Affairs and the Department of Defense have several very large health information exchange projects including FHIE, BHIE, CHDR, and VLER.
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References
[1] http:/ / www. sushoo. com/ [2] <http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=11113&cached=true> [3] Overhage JM, Evans L, Marchibroda J (2005). "Communities' readiness for health information exchange: the National Landscape in 2004" (http:/ / www. jamia. org/ cgi/ pmidlookup?view=long& pmid=15561785). J Am Med Inform Assoc 12 (2): 10712. doi:10.1197/jamia.M1680. PMC551542. PMID15561785. . [4] http:/ / healthit. hhs. gov/ portal/ server. pt?open=512& objID=1325& parentname=CommunityPage& parentid=1& mode=2 [5] http:/ / www. nchica. org/ GetInvolved/ NCHIE/ intro. htm [6] http:/ / www. ihie. org/ [7] http:/ / www. crisphealth. org/ [8] Sentementes, Gus G. (2009). "Md. takes lead in electronic medical records" (http:/ / www. baltimoresun. com/ technology/ bal-bz. records18sep18,0,4470380. story). . Retrieved 2009-11-26 [9] http:/ / www. novarhio. org [10] Washington Business Journal (2010-08-23). "INOVA pilots Electronic Records Program" (http:/ / washington. bizjournals. com/ washington/ stories/ 2010/ 08/ 23/ story9. html). . Retrieved 2010-10-09 [11] http:/ / ehealthnetworkli. org/ [12] http:/ / www. sthlny. com [13] http:/ / www. openhre. org/ [14] http:/ / www. healthmonitoringsystems. com/ [15] http:/ / www. lipix. org/ [16] http:/ / www. ha-sa. org/ [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] http:/ / www. carespark. com/ http:/ / www. ekcita. org/ http:/ / www. bynet-la. org/ http:/ / min-ns. org/ http:/ / www. kdheks. gov/ diabetes/ qcp. htm/ http:/ / www. bbrhio. org/ http:/ / www. idahohde. org/ http:/ / www. healthbridge. org/ http:/ / www. ihie. org/ http:/ / www. qualityhealthfirst. org http:/ / www. nehen. org http:/ / www. redwoodmednet. org/ index. html http:/ / www. midsoutheha. org/ http:/ / www. mhin. com/ http:/ / www. upmc. com http:/ / www. clalit. co. il/ HE-IL/ english. com http:/ / www. whie. org http:/ / whinit. org/ http:/ / www. medvirginia. net http:/ / www1. va. gov/ VADODHEALTHITSHARING/ index. asp
McGowan JJ, Overhage JM, Barnes M, McDonald CJ (April 2004). "Indianapolis I3: the third generation Integrated Advanced Information Management Systems". J Med Libr Assoc 92 (2): 17987. PMC385298. PMID15098046. eHealth Initiative, Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations, August, 2005 Hagland, Mark (2009). Transformative Quality: The Emerging Revolution in Health Care Performance (http:// www.productivitypress.com/shopping_cart/products/product_detail.asp?sku=PP8492& isbn=9781420084924&parent_id=4&pc). Productivity Press/Taylor & Francis Group, LLC, New York. ISBN 978-1-4200-8492-4.
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External links
HHS Health Information Technology (http://healthit.hhs.gov/) HIMSS information about HIE and RHIO (http://www.himss.org/ASP/topics_rhio.asp)
Hospital information system

There are various titles and acronyms which all declare similar approaches to managing the information flow and storage in hospital routine services, as Hospital Information System (HIS), or Healthcare Information System, or Clinical Information System (CIS), or Patient Data Management System (PDMS)
are comprehensive, integrated information systems designed to manage the medical, administrative, financial and legal aspects of a hospital and its service processing. Traditional approaches encompass paper-based information processing as well as resident work position and mobile data acquisition and presentation.
Architecture
Generally all breeds are supported in client-server architectures for networking and processing. Most work positions for HIS currently are resident types. Mobile computing started with wheeled PC stands and now comes to age with tablet-PC and smartphone applications. Up to date a cloud computing alternative is not recommended, as data security of individual patient records services are not well accepted by the public[1] [2] [3] [4] . HIS can be composed of one or a few software components with specialty-specific extensions as well as of a large variety of sub-systems in medical specialties, as e.g. Laboratory Information System (LIS), Radiology Information System (RIS) or Picture archiving and communication system (PACS). CISs are sometimes separated from HISs in that one focuses the flow management and clinical-state-related data and the other focuses the patient-related data with the doctor's letters and the electronic patient record. However, the naming varies from vendor to vendor and from hospital to hospital.
Standardization
There is no standardization but for data formats and for data interchange, as with the HL7 initiative supported by ISO.
Aim
As an area of medical informatics the aim of an HIS is to achieve the best possible support of patient care and outcome and administration by presenting data where needed and acquiring data when generated with networked electronic data processing.
Benefits of HIS
Easy Access to Patient Data to generate varied records, including classification based on demographic, gender, age, and so on. It is especially beneficial at ambulatory (out-patient) point, hence enhancing continuity of care. As well as, Internet-based access improves the ability to remotely access such data. [5]
Hospital information system It helps as a decision support system for the hospital authorities for developing comprehensive health care policies.[6] Efficient and accurate administration of finance, diet of patient, engineering, and distribution of medical aid. Improved monitoring of drug usage, and study of effectiveness. This leads to the reduction of adverse drug interactions while promoting more appropriate pharmaceutical utilization. Enhances information integrity, reduces transcription errors, and reduces duplication of information entries.[7]
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Further reading
Shortliffe EH, Cimino JJ eds. Biomedical Informatics: Computer Applications in Health Care and Biomedicine (3rd edition). New York: Springer, 2006 National Institute of Clinical Excellence, Principles of Best Practice in Clinical Audit. London: NICE, 2002. (ISBN 1-85775-976-1) Olmeda, Christopher J. (2000). Information Technology in Systems of Care. Delfin Press. ISBN 978-0-9821442-0-6 Payne PR, Greaves AW, Kipps TJ., CRC Clinical Trials Management System (CTMS): an integrated information management solution for collaborative clinical research, AMIA Annu Symp Proc. 2003;:967.
References
[1] Google to launch consumer health care service later this year (2008) (http:/ / www. betanews. com/ article/ Google-to-launch-consumer-health-care-service-later-this-year/ 1204759033) [2] Google's No Bellwether for Healthcare Cloud Services (2011) (http:/ / www. ecommercetimes. com/ story/ 72829. html) [3] Google Health Service Discontinued (2011) (http:/ / www. ehealthnews. eu/ industry/ 2672-google-health-service-discontinued) [4] Google Health termination statement on log-in webpage (https:/ / www. google. com/ accounts/ ServiceLogin?service=health& nui=1& continue=https:/ / health. google. com/ health/ p/ & followup=https:/ / health. google. com/ health/ p/ & rm=hide) [5] Clinical information systems definition in biohealthmatics.com, a US based career networking portal for biotechnology and healthcare informatics (http:/ / www. biohealthmatics. com/ technologies/ his/ cis. aspx) [6] Healthcare information systems definition in Centre for Development of Advanced Computing, an Indian research centre for health informatics (http:/ / www. cdac. in/ html/ his/ sushrut. aspx) [7] Hospital information systems definition given by US based EMRConsultant.com (http:/ / www. emrconsultant. com/ education/ hospital-information-systems)
Healthcare workflow
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Healthcare workflow
Workflow in healthcare is an important term for today's physicians. The workflow describes the full process of how the office and patient work with each other. From the moment the patient calls to setup and exam, to the billers working on the claims, this is all inclusive in a true workflow. Office administrators are tasked with improving the workflow and making it more econimical and more time efficient. Workflow in recent years has started to conjurr an additional meaning - how an EMR operates. See also healthcare procedures. Workflow management technology (see workflow) is not used in healthcare as often as in other domains. However workflow engines can be very useful to manage processes. Workflow software can be also used as a clinical guideline (see clinical guideline execution engine. guideline execution engine
External links
http://healthcareworkflow.wordpress.com
Computer physician order entry

Computerized physician order entry (CPOE) is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at point-of-care or off-site, provides error-checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges. Although manufacturers use the term Computerized Physician Order Entry, a more accurate term would be Computerized Prescriber Order Entry or Computerized Pharmacist Order Entry. Order Entry is in the domain of the pharmacist because it is the pharmacist's responsibility to verify any entry into the system concerning the use of medications within the hospital or health care system. Order clarification requests will be enhanced by improved communication and collaboration amongst the health care team.
Terminology related to order entry

Filler
The application responding to, i.e., performing, a request for services (orders) or producing an observation. The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.
Order
A request for a service from one application to a second application. In some cases an application is allowed to place orders with itself.
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Order detail segment

One of several segments that can carry order information. Future ancillary specific segments may be defined in subsequent releases of the Standard if they become necessary.
Placer
The application or individual originating a request for services (order).
Placer order group

A list of associated orders coming from a single location regarding a single patient.
Features of CPOE systems

Features of the ideal computerized physician order entry system (CPOE) include: Ordering Physician orders are standardized across the organization, yet may be individualized for each doctor or specialty by using order sets. Orders are communicated to all departments and involved caregivers, improving response time and avoiding scheduling problems and conflict with existing orders. Patient-centered decision support The ordering process includes a display of the patient's medical history and current results and evidence-based clinical guidelines to support treatment decisions. Often uses medical logic module and/or Arden syntax to facilitate fully integrated Clinical Decision Support Systems (CDSS). Patient safety features The CPOE system allows real-time patient identification, drug dose recommendations, adverse drug reaction reviews, and checks on allergies and test or treatment conflicts. Physicians and nurses can review orders immediately for confirmation. Intuitive Human interface The order entry workflow corresponds to familiar "paper-based" ordering to allow efficient use by new or infrequent users. Regulatory compliance and security Access is secure, and a permanent record is created, with electronic signature. Portability The system accepts and manages orders for all departments at the point-of-care, from any location in the health system (physician's office, hospital or home) through a variety of devices, including wireless PCs and tablet computers. Management The system delivers statistical reports online so that managers can analyze patient census and make changes in staffing, replace inventory and audit utilization and productivity throughout the organization. Data is collected for training, planning, and root cause analysis for patient safety events. Billing Documentation is improved by linking diagnoses (ICD-9-CM or ICD-10-CM codes) to orders at the time of order entry to support appropriate charges.
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Patient safety benefits of CPOE

In the past, physicians have traditionally hand-written or verbally communicated orders for patient care, which are then transcribed by various individuals (such as unit clerks, nurses, and ancillary staff) before being carried out. Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to errors and injuries to patients, according to a 1999 Institute of Medicine (IOM) report.[1] A follow up IOM report in 2001 advised use of electronic medication ordering, with computer- and internet-based information systems to support clinical decisions.[2] Prescribing errors are the largest identified source of preventable hospital medical error. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay.[3] Studies of computerized physician order entry (CPOE) has yielded evidence that suggests the medication error rate can be reduced by 80%, and errors that have potential for serious harm or death for patients can be reduced by 55%,[4] and other studies have also suggested benefits.[5] Further, in 2005, CMS and CDC released a report that showed only 41 percent of prophylactic antibacterials were correctly stopped within 24 hours of completed surgery. The researchers conducted an analysis over an eight-month period, implementing a CPOE system designed to stop the administration of prophylactic antibacterials. Results showed CPOE significantly improved timely discontinuation of antibacterials from 38.8 percent of surgeries to 55.7 percent in the intervention hospital.[6] CPOE/e-Prescribing systems can provide automatic dosing alerts (for example, letting the user know that the dose is too high and thus dangerous) and interaction checking (for example, telling the user that 2 medicines ordered taken together can cause health problems). In this way, specialists in pharmacy informatics work with the medical and nursing staffs at hospitals to improve the safety and effectiveness of medication use by utilizing CPOE systems.
Risks of CPOE
CPOE presents several possible dangers by introducing new types of errors.[7] [8] Prescriber and staff inexperience may cause slower entry of orders at first, use more staff time, and is slower than person-to-person communication in an emergency situation. Physician to nurse communication can worsen if each group works alone at their workstations. Automation causes a false sense of security, a misconception that when technology suggests a course of action, errors are avoided. These factors contributed to an increased mortality rate in the Children's Hospital of Pittsburgh's Pediatric ICU when a CPOE systems was introduced.[9] In other settings, shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses. Frequent alerts and warnings can interrupt work flow, causing these messages to be ignored or overridden due to alert fatigue. CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia.[10] Introducing CPOE to a complex medical environment requires ongoing changes in design to cope with unique patients and care settings, close supervision of overrides caused by automatic systems, and training, testing and re-training all users.
Implementation
CPOE systems can take years to install and configure. Despite ample evidence of the potential to reduce medication errors, adoption of this technology by doctors and hospitals in the United States has been slowed by resistance to changes in physician's practice patterns, costs and training time involved, and concern with interoperability and compliance with future national standards.[11] According to a study by RAND Health, the US healthcare system could save more than 81 billion dollars annually, reduce adverse medical events and improve the quality of care if it were to widely adopt CPOE and other health information technology.[12] As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computers enter practice, increased use of CPOE is predicted. A 2004 survey by Leapfrog found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOE within 2 years.[13] Several high profile failures of CPOE implementation have occurred,[14] so a major effort must be focused on change management, including restructuring workflows, dealing
Computer physician order entry with physicians' resistance to change, and creating a collaborative environment. An early success with CPOE by the United States Department of Veterans Affairs (VA) is the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patients record at any computer in the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders by CPOE, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests. The world's first successful implementation of a CPOE system was at El Camino Hospital in Mountain View, California in the early 1970s. The Medical Information System (MIS) was originally developed by a software and hardware team at Lockheed in Sunnyvale, California, which became the TMIS group at Technicon Instruments Corporation. The MIS system used a light pen to allow physicians and nurses to quickly point and click items to be ordered. As of 2005, one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT). The NHS component, known as the "Connecting for Health Programme",[15] includes office-based CPOE for medication prescribing and test ordering and retrieval, although some concerns have been raised about patient safety features.[16] In 2008, the Massachusetts Technology Collaborative and the New England Healthcare Institute (NEHI) published research showing that 1 in 10 patients admitted to a Massachusetts community hospital suffered a preventable medication error. The study argued that Massachusetts hospitals could prevent 55,000 adverse drug events per year and save $170 million annually if they fully implemented CPOE. The findings prompted the Commonwealth of Massachusetts to enact legislation requiring all hospitals to implement CPOE by 2012 as a condition of licensure.[17] In addition, the study [18] also concludes that it would cost approximately $2.1 million to implement a CPOE system, and a cost of $435,000 to maintain it in the state of Massachusetts while it saves annually about $2.7 million per hospital. And the hospitals will still see payback within 26 months through reducing hospitalizations generated by error. Despite the advantages and cost savings, the CPOE is still not well adapted by many hospitals in the US. The Leapfrogs 2008 Survey[19] showed that most hospitals are still not complying with having a fully implemented, effective CPOE system. The CPOE requirement became more challenging to meet in 2008 because the Leapfrog introduced a new requirement: Hospitals must test their CPOE systems with Leapfrogs CPOE Evaluation Tool. So the number of hospitals in the survey considered to be fully meeting the standard dropped to 7% in 2008 from 11% the previous year. Though the adoption rate seems very low in 2008, it is still an improvement from 2002 when only 2% of hospitals met this Leapfrog standard.
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External links
Certification Commission for Healthcare Information Technology (CCHIT) [20] AHRQ National Resource Center for Health IT [21]
Notes
[1] Institute of Medicine (1999). "To Err Is Human: Building a Safer Health System (1999)" (http:/ / fermat. nap. edu/ catalog/ 9728. html#toc). The National Academies Press. . Retrieved 2006-06-20. [2] Institute of Medicine (2001). "Crossing the Quality Chasm: A New Health System for the 21st Century" (http:/ / www. nap. edu/ books/ 0309072808/ html). The National Academies Press. . Retrieved 2006-06-29. [3] The Institute of Medicine (2006). "Preventing Medication Errors" (http:/ / www. nap. edu/ catalog/ 11623. html). The National Academies Press. . Retrieved 2006-07-21. [4] David W. Bates, MD, et al. (1998). "Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors" (http:/ / jama. ama-assn. org/ cgi/ content/ abstract/ 280/ 15/ 1311) (abstract). JAMA 280 (15): 13111316. doi:10.1001/jama.280.15.1311. PMID9794308. . Retrieved 2006-06-20.

[5] http:/ / www. eurekalert. org/ pub_releases/ 2010-05/ sumc-ssf042710. php [6] http:/ / www. beckersasc. com/ asc-quality-infection-control/ study-cpoe-systems-improve-prophylactic-antibacterial-use-in-surgical-patients. html [7] Ross Koppel, PhD, et al. (2005). "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors" (http:/ / jama. ama-assn. org/ cgi/ content/ abstract/ 293/ 10/ 1197) (abstract). JAMA 293 (10): 11971203. doi:10.1001/jama.293.10.1197. PMID15755942. . Retrieved 2006-06-28. [8] Lohr, Steve (2005-03-09). "Doctors' Journal Says Computing Is No Panacea" (http:/ / www. nytimes. com/ 2005/ 03/ 09/ technology/ 09compute. html?ei=5089& en=402b792e748d99a2& ex=1268110800& adxnnl=1& partner=rssyahoo& adxnnlx=1150474153-xVix1BcYkvTKJpuLyHStrQ). The New York Times. . Retrieved 2006-07-15. [9] Yong Y. Han, Joseph A. Carcillo, Shekhar T. Venkataraman, Robert S.B. Clark, R. Scott Watson, Trung C. Nguyen, Hlya Bayir, and Richard A. Orr (2005). "Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System" (http:/ / pediatrics. aappublications. org/ cgi/ gca?submit. x=79& submit. y=13& submit=sendit& gca=116/ 6/ 1506). Pediatrics 116 (6): 15061512. doi:10.1542/peds.2005-1287. PMID16322178. . Retrieved 2006-07-30. [10] Santell, John P (2004). "Computer Related Errors: What Every Pharmacist Should Know" (http:/ / www. usp. org/ pdf/ EN/ patientSafety/ slideShows2004-12-09. pdf) (PDF). United States Pharmacopia. . Retrieved 2006-06-20. [11] Kaufman, Marc (2005-07-21). "Medication Errors Harming Millions, Report Says. Extensive National Study Finds Widespread, Costly Mistakes in Giving and Taking Medicine" (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2006/ 07/ 20/ AR2006072000754. html). The Washington Post. pp.A08. . Retrieved 2006-07-21. [12] RAND Healthcare: Health Information Technology: Can HIT Lower Costs and Improve Quality? (http:/ / www. rand. org/ pubs/ research_briefs/ RB9136/ index1. html) Retrieved on July 8, 2006 [13] "Hospital Quality & Safety Survey" (http:/ / www. leapfroggroup. org/ media/ file/ Leapfrog-Survey_Release-11-16-04. pdf) (PDF). The Leapfrog Group. 2004. . Retrieved 2006-07-08. [14] Connolly, Ceci (2005-03-21). "Cedars-Sinai Doctors Cling to Pen and Paper" (http:/ / www. washingtonpost. com/ wp-dyn/ articles/ A52384-2005Mar20. html). The Washington Post. . Retrieved 2006-08-03. [15] NHS Connecting for Health: Delivering the National Programme for IT (http:/ / www. connectingforhealth. nhs. uk/ delivery/ ) Retrieved August 4, 2006 [16] C J Morris, B S P Savelyich, A J Avery, J A Cantrill and A Sheikh (2005). "Patient safety features of clinical computer systems: questionnaire survey of GP views" (http:/ / qhc. bmjjournals. com/ cgi/ content/ full/ 14/ 3/ 164). Quality and Safety in Health Care 14 (3): 164168. doi:10.1136/qshc.2004.011866. PMC1744017. PMID15933310. . Retrieved 2006-07-08. [17] http:/ / www. todayshospitalist. com/ index. php?b=articles_read& cnt=614 [18] Dolan, Pamela L. (2008). "Insurer finds EMRs won't pay off for its doctors." (http:/ / www. ama-assn. org/ amednews/ 2008/ 03/ 10/ bil20310. htm). American Medical News. . Retrieved 2009-10-13. [19] "Leapfrog Hospital Survey Results." (http:/ / www. leapfroggroup. org/ media/ file/ leapfrogreportfinal. pdf) (PDF). The Leapfrog Group. 2008. . Retrieved 2009-10-13. [20] http:/ / www. cchit. org/ [21] http:/ / healthit. ahrq. gov/ cpoe
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ICU quality and management tools
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The intensive care unit (ICU) is one of the major components of the current health care system. The advances in supportive care and monitoring resulted in significant improvements in the care of surgical and clinical patients. Nowadays aggressive surgical therapies as well as transplantation are made safer by the monitoring in a closed environment, the surgical ICU, in the post-operative period. Moreover, the care and full recovery of many severely ill clinical patients as those with life-threatening infections occurs as a result of intensive care. However, despite many significant advances in various fields as mechanical ventilation, renal replacement therapy, antimicrobial therapy and hemodynamic monitoring this increased knowledge and the wise use of such technology is not available for all patients. Shortage of ICU beds are an important issue, however even when ICU beds are available significant variability in treatment and in the adherence to evidence-based interventions do not occur.
Tools for ICU quality monitoring

Several measures of ICU performance have been proposed in the past 30 years. It is intuitive, and correct, to assume that ICU mortality may be a useful marker of quality. However, crude mortality rates does not take into consideration the singular aspects of each specific patient population that is treated in a certain geographic region, hospital or ICU. Therefore approaches looking for standardized mortality ratios that are adjusted for disease severity, comorbidities and other clinical aspects are often sought. Severity of illness is usually evaluated by scoring systems that integrates clinical, physiologic and demographic variables. Scoring systems are interesting tools to describe ICU populations and explain their different outcomes. The most frequently used are the APACHE II, SAPS II and MPM. However, newer scores as APACHE IV and SAPS III have been recently introduced in clinical practice. More than only using scoring systems, one should search for a high rate of adherence to clinically effective interventions. Adherence to interventions as deep venous thrombosis prophylaxis, reduction of ICU-acquired infections, adequate sedation regimens and decreasing and reporting serious adverse events are essential and have been accepted as benchmarking of quality. The complex task of collecting and analyzing data on performance measures are made easier when clinical information systems are available. Although several clinical information systems focus on important aspects as computerized physician order entry systems and individual patient tracking information, few have attempted to gather clinical information generating full reports that provide a panorama of the ICU performance and detailed data on several domains as mortality, length of stay, severity of illness, clinical scores, nosocomial infections, adverse events and adherence to good clinical practice. Through implementing quality initiatives, increasing the quality of care and patient safety are major and feasible goals. Such systems (for example: Epimed Monitor [1]) are available for clinical use and may facilitate the process of care on a daily basis and provide data for an in-depth analysis of ICU performance.
References
A.O. Gallesio,D. Ceraso,F. Palizas (July 2006). "Improving quality in the intensive care unit setting". Crit Care Clin. 22 (3): 547571. doi:10.1016/j.ccc.2006.04.002. ISSN3. PMID16893740. A. Garland (June 2005). "Improving the ICU: part 1" [2]. Chest (American College of Chest Physicians) 127 (6): 21512164. doi:10.1378/chest.127.6.2151. PMID15947333. A. Garland (June 2005). "Improving the ICU: part 2" [3]. Chest (American College of Chest Physicians) 127 (6): 21652179. doi:10.1378/chest.127.6.2165. PMID15947334. T.R. McMillan and R.C. Hyzy (February 2007). "Bringing quality improvement into the intensive care unit" [4]. Critical Care Medicine (Society of Critical Care Medicine and Lippincott Williams & Wilkins) 35 (2 Suppl): S59S65. doi:10.1097/01.CCM.0000252914.22497.44. PMID17242607.
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References
[1] [2] [3] [4] http:/ / www. epimedsolutions. com/ index. php?lang=english http:/ / www. chestjournal. org. / cgi/ content/ full/ 127/ 6/ 2151 http:/ / www. chestjournal. org. / cgi/ content/ full/ 127/ 6/ 2165 http:/ / www. ccmjournal. com. / pt/ re/ ccm/ abstract. 00003246-200702001-00009. htm
Laboratory information management system

Sometimes known as a laboratory information system (LIS) or laboratory management system (LMS),[1] a laboratory information management system (LIMS) is a software-based laboratory and information management system that offers a set of key features that support a modern laboratory's operations. Those key features include but are not limited to workflow and data tracking support, flexible architecture, and smart data exchange interfaces, which fully "support its use in regulated environments."[2] The features and uses of a LIMS have evolved over the years from simple sample tracking to an enterprise resource planning tool that manages multiple aspects of laboratory informatics.[3]
Laboratories around the world depend on a LIMS to manage data, assign rights, manage inventory, and more.
Due to the rapid pace at which laboratories and their data management needs shift, the definition of LIMS has become somewhat controversial. As the needs of the modern laboratory vary widely from lab to lab, what is needed from a laboratory information management system also shifts. The end result is the definition of a LIMS will shift based on who you ask and what their vision of the modern lab is.[2] Dr. Alan McLelland of the Institute of Biochemistry, Royal Infirmary, Glasgow highlighted this problem in the late 1990s by explaining how a LIMS is perceived by an analyst, a laboratory manager, an information systems manager, and an accountant, "all of them correct, but each of them limited by the users' own perceptions."[4] Historically the LIMS, LIS, and process development execution system (PDES) have all performed similar functions. A LIMS has generally targeted environmental, research, or commercial analysis, such as pharmaceutical or petrochemical work, whereas the term "LIS" has tended to be used to reference lab informatics systems in the forensics and clinical markets, which often required special case management tools. The distinction between a LIS and LIMS has blurred in recent times, however, as most LIMS now fully support comprehensive case-centric data.[5] The PDES normally addresses a wider scope, including, for example, virtual manufacturing techniques, while not necessarily integrating with laboratory equipment. More recently, LIMS products have been expanding even farther beyond their original purpose of sample management. Assay data management, data mining, data analysis, and electronic laboratory notebook (ELN) integration are all features that have been added to many LIMS,[6] enabling the realization of translational medicine completely within a single software solution.
History of LIMS
Up until the late 1970s, the management of laboratory samples and the associated analysis and reporting were time-consuming manual processes often riddled with transcription errors. This gave some organizations impetus to streamline the collection of data and how it was reported. Custom in-house solutions were developed by a few individual laboratories, while some enterprising entities at the same time sought to develop a more commercial reporting solution in the form of special instrument-based systems.[7]
Laboratory information management system In 1982 the first generation of LIMS was introduced in the form of a single centralized minicomputer, which offered laboratories the first opportunity to utilize automated reporting tools. As the interest in these early LIMS grew, industry leaders like Gerst Gibbon of the Federal Energy Technology Centre in Pittsburgh began planting the seeds of LIMS-related conferences. By 1988 the second-generation commercial offerings were tapping into relational databases to expand LIMS into more application-specific territory, and International LIMS Conferences were in full swing. As personal computers became more powerful and prominent, a third generation of LIMS emerged in the early 1990s. These new LIMS took advantage of the developing client/server architecture, allowing laboratories to implement better data processing and exchanges.[7] By 1995 the client/server tools had developed to the point of allowing processing of data anywhere on the network. Web-enabled LIMS were introduced the following year, enabling researchers to extend operations outside the confines of the laboratory. From 1996 to 2002 additional functionality was included in LIMS, from wireless networking capabilities and georeferencing of samples, to the adoption of XML standards and the development of Internet purchasing.[7]
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Technology
Laboratory information management operations
Sample management The core function of LIMS has traditionally been the management of samples.[7] This typically is initiated when a sample is received in the laboratory, at which point the sample will be registered in the LIMS. This registration process may involve accessioning the sample and producing barcodes to affix to the sample container. Various other parameters such as clinical or phenotypic information corresponding with the sample are also often recorded. The LIMS then tracks chain of custody as well as sample location. Location tracking usually involves assigning the sample to a particular freezer location, often down to the granular level of shelf, rack, box, row, and column. Other event tracking such as freeze and thaw cycles that a sample undergoes in the laboratory may be required.
A lab worker matches blood samples to documents. With a LIMS, this sort of sample management is made more efficient.
Modern LIMS have implemented extensive configurability as each laboratory's needs for tracking additional data points can vary widely. LIMS vendors cannot typically make assumptions about what these data tracking needs are, and therefore vendors must create LIMS that are adaptable to individual environments. LIMS users may also have regulatory concerns to comply with such as CLIA, HIPAA, GLP, and FDA specifications, affecting certain aspects of sample management in a LIMS solution.[8] One key to compliance with many of these standards is audit logging of all changes to LIMS data, and in some cases a full electronic signature system is required for rigorous tracking of field-level changes to LIMS data. Instrument and application integration Modern LIMS offer an increasing amount of integration with laboratory instruments and applications. A LIMS may create control files that are "fed" into the instrument and direct its operation on some physical item such as a sample tube or sample plate. The LIMS may then import instrument results files to extract data for quality control assessment of the operation on the sample. Access to the instrument data can sometimes be regulated based on chain of custody assignments or other security features if need be.
Laboratory information management system A relatively new development in LIMS products is the ability to import and manage raw assay data results. Modern targeted assays such as qPCR and deep sequencing can produce tens of thousands of data points per sample. Furthermore, in the case of drug and diagnostic development as many as 12 or more assays may be run for each sample. In order to track this data, a LIMS solution needs to be adaptable to many different assay formats at both the data layer and import creation layer, while maintaining a high level of overall performance. Some LIMS products address this by simply attaching assay data as BLOBs to samples, but this limits the utility of that data in data mining and downstream analysis. Electronic data exchange The exponentially growing volume of data created in laboratories coupled with increased business demands and focus on profitability have pushed LIMS vendors to increase attention to how their LIMS handles electronic data exchanges. Attention must be paid to how an instrument's input and output data is managed, how remote sample collection data is imported and exported, and how PDAs and tablet technology integrates with the LIMS. The successful transfer of data files in Microsoft Excel and other formats, as well as the import and export of data to Oracle, SQL, and Microsoft Access databases is a pivotal aspect of a the modern LIMS.[9] In fact, the transition "from proprietary databases to standardized database management systems such as Oracle ... and SQL" has arguably had one of the biggest impacts on how data is managed and exchanged in laboratories.[10] Additional functions Aside from the key functions of sample management, instrument and application integration, and electronic data exchange, there are numerous additional operations that can be managed in a LIMS. This includes but is not limited to[3] [6] [11] : audit management fully track and maintain an audit trail barcode handling assign one or more data points to a barcode format; read and extract information from a barcode chain of custody assign roles and groups that dictate access to specific data records and who is managing them compliance follow regulatory standards that affect the laboratory customer relationship management handle the demographic information and communications for associated clients document management process and convert data to certain formats; manage how documents are distributed and accessed instrument calibration and maintenance schedule important maintenance and calibration of lab instruments and keep detailed records of such activities inventory and equipment management measure and record inventories of vital supplies and laboratory equipment manual and electronic data entry provide fast and reliable interfaces for data to be entered by a human or electronic component method management provide one location for all laboratory process and procedure (P&P) and methodology to be housed and managed
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Laboratory information management system personnel and workload management organize work schedules, workload assignments, employee demographic information, and financial information quality assurance and control gauge and control sample quality, data entry standards, and workflow reports create and schedule reports in a specific format; schedule and distribute reports to designated parties time tracking calculate and maintain processing and handling times on chemical reactions, workflows, and more
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Client-side LIMS options

A LIMS can use many delivery technologies. Thin-client LIMS implementations including Java-based solutions often require no special client-side installation resulting in less IT involvement in their deployment. An exception is a web-based solution based on .NET technologies, requiring a special plug-in on the client and may be limited to Microsoft only browsers. This can lead to issues in instances where there is a high penetration of Apple and Linux usage by lab technicians or researchers. Another concern regarding web-based and web-enabled deployment is possible exploitation by hackers where highly sensitive laboratory and research data may be compromised. Even with modern security methods in place, deploying a LIMS solution "outside the firewall" of an organization opens the LIMS to potential intrusion. The following represent the four most-used LIMS architectures, and their associated strengths and weaknesses: Thick-client A thick-client LIMS is a more traditional client/server architecture, with some of the system residing on the computer or workstation of the user (the client) and the rest on the server. The LIMS software is installed on the client computer, which does all of the data processing. Later it passes information to the server, which has the primary purpose of data storage. Most changes, upgrades, and other modifications will happen on the client side. This was one of the first architectures implemented into a LIMS, having the advantage of providing higher processing speeds (because processing is done on the client and not the server) and slightly more security (as access to the server data is limited only to those with client software). Additionally, thick-client systems have the added advantage of providing more interactivity and customization, though often at a greater learning curve. The disadvantages of client-side LIMS include the need for more robust client computers and more time-consuming upgrades, as well as a lack of base functionality through a web browser. The thick-client LIMS can become web-enabled through an add-on component.[12] [13] Thin-client A thin-client LIMS is a more modern architecture which offers full application functionality accessed through a device's web browser. The actual LIMS software resides on a server (host) which feeds and processes information without saving it to the user's hard disk. Any necessary changes, upgrades, and other modifications are handled by the entity hosting the server-side LIMS software, meaning all end-users see all changes made. To this end, a true thin-client LIMS will leave no "footprint" on the client's computer, and only the integrity of the web browser need be maintained by the user. The advantages of this system include significantly lower cost of ownership and fewer network and client-side maintenance expenses. However, this architecture has the disadvantage of requiring real-time server access, a need for increased network throughput, and slightly less functionality. A sort of hybrid architecture that incorporates the features of thin-client browser usage with a thick client exists in the form of a web-based LIMS.[12] [13]
Laboratory information management system Some LIMS vendors are beginning to rent hosted, thin-client solutions as "software as a service" (SaaS). These solutions tend to be less configurable than on premise solutions and are therefore considered for less demanding implementations such as laboratories with few users and limited sample processing volumes. Another implementation of the thin client architecture that's offered is the maintenance, warranty, and support (MSW) agreement. Pricing levels are typically based on a percentage of the license fee, with a standard level of service for 10 concurrent users being approximately 10 hours of supports and additional customer service at $200 per hour.[14] Though some may choose to opt out of an MSW after the first year, it's often more economical to continue the plan in order to receive updates to the LIMS, giving it a longer life span in the laboratory. Web-enabled A web-enables LIMS architecture is essentially a thick-client architecture with an added web browser component. In this setup, the client-side software has additional functionality that allows users to interface with the software through their device's browser. This functionality is typically limited only to certain functions of the web client. The primary advantage of a web-enabled LIMS is the end-user can access data both on the client side and the server side of the configuration. As in a thick-client architecture, updates in the software must be propagated to every client machine. However, the added disadvantages of requiring always-on access to the host server and the need for cross-platform functionality mean that additional overhead costs may arise.[12] [13] Web-based Arguably one of the most confusing architectures, web-based LIMS architecture is a hybrid of the thick- and thin-client architectures. While much of the client-side work is done through a web browser, the LIMS also requires the additional support of Microsoft's .NET Framework technology installed on the client device. The end result is a process that is apparent to the end-user through the Microrosoft-compatible web browser, but perhaps not so apparent as it runs thick-client-like processing in the background. In this case, web-based architecture has the advantage of providing more functionality through a more friendly web interface. The disadvantages of this setup are more sunk costs in system administration and support for Internet Explorer and .NET technologies, and reduced functionality on PDAs and tablets.[12] [13]
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LIMS configurability
LIMS implementations are notorious for often being lengthy and costly.[15] This is due in part to the diversity of requirements within each lab, but also to the inflexible nature of LIMS products for adapting to these widely varying requirements. Newer LIMS solutions are beginning to emerge that take advantage of modern techniques in software design that are inherently more configurable and adaptable particularly at the data layer than prior solutions. This means not only that implementations are much faster, but also that the costs are lower and the risk of obsolescence is minimized.
Standards covered by LIMS

A LIMS covers standards such as: 21 CFR Part 11 from the Food and Drug Administration (United States) ISO/IEC 17025 ISO 15189 Good laboratory practice
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LIMS vendors
Pardus eQMS::LIMS [16] Analytik Jena PerkinElmer LABWORKS LIMS LabLynx LabWare Labvantage Promium Sapio Sciences STARLIMS Thermo Fisher Scientific Waters Corporation The Weaver Group Inc. Kalliste Systems
Further reading
Gibbon, G.A. (1996). "A brief history of LIMS" [17] (PDF). Laboratory Automation and Information Management 32 (1): 15. doi:10.1016/1381-141X(95)00024-K. Wood, Simon (2007). "Comprehensive Laboratory Informatics: A Multilayer Approach" [18] (PDF). pp. 13.
References
[1] "2011 LIMS Buyers Guide: Introduction" (http:/ / files. limstitute. com/ share/ lbgonline/ introduction. htm). Laboratory Informatics Institute, Inc.. . Retrieved 2011-04-25. [2] "2011 Laboratory Information Management: So what is a LIMS?" (http:/ / sapiosciences. blogspot. com/ 2010/ 07/ so-what-is-lims. html). Sapio Sciences. . Retrieved 2011-04-25. [3] Vaughan, Alan. "LIMS: The Laboratory ERP" (http:/ / www. limsfinder. com/ BlogDetail. aspx?id=30648_0_29_0_C). LIMSfinder.com. . Retrieved 2011-04-25. [4] McLelland, Alan (1998). "What is a LIMS - a laboratory toy, or a critical IT component?" (http:/ / www. rsc. org/ pdf/ andiv/ tech. pdf), pp. 1. [5] "2011 LIMS Buyers Guide: How Do I Find the Right LIMS?" (http:/ / files. limstitute. com/ share/ lbgonline/ how_do_i_find_the_right_lims. htm). Laboratory Informatics Institute, Inc.. p. 3. . Retrieved 2011-04-25. [6] "2011 LIMS Buyers Guide: How Do I Find the Right LIMS?" (http:/ / files. limstitute. com/ share/ lbgonline/ how_do_i_find_the_right_lims. htm). Laboratory Informatics Institute, Inc.. pp. 14. . Retrieved 2011-04-25. [7] Gibbon, G.A. (1996). "A brief history of LIMS" (http:/ / www. sciencedirect. com/ science?_ob=ArticleURL& _udi=B6TH3-3VJRS4M-1& _user=10& _coverDate=05/ 31/ 1996& _rdoc=2& _fmt=high& _orig=browse& _origin=browse& _zone=rslt_list_item& _srch=doc-info(#toc#5271#1996#999679998#49189#FLP#display#Volume)& _cdi=5271& _sort=d& _docanchor=& _ct=30& _acct=C000050221& _version=1& _urlVersion=0& _userid=10& md5=f1570c2b4a71b1ea7fa0477673837b49& searchtype=a) (PDF). Laboratory Automation and Information Management 32 (1): 15. doi:10.1016/1381-141X(95)00024-K. . Retrieved 2011-04-26. [8] "Regulatory compliance drives LIMS" (http:/ / www. designworldonline. com/ articles/ 251/ 4/ Regulatory-compliance-drives-LIMS. aspx). Design World. 2007-02-21. . Retrieved 2011-04-26. [9] "2011 LIMS Buyers Guide: How Do I Find the Right LIMS?" (http:/ / files. limstitute. com/ share/ lbgonline/ how_do_i_find_the_right_lims. htm). Laboratory Informatics Institute, Inc.. p. 2. . Retrieved 2011-04-25. [10] Wood, Simon (2007). "Comprehensive Laboratory Informatics: A Multilayer Approach" (http:/ / www. starlims. com/ AL-Wood-Reprint-9-07. pdf), pp. 1. [11] "ASTM E1578 - 06 Standard Guide for Laboratory Information Management Systems (LIMS)" (http:/ / www. astm. org/ Standards/ E1578. htm). ASTM International. . Retrieved 2011-04-25. [12] O'Leary, Keith M.. "Selecting the Right LIMS: Critiquing technological strengths and limitations" (http:/ / www. scimag. com/ Selecting-the-Right-LIMS. aspx). Scientific Computing. . Retrieved 2011-04-26. [13] LabVantage Solutions, Inc. (2011). "How Differences in Technology Affect LIMS Functionality, Cost, & ROI" (http:/ / www. labvantage. com/ resources/ pdf/ whitepapers/ ThinClient1101JY21CYL. pdf), pp. 23. [14] "2011 LIMS Buyers Guide: How Do I Find the Right LIMS?" (http:/ / files. limstitute. com/ share/ lbgonline/ how_do_i_find_the_right_lims. htm). Laboratory Informatics Institute, Inc.. p. 4. . Retrieved 2011-04-25.

[15] http:/ / www. scientificcomputing. com/ articles-In-Industry-Insights-Examining-the-Risks-Benefits-and-Trade-offs-of-Today-LIMS-033110. aspx?terms=cramer [16] http:/ / lims. pardus. hr [17] http:/ / www. sciencedirect. com/ science?_ob=ArticleURL& _udi=B6TH3-3VJRS4M-1& _user=10& _coverDate=05%2F31%2F1996& _rdoc=2& _fmt=high& _orig=browse& _origin=browse& _zone=rslt_list_item& _srch=doc-info(%23toc%235271%231996%23999679998%2349189%23FLP%23display%23Volume)& _cdi=5271& _sort=d& _docanchor=& _ct=30& _acct=C000050221& _version=1& _urlVersion=0& _userid=10& md5=f1570c2b4a71b1ea7fa0477673837b49& searchtype=a [18] http:/ / www. starlims. com/ AL-Wood-Reprint-9-07. pdf
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Laboratory information system

A lab information system ("LIS") is a class of software that receives, processes, and stores information generated by medical laboratory processes. These systems often must interface with instruments and other information systems such as hospital information systems (HIS). A LIS is a highly configurable application which is customized to facilitate a wide variety of laboratory workflow models. Deciding on an LIS vendor is a major undertaking for all labs. Vendor selection typically takes months of research and planning. Installation takes from a few months to a few years depending on the complexity of the organization. There are as many variations of LISs as there are types of lab work. Some vendors offer a full-service solution capable of handling a large hospital lab's needs; others specialize in specific modules. Disciplines of laboratory science supported by LISs include hematology, chemistry, immunology, blood bank (Donor and Transfusion Management), surgical pathology, anatomical pathology, flow cytometry and microbiology. This article covers clinical lab which encompasses hematology, chemistry and immunology.
Basic operation
Laboratory Information Systems are often part of an integrated informatics solution which involves many disparate applications. Use of an LIS is a critical piece of the clinical IT spectrum of systems and contributes significantly to the overall care given to patients. The LIS is used in inpatient and outpatient settings and in many cases is designed to support both. From an outpatient/ambulatory perspective, LIS interaction frequently begins after a physician has arrived at an initial diagnosis. For example, a patient enters the hospital looking pale and complaining of fatigue. The physician, suspecting anemia, might decide to order a complete blood count (CBC). In an inpatient setting when that patient is admitted into the hospital, the system is used to order tests, provide specimen processing assistance, receive the results from analyzers and deliver lab reports to the attending physician.
Order entry and check in

An order is placed in the system usually by a physician or laboratory scientist. The order or lab request contains a list of tests to be performed on one or more patient specimens (e.g., blood or urine). In many cases, each order is tracked with a unique identifier. This identifier (which is usually a number) is often referred to as Lab ID. In this hypothetical case, a CBC is ordered which is a panel of sub-tests including white blood cell count, red cell blood count and other blood-related tests. A phlebotomist will be called on to collect the specimen(s) from the patient. Often, different specimens will be collected, so as to provide different tubes (each with a specific cap color) for each analyzer that will process the samples. In this case, the appropriate specimen (using a vacutainer tube with a lavender top) is taken from the patient and labeled with a bar code specimen label produced by the LIS. The LIS will print barcode labels (with the unique lab ID) for the draw tubes. In some cases, more advanced LIS products will also provide a unique identifier for each specimen. The newest of these systems are using RFID to eliminate human errors and automate the data capture. Serialized data through barcode or RFID provides the ability to track the specimen's chain of custody from the point it is taken from the patient to the point that it gets discarded. The specimen-accession-patient hierarchy is linked in a
Laboratory information system tree like numeric structure. In other cases,the patient is identified by a Lab ID linked to the patient's demographic record through the Hospital number.
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Specimen receiving
After the specimen is collected, it is sent/brought to the lab for processing typically in a batch. This event should be recorded in the LIS. On reception of the specimen in the testing lab, either manual or automated lab work can begin. Many tests, such as CBCs or Chemistry profiles, are performed by automated analyzers.
Send test orders to analyzers

Most LIS systems can be configured to download the specimen data to an analyzer either after the order is placed or when a specimen is received in a testing lab. When the specimen's barcode is read by the instrument, the unique ID from the specimen label is matched with the order previously downloaded to the instrument. This system is often called "Batch Download". A more efficient system is called "Host Query", where the instrument reads the barcode on the specimen and "queries" the LIS for the test orders. The LIS will be listening on a communication port for queries and will download the requests only when required. In cases where the LIS transmits data such as test orders or control messages to analyzers the communication is set up to be bi-directional.
Results entry
When results of lab tests are available, they are entered into the system manually or automatically downloaded from an instrument. Once these results are double-checked by the Medical Laboratory Scientist or autoverified, they are released. Released results are often automatically printed or written on lab reports which are delivered to the attending physician or clinic. Results must be verified and released to attending physicians as soon as possible.
Lab reporting
Lab Reports are the final output of all LIS systems and, in many cases, the primary LIS interaction with healthcare professionals outside the lab. The reports can either be printed or faxed in paper-based labs; they can be delivered via email or file in paperless labs. The degree to which an LIS supports customizable lab reports and flexibility in modes of delivery of results is one major factor in determining its success in the marketplace.
Basic features
Laboratory Information Systems commonly support the following features: Patient Check In Order Entry Specimen Processing Result(s) Entry Reporting Patient Demographics Physician Demographics
Laboratory information system
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Additional features
In addition LISs commonly support the following: Web-based order entry Web-based results inquiry Faxing and emailing of lab reports Custom report creation HL7 interfaces with reference labs and EMRs Preliminary reporting Final reporting Med tech worksheets Workload balancing Medicare medical necessity checking Billing Public health reporting Rule engines Report check by reputed pathologist and senior technologist
Types
There are many laboratory disciplines requiring the support of computerized informatics. These include: Hematology Chemistry Immunology Blood bank donor center Blood bank transfusion Surgical Pathology Pathology Cytology (Cytopathology) Microbiology Flow cytometry TB
External links
2005 Survey of LISs [1], College of American Pathologists
References
[1] http:/ / www. cap. org/ apps/ docs/ cap_today/ surveys/ 11_05_24-56_LISsurvey. pdf
mHealth
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mHealth
mHealth (also written as m-health or mobile health) is a term used for the practice of medicine and public health, supported by mobile devices. The term is most commonly used in reference to using mobile communication devices, such as mobile phones and PDAs, for health services and information. The mHealth field has emerged as a sub-segment of eHealth, the use of information and communication technology (ICT), such as computers, mobile phones, communications satellite, patient monitors, etc., for health services and information.[1] mHealth applications include the use of mobile devices in collecting community and clinical health data, delivery of healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vital signs, and direct provision of care (via mobile telemedicine).[2]
Medical nurse uses a mobile phone in Accra, Ghana
While mHealth certainly has application for industrialized nations, the field has emerged in recent years as largely an application for developing countries, stemming from the rapid rise of mobile phone penetration in low-income nations. The field, then, largely emerges as a means of providing greater access to larger segments of a population in developing countries, as well as improving the capacity of health systems in such countries to provide quality healthcare. Within the mHealth space, projects operate with a variety of objectives, including increased access to healthcare and health-related information (particularly for hard-to-reach populations); improved ability to diagnose and track diseases; timelier, more actionable public health information; and expanded access to ongoing medical education and training for health workers.[1]
Definitions
Mobile eHealth or mHealth broadly encompasses the use of mobile telecommunication and multimedia technologies as they are integrated within increasingly mobile and wireless health care delivery systems. The field broadly encompasses the use of mobile telecommunication and multimedia technologies in health care delivery. The term mHealth was coined by Professor Robert Istepanian as use of "emerging mobile communications and network technologies for healthcare."[3] A definition used at the 2010 mHealth Summit of the Foundation for the National Institutes of Health (FNIH) was the delivery of healthcare services via mobile communication devices.[4]
While there are some projects that are considered solely within the field of mHealth, the linkage between mHealth and eHealth is unquestionable. For example, an mHealth project that uses mobile phones to access data on HIV/AIDS rates would required an eHealth system in order to manage, store, and assess the data. Thus, eHealth projects many times operate as the backbone of mHealth projects.[1] In a similar vein, while not clearly bifurcated by such a definition, eHealth can largely be viewed as technology that supports the functions and delivery of healthcare, while mHealth rests largely on providing healthcare access.[4] Because mHealth is by definition based on mobile technology such as IPhones, healthcare, through information and
Malaria Clinic in Tanzania helped by SMS for Life program which uses cell phones to efficiently deliver malaria vaccine
mHealth delivery, can better reach areas, people, and/or healthcare practitioners with previously limited exposure to certain aspects of healthcare.
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Motivation of mHealth
MHealth is one aspect of eHealth which is pushing the limits of how to acquire, transport, store, process, and secure the raw and processed data to deliver meaningful results. mHealth offers the ability of remote individuals to participate in the health care value matrix, which may not have been possible in the past. Participation does not imply just consumption of health care services. In many cases remote users are valuable contributors to gather data regarding disease and public health concerns such as outdoor pollution, drugs and violence. The motivation behind the development of the mHealth field arises from two factors. The first factor concerns the myriad constraints felt by healthcare systems of developing nations. These constraints include high population growth, a high burden of disease prevalence,[5] low health care workforce, large numbers of rural inhabitants, and limited financial resources to support healthcare infrastructure and health information systems. The second factor is the recent rapid rise in mobile phone penetration in developing countries to large segments of the healthcare workforce, as well as the population of a country as a whole.[6] With greater access to mobile phones to all segments of a country, including rural areas, the potential of lowering information and transaction costs in order to deliver healthcare improves. The combination of these two factors have motivated much discussion of how greater access to mobile phone technology can be leveraged to mitigate the numerous pressures faced by developing countries healthcare systems. Both factors are discussed here.
Healthcare in low- and middle-income countries

Middle income and especially low-income countries Disability-adjusted life year for all causes per 100,000inhabitants in 2004. "WHO Disease and injury country estimates". World Health Organization. face 2009. . Retrieved Nov. 11, 2009.no dataless than 92509250-1600016000-2275022750-2950029500-3625036250-4300043000-4975049750-5650056500-6325063250-7000070000-80000more a than 80000 plethora of constraints in their healthcare systems. These countries face a severe lack of human and physical resources, as well as some of the largest burdens of disease, extreme poverty, and large population growth rates. Additionally, healthcare access to all reaches of society is generally low in these countries. The WHO notes an extreme deficit within the global healthcare workforce. The WHO notes critical healthcare workforce shortages in 57 countriesmost of which are characterized as developing countriesand a global deficit of 2.4 million doctors, nurses, and midwives.[8] The WHO, in a study of the healthcare workforce in 12 countries of Africa, finds an average density of physicians, nurses and midwives per 1000 population of 0.64.[9] The density of the same metric is four times as high in the United States, at 2.6.[10] The burden of disease is additionally much higher in low- and middle-income countries than high-income countries. The burden of disease, measured in disability-adjusted life year (DALY), which can be thought of as a measurement of the gap between current health status and an ideal situation where everyone lives into old age, free of disease and disability, is about five times higher in Africa than in high-income countries.[11] In addition, low- and middle-income countries are forced to face the burdens of both extreme poverty and the growing incidence of chronic diseases, such
mHealth as diabetes and heart disease, an effect of new-found (relative) affluence.[1] Considering poor infrastructure and low human resources, the WHO notes that the healthcare workforce in sub-Saharan Africa would need to be scaled up by as much as 140% to attain international health development targets such as those in the Millennium Declaration.[12] The WHO, in reference to the healtcare condition in sub-saharan Africa, states: "The problem is so serious that in many instances there is simply not enough human capacity even to absorb, deploy and efficiently use the substantial additional funds that are considered necessary to improve health in these countries. [12] Health and development The link between health and development can be found in three of the Millennium Development Goals (MDGs), as set forth by the United Nations Millennium Declaration in 2000. The MDGs that specifically address health include reducing child mortality; improving maternal health; combating HIV and AIDS, malaria, and other diseases; and increasing access to safe drinking water.[13] A progress report published in 2006 indicates that childhood immunization and deliveries by skilled birth attendants are on the rise, while many regions continue to struggle to achieve reductions in the prevalence of the diseases of poverty including malaria, HIV and AIDS and tuberculosis.[14]
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Mobile Technology in Low- and Middle-income Countries

Mobile technology has made a recent and rapid appearance into low- and middle-income nations.[15] While, in the mHealth field, mobile technology usually refers to mobile phone technology, the entrance of other technologies into these nations to facilitate healthcare are also discussed here. Mobile Phones Penetration and Drivers of Growth Mobile phones have made a recent and rapid entrance into many parts of the low- and middle-income world, with the global Mobile phone penetration rate drastically increasing over the last decade. Improvements in telecommunications technology infrastructure, reduced costs of mobile handsets, and a general increase in non-food expenditure have influenced this trend. Low- and middle-income countries are utilizing mobile phones as leapfrog technology (see leapfrogging). That is, mobile phones have allowed many developing countries, even those with relatively poor infrastructure, to bypass 20th century fixed-line technology and jump to modern mobile technology.[16]
Mobile phone subscribers per 100 inhabitants 19972007
The number of global mobile phone subscribers in 2007 was estimated at 3.1 billion of an estimated global population of 6.6 billion (47%).[17] These figures are expected to grow to 4.5 billion by 2012, or a 64.7% mobile penetration rate. The greatest growth is expected in Asia, the Middle East, and Africa. In many countries, the number of mobile phone subscribers has by-passed the number of fixed-line telephones, this is particularly true in developing countries.[18] Globally, there were 4.1 billion mobile phones in use in December 2008 . See List of countries by number of mobile phones in use.
mHealth While mobile phone penetration rates are on the rise, globally, the growth within countries is not generally evenly distributed. In India, for example, while mobile penetration rates have increased markedly, by far the greatest growth rates are found in urban areas. Mobile penetration, in September 2008, was 66% in urban areas, while only 9.4% in rural areas. The all India average was 28.2% at the same time.[19] So, while mobile phones may have the potential to provide greater healthcare access to a larger portion of a population, there are certainly within-country equity issues to consider. Mobile phones are spreading because the cost of mobile technology deployment is dropping and people are, on average, getting wealthier in low- and middle-income nations.[20] Vendors, such as Nokia, are developing cheaper infrastructure technologies (CDMA) and cheaper phones (sub $50100, such as Sun's Java phone). Non-food consumption expenditure is increasing in many parts of the developing world, as disposable income rises, causing a rapid increase spending on new technology, such as mobile phones. In India, for example, consumers have become and continue to become wealthier. Consumers are shifting their expenditure from necessity to discretionary. For example, on average, 56% of Indian consumers consumption went towards food in 1995, compared to 42% in 2005. The number is expected to drop to 34% by 2015. That being said, although total share of consumption has declined, total consumption of food and beverages increased 82% from 1985 to 2005, while per-capita consumption of food and beverages increased 24%. Indian consumers are getting wealthier and they are spending more and more, with a greater ability to spend on new technologies.[21] Technology Basic SMS functions and real-time voice communication serve as the backbone and the current most common use of mobile phone technology. The broad range of potential benefits to the health sector that the simple functions of mobile phones can provide should not be understated.[22] The appeal of mobile communication technologies is that they enable communication in motion, allowing individuals to contact each other irrespective of time and place.[23] [24] This is particularly beneficial for work in remote areas where the mobile phone, and now increasingly wireless infrastructure, is able to reach more people, faster. As a result of such technological advances, the capacity for improved access to information and two-way communication becomes more available at the point of need. More advanced mobile phone technologies are enabling the potential for further healthcare delivery. Smartphone technologies are now in the hands of a large number of physicians and other healthcare workers in low- and middle-income countries. Although far from ubiquitous, the spread of Smartphone technologies opens up doors for mHealth projects such as technology-based diagnosis support, remote diagnostics and telemedicine, web browsing, GPS navigation, access to web-based patient information, and decentralized health management information systems (HMIS). While uptake of Smartphone technology by the medical field has grown in low- and middle-income countries, it is worth noting that the capabilities of mobile phones in low- and middle-income countries has not reached the sophistication of those in high-income countries. The infrastructure that enables web browsing, GPS navigation, and email through Smartphones is not as well developed in much of the low- and middle-income countries.[25] Increased availability and efficiency in both voice and data-transfer systems in addition to rapid deployment of wireless infrastructure will likely accelerate the deployment of mobile-enabled health systems and services throughout the world.[26]
60
mHealth Other mHealth Technologies Beyond mobile phones, wireless-enabled laptops and specialized health-related software applications are currently being developed, tested, and marketed for use in the mHealth field. Many of these technologies, while having some application to low- and middle-income nations, are developing primarily in high-income countries. However, with broad advocacy campaigns for free and open source software (FOSS), applications are beginning to be tailored for and make inroads in low- and middle-income countries. Some other mHealth technologies include Patient monitoring devices Mobile telemedicine/telecare devices MP3 players for mLearning Laptop computers Microcomputers Data collection software Mobile Operating System Technology
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Mobile Device Operating System Technology Technologies relates to the Operating Systems which orchestrate mobile device hardware while maintaining confidentiality, integrity and availability are required to build trust. This may foster greater adoption of mHealth Technologies and Services, by exploiting lower cost multi purpose mobile devices such as tablets pcs and smart phones. Devices in this class may include Apple's iPad 1&2 and Motorola's Xoom. Operating systems which control these emerging classes of devices include Googles Android, Apples iPhone OS, Microsoft's Windows Mobile, Nokia Symbian OS and RIM's BlackBerry OS. Operating Systems must be agile and evolve to effectively balance and deliver the desired level of service to an application and end user, while managing display real estate, power consumption and security posture. As advances in capabilities such as integrating voice, video and Web 2.0 collaboration tools into mobile devices, significant benefits can be achieved in the delivery of health care services. New sensor technologies [27] such as HD video and audio capabilities, accelerometers, GPS, ambient light detectors, barometers and gyroscopes[28] can enhance the methods of describing and studying cases, close to the patient or consumer of the health care service. This could include diagnosis, education, treatment and monitoring. Air Quality Sensing Technologies Environmental conditions have a significant impact to public health. Per the World Health Organization, outdoor air pollution accounts for about 1.4% of total mortality.[29] Utilizing Participatory sensing technologies in mobile telephone, public health research can exploit the wide penetration of mobile devices to collect air measurements,[28] which can be utilize to assess the impact of pollution. Projects such as the Urban Atmospheres [30] are utilizing embedded technologies in mobile phones to acquire real time conditions from millions of user mobile phones. By aggregating this data, public health policy shall be able to craft initiatives to mitigate risk associated with outdoor air pollution. Data has become an especially important aspect of mHealth. Data collection requires both the collection device (mobile phones, computer, or portable device) and the software that houses the information. Data is primarily focused on visualizing static text but can also extend to interactive decision support algorithms, other visual image information, and also communication capabilities through the integration of e-mail and SMS features. Integrating use of GIS and GPS with mobile technologies adds a geographical mapping component that is able to tag voice and data communication to a particular location or series of locations. These combined capabilities have been used for emergency health services as well as for disease surveillance, health facilities and services mapping, and other health-related data collection.
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mHealth and Health Outcomes

The mHealth field operates on the premise that technology integration within the health sector has the great potential to promote a better health communication to achieve healthy lifestyles, improve decision-making by health professionals (and patients) and enhance healthcare quality by improving access to medical and health information and facilitating instantaneous communication in places where this was not previously possible.[31] [32] It follows that the increased use of technology can help reduce health care costs by improving efficiencies in the health care system and promoting prevention through behavior change communication (BCC). The mHealth field also houses the idea that there exists a powerful potential to advance clinical care and public health services by facilitating health professional practice and communication and reducing health disparities through the use of mobile technology. Efforts are ongoing to explore how a broad range of technologies, and most recently mHealth technologies, can improve such health outcomes as well as generate cost savings within the health systems of low- and middle-income countries. In some ways, the potential of mHealth lies in its ability to offer opportunities for direct voice communication (of particular value in areas of poor literacy rates and limited local language-enable phones) and information transfer capabilities that previous technologies did not have. Overall, mobile communication technologies are tools that can be leveraged to support existing workflows within the health sector and between the health sector and the general public.[33] Within the mHealth space, projects operate with a variety of objectives, as stated by the UN Foundation and Vodafone Foundation's report on mHealth for Development: increased access to healthcare and health-related information (particularly for hard-to-reach populations) improved ability to diagnose and track diseases timelier, more actionable public health information expanded access to ongoing medical education and training for health workers [1]
Applications in the mHealth Field

While others exist, the UN Foundation and Vodafone Foundation[1] report presents six application categories within the mHealth field. Education and awareness Helpline Diagnostic and treatment support Communication and training for healthcare workers Disease and epidemic outbreak tracking Remote monitoring Remote data collection
Each application category as well as specific project within the category will be described.
Education and awareness

Education and awareness programs within the mHealth field are largely about the spreading of mass information from source to recipient through short message services (SMS). In education and awareness applications, SMS messages are sent directly to users phones to offer information about various subjects, including testing and treatment methods, availability of health services, and disease management. SMSs provide an advantage of being relatively unobtrusive, offering patients confidentiality in environments where disease (especially HIV/AIDS) is often taboo. Additionally, SMSs provide an avenue to reach far-reaching areassuch as rural areaswhich may have limited access to public health information and education, health clinics, and a deficit of healthcare workers[1] . Below is a list of mHealth Education and Awareness projects:
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Country
Name Inception
Program size
Major services
Insights and Outcomes
Sponsors
Charges
Telcom partner role
Mexico
Vidanet
Vidanet gives People Living With HIV (PLWHIV) the ability to register to receive messages to help improve their adherence to their specific treatment. The main objective of this Project for ICS is to develop a strategic model of educational communication by promoting projects involving a telecommunication revolution in favor of health. With these tools they can generate changes in attitude towards a self-health care, health risk prevention, and adherence to specific prescribed treatments assigned to PLWHIV.
Voxiva has partnered with the Instituto Carso de la Salud (ICS)
mHealth
64
Cardionet Voxiva, along with ICS, has developed CardioNet, a solution in self-health care, health risk prevention, and adherence to prescribed treatments. Individuals complete a questionnaire asking them questions such as sex, age, weight, height, other health problems they have (i.e. diabetes or smoking) as well as blood pressure and cholesterol if known. Based on these answers, the individual is evaluated according to the standards set by the World Health Organization (WHO). From this assessment the individual begins receiving educational messages encouraging him/her to exercise and eat healthy. Examples of health foods and exercise are given to increase the messages effectiveness. ResultsSMS is an open-source platform compatible with OpenMRS designed to disseminate test results, patient education, follow-up appointments and adherence reminders to patients via SMS. Voxiva has partnered with the Instituto Carso de la Salud (ICS)
Mexico
Rwanda/Uganda ResultsSMS.org [34]
ResultsSMS is a partnership between [35] GPAS , FrontlineSMS [36] and Support for International [37] Change with seed funding from the Harvard Initiative for Global Health [38]
mHealth
65
2005 Freedom HIV/AIDS comprises four mobile games targeting different mindsets and psychology of mobile users. The games are deployed on low-end black/white to sophisticated high-end colored devices.
India
Freedom [39] HIV/AIDS [40]
In the first phase, ZMQ [41] launched four games on Reliance Infocomm one of the largest mobile operators of India and was able to reach out to over 9 million handsets. Later, the games were made available on other mobile carriers taking to 30 million handsets. In a span of 15 months, there have been a download of 10,3 million game sessions 276 Million text messages one million per day being sent (20082009). 1,060,000 calls answered. Messages in local languages are especially well received.
Freedom HIV/AIDS [42] is a social initiative of ZMQ Software Systems (A Technology for Development Social Enterprise) [41] . The initiative is supported by Delhi State AIDS Control Society and was launched by Chief Minister of Delhi Shrimati Sheila Dikshit.
Games are free for download through the corporate social responsibility program of [43] ZMQ
South Africa
Project [1] Masiluleke
Build awareness of HIV status, encourage HIV/AIDS testing and treatment and halt the diseases spread. Stigma is a major barrier, causing people to only seek care very late in the illness.
SMS message campaign promoting HIV/AIDS awareness resulted in nearly a tripling of call volume to a local HIV/AIDS helpline.
Praekelt Foundation, iTeach, National Geographic, Nokia Siemens Networks, MTN, Ghetto Ruff, Children of South African Legacies, Aricent, PopTech!, frog design and National AIDS Helpline
Please Call Me service -free text messages. 95% of South Africa uses prepaid cellular plans, and can send please call me message. There is 120 empty characters left in a please call me SMS message.
MTN has allowed program to use total inventory of please call me messages.
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66
15,000 mobile phone subscribers in rural Uganda sent the quiz in the three month pilot test HIV/AIDS awareness via an SMS-based multiple choice quiz in exchange for free airtime; correct answers provided; participants encouraged to come in for testing (fee waived for participants) 40% increase in the number of patients who came in for HIV/AIDS testing. Actionable insight: Many quiz takers did not think AIDS testing was accurate nor anonymou. -Celtel, AIDs Information Centre (AIC), Merck, and the Dutch Ministry of Foreign Affairs SMS-based quiz in exchange for free airtime
Uganda
Text to Change [1]
India
PaDiSys (NowPos M Solutions)
--
Patient Reported Outcome data capture and treatment adherence system via text messaging Freedom HIV/AIDS introduced two HIV/AIDS awareness games to countries in Africa. Apart from English, the games have been developed in local languages - Swahili and Shen.
--
--
Uganda, Tanzania and Kenya in Eastern Africa, and Malawi, Mozambique and Namibia in Southern Africa
[44]
Africa Reach Program [39] [40]
2006
In the first phase, ZMQ launched four games on Reliance Infocomm one of the largest mobile operators of India and was able to reach out to over 9 million handsets. Later, the games were made available on other mobile carriers taking to 30 million handsets. In a span of 15 months, there have been a download of 10,3 million game sessions
Freedom HIV/AIDS is a social initiative of ZMQ - A Technology for Development Social Enterprise [41] . Africa Reach Program supported by Hivos, a leading Dutch development organization, and KPN, the largest Dutch telecom company, under the "Star Programme"
Games are free for download through the corporate social responsibility program of ZMQ
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67
Free open source software that turns a laptop and a mobile phone into a central communications hub that enables users to send and receive text messages with large groups of people through mobile phones, without requiring an internet connection
Many countries
FrontlineSMS [39]
UNICEF/Georgia [39] Mobile4Good [39] New Zealand Vensa Health Coverage includes the whole country of 4 million plus New Zealanders receiving daily messages from their GP doctors and Hospitals Improve access to primary care services and hospital appointment attendance in accordance to Ministry of Health targets. Daily text messages sent to patients to improve appointment attendance, Immunisations rates of children, Cervical Smear Screenings, Breast screening, Flu Vaccinations and more... On average GP Surgeries and Hospitals achieve 50% reduction in missed appointment rates and achieve 6 time greater response in recall / pre-call activities with patients District Health Boards, Primary Health Organisations and General Practice around New Zealand Patients receive the messages for free from health organisations
Helpline
Helpline typically consists of a specific phone number which any individual is able to call to gain access to a range of medical services. These include phone consultations, counseling, service complaints, and information on facilities, drugs, equipment, and/or available mobile health clinics [1] Below is a list of mHealth Helpline projects:
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68
Country
Name Inception Program size
Major services
Sponsors
Charges
Telcom partner role
Australia
National Health Call Centre Network or healthdirect [45] HealthDirect (Western [45] Australia) HealthDirect (Northern [45] Territory) Nurse-on-Call [45] (Victoria) HealthDirect (South [45] Australia) Health First (Australia Capital [45] Territory)
2007
Government-sponsored
Australia
1999
Australia
Australia
2006
Australia
2006
Australia
Bangladesh Healthline [45] 2006
10000 Calls per day
Phone consults, information on facilities, drugs, test result interpretation, discounts on hospital visits. Mission: be a first reference point to complement conventional health solutions.
Top health MNO-sponsored: complaints: Telemedicine firm and Chronic diseases MNO (40%), ENT, early pregnancy, malaria, pneumonia (each 8%), diarrhea (7%)
For profit. Service is US$ 0.21 (BDT 15) for 3 minute call
Marketing and promotion, Billing and revenue collection, Voice bearer
Canada
Fonemed (for USA callers) [45] Telehealth [45] (Ontario) Telemedic Telemed [45]
1999
Canada
2001
Colombia Dominican Republic
Independent Independent
[45]
mHealth
[45]
69
2007 50000 Calls per day Phone consults, counseling and complaints, information on facilities, drugs, mobile health clinics (vans). Mission: create platform to enable 1 billion virtual and 1 billion physical service contacts. Top health complaints: Recurring abdominal pain (13%), back pain (9%), knee pain (8%) Government-sponsored: Not for Government and a profit. private charity Service is free. Voice bearer
India
HMRI
Mexico Mexico
Telemedic
[45] 10000 Calls per day Phone consults, information on facilities, drugs, discounts at clinics, pharmacies. Mission: be the first choice in private health services.
Independent Independent: Call center entrepreneurs For profit. Subscription: unlimited calls for US$ 5.00 monthly Shareholder, Billing and revenue collection, Voice bearer
MedicallHome 1998 [45]
New Zealand Pakistan
Healthline
[45] 2006
Teledoctor [45]
2008
1000 Calls per day
Phone consults, information on facilities, drugs. Mission: provide cheap, easy access to experienced doctors.
Top health complaints: Diarrhea and vomiting (gastro-enteritis), Gynecological ailments and obstetrics, Fever (usually associated with respiratory tract infections)
MNO-sponsored: Telemedicine firm and MNO
For profit. Service is US$ 0.30 (PKR 24) for 3 minute call
Marketing and promotion, Billing and revenue collection, Voice bearer
Philippines Fonemed Asia-Pacific [45] South Africa Eastern Cape Health Call [45] Centre MedStar Health Information [45] NHS Direct [45]
planned
Independent
2007
Trinidad and Tobago
2004
Independent
United Kingdom
1999
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Healthcare provider-sponsored Healthcare provider-sponsored
United States United States
MedicareBlue [45] PPO FirstHelp Nurse Advice [45] Line Telemed (Puerto Rico) [45] Informed Health Line [45] (Aetna) Teladoc [45] 2007
United States
Independent
United States
Healthcare provider-sponsored
United States United States
Independent
MedicallHome [45] USA
Independent
Diagnostic support, treatment support, communication and training for healthcare workers
Diagnostic and treatment support systems are typically designed to provide healthcare workers in remote areas advice about diagnosis and treatment of patients. While some projects may provide mobile phone applicationssuch as a step-by-step medical decision tree systemsto help healthcare workers diagnosis, other projects provide direct diagnosis to patients themselves. In such cases, known as telemedicine, patients might take a photograph of a wound or illness and allow a remote physician diagnose to help treat the medical problem. Both diagnosis and treatment support projects attempt to mitigate the cost and time of travel for patients located in remote areas[1] mHealth projects within the communication and training for healthcare workers subset involve connecting healthcare workers to sources of information through their mobile phone. This involves connecting healthcare workers to other healthcare workers, medical institutions, ministries of health, or other houses of medical information. Such projects additionally involve using mobile phones to better organize and target in-person training. Improved communication projects attempt to increase knowledge transfer amongst healthcare workers and improve patient outcomes through such programs as patient referral processes[1] Below is a list of mHealth projects for both diagnostic and treatment support, and communication and training for healthcare workers
Country Name Inception Program size Major services Insights and Outcomes Sponsors Charges Telcom partner role
India
Tele-Doc [39] [46]
2003
Launched as a pilot project in 15 villages in Haryana in April 2003
TeleDoc provided handheld mobile phone devices to village health workers in India, permitting them to communicate with doctors who use a web application to help diagnose and prescribe for patients.
TeleDoc was a project of Jiva Institute, an India-based non-profit. Supported by the Soros Foundation.
The approximate cost of the entire TeleDoc process was 70 rupees (US$1.50) per consultation.
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71
2010 Services operational across India mQure provides innovative solutions to make healthcare more accessible, convenient and at the lowest possible cost. Patients can get medical help on their mobile phone 24x7 or second opinions, information on latest hospital bed availability. Patients can also manage their chronic conditions or remember to take their medicines on time via Med Reminders. Relevant health content is made available to patients to take care of chronic conditions such as diabetes, heart conditions or pregnant mother/newborn care. Nacer is a phone- and webbased information and communication system for maternal and child health that allows health professionals in remote locations to communicate and exchange critical health information between themselves, medical experts, and regional hospitals. All reported data is recorded in a central database, and is available to health officials in real-time for analysis and decision-making. Health workers in locations without Internet connectivity can access the system using any phone (satellite, fixed-line, mobile, or community pay phone). Over 10,000 active clients across India Independent entrepreneurs Social venture with services starting as low as $1 per month
India
mQure [47]
Peru
Nacer [39] [48]
The USAID-funded Pathfinder International program and Voxiva worked with the Regional Health Directorate of Ucayali and the Peru Ministry of Health
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72
TRACnet is Rwandas dynamic Information Technology solution designed to collect, store, retrieve, and disseminate critical program, drug, and patient information related to HIV/AIDS care and treatment. The system was implemented to support the Rwandan Governments vision of rapidly scaling up HIV/AIDS clinical services in a variety of health care settings. Under the leadership of the Ministry of Health and the Treatment Research and AIDS Centre (TRAC), TRACnet is being deployed to increase the efficiency of Rwandas HIV/AIDS program management, and enhance the quality of patient care. Information and communications technologies (ICT) initiatives through the USA-based not-for-profit Academy for Educational Development providing support for HIV/AIDS, malaria, child and maternal health, and health systems management programs. Voxiva and The Rwanda Ministry of Health
Rwanda
TRACnet [39] [49]
Uganda, AED Mozambique Satellife [39] [50]
Disease surveillance, remote data collection, and epidemic outbreak tracking

Projects within this area operate to utilize mobile phones ability to collect and transmit data quickly, cheaply, and relatively efficiently. Data concerning the location and levels of specific diseases (such as malaria, HIV/AIDS, TB, Avian Flu) can help medical systems or ministries of health or other organizations identify outbreaks and better target medical resources to areas of greatest need. Such projects can be particularly useful during emergencies, in order to identify where the greatest medical needs are within a country[1] Policymakers and health providers at the national, district, and community level need accurate data in order to gauge the effectiveness of existing policies and programs and shape new ones. In the developing world, collecting field information is particularly difficult since many segments of the population are rarely able to visit a hospital, even in the case of severe illness. A lack of patient data creates an arduous environment in which policy makes can decide where and how to spend their (sometimes limited) resources. While some software within this area is specific to a particular content or area, other software can be adapted to any data collection purpose. Below is a list of mHealth disease and epidemic outbreak tracking projects, and data collection software. There is also a list of mobile phone-based data collection software, from a practical perspective, at this link [51] (the list is maintained by DataDyne.org but each developer organization mentioned has edit access, in order to provide current information on their product)
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73
Country
Name Inception
Program size
Major services
Sponsors
Charges Telcom partner role
Brazil
Name?
[1]
400 test results gathered by 20 field professionals in two days, all with GPS information
Containing the spread of the Dengue virus. Customized questionnaires distributed to field health agents mobile phones. Health data and GPS location information are integrated to enable immediate analysis and identification of areas with high infection levels.
Data collection times dramatically reduced (paper-based system would have taken 23 months for lesser information). End-user acceptance very high.
Nokia, Amazonas State Health Ministry
AESSIMS [52]
[39]
AESSIMS is designed to build health capacity at the field level by enabling front-line health workers to report disease incidence through an innovative combination of telephone and web based technology that leverages available infrastructure. AESSIMS enables health officials to better understand the scope of disease impact and strategically allocate resources to areas with the highest prevalence and need.
PATH, Voxiva, and the Government of Andhra Pradesh (GoAP)
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74
Major insight: if you make an easy-to-use tool available to anyone online, many people will find and use it. EpiSurveyor is not a "project" or a "pilot": it is a fully, functional system for creating mobile data collection systems, and it is available to anyone, for free, right now. "Like Gmail for data collection" :-)
Kenya and EpiSurveyor.org 2003 worldwide [53]
Since moving from older, PDA-based version to online version, more than 3500 users from hundreds of organizations in more than 170 countries have uploaded more than 150,000 completed data records from phones (updated [53] stats here )
EpiSurveyor is an online system developed by [54] DataDyne.org that allows rapid development of forms which can then be downloaded to mobile phones for data collection: user can go from concept to fully functional mobile data collection system in hours. Used in more than 170 countries worldwide for outbreak investigation, disease surveillance, drug stock tracking . . . as well as health and economic surveys, veterinary studies, even the tracking of mountain gorillas in Uganda: if you are collecting data on paper, you could be using EpiSurveyor, regardless of the topic. Development and support based in Nairobi, Kenya. Winner of Wall Street Journal Technology Innovation [55] Award , Lemelson-MIT Award for [56] Sustainability , Stockholm Challenge Award, and Tech Museum Award, and covered by [57] Wired , the Economist [58] [59] , the Guardian , [60] Voice of America , and others. Voxiva HealthWatch is an integrated surveillance platform used by public health agencies around the world to support integrated disease surveillance, syndromic surveillance, and coordinated response.
Developed with funding from the United Nations Foundation [61] , the Vodafone Foundation, and the World Bank
Basic service, used by 99% of users, is completely free and requires "no money, no meetings, and no MOU". Premium version available. More info [62]
Voxiva Health [39] [63] Watch
InSTEDD
[39]
mHealth
75
Treatment support and medication compliance for patients, including chronic disease management
Remote monitoring and treatment support allows for greater involvement in the continued care of patients. Within environments of limited resources and bedsand subsequently a outpatient cultureremote monitoring allows healthcare workers to better track patient conditions, medication regimen adherence, and follow-up scheduling. Such projects can operate through either one- or two-way communications systems. Remote monitoring has been used particularly in the area of medication adherence for AIDS and diabetes[1] Below is a list of mHealth treatment support and remote monitoring projects:
Name Country Inception Program size Major services Insights and Outcomes Sponsors Charges Telcom partner role The US Centers for Disease Control and Prevention (CDC) PEPFAR Public Health Evaluation (PHE) and the International Development Research Centre's Africa Health Systems Initiative Support to African Research Partnerships (AHSI-RES) Voxiva has partnered with the Instituto Carso de la Salud (ICS)
Kenya
Weltel
[64]
2008
1 year clinical trial. ~500 participants.
HIV-positive patents were sent weekly text messages inquiring about their well-being. Patients responded to these message by saying everything was OK, or they had a problem. If there was a problem, a Health Worker would call back to assist them.
Positive results showing that mobile phones can be a useful tool in supporting HIV-positive patients.
Mexico
Diabediario
Voxiva, along with ICS, has developed Diabediario, a solution for changing diabetics lifestyles and for controlling and improving their adherence to their diabetic treatment. Any diabetic person, who has a TelCel cell phone, can participate in the program. Diabediario uses telecommunication to generate changes in attitude towards risk prevention and adherence to prescribed treatments. Diabediario does not replace doctors visits or pills but is meant to act as a supplement to outside care. This system empowers the patient to take control of their health by taking all the necessary steps to control their diabetes.
mHealth
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Cell-Preven health workers use mobile phones to send SMS messages with real-time data on symptoms experienced by clinical trial participants. This enables immediate response to adverse symptoms TB patients were given mobile phones and called daily with a reminder to take their TB medication 2009 US Army Medical Department mobile phone messaging application for the case management of reintegrated wounded soldiers. SMS-based wellness tips, appointment reminders for US service members returning from duty. Ported content from "afterdeployment.org" to a cell phone. HIPAA compliant. 6-week pilot study with 20 participants. Mobile health application for dietary insight for a chronically Ill, low-literacy diabetic population The device has a voice recorder and a bar code scanner. By the end of the study the participants were only using the voice recorder. Patients use "beam" bar code scanner more easily than pen bar code scanner. The device was not stigmatizing, rather seen as a status symbol. Many behavior Legacy change things are Foundation characterized by success and relapse. Measuring real time behavior, along with context and psychological factors. "Are you feeling happy?" 90% of patients took their medication. Powered by Voxiva
Peru
Cell-Preven [1]
Thailand Name? [1]
United States
mCare
US Army Medical Department
DIMA Dietary Intake Monitoring Application
2009
United States
Web-based Mobile Support for the Washington D.C. Tobacco Quitline
2009
Currently updating the system to take real time patient smoking cessation data and "close the loop" feedback to improve adherence. Adding web interface to integrate with telephone quitline
mHealth
77
MAHI Mobile Access to Health Information 2009 49 participants, recently diagnosed with diabetes. 5 month study. Each time a diabetic patient used a glucose meter the phone would give them a call to gather data on why they were using it. Nokia or any java-enabled cell phone. Used bluetooth glucose meter. ndividuals record several messages per day. Data that were typically collected: pictures of food, pictures of confusing food labels, voice notes with specific problems. Outcomes: significant fraction of participants switched from "external" to "internal" locus of control, which meant they felt more in charge. Participants became better problem solvers with the condition, and better achieved dietary goals. Georgia Tech, CDC, Google Health, Siemens Corporate Research
United States
Virtual Health Pet [39] On-Cue SIMpill [39] [39] SMS appliance that monitors medicine compliance by sending a text message when the patient takes medicine. SMS data gathering applications
Cell-Life [39]
Emerging trends and areas of interest in mHealth

Emergency response systems (e.g., road traffic accidents, emergency obstetric care) Human resources coordination, management, and supervision Mobile synchronous (voice) and asynchronous (SMS) telemedicine diagnostic and decision support to remote clinicians[65] Clinician-focused, evidence-based formulary, database and decision support information available at the point-of-care[65] Pharmaceutical Supply Chain Integrity & Patient Safety Systems (e.g. Sproxil and mPedigree) [66] Clinical care and remote patient monitoring Health extension services Health services monitoring and reporting Health-related mLearning for the general public Training and continuing professional development for health care workers Health promotion and community mobilization Support of long-term conditions *[67] According to Vodafone Group Foundation on February 13, 2008, a partnership for emergency communications was created between the group and United Nations Foundation. Such partnership will increase the effectiveness of the information and communications technology response to major emergencies and disasters around the world. Being connected by mobile health services, different novel networking among various entities, (which were previously isolated) directly or indirectly related to health care delivery mechanism, are on the verge of
mHealth development. This networking is now being known as mHealth Ecosystem.
78
References
[1] Vital Wave Consulting (February 2009). mHealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World (http:/ / www. vitalwaveconsulting. com/ pdf/ mHealth. pdf). United Nations Foundation, Vodafone Foundation. p.9. . [2] Germanakos P., Mourlas C., & Samaras G. "A Mobile Agent Approach for Ubiquitous and Personalized eHealth Information Systems." (http:/ / www. media. uoa. gr/ ~pgerman/ publications/ published_papers/ A_Mobile_Agent_Approach_for_Ubiquitous_and_Personalized_eHealth_Information_Systems. pdf) Proceedings of the Workshop on 'Personalization for e-Health' of the 10th International Conference on User Modeling (UM'05). Edinburgh, July 29, 2005, pp. 67-70. [3] Istepanian, Robert; Laxminarayan, Swamy; Pattichis, Constantinos S., eds (2005). M-Health: Emerging Mobile Health Systems. Springer. ISBN978-0-387-26558-2. [4] Torgan, Carol (November 6, 2009). "The mHealth Summit: Local & Global Converge" (http:/ / www. caroltorgan. com/ mhealth-summit/ ). caroltorgan.com. . Retrieved July 29, 2011. [5] The Global Burden of Disease 2004 Update 2008 [6] Global Mobile Phone Subscribers to Reach 4.5 Billion by 2012 (http:/ / www. cellular-news. com/ story/ 29824. php). Cellular-news.com. 4/1/2010 [7] "WHO Disease and injury country estimates" (http:/ / www. who. int/ healthinfo/ global_burden_disease/ estimates_country/ en/ index. html). World Health Organization. 2009. . Retrieved Nov. 11, 2009. [8] World Health Organization, The World Health Report 2006: Working Together for Health. 2006, WHO: Geneva. [9] Kinfu, Y., Dal Poz, M., Mercer, H., Evans, D.B., The health worker shortage in Africa: are enough physicians and nurses being trained? (http:/ / www. who. int/ bulletin/ volumes/ 87/ 3/ 08-051599-table-T3. html) Bulletin of the World Health Organization, Vol. 87, No. 3, March 2009, 225-230 [10] UNData. Statistics Physicians density (per 10 000 population) (http:/ / data. un. org/ Data. aspx?d=WHO& f=inID:HSR02). WHO Data [11] The Global Burden of Disease 2004 Update 2008, [12] Kinfu, Y., Dal Poz, M., Mercer, H., Evans, D.B., The health worker shortage in Africa: are enough physicians and nurses being trained? (http:/ / www. who. int/ bulletin/ volumes/ 87/ 3/ 08-051599/ en/ index. html) Bulletin of the World Health Organization Vol. 87, No. 3, March 2009, 225-230 [13] United Nations, United Nations Millennium Declaration (General Assembly Resolution 55/2). 2000, United Nations: New York. [14] United Nations, The Millennium Development Goals Report. 2006, United Nations: New York. [15] Economist. The power of mobile money. The Economist 14 Sept, 2009. [16] Economist. Leaders: The limits of leapfrogging; Technology and development. The Economist: 2008 [17] Global Mobile Phone Subscribers to Reach 4.5 Billion by 2012. Cellular-news.com. 4/1/2010 http:/ / www. cellular-news. com/ story/ 29824. php [18] ITU (2003). Mobile overtakes fixed: Implications for policy and regulation. Geneva: International Telecommunications Union [19] Kathuria, R, Uppal M., Mamta (2009). An econometric analysis of the impact of mobile. Case paper in India: The impact of mobile phones. Vodafone Group Plc. The Policy Paper Series. November 2009 [20] Global Economic Prospects 2007: Managing the Next Wave of Globalization (http:/ / econ. worldbank. org/ WBSITE/ EXTERNAL/ EXTDEC/ EXTDECPROSPECTS/ GEPEXT/ EXTGEP2007/ 0,,menuPK:3016160~pagePK:64167702~piPK:64167676~theSitePK:3016125,00. html). World Bank report. [21] McKinsey&Company (2007). The bird of gold: the rise of Indias consumer market. McKinsey Global Institute [22] Mechael, P. (2006). Exploring Health-related Uses of Mobile Phones: An Egyptian Case Study, Public Health & Policy (p. 264). London: London School of Hygiene and Tropical Medicine [23] Agar, J. (2003). Constant Touch: A Global History of the Mobile Phone Cambridge: Icon Books Ltd. [24] Ling, R. (2004). The mobile connection: The cell phone's impact on society London: Morgan Kaufmann [25] Mechael, P. (2006). Exploring Health-related Uses of Mobile Phones: An Egyptian Case Study, Public Health & Policy (p. 264). London: London School of Hygiene and Tropical Medicine. [26] Istepanian, R. (2004). Introduction to the Special Section on M-Health: Beyond Seamless Mobility and Global Wireless Health-care Connectivity. IEEE Transactions on Information Technology in Biomedicine, 8(4), 405-413. [27] http:/ / citeseerx. ist. psu. edu/ viewdoc/ download?doi=10. 1. 1. 141. 6348& rep=rep1& type=pdf [28] Lane, Nicholas; Miluzzo, Emiliano, Lu, Hong, Peebles, Daniel, Choudhury, Tanzeem, Campbell, Andrew (NaN undefined NaN). "A survey of mobile phone sensing". IEEE Communications Magazine 48 (9): 140150. doi:10.1109/MCOM.2010.5560598. [29] Ostro, Bart (2004). Outdoor air pollution : assessing the environmental burden of disease at national and local levels (null ed.). Geneva: World Health Organization, Protection of the Human Environment. ISBN9241591463. [30] http:/ / www. urban-atmospheres. net/ ParticipatoryUrbanism/ index. html [31] Shields, T., A. Chetley, and J. Davis, ICT in the health sector: Summary of the online consultation. 2005, infoDev. [32] World Health Organization, eHealth Tools and Services: Needs of Member States. 2005, WHO: Geneva. [33] Malhotra K, Gardner S, Rees D. (2005). Evaluation of GPRS Enabled Secure Remote Patient Monitoring System. ASMTA 2005, Riga, Latvia, 41-48.
mHealth
[34] http:/ / resultssms. org [35] http:/ / globalpas. org [36] http:/ / www. frontlinesms. com/ [37] http:/ / sichange. org/ [38] http:/ / www. globalhealth. harvard. edu/ icb/ icb. do [39] UN Foundation, Vodafone Foundation, Vital Wave Consulting, mHealth for Development (http:/ / www. unfoundation. org/ global-issues/ technology/ mhealth-report. html), 2008. [40] Freedom HIV/AIDS (http:/ / www. freedomhivaids. in/ FreedomHivAids. htm) An HIV/AIDS awareness initiative using mobile phone games [41] http:/ / www. zmqsoft. com [42] http:/ / www. freedomhivaids. in [43] ZMQ - A Technology for Development Company http:/ / www. zmqsoft. com [44] Freedom HIV/AIDS - Serios Games Initiative to COmbat HIV/AIDS (http:/ / www. freedomhivaids. in) [45] GSMA Foundation, A Doctor in Your Pocket: Health Hotlines in Developing Countries [46] Tele-doc India (http:/ / www. comminit. com/ en/ node/ 116145) [47] [www.mqure.com] [48] Voxiva Case Study: Peru Nacer (http:/ / www. voxiva. com/ casestudies. php?caseid=29) [49] Voxiva Case Study: TRACnet (http:/ / voxiva. com/ casestudies. php?caseid=22) [50] AED-Satellife Center for Health Information and Technology (http:/ / www. healthnet. org/ ) Information and communications technologies (ICT) initiatives through the USA-based not-for-profit Academy for Educational Development providing support for HIV/AIDS, malaria, child and maternal health, and health systems management programs in Uganda and Mozambique [51] http:/ / spreadsheets. google. com/ ccc?key=0ArG7kkc9mE75dEdNNktocmVwT0hNbHVjTXl2ZU1VMXc& hl=en& authkey=CKiRppwM [52] Voxiva Case Study: AESSIMS (http:/ / voxiva. com/ casestudies. php?caseid=21) [53] http:/ / www. episurveyor. org [54] http:/ / www. datadyne. org [55] http:/ / online. wsj. com/ article/ SB10001424052970203440104574399714096167656. html [56] http:/ / datadyne. org/ news/ lemelsonmit2009 [57] http:/ / datadyne. org/ news/ wiredukjune2010 [58] http:/ / www. economist. com/ specialreports/ displaystory. cfm?story_id=10950499 [59] http:/ / www. guardian. co. uk/ activate/ phones-revolution-developing-world [60] http:/ / www. voanews. com/ MediaAssets2/ english/ 2010_01/ MakingADifferenceSelanikio-fixed-20fps-256k. wmv [61] http:/ / www. unfoundation. org [62] http:/ / datadyne. org/ episurveyor/ faq [63] Voxiva Website: Health Watch (http:/ / voxiva. com/ solutionspage. php?catname=HealthWatch) [64] Home (http:/ / www. weltel. org/ ). weltel.org. Retrieved on 2010-08-14. [65] Mechael, P. "WHO mHealth Review: Towards the Development of an mHealth Strategy." August 2007. [66] Ghana News :: West African Innovation Hits Global Stage ::: Breaking News | News in Ghana | features (http:/ / news. myjoyonline. com/ features/ 201005/ 46200. asp). News.myjoyonline.com (2010-05-14). Retrieved on 2010-08-14. [67] http:/ / news. bbc. co. uk/ 1/ hi/ health/ 8436092. stm
79
Further reading
"Technology plays crucial role in vaccination distribution" Computer Weekly: April 2008. Technology plays crucial role in vaccination distribution - 03/04/2008 (http://www.computerweekly.com/Articles/2008/04/03/ 230128/technology-plays-crucial-role-in-vaccination-distribution.htm). Computer Weekly (2008-04-03). Retrieved on 2010-08-14.. Discusses use of handheld electronic data collection in managing public health data and activities. "A world of witnesses" The Economist: January 2008. A survey of mobility: A world of witnesses (http://www. economist.com/surveys/displaystory.cfm?story_id=10950499). The Economist. Retrieved on 2010-08-14. Discusses use of EpiSurveyor (http://www.episurveyor.org) software in public health monitoring in Africa. "Globally, deaths from measles drop sharply" The Washington Post: November 2007. Globally, Deaths From Measles Drop Sharply (http://www.washingtonpost.com/wp-dyn/content/article/2007/11/29/ AR2007112902021.html). washingtonpost.com. Retrieved on 2010-08-14. Describes role of EpiSurveyor mobile data collection software in contributing to the highly successful fight against measles mortality. Kaplan, Warren. "Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries?" Globalization and Health 2 (2006): 9. Full text | Can the ubiquitous power of mobile phones be used
mHealth to improve health outcomes in developing countries? (http://www.globalizationandhealth.com/content/2/1/ 9). Globalization and Health. Retrieved on 2010-08-14. Olmeda, Christopher J. (2000). Information Technology in Systems of Care. Delfin Press. ISBN 978-0-9821442-0-6 United Nations. "Compendium of ICT Applications on Electronic Government, Volume 1: Mobile Applications on Health and Learning." United Nations: 2006.http://unpan1.un.org/intradoc/groups/public/documents/UN/ UNPAN030003.pdf Economist "The doctor in your pocket [Medical technology: Nearly everyone in the developed world carries a mobile phone- so why not use it to deliver health care?]" The Economist: 2005. MONITOR | The doctor in your pocket | Economist.com (http://www.wirelesslifesciences.org/pdfs/ MONITOR_doctorinyourpocket_Economist.pdf). (PDF) . Retrieved on 2010-08-14. Mechael, P. "Exploring Health-related Uses of Mobile Phones: An Egyptian Case Study." Public Health & Policy (p.264). London: London School of Hygiene and Tropical Medicine 2006. (http://open.intrahealth.org/wiki/ upload/PatriciaMechaelThesisFinalDecember2006.pdf) Mechael, Patricia (2009). The Case for mHealth in Developing Countries. Mobilizing Markets: Special Edition of MIT Innovations Journal for the GSMA Mobile World Congress 2009. Cambridge: MIT Press, pages 153-168.
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Mechael, P and D. Sloninsky. Towards the Development of an mHealth Strategy: A Literature Review. New York: Earth Institute at Columbia University: Working Document. Istepanian, R. "Introduction to the Special Section on M-Health: Beyond Seamless Mobility and Global Wireless Health-care Connectivity." IEEE Transactions on Information Technology in Biomedicine: 2004. 8(4), 405-413. Istepanian, Robert et al., eds. (2006) M-Health: Emerging Mobile Health Systems. Springer Verlag. ISBN 0-387-26558-9 UNICEF and Women's Net (2007). Rapid Assessment of Cell Phones for Development. Written and compiled by Sally-Jean Shackleton. Vital Wave Consulting (February 2009). mHealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World (http://www.vitalwaveconsulting.com/pdf/mHealth.pdf). United Nations Foundation, Vodafone Foundation. Anta R., El-Wahab S., and Giuffrida A. [Mobile Health: The potential of mobile telephony to bring health care to the majority.]http://www.iadb.org/document.cfm?id=1861959 Inter-American Development Bank. February 2009. Adesina Iluyemi, [Community-based health workers in developing countries and the role of m-health. In Telehealth in Developing Countries]http://www.idrc.ca/en/ev-137420-201-1-DO_TOPIC.htm mHealthInfo.org (http://www.mhealthinfo.org) offers information on the current use, potential and limitations of mHealth in low-resource settings
Practice management software
81

Practice management software (PMS) is a category of software that deals with the day-to-day operations of a medical practice. Such software frequently allows users to capture patient demographics, schedule appointments, maintain lists of insurance payers, perform billing tasks, and generate reports. In the United States, most PMS systems are designed for small to medium-sized medical offices. Some of the software is designed for or used by third-party medical billing companies. PMS is often divided amongst desktop-only software, client-server software, or Internet-based software. The desktop variety is intended to be used only on one computer by one or a handful of users sharing access. Client-server software typically necessitates that the practice acquire or lease server equipment and operate the server software on that hardware, while individual users' workstations contain client software that accesses the server. Client-server software's advantage is in allowing multiple users to share the data and the workload; a major disadvantage is the cost of running the server. Internet-based software is a relatively newer breed of PMS. Such software decreases the need for the practice to run their own server and worry about security and reliability. However, such software removes patient data from the practice's premises, which can be seen as a security risk of its own. PMS is often connected to electronic medical records (EMR) systems. While some information in a PMS and an EMR overlaps for example, patient and provider data in general the EMR system is used for the assisting the practice with clinical matters, while PMS is used for administrative and financial matters. Medical practices often hire different vendors to provide the EMR and PMS systems. The integration of the EMR and PMS software is considered one of the most challenging aspects of the medical practice management software implementation.[1] [2]
Components of practice management software

Most practice management software contains systems that allow users to enter and track patients, schedule and track patient appointments, send out insurance claims and patient statements as part of the collection process, process insurance, patient and third party payments, and generate reports for the administrative and clinical staff of the practice. Typically, using a PMS also involves keeping up to date large sets of data including lists of diagnosis and procedures, lists of insurance companies, referring physicians, providers, facilities, and much more.
Patient demographics
The capture of patient demographics often starts when a new patient fills out a patient information chart. This information includes the patient's name, address and contact information, birthdate, employer, and insurance information. Practice staff typically enters this information into the software. The software may automatically verify the patient's eligibility for receiving benefits with the insurance company using a standard electronic data interchange connection.
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Appointment scheduling
Practice Management systems often include a calendaring or scheduling component that allows staff to create and track upcoming patient visits. Software is often differentiated by whether it allows double-booking, or whether it uses a scheduling or a booking model. Schedules are often color-coded to allow healthcare providers (i.e. doctors, nurses, assistants) to easily identify blocks of time or sets of patients.
Claims and statements

After a patient visit, the PMS is used to enter a set of charges. Each charge usually corresponds to a particular service that was performed on the patient, and is usually associated with one or more diagnoses. Most charges are entered using a code or codes from the Healthcare Common Procedure Coding System (HCPCS) or its subset, the Current Procedural Terminology (CPT). The diagnoses are indicated using International Classification of Diseases (ICD) codes. Each charge will typically have a fee associated with it. If the patient carried a valid private or public insurance policy at the time these services were provided, the charges are then sent out as an insurance claim. The process of sending charges may happen on paper, usually with the use of the CMS-1500 form. This form lists the provider who performed the service, the patient, the services performed and the related diagnoses. For institutional (typically hospital) charges, claims may also be sent out on the UB-04 forms (formerly the UB-92 which use of was discontinued in 2007). Claims may also be sent out electronically using industry-standard electronic data interchange standards. In most cases, electronic claims are submitted using an automated software process. Some practice management system vendors will update CPT/ICD-9 codes in the practice software on an annual basis. Some, especially smaller firms, leave it entirely up to medical practices.[3] While a lot of insurance payers have created methods for direct submission of electronic claims, many software vendors or practice users use the services of an electronic claim clearinghouse to submit their claims. Such clearinghouses commonly maintain connections to a large number of payers, and make it easy for practices to submit claims to any of these payers. Instead of creating a connection to every payer, the practice user or software vendor must only connect to the clearinghouse. Once a claim is adjudicated by the payer, some sort of a response is sent to the submitter. This usually comes as a paper Explanation of Benefits (EOB) or an Electronic Remittance Advice (ERA). These describe the actions that the payer took on each claim: amounts paid, denied, adjusted, etc. In cases where a patient did not have proper insurance, or where insurance coverage did not fully pay the charges, the practice will usually send out patient statements. Practice management software often contains a way for a practice to print and mail their own statements (or other correspondence), and may even contain a way to interface to third-party patient statement printing companies.
Reporting
Almost invariably, the process of running a medical practice requires some introspection, and practice management software usually contains reporting capabilities to allow users to extract detailed data on financial performance and patient financial histories. PMS often has both pre-setup reports as well as allow users to design their own, ad-hoc reports. In some cases, the reporting functionality of PMS interfaces with Decision Support Systems or has similar functionality built-in.
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Practice management software and commerce

Practice management software has traditionally been commercial; few viable free practice management systems exist, though a few open source systems are under development. PMS usually costs about $100 to tens of thousands of dollars to license and operate.
Interfaces and dependencies

PMS often needs to interface with the outside world. There are a number of standards that are used: HL7 used to communicate with hospitals, or EMR systems ANSI X12 EDI transactions, including: 270 eligibility & benefit inquiry - Is the patient an insured of this payer? 271 eligibility & benefit response (response to 270) - A yes or no response that the patient is insured. 276 claims status inquiry (follows 837 submission) 277 claim status response (response to 276) 835 claim payment/advice (follows 837) - 837 medical claim is paid, and amount of payment and the patient's financial responsibility 837D claim submission for dental claims 837I claim submission for institutional claims 837P claim submission for professional claims
Comparison of PMS software solutions

Basic general information about major software solutions: creator/company, license/price etc.
Creator Latest stable version [5] Current Cost (USD) Software license Website
CareCloud Central [4] Cliniko [6]
CareCloud
$249 per month
Proprietary
Website [5] Website [6] Website [8] Website [9] Website [10] Website [12]
RedGuava
[7]
Current
Plans from $45 p/month AUD. 10c AUD per SMS message.
Proprietary
Crosscare
Advanced Health & Care Nuesoft
2.2
Full Practice Management Solution
Proprietary
NueMD
3.10
$350 per month for one provider
Proprietary
Centricity Practice Management Medical and Practice Management Suite Medisoft / Clinical EMR PeakPractice
GE Healthcare
9.2
Proprietary
LSS Data Systems
5.6
ONC-ATCB 2011/2012 Complete EHR Certified; CCHIT [11] Certified - HIPAA Compliant CCHIT Certified - Direct Purchase: $5480 for first doc, $3400 for subsequent CCHIT Certified - Monthly fee; Direct Purchase: $10,000 for first doc, $5,000 for subsequent
Proprietary
McKesson Corp
V17
Proprietary
Website [13] Website [14]
Allscripts (Formerly Eclipsys) Drchrono.com
Current
Proprietary
Dr. Chrono Professional
Current
$99.95 per month
Proprietary
Website [15]
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6.20 HIPAA compliant; CCHIT Certified; scheduling; billing; electronic claims; electronic prescriptions; electronic labs; EMR etc. ONC-ATCB 2011/2012 Certified for Complete EHR; HIPAA compliant; CCHIT Certified; scheduling; billing; electronic claims; electronic prescriptions; electronic labs; EMR etc. Full practice management solution. Proprietary
Sage Intergy
Sage Software
Website [16]
Nortec EHR
Nortec Software
7.0
Proprietary
Website [17]
Private Practice Software WonderDoc Elite
Rushcliff Ltd
4.0.64
Proprietary
Website [18] Website [19]
Doctorsync, LLC
1.3
ONC-ATCB 2011/2012 Certified for EHR module; HIPAA compliant; CCHIT Certified; scheduling; billing; EMR; free electronic claims; marketing; statistics.
Proprietary
Operating system compatibility:

Client CareCloud Cliniko [5] Windows Mac OS X Linux BSD Unix Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No Yes No No No Yes Yes Yes No No No Yes No No No Yes Yes Yes No No No Yes No No No Yes Yes Yes No No No Yes No No No
[6]
Nuesoft Medical and Practice Management Suite (MPM) Medisoft PeakPractice Dr. Chrono Professional Sage Intergy Nortec EHR WonderDoc Elite Client
Windows Mac OS X Linux BSD Unix
References
[1] Managing a Smoother Vendor Integration (http:/ / www. nuesoft. com/ news-events/ medical-software-vendor-integration. html) Retrieved May 8, 2008 [2] How to Evaluate Medical Practice Management Software (http:/ / www. versaform. com/ news/ 4/ 139/ How-to-Evaluate-Medical-Practice-Management-Software) Retrieved May 20, 2009 [3] Terry, Ken "Coding Software Upgrades" (http:/ / www. physicianspractice. com/ index/ fuseaction/ articles. details/ articleID/ 1264. htm) Physicians Practice journal, volume 19, number 1, year 2009, access date July 2, 2009 [4] http:/ / www. carecloud. com/ central [5] http:/ / www. carecloud. com [6] http:/ / www. cliniko. com [7] http:/ / www. redguava. com. au [8] http:/ / www. advancedcomputersoftware. com/ ahc/ [9] http:/ / www. nuesoft. com/ [10] https:/ / www2. gehealthcare. com [11] "LSS Data Systems' Medical and Practice Management (MPM) Suite Client/Server 5.6 Receives 08 CCHIT Certification" (http:/ / www. cchit. org/ products/ 2008/ ambulatory/ 905). Certification Commission for Health Information Technology. 2009-05-21. . [12] http:/ / www. lssdata. com/ [13] http:/ / www. medisoft. com/ [14] http:/ / www. eclipsys. com/ [15] https:/ / drchrono. com/ ipad [16] http:/ / www. sagehealth. com [17] http:/ / www. nortecehr. com/

[18] http:/ / www. rushcliff. com [19] http:/ / www. wonderdoc. com
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Clinical Quality Management System

A Clinical Quality Management System (CQMS) allows an entire practice staff to take part in increasing the quality of care delivered to their patients. Acting as a real-time dashboard on care, a CQMS lets a care team know the status of each of their patients regarding needed preventive, screening and chronic disease management services based on practice-specified care guidelines. With tools to reach patients at the point-of-care and those not scheduled for a visit, a CQMS ensures the entire patient population is managed effectively and efficiently.
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Health Electronic Records

Electronic health record
An electronic health record (EHR) (also electronic patient record (EPR) or computerised patient record) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations.[1] It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems. Such records may include a whole range of data in comprehensive or summary form, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information. Its purpose can be understood as a complete record of patient encounters that allows the automation and streamlining of the workflow in health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting.[2]
Sample view of an electronic health record based on images
Terminology
The terms EHR, EPR and EMR (electronic medical record) are often used Sample view of an electronic health record interchangeably, although a difference between them can be defined. The EMR can be defined as the legal patient record created in hospitals and ambulatory environments that is the data source for the EHR.[3] It is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health care providers, employers, and payers or insurers access to a patient's medical records across facilities.[4] A personal health record is, in modern parlance, generally defined as an EHR that the individual patient controls.
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Philosophical views of the EHR

Within a meta-narrative systematic review of research in the field, Prof. Trish Greenhalgh and colleagues defined a number of different philosophical approaches to the EHR.[5] The health information systems literature has seen the EHR as a container holding information about the patient, and a tool for aggregating clinical data for secondary uses (billing, audit etc.). However, other research traditions see the EHR as a contextualised artefact within a socio-technical system. For example, actor-network theory would see the EHR as an actant in a network (e.g. [6] ), while research in computer supported cooperative work (CSCW) sees the EHR as a tool supporting particular work. Prof. Barry Robson and OK Baek also reviewed these aspects and see the EHR as pivotal in human history.[7]
Advantages
Several possible advantages to EHRs over paper records have been proposed, but there is debate about the degree to which these are achieved in practice (e.g. [8] ).
Reduction of cost
In the U.S. a vast amount of funds are allocated towards the health care industrymore than $1.7 trillion per year.[9] If savings are allocated using the current level of spending from the National Health Accounts, Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year.[9]
Improve quality of care

The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality.[9] Information Technology is being used today to automate day-to-day processes, thus helping to reduce administration costs which then in turn can free up time and money for patient care.[10] EHR systems can help reduce medical errors by providing healthcare workers with decision support.[11] Fast access to medical literature and current best practices in medicine are hypothesised to enable proliferation of ongoing improvements in healthcare efficacy.[11] Improved usage of EHR is achieved if the presentation on screen or on paper is not just longitudinal, but hierarchically ordered and layered. During compilation while hospitalisation or ambulant serving of the patient, easing to get access on details is improved with browser capabilities applied to screen presentations also cross referring to the respective coding concepts ICD, DRG and medical procedures information. Computerized Physician Order Entry (CPOE)one component of EHRincreases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.[12]
Promote evidence-based medicine

EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices. Realistically, these benefits may only be realized if the EHR systems are interoperable and wide spread (for example, national or regional level) so that various systems can easily share information. Also, to avoid failures that can cause injury to the patient and violations to privacy, the best practices in software engineering and medical informatics must be deployed.[13]
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Record keeping and mobility

EHR systems have the advantages of being able to connect to many electronic medical record systems. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure.
Disadvantages
Critics point out that while EHRs may save the "health system" money, physicians, those who buy the systems, may not benefit financially. EHR price tags range widely, depending on what's included, how robust the system is, and how many providers use it. Asked what they paid in an online survey, about a third of respondents paid between $500 and $3,000 per physician. A third paid between $3,001 and $6,000, and 33 percent paid more than $6,000 per physician for their EHR.[14] Physicians do tend to see at least short-term decreases in productivity as they implement an EHR. They spend more time entering data into an empty EHR than they used to spend updating a paper chart with a simple dictation. Such hurdles can be overcome once the software has some data, as physicians learn to use templates for data entry, and as workflow in the practice changes, but not every practice gets that far. Studies also call into question whether, in real life, EHRs improve quality.[15] raising doubts about EHR benefits.[17] [18] [19]
[16]
2009 produced several articles
Costs
The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption.[20] In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.[20] The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a productand may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians." If a physician performs tests in the office, it might reduce his or her income. "Given the ease at which information can be exchanged between health IT systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used."[21] [22]
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Time
Often, doctors do not want to spend the time to learn a new system. Some doctors believe that adopting a system with EHRs could reduce clinical productivity.[23]
Governance, privacy and legal issues

Privacy concerns
In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern.[24] [25] Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also.[26] Recent revelations of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location.[27] Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet. The Health Insurance Portability and Accountability Act (HIPAA) was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of these standards.[28] In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[29] Personal Information Protection and Electronic Documents Act (PIPEDA) was given Royal Assent in Canada on April 13, 2000 to establish rules on the use, disclosure and collection of personal information. The personal information includes both non-digital and electronic form. In 2002, PIPEDA extended to the health sector in Stage 2 of the law's implementation.[30] There are four provinces where this law does not apply because its privacy law was considered similar to PIPEDA: Alberta, British Columbia, Ontario and Quebec. One major issue that has risen on the privacy of the US network for electronic health records is the strategy to secure the privacy of patients. Former US president Bush called for the creation of networks, but federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers.[31] The privacy threat posed by the interoperability of a national network is a key concern. One of the most vocal critics of EMRs, New York University Professor Jacob M. Appel, has claimed that the number of people who will need to have access to such a truly interoperable national system, which he estimates to be 12 million, will inevitable lead to breaches of privacy on a massive scale. Appel has written that while "hospitals keep careful tabs on who accesses the charts of VIP patients," they are powerless to act against "a meddlesome pharmacist in Alaska" who "looks up the urine toxicology on his daughter's fiance in Florida, to check if the fellow has a cocaine habit."[32] This is a significant barrier for the adoption of an EHR. Accountability among all the parties that are involved in the processing of electronic transactions including the patient, physician office staff, and insurance companies, is the key to successful advancement of the EHR in the US Supporters of EHRs have argued that there needs to be a fundamental shift in attitudes, awareness, habits, and capabilities in the areas of privacy and security of individuals health records if adoption of an EHR is to occur.[33]
Electronic health record According to the Wall Street Journal, the DHHS takes no action on complaints under HIPAA, and medical records are disclosed under court orders in legal actions such as claims arising from automobile accidents. HIPAA has special restrictions on psychotherapy records, but psychotherapy records can also be disclosed without the client's knowledge or permission, according to the Journal. For example, Patricia Galvin, a lawyer in San Francisco, saw a psychologist at Stanford Hospital & Clinics after her fiance committed suicide. Her therapist had assured her that her records would be confidential. But after she applied for disability benefits, Stanford gave the insurer her therapy notes, and the insurer denied her benefits based on what Galvin claims was a misinterpretation of the notes. Stanford had merged her notes with her general medical record, and the general medical record wasn't covered by HIPAA restrictions.[34] Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector.[33] Private companies have promised to have stringent privacy policies and procedures. If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it.[31] So, the private sector know the importance of privacy and the security of the systems and continue to advance well ahead of the federal government with electronic health records.
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Legal issues
Liability Legal liability in all aspects of healthcare was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys[35] and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.[36] Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.[37] Similarly, it's important to recognize that the implementation of electronic health records carries with it significant legal risks.[38] This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate.[39] Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults. In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital's software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers.[40] In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.[41] [42] Legal interoperability In cross-border use cases of EHR implementations, the additional issue of legal interoperability arises. Different countries may have diverging legal requirements for the content or usage of electronic health records, which can require radical changes of the technical makeup of the EHR implementation in question. (especially when fundamental legal incompatibilities are involved) Exploring these issues is therefore often necessary when implementing cross-border EHR solutions.[43]
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Regulatory compliance
Consumer Credit Act 2006 HIPAA Health Level 7
Technical issues
Standards
ANSI X12 (EDI) - transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data. CEN's TC/251 provides EHR standards in Europe including: EN 13606, communication standards for EHR information CONTSYS (EN 13940), supports continuity of care record standardization. HISA (EN 12967), a services standard for inter-system communication in a clinical information environment. Continuity of Care Record - ASTM International Continuity of Care Record standard DICOM - an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association) HL7 - a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems ISO - ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures The U.S. federal government has issued new rules of electronic health records.[44] Open Specifications openEHR: an open community developed specification for a shared health record with web-based content developed online by experts. Strong multilingual capability. Virtual Medical Record: HL7's proposed model for interfacing with clinical decision support systems. SMArt Platforms [45]: an open platform specification to provide a standard base for healthcare applications. Customization Each healthcare environment functions differently, often in significant ways. It is difficult to create a "one-size-fits-all" EHR system. An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization. This customization can often be done so that a physician's input interface closely mimics previously utilized paper forms.[46] At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized.[47] Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.[48] Customization can have its disadvantages. There is, of course, higher costs involved to implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs. Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance costs.[49] [50]
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Long-term preservation and storage of records

An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives. Additionally, considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al. have noted that choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information.[51] The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research "describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures."[52] In addition to the TNA archive described by Ruotsalainen and Manning, other combinations of EHR systems and archive systems are possible. Again, overall requirements for the design and security of the system and its archive will vary and must function under ethical and legal principles specific to the time and place. While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language. Olhede and Peterson report that the basic XML-format has undergone preliminary testing in Europe by a Spri project and been found suitable for EU purposes. Spri has advised the Swedish National Board of Health and Welfare and the Swedish National Archive to issue directives concerning the use of XML as the archive-format for EHCR (Electronic Health Care Record) information."[53]
Synchronization of records
When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion. Two models have been used to satisfy this problem: a centralized data server solution, and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks). Synchronization programs for distributed storage models, however, are only useful once record standardization has occurred. Merging of already existing public healthcare databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve healthcare delivery.[54] [55] [56]
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eHealth and teleradiology

The sharing of patient information between health care organizations and IT systems is changing from a "point to point" model to a "many to many" one. The European Commission is supporting moves to facilitate cross-border interoperability of e-health systems and to remove potential legal hurdles, as in the project www.epsos.eu/. To allow for global shared workflow, studies will be locked when they are being read and then unlocked and updated once reading is complete. Radiologists will be able to serve multiple health care facilities and read and report across large geographical areas, thus balancing workloads. The biggest challenges will relate to interoperability and legal clarity. In some countries it is almost forbidden to practice teleradiology. The variety of languages spoken is a problem and multilingual reporting templates for all anatomical regions are not yet available. However, the market for e-health and teleradiology is evolving more rapidly than any laws or regulations.[57]
National contexts
United States
As of 2000, adoption of EHRs and other health information technology (HITs) (such as computer physician order entry (CPOE)) was minimal in the United States (outside of the VA system). Fewer than 10% of American hospitals had implemented HIT,[58] while a mere 16% of primary care physicians used EHRs.[59] In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system.[60] [61] In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in 2001.[61] However, less than one-tenth of these physicians actually had a "complete EMR system" (with US medical groups' adoption of EHR (2005) computerized orders for prescriptions, computerized orders for [62] tests, reporting of test results, and physician notes). The CDC more recently reported that the EMR adoption rate has steadily risen to 48.3 percent at the end of 2009.[63] The healthcare industry spends only 2% of gross revenues on HIT, which is low compared to other information intensive industries such as finance, which spend upwards of 10%.[64] [65] [66] Incentives and penalties Until recently, with the American Recovery and Reinvestment Act of 2009,[67] (ARRA) providers were expected to take the full risk of investing in healthcare IT. Notably, healthcare payers, such as the government through Medicare, also have potential for significant cost savings if providers adopt EHR systems. The HITECH Act, part of the 2009 economic stimulus package (ARRA) passed by the US Congress, aims at inducing more physicians to adopt EHR. Title IV of the act promises maximum incentive payments for Medicaid to those who adopt and use "certified EHRs" of $63,750 over 6 years beginning in 2011. Eligible professionals must begin receiving payments by 2016 to qualify for the program. For Medicare the maximum payments are $44,000 over 5 years. Doctors who do not adopt an EHR by 2015 will be penalized 1% of Medicare payments, increasing to 3% over 3 years. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to show "meaningful use" of an EHR system. As of June 2010, there are no penalty provisions for Medicaid.[3] Health information exchange (HIE) has emerged as a core capability for hospitals and physicians to achieve "meaningful use" and receive stimulus funding. Healthcare vendors are pushing HIE as a way to allow EHR systems to pull disparate data and function on a more interoperable level.
Electronic health record Starting in 2015, hospitals and doctors will be subject to financial penalties under Medicare if they are not using electronic health records.[44] Meaningful use Meaningful use describes the use of health information technology (HIT) that leads to improvements in healthcare and furthers the goals of information exchange among health care professionals. The meaningful use rule is part of a coordinated set of regulations to help create a private and secure 21st-century electronic health information system. To become Meaningful Users providers need to demonstrate they're using certified EHR technology in ways that can be measured significantly in quantity and in quality. The American Recovery and Reinvestment Act of 2009 specify three main components of Meaningful Use: The use of a certified EHR in a meaningful manner, such as e-prescribing. The use of certified EHR technology for electronic exchange of health information to improve quality of health care. The use of certified EHR technology to submit clinical quality and other measures.[68] The meaningful use of EHRs intended by the US government incentives is categorized as follows: Improve care coordination Reduce healthcare disparities Engage patients and their families Improve population and public health Ensure adequate privacy and security The Obama Administrations Health IT program intends to use federal investments to stimulate the market of electronic health records: Incentives: to providers who use IT Strict and open standards: To ensure users and sellers of EHRs work towards the same goal Certification of software: To provide assurance that the EHRs meet basic quality, safety, and efficiency standards The detailed definition of meaningful use is to be rolled out in 3 stages over a period of time until 2015. Details of each stage are hotly debated by various groups. Only stage 1 has been defined while the remaining stages will evolve over time.[69] Meaningful use Stage 1 The first steps in achieving meaningful use are to have a certified electronic health record (EHR) and to be able to demonstrate that it is being used to meet the requirements. Stage 1 contains 25 objectives/measures for Eligible Providers (EPs) and 24 objectives/measures for eligible hospitals. The objectives/measures have been divided into a core set and menu set. EPs and eligible hospitals must meet all objectives/measures in the core set (15 for EPs and 14 for eligible hospitals). EPs must meet 5 of the 10 menu-set items during Stage 1.[70] Full list of the Core Requirements and a full list of the Menu Requirements. Core Requirements: 1. 2. 3. 4. 5. 6. Use computerized order entry for medication orders. Implement drug-drug, drug-allergy checks. Generate and transmit permissible prescriptions electronically. Record demographics. Maintain an up-to-date problem list of current and active diagnoses. Maintain active medication list.
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7. Maintain active medication allergy list. 8. Record and chart changes in vital signs. 9. Record smoking status for patients 13 years old or older.
Electronic health record 10. 11. 12. 13. 14. 15. Implement one clinical decision support rule. Report ambulatory quality measures to CMS or the States. Provide patients with an electronic copy of their health information upon request. Provide clinical summaries to patients for each office visit. Capability to exchange key clinical information electronically among providers and patient authorized entities. Protect electronic health information (privacy & security)
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Menu Requirements: 1. Implement drug-formulary checks. 2. Incorporate clinical lab-test results into certified EHR as structured data. 3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach. 4. Send reminders to patients per patient preference for preventive/ follow-up care 5. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) 6. Use certified EHR to identify patient-specific education resources and provide to patient if appropriate. 7. Perform medication reconciliation as relevant 8. Provide summary care record for transitions in care or referrals. 9. Capability to submit electronic data to immunization registries and actual submission. 10. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission. Start-up costs In a 2006 survey, lack of adequate funding was cited by 729 health care providers as the most significant barrier to adopting electronic records.[71] At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month (including the amortization of startup investment).[72] [73] [74] Vendor costs account for 60-80% of these costs.[75] There are exceptions. A November 2006 survey of a widely available open source EHR reported startup costs of only $1083 $7500/provider and $67 $750/month per provider.[76] Some proponents of EHR systems suggest that startup costs will be recouped within 3 years.[77] A study of the effects of EHRs in primary care settings published in the American Journal of Medicine estimated net benefits from EHR use of over $86,000 per provider over a five-year period.[78] Some physicians are skeptical of such published cost-savings claims, however. They believe the data is skewed by vendors and by others who have a stake in the success of EHR implementation. Many are resistant to invest in a system which they are not confident will provide them with a return on their investment.[79] [80] Brigham and Womens Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.[81] Software maintenance costs Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Costs for upgrades and associated regression testing can be particularly high where the applications are governed by FDA regulations (e.g. Clinical Laboratory systems). Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation.
Electronic health record Training costs Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.[82] In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the Veterans Health Information Systems and Technology Architecture (VistA) electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Older practitioners who are less experienced in the use of electronic health record systems will retire over time. Implementations In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A key component in VistA is their VistA imaging System which provides a comprehensive multimedia data from many specialties, including cardiology, radiology and orthopedics. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patients electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests.[83] The 2003 National Defense Authorization Act (NDAA) ensured that the VA and DoD would work together to establish a bidirectional exchange of reference quality medical images. Initially, demonstrations were only worked in El Paso, Texas, but capabilities have been expanded to six different locations of VA and DoD facilities. These facilities include VA polytrauma centers in Tampa and Richmond, Denver, North Chicago, Biloxi, and the National Capitol Area medical facilities. Radiological images such as CT scans, MRIs, and x-rays are being shared using the BHIE. Goals of the VA and DoD in the near future are to use several image sharing solutions (VistA Imaging and DoD Picture Archiving & Communications System (PACS) solutions).[84] [84] Clinical Data Repository/Health Data Repository (CDHR)is a program that allows for sharing of patient records, especially allergy and pharmaceutical information, between the Department of Veteran Affairs (VA) and the Department of Defense (DoD) in the United States. The program shares data by translating the various vocabularies of the information being transmitted, allowing all of the VA facilities to access and interpret the patient records.[85] The Laboratory Data Sharing and Interoperability (LDSI) application is a new program being implemented to allow sharing at certain sites between the VA and DoD of chemistry and hematology laboratory tests. Unlike the CHDR, the LDSI is currently limited in its scope.[86]
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Electronic health records flow chart
One attribute for the start of implementing EHRs in the States is the development of the Nationwide Health Information Network which is a work in progress and still being developed. This started with the North Carolina Healthcare Information and Communication Alliance founded in 1994 and who received funding from Department of Health and Human Services.[87] The Department of Veterans Affairs works with Kaiser Permanente to further develop a software which allows to share information with private health care providers.[88] This software called 'CONNECT' uses Nationwide Health Information Network standards and governance to make sure that health information exchanges are compatible with other exchanges being set up throughout the country. CONNECT is an open source software solution that supports electronic health information exchange.[89] The CONNECT initiative is a Federal Health Architecture project that was conceived in 2007 and initially built by 20 various federal agencies and now comprises more than 500
Electronic health record organizations including federal agencies, states, healthcare providers, insurers, and health IT vendors.[90] The US Indian Health Service uses an EHR similar to VistA called RPMS. VistA Imaging is also being used to integrate images and co-ordinate PACS into the EHR system.
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UK
As of 2005, the National Health Service (NHS) in the United Kingdom also began an EHR system. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practitioners in England access to the National Programme for IT (NPfIT).[91] However, the plan has been greatly delayed and frequently criticised.[92] [93] [94]
Australia
Australia is dedicated to the development of a lifetime electronic health record for all its citizens. HealthConnect is the major national EHR initiative in Australia, and is made up of territory, state, and federal governments. MediConnect is a related program that provides an electronic medication record to keep track of patient prescriptions and provide stakeholders with drug alerts to avoid errors in prescribing.[95]
Canada
The Canadian province of Alberta started a large-scale operational EHR system project in 2005 called Alberta Netcare, which is expected to encompass all of Alberta by 2008.
Estonia
Estonia is the first country in the world that has implemented a nationwide EHR system, registering virtually all residents' medical history from birth to death.[96]
UAE
Abu Dhabi is leading the way in using national EHR data as a live longitudinal cohort in the assessment of risk of cardiovascular disease.[97]
Saudi Arabia
Arab Health Awards 2010 recognizes Saudi Arabia National Guard Health Affairs for greatest advancement in EHR development.[98]
References
[1] Gunter, T.D. and Terry, N.P. 2005 The Emergence of National Electronic Health Record Architectures in the United States and Australia: Models, Costs, and Questions (http:/ / www. pubmedcentral. nih. gov/ articlerender. fcgi?artid=1550638) in J Med Internet Res 7(1) [2] HIMSS - Electronic Health Record (EHR) (http:/ / www. himss. org/ ASP/ topics_ehr. asp) [3] Habib JL. EHRs, meaningful use, and a model EMR (http:/ / dbt. consultantlive. com/ display/ article/ 1145628/ 1581538). Drug Benefit Trends. May 2010;22(4):99-101. [4] Electronic Health Records Overview (http:/ / www. ncrr. nih. gov/ publications/ informatics/ EHR. pdf) [5] Greenhalgh T, Potts HWW, Wong G, Bark P, Swinglehurst D (2009). Tensions and paradoxes in electronic patient record research: A systematic literature review using the meta-narrative method. Milbank Quarterly, 87(4), 729-88 [6] Berg, M. 1997. Of Forms, Containers, and the Electronic Medical Record: Some Tools for a Sociology of the Formal. Science, Technology, & Human Values 22(4):40333 [7] Robson, B, Baek, OK. (2009). The Engines of Hippocrates: From the Dawn of Medicine to Medical and Pharmaceutical Informatics. John Wiley & Sons [8] http:/ / www. bmj. com/ cgi/ content/ full/ 340/ jun16_4/ c3111 Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HWW (2010). Adoption and non-adoption of a shared electronic summary care record in England: A mixed-method case study. BMJ, 340, c3111

[9] Hillestad, Richard et al.: "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs", Health Affairs, 2005 (http:/ / 64. 233. 169. 104/ search?q=cache:Hqus71_PhKAJ:www. eecs. harvard. edu/ cs199r/ readings/ RAND_benefits. pdf+ + "Can+ Electronic+ Medical+ Record+ Systems+ Transform+ Health+ Care?+ Potential+ Health+ Benefits,+ Savings,+ and+ Costs"& hl=en& ct=clnk& cd=5& gl=us), Retrieved February 19, 2008 [10] "HP global citizenship report." (http:/ / www. hp. com/ hpinfo/ globalcitizenship/ globalissues/ healthcare. html?jumpid=reg_R1002_USEN) [11] Arizona Republic: Electronic Health Records: About $500 Million at stake in digital move. Ken Alltucker. March 20, 2011. [12] .Hillestad, Richard et al.: "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs", Health Affairs, 2005 (http:/ / 64. 233. 169. 104/ search?q=cache:Hqus71_PhKAJ:www. eecs. harvard. edu/ cs199r/ readings/ RAND_benefits. pdf+ + "Can+ Electronic+ Medical+ Record+ Systems+ Transform+ Health+ Care?+ Potential+ Health+ Benefits,+ Savings,+ and+ Costs"& hl=en& ct=clnk& cd=5& gl=us), Retrieved February 19, 2008 [13] Hoffman S, Podgurski, A (Fall 2008). "Finding a Cure; The Case for Regulation and Oversight of Electronic Health Record Systems" (http:/ / jolt. law. harvard. edu/ articles/ pdf/ v22/ 22HarvJLTech103. pdf) (PDF). Harvard Journal of Law & Technology 22 (1): 107. . [14] Moore, Pamela (2008). "Navigating The Tech Maze" (http:/ / www. physicianspractice. com/ index/ fuseaction/ articles. details/ articleID/ 1214/ page/ 1. htm). Physicians Practice. . Retrieved 2009-08-23. [15] Gabriel, Barbara (2008). "Do EMRs Make You a Better Doctor?" (http:/ / www. physicianspractice. com/ index/ fuseaction/ articles. details/ articleID/ 1203/ page/ 1. htm). Physicians Practice. . Retrieved 2009-08-23. [16] Electronic health records not a panacea (http:/ / www. healthcareitnews. com/ news/ electronic-health-records-not-panacea-researchers-say) [17] Silverstein, Scot (2009). "2009 a pivotal year in healthcare IT" (http:/ / www. ischool. drexel. edu/ faculty/ ssilverstein/ cases/ ?loc=cases& sloc=2009). Drexel University. . Retrieved 2010-01-05. [18] Greenhalgh T, Potts HWW, Wong G, Bark P, Swinglehurst D (2009). Tensions and paradoxes in electronic patient record research: A systematic literature review using the meta-narrative method. Milbank Quarterly, 87(4), 729-88 ( full text (http:/ / eprints. ucl. ac. uk/ 18821/ )) [19] Himmelstein DU, Wright A, Woolhandler S (2009). Hospital Computing and the Costs and Quality of Care: A National Study. American Journal of Medicine, doi:10.1016/j.amjmed.2009.09.004 ( full text (http:/ / www. ischool. drexel. edu/ faculty/ ssilverstein/ AJM-Himmelstein-Hospital-Computing. pdf)) [20] RWIF,GWUMC, and IHP Staff: "Health Information Technology in the United States: The Information Base for Progress", Robert Wood Johnson Foundation, George Washington University Medical Center, and Institute for Health Policy, 2006 (http:/ / www. rwjf. org/ files/ publications/ other/ EHRReport0609. pdf), Retrieved February 17, 2008 [21] Evidence on the costs and benefits of health information technology. (http:/ / www. cbo. gov/ doc. cfm?index=9168) Congressional Budget Office, May 2008. [22] Journal of Surgical Radiology. (http:/ / www. surgisphere. com/ SurgRad/ current-issue/ 119-column-why-mds-dread-emrs. html) [23] Kluger, Jeffrey (March 25, 2009). "Electronic Health Records: What's Taking So Long?" (http:/ / www. time. com/ time/ health/ article/ 0,8599,1887658,00. html). Time. . [24] "Opposition calls for rethink on data storage" (http:/ / www. e-health-insider. com/ news/ 3343/ opposition_calls_for_rethink_on_data_storage). e-Health Insider (UK). December 2007. . [25] "German doctors say no to centrally stored patient records" (http:/ / www. e-health-insider. com/ news/ 3384/ german_doctors_say_no_to_centrally_stored_patient_records). e-Health Insider (UK). January 2008. . [26] Health & Medicine (2006-06-26). "At risk of exposure: In the push for electronic medical records, concern is growing about how well privacy can be safeguarded." (http:/ / web. archive. org/ web/ 20060813005017/ http:/ / www. latimes. com/ features/ health/ medicine/ la-he-privacy26jun26,1,3180537. column?ctrack=1& cset=true). Los Angeles Times. Archived from the original (http:/ / www. latimes. com/ features/ health/ medicine/ la-he-privacy26jun26,1,3180537. column?ctrack=1& cset=true) on 2006-08-13. . Retrieved 2006-08-08. [27] CNN.com (May 23, 2006): FBI seeks stolen personal data on 26 million vets (http:/ / www. cnn. com/ 2006/ US/ 05/ 22/ vets. data/ index. html) Retrieved July 30, 2006 [28] Tim Wafa (J.D.). "How the Lack of Prescriptive Technical Granularity in HIPAA Has Compromised Patient Privacy" (http:/ / papers. ssrn. com/ sol3/ papers. cfm?abstract_id=1547425). Northern Illinois University Law Review, Volume 30, Number 3, Summer 2010. . [29] European Parliament and Council (24 October 1995): EU Directive 95/46/EC - The Data Protection Directive (http:/ / www. dataprivacy. ie/ viewdoc. asp?m=& fn=/ documents/ LEGAL/ 6aii. htm) Retrieved July 30, 2006 [30] "Personal Information Protection and Electronic Documents Act - Implementation Schedule." Office of the Privacy Commissioner of Canada. April 1, 2004. Accessed February 12, 2008 <http://www.privcom.gc.ca/legislation/02_06_02a_e.asp>. [31] Pear, Robert. Warnings Over Privacy of U.S. Health Network. New York Times, February 18, 2007. [32] JM Appel. Why shared medical database is wrong prescription. Orlando Sentinel, December 30, 2008. http:/ / www. orlandosentinel. com/ news/ opinion/ views/ orl-opappel3008dec30,0,4065787. story [33] Nulan C (2001). "HIPAA--a real world perspective". Radiol Manage 23 (2): 2937; quiz 3840. PMID11302064. [34] Theo Francis, Spread of records stirs fears of privacy erosion, The Wall Street Journal, December 28, 2006 (http:/ / online. wsj. com/ article_print/ SB116709136139859229. html) (http:/ / www. post-gazette. com/ pg/ 06362/ 749444-114. stm) [35] "Lawyers Per 100,000 Population 1980-2003" (http:/ / www. newsbatch. com/ tort-lawyerinc. html). Congressional Budget Office. . Retrieved 2007-07-10. [36] "Tort reform" (http:/ / www. newsbatch. com/ tort. htm). News Batch. 2006-05. .
98

[37] "Bigger focus on compliance needed in EMR marketplace" (http:/ / www. healthimaging. com/ content/ view/ 5885/ 89/ ). Health Imaging News. 2007-02-05. . [38] "Ben Kerschberg, Electronic Health Records Dramatically Increase Corporate Risk" (http:/ / www. huffingtonpost. com/ ben-kerschberg/ how-electronic-health-rec_b_806793. html). The Huffington Post. 2010-01-10. . [39] Medical Manager History (http:/ / docs. mirrormed. org/ index. php/ Medical_Manager_History) [40] Laura Dunlop (2007-04-06). "Electronic Health Records: Interoperability Challenges and Patient's Right for Privacy" (http:/ / www. lctjournal. washington. edu/ Vol3/ a016Dunlop. html). Shidler Journal of Computer and Technology 3:16. . [41] "Newly Issued Final Rules under Stark and Anti-kickback Laws Permit Furnishing of [[Electronic prescribing|Electronic Prescribing (http:/ / www. gklaw. com/ publication. cfm?publication_id=525)] and Electronic Health Records Technology"]. GKLaw. August 2006. . [42] "New Stark Law Exceptions and Anti-Kickback Safe Harbors For Electronic Prescribing and Electronic Health Records" (http:/ / www. ssd. com/ publications/ pub_detail. aspx?pubid=9675). SSDlaw. August 2006. . [43] European Patient Smart Open Services Work Plan: epSOS: Legal and Regulatory Issues (http:/ / www. epsos. eu/ about-epsos/ work-plan-new. html#c501) Retrieved May 4, 2008 [44] Pear, Robert (July 13, 2010). "U.S. Issues Rules on Electronic Health Records" (http:/ / www. nytimes. com/ 2010/ 07/ 14/ health/ policy/ 14health. html?_r=1& hpw). The New York Times. . [45] http:/ / www. smartplatforms. org/ [46] Clayton L. Reynolds MD, FACP, FACPE (March 2006): Paper on Concept Processing (http:/ / www. infor-med. com/ downloads/ why_praxis_downloads/ Charting_Bass_Ackward. pdf) Retrieved July 27, 2006 [47] Maekawa Y, Majima Y.; Issues to be improved after introduction of a non-customized Electronic Medical Record system (EMR) in a Private General Hospital and efforts toward improvement; Studies in Health Technology and Informatics 2006 [48] Tttelmann F, Luetjens CM, Nieschlag E.; "Optimising workflow in andrology: a new electronic patient record and database"; Asian Journal of Andrology March 2006 [49] The Digital Office, September 2007, vol 2, no.9. HIMSS [50] Gina Rollins."The Perils of Customization." Journal of AHIMA 77, no.6 (2006):24-28. [51] Mandl KD, Szolovits P, Kohane IS (February 2001). "Public standards and patients' control: how to keep electronic medical records accessible but private" (http:/ / bmj. com/ cgi/ pmidlookup?view=long& pmid=11157533). BMJ 322 (7281): 2837. doi:10.1136/bmj.322.7281.283. PMC1119527. PMID11157533. . [52] Ruotsalainen P, Manning B (2007). "A notary archive model for secure preservation and distribution of electrically signed patient documents". Int J Med Inform 76 (56): 44953. doi:10.1016/j.ijmedinf.2006.09.011. PMID17118701. [53] Olhede T, Peterson HE (2000). "Archiving of care related information in XML-format". Stud Health Technol Inform 77: 6426. PMID11187632. [54] "Integrating the New York citywide immunization registry and the childhood blood lead registry". Journal of Public Health Management and Practice: S7280. 2004.The Master Child Index consolidated 4,610,585 records that were contained in both databases into 2,977,290 records through a match and merge system. [55] "Quality improvements in pediatric well care with an electronic record". Proc AMIA Symp: 20913. 2001. [56] "Perspectives on integrated child health information systems: Parents, providers, and public health". Journal of Public Health Management Practice: S57S60. 2004. [57] Pohjonen H. Images can now cross borders, but what about the legislation? (http:/ / www. diagnosticimaging. com/ imaging-trends-advances/ ultrasound-source/ archive/ article/ 113619/ 1584986) Diagnostic Imaging Europe. June/July 2010;26(4):16. [58] DJ Ringold, JP Santell, and PJ Schneider; S; S (1 October 2000). "ASHP national survey of pharmacy practice in acute care settings: dispensing and administration1999" (http:/ / www. ajhp. org/ cgi/ content/ abstract/ 57/ 19/ 1759). American Journal of Health-System Pharmacy 57 (19): 175975. PMID11030028. . [59] Johnston, Doughlas, et al. "The Value of Computerize Provider Order Entry in Ambulatory Settings: Executive Preview." Wellesley, MA: Center for Information Technology Leadership, 2003 [60] Linder JA, Ma J, Bates DW, Middleton B, Stafford RS (July 2007). "Electronic health record use and the quality of ambulatory care in the United States" (http:/ / archinte. ama-assn. org/ cgi/ content/ short/ 167/ 13/ 1400). Arch. Intern. Med. 167 (13): 14005. doi:10.1001/archinte.167.13.1400. PMID17620534. . [61] National Center for Health Statistics: Electronic Medical Record Use by Office-Based Physicians:, United States, 2005 (http:/ / www. cdc. gov/ nchs/ products/ pubs/ pubd/ hestats/ electronic/ electronic. htm) Retrieved July 24, 2006 [62] CDC's National Center for Health Statistics: More Physicians Using Electrical Medical Records (http:/ / www. cdc. gov/ od/ oc/ media/ pressrel/ a060721. htm) Retrieved July 27, 2006 [63] Are More Doctors Adopting EHRs? (http:/ / www. nuesoft. com/ blog/ are-more-doctors-adopting-ehrs/ ) Retrieved March 31, 2011 [64] Raymond, B. and C. Dold (2002). "Clinical Information Systems: Achieving the Vision" (http:/ / www. informatics-review. com/ thoughts/ vision. html). Kaiser Permanente Institute for Health Policy. . [65] Simon SR, Kaushal R, Cleary PD, (2007). "Correlates of electronic health record adoption in office practices: a statewide survey". J Am Med Inform Assoc 14 (1): 1107. doi:10.1197/jamia.M2187. PMC2215070. PMID17068351. [66] Menachemi N, Perkins RM, van Durme DJ, Brooks RG (2006). "Examining the adoption of electronic health records and personal digital assistants by family physicians in Florida" (http:/ / openurl. ingenta. com/ content/ nlm?genre=article& issn=1476-0320& volume=14& issue=1& spage=1& aulast=Menachemi). Inform Prim Care 14 (1): 19. PMID16848961. .
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[67] http:/ / recovery. gov [68] https:/ / www. cms. gov/ apps/ media/ press/ factsheet. asp?Counter=3794& intNumPerPage=10& checkDate=& checkKey=& srchType=1& numDays=3500& srchOpt=0& srchData=& keywordType=All& chkNewsType=6& intPage=& showAll=& pYear=& year=& desc=& cboOrder=date [69] http:/ / healthit. hhs. gov/ portal/ server. pt?open=512& objID=1325& parentname=CommunityPage& parentid=21& mode=2& in_hi_userid=10741& cached=true [70] http:/ / healthit. hhs. gov/ portal/ server. pt?CommunityID=1206& spaceID=399& parentname=& control=SetCommunity& parentid=& PageID=0& space=CommunityPage& in_hi_totalgroups=1& in_hi_req_ddfolder=6652& in_ra_topoperator=or& in_hi_depth_1=0& in_hi_req_page=20& control=advancedstart& in_hi_req_objtype=18& in_hi_req_objtype=512& in_hi_req_objtype=514& in_hi_req_apps=1& in_hi_revealed_1=0& in_hi_userid=8969& in_hi_groupoperator_1=or& in_hi_model_mode=browse& cached=false& in_ra_groupoperator_1=or& in_tx_fulltext=stage+ 1 [71] Medical Records Institute (http:/ / www. medrecinst. com/ ), Retrieved December 6, 2006 [72] "We've got to adopt health information technology, and get on with it" (http:/ / www. healthcareitnews. com/ news/ weve-got-adopt-health-information-technology-and-get-it). Healthcare IT News. 2006-10-11. . [73] "CEO Survival Guide to Electronic Health Records" (http:/ / www. nqfexecutiveinstitute. org/ executiveinstitute/ EHRbookfinal. pdf) (PDF). National Committee for Quality Health Care. 2006. . [74] Columbus, Suzanne. (May 2006). "Small Practice, Big Decision: Selecting an EHR System for Small Physician Practices" (http:/ / library. ahima. org/ xpedio/ groups/ public/ documents/ ahima/ bok1_031357. hcsp?dDocName=bok1_031357). Journal of AHIMA 77, no.5 (May2006):4246. . [75] "Towards the Electronic Patient Record: Ambulatory Market Trends: Discussion and Analysis" (http:/ / www. acgroup. org/ images/ 2007_TEPR_Meeting_-_Ambulatory_Care_Market_Trends_v2. pdf) (PDF). AC Group (Presentation). . [76] "An Evaluation of Vista-Office EHR in the Small Practice Setting: Functional Performance, Economic Costs, and Implementation/Support Processes" (http:/ / www. sujansky. com/ docs/ VistaOfficeEHR_EvaluationReport_2006-11-30. pdf) (PDF). Sujansky & Associates, LLC. . [77] "The Value of Electronic Health Records in Solo or Small Group Practices" (http:/ / www. cmwf. org/ publications/ publications_show. htm?doc_id=296446). The Commonwealth Fund. . [78] "Potential Benefits of Electronic Medical Records" (http:/ / web. archive. org/ web/ 20071009181502/ http:/ / www. wcit2006. org/ Healthcare/ media/ whitepaper/ emr. pdf) (PDF). LBJ School of Public Affairs. Archived from the original (http:/ / www. wcit2006. org/ Healthcare/ media/ whitepaper/ emr. pdf) on 2007-10-09. . Retrieved 2007-07-10. [79] Meinert, D.B. (2006). "Resistance to Electronic Medical Records (EMRs): A Barrier to Improved Quality of Care" (http:/ / proceedings. informingscience. org/ InSITE2005/ I41f100Mein. pdf) (PDF). Issues in Informing Science and Information Technology. . [80] http:/ / www. himss. org/ content/ files/ vantagepoint/ pdf/ vantagepoint_0405. pdf [81] "A State Policy Approach: Promoting Health Information Technology in California" (http:/ / www. lao. ca. gov/ 2007/ health_info_tech/ health_info_tech_021307. aspx). California Legislative Analyst Office. February 2007. . [82] Parish, Colin (March 20, 2006). Edging towards a brave new IT world. Nursing Standard 27:15-16 [83] HP case study: VA Medical Inspectors Office can now retrieve records in minutes. Feb. 2011. (http:/ / h20195. www2. hp. com/ v2/ GetPDF. aspx/ 4AA3-3376ENW. pdf) [84] http:/ / www1. va. gov/ vadodhealthitsharing/ page. cfm?pg=23 Retrieved March 4, 2010 [85] http:/ / www1. va. gov/ vadodhealthitsharing/ page. cfm?pg=9 Retrieved March 4, 2010 [86] http:/ / www1. va. gov/ vadodhealthitsharing/ page. cfm?pg=4 Retrieved March 4, 2010 [87] Traynor, Kate (2008) National health information network passes live test. American Journal of Health-System Pharmacy 65.22: 2086-2087 [88] http:/ / gcn. com/ microsites/ 2009-health-technology-solutions/ federal-health-information-exchange. aspx Retrieved March 4, 2010 [89] http:/ / www. connectopensource. org/ about/ what-is-CONNECT Retrieved March 4, 2010 [90] http:/ / connectopensource. osuosl. org/ sites/ connectopensource. osuosl. org/ files/ CONNECTOverview. pdf Retrieved March 4, 2010 [91] NHS Connecting for Health:Delivering the National Programme for IT (http:/ / www. connectingforhealth. nhs. uk/ delivery/ ) Retrieved August 4, 2006 [92] Ian Quinn, "Electronic records are less efficient than paper, finds DH research lead" (http:/ / www. pulsetoday. co. uk/ story. asp?sectioncode=35& storycode=4124614& c=2) [93] Health e-records 'struggling to fulfil potential' (http:/ / news. bbc. co. uk/ 1/ hi/ health/ 10333432. stm) [94] Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HWW (2010). Adoption and non-adoption of a shared electronic summary care record in England: A mixed-method case study. BMJ, 340, c3111 [95] Mason, Moya K. (2005). What Can We Learn from the Rest of the World? A Look at International Electronic Health Record Best Practices (http:/ / www. moyak. com/ papers/ best-practices-ehr. html). . [96] http:/ / recordaccess. icmcc. org/ tag/ portal/ [97] http:/ / www. 3four50. com/ v2/ ?page=summit10-vid23 [98] http:/ / www. quadramed. com/ news/ pr_detail. cfm?pr_id=474
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External links
Can Electronic Health Record Systems Transform Health Care? (http://www.eecs.harvard.edu/cs199r/ readings/RAND_benefits.pdf) Health Information Technology in the United States (http://www.rwjf.org/files/publications/other/ EHRReport0609.pdf) How to Enable Standard-Compliant Streaming of Images in Electronic Health Records (http://www.aware. com/imaging/whitepapers/wp_jpipwado.htm) a white paper by Aware Inc. (http://www.aware.com/imaging/ whitepapers.htm) Open-Source EHR Systems for Ambulatory Care: A Market Assessment (http://www.chcf.org/topics/view. cfm?itemID=133551)(California HealthCare Foundation, January 2008) US Department of Health and Human Services (HHS), Office of the National Coordinator for Health Information Technology (ONC) (http://www.hhs.gov/healthit/) US Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ), National Resource Center for Health Information Technology (http://healthit.ahrq.gov/emr) ICMCC portal: EHR info and blogs (http://recordaccess.icmcc.org/) Security Aspects in Electronic Personal Health Record: Data Access and Preservation (http://www. digitalpreservationeurope.eu/publications/briefs/security_aspects.pdf) - a briefing paper at Digital Preservation Europe
Electronic medical record

An electronic medical record (EMR) is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office.[1] Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records.
Contrast with paper-based record

Paper based records are still by far the most common method of recording patient information for most hospitals and practices in the U.S.[2] The majority of doctors still find their ease of data entry and low cost hard to part with. However, as easy as they are for the doctor to record medical data at the point of care, they require a significant amount of storage space compared to digital records. In the US, most states require physical records be held for a minimum of seven years. The costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media. When paper records are stored in different locations, collating them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. This is particularly true in the case of person-centred records, which are impractical to maintain if not electronic (thus difficult to centralise or federate). When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records. Because of these many "after entry" benefits, federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic medical records. Congress included a formula of both incentives (up to $44K per physician under Medicare or up to $65K over 6 years, under Medicaid) and penalties (i.e. decreased Medicare/Medicaid reimbursements for covered patients to doctors who fail to use EMR's by 2015) for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.[3] One study estimates electronic medical records improve overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of only a few "unnecessary" tests or
Electronic medical record admissions.[4] [5] Jerome Groopman disputed these results, publicly asking "how such dramatic claims of cost-saving and quality improvement could be true".[6] However, the increased portability and accessibility of electronic medical records may also increase the ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users versus paper medical records as acknowledged by the increased security requirements for electronic medical records included in the Health Information and Accessibility Act and by recent large-scale breaches in confidential records reported by EMR users.[7] [8] Concerns about security contribute to the resistance shown to their widespread adoption. Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.[9] Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.[10] [11] In contrast, EMRs can be continuously updated (within certain legal limitations - see below). The ability to exchange records between different EMR systems ("interoperability"[12] ) would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.[13]
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Contribution under UN administration and accredited organisations

The United Nations World Health Organisation (WHO) administration intentionally does not contribute to an internationally standardized view of medical records nor to personal health records. However, WHO contributes to minimum requirements definition for developing countries.[14] The United Nations accredited standardisation body International Organization for Standardization (ISO) however has settled thorough word for standards in the scope of the HL7 platform for health care informatics. Respective standards are available with ISO/HL7 10781:2009 Electronic Health Record-System Functional Model, Release 1.1[15] and subsequent set of detailing standards.
EMRs in the United States

Usage
Even though EMR systems with a computerized provider order entry (CPOE) have existed for more than 30 years, fewer than 10 percent of hospitals as of 2006 have a fully integrated system.[16] In the United States, the CDC reported that the EMR adoption rate has steadily risen to 48.3 percent at the end of 2009.[17] This is an increase since 2008 when 38.4% of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2008.[18] However, the same study found that only 20.4% of all physicians reported using a system described as minimally functional and including the following features: orders for prescriptions, orders for tests, viewing laboratory or imaging results, and clinical notes.
Legal status
Electronic medical records, like medical records, must be kept in unaltered form and authenticated by the creator.[19] Under data protection legislation, responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law.[20]
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Technical features
Using an EMR to read and write a patient's record is not only possible through a workstation but depending on the type of system and health care settings may also be possible through mobile devices that are handwriting capable.[21] Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from an EMR readily visible and accessible for consumers.
Event monitoring
Some EMR systems automatically monitor clinical events, by analyzing patient data from an Electronic Health Record to predict, detect and potentially prevent adverse events. This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes.[22]
EMRs in Europe
There is no common standard on EMR in Europe neither in the entire member states of the European Union. Exception is with those states where health care system is unified, as in United Kingdom.
EMRs in Ambulances
Ambulance Services in Australia have recently introduced the use of EMR systems [23] The benefits of EMR in Ambulance include the following: better training for paramedics, review of clinical standards, better research options for pre-hospital care and design of future treatment options [24]
GP2GP project
GP2GP is an NHS Connecting for Health project in the United Kingdom. It enables GPs to transfer a patient's electronic medical record to another practice when the patient moves onto the listctice.[25]
Privacy concerns
A major concern is adequate confidentiality of the individual records being managed electronically. According to the LA Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and over 600,000 payers, providers and other entities that handle providers' billing data have some access.[26] In the United States, this class of information is referred to as Protected Health Information (PHI) and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws.[27] In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[28]
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Technical standards
Though there are few standards for modern day EMR systems as a whole, there are many standards relating to specific aspects of EMRs. These include: HL7 - messages format for interchange between different record systems and practice management systems. ANSI X12 (EDI) - A set of transaction protocols used in the US for transmitting virtually any aspect of patient data. CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care. CEN - EHRcom (EN 13606), a standard for the communication of information from EHR systems. CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment. DICOM - a standard for representing and communicating radiology images and reporting
Interoperability towards sharing records

In the United States, the development of standards for EMR interoperability is at the forefront of the national health care agenda.[29] EMRs, while an important factor in interoperability, are not a critical first step to sharing data between practicing physicians, pharmacies and hospitals. Many physicians currently have computerized practice management systems that can be used in conjunction with a health information exchange (HIE), allowing for first steps in sharing patient information (lab results, public health reporting) which are necessary for timely, patient-centered and portable care. The future vision of many connected health systems is the ability to connect the electronic medical record system to a personal health record creating a "shared record". This sharing will have to include elements of granular permissions at the data type level and the ability for patient generated content to be "tagged" allowing the provider to maintain clinical integrity of information. An example of this can be seen in implementations of connected health platforms that have this capability built in like HealthyCircles. [30]
Regulatory compliance
HIPAA Health Level 7 DICOM Title 21 CFR Part 11
Electronic Medical Records in Veterinary Medicine

In UK veterinary practice, the replacement of paper recording systems with electronic methods of storing animal patient information escalated from the 1980s and the majority of clinics now use electronic medical records. In a sample of 129 veterinary practices, 89% used a Practice Management System (PMS) for data recording.[31] There are more than 10 PMS providers currently in the UK. Collecting data directly from PMSs for epidemiological analysis abolishes the need for veterinarians to manually submit individual reports per animal visit and therefore increases the reporting rate.[32] Veterinary electronic medical record data are being used to investigate antimicrobial efficacy; risk factors for canine cancer; and inherited diseases in dogs and cats, in the small animal disease surveillance project 'VEctAR' [33] (Veterinary Electronic Animal Record) at the Royal Veterinary College, London, in collaboration with the University of Sydney and RxWorks [34].[35]
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References
[1] http:/ / www. providersedge. com/ ehdocs/ ehr_articles/ Electronic_Patient_Records-EMRs_and_EHRs. pdf [2] "Use of Electronic Health Records in U.S. Hospitals," New England Journal of Medicine, March 25, 2009 [3] U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 412, 413, 422 et al. Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule [4] Evans DC, Nichol WP, Perlin JB (April 2006). "Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration" (http:/ / journals. cambridge. org/ action/ displayAbstract;jsessionid=7C274D08947B0625B3B540BEF2E70367. tomcat1?fromPage=online& aid=416400). Health Econ Policy Law 1 (Pt 2): 1639. doi:10.1017/S1744133105001210. PMID18634688. . [5] "VistA:Winner of the 2006 Innovations in American Government Award" (http:/ / www. innovations. va. gov/ innovations/ docs/ InnovationsVistAInfoPackage. pdf) (PDF). The Ash Institute for Democratic Governance and Innovation at Harvard University's John F. Kennedy School of Government. . [6] Jerome Groopman & Pamela Hartzband (12 March 2009). "Obama's $80 Billion Exaggeration" (http:/ / online. wsj. com/ article/ SB123681586452302125. html). Wall Street Journal. . Retrieved 3 March 2010. [7] "Griffin Hospital reports breach of dozens of patient medical records", CtPost.com, March, 29, 2010 [8] Kate Ramunni; "UCLA hospital scandal grows" Los Angeles Times, August 05, 2008 [9] Institute of Medicine (1999). "To Err Is Human: Building a Safer Health System (1999)" (http:/ / fermat. nap. edu/ catalog/ 9728. html#toc). The National Academies Press. . Retrieved 2006-06-20. [10] "EMR Software Information Exchange, January 25, 2011" (http:/ / emrsoftwarepro. com/ health-information-exchanges-and-the-emr-selection-process/ ). EMR Software Pro. 2011. . [11] "Health Information Exchanges and Your EMR Selection Process," New England Journal of Medicine, January 25, 2011 [12] Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601) [13] "EHR Definition, Attributes and Essential Requirements" (http:/ / www. himss. org/ content/ files/ EHRAttributes. pdf) (PDF). Healthcare Information and Management Systems Society. 2003. . Retrieved 2006-07-28. [14] (http:/ / whqlibdoc. who. int/ wpro/ 2002/ 9290610050. pdf) [15] (http:/ / www. iso. org/ iso/ iso_catalogue/ catalogue_tc/ catalogue_detail. htm?csnumber=46087) [16] Smaltz, Detlev and Eta Berner. The Executive's Guide to Electronic Health Records. (2007, Health Administration Press) p.03 [17] Are More Doctors Adopting EHRs? (http:/ / www. nuesoft. com/ blog/ are-more-doctors-adopting-ehrs/ ) Retrieved March 31, 2011 [18] National Center for Health : United States, 2008] Retrieved December 15, 2009 [19] National Archives and Records Administration (NARA): Long-Term Usability of Optical Media (http:/ / palimpsest. stanford. edu/ bytopic/ electronic-records/ electronic-storage-media/ critiss. html) Retrieved July 30, 2006 [20] Medical Board of California: Medical Records - Frequently Asked Questions (http:/ / medbd. ca. gov/ consumer/ complaint_info_questions_records. html) Retrieved July 30, 2006 [21] Handwriting and mobile computing experts: (http:/ / www. medscribbler. com/ handwriting_electronic_medical_records. html) Retrieved August 20, 2008 [22] M958 revision-Event monitors in PHS 1-02-02.PDF (http:/ / rods. health. pitt. edu/ Technical Reports/ 2002 JAMIA Event monitors in PHS. pdf) [23] EMR in Ambulances (http:/ / emergencymedicalparamedic. com/ emr-for-paramedics), "Emergency Medical Paramedic", May 5th 2011, Retrieved Jun 4th 2011 [24] Ambulance Victoria Annual Report (http:/ / www. ambulance. vic. gov. au/ annualreport0809/ VACIS. htm), Ambulance Victoria, October 4 2009, Retrieved Jun 4th 2011 [25] GPsGP Website (http:/ / www. connectingforhealth. nhs. uk/ delivery/ programmes/ gp2gp) [26] Foreman, Judy (26 June 2006). "At risk of exposure" (http:/ / articles. latimes. com/ 2006/ jun/ 26/ health/ he-privacy26). Los Angeles Times. . Retrieved 9 September 2010. [27] US Code of Federal Regulations, Title45, Volume 1 (Revised October 1, 2005): of Individually Identifiable Health Information (45CFR164.501) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?YEAR=current& TITLE=45& PART=164& SECTION=501& SUBPART=& TYPE=TEXTPrivacy) Retrieved July 30, 2006 [28] European Parliament and Council (24 October 1995): EU Directive 95/46/EC - The Data Protection Directive (http:/ / www. dataprivacy. ie/ viewdoc. asp?m=& fn=/ documents/ LEGAL/ 6aii. htm) Retrieved July 30, 2006 [29] (http:/ / www. cms. hhs. gov/ MissionVisionGoals/ Downloads/ CMSStrategicActionPlan06-09_061023a. pdf) [30] [HealthyCircles Record Sharing Framework https:/ / www. healthycircles. com/ p_record_sharing. aspx] [31] Gill, M. (2007) Attitudes to clinical audit in veterinary practice, Royal Veterinary College elective project, unpublished work [32] Carruthers, H. (2009) Disease surveillance in small animal practice, In Pract, 31(7): 356-358 [33] http:/ / www. rvc. ac. uk/ VEctAR [34] http:/ / www. rxworks. com [35] VEctAR (Veterinary Electronic Animal Record) (2010) from http:/ / www. rvc. ac. uk/ VEctAR/
Personal health record
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A personal health record or PHR is a health record where health data is curated by an individual user themselves. This stands in contrast with the more widely used electronic medical record which is held by institutions such as a hospital and contains data entered by clinicians or billing data in order to support insurance claims. The intention of a PHR is to provide a complete and accurate summary of an individual's medical history which is accessible online. The health data on a PHR might include patient-reported outcome data, lab results (either entered by a patient or downloaded from the testing lab itself), data from devices such as wireless electronic weighing scales or collected passively from a smartphone.
Definition
The term personal health record is not new. The earliest mention of the term was in an article indexed by PubMed dated June 1978;[1] and even earlier in 1956 reference is made to a personal health log[2] however, search results from PubMed also reveal that most scientific articles written about PHRs have been published since 2000. The term "PHR" has been applied to both paper-based and computerized systems; however, current usage usually implies an electronic application used to collect and store health data. In recent years, several formal definitions of the term have been proposed by various organizations.[3] [4] [5] It is important to note that PHRs are not the same as EHRs (electronic health records). The latter are software systems designed for use by health care providers. Like the data recorded in paper-based medical records, the data in EHRs are legally mandated notes on the care provided by clinicians to patients. There is no legal mandate that compels a consumer or patient to store her personal health information in a PHR. PHRs can contain a diverse range of data but usually include information about: allergies and adverse drug reactions chronic diseases family history illnesses and hospitalizations imaging reports (e.g. x-ray) immunization records laboratory test results medications and dosing including over the counter medications and herbal remedies surgeries and other procedures vaccinations and Observations of Daily Living (ODLs)
In addition to storing an individual's personal health information, some PHRs provide added-value services such as drug-drug interaction checking, electronic messaging between patients and providers, managing appointments, and reminders.[6]
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PHR Solution Types

One of the principle distinguishing features of a PHR is the platform by which it is delivered. The types of platforms include: paper, electronic device, and web.
Paper-based PHRs
Personal health information is recorded and stored in paper format. Printed laboratory reports, copies of clinic notes, and health histories created by the individual may be parts of a paper-based PHR. This method is low cost, reliable, and accessible without the need for a computer or any other hardware. Paper-based PHRs may be difficult to locate, update, and share with others. Paper-based PHRs are subject to physical loss and damage, such as can occur during a natural disaster. Paper records can also be printed from most electronic PHRs. Example from New Zealand from 1984 to present. Dr Larry Skiba http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC1959601/ pdf/ jroyalcgprac00170-0046. pdf Child Health and Development Record book http:/ / onlinelibrary. wiley. com/ doi/ 10. 1111/j.1365-2648.2010.05285.x/full
Electronic device-based PHRs

Personal health information is recorded and stored in personal computer-based software that may have the capability to print, backup, encrypt, and import data from other sources such as a hospital laboratory. The most basic form of a PC-based PHR would be a health history created in a word-processing program. The health history created in this way can be printed, copied, and shared with anyone with a compatible word processor. PHR software can provide more sophisticated features such as data encryption, data importation, and data sharing with health care providers. Some PHR products allow the copying of health records to a mass-storage device such as a CD-ROM, DVD, smart card, or USB flash drive. PC-based PHRs are subject to physical loss and damage of the personal computer and the data that it contains. Some other methods of device solution may entail cards with embedded chips containing health information that may or may not be linked to a personal computer application or a web solution.
Web-based PHR Solutions

Web-based PHR solutions are essentially the same as electronic device PHR solutions, however, web-based solutions have the advantage of being easily integrated with other services. For example, some solutions allow for import of medical data from external sources. Solutions including HealthVault and PatientsLikeMe allow for data to be shared with other applications or specific people. Mobile solutions often integrate themselves with web solutions and use the web-based solution as the platform.
EHRs, PHRs, Patient Portals and UHRs

The terms electronic health records, personal health records, and patient portals are not always used correctly. The generally agreed upon definition of these terms relates mainly to the ownership of the data. Although most patients might believe, "my body, my data" the FDA has started to weigh in on the issue of who owns healthcare data Million Dollar Question - Who owns your health data [7]. Once data is in a PHR it is owned and controlled by the patient. In most EHRs, however, it the property of the provider, although the content can be co-created by both the provider and patient. A patient has a legal right in most states to request their healthcare data and under recent legislation those providers using a certified EHR will be required to provide an electronic copy as well. Electronic health records and electronic medical records contain clinical data created by and for health professionals in the course of providing care. The data is about the patient but the data resides in a health care provider's system. The patient portal is typically defined as a view into the electronic medical records. In addition ancillary functions that support a health care provider's interaction with a patient are also found in those systems e.g. prescription refill requests, appointment
Personal health record requests, electronic case management, etc. Finally PHRs are data that resides with the patient, in a system of a patient's choosing. This data may have been exported directly from an EMR, but the point is it now resides in a location of the patient's choosing. Access to that information is controlled entirely by the patient. A new concept being discussed (as of March 2010) is the UHR or "universal health record",[8] which would be a patient-centered and patient-controlled body of information that could be shared in a granular way with particular health care providers at the patient's discretion in support of the patient's work with health care providers. This project would enlist open source contributions and enhancements from developers, with particular emphasis on supporting patient expectations of privacy and responsible patient control of private health information (PHI). It is anticipated that effective implementation of one or more "open source" approaches to the UHR would benefit both providers and patients ("Some of us are sometimes providers - All of us are sometimes patients...") including providing more cost-effective solutions to currently difficult problems including entry/verification/update of personal health data, enabling responsible patient-controlled granular release of PHI, and supporting interoperability and effective collaboration of patients and physicians across disparate EHR/PHR platforms. While PHRs can help patients keep track of their personal health information, the value of PHRs to healthcare organizations is still unclear.[9]
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PHRs and public health

PHRs have the ability to benefit the public health sector by providing health monitoring, outbreak monitoring, empowerment, linking to services, and research. PHRs can give consumers the potential to play a large role in protecting and promoting the public's health.[10]
References
[1] "Computerisation of personal health records". Health Visitor 51 (6): 227. Jun 1978. PMID248054. [2] DRAGSTEDT, CA (1956-04-14). "Personal health log.". Journal of the American Medical Association 160 (15): 1320. PMID13306552. [3] Connecting for Health. (http:/ / www. connectingforhealth. org/ resources/ final_phwg_report1. pdf) The Personal Health Working Group Final Report. July 1, 2003. [4] American Health Information Management Association. (http:/ / library. ahima. org/ xpedio/ groups/ public/ documents/ ahima/ bok1_027539. hcsp?dDocName=bok1_027539) The Role of the Personal Health Record in the EHR. July 25, 2005. [5] America's Health Insurance Plans. (http:/ / www. ahip. org/ content/ default. aspx?docid=18330) What are Personal Health Records (PHRs)? December 13, 2006. [6] "MyChart" (http:/ / my. clevelandclinic. org/ eclevelandclinic/ mychart/ default. aspx?utm_campaign=mychart-redirect& utm_medium=offline& utm_source=redirect& wt. mc_id=1400). Cleveland Clinic. . Retrieved 29 March 2011. [7] http:/ / www. fastcompany. com/ blog/ kate-rockwood/ bizzy-body/ million-dollar-question-who-owns-your-health-data [8] Moving Toward an Open Standard, Universal Health Record (http:/ / www. smart-publications. com/ health_commentaries/ Universal_Health_Record. php), by John Morgenthaler [9] Kaelber, David; Pan, Eric (2008). "The Value of Personal Health Record (PHR) Systems". AMIA Annu Symp Proc: 343347. PMC2655982. PMID18999276. [10] Weitzman, E, Grajales, F, Bonander, J, Gates, S (2010). "Public health in an era of personal health records: Opportunity for innovation and new partnerships." J Med Internet Res, 12(3) e33. Full text at PMC: 2956336 (http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC2956336/ )
109
Bibliography
Books 1. Agarwal R, Angst CM. Technology-enabled transformations in U.S. health care: early findings on personal health records and individual use, In Galletta G, Zhang P, (Eds.), Human-Computer Interaction and Management Information Systems: Applications (Vol. 5). Armonk, NY: M.E. Sharpe, Inc., pp.357378. 2006. 2. Lewis D, Eysenbach G, Kukafka R, Stavri PZ, Jimison H. Consumer health informatics: informing consumers and improving health care. New York: Springer. 2005. Journal Articles 1. The benefits of an internet based personal health record versus a paper based personal health record is expected to grow rapidly within the next three years. See interview with CEO, Glen Tullman of Allscripts http://www.ehrtv. com/allscripts-glen-tullman-mar-2010/ 2. "Computerisation of personal health records". Health visitor 51 (6): 227. Jun 1978. PMID248054. 3. "Recordkeeping systems: personal health records". J Am Med Rec Assoc. 55 (12): 42. Dec 1984. PMID10310901. 4. "Concepts of the Health Vault" (http://www.munnecke.com/papers/D03.doc). 1999 Paper by Tom Munnecke describing an architecture for the Personal Health Record 5. "[Personal medical records and identification card, synchronized information systems] [Personal medical records and identification card, synchronized information systems]" (in French). Rev Infirm. (106): 456. Dec 2004. PMID15672518. 6. Swain, M; Lawn, B (Apr 2005). "Information prescriptions (Ix): bringing internet-based health content into the treatment process; patients to your site". Internet Healthc Strateg. 7 (4): 48. doi:10.1016/0148-9062(76)91830-1. PMID15929640. 7. "Report on attitudes about personal health records". Internet Healthc Strateg. 6 (9): 101. Sep 2004. PMID15526437. 8. "New-age PHR comes with decision-support, multiple opportunities for DM". Dis Manag Advis. 12 (12): 1402, 133. Dec 2006. PMID17225631. 9. Kupchunas WR (2007). "Personal health record: new opportunity for patient education". Orthop Nurs. 26 (3): 18591; quiz 1923. doi:10.1097/01.NOR.0000276971.86937.c4. PMID17538475. 10. "Readers' perspective. Personal health records will be widely used within five years, supplanting the need for regional health information organizations". Health Data Manag. 15 (10): 8. Oct 2007. PMID17941305. 11. Ackerman MJ (2007). "The personal health record". J Med Pract Manage. 23 (2): 845. PMID17974083. 12. Adler KG (2006). "Web portals in primary care: an evaluation of patient readiness and willingness to pay for online services" (http://www.jmir.org/2006/4/e26). J Med Internet Res. 8 (4): e26. doi:10.2196/jmir.8.4.e26. PMC1794005. PMID17213045. 13. Burrington-Brown J, Fishel J, Fox L et al. (Jun 2005). "Defining the personal health record. AHIMA releases definition, attributes of consumer health record". J Ahima. 76 (6): 245. PMID15986557. 14. AHIMA e-HIM Personal Health Record Work Group (Jul 2005). "Practice brief. The role of the personal health record in the EHR". Journal of AHIMA / American Health Information Management Association 76 (7): 64A64D. PMID16097127. 15. Albright B (Feb 2007). "Prepping for PHRs. The growing trend of consumer empowerment includes the speedy rise of personal health records". Healthc Inform. 24 (2): 44, 46. PMID17370879. 16. American Health Information Management Association; American Medical Informatics Association (Oct 2006). "The value of personal health records. A joint position statement for consumers of healthcare". J Ahima. 77 (9): 24. PMID17111904. 17. American Health Information Management Association; American Medical Informatics Association (Apr 2007). "The value of personal health records. A joint position statement for consumers of healthcare by the American
Personal health record Health Information Management Association and the American Medical Informatics Association". J Ahima. 78 (4): 22, 24. PMID17455841. 18. Atkinson NL, Massett HA, Mylks C, Hanna B, Deering MJ, Hesse BW (2007). "User-centered research on breast cancer patient needs and preferences of an Internet-based clinical trial matching system". J Med Internet Res. 9 (2): e13. doi:10.2196/jmir.9.2.e13. PMC1874719. PMID17513284. 19. Bakker A (Mar 2004). "Access to EHR and access control at a moment in the past: a discussion of the need and an exploration of the consequences". Int J Med Inform. 73 (3): 26770. doi:10.1016/j.ijmedinf.2003.11.008. PMID15066557. 20. Ball MJ, Gold J (2006). "Banking on health: Personal records and information exchange". Journal of healthcare information management : JHIM 20 (2): 7183. PMID16669591. 21. Ball MJ, Smith C, Bakalar RS (2007). "Personal health records: empowering consumers". J Healthc Inf Manag. 21 (1): 7686. PMID17299929. 22. Black D (Mar 1992). "Personal health records". J Med Ethics 18 (1): 56. doi:10.1136/jme.18.1.5. PMC1376076. PMID1573654. 23. Burrington-Brown J, Friedman B (Oct 2005). "Educating the public about personal health records". J Ahima. 76 (9): 945. PMID16274211. 24. Cimino JJ, Patel VL, Kushniruk AW (Dec 2002). "The patient clinical information system (PatCIS): technical solutions for and experience with giving patients access to their electronic medical records" (http://linkinghub. elsevier.com/retrieve/pii/S1386505602000709). Int J Med Inform. 68 (13): 11327. doi:10.1016/S1386-5056(02)00070-9. PMID12467796. 25. Clarke JL, Meiris DC, Nash DB (2006). "Electronic personal health records come of age". American Journal of Medical Quality 21 (3 Suppl): 5S15S. doi:10.1177/1062860606287642. PMID16621927. 26. Conn J (2006). "Personal and (maybe) confidential. Questions over privacy, formats and definitions remain, but personal health records are on the way". Mod Healthc. 36 (27): 2831. PMID16898550. 27. Cooke T, Watt D, Wertzler W, Quan H (May 2006). "Patient expectations of emergency department care: phase II--a cross-sectional survey". CJEM. 8 (3): 14857. PMID17320008. 28. D'Alessandro DM, Dosa NP (Oct 2001). "Empowering children and families with information technology" (http://archpedi.ama-assn.org/cgi/pmidlookup?view=long&pmid=11576008). Arch Pediatr Adolesc Med. 155 (10): 11316. PMID11576008. 29. Denton IC (Sep 2001). "Will patients use electronic personal health records? Responses from a real-life experience". J Healthc Inf Manag. 15 (3): 2519. PMID11642143. 30. Earnest MA, Ross SE, Wittevrongel L, Moore LA, Lin CT (Sep 2004). "Use of a patient-accessible electronic medical record in a practice for congestive heart failure: patient and physician experiences". J Am Med Inform Assoc. 11 (5): 4107. doi:10.1197/jamia.M1479. PMC516248. PMID15187074. 31. Edlin M (2006). "Implementing personal health records". AHIP Coverage 47 (2): 146, 19. PMID16700448. 32. Einbinder JS, Bates DW (2007). "Leveraging information technology to improve quality and safety". Yearbook of medical informatics: 229. PMID17700900. 33. Endsley S, Kibbe DC, Linares A, Colorafi K (May 2006). "An introduction to personal health records". Fam Pract Manag. 13 (5): 5762. PMID16736906. 34. Fowles JB, Kind AC, Craft C, Kind EA, Mandel JL, Adlis S (Apr 2004). "Patients' interest in reading their medical record: relation with clinical and sociodemographic characteristics and patients' approach to health care". Arch Intern Med. 164 (7): 793800. doi:10.1001/archinte.164.7.793. PMID15078650. 35. Foxhall K (Mar 2007). "Now it's personal. Personal health records may be next on deck for the certification process". Healthc Inform. 24 (3): 30. PMID17427793. 36. Friedman RH (2006). "Medicaid information technology architecture: an overview". Health Care Financ Rev 28 (2): 19. PMID17427840. 37. Gawthorn EC (Jun 1983). "Personal health records (PHR)". Aust Fam Physician. 12 (6): 4668. PMID6626044.
110
Personal health record 38. Greene J (2007). "The personal health record: a key to improving health care for seniors". AHIP Coverage 48 (5): 468, 512, 55. PMID17941574. 39. Halamka JD, Mandl KD, Tang PC (2008). "Early experiences with personal health records". J Am Med Inform Assoc. 15 (1): 17. doi:10.1197/jamia.M2562. PMC2274878. PMID17947615. 40. Hassol A, Walker JM, Kidder D et al. (Nov-Dec 2004). "Patient experiences and attitudes about access to a patient electronic health care record and linked web messaging". J Am Med Inform Assoc. 11 (6): 50513. doi:10.1197/jamia.M1593. PMC524631. PMID15299001. 41. Hess R, Bryce CL, Paone S et al. (Oct 2007). "Exploring challenges and potentials of personal health records in diabetes self-management: implementation and initial assessment". Telemed J E Health. 13 (5): 50917. doi:10.1089/tmj.2006.0089. PMID17999613. 42. Honeyman A, Cox B, Fisher B (2005). "Potential impacts of patient access to their electronic care records" (http://openurl.ingenta.com/content/nlm?genre=article&issn=1476-0320&volume=13&issue=1& spage=55&aulast=Honeyman). Informatics in Primary Care. 13 (1): 5560. PMID15949176. 43. Iakovidis I. Towards personal health record: current situation, obstacles and trends in implementation of electronic healthcare record in Europe. Int J Med Info. Oct 1998. 52(1-3); 105-15. 44. Jeffs D, Harris M (Aug 1993). "The personal health record. Making it work better for general practitioners". Aust Fam Physician. 22 (8): 14179, 1421, 14247. PMID8379881. 45. Jeffs D, Nossar V, Bailey F, Smith W, Chey T (Jun 1994). "Retention and use of personal health records: a population-based study". J Paediatr Child Health. 30 (3): 24852. doi:10.1111/j.1440-1754.1994.tb00627.x. PMID8074911. 46. Johnson S, Mayor P (Apr 2002). "A patient-held record for cancer patients from diagnosis onwards". Int J Palliat Nurs. 8 (4): 182, 1849. PMID12048447. 47. Joshi P, Jones KV, Hanson RM, Alperstein G, Fasher B (Oct 1993). "Personal health records". J Paediatr Child Health 29 (5): 4001. doi:10.1111/j.1440-1754.1993.tb00549.x. PMID8240876. 48. Jossi F (Feb 2006). "Personal health records". Healthc Inform. 23 (2): 52, 54. PMID16597007. 49. Kardas G, Tunali ET (Jan 2006). "Design and implementation of a smart card based healthcare information system". Comput Methods Programs Biomed. 81 (1): 6678. doi:10.1016/j.cmpb.2005.10.006. PMID16356586. 50. Kim E, Mayani A, Modi S, Kim Y, Soh C. Evaluation of patient-centered electronic health record to overcome digital divide. Conf Proc IEEE Eng Med Biol Soc. 2005. 2;593-6. 51. Kim MI, Johnson KB (Mar-Apr 2002). "Personal health records: evaluation of functionality and utility" (http:// www.jamia.org/cgi/pmidlookup?view=long&pmid=11861632). J Am Med Inform Assoc. 9 (2): 17180. doi:10.1197/jamia.M0978. PMC344574. PMID11861632. 52. Kim MI, Johnson KB (May 2004). "Patient entry of information: evaluation of user interfaces" (http://www. jmir.org/2004/2/e13). J Med Internet Res. 6 (2): e13. doi:10.2196/jmir.6.2.e13. PMC1550597. PMID15249262. 53. Kimmel Z, Greenes RA, Liederman E (Nov-Dec 2005). "Personal health records". J Med Pract Manage. 21 (3): 14752. PMID16471387. 54. Klein-Fedyshin MS (2002). "Consumer Health Informatics--integrating patients, providers, and professionals online". Med Ref Serv Q. 21 (3): 3550. doi:10.1300/J115v21n03_03. PMID12238015. 55. Kupchunas WR (2007). "Personal health record: new opportunity for patient education". Orthop Nurs. 26 (3): 18591; quiz 1923. doi:10.1097/01.NOR.0000276971.86937.c4. PMID17538475. 56. Kun LG. Homecare and disease prevention: reviewing a decade of evolution - privacy still the biggest hurdle. Conf Proc IEEE Eng Med Biol Soc. 2006;1:4685. Medline (http://www.ncbi.nlm.nih.gov/sites/ entrez?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17947108&itool=pubmed_DocSum) 57. Lafky DB, Tulu B, Horan TA. A user-driven approach to personal health records. Communications of the Association for Information Systems. Jun 2006. 17(46).
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Personal health record 58. Lee M, Delaney C, Moorhead S (Oct 2007). "Building a personal health record from a nursing perspective". Int J Med Inform. 76 Suppl 2: S30816. doi:10.1016/j.ijmedinf.2007.05.010. PMID17616432. 59. Lin CT, Wittevrongel L, Moore L, Beaty BL, Ross SE (Aug 2005). "An Internet-based patient-provider communication system: randomized controlled trial" (http://www.jmir.org/2005/4/e47). J Med Internet Res. 7 (4): e47. doi:10.2196/jmir.7.4.e47. PMC1550679. PMID16236699. 60. Lober WB, Zierler B, Herbaugh AL, Shinstrom SE, Stolyar A, Kim EH, Kim Y. Barriers to the use of a Personal Health Record by an Elderly Population. AMIA Annu Symp Proc. 2006. 514-8. 61. Lowes R (Feb 2006). "Personal health records: What's the status now?". Med Econ. 83 (4): TCP134, TCP16. PMID16573223. 62. Lu SC (2007). "CCR exchange: building a patient-driven web-based healthcare community around an emerging personal health record standard" (http://booksonline.iospress.nl/Extern/EnterMedLine. aspx?ISSN=0926-9630&Volume=127&SPage=58). Stud Health Technol Inform. 127: 5864. PMID17901599. 63. Masys D, Baker D, Butros A, Cowles KE (Mar-Apr 2002). "Giving patients access to their medical records via the internet: the PCASSO experience" (http://www.jamia.org/cgi/pmidlookup?view=long&pmid=11861633). J Am Med Inform Assoc. 9 (2): 18191. doi:10.1197/jamia.M1005. PMC344575. PMID11861633. 64. McCarthy CP (May 2010). "Paging Dr. Google: Personal Health Records and Patient Privacy" (http:// scholarship.law.wm.edu/cgi/viewcontent.cgi?article=1047&context=wmlr). William & Mary Law Review 51 (6): 224368. 65. McSherry B (Aug 2006). "Access to confidential medical records by courts and tribunals: the inapplicability of the doctrine of public interest immunity". J Law Med. 14 (1): 159. PMID16937777. 66. Moen A, Brennan PF (2005). "Health@Home: the work of health information management in the household (HIMH): implications for consumer health informatics (CHI) innovations". J Am Med Inform Assoc. 12 (6): 64856. doi:10.1197/jamia.M1758. PMC1294036. PMID16049230. 67. Morales Rodriguez M, Casper G, Brennan PF (Apr 2007). "Patient-centered design. The potential of user-centered design in personal health records". J Ahima. 78 (4): 446; quiz 4950. PMID17455846. 68. Morrissey J (Nov-Dec 2005). "What does the public think? For consumers to adopt PHRs, they need reasons that hit home". J Ahima 76 (10): 424. PMID16333943. 69. Neame R (Feb 2000). "Creating an infrastructure for the productive sharing of clinical information". Top Health Inf Manage. 20 (3): 8591. PMID10747439. 70. Nelson R (Sep 2007). "The personal health record". Am J Nurs. 107 (9): 278. doi:10.1097/01.NAJ.0000287504.92887.de. PMID17721144. 71. Nobel JJ (Nov-Dec 2005). "Health plan sponsored personal health records: a tool for information driven quality improvement". AHIP Coverage 46 (6): 146, 18, 205. PMID16450491. 72. O'Flaherty S, Jandera E, Llewellyn J, Wall M (Nov 1987). "Personal health records: an evaluation". Arch Dis Child. 62 (11): 11525. doi:10.1136/adc.62.11.1152. PMC1778532. PMID3688919. 73. Odom-Wesley B (Nov-Dec 2000). "Envisioning the personal medical record". J Ahima 71 (10): 3945. PMID11185857. 74. Pagliari C, Detmer D, Singleton P (Aug 2007). "Potential of electronic personal health records". BMJ 335 (7615): 3303. doi:10.1136/bmj.39279.482963.AD. PMC1949437. PMID17703042. 75. Poon EG, Wald J, Schnipper JL et al. (2007). "Empowering patients to improve the quality of their care: design and implementation of a shared health maintenance module in a US integrated healthcare delivery network" (http://booksonline.iospress.nl/Extern/EnterMedLine.aspx?ISSN=0926-9630&Volume=129&SPage=1002). Studies in health technology and informatics 129 (Pt 2): 10026. PMID17911866. 76. Pyper C, Amery J, Watson M, Crook C, Thomas B (2002). "Patients' access to their online electronic health records". J Telemed Telecare. 8 Suppl 2 (2): 1035. doi:10.1258/135763302320302244. PMID12217158. 77. Pyper C, Amery J, Watson M, Crook C (Nov 2004). "Access to electronic health records in primary care-a survey of patients' views" (http://www.medscimonit.com/fulltxt.php?ICID=11808). Med Sci Monit. 10 (11):
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Personal health record SR1722. PMID15507869. 78. Ralston JD, Revere D, Robins LS, Goldberg HI (May 2004). "Patients' experience with a diabetes support programme based on an interactive electronic medical record: qualitative study". BMJ 328 (7449): 1159. doi:10.1136/bmj.328.7449.1159. PMC411089. PMID15142919. 79. Rahul Shetty: Portable Digital Personal Health Record : To Bridge the Digital gap in Medical Information Storage of Individuals with Personal Health Records in Flash Drives. The Internet Journal of Health. 2007. Volume 5 Number 2. 80. Rhoads J, Metzger J (Jan-Feb 2007). "Personal health records: prospects and challenges for health plans". AHIP Coverage 48 (1): 50, 53. PMID17315559. 81. Rocha RA, Romeo AN, Norlin C (2007). "Core features of a parent-controlled pediatric medical home record" (http://booksonline.iospress.nl/Extern/EnterMedLine.aspx?ISSN=0926-9630&Volume=129&SPage=997). Stud Health Technol Inform. 129 (Pt 2): 9971001. PMID17911865. 82. Roop L (Feb 2007). "Technology. Big business charges ahead with personal health records". Hosp Health Netw. 81 (2): 17. PMID17373527. 83. Ross SE, Lin CT (Mar-Apr 2003). "The effects of promoting patient access to medical records: a review" (http:/ /www.jamia.org/cgi/pmidlookup?view=long&pmid=12595402). J Am Med Inform Assoc. 10 (2): 12938. doi:10.1197/jamia.M1147. PMC150366. PMID12595402. 84. Ross SE, Moore LA, Earnest MA, Wittevrongel L, Lin CT (May 2004). "Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial" (http://www.jmir.org/2004/2/e12). J Med Internet Res. 6 (2): e12. doi:10.2196/jmir.6.2.e12. PMC1550594. PMID15249261. 85. Ross SE, Todd J, Moore LA, Beaty BL, Wittevrongel L, Lin CT (May 2005). "Expectations of patients and physicians regarding patient-accessible medical records" (http://www.jmir.org/2005/2/e13). J Med Internet Res. 7 (2): e13. doi:10.2196/jmir.7.2.e13. PMC1550642. PMID15914460. 86. Sachinopoulou A, Leppnen J, Kaijanranta H, Lhteenmki J (2007). "Ontology-based approach for managing personal health and wellness information". Conf Proc IEEE Eng Med Biol Soc. 2007: 18025. doi:10.1109/IEMBS.2007.4352662. ISBN978-1-4244-0787-3. PMID18002328. 87. Sax U, Kohane I, Mandl KD (May-Jun 2005). "Wireless technology infrastructures for authentication of patients: PKI that rings". J Am Med Inform Assoc. 12 (3): 2638. doi:10.1197/jamia.M1681. PMC1090456. PMID15684133. 88. Schneider JH (Aug 2001). "Online personal medical records: are they reliable for acute/critical care?" (http:// meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0090-3493& volume=29&issue=8&spage=N196). Crit Care Med. 29 (8 Suppl): N196201. doi:10.1097/00003246-200108001-00009. PMID11496043. 89. Schoenberg R, Safran C (Nov 2000). "Internet based repository of medical records that retains patient confidentiality". BMJ 321 (7270): 1199203. doi:10.1136/bmj.321.7270.1199. PMC1118958. PMID11073513.. 90. Sittig DF (Apr 2002). "Personal health records on the internet: a snapshot of the pioneers at the end of the 20th Century" (http://linkinghub.elsevier.com/retrieve/pii/S1386505601002155). Int J Med Inform. 65 (1): 16. doi:10.1016/S1386-5056(01)00215-5. PMID11904243. 91. Skiba, Larry W (February 1984). "Patient Retained Records - the Health Identity Card". JRCGP 34 (259): 104106. PMC1959601. PMID6471017.. 92. Smith SP, Barefield AC (Oct-Dec 2007). "Patients meet technology: the newest in patient-centered care initiatives" (http://journals.lww.com/healthcaremanagerjournal/Abstract/2007/10000/ Patients_Meet_Technology__The_Newest_in.11.aspx). Health Care Manag (Frederick). 26 (4): 35462. doi:10.1097/01.HCM.0000299254.29678.50 (inactive 2008-10-21). PMID17992110. 93. Sprague L (Nov 2006). "Personal health records: the people's choice?". NHPF Issue Brief. (820): 113. PMID17146910.
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Personal health record 94. Smolij K, Dun K (Dec 2006). "Patient health information management: searching for the right model". Perspect Health Inf Manag. 3: 10. PMC2047307. PMID18066368. 95. Tang PC, Ash JS, Bates DW, Overhage JM, Sands DZ. Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption. Journal of Medical Informatics Association. Mar 2006. 13(2); 121-126. 96. Tang PC, Lansky D (Sep 2005). "The missing link: bridging the patient-provider health information gap". Health Affairs. 24 (5): 12905. doi:10.1377/hlthaff.24.5.1290. PMID16162575. 97. Tobacman JK, Kissinger P, Wells M et al. (Jul 2004). "Implementation of personal health records by case managers in a VAMC general medicine clinic". Patient Educ Couns. 54 (1): 2733. doi:10.1016/S0738-3991(03)00184-8. PMID15210257. 98. Tracy CS, Dantas GC, Upshur RE (Sep 2004). "Feasibility of a patient decision aid regarding disclosure of personal health information: qualitative evaluation of the Health Care Information Directive". BMC Med Inform Decis Mak. 4: 13. doi:10.1186/1472-6947-4-13. PMC518970. PMID15361257. 99. Ueckert F, Goerz M, Ataian M, Tessmann S, Prokosch HU (Jul 2003). "Empowerment of patients and communication with health care professionals through an electronic health record" (http://linkinghub.elsevier. com/retrieve/pii/S1386505603000522). Int J Med Inform. 70 (23): 99108. doi:10.1016/S1386-5056(03)00052-2. PMID12909161. 100. Waegemann CP (May 2005). "Closer to reality. Personal health records represent a step in the right direction for interoperability of healthcare IT systems and accessibility of patient data". Health Manag Technol. 26 (5): 16, 18. PMID15932068. 101. Weingart SN, Rind D, Tofias Z, Sands DZ (Jan-Feb 2006). "Who uses the patient internet portal? The PatientSite experience". J Am Med Inform Assoc. 13 (1): 915. doi:10.1197/jamia.M1833. PMC1380201. PMID16221943. 102. Winkelman WJ, Leonard KJ (Mar-Apr 2004). "Overcoming structural constraints to patient utilization of electronic medical records: a critical review and proposal for an evaluation framework". J Am Med Inform Assoc. 11 (2): 15161. doi:10.1197/jamia.M1274. PMC353022. PMID14633932. 103. Winkelman WJ, Leonard KJ, Rossos PG (May-Jun 2005). "Patient-perceived usefulness of online electronic medical records: employing grounded theory in the development of information and communication technologies for use by patients living with chronic illness". J Am Med Inform Assoc. 12 (3): 30614. doi:10.1197/jamia.M1712. PMC1090462. PMID15684128. 104. Wright A, Sittig DF (Feb 2007). "Security threat posed by USB-based personal health records". Ann Intern Med. 146 (4): 3145. PMID17310061. 105. Wolter J, Friedman B (Nov-Dec 2005). "Health records for the people. Touting the benefits of the consumer-based personal health record". J Ahima. 76 (10): 2832, quiz 356. PMID16333941. 106. Woolf SH, Krist AH, Johnson RE et al. (Mar-Apr 2006). "A practice-sponsored Web site to help patients pursue healthy behaviors: an ACORN study". Ann Fam Med. 4 (2): 14852. doi:10.1370/afm.522. PMC1467008. PMID16569718. 107. Wright A, Sittig DF (2007). "Encryption characteristics of two USB-based personal health record devices". J Am Med Inform Assoc. 14 (4): 3979. doi:10.1197/jamia.M2352. PMC2244899. PMID17460132. 108. Wright A, Sittig DF (Feb 2007). "Security threat posed by USB-based personal health records". Ann Intern Med. 146 (4): 3145. PMID17310061. 109. Zeng-Treitler Q, Kim H, Goryachev S, Keselman A, Slaughter L, Smith CA (2007). "Text characteristics of clinical reports and their implications for the readability of personal health records" (http://booksonline.iospress. nl/Extern/EnterMedLine.aspx?ISSN=0926-9630&Volume=129&SPage=1117). Stud Health Technol Inform. 129 (Pt 2): 111721. PMID17911889. Conference Proceedings
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Personal health record 1. Angst CM, Agarwal, R, Downing, J. An empirical examination of the importance of defining the PHR for research and for practice, Proceedings of the 41st Annual Hawaii International Conference on System Sciences. Jan 2008. 2. Cimino JJ, Li J, Mendoca EA, Sengupta S, Patel VL, Kuhniruk AW. An evaluation of patient access to their electronic medical records via the World Wide Web. AMIA Symposium. Sep 2000. 3. Dorr D, Bonner LM, Cohen AN et al. (2007). "Informatics systems to promote improved care for chronic illness: a literature review". J Am Med Inform Assoc. 14 (2): 15663. doi:10.1197/jamia.M2255. PMC2213468. PMID17213491. 4. Iakovidis I. From electronic medical record to personal health records: present situation and trends in European Union in the area of electronic healthcare records. Medinfo. Sep 1998. 9(1 suppl); 18-22. 5. Ross S, Lin CT (2003). "A randomized controlled trial of a patient-accessible electronic medical record". AMIA Annu Symp Proc.: 990. PMC1480093. PMID14728493. 6. Stroetmann KA, Pieper M, Stroetmann VN. Understanding patients: participatory approaches for the user evaluation of vital data presentation. ACM Conference on Universal Usability; Proceedings of the 2003 Conference on Universal Usability . Nov 2003. 93-97. 7. Wuerdeman L, Volk L, Pizziferri L et al. (2005). "How accurate is information that patients contribute to their Electronic Health Record?". AMIA Annu Symp Proc.: 8348. PMC1560697. PMID16779157. Other 1. Americas Health Insurance Plans. Consumer and provider focus groups on PHR. Unpublished. Jan 2005. 2. Angst CM, Agarwal R, Downing J. An empirical examination of the importance of defining the PHR for research and for practice. Robert H. Smith School Research Paper. May 2006. RHS-06-011. 3. California Health Care Foundation. National consumer health privacy survey 2005. Nov 2005. 4. Canedy JT. SimplyWell PHR. AHIC Consumer Empowerment Workgroup Meeting 7/23/06. Jul 2006. 5. Connecting for Health. Americans want benefits of personal health records Jun 2003. 6. Connecting for Health. The personal health working group. Jul 2003. 7. Connecting for Health. Connecting Americans to their Healthcare final report: working group on policies for electronic information sharing between doctors and patients. Jul 2004. 8. Connecting for Health. Connecting Americans to Their Health Care: A Common Framework for Networked Personal Health Information. Dec 2006. 9. Department of Health and Human Services. Standards for privacy of individually identifiable health information. Federal Register. Dec 2000. Billing Code 4150-05M; 82461-82829 (45 CFR Parts 160-164). 10. Detmer D, Steen E. Learning from abroad: lessons and questions on personal health records for national policy. AARP. Mar 2006. 11. Haslmaier EF. Health care information technology getting the policy right. Web Memo Heritage Foundation. Jun 2006. No. 1131. 12. Markle Foundation. Attitudes of Americans regarding personal health records and nationwide electronic health information exchange: key findings from two surveys of Americans. Oct 2005. 13. Miller RH, Sim I. Physicians' use of electronic medical records: barriers and solutions. California HealthCare Foundation. Mar 2004. 116-126. 14. Skewes JL. Shared Health, Inc. AHIC Consumer Empowerment Workgroup Meeting 7/23/06. Jul 2006. 15. Taylor H. Two in five adults keep personal or family health records and almost everybody think this is a good idea. Harris Interactive. Aug 2004.
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External links
Video Interview of MIT Professor Peter Szolovitz about early developments of the Personal Health Record (http:/ /blip.tv/file/1185844/) MedlinePlus - Personal Health Records (http://www.nlm.nih.gov/medlineplus/personalhealthrecords.html) The U.S. National Library of Medicine & National Institutes of Health.
COmputer STored Ambulatory Record

COmputer STored Ambulatory Record (COSTAR) is an electronic medical record using the MUMPS programming language. It was developed by the Laboratory of Computer Science at Massachusetts General Hospital between 1968 and 1971 for Harvard Community Health Plan by Octo Barnett and Jerome Grossman.
References
Hattwick, Michael A. W. Computer Stored Ambulatory Record Systems in Real Life Practice [1]. Proc Annu Symp Comput Appl Med Care. 1979 October 17; 761764. Barnett, G. Octo. Computer-stored ambulatory record (COSTAR) [2]. 1976. Agency for Healthcare Research and Quality (AHRQ). Medical Informatics for Better and Safer Health Care [3]. Research in Action, Issue 6. June 2002 Kerlin, Barbara D (1986). Dissemination of COSTAR: Promises and Realities. Journal of Medical Systems doi:10.1007/BF00992821 Clinfowiki - COmputer STored Ambulatory Record (COSTAR) [4]
References
[1] [2] [3] [4] http:/ / www. pubmedcentral. nih. gov/ pagerender. fcgi?artid=2231858& pageindex=1 http:/ / openlibrary. org/ b/ OL15209465M/ Computer-stored-ambulatory-record-(COSTAR) http:/ / www. ahrq. gov/ data/ informatics/ informatria. htm http:/ / www. clinfowiki. org/ wiki/ index. php/ COmputer_STored_Ambulatory_Record_(COSTAR)
ProRec
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ProRec
The ProRec initiative of 1996 is a network of national non-profit organisations (the "ProRec centres"). The initiative was a consequence of the conclusions of the Concerted Action MEDIREC (1994-1995) regarding the reasons why Electronic Health Record (EHR) systems were not used more widely in any of the European Union. As part of the Lisbon Declaration suggestions were made to remedy this situation. The ProRec initiative is supported by the DG Information Society of the European Union. The DG Information Society supported the ProRec initiative with the ProRec Support Action (1996-1998), and the WIDENET Accompanying Measure (2000-2003). The goal of the initiative is to build awareness of the limitations, shortcomings and obstacles on the way towards widespread development, implementation and use of quality Electronic Health Records (EHRs) and pointing them out. Especially significant for implementing Electronic Health Record systems is the ability to communicate and interoperate.
External links
ProRec-BE [1] ProRec-RO [2]
References
[1] http:/ / www. prorec. be/ [2] http:/ / www. prorec. ro/
Health record trust

A health record trust (also independent health record trust or health record data bank) provides a secure and protected place for individuals to create, use, and maintain their lifetime electronic health record (EHR). A health record trust protects patient privacy by establishing that the patient is the owner of his or her health care records. It gives patients authority to access and review the entire record at any time as well as the authority to allow health care professionals, facilities, and organizations to view the records. Patients cannot alter their health records but instead add notes and request corrections. They can also view every provider who downloads their EHR. Legislation has been introduced in Congress to establish a regulatory framework for the establishment of health record trusts. The Independent Health Record Trust Act (H.R. 2991) was introduced by Rep. Dennis Moore (D-KS) and Rep. Paul Ryan (R-WI) on July 11, 2007. Similar legislation (S.3454) was introduced in the 109th Congress by Senator Sam Brownback (R-KS). The legislation seeks to give consumers control over their lifetime health records, with the broader goal of reducing health care costs that result from inefficiency, medical errors, inappropriate care, and incomplete information. With the availability of a longitudinal health record protected by a health record trust, patients receive better quality of care and are able to pass along their medical records to future generations. Health record trusts promote wellness and improve patient care through quick and easy access to critical health information.
Health record trust
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External links
HR 2991 [1] GovTrack Summary of H.R. 2991 [2] Health Banking information [3]
References
[1] http:/ / frwebgate. access. gpo. gov/ cgi-bin/ getdoc. cgi?dbname=110_cong_bills& docid=f:h2991ih. txt. pdf [2] http:/ / www. govtrack. us/ congress/ bill. xpd?bill=h110-2991 [3] http:/ / www. ehrbanks. com
Canadian EMR
CanadianEMR is a free, award-winning, resource for all health-care professionals. At its core, hundreds of users evaluate EMR vendors and their products on a variety of characteristics allowing others the benefit of first-hand reports on reliability and usefulness. CanadianEMR helps hospitals and doctor's offices to make an informed decision about where to spend their money and which system is the right fit for their unique circumstances.
History of the company

CanadianEMR was founded in December 2003 by Dr. Alan Brookstone, a family physician and Electronic Medical Record enthusiast in Richmond, British Columbia. The basic philosophy behind CanadianEMR was the belief that high quality, physician generated expert discussion on Electronic Medical Record systems adoption and use would be of interest to physicians, medical office managers, regional health authorities, system administrators, vendors and government. The CanadianEMR Blog contains over 900 postings and discussion items contributed by physicians. Since 2003, the CanadianEMR site has grown significantly. In 2004, the site received 11,000 page views. Currently the site receives 18,000 page views per month and has more than 500 registered members. The CanadianEMR site now includes a dynamic EMR comparison engine and EMR Satisfaction Rating system that allows physicians to compare EMR systems available in Canada and enables physicians to forward a side-by-side EMR comparison to a colleague or staff member. The site also allows EMR vendors to publish an Enhanced Profile which provides the EMR vendor with high exposure amongst their audience of users. Visitors to CanadianEMR are generally physicians or practices who are looking to purchase an EMR system or change an EMR system. November 2007 saw CanadianEMR beat more than 1000 other sites to win the Best Site Design award from the eHealthcare Leadership Awards.[1] These awards were given out at the 11th Annual Healthcare Internet Conference in Las Vegas.[2] In February 2008, CanadianEMR released a Free Version of the CanadianEMR Satisfaction Ranking Tool for use by public organizations across Canada.[3] The tool allows users to rate their experience with specific EMR vendors such as Practice Solutions Software [4], Wolf Medical Systems [5], CLINICARE [6], Purkinje, Cerner, ABELSoft [7], EMIS, Epic Systems Corporation, Nightingale EMR [8], P&P Data Systems [9] and more.
Canadian EMR
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References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / blog. canadianemr. ca/ canadianemr/ 2007/ 11/ canadianemr-win. html (eHealthcare Awards) http:/ / www. strategichealthcare. com/ awards/ index. php (eHealthcare Awards) http:/ / www. canadianemr. ca/ index. aspx?PID=41 (Free Satisfaction/Rating Tool) http:/ / www. practicesolutions. ca http:/ / www. wolfmedical. com http:/ / www. clinicare. com/ http:/ / www. abelsoft. com/ http:/ / www. nightingalemd. ca http:/ / www. p-pdata. com
External links
CanadianEMR (http://www.canadianemr.ca/) The site includes a blog (http://blog.canadianemr.ca/) to foster discussions about the EMR scene in Canada and around the world. OpenClinical - Electronic Medical Records (http://www.openclinical.org/emr.html) The ICMCC portal on access to electronic medical records. (http://recordaccess.icmcc.org/) The portal includes a blog (http://blog.icmcc.org/) to share and discuss experiences for both patients and clinicians as well as an extended overview of relevant literature.
ClearHealth
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ClearHealth
ClearHealth
Developer(s) Initial release Open source community 2003
Development status Current Written in Operating system Available in Type License Website PHP Cross-platform Multilingual [1]
Medical Software GNU General Public License ClearHealth Website [2]
ClearHealth is an Open Source practice management (PM) and electronic medical records (EMR/EHR/PHR) system available under the GNU General Public License. It has received attention as a possible open source option for FQHC and CHC sites.[3] It is currently deployed at approximately 600 sites worldwide including commercially supported and self-supported open source installations. There are number of high profile installations in non-profit health settings including the Primary Care Coalition network, powering the Community Healthlink System, in Maryland, USA, which includes approximately 50 sites and 1,500 users[4] and Operation Samahan,[5] a Federally Qualified Health Center (FQHC) facility in National City, CA with 5 locations. OsNews provides an introduction to the system.[6]
History
The history of ClearHealth began with the core developers of several other Open Source healthcare software systems including OpenEMR and FreeMed. ClearHealth released its first version in 2003, supporting mainly scheduling capabilities. Its 1.0 release was in October 2005 and included additions to the original scheduling capabilities, including support for patient registration/demographics, and electronic billing. In July 2007, its 2.0 version was released which added electronic medical records capabilities and an integrated SQL based reporting system. In 2006, the Tides Foundation provided a grant which funded the development of a set of feature additions to support the specialized needs of Federally Qualified Health Centers (FQHC) and other CHC/RNC facilities. Written in the PHP language and capable of running on most server configurations, Windows, Linux or Mac OS X, under Apache and MySQL (LAMP), ClearHealth is compliant with the expectations of most Open Source web-based systems. Amongst several open source solutions for the healthcare industry, the California Healthcare Foundation identified ClearHealth specifically as a viable solution based on its evaluation of sites and support in its Open Source Primer on healthcare software.[7]
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Features
ClearHealth is a comprehensive practice management and EMR system incorporating the key categories of functionality for scheduling, patient registration, electronic medical records and CPOE, electronic and paper billing, and SQL reporting. As an open source reference implementation of several interoperability protocols, ClearHealth has support for working with data in HL7[8] and Continuity of Care Record (CCR) formats. The ClearHealth system is fully compliant with HIPAA security provisions.[9]
References
[1] [2] [3] [4] [5] [6] [7] [8] [9] See (http:/ / www. clear-health. com/ forum/ index. php?t=msg& goto=3756) http:/ / www. clear-health. com/ CHCF Market Assessment California Healthcare Foundation (http:/ / www. chcf. org/ topics/ view. cfm?itemID=133551) VistA and Open Healthcare News May/June 2008 Operation Samahan LinuxMedNews Coverage of Operation Samahan (http:/ / linuxmednews. com/ 1142379128/ index_html) OsNews OsNews Introduction (http:/ / osnews. com/ story/ 10740) CHCF CHCF Open Source Primer (http:/ / www. chcf. org/ topics/ view. cfm?itemID=119091) Fred Trotter Interview HL7 Support (http:/ / linuxmednews. com/ 1113401258/ index_html) CHCF Open Source Healthcare Market Assessment California Healthcare Foundation (http:/ / www. chcf. org/ topics/ view. cfm?itemID=133551)
External links
"ClearHealth User Forums" (http://www.clear-health.com/forum). "GitHub Site" (http://github.com/clearhealth/). (GitHub) "Primary Care Coalition" (http://www.primarycarecoalition.org/).
Laika
Laika is an open source Electronic Health Record (EHR) testing framework. Laika analyzes and reports on the interoperability capabilities of EHR systems. This includes the testing for certification of EHR software products and networks. Laika is designed to verify the input and output of EHR data against the standards and criteria identified by the Certification Commission for Healthcare Information Technology (CCHIT). Since June 2008, Laika has been used by CCHIT to perform the machine-automated testing of EHR systems for interoperability.
Laika Interoperability Packages

Laika C32: Laika C32 was the first tool to be created in the Laika framework suite, and supports testing of the HL7/ASTM Continuity of Care Document (CCD) constrained by the HITSP C32 version 2.1 specification. Laika ORU: was released in September 2008 to test the interoperability of HL7 2.5.1 lab messages. Laika ORU can be used with Mirth, an open source health informatics messaging package, to manage the routing of HL7 2.5.1 lab messages with Laika. Laika XDS: is scheduled to be released in March 2009 to test EHR systems and Health Information Exchange systems with XDS registries and repositories.
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CCHIT and MITRE Collaboration

Laika is an active collaborative effort between CCHIT and The MITRE Corporation. CCHIT is leading the functional requirements definition of the Laika testing framework. MITRE is leading the technical software design and is prototyping the software service. The Certification Commission is a private, not-for-profit organization whose mission is to accelerate adoption of health information technology in the United States. MITRE is a 501(c)(3) not-for-profit corporation that manages three Federally Funded Research and Development Centers (FFRDCs) and works in partnership with the US government applying systems engineering and advanced technology to address issues of critical national importance in the USA.
Deployment in Virtual Environments

Laika has been deployed in virtual environments using, for example, the Amazon cloud environment. This allows centralized testing of multiple EHRs in segmented environments. It also allows portable implementations, so that field testing can be achieved.
Technical Details
Laika is licensed under an Apache 2.0 open source license. Laika uses the Ruby on Rails framework, the Java programming language, the open source PostgreSQL database, and several Web 2.0 JavaScript libraries including Scriptaculous and Prototype.
Laika and popHealth

In 2010, the core Laika software infrastructure, consisting of the Laika database and Rails controllers, was forked to support the open source popHealth [1] project. The popHealth project was developed from resources provided by the Federal Health Architecture (FHA [2]) within the Office of the National Coordinator (ONC [3]). popHealth integrates with a healthcare provider's electronic health record (EHR) system to produce summary quality measures on the provider's patient population. The MITRE Corporation was also tasked as the technical lead team for the popHealth activity.
Background of Project Name Laika

Laika is named after the dog and first living animal to enter earth orbit, paving the way for human space flight.
External links
The Laika open source project website [4] The Certification Commission for Healthcare Information Technology website [20] The MITRE Corporation website [5]
References
[1] [2] [3] [4] [5] http:/ / projectpophealth. org http:/ / www. hhs. gov/ fedhealtharch/ http:/ / healthit. hhs. gov/ portal/ server. pt?open=512& objID=1263& mode=2 http:/ / projectlaika. org/ http:/ / www. mitre. org/
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openEHR
openEHR is an open standard specification in health informatics that describes the management and storage, retrieval and exchange of health data in electronic health records (EHRs). In openEHR, all health data for a person is stored in a "one lifetime", vendor-independent, person-centred EHR. The openEHR specification is not concerned with the exchange of data between EHR-systems as this is the primary focus of other standards such as EN 13606 and HL7. The openEHR specifications are maintained by the openEHR Foundation, a not for profit foundation supporting the open research, development, and implementation of openEHR EHRs. The openEHR specifications are based on a combination of 15 years of European and Australian research and development into EHRs and new paradigms, including what has become known as the archetype methodology[1] [2] for specification of content. The openEHR specifications include information and service models for the EHR, demographics, clinical workflow and archetypes. They are designed to be the basis of a medico-legally sound, distributed, versioned EHR infrastructure.
Two level modelling with archetypes

The key innovation in the openEHR framework is to leave all specification of clinical information out of the information model but, most importantly, to provide a powerful means of expressing what clinicians and patients report that they need to record so that the information can be understood and processed wherever there is a need. Clinical information models are specified in a formal way ensuring the specifications, known as 'archetypes', are computable.[3] The set of openEHR archetypes need to be quality managed to conform to a number of axioms such as being mutually exclusive. The archetypes can be managed independently from software implementations and infrastructure, in the hands of clinician groups to ensure they meet the real needs on the ground. Archetypes are designed to allow the specification of clinical knowledge to evolve and develop over time. Challenges in implementation of information designs expressed in openEHR centre on the extent to which actual system constraints are in harmony with the information design. In the field of Electronic health records there are a number of existing information models with overlaps in their scope which are difficult to manage, such as between HL7 V3 and SNOMED CT. The openEHR approach faces harmonisation challenges unless used in isolation. While individual health records may be vastly different in content, the core information in openEHR data instances always complies to archetypes. The way this works is by creating archetypes which express clinical information in a way that is highly reusable, even universal in some cases. To get to the point where information is suitably presented for clinical care it always involves a number of archetypes. These combinations of archetypes are called 'templates'; aggregations of archetypes which may also be refined for use in a particular situation. Templates may be used to specify forms, documents or even messages. The openEHR approach uses the CEN- and ISO-standardised "archetype definition language" (expressed in ADL syntax or its XML equivalent) to build archetypes; these are reusable, formal models of domain concepts.[4] Archetypes are used in openEHR to model clinical concepts such as "blood pressure" or "medical prescription".
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International collaboration
Following the openEHR approach, the use of shared and governed archetypes globally would ensure openEHR health data could be consistently manipulated and viewed, regardless of the technical, organisational and cultural context. This approach also means the actual data models used by any EHR are flexible, given that new archetypes may be defined to meet future needs of clinical record keeping. Recently work in Australia has demonstrated how archetypes and templates may be used to facilitate the use of legacy health record and message data in an openEHR health record system, and output standardised messages and CDA documents. The prospect of gaining agreement on design and on forms of governance at the international level remains speculative, with influences ranging from the diverse medico-legal environments to cultural variations, to technical variations such as the extent to which a reference clinical terminology is to be integral. The openEHR Framework is consistent with the new Electronic Health Record Communication Standard (EN 13606). It is being used in parts of the UK NHS Connecting for Health Programme and has been selected as the basis for the national program in Sweden. It is also under evaluation in a number of countries including Denmark, Slovakia, Chile and Brazil. It is beginning to be utilised in commercial systems throughout the world.
Clinical Knowledge Manager

One of the key features of openEHR is the development of structures and terminologies to represent health data. Due to the open nature of openEHR, these structures are publicly available to be used and implemented in health information systems. Commonly, community users share, discuss and aprove these structures in a repository known as Clinical Knowledge Manager (CKM). The most known openEHR CKMs are presented below: openEHR Clinical Knowledge Manager [5] NEHTA Clinical Knowledge Manager [6] Swedish openEHR Clinical Knowledge Manager [7]
References
[1] Beale, Thomas (2002). "Archetypes: Constraint-based Domain Models for Future-proof Information Systems" (http:/ / www. openehr. org/ publications/ archetypes/ archetypes_beale_oopsla_2002. pdf). Proceedings of the 11th OOPSLA Workshop on Behavioural Semantics. . (PDF) [2] S. Heard & T. Beale. (eds.) (2007). "openEHR Architecture Overview" (http:/ / www. openehr. org/ svn/ specification/ BRANCHES/ Release-1. 0. 2-candidate/ publishing/ architecture/ overview. pdf). openEHR. . Retrieved 21 June 2010. (PDF) [3] S. Heard & T. Beale. (eds.) (2005). "Archetype definitions and principles" (http:/ / www. openehr. org/ svn/ specification/ BRANCHES/ Release-1. 0. 2-candidate/ publishing/ architecture/ am/ archetype_principles. pdf). openEHR. . Retrieved 21 June 2010. (PDF) [4] "Archetypes FAQs" (http:/ / www. openehr. org/ shared-resources/ faqs/ archetypes. html). openEHR.org. . Retrieved 21 June 2010. [5] http:/ / openehr. org/ knowledge [6] http:/ / dcm. nehta. org. au/ ckm/ [7] http:/ / sllocean. karolinska. se/ ckm/
External links
openEHR Foundation website (http://www.openEHR.org) openEHR specifications (http://www.openehr.org/releases/1.0.2/roadmap.html)
OpenEMR
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OpenEMR
OpenEMR
Stable release
4.0.0 / March 26, 2011
Operating system Any Unix-like, Mac OS, Windows Platform Type License Website Cross-platform Free and Open Source, Practice management, Electronic Medical Records GNU General Public License OpenEMR web site [1]
OpenEMR is a Free and Open Source, Practice management, Electronic Medical Records, prescription writing and medical billing application for Unix-like systems (Linux, UNIX, and BSD systems), Microsoft systems, Mac OS X and other platforms.
Features
Free
Freely available Free to download, use, modify, and upgrade Free documentation[2] Free support forum[3] Open source Released under the GNU General Public License
ONC certified
Ambulatory ONC Modular "Meaningful Use" certified[4]
Login
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Patient Demographics
Track patient demographics Primary information (name, date of birth, sex, identification) Marital status Contact information of patient and patient's employer Primary provider HIPAA information
Language and ethnicity Insurance coverage Fully Customizable
Demographics
Patient Scheduling
Supports multiple facilities Patient appointment notification via email and sms Compact and flexible appointment calendar Calendar features include: Find open appointment slots Categories for appointment types Colors associated with appointment types Repeating appointments
Scheduling
Restricting appointments based on type
Electronic Medical Records

Encounters Medical Issues Medications Immunizations Forms and clinical notes: Vitals (growth charts included) SOAP note Review of systems Ability to create and customize forms
Vitals
Patient Reports Electronic digital document management Voice recognition ready (MS Windows Operating Systems) Paper chart tracking
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Prescriptions
Online drug search Track patient prescriptions and medications Create and send prescriptions Print Fax Email
Prescription
In-house pharmacy dispensary support
Medical Billing
Flexible system of coding including CPT, HCPCS and ICD codes and the ability to add others Support for electronic billing to clearing houses such as Medavant/Capario [5] and ZirMED [6] using ANSI X12 Support for paper claims Medical claim management interface
Billing
Insurance tracking interface Accounts receivable interface EOB entry interface Customizable to work with a clearing house for automated 835 or ERA entry
Multilanguage Support
Supports use of multiple languages within the same clinic Currently supports English (American), English (Indian), Dutch, Greek, Portuguese (Brazilian), Portuguese (European), Spanish, and Turkish[7] Any language can be added and translated in a collaborative Google Docs spreadsheet maintained by the OpenEMR community[8] Fully supports UTF-8 encoding
Greek Screenshot
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Security
Supports fine-grained per-user access controls Remotely accessible from any modern web browser with a suitable security certificate installed
Support
Free online support[3] Vast online documentation[2]
Access Controls
History
OpenEMR was originally developed by Synitech and version 1.0 was released in June 2001 as MP Pro (MedicalPractice Professional). Much of the code was then reworked for HIPAA compliance and improved security, and the product was reintroduced as OpenEMR version 1.3 a year later, in July 2002.[9] The project evolved through version 2.0 and the Pennington Firm (Pennfirm) took over as its primary maintainer in January 2004. Pennfirm made the medical community more aware of OpenEMR, and attracted a number of independent developers who became increasingly active in making improvements (Sunset Systems [10] was the most prolific of these). Walt Pennington transferred the OpenEMR software repository to SourceForge in March 2005, where it remains today. Mr. Pennington also established Rod Roark, Andres Paglayan and James Perry, Jr. as administrators of the project. The SourceForge OpenEMR home web page was maintained at oemr.org [11] for several years. To improve organization, in July 2011, the SourceForge OpenEMR Project web page was migrated to open-emr.org [12] while the OEMR (the non-profit company supporting OpenEMR) remains at oemr.org [11].
Community
The OpenEMR community is dedicated to guarding OpenEMR's status as a free, open source software solution for medical practices. Its members are composed of software developers, as well as physicians and others with extensive medical and billing knowledge, all with the common goal of making OpenEMR a superior alternative to its proprietary counterparts. Following are some of the guiding principles that have been formulated by the project's most active members: OpenEMR will remain 100% free software under the GNU GPL. Maintain a spirit of openness, kindness and cooperation. Give back to the free software community. Document our changes and improvements. Do not hide problems. Do not discriminate against persons or groups, subject to our focus on the field of medicine and we encourage the use of OpenEMR in other languages. Avoid needless complexity, to include software design, installation, maintenance and usability. The OpenEMR community is thriving and enjoying some of the broadest user support and developer support. OpenEMR is one of the most popular free electronic medical records in use today with over 3,700 downloads per month.[13] The development group has professional developers, security specialists, and physicians involved in the development process. The project is supported by OEMR [11] (a non-profit company). The community maintains the
OpenEMR official OpenEMR home web page at open-emr.org [12].[14] [15] [16] [17] [18] [19]
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Deployments
Because this is an open source project that does not register its users, it is very difficult to estimate the number of practitioners that are using this software. A survey of commercial supporters[20] of this software in the US show at least 100 clinical facilities (with an average of 5 practitioners per facility) are using this software with commercial help. There are also articles describing single clinician deployments[21] [22] [23] and a free clinic deployment.[24] Internationally, it is known that there are practitioners in Pakistan,[25] Puerto Rico, Australia, Sweden, Holland, Israel, India,[26] Malaysia, Nepal, Indonesia, Bermuda, Armenia, Kenya, and Greece that are either testing or actively using OpenEMR for use as a free electronic medical records program.
Architecture
OpenEMR is a "LAMP" type of web based software application that uses a web server such as Apache, MySQL as the database and PHP as its programming language. As with most "LAMP" architecture, OpenEMR can run on Linux, Unix, BSD, Mac OS X, and Microsoft architectures.
Certification
On 3/17/2011, OpenEMR was ONC certified as a modular EHR.[4] The community is committed to having the next release of OpenEMR (version 4.1) certified as a complete EHR.[27]
References
[1] [2] [3] [4] http:/ / www. open-emr. org/ "OpenEMR Official Wiki" (http:/ / www. openmedsoftware. org). . Retrieved 2009-11-25. "Free OpenEMR Support at Sourceforge" (http:/ / sourceforge. net/ projects/ openemr/ support). . Retrieved 2009-11-25. "Ambulatory ONC Modular "Meaningful Use" certified" (http:/ / onc-chpl. force. com/ ehrcert/ EHRProductDetail?id=a0X30000003jFmdEAE& retURL=/ ehrcert/ EHRProductSearch& setting=). . Retrieved 2011-07-31. [5] http:/ / www. capario. com/ [6] http:/ / www. zirmed. com/ [7] "OpenEMR Translation Database Statistics" (http:/ / www. openmedsoftware. org/ wiki/ Internationalization_Project_Status). . Retrieved 2009-11-25. [8] "OpenEMR Internationalization Project" (http:/ / www. openmedsoftware. org/ wiki/ OpenEMR_Internationalization_Development). . Retrieved 2009-11-25. [9] Stack, Matthew (2002-07-05). "OpenEMR Released" (http:/ / linuxmednews. org/ linuxmednews/ 1025910430/ index_html). . Retrieved 2009-11-26. [10] http:/ / www. sunsetsystems. com/ [11] http:/ / www. oemr. org [12] http:/ / www. open-emr. org [13] "OpenEMR Sourceforge Download Statistics" (http:/ / sourceforge. net/ project/ stats/ detail. php?group_id=60081& ugn=openemr& type=prdownload& mode=12months& file_id=0). . Retrieved 2010-02-23. [14] "OpenEMR on Sourceforge" (http:/ / sourceforge. net/ projects/ openemr/ ). . Retrieved 2011-08-19. [15] "OpenEMR on Github" (http:/ / github. com/ openemr/ openemr). . Retrieved 2011-08-19. [16] "OpenEMR on Google Code" (http:/ / code. google. com/ p/ openemr). . Retrieved 2011-08-19. [17] "OpenEMR on Gitorious" (http:/ / gitorious. org/ ~openemr). . Retrieved 2011-08-19. [18] "OpenEMR on repo.or.cz" (http:/ / repo. or. cz/ w/ openemr. git). . Retrieved 2011-08-19. [19] "OpenEMR achieves full ONC certification" (http:/ / linuxmednews. com/ 1313842854/ index_html). . Retrieved 2011-08-22. [20] "OpenEMR Commercial Help" (http:/ / www. openmedsoftware. org/ wiki/ OpenEMR_Commercial_Help). . Retrieved 2009-12-14. [21] Holzer, Joe (2009-11-25). "OpenEMR Success Story" (http:/ / www. emrandhipaa. com/ emr-and-hipaa/ 2009/ 11/ 25/ openemr-success-story/ ). . Retrieved 2009-12-14. [22] Leeds, Mark (2006-01-29). "Using OpenEMR in Family Practice" (http:/ / linuxmednews. com/ 1138557562/ index_html). . Retrieved 2009-12-14. [23] Bowen, Samuel. "OpenEMR Case Study" (http:/ / www. ehrlive. com/ docs/ bowen_cs. pdf). . Retrieved 2009-12-14.
OpenEMR
[24] Clifford, Kevin (2009-11-15). "Guest Article: Open Source EMRs for free clinics" (http:/ / www. healthcareguy. com/ 2009/ 11/ 15/ guest-article-open-source-emrs-for-free-clinics/ ). . Retrieved 2009-12-14. [25] Mushtaq, Hina (2010-01-18). "Jaroka Electronic Health Record System provides opportunities for further Research and Analysis" (http:/ / blogs. tele-healthcare. org/ 2010/ 01/ jaroka-electronic-health-record-system. html). . Retrieved 2010-01-23. [26] DIMAPUR (2010-04-05). "FPAI conducts training on OpenEMR" (http:/ / nagalandpost. com/ ShowStory. aspx?npoststoryiden=UzEwMjQyOTE=-u5jpoTKCit0=). . Retrieved 2010-04-05. [27] "OpenEMR Certification" (http:/ / www. openmedsoftware. org/ wiki/ OpenEMR_Certification). . Retrieved 2011-07-31.
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AG (2010-02-12). " OpenEMR - At a glance (http://bkaeg.org/blog/archives/2010/02/openemr---at-a.html)". Retrieved 2010-02-16. Lewis, Hans (2010-01-18). " Electronic Medical and Health Records Usage Increases in U.S.: Report (http:// healthcare.tmcnet.com/topics/healthcare/articles/ 72903-electronic-medical-health-records-usage-increases-us-report.htm)". Retrieved 2010-01-23. Bowen, Samuel; Hoyt, Robert; Glenn, Ladeana; McCormick, Donald; Gonzalez, Xavier. " Open Source Electronic Health Records: in Practice (http://www.openmedsoftware.org/wiki/ Open_Source_EHR_in_Practice)". Retrieved 2009-11-27. Bowen, Samuel; Valdes, Ignacio; Hoyt, Robert; Glenn, Ladeana; McCormick, Donald; Gonzalez, Xavier. " Open Source Electronic Health Records: In Public Policy (http://www.openmedsoftware.org/wiki/ Open_Source_EHR_Public_Policy)". Retrieved 2009-11-27. Shah, Shahid (2007-01-07). " Open Source EMR and Practice Management Software Appliance (http://www. healthcareguy.com/2007/01/07/open-source-emr-and-practice-management-software-appliance/341/)". Retrieved 2009-12-07. Weatherby, Julia (2006-02-16). " Technical Aspects of OpenEMR (http://www.openmedsoftware.org/wiki/ Technical_Aspects_of_OpenEMR)". Retrieved 2009-11-27. Simbini, T. (2006-02-16). " OpenEMR Architecture (http://www.openmedsoftware.org/wiki/ OpenEMR_Architecture)". Retrieved 2009-11-27. Donahue, Margaret (2006-02-16). " The OpenEMR Community (http://www.openmedsoftware.org/wiki/ The_OpenEMR_Community)". Retrieved 2009-11-27.
External links
OpenEMR Official Website (http://www.open-emr.org/) OpenEMR Official Wiki (http://www.openmedsoftware.org) OpenEMR Official Support Forums (http://sourceforge.net/projects/openemr/forums) OpenEMR Official Development Center (http://sourceforge.net/projects/openemr/develop) OpenEMR Official Source Code Repository (http://sourceforge.net/projects/openemr/) OEMR - Non-profit company supporting OpenEMR (http://www.oemr.org/) Open Source Medical Software - Non-profit company dedicated to open source electronic health records software (http://www.openmedsoftware.org/wiki/Open_Source_Medical_Software/) OpenEMR Open Source Virtual Appliance (http://www.bradymd.com/appliance) OpenEMR Official Commercial Affiliates (http://www.openmedsoftware.org/wiki/ OpenEMR_Commercial_Help)
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OpenMRS
OpenMRS [1] is a collaborative open source project to develop excellent software to support the delivery of health care in developing countries.[2] It grew out of the critical need to scale up the treatment of HIV in Africa but from the start was conceived as a general purpose electronic medical record system that could support the full range of medical treatments. The first ideas and prototype of OpenMRS were conceived by Paul Biondich and Burke Mamlin from the Regenstrief Institute, Indiana on a visit to the AMPATH [3] project in Eldoret, Kenya in February 2004. Around the same time the EMR team at Partners In Health led by Hamish Fraser and Darius Jazayeri were looking at ways to scale up the PIH-EMR [4][5] [6] web-based medical record system developed to manage drug resistant tuberculosis in Peru, and HIV in rural Haiti. Paul, Burke and Hamish met in September 2004 at the Medinfo conference in San Francisco, and recognized they had a common approach to medical information systems and a similar philosophy for healthcare and development and OpenMRS was born. Later, Chris Seebregts of the South African Medical Research Council [7] (MRC) became the fourth founding member. OpenMRS is founded on the principles of openness and sharing of ideas, software and strategies for deployment and use. The system is designed to be usable in very resource poor environments and can be modified with the addition of new data items, forms and reports without programming. It is intended as a platform that many organizations can adopt and modify avoiding the need to develop a system from scratch.
Design
OpenMRS is based on a "concept dictionary" that describes all the data items that can be stored in the system such as clinical findings, laboratory test results or socio-economic data. This approach avoids the need to modify the database structure to add new diseases for example, and facilitates sharing of data dictionaries between projects and sites. An important features of OpenMRS is its modular construction which allows the programming of new functions without modifying the core code. OpenMRS is web based but can be deployed on a single laptop or on a large server and runs on Linux, Windows or Mac OS X. Other key features of OpenMRS: Built on the MySQL database (but uses Hibernate allowing it to be ported to other databases) programmed in Java Includes tools for data export and reporting Versions currently exist for HIV/AIDS, Drug resistant TB, primary care and oncology Supports open standards for medical data exchange including HL7, LOINC and IXF
New features: New open source form based tools, OpenXdata, and HTMLForm entry Tools to link to hand held devices and cell phones (JavaROSA [8] project) Research data collection tools for clinical trials and community data collection projects A "logic service" that allows clinical alerts and reminders to be created in a medical standard Arden Syntax Support for report generation and transmission to national reporting systems like DHIS and TRACnet using the SDMX-HD standard
Currently being tested: Tools for data synchronization between systems connected by slow or unreliable internet User interface improvements Links to cell phone based data collection and messaging tools using SMS
OpenMRS Touch screen patient registration systems supporting bar coded patient IDs, in collaboration with Baobab Health Systems [9]
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Deployments
The first deployment was in Eldoret, Kenya in February 2006[10] followed by the PIH hospital in Rwinkwavu [11], Rwanda[12] in August 2006 and Richmond Hospital in the KwaZulu-Natal province of South Africa later that year. As of March 2010, OpenMRS is in use in at least 23 developing countries (mostly in Africa) and it has been used to record over 1 million patient records around the world. Most deployments are run by independent groups who carry out the work on the ground with technical support and training provided by the core team of OpenMRS developers, and other implementers. There have been four annual OpenMRS meetings in South Africa, organized by Chris Seebregts, who also leads the OpenMRS implementers community. Shorter meetings were held in Boston in May 2009, and a developer training in Indianapolis in February 2010. There are five known deployments supporting clinical care in the US - three in Indianapolis, one in Los Angeles, and one in Maryland. OpenMRS use will be expanded in Haiti to assist with the patients recovering from the January 2010 earthquake.
Support
OpenMRS is supported by core teams from Partners In Health, Regenstrief Institute, and the South African Medical Research Council. Other organizations that collaborate on OpenMRS are the Millennium Villages Project, based at Columbia University, and Baobab Health Systems [9] in Malawi. There are several groups of programmers working on OpenMRS in developing countries including Kenya, Rwanda, Uganda, South Africa, Pakistan, Chile, and India. In Rwanda, a training program for software developers to learn advanced Java skills and OpenMRS development, graduated 10 students in October 2009 after an intensive 11-month training program. Nine graduates are currently working on OpenMRS and related eHealth technologies.
Community
The OpenMRS community includes developers, implementers, and users from multiple countries who collaborate through mailing lists [13], #openmrs IRC [14], and annual conferences.[15] OpenMRS has participated in Google Summer of Code in 2007, 2008, 2009, and 2010; according to that program's manager, it receives more student applications [16] than the Apache Software Foundation.
External links
OpenMRS [1] Regenstrief Institute [17] Partners In Health [18] Podcast/MP3 of an episode of the BBC radioprogramme Digital Planet. [19] Described OpenMRS on 2008-06-23; 07m 02s - 14 m 23s. OpenMRS presentation for Google Tech Talks. August 23, 2007 [20] Lecture slides on OpenMRS from the May 2009 meeting, Boston, MA, USA [21]
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References
[1] http:/ / openmrs. org [2] Mamlin, BW; Biondich, PG; Wolfe, BA; Fraser, H; Jazayeri, D; Allen, C; Miranda, J; Tierney, WM (2006). "Cooking up an open source EMR for developing countries: OpenMRS - a recipe for successful collaboration". AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium: 52933. PMC1839638. PMID17238397. [3] http:/ / www. iukenya. org/ [4] http:/ / model. pih. org/ electronic_medical_records/ pih_emr_overview [5] Fraser, HS; Jazayeri, D; Nevil, P; Karacaoglu, Y; Farmer, PE; Lyon, E; Fawzi, MK; Leandre, F et al. (2004). "An information system and medical record to support HIV treatment in rural Haiti". BMJ (Clinical research ed.) 329 (7475): 11426. doi:10.1136/bmj.329.7475.1142. PMC527691. PMID15539669. [6] Fraser, HS; Blaya, J; Choi, SS; Bonilla, C; Jazayeri, D (2006). "Evaluating the impact and costs of deploying an electronic medical record system to support TB treatment in Peru". AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium: 2648. PMC1839453. PMID17238344. [7] http:/ / www. mrc. ac. za/ [8] http:/ / code. javarosa. org/ [9] http:/ / www. baobabhealth. org/ [10] Mamlin, BW; Biondich, PG (2005). "AMPATH Medical Record System (AMRS): collaborating toward an EMR for developing countries". AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium: 4904. PMC1560633. PMID16779088. [11] http:/ / pih. org/ where/ Rwanda/ Rwanda. html [12] Allen, C; Jazayeri, D; Miranda, J; Biondich, PG; Mamlin, BW; Wolfe, BA; Seebregts, C; Lesh, N et al. (2007). "Experience in implementing the OpenMRS medical record system to support HIV treatment in Rwanda". Studies in health technology and informatics 129 (Pt 1): 3826. PMID17911744. [13] http:/ / openmrs. org/ wiki/ Community [14] irc:/ / irc. freenode. net [15] Seebregts, CJ; Mamlin, BW; Biondich, PG; Fraser, HS; Wolfe, BA; Jazayeri, D; Allen, C; Miranda, J et al. (2009). "The OpenMRS Implementers Network". International journal of medical informatics 78 (11): 71120. doi:10.1016/j.ijmedinf.2008.09.005. PMID19157968. [16] http:/ / twitter. com/ HFOSS/ status/ 10280000103 [17] http:/ / regenstrief. org [18] http:/ / www. pih. org [19] http:/ / downloads. bbc. co. uk/ podcasts/ worldservice/ digitalp/ digitalp_20080623-1726. mp3 [20] http:/ / video. google. com/ videoplay?docid=5181254373166129293 [21] http:/ / www. slideshare. net/ hamishfraser/ presentations
Kind Messages for Electronic Healthcare Record
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Kind Messages for Electronic Healthcare Record

KMEHR or Kind Messages for Electronic Healthcare Record is a proposed Belgian medical data standard, in order to enable the exchange of structured clinical information. It is funded by the Belgian federal Ministry of public health and assessed in collaboration with Belgian industry. The initiative lead to the specification of about 20 specific XML messages (the Kind Messages for Electronic Healthcare Records - Belgian implementation standard or KMEHR-bis).
Structure
The KMEHR standard consists of the following elements: An XML (eXtensible Markup Language) message format defined by the KMEHR XML Schema A set of reference tables
Message structure
A KMEHR XML message is composed of two components a header and at least one folder. The header of the message describes the sender, the recipient(s) and a few technical statuses. The folder itself gathers the information about a patient, where each folder identifies the subject of care (patient) and contains at least one medical transaction. The medical transaction item gathers the information reported by one healthcare professional at a given instance. Its attributes are type, author, date and time.
Coding
The KMEHR-bis standard comprises a set of dictionaries which define the transaction types, heading types, item types, severity levels and administration routes.
External links
The KMEHR-bis standard supports links to either internal or external objects, e.g. an image or another KMEHR-message.
Services
The KMEHR-Bis specification is extended with web services, based on SOAP, which define request and response elements to offer standard web services.
Source
KMEHR: Kind Messages for Electronic Healthcare Record, Belgian implementation standard [1] Advice nr 4 of the Telematics Commission [2]
References
[1] https:/ / www. ehealth. fgov. be/ standards/ kmehr/ [2] https:/ / portal. health. fgov. be/ pls/ portal/ docs/ PAGE/ INTERNET_PG/ HOMEPAGE_MENU/ GEZONDHEIDZORG1_MENU/ AUTOMATISERING1_MENU/ SYMPOSIA1_MENU/ AVIS25_MENU/ AVIS25_DOCS/ A04-UK. PDF
Summarized Electronic Health Record
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Summarized Electronic Health Record

SumEHR or Summarised Electronic Health Record is a KMEHR message, used for the exchange of medical information. It summarizes the minimal set of data that a physician needs in order to understand the medical status of the patient in a few minutes and to ensure the continuity of care. The SumEHR standard was introduced by the Belgian government in 2005 and an EMD software package used by a physician (GP) should be capable of exporting a SumEHR message (KMEHR message level 4) for any given patient.
Layout
Date of creation Author Patient Identification Health Number (mandatory item empty if no available number) Patient Presentation Family name Forenames Sex Birth date Usual language Contact person Risks Allergies Adverse drug reactions Social factors Other factors Relevant personal antecedents IBUI (French: Identificateur Belge Unique, Dutch: Belgische Unieke Identificator) and ICPC-2 and ICD-10 (empty IBUI allowed) Begin date End date Text Actual problems list IBUI and ICPC-2 and ICD-10 (empty IBUI allowed) Begin date Text Relevant medications CNK (Code National(e) Kode) or other ID (if no available CNK) Administration information Instructions for patient Begin date End date Text
Vaccination status Administrated CNK and/or ATC (Anatomical Therapeutic Chemical-code)
Summarized Electronic Health Record Date To be administered CNK and/or ATC Date Contextual comment
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Source
Sumehr [1] Transaction: Summarised Electronic Healthcare Record [2]
References
[1] https:/ / portal. health. fgov. be/ pls/ portal/ docs/ PAGE/ INTERNET_PG/ HOMEPAGE_MENU/ GEZONDHEIDZORG1_MENU/ AUTOMATISERING1_MENU/ HOPITAUX9_MENU/ SUMEHRPHOTOSANTE1_MENU/ SUMEHRPHOTOSANTE1_DOCS/ SUMEHR-CONTENTS. PDF [2] https:/ / www. ehealth. fgov. be/ standards/ kmehr/ en/ transaction_detail/ home/ transactions/ transaction_detail/ Sumehr-1-1. xml
VistA
The Veterans Health Information Systems and Technology Architecture (VistA) is an enterprise-wide information system built around an Electronic Health Record (EHR), used throughout the United States Department of Veterans Affairs (VA) medical system, known as the Veterans Health Administration (VHA).[1] It's a collection of about 100 integrated software modules. By 2003, the VHA was the largest single medical system in the United States,[2] The VistA Computerized Patient Record System (CPRS) cover sheet view providing care to over 4 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics, and 135 nursing homes.[3] About a quarter of the nation's population is potentially eligible for VA benefits and services because they are veterans, family members, or survivors of veterans.[4] By providing electronic health records capability, VistA is thereby one of the most widely used EHRs in the world. Nearly half of all US hospitals that have a full implementation of an EHR are VA hospitals using VistA.[5] [6]
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Features
The Department of Veterans Affairs (VA) has had automated data processing systems, including extensive clinical and administrative capabilities, within its medical facilities since before 1985.[7] Initially called the Decentralized Hospital Computer Program (DHCP) information system, DHCP was enshrined as a recipient of the Computerworld Smithsonian Award for best use of Information Technology in Medicine in 1995.
Sample patient record view from VistA Imaging
VistA supports both ambulatory and inpatient care, and includes several significant enhancements to the original DHCP system. The most significant is a graphical user interface for clinicians known as the Computerized Patient Record System (CPRS), which was released in 1997. In addition, VistA includes computerized order entry, bar code medication administration, electronic prescribing and clinical guidelines. CPRS provides a clientserver interface that allows health care providers to review and update a patient's electronic medical record. This includes the ability to place orders, including those for medications, special procedures, X-rays, nursing interventions, diets, and laboratory tests. CPRS provides flexibility in a wide variety of settings so that a consistent, event-driven, Windows-style interface is presented to a broad spectrum of health care workers.
Achievements
For its development of VistA, the United States Department of Veterans Affairs (VA) / Veterans Health Administration (VHA) was named the recipient of the prestigious Innovations in American Government Award presented by the Ash Institute of the John F. Kennedy School of Government at Harvard University in July, 2006. The VistA electronic medical records system is estimated to improve efficiency by 6% per year, and the monthly cost of the EHR is offset by eliminating the cost of even a few unnecessary tests or admissions.[8] [9] The adoption of VistA has allowed the VA to achieve a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms most public sector hospitals on a variety of criteria, enabled by the implementation of VistA.[10] VA hospitals using VistA are one of only thirteen hospital systems that have achieved the qualifications for HIMSS stage 7, the highest level of electronic health record integration,[11] [12] while a non-VA hospital using VistA is one of only 42 US hospitals that has achieved HIMSS stage 6.[13] [14]
Licensing and dissemination

The VistA system is public domain software, available through the Freedom Of Information Act directly from the VA website,[15] or through a growing network of distributors. Astronaut is an automated VistA installer suite which installs VistA in less than 30 minutes. Installation instructions for the Astronaut VistA Installer Suite can be found here [16]. Astronaut has done many bug fixes, upgrades and enhancements to VistA making it suitable for use in the private sector.
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VistA modules and projects

Database backend
VistA was developed using the M or MUMPS language/database. The VA currently runs a majority of VistA systems on the proprietary InterSystems Cach version of MUMPS, but an open source MUMPS database engine, called GT.M, for Linux and Unix computers has also been developed. Although initially separate releases, publicly available VistA distributions are now often bundled with the GT.M database in an integrated package. This has considerably eased installation. In addition, the free and open source nature of GT.M allows redundant and cost-effective failsafe database implementations, increasing reliability for complex installations of VistA. An open source project called EsiObjects [17] has also allowed the (ANSI- Standard) MUMPS language and database technology to evolve into a modern object-oriented language (and persistent-object store) that can be integrated into mainstream, state-of-the-art technologies. For the Cach MUMPS database, a similar object-oriented extension to MUMPS called Cach ObjectScript has been developed. Both of these have allowed development of the MUMPS database environment (by programmers) using modern object-oriented tools. M2Web [18] is an open source web gateway to MUMPS for use with VistA. A free open source module from M/Gateway [19] called MGWSI has been developed to act as a gateway between GT.M, Cache, or M21 MUMPS databases and programming tools such as PHP, ASP.NET, or Java, in order to create a web-based interface.
HealtheVet
The VHA has an ongoing pilot project, known as HealtheVet [20] (HeV) that envisions the next generation of VistA, with further modernization of database capabilities and interfaces. MyHealtheVet [21] is another initiative that allows veterans to access, and create a copy of, their health records online. This allows veterans to port their health records to institutions outside the VA health system or keep a personal copy of their health records, a Personal Health Record (PHR).
VistA Imaging
The Veterans Administration has also developed VistA Imaging, a coordinated system for communicating with PACS (radiology imaging) systems and for integrating others types of image-based information, such as EKGs, pathology slides, and scanned documents, into the VistA electronic medical records system. This type of integration of information into a medical record is critical to efficient utilization.[22] VistA Imaging has been made freely available in the public domain for private/public hospital use through the Freedom of Information Act. It is available through the Department of Veteran's Affairs software request [23] office. (Licensing of several proprietary modules are required for it to function correctly.)[24] It can be used independently or integrated into the VistA electronic health record system (as is done in VA health facilities).
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Deployments and uses

Role in development of a national healthcare network
The VistA electronic healthcare record has been widely credited for reforming the VA healthcare system, improving safety and efficiency substantially. The results have spurred a national impetus to adopt electronic medical records similar to VistA nationwide. VistA Web collectively describes a set of protocols that in 2007 was being developed and used by the VHA to transfer data (from VistA) between hospitals and clinics within the pilot project. This is the first effort to view a single patient record so that VistA becomes truly interoperable among the more than 128 sites running VistA today. BHIE enables real-time sharing of electronic health information between DoD and VA for shared patients of allergy, outpatient pharmacy, demographic, laboratory, and radiology data. This became a priority during the Second Iraq War, when a concern for the transition of healthcare for soldiers as they transferred from active military status to veteran status became a national focus of attention.[25] A Clinical Data Repository/ Health Data Repository (CHDR [26]) allows interoperability between the DoD's Clinical Data Repository (CDR) & the VA's Health Data Repository (HDR). Bidirectional real time exchange of computable pharmacy, allergy, demographic and laboratory data occurred in phase 1. Phase 2 involved additional drugdrug interaction and allergy checking. Initial deployment of the system was completed in March 2007 at the El Paso, Augusta, Pensacola, Puget Sound, Chicago, San Diego, and Las Vegas facilities. The combination of VistA and the interoperable projects listed above in the VA/DoD systems will continue to expand to meet the objectives that all citizens will have an electronic record by 2014. Because of the success of these programs, a national move to standardize healthcare data transmission across the country was started. Text based information exchange is standardized using a protocol called HL7 (Health Level 7), which is approved by the American National Standards Institute. DICOM is an international image communications protocol standard. VistA is compliant with both. VistA has been interfaced with commercial off-the-shelf products, as well. Standards and protocols used by VA are consistent with current industry standards and include HL7, DICOM, and other protocols. Tools for CCR/CCD support have been developed for VistA, allowing VistA to communicate with other EHRs using these standardized information exchange protocols.[27] This includes the Mirth open source cross platform HL7 interface and NHIN Connect, the open source health information exchange adaptor. In 2009, a project was undertaken to facilitate EHR communication between the VA (using VistA) and Kaiser Permanente (using Epic) using NHIN Connect.[28] (Both VistA and the commercial EHR Epic use a derivative of the MUMPS database, thereby facilitating data exchange.) When completed, two of the largest medical record systems in the US will be able to exchange health data. Public-domain VistA derivatives are also expected to be able to use NHIN Connect. The VistA EHR has been used by the VA in combination with Telemedicine to provide surgical care to rural areas in Nebraska and Western Iowa over a 400000-square-mile ( km2) area.[29]
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Usage in non-governmental hospitals

Under the Freedom of Information Act (FOIA), the VistA system, the CPRS interface, and unlimited ongoing updates (500600 patches per year) are provided as public domain software.[30] This was done by the US government in an effort to make VistA available as a low cost Electronic Health Record (EHR) for non-governmental hospitals and other healthcare entities. With funding from The Pacific Telehealth & Technology Hui, the Hui 7 produced a version of VistA that ran on GT.M in a Linux operating system, and that was suitable for use in private settings. VistA has since been adopted by companies such as Blue Cliff [31], DSS, Inc. [32], Medsphere [33], and Sequence Managers Software [34] to a variety of environments, from individual practices to clinics to hospitals, to regional healthcare co-ordination between far-flung islands. In addition, VistA has been adopted within similar provider environments worldwide. Universities, such as UC Davis and Texas Tech implemented these systems. A non-profit organization, WorldVistA, has also been established to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting. VistA (and other derivative EMR/EHR systems) can be interfaced with healthcare databases not initially used by the VA system, including billing software, lab databases, and image databases (radiology, for example). VistA implementations have been deployed (or are currently being deployed) in non-VA healthcare facilities in Texas,[35] Arizona,[36] Florida, Hawaii,[37] New Jersey,[38] Oklahoma,[37] West Virginia,[39] [40] California,[41] [42] New York,[43] and Washington, D.C.[37] [44] In one state, the cost of a multiple hospital VistA-based EHR network was implemented for one tenth the price of a commercial EHR network in another hospital network in the same state ($9 million versus $90 million for 78 hospitals each). (Both VistA and the commercial system used the MUMPS database). [45] VistA has even been adapted into a Health Information System (VMACS) at the veterinary medical teaching hospital at UC Davis.[46]
International deployments
VistA software modules have been installed around the world, or are being considered for installation, in healthcare institutions such as the World Health Organization,[39] and in countries such as Mexico,[37] [39] [47] Samoa,[37] Finland, Jordan,[48] Germany,[49] Kenya,[39] Nigeria,[50] Egypt,[37] Malaysia, India,[51] Brazil, Pakistan,[44] and Denmark.[52] In September 2009, Dell Computer bought Perot Systems, the company installing VistA in Jordan.[53]
History
The concept that eventually became VistA was initiated and planned at the beginning of the 1970s by the National Center for Health Services Research and Development of the U.S. Public Health Service (NCHSR&D/PHS). (The NCHSR&D is now known as the Agency for Healthcare Research and Quality (AHRQ).) As a proof of concept, the U.S. Navy's clinic at the Brunswick Naval Air Station had used an early version of the system software to develop an operational, automated, clinic-management and medical-record system that was "paperless". The National Center for Health Sciences Research and Development then turned to an agency of the U.S. Department of Commerce, the National Bureau of Standards (NBS, reorganized in 1988 as the National Institute of Standards and Technology), to turn the systems-technology strategy into a systems-architecture design. Under the farsighted leadership of the VA's Chief Medical Director, Dr. John Chase, the VA's Department of Medicine and Surgery (now known as the Veterans Health Administration (VHA)), then agreed to deploy the system at the largest medical system of that time, the VA hospitals.
VistA Both Dr. Robert Kolodner (National Health Information Technology Coordinator [54]) and George Timson (an architect of VistA who has been involved with it since the early years) date VistA's actual architecture genesis, then, to 1977.[55] [56] The program was launched in 1978 with the deployment of the initial modules in about twenty VA Medical Centers. The program was named the Decentralized Hospital Computer Program (DHCP) in 1981. The physicians in VA Medical Centers, with leadership from the National Association of VA Physicians (NAVAP, renamed NAVAPD [57] in 1989 when Dentists were added) and its Executive Director, Dr. Paul Shafer, made sure that the VA understood the importance of clinician-directed development and refinement of this new clinical-information system. In December 1981, Congressman Sonny Montgomery of Mississippi arranged for the Decentralized Hospital Computer Program (DHCP) to be written into law as the medical-information systems development program of the VA. VA Administrator Robert P. Nimmo signed an Executive Order in February 1982 describing how the DHCP was to be organized and managed within the VA's Department of Medicine and Surgery. In consultation with F. Whitten Peters and Vincent Fuller of the Williams and Connolly law firm, it was established at the beginning of the 1980s that the software existing in the VA (derived from the PHS projects) was legally in the public domain and must be made available without proprietary or other restrictions to other government and private-sector organizations for their use. In parallel with the VA's DHCP development, the (PHS) Indian Health Service deployed a system with similar structure throughout their hospitals and clinics as the Resource and Patient Management System (RPMS [58]). This implementation emphasized the integration of outpatient clinics into the system, and many of its elements were soon re-incorporated into the VA system (through a system of technology sharing). Subsequent VistA systems therefore included elements from both RPMS and DHCP. The U.S. Department of Defense (DoD) then modified the PHS/VA system for use in DoD healthcare facilities and renamed it the Composite Health Care System (CHCS). Meanwhile, in the early 1980s, major hospitals in Finland[59] were the first institutions outside of the United States to adopt and adapt the VistA system to their language and institutional processes, creating a suite of applications called MUSTI and Multilab. (Since then, institutions in Germany, Egypt,[37] Nigeria,[50] and other nations abroad have adopted and adapted this system for their use, as well.) The name "VistA" (Veterans Health Information System and Technology Architecture) was adopted by the VA in 1994, when the Under Secretary for Health of the U.S. Department of Veterans Affairs (VA), Dr. Ken Kizer, renamed what had previously been known as the Decentralized Hospital Computer Program (DHCP). The four major adopters of VistA VA (VistA), DoD (CHCS), IHS (RPMS), and the Finnish Musti consortium [60] each took VistA in a different direction, creating related but distinct "dialects" of VistA. VA VistA and RPMS exchanged ideas and software repeatedly over the years, and RPMS periodically folded back into its code base new versions of the VA VistA packages. These two dialects are therefore the most closely related. The Musti software drifted further away from these two but retained compatibility with the infrastructure of RPMS and VA VistA (while adding additional GUI and web capabilities to improve function). Meanwhile, the CHCS code base diverged from that of the VA's VistA in the mid-eighties and has never been reintegrated. The VA and the DoD had been instructed for years to improve the sharing of medical information between the two systems, but for political reasons made little progress toward bringing the two dialects back together. More recently, CHCS's development was brought to a complete stop by continued political opposition within the DoD, and it has now been supplanted by a related, but different, system called AHLTA [61]. While AHLTA is the new system for DoD, the core systems beneath AHLTA (for Computerized Physician Order Entry, appointing, referral management, and creation of new patient registrations) remain those of the underlying CHCS system. (While some ongoing development has occurred for CHCS, the majority of funds are consumed by the AHLTA project.) Thus, the VistA code base was split four ways.
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VistA Many VistA professionals then informally banded together as the "Hardhats" (a name the original VistA programmers used for themselves) to promote that the FOIA (Freedom of Information Act) release of VA VistA (that allows it to be in the public domain) be standardized for universal usage. WorldVistA was formed from this group and was incorporated in March 2003 as a non-profit corporation. This allowed the WorldVistA board of directors to pursue certain activities (obtaining grants, creating contracts, and making formal alliances) that they otherwise could not pursue as an informal organization. It is, however, an organization independent of the VA system and its version of VistA therefore differs from that of the VA's. Nevertheless, it maintains as an objective that its public version be compatible (interoperable) with the VA's official version. It has developed packages of WorldVistA [62] for multiple operating systems, including Linux (Debian/Ubuntu and Red Hat)-based and Microsoft Windows-based operating systems. Co-operation with the maintainers and vendors of OpenVistA [63], another widely deployed open source public version of VistA, helps maintain interoperability and a standardized framework. Therefore, it is through the joint achievement of thousands of clinicians and professional systems experts from the United States and other nations that the VistA system has developed, many of them volunteers.
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Supporters of VistA
There have been many champions of VistA as the electronic healthcare record system for a universal healthcare plan. VistA can act as a standalone system, allowing self-contained management and retention of healthcare data within an institution. Combined with BHIE (or other data exchange protocol) it can be part of a peer-to-peer model of universal healthcare. It is also scalable to be used as a centralized system (allowing regional or even national centralization of healthcare records). It is, therefore, the electronic records system most adaptable to a variety of healthcare models. In addition to the unwavering support of congressional representatives such as Congressman Sonny Montgomery of Mississippi, numerous IT specialists, physicians, and other healthcare professionals have donated significant amounts of time in adapting the VistA system for use in non-governmental healthcare settings. The ranking member of the House Veterans Affairs Committee's Oversight and Investigation Subcommittee, Rep. Ginny Brown-Waite of Florida, recommended that the Department of Defense (DOD) adopt VA's VistA system following accusations of inefficiencies in the DOD healthcare system. The DOD hospitals use Armed Forces Health Longitudinal Technology Application (AHLTA [64]) which has not been as successful as VistA and has not been adapted to non-military environments (as has been done with VistA).[25] In November 2005, the U.S. Senate passed the Wired for Health Care Quality Act, introduced by Sen. Enzi of Wyoming with 38 co-sponsors, that would require the government to use the VA's technology standards as a basis for national standards allowing all health care providers to communicate with each other as part of a nationwide health information exchange. The legislation would also authorize $280 million in grants, which would help persuade reluctant providers to invest in the new technology.[65] There has been no action on the bill since December 2005. Two similar House bills were introduced in late 2005 and early 2006; no action has been taken on either of them, either.[66] In late 2008, House Ways and Means Health Subcommittee Chair Congressman Pete Stark (D-CA) introduced the Health-e Information Technology Act of 2008 (H.R. 6898) that calls for the creation of a low-cost public IT system for those providers who do not want to invest in a proprietary one.[67] In April 2009, Sen. John D. Rockefeller of West Virginia introduced the Health Information Technology Public Utility Act of 2009 calling for the government to create an open source electronic health records solution and offer it at little or no cost to safety-net hospitals and small rural providers.[68] [69]
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VistA Derivatives
Astronaut VistA [70] -- a installer suite for different versions of VistA with multiple enhancements and bug fixes. WorldVistA or WorldVistA EHR [71] OpenVistA [72] (Medsphere) vxVistA [73] (DSS) OnDemandCARE [74] a VistA-based EHR package (Sequence Managers Software) BlueCliff VistA-EMR [75] (Blue Cliff)
An effort has been made by the Astronaut team, WorldVistA team and members of the VistA Software Alliance to standardize structure between the platform derivatives to allow for future interoperability, as part of the vision for a national healthcare network record system.
References
[1] Department of Veterans Affairs: Veterans Health Administration (http:/ / www1. va. gov/ health/ ) [2] "Nation's Largest Healthcare System Pledges Involvement in Healthy Hospital Initiative" (http:/ / yosemite. epa. gov/ opa/ admpress. nsf/ 8822edaadaba0243852572a000656841/ 66a4a31db7c1ae178525703d0067d18b!OpenDocument). US Environmental Protection Agency (Sep 2003). . [3] Department of Veterans Affairs: List of Medical facilities (http:/ / www1. va. gov/ directory/ guide/ division. asp?dnum=1) [4] "Fact Sheet: Facts About the Department of Veterans Affairs" (http:/ / www1. va. gov/ opa/ fact/ vafacts. asp). VA Administration (Jan 2009). . [5] "NEJM: VA VistA nearly doubles proportion of computerized hospitals." (http:/ / linuxmednews. com/ 1238189242). LinuxMedNews (Mar 2009). . [6] Use of Electronic Health Records in U.S. Hospitals (http:/ / content. nejm. org/ cgi/ content/ full/ NEJMsa0900592). New England Journal of Medicine (Mar 25, 2009). . [7] Brown, Stephen H. (2003). "VistA, U.S. Department of Veterans Affairs national scale HIS" (http:/ / www1. va. gov/ cprsdemo/ docs/ VistA_Int_Jrnl_Article. pdf) (PDF). International Journal of Medical Informatics 69: 135156, Bethesda, MD (USA) 69 (23): 135. doi:10.1016/S1386-5056(02)00131-4. . [8] Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration (http:/ / journals. cambridge. org/ action/ displayAbstract;jsessionid=7C274D08947B0625B3B540BEF2E70367. tomcat1?fromPage=online& aid=416400). Health Economics: Policy and Law (2006): 1, 163169. . [9] "VistA:Winner of the 2006 Innovations in American Government Award" (http:/ / www. innovations. va. gov/ innovations/ docs/ InnovationsVistAInfoPackage. pdf) (PDF). The Ash Institute for Democratic Governance and Innovation at Harvard University's John F. Kennedy School of Government. . [10] "The Best Medical Care In The U.S. How Veterans Affairs transformed itself -- and what it means for the rest of us" (http:/ / www. businessweek. com/ magazine/ content/ 06_29/ b3993061. htm?chan=tc& chan=technology_technology+ index+ page_best+ of+ the+ magazine). BusinessWeek, Red Oak, IA (USA). July 16, 2006. . [11] VA Testimony of Roger Baker before Congress on July 14, 2009 - Congressional and Legislative Affairsva.gov. "Open Source Healthcare IT at a National Level" (http:/ / www4. va. gov/ OCA/ testimony/ hvac/ soi/ 090714RB. asp). United States Department of Veterans Affairs (2009). . [12] HIMSS Analytics Stage 7 Hospitalshimssanalytics.org. "HIMSS Analytics Stage 7 Hospitals" (http:/ / www. himssanalytics. org/ hc_providers/ stage7Hospitals. asp). HIMSS Analytics. . [13] "Honored for EMR Sophistication, HIMSS Analytics Announces Stage 6 Hospitals" (http:/ / www. himssanalytics. org/ general/ pr_02262009. asp). HIMSS Analytics (Feb 2009). . [14] "Midland Memorial Hospital Uses OpenVista Clinical Framework to Improve Patient Care and Reduce Costs" (http:/ / www. medsphere. com/ press/ 20080304). Medsphere (Mar 2008). . [15] Department of Veterans Affairs: VistA website (http:/ / www. va. gov/ vista/ ) [16] http:/ / astronautvista. com/ astronaut-help/ how-to/ how-to-install-astronaut-vista-server-and-client [17] http:/ / www. esiobjects. org/ [18] http:/ / vistapedia. net/ index. php?title=M2Web_Overview [19] http:/ / gradvs1. mgateway. com/ main/ index. html [20] http:/ / www. health-evet. va. gov/ [21] http:/ / www. myhealth. va. gov/ [22] "PACS Lessons Learned at the Baltimore VA" (http:/ / www. imagingeconomics. com/ issues/ articles/ 2002-12_01. asp) (subscription required). Imaging Economics, Skokie, IL (USA). December 2002. . [23] http:/ / www1. va. gov/ VHA_OI/ page. cfm?pg=37
VistA
[24] "VistA Imaging Installation Guide" (http:/ / www. va. gov/ vdl/ documents/ Clinical/ Vista_Imaging_Sys/ imginstallgd_f. pdf). Department of Veterans Affairs (2010). . [25] Mosquera, Mary (2007-05-09). "Full VA/DOD e-health sharing several years off" (http:/ / govhealthit. com/ article102670-05-09-07-Web). Government Health IT, Falls Church, VA (USA). . [26] http:/ / www1. va. gov/ vadodhealthitsharing/ page. cfm?pg=9 [27] "Opensource CCR and CCD support for VistA based systems Project Update (Powerpoint slideshow)" (http:/ / groups. google. com/ group/ ccd-ccr-project/ web/ CCR-CCD-Update-090219. ppt). WorldVistA.org (Feb 2010). . [28] "VA, Kaiser plan to link electronic medical records" (http:/ / www. healthcareitnews. com/ news/ va-kaiser-plan-link-electronic-medical-records). Healthcare IT News (Nov 2009). . [29] "VA Telemedicine Program Expands Access to Bariatric Surgery" (http:/ / www. generalsurgerynews. com/ index. asp?section_id=410& show=dept& issue_id=588& article_id=14411). General Surgery News Vol. 36, Number 12 p.40 (Dec 2009). . [30] "Introduction to VistA software and the FTP site" (http:/ / www1. va. gov/ cprsdemo/ page. cfm?pg=1). US Department of Veterans Affairs. . [31] http:/ / www. bluecliffinc. com [32] http:/ / www. docstorsys. com [33] http:/ / www. medsphere. com/ [34] http:/ / sequencemanagers. com [35] "Old code proves key to modern IT at Midland Memorial Hospital" (http:/ / www. computerworld. com/ action/ article. do?command=viewArticleBasic& taxonomyName=Knowledge+ Center& articleId=9120541& taxonomyId=1& pageNumber=1). Computerworld (Nov 2008). . [36] "Statement of Matthew King, M.D., Chief Medical Officer, Clinica Adelante, Inc, Surprise, Arizona" (http:/ / waysandmeans. house. gov/ hearings. asp?formmode=printfriendly& id=7233). US Congress House Committee on Ways and Means (July 2008). . [37] "VistA has been implemented in a variety of locations worldwide." (http:/ / www. vistasoftware. org/ why/ ss. html). Vista Software Alliance. . [38] "Hoboken University Medical Center Selects Medsphere's OpenVista Solution" (http:/ / www. medsphere. com/ news/ 159-hoboken-university-medical-center-selects-medspheres-openvista-solution-to-improve-patient-care-achieve-meaningful-use). Medsphere (Oct 2009). . [39] "VistA Tour Announcement (Oct 2008)" (http:/ / vistatour. blogspot. com/ ). . [40] "VA's health record system cited as model for a national network" (http:/ / www. nextgov. com/ nextgov/ ng_20090327_6548. php). Nextgov (Mar 2009). . [41] "Oroville Hospital to Deploy Medsphere OpenVista Electronic Health Record" (http:/ / www. businesswire. com/ portal/ site/ google/ ?ndmViewId=news_view& newsId=20070116006067& newsLang=en). Businesswire, (Jan 2007). . [42] "Kern Medical Center Selects OpenVista" (http:/ / www. medsphere. com/ news/ 144-kern-medical-center-selects-openvista-system-for-clinical-transformation-and-meaningful-use). Medsphere, (Dec 2009). . [43] "Brooklyn's Lutheran Medical Center Selects Medsphere OpenVista for Electronic Health Record Deployment" (http:/ / findarticles. com/ p/ articles/ mi_m0EIN/ is_2007_Jan_8/ ai_n17096323/ ). BNET, (Jan 2007). January 8, 2007. . [44] "Implementation of the Veterans Health Administration VistA Clinical Information System around the World" (http:/ / www. shepherd. edu/ surc/ cosi/ VistA around the world 2008. doc). ElectronicHealthcare, 7(2) 2008: 8389. . [45] "Ten Fold (10X): Is There Really an Order of Magnitude Difference?" (http:/ / blog. crossoverhealth. com/ 2009/ 01/ 30/ ten-fold-10x-is-there-really-an-order-of-magnitude-difference/ ). CrossOver Health (Jan 2009). . [46] "Demonstration of M2Web" (http:/ / vista. vmth. ucdavis. edu/ notebook/ index). UC Davis VMTH (Veterinary Medical Hospital) (Dec 2008). . [47] "VistA use continues to grow in Mexico" (http:/ / www. modernhealthcare. com/ article/ 20070112/ FREE/ 70112018). ModernHealthcare.com (Jan 2007). . [48] "Jordan picks Perot to help implement VistA" (http:/ / www. ehealthonline. org/ news/ news-details. asp?News=Jordan-picks-Perot-to-help-implement-VistA& NewsID=15810). EHealth (Jan 2009). . [49] Implemented in 1992 at the Berlin Heart Institute, VistA is still in use there. "VistA News - July 18, 2006 - Harvard Honors the VA, VistA" (http:/ / www. mail-archive. com/ hardhats-members@lists. sourceforge. net/ msg16312. html). HardHats. . [50] "MINPHIS: Nigeria's experience using VistA, MUSTI, and other technologies in building their own national health information system" (http:/ / www. hoise. com/ vmw/ 05/ articles/ vmw/ LV-VM-10-05-19. html). Virtual Medical Worlds (August 2005). . [51] "Global Tender for Computerization and Hospital Information System Jai Prakash Narayan Apex Trauma Center" (http:/ / www. aiims. ac. in/ aiims/ tender/ TC-578-CF(Specification). pdf). Jai Prakash Narayan Apex Trauma Center. . [52] "Lge: Open source vil kunne lse Danmarks EPJ-problemer" (http:/ / www. version2. dk/ artikel/ 8238-laege-open-source-vil-kunne-loese-danmarks-epj-problemer). Version 2 (August 2008). . [53] "Dell To Acquire Perot Systems For $3.9 Billion, Creating Comprehensive, Customer-Focused It-Solutions Company" (http:/ / www. perotsystems. com/ MediaRoom/ PressRelease092009). Perot Systems (Sep 2009). . [54] http:/ / www. hhs. gov/ healthit/ onc/ mission/ [55] Robert Kolodner, MD (1997). Computerizing Large Integrated Health Networks: The VA Success. [56] "The History of the Hardhats" (http:/ / www. hardhats. org/ history/ hardhats. html). Hardhats.org. .
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[57] http:/ / www. navapd. org/ [58] http:/ / www. ihs. gov/ CIO/ EHR/ index. cfm [59] Douglas E. Goldstein, et. al. (2007). Medical informatics 20/20 (Case Studies of VistA Implementation United States and International) p. 276 (http:/ / books. google. com/ ?id=JivKd9gTA5cC& pg=PT312& lpg=PT312& dq=M+ database+ medical+ finland+ Musti). Jones & Bartlett Learning. ISBN9780763739256. . [60] http:/ / messi. uku. fi/ tike/ his/ english/ musti. html [61] http:/ / www. health. mil/ ahlta/ default. cfm [62] http:/ / sourceforge. net/ projects/ worldvista/ files/ [63] http:/ / medsphere. com [64] http:/ / www. ha. osd. mil/ AHLTA/ [65] "Senator Endorses VistA for EHR Standard" (http:/ / www. linuxmednews. com/ 1137769193). Linux MedNews. January 20, 2006. . [66] "Library of Congress: Thomas: Bills, resolutions: S.1418" (http:/ / thomas. loc. gov/ cgi-bin/ bdquery/ z?d109:s. 01418:). Library of Congress. . Retrieved June 10, 2007. [67] "Representative Stark Introduces Health-e Information Technology Act of 2008" (http:/ / medicareupdate. typepad. com/ medicare_update/ 2008/ 09/ representative. html). Medicare Update. September 16, 2008. . [68] Landro, Laura (April 30, 2009). "An Affordable Fix for Modernizing Medical Records" (http:/ / online. wsj. com/ article/ SB124104350516570503. html). Wall Street Journal. . [69] "Rockefeller Introduced Legislation Calling For Universal Adoption of Electronic Health Records" (http:/ / rockefeller. senate. gov/ press/ record. cfm?id=311951). United States Senator Jay Rockefeller. April 23, 2009. . [70] http:/ / astronautvista. com/ [71] http:/ / www. worldvista. org [72] http:/ / medsphere. org/ index. jspa [73] http:/ / www. docstorsys. com/ index. htm [74] http:/ / www. sequencemanagers. com [75] http:/ / www. bluecliffinc. com/ vistaemr/
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External links
Vistapedia: the WorldVistA Wiki (http://vistapedia.net/index.php?title=Main_Page) Hardhats (http://www.hardhats.org) a VistA user community Hardhats Google Group (http://groups.google.com/group/Hardhats/) a forum to discuss installation of WorldVistA VISTA Monograph (http://www.va.gov/vista_monograph/) (Veterans Administration) VistA Monograph wiki (http://wiki.laptop.org/go/VistA_Monograph_Wiki) (OLPC project) VistA Software Alliance (http://www.vistasoftware.org) (VistA Software Vendor Trade Organization) VistA / CPRS Demo site (http://www1.va.gov/cprsdemo/) (Department of Veterans Affairs) VA VistA software FTP site (http://www1.va.gov/CPRSdemo/page.cfm?pg=1) (Department of Veterans Affairs) The Pacific Telehealth & Technology Hui (http://www.pacifichui.org/) VistA Imaging overview (http://www1.va.gov/imaging/page.cfm?pg=3) (Department of Veterans Affairs) BHIE (http://www1.va.gov/VADODHEALTHITSHARING/Bidirectional_Health_Information_Exchange. asp) Bidirectional Health Information Exchange protocols of the Department of Veterans Affairs Why is VistA good? (http://www.fredtrotter.com/2007/11/10/ why-is-vista-good-the-vista-open-source-development-model/) "Innovations Award" (http://www.ashinstitute.harvard.edu/Ash/pdfs/VAVistAreleasefinale.pdf) (PDF). Retrieved July 25, 2006. Ash Institute News Release VistA Glossary (http://liutiu.narod.ru/VistA_Glossary.htm) LiuTiu Medical Administrative Lexicon (Brokenly translated into English from Russian) Ubuntu Doctors Guild (http://www.ubuntudoctorsguild.org/public/index.php/ Main_Page#Electronic_Medical_Records_.28EMRs.2FEHRs.29) Information about implementing VistA and other open source medical applications in Ubuntu Linux Videos about VistA:
VistA VistA at the VA (http://www1.va.gov/vha_oi/docs/vha_intel_chime.asx) History of Vista Architecture (http://blip.tv/file/405389) Interview with Tom Munnecke Interview with Rob Kolodner (http://blip.tv/file/1187881) regarding VistA's potential for the National Health Information Network Impact of VistA (http://blip.tv/file/1187881) Interview with Dr. Ross Fletcher Interview with Philip Longman (http://blip.tv/file/1188770) Events leading up to the development of VistA (http://blip.tv/file/1187514/) Interview with Henry Heffernan History of Vista (http://blip.tv/file/1187241/) Interview with Ruth Dayhoff Early development of the Decentralized Hospital Computer Program (http://blip.tv/file/1186772/) Interview with Marty Johnson Early days of the VA "Underground Railroad" (http://blip.tv/file/1188922/) Interview with Tom Munnecke
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VistA imaging
VistA Imaging is an FDA-approved Image Management system used in the Department of Veterans Affairs healthcare facilities nationwide. It is one of the most widely used image management systems in routine healthcare use, and is used to manage many different varieties of images associated with a patient's medical record.
Hardware requirements
The VistA Imaging System uses hardware components to provide short- and long-term storage. It takes advantage of network servers for storage. It uses a DICOM Sample patient record view from VistA Imaging gateway system to communicate with commercial Picture Archiving and Communication Systems (PACS) and modalities such as CT, MR, and Computed Radiography (x-ray) devices for image capture. It utilizes a background processor for moving the images to the proper storage device and for managing storage space.
Types of data managed

The system not only manages radiologic images, but also is able to capture and manage EKGs, pathology images, gastroenterology (endoscopic) images, laparoscopic images, scanned paperwork, or essentially any type of health care image.
Integration with Electronic Health Record systems

VistA Imaging is currently integrated into the VistA EMR (electronic medical record) system used nationwide in Department of Veterans Affairs hospitals. This integration is able to provide increased efficiency of retrieval of images.[1] It has also been used as a separate software package and can be used with EHRs other than VistA. VistA Imaging now connects to a nationwide backbone that allows clinicians to access the 350 million images stored in the VA system via Remote Image View software.[2]
VistA imaging The VA has developed interfaces for more than 250 medical devices in VistA Imaging, the images from which can be accessed through the desktop VistA Imaging Viewer. The Department of Defense will use the VistA Imaging Viewer to enhance its own EHR.[2]
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Usage in a National Network of Healthcare Records

As part of the US national mandate to co-ordinate care between Department of Defense and the VA, VistA Imaging is forming a cornerstone of the effort to exchange medical imagery between the two systems. When soldiers come back from Iraq and Afghanistan and eventually enter the VA system, images will be able to move from DOD to VA seamlessly." Eventually, DOD and VA should be able to share all image file types from all sites. Additional enhancements to VistA Imaging include development of a central archive for all VA images (whether acquired through VistA or a commercial system) and new indexing and search capabilities.[3]
Availability
The software for VistA Imaging has been made available through the Freedom of Information Act so that it is in the public domain. Due to its designation as a medical device, however, it can not be designated as free open source software and therefore can not be altered or implemented without FDA approval. This was done intentionally to limit the distribution of VistA Imaging. Although it can be used in healthcare facilities that are outside the Department of Veterans Affairs, this is possible only if the proprietary modules that have been integrated into it are also licensed and implementation is registered with the FDA. This has effectively limited its use to government institutions who have licensed the proprietary modules. It is nominally available through the Department of Veterans Affairs software request [23] office for a fee of around $15.
Proprietary modules required

VistA Imaging uses proprietary modules not in the public domain. This makes its public domain use limited. These modules include (Accusoft [4]) ImageGear OCX-32 Pro Gold Version 8.0.4, (Accusoft) Medical Extension/OCX-32 Version 1.1.40, Borland Delphi Professional Version 5.0 build 6.18, Borland Delphi Professional Version 7.0 build 8.1, (GE Marquette Medical) MUSE API Version 005A and Version 005B build 19990324, Matrox ActiveMIL 7.5, Dome Version 4.0.2.3, (Outrider Systems) SPIN32.OCX, (Kodak) Admin Control Version 5.0.2134.1, (Kodak) Edit Control Version 5.0.2195.6601, (Macromedia) RoboHelp HTML x5.0.2, (Intersystems) MSM Version 4.4.0, (Intersystems) Cach Version 5.0.20, (Aware, Inc.) AccuRad J2KSuite for Compression and Decompression [5] Version V3.8.0.0, (Laurel Bridge Software [6]) DICOM Toolkit [7] version 2.8.7a, (Sentillion) Vergence Locator version 3.3.1.8907.
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Open Source Alternative compatible with VistA

A multi-platform open source product O3-DPACS [8] (Open Three ( O3 ) - Data & Picture Archiving and Communication System) is a Java-based alternative for the open-source VistA implementations that is likely to fulfill the same functions provided by VistA Imaging within the VA.[9]
Information retrieval after a natural disaster

The VistA Imaging system was robust enough to be restored after Hurricane Katrina damaged the data facility at the New Orleans VA.[10] This type of backup proved superior to a paper record system.
References
[1] "PACS Lessons Learned at the Baltimore VA" (http:/ / www. imagingeconomics. com/ issues/ articles/ 2002-12_01. asp). Imaging Economics, Skokie, IL (USA). December 2002. . [2] "VistA's horizons: The VA's VistA Imaging system had its beginnings in a government worker's basement home office. Now it straddles three departments and hundreds of clinical offices." (http:/ / govhealthit. com/ article96354-10-09-06-Print) ( Scholar search (http:/ / scholar. google. co. uk/ scholar?hl=en& lr=& q=author:+ intitle:VistA's+ horizons:+ The+ VA's+ VistA+ Imaging+ system+ had+ its+ beginnings+ in+ a+ government+ worker's+ basement+ home+ office. + Now+ it+ straddles+ three+ departments+ and+ hundreds+ of+ clinical+ offices. & as_publication=Government+ Health+ IT+ (USA)& as_ylo=& as_yhi=& btnG=Search)). Government Health IT (USA). October 9, 2006. . [3] "VistA Imaging upgrades will enhance exchanges with DOD" (http:/ / govhealthit. com/ articles/ 2008/ 11/ vista-imaging-upgrades-will-enhance-exchanges-with-dod_633662645039172840. aspx). November 2008. . [4] http:/ / www. accusoft. com [5] http:/ / www. aware. com/ imaging/ accuradj2k. htm [6] http:/ / www. laurelbridge. com [7] http:/ / www. laurelbridge. com/ dcf. php [8] http:/ / sourceforge. net/ projects/ o3-dpacs [9] "VistA Monograph Wiki" (http:/ / wiki. laptop. org/ go/ VistA_Monograph_Wiki#VistA_Imaging_System). OLPC Health Project (June 2008). . [10] "New Orleans VA medical center restores data lost to Katrina" (http:/ / www. diagnosticimaging. com/ pacsweb/ showArticle. jhtml?articleID=180100058). Diagnostic Imaging:PACSWeb (Feb. 11, 2006). .
External links
"VistA Imaging overview" (http://www.va.gov/IMAGING/overview.asp). Department of Veterans Affairs. Retrieved July 16, 2010. "Capture devices approved for use with VistA Imaging (IHS intranet)" (http://vhacollaboration.ihs.gov/ VistAImaging/Shared Documents/VistA Imaging Training Documentation/ Approved_Clinical_Capture_Devices.pdf). March 2007. "DICOM devices approved for use with VistA Imaging" (http://www1.va.gov/imaging/docs/ VistA_Imaging_DICOM_Modality_Interfaces.pdf). "VistA Imaging in the IHS RPMS EHR" (http://www.ihs.gov/vistaimaging/). Nov 2009.
VistA Web
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VistA Web
VistAWeb is a portal accessible through CPRS (Computerized Patient Recordkeeping System), the graphical user interface for the Veterans Health Information Systems and Technology Architecture (VistA), the electronic health record used throughout the United States Department of Veterans Affairs (VA) medical system (known as the Veterans Health Administration (VHA)). This portal has been implemented throughout the VA system, allowing healthcare providers at remote VA facilities to view records contained within the VistA electronic health record system at the patient's primary facility. As originally created, the VA health systems has 21 regional data systems (VISN), each with some differences in data collection and storage. The usage of VistA throughout the VA has helped to standardize records, but there has until recently not been an easy way for accessing records from a different VISN service area. If a patient travels or is injured or sick and visits a VA facility far from their home, VistAWeb will allow the physician or other healthcare provider access to the records at that patient's home institution.
Introduction
Veterans Health Information Systems and Technology Architecture (VistA) VistAWeb is an intranet web application used to review remote patient information found in VistA, the Federal Health Information Exchange (FHIE) system, and the Health Data Repository (HDR) databases. To a large extent, VistAWeb mirrors the reports behavior of the Computerized Patient Record System (CPRS) and Remote Data View (RDV). However, by permitting a more robust and timely retrieval of remote-site patient data, VistAWeb is also an enhancement to CPRS/RDV. There are three ways to access VistAWeb. VistAWeb can be made available by adding it to the CPRS Tools Menu, and it can be selected as the default method of retrieving data from the Remote Data Available button in CPRS. These two methods are referred to as CPRS-spawned versions of VistAWeb. They are compliant with the Health Level 7 (HL7) Clinical Context Object Workgroup (CCOW) standards and therefore maintain context with the patient selected in CPRS. As a third option, VistAWeb can be accessed in a standalone mode from its website at https://vistaweb.med.va.gov/ [1]. The standalone version of VistAWeb is connected to neither CPRS nor the clinical context management application. Standalone VistAWeb serves an important function for users who have been granted special access to multiple sites, such as for National Programs, Veterans Administration (VA) researchers, and others.
Usage for record access following natural disaster

VistAWeb was also made available more broadly, though temporarily, to assist clinical staff with the retrieval of patient information from the sites affected by damage caused by hurricane Katrina.[2]
Availability
The VistAWeb package is distributed in the public domain as a module of the VistA software package under the Freedom of Information Act (FOIA). It is therefore available from the VA FTP site, from the VA software distribution office, and in bundled packages. Its capabilities, therefore, can be achieved by a healthcare institution that installs the VistA electronic health record.
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References
[1] https:/ / vistaweb. med. va. gov/ [2] Brown, SH; Fischetti, LF; Graham, G; Bates, J; Lancaster, AE; McDaniel, D; Gillon, J; Darbe, M et al. (April 2007). "Use of Electronic Health Records in Disaster Response: The Experience of Department of Veterans Affairs After Hurricane Katrina" (http:/ / www. ajph. org/ cgi/ content/ abstract/ 97/ Supplement_1/ S136). American Journal of Public Health 97, Suppl. 1: S13641. doi:10.2105/AJPH.2006.104943. PMC1854987. PMID17413082. .
External links
"VISTA Monograph" (http://www.va.gov/vista_monograph/). Veterans Administration. "VistA / CPRS Demo site" (http://www1.va.gov/cprsdemo/). (Department of Veterans Affairs) "VA VistA software FTP site" (http://www1.va.gov/CPRSdemo/page.cfm?pg=1). (Department of Veterans Affairs) "VistA Software Alliance" (http://www.vistasoftware.org). (VistA Software Vendor Trade Organization) "The Pacific Telehealth & Technology Hui" (http://www.pacifichui.org/). "WorldVistA" (http://www.worldvista.org). - Home of the WorldVistA EHR "WorldVistA Wiki" (http://openforum.worldvista.org/~forum/index.php?title=Main_Page). "Hardhats" (http://www.hardhats.org). - a VistA user community "Innovations Award" (http://www.ashinstitute.harvard.edu/Ash/pdfs/VAVistAreleasefinale.pdf). Retrieved July 25, 2006. - Ash Institute News Release "Sequence Managers Software" (http://www.sequencemanagers.com/). Retrieved June 11, 2007. -- provides a VistA-based EMR package, based in Raleigh, North Carolina "VistA Imaging overview" (http://www1.va.gov/imaging/page.cfm?pg=3). Department of Veterans Affairs. "BHIE" (http://www1.va.gov/vadodhealthitsharing/page.cfm?pg=14). Bidirectional Health Information Exchange protocols of the Department of Veterans Affairs
WorldVistA
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WorldVistA
WorldVistA is an open source implementation of the Veteran Administration's Electronic Health Record system intended for use in health care facilities outside the VA.
Background
The US Veterans Administration developed the most widely distributed Electronic Health Record used in the US, the Veterans Health Information Systems and Technology Architecture (VistA). In an effort to make the system widely available to institutions outside the Veterans Administration health system, the software code was placed in the Public Domain under the Freedom of Information Act. The foundation for the WorldVistA EHR was formed to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting. It was originally developed as part of the VistA-Office project, a collaborative effort funded by the United States Centers for Medicare and Medicaid Services (CMS), an agency of the US Department of Health and Human Services (DHHS). WorldVistA EHR VOE/ 1.0 is based on and compatible with the U.S. Department of Veterans Affairs (VA) world renowned EHR, Veterans Health Information Systems and Technology Architecture (VistA). A fully open-source (GPL v2 licensed) project, WorldVistA has also developed software modules (such as pediatrics, obstetrics, and other functions) not used in the veterans' healthcare setting. In 2006, WorldVistA EHR VOE/ 1.0 was the only open source EHR that met Certification Commission for Healthcare Information Technology (CCHITSM) ambulatory electronic health record (EHR) criteria, and in January 2008, it was released with full CCHITSM EHR. As a free product developed in co-operation with the US government, WorldVistA is not marketed in a similar fashion to commercial EHRs.
Core VistA functions

patient registration clinical reminders for chronic disease management clinical order entry progress note templates results reporting
Customizable functions
The structure of WorldVistA is modular, and a wide variety of customization is possible. Because it is fully open source, this can be done without restriction (although CCHIT certification is granted only to the officially maintained package). ability to interface to existing practice management / billing systems, lab services and other applications scanning and inclusion of scanned documents into the medical record prescription finishing and faxing clinical quality measure reporting capabilities support for disease management, using clinical reminders templates for obstetrics/gynecology (OB/GYN) and pediatrics care
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Server Platforms
For Linux-based servers, WorldVistA server uses the (free open source) Fidelity GT.M MUMPS database, available as an integrated package along with WorldVistA Server. This software is part of the VistA Public Domain software, and does not require licensing. For Windows-based servers, WorldVistA can be implemented used the commercial Cach MUMPS database, which requires a database license and software from Intersystems Corporation. For Mac OS-X-based servers, a development effort to port GT.M (and the Server software) to that platform has begun.
Client platforms
The Client software is an implementation of CPRS, which is Windows-based. This allows Windows terminals to access the central server database. This software is part of the VistA Public Domain software, and does not require licensing. For Linux terminals, CPRS can be run as a Wine package or from within a virtual machine. A separate (Windows-based) module is available to capture and view vital signs as well as graphing of other clinical data. This is meant to be used on client terminals. A separate (Windows-based) module allows the scanning, capture and integration of paper documents as part of an individuals medical record. It can also be used to add a variety of non-diagnostic quality images to the medical record. This is meant to be used on client terminals.
Development History
WorldVistA is developed by a series of physicians (and other medical professionals) and software professionals that donate their efforts as volunteers. This group loosely referred to themselves as Hardhats (and continues to do so) before the name of the project was officially changed to WorldVistA. WorldVistA has developed and distributes a "toaster" version of VistA, which is a self-contained software package [1] that integrates both the MUMPS database (GT.M version) and the VistA software. In 2009, the self-installing Linux toaster version was enhanced with a GUI-based patient registration module, web interface, and other enhancements, and incorporated into a self-installing package for both Debian/Ubuntu and Red Hat Linux. This freely available version of WorldVistA is known as Astronaut VistA [70]. This version is packaged with both an enhanced GUI as well as a web interface (which allows connection through an intranet or through the Internet). An introduction to this package is here in a PDF slide presentation [2]. A similar package for Windows-based servers is in alpha (early development) stage.
Grants opportunities to help further development

NIH grants [3] -- Supported by the American Recovery & Reinvestment Act of 2009 (ARRA), NIH grants can be used efforts to further technology that advances the goals of the NIH Robert Woods Johnson Foundation [4] -- This foundation has a goal of helping integrate personal access to electronic health records nationwide, similar to the VA's HealtheVet [20] project.
Adoption
Clinica Adelante [5] implemented the open source version of VistA for its 30,000 member community health clinic, and has testified before the US Congress [6] regarding its success. Oroville Hospital [7] is installing the WorldVistA version into a co-ordinated hospital and clinic system.
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References
[1] http:/ / sourceforge. net/ projects/ worldvista [2] http:/ / worldvista. org/ conference_presentations/ 19th-vista-community-meeting/ AstroVistAInstaller_VCM_06_18_2009. pdf/ at_download/ file [3] http:/ / grants. nih. gov/ recovery/ [4] http:/ / www. rwjf. org/ applications/ solicited/ cfp. jsp?ID=20762 [5] http:/ / www. clinicaadelante. com/ [6] http:/ / waysandmeans. house. gov/ hearings. asp?formmode=printfriendly& id=7233 [7] http:/ / www. orovillehospital. com
External links
"WorldVistA" (http://www.worldvista.org). - Home of the WorldVistA EHR "Vistapedia: the WorldVistA Wiki" (http://vistapedia.net/index.php?title=Main_Page). "Hardhats" (http://www.hardhats.org). - a WorldVistA user community "Astronaut WorldVistA on Ubuntu" (http://www.ubuntudoctorsguild.org/public/index.php/ Astronaut_VistA). - Tips for installation of the Astronaut WorldVistA server on Ubuntu/Kubuntu Linux (from Ubuntu Doctors Guild)
ZEPRS
The Zambia Electronic Perinatal Record System (ZEPRS) is an Electronic Medical Record (EMR) system used by public obstetric clinics and a hospital (the University Teaching Hospital) in Lusaka, Zambia.
Background
In early 2001 a team of physicians at the University of Alabama at Birmingham (UAB) and visiting Zambian physician Dr. Moses Sinkala conceived the idea based on a successful electronic perinatal record system that the UAB had developed and proven in clinics in Birmingham. in July 2001 the Bill & Melinda Gates Foundation awarded a grant to the UAB to develop a similar system to serve public obstetric clinics in Lusaka, Zambia.[1] The UAB team solicited proposals for the technical design and implementation of the system from several private sector information technology firms, including Electronic Data Systems, before awarding a contract to RTI International [2] (RTI), a large 501(c)3 not-for-profit research organization based in Research Triangle Park, North Carolina. Other project partners included the Center for Infectious Disease Research in Zambia (CIDRZ) and the Lusaka District Health Management Team of the Zambian Central Board of Health [3].
Objectives
ZEPRS was designed to improve maternal and perinatal outcomes by: 1. Improving perinatal care for women and postnatal care for neonates by: 1. Promoting adherence to good standard of care practices 2. Identifying and document potential medical/ obstetrical problems so that effective therapies can be administered 3. Improving communication and referrals among providers 4. Enhancing monitoring and evaluation of outcomes, clinics, and providers 2. Improving efficiency, completeness, accuracy of documentation and reporting
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Major components
ZEPRS achieves these objectives by providing the following: An electronic patient record system with patient record database shared among facilities A system that guides clinicians through the Zambian standard of care Intelligent rules that alert clinicians to problems and recommend patient referral when appropriate Standard & ad hoc reporting for supportive supervision, surveillance, and analysis An electronic-first system used by clinicians during the course of patient care An electronic referral system to improve the efficiency and effectiveness of referrals
ZEPRS components include a high-speed point-to-point voice and data wireless network [4] that interconnects facilities; wired and wireless networks within facilities; a data center managed by CIDRZ; and an electronic perinatal record system with integrated patient referral system. ZEPRS uses a tabbed user interface and role-based access control system to enable several clinicians to share the same computer to retrieve and enter data for different patients.
Software architecture
ZEPRS has been developed using the Java programming language. Other technologies used include AJAX, Quartz [5] , MySQL, and others. ZEPRS has its own content management system called DynaSite, that makes it easy to add forms, fields, form flows, and business rules without programming. RTI has developed a locally installable version of the software using the Eclipse Rich Client Platform (RCP) and the Apache Derby embedded database. This version uses the free and open source zcore [6] platform, which uses an implementation of RSS to transmit data over intermittent networks, such as mobile phone networks.
Development history
RTI worked with South African firm Communications Solutions [7] (Comsol) to conduct a wireless site survey of all facilities, and to design a line-of-sight wireless network to connect them. By March 2003 this network was operational. Before the end of 2003 RTI had worked with Comsol to add Voice over Internet Protocol (VoIP) to provide voice communication between facilities, and had extended the network to connect multiple buildings in clinic compounds and to multiple wards of the University Teaching Hospital. Three to nine networked PCs and one laser printer were installed in each clinic, as well as additional PCs and printers in the University Teaching Hospital and administrative offices. The ZEPRS data center was installed at CIDRZ, which housed the combined ZEPRS technical support team. Approximately 800 clinicians, many of whom had never used a computer, were trained in basic computer literacy. Standard clinical protocol reference works and email were made available to clinicians electronically over the ZEPRS network. By early May 2004 RTI had completed an open source electronic patient referral system. This was launched into production use in clinics on 22 June 2004. Clinicians adopted this component readily and the system was soon rolled out to all 24 clinics and the University Teaching Hospital. Also in May 2004, CIDRZ asked RTI whether the ZEPRS software could be adapted to help in managing antiretroviral therapy (ART) to treat patients infected with the Human immunodeficiency virus (HIV). Version 1.0 of this software, the ART Patient Tracking System (ART/PTS), was launched into use at Kalingalinga Clinic on 1 June 2004.[8] RTI reviewed the completed Beta version of the fully integrated perinatal record system with the UAB team in July 2005, and released Version 1.0 on 21 November 2005. This version was pilot tested in a limited number of clinics in Lusaka from December 2005 through January 2006. ZEPRS was launched into production use in two clinics in
ZEPRS February 2006. The system was rolled out to all clinics at the average rate of one clinic each month until the roll out was completed in August 2007.
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Current status
Since roll out was completed in August 2007, ZEPRS has been used by 24 public obstetrics clinics, as well as six wards (blocks A-D, adult ARV ward, and pediatric ARV ward) within the University Teaching Hospital in Lusaka. The ZEPRS patient record database has been used since February 2006 for routine health surveillance, monitoring, and supervision of health care. A 2006 study cited the use of a ZEPRS-based patient record system as one of four key factors in the successful rapid scale-up of antiretroviral therapy at primary care sites in Zambia.[9] By September 2011 ZEPRS contained medical records for more than 510,000 patients.[10] In 2011 an average of more than 8,000 new antenatal patients are being registered in the system each month. Clinicians in 25 facilities have used ZEPRS during more than 5,000,000 patient encounters to manage perinatal care. ZEPRS links multiple pregnancies of the same mother to the mother's record. ZEPRS had been used to manage multiple pregnancies for more than 20,000 mothers. In 2011 ZEPRS has been used by 278 individual users to help care for perinatal patients and analyze related health care data in Lusaka. Information regarding the impact of ZEPRS on the quality of health care and health outcomes can be obtained by contacting the Center for Infectious Disease Research in Zambia or the Zambian Central Board of Health.
Ongoing development
Since ZEPRS was launched in February 2006 it has been continually refined and enhanced based on input from clinicians and emerging needs. In 2008 RTI worked with CIDRZ to implement an interface with the Laboratory Information Management System (LMIS) at Kalingalinga Clinic, enabling lab test results such as CD4 counts to be transferred to patient records automatically twice daily. RTI has developed a version of the software that can be installed locally, be used within a facility in the absence of network connectivity, and can synchronize records automatically when connectivity is detected. This version is based on the free and open source Zcore [11] platform, which can transmit data automatically over intermittent networks, such as mobile phone networks.
Adaptability
The Zcore software platform that emerged from ZEPRS has been used for managing pharmaceutical supplies [12] in health centers in Nairobi, Kenya, managing malaria indoor residual spraying operations [13] in Kenya, and managing medical and legal care for rape survivors [14] in South Africa.
Availability
ZEPRS has been released by RTI [15] as free and open source software under the Apache Software License (Version 2.0). RTI has released ZEPRS documentation under a Creative Commons Attribution-NonCommercial-ShareAlike 2.5 License.
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Related systems
OpenMRS OpenEMR SmartCare WorldVistA
Footnotes
[1] 1 (http:/ / www. gatesfoundation. org/ GlobalHealth/ Pri_Diseases/ ReproductiveMaternalHealth/ Announcements/ Announce-403. htm) US-Zambian Collaboration Receives $4 Million To Establish Electronic Obstetric And Newborn Medical Record In Lusaka, Zambia [2] http:/ / www. rti. org [3] http:/ / www. cboh. gov. zm/ [4] http:/ / www. rtidemo. org/ front/ node/ 160 [5] http:/ / www. opensymphony. com/ quartz/ [6] http:/ / www. rtidemo. org/ front/ zcore [7] http:/ / www. comsol. co. za/ [8] 2 (http:/ / jama. ama-assn. org/ cgi/ content/ abstract/ 296/ 7/ 782) Hubschman T, Mweetwa V, Fusco H, Chi B, Levy J, Sinkala M, Shields M, Stringer J. Electronic patient tracking supports rapid expansion of HIV care and treatment in Lusaka, Zambia. Presidents Emergency Plan for AIDS Relief 2nd Annual Meeting, Supporting National Strategies: Building on Success. Addis Ababa, Ethiopia, May 22-27, 2005. [9] 3 (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 16905784?dopt=AbstractPlus) Stringer JS, Zulu I, Levy J, Stringer EM, Mwango A, Chi BH, Mtonga V, Reid S, Cantrell RA, Bulterys M, Saag MS, Marlink RG, Mwinga A, Ellerbrock TV, Sinkala M. Rapid Scale-Up of Antiretroviral Therapy at Primary Care Sites in Zambia: Feasibility and Early Outcomes. JAMA. 2006 Aug 16;296(7):782-93. [10] 3 (http:/ / www. ictedge. org) Data based on queries of the ZEPRS database performed on 9 September 2011. [11] http:/ / www. ictedge. org/ zcore [12] http:/ / www. ictedge. org/ projects/ wrKenya [13] http:/ / www. ictedge. org/ projects/ irsa [14] http:/ / www. ictedge. org/ projects/ rape_case_mgmt [15] http:/ / www. ictedge. org/ projects/ zeprs
Other References
Chi BH, Vwalika B, Killam WP, Wamalume C, Giganti MJ, Mbewe R, Stringer EM, Chintu NT, Putta NB, Liu KC, Chibwesha CJ, Rouse DJ, Stringer JS. Implementation of the Zambia Electronic Perinatal Record System for comprehensive prenatal and delivery care. (http://www.sciencedirect.com/science?_ob=ArticleURL& _udi=B6T7M-524XP6X-8&_user=775537&_coverDate=02/10/2011&_rdoc=1&_fmt=high& _orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_acct=C000042938&_version=1& _urlVersion=0&_userid=775537&md5=e25edd87bd7e0e4bdff82ce9cbe7298f&searchtype=a) Int J Gynaecol Obstet. 2011 Feb 9. Darcy N, Kelley C, Reynolds E, and Cressman G. (2010) An Electronic Patient Referral Application:A Case Study from Zambia (http://www.google.com/url?q=http://www.rti.org/pubs/rr-0011-1003-darcy.pdf& sa=U&ei=5kx2TfbGKoaU0QGL7NntBg&ved=0CAoQFjAA& usg=AFQjCNE9LSWhVbQSJk3YhXwtLGLJYYL1Og), RTI Press, Research Report Series, RTI International. Morris M, Chapula B, Chi, B, Mwango A, Chi F, Mwanza J, Manda1 H, Bolton C, Pankratz D, Stringer J, and Reid S. (2009) "Use of task-shifting to rapidly scale-up HIV treatment services: experiences from Lusaka, Zambia" (http://www.biomedcentral.com/content/pdf/1472-6963-9-5.pdf), BMC Health Services Research. Cressman G, Darcy N, Destefanis P, Kelley C, Reynolds E. (2008) "Can an Electronic Medical Record System Improve Health Care in Lusaka, Zambia?" (http://www.gpphi.org/conferences/PHI2008/images-and-docs/ PHI2008 Abstract List.pdf), Poster Presentation, PHI2008 Conference, Seattle, Washington, USA. Stergachis A, Keene D, Somani S. (2008) "Informatics for Medicines Management Systems in Resource-Limited Settings" (http://www.ehealth-connection.org/files/conf-materials/Informatics for Medicines Mngmt Systems_0.pdf) Making the eHealth Connection Conference, Bellagio, Italy.
ZEPRS RTI International (2008) ICT Improves Patient Care in Africa: ZEPRS -- An Electronic Perinatal Record System in Zambia (http://www.rti.org/page.cfm?nav=370&objectid=09C970A2-AB6E-504A-37FCAF624F0E9927), RTI International Website. RTI International (2008) "ZEPRS wins Computerworld's Mobile & Wireless World 'Best Practices in Mobile and Wireless' Award for 2008" (http://www.rti.org/newsroom/news.cfm?nav=370& objectid=5A57BC36-50C1-4A2F-A8402DC050533D32), RTI International Press Release. Computerworld (2008) "2008 'Best Practices in Mobile & Wireless' Awards" (http://www.mwwusa.com/ awards.aspx), Computerworld, Mobile & Wireless World. Cressman G, Darcy N, Destefanis P, Kelley C, Reynolds E. (2007) "Can an Electronic Medical Record System Improve Health Care in Lusaka, Zambia?" (http://www.aidsimpact.com/2007/Programme/abstract/?id=411), Presentation, AIDSIMPACT 2007, Marseilles, France. Ajita S, Dipsikha S, Sahajad A. (2006) " e-Health Perspective: Healing touch to health (http://www.i4donline. net/articles/current-article.asp?articleid=629&typ=Features)", i4D Magazine.
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Decision Support Applications

Clinical decision support system
Clinical decision support system (CDSS or CDS) is an interactive decision support system (DSS) Computer Software, which is designed to assist physicians and other health professionals with decision making tasks, as determining diagnosis of patient data. A working definition has been proposed by Dr. Robert Hayward of the Centre for Health Evidence; "Clinical Decision Support systems link health observations with health knowledge to influence health choices by clinicians for improved health care". This definition has the advantage of simplifying Clinical Decision Support to a functional concept.
Role & Characteristics

A clinical decision support system has been coined as an active knowledge systems, which use two or more items of patient data to generate case-specific advice.[1] This implies that a CDSS is simply a DSS that is focused on using knowledge management in such a way to achieve clinical advice for patient care based on some number of items of patient data.
Purpose/Goal
The main purpose of modern CDSS is to assist clinicians at the point of care.[2] This means that a clinician would interact with a CDSS to help determine diagnosis, analysis, etc. of patient data. Previous theories of CDSS were to use the CDSS to literally make decisions for the clinician. The clinician would input the information and wait for the CDSS to output the right choice and the clinician would simply act on that output. The new methodology of using CDSS to assist forces the clinician to interact with the CDSS utilizing both the clinicians knowledge and the CDSS to make a better analysis of the patients data than either human or CDSS could make on their own. Typically the CDSS would make suggestions of outputs or a set of outputs for the clinician to look through and the clinician officially picks useful information and removes erroneous CDSS suggestions.[1] There are two main types of CDSS[2] : Knowledge-Based NonKnowledge-Based An example of how a CDSS might be used by a clinician comes from the subset of CDSS, DDSS (Diagnosis Decision Support Systems). A DDSS would take the patients data and propose a set of appropriate diagnoses. The doctor then takes the output of the DDSS and figures out which diagnoses are relevant and which are not.[2] Another important classification of a CDSS is based on the timing of its use. The doctor uses these systems at point of care to help them as they are dealing with a patient, with the timing of use as either pre-diagnoses, during diagnoses, or post diagnoses. Pre-diagnoses CDSS systems are used to help the physician prepare the diagnoses. CDSS used during diagnoses help review and filter the physicians preliminary diagnostic choices to improve their final results. And post-diagnoses CDSS systems are used to mine data to derive connections between patients and their past medical history and clinical research to predict future events.[2]
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Features of a Knowledge-Based CDSS

Most CDSS consist of three parts, the knowledge base, inference engine, and mechanism to communicate. The knowledge base contains the rules and associations of compiled data which most often take the form of IF-THEN rules. If this was a system for determining drug interactions, then a rule might be that IF drug X is taken AND drug Y is taken THEN alert user. Using another interface, an advanced user could edit the knowledge base to keep it up to date with new drugs. The inference engine combines the rules from the knowledge base with the patients data. The communication mechanism will allow the system to show the results to the user as well as have input into the system.[1] [2]
Features of a non-Knowledge-Based CDSS

CDSSs that do not use a knowledge base use a form of artificial intelligence called machine learning, which allow computers to learn from past experiences and/or find patterns in clinical data. Two types of non-knowledge-based systems are artificial neural networks and genetic algorithms. Artificial neural networks use nodes and weighted connections between them to analyze the patterns found in the patient data to derive the associations between the symptoms and a diagnosis. This eliminates the need for writing rules and for expert input. However since the system cannot explain the reason it uses the data the way it does, most clinicians dont use them for reliability and accountability reasons.[1] [2] Genetic Algorithms are based on simplified evolutionary processes using directed selection to achieve optimal CDSS results. The selection algorithms evaluate components of random sets of solutions to a problem. The solutions that come out on top are then recombined and mutated and run through the process again. This happens over and over till the proper solution is discovered. They are the same as neural networks in that they derive their knowledge from patient data. Non-knowledge-based networks often focus on a narrow list of symptoms like ones for a single disease as opposed to the knowledge based approach which cover many different diseases to diagnosis[1] [2]
Effectiveness
A 2005 systematic review by Garg et al. of 100 studies concluded that CDSs improved practitioner performance in 64% of the studies. The CDSs improved patient outcomes in 13% of the studies. Sustainable CDSs features associated with improved practitioner performance include the following: 1. automatic electronic prompts rather than requiring user activation of the system Garg et al. concluded that the number and methodologic quality of studies have improved from 1973 through 2004.
[3]
Another 2005 systematic review (quantitative analysis) of 70 studies by Kawamoto et al. found... "Decision support systems significantly improved clinical practice in 68% of trials." The CDSs features associated with success include the following: 1. the CDSs is integrated into the clinical workflow rather than as a separate log-in or screen. 2. the CDSs is electronic rather than paper-based templates. 3. the CDSs provides decision support at the time and location of care rather than prior to or after the patient encounter. 4. the CDSs provides (active voice) recommendations for care, not just assessments.
[4]
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Current U.S. Regulations

With the enactment of the American Recovery and Reinvestment Act of 2009 (ARRA), there is a push for widespread adoption of health information technology by President Obama administration through the Health Information Technology for Economic and Clinical Health Act (HITECH). Through these initiatives, more hospitals and clinics are integrating Electronic Medical Records (EMRs) and Computerized physician order entry (CPOE) within their health information processing and storage. Consequently, the Institute of Medicine (IOM) promoted usage of health information technology including Clinical Decision Support Systems to advance quality of patient care. The IOM had published a startling report which focused on patient safety crisis in the United States pointing to the incredibly high number of deaths. This statistic gained great attention to the quality of patient care. With the recent enactment of the HITECH Act included in the ARRA, encouraging the adoption of health IT, more detailed case laws for CDSS and EMRs are still being defined by the Office of National Coordinator (ONC) and approved by Department of Health and Human Services (HHS). Meaningful use definition is yet to be polished. Despite the absence of laws, the CDSS vendors would almost certainly be viewed as having a legal duty of care to both the patients who may adversely be affected due to CDSS usage and the clinicians who may use the technology for patient care. Therefore, the duties of care legal regulations are not explicitly defined as of yet. With recent effective legislations related to performance shift payment incentives, CDSS are appealing as more attractive.
Challenges to Adoption
Clinical Challenges
Much effort has been put forth by medical institutions and software companies to produce viable CDSSs to cover all aspects of clinical tasks. However, with the complexity of clinical workflows and the demands on staff time high, care must be taken by the institution deploying the support system to ensure that the system becomes a fluid and integral part of the workflow. To this end CDSSs have met with varying amounts of success, while others suffer from common problems preventing or reducing successful adoption and acceptance. Two sectors of the healthcare domain in which CDSSs have had a large impact are the pharmacy and billing sectors. Pharmacy and prescription ordering systems now do batch-based checking of orders for negative drug interactions and report warnings to the ordering professional. Such systems commonly exist both in clinical settings as well as in more commercial settings, such as in the software used by local or chain pharmacy stores. Another sector of success for CDSS is in billing and claims filing. Since many hospitals rely on Medicare reimbursements to maintain their operational status, systems have been created to help examine both a proposed treatment plan and the current rules of Medicare in order to suggest a plan that attempts to maximize both the care of the patient and the financial needs of the institution. Other CDSSs that are aimed at the diagnostic tasks have found success but are often very limited in deployment and scope. The Leeds Abdominal Pain System went operational in 1971 for the University of Leeds hospital, and found fantastic levels of success where the CDSS produced a correct diagnosis 91.8% of cases compared to the clinicians rating of 79.6%. Despite the wide range of efforts by institutions to produce and use these systems, widespread adoption and acceptance has still not yet been achieved for most offerings. One large roadblock to acceptance is workflow integration. A tendency to focus only on the functional decision making core of the CDSS exists, causing a deficiency in planning for how the clinician will actually use the product in situ. Often these systems are stand-alone applications, requiring the clinician to cease working on their current report system, switch to the CDSS, input the necessary data, and receive the information. These additional steps break the flow from the clinicians perspective and cost precious time. An additional irritant is that the data the clinician may need to enter is already contained
Clinical decision support system elsewhere in a digital form in that hospitals system, and some CDSSs are not equipped to automatically pull this relevant information. Another source of contention with many pharmaceutical support systems as well as others comes in the form of alert fatigue. This occurs when systems produce so many warnings for things like drug interactions that clinicians cease to pay attention to the content of those warnings. This both prevents possible salient warnings from being heeded as well as cause irritation in the clinician.
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Technical Challenges & Barriers to Implementation

Clinical decision support systems face steep technical challenges in a number of areas. Biological systems are profoundly complicated, and a clinical decision may utilize an enormous range of potentially relevant data. For example, an electronic evidence-based medicine system may potentially consider a patients symptoms, medical history, family history and genetics, as well as historical and geographical trends of disease occurrence, and published clinical data on medicinal effectiveness when recommending a patients course of treatment. Clinically, a large deterrent to CDSS acceptance is workflow integration. Inclination to focus only on functional decision making core of the CDSS causes a deficient plan on how the clinician will actually utilize the system in situations. Generally extra steps are required of the clinician which then causes a disruption in workflow affecting efficiency. Generally these systems are stand-alone applications which are not integrated with existing healthcare systems, the clinical user must stop work on the current system, switch to the CDSS, and reenter data necessary into the CDSS that may already exist in another electronic system. Another source of contention with many medical support systems produces mass amounts of alert. When systems produce high volume of warnings (especially those that do not require escalation), aside from the annoyance, clinicians may pay less attention to warnings, causing potentially critical alerts to be missed. Maintenance One of the core challenges facing CDSS is difficulty in incorporating the extensive quantity of clinical research being published on an ongoing basis. In a given year, tens of thousands of clinical trials are published.[5] Currently, each one of these studies must be manually read, evaluated for scientific legitimacy, and incorporated into the CDSS in an accurate way. In addition to being laborious, integration of new data can sometimes be difficult to quantify or incorporate into the existing decision support schema, particularly in instances where different clinical papers may appear conflicting. Properly resolving these sorts of discrepancies is often the subject of clinical papers itself (see meta-analysis), which often take months to complete. One primary example of a project that attempts to dynamically incorporate new clinical data Isabel [6]. Evaluation In order for a CDSS to offer value, it must demonstrably improve clinical workflow or outcome. Evaluation of CDSS is the process of quantifying its value to improve a systems quality and measure its effectiveness. Because different CDSSs serve different purposes, there is no generic metric which applies to all such systems; however, attributes such as consistency (with itself, and with experts) often apply across a wide spectrum of systems. The evaluation benchmark for a CDSS depends on the systems goal: for example, a diagnostic decision support system may be rated based upon the consistency and accuracy of its classification of disease (as compared to physicians or other decision support systems). An evidence-based medicine system might be rated based upon a high incidence of patient improvement, or higher financial reimbursement for care providers.
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Methodological Basis of CDSS

There are many different methodologies that can be used by a CDSS in order to provide support to the health care professional. The basic components of a CDSS include a dynamic (medical) knowledge base and an inferencing mechanism (usually a set of rules derived from the experts and evidence-based medicine) and implemented through medical logic modules based on a language such as Arden syntax. It could be based on Expert systems or artificial neural networks or both (connectionist expert systems).
Bayesian Network
The Bayesian network is a knowledge-based graphical representation that shows a set of variables and their probabilistic relationships between diseases and symptoms. They are based on conditional probabilities, the probability of an event given the occurrence of another event, such as the interpretation of diagnostic tests. Bayes rule helps us compute the probability of an event with the help of some more readily available information and it consistently processes options as new evidence is presented. In the context of CDSS, the Bayesian network can be used to compute the probabilities of the presence of the possible diseases given their symptoms. Some of the advantages of Bayesian Network include the knowledge and conclusions of experts in the form of probabilities, assistance in decision making as new information is available and are based on unbiased probabilities that are applicable to many models. Some of the disadvantages of Bayesian Network include the difficulty to get the probability knowledge for possible diagnosis and not being practical for large complex systems given multiple symptoms. The Bayesian calculations on multiple simultaneous symptoms could be overwhelming for users. Example of a Bayesian network in the CDSS context is the Iliad system which makes use of Bayesian reasoning to calculate posterior probabilities of possible diagnoses depending on the symptoms provided. The system now covers about 1500 diagnoses based on thousands of findings. Another example is the DXplain system that uses a modified form of the Bayesian logic. This CDSS produces a list of ranked diagnoses associated with the symptoms. A third example is SimulConsult [7], which began in the area of neurogenetics. By the end of 2010 it covered ~2,600 diseases in neurology and genetics, or roughly 25% of known diagnoses. It addresses the core issue of Bayesian systems, that of a scalable way to input data and calculate probabilities, by focusing specialty by specialty and achieving completeness. Such completeness allows the system to calculate the relative probabilities, rather than the person inputting the data. Using the peer-reviewed medical literature as its source, and applying two levels of peer-review to the data entries, SimulConsult can add a disease with less than a total of four hours of clinician time. It is widely used by pediatric neurologists today in the US and in 85 countries around the world.
Neural Network
Artificial Neural Networks (ANN) is a nonknowledge-based adaptive CDSS that uses a form of artificial intelligence, also known as machine learning, that allows the systems to learn from past experiences / examples and recognizes patterns in clinical information. It consists of nodes called neuron and weighted connections that transmit signals between the neurons in a forward or looped fashion. An ANN consists of 3 main layers: Input (data receiver or findings), Output (communicates results or possible diseases) and Hidden (processes data). The system becomes more efficient with known results for large amounts of data. The advantages of ANN include the elimination of needing to program the systems and providing input from experts. The ANN CDSS can process incomplete data by making educated guesses about missing data and improves with every use due to its adaptive system learning. Additionally, ANN systems do not require large databases to store outcome data with its associated probabilities. Some of the disadvantages are that the training process may be
Clinical decision support system time consuming leading users to not make use of the systems effectively. The ANN systems derive their own formulas for weighting and combining data based on the statistical recognition patterns over time which may be difficult to interpret and doubt the systems reliability. Examples include the diagnosis of appendicitis, back pain, myocardial infarction, psychiatric emergencies and skin disorders. The ANNs diagnostic predictions of pulmonary embolisms were in some cases even better than physicians predictions[citation needed]. Additionally, ANN based applications have been useful in the analysis of ECG (A.K.A. EKG) waveforms.
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Genetic Algorithms
A Genetic Algorithm (GA) is a nonknowledge-based method developed in the 1940s at the Massachusetts Institute of Technology based on Darwins evolutionary theories that dealt with the survival of the fittest. These algorithms rearrange to form different re-combinations that are better than the previous solutions. Similar to neural networks, the genetic algorithms derive their information from patient data. An advantage of genetic algorithms is these systems go through an iterative process to produce an optimal solution. The fitness function determines the good solutions and the solutions that can be eliminated. A disadvantage is the lack of transparency in the reasoning involved for the decision support systems making it undesirable for physicians. The main challenge in using genetic algorithms is in defining the fitness criteria. In order to use a genetic algorithm, there must be many components such as multiple drugs, symptoms, treatment therapy and so on available in order to solve a problem. Genetic algorithms have proved to be useful in the diagnosis of female urinary incontinence.
Rule-Based System
A rule-based expert system attempts to capture knowledge of domain experts into expressions that can be evaluated known as rules; an example rule might read, "If the patient has high blood pressure, he or she is at risk for a stroke." Once enough of these rules have been compiled into a rule base, the current working knowledge will be evaluated against the rule base by chaining rules together until a conclusion is reached. Some of the advantages of a rule-based expert system are the fact that it makes it easy to store a large amount of information, and coming up with the rules will help to clarify the logic used in the decision-making process. However, it can be difficult for an expert to transfer their knowledge into distinct rules, and many rules can be required for a system to be effective. Rule-based systems can aid physicians in many different areas, including diagnosis and treatment. An example of a rule-based expert system in the clinical setting is MYCIN. Developed at Stanford University by Dr. Edward Shortliffe in the 1970s, MYCIN was based on around 600 rules and was used to help identify the type of bacteria causing an infection. While useful, MYCIN can help to demonstrate the magnitude of these types of systems by comparing the size of the rule base (600) to the narrow scope of the problem space. The Stanford AI group subsequently developed ONCOCIN, another rules-based expert system coded in Lisp in the early 1980s <ONCOCIN: An expert system for oncology protocol management E. H. Shortliffe, A. C. Scott, M. B. Bischoff, A. B. Campbell, W. V. Melle, C. D. Jacobs Seventh International Joint Conference on Artificial Intelligence, Vancouver, B.C.. Published in 1981>. The system was intended to reduce the number of clinical trial protocol violations, and reduce the time required to make decisions about the timing and dosing of chemotherapy in late phase clinical trials. As with MYCIN, the domain of medical knowledge addressed by ONCOCIN was limited in scope and consisted of a series of eligibility criteria, laboratory values, and diagnostic testing and chemotherapy treatment protocols that could be translated into unambiguous rules. Oncocin was put into production in the Stanford Oncology Clinic.
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Logical Condition
The methodology behind logical condition is fairly simplistic; given a variable and a bound, check to see if the variable is within or outside of the bounds and take action based on the result. An example statement might be "Is the patient's heart rate less than 50 BPM?" It is possible to link multiple statements together to form more complex conditions. Technology such as a decision table can be used to provide an easy to analyze representation of these statements. In the clinical setting, logical conditions are primarily used to provide alerts and reminders to individuals across the care domain. For example, an alert may warn an anesthesiologist that their patient's heart rate is too low; a reminder could tell a nurse to isolate a patient based on their health condition; finally, another reminder could tell a doctor to make sure he discusses smoking cessation with his patient. Alerts and reminders have been shown to help increase physician compliance with many different guidelines; however, the risk exists that creating too many alerts and reminders could overwhelm doctors, nurses, and other staff and cause them to ignore the alerts altogether.
Causal Probabilistic Network

The primary basis behind the causal network methodology is cause and effect. In a clinical causal probabilistic network, nodes are used to represent items such as symptoms, patient states or disease categories. Connections between nodes indicate a cause and effect relationship. A system based on this logic will attempt to trace a path from symptom nodes all the way to disease classification nodes, using probability to determine which path is the best fit. Some of the advantages of this approach are the fact that it helps to model the progression of a disease over time and the interaction between diseases; however, it is not always the case that medical knowledge knows exactly what causes certain symptoms, and it can be difficult to choose what level of detail to build the model to. The first clinical decision support system to use a causal probabilistic network was CASNET, used to assist in the diagnosis of glaucoma. CASNET featured a hierarchical representation of knowledge, splitting all of its nodes into one of three separate tiers: symptoms, states and diseases.
Examples of CDSS
Zynx Health [8] - the market leader in evidence-based clinical decision support solutions proven to measurably improve the quality, safety, and efficiency of patient care. PKC Corporation, PKC designs dynamic healthcare decision support software and medical informatics software to meet the information requirements of your organization. MYCIN, one of the first expert systems to be developed in the 1970s, it does ethiological diagnoses of bacterial diseases. CADUCEUS, a medical expert system that could diagnose 1000 diseases. Internist-I, a computer-assisted diagnostic tool. Dxplain DiagnosisPro Iliad uses Bayesian reasoning to calculate probabilities of various diagnoses under consideration in internal medicine. It now covers around 1500 different diagnoses.[9] TheraDoc A suite of real-time monitoring products as well as Infection prevention, mediation, and correction. TheraDoc uses a variety of standards compliant messaging taxonomies to work with currently existing software in the clinical setting to guide decision making as well as report trends in problems your institution is encountering.[10] Lifecom Lifecom has developed an entirely new form of artificial intelligence technology and a supporting suite of knowledge development tools. The Lifecom technology portfolio includes novel knowledge extraction and management tools, the artificial intelligence engine, and a highly graphical user interface.[11]
Clinical decision support system VisualDx [12] point-of-care diagnostic resource that allows clinicians to build patient-centric visual differential diagnoses based on the patients signs, symptoms, medical history, and more. Clinicians have immediate access to more than 17,000 images as well as expert-reviewed information for nearly 1,000 visually identifiable diseases, drug reactions, and infections represented in all age ranges and skin types.[13] RODIA Relative Optical Density Image Analysis used in medical imaging, medical diagnostics, orthopedic and other medical disciplines. SimulConsult - Uses a Bayesian model with temporal reasoning and family history to deliver a differential diagnosis and suggested additional findings ranked by usefulness (based on the evolving differential). It considers both cost and treatability. The database is open, crowd sourced (typically by specialist clinicians), peer-reviewed and referenced to the literature.[14] MEDgle - MEDgle's Clinical GPS is a collaborative clinical decision making tool that instantly calculates statistically relevant diagnoses, level of emergency care acuity, relevant procedures and tests that should be considered, as well as the impact of test results.[15] Diagnoz-it (The digital doctor) [16] Nambison's SoftroniX based in India brings clinical decision support system Powered by latest MDSE (Medical Database Search Engine) for powerful search. With clinical input it suggests a list of diseases & the managment of disease required thereto. Stand alone application with several utilities for Individuals/Institutions. Essential Evidence Plus [17] A powerful resource packed with content, tools, calculators and alerts for clinicians who deliver first-contact care. Bulletproof Expert Systems [18], designed by Tim Richardson and Robert Burkhardt is a web application rules based Clinical Decision Support System for Physical Therapists which provides a calculated Plan of Care based on pre-selected predictor variables. Free Demo available.
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References
[1] "Decision support systems ." 26 July 2005. 17 Feb. 2009 <http://www.openclinical.org/dss.html>. [2] Berner, Eta S., ed. Clinical Decision Support Systems. New York, NY: Springer, 2007. [3] Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J et al. (2005). "Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& tool=clinical. uthscsa. edu/ cite& retmode=ref& cmd=prlinks& id=15755945). JAMA 293 (10): 122338. doi:10.1001/jama.293.10.1223. PMID15755945. . [4] Kensaku Kawamoto, Caitlin A Houlihan, E Andrew Balas, David F Lobach. (2005). "Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success." (http:/ / www. bmj. com/ content/ 330/ 7494/ 765. full. pdf+ html). BMJ. doi:10.1136/bmj.38398.500764.8F. . [5] Gluud C, Nikolova D (2007). "Likely country of origin in publications on randomised controlled trials and controlled clinical trials during the last 60 years." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& tool=clinical. uthscsa. edu/ cite& retmode=ref& cmd=prlinks& id=17326823). Trials 8: 7. doi:10.1186/1745-6215-8-7. PMC1808475. PMID17326823. . [6] http:/ / www. isabelhealthcare. com/ home/ default [7] http:/ / www. SimulConsult. com [8] http:/ / www. zynxhealth. com [9] Warner HR, Bouhaddou O (1994). "Innovation review: Iliad--a medical diagnostic support program." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& tool=clinical. uthscsa. edu/ cite& retmode=ref& cmd=prlinks& id=10134761). Top Health Inf Manage 14 (4): 518. PMID10134761. . [10] http:/ / www. theradoc. com/ [11] http:/ / www. ohsu. edu/ champ/ ch_champ. html [12] http:/ / www. visualdx. com [13] Tleyjeh IM, Nada H, Baddour LM (2006). "VisualDx: decision-support software for the diagnosis and management of dermatologic disorders." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& tool=clinical. uthscsa. edu/ cite& retmode=ref& cmd=prlinks& id=17029139). Clin Infect Dis 43 (9): 117784. doi:10.1086/508283. PMID17029139. . [14] www.simulconsult.com [15] [16] [17] [18] www.medgle.com http:/ / www. diagnozit. com http:/ / essentialevidenceplus. com/ http:/ / www. bulletproofpt. com/
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External links
CDSS from Dr Y Health Informatics Knowledge Base (http://hayajneh.org/g/2011/02/ clinical-decision-support-systems/) Decision support chapter from Coiera's Guide to Health Informatics (http://www.coiera.com/aimd.htm) OpenClinical (http://www.openclinical.org) maintains an extensive archive of Artificial Intelligence systems in routine clinical use. Robert Trowbridge/ Scott Weingarten. Chapter 53. Clinical Decision Support Systems (http://www.ahrq.gov/ clinic/ptsafety/chap53.htm) Stanford CDSS (http://clinicalinformatics.stanford.edu/scci_seminars/12_5_03.html)
Computer-aided diagnosis
Computer-aided detection (CADe) and computer-aided diagnosis (CADx) are procedures in medicine that assist doctors in the interpretation of medical images. Imaging techniques in X-ray, MRI, and Ultrasound diagnostics yield a great deal of information, which the radiologist has to analyze and evaluate comprehensively in a short time. CAD systems help scan digital images, e.g. from computed tomography, for typical appearances and to highlight conspicuous sections, such as possible diseases. CAD is a relatively young interdisciplinary technology combining elements of artificial intelligence and digital image processing with radiological image processing. A typical application is the detection of a tumor. For instance, some hospitals use CAD to support preventive medical check-ups in mammography (diagnosis of breast cancer), the detection of polyps in the colon, and lung cancer.
Overview
Computer-aided detection (CADe) systems are usually confined to marking conspicuous structures and sections. Computer-aided diagnosis (CADx) systems evaluate the conspicuous structures. For example, in mammography CAD highlights micro calcification clusters and hyperdense structures in the soft tissue. This allows the radiologist to draw conclusions about the condition of the pathology. Another application is CADq, which quantifies, e.g., the size of a tumor or the tumors behavior in contrast medium uptake. At the present stage of the technology, CAD cannot and may not substitute the doctor, but rather plays a supporting role. The doctor (generally a radiologist) is always responsible for the final interpretation of a medical image.
Computer-aided diagnosis topics

Methodology
CAD is fundamentally based on highly complex pattern recognition. X-ray images are scanned for suspicious structures. Normally a few thousand images are required to optimize the algorithm. Digital image data are copied to a CAD server in a DICOM-format and are prepared and analyzed in several steps. 1. Preprocessing for Reduction of artifacts (bugs in images) Image noise reduction Leveling (harmonization) of image quality for clearing the images different basic conditions e.g. different exposure parameter. 2. Segmentation for Differentiation of different structures in the image, e.g. heart, lung, ribcage , possible round lesions
Computer-aided diagnosis Matching with anatomic databank 3. Structure/ROI (Region of Interest) Analyze Every detected region is analyzed individually for special characteristics: Compactness Form, size and location Reference to close-by structures / ROIs Average greylevel value analyze within a ROI Proportion of greylevels to border of the structure inside the ROI
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4. Evaluation / classification After the structure is analyzed, every ROI is evaluated individually (scoring) for the probability of a TP. Therefore the procedures are: Nearest-Neighbor Rule Minimum distance classifier Cascade Classifier Bayesian Classifier Multilayer perception Radial basis function network (RBF) SVM
If the detected structures have reached a certain threshold level, they are highlighted in the image for the radiologist. Depending on the CAD system these markings can be permanently or temporary saved. The latters advantage is that only the markings which are approved by the radiologist are saved. False hits should not be saved, because an examination at a later date becomes more difficult then.
Sensitivity and specificity

CAD systems seek to highlight suspicious structures. Today's CAD systems cannot detect 100% of pathological changes. The hit rate (sensitivity) can be up to 90% depending on system and application.[1] A correct hit is termed a True Positive (TP), while the incorrect marking of healthy sections constitutes a False Positive (FP). The less FPs indicated, the higher the specificity is. A low specificity reduces the acceptance of the CAD system because the user has to identify all of these wrong hits. The FP-rate in lung overview examinations (CAD Chest) could be reduced to 2 per examination. In other segments (e.g. CT lung examinations) the FP-rate could be 25 or more.
Absolute detection rate

The absolute detection rate of the radiologist is an alternative metric to sensitivity and specificity. Overall, results of clinical trials about sensitivity, specificity, and the absolute detection rate can vary markedly. Each study result depends on its basic conditions and has to be evaluated on those terms. The following facts have a strong influence: Retrospective or prospective design Quality of the used images Condition of the x-ray examination Radiologist's experience and education Type of tumor Size of the considered tumor
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Applications
CAD is used in the diagnosis of breast cancer, lung cancer, colon cancer, prostate cancer, bone metastases, coronary artery disease and congenital heart defect.
Breast cancer
CAD is used in screening mammography (X-ray examination of the female breast). Screening mammography is used for the early detection of breast cancer. CAD is especially established in US and the Netherlands and is used in addition to human evaluation, usually by a radiologist. The first CAD system for mammography was developed in a research project at the University of Chicago. Today it is commercially offered by iCAD and Hologic. There are currently some non-commercial projects being developed, such as Ashita Project, a gradient-based screening software by Alan Hshieh, as well. However, while achieving high sensitivities, CAD systems tend to have very low specificity and the benefits of using CAD remain uncertain. Some studies suggest a positive impact on mammography screening programs,[2] [3] but others show no improvement.[4] [5] A 2008 systematic review on computer-aided detection in screening mammography concluded that CAD does not have a significant effect on cancer detection rate, but does undesirably increase recall rate (i.e. the rate of false positives). However, it noted considerable heterogeneity in the impact on recall rate across studies.[6] Procedures to evaluate mammography based on magnetic resonance imaging exist too.
Lung cancer (bronchial carcinoma)

In the diagnosis of lung cancer, computed tomography with special three-dimensional CAD systems are established and considered as gold standard. At this a volumetric dataset with up to 3,000 single images is prepared and analyzed. Round lesions (lung cancer, metastases and benign changes) from 1mm are detectable. Today all well-known vendors of medical systems offer corresponding solutions. Early detection of lung cancer is valuable. The 5-year-survival-rate of lung cancer has stagnated in the last 30 years and is now at approximately just 15%. Lung cancer takes more victims than breast cancer, prostate cancer and colon cancer together. This is due to the asymptomatic growth of this cancer. In the majority of cases it is too late for a successful therapy if the patient develops first symptoms (e.g. chronic croakiness or hemoptysis). But if the lung cancer is detected early (mostly by chance), there is a survival rate at 47% according to the American Cancer Society.[7] At the same time the standard x-ray-examination of the lung is the most frequently x-ray examination with a 50% share. Indeed the random detection of lung cancer in the early stage (stage 1) in the x-ray image is difficult. It is a fact that round lesions vary from 510mm are easily overlooked.[8] The routine application of CAD Chest Systems may help to detect small changes without initial suspicion. Philips was the first vendor to present a CAD for early detection of round lung lesions on x-ray images.[9]
Colon cancer
CAD is available for detection of colorectal polyps in the colon. Polyps are small growths that arise from the inner lining of the colon. CAD detects the polyps by identifying their characteristic "bump-like" shape. To avoid excessive false positives, CAD ignores the normal colon wall, including the haustral folds. In early clinical trials, CAD helped radiologists find more polyps in the colon than they found prior to using CAD.[10] [11]
Coronary artery disease

CAD is available for the automatic detection of significant (causing more than 50% stenosis) coronary artery disease in coronary CT angiography (CCTA) studies. A low false positives rate (60-70% specificity per patient)[12] [13] allows using CAD as a screening device distinguishing between positive and negative studies and yielding a preliminary report. This, for example, can be used for chest pain patients' triage in an emergency setting.
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Congenital heart defect

Early detection of pathology can be the difference between life and death. CADe can be done by auscultation with a digital stethoscope and specialized software, also known as Computer-aided auscultation. Murmurs, irregular heart sounds, caused by blood flowing through the a defective heart, can be detected with high sensitivity and specificity. Computer-aided auscultation is sensitive to external noise and bodily sounds and requires an almost silent environment to function accurately.
Nuclear medicine
CADx is available for nuclear medicine images. Commercial CADx systems for the diagnosis of bone metastases in whole-body bone scans and coronary artery disease in myocardial perfusion images exist.[14]
References
[1] T. Wollenweber, B. Janke, A. Teichmann, M. Freund: Korrelation zwischen histologischem Befund und einem Computer-assistierten Detektionssystem (CAD) fr die Mammografie. Geburtsh Frauenheilk 2007; 67: 135-141 DOI:10.1055/s-2006-955983 [2] Fiona J. Gilbert, F.R.C.R., Susan M. Astley, Ph.D., Maureen G.C. Gillan, Ph.D., Olorunsola F. Agbaje, Ph.D., Matthew G. Wallis, F.R.C.R., Jonathan James, F.R.C.R., Caroline R.M. Boggis, F.R.C.R., Stephen W. Duffy, M.Sc., for the CADET II Group (2008). Single Reading with Computer-Aided Detection for Screening Mammography, The New England Journal of Medicine, Volume 359:1675-1684 Full text (http:/ / content. nejm. org/ cgi/ reprint/ 359/ 16/ 1675. pdf) [3] Effect of Computer-Aided Detection on Independent Double Reading of Paired Screen-Film and Full-Field Digital Screening Mammograms Per Skaane, Ashwini Kshirsagar, Sandra Stapleton, Kari Young and Ronald A. Castellino [4] Taylor P, Champness J, Given-Wilson R, Johnston K, Potts H (2005). Impact of computer-aided detection prompts on the sensitivity and specificity of screening mammography. Health Technology Assessment 9(6), 1-70. [5] Fenton JJ, Taplin SH, Carney PA, Abraham L, Sickles EA, D'Orsi C et al. Influence of computer-aided detection on performance of screening mammography. N Engl J Med 2007 April 5;356(14):1399-409. Full text (http:/ / content. nejm. org/ cgi/ reprint/ 356/ 14/ 1399. pdf) [6] Taylor P, Potts HWW (2008). Computer aids and human second reading as interventions in screening mammography: Two systematic reviews to compare effects on cancer detection and recall rate. European Journal of Cancer. doi:10.1016/j.ejca.2008.02.016 Full text (http:/ / eprints. ucl. ac. uk/ 5173/ ) [7] http:/ / www. cancer. org/ downloads/ CRI/ 6976. 00. pdf [8] Wu N, Gamsu G, Czum J, Held B, Thakur R, Nicola G: Detection of small pulmonary nodules using direct digital radiography and picture archiving and communication systems. J Thorac Imaging. 2006 Mar;21(1):27-31. PMID 16538152 [9] xLNA (x-Ray Lung Nodule Assessment) (http:/ / www. medical. philips. com/ main/ products/ xray/ products/ radiography/ cad_chest) [10] Petrick N, Haider M, Summers RM, Yeshwant SC, Brown L, Iuliano EM, Louie A, Choi JR, Pickhardt PJ. CT colonography with computer-aided detection as a second reader: observer performance study. Radiology 2008 Jan;246(1):148-56. Erratum in: Radiology. 2008 Aug;248(2):704. PMID 18096536 [11] Halligan S, Altman DG, Mallett S, Taylor SA, Burling D, Roddie M, Honeyfield L, McQuillan J, Amin H, Dehmeshki J. Computed tomographic colonography: assessment of radiologist performance with and without computer-aided detection. Gastroenterology 2006 Dec;131(6):1690-9. Epub 2006 Oct 1. PMID 17087934 [12] E. Arnoldi, M. Gebregziabher, U. J. Schoepf, R. Goldenberg, L. Ramos-Duran, P. L. Zwerner, K. Nikolaou, M. F. Reiser, P. Costello and C. Thilo, Automated computer-aided stenosis detection at coronary CT angiography: initial experience, European Radiology, 20(5):1160-7, May 2010 PMID 19890640 [13] E. J. Halpern, D. J. Halpern, Diagnosis of coronary stenosis with CT angiography: comparison of automated computer diagnosis with expert readings, Academic Radiology, 18(3):324-33, Mar 2011 PMID 21215663 [14] EXINI Diagnostics (http:/ / www. exini. com)
Medical algorithm
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Medical algorithm
A medical algorithm is any computation, formula, statistical survey, nomogram, or look-up table, useful in healthcare. Medical algorithms include decision tree approaches to healthcare treatment (i.e., if symptoms A, B, and C are evident, then use treatment X) and also less clear-cut tools aimed at reducing or defining uncertainty.
Scope
Medical algorithms are part of a broader field which is usually fit under the aims of medical informatics and A medical algorithm for assessment and treatment of overweight and obesity. medical decision making. Medical decisions occur in several areas of medical activity including medical test selection, diagnosis, therapy and prognosis, and automatic control of medical equipment. In relation to logic-based and artificial neural network-based clinical decision support system, which are also computer applications to the medical decision making field, algorithms are less complex in architecture, data structure and user interface. Medical algorithms are not necessarily implemented using digital computers. In fact, many of them can be represented on paper, in the form of diagrams, nomographs, etc.
Examples
A wealth of medical information exists in the form of published medical algorithms. These algorithms range from simple calculations to complex outcome predictions. Most clinicians use only a small subset routinely. Examples of medical algorithms are: Calculators,. e.g., an on-line or stand-alone calculator for body mass index (BMI) when stature and body weight are given; Flowcharts, e.g., a binary decision tree for deciding what is the etiology of chest pain Look-up tables, e.g., for looking up food energy and nutritional contents of foodstuffs Nomographs, e.g., a moving circular slide to calculate body surface area or drug dosages. A common class of algorithms are embedded in guidelines on the choice of treatments produced by many national, state, financial and local healthcare organisations and provided as knowledge resources for day to day use and for induction of new physicians. A field which has gained particular attention is the choice of medications for psychiatric conditions. In the United Kingdom guidelines or algorithms for this have been produced by most of the circa 500 primary care trusts, substantially all of the circa 100 secondary care psychiatric units and many of the circa 10 000 general practices. In the US there is a national (federal) initiative to provide them for all states, and by 2005 six states were adapting the approach of the Texas Medication Algorithm Project or otherwise working on their production.
Medical algorithm A grammar - the Arden syntax - exists for describing algorithms in terms of medical logic modules. An approach such as this should allow exchange of MLMs between doctors and establishments, and enrichment of the common stock of tools.
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Purpose
The intended purpose of medical algorithms is to improve and standardize decisions made in the delivery of medical care. Medical algorithms assist in standardizing selection and application of treatment regimens, with algorithm automation intended to reduce potential introduction of errors. Some attempt to predict the outcome, for example critical care scoring systems. Computerized algorithms can provide timely clinical decision support, improve adherence to evidence-based guidelines, and be a resource for education and research. Medical algorithms based on best practice can assist everyone involved in delivery of standardized treatment via a wide range of clinical care providers. Many are presented as protocols and it is a key task in training to ensure people step outside the protocol when necessary. In our present state of knowledge, generating hints and producing guidelines may be less satisfying to the authors, but more appropriate.
Cautions
In common with most science and medicine, algorithms whose contents are not wholly available for scrutiny and open to improvement should be regarded with suspicion. Computations obtained from medical algorithms should be compared with, and tempered by, clinical knowledge and physician judgment.
External links
AlternativeMentalHealth.com [1] - 'Alternative Health Medical Evaluation Field Manual', Lorrin M. Koran, MD, Stanford University Medical Center (1991) MedAl.org [2] - 'The Medical Algorithms Project' NIH.gov [3] - 'Automated Medical Algorithms: Issues for Medical Errors', Kathy A. Johnson, PhD, John R. Svirbely, MD, M. G. Sriram, PHD, Jack W. Smith, MD, PHD, Gareth Kantor, MD, and Jorge Raul Rodriguez, MD, Journal of the American Medical Informatics Association Regenstrief Institute [4] MedFormula - a palm pilot based medical algorithm/calculator [5]
References
[1] [2] [3] [4] [5] http:/ / www. alternativementalhealth. com/ articles/ fieldmanual. htm http:/ / medal. org http:/ / www. pubmedcentral. nih. gov/ articlerender. fcgi?artid=419420 http:/ / www. regenstrief. org/ http:/ / www. internal-med. org/ palm. htm
Medical logic module
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Medical logic module

A medical logic module (MLM) is an independent unit in a healthcare knowledge base that represents the knowledge published on a requirement for treating a patient according to a single medical decision. Possible usage is with an event monitor program in an intensive care ward or with hospital information system on occurrence of defined conditions. See Arden syntax reference for examples. Early introduction is given with monographs[1] .
Implementation
The Arden syntax has been defined as a grammar which could make MLMs swappable between various platforms. There is no reference stated for general implementation as a transfer method between different information systems.
References
[1] Hripcsak G., Writing Arden Syntax Medical Logic Modules, Comput Biol Med. 1994 Sep;24(5):331-63
Arden syntax
The Arden syntax is an artificial intelligence (AI) frame-based grammar for representing and processing medical conditions and recommendations as "Medical Logic Modules (MLMs)", used in Medical algorithms. Medical logic modules are written in Arden syntax, and are called by a program - an event monitor - when the condition they are written to help with occurs. Arden syntax was formerly a standard under ASTM, and is now part of HL7. The Regenstrief Institute, Inc. [4] uses Arden Syntax MLMs in its CARE system to deliver reminders or hints to clinicians regarding patient treatment recommendations (e.g. the next clinic appointment, based on rules applied to the digitized notes and pertinent patient data stored in the system. Regenstrief Institute is an international non-profit medical research organization with one of the world's largest brain trusts of physician Medical Informaticians [1] as well as Health Services Researchers. Additionally, LDS hospital in Salt Lake City (HELP System...) has contributed much to this standard as well as body of knowledge. Arden Syntax and its first applications were conceived and developed as the primary deliverables of a multimillion-dollar joint research and development (R&D) program between Columbia Presbyterian Medical Center (CPMC) in New York City and IBM Health Industry Marketing in Atlanta, Georgia from 1989-1993. IBM provided program funding, S/370 mainframe hardware, software, peripheral equipment, and other materials for the work, and program management oversight of the collaborative effort. IBM's artificial intelligence product, KnowledgeTool, provided the original basis for MLM syntax representation and processing, as enhanced and applied by CPMC researchers Drs. James J. Cimino, George Hripcsak, Steve Johnson, Carol Friedman, and others at CPMC, under the leadership of Dr. Paul D. Clayton. In a related effort under the same program, another prototype implementation of the syntax was developed by Peter Ludemann using Quintus Prolog. IBM program management and AI technology services were provided by Terry Rankin, Pete Smith, and Eddie Sanders. The name, "Arden Syntax", was adopted from Arden House, located about 90 minutes north of Manhattan in Orange County, New York. Originally purchased by Edward Henry (E. H.) Harriman in 1885, the estate was given to Columbia University by his son William Averell Harriman in 1950 following its use by the Navy in World War II. The house and grounds became a National Historic Landmark in 1966, and it is now a conference center. During the
Arden syntax five-year IBM/CPMC R&D program, conferences and working sessions were hosted and led by CPMC at Arden House and attended by medical informaticians from several leading universities and hospitals, IBM personnel, and others directly or indirectly involved in the program. The "Arden Syntax" name was chosen in recognition of important milestones achieved at Arden House in the development and refinement of the syntax and its implementation.
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External links
Introduction to the HL7 Standards [2] Open Source Arden Syntax compiler implementation [3] Can someone post a link to an example of this?
References
[1] http:/ / www. regenstrief. org/ medinfo/ [2] http:/ / www. HL7. com. au/ FAQ. htm [3] http:/ / github. com/ dgrunwald/ arden2bytecode
Concept Processing
Concept Processing is a technology that uses an artificial intelligence engine to provide flexible user interfaces. This technology is used in some Electronic Medical Record (EMR) software applications, as an alternative to the more rigid template-based technology.
Some methods of data entry in electronic medical records

The most widespread methods of data entry into an EMR are templates, voice recognition, transcription, and concept processing.
Templates
The physician selects either a general, symptom-based or diagnosis-based template pre-fabricated for the type of case at that moment, making it specific through use of forms, pick-lists, check-boxes and free-text boxes. This method became predominant especially in Emergency Room Medicine during the late 1990's.
Voice recognition
The physician dictates into a computer voice recognition device that enters the data directly into a free-text area of the EMR.
Concept Processing
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Transcription
The physician dictates the case into a recording device, which is then sent to a transcriptionist for entry into the EMR, usually into free text areas.
Concept Processing
Based on artificial intelligence technology and Boolean logic, Concept Processing attempts to mirror the mind of each physician by recalling elements from past cases that are the same or similar to the case being seen at that moment.
The theory behind Concept Processing

For years the US healthcare industry has been heralding the widespread adoption of Electronic Medical Records throughout the nation. However, the reality is that up to now most doctors have not been convinced the technology will help their specific clinical needs. One reason behind the slow EMR adoption rate among physicians is the lack of an acceptable user interface. Filling out electronic forms, searching through pick-lists, and forcing patients into preset boilerplates have all put physicians off the switch to electronic charting. Template-based software can slow physicians down, rather than making documentation easier. Most significantly, if the software is made to serve physicians, they should not be forced to conform to the computer; the computer must conform to the physician. Concept Processing is a reaction to this age-old user interface problem.
How Concept Processing works

For every physician the bell-shaped curve effect is found, representing a frequency distribution of case types. Some cases are so rare that physicians will have never handled them before. The majority of other cases become repetitive, and are found on top of this bell shape curve. A Concept Processor brings forward the closest previous encounter in relation to the one being seen at that moment, putting that case in front of the physician for fine-tuning. There are only three possibilities of cases : The closest encounter could be identical to the current encounter (not an impossible event). It could be similar to the current note, or it could be a rare new case.
If the closest encounter is identical to your present one, the physician has effectively completed charting. A Concept Processor will pull through all the related information needed. If the encounter is similar but not identical, the physician modifies the differences from the closest case using hand-writing recognition, voice recognition, or keyboard. A Concept Processor then memorizes all the changes, so that when the next encounter falls between two similar cases, the editing is cut in half, and then by a quarter for the next case, and then by an eighth....and so on. In fact, the more a Concept Processor is used, the faster and smarter it
Concept Processing becomes. Concept Processing also can be used for rare cases. These are usually combinations of SOAP note elements, which in themselves are not rare. If the text of each element is saved for a given type of case, there will be elements available to use with other cases, even though the other cases may not be similar overall. The role of a concept processor is simply to reflect that thinking process accurately in a doctors own words.
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External links
Free EMR Software [1] On EMR Website Waiting Room Solutions EMR [2] technology. Praxis EMR [3] technology. OmniMD EMR [4] technology. EMR Software [5] based on Concept Processing [6] technology. Article on Concept Processing [7]. Concept Processing page [8] on OpenClinical website. AvivaEMR Template-based EMR [9] on AvivaEMR website
References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. medicalsoftware. com http:/ / www. waitingroomsolutions. com http:/ / www. praxisemr. com http:/ / www. omnimd. com http:/ / www. infor-med. com http:/ / www. infor-med. com/ concept-processing. htm http:/ / www. orthopedictechreview. com/ issues/ julaug05/ pg20. htm http:/ / www. openclinical. org/ sp_praxisEMR. html http:/ / www. avivaemr. com/ index. html
Guideline execution engine
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Guideline execution engine

A Guideline Execution Engine is a computer program which can interpret a clinical guideline represented in a computerized format and perform actions towards the user of an electronic medical record. A Guideline Execution Engine needs to communicate with a host Clinical information system. vMR is one possible interface which can be used. The engine's main function is to manage instances of executed guidelines of individual patients. Delivering the inferred engine recommendations or impacts to the host Clinical information system has to carefully respect current workflow of the clinicians (physicians, nurses, clerks, etc.)
Architecture of Guideline Execution Engine

The following modules are generally needed for any engine interface to Clinical Information System new guidelines loading module guideline interpreter module clinical events parser alert/recommendations dispatch
Guideline Interchange Format

The Guideline Interchange Format (GLIF) is computer representation format for clinical guidelines.[1] Represented guidelines can be executed using a guideline execution engine. The format has several versions as it has been improved. In 2003 GLIF3 was introduced.
References
[1] "Guideline Representation Page: GLIF 2.0, 3.4, 3.5 Specifications" (http:/ / mis. hevra. haifa. ac. il/ ~morpeleg/ Intermed/ ). Stanford University, School of Medicine, InterMed Collaboratory. .
External links
Wang D, Peleg M, Tu SW, et al. (October 2004). "Design and implementation of the GLIF3 guideline execution engine" (http://linkinghub.elsevier.com/retrieve/pii/S1532046404000668). J Biomed Inform 37 (5): 30518. doi:10.1016/j.jbi.2004.06.002. PMID15488745. (PDF) (http://bmir.stanford.edu/file_asset/index.php/940/ BMIR-2004-1008.pdf) Ram P, Berg D, Tu S, et al. (2004). "Executing clinical practice guidelines using the SAGE execution engine". Stud Health Technol Inform 107 (Pt 1): 2515. PMID15360813. Tu SW, Campbell J, Musen MA (2003). "The structure of guideline recommendations: a synthesis". AMIA Annu Symp Proc: 67983. PMC1480008. PMID14728259. (PDF) (http://bmir.stanford.edu/file_asset/index.php/ 1511/BMIR-2003-0966.pdf) Tu SW, Musen MA (1999). "A flexible approach to guideline modeling". Proc AMIA Symp: 4204. PMC2232509. PMID10566393. (PDF) (http://bmir.stanford.edu/file_asset/index.php/211/ BMIR-1999-0789.pdf)
CADUCEUS
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CADUCEUS
CADUCEUS was a medical expert system finished in the mid-1980s (first begun in the 1970s- it took a long time to build the knowledge base) by Harry Pople (of the University of Pittsburgh), building on Pople's years of interviews with Dr. Jack Meyers, one of the top internal medicine diagnosticians and a professor at the University of Pittsburgh. Their motivation was an intent to improve on MYCIN - which focused on blood-borne infectious bacteria - to focus on more comprehensive issues than a narrow field like blood poisoning (though it would do it in a similar manner); instead embracing all internal medicine. CADUCEUS eventually could diagnose up to 1000 different diseases. While CADUCEUS worked using an inference engine similar to MYCIN's, it made a number of changes (like incorporating abductive reasoning) to deal with the additional complexity of internal disease- there can be a number of simultaneous diseases, and data is generally flawed and scarce. CADUCEUS has been described as the "most knowledge-intensive expert system in existence".[1]
References
[1] The Fifth Generation. Edward A. Feigenbaum and Pamela McCorduck. Addison-Wesley, Reading, Ma 01867, 275 Pp. Feb 1, 1984
Banks, G (1986). "Artificial intelligence in medical diagnosis: the INTERNIST/CADUCEUS approach". Critical reviews in medical informatics 1 (1): 2354. PMID3331578. Wolfram, D (1995). "An appraisal of INTERNIST-I". Artificial Intelligence in Medicine 7: 93. doi:10.1016/0933-3657(94)00028-Q. First, MB; Soffer, LJ; Miller, RA (1985). "QUICK (QUick Index to Caduceus Knowledge): using the INTERNIST-1/CADUCEUS knowledge base as an electronic textbook of medicine". Computers and biomedical research, an international journal 18 (2): 13765. PMID3886276. "Expert systems: perils and promise" (http://portal.acm.org/citation.cfm?id=6597), D. G. Bobrow, S. Mittal, M. J. Stefik. Communications of the ACM, pp 880 - 894, issue 9, volume 29, (September 1986) The AI Business: The commercial uses of artificial intelligence, ed. Patrick Winston and Karen A. Prendergast. 1984. ISBN 0-262-23117-4
DXplain
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DXplain
DXplain is a Clinical decision support system (CDSS) available through the World Wide Web that assists clinicians by generating stratified diagnoses based on user input of patient signs and symptoms, laboratory results, and other clinical findings [1] . Evidential support for each differential diagnosis is presented, along with recommended follow-up that may be conducted by the clinician to arrive at a more definitive diagnosis. The system also serves as a clinician reference with a searchable database of diseases and clinical manifestations.
History
Designed by the Laboratory of Computer Science at the Massachusetts General Hospital, work on DXplain began in 1984 with a first version being released in 1986 [2] . DXplain contains a database with crude probabilities for over 4,900 clinical manifestations that are associated with over 2,200 unique diseases, yielding a total of over 230,000 unique finding-disease interconnections [2] .
Educational tool
Use of DXplain as a tool for medical consultation has been common to some institutions since it fills a gap, particularly for medical students in clinical rotations, that is not adequately covered by textbook literature [3] . The system's large knowledge base combined with its ability to formulate diagnostic hypotheses have made it a popular education tool for US-based medical schools; by 2005, DXplain was supporting more than 33,189 total users [4] .
Methodology
DXplain generates ranked differential diagnoses using a pseudo-probabilistic algorithm[5] . Each clinical finding entered into DXplain is assessed by determining the importance of the finding and how strongly the finding supports a given diagnosis for each disease in the knowledge base. Using this criterion, DXplain generates ranked differential diagnoses with the most likely diseases yielding the lowest rank. Using stored information regarding each diseases prevalence and significance, the system differentiates between common and rare diseases.
Accuracy
Analysis of accuracy has shown promise in DXplain and similar clinical decision support systems. In a preliminary trial investigation of 46 benchmark cases with a variety of diseases and clinical manifestations, the ranked differential diagnoses generated by DXplain were shown to be in alignment with a panel of five board-certified physicians [6] . In another study investigating how well decision support systems work at responding to a bioterrorism event, an evaluation of 103 consecutive internal medicine cases showed that Dxplain correctly identified the diagnosis in 73% of cases, with the correct diagnosis averaging a rank of 10.7 [7] .
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Clinical usage
Despite its usage in clinician training, similar to other clinical decision support systems, DXplain has not expanded beyond the research laboratory or medical training setting, due in part to a lack of support by clinicians in real-world settings [8] .
References
[1] Barnett GO, Cimino JJ, Hupp JA, Hoffer EP. DXplain. An evolving diagnostic decision-support system. JAMA. 1987 Jul 3;258(1):67-74. [2] MGH Laboratory of Computer Science projects dxplain, Laboratory of Computer Science, Massachusetts General Hospital. 2007. (http:/ / lcs. mgh. harvard. edu/ projects/ dxplain. html) [3] London S. DXplain: a Web-based diagnostic decision support system for medical students. Med Ref Serv Q. 1998 Summer;17(2):17-28. [4] Computer Science and Artificial Intelligence Laboratory (CSAIL), MIT. 2005. (http:/ / groups. csail. mit. edu/ medg/ courses/ 6872/ 2004/ DXp HST Lec 05. pdf) [5] Detmer WM, Shortliffe EH. Using the Internet to Improve Knowledge Diffusion in Medicine. Communications of the Association of Computing Machinery. 1997; 40(8):101-108. 1997. [6] Feldman MJ, Barnett GO. An approach to evaluating the accuracy of DXplain. Comput Methods Programs Biomed. 1991 Aug;35(4):261-6. [7] Bravata DM, Sundaram V, McDonald KM, Smith WM, Szeto H, Schleinitz MD, et al. Detection and diagnostic decision support systems for bioterrorism response. Emerg Infect Dis. 2004 Jan. (http:/ / www. cdc. gov/ ncidod/ EID/ vol10no1/ 03-0243. htm) [8] Coiera E. Guide to Health Informatics: 2nd Edition. Arnold, 2003; 332-343.
External links
DXplain at the MGH Lab of Computer Science (http://www.lcs.mgh.harvard.edu/projects/dxplain.html)
Internist-I
INTERNIST-I was a broad-based computer-assisted diagnostic tool developed in the early 1970s at the University of Pittsburgh as an educational experiment. The system was designed to capture the expertise of just one man, Jack D. Myers, MD, chairman of internal medicine in the University of Pittsburgh School of Medicine. The Division of Research Resources and the National Library of Medicine funded INTERNIST-I. Other major collaborators on the project included Randolph A. Miller and Harry E. Pople.
Development
INTERNIST-I is the successor of the DIALOG system. For ten years, INTERNIST-I was the centerpiece of a Pittsburgh course entitled The Logic of Problem-Solving in Clinical Diagnosis. In consultation with faculty experts, much responsibility for data entry and updating of the system fell to the fourth-year medical students enrolled in the course. These students encoded the findings of standard clinicopathological reports. By 1982, the INTERNIST-I project represented fifteen person-years of work, and by some reports covered 70-80% of all the possible diagnoses in internal medicine. Data input into the system by operators included signs and symptoms, laboratory results, and other items of patient history. The principal investigators on INTERNIST-I did not follow other medical expert systems designers in adopting Bayesian statistical models or pattern recognition. This was because, as Myers explained, The method used by physicians to arrive at diagnoses requires complex information processing which bears little resemblance to the statistical manipulations of most computer-based systems. INTERNIST-I instead used a powerful ranking algorithm to reach diagnoses in the domain of internal medicine. The heuristic rules that drove INTERNIST-I relied on a partitioning algorithm to create problems areas, and exclusion functions to eliminate diagnostic possibilities. These rules, in turn, produce a list of ranked diagnoses based on disease profiles existing in the systems memory. When the system was unable to make a determination of diagnosis it asked questions or offered recommendations
Internist-I for further tests or observations to clear up the mystery. INTERNIST-I worked best when only a single disease was expressed in the patient, but handled complex cases where more than one disease was present poorly. This was because the system exclusively relied on hierarchical or taxonomic decision-tree logic, which linked each disease profile to only one parent disease class.
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Use of INTERNIST-I
By the late 1970s, INTERNIST-I was in experimental use as a consultant program and educational quizmaster at Presbyterian-University Hospital in Pittsburgh. INTERNIST-Is designers hoped that the system could one day become useful in remote environmentsrural areas, outer space, and foreign military bases, for instancewhere experts were in short supply or unavailable. Still, physicians and paramedics wanting to use INTERNIST-I found the training period lengthy and the interface unwieldy. An average consultation with INTERNIST-I required about thirty to ninety minutes, too long for most clinics. To meet this challenge, researchers at nearby Carnegie-Mellon University wrote a program called ZOG that allowed those unfamiliar with the system to master it more rapidly. INTERNIST-I never moved beyond its original status as a research tool. In one instance, for example, a failed attempt to extract synthetic case studies of artificial patients from the systems knowledge base in the mid-1970s overtly demonstrated its shallowness in practice.
INTERNIST-I/QMR
In the first version of INTERNIST-I (completed in 1974) the computer program treated the physician as unable to solve a diagnostic problem, or as a passive observer who merely performed data entry. Miller and his collaborators came to see this function as a liability in the 1980s, referring to INTERNIST-I derisively as an example of the outmoded Greek Oracle model for medical expert systems. In the mid-1980s INTERNIST-I was succeeded by a powerful microcomputer-based consultant developed at the University of Pittsburgh called Quick Medical Reference (QMR). QMR, meant to rectify the technical and philosophical deficiencies of INTERNIST-I, still remained dependent on many of the same algorithms developed for INTERNIST-I, and the systems are often referred to together as INTERNIST-I/QMR. The main competitors to INTERNIST-I included CASNET, MYCIN, and PIP.
References
Gregory Freiherr, The Seeds of Artificial Intelligence: SUMEX-AIM (NIH Publication 80-2071, Washington, D.C.: National Institutes of Health, Division of Research Resources, 1979). Randolph A. Miller, et al., INTERNIST-1: An Experimental Computer-Based Diagnostic Consultant for General Internal Medicine, New England Journal of Medicine 307 (August 19, 1982): 468-76. Jack D. Myers, The Background of INTERNIST-I and QMR, in A History of Medical Informatics, eds. Bruce I. Blum and Karen Duncan (New York: ACM Press, 1990), 427-33. Jack D. Myers, et al., INTERNIST: Can Artificial Intelligence Help? in Clinical Decisions and Laboratory Use, eds. Donald P. Connelly, et al., (Minneapolis: University of Minnesota Press, 1982), 251-69. Harry E. Pople, Jr., Presentation of the INTERNIST System, in Proceedings of the AIM Workshop (New Brunswick, N.J.: Rutgers University, 1976).
Mycin
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Mycin
MYCIN was an early expert system developed over five or six years in the early 1970s at Stanford University. It was written in Lisp as the doctoral dissertation of Edward Shortliffe under the direction of Bruce Buchanan, Stanley N. Cohen and others. It arose in the laboratory that had created the earlier Dendral expert system, but emphasized the use of judgmental rules that had elements of uncertainty (known as certainty factors) associated with them. This expert system was designed to identify bacteria causing severe infections, such as bacteremia and meningitis, and to recommend antibiotics, with the dosage adjusted for patient's body weight the name derived from the antibiotics themselves, as many antibiotics have the suffix "-mycin". The Mycin system was also used for the diagnosis of blood clotting diseases...
Method
MYCIN operated using a fairly simple inference engine, and a knowledge base of ~600 rules. It would query the physician running the program via a long series of simple yes/no or textual questions. At the end, it provided a list of possible culprit bacteria ranked from high to low based on the probability of each diagnosis, its confidence in each diagnosis' probability, the reasoning behind each diagnosis (that is, MYCIN would also list the questions and rules which led it to rank a diagnosis a particular way), and its recommended course of drug treatment. Despite MYCIN's success, it sparked debate about the use of its ad hoc, but principled, uncertainty framework known as "certainty factors". The developers performed studies showing that MYCIN's performance was minimally affected by perturbations in the uncertainty metrics associated with individual rules, suggesting that the power in the system was related more to its knowledge representation and reasoning scheme than to the details of its numerical uncertainty model. Some observers felt that it should have been possible to use classical Bayesian statistics. MYCIN's developers argued that this would require either unrealistic assumptions of probabilistic independence, or require the experts to provide estimates for an unfeasibly large number of conditional probabilities.[1] [2] Subsequent studies later showed that the certainty factor model could indeed be interpreted in a probabilistic sense, and highlighted problems with the implied assumptions of such a model. However the modular structure of the system would prove very successful, leading to the development of graphical models such as Bayesian networks.[3]
Results
Research conducted at the Stanford Medical School found MYCIN to propose an acceptable therapy in about 69% of cases, which was better than the performance of infectious disease experts who were judged using the same criteria. This study is often cited as showing the potential for disagreement about thereapeutic decisions, even among experts, when there is no "gold standard" for correct treatment.[4]
Practical use
MYCIN was never actually used in practice. This wasn't because of any weakness in its performance. As mentioned, in tests it outperformed members of the Stanford medical school faculty. Some observers raised ethical and legal issues related to the use of computers in medicine if a program gives the wrong diagnosis or recommends the wrong therapy, who should be held responsible? However, the greatest problem, and the reason that MYCIN was not used in routine practice, was the state of technologies for system integration, especially at the time it was developed. MYCIN was a stand-alone system that required a user to enter all relevant information about a patient by typing in response to questions that MYCIN would pose. The program ran on a large time-shared system, available over the early Internet (ARPANet), before personal computers were developed. In the modern era, such a system would be integrated with medical record systems, would extract answers to questions from patient databases, and would be much less dependent on physician entry of information. In the 1970s, a session with MYCIN could easily consume
Mycin 30 minutes or morean unrealistic time commitment for a busy clinician. MYCIN's greatest influence was accordingly its demonstration of the power of its representation and reasoning approach. Rule-based systems in many non-medical domains were developed in the years that followed MYCIN's introduction of the approach. In the 1980s, expert system "shells" were introduced (including one based on MYCIN, known as E-MYCIN (followed by KEE)) and supported the development of expert systems in a wide variety of application areas. A difficulty that rose to prominence during the development of MYCIN and subsequent complex expert systems has been the extraction of the necessary knowledge for the inference engine to use from the human expert in the relevant fields into the rule base (the so-called knowledge engineering).
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References
[1] Shortliffe, E.H.; Buchanan, B.G. (1975). "A model of inexact reasoning in medicine". Mathematical Biosciences 23 (3-4): 351379. doi:10.1016/0025-5564(75)90047-4. MR381762. [2] Buchanan, B.G.; Shortliffe, E.H. (1984). Rule Based Expert Systems: The MYCIN Experiments of the Stanford Heuristic Programming Project (http:/ / www. aaai. org/ AITopics/ pmwiki/ pmwiki. php/ AITopics/ RuleBasedExpertSystems). Reading, MA: Addison-Wesley. ISBN9780201101720. . [3] Heckerman, D.; Shortliffe, E. (1992). "From certainty factors to belief networks" (http:/ / research. microsoft. com/ en-us/ um/ people/ heckerman/ HS91aim. pdf). Artificial Intelligence in Medicine 4 (1): 3552. doi:10.1016/0933-3657(92)90036-O. . [4] Yu, V.L., et al. (1979). "Antimicrobial selection by a computer: a blinded evaluation by infectious disease experts" (http:/ / bmir. stanford. edu/ file_asset/ index. php/ 885/ BMIR-1979-0032. pdf). Journal of the American Medical Association 242 (12): 12791282. PMID480542. .
The AI Business: The commercial uses of artificial intelligence, ed. Patrick Winston and Karen A. Prendergast. ISBN 0-262-23117-4
External links
Rule-Based Expert Systems: The MYCIN Experiments of the Stanford Heuristic Programming Project (http:// www.aaai.org/AITopics/pmwiki/pmwiki.php/AITopics/RuleBasedExpertSystems) -(edited by Bruce G. Buchanan and Edward H. Shortliffe; ebook version) TMYCIN (http://www.cs.utexas.edu/users/novak/tmycin.html), system based on MYCIN "Mycin Expert System (http://raa.ruby-lang.org/project/mycin/): A Ruby Implementation" "MYCIN: A Quick Case Study" (http://www.cee.hw.ac.uk/~alison/ai3notes/section2_5_5.html) " SOME EXPERT SYSTEM NEED COMMON SENSE" (http://www-formal.stanford.edu/jmc/someneed/ someneed.html) -(by John McCarthy) "Expert Systems" (http://www.cs.cf.ac.uk/Dave/AI1/mycin.html)
Physicians' Information and Education Resource
183

The Physicians' Information and Education Resource (PIER) is an electronic, evidence-based, decision-support tool designed for point-of-care use by internists and other physicians. PIER is a product of the American College of Physicians and was launched in 2002.[1] Information in PIER is presented in a "drill down" format, in which the user clicks from an opening guidance statement through to specific recommendations for treatment and the evidence used to formulate the recommendations. The South Central Chapter of the Medical Library Association (SCC/MLA) ranked ACP's Physicians' Information and Education Resource (PIER) as the leading evidence-based, point-of-care tool compared to 13 other major evidence-based medical resources.[2] This top grade given by the South Central Chapter is significant, as the national organization represents more than 1,100 institutions in the health sciences information field. Recently, at the Medical Library Association Annual Meeting, a poster was presented by researchers at the University of Toronto Libraries that placed PIER at the top of the distillation pyramid, where evidence-based material is at its most distilled.[3]
Breadth
Over 490 modules are included on topics in five areas: Diseases Screening and Prevention Complementary/Alternative Medicine Ethical and Legal Issues Procedures
Depth
All guidance statements and recommendations are given a strength of recommendation rating to help clinicians assess their usefulness. All references included in PIER are also rated on the level of evidence they represent. All PIER modules are written by experts in the field and are peer reviewed. Modules are updated on a regular basis.[4] The disease-based modules are PIER's core. Each module presents a series of succinct guidance statements and practice recommendations supported by more detailed levels of pertinent rationale and evidence. There are links to abstracts and the full text of carefully selected references; to a comprehensive drug resource; to other ACP knowledge resources, including guidelines, the Medical Knowledge Self-Assessment Program (MKSAP [5]), and Annals of Internal Medicine (including ACP Journal Club [6]); and other resources, including PubMed and various Web sites. Tables, figures, algorithms, and video and audio clips are also included.
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Availability
PIER is freely available to members of the American College of Physicians as a Web-based service. ACP licenses PIER to institutions and other customers directly or through business partners, who provide it in stand-alone form or integrated with other resources. It is available in desktop and handheld formats. PIER has also been integrated into electronic health records systems.
References
[1] PIER - Who We Are (http:/ / pier. acponline. org/ who_we_are. html) [2] Trumble JM, et al. 2006. A Systematic Evaluation of Evidence Based Medicine Tools for Point-of-Care. Presented at South Central Chapter/Medical Library Association, October 2006. original paper (http:/ / ils. mdacc. tmc. edu/ papers. html) summary (http:/ / pier. acponline. org/ ebmstudy. html) [3] R. Vine, R. Shaughnessy, M. Thuna. 2008. EBM Tool-Picking Made Easy. Presented at Medical Library Association Annual Meeting 2008. poster PDF (http:/ / www. mlanet. org/ am/ am2008/ e-present/ 20080518_056_shaughnessy. pdf) [4] PIER Update Process (http:/ / pier. acponline. org/ overview. html) - development and update process [5] http:/ / mksap. acponline. org [6] http:/ / www. acpjc. org
External links
Official website (http://pier.acponline.org)
RetroGuide
RetroGuide
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RetroGuide is a name of a research project in medical informatics (or more precisely clinical informatics) focusing on using workflow technology in healthcare. In 2009, RetroGuide became a component in a larger project/system called HealthFlow This is an ongoing project. Several past phases could be described. Initial phase was at Intermountain Health Care in Utah, USA and happened during 2004-2007. The main mode was retrospective use. The development continues at Marshfield Clinic (Marshfield Clinic Biomedical Informatics Research Center) during 2008-2010. The prospective version of the RetroGuide system has been developed (called FlowGuide) and the overal system which is using a workflow engine within an EHR system is called HealthFlow [1] . RetroGuide uses a flowchart paradigm to represent knowledge. Knowledge represented can be a prospective alert logic or retrospective EHR query question. RetroGuide has been used on several clinical problems investigating blood pressure control in diabetics patients investigating pregnancy rate in female patients after treatment of Hodgkin lymphoma investigating HEDIS quality improvement measures from NCQA osteoporosis measure (OMW) cholesterol control in cardiovascular patients (CMC) investigating alternative glucose protocol logic for blood glucose control in ICU patients course of care for diabetes course of care for AMI course of care for chronic kidney disease detecting adverse drug events (respiratory failure after use of narcotics, Naloxone)
Scenario in RetroGuide
Evaluation
RetroGuide graphical approach to model queries has been formally evaluated in a study involving 18 human subjects with limited database expertise [2] . The study compared RetroGuide technology with SQL. Each subject had to solve 14 analytical tasks using both compared technologies. The qualitative comparison of average test scores showed that the study subjects achieved significantly higher scores using the RG technology. Each subject also filled a follow-up questionnaire which compared both technologies qualitatively. The results of this qualitative study showed that 94% of subjects preferred RG to SQL because RetroGuide was easier to learn, it better supported temporal tasks, and it seemed to be a more logical modeling paradigm. The second part of the follow-up qualitative questionnaire also asked RG-specific questions based on validated constructs from the Unified Theory of Acceptance and Use of Technology. The results of this second part suggested that a fully developed, RetroGuide-like technology would be well accepted by users.
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References
[1] Huser, V.; Rasmussen, L. V.; Oberg, R.; Starren, J. B. (2011). "Implementation of workflow engine technology to deliver basic clinical decision support functionality". BMC Medical Research Methodology 11: 43. doi:10.1186/1471-2288-11-43. PMC3079703. PMID21477364. [2] "PhD dissertation: Chapter 5: RetroGuide evaluation study" (http:/ / content. lib. utah. edu/ u?/ ir-main,13344). .
Scientific Articles
Huser V, Rocha RA, James BC, "Use of Workflow Technology Tools to Analyze Medical Data," pp. 455-460, 19th IEEE Symposium on Computer-Based Medical Systems (CBMS'06), 2006. article (doi) (http://doi. ieeecomputersociety.org/10.1109/CBMS.2006.162) Huser V, "Running Decision Support Logic Retrospectively to Determine Guideline Adherence: a Case Study With Diabetes," Spring AMIA2007 symposium poster (http://workflow.minfor.net/ebox/posters/ RetroGuide-diabetes_and_hypertension.jpg) conference (http://www.amia.org/meetings/s07/track_cds.asp) Huser V, Rocha, RA, "Analyzing medical data from multi-hospital healthcare information system using graphical flowchart models," BMIC Symposium, Orlando, 2007 (accepted). Huser V, Rocha RA, Huser M, "Conducting Time Series Analyses on Large Data Sets: a Case Study With Lymphoma," Medinfo 2007, Brisbane, 2007. Huser V, Rocha RA, "Retrospective Analysis of the Electronic Health Record of Patients Enrolled in a Computerized Glucose Management Protocol," CBMS 2007 DOI link (http://doi.ieeecomputersociety.org/10. 1109/CBMS.2007.93) Huser V, Rocha RA, "Graphical Modeling of HEDIS Quality Measures and Prototyping of Related Decision Support Rules to Accelerate Improvement", AMIA Fall Symposium, 2007, Chicago, USA poster (http:// vojtechhuser.minfor.net/ebox/15-posters/2007_huser-hedis-amia.pdf) Huser V, Rocha RA, "Graphical Modeling of HEDIS Quality Measures and Prototyping of Related Decision Support Rules to Accelerate Improvement", AMIA Fall Symposium, 2007, Chicago, USA poster (http:// vojtechhuser.minfor.net/ebox/15-posters/2007_huser-hedis-amia.pdf) Huser V, Peissig PL, Christensen CA, Starren JB. Evaluation of commercial workflow engine for modeling clinical processes in quality improvement and decision support. Proc of 15th Annual HMO Research Network Conference 2009. Huser V, Rocha RA, Narus SP. Evaluation of a flowchart-based EHR query system: a case study of RetroGuide. J Biomed Inform 2009;ePub ahead of print PubMed (http://www.ncbi.nlm.nih.gov/pubmed/19560553) DOI link (http://dx.doi.org/10.1016/j.jbi.2009.06.001) Huser V, Rasmussen L, Starren JB. Representing clinical processes in XML process definition language (XPDL). AMIA Spring Symp 2009. Huser V, Starren JB. EHR Data Pre-processing Facilitating Process Mining: an Application to Chronic Kidney Disease. AMIA Annu Symp Proc 2009 (accepted) 2009.
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External links
http://workflow.minfor.net http://minfor.wikispaces.com/RetroGuide http://retroguide.blip.tv RetroGuide on SourceForge (RetroGuide Express) (http://retroguideexpr.wiki.sourceforge.net) http://healthcareworkflow.wordpress.com
Symptomat
Symptomat is a medical diagnostics program that finds links between patient's complaints and diagnoses. The Diagnostic Robot is designed to ask several thousands questions. The artificial logic behind the machine compares your answers with known medical knowledge. The robot does a complex analysis of all information gathered about the symptoms. It compares responses to the values described by doctors. Then, it produces a list of all possible conditions matching the symptoms. This program-robot is designed to give the list of the most probable diagnoses. It uses an Artificial Intelligence to give answers based on your questions. Patient sees the list of possible diagnosis and chosen options on the screen. He may print complaints and show to a medical provider. There is two-step evaluation system. Advanced third section has more focused questions. This broad-based computer-assisted diagnostic tool was developed in the 2006 at the University of Gulam Khan as an educational experiment. The system was designed to capture the expertise of the team of doctors, led by Aleksandr Kavokin, MD, PhD. The Division of Research Resources and the University funded Symptomat. Other major collaborators on the project included Oleg Kavokin, MD, Alexey Kavokin, PhD *[1].
Development of Symptomat
For two years, Symptomat was the centerpiece of the University course entitled The Logic of Problem-Solving in Clinical Diagnosis. Faculty experts encoded the findings of standard clinicoal questionnaires, lisitng possible diagnoses in internal medicine and surgery. Data input into the system by operators included signs and symptoms, laboratory results, and other items of patient history. Symptomat uses a powerful ranking algorithm to reach diagnoses in the domain of medicine. The heuristic rules that drove Symptomat relied on a partitioning algorithm to create problems areas, and exclusion functions to eliminate diagnostic possibilities. These rules, in turn, produce a list of ranked diagnoses based on disease profiles existing in the systems memory.
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Use of Symptomat
By the 2006, Symptomat was in experimental use as a consultant program and educational tool and went on-line. Symptomat designers hope that the system could one day become useful in remote environmentsrural areas, where experts are in short supply or unavailable.
Competitors
The main competitors to Symptomat include CASNET, MYCIN, and PIP.
References
Transcript of an Symptomat Consultation [2]
References
[1] http:/ / www. giki. edu. pk/ [2] http:/ / symptomat. com
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STD Wizard
Sexually transmitted disease
Classification and external resources
U.S. propaganda poster targeted at World War II soldiers and sailors appealed to their patriotism in urging them to protect themselves. The text at the bottom of the poster reads, "You can't beat the Axis if you get VD." Images of women were used to catch the eye on many VD posters. ICD-10 ICD-9 DiseasesDB MeSH A64. [1] [2] [3] [4]
099.9 27130
D012749
A sexually transmitted disease (STD), also known as a sexually transmitted infection (STI), or venereal disease (VD), is an illness that has a significant probability of transmission between humans by means of human sexual behavior, including vaginal intercourse, oral sex, and anal sex. While in the past, these illnesses have mostly been referred to as STDs or VD, in recent years the term sexually transmitted infections (STIs) has been preferred, as it has a broader range of meaning; a person may be infected, and may potentially infect others, without having a disease. Some STIs can also be transmitted via the use of IV drug needles after its use by an infected person, as well as through childbirth or breastfeeding. Sexually transmitted infections have been well known for hundreds of years.
Classification and terminology

Until the 1990s, STDs were commonly known as venereal diseases :Veneris is the Latin genitive form of the name Venus, the Roman goddess of love. Social disease was another euphemism. Sexually transmitted infection is a broader term than sexually transmitted disease.[5] An infection is a colonization by a parasitic species, which may not cause any adverse effects. In a disease the infection leads to impaired or abnormal function. In either case the condition may not exhibit signs or symptoms. Increased understanding of infections like HPV, which infects most sexually active individuals but cause disease in only a few has lead to increased use of the term STI. Public health officials originally introduced the term sexually transmitted infection, which clinicians are increasingly using alongside the term sexually transmitted disease in order to distinguish it from the former.
STD Wizard STD may refer only to infections that are causing diseases, or it may be used more loosely as a synonym for STI. Because most of the time people do not know that they are infected with an STD until they are tested or start showing symptoms of disease, most people use the term STD, even though the term STI is also appropriate in many cases. Moreover, the term sexually transmissible disease is sometimes used since it is less restrictive in consideration of other factors or means of transmission. For instance, meningitis is transmissible by means of sexual contact but is not labeled as an STI because sexual contact is not the primary vector for the pathogens that cause meningitis. This discrepancy is addressed by the probability of infection by means other than sexual contact. In general, an STI is an infection that has a negligible probability of transmission by means other than sexual contact, but has a realistic means of transmission by sexual contact (more sophisticated meansblood transfusion, sharing of hypodermic needlesare not taken into account). Thus, one may presume that, if a person is infected with an STI, e.g., chlamydia, gonorrhea, genital herpes, it was transmitted to him/her by means of sexual contact. The diseases on this list are most commonly transmitted solely by sexual activity. Many infectious diseases, including the common cold, influenza, pneumonia, and most others that are transmitted person-to-person can also be transmitted during sexual contact, if one person is infected, due to the close contact involved. However, even though these diseases may be transmitted during sex, they are not considered STDs.
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Cause
Bacterial
Chancroid (Haemophilus ducreyi) Chlamydia (Chlamydia trachomatis) Granuloma inguinale or (Klebsiella granulomatis) Gonorrhea (Neisseria gonorrhoeae) Syphilis (Treponema pallidum)
Fungal
Candidiasis (yeast infection)
Viral
Viral hepatitis (Hepatitis B virus)saliva, venereal fluids. (Note: Hepatitis A and Hepatitis E are transmitted via the fecal-oral route; Hepatitis C is rarely sexually transmittable,[6] and the route of transmission of Hepatitis D (only if infected with B) is uncertain, but may include sexual transmission.[7] [8] [9] ) Herpes simplex (Herpes simplex virus 1, 2) skin and mucosal, transmissible with or without visible blisters HIV (Human Immunodeficiency Virus) venereal fluids, semen, breast milk, blood HPV (Human Papillomavirus) skin and mucosal contact. 'High risk' types of HPV cause almost all cervical cancers, as well as some anal, penile, and vulvar cancer. Some other types of HPV cause genital warts.
Micrograph showing the viral cytopathic effect of herpes (ground glass nuclear inclusions, multi-nucleation). Pap test. Pap stain.
Molluscum contagiosum (molluscum contagiosum virus MCV)close contact
Parasites
STD Wizard Crab louse, colloquially known as "crabs" or "pubic lice" (Pthirus pubis) Scabies (Sarcoptes scabiei)
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Protozoal
Trichomoniasis (Trichomonas vaginalis)
Transmission probability
The risks and transmission probabilities of sexually transmitted diseases are summarized by act in the table below.[10] [11] [12] [13] [14] [15] [16]
Odds of transmission per unprotected sexual act with an infected person

Known risks Performing oral sex on a man Chlamydia Gonorrhea Herpes (rare) HPV [13] Syphilis (1%) With ass to mouth practices: Performing oral sex on a woman Receiving oral sex - man Hepatitis A Shigella Herpes (rare) Chlamydia Gonorrhea Non-gonococcal urethritis Herpes [13] Syphilis (1%) Herpes [15] Chlamydia (30-50%) Crabs Scabies [16] Gonorrhea (20%) Hepatitis B Herpes [11] HIV (0.05%) [14] HPV (at least 5%) Non-gonococcal urethritis Syphilis Trichomoniasis HPV HPV Possible or unknown risks [15] Hepatitis B (low risk) [11] HIV (very low risk; 0.01%) Hepatitis C (unknown)
Receiving oral sex - woman Vaginal sex - man
HPV Hepatitis C
Vaginal sex - woman
[15] Chlamydia (3050%) Crabs Scabies [16] Gonorrhea (50 to 90%) Hepatitis B Herpes [11] HIV (0.1%) [15] [14] HPV (high; at least 5%) Syphilis Trichomoniasis
Hepatitis C
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Anal sex - insertive Hepatitis C
Chlamydia Crabs Scabies Gonorrhea Hepatitis B Herpes [12] HIV (0.62%) HPV Non-gonococcal urethritis [13] Syphilis (1.4%) Chlamydia Crabs Scabies Gonorrhea Hepatitis B Herpes [12] HIV (1.7%) HPV [13] Syphilis (1.4%) Amebiasis Cryptosporidiosis Giardiasis Hepatitis A Shigellosis
Anal sex - receptive
Hepatitis C
Oral-anal sex
HPV
Pathophysiology
Many STDs are (more easily) transmitted through the mucous membranes of the penis, vulva, rectum, urinary tract and (less oftendepending on type of infection) the mouth, throat, respiratory tract and eyes. The visible membrane covering the head of the penis is a mucous membrane, though it produces no mucus (similar to the lips of the mouth). Mucous membranes differ from skin in that they allow certain pathogens into the body.[17] Pathogens are also able to pass through breaks or abrasions of the skin, even minute ones. The shaft of the penis is particularly susceptible due to the friction caused during penetrative sex. The primary sources of infection in ascending order are venereal fluids, saliva, mucosal or skin (particularly the penis), infections may also be transmitted from feces, urine and sweat.[18] The amount of contact with infective sources which causes infection varies with each pathogen but in all cases a disease may result from even light contact from fluid carriers like veneral fluids onto a mucous membrane. This is one reason that the probability of transmitting many infections is far higher from sex than by more casual means of transmission, such as non-sexual contacttouching, hugging, shaking handsbut it is not the only reason. Although mucous membranes exist in the mouth as in the genitals, many STIs seem to be easier to transmit through oral sex than through deep kissing. According to a safe sex chart, many infections that are easily transmitted from the mouth to the genitals or from the genitals to the mouth, are much harder to transmit from one mouth to another.[19] With HIV, genital fluids happen to contain much more of the pathogen than saliva. Some infections labeled as STIs can be transmitted by direct skin contact. Herpes simplex and HPV are both examples. KSHV, on the other hand, may be transmitted by deep-kissing but also when saliva is used as a sexual lubricant. Depending on the STD, a person may still be able to spread the infection if no signs of disease are present. For example, a person is much more likely to spread herpes infection when blisters are present (STD) than when they are absent (STI). However, a person can spread HIV infection (STI) at any time, even if he/she has not developed symptoms of AIDS (STD).
STD Wizard All sexual behaviors that involve contact with the bodily fluids of another person should be considered to contain some risk of transmission of sexually transmitted diseases. Most attention has focused on controlling HIV, which causes AIDS, but each STD presents a different situation. As may be noted from the name, sexually transmitted diseases are transmitted from one person to another by certain sexual activities rather than being actually caused by those sexual activities. Bacteria, fungi, protozoa or viruses are still the causative agents. It is not possible to catch any sexually transmitted disease from a sexual activity with a person who is not carrying a disease; conversely, a person who has an STD got it from contact (sexual or otherwise) with someone who had it, or his/her bodily fluids. Some STDs such as HIV can be transmitted from mother to child either during pregnancy or breastfeeding. Although the likelihood of transmitting various diseases by various sexual activities varies a great deal, in general, all sexual activities between two (or more) people should be considered as being a two-way route for the transmission of STDs, i.e., "giving" or "receiving" are both risky although receiving carries a higher risk. Healthcare professionals suggest safer sex, such as the use of condoms, as the most reliable way of decreasing the risk of contracting sexually transmitted diseases during sexual activity, but safer sex should by no means be considered an absolute safeguard. The transfer of and exposure to bodily fluids, such as blood transfusions and other blood products, sharing injection needles, needle-stick injuries (when medical staff are inadvertently jabbed or pricked with needles during medical procedures), sharing tattoo needles, and childbirth are other avenues of transmission. These different means put certain groups, such as medical workers, and haemophiliacs and drug users, particularly at risk. Recent epidemiological studies have investigated the networks that are defined by sexual relationships between individuals, and discovered that the properties of sexual networks are crucial to the spread of sexually transmitted diseases. In particular, assortative mixing between people with large numbers of sexual partners seems to be an important factor. It is possible to be an asymptomatic carrier of sexually transmitted diseases. In particular, sexually transmitted diseases in women often cause the serious condition of pelvic inflammatory disease.
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Prevention
Prevention is key in addressing incurable STIs, such as HIV & herpes. Sexual health clinics fight to promote the use of condoms and provide outreach for at-risk communities. The most effective way to prevent sexual transmission of STIs is to avoid contact of body parts or fluids which can lead to transfer with an infected partner. Not all sexual activities involve contact: cybersex, phonesex or masturbation from a distance are methods of avoiding contact. Proper use of condoms reduces contact and risk. Although a condom is effective in limiting exposure, some disease transmission may occur even with a condom.[20] Ideally, both partners should get tested for STIs before initiating sexual contact, or before resuming contact if a partner engaged in contact with someone else. Many infections are not detectable immediately after exposure, so enough time must be allowed between possible exposures and testing for the tests to be accurate. Certain STIs, particularly certain persistent viruses like HPV, may be impossible to detect with current medical procedures.
San Francisco City Clinic a municipal STD testing center in San Francisco.
STD Wizard Many diseases that establish permanent infections can so occupy the immune system that other diseases become more easily transmitted. The innate immune system led by defensins against HIV can prevent transmission of HIV when viral counts are very low, but if busy with other viruses or overwhelmed, HIV can establish itself. Certain viral STI's also greatly increase the risk of death for HIV infected patients.
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Vaccines
Vaccines are available that protect against some viral STIs, such as Hepatitis A, Hepatitis B, and some types of HPV. Vaccination before initiation of sexual contact is advised to assure maximal protection.
Condoms
Condoms and female condoms only provide protection when used properly as a barrier, and only to and from the area that it covers. Uncovered areas are still susceptible to many STDs. In the case of HIV, sexual transmission routes almost always involve the penis, as HIV cannot spread through unbroken skin, thus properly shielding the insertive penis with a properly worn condom from the vagina or anus effectively stops HIV transmission. An infected fluid to broken skin borne direct transmission of HIV would not be considered "sexually transmitted", but can still theoretically occur during sexual contact, this can be avoided simply by not engaging in sexual contact when having open bleeding wounds. Other STDs, even viral infections, can be prevented with the use of latex, polyurethane or polyisoprene condoms as a barrier. Some microorganisms and viruses are small enough to pass through the pores in natural skin condoms, but are still too large to pass through latex or synthetic condoms. Proper usage entails: Not putting the condom on too tight at the end, and leaving 1.5cm (3/4inch) room at the tip for ejaculation. Putting the condom on snug can and often does lead to failure. Wearing a condom too loose can defeat the barrier. Avoiding inverting, spilling a condom once worn, whether it has ejaculate in it or not. Avoiding condoms made of substances other than latex, polyisoprene or polyurethane that do not protect against HIV. Avoiding the use of oil based lubricants (or anything with oil in it) with latex condoms, as oil can eat holes into them. Using flavored condoms for oral sex only, as the sugar in the flavoring can lead to yeast infections if used to penetrate. Not following the first five guidelines above perpetuates the common misconception that condoms are not tested or designed properly. In order to best protect oneself and the partner from STIs, the old condom and its contents should be assumed to be infectious. Therefore the old condom must be properly disposed of. A new condom should be used for each act of intercourse, as multiple usage increases the chance of breakage, defeating the effectiveness as a barrier.
Nonoxynol-9
Researchers had hoped that nonoxynol-9, a vaginal microbicide would help decrease STD rates. Trials, however, have found it ineffective.[21] In fact, the use of nonoxynol-9 can put women at a higher risk of HIV infection.[22]
Diagnosis
STI tests may test for a single infection, or consist of a number of individual tests for any of a wide range of STIs, including tests for syphilis, trichomonas, gonorrhea, chlamydia, herpes, hepatitis and HIV tests. No procedure tests for all infectious agents. STI tests may be used for a number of reasons:
STD Wizard as a diagnostic test to determine the cause of symptoms or illness as a screening test to detect asymptomatic or presymptomatic infections as a check that prospective sexual partners are free of disease before they engage in sex without safer sex precautions (for example, when starting a long term mutually monogamous sexual relationship, in fluid bonding, or for procreation). as a check prior to or during pregnancy, to prevent harm to the baby as a check after birth, to check that the baby has not caught an STI from the mother to prevent the use of infected donated blood or organs as part of the process of contact tracing from a known infected individual as part of mass epidemiological surveillance Not all STIs are symptomatic, and symptoms may not appear immediately after infection. In some instances a disease can be carried with no symptoms, which leaves a greater risk of passing the disease on to others. Depending on the disease, some untreated STIs can lead to infertility, chronic pain or even death.[23] Early identification and treatment results in less chance to spread disease, and for some conditions may improve the outcomes of treatment. There is often a window period after initial infection during which an STI test will be negative. During this period the infection may be transmissible. The duration of this period varies depending on the infection and the test. Diagnosis may also be delayed by reluctance of the infected person to seek a medical professional. One report indicated that afflicted people turn to the Internet rather than to a medical professional for information on STIs to a higher degree than for other sexual problems.[24]
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STD Wizard
The STD Wizard is a publicly available expert system for determining which screening tests, vaccinations, and evaluations are recommended, related to sexually transmitted diseases. The information included within the STD Wizard is based on the Centers for Disease Control and Prevention "Sexually Transmitted Diseases Treatment Guidelines - 2006". The system has English and Spanish language interfaces. The STD Wizard runs in a web browser. The program asks a series of questions, related to demographics, behaviors, and symptoms. There are potentially over 100 questions, but most users get asked about 20. The exact questions asked depend on the user's responses. Typical questions include: Demographics - How old are you, in years? Behaviors - Have you had more than one sex partner within the past six months? Symptoms - Are you having a discharge from your penis or burning during urination? Typical recommendations include: Screening tests - e.g., HIV screening test Vaccinations - e.g., Hepatitis B vaccination Evaluations - e.g., Seek medical attention in the next week for rash
Management
High risk exposure such as that which occurs in rape cases may be treated prophylacticly using antibiotic combinations such as azithromycin, cefixime, and metronidazole. An option for treating partners of patients (index cases) diagnosed with chlamydia or gonorrhea is patient-delivered partner therapy, which is the clinical practice of treating the sex partners of index cases by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.[25]
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Epidemiology
STD incidence rates remain high in most of the world, despite diagnostic and therapeutic advances that can rapidly render patients with many STDs noninfectious Age-standardized, disability-adjusted life years for STDs (excluding HIV) per 100,000 inhabitants in 2004. and cure most. In "WHO Disease and injury country estimates". World Health Organization. 2004. . Retrieved Nov. 11, 2009.no many cultures, data<6060-120120-180180-240240-300300-360360-420420-480480-540540-600600-1000>1000 changing sexual morals and oral contraceptive use have eliminated traditional sexual restraints, especially for women, and both physicians and patients have difficulty dealing openly and candidly with sexual issues. Additionally, development and spread of drug-resistant bacteria (e.g., penicillin-resistant gonococci) makes some STDs harder to cure. The effect of travel is most dramatically illustrated by the rapid spread of the AIDS virus (HIV-1) from Africa to Europe and the Americas in the late 1970s.[27] In 1996, the World Health Organization estimated that more than 1 million people were being infected daily. About 60% of these infections occur in young people <25 years of age, and of these 30% are <20 years. Between the ages of 14 and 19, STDs occur more frequently in girls than boys by a ratio of nearly 2:1; this equalizes by age 20. An estimated 340 million new cases of syphilis, gonorrhea, chlamydia and trichomoniasis occurred throughout the world in 1999.[28] [29] Commonly reported prevalences of STIs among sexually active adolescent girls both with and without lower genital tract symptoms include chlamydia (1025%), gonorrhea (318%), syphilis (03%), Trichomonas vaginalis (816%), and herpes simplex virus (212%). Among adolescent boys with no symptoms of urethritis, isolation rates include chlamydia (911%) and gonorrhea (23%). At least one in four U.S. teenage girls has a sexually transmitted disease,[30] a CDC study found.[31] Among girls who admitted ever having sex, the rate was 40%.[32] AIDS is the single largest cause of mortality in present-day Sub-Saharan Africa.[33] The majority of HIV infections are acquired through unprotected sexual relations between partners, one of whom has HIV. Approximately 1.1 million persons are living with HIV/AIDS in the United States,[34] and AIDS remains the leading cause of death among African American women between ages 25 and 34.[35] Hepatitis B is also classed as a sexually transmitted disease because it can be passed on sexually.[36] The disease is found globally, with the highest rates in Asia and Africa and lower rates in the Americas and Europe.[37] Worldwide, an estimated two billion people have been infected with the hepatitis B virus.[38]
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History
The first well-recorded European outbreak of what is now known as syphilis occurred in 1494 when it broke out among French troops besieging Naples.[39] From this centre, the disease swept across Europe, killing more than five million people.[40] As Jared Diamond describes it, "[W]hen syphilis was first definitely recorded in Europe in 1495, its pustules often covered the body from the head to the knees, caused flesh to fall from people's faces, and led to death within a few months," rendering it far more fatal than it is today. Diamond concludes,"[B]y 1546, the disease had evolved into the disease with the symptoms so well known to us today."[41] Prior to the invention of modern medicines, sexually transmitted diseases were generally incurable, and treatment was limited to treating the symptoms of the disease. The first voluntary hospital for venereal diseases was founded in 1746 at London Lock Hospital.[42] Treatment was not always voluntary: in the second half of the 19th century, the Contagious Diseases Act was used to arrest suspected prostitutes. The first effective treatment for a sexually transmitted disease was 1930s Works Progress Administration poster salvarsan, a treatment for syphilis. With the discovery of antibiotics, a large number of sexually transmitted diseases became easily curable, and this, combined with effective public health campaigns against STDs, led to a public perception during the 1960s and 1970s that they have ceased to be a serious medical threat. During this period, the importance of contact tracing in treating STIs was recognized. By tracing the sexual partners of infected individuals, testing them for infection, treating the infected and tracing their contacts in turn, STI clinics could be very effective at suppressing infections in the general population. In the 1980s, first genital herpes and then AIDS emerged into the public consciousness as sexually transmitted diseases that could not be cured by modern medicine. AIDS in particular has a long asymptomatic periodduring which time HIV (the human immunodeficiency virus, which causes AIDS) can replicate and the disease can be transmitted to othersfollowed by a symptomatic period, which leads rapidly to death unless treated. HIV/AIDS entered the United States in about 1969 likely through a single infected immigrant from Haiti.[43] Recognition that AIDS threatened a global pandemic led to public information campaigns and the development of treatments that allow AIDS to be managed by suppressing the replication of HIV for as long as possible. Contact tracing continues to be an important measure, even when diseases are incurable, as it helps to contain infection.
References
[1] [2] [3] [4] http:/ / apps. who. int/ classifications/ apps/ icd/ icd10online/ ?ga50. htm+ a64 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=099. 9 http:/ / www. diseasesdatabase. com/ ddb27130. htm http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D012749
[5] Are sexually transmitted infections (STIs) different from sexually transmitted diseases (STDs)? (http:/ / www. etharc. org/ faq/ faqstd. htm#P15_1221), Frequently asked questions (FAQ) About Sexually Transmitted Diseases (STDs), Ethiopian AIDS Resource Center "Sometimes the terms STI and STD are used interchangeably. This can be confusing and not always accurate, so it helps first to understand the difference between infection and disease. Infection simply means that a germvirus, bacteria, or parasitethat can cause disease or sickness is present inside a persons body. An infected person does not necessarily have any symptoms or signs that the virus or bacteria is actually hurting his or her body; they do not necessarily feel sick. A disease means that the infection is actually causing the infected person to feel sick, or to notice something is wrong. For this reason, the term STIwhich refers to infection with any germ that can cause an STD, even if the infected person has no symptomsis a much broader term than STD."
STD Wizard
[6] Workowski K, Berman S (2006). "Sexually transmitted diseases treatment guidelines, 2006." (http:/ / www. cdc. gov/ mmwr/ PDF/ rr/ rr5511. pdf). MMWR Recomm Rep 55 (RR-11): 194. PMID16888612. . [7] Wu J, Chen C, Sheen I, Lee S, Tzeng H, Choo K (1995). "Evidence of transmission of hepatitis D virus to spouses from sequence analysis of the viral genome.". Hepatology 22 (6): 165660. PMID7489970. [8] Farci P (2003). "Delta hepatitis: an update.". J Hepatol 39 (Suppl 1): S2129. doi:10.1016/S0168-8278(03)00331-3. PMID14708706. [9] Shukla N, Poles M (2004). "Hepatitis B virus infection: co-infection with hepatitis C virus, hepatitis D virus, and human immunodeficiency virus.". Clin Liver Dis 8 (2): 44560, viii. doi:10.1016/j.cld.2004.02.005. PMID15481349. [10] Department of Public Health, City & County of San Francisco (2011). STD Risks Chart (http:/ / www. sfcityclinic. org/ stdbasics/ stdchart. asp) [11] Varghese B, Maher JE, Peterman TA, Branson BM,Steketee RW (2002). "Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use". Sex. Transm. Dis. 29 (1): 3843. PMID11773877. [12] Jin F et al. (March 2010). "Per-contact probability of HIV transmission in homosexual men in Sydney in the era of HAART". AIDS 24 (6): 907913. doi:10.1097/QAD.0b013e3283372d90. PMC2852627. PMID20139750. [13] Hoare A (2010). models of HIV epidemics in Australia and Southeast Asia (http:/ / www. google. co. uk/ url?sa=t& source=web& cd=4& ved=0CG4QFjAD& url=http:/ / unsworks. unsw. edu. au/ fapi/ datastream/ unsworks:9027/ SOURCE02& rct=j& q="Sensitivity of syphilis test for detecting current infection"& ei=d6M-TqHFA8a3hAfJhOGdAg& usg=AFQjCNEqIN0_S51KuLf0SiaJQoPox40YwA& cad=rjaMathematical) [14] Burchell A et al. (March 2006). "Modeling the Sexual Transmissibility of Human Papillomavirus Infection using Stochastic Computer Simulation and Empirical Data from a Cohort Study of Young Women in Montreal, Canada". American Journal of Epidemology 169 (3): 534-543. doi:10.1093/aje/kwj077. [15] Australasian contact tracing manual. Specific infections where contact tracing is generally recommended (http:/ / ctm. ashm. org. au/ Default. asp?PublicationID=6& ParentSectionID=694& SectionID=670) [16] Bryan C (2011) INFECTIOUS DISEASE CHAPTER EIGHT SEXUALLY TRANSMITTED DISEASES (http:/ / pathmicro. med. sc. edu/ infectious disease/ sexually transmitted diseases. htm) [17] Virus Pathogenesis (http:/ / www. microbiologybytes. com/ virology/ VirPath. html), Microbiology Bytes [18] HIV/AIDS Glossary (http:/ / go. worldbank. org/ QTULIN4ZZ0), World Bank [19] Safe Sex Chart (http:/ / www. tinynibbles. com/ safesexchart. html), violet blue: open source sex [20] Villhauer, Tanya (2005-05-20). "Condoms Preventing HPV?" (http:/ / www. uistudenthealth. com/ question/ default. aspx?q=738). University of Iowa Student Health Service/Health Iowa. . Retrieved 2009-07-26. [21] Wilkinson D, Ramjee G, Tholandi M, Rutherford G (2002). "Nonoxynol-9 for preventing vaginal acquisition of sexually transmitted infections by women from men". Cochrane Database Syst Rev (4): CD003939. doi:10.1002/14651858.CD003939. PMID12519623. [22] Williams, M. Healthy Choices for Fertility Control. CreateSpace, Scotts Valley, CA, 2009. ISBN 1448664721 [23] "Male STI check-up video" (http:/ / sexperienceuk. channel4. com/ education/ about/ male-sti-check-up). Channel 4. 2008. . Retrieved 2009-01-22. [24] 'The Cringe Report' (http:/ / www. medscape. com/ viewarticle/ 743689_3) By Susan Quilliam. Posted: 06/28/2011; J Fam Plann Reprod Health Care. 2011;37(2):110-112. [25] Expedited Partner Therapy in the Management of Sexually Transmitted Diseases (2 February 2006) (http:/ / www. cdc. gov/ std/ treatment/ EPTFinalReport2006. pdf) U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE. Centers for Disease Control and Prevention National Center for HIV, STD, and TB Prevention [26] "WHO Disease and injury country estimates" (http:/ / www. who. int/ healthinfo/ global_burden_disease/ estimates_country/ en/ index. html). World Health Organization. 2004. . Retrieved Nov. 11, 2009. [27] Mary-Ann Shafer, Anna-Barbara Moscicki (2006). Sexually Transmitted Infections (http:/ / www. health. am/ sex/ more/ sexually_transmitted_infections/ ), 2006.. pp. 18. [28] "STD Statistics Worldwide" (http:/ / www. avert. org/ stdstatisticsworldwide. htm). Avert.org. . Retrieved 2011-01-09. [29] U.S. Medicine Information Central (http:/ / www. usmedicine. com/ dailyNews. cfm?dailyID=59) [30] " One In Four Teenage Girls In U.S. Has Sexually Transmitted Disease, CDC Study Shows (http:/ / www. sciencedaily. com/ releases/ 2008/ 03/ 080312084645. htm)". Science Daily. March 12, 2008. [31] " Sex Infections Found in Quarter of Teenage Girls (http:/ / www. nytimes. com/ 2008/ 03/ 12/ science/ 12std. html?_r=1)". The New York Times. March 12, 2008. [32] " CDC study says at least 1 in 4 teen girls has a sexually transmitted disease; HPV most common (http:/ / newsok. com/ article/ 3214748/ 1205233095)". The Oklahoman. March 11, 2008. [33] UNAIDS, WHO (December 2007). "2007 AIDS epidemic update" (http:/ / data. unaids. org/ pub/ EPISlides/ 2007/ 2007_epiupdate_en. pdf) (PDF). . Retrieved 2008-03-12. [34] " Obama Ends U.S. Travel Ban On Visitors, Immigrants With HIV-AIDS (http:/ / blogs. abcnews. com/ politicalpunch/ 2009/ 10/ obama-ends-travel-ban-on-foreigners-with-hivaids. html)". ABC News. October 30, 2009. [35] " Report: Black U.S. AIDS rates rival some African nations (http:/ / www. cnn. com/ 2008/ HEALTH/ conditions/ 07/ 29/ black. aids. report/ index. html)". CNN.com. July 29, 2008. [36] " Hepatitis: Type B (caused by hepatitis B virus) (http:/ / www. health. state. mn. us/ divs/ idepc/ diseases/ hepb/ hepbstd. html)". Minnesota Department of Health.
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STD Wizard
[37] " Hepatitis B (http:/ / www. fda. gov/ ohrms/ dockets/ ac/ 02/ slides/ 3885S2_02_Hoofnagle/ tsld002. htm)". U.S. Food and Drug Administration. [38] "FAQ about Hepatitis B" (http:/ / liver. stanford. edu/ Education/ faq. html). Stanford School of Medicine. 2008-07-10. . Retrieved 2009-09-19. [39] Oriel, J.D. (1994). The Scars of Venus: A History of Venereology. London: Springer-Verlag. ISBN354019844X. [40] CBC News Staff (January 2008). "Study traces origins of syphilis in Europe to New World" (http:/ / www. cbc. ca/ health/ story/ 2008/ 01/ 14/ syphilis-columbus. html). . Retrieved 2008-01-15. [41] Diamond, Jared (1997). Guns, Germs and Steel. New York: W.W. Norton. p.210. ISBN848306667X. [42] Archives in London and the M25 area ( AIM25 (http:/ / www. aim25. ac. uk/ index. stm)) London Lock Hospital records (http:/ / www. aim25. ac. uk/ cgi-bin/ search2?coll_id=859& inst_id=9) [43] Gilbert MT, Rambaut A, Wlasiuk G, Spira TJ, Pitchenik AE, Worobey M (November 2007). "The emergence of HIV/AIDS in the Americas and beyond" (http:/ / www. pnas. org/ cgi/ pmidlookup?view=long& pmid=17978186). Proc. Natl. Acad. Sci. U.S.A. 104 (47): 1856670. doi:10.1073/pnas.0705329104. PMC2141817. PMID17978186. . Retrieved March 20, 2010.
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Further reading
Aral, Sevgi O (2008), Behavioral Interventions for Prevention and Control of Sexually Transmitted Diseases (http://books.google.ca/books?id=F1RIOW0x5gAC&lpg=PR1&dq=Sexually transmitted disease& pg=PR1#v=onepage&q&f=true), : Springer Singapore Pte. Limited, ISBN9780387857688 Faro, Sebastian (2003), Sexually transmitted diseases in women (http://books.google.ca/ books?id=l0xZNxirdx0C&lpg=PP1&dq=Sexually transmitted disease&pg=PP1#v=onepage&q&f=true), Lippincott Williams & Wilkins, ISBN0397513038 Ford, Carol A; Elizabeth Shimer Bowers (2009), Living with Sexually Transmitted Diseases (http://books. google.ca/books?id=kSVqn-w8kSUC&lpg=PA17&dq=Sexually transmitted disease&pg=PP1#v=onepage& q&f=true), Facts On File, ISBN9780816076727 Sehgal, Virendra N (2003), Sexually Transmitted Diseases (http://books.google.ca/ books?id=VORwYIzp__wC&lpg=PP1&dq=Sexually transmitted disease&pg=PP1#v=onepage&q&f=true) (4th ed.), Jaypee Bros. Medical Publishers, ISBN8180611051 Shoquist, Jennifer; Diane Stafford (2003), The encyclopedia of sexually transmitted diseases (http://books. google.ca/books?id=LFMvJNyVoUgC&lpg=PA177&dq=Sexually transmitted disease&pg=PP1#v=onepage& q&f=true), Facts On File, ISBN0816048819
External links
CDC Sexually Transmitted Diseases Treatment Guidelines, 2010 (http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5912a1.htm) Sexually Transmitted Diseases Treatment Guidelines - 2006 (http://www.cdc.gov/std/treatment/) STD photo library (http://www.dermnet.com/moduleIndex.cfm?moduleID=16) at Dermnet UNFPA: Breaking the Cycle of Sexually Transmitted Infections (http://www.unfpa.org/rh/stis.htm) at UNFPA Sexually Transmitted Infections (http://www3.niaid.nih.gov/topics/sti/) from the National Institute of Allergy and Infectious Diseases STDs In Color: Sexually Transmitted Disease Facts and Photos (http://www.stdsincolor.com/) (http://wonder.cdc.gov/std.html): Sexually Transmitted Diseases in the U.S.
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Medical Imaging Applications

Digital radiography
Digital radiography is a form of x-ray imaging, where digital X-ray sensors are used instead of traditional photographic film. Advantages include time efficiency through bypassing chemical processing and the ability to digitally transfer and enhance images. Also less radiation can be used to produce an image of similar contrast to conventional radiography. Digital Radiography (DR) or (DX) is essentially filmless X-ray image capture. In place of X-ray film, a digital image capture device is used to record the X-ray image and make it available as a digital file that can be presented for interpretation and saved as part of the patients medical record. The advantages of DR over film include immediate image preview and availability, a wider dynamic range which makes it more forgiving for over- and under-exposure as well as the ability to apply special image processing techniques that enhance overall display of the image. The largest motivator for healthcare facilities to adopt DR is its potential to reduce costs associated with processing, managing and storing films. Typically there are two variants of digital image capture devices. These devices include Flat Panel detectors (FPDs), and High Density Line Scan Solid State detectors. FPDs are classified in two main categories: 1. Indirect FPD's - Amorphous silicon (a-Si) is the most frequent type of FPD sold in the medical imaging industry today. Combining a-Si detectors with a scintillator in the detectors outer layer, which is made from Cesium Iodide (CsI), or Gadolinium Oxysulfide (Gd2O2S), converts X-ray to light. Because the X-ray energy is converted to light, the a-Si detector is considered an indirect image capture technology. The light is then channeled through the a-Si photodiode layer where it is converted to a digital output signal. The digital signal is then read out by Thin Film Transistors (TFTs) or by fiber coupled Charged Couple Devices (CCDs). The image data file is sent to a computer for display where the X-ray technologist can determine whether the image is appropriate for the intended anatomy. Once the Technologist determines the image is appropriate it can be sent to the radiologists workstation or printed on film for interpretation. 2. Direct FPD's - Amorphous Selenium Flat Panel Detectors (a-Se) are known as direct detectors because X-ray photons are converted directly to charge. The outer layer of the flat panel in this design is typically a high voltage bias electrode. The bias electrode accelerates the captured energy from an X-ray exposure through the amorphous selenium layer. X-ray photons flowing through the selenium layer create electron hole pairs. These electron holes transit through the selenium based on the potential of the bias voltage charge. As the electron holes are replaced with electrons, the resultant charge pattern in the selenium layer is read out by a TFT array, Active Matrix Array, Electrometer Probes or Microplasma Line Addressing. The image data file is sent to a computer for display where the X-ray technologist can review the image and check positioning and if desired, transmit the image to the radiologists workstation for diagnosis. A High Density Line Scan Solid State detector device is composed of a Photostimulable Barium Fluoro Bromide doped with Europium (BaFlBr:Eu) or Cesium Bromide (CsBr) phosphor. The phosphor detector records the X-ray energy during exposure and is scanned by a linear laser diode to excite the stored energy which is released and read out by a digital image capture array of Charge Coupled Devices (CCDs). The image data file is transmitted to the X-ray technologist at a computer for review and then sent to the radiologist for further interpretation. Note: this term is restricted to flat, two-dimensional imaging. For more advanced forms of three-dimensional calculated images, see Computed tomography.
Digital radiography
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Radiological examinations
Dental
The radiological examinations in dentistry may be classified in: intraoral - where the film or the sensor is placed in the mouth, the purpose being to visualize a limited region and extraoral where the film or the sensor is outside the mouth and the purpose is to visualize a wide region. In dentistry, extraoral imaging splits in: Panoramic X-ray (aka "panorex" or "pano") showing a section, curved following more or less mandible shape, of the whole maxillo-facial block and the Cephalometric X-ray showing a projection, as parallel as possible, of the whole skull.
Digital radiographic systems

One particular type of digital system uses a Memory Phosphor Plate (a.k.a. PSPPhotostimulable Phosphor) in place of the film. After X-ray exposure the plate (sheet) is placed in a special scanner where the latent formed image is retrieved point by point and digitized, using laser light scanning. The digitized images are stored and displayed on the computer screen. This method is halfway between old film-based technology and current direct digital imaging technology. It is similar to the film process because it involves the same image support handling but differs because the chemical development process is replaced by the scanning process. This is not much faster than film processing and the resolution and sensitivity performances are contested. However, it has the clear advantage to be able to fit within any pre-existing equipment without modification because it replaces just the existing film. Also, sometimes the term "Digital X-rays" is used to designate the scanned film documents which are handled by further computer processing. Other types of digital imaging technologies use electronic sensors. A majority of them first convert the X-rays into visible light (using a GdO2S or CsI layer), which is further captured using a CCD or a CMOS image sensor. Some of them use a hybrid arrangement which first converts the X-rays into electricity (using a CdTe layer) and then captures this electricity as an image with a reading section based on CMOS technology.
Historical milestones for Digital Intraoral Sensors

1987 - RVG (radiovisiography), Trophy Radiology (France) introduced the world's first intraoral X-rays imaging sensor. Trophy Radiology patented it under the restricted name radiovisiography (other companies use the phrase digital radiography) and continues to produce intraoral sensors today using the Kodak name which is used under license by Carestream (Canada). Trophy has released a wireless version of their RVG Intra-Oral sensor named the RVG 6500. 1992 - Sens-a-Ray of Regam Medical System AB (Sundsvall, Sweden) is offered. They closed the business and their technology is currently owned by Dent-X now part of ImageWorks (USA). 1993 - VisualX of Gendex-Italy (subsidiary of USA company). 1994 - CDR of [Schick Technologies] http:/ / www. schicktech. com (USA). Also Schick Technologies introduced last year a wireless CDR version . This company is owned actually by Sirona (Germany). 1995 - SIDEXIS of Sirona, DEXIS of ProVison Dental Systems, Inc. (renamed DEXIS, LLC following its acquisition by Danaher Corp.), DIGORA (PSP solution) of Soredex (Finland) Today there are many other products available under a lot of different names (rebranding is quite usual for this type of product) The manufacturers claim the resolution is between 12 to 25 LP/mm. A useful precise comparison is difficult because depends on many parameters including the post processing or imaging software. Historical milestones for Digital Panoramic Systems 1995 - DXIS, the world wide first dental digital panoramic X-rays system available on the market, introduced by Signet (France). DXIS targets to retrofit all the panoramic models.
Digital radiography 1997 - SIDEXIS, of Siemens (currently Sirona, Germany) offered for Ortophos Plus panoramic unit, DigiPan of Trophy Radiology (France) offered for the OP100 panoramic made by Instrumentarium (Finland). 1998-2004 - many panoramic manufacturers offered their own digital system. 2005 - SCAN300FP, of 'Ajat' (Finland) is the latest innovation offered. It shows the feature to acquire many hundreds of mega bytes of image information at high frame rate and to reconstruct the panoramic layer by intensive post acquisition computing like a computed tomography. The main advantage is the ability to reconstruct focused differently. The drawback is the low signal/noise ratio of primary information which involves much software work for correction. Also the ability to reconstruct various layers raises the importance of the geometrical distortions already high in dental panoramic radiography. Since 2008 the SCAN300FP system is available in Ajat ART PLUS and ART PLUS C system. Currently there are several digital systems for panoramic digital radiology. Some of them are rebranded. Examples: SCAN300FP of Ajat was or is sold as SuniPan or RetroPan or Panoramic Corporation pan, DXIS of Signet was or is sold also as of LightYear, Sigma Biomedics, Panoramic Corporation, AFP Digital or Bluex, iPan of Schick was or is sold as of Bluex or Panoramic Corporation, I-MAX of Owandy sold as of Villa, etc.
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External links
Sirotech - The UK's No. 1 Sidexis & Sirona Digital Support Team [1] Carestream Health [2] ImageWorks [3]
References
[1] http:/ / www. sirotech. co. uk/ [2] http:/ / www. carestreamhealth. com/ default. aspx?LangType=1033 [3] http:/ / www. ImageWorksCorporation. com/ default. aspx?LangType=1033
Imaging informatics
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Imaging informatics
Introduction
Imaging Informatics, also known as Radiology Informatics or Medical Imaging Informatics, is a subspecialty of Biomedical Informatics that aims to improve the efficiency, accuracy, usability and reliability of medical imaging services within the healthcare enterprise.[1] It is devoted to the study of how information about and contained within medical images is retrieved, analyzed, enhanced, and exchanged throughout the medical enterprise. As radiology is an inherently data-intensive and technology-driven specialty of medicine, radiologists have become leaders in Imaging Informatics. However, with the proliferation of digitized images across the practice of medicine to include fields such as cardiology, dermatology, surgery, gastroenterology, obstetrics, gynecology and pathology, the advances in Imaging Informatics are also being tested and applied in other areas of medicine. Various industry players and vendors involved with medical imaging, along with IT experts and other biomedical informatics professionals, are contributing and getting involved in this expanding field. Imaging informatics exists at the intersection of several broad fields: biological science - includes bench sciences such as biochemistry, microbiology, physiology and genetics clinical services - includes the practice of medicine, bedside research, including outcomes and cost-effectiveness studies, and public health policy information science - deals with the acquisition, retrieval, cataloging, and archiving of information medical physics / biomedical engineering - entails the use of equipment and technology for a medical purpose cognitive science - studying human computer interactions, usability, and information visualization computer science - studying the use of computer algorithms for applications such as computer assisted diagnosis and computer vision
Areas of Interest
Key areas relevant to Imaging informatics include: Picture Archiving and Communication System (PACS) and Component Systems Imaging Informatics for the Enterprise Image-Enabled Electronic Medical Records Radiology Information Systems (RIS) and Hospital Information Systems (HIS) Digital image acquisition Image processing and enhancement Image data compression 3D visualization and multimedia Speech recognition Computer-aided diagnosis (CAD). Imaging facilities design Imaging vocabularies and ontologies Data mining from medical images databases Transforming the Radiological Interpretation Process (TRIP)[2] DICOM, HL7 and other standards Workflow and process modeling and process simulation Quality assurance
Archive integrity and security Teleradiology
Imaging informatics Radiology informatics education Digital imaging
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Training
Radiologists who wish to pursue sub-specialty training in this field can undergo fellowship training in Imaging Informatics. Medical Imaging Informatics Fellowships are done after completion of Board Certification in Diagnostic Radiology, and may be pursued concurrently with other sub-specialty radiology fellowships. The American Board of Imaging Informatics (ABII) also administers a certification examination for Imaging Informatics Professionals.
References
[1] Branstetter, B (2007). "Basics of Imaging Informatics". Radiology 243 (3): 65667. doi:10.1148/radiol.2433060243. PMID17431128. [2] TRIP - an initiative between the then Society of Computer Applications in Radiology (SCAR), now known as the Society of Imaging Informatics in Medicine (SIIM) (http:/ / www. scarnet. net/ trip/ html/ What_is_TRIP. htm)
External links
The Society for Imaging Informatics in Medicine (http://www.siimweb.org/) American Board of Imaging Informatics (https://www.abii.org/)
Patient registration
Patient registration is the concept and set of methods needed to correlate the reference position of a virtual 3D dataset gathered by computer medical imaging with the reference position of the patient. This procedure is crucial in computer assisted surgery, in order to insure the reproducitibility of the preoperative registration and the clinical situation during surgery. The use of the term "patient registration" out of this context can lead to a confusion with the procedure of registering a patient into the files of a medical institution.
The larger context

In computer assisted surgery, the first step is to gather a 3D dataset that reproduces with great accuracy the geometry of the normal and pathological tissues in the region that has to be operated on. This is mainly obtained by using CT or MRI scans of that region. The role of patient registration is to obtain a close-to-ideal reference reproducitibility of the dataset in order to correlate the position (offset) of the gathered dataset with the patient's position during the surgical intervention. Patient registration (1) eliminates the necessity of maintaining the same strict position of the patient during both preoperative scanning and surgery, and (2) provides the surgical robot the necessary reference information to act accurately on the patient, even if he has (been) moved during the intervention.
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Evolution of the concept

Patient registration was used mostly in head surgery oral and maxillofacial surgery, neurosurgery, otolaryngology. With the advent of marker- and markerless-registration, the concept has been extended for abdominal surgery.
Patient registration using headframes

The first attempts in 3D mapping of human tissues were made by V. Horsley and R. Clarke in 1906[1] . They have built a rectangular stereotactic headframe that had to be fixed to the head. It was based on cartesian principles and allowed them to accurately and reproductibly guide needle-like electrodes for neurophysiological experiments. They have experimented animals and were able to contribute to the mapping of the cerebellum. Improved versions of the HorsleyClarke apparatus are still in used today in experimental neurosurgery. The first stereotactic device for humans was also developed in neurosurgery, by E. Spiegel and H. Wycis in 1947[2] . It was used for surgical treatment of Parkinson's disease and, during time, its applicability was extended for the surgical treatment of tumors, vascular malformations, functional neurosurgery etc. The system was based both on headframes and X-ray images taken for all three planes of space. Further development of stereotactic surgery was made by Brown, Roberts and Wells in 1980[3] . They have developed a halo ring that was applied on the skull, during a CT scan and neurosurgical interventions. This method provided improved surgical guidance and was in fact the first development of computer guided surgery. Patient registration for the head area has developed for nearly two decades on the same principle of combining CT scans with mechanical reference devices such as headframes or halo rings. But the clinical experience showed that headgear is very uncomfortable to wear and even impossible to apply on little children, because their lack of cooperation; furthermore, the headframes can create artifacts in preoperative data gathering, or during surgery.
Patient registration using reference markers

Patient registration using skin markers In 1986, a different approach was developed by Roberts und Strohbehn[4] . They have used as landmarks several markers on the patient's skin both preoperative CT registration, and intraoperatively. This was a new current of the time in patient registration. Still, the method is time-consuming, and the exact reproducitibility of the marker positions is questionable. Patient registration using bone markers The bony structures can provide a much better stability and reproducibility of the landmarks for patient registration. Based on this concept, a further technique was used: to implant temporary markers into bone structures that are superficial to the skin, under local anestesia[5] . This was also combined with surface markers and CT registration[6] . The technique has the disadvantage of a further minimal surgical procedure of placing the bone implants, with some risk of infection for the patient.
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Patient registration using markers on a dental splint Dental splints have been traditionally used for transferring and reproducing 3D reference landmarks for positioning cast models in articulators in dental prosthetics, orthodontics and orthognatic surgery. By applying several infrared markers on the splints and using an infrared camera, a better registration was obtained[7] .
Markerless patient registration

Markerless patient registration using anatomical landmarks
Surgical planning using bone segment navigation for the osteotomy of the jaw bones, based on models fixed into an articulator (registration based on infrared devices)
The first attempts, based on the identification of anatomical landmarks were made by Caversaccio and Zulliger[8] . The method was based on identifying certain antropometrical points and other anatomical landmarks on the skull, in correlation with the CT registration. But the landmarks cannot be exactly pointed out and reproduced during patient dataset registration and surgery, therefore the method is not precise enough. Markerless patient registration using surface registration Since 1998, new procedures have been developed by Marmulla and co-workers, using a different approach to the problem[9] [10] . Both during CT dataset gathering and surgical intervention, the patient registration was made by registering complete areas and surfaces, instead of distinctive surface markers. This was achieved by using laser scanners and a small guiding transmitter. The precision of the patient registration was significantly improved with this method. Based on this concept, several registration and navigation systems were built by the same team. The Surgical Segment Navigator (SSN and SSN++) is such a system, developed for the first time for oral and maxillofacial surgery. This system correlates three different coordinate sets: CT data set, surface laser scan data set and the dataset produced by a small guiding transmitter, placed on the patient's head. The Laboratory Unit for Computer-Assisted Surgery (LUCAS) is used for planning surgery in the laboratory. This technological and surgical advance has permitted the elimination of mechanical guidance systems and improved the accuracy of the determinations, and thus the surgical act.
Schematic representation of the SSN system
References
[1] Clarke RH, Horsley V: On a method of investigating the deep ganglia and tracts of the central nervous system (cerebellum), Br Med J 2: 17991800, 1906 [2] Spiegel EA, Wycis HT, Marks M, Lee AS: Stereotaxic apparatus for operations on the human brain, Science 106:349350, 1947 [3] Heilbrun MP, Roberts TS, Apuzzo MLJ, Wells TH, Sabshin JK: Preliminary experience with BrownRobertsWells (BRW) computerized-tomography stereotaxic guidance-system, J Neurosurg 59(2):217222, 1983
Actual usage of the SSN system in the operating room
[4] Roberts DW, Strohbehn JW, Hatch JF, Murray W, Kettenberger H: A frameless stereotaxic integration of computerized tomographic imaging and the operating microscope, J Neurosurg 65: 545549, 1986 [5] Alp MS, Dujovny M, Misra M et al.: Head registration techniques for image-guided surgery. Neurological Research 20: 3137, 1998 [6] Maurer C, Aboutanos G, Dawant B: Registration of CT and MR brain images using a combination of points and surfaces medical imaging: image processing. Spie Press 2434:109123, 1995 [7] Hassfeld S, Mhling J, Zller J: Intraoperative navigation in oral and maxillofacial surgery, Int J Oral Maxillofac Surg 24: 111119, 1995 [8] Caversaccio M., Zulliger D., Bchler R., et al.: Practical Aspects for Optimal Registration (Matching) on the Lateral Skull Base With an Optical Frameless Computer-Aided Pointer System. The American Journal of Otology 21:863870, 2000 [9] Marmulla R, Niederdellmann H: Computer-assisted bone segment navigation, J Craniomaxillofac Surg 26:347359, 1998 [10] Marmulla R, Lth T, Mhling J, Hassfeld S: Markerless Laser Registration in Image-Guided Oral and Maxillofacial Surgery, J Oral Maxillofac Surg 62:845851, 2004
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Radiology information system

A radiology information system (RIS) is a computerized database used by radiology departments to store, manipulate and distribute patient radiological data and imagery. The system generally consists of patient tracking and scheduling, result reporting and image tracking capabilities. RIS complements HIS (Hospital Information Systems) and is critical to efficient workflow to radiology practices.
Basic Features
Radiology information systems commonly support the following features: Patient Registration and scheduling Patient List Management Interface with modality via Worklist. Radiology Department workflow management Request and document scanning Result(s) Entry Reporting and printout Result(s) Delivery including faxing and e-mailing of clinical reports Patient Tracking Interactive Documents Technical Files Creation Modality and Material management.
Additional Features
In addition a RIS often supports the following: Appointment booking PACS workflow Custom report creation HL7 interfaces with a PACS. HL7 also enables communication between HIS and RIS in addition to RIS and PACS. Billing Rule engines
Picture archiving and communication system
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A picture archiving and communication system (PACS) is a medical imaging technology which provides economical storage of, and convenient access to, images from multiple modalities (source machine types).[1] Electronic images and reports are transmitted digitally via PACS; this eliminates the need to manually file, retrieve, or transport film jackets. The universal format for PACS image storage and transfer is DICOM (Digital Imaging and Communications in Medicine). Non-image data, such as scanned documents, may be incorporated using consumer industry standard formats like PDF (Portable Document Format), once encapsulated in DICOM. A PACS consists of four major components: The imaging modalities such as X-ray computed tomography (CT) and magnetic resonance imaging (MRI), a secured network for the transmission of patient information, workstations for interpreting and reviewing images, and archives for the storage and retrieval of images and reports. Combined with available and emerging web technology, PACS has the ability to deliver timely and efficient access to images, interpretations, and related data. PACS breaks down the physical and time barriers associated with traditional film-based image retrieval, distribution, and display.
An image as stored on a picture archiving and communication system (PACS)
Types of images
Most PACSs handle images from various medical imaging instruments, including ultrasound (US), magnetic resonance (MR), positron emission tomography (PET), computed tomography (CT), endoscopy (ENDO), mammograms (MG), Digital radiography The same image following contrast adjustment, (DR), computed radiography (CR) ophthalmology, etc. Additional sharpening and measurement tags added by the system types of image formats are always being added. Clinical areas beyond radiology; cardiology, oncology, gastroenterology and even the laboratory are creating medical images that can be incorporated into PACS. (see DICOM Application areas).
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Uses
PACS has four main uses: Hard copy replacement: PACS replaces hard-copy based means of managing medical images, such as film archives. With the decreasing price of digital storage, PACSs provide a growing cost and space advantage over film archives in addition to the instant access to prior images at the same institution. Digital copies are referred to as Soft-copy. Remote access: It expands on the possibilities of conventional systems by providing capabilities of off-site viewing and reporting (distance education, telediagnosis). It enables practitioners in different physical locations to access the same information simultaneously for teleradiology. Electronic image integration platform: PACS provides the electronic platform for radiology images interfacing with other medical automation systems such as Hospital Information System (HIS), Electronic Medical Record (EMR), Practice Management Software, and Radiology Information System (RIS). Radiology Workflow Management: PACS is used by radiology personnel to manage the workflow of patient exams. PACS is offered by virtually all the major medical imaging equipment manufacturers, medical IT companies and many independent software companies. Basic PACS software can be found free on the Internet.
Architecture
The architecture is the physical implementation of required functionality, or what one sees from the outside. There are different views, depending on the user. A radiologist typically sees a viewing station, a technologist a QA workstation, while a PACS administrator might spend most of their time in the climate-controlled computer room. The composite view is rather different for the various vendors.[2] Typically a PACS consists of a multitude of devices. The first step in PACS workflow diagram typical PACS systems is the modality. Modalities are typically computed tomography (CT), ultrasound, nuclear medicine, positron emission tomography (PET), and magnetic resonance imaging (MRI). Depending on the facility's workflow most modalities send to a quality assurance (QA) workstation or sometimes called a PACS gateway. The QA workstation is a checkpoint to make sure patient demographics are correct as well as other important attributes of a study. If the study information is correct the images are passed to the archive for storage. The central storage device (archive) stores images and in some cases reports, measurements and other information that resides with the images. The next step in the PACS workflow is the reading workstations. The reading workstation is where the radiologist reviews the patient's study and formulates their diagnosis. Normally tied to the reading workstation is a reporting package that assists the radiologist with dictating the final report. Reporting software is optional and there are various ways in which doctors prefer to dictate their report. Ancillary to the workflow mentioned, there is normally CD/DVD authoring software used to burn patient studies for distribution to patients or referring physicians. The diagram above shows a typical workflow in most imaging centers and hospitals. Note that this section does not cover integration to a Radiology Information System, Hospital Information System and other such front-end system that relates to the PACS workflow. More and more PACS include web-based interfaces to utilize the internet or a Wide Area Network as their means of communication, usually via VPN (Virtual Private Network) or SSL (Secure Sockets Layer). The client side software may use ActiveX, JavaScript and/or a Java Applet. More robust PACS clients are full applications which can utilize the full resources of the computer they are executing on and are unaffected by the frequent unattended Web Browser and Java updates. As the need for distribution of images and reports become more widespread there is a push for PACS systems to support DICOM part 18 of the DICOM standard. Web Access to DICOM Objects (WADO)
Picture archiving and communication system creates the necessary standard to expose images and reports over the web through truly portable medium. Without stepping outside the focus of the PACS architecture, WADO becomes the solution to cross platform capability and can increase the distribution of images and reports to referring physicians and patients. PACS image backup is a critical, but sometimes overlooked, part of the PACS Architecture (see below). HIPAA requires that backup copies of patient images be made in case of image loss from the PACS. There are several methods of backing up the images, but they typically involve automatically sending copies of the images to a separate computer for storage, preferably off-site.
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Querying (C-FIND) and Image Retrieval (C-MOVE)

The communication with the PACS server is done through dicom objects that are similar to dicom images, but with different tags. A query typically looks as follows: The client establishes the network connection to the PACS server. The client prepares a query object which is an empty dicom dataset object. The client fills in the query object with the keys that should be matched. E.g. to query for a patient ID, the patient ID tag is filled with the patient's ID. The client creates empty tags (tags with zero length string values) for all the tags it wishes to receive from the server. E.g. if the client wishes to receive an ID that it can use to receive images (see image retrieval) it should create the tag SOPInstanceID (0008,0018) in the query object. The query object is sent to the server. The server sends back to the client a list of response dicom objects. The client extracts the tags that are of interest from the response dicom objects. Images are retrieved from a PACS server through a C-MOVE request, as defined by the DICOM network protocol. This request specifies where an image instance should be sent through an identifier known as the destination Application Entity Title (AE Title). The server must be configured with mapping of the AE Title to a TCP/IP address and port, and as a consequence the server must know in advance all the AE Titles that it will ever be requested to send images to. Typically a radiologist is looking for prior studies on a patient to compare the progression of some pathology. In some cases prior studie(s) may be on an off-site archive or a long term storage device. In the example being used, the radiologist or radiology technical must query the off-site or long term archive for the prior exam(s). The archive receives the C-FIND and if the C-FIND is successful the archive invokes a C-MOVE on the study to the called AE Title, in-turn sending the study from the archive to the device requesting the study.
Image archival and backup

Digital medical images are typically stored locally on a PACS for retrieval. It is important (and required in the USA by the Security Rule's Administrative Safeguards section of HIPAA) that facilities have a means of recovering images in the event of an error or disaster. While each facility is different, the goal in image back-up is to make it automatic and as easy to administer as possible. The hope is that the copies won't ever be needed, but, as with other disaster recovery and business continuity planning, they need to be available if needed. Ideally, copies of images should be streamed off-site as they are created. (If using the Internet, the Security Rule's Technical Safeguards section of HIPAA requires that the images be encrypted during transmission.) Depending on upload bandwidth and image volume, this may not be practical if the back-up system cannot be configured to tune bandwidth usage and frequency of back-ups. Other options include removable media (hard drives, DVDs or other media that can hold many patients' images) that is physically transferred off-site. The content of these copies must be protected via encryption from exposure to unauthorized personnel or stiff penalties can be assessed.[3]
Picture archiving and communication system Images may be stored both locally and remotely on off-line media such as tape or optical media, or partially or exclusively on hard disks ("spinning") media. The latter is becoming more common. The hard drives may be configured and attached to the PACS server in various ways, either as Direct-Attached Storage (DAS), Network-attached storage (NAS), or via a Storage Area Network (SAN). However the storage is attached, the drives themselves are usually configured as a Redundant Array of Inexpensive (or Independent) Discs RAID, which may be configured to provide appropriate combination of faster disk access or protection against the failure of one (or even two) discs in the physical RAID array. Typically, failed drives may be physically replaced (hot swapping) without interruption of service. Since costs of computers has fallen, some sites opt for fully redundant Archives, rather than just protecting the drives through RAID. Further, RAIDs are fragile and can be rendered useless by one erroneous hit on the controller. Data stored on disk may also be backed up to tape or optical media or copied, in real time, to a slower, inexpensive disc in another machine at another location. Some sites make two such backups and remove them from the site on a rotating basis. In the event that it is necessary to reconstruct a PACS partially or completely from the back-up images, some means of rapidly transferring all of its images back to the PACS is required, preferably whilst the PACS continues to receive and provide current images. The back-up infrastructure may also be capable of supporting the migration of images to a new PACS.
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Integration
A full PACS should provide a single point of access for images and their associated data. That is, it should support all digital modalities, in all departments, throughout the enterprise. However, until PACS penetration is complete, individual islands of digital imaging not yet connected to a central PACS may exist. These may take the form of a localized, modality-specific network of modalities, workstations and storage (a so-called "mini-PACS"), or may consist of a small cluster of modalities directly connected to A chest image displayed via a PACS reading workstations without long term storage or management. Such systems are also often not connected to the departmental information system. Historically, Ultrasound, Nuclear Medicine and Cardiology Cath Labs are often departments that adopt such an approach. More recently, Full Field digital mammography (FFDM) has taken a similar approach, largely because of the large image size, highly specialized reading workflow and display requirements, and intervention by regulators. The rapid deployment of FFDM in the US following the DMIST study has led to the integration of Digital Mammography and PACS becoming more commonplace. All PACS, whether they span the entire enterprise or are localized within a department, should also interface with existing hospital information systems: Hospital information system (HIS) and Radiology Information System (RIS). There are several data flowing into PACS as inputs for next procedures and back to HIS as results corresponding inputs: In: Patient Identification and Orders for examination. These data are sent from HIS to RIS via integration interface, in most of hospital, via HL7 protocol. Patient ID and Orders will be sent to Modality (CT,MR,etc) via DICOM protocol (Worklist). Images will be created after images scanning and then forwarded to PACS Server. Diagnosis Report is created based on the images retrieved for presenting from PACS Server by physician/radiologist and then saved to RIS System. Out: Diagnosis Report and Images created accordingly. Diagnosis Report is sent back to HIS via HL7 usually and Images are sent back to HIS via DICOM usually if there is a DICOM Viewer integrated
Picture archiving and communication system with HIS in hospitals (In most of cases, Clinical Physician gets reminder of Diagnosis Report coming and then queries images from PACS Server). Interfacing between multiple systems provides a more consistent and more reliable dataset: Less risk of entering an incorrect patient ID for a study modalities that support DICOM worklists can retrieve identifying patient information (patient name, patient number, accession number) for upcoming cases and present that to the technologist, preventing data entry errors during acquisition. Once the acquisition is complete, the PACS can compare the embedded image data with a list of scheduled studies from RIS, and can flag a warning if the image data does not match a scheduled study. Data saved in the PACS can be tagged with unique patient identifiers (such as a social security number or NHS number) obtained from HIS. Providing a robust method of merging datasets from multiple hospitals, even where the different centers use different ID systems internally. An interface can also improve workflow patterns: When a study has been reported by a radiologist the PACS can mark it as read. This avoids needless double-reading. The report can be attached to the images and be viewable via a single interface. Improved use of online storage and nearline storage in the image archive. The PACS can obtain lists of appointments and admissions in advance, allowing images to be pre-fetched from off-line storage or near-line storage onto online disk storage. Recognition of the importance of integration has led a number of suppliers to develop fully integrated RIS/PACS. These may offer a number of advanced features: Dictation of reports can be integrated into a single system. The recording is automatically sent to a transcript writer's workstation for typing, but it can also be made available for access by physicians, avoiding typing delays for urgent results, or retained in case of typing error. Provides a single tool for quality control and audit purposes. Rejected images can be tagged, allowing later analysis (as may be required under radiation protection legislation). Workloads and turn-around time can be reported automatically for management purposes.
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History
The principles of PACS were first discussed at meetings of radiologists in 1982. Various people are credited with the coinage of the term PACS. Cardiovascular radiologist Dr Andre Duerinckx reported in 1983 that he had first used the term in 1981.[4] Dr Samuel Dwyer, though, credits Dr Judith M. Prewitt for introducing the term.[5] Dr Harold Glass, a medical physicist working in London in the early 1990s secured UK Government funding and managed the project over many years which transformed Hammersmith Hospital in London as the first filmless hospital in the United Kingdom.[6] Dr Glass died a few months after the project came live but is credited with being one of the pioneers of PACS. The first large-scale PACS installation was in 1982 at the University of Kansas, Kansas City.[2] This first installation became more of a teaching experience of what not to do rather than what to do in a PACS installation.
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Regulatory concerns
In the US PACS are classified as Medical Devices, and hence if for sale are regulated by the USFDA. In general they are subject to Class 2 controls and hence require a 510(k), though individual PACS components may be subject to less stringent general controls.[7] Some specific applications, such as the use for primary mammography interpretation, are additionally regulated[8] within the scope of the Mammography Quality Standards Act.
References
[1] Choplin, R., (1992). Picture archiving and communication systems: an overview. Radiographics January 1992 12:127-129 [2] Oosterwijk, Herman. PACS Fundamentals. Aubrey: OTech Inc, 2004. ISBN 9780971886735 [3] HealthcareITnews: HHS cracks down: provider to pay $100,000 in HIPAA penalties over lost laptops. July 17, 2008, Diana Manos, Senior Editor (http:/ / www. healthcareitnews. com/ news/ hhs-cracks-down-provider-pay-100000-hipaa-penalties-over-lost-laptops) [4] Duerinckx AJ, Pisa EJ. Filmless Picture Archiving and Communication System (PACS) in Diagnostic Radiology. Proc SPIE 1982;318;9-18. Reprinted in IEEE Computer Society Proceedings of PACS'82, order No 388. [5] Samuel J. Dwyer III. A personalized view of the history of PACS in the USA. In: Proceedings of the SPIE, "Medical Imaging 2000: PACS Design and Evaluation: Engineering and Clinical Issues", edited by G. James Blaine and Eliot L. Siegel. 2000;3980:2-9. [6] Bryan S, Weatherburn GC, Watkins JR, Buxton MJ (1999). "The benefits of hospital-wide picture archiving and communication systems: a survey of clinical users of radiology services". Br J Radiol 72 (857): 46978. PMID10505012. [7] USFDA (27 July 2000). "Guidance for the Submission Of Premarket Notifications for Medical Image Management Devices" (http:/ / www. fda. gov/ MedicalDevices/ DeviceRegulationandGuidance/ GuidanceDocuments/ ucm073720. htm). . Retrieved 11 February 2010. [8] USFDA (30 May 2008). "Guidance for Industry and FDA Staff: Display Accessories for Full-Field Digital Mammography Systems-Premarket Notification (510(k)) Submissions" (http:/ / www. fda. gov/ MedicalDevices/ DeviceRegulationandGuidance/ GuidanceDocuments/ ucm107549. htm). . Retrieved 11 February 2010.
External links
Teleradiology, PACS and DICOM Software (http://www.rtstudents.com/pacs/free-dicom-viewers.htm) List of free PACS and DICOM software available on the web History of PACS (http://www.imagingeconomics.com/library/200505-01.asp) PACS History Web Site (http://www.pacshistory.org/) USC IPILab Research Article on Backup (http://adsabs.harvard.edu/abs/2003SPIE.5033...63L)
Analysis of Functional NeuroImages
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AFNI
AFNI displaying a statistical parametric map generated from a finger-tapping FMRI experiment. Original author(s) Developer(s) Operating system Type License Website Robert W. Cox NIMH Scientific and Statistical Computing Core Cross-platform (list) [2] [1]
Neuroimaging data analysis GPL AFNI/NIfTI Server [3]
Analysis of Functional NeuroImages (AFNI) is an open source environment for processing and displaying functional MRI dataa technique for mapping human brain activity. AFNI is an agglomeration of programs that can be used interactively or flexibly assembled for batch processing using shell script. The term AFNI refers both to the entire suite and to a particular interactive program often used for visualization. AFNI is actively developed by the NIMH Scientific and Statistical Computing Core and its capabilities are continually expanding. AFNI runs under many Unix-like operating systems that provide X11 and Motif libraries, including SGI IRIX, Solaris, Linux, FreeBSD and Mac OS X. Precompiled binaries are available for some platforms. AFNI is available for research use under the GNU General Public License. AFNI now comprises over 300,000 lines of C source code, and a skilled C programmer can add interactive and batch functions to AFNI with relative ease.
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History and Development

AFNI was originally developed at the Medical College of Wisconsin beginning in 1994, largely by Robert W. Cox. Robert Cox brought development to the NIH in 2001 and development continues at the NIMH Scientific and Statistical Computing Core.
External links
AFNI main page [3] NIMH Scientific and Statistical Computing Core [1]
References
[1] http:/ / afni. nimh. nih. gov/ sscc/ [2] http:/ / afni. nimh. nih. gov/ afni/ download/ afni/ releases/ latest [3] http:/ / afni. nimh. nih. gov/ afni/
3DSlicer
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3DSlicer
Original author(s) The Slicer Community [1] Stable release Operating system Available in Type License Website 3.6.3 / March 4, 2011 Cross-platform C++, Tcl, Python, Java Scientific visualization and image computing BSD-styleOpen Source [www.slicer.org www.slicer.org]
3D Slicer (Slicer) is a free, open source software package for image analysis[2] and scientific visualization. Slicer is used in a variety of medical applications, including autism, multiple sclerosis, systemic lupus erythematosus, prostate cancer, schizophrenia, orthopedic biomechanics, COPD, cardiovascular disease and neurosurgery.
About Slicer
3D Slicer is a free open source software (BSD license) that is a flexible, modular platform for image analysis and visualization. 3D Slicer can be easily extended to enable development of both interactive and batch processing tools for a variety of applications. 3D Slicer provides image registration, processing of DTI (diffusion tractography), an interface to external devices for image guidance support, and GPU-enabled volume rendering, among other capabilities. 3D Slicer has a modular organization that allows the easy addition of new functionality and provides a number of generic features not available in competing tools. The interactive visualization capabilities of 3D Slicer include the ability to display arbitrarily oriented image slices, build surface models from image labels, and high performance volume rendering. 3D Slicer also supports a rich set of annotation features (fiducials and measurement widgets, customized colormaps). Slicer's capabilities include:[3] Handling DICOM images and reading/writing a variety of other formats Interactive visualization of volumetric Voxel images, polygonal meshes, and volume renderings Manual editing Fusion and co-registering of data using rigid and non-rigid algorithms Automatic image segmentation Analysis and visualization of diffusion tensor imaging data Tracking of devices for image-guided procedures.
Slicer is compiled for use on multiple platforms, including Windows, Linux, and Mac OS X. Slicer is distributed under a BSD style, free, open source license. The license has no restrictions on use of the software. However, no claims are made on the software being useful for any particular task. It is entirely the responsibility of the user to ensure compliance with local rules and regulations. Slicer has not been approved for clinical use in the US or elsewhere.
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Image gallery
Hardware accelerated volume rendering with nVidia drivers, (on Windows and Linux only).
ProstateNav Module for MRI guided robot assisted biopsy of the prostate.
Left: 3D rendering. Right: Open MR system
Visualization of some atlas-based ROIs which correspond to major anatomical fiber tracts. The atlas was provided as part of a download of [4] DTI studio .
High resolution data acquired on 3-Tesla magnet and post-processed using automated tracking procedure.
High-dimensional white matter atlas generation and group analysis: result of automatic segmentation of novel subjects.
Patient-specific modeling in a patient with congenital heart disease.
Left: Three-dimensional model of levator ani subdivisions including the pubic bone and pelvic viscera. Right: The same model without the pubic bone.
3DSlicer
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Cortical parcellations derived from SPGR images obtained from a tumor patient.
Intraoperative colocalization using iMRI images and 3-D Slicer software.
History
Slicer started as a masters thesis project between the Surgical Planning Laboratory at the Brigham and Women's Hospital and the MIT Artificial Intelligence Laboratory in 1998.[5] 3D Slicer version 2 has been downloaded several thousand times. In 2007 a completely revamped version 3 of Slicer was released. The next major refactoring of Slicer was initiated in 2009, which aims to transition the GUI of Slicer from using KWWidgets [6] to Qt. Qt-enabled Slicer version 4 is expected to be released in 20102011. Slicer software has enabled a variety of research publications, all aimed at improving image analysis.[7] This significant software project has been enabled by the participation of several large-scale NIH funded efforts, including the NA-MIC [8], NAC [9], BIRN, CIMIT [10], Harvard Catalyst [11] and NCIGT [12] communities. The funding support comes from several federal funding sources, including NCRR, NIBIB, NIH Roadmap, NCI, NSF and the DOD.
Users
Slicer's platform provides functionalities for segmentation, registration and three-dimensional visualization of multimodal image data, as well as advanced image analysis algorithms for diffusion tensor imaging, functional magnetic resonance imaging and image-guided radiation therapy. Standard image file formats are supported, and the application integrates interface capabilities to biomedical research software. Slicer has been used in a variety of clinical research. In image-guided therapy research, Slicer is frequently used to construct and visualize collections of MRI data that are available pre- and intra-operatively to allow for the acquiring of spatial coordinates for instrument tracking.[13] In fact, Slicer has already played such a pivotal role in image-guided therapy, it can be considered as growing up alongside that field, with over 200 publications referencing Slicer since 1998.[14] In addition to producing 3D models from conventional MRI images, Slicer has also been used to present information derived from fMRI (using MRI to assess blood flow in the brain related to neural or spinal cord activity),[15] DTI (using MRI to measure the restricted diffusion of water in imaged tissue),[16] and electrocardiography.[17] For example, Slicer's DTI package allows the conversion and analysis of DTI images. The results of such analysis can be integrated with the results from analysis of morphologic MRI, MR angiograms and fMRI. Other uses of Slicer include paleontology[18] and neurosurgery planning.[19]
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Developers
Slicer is based on VTK, a graphical library that provides a high-level interface to OpenGL and a pipeline mechanism to connect graphical filters. The library is implemented in C++ but provides a Tcl wrapper to instantiate and execute its methods. Tcl/Tk comprises the rest of 3D Slicer user interface and event handling. Slicer software supports automatic testing and employs an extreme programming approach with nightly builds natively on multiple platforms. Recent accomplishments include added capability for plugging-in external modules using an XML-based command line interface. The Slicer effort also incorporates a light-weight user-centered design effort to promote overall software usability. Slicer.org [20] offers resources for those who would like to improve or modify Slicer designs and applications. Various tutorials and instructions, along with access to a community of other developers can be found there. Development still in progress, Slicer is sometimes accused by academic users of being poorly documented and a lack of automation facilities (which is useful in batch processing). Although bugs can be reported to the mail list, they are not guaranteed to be fixed timely, which is determined by its freely available nature. A new version would come out every few weeks, but is only available as a fresh installation in lieu of an in-place manner, which adds to maintenance difficulty.
Components of Slicer
VTK ITK CMake CPack Python Tcl nrrd [21] MRML [22] IGSTK KWWidgets [6] Qt
External links
Slicer [23] the Slicer Image Gallery [24]. NA-MIC Kit [25] Ohloh Open Source Assessment of Slicer [26]
References
[1] http:/ / slicer. org/ pages/ Acknowledgements [2] Pieper S., Halle M., Kikinis R. 3D SLICER. Proceedings of the 1st IEEE International Symposium on Biomedical Imaging: From Nano to Macro 2004; 1:632635. [3] Pieper S., Lorensen B., Schroeder W., Kikinis R. The NA-MIC Kit: ITK, VTK, Pipelines, Grids and 3D Slicer as an Open Platform for the Medical Image Computing Community. Proceedings of the 3rd IEEE International Symposium on Biomedical Imaging: From Nano to Macro 2006; 1:698-701. [4] http:/ / www. dtistudio. org [5] Hirayasu, Y; Shenton, ME; Salisbury, DF; Dickey, CC; Fischer, IA; Mazzoni, P; Kisler, T; Arakaki, H et al. (1998). "Lower left temporal lobe MRI volumes in patients with first-episode schizophrenia compared with psychotic patients with first-episode affective disorder and normal subjects". The American journal of psychiatry 155 (10): 138491. PMID9766770. [6] http:/ / www. kwwidgets. org/ Wiki/ KWWidgets
3DSlicer
[7] Pieper S., Lorensen B., Schroeder W., Kikinis R. The NA-MIC Kit: ITK, VTK, Pipelines, Grids and 3D Slicer as an Open Platform for the Medical Image Computing Community. Proceedings of the 3rd IEEE International Symposium on Biomedical Imaging: From Nano to Macro 2006; 1:698701. [8] http:/ / www. na-mic. org [9] http:/ / nac. spl. harvard. edu [10] http:/ / www. cimit. org [11] http:/ / catalyst. harvard. edu/ home. html [12] http:/ / www. ncigt. org/ [13] Hata, N; Piper, S; Jolesz, FA; Tempany, CM; Black, PM; Morikawa, S; Iseki, H; Hashizume, M et al. (2007). "Application of open source image guided therapy software in MR-guided therapies". Medical image computing and computer-assisted intervention : MICCAI ... International Conference on Medical Image Computing and Computer-Assisted Intervention 10 (Pt 1): 4918. PMID18051095. [14] For a list of publications citing Slicer usage since 1998, visit: http:/ / www. slicer. org/ publications/ pages/ display/ ?collectionid=11 [15] Archip, N; Clatz, O; Whalen, S; Kacher, D; Fedorov, A; Kot, A; Chrisochoides, N; Jolesz, F et al. (2007). "Non-rigid alignment of pre-operative MRI, fMRI, and DT-MRI with intra-operative MRI for enhanced visualization and navigation in image-guided neurosurgery". NeuroImage 35 (2): 60924. doi:10.1016/j.neuroimage.2006.11.060. PMID17289403. [16] Ziyan, U; Tuch, D; Westin, CF (2006). "Segmentation of thalamic nuclei from DTI using spectral clustering". Medical image computing and computer-assisted intervention : MICCAI ... International Conference on Medical Image Computing and Computer-Assisted Intervention 9 (Pt 2): 80714. PMID17354847. [17] Verhey, JF; Nathan, NS; Rienhoff, O; Kikinis, R; Rakebrandt, F; D'ambra, MN (2006). "Finite-element-method (FEM) model generation of time-resolved 3D echocardiographic geometry data for mitral-valve volumetry". Biomedical engineering online 5: 17. doi:10.1186/1475-925X-5-17. PMC1421418. PMID16512925. [18] http:/ / openpaleo. blogspot. com/ 2009/ 03/ 3d-slicer-tutorial-part-vi. html [19] [20] [21] [22] [23] [24] [25] [26] http:/ / picasaweb. google. com/ 107065747472066371420 http:/ / www. slicer. org/ pages/ DeveloperOrientation http:/ / teem. sourceforge. net/ nrrd/ http:/ / www. slicer. org/ slicerWiki/ index. php/ Slicer3:Data_Model http:/ / www. slicer. org http:/ / www. slicer. org/ pages/ Special:PubDB_Gallery?collection=11 http:/ / wiki. na-mic. org/ Wiki/ index. php/ NA-MIC-Kit http:/ / www. ohloh. net/ projects/ 3376
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Analyze
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Analyze
Analyze is a software package developed by the Biomedical Imaging Resource (BIR) at Mayo Clinic for multi-dimensional display, processing, and measurement of multi-modality biomedical images. It is a commercial program and is used for medical tomographic scans from magnetic resonance imaging, computed tomography and positron emission tomography. The Analyze 7.5 file format[1] has been widely used in the functional neuroimaging field, and other programs such as SPM, FreeSurfer, AIR, MRIcro and Mango are able to read and write the format. The files can be used to store voxel-based volumes. One data item consists of two files: One file with the actual data in a binary format with the filename extension .img and another file (header with filename extension .hdr) with information about the data such as voxel size and number of voxel in each dimension. SPM has defined changes to this format, among other things the voxel ordering within the file.
References
[1] "The Mayo Clinic" (http:/ / web. archive. org/ web/ 20070927191351/ http:/ / www. mayo. edu/ bir/ PDF/ ANALYZE75. pdf). Archived from the original (http:/ / www. mayo. edu/ bir/ PDF/ ANALYZE75. pdf) on September 27, 2007. . Retrieved 2009-08-28.
External links
AnalyzeDirect (http://www.analyzedirect.com/) - homepage for Analyze. Biomedical Imaging Resource (http://mayoresearch.mayo.edu/mayo/research/robb_lab/) - Mayo Clinic. Graham Wideman, Mayo/SPM "Analyze" Format Spec Compilation (http://wideman-one.com/gw/brain/ analyze/formatdoc.htm). Explains voxel ordering.
CARET
CARET (Computerized Anatomical Reconstruction Toolkit) is a software application for the structural and functional analysis of the cerebral and cerebellar cortex. CARET is developed in the Van Essen Laboratory in the Department of Anatomy and Neurobiology at the Washington University School of Medicine in St. Louis, Missouri. CARET is a free, open-source application distributed in both binary and source formats under the GNU General Public License. CARET runs on FreeBSD, Linux, Mac OS X, and Microsoft Windows.
CARET
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Image of CARET main window with functional and foci data on surface
CARET's capabilities
Analysis of group anatomical differences using sulcal depth morphometry. Display of activation foci. Generation of flat, inflated, spherical surfaces. Mapping of fMRI volumes onto surfaces. Surface reconstruction from anatomical MRI volumes using the SureFit algorithm. Surface reconstruction from contours. Surface-based registration. Visualization of contours, surfaces, and volumes.
Related Software
SuMS Database and WebCaret [1] provided on-line storage of surface and volume-based data along with web-based visualization of the data.
References
Steven H. Koslow and Shankar Subramaniam. Databasing the Brain: From Data to Knowledge, (Neuroinformatics). Wiley. ISBN0471309214.
External links
CARET Home Page [2]
CARET
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References
[1] http:/ / sumsdb. wustl. edu [2] http:/ / brainmap. wustl. edu
CAVEman
CAVEman is a 4D high-resolution model of a functioning human elaborated by University of Calgary. It resides in a cube-shaped virtual reality room, like a cave, also known as the "research holodeck", in which the human model floats in space, projected from three walls and the floor below.
References External links

University of Calgary Unveils the CAVEman Virtual Human (http://www.medgadget.com/archives/2007/05/ university_of_calgary_unveils_the_caveman_virtual_human.html) CAVEman unveiled (http://www.ucalgary.ca/news/may2007/CAVEman) Meet the CAVEman of the future (http://www.theglobeandmail.com/servlet/story/RTGAM.20070523. wlbody0524/BNStory/Science/home)
FreeSurfer
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FreeSurfer
FreeSurfer
Developer(s) Stable release Martinos Center for Biomedical Imaging 5.1.0 [1]
Operating system Linux or Mac OS X Type License Website Neuroimaging data analysis Freeware FreeSurfer [2]
FreeSurfer is an MRI brain imaging software package developed by the Athinoula A. Martinos Center for Biomedical Imaging at Massachusetts General Hospital. It is an important tool in functional brain mapping and facilitates the visualization of the functional regions of the highly-folded cerebral cortex. It contains both volume based and surface based analysis, which primarily use the white matter surface [3] . FreeSurfer includes tools for the reconstruction of topologically correct and geometrically accurate models of both the gray/white and pial surfaces, for measuring cortical thickness, surface area and folding, and for computing inter-subject registration based on the pattern of cortical folds. In addition, an automated labeling of 35 non-cortical regions is included in the package.
Usage
The FreeSurfer processing stream is controlled by a shell script called recon-all[4] . The script calls component programs that organize raw MRI images into formats easily usable for morphometric and functional MRI statistical analysis with the FS-FAST package. Freesurfer uses a morphed spherical method to average across subjects for a GLM group analysis with the QDEC tool. Two editing and visualization tools, Tkmedit and Tksurfer, respectively, are included in the package, but they will be replaced by Freeview when it is completed. FreeSurfer automatically segments the volume and parcellates the surface into standardized regions of interest (ROIs). The package has a broad spectrum of other uses, including retinotopy and cortical thickness analysis.
Interoperation
FreeSurfer interoperates easily with the FMRIB Software Library (FSL), which is a comprehensive library for image analysis, written by the Functional MRI of the Brain (FMRIB) group at Oxford, UK. The functional activation results obtained using either the FreeSurfer Functional Analysis Stream (FS-FAST) or the FSL tools can be overlayed onto inflated, sphered or flattened cortical surfaces using FreeSurfer. FreeSurfer also uses toolkits from MNI MINC [5], VXL, Tcl/Tk/Tix/BLT, VTK., KWWidgets and Qt,[6] which are all available with the distribution. Other neuroimaging programs like Caret, AFNI/SUMA, and 3D Slicer can also import data processed by FreeSurfer.
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Download
FreeSurfer runs on Mac OS and Linux. Free registration and installation are available. Documentation can be found on the FreeSurfer Wiki[7] and limited support is available from the developers and community through the FreeSurfer mailing list.
References
[1] http:/ / www. nmr. mgh. harvard. edu/ martinos/ noFlashHome. php [2] http:/ / www. freesurfer. net/ [3] (ftp:/ / ftp. nmr. mgh. harvard. edu/ pub/ flat/ freesurfer/ docs/ recon1. ps) Dale, A. M., B. Fischl, et al. (1999). "Cortical surface-based analysis: Segmentation and surface reconstruction." Neuroimage 9(2): 179-94. [4] (http:/ / surfer. nmr. mgh. harvard. edu/ fswiki/ recon-all) recon-all script usage [5] http:/ / www. bic. mni. mcgill. ca/ software [6] (http:/ / surfer. nmr. mgh. harvard. edu/ fswiki/ DevelopersGuide) Developer's Guide [7] (http:/ / surfer. nmr. mgh. harvard. edu/ fswiki) FreeSurfer Wiki
External links
FreeSurfer Home (http://www.freesurfer.net/)
ImageJ
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ImageJ
ImageJ
Screenshot of ImageJ Developer(s) Stable release Wayne Rasband (NIH) 1.45e / April 8, 2011
Operating system Any (Java-based) Type License Website Image processing Public Domain http:/ / rsb. info. nih. gov/ ij/
ImageJ is a public domain, Java-based image processing program developed at the National Institutes of Health.[1] ImageJ was designed with an open architecture that provides extensibility via Java plugins and recordable macros.[2] Custom acquisition, analysis and processing plugins can be developed using ImageJ's built-in editor and a Java compiler. User-written plugins make it possible to solve many image processing and analysis problems, from three-dimensional live-cell imaging,[3] to radiological image processing,[4] multiple imaging system data comparisons[5] to automated hematology systems.[6] ImageJ's plugin architecture and built in development environment has made it a popular platform for teaching image processing.[7] [8] ImageJ can be run as an online applet, a downloadable application, or on any computer with a Java 5 or later virtual machine. Downloadable distributions are available for Microsoft Windows, Mac OS, Mac OS X, Linux, and the Sharp Zaurus PDA. The source code for ImageJ is freely available [9].[10] The project developer, Wayne Rasband, is at the Research Services Branch of the National Institute of Mental Health.
Features
ImageJ can display, edit, analyze, process, save, and print 8-bit, 16-bit and 32-bit images. It can read many image formats including TIFF, PNG, GIF, JPEG, BMP, DICOM, FITS, as well as raw formats. ImageJ supports image stacks, a series of images that share a single window, and it is multithreaded, so time-consuming operations can be performed in parallel on multi-CPU hardware. ImageJ can calculate area and pixel value statistics of user-defined selections and intensity thresholded objects. It can measure distances and angles. It can create density histograms and line profile plots. It supports standard image processing functions such as logical and arithmetical operations between images, contrast manipulation, convolution, Fourier analysis, sharpening, smoothing, edge detection and median filtering. It does geometric transformations such as scaling, rotation and flips. The program supports any number of images simultaneously, limited only by available memory.
ImageJ
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History
Prior to the release of ImageJ in 1997, a similar freeware image analysis program known as NIH Image had been developed for Macintosh computers running pre-Mac OS X operating systems. Further development of this code continues in the form of Image SXM, a variant tailored for physical research of scanning microscope images. A Windows version ported by Scion Corporation, so called Scion Image for Windows [11] was also developed. Both versions are still available.[12]
References
[1] Collins TJ (July 2007). "ImageJ for microscopy". BioTechniques 43 (1 Suppl): 2530. doi:10.2144/000112517. PMID17936939. [2] Girish V, Vijayalakshmi A (2004). "Affordable image analysis using NIH Image/ImageJ" (http:/ / www. bioline. org. br/ request?cn04009). Indian J Cancer 41 (1): 47. PMID15105580. . [3] Eliceiri K, Rueden C (2005). "Tools for visualizing multidimensional images from living specimens". Photochem Photobiol 81 (5): 111622. doi:10.1562/2004-11-22-IR-377. PMID15807634. [4] Barboriak D, Padua A, York G, Macfall J (2005). "Creation of DICOMaware applications using ImageJ". J Digit Imaging 18 (2): 919. doi:10.1007/s10278-004-1879-4. PMID15827831. [5] Rajwa B, McNally H, Varadharajan P, Sturgis J, Robinson J (2004). "AFM/CLSM data visualization and comparison using an open-source toolkit". Microsc Res Tech 64 (2): 17684. doi:10.1002/jemt.20067. PMID15352089. [6] Gering E, Atkinson C (2004). "A rapid method for counting nucleated erythrocytes on stained blood smears by digital image analysis". J Parasitol 90 (4): 87981. doi:10.1645/GE-222R. PMID15357090. [7] Burger W, Burge M (2007). Digital Image Processing: An Algorithmic Approach Using Java (http:/ / www. imagingbook. com/ ). Springer. ISBN1846283795. . [8] Dougherty, G (2009). Digital Image Processing for Medical Applications (http:/ / www. cambridge. org/ 9780521860857). Cambridge University Press. ISBN9780521860857. . [9] http:/ / rsb. info. nih. gov/ ij/ developer/ index. html [10] Rueden CT, Eliceiri KW (July 2007). "Visualization approaches for multidimensional biological image data". BioTechniques 43 (1 Suppl): 31, 336. doi:10.2144/000112511. PMID17936940. [11] http:/ / en. wikiversity. org/ wiki/ Graphics_software/ Scion_Image [12] "NIH Image: About" (http:/ / rsbweb. nih. gov/ nih-image/ about. html). . Retrieved 2008-11-18.
External links
ImageJ home (http://rsb.info.nih.gov/ij) ImageJ Documentation Wiki (http://imagejdocu.tudor.lu/) ImageJ User and Developer Conference (http://imagejconf.tudor.lu/) ImageJ for CUDA GPUs (http://jcuda.org/ImageJ/ImageJHowTo.html) Accelerate ImageJ using GPUs Review of ImageJ (http://www.sas.org/tcs/weeklyIssues_2005/2005-10-21/feature2/) by Forrest Mims III in The Citizen Scientist, the journal of the Society for Amateur Scientists. ImageJ Online (http://nanohub.org/resources/imagej) A good resource to run ImageJ without installation.
Distributions
ImageJ for Microscopy (http://www.macbiophotonics.ca/imagej/) - from the McMaster Biophotonics Facility Fiji (http://pacific.mpi-cbg.de/wiki/) (Fiji is Just ImageJ): An ImageJ bundled distribution; many scripting languages supported (see Scripting (http://pacific.mpi-cbg.de/wiki/index.php/Category:Scripting)). Fiji focuses on image registration, stitching, segmentation and 3D visualization.
Plug-ins
ImageJ Plugin home (http://rsb.info.nih.gov/ij/plugins/index.html) ImageJ Plugin Project (http://ij-plugins.sourceforge.net/) @ Sourceforge.net Bio-medical Imaging plugins (http://bij.isi.uu.nl/)
ImageJ The Image Stabilizer plugin (http://www.kangli.org/code/Image_Stabilizer.html): Stabilizes jittery image stacks. OptiNav plugin set (http://www.optinav.com/imagej.html): Aeroacoustics, real time histograms, deconvolutions. Large set of plugins (http://www.dentistry.bham.ac.uk/landinig/software/software.html) by Gabriel Landini Mathematical morphology plugins of Dimiter Prodanov (http://www.diagnosticarea.com/plugins.html). Albert Cardona's 3D editing plugins (http://www.mcdb.ucla.edu/research/hartenstein/software/imagej/ index.html). Plugins for surface assessment (http://www.gcsca.net) from GCSCA TrakEM2 (http://www.ini.unizh.ch/~acardona/trakem2.html): a plugin for morphological data mining, 3D modeling, and image stitching, registration, editing and annotation. Various plugins (http://www.ulfdittmer.com/imagej/) by Ulf Dittmer: Expression, HPGLReader, OpenGLExample, Pixellate, Seam Carving, Warp, Animated PNG Writer SIFT-implementation (http://fly.mpi-cbg.de/~saalfeld) by Stephan Saalfeld: A lightweight SIFT-implementation under GPL, see more about SIFT algorithm bUnwarpJ (http://biocomp.cnb.csic.es/~iarganda/bUnwarpJ/) by Ignacio Arganda-Carreras: a plugin for consistent and elastic image registration. Plugins (http://bigwww.epfl.ch/algorithms.html) of the Biomedical Imaging Group (EPFL) Teaching image-processing programming in Java (http://bigwww.epfl.ch/iplab/) with plugins of ImageJ
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NIH Image
NIH Image home page (http://rsbweb.nih.gov/nih-image/) Scion Image Download (http://www.scioncorp.com/pages/scion_image_windows.htm)
InVesalius
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InVesalius
InVesalius
Developer(s) Stable release Written in
CTI
[1]
3.0 / 2010 Python
Operating system GNU Linux, Windows Available in Type License Website English, French, Portuguese, Spanish Medical software GNU GPL2 [2]
InVesalius is a free medical software used to reconstruct structures of the human body. Based on two-dimensional images, acquired using Computed tomography or Magnetic resonance imaging equipments, the software generates virtual three-dimensional models correspondent to anatomical parts of the human body. After reconstructing three-dimensionally DICOM images, the software allows the generation of STL (stereolithography) files. These files can be used for Rapid Prototyping. InVesalius was developed at CTI (Renato Archer Technology of Information Center), a research institute of the Brazilian Science and Technology Center and is available at no cost at the homepage of Public Software Portal homepage [2]. The software license is CC-GPL 2. It is available both in English, Brazilian Portuguese, French and Spanish. InVesalius was developed using Python and works under GNU Linux and Windows (both XP, Vista and 7) (MacOS X version on the way). It also uses graphic libraries VTK, wxPython, GDCM and ITK. The softwares name is a tribute to Belgian physician Andreas Vesalius (15141564), considered the "father of modern anatomy". Developed since 2001 for attending Brazilian Public Hospitals demands, InVesalius development was directed for promoting social inclusion of individuals with severe facial deformities. Since then, however, it has been employed in various research areas of dentistry, medicine, veterinary medicine, paleontology and anthropology. It has been used not only in public hospitals, but also in private clinics and hospitals. Until 2010, the software had already been used for generating more than 1500 rapid prototyping models of anatomical structures at Promed project [3].
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Links
Official InVesalius website [2] InVesalius Translation page [4] at Transifex InVesalius at Ohloh [5] InVesalius at Twitter [6] Public Software Portal (Portuguese) [7] Rapid Prototyping for Medicine(Portuguese) [8]
Related works
Confex.com (in English) [9]
References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. cti. gov. br/ http:/ / svn. softwarepublico. gov. br/ trac/ invesalius http:/ / www. cti. gov. br/ index. php/ dt3d-programas/ promed. html http:/ / www. transifex. net/ projects/ p/ invesalius/ c/ gui/ https:/ / www. ohloh. net/ p/ invesalius/ http:/ / twitter. com/ invesalius http:/ / www. softwarepublico. gov. br http:/ / www. cti. gov. br/ promed http:/ / iadr. confex. com/ iadr/ brazil04/ preliminaryprogram/ abstract_57098. htm
ITK-SNAP
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ITK-SNAP
ITK-SNAP
ITK-SNAP Developer(s) Researchers at UPenn and UNC [1]
Initial release 2004 Written in Platform Available in Type License Website C++ Cross-platform English language Health Software GNU General Public License http:/ / www. itksnap. org [2]
ITK-SNAP is an interactive software application that allows users to navigate three-dimensional medical images, manually delineate anatomical regions of interest, and perform automatic image segmentation. The software was designed with the audience of clinical and basic science researchers in mind, and emphasis has been placed on having a user-friendly interface and maintaining a limited feature set to prevent feature creep. ITK-SNAP is most frequently used to work with magnetic resonance imaging (MRI) and computed tomography (CT) data sets.
Notable Features
The purpose of the tool is to make it easy for researchers to delineate anatomical structures and regions of interest in imaging data. The set of features is kept to a minimum. The main features of the program are Image navigation three orthogonal cut planes through the image volume are shown at all times. The cut planes are linked by a common cursor, so that moving the cursor in one cut plane updates the other cut planes. The cursor is moved by dragging the mouse over the cut planes, making for smooth navigation. The linked cursor also works across ITK-SNAP sessions, making it possible to navigate multimodality imaging data (e.g., two MRI scans of a subject from a single session). Manual segmentation ITK-SNAP provides tools for manual delineation of anatomical structures in images. Labeling can take place in all three orthogonal cut planes and results can be visualized as a three-dimensional rendering. This makes it easier to ensure that the segmentation maintains reasonable shape in 3D.
ITK-SNAP Automatic segmentation ITK-SNAP provides automatic functionality segmentation using the level set method. This makes it possible to segment structures that appear somewhat homogeneous in medical images using very little human interaction. For example, the lateral ventricles in MRI can be segmented reliably, as can some types of tumors in CT and MRI. ITK-SNAP is open source software distributed under the GNU General Public License. It is written in C++ and it leverages the Insight Segmentation and Registration Toolkit (ITK) library. ITK-SNAP can read and write a variety of medical image formats, including DICOM, NIfTI, and Mayo Analyze. It also offers limited support for multi-component (e.g., diffusion tensor imaging) and multi-variate imaging data.
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Applications
ITK-SNAP has been applied in the following areas Carotid artery segmentation [3] Diffusion MRI Analysis [4] Target definition for cancer radiotherapy lung cancer radiotherapy [5] Prenatal Image Analysis Diagnosis of spina bifida [6] Virtual Reality in Medicine[7] Orthodontics[8] Brain morphometry Corpus callosum and ventricle analysis in 22q11.2 deletion syndrome [9] Hippocampus size and shape measurement in neurodegenerative disorders.[10] [11]
References
[1] http:/ / www. itksnap. org/ credits. php [2] http:/ / www. itksnap. org [3] Spangler, E.L.; Brown, C.; Roberts, J.A.; Chapman, B.E. (2007). "Evaluation of internal carotid artery segmentation by InsightSNAP" (http:/ / link. aip. org/ link/ ?PSISDG/ 6512/ 65123F/ 1). Proceedings of SPIE 6512 (5): 65123F. Bibcode2007SPIE.6512E.120S. doi:10.1117/12.709954. . Retrieved 2007-11-08. [4] Corouge, I.; Fletcher, T.; Joshi, S.; Gouttard, S.; Gerig, G. (Oct 2006). "Fiber tract-oriented statistics for quantitative diffusion tensor MRI analysis". Medical image analysis 10 (5): 786798. doi:10.1016/j.media.2006.07.003. ISSN1361-8415. PMID16926104. [5] Xiao, Y.; Werner-wasik, M.; Curran, W.; Galvin, J. (2006). "SU-EE-A2-03: Evaluation of Auto-Segmentation Tools for the Target Definition for the Treatment of Lung Cancer" (http:/ / link. aip. org/ link/ ?MPHYA6/ 33/ 1992/ 4). Medical Physics 33: 1992. doi:10.1118/1.2240194. . Retrieved 2007-11-08. [6] D'addario, V.; Pinto, V.; Pintucci, A.; Di Cagno, L. (2007). "OP13. 04: Accuracy of six sonographic signs in the prenatal dignosis of spina bifida" (http:/ / www. ingentaconnect. com/ content/ jws/ uog/ 2007/ 00000030/ 00000004/ art00428). Ultrasound in Obstetrics and Gynecology 30 (4): 498498. doi:10.1002/uog.4534. . Retrieved 2007-11-08. [7] Rizzi, S.H.; Banerjee, P.P.; Luciano, C.J. (2007). "Automating the Extraction of 3D Models from Medical Images for Virtual Reality and Haptic Simulations" (http:/ / ieeexplore. ieee. org/ xpls/ abs_all. jsp?arnumber=4341748). Automation Science and Engineering, 2007. CASE 2007. IEEE International Conference on. pp.152157. . [8] Cavidanes, L.H.; Styner, M.; Proffit, W.R. (2006). "Image analysis and superimposition of 3-dimensional cone beam computed tomography models" (http:/ / linkinghub. elsevier. com/ retrieve/ pii/ S0889540605012758). American Journal of Orthodontics and DentoFacial Orthopedics 129 (5): 611618. doi:10.1016/j.ajodo.2005.12.008. PMID16679201. . Retrieved 2007-11-08. [9] MacHado, A.M.C.; Simon, T.J.; Nguyen, V.; McDonald-mcginn, D.M.; Zackai, E.H.; Gee, J.C. (2007). "Corpus callosum morphology and ventricular size in chromosome 22q11. 2 deletion syndrome". Brain research 1131 (1): 197210. doi:10.1016/j.brainres.2006.10.082. PMC1802103. PMID17169351. [10] Apostolova, L.G.; Thompson, P.M. (2007). "Brain mapping as a tool to study neurodegeneration". Neurotherapeutics 4 (3): 387400. doi:10.1016/j.nurt.2007.05.009. PMC2634605. PMID17599704.
ITK-SNAP
[11] Krishnan, S.; Slavin, M.J.; Tran, T.T.; Doraiswamy, P.M.; Petrella, J.R. (2006). "Accuracy of spatial normalization of the hippocampus: implications for fMRI research in memory disorders" (http:/ / linkinghub. elsevier. com/ retrieve/ pii/ S1053811906000115). Neuroimage 31 (2): 560571. doi:10.1016/j.neuroimage.2005.12.061. PMID16513371. . Retrieved 2007-11-08.
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External links
Main ITK-SNAP website (http://itksnap.org) (downloads, bugs, mailing lists) ITK-SNAP on [[Sourceforge (http://sourceforge.net/projects/itk-snap)]]
Mango
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Mango
Mango, the machine-to-machine domotics software, is at Mango (domotics software)
Mango
Mango interface Developer(s) University of Texas Health Science Center at San Antonio Jack L. Lancaster Michael J. Martinez 2.0 Java
Stable release Written in
Operating system Cross-platform Type License Website Neuroimaging software Freeware ric.uthscsa.edu/mango [1]
Mango (Multi-Image Analysis GUI) is a non-commercial software for viewing, editing and analyzing volumetric medical images. Mango is written in Java, and distributed freely in precompiled versions for Linux, Mac OS and Microsoft Windows. It supports NIFTI [2], ANALYZE, NEMA and DICOM formats, and is able to load and save 2D, 3D and 4D images. Mango provides tools for creation and editing of regions of interest (ROI) within the images, surface rendering, image stacking (overlaying), filtering in space domain and histogram analysis, among other functions that can be used in neuroimaging analysis[3] [4] for scientific (non-clinical) purposes. The software can be extended with user-defined functions (plug-ins), which can be created using the Java language and the Mango API.
References
[1] http:/ / ric. uthscsa. edu/ mango [2] http:/ / nifti. nimh. nih. gov/ [3] Szab CA, Narayana S, Franklin C, et al. (Nov 2008). ""Resting" CBF in the epileptic baboon: Correlation with ketamine dose and interictal epileptic discharges". Epilepsy Res. 82 (1): 5965. doi:10.1016/j.eplepsyres.2008.07.015. PMID18801644. [4] Narayana S, Jacks A, Robin DA, et al. (Nov 2008). "A Non-Invasive Imaging Approach to Understanding Speech Changes following Deep Brain Stimulation in Parkinson's Disease". Am J Speech Lang Pathol 18 (2): 14661. doi:10.1044/1058-0360(2008/08-0004). PMC2779712. PMID19029533.
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External links
Mango website (http://ric.uthscsa.edu/mango/)
OsiriX
OsiriX
Stable release
3.9.2 / June 15, 2011
[1]
Operating system Mac OS X Type License Website Medical GNU General Public License http:/ / www. osirix-viewer. com
OsiriX is an image processing application dedicated to DICOM images (".dcm" / ".DCM" extension) produced by medical equipment (MRI, CT, PET, PET-CT, ...). Osirix is complementary to existing viewers, in particular to nuclear medicine viewers. It can also read many other file formats: TIFF (8,16, 32 bits), JPEG, PDF, AVI, MPEG and Quicktime. It is fully compliant with the DICOM standard for image communication and image file formats. OsiriX is able to receive images transferred by DICOM communication protocol from any PACS or medical imaging modality (STORE SCP - Service Class Provider, STORE SCU - Service Class User, and Query/Retrieve) .
History
The OsiriX project started in 2004 at UCLA with Dr Antoine Rosset and Prof. Osman Ratib[2] . OsiriX has been developed by Rosset, working in LaTour Hospital [3] (Geneva, Switzerland) and Joris Heuberger, a computer scientist from Geneva. In 2010, a version of OsiriX for iPhone and iPod touch was released. A complete history of OsiriX [4] is available here: http://www.osirix-viewer.com/UserManualIntroduction.pdf
Features
OsiriX has been specifically designed for navigation and visualization of multimodality and multidimensional images: 2D Viewer, 3D Viewer, 4D Viewer (3D series with temporal dimension, for example: Cardiac-CT) and 5D Viewer (3D series with temporal and functional dimensions, for example: Cardiac-PET-CT). The 3D Viewer offers all modern rendering modes: Multiplanar reconstruction (MPR), Surface Rendering, Volume Rendering and Maximum intensity projection (MIP). All these modes support 4D data and are able to produce image fusion between two different series (for example: PET-CT). Osirix is simultaneously a DICOM PACS workstation for medical imaging and an image processing software package for medical research (radiology and nuclear imaging), functional imaging, 3D imaging, confocal microscopy and molecular imaging. Osirix supports a complete plug-in architecture that allows one to expand the capabilities of OsiriX for personal needs. OsiriX is released under a free software licence and runs under Mac OS X.
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OsiriX Foundation
In 2008, the OsiriX Foundation was founded[5] . OsiriX Foundation will promote research and development and distribution of software tools for scientic and medical applications. It will host and help to promote research projects in Open Source software development for medical applications.
Usage as a medical device

The usage of software for diagnostic or therapeutic purposes is regulated by authorities. There are certified versions available which are labeled as Medical Device class II (FDA, USA) and class IIb (CE-Label, Europe) for clinical use. Pixmeo SARL <http://www.pixmeo.com> distributes OsiriX MD, a FDA cleared version.
External links
OsiriX [6] OsiriX MD (FDA cleared) [7] OsiriX PRO (FDA cleared and CE-labeled) [8] Users group [9] Osirix Fan Group [10]
Journal of Digital Imaging: OsiriX: An Open-Source Software for Navigating in Multidimensional DICOM Images [11] Radiographics: Navigating the Fifth Dimension: Innovative Interface for Multidimensional Multimodality Image Navigation [12] List of OsiriX Plug-ins [13]
References
[1] (http:/ / www. macupdate. com/ info. php/ id/ 14362/ osirix) [2] Journal of Digital Imaging: OsiriX: An Open-Source Software for Navigating in Multidimensional DICOM Images (http:/ / www. springerlink. com/ content/ x57mul0frg64apmh/ ) [3] http:/ / www. latour. ch [4] http:/ / www. osirix-viewer. com/ UserManualIntroduction. pdf [5] OsiriX Foundation - Excerpt of the Commercial Register of the State of Geneva, Switzerland (http:/ / ge. ch/ hrcintapp/ externalCompanyReport. action?companyOfrcId13=CH-660-7631008-7& lang=EN) [6] http:/ / www. osirix-viewer. com [7] http:/ / www. pixmeo. com [8] http:/ / www. aycan. com/ main/ products/ aycan-osirix-pro. html [9] http:/ / groups. yahoo. com/ group/ osirix/ [10] http:/ / www. radrounds. com/ group/ osirix/ [11] http:/ / www. springerlink. com/ content/ x57mul0frg64apmh/ [12] http:/ / radiographics. rsna. org/ content/ 26/ 1/ 299. full/ [13] http:/ / www. osirixplugins. com/ plugins. html
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Medical and biological signal applications

Medical monitor
A medical monitor or physiological monitor or display, is an electronic medical device that measures a patient's vital signs and displays the data so obtained, which may or may not be transmitted on a monitoring network. Physiological data are displayed continuously on a CRT or LCD screen as data channels along the time axis, They may be accompanied by numerical readouts of computed parameters on the original data, such as maximum, minimum and average values, pulse and respiratory frequencies, and so on. In critical care units of hospitals, bedside units allow continuous monitoring of a patient, with medical staff being continuously informed of the changes in general condition of a patient. Some monitors can even warn of pending fatal cardiac conditions before visible signs are noticeable to clinical staff, such as atrial fibrillation or premature ventricular contraction (PVC).
Analog monitoring
Medical monitor as used in anesthesia
Old analog patient monitors were based on oscilloscopes, and had one channel only, usually reserved for electrocardiographic monitoring (ECG). So, medical monitors tended to be highly specialized. One monitor would track a patient's blood pressure, while another would measure pulse oximetry, another the ECG. Later analog models had a second or third channel displayed in the same screen, usually to monitor respiration movements and blood pressure. These machines were widely used and saved many lives, but they had several restrictions, including sensitivity to electrical interference, base level fluctuations, and absence of numeric readouts and alarms. In addition, although wireless monitoring telemetry was in principle possible (the technology was developed by NASA in the late 1950s for manned spaceflight) it was expensive and cumbersome.
Digital monitoring
With the development of digital signal processing (DSP) technology, however, medical monitors evolved enormously, and all current models are digital, which also has the advantages of miniaturization and portability. Today the trend is toward multiparameter monitors that can track many different vital signs at once. The parameters (or measurements) now consist of pulse oximetry (measurement of the saturated percentage of oxygen in the blood, referred to as SpO2, and measured by an infrared finger cuff), ECG (electrocardiograph of the QRS waves of the heart with or without an accompanying external heart pacemaker), blood pressure (either invasively through an inserted blood pressure transducer assembly, or non-invasively with an inflatable blood pressure cuff), and body temperature through an adhesive pad containing a thermoelectric transducer. In some situations, other parameters can be measured and displayed, such as cardiac output (via an invasive Swan-Ganz catheter), capnography (CO2
Medical monitor measurements, referred to as EtCO2 or end-tidal carbon dioxide concentration), respiration (through a thoracic transducer belt, an ECG channel or via EtCO2, when it is called AWRR or airway respiratory rate), etc. Besides the tracings of physiological parameters along time (X axis), digital medical monitors have automated numeric readouts of the peak and/or average parameters displayed on the screen, and high/low alarm levels can be set, which alert the staff when some parameter exceeds of falls the level limits, using audible signals. Several models of multiparameter monitors are networkable, i.e., they can send their output to a central ICU monitoring station, where a single staff member can observe and respond to several bedside monitors simultaneously. Ambulatory telemetry can also be achieved by portable, battery-operated models which are carried by the patient and which transmit their data via a wireless data connection.
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Monitor/Defibrillators
Some digital patient monitors, especially those used EMS services,often incorporate a defibrillator into the patient monitor itself. These monitor/defibrillators usually have the normal capabilities of an ICU monitor, but have manual (and usually semi-automatic AED)defibrillation capability. This is particular good for EMS services, who need a compact, easy to use monitor and defibrillator, as well as for inter- or intrafacility patient transport. Most monitor defibrillators also have transcutaneous pacing capability via large AED like adhesive pads (which often can be used for monitoring, defibrillation and pacing)that are applied to the patient in an anterior-posterior configuration. The monitor defibrillator units often have specialized monitoring parameters such as waveform capnography, invasive BP, and in some monitors, Masimo Rainbow SET pulse oximetry. Examples of monitor defibrillators are the Lifepak 12, 15 and 20 made by Physio Control, the Philips Heartstart MRx, and the E Series and R Series by ZOLL Medical.
[[File:Semi-automated-external-monitor-defibrillator.jpg|thumb|ZOLL R Series Plus external monitor/defibrillator]
A Welch Allyn PIC 50 monitor/defibrillator from an Austrian EMS service.
A closeup view of the screen of the PIC 50.
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Special applications
There are special patient monitors for several applications, such as anesthesia monitoring, which incorporate the monitoring of brain waves (EEG, gas anesthetic concentrations, bispectral index (BIS), etc. They are usually incorporated into anesthesia machines. In neurosurgery intensive care units, brain EEG monitors have a larger multichannel capability and can monitor other physiological events, as well. Portable heart monitors are now very common too, and they exist in several configurations, ranging from single-channel models for domestic use, which are capable Portable wireless ECG monitor of storing or transmitting the signals for appraisal by a physician, to 12-lead complete, portable ECG machines which can store for 24 hours or more (so-called Holter monitoring devices). There are also portable monitors for blood pressure (MAPA) and EEG.
Monitor types
Monitors may be classified as: 1. 2. 3. 4. 5. 6. 7. Handheld Portable Monitor/Defibrillator (usually portable) Tabletop Networkable / non-networkable Wired / wireless data transmission Mains powered or mains + battery powered
Integration with EHR

Digital monitoring has created the possibility, which is being fully developed, of integrating the physiological data from the patient monitoring networks into the emerging hospital electronic health record and digital charting systems, using appropriate health care standards which have been developed for this purpose by organizations such as IEEE and HL7. This newer method of charting patient data reduces the likelihood of human documentation error and will eventually reduce overall paper consumption. In addition, automated ECG interpretation incorporates diagnostic codes automatically into the charts. Medical monitor's embedded software can take care of the data coding according to these standards and send messages to the medical records application, which decodes them and incorporates the data into the adequate fields.
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Patient safety
Medical monitors have been safety engineered so that failures are either apparent or unimportant.. Some monitors (for example ECG and EEG) have an electrical contact with the patient, so they can be hazardous if electrical current passes through these electrodes in case of grounding failures. There are strict limits on how much current and voltage can be applied, even if the unit fails or becomes wet. They must typically withstand electrical defibrillation without damage.
Holter monitor
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Holter monitor
Holter monitor
Holter monitor Inventor Norman Holter
In medicine, a Holter monitor (often simply "Holter" or occasionally ambulatory electrocardiography device) is a portable device for continuously monitoring various electrical activity of the central nervous system for at least 24 hours (often for two weeks at a time). The Holter's most common use is for monitoring heart activity (electrocardiography or ECG), but it can also be used for monitoring brain activity (electroencephalography or EEG). Its extended recording period is sometimes useful for observing occasional cardiac arrhythmias or epileptic events which would be difficult to identify in a shorter period of time. For patients having more transient symptoms, a cardiac event monitor which can be worn for a month or more can be used. The Holter monitor is named for physicist Norman J. Holter who invented telemetric cardiac monitoring in 1949.[1] Clinical use started in the early 1960s.[1] When used for the heart, much like standard electrocardiography the Holter monitor records electrical signals from the heart via a series of electrodes attached to the chest. Electrodes are placed over bones to minimize artifacts from muscular activity. The number and position of electrodes varies by model, but most Holter monitors employ between three and eight. These electrodes are connected to a small piece of equipment that is attached to the patient's belt or hung around the neck, and is responsible for keeping a log of the heart's electrical activity throughout the recording period. Older devices used reel to reel tapes or a standard C90 or C120 audio cassette and ran at a 1.7mm or 2mm/second speed to record the data. Once a recording was made, it could be played back and analysed at 60x speed so 24 hours of recording could be analysed in 24 minutes. More modern units record onto digital flash memory devices. The data are uploaded into a computer which then automatically analyzes the input, counting ECG complexes, calculating summary statistics such as average heart rate, minimum and maximum heart rate, and finding candidate areas in the recording worthy of further study by the technician.
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Recorder
Each Holter system consists of two basic parts the hardware (called monitor or recorder) for recording the signal and software for review and analysis of the record. Advanced Holter recorders are able to display the signal, which is very useful for checking the signal quality. Very often there is also a patient button located on the front site allowing the patient to press it in specific cases such as sickness, going to bed, taking pills. A special mark will be then placed into the record so that the doctors or technicians can quickly pinpoint these areas when analyzing the signal. More modern devices also have the ability to record a vocal patient diary entry. Size of recorder differs depending on manufacturer of the device. The average dimensions of todays Holter monitors are about 110x70x30 mm. Most of the devices operate with two AA batteries. In case the batteries are depleted, some Holters allow their replacement even during monitoring. Most of the Holters monitor the ECG just in two or three channels. Depending on the model (manufacturer), different count of leads and lead systems are used. Todays trend is to minimize such number to insure the patients comfort during recording. Although 2/3 channel recording has been used for a long time in the Holter monitoring history, recently 12 channel Holters have appeared. These systems use the classic Mason-Likar lead system, thus producing the signal in the same representation as during the common rest ECG and/or stress test measurement. These Holters then allow to substitute stress test examination in cases the stress test is not possible for the current patient. They are also suitable when analyzing patients after myocardial infarction. Recordings from these 12-lead monitors are of a significantly lower resolution than those from a standard 12-lead ECG and in some cases have been shown to provide misleading ST segment representation, even though some device allow to set the sampling frequency up to 1000 Hz for special purposes exams like the late potential. Another interesting innovation is the presence of a triaxial movement sensor, which record the patient physical activity, and later show in the software three different status: sleep, stand-up, walking. This helps the cardiologist to better analyze the recorded events belong to the patient activity and diary.
Analysing software
When the recording of ECG signal is finished (usually after 24 or 48 hours), it is up to the physician to perform the signal analysis. Since it would be extremely time demanding to browse through such a long signal, there is an integrated automatic analysis process in each Holter software which automatically determines different sorts of heart beats, rhythms, etc. However the success of the automatic analysis is very closely associated with the signal quality. The quality itself mainly depends on the attachment of the electrodes to the patient body. If these are not properly attached, the electromagnetic disturbance surrounding us will influence the ECG signal resulting thus in a very noisy record. If the patient moves rapidly, the distortion will be even bigger. Such record is then very difficult to process. Besides the attachment and quality of electrodes, there are other factors affecting the signal quality, such as muscle tremors, sampling rate and resolution of the digitized signal (high quality devices offer 2000Hz and 16 bits or higher). The automatic analysis commonly provides the physician with information about heart beat morphology, beat interval measurement, heart rate variability, rhythm overview and patient diary (moments when the patient pressed the patient button). Advanced systems also perform spectral analysis, ischemic burden evaluation, graph of patients activity or PQ segment analysis. Another requirement is the ability of pacemaker detection and analysis. Such ability is useful when one wants to check the correct pacemaker function.
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Screenshot of Holter ECG software.
Wearing the monitor

Although some patients may feel uncomfortable about a Holter examination, there is nothing to worry about. No hazards are involved, and it should have little effect on one's normal daily life. The recording device can be worn in a case on a belt or on a strap across the chest. The device may be visible under light clothing, and those wearing a Holter monitor may wish to avoid shirts with a low neckline. Persons being monitored should not limit normal daily activities,since its purpose is to record how a heart works under various actual conditions over an extended period. It is an electrical device, however, and should be kept dry; showering or swimming should probably be avoided. Monitors can be removed for a few minutes without invalidating collected data, but proper reattachment is critical to avoid degradation of its signals. Beyond changing batteries, one should leave its handling to trained personnel.
Gallery
A Holter monitor can be worn for many days without causing significant discomfort.
Canine Holter Monitor with DogLeggs Vest
A Holter monitor with a US quarter dollar coin to show scale
Holter monitor can be worn with bra on woman, with no discomfort.
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References
[1] Hilbel, Thomas; Thomas M Helms, Gerd Mikus, Hugo A Katus, Christian Zugck (01/10/2008). "Telemetry in the clinical setting" (https:/ / www. researchgate. net/ publication/ 23423927_Telemetry_in_the_clinical_setting). Herzschrittmachertherapie & Elektrophysiologie 19 (3): 14664. ISSN0938-7412. . Retrieved 2009-Aug-04.
External links
Holter monitor - MedLine Plus (http://www.nlm.nih.gov/medlineplus/ency/article/003877.htm) Holter monitor - Texas Heart Institute (http://www.texasheart.org/HIC/Topics/Diag/diholt.cfm) Holter Monitor information (http://heart.seattlechildrens.org/what_to_expect/holter_monitor.asp) from Children's Hospital Heart Center, Seattle.
Automated ECG interpretation

Automated ECG interpretation is the use of artificial intelligence and pattern recognition software and knowledge bases to carry out automatically the interpretation, test reporting and computer-aided diagnosis of electrocardiogram tracings obtained usually from a patient.
History
The first automated ECG programs were developed in the 1970s, when digital ECG machines became possible by third generation digital signal processing boards. Commercial models, such as those developed by Hewlett Packard incorporated these programs into clinically-used devices.
Screenshot of a software for digital ECG processing
During the 1980s and 1990s, extensive research was carried out by companies and by university labs in order to improve the accuracy rate, which was not very large in the first models. For this purpose, several signal databases with normal and abnormal ECGs were built up by institutions such as MIT and used to test the algorithms and its accuracy.
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Phases
1. A digital representation of each recorded ECG channel is obtained, by means of an analog-digital conversion device and a special data acquisition software or a digital signal processing (DSP) chip. 2. The resulting digital signal is processed by a series of specialized algorithms, which start by conditioning it, e.g., removal of noise, baselevel variation, etc. 3. Feature extraction: matemathical analysis is now performed on the clean signal of all channels, to identify and measure a number of features which are important for interpretation and diagnosis, this will constitute the input to AI-based programs, such as the peak amplitude, area under the curve, displacement in relation to baseline, etc., Basic signal features of time and amplitude which are measured and form the basis of the P, Q, R, S and T waves[1] , the time for automated ECG analysis delay between these peaks and valleys, heart rate frequency (instantaneous and average), and many others. Some sort of secondary processing such as Fourier analysis and wavelet analysis[2] may also be performed in order to provide input to pattern recognition-based programs. 4. Logical processing and pattern recognition, using rule-based expert systems[3] , probabilistic Bayesian analysis or fuzzy logics algorithms, cluster analysis[4] , artificial neural networks[5] , genetic algorithms and others techniques are used to derive conclusions, interpreation and diagnosis 5. A reporting program is activated and produces a proper display of original and calculated data, as well as the results of automated interpretation. 6. In some applications, such as automatic defibrillators, an action of some sort may be triggered by results of the analysis, such as the occurrence of an atrial fibrillation or a cardiac arrest, the sounding of alarms in a medical monitor in intensive-care unit applications, and so on.
Applications
The manufacturing industries of ECG machines is now entirely digital, and many models incorporate embedded software for analysis and interpretation of ECG recordings with 3 or more leads. Consumer products, such as home ECG recorders for simple,1-channel heart arrhythmia detection, also use basic ECG analysis, essentially to detect abnormalities. Some application areas are: Incorporation into automatic defibrillators, so that autonomous decision can be reached wheter there is a cause for administering the electrical shock on basis of an atrial or ventricular arryhtmia; Portable ECG used in telemedicine. These machines are used to send ECG recordings via a telecommunications link, such as telephone, cellular data communication or Internet Conventional ECG machines to be used in primary healthcare settings where a trained cardiologist is not available
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References
[1] BioPac Systems. Application Note: Automated ECG Analysis (http:/ / www. biopac. com/ Manuals/ app_pdf/ app148. pdf) [2] Al-Fahoum, AS; Howitt,I. Combined wavelet transformation and radial basis neural networks for classifying life threatening cardiac arrhythmias, Med. Biol. Eng. Comput. 37 (1999), pp. 566573. [3] Mautgreve, W., et al. HES EKG expert-an expert system for comprehensive ECG analysis and teaching. Proc. Computers in Cardiology: Jerusalem, Israel was used by laalu prasad yadav and his servant george bush 1922 September 1989. (USA: IEEE Comput. Soc. Press, 1990. p. 77-80). [4] Bortolan, G., et al. ECG classification with neural networks and cluster analysis. Proc. Computers in Cardiology. Venice, Italy, 2326 September 1991. (USA: IEEE Comput. Soc. Press, 1991. p. 177-80). [5] Sabbatini, R.M.E. Applications of artificial neural networks in biological signal processing. MD Computing, 3(2), 165-172 March 1996.
Source
Sabbatini, RME: O computador no processamento de sinais biolgicos (http://www.informaticamedica.org.br/ informed/sinais.htm). Revista Informdica, 2 (12): 5-9, 1995. Computers in the processing of biological signals. (In Portuguese) Translated and reproduced by permission of the author.
External links
Kligfield, P. Automated Analysis of ECG Rhythm (http://www.clinicalwindow.liitin.net/dl/ Art20_1(Kligfield1_6f).pdf) Physionet (http://www.physionet.org)
Open ECG project

The openECGproject is an online community dedicated to developing an open-source hardware and software solution for electrocardiography. The project addresses the needs of doctors and hospitals, especially in the Third World, who are unable to afford expensive commercial products. The ultimate goal of the project is to produce a 12-lead PC-based ECG with interpretive software.[1] OpenECGproject also aims to develop a wireless ECG device as well as versions for handheld devices, including smartphones.
References
[1] "Get on Board with Open-Source ECG Project" (http:/ / www. medgadget. com/ archives/ 2008/ 12/ get_on_board_with_opensource_ecg_project. html). medGadget. December 4, 2008. .
External links
Open ECG Project (http://www.open-ecg-project.org/tiki-read_article.php?articleId=1)
MECIF Protocol
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MECIF Protocol
The MECIF Protocol (Medical Computer Interface Protcol), is a rare communications protocol originally developed by Hewlett-Packard to allow external devices (e.g. computers) to communicate with certain Hewlett-Packard patient monitors. It is a clientserver based protocol that uses a modified RS-232 cable to allow a client (e.g. a computer) to send commands to a server (e.g. patient monitor)[1] . The protocol can be used to retrieve vital data from patient monitors, such as ECG, blood pressure and heart-rate signals. Ownership of the protocol has changed hands many times and was most recently supported by Philips [2] . Due to the complexity of the protocol, very few software applications currently support it.
References
[1] (http:/ / anestit. unipa. it/ software/ TEngel_Abstracts. html#STA93), A Macintosh Client for the Hewlett-Packard Component Monitoring System [2] (https:/ / woc. dei. uc. pt/ weboncampus/ getFile. do?tipo=2& id=9816), RS232 Computer Interface Programming Guide
External links
MECIFView (http://www.mecifview.com) - Software application for acquiring data from patient monitors using the MECIF protocol record (http://physionet.caregroup.harvard.edu/physiotools/record/) - Software tools for communicating using the MECIF protocol
SCP-ECG
SCP-ECG, which stands for Standard communications protocol for computer assisted electrocardiography, is a standard for ECG traces, annotations, and metadata, that specifies the interchange format and a messaging procedure for ECG cart-to-host communication and for retrieval of SCP-ECG records from the host to the ECG cart. It is defined in the joint ANSI/AAMI standard EC71:2001 and in the CEN standard EN 1064:2005.
History
The SCP Standard was first developed between 1989 to 1991 during a European AIM R&D project.
External links
"OpenECG" [1] The [OpenECG] [1] Group supports SCP-ECG by providing and supporting open source implementations and consistent application the standard.
Other ECG data formats

DICOM, HL7 aECG
References
[1] http:/ / www. openecg. net/
European Data Format
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European Data Format

European Data Format (EDF) is a standard file format designed for exchange and storage of medical time series. Being an open and non-proprietary format, EDF(+) is commonly used to archive, exchange and analyse data from commercial devices in a format that is independent of the acquisition system. In this way, the data can be retrieved and analyzed by independent software. EDF(+) software (browsers, checkers, ...) and example files are freely available. EDF was published in 1992 and stores multichannel data, allowing different sample rates for each signal. Internally it includes a header and one or more data records. The header contains some general information (patient identification, start time...) and technical specs of each signal (calibration, sampling rate, filtering, ...), coded as ASCII characters. The data records contain samples as little-endian 16-bit integers. EDF is a popular format for polysomnography (PSG) recordings. EDF+ was published in 2003 and is largely compatible to EDF: all existing EDF viewers also show EDF+ signals. But EDF+ files also allow coding discontinuous recordings as well as annotations, stimuli and events in UTF-8 format. EDF+ has applications in PSG, electroencephalography (EEG), electrocardiography (ECG), electromyography (EMG), and Sleep scoring. EDF+ can also be used for nerve conduction studies, evoked potentials and other data acquisition studies.
References
Kemp B, Vrri A, Rosa AC, Nielsen KD, Gade J (May 1992). "A simple format for exchange of digitized polygraphic recordings". Electroencephalogr Clin Neurophysiol 82 (5): 3913. PMID1374708. EDF reference. Kemp B, Olivan J (September 2003). "European data format 'plus' (EDF+), an EDF alike standard format for the exchange of physiological data" [1]. Clin Neurophysiol 114 (9): 175561. PMID12948806. EDF specification, examples and tools [2]
External links
The EDFgroup [3] A sample of normal sleep recordings in EDF format [4]
References
[1] [2] [3] [4] http:/ / linkinghub. elsevier. com/ retrieve/ pii/ S1388245703001238 http:/ / www. edfplus. info/ http:/ / tech. groups. yahoo. com/ group/ EDF http:/ / www. physionet. org/ physiobank/ database/ sleep-edf/
OpenXDF
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OpenXDF
OpenXDF
Filename extension .xdf
Uniform Type Identifier org.openxdf.xdf Latest release Type of format 1.2 / June 30, 2009 Electroencephalography and Polysomnography
The Open eXchange Data Format, or OpenXDF, is an open, XML-based standard for the digital storage and exchange of time-series physiological signals and metadata. OpenXDF primarily focuses on electroencephalography and polysomnography.
History
Neurotronics began work on OpenXDF in 2003 with the goal of providing a modern, open, and extensible file format with which clinicians and researchers can share physiological data and metadata, such as signal data, signal montages, patient demographics, and event logs. Neurotronics released the first draft of the OpenXDF Specification just before the 18th meeting of the Associated Professional Sleep Societies in 2004. Neurotronics has since relinquished control of the format to the OpenXDF Consortium. As of version 1.0, OpenXDF is 100% backward compatible with the European Data Format (EDF), the current defacto standard format for physiological data exchange.
Features
Tiered Structure
OpenXDF is a tiered framework designed to allow standardized and custom specializations of the format while enforcing a common foundation that provides a high-level of compatibility between unrelated systems.
Metadata
OpenXDF expands on EDF by providing standardized support for extensive patient information, display montages, annotations, and scoring information.
UNICODE Support
OpenXDF requires the use of a XML 1.0 compliant parser that supports UTF-8 and UTF-16.
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Signal Configuration
OpenXDF supports fully and independently configurable data signals. Each signal specifies its byte order, whether its samples are signed, the size of its samples, and its sampling rate.
Security
OpenXDF supports encryption of the XML file using TwoFish in Cipher Feedback (CFB) mode with a 256-bit key created from a UTF-8 encoded password hashed with SHA-256. In addition, OpenXDF supports integrity verification using a SHA-512 hash of the original XML file.
References
OpenXDF Web Site (http://www.openxdf.org) OpenXDF Specification (http://www.openxdf.org/spec.php)
External links
European Data Format (EDF) Specifications (http://www.edfplus.info)
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Databases, Digital Libraries and Literature Retrieval

Biological database
Biological databases are libraries of life sciences information, collected from scientific experiments, published literature, high-throughput experiment technology, and computational analyses. They contain information from research areas including genomics, proteomics, metabolomics, microarray gene expression, and phylogenetics.[1] Information contained in biological databases includes gene function, structure, localization (both cellular and chromosomal), clinical effects of mutations as well as similarities of biological sequences and structures. Relational database concepts of computer science and Information retrieval concepts of digital libraries are important for understanding biological databases. Biological database design, development, and long-term management is a core area of the discipline of bioinformatics.[2] Data contents include gene sequences, textual descriptions, attributes and ontology classifications, citations, and tabular data. These are often described as semi-structured data, and can be represented as tables, key delimited records, and XML structures. Cross-references among databases are common, using database accession numbers.
Overview
Biological databases are an important tool in assisting scientists to understand and explain a host of biological phenomena from the structure of biomolecules and their interaction, to the whole metabolism of organisms and to understanding the evolution of species. This knowledge helps facilitate the fight against diseases, assists in the development of medications and in discovering basic relationships amongst species in the history of life. Biological knowledge is distributed amongst many different general and specialized databases. This sometimes makes it difficult to ensure the consistency of information. Biological databases cross-reference other databases with accession numbers as one way of linking their related knowledge together. An important resource for finding biological databases is a special yearly issue of the journal Nucleic Acids Research (NAR). The Database Issue of NAR [3] is freely available, and categorizes many of the publicly available online databases related to biology and bioinformatics.
Output
Biological data comes in many formats. These formats include text, sequence data, protein structure and links. Each of these can be found from certain sources, for example: Text formats are provided by PubMed and OMIM. Sequence data are provide by GenBank, in terms of DNA, and UniProt, in terms of protein. Protein structures are provided by PDB, SCOP, and CATH.
Biological database
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Problems associated with protein databases

Since discovery in the area of protein structure has not evolved quite as quickly as discoveries in the area sequence data, due to the 3D nature of protein structure, less information is available for it. Nonetheless, data can be accessed through members of the wwPDB (PDBe [4], PDBj [5] and RCSB PDB [6], SCOP-Structural Classification of Proteins- at ([7]), and CATH at ([8]).
Species-specific databases
Species-specific databases are available for some species, mainly those that are often used in research. For example, Colibase ([9]) is an E. coli database. Other popular species specific databases include, Flybase ([10]) for Drosophila, and WormBase ([11]) for the nematodes Caenorhabditis elegans and Caenorhabditis briggsae.
References
[1] Altman RB (March 2004). "Building successful biological databases" (http:/ / bib. oxfordjournals. org/ cgi/ pmidlookup?view=long& pmid=15153301). Brief. Bioinformatics 5 (1): 45. doi:10.1093/bib/5.1.4. PMID15153301. . [2] Bourne P (August 2005). "Will a biological database be different from a biological journal?". PLoS Comput. Biol. 1 (3): 17981. doi:10.1371/journal.pcbi.0010034. PMC1193993. PMID16158097. [3] http:/ / www3. oup. co. uk/ nar/ database/ c/ [4] http:/ / www. pdbe. org [5] http:/ / www. pdbj. org [6] http:/ / www. pdb. org [7] http:/ / scop. berkeley. edu/ [8] http:/ / www. cathdb. info/ [9] http:/ / colibase. bham. ac. uk/ [10] http:/ / flybase. bio. indiana. edu/ [11] http:/ / www. wormbase. org/
http://www.avatar.se/molbioinfo2001/databases.html
External links
Wiki of biological databases (http://biodatabase.org/index.php/Main_Page) Interactive list of biological databases (http://www.oxfordjournals.org/nar/database/c/), classified by categories, from Nucleic Acids Research, 2010 Genome Proteome Search Engine (http://www.gpse.org) to search across biological databases DBD: Database of Biological Databases (http://www.biodbs.info) CAMERA (http://camera.calit2.net/index.php) Cyberinfrastructure for Metagenomics, free data repository and bioinformatics tools for metagenomics.
Medical literature retrieval
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Medical literature retrieval

Medical literature retrieval or medical document retrieval is an activity that uses professional methods for medical research papers retrieval, report and other data to improve medicine research and practice.
Medical Search engine

Professional medical search engine
Pubmed GoPubMed[1] Pubget eTBLAST Cochrane Reviews, The Cochrane Library
Meta-search tools TRIP Database NLM Gateway Entrez, NLM's cross-database search SUMSearch
Consumer health search engine

MedlinePlus by the U.S. NLM Healthfinder by the U.S. HHS Mednar Healthline Medstory Healia
Reference
[1] http:/ / www. transinsight. com/ peopleAbout
External links
MEDLINE/PubMed (http://www.pubmed.gov/) William R. Hersh. Information Retrieval: A Health and Biomedical Perspective (http://medir.ohsu.edu/~hersh/ irbook/). 2003, Springer-Verlag. ISBN 0387955224 The Top Five Medical Search Engines on the Web (http://websearch.about.com/od/enginesanddirectories/tp/ medical.htm?terms=Medical+search engine) at About.com by Wendy Boswell
MEDLINE
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MEDLINE
MEDLINE (Medical Literature Analysis and Retrieval System Online) is a bibliographic database of life sciences and biomedical information. It includes bibliographic information for articles from academic journals covering medicine, nursing, pharmacy, dentistry, veterinary medicine, and health care. MEDLINE also covers much of the literature in biology and biochemistry, as well as fields such as molecular evolution. Compiled by the United States National Library of Medicine (NLM), MEDLINE is freely available on the Internet and searchable via PubMed and NLM's National Center for Biotechnology Information's Entrez system.
The database
The database contains more than 18 million records from approximately 5,000 selected publications[1] covering biomedicine and health from 1950 to the present. Originally the database covered articles starting from 1965, but this has been enhanced, and records as far back as 1950/51 are now available within the main index. The database is freely accessible on the Internet via the PubMed interface and new citations are added Tuesday through Saturday. For citations added during 1995-2003: about 48% are for cited articles published in the U.S., about 88% are published in English, and about 76% have English abstracts written by authors of the articles.
Retrieval
MEDLINE uses Medical Subject Headings (MeSH) for information retrieval. Engines designed to search MEDLINE (such as Entrez and PubMed) generally use a Boolean expression combining MeSH terms, words in abstract and title of the article, author names, date of publication, etc. Entrez and PubMed can also find articles similar to a given one based on a mathematical scoring system that takes into account the similarity of word content of the abstracts and titles of two articles.[2]
Importance
MEDLINE functions as an important resource for biomedical researchers and journal clubs from all over the world. Along with the Cochrane Library and a number of other databases, MEDLINE facilitates evidence-based medicine. Most systematic review articles published nowadays build on extensive searches of MEDLINE to identify articles that might be useful in the review. MEDLINE influences researchers in their choice of journals in which to publish: few biomedical researchers today consider publishing in a journal not indexed by MEDLINE, because other researchers would not find (or cite) their work.
Inclusion of journals
Approximately 5,000 biomedical journals are indexed in MEDLINE. New journals are not included automatically or immediately. Selection is based on the recommendations of a panel, the Literature Selection Technical Review Committee, based on scientific scope and quality of a journal.[3] The Journals Database (one of the Entrez databases) contains information, such as its name abbreviation and publisher, about all journals included in Entrez, including PubMed.[4]
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Usage
Searching MEDLINE effectively is a learned skill; untrained users are sometimes frustrated with the large numbers of articles returned by simple searches. Counterintuitively, a search that returns thousands of articles is not guaranteed to be comprehensive. Unlike using a typical internet search engine, PubMed searching of MEDLINE requires a little investment of time. Using the MeSH database to define the subject of interest is one of the most useful ways to improve the quality of a search. Using MeSH terms in conjunction with limits (such as publication date or publication type), qualifiers (such as adverse effects or prevention and control), and text-word searching is another. Finding one article on the subject and clicking on the "Related Articles" link to get a collection of similarly classified articles can expand a search that yields few results.
Online access
PubMed iPubMed: featuring instant search [5] MEDSUM [6] - MEDLINE Summary tool: Interface to MEDLINE that returns graphs and tables of summary data. GoPubMed - Explore PubMed/MEDLINE with Gene Ontology HubMed - An alternative interface to the PubMed medical literature database. eTBLAST - a natural language text similarity engine for MEDLINE and other text databases. Medscape Twease - an open-source biomedical search engine
References
[1] "Data, News and Update Information" (http:/ / www. nlm. nih. gov/ bsd/ revup/ revup_pub. html#med_update). NLM Systems. 2009-03-30. . Retrieved 2009-04-13. [2] "PubMed related articles: a probabilistic topic-based model for content similarity" (http:/ / www. biomedcentral. com/ 1471-2105/ 8/ 423). BMC Bioinformatics (2007) 8:423. 2007-10-30. . Retrieved 2011-05-30. [3] "MEDLINE Journal Selection Fact Sheet" (http:/ / www. nlm. nih. gov/ pubs/ factsheets/ jsel. html). LSTRC. . Retrieved 2009-04-13. [4] "PubMed Tutorial - Building the Search - Search Tools - Journals Database" (http:/ / www. nlm. nih. gov/ bsd/ disted/ pubmedtutorial/ 020_550. html). . Retrieved 2009-09-06. [5] http:/ / ipubmed. ics. uci. edu/ [6] http:/ / www. medsum. info
External links
iPubMed (http://ipubmed.ics.uci.edu) Search MEDLINE/PubMed through interactive and fuzzy search PubMed Tutorials (http://www.nlm.nih.gov/bsd/pubmed_tutorial/m1001.html) MEDLINE Journal Selection (http://www.nlm.nih.gov/pubs/factsheets/jsel.html) EMBASE information site (http://www.info.embase.com)
Entrez
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Entrez
The Entrez Global Query Cross-Database Search System is a powerful federated search engine, or web portal that allows users to search many discrete health sciences databases at the National Center for Biotechnology Information (NCBI) website. The NCBI is a part of the National Library of Medicine (NLM), which is itself a department of the National Institutes of Health (NIH), which in turn is a part of the United States Department of Health and Human Services. "Entrez" also happens to be the second person plural (or formal) form of the French verb "entrer (to enter)", meaning the invitation "Come in!".
The Entrez logo
Entrez Global Query is an integrated search and retrieval system that provides access to all databases simultaneously with a single query string and user interface. Entrez can efficiently retrieve related sequences, structures, and references. The Entrez system can provide views of gene and protein sequences and chromosome maps. Some textbooks are also available online through the Entrez system.
Features
The Entrez front page provides, by default, access to the global query. All databases indexed by Entrez can be searched via a single query string, supporting boolean operators and search term tags to limit parts of the search statement to particular fields. This returns a unified results page, that shows the number of hits for the search in each of the databases, which are also links to actual search results for that particular database. Entrez also provides a similar interface for searching each particular database and for refining search results. The Limits feature allows the user to narrow a search a web forms interface. The History feature gives a numbered list of recently performed queries. Results of previous queries can be referred to by number and combined via boolean operators. Search results can be saved temporarily in a Clipboard. Users with a MyNCBI account can save queries indefinitely and also choose to have updates with new search results e-mailed for saved queries of most databases. It is widely used in the field of biotechnology to enhance the knowledge of students worldwide.
Databases
Entrez searches the following databases: PubMed: biomedical literature citations and abstracts, including Medline - articles from (mainly medical) journals, often including abstracts. Links to PubMed Central and other full-text resources are provided to articles from the 1990s. PubMed Central: free, full text journal articles Site Search: NCBI web and FTP web sites Books: online books OMIM: online Mendelian Inheritance in Man OMIA: online Mendelian Inheritance in Animals Nucleotide: sequence database (GenBank) Protein: sequence database Genome: whole genome sequences and Mapping Structure: three-dimensional macromolecular structures Taxonomy: organisms in GenBank Taxonomy SNP: single nucleotide polymorphism
Entrez Gene [1]: gene-centered information HomoloGene: eukaryotic homology groups PubChem Compound: unique small molecule chemical structures PubChem Substance: deposited chemical substance records Genome Project: genome project information UniGene: gene-oriented clusters of transcript sequences CDD: conserved protein domain database UniSTS: markers and mapping data PopSet: population study data sets (epidemiology) GEO Profiles: expression and molecular abundance profiles GEO DataSets: experimental sets of GEO data Sequence read archive: high-throughput sequencing data Cancer Chromosomes: cytogenetic databases PubChem BioAssay: bioactivity screens of chemical substances GENSAT: gene expression atlas of mouse central nervous system[2] Probe: sequence-specific reagents
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NLM Catalog: NLM bibliographic data for over 1.2 million journals, books, audiovisuals, computer software, electronic resources, and other materials resident in LocatorPlus (updated every weekday).
Accessing Entrez
In addition to using the search engine forms to query the data in Entrez, NCBI provides the Entrez Programming Utilities [3] (eUtils) for more direct access to query results. The eUtils are accessed by posting specially formed URLs to the NCBI server, and parsing the XML response. There is also an eUtils SOAP interface.
References
[1] http:/ / www. ncbi. nlm. nih. gov/ sites/ entrez?db=gene [2] Gong, Shiaoching; et al. (2003). "A gene expression atlas of the central nervous based on bacterial artificial chromosomes" (http:/ / www. rockefeller. edu/ labheads/ chait/ pdf/ 03_gong_nature. pdf). Nature 425 (6961): 917925. doi:10.1038/nature02033. PMID14586460. . [3] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query/ static/ eutils_help. html
External links
Entrez search engine form (http://www.ncbi.nlm.nih.gov/sites/gquery) Entrez Help (http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=helpentrez.chapter.EntrezHelp) Genome Proteome Search Engine (http://www.gpse.org)
ETBLAST
258
ETBLAST
eTBLAST is a free text similarity service search engine currently offering access to the MEDLINE database, the National Institutes of Health (NIH) CRISP database, the Institute of Physics (IOP) database, Wikipedia, arXiv, the NASA technical reports database, Virginia Tech class descriptions and a variety of databases of clinical interest. It is continuously expanding with additional text-based databases. eTBLAST searches citation databases[1] [2] [3] and databases containing full text[4] , such as PUBMED. The eTBLAST server compares a user's natural text query to target databases using a hybrid search algorithm consisting of a low-sensitivity weighted keyword-based first pass followed by a novel sentence-alignment based second pass. eTBLAST is a free web-based service of The Innovation Laboratory [5] at the Virginia Bioinformatics Institute. eTBLAST, as a text similarity engine, made possible a large study of duplicate publications and potential plagiarisms in the biomedical literature. Thousands of random samples of Medline abstracts were submitted to eTBLAST, and those with the highest similarity were studied and entered into a on-line database. This study is on-going, with the database maturing as the entries are manually inspected and classified. This work revealed several trends, including an increasing rate of duplication in the biomedical literature, as reported in the journals Bioinformatics[6] [7] , Anaesthesia and Intensive Care [8] , Clinical Chemistry [9] , Urologic Oncology [10] , Nature[11] , and Science.[12]
Interface
Because eTBLAST is a text-similarity engine rather than a simple keyword-based search tool, it is claimed that the user need not identify and manipulate query keywords and Boolean operators, as must be done for other search engines. eTBLAST aims to help the user rapidly to find references, evaluate novelty, find experts and journals in a given topical area[13] and track the popularity of the topic as defined by the users query. There also is information found within the results as a set, in addition to those found within individual 'hits'. eTBLAST can also infer possible hypothese from inspection of implicit keywords found within the top most similar 'hits'. A matrix of similarity and a heat map are also displayed for the most similar 'hits'. A typical query of 120 words takes less than 10 seconds to return results after a comparison to MEDLINE that as of 8/1/2011 contains over 20 million records.
References
[1] Lewis J, Ossowski S, Hicks J, Errami M., and Garner HR. (2006). "Text Similarity: an alternative way to search MEDLINE". Bioinformatics 22 (18). [2] Pertsemlidis A, Prikhodko N, and Garner HR. (2003). Text comparison based on dynamic programming. Proceeding of the Pacific Symposium on Biocomputing, Kauai, Hawaii. [3] Pertsemlidis A and Garner HR. (2004). "Text Comparison Based on Dynamic Programming". IEEE Engineering in Biology and Medicine 23 (16). [4] Z. Sun, M. Errami, T. Long, C. Renard, N. Choradia, H.R. Garner (2010). "Systematic characterizations of text similarity in full text biomedical publications". PLoS ONE 9 (9). doi:10.1371. PMID18056062. [5] http:/ / etblast. org [6] Errami M, Hicks JM, Fisher W (January 2008). "Dj vu--a study of duplicate citations in Medline" (http:/ / bioinformatics. oxfordjournals. org/ cgi/ content/ full/ 24/ 2/ 243). Bioinformatics 24 (2): 2439. doi:10.1093/bioinformatics/btm574. PMID18056062. . [7] M. Errami, J. Sun, T. Long, A. George and H. R. Garner (2010). "Identifying duplicate content using Statistically Improbable Phrases". Bioinformatics 26 (11). [8] Loadsman JA, Garner HR, Drummond GB (2008). Anaesth Intensive Care 36 (5). [9] Tara Long, Angela George, Harold R. Garner (2010). "Quaere verum: Responding to the editorial, "Primum non Nocere"". Clinical Chemistry. [10] Harold R. Garner (2010). "Combating unethical publications with plagiarism detection services". Urol Oncol 29 (1).
ETBLAST
[11] Errami M (http:/ / m. errami. googlepages. com), Garner H (http:/ / www. utsouthwestern. edu/ findfac/ professional/ 0,,12465,00. html) (Jan 2008). "A tale of two citations". Nature 451 (7177): 3979. doi:10.1038/451397a. PMID18216832. [12] Long TC, Errami M (March 2009). "Scientific integrity. Responding to possible plagiarism." (http:/ / www. sciencemag. org/ cgi/ content/ summary/ 323/ 5919/ 1293). Science 323 (5919): 12934. doi:10.1126/science.1167408. PMID19265004. . [13] Errami M, Wren JD (http:/ / faculty-staff. ou. edu/ W/ Jonathan. D. Wren-1/ ), Hicks JM, Garner HR (July 2007). "eTBLAST: a web server to identify expert reviewers, appropriate journals and similar publications". Nucleic Acids Res. 35 (Web Server issue): W125. doi:10.1093/nar/gkm221. PMC1933238. PMID17452348.
259
eTBLAST, was highlighted on the NetWatch column (http://www.sciencemag.org/content/vol304/issue5673/ netwatch.shtml) in Science, May 14, 2004
External links
eTBLAST (http://etblast.org) Deja Vu: a database of duplicate publications (http://spore.vbi.vt.edu/dejavu) MEDLINE/PubMed (http://pubmed.gov/) PubMed Central (http://www.ncbi.nlm.nih.gov/pmc/) NIH Grants and Contracts Database (http://crisp.cit.nih.gov/) Institute of Physics (http://www.iop.org/) NASA Technical Reports (http://ntrs.nasa.gov/search.jsp)
PMID
260
PMID
PubMed
Content Contact Research center United States National Library of Medicine (NLM) Release date January 1996 Access Website [1] Tools Miscellaneous
PubMed is a free database accessing primarily the MEDLINE database of references and abstracts on life sciences and biomedical topics. The United States National Library of Medicine (NLM) at the National Institutes of Health maintains the database as part of the Entrez information retrieval system. PubMed was first released in January 1996.[2]
Content
In addition to MEDLINE, PubMed provides access to: older references from the print version of Index Medicus back to 1951 and earlier; references to some journals before they were indexed in Index Medicus and MEDLINE, for instance Science, BMJ, and Annals of Surgery; very recent entries to records for an article before it is indexed with Medical Subject Headings (MeSH) and added to MEDLINE; and a collection of books available full-text and other subsets of NLM records.[3] Many PubMed records contain links to full text articles, some of which are freely available, often in PubMed Central[4] and local mirrors such as UK PubMed Central.[5] Information about the journals indexed in PubMed is found in the NLM Catalog.[6] As of 1 July 2011, PubMed has over 21.0 million records going back to 1966, selectively to the year 1865, and very selectively to 1809; about 500,000 new records are added each year. As of 1 July 2011, 11.9 million articles are listed with their abstracts and 3.3 million articles are available full-text for free. To see the current size of the database type "1800:2100[dp]" or "all[sb]" into the PubMed search window.[7]
PMID
261
Characteristics
Standard searches
Simple searches on PubMed can be carried out by entering key aspects of a subject into PubMed's search window. PubMed translates this initial search formulation and automatically adds field names, relevant MeSH terms, synonyms, Boolean operators, and nests the resulting terms appropriately, enhancing the search formulation significantly, in particular by routinely combining (using the OR operator) textwords and MeSH terms. The examples given in a PubMed tutorial[8] demonstrate how this automatic process works: Causes Sleep Walking is translated as ("etiology"[Subheading] OR "etiology"[All Fields] OR "causes"[All Fields] OR "causality"[MeSH Terms] OR "causality"[All Fields]) AND ("somnambulism"[MeSH Terms] OR "somnambulism"[All Fields] OR ("sleep"[All Fields] AND "walking"[All Fields]) OR "sleep walking"[All Fields]) Likewise, Heart Attack Aspirin Prevention is translated as ("myocardial infarction"[MeSH Terms] OR ("myocardial"[All Fields] AND "infarction"[All Fields]) OR "myocardial infarction"[All Fields] OR ("heart"[All Fields] AND "attack"[All Fields]) OR "heart attack"[All Fields]) AND ("aspirin"[MeSH Terms] OR "aspirin"[All Fields]) AND ("prevention and control"[Subheading] OR ("prevention"[All Fields] AND "control"[All Fields]) OR "prevention and control"[All Fields] OR "prevention"[All Fields]) The new PubMed interface, launched in October 2009, encourages the use of such quick, Google-like search formulations; they have also been described as 'telegram' searches.[9]
Comprehensive searches
For comprehensive, optimal searches in PubMed, it is necessary to have a thorough understanding of its core component, MEDLINE, and especially of the MeSH (Medical Subject Headings) controlled vocabulary used to index MEDLINE articles. They may also require complex search strategies, use of field names (tags), proper use of limits and other features, and are best carried out by PubMed search specialists or librarians,[10] who are able to select the right type of search and carefully adjust it for recall and precision.[11] It has been suggested, though, that even complex literature reviews can be carried out using simple focused search formulations.[12]
Clinical queries/systematic reviews

A special feature of PubMed is its "Clinical Queries" section, where "Clinical Categories", "Systematic Reviews", and "Medical Genetics" subjects can be searched, with study-type 'filters' automatically applied to identify substantial, robust studies.[13] As these 'clinical queries' can generate small sets of robust studies with considerable precision, it has been suggested that this PubMed section can be used as a 'point-of-care' resource.[14]
Related articles
A reference which is judged particularly relevant can be marked and "related articles" can be identified. If relevant, several studies can be selected and related articles to all of them can be generated (on PubMed or any of the other NCBI Entrez databases) using the 'Find related data' option. The related articles are then listed in order of "relatedness". To create these lists of related articles, PubMed compares words from the title and abstract of each citation, as well as the MeSH headings assigned, using a powerful word-weighted algorithm.[15] The 'related articles' function has been judged to be so precise that some researchers suggest it can be used instead of a full search.[16]
PMID
262
Mapping to MeSH headings and subheadings

A strong feature of PubMed is its ability to automatically link to MeSH terms and subheadings. Examples would be: "bad breath" links to (and includes in the search) "halitosis", "heart attack" to "myocardial infarction", "breast cancer" to "breast neoplasms". Where appropriate, these MeSH terms are automatically "expanded", that is, include more specific terms. Terms like "nursing" are automatically linked to "Nursing [MeSH]" or "Nursing [Subheading]". This important feature makes PubMed searches automatically more sensitive and avoids false-negative (missed) hits by compensating for the diversity of medical terminology.
My NCBI
The PubMed optional facility "My NCBI" (with free registration) provides tools for saving searches filtering search results setting up automatic updates sent by e-mail saving sets of references retrieved as part of a PubMed search configuring display formats or highlighting search terms
and a wide range of other options.[17] The "My NCBI" area can be accessed from any computer with web-access. An earlier version of "My NCBI" was called "PubMed Cubby".[18]
LinkOut
LinkOut, a NLM facility to link (and make available full-text) local journal holdings.[19] Some 3,200 sites (mainly academic institutions) participate in this NLM facility (as of March 2010), from Aarhus Hospital in Denmark to ZymoGenetics in Seattle.[20] Users at these institutions see their institutions logo within the PubMed search result (if the journal is held at that institution) and can access the full-text.
PubMed for handhelds / mobiles

PubMed / MEDLINE can be accessed via handheld devices, using for instance the 'PICO' option (for focused clinical questions) created by the NLM.[21] A 'PubMed Mobile' option, providing access to a mobile friendly, simplified PubMed version, is also available.[22]
askMEDLINE
askMEDLINE, a free-text, natural language query tool for MEDLINE/PubMed, developed by the NLM, also suitable for handhelds.[23]
PubMed identifier
A PMID (PubMed identifier or PubMed unique identifier)[24] is a unique number assigned to each PubMed record. The assignment of a PMID or PMCID to a publication tells the reader nothing about the type or quality of the content. PMIDs are assigned to letters to the editor, editorial opinions, op-ed columns, and any other piece that the editor chooses to include in the journal, as well as peer-reviewed papers. The existence of the identification number is also not proof that the papers have not been retracted for fraud, incompetence, or misconduct. The announcement about any corrections to original papers may be assigned a PMID.
PMID
263
Alternative interfaces
The National Library of Medicine leases the MEDLINE information to a number of private vendors such as Ovid, Dialog, EBSCO, Knowledge Finder and many other commercial, non-commercial, and academic providers.[25] As of October 2008, more than 500 licences had been issued, more than 200 of them to non-US providers. As licences to use MEDLINE data are available for free, the NLM in effect provides a free testing ground for a wide range[26] of alternative interfaces and 3rd party additions to PubMed, one of a very few large, professionally curated databases which offers this option. Lu [26] identifies a sample of 28 current and free web based PubMed versions, requiring no installation or registration, which are grouped into four categories: Ranking search results, for instance: eTBLAST; Hakia; MedlineRanker[27] ; MiSearch[28] ; Clustering results by topics, authors, journals etc., for instance: Anne O'Tate[29] ; ClusterMed[30] ; Enhancing semantics and visualisation, for instance: CiteXplore; EBIMed[31] ; MedEvi[32] ; Improved search interface and retrieval experience, for instance: askMEDLINE[33] [34] ; BabelMeSH[35] ;PubCrawler[36] ;
As most of these and other alternatives rely essentially on PubMed / MEDLINE data leased under license from the NLM / PubMed, the term "PubMed derivatives" has been suggested.[26]
References
[1] http:/ / www. ncbi. nlm. nih. gov/ pubmed/ [2] "PubMed Celebrates its 10th Anniversary" (http:/ / www. nlm. nih. gov/ pubs/ techbull/ so06/ so06_pm_10. html). Technical Bulletin. United States National Library of Medicine. 2006-10-05. . Retrieved 2011-03-22. [3] "PubMed: MEDLINE Retrieval on the World Wide Web" (http:/ / www. nlm. nih. gov/ pubs/ factsheets/ pubmed. html). Fact Sheet. United States National Library of Medicine. 2002-06-07. . Retrieved 2011-03-22. [4] Roberts, R. J. (2001). "PubMed Central: The GenBank of the published literature". Proceedings of the National Academy of Sciences 98 (2): 381382. Bibcode2001PNAS...98..381R. doi:10.1073/pnas.98.2.381. PMC33354. PMID11209037. [5] McEntyre, J. R.; Ananiadou, S.; Andrews, S.; Black, W. J.; Boulderstone, R.; Buttery, P.; Chaplin, D.; Chevuru, S. et al. (2010). "UKPMC: A full text article resource for the life sciences". Nucleic Acids Research 39 (Database issue): D58D65. doi:10.1093/nar/gkq1063. PMC3013671. PMID21062818. [6] "NLM Catalogue: Journals referenced in the NCBI Databases" (http:/ / www. ncbi. nlm. nih. gov/ nlmcatalog/ journals). NCBI. 2011. . [7] "PubMed Help. NCBI Help Manual" (http:/ / www. ncbi. nlm. nih. gov/ books/ NBK3830/ ). NCBI. 2005. . [8] "Simple Subject Search with Quiz" (http:/ / www. nlm. nih. gov/ bsd/ viewlet/ search/ subject/ subject. html). NCBI. 2010. . [9] Clarke J, Wentz R (September 2000). "Pragmatic approach is effective in evidence based health care". BMJ 321 (7260): 566567. doi:10.1136/bmj.321.7260.566/a. PMC1118450. PMID10968827. [10] Jadad AR, McQuay HJ (July 1993). "Searching the literature. Be systematic in your searching". BMJ 307 (6895): 66. PMC1678459. PMID8343701. [11] Allison JJ, Kiefe CI, Carter J, Centor RM (Spring 1999). "The art and science of searching MEDLINE to answer clinical questions. Finding the right number of articles.". Int J Technol Assess Health Care 15 (2): 281296. PMID10507188. [12] Knipschild P (September 1994). "Systematic reviews. Some examples". BMJ 309 (6956): 719721. PMC2540847. PMID7950526. [13] "Clinical Queries Filter Terms explained" (http:/ / www. ncbi. nlm. nih. gov/ entrez/ query/ static/ clinicaltable. html). NCBI. 2010. . [14] Glasziou, P. (2007). "Do all fractures need full immobilisation?". BMJ 335 (7620): 612613. doi:10.1136/bmj.39272.565810.80. PMC1988981. PMID17884906. [15] "Computation of Related Articles explained" (http:/ / www. ncbi. nlm. nih. gov/ books/ bv. fcgi?rid=helppubmed. section. pubmedhelp. Appendices#pubmedhelp. Computation_of_Relat). NCBI. . [16] Chang AA, Heskett KM, Davidson TM (February 2006). "Searching the literature using medical subject headings versus text word with PubMed". Laryngoscope 116 (2): 366340. doi:10.1097/01.mlg.0000195371.72887.a2. PMID16467730. [17] "My NCBI explained" (http:/ / www. ncbi. nlm. nih. gov/ books/ NBK3842/ ). NCBI. 13 December 2010. . [18] "PubMed Cubby" (http:/ / www. nlm. nih. gov/ pubs/ techbull/ so00/ so00_hands_on_register. html). Technical Bulletin. United States National Library of Medicine. 2000. . [19] "LinkOut Overview" (http:/ / www. ncbi. nlm. nih. gov/ projects/ linkout/ ). NCBI. 2010. . [20] "LinkOut Participants 2011" (http:/ / www. ncbi. nlm. nih. gov/ projects/ linkout/ journals/ htmllists. cgi?type_id=6). NCBI. 2011. . [21] "PubMed via handhelds (PICO)" (http:/ / www. nlm. nih. gov/ pubs/ techbull/ mj04/ mj04_pico. html). Technical Bulletin. United States National Library of Medicine. 2004. .
PMID
[22] "PubMed Mobile Beta" (http:/ / www. nlm. nih. gov/ pubs/ techbull/ ma11/ ma11_pm_mobile_beta. html). Technical Bulletin. United States National Library of Medicine. 2011. . [23] "askMedline" (http:/ / askmedline. nlm. nih. gov/ ask/ ask. php). NCBI. 2005. . [24] "Search Field Descriptions and Tags" (http:/ / www. ncbi. nlm. nih. gov/ books/ bv. fcgi?rid=helppubmed. section. pubmedhelp. Search_Field_Descrip). National Center for Biotechnology Information. . Retrieved 27 November 2008. [25] "Leasing journal citations from PubMed / Medline" (http:/ / www. nlm. nih. gov/ databases/ journal. html). NLM. 2011. . [26] Lu, Z. (2011). "PubMed and beyond: A survey of web tools for searching biomedical literature". Database 2011: baq036baq036. doi:10.1093/database/baq036. PMC3025693. PMID21245076. [27] Fontaine, J. -F.; Barbosa-Silva, A.; Schaefer, M.; Huska, M. R.; Muro, E. M.; Andrade-Navarro, M. A. (2009). "MedlineRanker: Flexible ranking of biomedical literature". Nucleic Acids Research 37 (Web Server issue): W141W146. doi:10.1093/nar/gkp353. PMC2703945. PMID19429696. [28] States, D. J.; Ade, A. S.; Wright, Z. C.; Bookvich, A. V.; Athey, B. D. (2009). "MiSearch adaptive pubMed search tool". Bioinformatics 25 (7): 974976. doi:10.1093/bioinformatics/btn033. PMC2660869. PMID18326507. [29] Smalheiser, N. R.; Zhou, W.; Torvik, V. I. (2008). "Anne O'Tate: A tool to support user-driven summarization, drill-down and browsing of PubMed search results". Journal of Biomedical Discovery and Collaboration 3: 2. doi:10.1186/1747-5333-3-2. PMC2276193. PMID18279519. [30] "ClusterMed" (http:/ / demos. vivisimo. com/ clustermed). Vivisimo Clustering Engine. 2011. . [31] Rebholz-Schuhmann, D.; Kirsch, H.; Arregui, M.; Gaudan, S.; Riethoven, M.; Stoehr, P. (2007). "EBIMed--text crunching to gather facts for proteins from Medline". Bioinformatics 23 (2): e237e244. doi:10.1093/bioinformatics/btl302. PMID17237098. [32] Kim, J.-J.; Pezik, P.; Rebholz-Schuhmann, D. (2008). "MedEvi: Retrieving textual evidence of relations between biomedical concepts from Medline". Bioinformatics 24 (11): 14101412. doi:10.1093/bioinformatics/btn117. PMC2387223. PMID18400773. [33] Fontelo, P.; Liu, F.; Ackerman, M.; Schardt, C.; Keitz, S. (2006). "AskMEDLINE: A report on a year-long experience". AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium: 923. PMC1839379. PMID17238542. [34] Fontelo, P.; Liu, F.; Ackerman, M. (2005). "MeSH Speller + askMEDLINE: Auto-completes MeSH terms then searches MEDLINE/PubMed via free-text, natural language queries". AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium: 957. PMC1513542. PMID16779244. [35] Fontelo, P.; Liu, F.; Leon, S.; Anne, A.; Ackerman, M. (2007). "PICO Linguist and BabelMeSH: Development and partial evaluation of evidence-based multilanguage search tools for MEDLINE/PubMed". Studies in health technology and informatics 129 (Pt 1): 817821. PMID17911830. [36] Hokamp, K.; Wolfe, K. H. (2004). "PubCrawler: Keeping up comfortably with PubMed and GenBank". Nucleic Acids Research 32 (Web Server issue): W16W19. doi:10.1093/nar/gkh453. PMC441591. PMID15215341.
264
External links
Official website (http://www.ncbi.nlm.nih.gov/pubmed/) PubMed Online Tutorials (http://www.nlm.nih.gov/bsd/disted/pubmed.html) PubMed Help (http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=helppubmed.chapter.pubmedhelp) Other PubMed Search Engines Resource Guide (http://guides.library.vcu.edu/content.php?pid=111410)
Comparison of PubMed mobile apps (http://www.imedicalapps.com/2011/01/ best-top-pubmed-iphone-ipad-medical-apps/)
PubMed
265
PubMed
PubMed
Content Contact Research center United States National Library of Medicine (NLM) Release date January 1996 Access Website [1] Tools Miscellaneous
PubMed is a free database accessing primarily the MEDLINE database of references and abstracts on life sciences and biomedical topics. The United States National Library of Medicine (NLM) at the National Institutes of Health maintains the database as part of the Entrez information retrieval system. PubMed was first released in January 1996.[1]
Content
In addition to MEDLINE, PubMed provides access to: older references from the print version of Index Medicus back to 1951 and earlier; references to some journals before they were indexed in Index Medicus and MEDLINE, for instance Science, BMJ, and Annals of Surgery; very recent entries to records for an article before it is indexed with Medical Subject Headings (MeSH) and added to MEDLINE; and a collection of books available full-text and other subsets of NLM records.[2] Many PubMed records contain links to full text articles, some of which are freely available, often in PubMed Central[3] and local mirrors such as UK PubMed Central.[4] Information about the journals indexed in PubMed is found in the NLM Catalog.[5] As of 1 July 2011, PubMed has over 21.0 million records going back to 1966, selectively to the year 1865, and very selectively to 1809; about 500,000 new records are added each year. As of 1 July 2011, 11.9 million articles are listed with their abstracts and 3.3 million articles are available full-text for free. To see the current size of the database type "1800:2100[dp]" or "all[sb]" into the PubMed search window.[6]
PubMed
266
Characteristics
Standard searches
Simple searches on PubMed can be carried out by entering key aspects of a subject into PubMed's search window. PubMed translates this initial search formulation and automatically adds field names, relevant MeSH terms, synonyms, Boolean operators, and nests the resulting terms appropriately, enhancing the search formulation significantly, in particular by routinely combining (using the OR operator) textwords and MeSH terms. The examples given in a PubMed tutorial[7] demonstrate how this automatic process works: Causes Sleep Walking is translated as ("etiology"[Subheading] OR "etiology"[All Fields] OR "causes"[All Fields] OR "causality"[MeSH Terms] OR "causality"[All Fields]) AND ("somnambulism"[MeSH Terms] OR "somnambulism"[All Fields] OR ("sleep"[All Fields] AND "walking"[All Fields]) OR "sleep walking"[All Fields]) Likewise, Heart Attack Aspirin Prevention is translated as ("myocardial infarction"[MeSH Terms] OR ("myocardial"[All Fields] AND "infarction"[All Fields]) OR "myocardial infarction"[All Fields] OR ("heart"[All Fields] AND "attack"[All Fields]) OR "heart attack"[All Fields]) AND ("aspirin"[MeSH Terms] OR "aspirin"[All Fields]) AND ("prevention and control"[Subheading] OR ("prevention"[All Fields] AND "control"[All Fields]) OR "prevention and control"[All Fields] OR "prevention"[All Fields]) The new PubMed interface, launched in October 2009, encourages the use of such quick, Google-like search formulations; they have also been described as 'telegram' searches.[8]
Comprehensive searches
For comprehensive, optimal searches in PubMed, it is necessary to have a thorough understanding of its core component, MEDLINE, and especially of the MeSH (Medical Subject Headings) controlled vocabulary used to index MEDLINE articles. They may also require complex search strategies, use of field names (tags), proper use of limits and other features, and are best carried out by PubMed search specialists or librarians,[9] who are able to select the right type of search and carefully adjust it for recall and precision.[10] It has been suggested, though, that even complex literature reviews can be carried out using simple focused search formulations.[11]
Clinical queries/systematic reviews

A special feature of PubMed is its "Clinical Queries" section, where "Clinical Categories", "Systematic Reviews", and "Medical Genetics" subjects can be searched, with study-type 'filters' automatically applied to identify substantial, robust studies.[12] As these 'clinical queries' can generate small sets of robust studies with considerable precision, it has been suggested that this PubMed section can be used as a 'point-of-care' resource.[13]
Related articles
A reference which is judged particularly relevant can be marked and "related articles" can be identified. If relevant, several studies can be selected and related articles to all of them can be generated (on PubMed or any of the other NCBI Entrez databases) using the 'Find related data' option. The related articles are then listed in order of "relatedness". To create these lists of related articles, PubMed compares words from the title and abstract of each citation, as well as the MeSH headings assigned, using a powerful word-weighted algorithm.[14] The 'related articles' function has been judged to be so precise that some researchers suggest it can be used instead of a full search.[15]
PubMed
267
Mapping to MeSH headings and subheadings

A strong feature of PubMed is its ability to automatically link to MeSH terms and subheadings. Examples would be: "bad breath" links to (and includes in the search) "halitosis", "heart attack" to "myocardial infarction", "breast cancer" to "breast neoplasms". Where appropriate, these MeSH terms are automatically "expanded", that is, include more specific terms. Terms like "nursing" are automatically linked to "Nursing [MeSH]" or "Nursing [Subheading]". This important feature makes PubMed searches automatically more sensitive and avoids false-negative (missed) hits by compensating for the diversity of medical terminology.
My NCBI
The PubMed optional facility "My NCBI" (with free registration) provides tools for saving searches filtering search results setting up automatic updates sent by e-mail saving sets of references retrieved as part of a PubMed search configuring display formats or highlighting search terms
and a wide range of other options.[16] The "My NCBI" area can be accessed from any computer with web-access. An earlier version of "My NCBI" was called "PubMed Cubby".[17]
LinkOut
LinkOut, a NLM facility to link (and make available full-text) local journal holdings.[18] Some 3,200 sites (mainly academic institutions) participate in this NLM facility (as of March 2010), from Aarhus Hospital in Denmark to ZymoGenetics in Seattle.[19] Users at these institutions see their institutions logo within the PubMed search result (if the journal is held at that institution) and can access the full-text.
PubMed for handhelds / mobiles

PubMed / MEDLINE can be accessed via handheld devices, using for instance the 'PICO' option (for focused clinical questions) created by the NLM.[20] A 'PubMed Mobile' option, providing access to a mobile friendly, simplified PubMed version, is also available.[21]
askMEDLINE
askMEDLINE, a free-text, natural language query tool for MEDLINE/PubMed, developed by the NLM, also suitable for handhelds.[22]
PubMed identifier
A PMID (PubMed identifier or PubMed unique identifier)[23] is a unique number assigned to each PubMed record. The assignment of a PMID or PMCID to a publication tells the reader nothing about the type or quality of the content. PMIDs are assigned to letters to the editor, editorial opinions, op-ed columns, and any other piece that the editor chooses to include in the journal, as well as peer-reviewed papers. The existence of the identification number is also not proof that the papers have not been retracted for fraud, incompetence, or misconduct. The announcement about any corrections to original papers may be assigned a PMID.
PubMed
268
Alternative interfaces
The National Library of Medicine leases the MEDLINE information to a number of private vendors such as Ovid, Dialog, EBSCO, Knowledge Finder and many other commercial, non-commercial, and academic providers.[24] As of October 2008, more than 500 licences had been issued, more than 200 of them to non-US providers. As licences to use MEDLINE data are available for free, the NLM in effect provides a free testing ground for a wide range[25] of alternative interfaces and 3rd party additions to PubMed, one of a very few large, professionally curated databases which offers this option. Lu [25] identifies a sample of 28 current and free web based PubMed versions, requiring no installation or registration, which are grouped into four categories: Ranking search results, for instance: eTBLAST; Hakia; MedlineRanker[26] ; MiSearch[27] ; Clustering results by topics, authors, journals etc., for instance: Anne O'Tate[28] ; ClusterMed[29] ; Enhancing semantics and visualisation, for instance: CiteXplore; EBIMed[30] ; MedEvi[31] ; Improved search interface and retrieval experience, for instance: askMEDLINE[32] [33] ; BabelMeSH[34] ;PubCrawler[35] ;
As most of these and other alternatives rely essentially on PubMed / MEDLINE data leased under license from the NLM / PubMed, the term "PubMed derivatives" has been suggested.[25]
References
[1] "PubMed Celebrates its 10th Anniversary" (http:/ / www. nlm. nih. gov/ pubs/ techbull/ so06/ so06_pm_10. html). Technical Bulletin. United States National Library of Medicine. 2006-10-05. . Retrieved 2011-03-22. [2] "PubMed: MEDLINE Retrieval on the World Wide Web" (http:/ / www. nlm. nih. gov/ pubs/ factsheets/ pubmed. html). Fact Sheet. United States National Library of Medicine. 2002-06-07. . Retrieved 2011-03-22. [3] Roberts, R. J. (2001). "PubMed Central: The GenBank of the published literature". Proceedings of the National Academy of Sciences 98 (2): 381382. Bibcode2001PNAS...98..381R. doi:10.1073/pnas.98.2.381. PMC33354. PMID11209037. [4] McEntyre, J. R.; Ananiadou, S.; Andrews, S.; Black, W. J.; Boulderstone, R.; Buttery, P.; Chaplin, D.; Chevuru, S. et al. (2010). "UKPMC: A full text article resource for the life sciences". Nucleic Acids Research 39 (Database issue): D58D65. doi:10.1093/nar/gkq1063. PMC3013671. PMID21062818. [5] "NLM Catalogue: Journals referenced in the NCBI Databases" (http:/ / www. ncbi. nlm. nih. gov/ nlmcatalog/ journals). NCBI. 2011. . [6] "PubMed Help. NCBI Help Manual" (http:/ / www. ncbi. nlm. nih. gov/ books/ NBK3830/ ). NCBI. 2005. . [7] "Simple Subject Search with Quiz" (http:/ / www. nlm. nih. gov/ bsd/ viewlet/ search/ subject/ subject. html). NCBI. 2010. . [8] Clarke J, Wentz R (September 2000). "Pragmatic approach is effective in evidence based health care". BMJ 321 (7260): 566567. doi:10.1136/bmj.321.7260.566/a. PMC1118450. PMID10968827. [9] Jadad AR, McQuay HJ (July 1993). "Searching the literature. Be systematic in your searching". BMJ 307 (6895): 66. PMC1678459. PMID8343701. [10] Allison JJ, Kiefe CI, Carter J, Centor RM (Spring 1999). "The art and science of searching MEDLINE to answer clinical questions. Finding the right number of articles.". Int J Technol Assess Health Care 15 (2): 281296. PMID10507188. [11] Knipschild P (September 1994). "Systematic reviews. Some examples". BMJ 309 (6956): 719721. PMC2540847. PMID7950526. [12] "Clinical Queries Filter Terms explained" (http:/ / www. ncbi. nlm. nih. gov/ entrez/ query/ static/ clinicaltable. html). NCBI. 2010. . [13] Glasziou, P. (2007). "Do all fractures need full immobilisation?". BMJ 335 (7620): 612613. doi:10.1136/bmj.39272.565810.80. PMC1988981. PMID17884906. [14] "Computation of Related Articles explained" (http:/ / www. ncbi. nlm. nih. gov/ books/ bv. fcgi?rid=helppubmed. section. pubmedhelp. Appendices#pubmedhelp. Computation_of_Relat). NCBI. . [15] Chang AA, Heskett KM, Davidson TM (February 2006). "Searching the literature using medical subject headings versus text word with PubMed". Laryngoscope 116 (2): 366340. doi:10.1097/01.mlg.0000195371.72887.a2. PMID16467730. [16] "My NCBI explained" (http:/ / www. ncbi. nlm. nih. gov/ books/ NBK3842/ ). NCBI. 13 December 2010. . [17] "PubMed Cubby" (http:/ / www. nlm. nih. gov/ pubs/ techbull/ so00/ so00_hands_on_register. html). Technical Bulletin. United States National Library of Medicine. 2000. . [18] "LinkOut Overview" (http:/ / www. ncbi. nlm. nih. gov/ projects/ linkout/ ). NCBI. 2010. . [19] "LinkOut Participants 2011" (http:/ / www. ncbi. nlm. nih. gov/ projects/ linkout/ journals/ htmllists. cgi?type_id=6). NCBI. 2011. . [20] "PubMed via handhelds (PICO)" (http:/ / www. nlm. nih. gov/ pubs/ techbull/ mj04/ mj04_pico. html). Technical Bulletin. United States National Library of Medicine. 2004. . [21] "PubMed Mobile Beta" (http:/ / www. nlm. nih. gov/ pubs/ techbull/ ma11/ ma11_pm_mobile_beta. html). Technical Bulletin. United States National Library of Medicine. 2011. .
PubMed
[22] "askMedline" (http:/ / askmedline. nlm. nih. gov/ ask/ ask. php). NCBI. 2005. . [23] "Search Field Descriptions and Tags" (http:/ / www. ncbi. nlm. nih. gov/ books/ bv. fcgi?rid=helppubmed. section. pubmedhelp. Search_Field_Descrip). National Center for Biotechnology Information. . Retrieved 27 November 2008. [24] "Leasing journal citations from PubMed / Medline" (http:/ / www. nlm. nih. gov/ databases/ journal. html). NLM. 2011. . [25] Lu, Z. (2011). "PubMed and beyond: A survey of web tools for searching biomedical literature". Database 2011: baq036baq036. doi:10.1093/database/baq036. PMC3025693. PMID21245076. [26] Fontaine, J. -F.; Barbosa-Silva, A.; Schaefer, M.; Huska, M. R.; Muro, E. M.; Andrade-Navarro, M. A. (2009). "MedlineRanker: Flexible ranking of biomedical literature". Nucleic Acids Research 37 (Web Server issue): W141W146. doi:10.1093/nar/gkp353. PMC2703945. PMID19429696. [27] States, D. J.; Ade, A. S.; Wright, Z. C.; Bookvich, A. V.; Athey, B. D. (2009). "MiSearch adaptive pubMed search tool". Bioinformatics 25 (7): 974976. doi:10.1093/bioinformatics/btn033. PMC2660869. PMID18326507. [28] Smalheiser, N. R.; Zhou, W.; Torvik, V. I. (2008). "Anne O'Tate: A tool to support user-driven summarization, drill-down and browsing of PubMed search results". Journal of Biomedical Discovery and Collaboration 3: 2. doi:10.1186/1747-5333-3-2. PMC2276193. PMID18279519. [29] "ClusterMed" (http:/ / demos. vivisimo. com/ clustermed). Vivisimo Clustering Engine. 2011. . [30] Rebholz-Schuhmann, D.; Kirsch, H.; Arregui, M.; Gaudan, S.; Riethoven, M.; Stoehr, P. (2007). "EBIMed--text crunching to gather facts for proteins from Medline". Bioinformatics 23 (2): e237e244. doi:10.1093/bioinformatics/btl302. PMID17237098. [31] Kim, J.-J.; Pezik, P.; Rebholz-Schuhmann, D. (2008). "MedEvi: Retrieving textual evidence of relations between biomedical concepts from Medline". Bioinformatics 24 (11): 14101412. doi:10.1093/bioinformatics/btn117. PMC2387223. PMID18400773. [32] Fontelo, P.; Liu, F.; Ackerman, M.; Schardt, C.; Keitz, S. (2006). "AskMEDLINE: A report on a year-long experience". AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium: 923. PMC1839379. PMID17238542. [33] Fontelo, P.; Liu, F.; Ackerman, M. (2005). "MeSH Speller + askMEDLINE: Auto-completes MeSH terms then searches MEDLINE/PubMed via free-text, natural language queries". AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium: 957. PMC1513542. PMID16779244. [34] Fontelo, P.; Liu, F.; Leon, S.; Anne, A.; Ackerman, M. (2007). "PICO Linguist and BabelMeSH: Development and partial evaluation of evidence-based multilanguage search tools for MEDLINE/PubMed". Studies in health technology and informatics 129 (Pt 1): 817821. PMID17911830. [35] Hokamp, K.; Wolfe, K. H. (2004). "PubCrawler: Keeping up comfortably with PubMed and GenBank". Nucleic Acids Research 32 (Web Server issue): W16W19. doi:10.1093/nar/gkh453. PMC441591. PMID15215341.
269
External links
Official website (http://www.ncbi.nlm.nih.gov/pubmed/) PubMed Online Tutorials (http://www.nlm.nih.gov/bsd/disted/pubmed.html) PubMed Help (http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=helppubmed.chapter.pubmedhelp) Other PubMed Search Engines Resource Guide (http://guides.library.vcu.edu/content.php?pid=111410)
Comparison of PubMed mobile apps (http://www.imedicalapps.com/2011/01/ best-top-pubmed-iphone-ipad-medical-apps/)
GoPubMed
270
GoPubMed
GoPubMed is a knowledge-based search engine for biomedical texts. The Gene Ontology (GO) and Medical Subject Headings (MeSH) serve as "Table of contents" in order to structure the millions of articles of the MEDLINE database. The search engine allows its users to find relevant search results significantly faster (than what?). MeshPubMed was at one point a separate project, but now the two have been merged. The technologies used in GoPubMed are generic and can in general be applied to any kind of texts and any kind of knowledge bases. GoPubMed is one of the first Web 2.0 semantic search engines. The system was developed at the Technical University of Dresden by Michael Schroeder and his team at Transinsight. GoPubMed.com, the semantic search engine for the life sciences, has been recognized with the 2009 red dot: best of the best award in the category communication design graphical user interfaces and interactive tool and the German Industry Prize 2010.
References
Citations in Pubmed (http://www.gopubmed.org/search?q=gopubmed) Citations in Pubmed Central (http://www.ncbi.nlm.nih.gov/sites/entrez?tool=QuerySuggestion& cmd=search&db=pmc&term=gopubmed OR GoGene OR GoWeb OR Go3R) Books including GoPubMed's semantic search (http://www.google.de/search?q=gopubmed&um=1& ie=UTF-8&tbo=u&tbs=bks:1&source=og&sa=N&hl=de&tab=wp) People about GoPubMed (http://transinsight.com/about-us/?lang=en#People about us)
External links
GoPubMed (http://www.gopubmed.org) Transinsight (http://www.transinsight.com)
Pubget
271
Pubget
Pubget
Founded
Cambridge, MA, USA (2007)
Headquarters Boston, MA, USA Key people Ramy Arnaout, Ian Connor, Ryan Jones www.pubget.com [1]
Website
Pubget, Inc. is a private American company that develops cloud-based search and content access tools for scientists. It provides advertising services, enterprise search services, and a public search engine.[2] The company was founded in 2007 by Beth Israel Hospital clinical pathologist, Ramy Arnaout, out of his own need to find papers.[3] [4] [5] Pubget moved its headquarters from Cambridge, Massachusetts to Bostons Innovation District in 2011.[6] [7] Pubget.com is a free service for non-profit institutions and their libraries and researchers. The site provides direct access to full-text content from 450 libraries around the world. The company is privately funded and profitable.[8]
Products and Services

Search Engine Pubgets search engine retrieves article citations and full text PDFs from PubMed, ArXiv, JSTOR, IEEE, RSS feeds, XML from publishers, and Open Archive sources.[9] The companys search engine contains over 28 million scientific documents and adds 10,000 papers each day. Pubget creates a link directly from the article citation to the paper itself via a continuously updated database of links.[10] Because of this database, users are directly linked from a citation to the full-text paper. Access to closed full-text PDFs is granted through the institutions subscriptions. Pubget does not bypass copyright laws and will display only the abstract of restricted papers if the end user does not have institutional access. PaperStats Pubget PaperStats is a usage and spend analysis tool for libraries. PaperStats automatically harvests serials usage statistics delivering consolidated usage, cost, and other reports directly from publishers. Content performance can be assessed through cost-per-view analysis. Upon introduction, PaperStats was beta tested with the USC Norris Medical Library and yielded positive results for Pubget, USC and the library community.[11] [12] PaperStore The Pubget PaperStore provides Pubget.com users the option of purchasing full text papers from thousands of journals on the search engine results page. Content rights and delivery is provided by document delivery vendor, Reprints Desk [13].[14] Advertising Pubget provides several advertising solutions. Customers include Bio-Rad, Agilent, and other scientific brands. Ads are matched with paper content via contextual targeting. For example, manufacturers of a piece of scientific equipment will pay to advertise alongside a paper that mentions using said product.[15] [16] Pubget, however, does not reveal data on individual users and their searches.[17]
Pubget Textmining Pubgets textmining technology allows research and development teams to uncover specific text strings across large groups of papers.[18] PaperStream PaperStream is a web app that allows lab teams to share, store, and find documents all in one place.[19] PaperStream organizes companies subscriptions, purchased papers, and internal documents into an automated library database.[20]
[21]
272
API Pubgets API provides access to its search and linking technology from third-party websites or applications such as SharePoint.[22] [23]
References
[1] http:/ / www. pubget. com/ [2] "Pubget Everywhere" (http:/ / corporate. pubget. com/ about/ where_you_are). Pubget. . Retrieved 17 June 2011. [3] Kevin Davies (June 10, 2009). "Got PubMed? Pubget Searches and Delivers Scientific PDFs" (http:/ / www. bio-itworld. com/ news/ 06/ 10/ 09/ pubget-full-text-PDF-search. html). Bio-IT World. . Retrieved 17 June 2011. [4] "Founder's Friday: Pubget" (http:/ / greenhornconnect. com/ blog/ founders-friday-pubget). Greenhorn Connect. (January 7, 2011). . Retrieved 21 June 2011. [5] Goodison, Donna (28 May 2011). "Southie Firm Speeds Up Access to Research Papers" (http:/ / bostonherald. com/ jobfind/ news/ technology/ view. bg?articleid=1341114). Boston Herald. . Retrieved 21 June 2011. [6] "Welcome home, Pubget" (http:/ / www. innovationdistrict. org/ 2011/ 05/ 13/ welcome-pubget/ ). Innovation District. (May 13, 2011). . Retrieved 16 June 2011. [7] Goodison, Donna (28 May 2011). "Southie Firm Speeds Up Access to Research Papers" (http:/ / bostonherald. com/ jobfind/ news/ technology/ view. bg?articleid=1341114). Boston Herald. . Retrieved 21 June 2011. [8] Goodison, Donna (28 May 2011). "Southie Firm Speeds Up Access to Research Papers" (http:/ / bostonherald. com/ jobfind/ news/ technology/ view. bg?articleid=1341114). Boston Herald. . Retrieved 21 June 2011. [9] Featherstone, Robin; Denise Hersey (October 4, 2010). "The quest for full text: an in-depth examination of Pubget for medical searchers." (http:/ / www. tandfonline. com/ doi/ abs/ 10. 1080/ 02763869. 2010. 518911). Medical Reference Services Quarterly (Routledge) 29 (4): 307319. doi:10.1080/02763869.2010.518911. PMID21058175. . Retrieved 30 June 2011. [10] Murray, P.E. (August 4, 2009). "Analysis of Pubget - An Expedited Fulltext Service for Life Science Journal Articles" (http:/ / dltj. org/ article/ analysis-of-pubget-an-expedited-fulltext-service-for-life-science-journal-articles/ ). Disruptive Library Technology Jester. . Retrieved 21 June 2011. [11] Curran, Megan (March 2, 2011). "Debating Beta: Considerations for Libraries". Journal of Electronic Resources in Medical Libraries 8 (2): 117125. doi:10.1080/15424065.2011.576604. [12] Featherstone, Robin; Denise Hersey (October 4, 2010). "The quest for full text: an in-depth examination of Pubget for medical searchers." (http:/ / www. tandfonline. com/ doi/ abs/ 10. 1080/ 02763869. 2010. 518911). Medical Reference Services Quarterly (Routledge) 29 (4): 307319. doi:10.1080/02763869.2010.518911. PMID21058175. . Retrieved 30 June 2011. [13] http:/ / www2. reprintsdesk. com/ [14] Featherstone, Robin; Denise Hersey (October 4, 2010). "The quest for full text: an in-depth examination of Pubget for medical searchers." (http:/ / www. tandfonline. com/ doi/ abs/ 10. 1080/ 02763869. 2010. 518911). Medical Reference Services Quarterly (Routledge) 29 (4): 307319. doi:10.1080/02763869.2010.518911. PMID21058175. . Retrieved 21 June 2011. [15] "Media Kit: Pubget Ads" (http:/ / corporate. pubget. com/ pdfs/ mediakit_glossy. pdf). Pubget, Inc.. . Retrieved 24 June 2011. [16] Kevin Davies (June 10, 2009). "Got PubMed? Pubget Searches and Delivers Scientific PDFs" (http:/ / www. bio-itworld. com/ news/ 06/ 10/ 09/ pubget-full-text-PDF-search. html). Bio-IT World. . Retrieved 17 June 2011. [17] Kevin Davies (June 10, 2009). "Got PubMed? Pubget Searches and Delivers Scientific PDFs" (http:/ / www. bio-itworld. com/ news/ 06/ 10/ 09/ pubget-full-text-PDF-search. html). Bio-IT World. . Retrieved 17 June 2011. [18] "Textmining Fact Sheet" (http:/ / corporate. pubget. com/ pdfs/ Pubget_Textmine_2010. pdf). Pubget, Inc.. . Retrieved 15 June 2011. [19] "Pubget PaperStream" (http:/ / pubget. com/ paperstream). Pubget, Inc.. . Retrieved 24 June 2011. [20] "Pubget PaperStream For Companies" (http:/ / pubget. com/ paperstream/ forcompanies). Pubget, Inc.. . Retrieved 24 June 2011. [21] "Pubget PaperStream For Researchers" (http:/ / pubget. com/ paperstream/ forresearchers). Pubget, Inc.. . Retrieved 24 June 2011. [22] "PubgetCloud" (http:/ / corporate. pubget. com/ pdfs/ Pubget_API_2010. pdf). Pubget, Inc.. . Retrieved 16 June 2011. [23] Munger, Dave (June 10, 2009). "Pubget - Useful, Growing Resource for Anyone Interested in Research" (http:/ / researchblogging. org/ news/ ?p=126). Researchblogging News. . Retrieved 29 June 2011.
Pubget
273
External links
PubMed (http://www.pubmed.com) Pubget (http://pubget.com/site/contact/about) Got PubMed? Pubget Searches and Delivers Scientific PDFs (http://www.bio-itworld.com/news/06/10/09/ pubget-full-text-PDF-search.html) UCSF Pubget page (http://www.library.ucsf.edu/node/1836) PubMed Portuguese (http://www.pubmed.com.br) Pubget Speeds Up Science Journal Searches, Provides Marketing Tools (http://www.xconomy.com/boston/ 2009/06/23/pubget-speeds-up-science-journal-searches-provides-marketing-tools/) Pubget RSS and Firefox Download Extension (http://davidrothman.net/2009/03/05/ pubget-rss-and-firefox-download-extension/) Reprints Desk (http://www2.reprintsdesk.com/)
PubMed Central
PubMed Central is a free digital database of full-text scientific literature in biomedical and life sciences. It grew from the online Entrez PubMed biomedical literature search system. PubMed Central was developed by the U.S. National Library of Medicine (NLM) as an online archive of biomedical journal articles. The full text of all PubMed Central articles is available free. Some participating publishers, however, delay release of their articles for a set time after paper publication (often six months). As of July 2011, the archive contains approximately 2.2 million items, including articles, editorials and letters. It appears to be growing by at least 7% per year. As of September 2004, PubMed Central, PubMed, and related NLM services were handling approximately 1,300 hits per second, and supplying 1.3 terabytes of data per day.[1]
Adoption
The repository has grown rapidly, as the U.S. National Institutes of Health's "Policy on Enhancing Public Access to Archived Publications Resulting from NIH-Funded Research"[2] is designed to make all research funded by the National Institutes of Health (NIH) freely accessible to anyone, and, in addition, many publishers are working cooperatively with the NIH to provide free access to their works. In late 2007, the Consolidated Appropriations Act of 2008 (H.R. 2764) was signed into law and included a provision requiring the NIH to modify its policies and require inclusion into PubMed Central complete electronic copies of their peer-reviewed research and findings from NIH-funded research. These articles are required to be included within 12 months of publication. This is the first time the US government has required an agency to provide open access to research and is an evolution from the 2005 policy, in which the NIH asked researchers to voluntarily add the their research to PubMed Central.[3] A UK version of the PubMed Central system, UK PubMed Central (UKPMC), has been developed by the Wellcome Trust and the British Library as part of a nine-strong group of UK research funders. This system went live in January 2007. The Canadian member of the PubMed Central International network, PubMed Central Canada, was launched in October 2009. The National Library of Medicine "NLM Journal Publishing Tag Set" journal article markup language is freely available.[4] The Association of Learned and Professional Society Publishers comments that "it is likely to become the standard for preparing scholarly content for both books and journals."[5] A related DTD is available for books.[6] The Library of Congress and the British Library have announced support for the NLM DTD.[7] It has also been popular with journal service providers.[8]
PubMed Central
274
Technology
Articles are sent to PubMed Central by publishers in XML or SGML, using a variety of article DTDs. Older and larger publishers may have their own established in-house DTDs, but many publishers use the NLM Journal Publishing DTD (see above). Received articles are converted via XSLT to the very similar NLM Archiving and Interchange DTD. This process may reveal errors that are reported back to the publisher for correction. Graphics are also converted to standard formats and sizes. The original and converted forms are archived. The converted form is moved into a relational database, along with associated files for graphics, multimedia, or other associated data. Many publishers also provide PDF of their articles, and these are made available without change.[9] Bibliographic citations are parsed and automatically linked to the relevant abstracts in PubMed, articles in PubMed Central, and resources on publishers' Web sites. PubMed links also lead to PubMed Central. Unresolvable references, such as to journals or particular articles not yet available at one of these sources, are tracked in the database and automatically come "live" when the resources become available. An in-house indexing system provides search capability, and is aware of biological and medical terminology, such as generic vs. proprietary drug names, and alternate names for organisms, diseases and anatomical parts. When a user accesses a journal issue, a table of contents is automatically generated by retrieving all articles, letters, editorials, etc. for that issue. When an actual item such as an article is reached, PubMed Central converts the NLM markup to HTML for delivery, and provides links to related data objects. This is feasible because the variety of incoming data has first been converted to standard DTDs and graphic formats. In a separate submission stream, NIH-funded authors may deposit articles into PubMed Central using the NIH Manuscript Submission (NIHMS). Articles thus submitted typically go through XML markup in order to be converted to NLM DTD.
Reception
The Antelman study of open access publishing found that in philosophy, political science, electrical and electronic engineering and mathematics, open access papers had a greater research impact.[10] A randomised trial found that an increase in content downloads of open access papers, with no citation advantage over subscription access one year after publication.[11] The change in procedure has received criticism.[12] The American Physiological Society has expressed reservations about the implementation of the policy.[13]
Notes
[1] Minutes of the Board of Regents (http:/ / www. nlm. nih. gov/ od/ bor/ bor904. pdf) [2] Policy on Enhancing Public Access to Archived Publications Resulting from NIH-Funded Research (http:/ / publicaccess. nih. gov/ ) [3] Public access to NIH research made law (http:/ / www. sciencecodex. com/ public_access_mandate_made_law), science codex, Posted On: December 26, 2007 - 9:50pm [4] Journal Publishing Tag Set (http:/ / dtd. nlm. nih. gov/ publishing/ ) [5] ALPSP (http:/ / www. alpsp. org/ ) [6] NLM-NCBI Book Tag Set (http:/ / dtd. nlm. nih. gov/ book/ ) [7] News from the Library of Congress (http:/ / www. loc. gov/ today/ pr/ 2006/ 06-097. html) [8] Inera NLM DTD Resources (http:/ / www. inera. com/ nlmresources. shtml) [9] NLM Journal Archiving and Interchange Tag Suite (http:/ / dtd. nlm. nih. gov/ ), National Center for Biotechnical Information, National Library of Medicine [10] Kristin Antelman (September 2004). "Do Open-Access Articles Have a Greater Research Impact?" (http:/ / www. ala. org/ ala/ mgrps/ divs/ acrl/ publications/ crljournal/ 2004/ sep/ antelman. pdf). College & Research Libraries 65(5). pp. 372382. . and summarized by C&RL News (http:/ / www. ala. org/ ala/ mgrps/ divs/ acrl/ publications/ crlnews/ 2006/ dec/ scholarlycom. cfm) [11] Open access publishing, article downloads, and citations: randomised controlled trial (http:/ / www. bmj. com/ cgi/ content/ full/ 337/ jul31_1/ a568)
PubMed Central
[12] C&RL News: Scholarly Communication in Flux: Entrenchment and Opportunity (http:/ / www. ala. org/ ala/ mgrps/ divs/ acrl/ publications/ crlnews/ 2006/ dec/ scholarlycom. cfm) Kate Thomes, Science & Technology Libraries 22, no. 3/4 (220): 104 "Many faculty see the current system of scholarly communication as an effective, known, and reliable system that is not broken and therefore does not need to be fixed." [13] The American Physiological Society (http:/ / www. the-aps. org/ news/ nihaccessplan. htm)"Although the American Physiological Society (APS) supports the principle of public access, the NIH approach is a mallet rather than a scalpel. It is likely to harm publishers, which will in turn harm the dissemination of science through the literature."
275
External links
PubMed Central (http://www.ncbi.nlm.nih.gov/pmc/) PubMed Central FAQ (http://www.ncbi.nlm.nih.gov/pmc/about/faq.html) National Institutes of Health Submission System (NIHMS) (http://www.nihms.nih.gov/) NIH Public Access Policy (http://publicaccess.nih.gov/)
UK PubMed Central
276
UK PubMed Central
UKPMC
Content Description UKPMC: a full text article resource for the life sciences. Contact Research center Authors European Bioinformatics Institute Johanna R McEntyre
Primary Citation McEntyre et al. (2011)[1] Release date 2010 Access Website http:/ / ukpmc. ac. uk Tools Miscellaneous
UK PubMed Central [2] (UKPMC) is an on-line database that offers free access to a vast and growing collection of biomedical and health research information. The service, which was launched in January 2007 by the British Library, is based on the model of the American PubMed Central database, developed by the National Library of Medicine (NLM). Initially, UK PubMed Central provides a local mirror of the collection of full-text biomedical research articles of the PubMed Central database. In addition, UK PubMed Central currently offers a manuscript submission system, which allows scientists to submit their peer-reviewed research articles for inclusion in the UK PubMed Central collection. Plans for the future include the development of further UK-specific services, community forums, and enhanced content, such as links from the UKPMC collection to molecular and medical datasets. In this way, UK PubMed Central will grow into a unique online resource representing the UK's research output in biomedical and health research. The contract to develop a UK-version of the American PubMed Central database was awarded to the British Library together with University of Manchester and the European Bioinformatics Institute by an alliance of eight UK biomedical research funders, led by the Wellcome Trust, in July 2006. Many members of this group now require that articles describing the results of research they have supported are made available in UK PubMed Central with the aim of maximising its impact. UK PubMed Central will ensure that articles resulting from research paid for by any member of the funding consortium will become freely available. UKPMC is supported by the Arthritis Research Campaign, the Biotechnology and Biological Sciences Research Council, the British Heart Foundation, Cancer Research UK, the Chief Scientist Office of the Scottish Executive Health Department, the Department of Health, the Medical Research Council, and the Wellcome Trust.[3]
UK PubMed Central
277
References
[1] McEntyre, J. R.; Ananiadou, S.; Andrews, S.; Black, W. J.; Boulderstone, R.; Buttery, P.; Chaplin, D.; Chevuru, S. et al. (2010). "UKPMC: A full text article resource for the life sciences". Nucleic Acids Research 39 (Database issue): D58D65. doi:10.1093/nar/gkq1063. PMC3013671. PMID21062818. [2] http:/ / ukpmc. ac. uk/ [3] "UK PubMed Central Funders" (http:/ / ukpmc. ac. uk/ ppmc-localhtml/ funders. html). . Retrieved 2008-01-21.
External links
UK PubMed Central website (http://ukpmc.ac.uk/) PubMed Central (http://www.ncbi.nlm.nih.gov/pmc/) PubMed Central Canada (http://www.wajam.com/3uieh5) World Wide Science website (http://worldwidescience.org/)
TRIP Database
278
TRIP Database
TRIP Database
Developer(s) TRIP Database Ltd Type License Website Search Engine Freeware TRIP Database [1]
The TRIP Database is a free clinical search engine. Its primary function is to help clinicians identify the best available evidence with which to answer this clinical questions. Its roots are firmly in the world of Evidence-based medicine
History
The site was created in 1997 as a search tool to help the ATTRACT [2] staff answer clinical questions for GPs in Gwent, South Wales. Shortly afterwards Bandolier highlighted the TRIP Database and this helped establish the site. In 2003, after a period of steady growth, TRIP became a subscription only service. This was abandoned In September 2006 and since then the growth in usage has been significant.
The TRIP Process

The core to TRIPs system is the identification and incorporation of new evidence. The people behind TRIP are heavily involved in clinical question answering systems (e.g., NLH Q&A Service). Therefore, if resources are identified that are useful in the Q&A process they tend to be added to TRIP.
Who uses TRIP?

A site survey (September 2007 [3]) showed that the site is searched over 500,000 times per month, with 69% from health professionals and 31% from members of the public. Of the health professionals around 43% are doctors. Most users come from either the United Kingdom or the USA. In September 2008 the site was searched 1.4 million times.
Recent Updates
At the end of 2009 TRIP had a major upgrade which saw significant new enhancements: New content - widening the coverage of the TRIP Database. Evidence slider - allows users to easily select the highest quality evidence. New design. Improved algorithm - ensuring better search results. Advanced search. Better guideline filtering - introducing more geographic distinctions. Background knowledge boxes - showing contextual links to etextbooks based on the search terms used. TRIP fails - links to other sources should TRIP let you down. Search history. Related articles.
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Education Tracker on TRIP

TRIP has an education tracker which allows users to record their activity on TRIP which can then be used, subject to local regulations, for revalidation/re-licensing. For further detail click here [4].
TRIP and the developing world initiative

TRIP has recently launched an initiative for crowdsourcing the identification of content suitable for the developing world. Currently much of the evidence contained in TRIP is unsuitable for resource-poor setting - due to issue such as cost. By allowing users to indicate which articles are suitable it'll create a subset of data that users can view for a particular search term click here for further details [5].
TRIP Answers
In November 2008, TRIP released a new website, TRIP Answers [6]. This is a repository of clinical Q&As from a variety of Q&A services, at launch it had over 5,000 Q&As and currently has over 6,300. This content has been integrated into TRIP,
External links
TRIP Database [1] TRIP on Facebook [7] TRIP on Twitter [8] the TRIP Blog [9]
References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. tripdatabase. com http:/ / www. attract. wales. nhs. uk http:/ / blog. tripdatabase. com/ 2007/ 09/ trip-users. html http:/ / www. tripdatabase. com/ how-to-cpd http:/ / blog. tripdatabase. com/ 2010/ 03/ using-trip-to-help-identify-content. html http:/ / www. tripanswers. org http:/ / www. facebook. com/ tripdatabase http:/ / twitter. com/ jrbtrip http:/ / blog. tripdatabase. com/
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Twease
Twease is an open source biomedical web search engine at www.twease.org which searches MEDLINE. It provides searches based on relevance or chronology; highlights text passages that match the query; collects and exports references seamlessly to RefWorks, EndNote, BibTex; searches for articles similar to a group of articles; and offers a slider to control query expansion with common synonyms, word variants, mesh terms, etc. Its content is updated weekly and can be downloaded and set up locally to run unlimited searches against Medline.
External links
Twease home page [1] Library News & Announcements [2] at Weill Cornell Medical Library. See "Twease: A Tool to Enhance Your PubMed Searches" Twease source distribution [3]
References
[1] http:/ / www. twease. org/ [2] http:/ / library. med. cornell. edu/ Library/ HTML/ Special. html [3] http:/ / icb. med. cornell. edu/ crt/ twease/ index. xml
SciELO
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SciELO
SciELO
Producer Languages
FAPESP - BIREME (Brazil) English Access
Cost
Free Coverage
Disciplines Record depth Format coverage
Multidisciplinary Index, abstract & full-text Academic journal articles
Geospatial coverage South America Number of records 239,628 Links Database Homepage [2] Title List [1]
SciELO (Scientific Electronic Library Online) is a bibliographic database and a model for cooperative electronic publishing in developing countries originally from Brazil, supported by the Foundation for Research Support of the State of So Paulo (Fundao de Amparo Pesquisa do Estado de So Paulo, FAPESP) and the National Council of Scientific and Technological Development (Conselho Nacional de Desenvolvimento Cientfico e Tecnolgico, CNPq), in partnership with the Latin American and Caribbean Center on Health Sciences Information. The database contains 815 scientific journals from different countries in free and universal access, full-text format.[3] The SciELO Project's stated aims are to "envisage the development of a common methodology for the preparation, storage, dissemination and evaluation of scientific literature in electronic format." All journals are published by a special software suite which implements a scientific electronic virtual library accessed via several mechanisms, including a table of titles in alphabetic and subject list, subject and author indexes and a search engine.
References
[1] http:/ / www. scielo. org/ php/ index. php?lang=en [2] http:/ / www. scielo. org/ applications/ scielo-org/ php/ secondLevel. php?xml=secondLevelForAlphabeticList& xsl=secondLevelForAlphabeticList [3] SciELO: SciELO in numbers (http:/ / www. scielo. org/ php/ index. php?lang=en). Accessed 1 April 2011.
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Telehealth and Telemedicine

Connected Health
Connected Health is a term used to describe a model for healthcare delivery that uses technology to provide healthcare remotely. Connected health aims to maximize healthcare resources and provide increased, flexible opportunities for consumers to engage with clinicians and better self-manage their care. It uses technology often leveraging readily available consumer technologies to deliver patient care outside of the hospital or doctors office. Connected health encompasses programs in telehealth, remote care (such as home care) and disease and lifestyle management, often leverages existing technologies such as connected devices using existing cellular networks and is associated with efforts to improve chronic care. The United States and European Union are two dominant markets for the use of connected health in home care service, in part due to the high availability of telephone and Internet service as compared to other parts of the world. Within the United States, over 260 million people have a land line connected, over 190 million are cell phone users, and approximately 200 million are Internet users. The European Union has roughly an equivalent number of people connected to land lines, but prevails over the U.S. with more than 300 million cell phone users and 230 million Internet users. More recent data collected by Pew Internet: Americans and their Gadgets [1] suggest that 86% of US residents own a mobile phone and this number is as high as 96% among Americans aged 18 to 29 years. According to the International Communications Union, it is predicted that there will be 4 billion mobile phone users worldwide by the end of 20081. The vision of the connected health model can be implicitly understood by contemplating the significant impact of technology on other industries, such as in banking, shopping, logistics and personal communications. Proponents of connected health believe that technology can transform healthcare delivery and address many inefficiencies especially in the area of work flow management, chronic disease management and patient compliance of the US and global healthcare systems.
History
Connected health has its roots in telemedicine, and its more recent relative, telehealth. The first telemedicine programs were primarily undertaken to address healthcare access and/or provider shortages. Connected health is distinguished from telemedicine by: A broader concern for healthcare cost, quality and efficiency, particularly as related to the chronically ill Concomitant interests in making healthcare more patient centric by promoting healthcare consumerism through education, and patient feedback Efforts in the direction of integrating of data generated outside of traditional healthcare settings such as the home with centralised, often electronic patient record One of the first telemedicine clinics was founded by Dr. Kenneth Bird at Massachusetts General Hospital [2] in 1967. The clinic addressed the fundamental problems of delivering occupational and emergency health services to employees and travellers at Bostons Logan International Airport, located three congested miles from the hospital. Over 1,000 patients are documented as having received remote treatment from doctors at MGH using the clinics two-way audiovisual microwave circuit2. The timing of Dr. Birds clinic more or less coincided with NASAs foray into telemedicine through the use of physiologic monitors for astronauts3. Other pioneering programs in telemedicine were designed to deliver healthcare services to people in rural settings.
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Connected Health in Operation

Two core platforms are emphasized in connected health, self-care and remote care, with programs primarily focused on monitoring and feedback for the chronically ill, elderly, and those patients located at an untenable distance from primary or specialty providers. Programs designed to improve patient-provider communication within an individual medical practice (for example, the use of email to communicate with patients between office visits) also fall within the purview of connected health. There are also lifestyle coaching programs, in which an individual receives healthcare information to facilitate behavior change to improve their fitness and/or general well being, (see wellness) or to reduce or eliminate the impact of a particular behavior that presents a risk to their health status. Some of the most common types of connected health programs in operation today include: Home care via remote monitoring of chronically ill patients including surveillance connected devices or patient controlled monitoring of health parameters Traditional telehealth programs, where care is provided in remote areas by teams of local clinicians or community healthcare workers teamed up with specialists in medical centers Monitoring programs whose aim is to ensure the safety and quality of life of elderly parents living at a distance from their relatives Web-based second opinion services for patients in need of medical care Lifestyle and fitness coaching for wellness or health risk reduction The Center for Connected Health [3] is implementing a range of programs in high-risk, chronic and remotely located populations. Inherent in the concept of connected health is flexibility in terms of technological approaches to care delivery and specific program objectives. For instance, remote monitoring programs might use a combination of cell phone and smart phone technology, online communications or biosensors and may aim to increase patient-provider communication, involve patients in their care through regular feedback, or improve upon a health outcome measure in a defined patient population or individual. Digital pen technology, global positioning, videoconferencing and environmental sensors are all playing a role in connected health today.
Goals of Connected Health

Connected health is viewed by its proponents as a critical component of change in human healthcare. They envision: Reductions in the cost of providing quality care to the chronically ill, estimated by the Center for Health Care Economics at the Milken Institute [4] to be over $1 trillion per year Improved global and local public health surveillance, with a resultant reduction in epidemics, increased control over infectious disease and improved drug safety Diminished rate of medical errors Better customer service in healthcare Ongoing preventive health, with attendant reductions in: morbidity, mortality and the cost of care Consumer engagement in health and self-management Safer and more effective clinical trials
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The Evolution of Connected Health

Healthcare is consistently cited in political polls and in surveys as a chief concern for consumers, administrators, employers and clinicians alike.4 The formal establishment of quality improvement organizations in 2002 and rise of independent organizations such as The National Committee for Quality Assurance, The Leapfrog Group [5] and Bridges to Excellence [6] - all of which are dedicated to promoting and monitoring healthcare quality - illustrate intense concern over inefficiency, safety, and customer service in healthcare. In addition, skyrocketing costs, increases in chronic diseases, geographic dispersion of families, growing provider shortages, troubling ethnic disparities in care, better survival rates among patients fighting serious diseases, an aging U.S. population and longer lifespan are all factors pointing to a need for better ways of delivering healthcare.5,6,7 Consumer demand for better service and quality in healthcare is the latest source of pressure to improve the healthcare system. Experts speculate that, having acclimated to greater speed, efficiency and cost transparency - as well as vastly improved access to information about products and services - in other industries, consumers are calling for the same responsiveness from the healthcare system. Direct-to-consumer advertising is a demonstrated contributor to the rise in consumer demand, as is the mass availability of inexpensive technology and ubiquity of the Internet, cell phones and PDAs.8,9 Connected health experts such as Joseph C. Kvedar, M.D. [7], believe that consumer engagement in healthcare is on its way to becoming a major force for change. In summary, connected health has arisen from: 1) a desire on the part of individual physicians and healthcare organizations to provide better access, quality and efficiency of care 2) dynamics of the healthcare economy (such as rising costs and changing demographics) 3) consumerism in health care and a drive towards patient centric healthcare. Together, these factors are providing impetus for connected healthcare in the United States and many other industrialised nations and forcing innovation both from within and outside the system.
Evidence
While connected health is yet emerging, there is evidence of its benefit. For example, in a program being implemented by the Center for Connected Health [8] and Partners Home Care [9], over 500 heart failure patients have now been monitored remotely through the collection of vital signs, including heart rate, blood pressure and weight, using simple devices in the patients home. The information is sent daily to a home health nurse, who can identify early warning signs, notify the patients primary care physician, and intervene to avert potential health crises. A pilot of this program demonstrated reduced hospitalizations10. Another initiative at the Center for Connected Health uses cellular telephone technology and a smart pill bottle to detect when a patient has not taken their scheduled medication. A signal is then sent that lights up an ambient orb device in the patients home to remind them to take their medication.
Funding and Implementation

Today, it appears that connected health programs are operated and funded primarily by home care agencies and large healthcare systems. However, insurers and employers, who bear enormous cost to insure their employees, are increasingly interested in connected health for its potential to reduce direct and indirect healthcare costs. For example, EMC Corporation recently launched the first employer-sponsored connected health program, currently in the beta phase of implementation, which is aimed at improving outcomes and cost of care for patients with high blood pressure.11
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US Government and Connected Health

Government agencies involved in connected health include: The Office for the Advancement of Telehealth The Centers for Medicare & Medicaid Services (CMS), to the extent that Medicaid reimburses for telemedicine programs, at the states option. According to the CMS Web site, at least 18 states are allowing reimbursement for services provided via telemedicine for reasons that include improved access to specialists for rural communities and reduced transportation costs. The Office of the National Coordinator for Health Information Technology (ONC) is charged with creating an interoperable health information technology infrastructure for the nation. That infrastructure has been primarily defined as an electronic health records system, however, former National Coordinator David Brailer indicated his support for personal health records that are portable and controlled by consumers. It remains to be seen how his successor, Robert Kolodner, will interpret this charge.12
Personal Health Records

Personal health records, or PHRS, (see personal health record) are essentially medical records controlled and maintained by the healthcare consumer. PHRs intersect with connected health in that they attempt to increase the involvement of healthcare consumers in their care. By contrast, electronic medical records (EMRs) (see electronic medical record) are digital medical records or medical records systems maintained by hospitals or medical practices and are not part of connected health delivery.
Resources
American Telemedicine Association, http://www.americantelemed.org/i4a/pages/index.cfm?pageid=1 Association of Telehealth Service Providers, http://www.atsp.org/business/telehealth_books.asp Center for Connected Health, http://www.connected-health.org/ Center for Studying Health System Change, http://www.hschange.com/ Center for Telehealth & Ehealth Law, http://www.ctel.org/ Home Telehealth, Connecting Care Within the Community, Edited by Richard Wootton, Susan L. Dimmick, Joseph C. Kvedar, MD, Director, Center for Connected Health, Partners org/ media-center/
HealthCare. http:/ / www. connected-health. home-telehealth-connecting-care-within-the-community.aspx
Office of the National Coordinator for Health Information Technology, http://www.hhs.gov/healthit/onc/ mission/ Telemedicine Information Exchange, http://tie.telemed.org/default.asp
References
1
International Telecommunications Union website (Accessed December 10, 2008), http:/ / www. itu. int/ ITU-D/ ict/ newslog/Worldwide+Mobile+Cellular+Subscribers+To+Reach+4+Billion+Mark+Late+2008.aspx
2
Medscape website, Highlights from the Eighth Annual Meeting of the American Telemedicine Association (Accessed December 10, 2008), http://www.medscape.com/viewarticle/457684
3
Telemedicine Information Exchange website, A Brief History of Telemedicine (Accessed December 10, 2008), http://tie.telemed.org/articles/article.asp?path=articles&article=tmhistory_nb_tie95.xml
4
Gallup website, Gallups Pulse of Democracy (Accessed December 10, 2008), http:/ / www. gallup. com/ poll/ 17785/Election-2008.aspx
Connected Health
5
286
The New York Review of Books website, "The Health Care Crisis and What to Do About It (Accessed December 10, 2008) http://www.nybooks.com/articles/18802
6 7
Americans for Healthcare website (Accessed December 10, 2008), http://www.americansforhealthcare.org/facts/
Agency for Healthcare Research and Quality website, Health Care Costs: Why Do They Increase? What Can We Do? (Accessed December 10, 2008), http://www.ahrq.gov/news/ulp/costs/ulpcosts1.htm
8
PriceWaterhouseCoopers. 2006. The Factors Fueling Rising Healthcare Costs 2006, Prepared for Americas Health Insurance Plans, 2006
9
Kaiser Family Foundation website, How Changes in Medical Technology Affect Health Care Costs , March 2007 (Accessed December 10, 2008), http://www.kff.org/insurance/snapshot/chcm030807oth.cfm
10 11
BMJ 2007; 334: 942 (5 May); http://www.bmj.com/cgi/content/full/334/7600/942
Kowalczyk, L. Employees to get an online checkup: Care provider, EMC will test a program to cut health costs, The Boston Globe, March 3, 2007; http:/ / www. boston. com/ yourlife/ health/ diseases/ articles/ 2007/ 03/ 03/ employees_to_get_an_online_checkup/?page=1
12
Brailer, David J. Your Medical History, To Go. The New York Times. September 19, 2006.
References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / pewinternet. org/ Reports/ 2010/ Gadgets/ Overview. aspx/ http:/ / www. massgeneral. org/ http:/ / www. connected-health. org/ programs. aspx http:/ / www. milkeninstitute. org/ http:/ / www. leapfroggroup. org/ http:/ / www. bridgestoexcellence. org/ about-us/ http:/ / www. connected-health. org/ about-us/ leadership/ joseph-c-kvedar. aspx http:/ / www. connected-health. org/ http:/ / www. partnershomecare. org/
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Telehealth
Telehealth is the delivery of health-related services and information via telecommunications technologies. Telehealth could be as simple as two health professionals discussing a case over the telephone or as sophisticated as doing robotic surgery between facilities a different ends of the globe. Telehealth is an expansion of telemedicine, and unlike telemedicine (which more narrowly focuses on the curative aspect) it encompasses preventive, promotive and curative aspects. Originally used to describe administrative or educational functions related to telemedicine, today telehealth stresses a myriad of technology solutions. For example, physicians use email to communicate with patients, order drug prescriptions and provide other health services.
Clinical uses of telehealth technologies

Transmission of medical images for diagnosis (often referred to as store and forward telehealth) Groups or individuals exchanging health services or education live via videoconference (real-time telehealth) Transmission of medical data for diagnosis or disease management (sometimes referred to as remote monitoring) Advice on prevention of diseases and promotion of good health by patient monitoring and followup.
Health advice by telephone in emergent cases (referred to as teletriage)
Nonclinical uses of telehealth technologies

Distance education including continuing medical education, grand rounds, and patient education administrative uses including meetings among telehealth networks, supervision, and presentations research on telehealth online information and health data management healthcare system integration asset identification, listing, and patient to asset matching, and movement overall healthcare system management patient movement and remote admission
Telehealth modes
Store-and-forward telehealth
In store-and-forward telehealth, digital images, video, audio, Observations of Daily Living (ODLs)[1] , and clinical data are captured and "stored" on the client computer or mobile device; then at a convenient time transmitted securely ("forwarded") to a clinic at another location where they are studied by relevant specialists. The opinion of the specialist is then transmitted back. Based on the requirements of the participating healthcare entities, this roundtrip could take between 1 minute to 48 hours. In the simplest form of Telehealth application, basic vital signs like Blood Pressure, Weight, Pulse Oximeter, Blood Sugar values are monitored and trended for long term Chronic care. In many store-and-forward specialties, such as dermatology, radiology and pathology an immediate response is not critical and are conducive to store-and-forward technologies. Automated screening and diagnostic tele-audiology is fast becoming another specialty conducive to store-and-forward audiology.
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Real-time telehealth
In real-time telehealth, a telecommunications link allows instantaneous interaction. Videoconferencing equipment is one of the most common forms of synchronous telemedicine. Peripheral devices can also be attached to computers or the video-conferencing equipment which can aid in an interactive examination. With the availability of better and cheaper communication channels, direct two-way audio and video streaming between centers through computers is leading to lower costs. Examples of real-time clinical telehealth include: Tele-audiology Telecardiology Teledentistry Telemental Health -- the use of videoconferencing technology to connect a psychiatrist with a mental health client Teleneurology Telenursing Teleradiology Telerehabilitation
In an effort to enhance the real-time telehealth experience, Google Health, a personal health information centralization service, recently began establishing relationships with telehealth providers that will allow their users to sync the data shared during telehealth consultations with their online health records. To date, partnerships have been formed with the following companies: MDLiveCare and Hello Health.[2] In the UK Stoke on Trent Primary Care Trust together with mediaburst and the West Midlands Strategic Health Authority have sponsored the development of a low cost Simple Telehealth [3] system "Florence [4]" which primarily operates using text messaging (SMS) and a web application.
Remote patient monitoring

In remote monitoring, sensors are used to capture and transmit biometric data. For example, a tele-EEG device monitors the electrical activity of a patients brain and then transmits that data to a specialist. This could be done in either real time or the data could be stored and then forwarded. Examples of remote monitoring include: Home-based nocturnal dialysis [5] Cardiac and multi-parameter monitoring of remote ICUs Home telehealth Disease management
Benefits of telehealth
Telehealth adds a new paradigm in healthcare, where the patient is monitored between physician office visits. This has been shown to significantly reduce hospitalizations and visits to the Emergency Room, while improving patient's quality of life. Telehealth also benefits patients where traditional delivery of health services are affected by distance and lack of local specialist clinicians to deliver services. The rate of adoption of telehealth services in any jurisdiction is frequently influenced by factors such as the adequacy and cost of existing conventional health services in meeting patient needs; the policies of governments and/or insurers with respect to coverage and payment for telehealth services; and medical licensing requirements that may inhibit or deter the provision of telehealth second opinions or primary consultations by physicians. There may also be some significant carbon reductions for the NHS to be gained from developing Telehealth and therefore reducing the need to travel (often, in the case of patients, by car) as well as encouraging healthy, sustainable behaviour through monitoring and improved communications and reducing the requirements to expand
Telehealth sites to meet increases in Healthcare demands.
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The state of the market

Projections for the growth of the telehealth market are optimistic, and much of this optimism is predicated upon the increasing demand for remote medical care. According to a recent survey, nearly three-quarters of U.S. consumers say they would use telehealth.[6] At present, several major companies are scrambling to establish a foothold in a market that, according to market-research firm Datamonitor, is expected to grow to more than $6 billion by 2012 from 900 million in 2007.[7]
References
[1] [2] [3] [4] [5] Health in Everyday Living (http:/ / www. projecthealthdesign. org/ media/ file/ E-primer_3. pdf) Robert Wood Johnson Foundation primer. "Fall update on Google Health" (http:/ / googleblog. blogspot. com/ 2009/ 10/ fall-update-on-google-health. html). . Retrieved 2009-10-07. http:/ / www. stoke. nhs. uk/ simple http:/ / www. getflorence. co. uk/ Andreas Pierratos, MD. Nocturnal hemodialysis: dialysis for the new millennium (http:/ / www. cmaj. ca/ cgi/ content/ full/ 161/ 9/ 1137) Canadian Medical Association Journal, November 2, 1999; 161 (9), 2 November 1966. [6] "Survey: Consumers Keen on Telemedicine" (http:/ / www. healthdatamanagement. com/ news/ telemedicine-38701-1. html). . Retrieved 2010-04-26. [7] "Homecare telehealth expected to grow despite current barriers to adoption" (http:/ / it. tmcnet. com/ news/ 2007/ 08/ 30/ 2897900. htm). . Retrieved 2010-04-26.
Further reading
Telemedicine,Telehealth, and the Consumer (http://tie.telemed.org/articles/article.asp?path=consumer& article=tmcoming_nb_tie96.xml) Online introduction and primer to telehealth and telemedicine from the Telemedicine Information Exchange Norris, A. C. (2002). Essentials of Telemedicine and Telecare. West Sussex, England; New York: John Wiley & Sons, Ltd. ISBN 0-471-53151-0. Maheu, Marlene M.; Whitten, Pamela; & Allen, Ace (2001). E-Health, Telehealth, and Telemedicine: A Guide to Start-up and Success. San Francisco: Jossey Bass. ISBN 0-7879-4420-3. Olmeda, Christopher J. (2000). Information Technology in Systems of Care. Delfin Press. ISBN 978-0-9821442-0-6 Telehealth Technical Assistance Manual (http://www.nrharural.org/pubs/pdf/Telehealth.pdf) - A document to assist in the planning of telehealth and telemedicine projects for rural community and migrant health centers and other health care organizations. By Samuel G. Burgess, Ph.D. October 2006 Teleneurology and requirements of the european Medical Devices Directive (MDD) (http://www.baaske.net/ index.php?id=37&L=1) - Telemedical Systems and regulatory affairs for Europe, by Dipl. Ing. Armin Grtner
External links
Telehealth for Patients, Providers, Health Plans, Employers (http://www.americanwell.com/). American Well. Telemedicine and Telehealth (http://www.teladoc.com/). Teladoc. Post discharge follow-up calls (http://www.telenursefirst.com/). TeleNurse First. Center for Telehealth and Technology (http://t2health.org/) DOD Defense Centers of Excellence Telehealth wiki (http://www.ATAwiki.org) Telemental Health Guide (http://www.tmhguide.org) HealthLink BC (http://www.HealthLinkBC.ca)
Telehealth Ontario (http://www.health.gov.on.ca/english/public/program/telehealth/telehealth_mn.html) Ontario Telemedicine Network -- Making the Connection for Health (http://www.otn.ca)
Telehealth Tasmanian government (http://www.dhhs.tas.gov.au/service_information/services_files/telecare) GP2U Telehealth Australia (http://gp2u.com.au/) NHS Direct (http://www.nhsdirect.nhs.uk/), the UK National Health Service information service NHS Stoke on Trent (http://www.stoke.nhs.uk/simple) Simple Telehealth Project International Society for Telemedicine & eHealth (http://www.isft.net/) Med-e-Tel - The International Educational and Networking Forum for eHealth, Telemedicine and Health ICT (http://www.medetel.lu/) Community for Teledermatology (http://telederm.org) Scottish Centre for Telehealth (http://www.sct.scot.nhs.uk) British Columbia Alliance on Telehealth Policy and Research (http://www.bcatpr.ca) UCLA Wireless Health Institute (http://www.wirelesshealth.ucla.edu) Fit for the Future, Scenarios for low-carbon healthcare in 2030 (http://www.forumforthefuture.org/files/ Fit_for_the_Future_NHS_Sept09.pdf) Lifesize Case Study on Telehealth (http://www.lifesize.com/Industry_Solutions/Case_Studies/ Case-Study_Village-Church.aspx)
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United States oriented

Office for the Advancement of Telehealth (http://telehealth.hrsa.gov/index.htm) (established by the Health Resources and Services Administration) U.S. Department of Veterans Affairs Care Coordination/Telehealth Program (http://www.carecoordination.va. gov) American Telemedicine Association (http://www.americantelemed.org) National Rural Health Association (http://www.NRHArural.org/) National Center for Telehealth & Technology (http://www.t2health.org) Center for Telehealth & E-Health Law (http://www.telehealthlawcenter.org) Telemedicine Information Exchange (http://tie.telemed.org/) University of New Mexico Telehealth (http://hsc.unm.edu/som/telehealth/) University of Florida Center for Telehealth (http://telehealth.phhp.ufl.edu/)
Telemedicine
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Telemedicine
Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. It is also used to save lives in critical care and emergency situations. Although there were distant precursors to telemedicine, it is essentially a product of 20th century telecommunication and information U.S. Navy medical staff being trained in the use technologies. These technologies permit communications between of handheld telemedical devices (2006). patient and medical staff with both convenience and fidelity, as well as the transmission of medical, imaging and heath informatics data from one site to another. Early forms of telemedicine achieved with telephone and radio have been supplemented with videotelephony, advanced diagnostic methods supported by distributed client/server applications, and additionally with telemedical devices to support in-home care.[1]
Disambiguation
Other expressions similar to telemedicine are the terms "telehealth" and "eHealth", which are frequently used to denote broader definitions of remote healthcare not always involving active clinical treatments.[2] Telehealth and eHealth are at times incorrectly interchanged with telemedicine. Like the terms "medicine" and "health care", telemedicine often refers only to the provision of clinical services while the term telehealth can refer to clinical and non-clinical services involving medical education, administration, and research.[3] The term eHealth is often used, particularly in the U.K. and Europe, as an umbrella term that includes telehealth, electronic medical records, and other components of health information technology.
Early precursors
In its early manifestations, African villagers used smoke signals to warn people to stay away from the village in case of serious disease.[4] [5] In the early 1900s, people living in remote areas of Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor Service of Australia.
Types of telemedicine
Categories Telemedicine can be broken into three main categories: store-and-forward, remote monitoring and (real-time) interactive services. Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc.) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline.[2] It does not require the presence of both parties at the same time.[1] Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured medical record preferably in electronic form should be a component of this transfer. A key difference between traditional in-person patient meetings and telemedicine encounters is the omission of an actual physical examination and history. The 'store-and-forward' process requires the clinician to rely on a history report and audio/video information in lieu of a physical examination.
Telemedicine Remote monitoring, also known as self-monitoring or testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective. Interactive telemedicine services provide real-time interactions between patient and provider, to include phone conversations, online communication and home visits.[1] Many activities such as history review, physical examination, psychiatric evaluations and ophthalmology assessments can be conducted comparably to those done in traditional face-to-face visits. In addition, clinician-interactive telemedicine services may be less costly than in-person clinical visit Emergency telemedicine Common daily emergency telemedicine is performed by SAMU Regulator Physicians in France, Spain, Chile, Brazil. Aircraft and maritime emergencies are also handled by SAMU centres in Paris, Lisbon and Toulouse.[6]
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General health care delivery

Benefits and uses Telemedicine can be extremely beneficial for people living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Patients who live in such areas can be seen by a doctor or specialist, who can provide an accurate and complete examination, while the patient may not have to travel or wait the normal distances or times like those from conventional hospital or GP visits. Recent developments in mobile collaboration technology with the use of hand-held mobile devices allow healthcare professionals in multiple locations the ability to view, discuss and assess patient issues as if they were in the same room.[7] Telemedicine can be used as a teaching tool, by which experienced medical staff can observe, show and instruct medical staff in another location, more effective or faster examination techniques. It improved access to healthcare for patients in remote locations. "Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through better management of chronic diseases,shared health professional staffing, reduced travel times, and fewer or shorter hospital stays." Several studies have documented increase patient satisfaction of telemedicine over past fifteen years.[8] The first interactive telemedicine system, operating over standard telephone lines, for remotely diagnosing and treating patients requiring cardiac resuscitation (defibrillation) was developed and marketed by MedPhone Corporation in 1989 under the leadership of its president and founder, S.Eric Wachtel. A year later the company introduced a mobile cellular version, the MDphone. Twelve hospitals in the U.S. served as receiving and treatment centers.[9] Telemonitoring is a medical practice that involves remotely monitoring patients who are not at the same location as the health care provider. In general, a patient will have a number of monitoring devices at home, and the results of these devices will be transmitted via telephone to the health care provider. Telemonitoring is a convenient way for patients to avoid travel and to perform some of the more basic work of healthcare for themselves. In addition to objective technological monitoring, most telemonitoring programs include subjective questioning regarding the patient's health and comfort. This questioning can take place automatically over the phone, or telemonitoring software can help keep the patient in touch with the health care provider. The provider can then make decisions about the patient's treatment based on a combination of subjective and objective information similar to what would be revealed during an on-site appointment. Some of the more common things that telemonitoring devices keep track of include blood pressure, heart rate, weight, blood glucose, and hemoglobin. Telemonitoring is capable of providing information about any vital signs, as
Telemedicine long as the patient has the necessary monitoring equipment at his or her location. Depending on the severity of the patient's condition, the provider may check these statistics on a daily or weekly basis to determine the best course of treatment. The first Ayurvedic telemedicine center was established in India in 2007 by Partap Chauhan, an Indian Ayurvedic doctor and the Director of Jiva Ayurveda. Monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver is a fast growing emerging service. These remote monitoring solutions have a focus on current high morbidity chronic diseases and are mainly deployed for the First World. In developing countries a new way of practicing telemedicine is emerging better known as Primary Remote Diagnostic Visits, whereby a doctor uses devices to remotely examine and treat a patient. This new technology and principle of practicing medicine holds significant promise of improving on major health care delivery problems, in for instance, Southern Africa, because Primary Remote Diagnostic Consultations not only monitors an already diagnosed chronic disease, but has the promise to diagnose and manage the diseases patients will typically visit a general practitioner for. Telenursing Telenursing refers to the use of telecommunications and information technology in order to provide nursing services in health care whenever a large physical distance exists between patient and nurse, or between any number of nurses. As a field it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc. Telenursing is achieving significant growth rates in many countries due to several factors: the preoccupation in reducing the costs of health care, an increase in the number of aging and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions. Among its benefits, telenursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among telenurses.[10] Telepharmacy Telepharmacy is another growing trend for providing pharmaceutical care to patients at remote locations where they may not have physical contact with pharmacists. It encompasses drug therapy monitoring, patient counseling, prior authorization, refill authorization, monitoring formulary compliance with the aid of teleconferencing or videoconferencing. In addition, video-conferencing is vastly utilized in pharmacy for other purposes, such as providing education, training, and performing several management functions.[11] A notable telepharmacy program is in the United States, conducted at a federally qualified community health center, Community Health Association of Spokane (CHAS) in 2001, which allowed the low cost medication dispensing under federal governments program. This program utilized videotelephony for dispensing medication and patient counseling at six urban and rural clinics. There were one base pharmacy and five remote clinics in several areas of Spokane, Washington under the telepharmacy program at CHAS. The base pharmacy provided traditional pharmacy study to the clients at Valley clinic and served as the hub pharmacy for the other remote clinics. The remote site dispensing and patient education process was described as follows: once the prescription is sent from the remote clinics to the base pharmacy, the pharmacist verifies the hard copy and enters the order. The label is also generated simultaneously, and the label queue is transmitted to the remote site. When the label queue appears on the medication dispensing cabinet known as ADDS, the authorized person can access the medicine from ADDS followed by medication barcode scanning, and the printing and scanning of labels. Once those steps are done, the remote site personnel are connected to the pharmacist at base pharmacy via videoconferencing for medication verification and patient counseling.[12] In recent time, the U.S. Navy Bureau of Medicine took a significant step in advancing telepharmacy worldwide. The telepharmacy program was piloted in 2006 in the regions served by Naval Hospital Pensacola, Florida, and Naval
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Telemedicine Hospital Bremerton, Washington. Starting from March 2010, the Navy expanded its telepharmacy system to more sites throughout the world. According to Navy Lieutenant Justin Eubanks at Navy Hospital Pensacola, Florida, telepharmacy would be initiated at more than 100 Navy sites covering four continents by the end of 2010.[13] Telerehabilitation Telerehabilitation (or e-rehabilitation[14] [15] ) is the delivery of rehabilitation services over telecommunication networks and the Internet. Most types of services fall into two categories: clinical assessment (the patients functional abilities in his or her environment), and clinical therapy. Some fields of rehabilitation practice that have explored telerehabilitation are: neuropsychology, speech-language pathology, audiology, occupational therapy, and physical therapy. Telerehabilitation can deliver therapy to people who cannot travel to a clinic because the patient has a disability or because of travel time. Telerehabilitation also allows experts in rehabilitation to engage in a clinical consultation at a distance. Most telerehabilitation is highly visual. As of 2006 the most commonly used modalities are via webcams, videoconferencing, phone lines, videophones and webpages containing rich Internet applications. The visual nature of telerehabilitation technology limits the types of rehabilitation services that can be provided. It is most widely used for neuropsychological rehabilitation; fitting of rehabilitation equipment such as wheelchairs, braces or artificial limbs; and in speech-language pathology. Rich internet applications for neuropsychological rehabilitation (aka cognitive rehabilitation) of cognitive impairment (from many etiologies) was first introduced in 2001. This endeavor has recently (2006) expanded as a teletherapy application for cognitive skills enhancement programs for school children. Tele-audiology (hearing assessments) is a growing application. As of 2006, telerehabilitation in the practice of occupational therapy and physical therapy are very limited, perhaps because these two disciplines are more hands on. Two important areas of telerehabilitation research are (1) demonstrating equivalence of assessment and therapy to in-person assessment and therapy, and (2) building new data collection systems to digitize information that a therapist can use in practice. Ground-breaking research in telehaptics (the sense of touch) and virtual reality may broaden the scope of telerehabilitation practice, in the future. In the United States, the National Institute on Disability and Rehabilitation Research's (NIDRR) [16] supports research and the development of telerehabilitation. NIDRR's grantees include the "Rehabilitation Engineering and Research Center" (RERC) at the University of Pittsburgh, the Rehabilitation Institute of Chicago, the State University of New York at Buffalo, and the National Rehabilitation Hospital in Washington DC. Other federal funders of research are the Veterans Administration, the Health Services Research Administration in the US Department of Health and Human Services, and the Department of Defense. Outside the United States, excellent research is conducted in Australia and Europe. As of 2006, only a few health insurers in the United States will reimburse for telerehabilitation services. If the research shows that teleassessments and teletherapy are equivalent to clinical encounters, it is more likely that insurers and Medicare will cover telerehabilitation services.
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Specialist care delivery

Telemedicine can facilitate specialty care delivered by primary care physicians according to a controlled study of the treatment of hepatitis C.[17] Various specialties are contributing to telemedicine, in varying degrees. Telecardiology ECGs, or electrocardiographs, can be transmitted using telephone and wireless. Willem Einthoven, the inventor of the ECG, actually did tests with transmission of ECG via telephone lines. This was because the hospital did not allow him to move patients outside the hospital to his laboratory for testing of his new device. In 1906 Einthoven came up with a way to transmit the data from the hospital directly to his lab.[18]
Telemedicine Teletransmission of ECG using methods indigenous to Asia One of the oldest known telecardiology systems for teletransmissions of ECGs was established in Gwalior, India in 1975 at GR Medical college by Dr. Ajai Shanker, Dr. S. Makhija, P.K. Mantri using an indegenous technique for the first time in India. This system enabled wireless transmission of ECG from the moving ICU van or the patients home to the central station in ICU of the department of Medicine. Transmission using wireless was done using frequency modulation which eliminated noise. Transmission was also done through telephone lines. The ECG output was connected to the telephone input using a modulator which converted ECG into high frequency sound. At the other end a demodulator reconverted the sound into ECG with a good gain accuracy. The ECG was converted to sound waves with a frequency varying from 500Hz to 2500Hz with 1500Hz at baseline. This system was also used to monitor patients with pacemakers in remote areas. The central control unit at the ICU was able to correctly interpret arrhythmia. This technique helped medical aid reach in remote areas.[19] In addition, electronic stethoscopes can be used as recording devices, which is helpful for purposes of telecardiology. In Pakistan three pilot projects in telemedicine was initiated by the Ministry of IT & Telecom, Government of Pakistan (MoIT) through the Electronic Government Directorate in collaboration with Oratier Technologies (a pioneer company within Pakistan dealing with healthcare and HMIS) and PakDataCom (a bandwidth provider). Three hub stations through were linked via the Pak Sat-I communications satellite, and four districts were linked with another hub. A 312 Kb link was also established with remote sites and 1 Mbit/s bandwidth was provided at each hub. Three hubs were established: the Mayo Hospital (the largest hospital in Asia), JPMC Karachi and Holy Family Rawalpindi. These 12 remote sites were connected and on average of 1,500 patients being treated per month per hub. The project was still running smoothly after two years.[20] Telepsychiatry Telepsychiatry, another aspect of telemedicine, also utilizes videoconferencing for patients residing in underserved areas to access psychiatric services. It offers wide range of services to the patients and providers, such as consultation between the psychiatrists, educational clinical program, diagnosis and assessment, medication therapy management, etc. The following are some of the model programs and projects which are undergoing for implementation of telepsychiatry in rural areas in the US. 1. University of Colorado Health Sciences Center (UCHSC) supports two programs for American Indian and Alaskan Native populations a. The Center for Native American Telehealth and Tele-education (CNATT) and b. Telemental Health Treatment for American Indian Veterans with Posttraumatic Stress Disorder (PTSD) 2. Military Psychiatry, Walter Reed Army Medical Center. Links for several sites related to telemedicine, telepsychiatry policy, guidelines, and networking are available at the website for the American Psychiatric Association.[21]
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Telemedicine Teleradiology Teleradiology is the ability to send radiographic images (x-rays, CT, MR, PET/CT, SPECT/CT, MG, US...) from one location to another.[22] For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving-image review station. The most typical implementation are two computers connected via the Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. Sometimes the receiving computer will have a printer so that images can be printed for convenience.
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A CT exam displayed through teleradiology
The teleradiology process begins at the image sending station. The radiographic image and a modem or other connection are required for this first step. The image is scanned and then sent via the network connection to the receiving computer. Today's high-speed broadband based Internet enables the use of new technologies for teleradiology : the image reviewer can now have access to distant servers in order to view an exam. Therefore, they do not need particular workstations to view the images ; a standard Personal Computer (PC) and Digital Subscriber Line (DSL) connection is enough to reach keosys central server. No particular software is necessary on the PC and the images can be reached from wherever in the world. Teleradiology is the most popular use for telemedicine and accounts for at least 50% of all telemedicine usage. Telepathology Telepathology is the practice of pathology at a distance. It uses telecommunications technology to facilitate the transfer of image-rich pathology data between distant locations for the purposes of diagnosis, education, and research.[23] [24] Performance of telepathology requires that a pathologist selects the video images for analysis and the rendering diagnoses. The use of television microscopy, the forerunner of telepathology, did not require that a pathologist have physical or virtual hands-on involvement is the selection of microscopic fields-of-view for analysis and diagnosis. A pathologist, Ronald S. Weinstein,M.D., coined the term telepathology in 1986. In an editorial in a medical journal, Weinstein outlined the actions that would be needed to create remote pathology diagnostic services.[25] He, and his collaborators, published the first scientific paper on robotic telepathology.[26] Weinstein was also granted the first U.S. patents for robotic telepathology systems and telepathology diagnostic networks.[27] Dr. Weinstein is known to many as the "father of telepathology".[28] In Norway, Eide and Nordrum implemented the first sustainable clinical telepathology service in 1989.[29] This is still in operation, decades later. A number of clinical telepathology services have benefited many thousands of patients in North America, Europe, and Asia. Telepathology has been successfully used for many applications including the rendering histopathology tissue diagnoses, at a distance, for education, and for research. Although digital pathology imaging, including virtual microscopy, is the mode of choice for telepathology services in developed countries, analog telepathology imaging is still used for patient services in some developing countries.
Telemedicine Teledermatology Teledermatology is a subspecialty in the medical field of dermatology and probably one of the most common applications of telemedicine and e-health.[30] In teledermatology, telecommunication technologies are used to exchange medical information (concerning skin conditions and tumours of the skin) over a distance using audio, visual and data communication. Applications comprise health care management such as diagnoses, consultation and treatment as well as (continuous) education.[31] The dermatologists Perednia and Brown were the first to coin the term teledermatology in 1995. In a scientific publication, they described the value of a teledermatologic service in a rural area underserved by dermatologists.[32] Teledentistry Teledentistry is the use of information technology and telecommunications for dental care, consultation, education, and public awareness in the same manner as telehealth and telemedicine. Tele-audiology Tele-audiology is the utilization of telehealth to provide audiological services and may include the full scope of audiological practice. This term was first used by Dr Gregg Givens in 1999 in reference to a system being developed at East Carolina University in North Carolina, USA. The first Internet audiological test was accomplished in 2000 by Givens, Balch and Keller. The first Transatlantic teleaudiology test was performed in April 2009 when Dr James Hall tested a patient in South Africa from Dallas.
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U.S. licensing and regulatory issues

Restrictive licensure laws in the United States require a practitioner to obtain a full license to deliver telemedicine care across state lines. Typically, states with restrictive licensure laws also have several exceptions (varying from state to state) that may release an out-of-state practitioner from the additional burden of obtaining such a license. A number of States require practitioners who seek compensation to frequently deliver interstate care to acquire a full license. If a practitioner serves several states, obtaining this license in each state could be an expensive and time-consuming proposition. Even if the practitioner never practices medicine face-to-face with a patient in another state, he/she still must meet a variety of other individual state requirements, including paying substantial licensure fees, passing additional oral and written examinations, and traveling for interviews. Regulations concerning the practice of telemedicine vary from state to state.[33] Physicians who will be prescribing over the Internet to patients should mandate strict controls on their practice to insure that they stay compliant with the various State Medical Board Regulations concerning Internet Prescribing.[34]
Advanced and experimental services

Telesurgery Remote surgery (also known as telesurgery) is the ability for a doctor to perform surgery on a patient even though they are not physically in the same location. It is a form of telepresence. Remote surgery combines elements of robotics, cutting edge communication technology such as high-speed data connections and elements of management information systems. While the field of robotic surgery is fairly well established, most of these robots are controlled by surgeons at the location of the surgery.
Telemedicine Remote surgery is essentially advanced telecommuting for surgeons, where the physical distance between the surgeon and the patient is immaterial. It promises to allow the expertise of specialized surgeons to be available to patients worldwide, without the need for patients to travel beyond their local hospital.[35]
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Enabling technologies
Further information: List of video telecommunication services and product brands Videotelephony Videotelephony comprises the technologies for the reception and transmission of audio-video signals by users at different locations, for communication between people in real-time.[36] At the dawn of the technology, videotelephony also included image phones which would exchange still images between units every few seconds over conventional POTS-type telephone lines, essentially the same as slow scan TV systems. Currently videotelephony is particularly useful to the deaf and speech-impaired who can use them with sign language and also with a video relay service, and well as to those with mobility issues or those who are located in distant places and are in need of telemedical or tele-educational services. Health information technology Health information technology (HIT) provides the umbrella framework to describe the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, government and quality entities, and insurers. Health information technology (HIT) is in general increasingly viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system (Chaudhry et al., 2006). Broad and consistent utilization of HIT will: Improve health care quality; Prevent medical errors; Reduce health care costs; Increase administrative efficiencies Decrease paperwork; and Expand access to affordable care.
Interoperable HIT will improve individual patient care, but it will also bring many public health benefits including: Early detection of infectious disease outbreaks around the country; Improved tracking of chronic disease management; and Evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared.
Telemedicine
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References
[1] Sachpazidis, Ilias Image and Medical Data Communication Protocols for Telemedicine and Teleradiology (dissertation) (ftp:/ / 82. 135. 241. 67/ Articles/ article_11. pdf), Department of Computer Science, Technical University of Darmstadt, Germany, 10 July 2008. [2] American Telemedicine Association. Telemedicine/Telehealth Terminology (http:/ / www. americantelemed. org/ files/ public/ abouttelemedicine/ Terminology. pdf), American Telemedicine Association website, Washington, D.C. Retrieved August 21, 2011. [3] About Telehealth: Telehealth Definition (http:/ / www. coachorg. com/ CTF/ about_telehealth/ what_is_telehealth. htm), Canadian Telehealth Forum. Retrieved from Coach: Canada's Health Teleinformatics Association website on August 21, 2011. [4] Did You Know? New Insights Into A World That Is Full of Astonishing Stories and Astounding Facts (http:/ / books. google. ca/ books?id=4tgqsTknBcUC), Reader's Digest, Reader's Digest Association Limited, 1990, pg.189, ISBN 0276420144, ISBN 9780276420146. [5] Nakajima, I.; Sastrokusumo, U.; Mishra, S.K.; Komiya, R.; Malik, A.Z.; Tanuma, T. The Asia Pacific Telecommunity's Telemedicine Activities (http:/ / ieeexplore. ieee. org/ xpl/ freeabs_all. jsp?arnumber=1717870), IEEE Xplore.com website, 17-19 Aug. 2006, pp. 280 - 282, ISBN 0-7803-9704-5, DOI: 10.1109/HEALTH.2006.246471 [6] George R. Schwartz, C. Gene Cayten; George R. Schwartz (editor). Principles and Practice of Emergency Medicine, Volume 2 (http:/ / books. google. ca/ books?id=NlZ_aST4_hcC), Lea & Febiger, 1992, pg.3202, ISBN 081211373X, ISBN 9780812113730. [7] Van't Haaff, Corey (March/April 2009). "Virtually On-sight" (http:/ / www. justforcanadiandoctors. com/ pastissues/ JFCD2009/ JFCD-Mar-Apr2009. pdf). Just for Canadian Doctors. pp.22. . [8] What Is Telemedicine? (http:/ / www. americantelemed. org/ files/ public/ abouttelemedicine/ What_Is_Telemedicine. pdf) [9] W. John Blyth. "Telecommunications, Concepts, Development, and Management", Second Edition, Glencoe/McCgraw-Hill Company,1990, pp.280-282. [10] Nurses Happier Using Telecare, Says International Survey (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=1263), eHealth Insider website, 15 June 2005, retrieved 2009-04-04; [11] Angaran, DM. "Telemedicine and Telepharmacy: Current Status and Future Implications", American Journal of Health-System Pharmacy, 1999 Jul 15; Vol. 56: 1405-26 [12] Dennis Clifton, G.; Byer, Heather; Heaton, Kristi; Haberman, Deborah J.; and Gill, Harbir. "Provision of Pharmacy Services to Underserved Populations Via Remote Dispensing and Two-Way Videoconferencing." American Journal of Health-System Pharmacy. 2003 Dec 15; Vol. 60:2577-82 [13] Traynor, Kate. "Navy takes Telepharmacy Worldwide", American Journal of Health-System Pharmacy. 2010 Jul 15; Vol. 67:1134-36 [14] E-health care information systems: an introduction for students and professionals, John Wiley and Sons, 2005, p.219, ISBN9780787966188 [15] Lisa Keaton; Linda L. Pierce; Victoria Steiner; Karen Lance. "An E-rehabilitation Team Helps Caregivers Deal with Stroke" (http:/ / ijahsp. nova. edu/ articles/ vol2num4/ pierce-keaton. htm). The Internet Journal of Allied Health Sciences and Practice (Ijahsp.nova.edu) 2.4. ISSN1540-580X. . Retrieved 2011-03-26. [16] http:/ / www. ed. gov/ about/ offices/ list/ osers/ nidrr/ index. html?src=mr [17] Arora, Sanjeev; Karla Thornton, Glen Murata, Paulina Deming, Summers Kalishman, Denise Dion, Brooke Parish, Thomas Burke, Wesley Pak, Jeffrey Dunkelberg, Martin Kistin, John Brown, Steven Jenkusky, Miriam Komaromy, Clifford Qualls (2011-06). "Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers" (http:/ / www. nejm. org/ doi/ full/ 10. 1056/ NEJMoa1009370). New England Journal of Medicine: 110601140030042. doi:10.1056/NEJMoa1009370. ISSN0028-4793. . Retrieved 2011-06-02. [18] Telecardiology (http:/ / www. medetel. lu/ download/ 2009/ parallel_sessions/ presentation/ day1/ telecardiology_and_tele-ecg_network. pdf). [19] "Teletransmission of ECG Waveform: An Ingenious Low Priced Technique", Indian Heart Journal, 1982, Vol.34, No.6. [20] Pakistan telemedicine (http:/ / 202. 83. 164. 29/ egdsite04/ ?p=projimpu) [21] American Psychiatric Association (http:/ / www. psych. org/ Departments/ HSF/ UnderservedClearinghouse/ Linkeddocuments/ telepsychiatry. aspx) [22] Kontaxakis, George; Visvikis, Dimitris; Ohl, Roland; Sachpazidis, Ilias; Suarez, Juan Pablo; Selby, Boris Peter; et al.: "Integrated Telemedicine Applications and Services for Oncological Positron Emission Tomography", Oncology Reports, Vol.15: 10911100, 2006 [23] Weinstein, RS; Graham, AM; Richter, LC; Barker, GP; Krupinski, EA; Lopez, AM; Yagi, Y; Gilbertson, JR et al. (2009), "Overview of telepathology, virtual microscopy and whole slide imagining: Prospects for the future.", Hum Pathol 40: 10571069 [24] Kumar, S (2009), Kumar S, Dunn BE (editors), ed., "Telepathology: An Audit", In: Telepathology (Springer-Verlag Berlin Heidelberg): 225229 [25] Weinstein, RS (1986), "Prospect for telepatholgy (Editorial)", Hum Pathol 17: 443-434 [26] Weinstein, RS; Bloom, KJ (1987), "Telepathology and the networking of pathology diagnostic services.", Arch Path Lab Med 111: 646652 [27] Kayser, K; Szymas, J; Weinstein (1999), "Telepathology: Telecommunications, Electronic Education and Publication in Pathology", Springer, NY: 1186 [28] http:/ / www. union. edu/ N/ DS/ s. php?s=8942 [29] Nordrum, I; Engum, B; Rinde, E`; et al (1991), "Remote frozen section service: A telepathology project to northern Norway.", Hum Pathol 1991: 514518 [30] http:/ / www. atmeda. org/ icot/ sigtelederm. htm [31] Wooton et al. 2005 Roy soc of med press; Wurm et al. 2007 JDDG; Burg et al. 2005 Teledermatology
Telemedicine
[32] Perednia, Brown 1995 Bull Med Libr Assoc [33] Information Provided for Physicians: Doctors Seeking a Medical Licensing Service (http:/ / www. medlicense. com/ telemedicine_license. html), MedLicense.com website. [34] MedLicense.com - Practical Advise for Physicians Who Are Involved In Telemedicine (http:/ / www. medlicense. com/ telemedicine_advice. html), MedLicense.com website. [35] IST's Media Collection (http:/ / www. intersurgtech. com/ media. html), Interface Surgical Technologies website. Retrieved 21 August 2011. [36] McGraw-Hill Concise Encyclopedia of Engineering. Videotelephony (http:/ / encyclopedia2. thefreedictionary. com/ Videotelephony), McGraw-Hill, 2002. Retrieved from the FreeDictionary.com website, January 9, 2010
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Further reading
W. John Blyth. "Telecommunications, Concepts, Development, and Management", Second Edition, Glencoe/McCgraw-Hill Company,1990, pp.280282. Teleneurology and requirements of the european Medical Devices Directive (MDD) (http://www.baaske.net/ index.php?id=37&L=1) - Telemedical Systems and regulatory affairs for Europe, by Dipl. Ing. Armin Grtner Telemedicine 101: Telemedicine Coming of Age (http://tie.telemed.org/articles/article. asp?path=telemed101&article=tmcoming_nb_tie96.xml) - Telemedicine 101: Telemedicine Coming of Age, by Nancy Brown What is Telemedicine? (http://www.icucare.com/PageFiles/Telemedicine.pdf) - What is Telemedicine?, by Robert Higgs (www.icucare.com)
External links
Telemedicine and Telehealth (http://www.teladoc.com/) Teladoc. Telemedicine Pakistan(TelmedPak) (http://www.telmedpak.com) Wiki for telemedicine (ATAwiki) (http://www.ATAwiki.org) Agency for Healthcare Research and Quality (AHRQ) -- Telemedicine for the Medicare Population (http://www. ahrq.gov/clinic/epcsums/telemedsum.htm) Ontario Telemedicine Network -- Making the Connection for Health (http://www.otn.ca) American Telemedicine Association (http://www.americantelemed.org) Telemedicine Information Exchange (http://tie.telemed.org) Canadian Society of Telehealth (http://www.cst-sct.org) TELESYNERGY - Telemedicine at the National Institutes of Health (http://telesynergy.nih.gov) Telemedicine History (http://www.depts.ttu.edu/communications/vistas/archive/02-summer/stories/ miracle-of-telemedicine.php) National Rural Health Association (http://www.nrharural.org) International Society for Telemedicine & eHealth (ISfTeH) (http://www.isft.net) American Psychiatric Asscoiation (http://www.psych.org/Departments/HSF/UnderservedClearinghouse/ Linkeddocuments/telepsychiatry.aspx)
Telecare
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Telecare
Telecare is a term given to offering remote care of old and physically less able people, providing the care and reassurance needed to allow them to remain living in their own homes. The use of sensors may be part of a package which can provide support for people with illnesses such as dementia, or people at risk of falling. In 2005 the UK's Department of Health published Building Telecare in England to coincide with the announcement of a grant to help encourage its take up by local councils with social care responsibilities.[1] Most telecare mitigates harm by reacting to untoward events and raising a help response quickly. Some telecare, such as safety confirmation and lifestyle monitoring have a preventive function in that a deterioration in the telecare user's wellbeing can be spotted at an early stage. Telecare is specifically different from telemedicine and telehealth. Telecare refers to the idea of enabling people to remain independent in their own homes by providing person-centred technologies to support the individual or their carers. In its simplest form, it can refer to a fixed or mobile telephone with a connection to a monitoring centre through which the user can raise an alarm. Technologically more advanced systems use sensors, whereby a range of potential risks can be monitored. These may include falls, as well as environmental changes in the home such as floods, fire and gas leaks. Carers of people with dementia my be alerted if the person leaves the house or other defined area. When a sensor is activated it sends a radio signal to a central unit in the user's home, which then automatically calls a 24-hour monitoring centre where trained operators can take appropriate action, whether it be contacting a local key holder, doctor or the emergency services. Telecare also comprises standalone telecare which does not send signals to a response centre but supports carers through providing local (in-house) alerts in a person's home to let the carer know when a person requires attention. The meaning and usage of the term 'telecare' has not yet settled into consistent use. In the UK it is grounded in the social care framework and focuses on the meaning described above. In other countries 'telecare' may be applied to the practice of healthcare at a distance. Technological advances result in the possibility of promoting independence and for providing care from the social initiative sector, which now contemplates eCare, and navigation/positioning systems, such as GPS for people with dementia or other cognitive impairments. It is important to note that 'telecare' is not just a warning system if someone strays from home but is also preventative measure whereby people are brought back and kept in the community through regular communication.[2] There are now a large range of telecare services available with some of the most well known being the pendant alarm[3] , pill dispenser[4] , telephone prompt service [5] , the movement monitoring[6] and more. All play a role in maintaining people's independence and allowing people to stay in their own homes.
References
[1] Building Telecare in England (http:/ / www. dh. gov. uk/ en/ Publicationsandstatistics/ Publications/ PublicationsPolicyAndGuidance/ DH_4115303) [2] Independent Living Telecare (http:/ / www. independentliving. co. uk/ telecare. html) [3] Tunstall - Pendant Alarm (http:/ / www. tunstall. co. uk) [4] Pivotell - Pill Dispenser (http:/ / www. pivotell. co. uk) [5] Telecare Technology - Telephone Prompt Service (http:/ / www. telecaretechnology. com) [6] Just Checking - Movement Monitoring (http:/ / www. justchecking. co. uk)
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External links
International Society for Telemedicine & eHealth (http://www.isft.net/)
Telephone triage
Telephone triage is defined as the management of patient health concerns and symptoms via a telephone interaction (telecommunications) by advice nurses. It is thus an aspect of telenursing. It can also be considered an aspect of telemedicine and telehealth utilizing an older form of technology (telephone lines). Telehealth is defined as the delivery of health related services and information via telecommunications technologies and is now the umbrella term describing all the possible variations of healthcare services using telecommunications.
Uses of Telephone Triage

Triage means a sorting out. Telephone triage nurses utilize protocols or guidelines, in paper or electronic format to help sort symptoms, from chest pain to chicken pox. Telephone triage involves ranking clients' health problems according to their urgency, educating and advising clients, and making safe, effective, and appropriate dispositionsall by telephone. It may include everything from disease management, AIDS counseling and child abuse hotlines to 911 and telemetry monitoring, and takes place in settings as diverse as emergency rooms, large call centers and hospices. Telephone triage nurses have a range of titles: advice nurses, telepractitioners, telenurses, telepractice nurses or consulting nurses. In one 8-hour shift, a telenurse may field 60-80 telephone callsone every 6 10 minutespainstakingly assessing headaches, newborn rashes, chest pain, possible allergic reactions, medication questions, and seasonal flu and fevers. Nurses may also direct clients to obtain a second medical opinion, or advise them where to find relevant, current health information. They might counsel or perform crisis intervention for a threatened suicide. What was traditionally done informally in emergency rooms, clinics, and physicians' offices for years has evolved into a new nursing subspecialty called telephone triage. Telenurses practice in a range of settings, from large medical call centers, physicians offices, clinics, hospices, college health centers, disease management call centers, poison centers, and emergency departments.
Research on Telenurse Decision-making

Telephone triage the safe, effective and appropriate disposition of health related problems by RNs always involves decision-making under conditions of uncertainty and urgency. (Patel, 1996) Uncertainty because decisions are often made based on partial or inaccurate information; urgency because calls must be processed within a brief time frame usually 610 minutes average. In new research, telephone triage has been compared to the work of air traffic controllers, EMDs and firefighters all high stakes activities. Vimla Patel, Ph.D., described how a group of RNs working in an emergency department setting made real world decisions in telephone triage. She discovered that these nurses used pattern recognition, rules of thumb and context as major strategies to make decisions.
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Protocols
Protocols or guidelines are essentially standing orders for nurses for the assessment and management of a range of symptoms. Protocols may be in paper or electronic format. Some developers see protocols as decision-making tools; others as decision support tools. This is an area of controversy in this new field. The research on nurse decision-making by Patel and other experts has important implications for protocol design. The strategies of pattern recognition, rules of thumb and context should be incorporated into all elements of any decision support system as well as telenurse training and forms. The goal should be to mimic how the brain naturally solves problems in "real world" situations. Telephone triage is a high-risk area of practice, primarily because nurses cannot see the patient with whom they are speaking. Thus, training and guidelines are essential to support the nurse. Relying on protocols to take the place of formal instruction can be a mistake, and over reliance on a decision-making tool can lead to mistriage. Generally, experience and specialized training combined with strong decision support tools are the best approach to telepractice. Potential problems and misunderstandings can be averted through instruction in the correct and safe operation of the protocols and documentation form. gowri
Brief history
Informal telephone triage is as old as the telephone itself. In fact, one of the first calls made by Alexander Graham Bell was for assistance following a battery acid burn (Grumet, 1979). In the early days, physicians were quick to install telephones in their offices, seeing that these new tools could help their practices. Initially, physicians performed telephone advice. Telephone management has always comprised a large percentage of several physicians' practices pediatrics, Womens Health and Family Practice specialties. In the 1970s, several health maintenance organizations began utilizing nurses to give telephone advicein the role that physicians once served. A wide variety of similar systems have sprung up over the last decade. In 1990, the term "telephone triage" appeared on Medline indexesa formal acknowledgement of this new subspecialty.
Telephone triage formalization

In the early 70s, telephone triage had few job qualificationsmost nurses were felt to be qualified. As the field evolved into a recognized subspecialty, managers discovered that the high-stakes, high stress work required seasoned RNs with many years of bedside decision-making experience. Thus, new graduates were not considered the best candidates for the task of telephone triage. Certainly, there are exceptions to this rule. However, we know that less experience results in over triage (Patel, 1996), while increased experience results in more appropriate decisions. The new RN, with little or no bedside decision-making experience will require time to build up these skills. Whether in the clinic, office, hospital or in the emergency department setting, five to ten years experience provides the foundation necessary for good decision making by phonea considerably more difficult task. RNs are considered the best choice not only because they are autonomous professionals, but they are also the lowest paid person who can safely do the job (Schmitt, 1980). Telephone triage requires excellence in interpersonal skill or telephone charisma (articulate, personable, resourceful, dedication to service). There must be a good match between the workhigh volume, high-pressure decision making under conditions of uncertainty and urgentand the practitioners temperamentcalm, mature and patient. Computer literacy is desirable. Since the 70s most training was on the job, essentially see one, do one, teach one. Each new advice nurse had to learn through trial and error, essentially reinventing the training wheel with each new employee. In the 90s, formal training programs emerged. Currently, the best training programs have a minimum of 40 hours. Orientation addresses an overview of the field and the nursing role, the nursing process, communication aspects, history taking,
Telephone triage interview and documentation skills, protocol use and medical legal aspects. Two types of training and education currently existin-house and national conferences. In house trainers employ a variety of training methodologies, since research demonstrates that individuals learn differently and learning happens best when all senses are utilized. In-house training techniques include reading, lecture, discussion, shadowing, written exercises in interview and documentation, audiotapes analysis/critique, preceptor programs and role-play of mock calls. Role-play is an excellent method to cumulatively integrate the new skills and tools (protocols and documentation form) and to simulate the actual task. Preceptors can support and counsel the new advice nurse in the first three to six months. National conferences provide a broad perspective and opportunity to network and problem solves. Since 1994, conferences on telephone triage have provided a national forum for manager and practitioner alike to network and share experience and expertise. The final step in formal education will be accreditationnot yet a realitybut anticipated within the next five to ten years.
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References
Wheeler, S.Q, and Windt, J. (1993) Telephone Triage: Theory, Practice and Protocol Development, Delmar Thomson, Albany, NY. Wheeler, S.Q. (2003) Telephone Triage Protocols for Adult and School Age Populations with Womens Health and Infant/Child Protocols, Aspen Publishers, Gaithersburg, MD. Wheeler, S.Q. (2000) Telephone Triage: Past, Present and Future www.teletriage.com
Resources
Post discharge follow up calls [1]. Telenurse First Teletriage consulting site by Sheila Wheeler [2] Teletriage consulting site by Carol Rutenberg [3] Association of Telehealth Service Providers [4] American Academy of Ambulatory Care Nursing (AAACN) [5] Nurse Triage site specializing in personalized health information and support [6]
References
[1] [2] [3] [4] [5] [6] http:/ / www. telenursefirst. com/ http:/ / www. teletriage. com/ http:/ / www. telephone-triage. com/ http:/ / www. atsp. org/ homepage. asp http:/ / www. aaacn. org/ http:/ / www. healthcontactpartners. com/
Remote guidance
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Remote guidance
Remote guidance, in the medical context, refers to the supervision or guidance of a medical task, usually a procedures or test, from a remote location. This falls in the realm of real time telemedicine applications. By way of example, a radiologist may guide an ultrasound examination from a remote location. As such the proximate requisite expertise to accomplish a medical task is significantly diminished. In the previous example, a diagnostic quality ultrasound can be accomplished by non-medically trained individuals manipulating an ultrasound device located with the patient under guidance from a remote location. This is an example of teleradiology If appropriately configured, the remote guidance can originate from another room or floor in the same building, to as far away as another continent or even planet. NASA researchers have successfully demonstrated remote guidance of diagnostic level cardiac ultrasonography using an ultrasound on the space station, non-medical astronauts performing the exam as guided by a terrestrially located expert.
Remote diagnostics
Remote diagnostics refers to a real time telemedical application which achieves diagnostic level quality and information exchange. In this sense, it refers to an expectation for quality sufficient for making or excluding a medical diagnosis. In the tele-medical context specific to radiologic images these images often are consistent with the DICOM standard. Given bandwidth issues universally plaguing the healthcare environment imagery beyond still images and brief video has not yet become standard expectation of care environments or PACS systems. Ultrasound scanning commonly utilized for abdomen, musculoskeletal, pelvis, gynecologic, cardiac and vascular evaluations has shown potential for remote diagnosis only of late. More general Remote Diagnostics (RD) refers to detecting which fault or faults are present in a system, body of object, from a distance. Examples of use: aeroplanes, spacecrafts, Formula 1 and major assests such as ships,trains etc. In cases where also corrective actions are made, the term 'Remote Diagnostic & Maintenance' is more appropriate.
Technical aspects
While still imagery can be e-mailed and forwarded in a multitude of methods, video product of medical devices has typically not been available for remote interaction. Recent improvements in scanning devices, for example ultrasound machines has facilitated this new capability. The inclusion of the VGA output gives the opportunity for frame grabber devices to stream such outputs to the internet.
References
see also Remote diagnostics for RD in technical systems http://www.remoteguidance.org/laparascopic-surgery/lights-lap-camera-tele-action/ http://www.gizmag.com/go/5283/ http://www.sportandtechnology.com/features/0335.html
Froehlich J, Easily capture video from any VGA or DVI device, MacTech Magazine, 2007
Tele-epidemiology
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Tele-epidemiology
Tele-epidemiology is a methodological and application area of epidemiology concerned with the application of space-based systems (communication, Earth observation, positioning systems, Geographical Information Systems, biostatistics, etc.) in the study of the space and time distribution of health events or disease process in populations. In this broader sense, the term includes applications of all space-based systems to the field of epidemiology. The use of a satellite communication system to support the investigation of an infectious disease outbreak, the use of a remote-sensing satellite to recognize and locate physical features on Earth (for example, an industrial plant suspected of a point source contamination of air or water) or non-visible characteristics of a land area (for example, calculation of the NDVI index in relation to the distribution of species of mosquitoes) to assess health risk in surrounding populations, or the use of global positioning satellites (GPS) to track the migration of animals to better understand possible route of malaria transmission are all illustrations of tele-epidemiology. By recent usage, the term often designates the cross-disciplinary area linking specifically the applications of satellite technologies for earth observations (remote-sensing) to epidemiological research, health surveillance, and field support during health emergency response. In this restricted sense, the area of tele-epidemiology is closely related to the domain of landscape epidemiology. The United Nation Programme on Space Applications often refers to telehealth for applications linking communication systems (and for all health disciplines such as teleophtalmology, telesurgery etc...) and to "tele-epidemiology" in this more restricted sense.
External links
Tl-pidemiologie, MEDES: [1] United Nation Office for Outer Space Affairs: [2] Redgems website [3]
References
[1] http:/ / www. medes. fr/ home_fr/ telemedecine/ teleepidemiologie. html [2] http:/ / www. oosa. unvienna. org/ oosa/ SAP/ comm/ tele. html [3] http:/ / www. redgems. org/ spip. php?rubrique64
Telenursing
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Telenursing
Telenursing refers to the use of telecommunications and information technology for providing nursing services in health care whenever a large physical distance exists between patient and nurse, or between any number of nurses. As a field it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc. Telenursing is achieving a large rate of growth in many countries, due to several factors: the preoccupation in driving down the costs of health care, an increase in the number of aging and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions. Among its many benefits, telenursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among telenurses.[1]
Applications
One of the most distinctive telenursing applications is home care. For example, patients who are immobilized, or live in remote or difficult to reach places, citizens who have chronic ailments, such as chronic obstructive pulmonary disease, diabetes, congestive heart disease, or disabilitating diseases, such as neural degenerative diseases (Parkinson's disease, Alzheimer's disease, ALS), etc., may stay at home and be "visited" and assisted regularly by a nurse via videoconferencing, internet, videophone, etc. Still other applications of home care are the care of patients in immediate post-surgical situations, the care of wounds, ostomies, handicapped individuals, etc. In normal home health care, one nurse is able to visit up to 5-7 patients per day. Using telenursing, one nurse can visit 12-16 patients in the same amount of time. [Needs source] A common application of telenursing is also used by call centers operated by managed care organizations, which are staffed by registered nurses who act as case managers or perform patient triage, information and counseling as a means of regulating patient access and flow and decrease the use of emergency rooms. Telenursing can also involve other activities such as patient education, nursing teleconsultations, examination of results of medical tests and exams, and assistance to physicians in the implementation of medical treatment protocols.
Legal, ethical and regulatory issues

Telenursing is fraught with legal, ethical and regulatory issues, as it happens with telehealth as a whole. In many countries, interstate and intercountry practice of telenursing is forbidden (the attending nurse must have a license both in her state/country of residence and in the state/country where the patient receiving telecare is located). Legal issues such as accountability and malpractice, etc. are also still largely unsolved and difficult to address. In addition, there are many considerations related to patient confidentiality and safety of clinical data.
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References
Notes
[1] Nurses Happier Using Telecare, Says International Survey (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=1263), eHealth Insider website, 15 June 2005, retrieved 2009-04-04;
Bibliography Telenursing: Nursing Practice in Cyberspace. By Charles C Sharpe, 2000. 280 pg. Textbook in Health Informatics: A Nursing Perspective. Edited by J. Mantas, A. Hasman, 2002. IOS Press, 504 pg. International Standards for Telenursing Programmes, International Council of Nurses, 2001. 40 pg. (http:// www.icn.ch/bookshop.htm)
External links
Post discharge follow-up calls (http://www.telenursefirst.com/). TeleNurse First. Telenursing (http://www.allhealthnet.com/Nursing/Telenursing/). AllHealth.net Telehealth: Issues for Nursing (http://www.ana.org/readroom/tele2.htm). American Nursing Association. New nursing technologies: What you need to know (http://www.findarticles.com/p/articles/mi_qa3689/ is_199708/ai_n8760283). By Simpson, Roy L. Nursing. August 1997. Telehome Care Clinical Guidelines^ (http://www.atmeda.org/news/list.html). American Telemedicine Association. Telenursing and Licensure (http://www.bne.state.tx.us/telenurse.htm). Board of Nursing Examiners. Interstate Licensure for Telenursing (http://tie.telemed.org/articles/article.asp?path=articles& article=telenursingLicensure_gw_tie02.xml). By Glenn W. Wachter, May, 2002. TIE. Telehealth: Are you at risk? (http://www.afip.org/Departments/legalmed/jnrm2002/georgia.htm) By Georgia A. Martin. Nursing Risk Management 2002. AFIP. Telemedicine Applications in Telenursing 2003 (http://www.atmeda.org/news/selected2004.htm#nursing) and Telemedicine Applications in Telenursing 2004 (http://www.atmeda.org/news/selected2003. htm#nursing). Powerpoint presentations during the Annual Conference of the American Telemedicine Association. Telenursing Fact Sheet (http://www.icn.ch/matters_telenursing.htm). International Council of Nurses. Nurse Triage site specializing in personalized health information and support (http://www. healthcontactpartners.com/) The National Council of State Boards of Nursing Position Paper on Telenursing: A Challenge to Regulation (http://www.ncsbn.org/public/news/res/Telenursing Paper.pdf). The National Council of State Boards. August 1999. International Society for Telemedicine & eHealth (ISfTeH) (http://www.isft.net) - Telenursing Working Group
Teledermatology
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Teledermatology
Teledermatology is a subspecialty in the medical field of dermatology and probably one of the most common applications of telemedicine and e-health.[1] In teledermatology, telecommunication technologies are used to exchange medical information (concerning skin conditions and tumours of the skin) over a distance using audio, visual and data communication. Applications comprise health care management such as diagnoses, consultation and treatment as well as (continuous) education.[2] The dermatologists Perednia and Brown were the first to coin the term teledermatology in 1995. In a scientific publication, they described the value of a teledermatologic service in a rural area underserved by dermatologists.[3]
Modes of data transmission

Teledermatology (as telemedicine) is practised on the basis of two concepts: Store and forward (SAF) and real time/live interactive teledermatology. Hybrid modes also exist (combining SAF and real time applications). The SAF method is most commonly used in teledermatology: It involves sending (forwarding) digital images associated with (anonymous) medical information to the data storage unit of a consulted specialist. It can be as easy as sending an email with a digital image of a lesion to seek advice for a skin condition. Advantages of this method are that it does not demand the presence of both parties at the same time and does not usually require expensive equipment. In real-time/ live interactive teledermatology applications, provider and individuals usually interact via live videoconferencing. It may also involve remote surgery and the use of telerobotic microscopes in dermatopathology. This mode generally requires more sophisticated and costly technology than used in the SAF mode. Both participants must be available at the same time.
Areas of application
Health care management
Direct consultation involves an individual with a skin condition contacting a dermatologist via telecommunication to request diagnosis and treatment. In this field, mobile applications of teledermatology gain importance. Telediagnosis in the absence of personal contact with health care workers to the individual is complex. It requires active participation of the individual and without appropriate guidance may lead to improper management. However, as a triage tool, leading the individual directly to the appropriate specialist for his/her disease, it could be very valuable in the near future. Specialist referral is a major area of application in teledermatology A general practitioner (or other medical professional) that sees the individual consults a specialist/ specialised centre via telecommunication in order to get a second opinion. The specialist then helps the GP in rendering a diagnosis, providing management options et cetera.[4] Home telehealth/telehomecare involves an individual with a chronic condition being examined and managed remotely at home. An important field of interest of telehomecare in dermatology is the follow-up treatment of individuals with skin conditions requiring regular follow-up such as crural ulcers. Crural ulcers are a common skin condition that needs follow up visits up to twice a week demanding significant time commitments by the individuals in addition to causing a financial burden on the health care system. Teledermatology can help to reduce the time and costs involved in the follow-up of such conditions.[5]
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Education and information

Medical education/continuous education are a major advantage of telemedicine/e-health. Numerous universities offer online courses, computer based training and Web applications in this field principally aimed at medical students. Specialist training courses via internet are also available, particularly in dermoscopy.[6] General medical/health information may be accessed by non-professionals, such as individuals affected by a skin condition, and their relatives, through the internet. They are also able to join peer support groups with others affected by the same condition.[7]
Domains with special interest

Teledermoscopy
In teledermoscopy, digital dermoscopic lesion images (with or without clinical images) are transmitted electronically to a specialist for examination. This can be done on the web-based telediagnostic network Campus Medicus [8] Dermoscopy (dermatoscopy, epiluminescence microscopy) is the technical field of using an epiluminescence microscope for viewing skin lesions in magnification in-vivo. It is particularly useful in the early detection of malignant skin lesions (i.e., melanoma). Digital dermoscopic images can be taken with a digital camera attached to a dermatoscope or special video cameras suited for dermoscopy, e.g. the FotoFinder. Since dermoscopy is based on examination of a two-dimensional image it is very well suited for digital imaging and teledermatology.
Teledermatopathology
Teledermatopathology is the transmission of dermatopathologic images either in real-time with the aid of a robotic microscope or using a store-and-forward system (transmission as a single file). In the latter method (SAF) a rather new development is the introduction of virtual slide systems (VSS).[9] Virtual slides are made by digitally scanning an entire glass slide at a high resolution and then sending the images to a storage system. These can be then assessed on a computer screen similar to conventional microscopy, allowing the pathologist to maneuver around the image and view every part of the slide at any magnification.
Teledermoscopically-aided dermatopathology
This is the transmission of crucial medical data and dermoscopic as well as clinical images to a pathologist who renders the conventional histopathologic diagnosis. In the everyday clinical setting, skin biopsies are taken by the physician directly responsible for the individual and are assessed by a dermatopathologist. This pathologist has most likely never seen the clinical aspect of the lesion and might not have any information about the person. These limitations can be overcome by teledermoscopically-aided dermatopathology whereby a patient history and clinical data may increase the sensitivity of diagnosis.[10] Additionally it has been shown that provision of such data may improve the level of diagnostic confidence held by the assessing dermatopathologists.
Mobile Teledermatology
Mobile telemedicine is a system in which at least one participant (the person seeking advice or the doctor, for instance) uses wireless or mobile equipment[11] (i.e. mobile phones, handheld devices), in contrast to conventional stationary telemedicine platforms. Travellers who develop skin lesions as well as doctors who are on the move in hospital/non-hospital area can benefit from this new development in teledermatology. In order to facilitate access to medical advice and enable individuals to play a more active role in managing their own health status, mobile teledermatology seems to be especially suited for patient filtering or triage. (i.e. referral based on the severity and character of their skin condition). Another possible practical application is for follow-up of individuals with chronic
Teledermatology skin conditions mentioned above (see home care).[12] [13]
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Suitability of cases for Teledermatology

Not all cases are suitable for teledermatology.The type of cases suited for teledermatology is a topic, which requires more studies. Some studies have observed that eczema and follicular lesions were diagnosed with relatively more certainty,while in some other studies it was seen that diagnoses were made with more certainty in cases like viral warts, herpes zoster, acne vulgaris, irritant dermatitis, vitiligo, and superficial bacterial and fungal infections. Unlike in western studies where pigmented lesions suspicious of melanomas are one of the most referred cases for teledermatology (with or without teledermatoscopy), Asian studies have fewer cases referred based on the suspicion of melanoma.[14]
Footnotes
[1] [2] [3] [4] [5] [6] http:/ / www. atmeda. org/ icot/ sigtelederm. htm Wooton et al. 2005 Roy soc of med press; Wurm et al. 2007 JDDG; Burg et al. 2005 Teledermatology Perednia, Brown 1995 Bull Med Libr Assoc see http:/ / www. telederm. org/ Binder et al. 2008, Arch Derm see http:/ / www. medunigraz. at/ IDD
[7] see http:/ / www. dermnetnz. org [8] http:/ / www. campusmedicus. com [9] Massone et al. 2007 Human Pathology [10] Bauer et al. 2006 Br J Dermatol [11] http:/ / www. handyscope. net [12] Ebner et al. 2006 e&i [13] http:/ / www. pubmedcentral. nih. gov/ picrender. fcgi?artid=1868781& blobtype=pdf [14] Kaliyadan et al. 2009 Indian J Dermatol Venereol Leprol
References
R Wootton R, Oakley A: Teledermatology. Royal Society of Medicine Press Ltd, 2002 Burg G, Soyer H.P, Chimenti S. (2005): Teledermatology In: Frisch P, Burgdorf W.: EDF White Book, Skin Diseases in Europe. Berlin, 130-133 Perednia DA, Brown NA.: Teledermatology: one application of telemedicine. Bull Med Libr Assoc. 1995; 83(1): 4247 Wurm EM, Hofmann-Wellenhof R, Wurm R, Soyer HP.: Telemedizin und Teledermatologie: Vergangenheit Gegenwart und Zukunft. JDDG 6:106-12, 2007 Soyer HP, Hofmann-Wellenhof R, Massone C, Gabler G, Dong H, Fezal Ozdemir F, Argenziano G: telederm.org: Freely Available Online Consultations in Dermatology. PLoS Med 2005, 2(4): e87 - see http://dx.doi.org/10. 1371/journal.pmed.0020087 Binder B, Hofmann-Wellenhof R, Salmhofer W, Okcu A, Kerl H, Soyer HP.: Teledermatological monitoring of leg ulcers in cooperation with home care nurses. Arch Dermatol. 2007 Dec;143(12):1511-4. Ebner C, Gabler G, Massone C, Hofmann-Wellenhof R, Lozzi G P, Wurm EM, Soyer H P.: Mobile Teledermatology coming of age. 2006; e & i. 4:148-151 Massone C, Soyer HP, Lozzi GP, Di Stefani A, Leinweber B, Gabler G, Asgari M, BoldrinI R, Bugatti L, Canzonieri V, Ferrara G, Kodama K, Mehregan C, Rongioletti F, * A. Janjua S, Mashayekhi V, Vassilaki I, Zelger B, gavec B, Cerroni L, Kerl H.: Feasibility and diagnostic agreement in teledermatopathology using a virtual slide system. Human Pathol. 2007; 38(4): 546-554 Bauer J, Leinweber B, Metzler G, Blum A, Hofmann-Wellenhof R, Leitz N, Dietz K, Soyer HP, Garbe C.: Correlation with digital dermoscopic images can help dermatopathologists to diagnose equivocal skin tumours. Br J Dermatol. 2006;155(3):546-51
Teledermatology Scheinfeld N, Fisher M, Genis P, Long H. Evaluating Patient Acceptance of a Teledermatology Link. Skinmed. 2003;2:159-167. "PMID 14673291" Kaliyadan F, Venkitakrishnan S. Teledermatology: Clinical case profiles and practical issues. Indian J Dermatol Venereol Leprol 2009;75:32-5.
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Telemental Health
Telemental Health is the use of telecommunications technology to provide mental health services to individuals in communities or locations that are underserviced, typically as a result of geographic isolation. Examples of telemental health services include providing health workers in remote areas with continuing education on mental health topics, videoconferenced consultations on routine and urgent mental health cases using a "virtual" case management team, and providing direct mental health care services through two-way interactive systems. One of the most controversial telemental health care applications is providing treatment services over the Internet directly which, while showing early promise, will likely require considerable development to be made practical. While telecommunications have been used for decades to provide some mental health services (usually on an emergency basis or for experimental purposes), it was only in the 1990s that telemental health care services truly came into their own. Despite the early success of telemental health care services however, wide-scale implementation remains dependent on policy and funding initiatives although the outlook remains positive.
External links
Telemental Health Guide [1]
References
[1] http:/ / www. tmhguide. org
Telepsychiatry
313
Telepsychiatry
Telepsychiatry is the application of Telemedicine to the field of Psychiatry. It has been the most successful of all the telemedicine applications so far, because of its need for only a good videoconferencing facility between the patient and the psychiatrist, especially for follow-up. There are sub-specialties like forensic telepsychiatry,[1] in which the patient is typically an inmate accessing the psychiatrist who is from a supporting institution, and home-based telepsychiatry,[2] whereby the patient is in his own home or office, accessing the physician via webcam and high-speed internet. Another common application is for patients in rural or underserved areas, and there are a large number of grass roots telepsychiatry programs springing up in the United States and elsewhere to address this problem. In the U.S., Medicare and the various state Medicaids, as well as nearly all private health insurance providers, pay equally for telepsychiatry as for face to face psychiatric medication management visits.[3] A recent innovation is the development of the subspecialty of emergency psychiatry via telemedicine. Research is currently on-going to develop the unique guidelines required to provide consultation for emergency psychiatric patients such as the evaluation of the suicidal, homidical, violent, psychotic, depressed, manic, and acutely anxious patient.[4] Emergency telepsychiatry services are being provided to hospital emergency departments, jails, community mental health centers, substance abuse treatment facilities, and schools.[5]
References
[1] Jardine, Richard. "Forensic Telepsychiatry" (http:/ / www. telepsychiatry. slam. nhs. uk/ Home/ ForensicTP/ tabid/ 332/ Default. aspx) (Electronic). . Retrieved 07-10-2010. [2] "Treatment of Opioid Dependence via Home-Based Telepsychiatry - Ikelheimer 59 (10): 1218 - Psychiatr Serv" (http:/ / psychservices. psychiatryonline. org/ cgi/ content/ full/ 59/ 10/ 1218-a). Psychservices.psychiatryonline.org. doi:10.1176/appi.ps.59.10.1218-a. . Retrieved 2010-07-10. [3] Surface, David (January/February 2007), "Country Comfort: Mental Health Telemedicine in Rural America", Social Work 7 (1): 2831 [4] Shore JH, Hilty DM, Yellowlees P (2007). "Emergency management guidelines for telepsychiatry". General Hospital Psychiatry 29 (3): 199206. doi:10.1016/j.genhosppsych.2007.01.013. PMC1986661. PMID17484936. [5] "Telepsychiatry in the Emergency Department: Overview and Case Studies" (http:/ / www. chcf. org/ ~/ media/ Files/ PDF/ T/ TelepsychiatryProgramsED. pdf) (PDF). . Retrieved 2010-07-10.
Further reading
Frueh BC, Monnier J, Elhai JD, Grubaugh AL, Knapp RG (2004). "Telepsychiatry treatment outcome research methodology: efficacy versus effectiveness". Telemedicine Journal and E-health 10 (4): 4558. doi:10.1089/tmj.2004.10.455. PMID15689650. Hilty DM, Marks SL, Urness D, Yellowlees PM, Nesbitt TS (January 2004). "Clinical and educational telepsychiatry applications: a review". Canadian Journal of Psychiatry 49 (1): 1223. PMID14763673. Frueh BC, Monnier J, Elhai JD, Grubaugh AL, Knapp RG (2004). "Telepsychiatry treatment outcome research methodology: efficacy versus effectiveness". Telemedicine Journal and E-health 10 (4): 4558. doi:10.1089/tmj.2004.10.455. PMID15689650. Monnier J, Knapp RG, Frueh BC (December 2003). "Recent advances in telepsychiatry: an updated review". Psychiatric Services 54 (12): 16049. doi:10.1176/appi.ps.54.12.1604. PMID14645799.
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External links
Telemental Health Guide (http://www.tmhguide.org) http://www.cpa-apc.org/publications/archives/Bulletin/2003/october/hilty.asp A review on the effectiveness Some related links (http://telemed.org/europe/links/telepsych.asp) A feasibility study (http://www.telepsychiatry.slam.nhs.uk/Portals/9/douments/final.version.feasibility.08. 03.doc) American Association for Emergency Psychiatry (http://emergencypsychiatry.org) (http://www.telelive.org) Voyager Telepsychiatry (http://www.telepsychiatry.com) JSA Health Telepsychiatry (http://www.jsahealthmd.com)
Teleradiology
Teleradiology is the transmission of radiological patient images, such as x-rays, CTs, and MRIs, from one location to another for the purposes of interpretation and/or consultation. Teleradiology is a growth technology given that imaging procedures are growing approximately 15% annually against an increase of only 2% in the Radiologist population. Teleradiology improves patient care by allowing Radiologists to provide services without actually having to be at the location of the patient. This is particularly important when a sub-specialist such as a MRI Radiologist, Neuroradiologist, Pediatric Radiologist, or Musculoskeletal Radiologist is needed, since these professionals are generally only located in large metropolitan areas working during day time hours. Teleradiology allows for trained specialists to be available 24/7. Teleradiology utilizes standard network technologies such as the internet, telephone lines, wide area network (WAN), or over a local area network (LAN). Specialized software is used to transmit the images and enable the Radiologist to effectively analyze what can be hundreds of images for a given study. Technologies such as advanced graphics processing, voice recognition, and image compression are often used in Teleradiology. Through Teleradiology, images can be sent to another part of the hospital, or to other locations around the world.
Reports
Teleradiologists can provide a Preliminary Read for emergency room cases and other emergent cases or a Final Read for the official patient record and for use in billing. Preliminary Reports include all pertinent findings and a phone call for any critical findings. For some Teleradiology services, the turnaround time is extremely rapid with a 30 minute standard turnaround and expedited for critical and stroke studies. Teleradiology Final Reports can be provided for emergent and non-emergent studies. Final reports include all findings and require access to prior studies and all relevant patient information for a complete diagnosis. Phone calls with any critical findings are signs of quality services. Teleradiology Preliminary or Final Reports can be provided for all doctors and hospitals overflow studies. Teleradiology can be available for intermittent coverage as an extension of practices and will provide patients with the highest quality care.
Teleradiology
315
Subspecialties
Some teleradiologists are fellowship trained and have a wide variety of subspecialty expertise including such difficult-to-find areas as Neuroradiology, Pediatric Neuroradiology, Musculo-skeletal MRI, Mammography, Nuclear Cardiology.
Regulations
In the United States, Medicare and Medicaid laws require the Teleradiologist to be on U.S. soil in order to qualify for reimbursement of the Final Read. In addition, advanced teleradiology systems must also be HIPAA compliant, which helps to ensure patients privacy. HIPAA (Health Insurance Portability and Accountability Act of 1996) is a uniform, federal floor of privacy protections for consumers. It limits the ways that entities can use patients personal information and protects the privacy of all medical information no matter what form it is in. Quality teleradiology must abide by important HIPAA rules to ensure patients privacy is protected. Also State laws governing the licensing requirements and medical malpractice insurance coverage required for physicians vary from state to state. Ensuring compliance with these laws is a significant overhead expense for larger multi-state teleradiology groups.
Industry growth
Until the late 1990s teleradiology was primarily used by individual radiologists to interpret occasional emergency studies from offsite locations, often in the radiologists home. The connections were made through standard analog phone lines. Teleradiology expanded rapidly as the growth of the internet and broad band combined with new CT scanner technology to become an essential tool in trauma cases in emergency rooms throughout the country. The occasional 2-3 x ray studies a week soon became 3-10 CT scans, or more, a night. Because ER physicians are not trained to read CT scans or MRI's, radiologists went from working 810 hours a day, five and half days a week to a schedule of 24 hours a day, 7 days a week coverage. This became a particularly acute challenge in smaller rural facilities that only had one solo radiologist with no other to share call. These circumstances spawned a post dot.com boom of firms and groups that provided outsourced, off-site teleradiology on-call services to hospitals and Radiology Groups around the country. As an example, a teleradiology firm might cover trauma at a hospital in Indiana with doctors based in Texas. Some firms even used overseas doctors in locations like Australia and India. Nighthawk, founded by Dr. Paul Berger, was the first to station U.S. licensed radiologists overseas (initially Australia and later Switzerland) to maximize the time zone difference to provide nightcall in U.S. hospitals. The early innovators in this field like Teleradiology Solutions, Nighthawk Radiology, The Radlinx Group, and Virtual Radiology Consultants (VRC or VRN most recently), became multi million dollar companies today. Nighthawk (symbol: NHWK) and VRC (symbol: VRAD) ultimately went public and established almost a billion dollars in market capitalization. However, on May 17, 2010, Providence Equity Partners acquired and took private Virtual Radiologic.[1] Moreover, on September, 27, 2010, Virtual Radiologic and NightHawk Radiology Announced their Merger.[2] Finally, on December 23, 2010, Virtual Radiologic (vRad) and NightHawk Radiology announced the completion of their previously announced merger, with NightHawk continuing as a wholly owned subsidiary of vRad. [3] The Radlinx Group, founded by Greg Lowenstein and Mark Bakken, pioneered the expansion of teleradiology services beyond just night coverage to also provide coverage to hundreds of small rural hospitals and clinics, throughout the U.S., who otherwise had no on-site access to full-time radiologists.
Teleradiology Currently teleradiology firms are facing pricing pressures. Industry consolidation is likely as there are more than 500 of these firms, large and small, throughout the United States.
316
References
[1] "Providence to Take Virtual Radiologic Private." (http:/ / dealbook. nytimes. com/ 2010/ 05/ 17/ providence-to-take-virtual-radiologic-private/ ). New York Times. 2010-05-17. . [2] "Virtual Radiologic and NightHawk Radiology Announced a Merger." (http:/ / www. prnewswire. com/ news-releases/ virtual-radiologic-and-nighthawk-radiology-announce-merger-103849613. html). PR Newswire. 2010-09-27. . [3] "VRad and Nighthawk Radiology Complete Merger." (http:/ / www. itnonline. net/ node/ 38565/ 3/ ). Imaging Technology News. 2010-12-23. .
Telerehabilitation
Telerehabilitation (or e-rehabilitation[1] [2] ) is the delivery of rehabilitation services over telecommunication networks and the internet. Most types of services fall into two categories: clinical assessment (the patients functional abilities in his or her environment), and clinical therapy. Some fields of rehabilitation practice that have explored telerehabilitation are: neuropsychology, speech-language pathology, audiology, occupational therapy, and physical therapy. Telerehabilitation can deliver therapy to people who cannot travel to a clinic because the patient has a disability or because of travel time. Telerehabilitation also allows experts in rehabilitation to engage in a clinical consultation at a distance. Most telerehabilitation is highly visual. As of 2006 the most commonly used modalities are via webcams, videoconferencing, phone lines, videophones and webpages containing rich Internet applications. The visual nature of telerehabilitation technology limits the types of rehabilitation services that can be provided. It is most widely used for neuropsychological rehabilitation; fitting of rehabilitation equipment such as wheelchairs, braces or artificial limbs; and in speech-language pathology. Rich internet applications for neuropsychological rehabilitation (aka cognitive rehabilitation) of cognitive impairment (from many etiologies) was first introduced in 2001. This endeavor has recently (2006) expanded as a teletherapy application for cognitive skills enhancement programs for school children. Tele-audiology (hearing assessments) is a growing application. As of 2006, telerehabilitation in the practice of occupational therapy and physical therapy are very limited, perhaps because these two disciplines are more hands on. Two important areas of telerehabilitation research are (1) demonstrating equivalence of assessment and therapy to in-person assessment and therapy, and (2) building new data collection systems to digitize information that a therapist can use in practice. Ground-breaking research in telehaptics (the sense of touch) and virtual reality may broaden the scope of telerehabilitation practice, in the future. In the United States, the National Institute on Disability and Rehabilitation Research's (NIDRR) [16] supports research and the development of telerehabilitation. NIDRR's grantees include the "Rehabilitation Engineering and Research Center" (RERC) at the University of Pittsburgh, the Rehabilitation Institute of Chicago, the State University of New York at Buffalo, and the National Rehabilitation Hospital in Washington DC. Other federal funders of research are the Veterans Administration, the Health Services Research Administration in the US Department of Health and Human Services, and the Department of Defense. Outside the United States, excellent research is conducted in Australia and Europe. As of 2006, only a few health insurers in the United States will reimburse for telerehabilitation services. If the research shows that tele-assessments and tele-therapy are equivalent to clinical encounters, it is more likely that insurers and Medicare will cover telerehabilitation services.
Telerehabilitation
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History
In 1999, D.M. Angaran published Telemedicine and Telepharmacy: Current Status and Future Implications in the American Journal of Health-System Pharmacy. He provided a comprehensive history of telecommunications, the internet and telemedicine since the 1950s. The Department of Defense (DoD) and the National Aeronautics and Space Administration (NASA) spearheaded the technology in the United States during the Vietnam War and the space program; both agencies continue to fund advances in telemedicine. Three early adopters of telemedicine were state penitentiary systems, rural health care systems, and the radiology profession. Telemedicine makes business sense for the states because they do not have to pay for security escorts to have a prisoner receive care outside the prison. Rural telemedicine in the United States is heavily subsidized through federal agency grants for telecommunications operations. Most of this funding comes through the Health Services Research Administration and the Department of Commerce. Some state universities have obtained state funding to operate tele-clinics in rural areas. As of 2006, few (if any) of these programs are known to financially break-even, mostly because the Medicare program for people over age 65 (the largest payer) is very restrictive about paying for telehealth. In contrast, the Veterans Administration is relatively active in using telemedicine for people with disabilities. There are several programs that provide annual physical exams or monitoring and consultation for veterans with spinal cord injuries. Similarly, some state Medicaid programs (for poor people and people with disabilities) have pilot programs using telecommunications to connect rural practitioners with subspecialty therapists. A few school districts in Oklahoma and Hawaii offer school-based rehabilitation therapy using therapy assistants who are directed by a remote therapist. The National Rehabilitation Hospital in Washington DC and Sister Kenny Rehabilitation Institute in Minneapolis provided assessment and evaluations to patients living in Guam and American Samoa. Cases included post-stroke, post-polio, autism, and wheel-chair fitting. An argument can be made that "telerehabilitation" began in 1998 when NIDRR funded the first RERC on tele-rehabilitation. It was awarded to a consortium of biomedical engineering departments at the National Rehabilitation Hospital and The Catholic University of America, both located in Washington, DC; the Sister Kenny Rehabilitation Institute in Minnesota; and the East Carolina University in North Carolina. Some of this early research work, and its motivation, is reviewed in Winters (2002). The State of Science Conference held in 2002 convened most of military and civilian clinicians, engineers, and government officials interested in using telecommunications as a modality for rehabilitation assessment and therapy; a summary is provided in Rosen, Winters & Lauderdale (2002). The conference was attended by the incoming president of the American Telemedicine Association (ATA). This led to an invitation by ATA to the conference attendees to form a special interest group on telerehabilitation. NIDRR funded the second 5-year RERC on telerehabilitation in 2004, awarding it to the University of Pittsburgh. This RERC was renewed in 2010. In 2001, O. Bracy, a neuropsychologist, introduced the first web based, rich internet application, for the telerehabilitation presentation of cognitive rehabilitation therapy. This system first provides the subscriber clinician with an economical means of treating their own patients over the internet. Secondly, the system then provides, directly to the patient, the therapy prescription set up and controlled by the member clinician. All applications and response data are transported via the internet in real time. The patient can login to do their therapy from home, the library or anywhere they have access to an internet computer. In 2006, this system formed the basis of a new system designed as a cognitive skills enhancement program for school children. Individual children or whole classrooms can participate in this program over the internet. In 2006, M.J. McCue and S.E. Palsbo published an article in the Journal of Telemedicine and Telecare that explored how telemedicine can become a profitable business for hospitals. They argue that telerehabilitation should be expanded so that people with disabilities and people in pain (perhaps after hip-replacement surgery or people with arthritis) can get the rehabilitative therapy they need. It is unethical to limit paymente for telerehabilitation services only to patients in rural areas.
Telerehabilitation Research in telerehabilitation is in its infancy, with only a handful of equivalence trials. As of 2006, most peer-reviewed research in telemedicine are case reports of pilot programs or new equipment. Rehabilitation researchers need to conduct many more controlled experiments and present the evidence to clinicians (and payers) that telerehabilitation is clinically effective. The discipline of speech-language pathology is far head of occupational therapy and physical therapy in demonstrating equivalence over various types of telecommunications equipment.
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Technologies
1. Plain old telephone service (POTS) with videophones/Phones in telerehabilitation There are several types of connections used with real time exchanges. Plain old telephone service (POTS) uses standard analog telephone lines. Videophones are used with POTS lines and include a camera, display screen, and telephone. Videophones use telephone lines that are available in most homes, so are easy to set up; however small display screens make them problematic for individuals with vision problems. This can be solved by using a large screen or television as a screen. 2. Videotelephony/Videotelephony in telerehabilitation The use of improved quality video-assisted telecommunication devices, such as videoconferencing, webcams and telepresence to assist in treatments. 3. Virtual reality/Virtual reality in telerehabilitation Virtual reality in telerehabilitation is one of the newest tools available in that area. This computer technology allows the development of three-dimensional virtual environments. 4. Motion technology/Motion technology in telerehabilitation 5. Web-based approaches/Web-based approaches in telerehabilitation Applications that run over the internet, just as if they were installed in your computer (called Rich Internet Applications), represent a new direction in software development. A person subscribes to the website rather than purchase the software. Any updates or changes to the software system are instantly available to all subscribers. The applications can be accessed from any location where one has access to an internet connected computer. Likewise, a patient's data is accessible from where ever the therapist is located. Neither the application nor the patient's data is tied to one computer. 6. Sensors and body monitoring/Sensors and body monitoring in telerehabilitation 7. Haptic technology/Haptic technology in telerehabilitation 8. Artificial intelligence/Artificial intelligence in telerehabilitation 9. Wireless technology/Wireless technology in telerehabilitation 10. PDAs/PDA in telerehabilitation 11. Mobile telephony/Mobile telephony in telerehabilitation 12. Electronic medical records/Electronic medical record telerehabilitation
Clinical applications of telerehabilitation

1. 2. 3. 4. Review of telerehabilitation research on clinical populations Professional to professional (clinic to clinic applications) Telehealth Information access Clinical approaches 1. Assessment 2. Monitoring 3. Intervention 4. Telesupervision (of licensed assistants) 5. Telementoring
Telerehabilitation 6. Tele-education 7. Telementoring
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Speech-language pathology
The clinical services provided by speech-language pathology readily lend themselves to telerehabilitation applications due to the emphasis on auditory and visual communicative interaction between the client and the clinician. As a result, the number of telerehabilitation applications in speech-language pathology tend to outnumber those in other allied health professions. To date, applications have been developed to assess and/or treat acquired adult speech and language disorders, stuttering, voice disorders, speech disorders in children, and swallowing dysfunction. The technology involved in these applications has ranged from the simple telephone (Plain Old Telephone System POTS) to the use of dedicated Internet-based videoconferencing systems. Early applications to assess and treat acquired adult speech and language disorders involved the use of the telephone to treat patients with aphasia and motor speech disorders (Vaughan, 1976, Wertz, et al., 1987), a computer controlled video laserdisc over the telephone and a closed-circuit television system to assess speech and language disorders (Wertz et al, 1987), and a satellite-based videoconferencing system to assess patients in rural areas (Duffy, Werven & Aronson, 1997). More recent applications have involved the use of sophisticated Internet-based videoconferencing systems with dedicated software which enable the assessment of language disorders (Georgeadis, Brennan, Barker, & Baron, 2004, Brennan, Georgeadis, Baron & Barker, 2004) and the assessment and treatment of motor speech disorders (Hill, Theodoros, Russell, Cahill, Ward, Clark, 2006; Theodoros, Constantinescu, Russell, Ward, Wilson & Wootton, in press) following brain impairment and Parkinson's disease. Collectively, these studies have revealed positive treatment outcomes, while assessment and diagnoses have been found to be comparable to face-to-face evaluations. The treatment of stuttering has been adapted to a telerehabilitation environment with notable success. Two Australian studies (Harrison, Wilson & Onslow, 1999; Wilson, Onslow & Lincoln, 2004) involving the distance delivery of the Lidcombe program to children who stutter have utilized the telephone in conjunction with offline video recordings to successfully treat several children. Overall, the parents and children responded positively to the program delivered at a distant. Using a high speed videoconferencing system link, Sicotte, Lehoux, Fortier-Blanc and Leblanc (2003) assessed and treated six children and adolescents with a positive reduction in the frequency of dysfluency that was maintained six months later. In addition, a videoconferencing platform has been used successfully to provide follow-up treatment to an adult who had previously received intensive therapy (Kully, 200). Reports of telerehabilitation applications in paediatric speech and language disorders are sparse. A recent Australian pilot study has investigated the feasibility of an Internet-based assessment of speech disorder in six children (Waite, Cahill, Theodoros, Russell, Busuttin, in press). High levels of agreement between the online and face-to-face clinicians for single-word articulation, speech intelligibility, and oro-motor tasks were obtained suggesting that the Internet-based protocol had the potential to be a reliable method for assessing paediatric speech disorders. Voice therapy across a variety of types of voice disorders has been shown to be effectively delivered via a telerehabilitation application. Mashima et al. (2003) using PC based videoconferencing and speech analysis software compared 23 patients treated online with 28 persons treated face-to-face. The authors reported positive post treatment results with no significant difference in measures between the traditional and videoconferencing group, suggesting that the majority of traditional voice therapy techniques can be applied to distance treatment. Although obvious limitations exist, telerehabilitation applications for the assessment of swallowing function have also been used with success. Lalor, Brown and Cranfield (2000) were able to obtain an initial assessment of the nature and extent of swallowing dysfunction in an adult via a videoconferencing link although a more complete evaluation was restricted due to the inability to physically determine the degree of laryngeal movement. A more sophisticated telerehabilitation application for the assessment of swallowing was developed by Perlman and Witthawaskul (2002) who described the use of real-time videofluoroscopic examination via the Internet. This system
Telerehabilitation enabled the capture and display of images in real-time with only a three to five second delay. There continues to be a need for ongoing research to develop and validate the use of telerehabilitation applications in speech-language pathology in a greater number and variety of adult and paediatric communication and swallowing disorders.
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Disciplines and therapies

1. 2. 3. 4. 5. 6. 7. 8. Speech-language pathology Audiology Physical therapy Occupational therapy Psychology Nursing Social work Rehabilitation counseling/Vocational rehabilitation
Standards and training requirements

1. 2. 3. 4. 5. Telerehabilitation standards Reimbursement policies/Reimbursement in telerehabilitation Legislative activities/Legislative activities in telerehabilitation Ethics and privacy issues/Ethics and privacy issues in telerehabilitation Clinical and technology training issues
Related organizations
American Telemedicine Association (ATA) American Speech-Language-Hearing Association (ASHA) Association of Telehealth Service Providers (ATSP) National Institute on Disability and Rehabilitation Research (NIDRR) Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) Special Interest Group on Telerehabilitation (SIGOT)
References
[1] E-health care information systems: an introduction for students and professionals, John Wiley and Sons, 2005, p.219, ISBN9780787966188 [2] Lisa Keaton; Linda L. Pierce; Victoria Steiner; Karen Lance. "An E-rehabilitation Team Helps Caregivers Deal with Stroke" (http:/ / ijahsp. nova. edu/ articles/ vol2num4/ pierce-keaton. htm). The Internet Journal of Allied Health Sciences and Practice (Ijahsp.nova.edu) 2.4. ISSN1540-580X. . Retrieved 2011-03-26.
External links
Telerehabilitation (http:/ / www. dmoz. org/ Health/ Medicine/ Informatics/ Telemedicine/ Projects/ / ) at the Open Directory Project
Virtual reality in telerehabilitation
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Virtual reality in telerehabilitation

Virtual reality in telerehabilitation is a method used first in the training of musculoskeletal patients using asynchronous patient data uploading, and an internet video link. Subsequently, therapists using virtual reality-based telerehabilitation prescribe exercise routines via the web which are then accessed and executed by patients through a web browser. Therapists then monitor the patient's progress via the web and modify the therapy asynchronously without real-time interaction or training.[1]
Background
The computer technology that allows development three-dimensional virtual environments consists of both hardware and software. The current popular, technical, and scientific interest in virtual environments is inspired, in large part, by the advent and availability of increasingly powerful and affordable visually oriented, interactive, graphical display systems and techniques lacking only sense and sensibility. The term "virtualized reality" (VR) was coined and introduced in a paper by Kanade. The traditional virtual reality world is typically constructed using simplistic, artificially created computer-aided design (CAD) models. VR starts with the real-world scene and virtualizes it.[2] Virtual reality is a practical, affordable technology for the practice of clinical medicine, and modern, high-fidelity virtual reality systems have practical applications in areas ranging from psychiatry to surgical planning and telemedicine.[3] Through VRs capacity to allow the creation and control of dynamic 3-dimensional, ecologically valid stimulus environments within which behavioral response can be recorded and measured, it offers clinical assessment and rehabilitation options not available with traditional methods.[4]
Application
The value of VR systems for the investigation and rehabilitation of cognitive and perceptual impairments and current and potential applications of VR technology address six neurorehabilitation issues.[5] Korean researchers developed and assessed the value of a new rehabilitation training system to improve postural balance control by combining virtual reality technology with an unfixed bicycle. The system was effective as a training device; in addition, the technology might have a wider applicability to the rehabilitation field.[6] Tracy and Lathan investigated the relationship between motor tasks and participants' spatial abilities by training participants within a VR based simulator and then observing their ability to transfer training from the simulator to the real world. The study demonstrated that subjects with lower spatial abilities achieved significant positive transfer from a simulator based training task to a similar real world robotic operation task.[7] Virtual environments were applied to assess the training of inexperienced powered wheelchair users and demonstrated that the two virtual environments represent a potentially useful means of assessing and training novice powered wheelchair users.[8] A recently completed project at the University of Strathclyde has resulted in the development of a wheelchair motion platform which, in conjunction with a virtual reality facility, can be used to address issues of accessibility in the built environment.[9] Many cases have applied virtual reality technology to telemedicine and telerehabilitation service development. Because telemedicine focuses principally on transmitting medical information, VR has potential to enhance the practice. State of the art of VR-based telemedicine applications is used in remote or augmented surgery as well as in surgical training, both of which are critically dependent on eyehand coordination. Recently, however, different researchers have tried to use virtual environments in medical visualization and for assessment and rehabilitation in neuropsychology.[10] Case studies for VR applications were conducted that were internet deliverable and they identified technical, practical, and user challenges of remote VR treatment programs.[11] To improve understanding of deficits in autism and in left visual-spatial neglect, Trepagnier et al. investigated face gaze behavior in autism and right hemisphere
Virtual reality in telerehabilitation stroke, using virtual reality and gaze sensing technology.[12] An at-home stroke telerehabilitation service was developed using virtual reality haptics.[13] Researchers from Rutgers University and Stanford University developed a virtual reality-based orthopedic telerehabilitation system.[14]
[15] [16]
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The use of virtual reality technologies in the rehabilitation of patients with vestibular system disorders and in the provision of remote medical consultation for those patients. He stated that an appropriately designed VR experience could greatly increase the rate of adaptation in these patients.[17]
References
[1] Westwood, James D.; Helene M. Hoffman, Randy S. Haluck, Greg T. Mogel, R. Phillips, Richard A. Robb, K.G. Vosburgh (2005). Medicine Meets Virtual Reality 13: The Magical Next Becomes The Medical Now. IOS Press. p.294. ISBN1586034987. [2] Kanade, T.; P.J. Narayanan and P.W. Rander (1995). "Virtualized Reality: Concepts and Early Results". IEEE Workshop on Representation of Visual Scenes, 1995, Proceedings. Los Alamitos, Calif. : IEEE Computer Society Press, c1995.. pp.6976. doi:10.1109/WVRS.1995.476854. ISBN0-8186-7122-X. [3] Bergeron, B. (2003). "Virtual reality applications in clinical medicine". Journal of Medical Practice Management 18 (4): 2115. PMID12661483. [4] Schultheis, Maria T.; Albert A. Rizzo (August 2001). "The application of virtual reality technology in rehabilitation". Rehabilitation Psychology 46 (3): 296311. doi:10.1037/0090-5550.46.3.296. ISSN0090-5550. [5] Trepagnier, Cheryl C. (January 1999). "Virtual environments for the investigation and rehabilitation of cognitive and perceptual impairments" (http:/ / iospress. metapress. com/ link. asp?id=k3w4811mjpgulujd). NeuroRehabilitation 12 (1): 6372. . Retrieved 2007-07-26. [6] Song, Chul Gyu; Jong Yun Kim and Nam Gyun Kim (June 2004). "A new postural balance control system for rehabilitation training based on virtual cycling". IEEE Transactions on Information Technology in Biomedicine 8 (2): 200207. doi:10.1109/TITB.2004.828887. PMID15217265. [7] Tracey, M. R.; C. E. Lathan (2001). "The interaction of spatial ability and motor learning in the transfer of training from a simulator to a real task". Studies in Health Technology and Informatics 81: 5217. PMID11317801. ISBN 1-58603-143-0,. [8] Harrison, A.; G. Derwent, A. Enticknap, F. D. Rose, E. A. Attree (2002). "The role of virtual reality technology in the assessment and training of inexperienced powered wheelchair users". Disability & Rehabilitation 24 (11-12): 599606. doi:10.1080/09638280110111360. PMID12182799. [9] Grant, M.. "Wheelchair Simulation in Virtual Reality" (http:/ / www. ap. buffalo. edu/ idea/ space workshop/ Papers/ Michael Grant/ M Grant - wheelchair simulation in VR. htm). Space Requirements for Wheeled Mobility: An International Workshop, Amherst, 2003. . Retrieved 2006-07-26. [10] Riva, Giuseppe; Luciano Gamberini (2000). "Virtual reality in telemedicine". Telemedicine Journal and e-Health 6 (3): 32740. doi:10.1089/153056200750040183. PMID11110636. [11] Rizzo, Albert A.; Dorothy Strickland and Stphane Bouchard (2004). "The challenge of using virtual reality in telerehabilitation". Telemedicine Journal and e-Health 10 (2): 18495. doi:10.1089/tmj.2004.10.184. PMID15319048. [12] Trepagnier, Cheryl; Michael J. Rosen and Corinna Lathan. "Telerehabilitation and virtual reality technology for rehabilitation: preliminary results" (http:/ / www. dinf. org/ csun_99/ session0241. html). Conference on Technology and Persons with Disabilities, California State University at Northridge, 1999. . [13] Rydmark, M.; J. Boeren and R. Pasher (2002). "Stroke rehabilitation at home using virtual reality, haptics and telemedicine". Studies in Health Technology and Informatics 85: 4347. PMID15458128. ISBN 1-58603-203-8,. [14] Burdea, G. C.; V. G. Popescu, V. R. Hentz and K. Colbert (September 2000). "Virtual reality-based orthopedic telerehabilitation". IEEE Transactions on Rehabilitation Engineering 8 (3): 4302. doi:10.1109/86.867886. PMID11001524. [15] Popescu, V. G.; G. C. Burdea, M. Bouzit and V. R. Hentz (March 2000). "A virtual-reality-based telerehabilitation system with force feedback". IEEE Transactions on Information Technology in Biomedicine 4 (1): 4551. doi:10.1109/4233.826858. PMID10761773. [16] Burdea, G. C. (2003). "Virtual rehabilitationbenefits and challenges". Methods of Information in Medicine 42 (5): 51923. doi:10.1267/METH03050519 (inactive 2010-03-20). PMID14654886. [17] Viirre, E. (1996). "Vestibular telemedicine and rehabilitation". Studies in Health Technology and Informatics 29: 299305. PMID10163763. ISBN 90-5199-250-5,.
Campus medicus
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Campus medicus
Campus Medicus is a content management system for telemedicine use. It has three main applications.
Clinical decision support

It allows doctors (surgeons, pathologists, cytologists, radiologists etc.) to communicate all over the world. Campus Medicus can be used for diagnostic consultations. Images can even be sent by email to that platform. Using the mobile health function of Campus Medicus means, doctors can send images and text and receive diagnosis via a mobile phone. Doctors can discuss about a tumour or other diseases. Campus Medicus allows the doctors to have a live discussion with several doctors while they see the stored images or a live image. They can have a videoconference and they can chat at the same time they see the images. A single image or a whole slide image can be viewed. What is required is a camera for macroscopy or microscopy and a computer with internet connection.
Documentation
Campus Medicus can also be used for cancer registry and epidemiology. Ready-to-use forms are available and forms can be generated easily. The results may be viewed as a statistic.
Teaching
Ready-to-use lecture notes are available, such as gynaecology, pathology, cytology, surgery, nursing and others. The videoconference module allows holding individual lectures for doctors and students all over the world. The lectures may be held as a live lecture or they can be stored and reviewed as a video. The written lectures may be printed out as a book.
Source
Telemedizin in der Mongolei [1]
References
[1] http:/ / www. openpr. de/ news/ 352298/ Telemedizin-in-der-Mongolei. html
Wireless Medical Telemetry Service
324
Wireless Medical Telemetry Service

Wireless Medical Telemetry Service (WMTS) is a wireless service specifically defined in the United States by the Federal Communications Commission (FCC) for transmission of data related to a patient's health (biotelemetry). It was created in 2000 because of interference issues due to establishment of digital television. The bands defined are 608-614MHz, 1395-1400MHz and 1427-1432MHz. Devices using these bands are typically proprietary. Further, the use of these bands has not been internationally agreed to, so many times devices cannot marketed or used freely in countries other than the United States. Because of this, in addition to WMTS, many manufacturers have created devices that transmit data in the ISM bands such as 902-928MHz, and, more typically, 2.4-2.5GHz, often using IEEE 802.11 or Bluetooth radios.
FCC statements
There is an FCC statement on coexistence[1] of WMTS in various frequency bands. Prior to the establishment of the WMTS, medical telemetry devices generally could be operated on an unlicensed basis on vacant television channels 7-13 (174-216 MHz) and 14-46 (470-668 MHz) or on a licensed but secondary basis to private land mobile radio operations in the 450-470 MHz frequency band. This meant that wireless medical telemetry operations had to accept interference from the primary users of these frequency bands, i.e., the television broadcasters and private land mobile radio licensees. Further, if a wireless medical telemetry operation caused interference to television or private land mobile radio transmissions, the user of the wireless medical telemetry equipment would be responsible for rectifying the problem, even if that meant shutting down the medical telemetry operation. The FCC was concerned that certain regulatory developments, including the advent of digital television (DTV) service, would result in more intensive use of these frequencies by the primary services, subjecting wireless medical telemetry operations to greater interference than before and perhaps precluding such operations entirely in many instances. To ensure that wireless medical telemetry devices can operate free of harmful interference, the FCC decided to establish the WMTS. In a Report and Order released on June 12, 2000, the FCC allocated a total of 14 megahertz of spectrum to WMTS on a primary basis. At the same time, it adopted a number of regulations to ensure that the WMTS frequencies are used effectively and efficiently for their intended medical purpose. The WMTS rules took effect on October 16, 2000
WMTS rules by FCC

Band Plan[2] : The frequencies currently allocated for WMTS are divided into three blocks: the 608-614 MHz frequency band (which corresponds to UHF TV channel 37 but is not used by any TV station because it is used for radio astronomy) and the 1395-1400 MHz and 1427-1432 MHz frequency bands (both of which had been used by the Federal Government but were reallocated to the private sector under the Omnibus Budget Reconciliation Act of 1993). The frequencies in the 1427-1432 MHz band are shared by WMTS with non-medical telemetry operations, such as utility telemetry operations, that are regulated under Part 90 of the FCC's Rules. Generally, WMTS operations are accorded primary status over non-medical telemetry operations in the 1427-1429.5 MHz band, but are treated as secondary to non-medical telemetry operations in the 1429.5-1432 MHz band. However, there are seven geographical areas in which WMTS and non-medical telemetry operations have "flipped" the bands in which each enjoys primary status. These seven areas, termed the "carve-out" areas, are (1) Pittsburgh, PA; (2) the Washington, D.C. metropolitan area; (3) Richmond/Norfolk, VA; (4) Austin/Georgetown, TX; (5) Battle Creek, MI; (6) Detroit, MI; and (7) Spokane, WA. In these seven areas, in contrast to the rest of the country, WMTS has primary status in the 1429-1431.5 MHz band, but is secondary
Wireless Medical Telemetry Service to non-medical telemetry operations in the 1427-1429 MHz band.
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FDA comments
Comments from US FDA[3] , in part: Because of concerns for interference with the present wireless medical telemetry systems, and the introduction of the WMTS, CDRH has issued a public health advisory to hospital administrators, risk managers, directors of biomedical/clinical engineering, and nursing home directors. In general, CDRH encourages manufacturers and users of medical telemetry devices to move to the new spectrum because of its protections against interference from other intentional transmitters and because frequency coordination will be provided.
References
[1] FCC statement on coexistence (http:/ / wireless. fcc. gov/ services/ index. htm?job=about& id=wireless_medical_telemetry) [2] (http:/ / wireless. fcc. gov/ services/ index. htm?job=service_bandplan& id=wireless_medical_telemetry) [3] (http:/ / www. fda. gov/ Radiation-EmittingProducts/ RadiationSafety/ ElectromagneticCompatibilityEMC/ ucm116574. htm)
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Computer-Aided Surgery, Medical Robotics and Virtual Reality

Computer assisted surgery
Computer-assisted surgery
Intervention ICD-9-CM 00.3
Computer assisted surgery (CAS) represents a surgical concept and set of methods, that use computer technology for presurgical planning, and for guiding or performing surgical interventions. CAS is also known as computer aided surgery, computer assisted intervention, image guided surgery and surgical navigation, but these terms that are more or less synonyms with CAS. CAS has been a lead in factor for the development of robotic surgery.
General principles
Creating a virtual image of the patient
The most important component for CAS is the development of an accurate model of the patient. This can be conducted through a number of medical imaging technologies including CT, MRI, x-rays, ultrasound plus many more. For the generation of this model, the anatomical region to be operated has to be scanned and uploaded into the computer system. It is possible to employ a number of scanning methods, with the datasets combined through data fusion techniques. The final objective is the creation of a 3D dataset that reproduces the Image gathering ("segmentation") on the LUCAS workstation exact geometrical situation of the normal and pathological tissues and structures of that region. Of the available scanning methods, the CT is preferred,[1] because MRI data sets are known to have volumetric deformations that may lead to inaccuracies. An example data set can include the collection of data compiled with 180 CT slices, that are 1mm apart, each having 512 by 512 pixels. The contrasts of the 3D dataset (with its tens of millions of pixels) provide the detail of soft vs hard tissue structures, and thus allow a computer to differentiate, and visually separate for a human, the different tissues and structures. The image data taken from a patient will often include intentional landmark features, in order to be able to later realign the virtual dataset against the actual patient during surgery. See patient registration.
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Image analysis and processing

Image analysis involves the manipulation of the patients 3D model to extract relevant information from the data. Using the differing contrast levels of the different tissues within the imagery, as examples, a model can be changed to show just hard structures such as bone, or view the flow of arteries and veins through the brain.
Diagnostic, preoperative planning, surgical simulation

Using specialized software, such as OsiriX, the gathered dataset can be rendered as a virtual 3D model of the patient, this model can be easily manipulated by a surgeon to provide views from any angle and at any depth within the volume. Thus the surgeon can better assess the case and establish a more accurate diagnostic. Furthermore, the surgical intervention will be planned and simulated virtually, before actual surgery takes place. Using dedicated software, the surgical robot will be programmed to carry out the pre-planned actions during the actual surgical intervention.
Surgical navigation
In computer assisted surgery, the actual intervention is defined as surgical navigation. This consists of the correlated actions of the surgeon and the surgical robot (that has been programmed to carry out certain actions during the preoperative planning procedure). A surgical robot is a mechanical device (generally looking like a robotic arm) that is computer controlled. Robotic surgery can be divided into three types, depending on the degree of surgeon interaction during the procedure: supervisory-controlled, telesurgical, and shared-control.[2] In a supervisory-controlled system, the procedure is executed solely by the robot, which will perform the pre-programmed actions. A telesurgical system, also known as remote surgery, requires the surgeon to manipulate the robotic arms during the procedure rather than allowing the robotic arms to work from a predetermined program. With shared-control systems, the surgeon carries out the procedure with the use of a robot that offers steady-hand manipulations of the instrument. In most robots, the working mode can be chosen for each separate intervention, depending on the surgical complexity and the particularities of the case.
Applications
Computer assisted surgery is the beginning of a revolution in surgery. It already makes a great difference in high precision surgical domains, but it is also used in standard surgical procedures.
Computer assisted neurosurgery

Telemanipulators have been used for the first time in neurosurgery, in the 1980s. This allowed a greater development in brain microsurgery (compensating surgeons physiological tremor by 10-fold), increased accuracy and precision of the intervention. It also opened a new gate to minimally invasive brain surgery, furthermore reducing the risk of post-surgical morbidity by accidentally damaging adjacent centers.
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Computer assisted oral and maxillofacial surgery

Bone segment navigation is the modern surgical approach in orthognathic surgery (correction of the anomalies of the jaws and skull), in temporo-mandibular joint (TMJ) surgery, or in the reconstruction of the mid-face and orbit.[3]
Computer assisted ENT surgery

Robotic surgery fits most of the surgeons needs in areas with limited surgical access and requiring high-precision actions, such as middle-ear surgery.[4]
Computer assisted orthopedic surgery (CAOS)

The application of robotic surgery is widespread in orthopedics, especially in routine interventions, like total hip replacement.[5] It is also useful in pre-planning and guiding the correct anatomical position of displaced bone fragments in fractures, allowing a good fixation by osteosynthesis. Early CAOS systems include the HipNav, OrthoPilot, and Praxim.
Computer assisted visceral surgery

With the advent of Computer assisted surgery, great progresses have been made in general surgery towards minimal invasive approaches. Laparoscopy in abdominal and gynecologic surgery is one of the beneficiaries, allowing surgical robots to perform routine operations, like colecystectomies, or even hysterectomies. In cardiac surgery, shared control systems can perform mitral valve replacement or ventricular pacing by small thoracotomies. In urology, surgical robots contributed in laparoscopic approaches for pyeloplasty or nephrectomy or prostatic interventions.[6] [7]
Computer assisted radiosurgery

Radiosurgery is also incorporating advanced robotic systems. CyberKnife is such a system that has a lightweight linear accelerator mounted on the robotic arm. It is guided towards tumor processes, using the skeletal structures as a reference system (Stereotactic Radiosurgery System). During the procedure, real time X-ray is used to accurately position the device before delivering radiation beam.
Advantages of computer assisted surgery

CAS starts with the premise of a much better visualization of the operative field, thus allowing a more accurate preoperative diagnostic and a well-defined surgical planning, by using surgical planning in a preoperative virtual environment. This way, the surgeon can easily assess most of the surgical difficulties and risks and have a clear idea about how to optimize the surgical approach and decrease surgical morbidity.cience of designing user interaction with equipment and work places to fit the user. During the operation, the computer guidance improves the geometrical accuracy of the surgical gestures and also reduce the redundancy of the surgeons acts. This significantly improves ergonomy in the operating theatre, decreases the risk of surgical errors and reduces the operating time.
Most notable computer assisted surgery systems

From 1989 to 2007, more than 200 CAS systems have been developed by different universities and research institutes, almost all remaining experimental devices. Currently, the most widely-used commercially-available systems approved for clinical use are StealthStation (Medtronic, USA), eNLight and NavSuite (Stryker Corporation, USA), VectorVision (Brainlab, Germany), and DigiPointeur (Dr Lombard / Ste COLLIN, France). All of these except DigiPointeur use an optical IR tracking system. DigiPointeur uses an electromagnetic tracking system. StealthStation uses both an electromagnetic (AxiEM) and an optical IR tracking system. The first surgical robot was called Aesop (Computer Motion, USA); Aesop 1000 received the U.S. Food and Drug Administration (FDA)
Computer assisted surgery approval in 1993. It had multiple improvements and variants, such as Zeus or Hermes. The daVinci Surgical System was developed by Intuitive Surgical, derived from the Stanford Research Institute, USA. In 1997 it had received the FDA approval to assist the surgeon, and was the first Remote manipulator to have the FDA approval to perform stand-alone surgery, in 2000. It is a telesurgical system, mostly used for laparoscopic abdominal surgery. After harsh disputes and trials, the two producers merged, still under the brand name of Intuitive Surgical. Orthodoc and Robodoc are robots developed for assistance in orthopedic surgery, developed by Integrated Surgical Systems. The same company has produced Neuromate, to be used in conjunction with Orthodoc/Robodoc in neurosurgery. CyberKnife (Accuray Incorporated) is a robot that incorporates a linear accelerator, and is used since 2001 in radiosurgery.
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Ethical issues
New and developing technologies in the medical/surgical field, and furthermore experimental devices might rise new and unforeseen risks for the patient and/or the surgical team. Ethical committees of the medical institutions have to analyze the ethical issues involved for each and every new developed device or technology. Furthermore, the high costs of the initial development of such technologies, that can be covered mostly by major hospitals, might rise questions about providing equal access to medical care for the patients.
References
[1] Mischkowski RA, Zinser MJ, Ritter L, Neugebauer J, Keeve E, Zoeller JE (2007b) Intraoperative navigation in the maxillofacial area based on 3D imaging obtained by a cone-beam device. Int J Oral Maxillofac Surg 36:687-694 [2] Bale RJ, Melzer A et al.: Robotics for interventional procedures. Cardiovascular and Interventional Radiological Society of Europe Newsletter, 2006 [3] Marmulla R, Niederdellmann H: Computer-assisted bone segment navigation. J Cranio-Maxillofac Surg 26:347-359, 1998 [4] Berlinger NT:Robotic Surgery - Squeezing into Tight Places. New England Journal of Medicine 354:2099-2101, 2006 [5] Haaker RG, Stockheim M, Kamp M, Proff G, Breitenfelder J, Ottersbach A: Computer-assisted navigation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res 433:152-9, 2005 [6] Muntener M, Ursu D, Patriciu A, Petrisor D, Stoianovici D: Robotic prostate surgery. Expert Rev Med Devices 3(5):575-84 [7] Guillonneau, Bertrand: What Robotics in Urology? A Current Point of View. European Urology. 43: 103-105 2003
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Remote surgery
Remote surgery (also known as telesurgery) is the ability for a doctor to perform surgery on a patient even though they are not physically in the same location. It is a form of telepresence. Remote surgery combines elements of robotics, cutting edge communication technology such as high-speed data connections and elements of management information systems. While the field of robotic surgery is fairly well established, most of these robots are controlled by surgeons at the location of the surgery. Remote surgery is essentially advanced telecommuting for surgeons, where the physical distance between the surgeon and the patient is immaterial. It promises to allow the expertise of specialized surgeons to be available to patients worldwide, without the need for patients to travel beyond their local hospital.
The Lindbergh Operation

One of the earliest remote surgeries was conducted on 7 September 2001 across the Atlantic Ocean, with a surgeon (Dr. Jacques Marescaux) in New York performing a cholecystectomy on a 68-year-old female patient 6,230km away in Strasbourg, France named Operation Lindbergh.[1] That operation, called Project Lindbergh after Charles Lindberghs pioneering transatlantic flight from New York to Paris, was conducted over a dedicated fiberoptic link to ensure guaranteed connectivity and minimal lag.[2]
Applications
Since then, remote surgery has been conducted many times in numerous locations. To date Dr. Anvari, a laparoscopic surgeon in Hamilton, Canada, has conducted numerous remote surgeries on patients in North Bay, a city 400 kilometres from Hamilton. Even though he uses a VPN over a non-dedicated fiberoptic connection that shares bandwidth with regular telecommunications data, Dr. Anvari has not had any connection problems during his procedures. Rapid development of technology has allowed remote surgery rooms to become highly specialized. At the Advanced Surgical Technology Centre at Mt. Sinai Hospital in Toronto, Canada, the surgical room responds to the surgeons voice commands in order to control a variety of equipment at the surgical site, including the lighting in the operating room, the position of the operating table and the surgical tools themselves. With continuing advances in communication technologies, the availability of greater bandwidth and more powerful computers, the ease and cost effectiveness of deploying remote surgery units is likely to increase rapidly. The possibility of being able to project the knowledge and the physical skill of a surgeon over long distances has many attractions. There is considerable research underway in the subject. The armed forces have an obvious interest since the combination of telepresence, teleoperation, and telerobotics can potentially save the lives of battle casualties by providing them with prompt attention in mobile operating theatres. Another potential advantage of having robots perform surgeries is accuracy. A study conducted at Guys Hospital in London, England compared the success of kidney surgeries in 304 dummy patients conducted traditionally as well as remotely and found that those conducted using robots were more successful in accurately targeting kidney stones [3] .
Unassisted robotic surgery

As the techniques of expert surgeons are studied and stored in special computer systems, robots might one day be able to perform surgeries with little or no human input. Carlo Pappone, an Italian surgeon, has developed a software program that uses data collected from several surgeons and thousands of operations to perform the surgery without human intervention [4] . This could one day make expensive, complicated surgeries much more widely available, even to patients in regions which have traditionally lacked proper medical facilities.
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Force-Feedback and Time Delay

The ability to carry out delicate manipulations relies greatly upon feedback. For example it is easy to learn how much pressure is required to handle an egg. In robotic surgery, surgeons need to be able to perceive the amount of force being applied without directly touching the surgical tools. Systems known as force-feedback, or Haptic technology, have been developed to simulate this. However these systems are very sensitive to time-delays such as those present in the networks used in remote surgery.
Depth Perception
Being able to gauge the depth of an incision is crucial. Humans binocular vision make this easy in a three dimensional environment. However this can be much more difficult when the view is presented on a flat computer screen.
Possible Uses
One possible use of remote surgery is the Trauma-Pod project conceived by the US military under the Defense Advanced Research Agency. This system is intended to aid wounded soldiers in the battlefield by making use of the skills of remotely located medical personnel. Another future possibility could be the use of remote surgery during long space exploration missions.
Limitations
For now, remote surgery is not a widespread technology in part because it does not have sponsorship by the governments.[citation needed] Before its acceptance on a broader scale, many issues will need to be resolved. For example, established clinical protocols, training, and global compatibility of equipment must be developed. Also, there is still the need for an anesthesiologist and a backup surgeon to be present in case there is a disruption of communications or a malfunction in the robot. Nevertheless, Operation Lindbergh proved that the technology exists today to enable delivery of expert care to remote areas of the globe.
References
[1] http:/ / www. intersurgtech. com/ media. html [2] Event videos: http:/ / www. intersurgtech. com/ media. html [3] Robo-ops set to cut out the human factor | Special reports | Guardian Unlimited (http:/ / www. guardian. co. uk/ medicine/ story/ 0,11381,805662,00. html) [4] Robot Successfully Completes Unassisted Heart Surgery Digital Lifestyle Magazine @ dlmag.com (http:/ / web. archive. org/ web/ 20060820022121/ http:/ / www. dlmag. com/ 1653/ robot-successfully-completes-unassisted-heart-surgery. html)
External links
Article and Media Gallery for telesurgery (http://www.intersurgtech.com/tele-medicine.html) PBS article on telesurgery (http://www.pbs.org/wnet/innovation/episode7_essay1.html) Using remote surgery as a teaching tool (http://www.mtsinai.on.ca/Publications/YHRFall2001/Hospital/ virtualreality.htm) How robotic surgery works (http://electronics.howstuffworks.com/robotic-surgery.htm) Article in Pulse of the Planet about remote surgery (http://www.pulseplanet.com/archive/Aug96/1290.html) BBC News SCI/TECH -- First transatlantic surgery (http://news.bbc.co.uk/1/hi/sci/tech/1552211.stm) High Performance Network Video in support of Telesurgery / NEEMO7 Mission - Revolutionary Telemedicine Techniques (http://www.haivision.com/download-center/case-studies/telesurgery-cmas)
Remote surgery Robot Successfully Completes Unassisted Heart Surgery (http://web.archive.org/web/20061106000002/http:/ /www.dlmag.com/1653/robot-successfully-completes-unassisted-heart-surgery.html)
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Robotic surgery
Robotic surgery, computer-assisted surgery, and robotically-assisted surgery are terms for technological developments that use robotic systems to aid in surgical procedures. Robotically-assisted surgery was developed to overcome the limitations of minimally invasive surgery. Instead of directly moving the instruments, the surgeon uses one of two methods to control the instruments ; either a direct telemanipulator or by computer control. A telemanipulator is a remote manipulator that allows the surgeon to perform the normal movements associated with the surgery whilst the robotic arms carry out those movements using end-effectors and manipulators to perform the actual surgery on the patient. In computer-controlled systems the surgeon uses a computer to control the robotic arms and its end-effectors, though these systems can also still use telemanipulators for their input. One advantage of using the computerised method is that the surgeon does not have to be present, indeed the surgeon could be anywhere in the world, leading to the possibility for remote surgery.
A robotically assisted surgical system used for prostatectomies, cardiac valve repair and gynecologic surgical procedures
History
In 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance.[1] In 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery. The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill out precise fittings in the femur for hip replacement. Further development of robotic systems was carried out by Intuitive Surgical with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system. (Intuitive Surgical bought Computer Motion in 2003; ZEUS is no longer being actively marketed.[2] ) The da Vinci Surgical System comprises three components: a surgeons console, a patient-side robotic cart with 4 arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high-definition 3D vision system. Articulating surgical instruments are mounted on the robotic arms which are introduced into the body through cannulas. The original telesurgery robotic system that the da Vinci was based on was developed at SRI International in Menlo Park with grant support from DARPA and NASA. Although the telesurgical robot was originally intended to facilitate remotely performed surgery in battlefield and other remote environments, it turned out to be more useful for minimally invasive on-site surgery. The patents for the early prototype were sold to Intuitive Surgical in Mountain View, California. The da Vinci senses the surgeons hand movements and translates them electronically into scaled-down micro-movements to manipulate the tiny proprietary instruments. It also detects and filters out any tremors in the surgeon's hand movements, so that they are not duplicated robotically. The camera used in the system provides a true stereoscopic picture transmitted to a surgeon's console. The da Vinci System is FDA cleared for a variety of surgical procedures including surgery for prostate cancer, hysterectomy and mitral valve repair, and is used in more than 800 hospitals in the Americas and Europe. The da Vinci System was used in 48,000 procedures in 2006 and sells for
Robotic surgery about $1.2 million. The new da Vinci HD SI released in April, 2009 currently sells for $1.75 million. The first robotic surgery took place at The Ohio State University Medical Center in Columbus, Ohio under the direction of Dr. Robert E. Michler, Professor and Chief, Cardiothoracic Surgery.[3]
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Timeline
In 1997 a reconnection of the fallopian tubes operation was performed successfully in Cleveland using ZEUS.[4] In May 1998, Dr. Friedrich-Wilhelm Mohr using the da Vinci Surgical System performed the first robotically assisted heart bypass at the Leipzig Heart Centre in Germany. On 2 September 1999, Dr. Randall Wolf and Dr. Robert Michler performed the first robotically assisted heart bypass in the USA at The Ohio State University. In October 1999 the world's first surgical robotics beating heart coronary artery bypass graft (CABG) was performed in Canada by Dr. Douglas Boyd and Dr. Reiza Rayman using the ZEUS surgical robot.[5] On November 22, 1999 - the first closed-chest beating heart cardiac hybrid revascularization procedure is performed at the London Health Sciences Centre (London, Ontario). In the first step of a two step procedure Dr. Douglas Boyd used Zeus to perform an endoscopic, single-vessel heart bypass surgery on a 55 year-old male patient's left anterior descending artery. In the next step of the procedure William Kostuk, MD, Professor of Cardiology of the University of Western Ontario, completed an angioplasty revascularization on the patient's second occluded coronary vessel. This multi-step procedure marked one of the first integrative approaches to treating coronary disease.[6] On September 7, 2001, Dr. Jacques Marescaux and Dr. Michel Gagner, while in New York, used the Zeus robotic system to remotely perform a cholecystectomy on a 68-year-old female patient who was in Strasbourg, France.[7] (See: the Lindbergh Operation.) In May 2006 the first AI doctor-conducted unassisted robotic surgery on a 34 year old male to correct heart arythmia. The results were rated as better than an above-average human surgeon. The machine had a database of 10,000 similar operations, and so, in the words of its designers, was "more than qualified to operate on any patient." The designers believe that robots can replace half of all surgeons within 15 years. [8] [9] In February 2008, Dr. Mohan S. Gundeti of the University of Chicago Comer Children's Hospital performed the first robotic pediatric neurogenic bladder reconstruction. The operation was performed on a 10-year-old girl.[10] In January 2009, Dr. Todd Tillmanns reported the results of the largest multi-institutional study on the use of the da-Vinci robotic surgical system in gynecologic oncology and included learning curves for current and new users as a method to assess their acquisition of skills using the device. In January 2009, the first all-robotic-assisted kidney transplant was performed at Saint Barnabas Medical Center in Livingston, New Jersey by Dr. Stuart Geffner. The same team performed eight more fully robotic-assisted kidney transplants over the next six months.[11] In September 2010, the Eindhoven University of Technology announced the development of the Sofie surgical system, the first surgical robot to employ force feedback.[12] In September 2010, the first robotic operation at the femoral vasculature was performed at the University Medical Centre Ljubljana by a team led by Borut Gerak. The robot used was the first true robot, meaning it was not simply mirroring the movement of human hands, but was guided by pressing on buttons.[13] [14] (See the vascular surgery section of this article.)
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Advantages and disadvantages

Major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Some major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time. Further advantages are articulation beyond normal manipulation and three-dimensional magnification, resulting in improved ergonomics. Robotic techniques are also associated with reduced duration of hospital stays, blood loss, transfusions, and use of pain medication.[15] With the cost of the robot at $1,200,000 dollars and disposable supply costs of $1,500 per procedure, the cost of the procedure is higher. Additional surgical training is needed to operate the system.[16] Numerous feasibility studies have been done to determine whether the purchase of such systems are worthwhile. As it stands, opinions differ dramatically. Surgeons report that, although the manufacturers of such systems provide training on this new technology, the learning phase is intensive and surgeons must operate on twelve to eighteen patients before they adapt. Moreover during the training phase, minimally invasive operations can take up to twice as long as traditional surgery, leading to operating room tie ups and surgical staffs keeping patients under anesthesia for longer periods. Patient surveys indicate they chose the procedure based on expectations of decreased morbidity, improved outcomes, reduced blood loss and less pain.[15] Higher expectations may explain higher rates of dissatisfaction and regret.[16] Advantages of this technique are that the incisions are small and patient recovery is quick. In traditional open-heart surgery, the surgeon makes a ten to twelve-inch incision, then gains access to the heart by splitting the sternum (breast bone) and spreading open the rib cage. The patient is then placed on a heart-lung machine and the heart is stopped for a period of time during the operation. This approach can be associated with postoperative infection and pain, and prolonged time to complete recovery. Because patient recovery after robot-assisted heart surgery is quicker, the hospital stay is shorter. On average patients leave the hospital two to five days earlier than patients who have undergone traditional open-heart surgery and return to work and normal activity 50% more quickly. Reduced recovery times are not only better for the patient, they also reduce the number of staff needed during surgery, nursing care required after surgery, and, therefore, the overall cost of hospital stays. Compared with other minimally invasive surgery approaches, robot-assisted surgery gives the surgeon better control over the surgical instruments and a better view of the surgical site. In addition, surgeons no longer have to stand throughout the surgery and do not tire as quickly. Naturally occurring hand tremors are filtered out by the robots computer software. Finally, the surgical robot can continuously be used by rotating surgery teams.[17] While the use of robotic surgery has become an item in the advertisement of medical services, critics point out that studies that indicate that long-term results are superior to those after laparoscopic surgery are lacking.[18] The robotic system does not come cheap and has a learning curve. Data is absent that proves the increased costs can be justified. In medical literature, very experienced surgeons tend to publish their results with robotic systems. However, these may not be representative of surgeons with lesser experience.[18]
Applications
General surgery
In early 2000 the field of general surgical interventions with the daVinci device was explored by surgeons at Ohio State University. Reports were published in esophageal and pancreatic surgery for the first time in the world and further data was subsequently published by Horgan and his group at the University of Illinois and then later at the same institution by others.[19] [20] In 2007, the University of Illinois at Chicago medical team, led by Prof. Pier Cristoforo Giulianotti, reported a pancreatectomy and also the Midwests fully robotic Whipple surgery. In April 2008, the same team of surgeons performed the world's first fully minimally invasive liver resection for living donor transplantation, removing 60% of the patient's liver, yet allowing him to leave the hospital just a couple of days after the procedure, in very good condition. Furthermore the patient can also leave with less pain than a usual surgery due to the four puncture holes and not a scar by a surgeon.[21]
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Cardiothoracic surgery
Robot-assisted MIDCAB and Endoscopic coronary artery bypass (TECAB) operations are being performed with the da Vinci system. Mitral valve repairs and replacements have been performed. East Carolina University, Greenville (Dr W. Randolph Chitwood), Saint Joseph's Hospital, Atlanta (Dr Douglas A. Murphy), and Good Samaritan Hospital, Cincinnati (Dr J. Michael Smith) have popularized this procedure and proved its durability with multiple publications. Since the first robotic cardiac procedure performed in the USA in 1999, The Ohio State University, Columbus (Dr. Robert E. Michler, Dr. Juan Crestanello, Dr. Paul Vesco) has performed CABG, mitral valve, esophagectomy, lung resection, tumor resections, among other robotic assisted procedures and serves as a training site for other surgeons. In 2002, surgeons at the Cleveland Clinic in Florida (Dr. Douglas Boyd and Kenneth Stahl) reported and published their preliminary experience with minimally invasive "hybrid" procedures. These procedures combined robotic revascularization and coronary stenting and further expanded the role of robots in coronary bypass to patients with disease in multiple vessels. Ongoing research on the outcomes of robotic assisted CABG and hybrid CABG is being done by Dr. Robert Poston.
Cardiology and electrophysiology

The Stereotaxis Magnetic Navigation System (MNS) has been developed to increase precision and safety in ablation procedures for arrhythmias and atrial fibrillation while reducing radiation exposure for the patient and physician, and the system utilizes two magnets to remotely steerable catheters. The system allows for automated 3-D mapping of the heart and vasculature, and MNS has also been used in interventional cardiology for guiding stents and leads in PCI and CTO procedures, proven to reduce contrast usage and access tortuous anatomy unreachable by manual navigation. Dr. Andrea Natale has referred to the new Stereotaxis procedures with the magnetic irrigated catheters as "revolutionary."[22] The Hansen Medical Sensei robotic catheter system uses a remotely operated system of pulleys to navigate a steerable sheath for catheter guidance. It allows precise and more forceful positioning of catheters used for 3-D mapping of the heart and vasculature. The system provides doctors with estimated force feedback information and feasible manipulation within the left atrium of the heart. The Sensei has been associated with mixed acute success rates compared to manual, commensurate with higher procedural complications, longer procedure times but lower fluoroscopy dosage to the patient.[23] [24] [25] At present, three types of heart surgery are being performed on a routine basis using robotic surgery systems.[26] These three surgery types are: Atrial septal defect repair the repair of a hole between the two upper chambers of the heart, Mitral valve repair the repair of the valve that prevents blood from regurgitating back into the upper heart chambers during contractions of the heart, Coronary artery bypass rerouting of blood supply by bypassing blocked arteries that provide blood to the heart. As surgical experience and robotic technology develop, it is expected that the applications of robots in cardiovascular surgery will expand.
Gastrointestinal surgery
Multiple types of procedures have been performed with either the 'Zeus' or da Vinci robot systems, including bariatric surgery. Surgeons at various universities initially published case series demonstrating different techniques and the feasibility of GI surgery using the robotic devices.[20] Specific procedures have been more fully evaluated, specifically esophageal fundoplication for the treatment of gastroesophageal reflux[27] and Heller myotomy for the treatment of achalasia.[28] Other gastrointestinal procedures including colon resection, pancreatectomy, esophagectomy and robotic approaches to pelvic disease have also been reported.
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Gynecology
Robotic surgery in gynecology is one of the fastest growing fields of robotic surgery. This includes the use of the da Vinci surgical system in benign gynecology and gynecologic oncology. Robotic surgery can be used to treat fibroids, abnormal periods, endometriosis, ovarian tumors, pelvic prolapse, and female cancers. Using the robotic system, gynecologists can perform hysterectomies, myomectomies, and lymph node biopsies. The need for large abdominal incisions is virtually eliminated. Robot assisted hysterectomies and cancer staging are being performed using da Vinci robotic system. The University of Tennessee, Memphis (Dr. Todd Tillmanns, Dr. Saurabh Kumar), Northwestern University (Dr. Patrick Lowe), Aurora Health Center (Dr. Scott Kamelle), West Virginia University (Dr. Jay Bringman) and The University of Tennessee, Chattanooga (Dr. Donald Chamberlain) have extensively studied the use of robotic surgery and found it to improve morbidity and mortality of patients with gynecologic cancers. They have also for the first time reported robotic surgery learning curves for current and new users as a method to assess acquisition of their skills using the device. Dr.'s Joseph Prezzato and Burton Brodsky have utilized this equipment for gynecological procedures in Southeastern Michigan.
Neurosurgery
Several systems for stereotactic intervention are currently on the market. MD Robotic's NeuroArm is the worlds first MRI-compatible surgical robot.
Orthopedics
The ROBODOC system was released in 1992 by Integrated Surgical Systems, Inc. which merged into CUREXO Technology Corporation.[29] Also, The Acrobot Company Ltd. sells the "Acrobot Sculptor", a robot that constrains a bone cutting tool to a pre-defined volume.[30] Another example is the CASPAR robot produced by U.R.S.-Ortho GmbH & Co. KG, which is used for total hip replacement, total knee replacement and anterior cruciate ligament reconstruction.[31]
Pediatrics
Surgical robotics has been used in many types of pediatric surgical procedures including: tracheoesophageal fistula repair, cholecystectomy, nissen fundoplication, morgagni's hernia repair, kasai portoenterostomy, congenital diaphragmatic hernia repair, and others. On January 17, 2002, surgeons at Children's Hospital of Michigan in Detroit performed the nation's first advanced computer-assisted robot-enhanced surgical procedure at a children's hospital. The Center for Robotic Surgery at Children's Hospital Boston provides a high level of expertise in pediatric robotic surgery. Specially-trained surgeons use a high-tech robot to perform complex and delicate operations through very small surgical openings. The results are less pain, faster recoveries, shorter hospital stays, smaller scars, and happier patients and families. In 2001, Children's Hospital Boston was the first pediatric hospital to acquire a surgical robot. Today, surgeons use the technology for many procedures and perform more pediatric robotic operations than any other hospital in the world. Children's Hospital physicians have developed a number of new applications to expand the use of the robot, and train surgeons from around the world on its use.[32]
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Radiosurgery
The CyberKnife Robotic Radiosurgery System uses image guidance and computer controlled robotics to treat tumors throughout the body by delivering multiple beams of high-energy radiation to the tumor from virtually any direction. The system uses a German KUKA KR 240. Mounted on the robot is a compact X-band linac that produces 6MV X-ray radiation. Mounting the radiation source on the robot allows very fast repositioning of the source, which enables the system to deliver radiation from many different directions without the need to move both the patient and source as required by current gantry configurations.
Urology
Removing the prostate gland for cancer, repair obstructed kidneys, repair bladder abnormalities and remove diseased kidneys. New minimally invasive robotic devices using steerable flexible needles are currently being developed[33] [34] for use in prostate brachytherapy.[35] [36] [37] [38] [39] [40] [41] [42] In 2000, the first robot-assisted laparoscopic radical prostatectomy was performed.[16] Surgeons at the University of Illinois at Chicago College of Medicine were the first to offer robotic kidney transplantation to morbidly obese patients- having BMIs (body mass indexes) over 50- and since 2009, have done 13 procedures (100 percent patient and graft survival with no complications). They report fewer complications among this high-risk population (wound infections go from 15 percent in open surgery to 0 percent, pulmonary complications decrease to 0 percent from 9 percent, length of hospitalization is reduced from 8.5 days to 5 days). Most Illinois transplant centers do not take anyone for renal transplant with a BMI of over 40- and so those patients have no other access to kidney transplantation and experience high mortality rates while on dialysis, which becomes their only other available therapy. In March 2011, the President of Slovenia Danilo Trk underwent robot-assisted prostate cancer treatment at the Urology Institute in Innsbruck.[43]
Vascular surgery
In September 2010, the first robotic operations at the femoral vasculature were performed at the University Medical Centre Ljubljana (UMC Ljubljana), Slovenia. The research was led by Borut Gerak, the head of the Department of Cardiovascular Surgery at the centre. Gerak explained that the robot used was the first true robot in the history of robotic surgery, meaning the user interface was not resembling surgical instruments and the robot was not simply imitating the movement of human hands but was guided by pressing buttons, just like one would play a video game. The robot was imported to Slovenia from the United States.[13] [14]
Miniature robotics
As scientists seek to improve the versatility and utility of robotics in surgery, some are attempting to miniaturize the robots. For example, the University of Nebraska Medical Center has led a multi-campus effort to provide collaborative research on mini-robotics among surgeons, engineers and computer scientists.[44] There may also be a day and age where nanorobots may be inserted into peoples bloodstreams to act as general practitioners; Analysing the problem and sending the information back to the hospital.
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338
References
[1] Kwoh, Y. S., Hou, J., Jonckheere, E. A. and Hayall, S. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans. Biomed. Engng, February 1988, 35(2), 153161. [2] FDA: Computer-Assisted Surgery: An Update (http:/ / www. fda. gov/ fdac/ features/ 2005/ 405_computer. html) [3] McConnell, PI; Schneeberger, EW; Michler, RE (2003). "History and development of robotic cardiac surgery". Problems in General Surgery 20 (2): 2030. doi:10.1097/01.sgs.0000081182.03671.6e. [4] Leslie Versweyveld (September 29, 1999). "ZEUS robot system reverses sterilization to enable birth of baby boy" (http:/ / www. hoise. com/ vmw/ 99/ articles/ vmw/ LV-VM-11-99-1. html). Virtual Medical Worlds Monthly. . [5] "World's First Closed-Chest Beating Heart Bypass Surgery Successfully Performed" (http:/ / findarticles. com/ p/ articles/ mi_m0EIN/ is_1999_Oct_6/ ai_56012592/ ). Business Wire. October 6, 1999. . Retrieved January 19, 2011. [6] Robotics: the Future of Minimally Invasive Heart Surgery (http:/ / biomed. brown. edu/ Courses/ BI108/ BI108_2000_Groups/ Heart_Surgery/ Robotics. html) [7] "Linbergh Operation - IRCAD/EITS Laparoscopic Center" (http:/ / www. ircad. fr/ event/ lindbergh/ index. php?lng=en). . Retrieved January 19, 2011. [8] "Autonomous Robotic Surgeon performs surgery on first live human" (http:/ / www. engadget. com/ 2006/ 05/ 19/ robot-surgeon-performs-worlds-first-unassisted-operation). . [9] "Robot surgeon carries out 9 hour operation by itself" (http:/ / www. physorg. com/ news67222790. html). . [10] Surgeons perform world's first pediatric robotic bladder reconstruction (http:/ / esciencenews. com/ articles/ 2008/ 11/ 20/ surgeons. perform. worlds. first. pediatric. robotic. bladder. reconstruction) [11] New Robot Technology Eases Kidney Transplants (http:/ / wcbstv. com/ health/ da. vinci. robot. 2. 1055154. html), CBS News, June 22, 2009 - accessed July 8, 2009 [12] "Beter opereren met nieuwe Nederlandse operatierobot Sofie" (http:/ / w3. wtb. tue. nl/ nl/ nieuws/ artikel/ ?tx_ttnews[tt_news]=10041& tx_ttnews[backPid]=465& cHash=ebb243e7ff) (in Dutch). TU/e. 27 September 2010. . Retrieved 10 October 2010. [13] "V UKC Ljubljana prvi na svetu uporabili ilnega robota za posege na femoralnem ilju [The First Use of a Vascular Robot for Procedures on Femoral Vasculature]" (http:/ / med. over. net/ index. php?full=1& id=25545& title=V_UKC_Ljubljana_prvi___na_svetu_uporabili___ilnega_robota_za_posege_na_femoralnem___ilju) (in Slovene). 8 November 2010. . Retrieved 1 April 2011. [14] "UKC Ljubljana kljub finannim omejitvam uspeen v razvoju medicine [UMC Ljubljana Successfully Develops Medicine Despite Financial Limitations]" (http:/ / www. dnevnik. si/ novice/ zdravje/ 1042434634) (in Slovene). 30 March 2011. . [15] Estey, EP (2009). "Robotic prostatectomy: The new standard of care or a marketing success?". Canadian Urological Association Journal 3 (6): 48890. PMC2792423. PMID20019980. [16] Finkelstein J; Eckersberger E, Sadri H, Taneja SS, Lepor H, Djavan B (2010). "Open Versus Laparoscopic Versus Robot-Assisted Laparoscopic Prostatectomy: The European and US Experience". Reviews in Urology 12 (1): 3543. PMC2859140. PMID20428292. [17] Gerhardus, D (2003). "Robot-assisted surgery: the future is here" (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 12908224). Journal of Healthcare Management 48 (4): 242251. PMID12908224. . [18] Gina Kolata (February 13, 2010). "Results Unproven, Robotic Surgery Wins Converts" (http:/ / www. nytimes. com/ 2010/ 02/ 14/ health/ 14robot. html). The New York Times. . Retrieved March 11, 2010. [19] Melvin WS, Krause KR, Needleman BJ, Ellison EC. Robotic Resection of A Pancreatic Neuroendocrine Tumor. Journal of Laparoendoscopic & Advanced Surgical Techniques 13(1):33-36, 2003. [20] Talamini M, Chapman WC, Horgan S, Melvin WS. Evaluation of 211 Robotic Surgical Procedures. Surgical Endoscopy, 2003; 17: 1521-1524. [21] Ahmed K; Khan MS; Vats A; Nagpal K; Priest O; Patel V; Vecht JA; Ashrafian H; et al. (Oct 2009). Current status of robotic assisted pelvic surgery and future developments. Int J Surg. 7:431-440 (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 19735746?dopt=Abstract) [22] TCAI Press Release, March 3rd, 2009: http:/ / news. prnewswire. com/ ViewContent. aspx?ACCT=109& STORY=/ www/ story/ 03-03-2009/ 0004982135& EDATE [23] Natale et al., Lessons Learned and Techniques Altered Following Early Experience of the Hansen Robotic System During Catheter Ablation of Atrial Fibrillation, Poster Session II, HRS 2008 [24] Barnebei et al., Lahey Clinic, presented at HRS 2009: PO04-35 - Robotic versus Manual Catheter Ablation for Atrial Fibrillation [25] R. Liew, L. Richmond, V. Baker, F. Goromonzi, G. Thomas, M. Finlay, M. Dhinoja, M. Earley, S. Sporton, R. Schilling, National Heart Centre - Singapore - Singapore, Barts and the London NHS Trust - London - United Kingdom European Heart Journal ( 2009 ) 30 ( Abstract Supplement ), 910 [26] Kypson, Alan P; Chitwood Jr, W. Randolph (2004). "Robotic Applications in Cardiac Surgery". International Journal of Advanced Robotic Systems 1 (2): 8792. arXiv:cs/0412055. [27] Melvin WS, Needleman BJ, Krause KR, Schneider C, Ellison EC. ComputerEnhanced versus Standard Laparoscopic Antireflux Surgery. Journal of Gastrointestinal Surgery 6(1): 11-16. 2002 [28] Melvin WS, Dundon JM, Talamini MA, Horgan S. Computer Enhanced Robotic Telesurgery Reduces Esophageal Perforation During Heller Myotomy. Surgery. 2005 Oct;138(4):553-8; discussion 558-9. [29] ROBODOC history (http:/ / www. robodoc. com/ about. html)
Robotic surgery
[30] Acrobot Sculptor (http:/ / www. acrobot. co. uk/ Sculptor. html) [31] Siebert, W.; Mai, Sabine; Kober, Rudolf; Heeckt, Peter F. (2004-12-30). "Chapter 12 - Total knee replacement: robotic assistive technique". In DiGioia, Anthony M.; Jaramaz, Branislav; Picard, Frederic et al.. Computer and robotic assisted hip and knee surgery. Oxford University Press. pp.127156. ISBN019850943X. [32] Children's Hospital Center for Robotic Surgery (http:/ / www. childrenshospital. org/ robotics) [33] UC Berkeley: Needle Steering (http:/ / automation. berkeley. edu/ projects/ needlesteering) [34] Johns Hopkins University: Needle Steering (http:/ / lcsr. jhu. edu/ NeedleSteering) [35] Quick, Innovative Procedure Minimizes Prostate Incontinence After Prostatectomy (http:/ / www. sciencedaily. com/ releases/ 2007/ 05/ 070511203200. htm) [36] How is Prostate Cancer Detected? (http:/ / www. youtube. com/ watch?v=-KWsS6lPVK0) [37] The Robot Surgeon (http:/ / www. protomag. com/ assets/ the-robot-surgeon) [38] Robot Provides Guiding Hand (http:/ / health. usnews. com/ usnews/ health/ articles/ 060723/ 31robot_3. htm) [39] "Benefits of Robotic Surgery" (http:/ / video. google. com/ videoplay?docid=-1942642524056655700& hl=en/ ). ABC TV. . Retrieved May 7, 2009. [40] "The Robot Is In" (http:/ / www. foxnews. com/ search-results/ m/ 22119007/ the-robot-is-in. htm/ ). Fox News TV. . Retrieved May 7, 2009. [41] "Robotic Assisted Prostatectomy" (http:/ / www. or-live. com/ crozer/ 1818/ ). Orlive.com. . Retrieved May 7, 2009. [42] The Prostate Centre (http:/ / www. theprostatecentre. com/ about_us/ Specialist_Team/ Professor_Roger_Kirby. aspx) [43] "President Has Prostate Tumour Removed" (http:/ / www. sta. si/ en/ vest. php?id=1621924). Slovenian Press Agency. 31 March 2011. . [44] New Scientist Magazine, January 2006 (http:/ / www. newscientist. com/ article. ns?id=mg18925366. 400)
339
Sources
Monkman. G.J., S. Hesse, R. Steinmann & H. Schunk Robot Grippers - Wiley, Berlin 2007. Fchtmeier. B., S. Egersdoerfer, R. Mai, R. Hente, D. Dragoi, G.J. Monkman & M. Nerlich - Reduction of femoral shaft fractures in vitro by a new developed reduction robot system "RepoRobo" - Injury - 35 ppSA113-119, Elsevier 2004. Daniel Ichbiah. Robots : From Science Fiction to Technological Revolution. Dharia SP, Falcone T. Robotics in reproductive medicine. Fertil Steril 84:1-11,2005. Pott PP, Scharf H-P, Schwarz MLR, Todays State of the Art of surgical Robotics, Journal of Computer Aided Surgery, 10,2, 101-132, 2005. Lorincz A, Langenburg S, Klein MD. Robotics and the pediatric surgeon. Curr Opin Pediatr. 2003 Jun;15(3):262-6. Campbell A, Larenzo xR3Nz0x Jun. 14 1994 Jacob Rosen ; Blake Hannaford; Richard M. Satava (Eds.) (2011) Surgical Robotics - Systems Applications and Visions, Springer, ISBN 978-1-4419-1125-4
External links
Surgical Robotics - Bionics Lab - University of California - Santa Cruz (http://bionics.soe.ucsc.edu/research/ surgical_index.html) "Doctor Robot, I presume?" (http://www.iec.ch/etech/2011/etech_0711/ind-2.htm) Robots are set to revolutionize healthcare (International Electrotechnical Commission, July 2011) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356187/) (http://www.roboticsurgery.com/) (http://www.davinciiobgyn.com/services-procedures/) Robotic gynecological surgery in SE Michigan
Surgical Segment Navigator
340

The Surgical Segment Navigator (SSN) is a computer-based system for use in surgical navigation. It is integrated into a common platform, together with the Surgical Tool Navigator (STN), the Surgical Microscope Navigator (SMN) and the 6DOF Manipulator (MKM), developed by Carl Zeiss.
SSN
The SSN has been developed as a computer system for bone segment navigation in oral and maxillofacial surgery. It allows a very precise repositioning of bone fragments, with the advent of preoperative simulation and surgical planning.The system has been developed since 1997 at the University of Regensburg, Germany, with the support of the Carl Zeiss Company. Its principle is based on an infrared localisation system, composed of an infrared camera and at least three infrared transmitters attached to each bony fragment. The SSN is mainly used in orthognatic surgery (surgical correction of dysgnathia), but also for the surgical reconstruction of the orbit, or other surgical interventions to the midface.
Surgical navigation for the orbit and zygoma on the SSN system (Color coding for the preoperative, predicted and goal position of the fragments, respectively)
SSN++
Since 2001, at the University of Heidelberg, Germany, the SSN++ has been developed, a markerless-registration navigation system, based on a native (=markerless) CT or MRI. In this case, the patient registration is obtained on the operating table, using a surface scanner. The SSN++ corelates the surface scan data (gathered on the operating table) with the skin surface reconstruction from the dataset obtained preoperatively by CT or MRI. This principle complies with the terrain contour matching principle described for flying objects. The advantage of the new method is that the registration of the patient's position becomes a simple automated procedure; on the other hand, the radiation load for the patient is reduced, compared to the method using markers.
References
Marmulla R, Niederdellmann H: Computer-assisted Bone Segment Navigation, J Craniomaxillofac Surg 26: 347-359, 1998 Marmulla R, Niederdellmann H: Surgical Planning of Computer Assisted Repositioning Osteotomies, Plast Reconstr Surg 104 (4): 938-944, 1999 Marmulla R, Mhling J, Lth T, Eggers G, Hassfeld S: Advanced surface-recording techniques for computer-assisted oral and maxillofacial surgery, Br J Oral Maxillofac Surg, 42: 511-519, 2004
External links
SSN Homepage [1]
References
[1] http:/ / marmulla. com/ compengl. htm
Bone segment navigation
341
Bone segment navigation

Bone segment navigation is a surgical method used in the field to find the anatomical position of displaced bone fragments in fractures, allowing a good fixation by osteosynthesis. It has been developed for the first time in oral and maxillofacial surgery. After an accident or injury, a fracture can be produced and the resulting bony fragments can be displaced. In the oral and maxillofacial area, such a discplacement could have a major effect both on facial aesthetics and organ function: a fracture occurring in a bone that delimits the orbit can lead to diplopia; a mandibular fracture can induce significant modifications of the dental occlusion; in the same manner, a skull (neurocranium) fracture can produce an increased intracranial pressure.
Surgical planning and surgical simulation

An osteotomy is a surgical intervention that consists of cutting through bone and repositioning the resulting fragments in the correct anatomical place. To insure optimal repositioning of the bony structures by osteotomy, the intervention can be planned in advance and simulated. The surgical simulation is a key factor in reducing the actual operating time. Often, during this kind of operation, the surgical access to the bone segments is very limited by the presence of the soft tissues: muscles, fat tissue and skin - thus, the correct anatomical repositioning is very difficult to assess, or even impossible. This led to the necessity of a preoperative planning and simulation on models of the bare bony structures.
Simulating the movement of a selected bone fragment, on a 3D grid reconstructed model
Materials and devices needed for preoperative planning and simulation

The osteotomies performed in orthognathic surgery are classically planned on cast models of the tooth-bearing jaws, fixed in an articulator. For edentulous patients, the surgical planning is made by using stereolithographic models. These tridimensional models are then Textured image of the same virtual model cut along the planned osteothomy line, slid and fixed in the new position. Since the 1990s, modern techniques of presurgical planning were developed allowing the surgeon to plan and simulate the osteotomy in a virtual environment, based on a preoperative CT or MRI; this procedure reduces the costs and the duration of creating, positioning, cutting, repositioning and refixing the cast models for each patient. The first system that allowed such a surgical simulation environment is the Laboratory Unit for Computer Assisted Surgery (LUCAS), that was developed in 1998 at the University of Regensburg, Germany, with the support of the Carl Zeiss Company.
Transferring the preoperative planning to the operating theatre

The usefulness of the preoperative planning, no matter how accurate, depends on the accuracy of the reproduction of the simulated osteotomy in the surgical field. The transfer of the planning was mainly based on the surgeons visual skills. Different guiding headframes were further developed to mechanically guide bone fragment repositioning. Such a headframe is attached to the patients head, during CT or MRI, and surgery. There are certain difficulties in using this device. First, exact reproducibility of the headframe position on the patients head is needed, both during
Bone segment navigation CT or MRI registration, and during surgery. The headframe is relatively uncomfortable to wear, and very difficult or even impossible to use on small children, who can be uncooperative during medical procedures.
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The first system that allowed a seamless bone segment navigation for preoperative planning was the Surgical Segment Navigator (SSN), developed in 1997 at the University of Regensburg, Germany, with the support of the Carl Zeiss Company.[1] This new system does not need any mechanical surgical guides (such as a headframe). It is based on an infrared (IR) camera and IR transmitters attached to the skull. At least three IR transmitters are attached in the neurocranium area to compensate the movements of the patients head. There are three or more IR transmitters are attached to the bones where the osteotomy and bone repositioning is about to be performed onto. The 3D position of each transmitter is measured by the IR camera, using the same principle as in satellite navigation. The workstation of the Surgical Segment Navigator (SSN) is constantly visualizing the actual position of the bone fragments, compared with the predetermined position, and also makes real-time spatial determinations of the free-moving bony segments resulting from the osteotomy. Thus, fragments can be very accurately positioned into the target position, predetermined by surgical simulation.
Using the SSN in the operating theatre; 1=IR receiver, 2 and 4=IR Reference devices, 3=SSN-Workstation
Indications for the hard tissue segment navigation method

The hard tissue segment navigation is more and more frequently used in orthognatic surgery (correction of the anomalies of the jaws and skull), in temporo-mandibular joint (TMJ) surgery, or in the reconstruction of the mid-face and orbit.
Schematic representation of the principle of bone segment navigation; DRF1 and DRF2 = IR Reference devices
References
[1] Marmulla R, Niederdellmann H: Computer-assisted Bone Segment Navigation, J Craniomaxillofac Surg 26: 347-359, 1998
Robotic prostatectomy
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History
In 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance.[1] In 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery. The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill out precise fittings in the femur for hip replacement. Further development of robotic systems was carried out by Intuitive Surgical with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system. (Intuitive Surgical bought Computer Motion in 2003; ZEUS is no longer being actively marketed.[2] ) The da Vinci Surgical System comprises three components: a surgeons console, a patient-side robotic cart with 4 arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high-definition 3D vision system. Articulating surgical instruments are mounted on the robotic arms which are introduced into the body through cannulas. The original telesurgery robotic system that the da Vinci was based on was developed at SRI International in Menlo Park with grant support from DARPA and NASA. Although the telesurgical robot was originally intended to facilitate remotely performed surgery in battlefield and other remote environments, it turned out to be more useful for minimally invasive on-site surgery. The patents for the early prototype were sold to Intuitive Surgical in Mountain View, California. The da Vinci senses the surgeons hand movements and translates them electronically into scaled-down micro-movements to manipulate the tiny proprietary instruments. It also detects and filters out any tremors in the surgeon's hand movements, so that they are not duplicated robotically. The camera used in the system provides a true stereoscopic picture transmitted to a surgeon's console. The da Vinci System is FDA cleared for a variety of surgical procedures including surgery for prostate cancer, hysterectomy and mitral valve repair, and is used in more than 800 hospitals in the Americas and Europe. The da Vinci System was used in 48,000 procedures in 2006 and sells for about $1.2 million. The new da Vinci HD SI released in April, 2009 currently sells for $1.75 million. The first robotic surgery took place at The Ohio State University Medical Center in Columbus, Ohio under the direction of Dr. Robert E. Michler, Professor and Chief, Cardiothoracic Surgery.[3]
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Timeline

Major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Some major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time. Further advantages are articulation beyond normal manipulation and three-dimensional magnification, resulting in improved ergonomics. Robotic techniques are also associated with reduced duration of hospital stays, blood loss, transfusions, and use of pain medication.[15] With the cost of the robot at $1,200,000 dollars and disposable supply costs of $1,500 per procedure, the cost of the procedure is higher. Additional surgical training is needed to operate the system.[16] Numerous feasibility studies have been done to determine whether the purchase of such systems are worthwhile. As it stands, opinions differ
Robotic prostatectomy dramatically. Surgeons report that, although the manufacturers of such systems provide training on this new technology, the learning phase is intensive and surgeons must operate on twelve to eighteen patients before they adapt. Moreover during the training phase, minimally invasive operations can take up to twice as long as traditional surgery, leading to operating room tie ups and surgical staffs keeping patients under anesthesia for longer periods. Patient surveys indicate they chose the procedure based on expectations of decreased morbidity, improved outcomes, reduced blood loss and less pain.[15] Higher expectations may explain higher rates of dissatisfaction and regret.[16] Advantages of this technique are that the incisions are small and patient recovery is quick. In traditional open-heart surgery, the surgeon makes a ten to twelve-inch incision, then gains access to the heart by splitting the sternum (breast bone) and spreading open the rib cage. The patient is then placed on a heart-lung machine and the heart is stopped for a period of time during the operation. This approach can be associated with postoperative infection and pain, and prolonged time to complete recovery. Because patient recovery after robot-assisted heart surgery is quicker, the hospital stay is shorter. On average patients leave the hospital two to five days earlier than patients who have undergone traditional open-heart surgery and return to work and normal activity 50% more quickly. Reduced recovery times are not only better for the patient, they also reduce the number of staff needed during surgery, nursing care required after surgery, and, therefore, the overall cost of hospital stays. Compared with other minimally invasive surgery approaches, robot-assisted surgery gives the surgeon better control over the surgical instruments and a better view of the surgical site. In addition, surgeons no longer have to stand throughout the surgery and do not tire as quickly. Naturally occurring hand tremors are filtered out by the robots computer software. Finally, the surgical robot can continuously be used by rotating surgery teams.[17] While the use of robotic surgery has become an item in the advertisement of medical services, critics point out that studies that indicate that long-term results are superior to those after laparoscopic surgery are lacking.[18] The robotic system does not come cheap and has a learning curve. Data is absent that proves the increased costs can be justified. In medical literature, very experienced surgeons tend to publish their results with robotic systems. However, these may not be representative of surgeons with lesser experience.[18]
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Applications
General surgery
Robot-assisted MIDCAB and Endoscopic coronary artery bypass (TECAB) operations are being performed with the da Vinci system. Mitral valve repairs and replacements have been performed. East Carolina University, Greenville (Dr W. Randolph Chitwood), Saint Joseph's Hospital, Atlanta (Dr Douglas A. Murphy), and Good Samaritan Hospital, Cincinnati (Dr J. Michael Smith) have popularized this procedure and proved its durability with multiple publications. Since the first robotic cardiac procedure performed in the USA in 1999, The Ohio State University, Columbus (Dr. Robert E. Michler, Dr. Juan Crestanello, Dr. Paul Vesco) has performed CABG, mitral valve, esophagectomy, lung resection, tumor resections, among other robotic assisted procedures and serves as a training
Robotic prostatectomy site for other surgeons. In 2002, surgeons at the Cleveland Clinic in Florida (Dr. Douglas Boyd and Kenneth Stahl) reported and published their preliminary experience with minimally invasive "hybrid" procedures. These procedures combined robotic revascularization and coronary stenting and further expanded the role of robots in coronary bypass to patients with disease in multiple vessels. Ongoing research on the outcomes of robotic assisted CABG and hybrid CABG is being done by Dr. Robert Poston.
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Gynecology
Robotic surgery in gynecology is one of the fastest growing fields of robotic surgery. This includes the use of the da Vinci surgical system in benign gynecology and gynecologic oncology. Robotic surgery can be used to treat fibroids, abnormal periods, endometriosis, ovarian tumors, pelvic prolapse, and female cancers. Using the robotic system, gynecologists can perform hysterectomies, myomectomies, and lymph node biopsies. The need for large abdominal incisions is virtually eliminated.
Robotic prostatectomy Robot assisted hysterectomies and cancer staging are being performed using da Vinci robotic system. The University of Tennessee, Memphis (Dr. Todd Tillmanns, Dr. Saurabh Kumar), Northwestern University (Dr. Patrick Lowe), Aurora Health Center (Dr. Scott Kamelle), West Virginia University (Dr. Jay Bringman) and The University of Tennessee, Chattanooga (Dr. Donald Chamberlain) have extensively studied the use of robotic surgery and found it to improve morbidity and mortality of patients with gynecologic cancers. They have also for the first time reported robotic surgery learning curves for current and new users as a method to assess acquisition of their skills using the device. Dr.'s Joseph Prezzato and Burton Brodsky have utilized this equipment for gynecological procedures in Southeastern Michigan.
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Neurosurgery
Orthopedics
Pediatrics
Radiosurgery
348
Urology
Vascular surgery
Miniature robotics
References
[1] Kwoh, Y. S., Hou, J., Jonckheere, E. A. and Hayall, S. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans. Biomed. Engng, February 1988, 35(2), 153161. [2] FDA: Computer-Assisted Surgery: An Update (http:/ / www. fda. gov/ fdac/ features/ 2005/ 405_computer. html) [3] McConnell, PI; Schneeberger, EW; Michler, RE (2003). "History and development of robotic cardiac surgery". Problems in General Surgery 20 (2): 2030. doi:10.1097/01.sgs.0000081182.03671.6e. [4] Leslie Versweyveld (September 29, 1999). "ZEUS robot system reverses sterilization to enable birth of baby boy" (http:/ / www. hoise. com/ vmw/ 99/ articles/ vmw/ LV-VM-11-99-1. html). Virtual Medical Worlds Monthly. . [5] "World's First Closed-Chest Beating Heart Bypass Surgery Successfully Performed" (http:/ / findarticles. com/ p/ articles/ mi_m0EIN/ is_1999_Oct_6/ ai_56012592/ ). Business Wire. October 6, 1999. . Retrieved January 19, 2011. [6] Robotics: the Future of Minimally Invasive Heart Surgery (http:/ / biomed. brown. edu/ Courses/ BI108/ BI108_2000_Groups/ Heart_Surgery/ Robotics. html) [7] "Linbergh Operation - IRCAD/EITS Laparoscopic Center" (http:/ / www. ircad. fr/ event/ lindbergh/ index. php?lng=en). . Retrieved January 19, 2011. [8] "Autonomous Robotic Surgeon performs surgery on first live human" (http:/ / www. engadget. com/ 2006/ 05/ 19/ robot-surgeon-performs-worlds-first-unassisted-operation). . [9] "Robot surgeon carries out 9 hour operation by itself" (http:/ / www. physorg. com/ news67222790. html). .
[10] Surgeons perform world's first pediatric robotic bladder reconstruction (http:/ / esciencenews. com/ articles/ 2008/ 11/ 20/ surgeons. perform. worlds. first. pediatric. robotic. bladder. reconstruction) [11] New Robot Technology Eases Kidney Transplants (http:/ / wcbstv. com/ health/ da. vinci. robot. 2. 1055154. html), CBS News, June 22, 2009 - accessed July 8, 2009 [12] "Beter opereren met nieuwe Nederlandse operatierobot Sofie" (http:/ / w3. wtb. tue. nl/ nl/ nieuws/ artikel/ ?tx_ttnews[tt_news]=10041& tx_ttnews[backPid]=465& cHash=ebb243e7ff) (in Dutch). TU/e. 27 September 2010. . Retrieved 10 October 2010. [13] "V UKC Ljubljana prvi na svetu uporabili ilnega robota za posege na femoralnem ilju [The First Use of a Vascular Robot for Procedures on Femoral Vasculature]" (http:/ / med. over. net/ index. php?full=1& id=25545& title=V_UKC_Ljubljana_prvi___na_svetu_uporabili___ilnega_robota_za_posege_na_femoralnem___ilju) (in Slovene). 8 November 2010. . Retrieved 1 April 2011. [14] "UKC Ljubljana kljub finannim omejitvam uspeen v razvoju medicine [UMC Ljubljana Successfully Develops Medicine Despite Financial Limitations]" (http:/ / www. dnevnik. si/ novice/ zdravje/ 1042434634) (in Slovene). 30 March 2011. . [15] Estey, EP (2009). "Robotic prostatectomy: The new standard of care or a marketing success?". Canadian Urological Association Journal 3 (6): 48890. PMC2792423. PMID20019980. [16] Finkelstein J; Eckersberger E, Sadri H, Taneja SS, Lepor H, Djavan B (2010). "Open Versus Laparoscopic Versus Robot-Assisted Laparoscopic Prostatectomy: The European and US Experience". Reviews in Urology 12 (1): 3543. PMC2859140. PMID20428292. [17] Gerhardus, D (2003). "Robot-assisted surgery: the future is here" (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 12908224). Journal of Healthcare Management 48 (4): 242251. PMID12908224. . [18] Gina Kolata (February 13, 2010). "Results Unproven, Robotic Surgery Wins Converts" (http:/ / www. nytimes. com/ 2010/ 02/ 14/ health/ 14robot. html). The New York Times. . Retrieved March 11, 2010. [19] Melvin WS, Krause KR, Needleman BJ, Ellison EC. Robotic Resection of A Pancreatic Neuroendocrine Tumor. Journal of Laparoendoscopic & Advanced Surgical Techniques 13(1):33-36, 2003. [20] Talamini M, Chapman WC, Horgan S, Melvin WS. Evaluation of 211 Robotic Surgical Procedures. Surgical Endoscopy, 2003; 17: 1521-1524. [21] Ahmed K; Khan MS; Vats A; Nagpal K; Priest O; Patel V; Vecht JA; Ashrafian H; et al. (Oct 2009). Current status of robotic assisted pelvic surgery and future developments. Int J Surg. 7:431-440 (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 19735746?dopt=Abstract) [22] TCAI Press Release, March 3rd, 2009: http:/ / news. prnewswire. com/ ViewContent. aspx?ACCT=109& STORY=/ www/ story/ 03-03-2009/ 0004982135& EDATE [23] Natale et al., Lessons Learned and Techniques Altered Following Early Experience of the Hansen Robotic System During Catheter Ablation of Atrial Fibrillation, Poster Session II, HRS 2008 [24] Barnebei et al., Lahey Clinic, presented at HRS 2009: PO04-35 - Robotic versus Manual Catheter Ablation for Atrial Fibrillation [25] R. Liew, L. Richmond, V. Baker, F. Goromonzi, G. Thomas, M. Finlay, M. Dhinoja, M. Earley, S. Sporton, R. Schilling, National Heart Centre - Singapore - Singapore, Barts and the London NHS Trust - London - United Kingdom European Heart Journal ( 2009 ) 30 ( Abstract Supplement ), 910 [26] Kypson, Alan P; Chitwood Jr, W. Randolph (2004). "Robotic Applications in Cardiac Surgery". International Journal of Advanced Robotic Systems 1 (2): 8792. arXiv:cs/0412055. [27] Melvin WS, Needleman BJ, Krause KR, Schneider C, Ellison EC. ComputerEnhanced versus Standard Laparoscopic Antireflux Surgery. Journal of Gastrointestinal Surgery 6(1): 11-16. 2002 [28] Melvin WS, Dundon JM, Talamini MA, Horgan S. Computer Enhanced Robotic Telesurgery Reduces Esophageal Perforation During Heller Myotomy. Surgery. 2005 Oct;138(4):553-8; discussion 558-9. [29] ROBODOC history (http:/ / www. robodoc. com/ about. html) [30] Acrobot Sculptor (http:/ / www. acrobot. co. uk/ Sculptor. html) [31] Siebert, W.; Mai, Sabine; Kober, Rudolf; Heeckt, Peter F. (2004-12-30). "Chapter 12 - Total knee replacement: robotic assistive technique". In DiGioia, Anthony M.; Jaramaz, Branislav; Picard, Frederic et al.. Computer and robotic assisted hip and knee surgery. Oxford University Press. pp.127156. ISBN019850943X. [32] Children's Hospital Center for Robotic Surgery (http:/ / www. childrenshospital. org/ robotics) [33] UC Berkeley: Needle Steering (http:/ / automation. berkeley. edu/ projects/ needlesteering) [34] Johns Hopkins University: Needle Steering (http:/ / lcsr. jhu. edu/ NeedleSteering) [35] Quick, Innovative Procedure Minimizes Prostate Incontinence After Prostatectomy (http:/ / www. sciencedaily. com/ releases/ 2007/ 05/ 070511203200. htm) [36] How is Prostate Cancer Detected? (http:/ / www. youtube. com/ watch?v=-KWsS6lPVK0) [37] The Robot Surgeon (http:/ / www. protomag. com/ assets/ the-robot-surgeon) [38] Robot Provides Guiding Hand (http:/ / health. usnews. com/ usnews/ health/ articles/ 060723/ 31robot_3. htm) [39] "Benefits of Robotic Surgery" (http:/ / video. google. com/ videoplay?docid=-1942642524056655700& hl=en/ ). ABC TV. . Retrieved May 7, 2009. [40] "The Robot Is In" (http:/ / www. foxnews. com/ search-results/ m/ 22119007/ the-robot-is-in. htm/ ). Fox News TV. . Retrieved May 7, 2009. [41] "Robotic Assisted Prostatectomy" (http:/ / www. or-live. com/ crozer/ 1818/ ). Orlive.com. . Retrieved May 7, 2009. [42] The Prostate Centre (http:/ / www. theprostatecentre. com/ about_us/ Specialist_Team/ Professor_Roger_Kirby. aspx)
349
[43] "President Has Prostate Tumour Removed" (http:/ / www. sta. si/ en/ vest. php?id=1621924). Slovenian Press Agency. 31 March 2011. . [44] New Scientist Magazine, January 2006 (http:/ / www. newscientist. com/ article. ns?id=mg18925366. 400)
350
Sources
External links
Robot-assisted heart surgery
351

History
In 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance.[1] In 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery. The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill out precise fittings in the femur for hip replacement. Further development of robotic systems was carried out by Intuitive Surgical with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system. (Intuitive Surgical bought Computer Motion in 2003; ZEUS is no longer being actively marketed.[2] ) The da Vinci Surgical System comprises three components: a surgeons console, a patient-side robotic cart with 4 arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high-definition 3D vision system. Articulating surgical instruments are mounted on the robotic arms which are introduced into the body through cannulas. The original telesurgery robotic system that the da Vinci was based on was developed at SRI International in Menlo Park with grant support from DARPA and NASA. Although the telesurgical robot was originally intended to facilitate remotely performed surgery in battlefield and other remote environments, it turned out to be more useful for minimally invasive on-site surgery. The patents for the early prototype were sold to Intuitive Surgical in Mountain View, California. The da Vinci senses the surgeons hand movements and translates them electronically into scaled-down micro-movements to manipulate the tiny proprietary instruments. It also detects and filters out any tremors in the surgeon's hand movements, so that they are not duplicated robotically. The camera used in the system provides a true stereoscopic picture transmitted to a surgeon's console. The da Vinci System is FDA cleared for a variety of surgical procedures including surgery for prostate cancer, hysterectomy and mitral valve repair, and is used in more than 800 hospitals in the Americas and Europe. The da Vinci System was used in 48,000 procedures in 2006 and sells for about $1.2 million. The new da Vinci HD SI released in April, 2009 currently sells for $1.75 million. The first robotic surgery took place at The Ohio State University Medical Center in Columbus, Ohio under the direction of Dr. Robert E. Michler, Professor and Chief, Cardiothoracic Surgery.[3]
352
Timeline

Major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Some major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time. Further advantages are articulation beyond normal manipulation and three-dimensional magnification, resulting in improved ergonomics. Robotic techniques are also associated with reduced duration of hospital stays, blood loss, transfusions, and use of pain medication.[15] With the cost of the robot at $1,200,000 dollars and disposable supply costs of $1,500 per procedure, the cost of the procedure is higher. Additional surgical training is needed to operate the system.[16] Numerous feasibility studies have been done to determine whether the purchase of such systems are worthwhile. As it stands, opinions differ
Robot-assisted heart surgery dramatically. Surgeons report that, although the manufacturers of such systems provide training on this new technology, the learning phase is intensive and surgeons must operate on twelve to eighteen patients before they adapt. Moreover during the training phase, minimally invasive operations can take up to twice as long as traditional surgery, leading to operating room tie ups and surgical staffs keeping patients under anesthesia for longer periods. Patient surveys indicate they chose the procedure based on expectations of decreased morbidity, improved outcomes, reduced blood loss and less pain.[15] Higher expectations may explain higher rates of dissatisfaction and regret.[16] Advantages of this technique are that the incisions are small and patient recovery is quick. In traditional open-heart surgery, the surgeon makes a ten to twelve-inch incision, then gains access to the heart by splitting the sternum (breast bone) and spreading open the rib cage. The patient is then placed on a heart-lung machine and the heart is stopped for a period of time during the operation. This approach can be associated with postoperative infection and pain, and prolonged time to complete recovery. Because patient recovery after robot-assisted heart surgery is quicker, the hospital stay is shorter. On average patients leave the hospital two to five days earlier than patients who have undergone traditional open-heart surgery and return to work and normal activity 50% more quickly. Reduced recovery times are not only better for the patient, they also reduce the number of staff needed during surgery, nursing care required after surgery, and, therefore, the overall cost of hospital stays. Compared with other minimally invasive surgery approaches, robot-assisted surgery gives the surgeon better control over the surgical instruments and a better view of the surgical site. In addition, surgeons no longer have to stand throughout the surgery and do not tire as quickly. Naturally occurring hand tremors are filtered out by the robots computer software. Finally, the surgical robot can continuously be used by rotating surgery teams.[17] While the use of robotic surgery has become an item in the advertisement of medical services, critics point out that studies that indicate that long-term results are superior to those after laparoscopic surgery are lacking.[18] The robotic system does not come cheap and has a learning curve. Data is absent that proves the increased costs can be justified. In medical literature, very experienced surgeons tend to publish their results with robotic systems. However, these may not be representative of surgeons with lesser experience.[18]
353
Applications
General surgery
Robot-assisted MIDCAB and Endoscopic coronary artery bypass (TECAB) operations are being performed with the da Vinci system. Mitral valve repairs and replacements have been performed. East Carolina University, Greenville (Dr W. Randolph Chitwood), Saint Joseph's Hospital, Atlanta (Dr Douglas A. Murphy), and Good Samaritan Hospital, Cincinnati (Dr J. Michael Smith) have popularized this procedure and proved its durability with multiple publications. Since the first robotic cardiac procedure performed in the USA in 1999, The Ohio State University, Columbus (Dr. Robert E. Michler, Dr. Juan Crestanello, Dr. Paul Vesco) has performed CABG, mitral valve, esophagectomy, lung resection, tumor resections, among other robotic assisted procedures and serves as a training
Robot-assisted heart surgery site for other surgeons. In 2002, surgeons at the Cleveland Clinic in Florida (Dr. Douglas Boyd and Kenneth Stahl) reported and published their preliminary experience with minimally invasive "hybrid" procedures. These procedures combined robotic revascularization and coronary stenting and further expanded the role of robots in coronary bypass to patients with disease in multiple vessels. Ongoing research on the outcomes of robotic assisted CABG and hybrid CABG is being done by Dr. Robert Poston.
354

Gynecology
Robotic surgery in gynecology is one of the fastest growing fields of robotic surgery. This includes the use of the da Vinci surgical system in benign gynecology and gynecologic oncology. Robotic surgery can be used to treat fibroids, abnormal periods, endometriosis, ovarian tumors, pelvic prolapse, and female cancers. Using the robotic system, gynecologists can perform hysterectomies, myomectomies, and lymph node biopsies. The need for large abdominal incisions is virtually eliminated.
Robot-assisted heart surgery Robot assisted hysterectomies and cancer staging are being performed using da Vinci robotic system. The University of Tennessee, Memphis (Dr. Todd Tillmanns, Dr. Saurabh Kumar), Northwestern University (Dr. Patrick Lowe), Aurora Health Center (Dr. Scott Kamelle), West Virginia University (Dr. Jay Bringman) and The University of Tennessee, Chattanooga (Dr. Donald Chamberlain) have extensively studied the use of robotic surgery and found it to improve morbidity and mortality of patients with gynecologic cancers. They have also for the first time reported robotic surgery learning curves for current and new users as a method to assess acquisition of their skills using the device. Dr.'s Joseph Prezzato and Burton Brodsky have utilized this equipment for gynecological procedures in Southeastern Michigan.
355
Neurosurgery
Orthopedics
Pediatrics
Radiosurgery
356
Urology
Vascular surgery
Miniature robotics
References
[1] Kwoh, Y. S., Hou, J., Jonckheere, E. A. and Hayall, S. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans. Biomed. Engng, February 1988, 35(2), 153161. [2] FDA: Computer-Assisted Surgery: An Update (http:/ / www. fda. gov/ fdac/ features/ 2005/ 405_computer. html) [3] McConnell, PI; Schneeberger, EW; Michler, RE (2003). "History and development of robotic cardiac surgery". Problems in General Surgery 20 (2): 2030. doi:10.1097/01.sgs.0000081182.03671.6e. [4] Leslie Versweyveld (September 29, 1999). "ZEUS robot system reverses sterilization to enable birth of baby boy" (http:/ / www. hoise. com/ vmw/ 99/ articles/ vmw/ LV-VM-11-99-1. html). Virtual Medical Worlds Monthly. . [5] "World's First Closed-Chest Beating Heart Bypass Surgery Successfully Performed" (http:/ / findarticles. com/ p/ articles/ mi_m0EIN/ is_1999_Oct_6/ ai_56012592/ ). Business Wire. October 6, 1999. . Retrieved January 19, 2011. [6] Robotics: the Future of Minimally Invasive Heart Surgery (http:/ / biomed. brown. edu/ Courses/ BI108/ BI108_2000_Groups/ Heart_Surgery/ Robotics. html) [7] "Linbergh Operation - IRCAD/EITS Laparoscopic Center" (http:/ / www. ircad. fr/ event/ lindbergh/ index. php?lng=en). . Retrieved January 19, 2011. [8] "Autonomous Robotic Surgeon performs surgery on first live human" (http:/ / www. engadget. com/ 2006/ 05/ 19/ robot-surgeon-performs-worlds-first-unassisted-operation). . [9] "Robot surgeon carries out 9 hour operation by itself" (http:/ / www. physorg. com/ news67222790. html). .

[10] Surgeons perform world's first pediatric robotic bladder reconstruction (http:/ / esciencenews. com/ articles/ 2008/ 11/ 20/ surgeons. perform. worlds. first. pediatric. robotic. bladder. reconstruction) [11] New Robot Technology Eases Kidney Transplants (http:/ / wcbstv. com/ health/ da. vinci. robot. 2. 1055154. html), CBS News, June 22, 2009 - accessed July 8, 2009 [12] "Beter opereren met nieuwe Nederlandse operatierobot Sofie" (http:/ / w3. wtb. tue. nl/ nl/ nieuws/ artikel/ ?tx_ttnews[tt_news]=10041& tx_ttnews[backPid]=465& cHash=ebb243e7ff) (in Dutch). TU/e. 27 September 2010. . Retrieved 10 October 2010. [13] "V UKC Ljubljana prvi na svetu uporabili ilnega robota za posege na femoralnem ilju [The First Use of a Vascular Robot for Procedures on Femoral Vasculature]" (http:/ / med. over. net/ index. php?full=1& id=25545& title=V_UKC_Ljubljana_prvi___na_svetu_uporabili___ilnega_robota_za_posege_na_femoralnem___ilju) (in Slovene). 8 November 2010. . Retrieved 1 April 2011. [14] "UKC Ljubljana kljub finannim omejitvam uspeen v razvoju medicine [UMC Ljubljana Successfully Develops Medicine Despite Financial Limitations]" (http:/ / www. dnevnik. si/ novice/ zdravje/ 1042434634) (in Slovene). 30 March 2011. . [15] Estey, EP (2009). "Robotic prostatectomy: The new standard of care or a marketing success?". Canadian Urological Association Journal 3 (6): 48890. PMC2792423. PMID20019980. [16] Finkelstein J; Eckersberger E, Sadri H, Taneja SS, Lepor H, Djavan B (2010). "Open Versus Laparoscopic Versus Robot-Assisted Laparoscopic Prostatectomy: The European and US Experience". Reviews in Urology 12 (1): 3543. PMC2859140. PMID20428292. [17] Gerhardus, D (2003). "Robot-assisted surgery: the future is here" (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 12908224). Journal of Healthcare Management 48 (4): 242251. PMID12908224. . [18] Gina Kolata (February 13, 2010). "Results Unproven, Robotic Surgery Wins Converts" (http:/ / www. nytimes. com/ 2010/ 02/ 14/ health/ 14robot. html). The New York Times. . Retrieved March 11, 2010. [19] Melvin WS, Krause KR, Needleman BJ, Ellison EC. Robotic Resection of A Pancreatic Neuroendocrine Tumor. Journal of Laparoendoscopic & Advanced Surgical Techniques 13(1):33-36, 2003. [20] Talamini M, Chapman WC, Horgan S, Melvin WS. Evaluation of 211 Robotic Surgical Procedures. Surgical Endoscopy, 2003; 17: 1521-1524. [21] Ahmed K; Khan MS; Vats A; Nagpal K; Priest O; Patel V; Vecht JA; Ashrafian H; et al. (Oct 2009). Current status of robotic assisted pelvic surgery and future developments. Int J Surg. 7:431-440 (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 19735746?dopt=Abstract) [22] TCAI Press Release, March 3rd, 2009: http:/ / news. prnewswire. com/ ViewContent. aspx?ACCT=109& STORY=/ www/ story/ 03-03-2009/ 0004982135& EDATE [23] Natale et al., Lessons Learned and Techniques Altered Following Early Experience of the Hansen Robotic System During Catheter Ablation of Atrial Fibrillation, Poster Session II, HRS 2008 [24] Barnebei et al., Lahey Clinic, presented at HRS 2009: PO04-35 - Robotic versus Manual Catheter Ablation for Atrial Fibrillation [25] R. Liew, L. Richmond, V. Baker, F. Goromonzi, G. Thomas, M. Finlay, M. Dhinoja, M. Earley, S. Sporton, R. Schilling, National Heart Centre - Singapore - Singapore, Barts and the London NHS Trust - London - United Kingdom European Heart Journal ( 2009 ) 30 ( Abstract Supplement ), 910 [26] Kypson, Alan P; Chitwood Jr, W. Randolph (2004). "Robotic Applications in Cardiac Surgery". International Journal of Advanced Robotic Systems 1 (2): 8792. arXiv:cs/0412055. [27] Melvin WS, Needleman BJ, Krause KR, Schneider C, Ellison EC. ComputerEnhanced versus Standard Laparoscopic Antireflux Surgery. Journal of Gastrointestinal Surgery 6(1): 11-16. 2002 [28] Melvin WS, Dundon JM, Talamini MA, Horgan S. Computer Enhanced Robotic Telesurgery Reduces Esophageal Perforation During Heller Myotomy. Surgery. 2005 Oct;138(4):553-8; discussion 558-9. [29] ROBODOC history (http:/ / www. robodoc. com/ about. html) [30] Acrobot Sculptor (http:/ / www. acrobot. co. uk/ Sculptor. html) [31] Siebert, W.; Mai, Sabine; Kober, Rudolf; Heeckt, Peter F. (2004-12-30). "Chapter 12 - Total knee replacement: robotic assistive technique". In DiGioia, Anthony M.; Jaramaz, Branislav; Picard, Frederic et al.. Computer and robotic assisted hip and knee surgery. Oxford University Press. pp.127156. ISBN019850943X. [32] Children's Hospital Center for Robotic Surgery (http:/ / www. childrenshospital. org/ robotics) [33] UC Berkeley: Needle Steering (http:/ / automation. berkeley. edu/ projects/ needlesteering) [34] Johns Hopkins University: Needle Steering (http:/ / lcsr. jhu. edu/ NeedleSteering) [35] Quick, Innovative Procedure Minimizes Prostate Incontinence After Prostatectomy (http:/ / www. sciencedaily. com/ releases/ 2007/ 05/ 070511203200. htm) [36] How is Prostate Cancer Detected? (http:/ / www. youtube. com/ watch?v=-KWsS6lPVK0) [37] The Robot Surgeon (http:/ / www. protomag. com/ assets/ the-robot-surgeon) [38] Robot Provides Guiding Hand (http:/ / health. usnews. com/ usnews/ health/ articles/ 060723/ 31robot_3. htm) [39] "Benefits of Robotic Surgery" (http:/ / video. google. com/ videoplay?docid=-1942642524056655700& hl=en/ ). ABC TV. . Retrieved May 7, 2009. [40] "The Robot Is In" (http:/ / www. foxnews. com/ search-results/ m/ 22119007/ the-robot-is-in. htm/ ). Fox News TV. . Retrieved May 7, 2009. [41] "Robotic Assisted Prostatectomy" (http:/ / www. or-live. com/ crozer/ 1818/ ). Orlive.com. . Retrieved May 7, 2009. [42] The Prostate Centre (http:/ / www. theprostatecentre. com/ about_us/ Specialist_Team/ Professor_Roger_Kirby. aspx)
357

[43] "President Has Prostate Tumour Removed" (http:/ / www. sta. si/ en/ vest. php?id=1621924). Slovenian Press Agency. 31 March 2011. . [44] New Scientist Magazine, January 2006 (http:/ / www. newscientist. com/ article. ns?id=mg18925366. 400)
358
Sources
External links
Cyberknife
359
Cyberknife
The CyberKnife is a frameless robotic radiosurgery system used for treating benign tumors, malignant tumors and other medical conditions.[1] [2] The system was invented by John R. Adler, a Stanford University Professor of Neurosurgery and Radiation Oncology, and Peter and Russell Schonberg of Schonberg Research Corporation. The two main elements of the CyberKnife are (1) the radiation produced from a small linear particle accelerator and (2) a robotic arm which allows the energy to be directed at any part of the body from any direction. The CyberKnife system is a method of delivering radiotherapy, with the intention of targeting treatment more accurately than standard radiotherapy.[3]
Main features
Several generations of the CyberKnife system have been developed since its initial inception in 1990. There are two essential features of the CyberKnife system that set it apart from other stereotactic therapy methods.
Robotic mounting
The first is that the radiation source is mounted on a general purpose industrial robot. The original CyberKnife used a The main features of the CyberKnife system, shown on a Fanuc robot Japanese Fanuc robot,[4] however the more modern systems use a German KUKA KR 240.[5] Mounted on the Robot is a compact X-band linac that produces 6MV X-ray radiation. The linac is capable of delivering approximately 600 cGy of radiation each minute - a new 800 cGy / minute model was announced at ASTRO[6] [7] 2007. The radiation is collimated using fixed tungsten collimators (also referred to as cones) which produce circular radiation fields. At present the radiation field sizes are: 5, 7.5, 10, 12.5, 15, 20, 25, 30, 35, 40, 50 and 60 mm. ASTRO 2007 also saw the launch of the IRIS[7] variable-aperture collimator which uses two offset banks of six prismatic tungsten segments to form a blurred regular dodecagon field of variable size which eliminates the need for changing the fixed collimators. Mounting the radiation source on the robot allows near-complete freedom to position the source within a space about the patient. The robotic mounting allows very fast repositioning of the source, which enables the system to deliver radiation from many different directions without the need to move both the patient and source as required by current gantry configurations.
Image guidance
The image guidance system is the other essential item in the CyberKnife system. X-ray imaging cameras are located on supports around the patient allowing instantaneous X-ray images to be obtained. 6D skull The original (and still utilized) method is called 6D or skull based tracking. The X-ray camera images are compared to a library of computer generated images of the patient anatomy. Digitally Reconstructed Radiographs (or DRR's) and a computer algorithm determines what motion corrections have to be given to the robot because of patient movement. This imaging system allows the CyberKnife to deliver radiation with an accuracy of 0.5mm without
Cyberknife using mechanical clamps attached to the patient's skull.[8] The use of the image guided technique is referred to as frameless stereotactic radiosurgery. This method is referred to as 6D because corrections are made for the 3 translational motions (X,Y and Z) and three rotational motions. It should be noted that it is necessary to use some anatomical or artificial feature to orient the robot to deliver X-ray radiation, since the tumor is never sufficiently well defined (if visible at all) on the X-ray camera images. Xsight Additional image guidance methods are available for spinal tumors and for tumors located in the lung. For a tumor located in the spine, a variant of the image guidance called Xsight-Spine[9] is used. The major difference here is that instead of taking images of the skull, images of the spinal processes are used. Whereas the skull is effectively rigid and non-deforming, the spinal vertebrae can move relative to each other, this means that image warping algorithms must be used to correct for the distortion of the X-ray camera images. A recent enhancement to Xsight is Xsight-Lung[10] which allows tracking of some lung tumors without the need to implant fiduciary markers. Fiducial For soft tissue tumors, a method known as fiducial tracking can be utilized.[11] Small metal markers (fiducials) made out of gold for bio-compatibility and high density to give good contrast on X-ray images are surgically implanted in the patient. This is carried out by an interventional radiologist, or neurosurgeon. The placement of the fiducials is a critical step if the fiducial tracking is to be used. If the fiducials are too far from the location of the tumor, or are not sufficiently spread out from each other it will not be possible to accurately deliver the radiation. Once these markers have been placed, they are located on a CT scan and the image guidance system is programmed with their position. When X-ray camera images are taken, the location of the tumor relative to the fiducials is determined, and the radiation can be delivered to any part of the body. Thus the fiducial tracking does not require any bony anatomy to position the radiation. Fiducials are known however to migrate and this can limit the accuracy of the treatment if sufficient time is not allowed between implantation and treatment for the fiducials to stabilize.[12] [13] Synchrony The final technology of image guidance that the CyberKnife system can use is called the Synchrony system. The Synchrony system is utilized primarily for tumors that are in motion while being treated, such as lung tumors and pancreatic tumors.[14] The synchrony system uses a combination of surgically placed internal fiducials, and light emitting optical fibers (markers) mounted on the patient skin. Since the tumor is moving continuously, to continuously image its location using X-ray cameras would require prohibitive amounts of radiation to be delivered to the patients skin. The Synchrony system overcomes this by periodically taking images of the internal fiducials, and predicting their location at a future time using the motion of the markers that are located on the patient's skin. The light from the markers can be tracked continuously using a CCD camera, and are placed so that their motion is correlated with the motion of the tumor. A computer algorithm creates a correlation model that represents how the internal fiducial markers are moving compared to the external markers. The Synchrony system is therefore continuously predicting the motion of the internal fiducials, and therefore the tumor, based on the motion of the markers. The correlation model can be updated at any time if the patient breathing becomes in any way irregular. The advantage of the Synchrony system is that no
6D Skull tracking
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Cyberknife assumptions about the regularity or reproducibility of the patient breathing have to be made. To function properly, the Synchrony system requires that for any given correlation model there is a functional relationship between the markers and the internal fiducials. The external marker placement is also important, and the markers are usually placed on the patient abdomen so that their motion will reflect the internal motion of the diaphragm and the lungs.
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RoboCouch
A new robotic six degree of freedom patient treatment couch called RoboCouch[15] has been added to the CyberKnife which provides the capability for significantly improving patient positioning options for treatment.
Frameless
The frameless nature of the CyberKnife also increases the clinical efficiency. In conventional frame-based radiosurgery, the accuracy of treatment delivery is determined solely by connecting a rigid frame to the patient which is anchored to the patients skull with invasive aluminum or titanium screws. The CyberKnife is the only radiosurgery device that does not require such a frame for precise targeting.[16] Once the frame is connected, the relative position of the patient anatomy must be determined by making a CT or MRI scan. After the CT or MRI scan has been made, a radiation oncologist must plan the delivery of the radiation using a dedicated computer program, after which the treatment can be delivered, and the frame removed. The use of the frame therefore requires a linear sequence of events that must be carried out sequentially before another patient can be treated. Staged CyberKnife radiosurgery is of particular benefit to patients who have previously received large doses of conventional radiation therapy and patients with gliomas located near critical areas of the brain. Unlike whole brain radiotherapy, which must be administered daily over several weeks, radiosurgery treatment can usually be completed in 1-5 treatment sessions. Radiosurgery can be used alone to treat brain metastases, or in conjunction with surgery or whole brain radiotherapy, depending on the specific clinical circumstances.[17] By comparison, using a frameless system, a CT scan can be carried out on any day prior to treatment that is convenient. The treatment planning can also be carried out at any time prior to treatment. During the treatment the patient need only be positioned on a treatment table and the predetermined plan delivered. This allows the clinical staff to plan many patients at the same time, devoting as much time as is necessary for complicated cases without slowing down the treatment delivery. While a patient is being treated, another clinician can be considering treatment options and plans, and another can be conducting CT scans. In addition, very young patients (pediatric cases) or patients with fragile heads because of prior brain surgery cannot be treated using a frame based system.[18] Also, by being frameless the CyberKnife can efficiently re-treat the same patient without repeating the preparation steps that a frame-based system would require. The delivery of a radiation treatment over several days or even weeks (referred to as fractionation) can also be beneficial from a therapeutic point of view. Tumor cells typically have poor repair mechanisms compared to healthy tissue, so by dividing the radiation dose into fractions the healthy tissue has time to repair itself between treatments.[19] This can allow a larger dose to be delivered to the tumor compared to a single treatment.[20]
Comparison with other stereotactic systems

Gamma Knife
One of the most widely known stereotactic radiosurgery systems is the Gamma Knife. The Gamma Knife was originally developed by Lars Leksell, remains the gold standard method for delivery of stereotactic radiosurgery to the brain and is manufactured by Elekta. John Adler, the inventor of the CyberKnife system spent time training with Lars Leksell in Stockholm at the Karolinska Institute in 1985. The GammaKnife system uses 201 Cobalt-60 sources located in a ring around a central treatment point ("isocenter"). The Gamma Knife system is equipped with a series
Cyberknife of 4 collimators of 4mm, 8mm, 12mm and 16mm diameter, and is capable of submillimeter accuracies. The Gamma Knife system does however require a head frame to be bolted onto the skull of the patient, and is only capable of treating cranial lesions. As a result of frame placement, treatment with Gamma Knife does not require real time imaging capability as the frame does not allow movement during treatment. This is the reason that the Gamma Knife system is likely to be more accurate than Cyber Knife.[21] The Cyberknife Society and Accuray maintain that there are no peer-reviewed published papers that establish Gamma Knife as being more accurate than CyberKnife.[22] [23]
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Novalis
Another popular Stereotactic system is the Novalis produced by Brainlab.[24] The Novalis radiosurgery system utilizes a small computer controlled micro Multi Leaf Collimator mMLC, that can produce many complicated shapes. The maximum radiation field size that the Novalis can produce is 98mm x 98mm, and the minimum is 3mm x 3mm allowing a considerable range of tumors to be treated. The Novalis system also has X-ray imaging using amorphous silicon flat panel X-ray detectors. A 2D/3D image fusion of the patient setup X-rays with digitally reconstructed radiographs from a planning CT scan quickly determines a correction vector for the patients position. Infrared fiducial markers attached to the patient then allow precise tracking of the correction vector's application to the patient's position via an infrared camera and a couch that can move in all six dimensions enables the precise positioning of the patient. Patient immobilization can also be performed framelessly using the patients internal anatomy as the frame of reference. An implanted marker based respiratory tracking option known as ExacTrac Gating is also an option. BrainLAB's Novalis has become a leading player in the world of neurosurgery.[25]
Conventional linac
Conventional X-ray therapy linear accelerators can be utilized for radiosurgery, either by the use of additional blocking cones or by a removable or built in micro MLC system. Examples of removable micro MLC units are the Ergo from 3D line,[26] the mMLC manufactured by Brainlab,[24] and the AccuKnife produced by Direx.,[27] or the Novalis TX
Clinical uses
Since August 2001, the CyberKnife system has FDA clearance for treatment of tumors in any location of the body.[28] Some of the tumors treated include: pancreas,[29] [30] liver,[31] prostate,[32] [33] Spinal Lesions,[34] head and neck cancers,[35] and benign tumors.[36] None of these studies have shown any general survival benefit over conventional treatment methods. By increasing the accuracy with which treatment is delivered there is a potential for dose escalation, and potentially a subsequent increase in effectiveness, particularly in local control rates. However the studies cited are so far limited in scope, and more extensive research will need to be completed in order to show any effects on survival.[30] In 2008 actor Patrick Swayze was among the people to be treated with Cyberknife radiotherapy.[37]
Cyberknife
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Cyberknife worldwide locations

CyberKnife systems have been installed in over 150 locations worldwide,[38] including 100 hospitals in the United States.[39] Stanford University has treated over 2,500 patients using the Cyberknife system, and worldwide over 40,000 patients have been treated.[40] [41] Overlook Hospital in Summit, New Jersey was the first hospital in the New York metro area to offer the CyberKnife Stereotactic Radiosurgery System. Today, Overlook has performed the second most treatments of prostate cancer with the cyberknife in the world.[42]
Accolades
The CyberKnife was recognized as an Innovative Medical Device in the 10th Annual Innovations in HealthcareSM ABBY Awards event. These awards are given based on reducing the cost of quality healthcare. "...proven with their CyberKnife Robotic Radiosurgery System that medical technology can actually lower the cost of providing quality healthcare -- and at the same time produce a result that saves time for the patient, not to mention providing a 'scarless' result," Mimi Grant, president of the ABL Organization [43]
References
[1] http:/ / med. stanford. edu/ neurosurgery/ patient_care/ radiosurgery. html Stanford Neurosurgery [2] Robotic Whole Body Stereotactic Radiosurgery: Clinical Advantages of the CyberKnife Integrated System. . . . Reprinted by permission from The International Journal of Medical Robotics and Computer Assisted Surgery - Robotics Online (http:/ / www. robotics. org/ content-detail. cfm/ Industrial-Robotics-News/ Robotic-Whole-Body-Stereotactic-Radiosurgery:-Clinical-Advantages-of-the-CyberKnife-Integrated-System/ content_id/ 1085) [3] Dr Nick Plowman, Senior Clinical Oncologist, London HCA - How CyberKnife Works (http:/ / www. hcahospitals. co. uk/ plowman-podcast. asp?play=4) [4] Fanuc Robotics http:/ / www. fanucrobotics. com/ [5] Kuka Roboter GmbH http:/ / www. kuka. com/ en/ [6] ASTRO annual meeting website (http:/ / www. astro. org/ Meetings/ AnnualMeetings/ ) [7] Accuray announce 4 new products at ASTRO (http:/ / accuray. com/ Content. aspx?id=674) [8] An Analysis of the Accuracy of the 6D Tracking With CyberKnife Inoue M, Sato K, Koike I International Journal of Radiation Oncology, Biology, Physics 01 November 2006 (Vol. 66, Issue 3 (Supplement), Page S611) [9] Accuray::Xsight Spine Tracking System (http:/ / accuray. com/ Products/ Xsight/ XsightSpine. aspx) [10] Accuray::Xsight Lung Tracking System (http:/ / accuray. com/ Products/ Xsight/ XsightLung. aspx) [11] CyberKnife Radiosurgery - Fiducial Overview (http:/ / www. sdcyberknife. com/ fiducial. htm) [12] Fuller CD, and Scarbrough TJ, MD Fiducial Markers in Image-guided Radiotherapy of the Prostate. U S ONCOLOGICAL DISEASE 2006 75-78 [13] Murphy MJ. Fiducial-based targeting accuracy for external-beam radiotherapy. Medical Physics March 2002 Volume 29, Issue 3, pp. 334344 [14] Phase I study of stereotactic radiosurgery in patients with locally advanced pancreatic cancer Koong AC, Le QT, Ho A, Fong B, Fisher G, Cho C, Ford J, Poen J, Gibbs IC, Mehta VK, Kee S, Trueblood W, Yang G, Bastidas JA International Journal of Radiation Oncology*Biology*Physics 15 March 2004 (Vol. 58, Issue 4, Pages 10171021) [15] Accuray::RoboCouch Patient Positioning System (http:/ / accuray. com/ Products/ RoboCouch/ index. aspx) [16] Rocky Mountain CyberKnife Center - Brain Metastases (http:/ / www. rockymountainck. com/ treatment/ brain_metastases. aspx) [17] Chang SD, Min W, Martin DP, Gibbs IC, Heilbrun MP. An analysis of the accuracy of the CyberKnife: A robotic frameless stereotactic radiosurgical system. Neurosurgery. 2003; 52: 140-147. [18] http:/ / biz. yahoo. com/ bw/ 070115/ 20070115005165. html?. v=1 [19] Radiobiology for the Radiologist Eric J. Hall Lippincott Williams & Wilkins; 5th edition (2000) [20] Comparisons between Gamma Knife, BrainLABs Novalis and Cyberknife (http:/ / www. peacehealth. org/ Oregon/ shmc/ GammaCenter/ PDFiles/ ELK-222_LGK_CntrAttk_Book_compet. pdf) [21] Gamma Knife vs. CyberKnife :: Gamma Knife Center :: Wake Forest University Baptist Medical Center (http:/ / www1. wfubmc. edu/ gammaknife/ Gamma+ Knife+ vs+ CyberKnife/ ) [22] Radiosurgery CyberKnife Overview (http:/ / www. cksociety. org/ PatientInfo/ radiosurgery. asp) [23] Yu, C, Main W, Taylor D, Kuduvalli G, Apuzzo M, Adler J, Wang M: An Anthropomorphic Phantom Study of the Accuracy of CyberKnife Spinal Radiosurgery. Neurosurgery, 55(5):11381149, 2004
Cyberknife
[24] Brainlab http:/ / www. brainlab. com/ [25] BBC news - Aug 2003 - Curing cancer with computers (http:/ / news. bbc. co. uk/ 1/ hi/ business/ 3092591. stm) [26] 3D line http:/ / www. 3dline. com/ [27] Direx http:/ / www. direx. co. il/ accu. htm [28] "CyberKnife::Reimbursement Information." CyberKnife. Web. 10 Mar. 2010.<http://www.cyberknife.com/reimbursement-insurance/index.aspx> [29] Phase I study of stereotactic radiosurgery in patients with locally advanced pancreatic cancer. Koong AC, Le QT, Ho A, Fong B, Fisher G, Cho C, Ford J, Poen J, Gibbs IC, Mehta VK, Kee S, Trueblood W, Yang G, Bastidas JA. International Journal of Radiation Oncology*Biology*Physics, 15 March 2004 (Vol. 58, Issue 4, Pages 10171021) [30] Phase II study to assess the efficacy of conventionally fractionated radiotherapy followed by a stereotactic radiosurgery boost in patients with locally advanced pancreatic cancer. Koong AC, Christofferson E, Le QT, Goodman KA, Ho A, Kuo T, Ford JM, Fisher GA, Greco R, Norton J, Yang GP. International Journal of Radiation Oncology*Biology*Physics, 01 October 2005 (Vol. 63, Issue 2, Pages 320-323) [31] Phase I Dose Escalation Study of CyberKnife Stereotactic Radiosurgery for Liver Malignancies. Lieskovsky YC, Koong A, Fisher G, Yang G, Ho A, Nguyen M, Gibbs I, Goodman K.International Journal of Radiation Oncology*Biology*Physics, 01 October 2005 (Vol. 63, Issue (Supplement 1), Page S283) [32] 2206: Hypofractionated Stereotactic Radiotherapy for Prostate Cancer: Early Results. Hara W, Patel D, Pawlicki T, Cotrutz C, Presti J, King C. International Journal of Radiation Oncology, Biology, Physics, 01 November 2006 (Vol. 66, Issue 3 (Supplement), Pages S324-S325) [33] Wall street Journal - November 2008 - Is CyberKnife Ready for Prime Time in Prostate Cancer? (http:/ / blogs. wsj. com/ health/ 2008/ 11/ 28/ is-cyberknife-ready-for-prime-time-in-prostate-cancer/ ) [34] Cyberknife frameless real-time image-guided stereotactic radiosurgery for the treatment of spinal lesions. Gerszten PC, Ozhasoglu C, Burton SA, Vogel WJ, Atkins BA, Kalnicki S, Welch WC. International Journal of Radiation Oncology*Biology*Physics, 01 October 2003 (Vol. 57, Issue 2 (Supplement), Pages S370-S371) [35] CyberKnife Fractionated Stereotactic Radiosurgery for the Treatment of Primary and Recurrent Head and Neck Cancer. Liao JJ, Judson B, Davidson B, Amin A, Gagnon G, Harter K. International Journal of Radiation Oncology*Biology*Physics, 01 October 2005 (Vol. 63, Issue (Supplement 1), Page S381) [36] Cyberknife frameless radiosurgery for the treatment of benign tumors. Bhatnagar AK, Gerzsten PC, Agarwal A, Ozhasoglu CW, Vogel WJ, Kalnicki S, Welch WC, Burton SA. International Journal of Radiation Oncology*Biology*Physics, September 2004 (Vol. 60, Issue 1 (Supplement), Page S548) [37] Patrick-Swayze has Cyberknife radiotherapy (http:/ / www. dailymail. co. uk/ tvshowbiz/ article-1036899/ Patrick-Swayze-smiling-miracle-response-cancer-treatment. html) [38] Reuters -December 2008 - Accuray Achieves Milestone of 150th CyberKnife System Installed Worldwide (http:/ / www. reuters. com/ article/ pressRelease/ idUS133527+ 08-Dec-2008+ PRN20081208) [39] Accuray Reaches 100th U.S. CyberKnife System Installation (http:/ / www. pressreleasepoint. com/ accuray-reaches-100th-us-cyberknife-system-installation) [40] Cutland, Laura (25 September 2005). "Maverick in a mind field - Silicon Valley / San Jose Business Journal:" (http:/ / sanjose. bizjournals. com/ sanjose/ stories/ 2005/ 09/ 26/ smallb1. html). . [41] Accuray FAQ (http:/ / www. accuray. com/ TabContent. aspx?id=470#/ AjaxContent. aspx?id=356) [42] Atlantic Health (http:/ / intranet. ahsys. org/ home/ News/ n05072808. asp) [43] "Innovations in Healthcare(SM) ABBY Award" (http:/ / www. redorbit. com/ news/ health/ 1364883/ accuray_wins_innovations_in_healthcaresm_abby_award/ index. html). .
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Principles and Practice of Stereotactic Radiosurgery (http://www.springer.com/medicine/surgery/book/ 978-0-387-71069-3), Lawrence Chin, MD and William Regine, MD, Editors (2008)
External links
Accuray - manufacturer of the CyberKnife (http://accuray.com/) CyberKnife patient Support (http://www.cyberknife.com) iprostatecancer.com (http://www.iprostatecancer.com) Wonky-eye.com Trigeminal Schwannoma controlled with CyberKnife Treatment (actual patient website) (http:// www.wonky-eye.com)
da Vinci Surgical System
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Da Vinci Surgical System
Manufacturer Intuitive Surgical Type Units sold Robotic surgery 1,032 units worldwide [1]
The Da Vinci Surgical System is a robotic surgical system made by Intuitive Surgical and designed to facilitate complex surgery using a minimally invasive approach. The system is controlled by a surgeon from a console. It is commonly used for prostatectomies and increasingly for cardiac valve repair and gynecologic surgical procedures.[2]
[3]
Overview
The da Vinci System consists of a surgeons console that is typically in the same room as the patient and a patient-side cart with four interactive robotic arms controlled from the console. Three of the arms are for tools that hold objects, act as a scalpel, scissors, bovie, or unipolar or dipolar electrocautery instruments. The fourth arm is for an endoscopic camera with two lenses that gives the surgeon full stereoscopic vision from the console. The surgeon sits at the console and looks through two eye holes at a 3-D image of the procedure, meanwhile maneuvering the arms with two foot pedals and two hand controllers. The da Vinci System scales, filters and translates the surgeon's hand movements into more precise micro-movements of the instruments, which operate through small incisions in the body. According to the manufacturer, the da Vinci System is called "da Vinci" in part "because Leonardo da Vinci invented the first robot", and also because he used anatomical accuracy and three-dimensional details to bring his works to life.[4] To perform a procedure, the surgeon uses the consoles master controls to maneuver the patient-side carts three or four robotic arms (depending on the model), which secures the instruments and a high-resolution endoscopic camera. The instruments jointed-wrist design exceeds the natural range of motion of the human hand; motion scaling and tremor reduction further interpret and refine the surgeons hand movements. The da Vinci System incorporates multiple, redundant safety features designed to minimize opportunities for human error when compared with traditional approaches. At no time is the surgical robot in control or autonomous; it operates on a "Master:Slave" relationship, the surgeon being the "Master" and the robot being the "Slave." The da Vinci System has been designed to improve upon conventional laparoscopy, in which the surgeon operates while standing, using hand-held, long-shafted instruments, which have no wrists. With conventional laparoscopy, the surgeon must look up and away from the instruments, to a nearby 2D video monitor to see an image of the target anatomy. The surgeon must also rely on his/her patient-side assistant to position the camera correctly. In contrast, the
da Vinci Surgical System da Vinci Systems ergonomic design allows the surgeon to operate from a seated position at the console, with eyes and hands positioned in line with the instruments. To move the instruments or to reposition the camera, the surgeon simply moves his/her hands. By providing surgeons with superior visualization, enhanced dexterity, greater precision and ergonomic comfort, the da Vinci Surgical System makes it possible for more surgeons to perform minimally invasive procedures involving complex dissection or reconstruction. For the patient, a da Vinci procedure can offer all the potential benefits of a minimally invasive procedure, including less pain, less blood loss and less need for blood transfusions. Moreover, the da Vinci System can enable a shorter hospital stay, a quicker recovery and faster return to normal daily activities.[5] The robot costs on average $1.3 million in addition to several hundred thousand dollars of annual maintenance fees. Surgical procedures performed with the robot take longer than traditional ones. Critics have pointed out that hospitals have a hard time recovering the cost and that most clinical data does not support the claim of improved patient outcomes.[3]
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FDA approval
The Food and Drug Administration (FDA) has cleared the da Vinci Surgical System in 2000 for adult and pediatric use in urologic surgical procedures, general laparoscopic surgical procedures, gynecologic laparoscopic surgical procedures, general non-cardiovascular thoracoscopic surgical procedures and thoracoscopically assisted cardiotomy procedures. The da Vinci System may also be employed with adjunctive mediastinotomy to perform coronary anastomosis during cardiac revascularization.[6]
Representative clinical uses

The da Vinci System has been successfully used in the following procedures[6] : Radical prostatectomy, pyeloplasty, cystectomy, nephrectomy, ureteral reimplantation;[7] Hysterectomy, myomectomy and sacrocolpopexy; Cholecystectomy, Nissen fundoplication, Heller myotomy, gastric bypass, donor nephrectomy, adrenalectomy, splenectomy and bowel resection; Internal mammary artery a blood vessel mobilization and cardiac tissue ablation; Mitral valve repair, endoscopic atrial septal defect closure; Mammary to left anterior descending coronary artery anastomosis for cardiac revascularization with adjunctive mediastinotomy Transoral resection of tumors of the upper aerodigestive tract (tonsil, tongue base, larynx), transaxillary thyroidectomy
Future
Although the general term "robotic surgery" is often used to refer to the technology, this term can give the impression that the robot (the da Vinci System) is performing the surgery. In contrast, the current da Vinci Surgical System cannotin any mannerrun on its own. This is due to the fact it was not designed as an autonomous system and lacks a decision making software, instead it relies on a human operator for all input, however all the functionalityincluding vision and motor functionsare performed through remote human-computer interaction and thus with the appropriate weak AI software the system could in principle perform partially or completely autonomously. The difficulty with creating an autonomous system of this kind is not trivial, a major obstacle is that surgery per se is not readily formalizablea requirement for weak AI. The current system is designed to merely seamlessly replicate the movement of the surgeon's hands with the tips of micro-instruments, not to make decisions or move without the surgeons direct input.
da Vinci Surgical System The da Vinci System could also potentially be used to perform truly remote operations. This was, in fact, what the Da Vinci system was originally designed for, though this was abandoned early.[8] The possibility of long distance operations depend on the patient having access to a da Vinci System and someone to put in the ports, but technically the system could allow a doctor in the United States, for example, to do surgery on a patient in Antarctica. The da Vinci Surgical System can theoretically be used to operate over long distances. According to the manufacturer, this capability, however, is not the primary focus of the company and thus is not available with the current da Vinci Surgical System.[9]
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Criticism
While the use of robotic surgery has become an item in the advertisement of medical services, critics point out a lack of studies that indicate long-term results are superior to results following laparoscopic surgery.[10] On the other hand, there is no question that some procedures that have traditionally been performed with large incisions can be converted to "minimally invasive" endoscopic procedures with the use of the Da Vinci, shortening length-of-stay in the hospital and reducing recovery times. But because of the hefty cost of the robotic system it is not clear that it is cost-effective for hospitals and physicians despite any benefits to patients since there is no additional reimbursement paid by the government or insurance companies when the system is used. Data are absent to show that these increased costs can be justified. Another problem is that in the medical literature very experienced surgeons tend to publish their results. These, however, may not be representative of surgeons with lesser experience.[10] And there is a steep learning curve for surgeons who adopt use of the system.
Pediatric use of robotic technology

Researchers from Children's Hospital Boston developed and perfected the technique for performing robotically-assisted pediatric pyeloplasties, and have recently completed an 18-month study that showed that the same technique is effective for bladder augmentation procedures. Results from research conducted at Children's have also led to advances and refinements in the robotic equipment, making it more suitable for use in pediatric surgery. The Center for Robotic Surgery's research program is focused on finding safe and innovative applications for robotic technology. Children's Hospital Boston is one of the only pediatric hospitals to perform clinical assessments and outcome analysis - measuring and analyzing the outcomes of robotic surgeries versus open surgeries to ensure the use of the surgical robot is always advantageous to the patient. A second surgical robot is dedicated exclusively to training surgeons and developing and perfecting new robotic procedures and surgical techniques before they are applied to patients.
References
[1] http:/ / www. intuitivesurgical. com/ products/ faq/ index. aspx [2] Robots as surgical enablers (http:/ / www. marketwatch. com/ news/ story/ fascinating-visit-high-tech-operating-room/ story. aspx?guid={2BE812BD-BE91-492C-A0B2-65A0C8324430}& dist=msr_2), MarketWatch, 3 February 2005 [3] Prepping Robots to Perform Surgery (http:/ / www. nytimes. com/ 2008/ 05/ 04/ business/ 04moll. html), The New York Times, 4 May 2008 [4] http:/ / www. intuitivesurgical. com/ products/ faq/ index. aspx#2 [5] J Minim Invasive Gynecol. 2008 May-Jun;15(3):286-91. Epub 2008 Mar 6. PMID 18439499 [6] http:/ / www. intuitivesurgical. com/ products/ fdaclearance/ index. aspx [7] Dorian Block (June 25, 2006). "Robot Does Quick Fix on Prostate; interview with Dr. [[Michael Palese (http:/ / www. nydailynews. com/ archives/ news/ 2006/ 06/ 25/ 2006-06-25_robot_does_a_quick_fix_on_pr. html)]"]. New York Daily News. . Retrieved February 23, 2011. [8] The Slow Rise of the Robot Surgeon (http:/ / www. technologyreview. com/ biomedicine/ 24850/ ) from Technology Review (MIT) [9] Corporate FAQ page [10] Gina Kolata (February 13, 2010). "Results Unproven, Robotic Surgery Wins Converts" (http:/ / www. nytimes. com/ 2010/ 02/ 14/ health/ 14robot. html). The New York Times. . Retrieved March 11, 2010.
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External links
Official website (http://www.intuitivesurgical.com/)
NeuroArm
NeuroArm is a surgical robot. It was specifically designed for neurosurgery. It is the first image-guided, MR-compatible surgical robot that can perform both microsurgery and stereotaxy.[1]
Design
NeuroArm was designed to be image-guided and can perform procedures inside an MRI. NeuroArm includes two remote detachable manipulators on a mobile base, a workstation and a system control cabinet. For biopsy-stereotaxy, either the left or right arm is transferred to a stereotactic platform that attaches to the MR bore. The procedure is performed with image-guidance, as MR images are acquired in near real-time. The end-effectors interface with surgical tools which are based on standard neurosurgical instruments. End-effectors are equipped with three-dimensional force-sensors, providing the sense of touch. The surgeon seated at the workstation controls the robot using force feedback hand controllers. The workstation recreates the sight and sensation of microsurgery by displaying the surgical site and 3D MRI displays, with superimposed tools. NeuroArm enables remote manipulation of the surgical tools from a control room adjacent to the surgical suite.[2] It was designed to function within the environment of 1.5 and 3.0 tesla intraoperative MRI systems. As neuroArm is MR-compatible, stereotaxy can be performed inside the bore of the magnet with near real-time image guidance. NeuroArm possesses the dexterity to perform microsurgery, outside of the MRI system. Telerobotic operations both inside and outside the magnet are performed using specialized tool sets based on standard neurosurgical instruments, adapted to the end effectors. Using these, NeuroArm is able to cut and manipulate soft tissue, dissect tissue planes, suture, biopsy, electrocauterize, aspirate and irrigate. NeuroArm is 3 feet (0.9m) tall and 2 feet (0.6m) wide, but it can be adjusted to fit any table height. The robot weighs 500 pounds (230kg) and has two ambidextrous arms.[3] It sits on casters and can be easily rolled in and out of position. It has a fail-safe braking mechanism that secures it to the floor preventing any movement.
History
The project began in 2002 when Daryl, B.J. and Don Seaman provided $2 million to begin design. Dr. Sutherland and his group established a collaboration with the Canadian space engineering company MacDonald Dettwiler and Associates (MDA).[4] Close collaboration between MDA space robotic engineers, who built the Canadarm and Dextre, and University of Calgary physicians, nurses and scientists contributed to the design and development of NeuroArm. Official launch of the project was on April 17, 2007.[5] NeuroArm was designed to take full advantage of the imaging environment provided by intraoperative MRI. The ability to couple near real-time, high resolution images to robotic technologies provides the surgeon with image guidance, precision, accuracy and dexterity.[6] MDA Engineers were immersed in the operating room to study typical tool and surgeon motions in order to use biomimicry for effective design of the computer-assisted surgical device. NeuroArm has been designed to replace the main neurosurgeon. The OR environment, personnel, surgical rhythm and instrumentation remain unchanged. The surgeon, sitting at the workstation, is provided a virtual environment that recreates the sight, sound and touch of surgery. Functions like tremor filtering and motion scaling were applied to increase precision and accuracy while functions like no-go zones and linear lock were applied to enhance safety. While surgical tools are near the patient's head the system is incapable of fully independent movement and is at all times slaved to the surgeons movement. Pre-planned automatic motions are used to move the robot arms away from
NeuroArm the patient's head for manual tool exchange, and then return them to the original position and orientation.
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References
[1] Pandya, Shawna; Motkoski, Jason W., Serrano-Almeida, Cesar, Greer, Alexander D., Latour, Isabelle, Sutherland, Garnette R. (1 December 2009). "Advancing neurosurgery with image-guided robotics" (http:/ / thejns. org/ doi/ abs/ 10. 3171/ 2009. 2. JNS081334?url_ver=Z39. 88-2003& rfr_id=ori:rid:crossref. org& rfr_dat=cr_pub=pubmed). Journal of Neurosurgery 111 (6): 11411149. doi:10.3171/2009.2.JNS081334. . Retrieved 2011-05-04. [2] "Canadian robot does better brain surgery" (http:/ / www. usatoday. com/ tech/ news/ robotics/ 2007-04-17-robot-brain-surgeon_N. htm). USA Today. 2007-04-17. . Retrieved 2011-05-04. [3] Jackson, Brian (2008-04-02). "Canadian robot set to perform brain surgery" (http:/ / www. itbusiness. ca/ it/ client/ en/ home/ News. asp?id=47785). IT Business. . Retrieved 2011-05-04. [4] "Robot set to revolutionize brain surgery" (http:/ / www. ctv. ca/ CTVNews/ TopStories/ 20070417/ surgical_robot_070417/ ). CTV. 2007-04-17. . Retrieved 2011-05-04. [5] "neuroArm - Worlds first image-guided surgical robot to enhance accuracy and safety of brain surgery" (http:/ / www. ucalgary. ca/ news/ april2007/ neuroarm). University of Calgary. . Retrieved 2011-05-03. [6] Dawn, Walton (2007-04-17). "As a matter of fact, it IS rocket science" (http:/ / www. theglobeandmail. com/ life/ article753999. ece). Globe and Mail. . Retrieved 2011-05-04.
External links
Project neuroArm (http://www.neuroarm.org) Seaman Family MR Research Centre (http://www.med.ucalgary.ca/mrcentre)
Videos
Video in press release for NeuroArm unveiling (http://www.ucalgary.ca/news/files/news/neuroArm.wmv), University of Calgary, April 17, 2007
Related patents
Canadian Patent 2246369 Surgical procedure with magnetic resonance imaging (http://patents1.ic.gc.ca/ details?patent_number=2246369&language=EN) US Patent 5,735,278 (at USPTO) Surgical procedure with magnetic resonance imaging (http://patft.uspto.gov/ netacgi/nph-Parser?Sect1=PTO2&Sect2=HITOFF&u=/netahtml/PTO/search-adv.htm&r=54&f=G&l=50& d=PTXT&s1=5,735,278&p=2&OS=5,735,278&RS=5,735,278) US Patent 5,735,278 (at Google) Surgical procedure with magnetic resonance imaging (http://www.google. com/patents?vid=USPAT5735278)
Laboratory Unit for Computer Assisted Surgery
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Laboratory Unit for Computer Assisted Surgery (LUCAS) is a system used for virtual surgical planning. Starting with 1998, LUCAS was developed at the University of Regensburg, Germany, with the support of the Carl Zeiss Company. The resulting surgical planning is then reproduced onto the patient by using a navigation system. In fact, LUCAS is integrated into the same platform together with the Surgical Segment Navigator (SSN), the Surgical Tool Navigator (STN), the Surgical Microscope Navigator (SMN) and the 6DOF Manipulator (or, in German, "Mehrkoordinatenmanipulator" - MKM), also from the Carl Zeiss Company.
Data gathering, based on CT "slices"
Workflow
Data from separate bidimensional slices generated by a CT or MRI scan are uploaded into the LUCAS system. The resulting dataset is then processed, in order to eliminate image noise, and to enhance the anatomical contours and also the general contrast of the images. The next step is to create a virtual 3D model from the gathered collection of 2D images. The bone segment that is to be repositioned is marked, on the 3D grid reconstructed model; then, the actual repositioning of that bone segment is done on the virtual model, until the optimal anatomical position is obtained. The criteria for the optimal position of the bone segment are: symmetry with the opposite side, the continuity of the normal bone contours, or the normal volume of an anatomical region (such as the Orbit. Afterwards, a textured final image is rendered. The calculated vectors for the bone segment repositioning, together with the whole virtual model are finally transferred to the Surgical Segment Navigator.
Segmentation obtained from the CT "slices"
References
Marmulla R, Niederdellmann H: Surgical Planning of Computer Assisted Repositioning Osteotomies, Plast Reconstr Surg 104 (4): 938-944, 1999 [1]
Simulating the movement of a selected bone fragment, on a 3D grid reconstructed model
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Textured image of the same virtual model
References
[1] http:/ / www. plasreconsurg. com/ pt/ re/ prs/ abstract. 00006534-199909040-00007. htm;jsessionid=H8FQBGq1ly19ldpw1vTY1LyWGCnvsDrpFpHgTjZ4R9zbvQ5RQVbB!-383192544!181195628!8091!-1
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Legislation and Regulation

Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-191) [HIPAA] was enacted by the U.S. Congress and signed by President Bill Clinton in 1996. It was originally sponsored by Sen. Edward Kennedy (D-Mass.) and Sen. Nancy Kassebaum (R-Kan.). Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.[1] The Administration Simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the U.S. health care system.
Title I: Health Care Access, Portability, and Renewability

Title I of HIPAA regulates the availability and breadth of group health plans and certain individual health insurance policies. It amended the Employee Retirement Income Security Act, the Public Health Service Act, and the Internal Revenue Code. Title I also limits restrictions that a group health plan can place on benefits for preexisting conditions. Group health plans may refuse to provide benefits relating to preexisting conditions for a period of 12 months after enrollment in the plan or 18 months in the case of late enrollment.[2] However, individuals may reduce this exclusion period if they had group health plan coverage or health insurance prior to enrolling in the plan. Title I allows individuals to reduce the exclusion period by the amount of time that they had "creditable coverage" prior to enrolling in the plan and after any "significant breaks" in coverage.[3] "Creditable coverage" is defined quite broadly and includes nearly all group and individual health plans, Medicare, and Medicaid.[4] A "significant break" in coverage is defined as any 63 day period without any creditable coverage.[5] Some health care plans are exempted from Title I requirements, such as long-term health plans and limited-scope plans such as dental or vision plans that are offered separately from the general health plan. However, if such benefits are part of the general health plan, then HIPAA still applies to such benefits. For example, if the new plan offers dental benefits, then it must count creditable continuous coverage under the old health plan towards any of its exclusion periods for dental benefits. An alternate method of calculating creditable continuous coverage is available to the health plan under Title I. That is, 5 categories of health coverage can be considered separately, including dental and vision coverage. Anything not under those 5 categories must use the general calculation (e.g., the beneficiary may be counted with 18 months of general coverage, but only 6 months of dental coverage, because the beneficiary did not have a general health plan that covered dental until 6 months prior to the application date). Since limited-coverage plans are exempt from HIPAA requirements, the odd case exists in which the applicant to a general group health plan cannot obtain certificates of creditable continuous coverage for independent limited-scope plans such as dental to apply towards exclusion periods of the new plan that does include those coverages. Hidden exclusion periods are not valid under Title I (e.g., "The accident, to be covered, must have occurred while the beneficiary was covered under this exact same health insurance contract"). Such clauses must not be acted upon by
Health Insurance Portability and Accountability Act the health plan and also must be re-written so that they comply with HIPAA. To illustrate, suppose someone enrolls in a group health plan on January 1, 2006. This person had previously been insured from January 1, 2004 until February 1, 2005 and from August 1, 2005 until December 31, 2005. To determine how much coverage can be credited against the exclusion period in the new plan, start at the enrollment date and count backwards until you reach a significant break in coverage. So, the five months of coverage between August 1, 2005 and December 31, 2005 clearly counts against the exclusion period. But the period without insurance between February 1, 2005 and August 1, 2005 is greater than 63 days. Thus, this is a significant break in coverage, and any coverage prior to it cannot be deducted from the exclusion period. So, this person could deduct five months from his or her exclusion period, reducing the exclusion period to seven months. Hence, Title I requires that any preexisting condition begin to be covered on August 1.
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Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform
Title II of HIPAA defines numerous offenses relating to health care and sets civil and criminal penalties for them. It also creates several programs to control fraud and abuse within the health care system.[6] [7] [8] However, the most significant provisions of Title II are its Administrative Simplification rules. Title II requires the Department of Health and Human Services (HHS) to draft rules aimed at increasing the efficiency of the health care system by creating standards for the use and dissemination of health care information. These rules apply to "covered entities" as defined by HIPAA and the HHS. Covered entities include health plans, health care clearinghouses, such as billing services and community health information systems, and health care providers that transmit health care data in a way that is regulated by HIPAA.[9] [10] Per the requirements of Title II, the HHS has promulgated five rules regarding Administrative Simplification: the Privacy Rule, the Transactions and Code Sets Rule, the Security Rule, the Unique Identifiers Rule, and the Enforcement Rule.
Privacy Rule
The effective compliance date of the Privacy Rule was April 14, 2003 with a one-year extension for certain "small plans". The HIPAA Privacy Rule regulates the use and disclosure of certain information held by "covered entities" (generally, health care clearinghouses, employer sponsored health plans, health insurers, and medical service providers that engage in certain transactions.)[11] It establishes regulations for the use and disclosure of Protected Health Information (PHI). PHI is any information held by a covered entity which concerns health status, provision of health care, or payment for health care that can be linked to an individual.[12] This is interpreted rather broadly and includes any part of an individual's medical record or payment history. Covered entities must disclose PHI to the individual within 30 days upon request.[13] They also must disclose PHI when required to do so by law, such as reporting suspected child abuse to state child welfare agencies.[14] A covered entity may disclose PHI to facilitate treatment, payment, or health care operations,[15] or if the covered entity has obtained authorization from the individual.[16] However, when a covered entity discloses any PHI, it must make a reasonable effort to disclose only the minimum necessary information required to achieve its purpose.[17] The Privacy Rule gives individuals the right to request that a covered entity correct any inaccurate PHI.[18] It also requires covered entities to take reasonable steps to ensure the confidentiality of communications with individuals.[19] For example, an individual can ask to be called at his or her work number, instead of home or cell phone number. The Privacy Rule requires covered entities to notify individuals of uses of their PHI. Covered entities must also keep track of disclosures of PHI and document privacy policies and procedures.[20] They must appoint a Privacy Official and a contact person[21] responsible for receiving complaints and train all members of their workforce in procedures
Health Insurance Portability and Accountability Act regarding PHI.[22] An individual who believes that the Privacy Rule is not being upheld can file a complaint with the Department of Health and Human Services Office for Civil Rights (OCR).[23] [24] However, according to the Wall Street Journal, the OCR has a long backlog and ignores most complaints. "Complaints of privacy violations have been piling up at the Department of Health and Human Services. Between April of 2003 and November of 2006, the agency fielded 23,886 complaints related to medical-privacy rules, but it has not yet taken any enforcement actions against hospitals, doctors, insurers or anyone else for rule violations. A spokesman for the agency says it has closed three-quarters of the complaints, typically because it found no violation or after it provided informal guidance to the parties involved."[25] However, in July of 2011, UCLA agreed to pay $865,500 in a settlement regarding potential HIPAA violations. An HHS Office for Civil Rights investigation showed from 2005 to 2008 unauthorized employees, repeatedly and without legitimate cause, looked at the electronic protected health information of numerous UCLAHS patients.[26]
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Transactions and Code Sets Rule

The HIPAA/EDI provision was scheduled to take effect from October 16, 2003 with a one-year extension for certain "small plans". However, due to widespread confusion and difficulty in implementing the rule, CMS granted a one-year extension to all parties. On January 1, 2012 the newest version 5010 becomes effective, replacing the version 4010.[27] This allows for the larger field size of ICD-10-CM as well as other improvements. After July 1, 2005 most medical providers that file electronically did have to file their electronic claims using the HIPAA standards in order to be paid. Key EDI(X12) transactions used for HIPAA compliance are: EDI Health Care Claim Transaction set (837) is used to submit health care claim billing information, encounter information, or both, except for retail pharmacy claims (see EDI Retail Pharmacy Claim Transaction). It can be sent from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For example, a state mental health agency may mandate all healthcare claims, Providers and health plans who trade professional (medical) health care claims electronically must use the 837 Health Care Claim: Professional standard to send in claims. As there are many different business applications for the Health Care claim, there can be slight derivations to cover off claims involving unique claims such as for Institutions, Professionals, Chiropractors, and Dentists etc. EDI Retail Pharmacy Claim Transaction (NCPDP Telecommunications Standard version 5.1) is used to submit retail pharmacy claims to payers by health care professionals who dispense medications, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit claims for retail pharmacy services and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of retail pharmacy services within the pharmacy health care/insurance industry segment. EDI Health Care Claim Payment/Advice Transaction Set (835) can be used to make a payment, send an Explanation of Benefits (EOB), send an Explanation of Payments (EOP) remittance advice, or make a payment and send an EOP remittance advice only from a health insurer to a health care provider either directly or via a financial institution. EDI Benefit Enrollment and Maintenance Set (834) can be used by employers, unions, government agencies, associations or insurance agencies to enroll members to a payer. The payer is a healthcare organization that pays
Health Insurance Portability and Accountability Act claims, administers insurance or benefit or product. Examples of payers include an insurance company, health care professional (HMO), preferred provider organization (PPO), government agency (Medicaid, Medicare etc.) or any organization that may be contracted by one of these former groups. EDI Payroll Deducted and other group Premium Payment for Insurance Products (820) is a transaction set which can be used to make a premium payment for insurance products. It can be used to order a financial institution to make a payment to a payee. EDI Health Care Eligibility/Benefit Inquiry (270) is used to inquire about the health care benefits and eligibility associated with a subscriber or dependent. EDI Health Care Eligibility/Benefit Response (271) is used to respond to a request inquire about the health care benefits and eligibility associated with a subscriber or dependent. EDI Health Care Claim Status Request (276) This transaction set can be used by a provider, recipient of health care products or services or their authorized agent to request the status of a health care claim. EDI Health Care Claim Status Notification (277) This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient or authorized agent regarding the status of a health care claim or encounter, or to request additional information from the provider regarding a health care claim or encounter. This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set (835) and therefore, is not used for account payment posting. The notification is at a summary or service line detail level. The notification may be solicited or unsolicited. EDI Health Care Service Review Information (278) This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review. EDI Functional Acknowledgement Transaction Set (997) this transaction set can be used to define the control structures for a set of acknowledgments to indicate the results of the syntactical analysis of the electronically encoded documents. Although it is not specifically named in the HIPAA Legislation or Final Rule, it is necessary for X12 transaction set processing . The encoded documents are the transaction sets, which are grouped in functional groups, used in defining transactions for business data interchange. This standard does not cover the semantic meaning of the information encoded in the transaction sets.
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Security Rule
The Final Rule on Security Standards was issued on February 20, 2003. It took effect on April 21, 2003 with a compliance date of April 21, 2005 for most covered entities and April 21, 2006 for "small plans". The Security Rule complements the Privacy Rule. While the Privacy Rule pertains to all Protected Health Information (PHI) including paper and electronic, the Security Rule deals specifically with Electronic Protected Health Information (EPHI). It lays out three types of security safeguards required for compliance: administrative, physical, and technical. For each of these types, the Rule identifies various security standards, and for each standard, it names both required and addressable implementation specifications. Required specifications must be adopted and administered as dictated by the Rule. Addressable specifications are more flexible. Individual covered entities can evaluate their own situation and determine the best way to implement addressable specifications. Some privacy advocates have argued that this "flexibility" may provide too much latitude to covered entities. [28] The standards and specifications are as follows: Administrative Safeguards policies and procedures designed to clearly show how the entity will comply with the act Covered entities (entities that must comply with HIPAA requirements) must adopt a written set of privacy procedures and designate a privacy officer to be responsible for developing and implementing all required policies and procedures.
Health Insurance Portability and Accountability Act The policies and procedures must reference management oversight and organizational buy-in to compliance with the documented security controls. Procedures should clearly identify employees or classes of employees who will have access to electronic protected health information (EPHI). Access to EPHI must be restricted to only those employees who have a need for it to complete their job function. The procedures must address access authorization, establishment, modification, and termination. Entities must show that an appropriate ongoing training program regarding the handling of PHI is provided to employees performing health plan administrative functions. Covered entities that out-source some of their business processes to a third party must ensure that their vendors also have a framework in place to comply with HIPAA requirements. Companies typically gain this assurance through clauses in the contracts stating that the vendor will meet the same data protection requirements that apply to the covered entity. Care must be taken to determine if the vendor further out-sources any data handling functions to other vendors and monitor whether appropriate contracts and controls are in place. A contingency plan should be in place for responding to emergencies. Covered entities are responsible for backing up their data and having disaster recovery procedures in place. The plan should document data priority and failure analysis, testing activities, and change control procedures. Internal audits play a key role in HIPAA compliance by reviewing operations with the goal of identifying potential security violations. Policies and procedures should specifically document the scope, frequency, and procedures of audits. Audits should be both routine and event-based. Procedures should document instructions for addressing and responding to security breaches that are identified either during the audit or the normal course of operations. Physical Safeguards controlling physical access to protect against inappropriate access to protected data Controls must govern the introduction and removal of hardware and software from the network. (When equipment is retired it must be disposed of properly to ensure that PHI is not compromised.) Access to equipment containing health information should be carefully controlled and monitored. Access to hardware and software must be limited to properly authorized individuals. Required access controls consist of facility security plans, maintenance records, and visitor sign-in and escorts. Policies are required to address proper workstation use. Workstations should be removed from high traffic areas and monitor screens should not be in direct view of the public. If the covered entities utilize contractors or agents, they too must be fully trained on their physical access responsibilities. Technical Safeguards controlling access to computer systems and enabling covered entities to protect communications containing PHI transmitted electronically over open networks from being intercepted by anyone other than the intended recipient. Information systems housing PHI must be protected from intrusion. When information flows over open networks, some form of encryption must be utilized. If closed systems/networks are utilized, existing access controls are considered sufficient and encryption is optional. Each covered entity is responsible for ensuring that the data within its systems has not been changed or erased in an unauthorized manner. Data corroboration, including the use of check sum, double-keying, message authentication, and digital signature may be used to ensure data integrity. Covered entities must also authenticate entities with which they communicate. Authentication consists of corroborating that an entity is who it claims to be. Examples of corroboration include: password systems, two or three-way handshakes, telephone callback, and token systems. Covered entities must make documentation of their HIPAA practices available to the government to determine compliance.
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Health Insurance Portability and Accountability Act In addition to policies and procedures and access records, information technology documentation should also include a written record of all configuration settings on the components of the network because these components are complex, configurable, and always changing. Documented risk analysis and risk management programs are required. Covered entities must carefully consider the risks of their operations as they implement systems to comply with the act. (The requirement of risk analysis and risk management implies that the acts security requirements are a minimum standard and places responsibility on covered entities to take all reasonable precautions necessary to prevent PHI from being used for non-health purposes.)
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Unique Identifiers Rule (National Provider Identifier)

HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans, must use only the National Provider Identifier (NPI) to identify covered healthcare providers in standard transactions by May 23, 2007. Small health plans must use only the NPI by May 23, 2008. Effective from May 2006 (May 2007 for small health plans), all covered entities using electronic communications (e.g., physicians, hospitals, health insurance companies, and so forth) must use a single new NPI. The NPI replaces all other identifiers used by health plans, Medicare, Medicaid, and other government programs. However, the NPI does not replace a provider's DEA number, state license number, or tax identification number. The NPI is 10 digits (may be alphanumeric), with the last digit being a checksum. The NPI cannot contain any embedded intelligence; in other words, the NPI is simply a number that does not itself have any additional meaning. The NPI is unique and national, never re-used, and except for institutions, a provider usually can have only one. An institution may obtain multiple NPIs for different "subparts" such as a free-standing cancer center or rehab facility.
Enforcement Rule
On February 16, 2006, HHS issued the Final Rule regarding HIPAA enforcement. It became effective on March 16, 2006. The Enforcement Rule sets civil money penalties for violating HIPAA rules and establishes procedures for investigations and hearings for HIPAA violations; however, its deterrent effects seem to be negligible with few prosecutions for violations.[29]
HITECH Act: Privacy Requirements

Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH Act), enacted as part of the American Recovery and Reinvestment Act of 2009, addresses the privacy and security concerns associated with the electronic transmission of health information. This subtitle extends the complete Privacy and Security Provisions of HIPAA to business associates of covered entities. This includes the extension of newly updated civil and criminal penalties to business associates. These changes are also required to be included in any business associate agreements with covered entities. On November 30, 2009, the regulations associated with the new enhancements to HIPAA enforcement took effect.[30] Another significant change brought about in Subtitle D of the HITECH Act, is the new breach notification requirements. This imposes new notification requirements on covered entities, business associates, vendors of personal health records (PHR) and related entities if a breach of unsecured protected health information (PHI) occurs. On April 27, 2009, the Department of Health and Human Services (HHS) issued guidance on how to secure protected health information appropriately.[31] Both HHS and the Federal Trade Commission (FTC) were required under the HITECH Act to issue regulations associated with the new breach notification requirements. The HHS rule was published in the Federal Register on August 24, 2009,[32] and the FTC rule was published on August 25, 2009.[33]
Health Insurance Portability and Accountability Act The final significant change made in Subtitle D of the HITECH Act, implements new rules for the accounting of disclosures of a patient's health information. It extends the current accounting for disclosure requirements to information that is used to carry out treatment, payment and health care operations when an organization is using an electronic health record (EHR). This new requirement also limits the timeframe for the accounting to three years instead of six as it currently stands. These changes won't take effect until January 1, 2011, for organizations implementing EHRs between January 1, 2009 and January 1, 2011, and January 1, 2013, for organizations who had implemented an EHR prior to January 1, 2009.
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Effects on research and clinical care

The enactment of the Privacy and Security Rules has caused major changes in the way physicians and medical centers operate. The complex legalities and potentially stiff penalties associated with HIPAA, as well as the increase in paperwork and the cost of its implementation, were causes for concern among physicians and medical centers. An August 2006 article in the journal Annals of Internal Medicine detailed some such concerns over the implementation and effects of HIPAA.[34]
Effects on research
HIPAA restrictions on researchers have affected their ability to perform retrospective, chart-based research as well as their ability to prospectively evaluate patients by contacting them for follow-up. A study from the University of Michigan demonstrated that implementation of the HIPAA Privacy rule resulted in a drop from 96% to 34% in the proportion of follow-up surveys completed by study patients being followed after a heart attack.[35] Another study, detailing the effects of HIPAA on recruitment for a study on cancer prevention, demonstrated that HIPAA-mandated changes led to a 73% decrease in patient accrual, a tripling of time spent recruiting patients, and a tripling of mean recruitment costs.[36] In addition, informed consent forms for research studies now are required to include extensive detail on how the participant's protected health information will be kept private. While such information is important, the addition of a lengthy, legalistic section on privacy may make these already complex documents even less user-friendly for patients who are asked to read and sign them. These data suggest that the HIPAA privacy rule, as currently implemented, may be having negative impacts on the cost and quality of medical research. Dr. Kim Eagle, professor of internal medicine at the University of Michigan, was quoted in the Annals article as saying, "Privacy is important, but research is also important for improving care. We hope that we will figure this out and do it right."[34]
Effects on clinical care

The complexity of HIPAA, combined with potentially stiff penalties for violators, can lead physicians and medical centers to withhold information from those who may have a right to it. A review of the implementation of the HIPAA Privacy Rule by the U.S. Government Accountability Office found that health care providers were "uncertain about their legal privacy responsibilities and often responded with an overly guarded approach to disclosing information...than necessary to ensure compliance with the Privacy rule".[34] Reports of this uncertainty continue.[37]
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Costs of implementation
In the period immediately prior to the enactment of the HIPAA Privacy and Security Acts, medical centers and medical practices were charged with getting "into compliance". With an early emphasis on the potentially severe penalties associated with violation, many practices and centers turned to private, for-profit "HIPAA consultants" who were intimately familiar with the details of the legislation and offered their services to ensure that physicians and medical centers were fully "in compliance". In addition to the costs of developing and revamping systems and practices, the increase in paperwork and staff time necessary to meet the legal requirements of HIPAA may impact the finances of medical centers and practices at a time when insurance companies and Medicare reimbursement is also declining.
HIPAA and drug and alcohol rehabilitation organizations

Special considerations for confidentiality are needed for health care organizations that offer federally-funded drug or alcohol rehabilitation services. Predating HIPAA by over a quarter century are the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970[38] and language amended by the Drug Abuse Office and Treatment Act of 1972.[34] [39]
Legislative information
HHS Security Standards; Final Rule: 45 CFR Parts 160, 162, and 164 HHS Standards for Privacy of Individually Identifiable Health Information; Final Rule: 45 CFR Parts 160 and 164 Law: Pub. L. 104-191 [40], 110 Stat. 1936 United States House of Representatives: 104 H.R. 3103, H. Rept. 104-469, Pt. 1, H. Rept. 104-736 United States Senate: 104 S. 1028, 104 S. 1698, S. Rept. 104-156
References
[1] [2] [3] [4] [5] [6] [7] [8] [9] Centers for Medicare and Medicaid Services (http:/ / www. cms. gov/ HIPAAGenInfo/ ) 29 U.S.C. 1181(a)(2) (http:/ / www. law. cornell. edu/ uscode/ 29/ 1181. html) 29 U.S.C. 1181(a)(3) (http:/ / www. law. cornell. edu/ uscode/ 29/ 1181. html) 29 U.S.C. 1181(c)(1) (http:/ / www. law. cornell. edu/ uscode/ 29/ 1181. html) 29 U.S.C. 1181(c)(2)(A) (http:/ / www. law. cornell. edu/ uscode/ 29/ 1181. html) 42 U.S.C. 1320a-7c (http:/ / www. law. cornell. edu/ uscode/ 42/ 1320a-7c. html) 42 U.S.C. 1395ddd (http:/ / www. law. cornell. edu/ uscode/ 42/ 1395ddd. html) 42 U.S.C. 1395b-5 (http:/ / www. law. cornell. edu/ uscode/ 42/ 1395b-5. html) 45 C.F.R. 160.103 (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=160& SECTION=103) [10] Definitions of a Covered Entity (http:/ / hipaa. ohio. gov/ tools/ CEDefinition. pdf) [11] Terry, Ken "Patient Privacy - The New Threats" (http:/ / www. physicianspractice. com/ index/ fuseaction/ articles. details/ articleID/ 1299/ page/ 1. htm) Physicians Practice journal, volume 19, number 3, year 2009, access date July 2, 2009 [12] 45 C.F.R. 164.501 (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=501) [13] 45 C.F.R. 164.524(b) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=524) [14] 45 C.F.R. 164.512 (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=512) [15] 45 C.F.R. 164.524(a)(1)(ii) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=524) [16] 45 C.F.R. 164.502(a)(1)(iv) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=502) [17] 45 C.F.R. 164.502(b) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=502)

[18] 45 C.F.R. 164.526 (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=526) [19] 45 C.F.R. 164.522(b) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=522) [20] 45 C.F.R. 164.528 (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=528) [21] 45 C.F.R. 164.530(a) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=530) [22] 45 C.F.R. 164.530(b) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=164& SECTION=530) [23] "How to File A Health Information Privacy Complaint with the Office for Civil Rights" (http:/ / www. ihs. gov/ AdminMngrResources/ HIPAA/ documents/ OCR_HIPAA_ComplaintFormInstructions. pdf) [24] 45 C.F.R. 160.306 (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?TYPE=TEXT& YEAR=current& TITLE=45& PART=160& SECTION=306) [25] "Spread of records stirs fears of privacy erosion" (http:/ / www. post-gazette. com/ pg/ 06362/ 749444-114. stm), December 23, 2006, by Theo Francis, The Wall Street Journal [26] http:/ / www. beckershospitalreview. com/ news-analysis/ top-5-hospital-news-stories-of-the-week. html [27] CMS Transactions and Code Sets Regulations (http:/ / www. cms. gov/ TransactionCodeSetsStands/ 02_TransactionsandCodeSetsRegulations. asp#TopOfPage) [28] Tim Wafa (J.D.). "How the Lack of Prescriptive Technical Granularity in HIPAA Has Compromised Patient Privacy" (http:/ / papers. ssrn. com/ sol3/ papers. cfm?abstract_id=1547425). Northern Illinois University Law Review, Volume 30, Number 3, Summer 2010. . [29] Medical Privacy Law Nets No Fines. (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2006/ 06/ 04/ AR2006060400672. html) Rob Stein: The Washington Post. [30] HHS Strengthens HIPAA Enforcement (http:/ / www. hhs. gov/ news/ press/ 2009pres/ 10/ 20091030a. html) [31] Guidance for Securing Protected Health Information (http:/ / www. hhs. gov/ ocr/ privacy/ hipaa/ understanding/ coveredentities/ hitechrfi. pdf) [32] Health and Human Services Breach Notification Rule (http:/ / edocket. access. gpo. gov/ 2009/ pdf/ E9-20169. pdf) [33] Federal Trade Commission Breach Notification Rule (http:/ / edocket. access. gpo. gov/ 2009/ pdf/ E9-20142. pdf) [34] Wilson J (2006). "Health Insurance Portability and Accountability Act Privacy rule causes ongoing concerns among clinicians and researchers". Ann Intern Med 145 (4): 3136. PMID16908928. [35] Armstrong D, Kline-Rogers E, Jani S, Goldman E, Fang J, Mukherjee D, Nallamothu B, Eagle K (2005). "Potential impact of the HIPAA privacy rule on data collection in a registry of patients with acute coronary syndrome". Arch Intern Med 165 (10): 11259. doi:10.1001/archinte.165.10.1125. PMID15911725. [36] Wolf M, Bennett C (2006). "Local perspective of the impact of the HIPAA privacy rule on research". Cancer 106 (2): 4749. doi:10.1002/cncr.21599. PMID16342254. [37] "Keeping Patients Details Private, Even From Kin," New York Times, July 3, 2007. (http:/ / www. nytimes. com/ 2007/ 07/ 03/ health/ policy/ 03hipaa. html?ex=1341115200& en=19160c75b9633d68& ei=5090& partner=rssuserland& emc=rss) [38] Pub.L. 91-161; 42 U.S.C. 290dd-3 (1976); omitted and moved to 42 U.S.C. 290dd-2 (2006 through Pub.L. 102-321) [39] Pub.L. 92-255, 42 U.S.C. 290ee-3 (1976); omitted and moved to 42 U.S.C. 290dd-2 (2006 through Pub.L. 102-321) [40] http:/ / www. gpo. gov/ fdsys/ pkg/ PLAW-104publ191/ pdf/ PLAW-104publ191. pdf
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External links
California Office of HIPAA Implementation (http://www.ohi.ca.gov/calohi/) (CalOHI) "HIPAA" (http://www.cms.hhs.gov/HIPAAGenInfo/), Centers for Medicare and Medicaid Services Congressional Research Service (CRS) reports regarding HIPAA (http://digital.library.unt.edu/govdocs/crs/ search/?q=hipaa&t=fulltext), University of North Texas Libraries Full text of the Health Insurance Portability and Accountability Act (PDF/TXT) (http://www.gpo.gov/fdsys/ search/pagedetails.action?granuleId=CRPT-104hrpt736&packageId=CRPT-104hrpt736) U.S. Government Printing Office Full text of the Health Insurance Portability and Accountability Act (HTM) (http://www.legalarchiver.org/ hipaa.htm) Legal Archiver Office for Civil Rights page on HIPAA (http://www.hhs.gov/ocr/hipaa/) HIPAA documentation, resources and commentary (http://www.hipaa.com/)
Certification Commission for Healthcare Information Technology
381

The Certification Commission for Health Information Technology (CCHIT) is an independent, 501(c)3 nonprofit organization with the public mission of accelerating the adoption of robust, interoperable health information technology. The Commission has been certifying electronic health record technology since 2006 and is approved by the Office of the National Coordinator for Health Information Technology (ONC) of the U.S. Department of Health and Human Services (HHS) as an Authorized Testing and Certification Body (ONC-ATCB). The CCHIT Certified program is an independently developed certification that includes a rigorous inspection of an EHRs integrated functionality, interoperability and security using criteria developed by CCHITs broadly representative, expert work groups. These products may also be certified in the ONC-ATCB certification program.
History
CCHIT was founded in 2004 with support from three leading industry associations in healthcare information management and technology: the American Health Information Management Association (AHIMA), the Healthcare Information and Management Systems Society (HIMSS) and the National Alliance for Health Information Technology [1] (the Alliance). In September 2005, CCHIT was awarded a 3-year contract by the U.S. Department of Health and Human Services (HHS) to develop and evaluate the certification criteria and inspection process for EHRs and the networks through which they interoperate. In October 2006, HHS officially designated CCHIT as a Recognized Certification Body (RCB).[2] In July 2010, HHS published new rules for recognizing testing and certification bodies, scheduled to take effect when it named the new bodies. In September 2010, the Office of the National Coordinator (ONC) of HHS named CCHIT again under these new rules. CCHIT is an ONC Authorized Testing and Certification Body (ONC-ATCB).
Goals
Reduce the risk of Healthcare Information Technology (HIT) investment by physicians and other providers Ensure interoperability (compatibility) of HIT products Assure payers and purchasers providing incentives for electronic health records (EHR) adoption that the ROI will be improved quality Protect the privacy of patients' personal health information.
Operations
Present
CCHIT focused its first efforts on ambulatory EHR products[3] for the office-based physician and provider and began commercial certification in May 2006. CCHIT then developed a process of certification for inpatient EHR products[4] and launched that program in 2007. CCHIT then assessed the need for, and potential benefit of, certifying EHR for specialty medicine, special care settings, and special-needs populations.[5] [6] CCHIT, in a collaboration with the MITRE Corporation, also developed an open-source program called Laika to test EHR software for compliance with Federally-named interoperability standards.
Certification Commission for Healthcare Information Technology Announcements of CCHIT Certified Products On July 18, 2006, CCHIT released its first list of 20 certified ambulatory EMR and EHR products [7] On July 31, 2006, CCHIT announced that two additional EHR products had achieved certification.[8] On October 23, 2006, CCHIT released its second list of 11 certified vendors.[9] On April 30, 2007, CCHIT released its third list of 18 certified vendors.[10] On November 16, 2009, CCHIT released [11] its initial draft criteria for Behavioral Health [12], Clinical Research [13] , and Dermatology [14] EHRs, with expected final publication available July 2010.
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Future
The Commission is currently developing a special program for hospitals wishing to certify legacy, customized or self-developed EHR products in the ONC-ATCB 2011/2012 program. The program called the EHR Alternative Certification for Hospitals, or EACH, is scheduled to open in December 2010. The Commission is also planning to launch CCHIT Certified programs for EHRs used in Clinical Research, Oncology and Women's Health (obstetrics component) in 2011.
Commissioners
The Commission, chaired by Karen Bell, M.D., M.M.S, is currently composed of 21 members each serving two-year terms.
Stakeholders
Certified EHR products benefit many interested groups and individuals: Physicians, hospitals, health care systems, safety net providers, public health agencies and other purchasers of HIT products, who seek quality, interoperability, data portability and security Purchasers and payers from government to the private sector who are prepared to offer financial incentives for HIT adoption but need the assurance of having a mechanism in place to ensure that products deliver the expected benefits Quality improvement organizations that seek out an efficient means of measuring that criteria have been assessed and met Standards development and informatics experts that gain consensus on standards Vendors who benefit from having to meet a single set of criteria and from having a voice in the process Healthcare consumers, ultimately the most important stakeholders, who will benefit from a reliable, accurate and secure record of their health CCHIT and its volunteer workgroups strive to fairly represent the interests of each of these diverse groups in an open forum, communicating the progress of its work and seeking input from all quarters. CCHIT has received the endorsements of a number of professional medical organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the Physicians' Foundation for Health Systems Excellence and Physicians' Foundation for Health Systems Innovation.
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Notes
[1] http:/ / www. nahit. org [2] U.S. Department of Health and Human Services (October 26, 2006): HHS Officially Recognizes Certification Body to Evaluate Electronic Health Records (http:/ / www. hhs. gov/ news/ press/ 2006pres/ 20061026a. html) [3] Public postings of CCHIT work products for the ambulatory domain (http:/ / www. cchit. org/ work/ criteria. htm) [4] Public postings of CCHIT work products for the inpatient domain (http:/ / www. cchit. org/ work/ inpatient+ criteria. htm) [5] CCHIT to Expand Electronic Health Record Certification to Some Specialties (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Expands+ Electronic+ Health+ Record+ Certification+ to+ Specialties. htm) (November 28, 2006) [6] CCHIT: Certifying EHR for Specialty Medicine and Special Care Settings (http:/ / www. cchit. org/ vendors/ learn/ Certifying+ EHR+ for+ Specialty+ Medicine+ and+ Special+ Care+ Settings. htm) [7] Certification Commission for Health Information Technology (July 18, 2006): CCHIT Announces First Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ First+ Certified+ Electronic+ Health+ Record+ Products. htm) Retrieved July 26, 2006 [8] Certification Commission for Health Information Technology (July 31, 2006): CCHIT Announces Additional Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ Additional+ Certified+ Electronic+ Health+ Record+ Products. htm) Retrieved July 31, 2006 [9] CCHIT Announces New Certified Electronic Health Record Products (October 23, 2006): CCHIT Announces New Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ New+ Certified+ Electronic+ Health+ Record+ Products. htm) [10] CCHIT Announces New Certified Electronic Health Record Products (April 30, 2007): CCHIT Announces New Certified Electronic Health Record Products (http:/ / www. cchit. org/ certified/ 2006/ CureMD. htm) [11] http:/ / www. cchit. org/ media/ news/ 2009/ 11/ public-comment-period-expanded-2011-certification-criteria-open-0 [12] http:/ / www. cchit. org/ sites/ all/ files/ CCHIT%20Certified%202011%20Behavioral%20Health%20Criteria%20For%20Public%20Comment%2020091120. pdf [13] http:/ / www. cchit. org/ sites/ all/ files/ CCHIT%20Certified%202011%20Clinical%20Research%20Criteria%20For%20Public%20Comment%2020091116. pdf [14] http:/ / www. cchit. org/ sites/ all/ files/ CCHIT%20Certified%202011%20DERMATOLOGY%20Criteria%20For%20Public%20Comment%2020091116. pdf
External links
Official website (http://www.cchit.org)
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Software Systems
Medical software
In computers, medical software is a significant branch of software engineering. Many medical devices that monitor or control patients are predominantly controlled by software. Medical devices are frequently regulated and must comply with local and regional laws. In the European Union, these includes the Medical Devices Directive. In the United States, the Food and Drug Administration has increased its involvement in reviewing the development of medical device software starting in the mid-1980s, where coding errors in a radiation therapy device (Therac-25) resulted in the overdose of patients.[1] FDA is now Medical Software Logo, by Harry Gouvas focused on regulatory oversight on medical device software development process and system-level testing.[2] In the recent years,1995-2005 IEC 62304 has become the benchmark standard for the development of medical software.
Types of medical software

Monitors heart rate, blood pressure, breathing rate, use software to interpret the sensor information and display it in a meaningful way on a monitor. Medication pumps These devices are programmed to pump a certain amount of plasma, blood, saline solution, or other medication into a patient at a certain rate. The software provides the ability to control many aspects of treatment procedures. Analysis Many devices, such as X-ray computed tomography scanners (CT or CAT scans), measure raw data that is essentially meaningless to people. Software reinterprets this data to create images that doctors can read and understand. Expert Systems A variety of expert systems help clinicians and practitioners in decision making for diagnostic and therapeutic purposes. Therapy delivery The software in implantable pacemakers and defibrillators provides fault-tolerant, real-time, mission-critical monitoring of cardiac rhythms and associated therapy delivery. Medical and healthcare educational software Software used as an educational or study tool for health care professionals. Medical informatics Software for the business and informational aspect of medicine; these include electronic medical record (EMR), electronic health record (EHR), practice management, and the analytics software that works with these
Medical software systems.
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Classification of Medical Software

Medical Software could be classified simply into the following groups, depending on its use. This is called utilitarian classification by Harry Gouvas 1988, but sometimes there are overlaps: (I) Educational Medical Software (Educational Medical Software, EMS): (Ia): Built-in Device and (Ib): Not built-in appliances. (II) Medical Diagnostic Software (Diagnostic Medical Software, DMS): (IIa): Built-in Device and (IIb): Not built-in appliances. (III) Therapeutic Medical Software (Therapeutic Medical Software, TMS): (IIIa): Built-in Device and (IIIb): Not built-in appliances. (IV) Medical Design Software (Design Medical Software, DEMS): (IVa): Built-in Device and (IVb): Not built-in appliances. Examples: A program that monitors and shows the heart rate, blood pressure and blood oxygen, a monitor, is the built-in diagnostic software, Category IIa. A free medical program called eg "Infection" that accepts symptoms and makes diagnosis of infection, belongs to the Ib. A program for example the "Scan" which is loaded on a CT scanner and processed by the X-ray signal, to reproduce the picture, belongs to a class IIa. A program eg the "Press" built in "chip" a digital sphygmomanometer, belongs to a class IIa. A program example in "Coral" of a company that manufactures total hip and Freedoms (PC designer) belongs to the class IVb, while the program eg the "Coral-CAD" embedded in machines for cutting and construction of intentional belongs to IVa. The software that controls the machine Laser Surgeons in patients with myopia automatically belongs to the class IIIa. As noted above there may be overlaps. This is particularly true in the category (I). A medical education program, might well have as its object to diagnose or treat disease.[3]
Computer Aided Medical Diagnosis, CAD

Computer Aided Diagnosis is a procedure in which an appropriate medical Medical Software can diagnose illness, using patient data processed by the computer. These data were once only symptoms, laboratory findings, and radiographic findings, but were inputed as text only, not allowing image processing (eg software for bone tumors "TUMOR", 1991). Currently registered and processed at the Medical Software, and photos. For example, there is a Dermatology Software that processes a picture and give skin lesion diagnosis by comparison to a database (Skin Lesions, Expert System). The definition given by the English Wikipedia entry on Computer Aided Diagnosis, no literature, is obviously inadequate and wrong. He writes: "Computer aided Diagnosis are procedures in medicine that assist doctors in the interpretation of medical images". This article will not deal with the integrated diagnostic medical software industry, it is almost nonexistent communications and publications on this because of the confidentiality of manufacturing firms. We will deal with free Diagnostic Medical Software. As is known by the announcement in 1945 of the Computer ENIAC and the subsequent large-type systems IBM 360, o journalistic world had a new invention as "the machine in the future will answer all questions." It is characteristic of the two-page article in the newspaper "Acropolis" in 1967 entitled "Electronic Brain: A machine will answer all questions". Medicine that has been recognized as an apple and leave the eye, is the Differential Diagnosis of the process that is followed by their doctors to make diagnosis. No other profession or machine can do this work because it requires a complex algorithm thought that even in the hands of excellent doctors in the world, have error rates above 20%. Diagnosis is a complex process, and physicians should be trained 6 years to acquire the basic knowledge of (Medical School), and others 6-7 years to specialize in one subject (medical specialty). The gift of a doctor to memorize a lot of knowledge but rather to properly process this knowledge with sharp critical thinking is a valuable and scarce resource that is not presently be analyzed. There are rare cases of patients with unclear clinical picture, be hospitalized for a month, have done a test volume, and nobody knowing what they are. This course was previously
Medical software ad nauseam. Marshal Papagos for example in Greece, died months after hospitalization, and no one knows the cause of death, and marched on the bench tops European dozens of Medicine and Surgery. Today the phenomenon tends to decrease dramatically due to the high-tech, but still there. Early in the decades 1960-1980 Independent medical research and medical groups in the U.S. received the message from the invention of computers and watching in front, thought to use these machines (main frames) for differential diagnosis in difficult cases, designing the appropriate software. Of course the reaction was intense. Raised objections to the application of Computer in Diagnosis (Computer Aid Diagnosis) with the main argument as "If the computer makes a mistake, the failure of software, who will bear the criminal responsibility of medical error?". Of course, this is wrong, because the final diagnosis signing will bring the doctor, and the role of the PC will be helpful. Even today, the medical community sees with eyes half free medical diagnosis software, but accepts de facto when incorporated in a machine, because you can not do otherwise. Who ever complained, because CT or MRI or Ultrasound not catch any diseases? Before marketed the first Personal Computer IBM-PC (year 1983-1984), the U.S. already created the first experimental Medical Software Specifically target use. Perhaps the first Medical Software warming is the "BRAIN" of the neurologist D. Filkenstein (year 1976) for the differential diagnosis of complex neurological diseases. "MYCIN" software was followed by E. Shortliffe University Stanford USA, for the differential diagnosis of microbial infections. But what caused a lot of noise and optimism was the "INTERNIST / CADUCEUS" researchers Pople and Myers, University of Pittsburg, USA, which could process 4,000 symptoms and diagnostic parameters from 500 diseases of Internal Medicine (Internal Medicine). Since then , nobody knows what happened to these software, and if converted into a format suitable for running on PC.
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Medical Software Internationally

As mentioned above, today the internationally applied Medical Software has settled in the following areas: (I) Integrated Medical Software: The first major area is the Integrated Medical Software in Medical Devices of any kind (often unavailable). Of course there century companies that manufacture and sell medical software for imaging and other medical devices. Such is the SANTESOFT AEBE with many products on the website http:// www.santesoft.com/customers.html [26]. (II) Surgery Management Programs: The second segment is simple and Programs Management Clinic patient records. There is no single way to design these programs, and - unfortunately - when once the user have a problem, looking for the company that designed it, he discovers that no longer exists. Examples: The project concerns the management ORTHO orthopedic Surgery. The program "CardioData" to administer cardiac Surgery, etc. (III) Application Software Specifically: The third sector is usually On Line web programs, Software Specifically Application. Eg. There is free On Line web software that explores the interactions between drugs and inform your doctor or pharmacist what medicines do not match the shot. Designed by the company and called Medscape Drug Interaction Checker, website http://www.medscape.com/druginfo/druginterchecker [29] Remarkable is also the software of the National Formulary of Greece, something akin to those of other countries, the website http:// eof1.eof.gr/Syntagologio.The American Society for Medical Software Unbound Medicine offers free via its website http://www.unboundmedicine.com/store/android, a series of useful medical programs for the use of doctors and nurses as the Nursing Central, the Family Drug Guide, the Nurse's Clinical Pocket Guide, etc. Many of these work and new mobile phone i-phone. In the "other" camp, the Russian software company SoftwareGeek also order from Medical Software for various purposes. (IV) Computer Differential Diagnosis (Computer Aided Diagnosis): O The fourth area is the network On Line Software Differential Diagnosis. Existing diagnostic systems Computer Aided (CAD, Computer Aid Diagnosis) divided into two basic categories, as to how building (development): (a) Probability Systems (Propability Systems): These models are probabilistic type and not of particular interest . (B) Knowledge Base Systems (Knowlesge Based Systems): These are applications of AI (Artificial Intelligence) and known as Expert Systems (Expert Systems).One such free software on the internet, is the American DiagnosisPro website http://en.
Medical software diagnosispro.com/.A similar program is also designed by Microsoft for practicing telemedicine in remote and poor regions. Said NxOpinion located on site http://www.microsoft.com/presspass/features/2004/jan04/ 01-21NxOpinion.mspx. (V) Medical Software Telemedicine: Telemedicine is the use of combining IT and communication technology. We define a new, unimaginable a few decades ago, a possibility that the death of distance and reset the time on information exchange and assistance among physicians and patients. This option defines new levels in all areas that constitute the functioning of the Medical Sciences: Education, access to knowledge, research, clinical practice, control of medical instruments, assistance in inaccessible areas, prevention and generally minimizes the limitations of space and time in exercise. Education and medical practice over days, new prospects are enormous as are the following possibilities: 1) Exchange of educational medical programs in real time 2) Access to doctors in all medical libraries of the world 3) Medical Teleconferences, On Line Medical Conferences , On Line examining the patient, and transfer the dossier to the Medical e-mail. 4) telemedicine (eg, heart patients with a portable device that sends Elektroardiogram with mobile phone in a special center) 5) General control and monitoring of populations living in remote areas (islands, inaccessible areas). The offer medical care in places that are not available for immediate access to medical resources such as Seagoing ships, climbing plants or excluded areas, etc. A typical example being the control center of climbers to Everest which is connected with the University of YALE and tasked to monitor at any time the climbers climbing out over the 7,000 meters and equipped with sensors that continuously record the cardiopulmonary function and identify resistance limits the climbers. It is certain that the technology at the Medical Software and Medical Devices running fast. The average doctor, let alone the average citizen, unable to keep pace. But the years that medical knowledge and access to high quality medical services, was the prerogative of few, gone for good. Whether this development will bring improvement of health of the population of the earth, that is another question that requires much thought for a response.
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Medical Diagnostic Software in Greece

The first form of medical software for PC that were traded worldwide were operating programs for Clinic and Hospital Management, and of course they ran into a MS-DOS operating platform. Even today this is happening. Such programs are prevalent in the days during practice. So do register patients, record history and management of financial data. Just be improved and run on Windows. But especially in Greece was the inverse paradox. Even before release programs and historical patient records of patients, Harry Gouvas, Orthopaedic Surgeon and Presentation of Medical Software OSTOUN, Nick Polyzos, programmer,software engineer, designed in two years Athens,1987 1985-1987 and after working 6 months in 1987 showed public primordial for the current data plan on Artificial Intelligence software "OSTOUN", designed in language Turbo Pascal. This software, running on MS-DOS, announced its type and was issued in printed and electronic form. Facilitated a new doctor, to see instantly what can be hidden behind a range of musculoskeletal pain, and was the first Medical Software in Greece, and also in Europe [4] . In 1990 the two above Harry Gouvas and Nick Polyzos designed and presented the Medical Software "EXAM" an automatic guidance software for the Clinical Orthopaedic Examination of patients that "do not escape anything"[5] . In 1992 after
Medical software working 12 months, Harry Gouvas and Chris Karatzoglou, created a spectacular season for Medical Software in Greek and English Version, with the name "TUMOR". It was implemented on Artificial Intelligence in programming tool Clipper and D-BASE III PLUS and belonged to the group "Systems of Knowledge Base". In this software, the user at a time of 60 seconds, records clinical data from a patient with known bone tumor, and after the radiological signs of bone tumor by radiography. The program processes the data, compares with the database and is statistical diagnosis, in 10 seconds. Eg. Bone cyst (98%), Osteoeides Osteoma (68%), etc. Since the tests were the success rate of software TUMOR was 99%. Due to lack of funding, this Software is not converted for use in a Windows [6] Later in 1994 the two above, created the Medical Software "ORTHO" for recording patient orthopedic clinic and retrospective statistical analysis.
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References
[1] Jones, Paul (2010-02-09). "A Formal Methods-based verification approach to medical device software analysis" (http:/ / embeddeddsp. embedded. com/ design/ opensource/ 222700533). Embedded Systems Design. . Retrieved 2010-09-09. [2] FDA (2010-09-08). "Infusion Pump Software Safety Research at FDA" (http:/ / www. fda. gov/ MedicalDevices/ ProductsandMedicalProcedures/ GeneralHospitalDevicesandSupplies/ InfusionPumps/ ucm202511. htm). FDA. . Retrieved 2010-09-09. [3] Harry Gouvas and Nick Polyzos: OSTOUN, the first Medical Software in Europe, editions Ciba Geigy, Athens 1988 [4] Harry Gouvas and Nick Polyzos: "OSTOUN", Pain in Orthopaedics, Medical Software and manual, editions Ciba Geigy, Athens, 1987 [5] Harry Gouvas and Nick Polyzos: EXAM,Examination in Orthopaedics, Medical Software and manual, Athens, 1990 [6] Harry Gouvas and Chris Karatzoglou: TUMOR, A diagnostic medical Software in Human Bone Tumors. International Congress for Bone Tumors, Kifissia, Athens 1992
Dental software
Terminology
The term dental software defines software used in dentistry.
History
The history of the development of the dental software is brief. For the first time the computers have been used in the dental medicine in the 1960s[1]. Since then computers and information technologies spread progressively in the dental practice. According to Atkinson, J. in the year of 2000 85,1% of all dentists in the United States use computers[2].
Classification
There are many types of dental software, in dependence of the specific task, that they do to help the dental practice. One classification is given from Schleyer[3] and Kirsher[4]. They categorize three main categories of dental software: administrative, clinical, and for internet. The clinical category from other side is categorized in: electronic dental records, electronic dental designs, dental imaging software, and software used for diagnostics and treatment. Zimmerman[5] recognizes the following types of computer software, depending from their task: administration and management of patients documentation. electronic archives of the documentation. telecommunication computer aided education computerizing instruments and techniques in the dental office software helping the clinical decision making. All classifications of dental software are relative, since there are software products, designed for realizing more than one task. A larger classification based on the specific task shows more types of tasks and software. This classification of dental software is: Dental administration management Dental practitioners records management
Dental software Dental schedules and dental scheduling Patient dental records management Dental billing Dental imaging processing Dental diagnostics Dental treatment helping Computer aided dental education Software for usage of dental instruments and other techniques used in the dental practice
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Dental administration management software

Different administrative and government institutions in the different countries of the world demand requirements to the dental practitioners. Such institutions may be health insurance companies, health booking offices, government registers and others. The dental administration management software is made to help both the administration workers and the dentists for meeting these requirements.
Dental practitioners records management software

The dental practitioners management software is a software most frequently used in dental clinics, or in hospitals, where more than one dental or medical practitioner works. The dental practitioners records management is mostly used from the administration and helps the users to effectively manage the records of the practitioners. There are many dental practitioners management software projects, available in the market. Examples of Dental Software Products, that support dental practitioners records management are:
Dental schedules managing software

The dental schedules managing software is designed to distribute the obligations of the dental practitioner in such a way, so no time both of the dentist and of the patients to be unnecessary lost.
Patient records management dental software

Patient records management dental software is used by the dentists in order to organize the records of the patients in their practice. The computer patients management software is used for collecting, managing, saving, and retrieving medical information for the patients, and for creating reports for the patients. Computers in the dentistry were first used to record dental archives[1] as an alternative of paper dental documentation. Later the term "computer based dental documentation" was replaced with the term "electronic patient record (EPR)" since the last better describes the method and the environment in which the patient record is being managed[6]. In 1991 in an official report of the Institute of Medicine of the National Academies in Washington, USA gives definitions about what functions must implement a computer based system for health documentation. The American Dental Association (ADA) created Specification number 1000 and number 1004[8] concerning the structure and the content of the electronic health record. The medical data include identification and contact data, date of next visit, number of previous visits, anamnestic, clinical and paraclinical data, applied treatment, and treatment results data. Patient Records Management Dental Software is the most frequently used dental software. Many software products exist, however because of the requirement for not using list format only several will be listed. Web based dental patients records management software is also been proposed. The web based records save the information for the patients in a central web server instead in the computer in the dental office[9].
Dental software
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Dental imaging processing software

The dental imaging processing software, or imaging software, defines software used for creating, processing, viewing and storing dental rentgenografic (X-Rays), intra and extra-oral images. Generally, dental imaging software is included in the product package of dental rentgenographic devices or can be purchased separately. Most imaging software is DICOM ready or will be at an upgraded price. There are several types of imaging software: 1. Manufacturer proprietary 2. Open hardware (not to be confused with open source) 3. Practice management linked Manufacturer proprietary There are many dental hardware manufacturers that produce their own imaging software. A few even have their own practice management (PM) solutions that integrate very tightly between the two products to produce a near seamless environment (which can fall under practice management linked- see below). All have their own database engines to help link and locate patient images, or they utilize a linked database structure from the PM software, which is known as bridging. In some cases, bridged imaging software cannot be utilized without the PM software operating in the background. Manufacturer imaging software will have all the needed enhancements to make the X-Rays their product produces look the best. Generally, this sort of software comes free with the hardware and will have limited licensing usage or functionality unless an upgraded version is purchased. A couple of manufacturers will sell a full use, unlimited user license with their products. Most software of this nature will only operate with the hardware manufacturer they were designed for and will accept very few outside vendors. Because of this, the dental provider is generally required to use the manufacturer's hardware and support. Open hardware imaging Some software vendors have created imaging software that will work with multiple hardware vendors and in some cases will produce derivative copies for manufacturers and PM vendors. Open Hardware Imaging (OHI) also focuses completely on the end result after taking an X-Ray or intra/extra-oral image, and that is image management and manipulation. All OHI software requires the manufacturers software to be installed prior to usage. This insures the dental hardware's device software is operational and provides a default testing environment in the advent of a malfunction. It also provides a basis for the OHI software to obtain device settings. Bridging to PM software is the most common way OHI can retrieve patient info for its own databases. Some PM vendors provide ways to integrate imaging into their software by use of creating toolbar buttons and other methods. This requires delving to the deep recesses of PM software and will be unique per brand. In the case the PM software doesn't have a direct bridge integration, the use of a data grabber or bridger is required. Data grabbers or bridgers operate upon the displayed screens of the PM software. In most cases, the dental user is required to be in the patient information or the charting screen before the grabber can be used. This process generally works well, but once in awhile issues can develop such as patients with same names, the front office didn't input all the patient information correctly, or the use of middle initials/nicknames isn't properly defined in both software. Most of the time, these issues can be resolved with minimal fuss. OHI software generally works off of their own database engines and therefore require their own database utilities. An advantage of this type of software is if one part of the system fails, such as the PM software, the practice can continue to work and take images, which is what is used most of the time.
Dental software Practice management linked Practice management linked (PML) imaging software provides the tightest integration with PM vendors software. Because of this, patient images can be displayed in the patient charting screens. This generally doesn't combine the imaging and PM databases, but some vendors claim that is the case. Most PML software is open to most hardware vendors though generally the biggest brand names are accepted. Some PML vendors will not work with certain dental hardware manufacturers because of various contractual matters or preferences. Some popular brands of PM software favor certain hardware that they prefer to sell and thus have adjusted their imaging to work well with those devices. For all intents and purposes, PML software behaves like OHI software and can be used with other PM vendors.
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Dental diagnostics helping software

The software products are usually based on technologies, that try to simulate the human intellect, called artificial intelligence or AI. The expert systems designed to enhance the diagnostic process, are part of the dental expert systems software. Today for more appropriate definition is supposed to be decision support systems, or DSSs, and knowledge based systems(KBSs). The only one software product, designed to help the dentists with the diagnostication of hard for diagnose placement diseases, that can be found in internet is the Diagnostic Helper Software: http:/ / diagnostichelpersoftware. webs. com/
Dental treatment planning software

The usage of computer technologies for taking clinical decisions for the treatment of dental patients started at the end of the 1970s. The software products are usually based on technologies that try to simulate the human intellect, called artificial intelligence or AI. The expert systems designed to enhance the treatment process, by providing the dental practitioner with a treatment plan are dental expert systems software. Today for more appropriate definition is supposed to be decision support systems, or DSSs, and knowledge based systems(KBSs). Such software products are designed for the therapeutic dentistry[17], the prosthodontics[15, 16].
Dental internet and ethernet communication software

Telecommunication technologies found application in the medicine in the 1950s, which led to the defining of a new term "telemedicine". In 1997 Cook for first time uses the term "teledentistry"[11] and he defines it as the practice to be used videoconference technologies for diagnosis placement or consultations for the treatment from destination. Different variations of medical and dental data interchange using internet are developed[10]. It is expected this type of software to revolutionize the way for interchanging information between medical and dental practitioners. Today the teledentistry includes activities such as information interchange by phone lines, fax machines, and transfer of computer based documents by the use of internet. There are also special software products, designed specially for communication and information interchange between dentists, and software products specially designed to access dental information by the use of internet.
Computer-aided dental education

The computer-assisted education is an element from the remote education[12]. The term "electronic learning" or "e-learning" defines the usage of internet and multimedia in the educational course. Schleyer[13] describes the learning with the help of computer software as a means for overcoming the faults of the traditional forms of education. In 1997 Cook wrote about the usage of videoconference technologies by the means of their usage for dental education[11]. Today software for computer aided dental education are made for various dental specialities: orthodontics, dental imaging, endodontics, cariesology, oral pathology, pediatric dentistry, parodontology and prosthodontics[12, 13].
Dental software
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Software for usage of dental instruments

Instruments, used in dentistry, and needing software to operate are large number of models of digital rentgenography hardware, intraoral cameras, various diagnostic hardware products such as for early caries detection, parodontal probes, CAD/CAM systems[14].
Free dental software

There are several types of free dental software: shareware, freeware and open source dental software. Most frequently the free dental software is provided as shareware. This means, that the dental software license allows its usage only for evaluation purposes. These software products have limitations. However there is at least one freeware dental software project, which license allows it to be used free and for unlimited time from the dentists. It is localised at: http:/ / freedental. webs. com/ There is a very well developed Open Source dental project, that can be found on: http:/ / www. opendental. com/ However, even with open source, the open dental software is not absolutely free, because it uses third party intellectual properties, for which dentists have to pay for its usage.
Dental software versus special dental formats

Parallel with the development of the dental software many software products, that are not originally created as medical or dental software were adjusted to work for dental purposes. In many cases these adjustments were successful. For example patient database software in many dental offices were replaced by software products for general database management, such as Microsoft Access, Microsoft Excel, the legally free distributed Open Office variations of the above. Access and Excel files, structured according to the need of the patient management(defining fields as Patient Name, Ambulatory Number, Diagnose, etc.) in many cases are sufficient to represent functional, secure, powerful and intuitive for usage patients database, powerful concurrence of the expensive dental patient management software products. The disability of the text processing software to write the numbers of the dental teeth graphically(and thus unable to write and print dental patient reports) was overcame by the creation of dental fonts, that can be used in Microsoft Word and legally free text processing software products, such as Open Office Write and Abi Word. Readily made forms for dental patient report writing and printing appeared to be sufficient for the generation(by the dental practitioner, not automatically) dental patient records and their printing. Dental schedules management software can in a high degree be replaced with standard schedule management software projects, created for schedule management for general purposes, some of which can legally be downloaded for free. For processing of dental images were used many software products for genetral image processing, such as Adobe Photoshop, Irfwan View and others. Processing dental images with software products for general pictures processing proved to be powerful, easy to use, reliable, and much cheaper(in some cases free). Dental treatment planning software was "replaced" with legally scanned and legally purchased via internet books over the treatment topic, opened with ebooks opening software and shortcuts, designed to open the book on specific pages. For calculating hard to be calculated dental bills were used specially adjusted Microsoft Excell Sheets, instead of Dental Biling Softare. Many dentists are successful in receiving computer aided dental education without the usage of software for this purpose, by finding and purchasing ebooks, lectures from the websites of medical universities, browsing the Medline MEDLINE and other medical and dental databases, using usual email clients for communication via email and materials interchange via email, using internet explorer and other web browsers for participating in dental forums, and using e-learning, that do not require the purchasing of software. So far now the only type of dental software, for which special formats are not effective enough is the diagnostics helping software.
Dental software
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Recommendations for choosing software for the dental practice

For choosing the best management software for their practice, the dentists should have many things in mind, but the most important is whether the software fulfills the specific need of the dental practitioner. Another important advice to be considered the usage of special format and degree in which the special format will satisfy the practitioner's requirements. Dental imaging software has several factors to consider as well and is dependent upon the dentist's needs or wants. Some imaging software is proprietary and will accept very few outside hardware vendors, yet will produce good images for diagnosis. Others are more open and will work with a wide array of hardware and will have good image quality as well. Another factor is integration with the practice management software and how well it can incorporate patient info into itself.
References
1. Delrose, D.C. et R.W. Steinberg. The clinical significance of the dental patient record. -J.Am.Dent.Assoc., 131, 2000, Suppl., 57-60. 2. Atkinson, J. et al. Electronic patient records for dental schoolclinics: more than paperless systems. - J.Dent. Educ., 66, 2002, Vol. 5, 634 - 642. 3. Schleyer, T., H. Spallek et M. H. Torres-Urquidy. A profile of current Internet users in dentistry. 4. Kirshner, . The role of information technology and informatics research in the dentist-patient relationship. - Adv. Dent. Res., 17, 2003, Vol. 12, 77 - 81. 5. Zimmerman, J. L., M. J. Ball et S. P. Petrovski. Computers in dentistry. Dent. Clin. North Am., 30, 1986, Vol. 10, 739 - 743. 6. Heid, D. W., J. Chasteen et A. W. Forrey. The electronic oral health record. - J. Contemp. Dent. Pract., 3, 2002, Vol 1, 43 - 54. 7. Dick, R. S. et E. B. Steen. Committee on Improving the Patient Record. An Essential Technology for Health Care. Washington, National Academies Press, 1991. 8. ADA Specification 1004: Computer Software Performance for Dental Practice Software. New York: American National Standards Institute, 2001: http://www.ada.org/prof/resources/standarts/informatics_reports.asp 9. Schleyer, T. et V. Rado-Dasari. Computer basedoral health records on the World Wide Web. - Quintessence Int., 30, 1999, Vol.7, 451 - 460. 10.Schleyer, T. Digital dentistry in the computer age. - J. Am. Dent, Assoc., 130, 1999, Vol.12, 1713-1720. 11.Chen, J. et al. Teledentistry and its use in dental education. - J. Am. Dent. Assoc., 134, 2003, Vol. 3, 342 - 346. 12.Eaton, K. A., et M. Hammick. Distance learning materials for dentists - a users guide to quality. - Br.Dent.J., 194, 2003, Vol.5, 253 - 256. 13.Schleyer, T. et L. A. Johnson. Evaluation of educational software - J. Dent. Educ., 67, 2003, Vol.11, 1221 - 1228. 14.Hurston - Anderson, L. Integrated office technology: how technology can help improve officeefficiency. - J. Am. Dent. Assoc., 135, 2004, Vol.10, 18 - 22. 15.Beaumont, A. J. Jr. Microcomputer aided removable parture denture design. - J. Prosthet. Dent., 62, 1989, Vol.5, 551 - 556. 16.Davenport, J. C., P. Hammond et F. J. Fitzpatrick. Computerized design of removable partial dentures: a knowledge based system for the future. - Dent. Update, 20, 1993, Vol.5, 221 - 226. 17.Duncan R. C. et al. Using computer to diagnose and plan treatment of approximal caries. Detected in radiographs. - J. Am. Dent. Assoc., 126, 1995, Vol.7, 873 - 882.
List of freeware health software
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List of freeware health software

The following is a list of freeware software packages and applications for use in the health industry. This is not to be confused with free software. If the software is licensed under an open source license or in the public domain, do not list it here - put it in the List of open source healthcare software.
Imaging/Visualization
3DimViewer [1] a lightweight truly 3D DICOM viewer Ambivu 3D Workstation PC and Mac fast DICOM 3D/2D workstation IVUSAngio Tool [2] is an integrated tool that enables a complete analysis of both angiography and intravascular ultrasound (IVUS) image sequences, either in DICOM video or JPEG format. MedINRIA [3] free DICOM viewer and medical image processing software for Mac OS X, Windows and Linux. MicroDicom [4] is application for primary processing and preservation of medical images in DICOM format. Free DICOM viewer for Windows. PaxeraView [5] is application for Diagnostic and Visualization of 2D Imaging. SMIViewer [6] is a free (soon to be open source) DICOM volume analyzer for research/teaching on Windows. VistA imaging [7] Public domain fully integrated PACS, image, and scanned document information system. One of the most widely used in the world, but incorporates proprietary modules not available outside the VA. Agnosco DICOM viewer [8] a free DICOM viewer. RadiAnt DICOM Viewer [9] a simple, efficient and intuitive DICOM medical image viewer for Windows.
Diabetes
CareLogger a Paid, online logbook for Diabetes. Tracks glucose levels, blood pressure and medication intake. It offers only 10 logs as a trial.
Health Information Technology Messaging

Mirth Connect [10] Specifically designed for HL7, NCPDP, DICOM and X12 healthcare related message integration, Mirth Connect provides the necessary tools for developing, testing, deploying, and monitoring interfaces.
Mobile / Handheld Devices

EpiSurveyor Mobile data collection: the EpiSurveyor system is a product of Datadyne.org composed of a web application at www.episurveyor.org [53] allowing rapid form creation (as well as basic data analysis, mapping, and export) and a mobile app available for standard ("non-smart") phones, Blackberry, and Android. Programmed entirely in Nairobi, Kenya by DataDyne's Kenyan team, EpiSurveyor has nearly 4000 users in more than 170 countries worldwide, and those users have filled out more than 160,000 forms and uploaded them to the site (the most current statistics are updated live at the site). EpiSurveyor is used for data collection in health, conservation, management, economics, and a variety of other fields. User organizations include the CDC, the World Health Organization, the World Bank, the African Conservation Centre, TulaSalud, the US and Canadian governments, the International Federation of the Red Cross and Red Crescent, John Snow Inc, Abt Associates, and Management Sciences for Health, as well as many ministries of health. EpiSurveyor won the 2009 Wall Street Journal Award for Innovation in Healthcare (the first time an African-programmed software had won that distinction) and the 2009 Lemelson-MIT award for sustainable invention, as well as the Stockholm Challenge and Tech Museum Award. As reported on by Wired [57], the Wall Street Journal [55], The Guardian [59], Voice of America [60], and BBC's Digital Planet [11]. Most recently, EpiSurveyor was covered extensively in an Economist white paper on
List of freeware health software healthcare innovation (p 13) [12] and a World Bank study [13] noting a 71% decrease in evaluation cost by using EpiSurveyor compared with paper. FrontlineSMS [36] enables users to send and receive text messages with large groups of people through mobile phones.
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External links
Healthcare Freeware compendium [14]
References
[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] http:/ / www. 3dim-laboratory. cz/ en/ sw. html http:/ / mklab. iti. gr/ ivus http:/ / www-sop. inria. fr/ asclepios/ software/ MedINRIA/ http:/ / www. microdicom. com http:/ / www. millenmed. com http:/ / groups. google. com/ group/ medicalimagingscience/ web/ smiviewer-download-page http:/ / www1. va. gov/ imaging/ page. cfm?pg=3 http:/ / www. e-dicom. com http:/ / www. radiantviewer. com http:/ / www. mirthcorp. com/ community/ mirth-connect http:/ / www. bbc. co. uk/ programmes/ p006h6qf http:/ / download. economistconferences. asia/ HIA_White%20Paper_2011. pdf http:/ / siteresources. worldbank. org/ INTLAC/ Resources/ 257803-1269390034020/ EnBreve_166_Web. pdf http:/ / www. healthcarefreeware. com/
List of open source healthcare software

The following is a list of software packages and applications licensed under an open source license or in the public domain for use in the healthcare industry. Software that is freely available, but not licensed under an open source license should be placed in the List of freeware health software.
Categories
Public Health and Biosurveillance
Epi Info is public domain statistical software for epidemiology developed by Centers for Disease Control and Prevention. Spatiotemporal Epidemiological Modeler is a tool, originally developed at IBM Research, for modeling and visualizing the spread of infectious diseases.
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Dental Management and Patient Record

Open Dental is the first Open Source dental management package with very broad capabilities on record management, patient sceduling and dental office management.
Electronic health or medical record

(In alphabetical order) FreeMED is a practice management and electronic and computer records system. It allows the tracking of medical data, in detail, with preservation not just of the diagnosis but the reasons for medical encounters. FreeMED is released under the GPL (French) FreeMedForms is a full set of medical applications (EMR, prescriber, drug interaction checker)). The project is administrated and developed by a community of medical doctors and computer scientists. The whole applications are freely available and are released with the full code source (GPLv3). GNUmed is a WxPython application that uses PostgreSQL. GNU Health (aka "Medical") is a Free, centralized, highly scalable Health and Hospital Information System Hospital OS Open source hospital information system in Thai HOSxP Mirth (software) is an open source cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications over multiple transports. OpenEMR an open-source Electronic Medical Record (EMR) software. OpenMRS is a community-developed, open-source, enterprise EMR framework. Extensible and scalable EMR based on Java. OSCAR McMaster an open-source Electronic Medical Record (EMR) software. The billing component of the software is specialized for the needs of the Canadian health care providers. SmartCare THIRRA (EHR) is a web based EHR application designed primarily for narrowband. It was released under the Mozilla Public License and includes communicable diseases biosurveillance feature. THIRRA uses PHP5, CodeIgniter and PostgreSQL. VistA Veterans Administrations integrated Electronic Health Record system available for non-governmental use as OpenVista or WorldVistA. ZEPRS The ZEPRS application is an electronic patient record system that enables clinicians to enter data from patient visits using a web browser.
Medical Practice Management Software

ClearHealth covers the five major areas of practice operations including scheduling, billing, EMR, HIPAA Security and accounts receivable. It offers a fully comprehensive system which now offers tools like E-Prescribing, Drug Interactions, Electronic Labs and Lab ordering. It is the largest open source healthcare solution serving more than 500 sites including the Primary Care Coalition network in MD with 50 sites and around 100,000 patients. FreeMED is a practice management and electronic and computer records system. It allows the tracking of medical data, in detail, with preservation not just of the diagnosis but the reasons for medical encounters. FreeMED is released under the LGPL GNU license. FreeMED is an HIPAA compliant FOSS Practice Management System that handles billing. GNU Health (aka "Medical") is a Free, centralized, highly scalable Health and Hospital Information System MedinTux MedinTux is a French medical practice management system, with a web interface as well as a desktop one, that has been initially to manage a hospital emergency department. Being very modular, it has been extended to run also many different smaller practices. It works on GNU/Linux, Mac OS X, Microsoft Windows
List of open source healthcare software Open Dental Dental practice management OpenEMR A free medical practice management, electronic medical records, prescription writing, and medical billing application.
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Health System Management

DHIS Open-source district health management information system and data warehouse (license: BSD license) HRHIS Open-source human resource for health information system for management of human resources for health developed by University of Dar es Salaam, Department of Computer Science, for Ministry of Health and Social Welfare (Tanzania) and funded by the Japan International Cooperation Agency (JICA) (license: GPLv3)
Imaging/Visualization
Drishti is a volumetric visualisation package for viewing Computer Tomography data. Able to import DICOM image stacks. Endrov Image and data viewer and editor ITK Segmentation and Registration Toolkit InVesalius 3D Medical Imaging Reconstruction software ITK-SNAP Interactive software for 3D image navigation, annotation and automatic segmentation MicroDicom Free DICOM viewer for Windows OsiriX - 3D DICOM Medical Viewer for Mac OS X. Complete DICOM Viewer with DICOM network support ParaView Large Scale Visualization tool 3DSlicer Platform for medical image visualization and algorithm development. DICOM support, segmentation and registration, Diffusion MRI processing, and image guided surgery support. Voreen Volume Rendering Enginea library for visually exploring volume data sets. DICOM is supported and Voreen is used in medical visualization as well as for visualizing electron microscopy data. VTK Visualization Toolkit Xebra (medical imaging software) GIMIAS Workflow-oriented environment focused on biomedical image computing and simulation
Medical Information Systems

Caisis is a web based information system for the storage and analysis of cancer patient data intended to bridge the gap between clinic and research (license: GPL)
Research
LabKey Server is an extensible platform for integrating, analyzing and sharing all types of biomedical research data. It provides secure, web-based access to research data and includes a customizable data processing pipeline. OpenClinica is an open source platform for clinical research, including electronic data capture (EDC) and clinical data management capabilities.
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Mobile / Handheld Devices

Ushahidi Allows people to submit crisis information through text messaging using a mobile phone, email or web form. Displays information in map view. SMS for Life is program which uses an open source solution to assist in the delivery of malaria vaccine in Tanzania through the use of cell phones and mapping technology. Developed by IBM, Novartis and Vodafone
Out of the box distributions

BioLinux Debian-Med
Interoperability testing
The Certification Commission for Healthcare Information Technology (CCHIT) has developed an open-source program called Laika to test EHR software for compliance with CCHIT interoperability standards.
References External links

Open-Source EHR Systems for Ambulatory Care: A Market Assessment (http://www.chcf.org/topics/view. cfm?itemID=133551) (California HealthCare Foundation, January 2008). European Federation for Medical Informatics Libre/Free Open Source Software Working Group (EFMI LIFOSS WG) (http://www.helmholtz-muenchen.de/ibmi/efmi/index.php?Itemid=260&id=1076& option=com_content&task=view) International Medical Informatics Association Open Source Working group (IMIA OS WG) (http://www. differance-engine.net/imiaoswg/index.php) American Medical Informatics Association Open Source Working group (AMIA OS WG) (http://www.amia. org/) Open Source Software for Public Health (http://www.ibiblio.org/pjones/wiki/index.php/ Open_Source_Software_for_Public_Health)
List of neuroimaging software
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List of neuroimaging software

Neuroimaging software is used to study the structure and function of the brain. To see an NIH Blueprint for Neuroscience Research funded clearinghouse of many of these software applications, as well as hardware, etc. go to the NITRC web site [1]. 3D Slicer (from Harvard, multi-purposes processing software including [[diffusion tensor imaging [2]] tractography)] aidScans, tumor volume estimation [3] Analysis of Functional NeuroImages (AFNI) [4] Analyze developed by the Biomedical Imaging Resource (BIR) at Mayo Clinic. AnalyzeDirect homepage [5] Bioimage Suite [6]. BrainMagix [7] BESA (Brain Electrical Source Analysis) [8] Bergen EEG-fMRI Toolbox plugin for EEGLab (remove fMRI gradients from simultaneous EEG-fMRI recordings) [9] Brain Image Analysis Package [10] BrainVISA [11] BrainVoyager [12] CamBA [13] Camino Open-source toolkit for diffusion MRI. Camino homepage [14] Caret [15] Van Essen Lab, Washington University in St. Louis Fiasco/FIAT (from CMU) [16] FMRIB Software Library (FSL) [17] FMRLAB [18] FreeSurfer [19] ISAS (Ictal-Interictal SPECT Analysis by SPM) Leipzig Image Processing and Statistical Inference Algorithms (LIPSIA) [20] LONI Pipeline [21] Laboratory of Neuro Imaging, UCLA Mango, developed at the Research Imaging Center, University of Texas Health Science Center at San Antonio MNI MINC [22] McConnell Brain Imaging Center, Montreal Neurological Institute, McGill University MRIcro [23] MRIcron (Next generation of MRIcro) [24] mrVista (from Stanford) [25] MRVision [26] Net Station [27] Neuroimaging software installation support [28] NeuroLens [29] NIfTI [2] NITRC The Neuroimaging Informatics Tools and Resources Clearinghouse. An NIH funded database of neuroimaging tools [30] nordicICE [31] Olea Medical: PerfScape & NeuroScape (see also the Olea Medical website [32]) Prism suite [33] PyMVPA [34]
SHAring NeurOImaging Resources (Shanoir) is a neuroinformatics platform designed to share, archive, search and visualize neuroimaging data. Shanoir homepage [35]
List of neuroimaging software Signed differential mapping (SDM) [36] Statistical parametric mapping (SPM) [37] Stimulate (One of the earliest fMRI software package from CMRR at University of Minnesota) [38]
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References
[1] http:/ / nitrc. org [2] http:/ / www. slicer. org/ [3] http:/ / anyintelli. com/ tumor_volume_estimation. php [4] http:/ / afni. nimh. nih. gov [5] http:/ / www. analyzedirect. com/ [6] http:/ / www. bioimagesuite. org [7] http:/ / www. imagilys. com/ brainmagix-neuroimaging-fmri-software/ [8] http:/ / www. besa. de [9] http:/ / fmri. uib. no [10] http:/ / demunck. info/ software/ index. php [11] http:/ / brainvisa. info [12] http:/ / www. brainvoyager. com [13] http:/ / sourceforge. net/ projects/ camba [14] http:/ / www. cs. ucl. ac. uk/ research/ medic/ camino [15] http:/ / brainvis. wustl. edu/ caret/ [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] http:/ / www. stat. cmu. edu/ ~fiasco http:/ / www. fmrib. ox. ac. uk/ fsl http:/ / sccn. ucsd. edu/ fmrlab/ index. html http:/ / surfer. nmr. mgh. harvard. edu http:/ / www. cbs. mpg. de/ institute/ software/ lipsia/ index. html http:/ / pipeline. loni. ucla. edu/ http:/ / www. bic. mni. mcgill. ca/ ServicesSoftware/ HomePage http:/ / www. sph. sc. edu/ comd/ rorden/ mricro. html http:/ / www. nitrc. org/ projects/ mricron http:/ / white. stanford. edu/ newlm/ index. php/ Software http:/ / www. mrvision. com/ html/ main. shtml http:/ / www. egi. com/ http:/ / www. mri-tutorial. com/ software. html http:/ / www. neurolens. org http:/ / www. nitrc. org/ http:/ / www. nordicimaginglab. com/ http:/ / www. olea-medical. com| http:/ / www. prismclinical. com/ http:/ / www. pymvpa. org http:/ / shanoir. org/ http:/ / www. sdmproject. com/ http:/ / www. fil. ion. ucl. ac. uk/ spm http:/ / www. cmrr. umn. edu/ stimulate/
Mirth
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Mirth
Mirth is an open source cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications over multiple transports available under the Mozilla Public License (MPL) 1.1 license.
Background
HL7 has established itself as a standard in healthcare information exchange. In order for an electronic health record system to integrate or exchange data with HL7 systems, an adapter layer must be implemented to transform messages. Mirth allows messages to be filtered, transformed, and routed based on user-defined rules. A web-based interface and channel creation wizard associates applications with Mirth engine components. Mirth uses a channel-based architecture to connect systems with other HL7 systems. Channels consist of endpoints (both inbound and outbound), filters, and transformers. Multiple filters and a chain of transformers can be associated with a channel. The Mirth web interface allows for reuse of filters and transformers on multiple channels. Endpoints are used to configure connections and their protocol details. Inbound endpoints are used to designate the type of listener to use for incoming messages, such as TCP/IP or a web service. Outbound endpoints are used to designate the destination of outgoing messages, such as an application server, a JMS queue, or a database.
Connector varieties
Mirth Connect [10] can listen to and send HL7 messages and connect to a variety of protocols: TCP/MLLP Database (MYSQL, Postgres, Oracle, MS SQL, ODBC) File (local file system and network shares)/PDF JMS FTP/SFTP SOAP (over HTTP)
An open architecture allows for the easy addition of custom and legacy interfaces.
Types of transforms
Mapping transformer: map data from incoming message to variables Script transformer: execute custom script on message (Ex. JavaScript, Python, Tcl) HL7 message generator: construct HL7 messages from data source XSLT transformer: run XSL Transformations on incoming HL7 v3 or XML encoded messages
Supported OS's
Mirth supports all major operating systems (requires Sun Java 1.5/5.0 or later).
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Logging
All messages and transactions are logged to an internal database. Mirth can be configured to auto-generate an HL7 acknowledgement response (ACK).
Engine
Mirth is based on the open source Mule ESB engine environment
[1]
to provide speed, stability and security in a flexible
Adopters
The Certification Commission for Healthcare Information Technology (CCHIT), in a push to ensure interoperability standards between electronic health records, has adopted Laika, an open source standards software program. At the 2009 HIMSS, Mirth, was selected as one of the testing tools for the coming interoperability tests.[2]
References
[1] http:/ / www. mulesoft. com/ mule-esb-open-source-esb [2] "Archive for the HIMSS Category" (http:/ / www. fredtrotter. com/ category/ himss/ ). Fred Trotter blog. 2009-04-08. . Retrieved 2009-04-16.
External links
The Mirth project website (http://www.mirthproject.org/) Mirth support in Europe (http://www.amaron.be/) NIEUW. Mirth support in Nederland (http://www.telemedicine-solutions.com/)
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Mpro
PRO (Patient Reported Outcomes) is an umbrella term that covers a whole range of potential types of measurement but is used specifically to refer to questionnaires completed by the patient. PRO data may be collected via self-administered questionnaires completed by the patient or via interviewer-administered questionnaires. The latter will only qualify as a PRO where the interviewer is gaining the patients views, not where the interviewer uses patient responses to make a professional assessment or judgment of the impact of the patients condition. Thus, PROs are a means of gathering patient rather than clinical or other views on the content covered by the questionnaire. The term ePRO is used for electronic Patient Reported Outcomes. ePRO data is collected electronically via a range of devices including handheld PDA, PC or mobile / cell phone. The term mPRO refers specifically to the collection of PRO data on a mobile / cell phone. The most commonly used PRO questionnaires assess one of the following constructs: Symptoms (impairments) Functioning (disability) Health related quality of life (HRQL) Quality of life (QoL).
Nokia 6300 - based on Series 40
Questionnaires may be generic (designed to be used in any disease population and cover a broad aspect of the construct measured) or condition-specific (developed speficially to measure those aspects of outcome that are of importance for a people with a particular medical condition). mPRO is a product from OBS Medical and is a registered trademark of OBS Medical.
References
Debbie Kennedy, CRF Designer, Canary Publications, ISBN 0-9531174-7-2
External links
mPRO from t+ Medical [1] mobilePRO from Exco InTouch [2]
References
[1] http:/ / www. tplusclinical. com [2] http:/ / www. excointouch. com
Open Dental
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Open Dental
Practice Management Software Original author(s) Dr. Jordan Sparks Stable release Preview release Written in Operating system Type License Website 7.8 / April 22, 2011 7.1(Beta) / July 29, 2010 C# Microsoft Windows, Linux, Mac OS X, cross-platform Practice Management Software GNU General Public License www.opendental.com [1]
Open Dental, previously known as Free Dental, is dual licensed Practice Management Software available under both a commercial license and the GNU General Public License[2] . It is written in the C# programming language compatible with Microsoft .NET Framework and was first released in 2003. Current versions of the software require Microsoft Windows. Earlier versions of the software had supported other operating systems, but Linux support has been dropped[3] . The full function version is only available under the commercial license because it includes royalty bearing, licensed materials from the American Dental Association (ADA), the Code on Dental Procedures and Nomenclature (CDT). Open Dental is owned and sponsored by Open Dental Software, Inc., which is incorporated in the State of Oregon in the United States of America [4] . But since anyone has the freedom to develop and support Open Dental, in a sense it belongs to the entire dental community. The features and accessibility of Open Dental make it a considerable option for use in dental business. The first Free Dental customer bought the software July 22, 2003.[5]
Database
The database uses the dual licensed MySQL database program. The structure of the data, or schema, is available for all to see and use (the data is still very secure). It is totally different than the proprietary format that all other dental software uses. Other programs can only export certain fields. In Open Dental, access to and control over every single piece of data is held by the dentist. Both local preferences and those which apply to every computer in the office will be stored in the mySQL database. This also greatly simplifies working with preferences and settings, and adding new workstations without having to spend all day setting them up. The database schema is published OpenDentalDocumentation67.xml[6] . and publicly viewable at http:/ / www. opendental. com/
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Relational database benefits to dental practice

There are documented benefits to using a relational database when storing and retrieving data: the relational model offers "advantages over the hierarchical and network models through its simpler data representation, superior data independence and easy to use query language"[7] . Open Dental gives the user those benefits over the non-relational platforms used by other dental practice management software programs. Availability Relational databases like Oracle and MySQL have mechanisms that can be used to keep the availability (of the database) very high. For instance, with MySQL replication, "the active primary database ships transactions to one or more standby databases. These standby databases apply the transactions to their own copies of the data. Should the primary database fail, one of these standby databases can be activated to become the new primary database".[8] High availability is of clear importance when a customers (patients) have expectations of service at a particular time (an appointment). Open Dental provides replication support for users whose availability, mobility or multiple physical location needs demand it.[9] Mobility Mobile dental programs have special needs including offline data collection, central data availability and public health reporting. All of these needs are met with Open Dental. An example of a mobile dental program that has published[10] their experience using Open Dental is the St. David's Dental Program[11] Retrievability Structured Query Language (SQL) allows the user to pull data from the database for analysis. Open Dental provides over 250 user queries that have been requested by users,[12] and advanced users may write their own queries to get specialized information from the database.[13] . Scalability Open Dental can be scaled from a single, one-computer user in a small office to dozens of computers per server over multiple physical locations.[14]
Goals
The project wants "this software to become the world standard dental software. We want to make it easy to access and share data. We are tired of the restrictive policies of the current dental software companies. We want the user to always have total control, not the software company. And most of all, we want software that just works well[15] . There are about 2,000 dentists using OD, and an estimated 10,000,000 patient records. Dr. Jordan Sparks has done most of the programming. He has done the many thousands of hours of programming in his spare time over the last few years.
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Features
Appointment[16]
Support unlimited operatories and unlimited providers Customizable views, colors, default values Easy to set up and modify appointments, recalls Show pop-up alerts, financial and medical notes
Family[17]
Support complete patient records (HIPAA compliant) When possible, fields are filled automatically or checked for potential errors Save billing type and insurance information Track student status and referrals Track credit and contact notes Sign Procedure Notes: Digital Signatures. Sign or initial procedure notes using a Topaz signature pad or by using a stylus on a touchscreen.
Patient Info Terminal: A way for a new patient to enter their own information from the waiting room. The receptionist controls the terminal from another computer. Can also be used to let patient update their info if it has changed. New patients can check off items in list of diseases. Medical History Questionnaire: Customized list of questions and answers added to pt info terminal.
Account[18]
Customizable and easy recall scheduling Send letters and emails to patients Email appointment reminders, recare appointments. Supports SMTP servers that require a user name and password for sending email. Allows saving email to send later. Comprehensive billing system with e-claim support E-claims: go through a clearinghouse to submit all e-claims or submit directly to carries that support the X12 files/claims. The X12 EDI Format is the standard defined by ASC (ex-ANSI) and specified by HIPAA. Open dental claims to be the only dental practice management software which natively creates X12 format files without having to go through a clearing house for conversion. Track all referrals and lab cases Lab Cases: Each lab can be set up with its own turnaround times on each procedure type. Due dates are calculated automatically, taking into account holidays. Create and track payment plans Open Dental has built-in accounting that is intended to replace QuickBooks for small offices. Patient's finances are organized on a patient basis, not a family basis. Credit Card Processing Integrated credit card processor with swipe terminal.
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Treatment Plan[19]
Easy to view and prioritize patients' treatment plans Support multiple treatment plans Print or send electronically insurance preauthorization forms
Chart[20]
Easy to enter and organize patients' clinical information Full featured 3D tooth charting Track progress and treatment notes Simple to write and print prescriptions
Rx Alerts: Crosslink Diseases to Rx definitions so that an alert is triggered for allergies, etc. when writing an Rx. Procedure codes: Currently, the following sets of procedure codes are available as separate databases: blank, usa, canada, uk. Perio Charting: voice recognition software to help with charting
Images[21]
Add and manage all images Integrate with Radiography, scanner, digital camera devices Images can be zoomed in and out, rotated. Can attach Word, PDF, and Excel files
Manage[22]
Create and send e-claims or paper claims Billing automation Audio and visual office intercom Critical data backup Flexible user-defined queries and reports Track employees' hours and breaks Support daily, weekly & monthly task lists Built-in accounting module Secure remote access Language support: The code is all written to automatically adapt to the user's computer settings. The translations are specific to the culture (country), not just the language. Time Cards: Customizable pay periods added so that you don't have enter the date range each time. Tracks 40 hour workweek, computes overtime, allows adjustments, and prints. New Reporting Framework: The FLOSS RDL Project [23] is included with Open Dental. It will also allow export to PDF. Import from XML : This allows other programs to safely pass information to Open Dental without having to worry about accidentally corrupting the database. This will eventually lead to the ability to 'send' a patient 'chart' to another office electronically. The main purpose for now is to allow new patients to fill out their forms online. Multiple Server Support
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References
[1] http:/ / www. opendental. com/ [2] "FLOSS Licence" (http:/ / www. opendental. com/ manual/ openlicense. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [3] "Open Dental Software Manual - C#, Linux, and Macintosh" (http:/ / www. opendental. com/ manual/ clinuxmac. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [4] "Oregon Secretary of State Business Name Search (original url http:/ / egov. sos. state. or. us/ br/ pkg_web_name_srch_inq. show_detl?p_be_rsn=1173550& p_srce=BR_INQ& p_print=FALSE )" (http:/ / www. webcitation. org/ 5hGadINH4). State of Oregon. . Retrieved 2009-June 3. [5] Downes, P.K. (2007). "Putting it all Together: Dentistry and the Internet". British Dental Journal 203 (2): 7486. ISSN007-0610. PMID17660777. [6] "Open Dental Database Documentation" (http:/ / www. opendental. com/ OpenDentalDocumentation67. xml). Open Dental Software Inc.. . Retrieved 2009-June 12. [7] Coronel, Carlos; Peter Rob, Keeley Crocket (2008). Database Systems. Cengage Learning EMEA. pp.52. ISBN1844807320. [8] Sam Drake, Wei Hu, Dale M. McInnis, Martin Skld, Alok Srivastava, Lars Thalmann, Matti Tikkanen, ystein Torbjrnsen, Antoni Wolski (2004). Architecture of Highly Available Databases. pp. 116. [9] "Open Dental Software - Replication" (http:/ / www. opendental. com/ manual/ replication. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [10] Jackson DM, Jahnke LR, Kerber L, Nyer G, Siemens K, Clark C. (2007). "Creating a Successful School-based Mobile Dental Program". Journal of School Health 77 (1): 16. doi:10.1111/j.1746-1561.2007.00155.x. PMID17212753. [11] "St. David's Community Health Foundation Leadership: Dental Program" (http:/ / www. stdavidsfoundation. org/ dental. htm). St. David's Community Health Foundation. . Retrieved 2009-June 12. [12] "Open Dental Query Examples" (http:/ / 70. 90. 133. 65:1942/ ODQueryList/ QueryList. aspx). Open Dental Software Inc.. . Retrieved 2009-06-12. [13] "Open Dental Software Manual - User Query" (http:/ / www. opendental. com/ manual/ queryoverview. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [14] "Open Dental Software Manual - Multiple Locations" (http:/ / www. opendental. com/ manual/ multiplelocations. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [15] "FLOSS License" (http:/ / www. opendental. com/ manual/ openlicense. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [16] "Open Dental Software - Appointments Module" (http:/ / www. opendental. com/ manual/ appointments. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [17] "Open Dental Software - Family Module" (http:/ / www. opendental. com/ manual/ family. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [18] "Open Dental Software - Account Module" (http:/ / www. opendental. com/ manual/ account. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [19] "Open Dental Software - Treatment Plan Module" (http:/ / www. opendental. com/ manual/ treatmentplan. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [20] "Open Dental Software - Chart Module" (http:/ / www. opendental. com/ manual/ chart. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [21] "Open Dental Software - Images Module" (http:/ / www. opendental. com/ manual/ images. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [22] "Open Dental Software - Manage Module" (http:/ / www. opendental. com/ manual/ manage. html). Open Dental Software Inc.. . Retrieved 2009-June 12. [23] http:/ / www. fyireporting. com/
External websites
Open Dental Website (http://www.opendental.com/) MySQL Website (http://www.mysql.com/) ADA Vendor Directory of Practice Management Software (http://www.ada.org/prof/prac/tools/software/ vendor.asp) Sourceforge Website (http://sourceforge.net/projects/freedental)
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Personal Health Application

Personal Health Applications (PHA) are tools and services in medical informatics which utilizes information technologies to aid individuals to create their own personal health information. Personal Health Applications are claimed to be the next generation consumer-centric information system that helps improve health care delivery, self-management and wellness by providing clear and complete information, which increases understanding, competence and awareness. Personal Health Application is now part of the Medicine 2.0 movement.
Definition
Personal Health Application is an electronic tool of storing, managing and sharing health information in illness and wellness by an individual in a secure and confidential environment.
Benefits
Most people do not carry medical records when they leave home. They do not realize that in an emergency, which no one can predict, these medical records can make a big difference. In fact, they could save a life. Previous medications, history of allergy to medications, and other significant medical or surgical history can help a health professional through PHA tools to optimize treatment. A Personal Health Application (PHA) tool contains a patients personal data (name, date of birth and other demographic details). It also includes a patients diagnosis or health condition and details about the various treatment/assessments delivered by health professionals during an episode of care from a health care provider. It contains an individuals health-related information accumulated during an entire lifetime.
References
Wiki Personal Health Application [1] open medicine Personal Health Application [2]
References
[1] http:/ / www. clinfowiki. org/ wiki/ index. php/ Main_Page#Personal_Health_Applications_--_PHAs [2] http:/ / www. open. medicdrive. org
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The Texas Medication Algorithm Project (TMAP)[1] is a decision-tree medical algorithm, the design of which was based on the expert opinions of mental health specialists. It has provided and rolled out a set of psychiatric management guidelines for doctors treating certain mental disorders within Texas' publicly-funded mental health care system, along with manuals relating to each of them. The algorithms commence after diagnosis and cover pharmacological treatment (hence "Medication Algorithm").
History
TMAP was initiated in the fall of 1997 and the initial research covered around 500 patients. TMAP arose from a collaboration that began in 1995 between the Texas Department of Mental Health and Mental Retardation (TDMHMR), pharmaceutical companies, and the University of Texas Southwestern. The research was supported by the National Institute of Mental Health, the Robert Wood Johnson Foundation, the Meadows Foundation, the Lightner-Sams Foundation, the Nanny Hogan Boyd Charitable Trust, TDMHMR, the Center for Mental Health Services, the Department of Veterans Affairs, the Health Services Research and Development Research Career Scientist Award, the United States Pharmacopoeia Convention Inc. and Mental Health Connections. Numerous companies that invent and develop important antipsychotic medications(1) provided use of their medications and furnished some unrestricted funding for the project. Companies did not participate in the production of the guidelines, (which strangely seemed to promote expensive drugs over cheap ones). [2] In 2004 TMAP was mentioned as an example of a successful project in a paper regarding implementing mental health screening programs throughout the United States, by the President George W. Bush's New Freedom Commission on Mental Health, which looks to expand the program federally. The President had previously been Governor of Texas, in the period when TMAP was implemented. Similar programs have been implemented in about a dozen States, according to a 2004 report in the British Medical Journal. Similar algorithms with similar prescribing advice have been produced elsewhere, for instance at the Maudsley Hospital,[3] London. The development and implementation of TMAP was a result of numerous sponsors such as the National Institute of Mental Health, the Robert Wood Johnson Foundation, the Meadows Foundation, the Lightner-Sams Foundation, the Nanny Hogan Boyd Charitable Trust, TDMHMR, the Center for Mental Health Services, the Department of Veterans Affairs, the Health Services Research and Development Research Career Scientist Award, the United States Pharmacopoeia Convention Inc. and Mental Health Connections, Bristol-Myers Squibb Company, Eli Lilly and Company, Forest Laboratories, Janssen Pharmaceutica, Glaxo-Wellcome, Inc., Novartis Pharmaceuticals Corp., Pfizer, Inc., and Wyeth Laboratories.
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References
[1] DSHS.state.tx.us (http:/ / www. dshs. state. tx. us/ mhprograms/ TMAPtoc. shtm) - Texas Medication Algorithm Project (official site with algorithms etc), Texas Department of State Health Services [2] http:/ / www. ahrp. org/ infomail/ 05/ 10/ 14. php [3] (http:/ / www. mhc. com/ Algorithms/ AlgoLinks. HTML) Lists of Psychopharmacology Algorithms. Compiled by David N. Osser, M.D. and Robert D. Patterson, M.D. (viewed 17 March 2006)
External links
MentalHealthCommission.gov (http://www.mentalhealthcommission.gov/reports/reports.htm) - President's New Freedom Commission on Mental Health (official US government website)
Footnote
1. Risperdal, Zyprexa, Seroquel, Geodon, Depakote, Paxil, Zoloft, Celexa, Wellbutrin, Zyban, Remeron, Serzone, Effexor, Buspar, Adderall and Prozac.
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Languages and Development Platforms

MUMPS
MUMPS
Paradigm(s) Appeared in Designed by Stable release Procedural 1966 Neil Pappalardo ANSI X11.1-1995 (December 8, 1995)
Typing discipline typeless Influenced by Influenced OS JOSS PSL, Cach ObjectScript Cross-platform
MUMPS (Massachusetts General Hospital Utility Multi-Programming System), or alternatively M, is a programming language created in the late 1960s, originally for use in the healthcare industry. It was designed for the production of multi-user database-driven applications. It predates C and most other popular languages in current usage, and has very different syntax and terminology. It was largely adopted during the 1970s and early 1980s in healthcare and financial information systems/databases, and continues to be used by many of the same clients today. It is currently used in electronic health record systems as well as by multiple banking networks and online trading/investment services.
History
MUMPS was developed by Neil Pappalardo and colleagues in Dr. Octo Barnett's animal lab at Massachusetts General Hospital (MGH) in Boston during 1966 and 1967. The original MUMPS system was, like Unix a few years later, built on a spare DEC PDP-7. Octo Barnett and Neil Pappalardo were also involved with MGH's planning for a Hospital Information System, obtained a backward compatible PDP-9, and began using MUMPS in the admissions cycle and laboratory test reporting. MUMPS was then an interpreted language, yet even then, incorporated a hierarchical database file system to standardize interaction with the data. Some aspects of MUMPS can be traced from Rand Corporation's JOSS through BBN's TELCOMP and STRINGCOMP. The MUMPS team deliberately chose to include portability between machines as a design goal. Another feature, not widely supported for machines of the era, in operating systems or in hardware, was multitasking, which was also built into the language itself. The portability was soon useful, as MUMPS was shortly adapted to a DEC PDP-15, where it lived for some time. MUMPS was developed with the support of a government research grant, and so MUMPS was released to the public domain (no longer a requirement for grants), and was soon ported to a number of other systems including the popular DEC PDP-8, the Data General Nova and the DEC PDP-11 and the Artronix PC12 minicomputer. Word about MUMPS spread mostly through the medical community, and by the early 1970s was in widespread use, often being locally modified for their own needs.
MUMPS By the early 1970s, there were many and varied implementations of MUMPS on a range of hardware platforms. The most widespread was DEC's MUMPS-11 on the PDP-11, and MEDITECH's MIIS. In 1972, many MUMPS users attended a conference which standardized the then-fractured language, and created the MUMPS Users Group and MUMPS Development Committee (MDC) to do so. These efforts proved successful; a standard was complete by 1974, and was approved, on September 15, 1977, as ANSI standard, X11.1-1977. At about the same time DEC launched DSM-11 (Digital Standard MUMPS) for the PDP-11. This quickly dominated the market, and became the reference implementation of the time. During the early 1980s several vendors brought MUMPS-based platforms that met the ANSI standard to market. The most significant were Digital Equipment Corporation with DSM (Digital Standard MUMPS), InterSystems with ISM (InterSystems M) on VMS and UNIX, and M/11+ on the PDP-11 platform. Other companies developed important MUMPS implementations: Greystone Technology Corporation with a compiled version called GT.M DataTree Inc. with an Intel PC based product called DTM Micronetics Design Corporation with a product line called MSM for UNIX and Intel PC platforms (later ported to IBM's VM operating system) Comp Consultants (later renamed MGlobal), a Houston-based company originally created CCSM on 6800, then 6809 processors, which later became MacMUMPS, a Mac OS based product. They also worked on a the MGM MUMPS implementation. MGlobal also ported their implementation to the DOS platform where it ran as a guest operating system started from DOS. MGlobal MUMPS was the first commercial MUMPS for the IBM PC and the only Mac implementation. DSM-11 was superseded by VAX/DSM for the VAX/VMS platform, and that was ported to the Alpha in two variants: DSM for OpenVMS, and as DSM for Ultrix. This period also saw considerable MDC activity. The second revision of the ANSI standard for MUMPS (X11.1-1984) was approved on November 15, 1984. On November 11, 1990 the third revision of the ANSI standard (X11.1-1990) was approved. In 1992 the same standard was also adopted as ISO standard 11756-1992. Use of M as an alternative name for the language was approved around the same time. On December 8, 1995 the fourth revision of the standard (X11.1-1995) was approved by ANSI, and by ISO in 1999 as ISO 11756-1999. The MDC finalized a further revision to the standard in 1998 but this has not been presented to ANSI for approval. On 6 January 2005, and later again on 25 June 2010, ISO re-affirmed its MUMPS-related standards: ISO/IEC 11756:1999, language standard [1] , ISO/IEC 15851:1999, Open MUMPS Interconnect [2] and ISO/IEC 15852:1999, MUMPS Windowing Application Programmers Interface [3]. By 2000, the middleware vendor InterSystems had become the dominant player in the MUMPS market with the purchase of several other vendors. Initially they acquired DataTree Inc. in the early 1990s. And, on December 30, 1995, Intersystems acquired the DSM product line from DEC.[4] InterSystems consolidated these products into a single product line, branding them, on several hardware platforms, as OpenM. In 1997, InterSystems essentially completed this consolidation by launching a unified successor named Cach. This was based on their ISM product, but with influences from the other implementations. Micronetics Design Corporation assets were also acquired by InterSystems on June 21, 1998. Intersystems remains today (2007) the dominant MUMPS vendor, selling Cach to MUMPS developers who write applications for a variety of operating systems. Greystone Technology Corporation's GT.M implementation was sold to Sanchez Computer Associates Inc. (now part of Fidelity National Financial Inc.) in the mid 1990s. On November 7, 2000 Sanchez made GT.M for Linux available under the GPL license[5] and on October 28, 2005 GT.M for OpenVMS and Tru64 UNIX were also made available under the AGPL license.[6] GT.M continues to be available on other UNIX platforms under a traditional license. The newest implementation of MUMPS, released in April 2002, is an MSM derivative called M21 from the Real Software Company of Rugby, UK.
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MUMPS There are also several open source implementations of MUMPS, including some research projects. The most notable of these is Mumps/II [7], by Professor Kevin O'Kane (now at the University of Northern Iowa) and students' project. Dr. O'Kane and Ryan Murphy have also ported the interpreter to Mac OS X.[8] One of the original creators of the MUMPS language, Neil Pappalardo, early founded a company called MEDITECH. They extended and built on the MUMPS language, naming the new language MIIS (and later, another language named MAGIC). Unlike Intersystems, MEDITECH no longer sells middleware, so MIIS and MAGIC are now only used internally at MEDITECH.
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Current users of MUMPS applications

The U.S. Department of Veterans Affairs (formerly the Veterans Administration) was one of the earliest major adopters of the MUMPS language. Their development work (and subsequent contributions to the free MUMPS application codebase) was an influence on many medical users worldwide. In 1995, the Veterans Affairs' patient Admission/Tracking/Discharge system, Decentralized Hospital Computer Program (DHCP) was the recipient of the Computerworld Smithsonian Award for best use of Information Technology in Medicine. A decade later (July, 2006), the Department of Veterans Affairs (VA) / Veterans Health Administration (VHA) was the recipient of the Innovations in American Government Award presented by the Ash Institute of the John F. Kennedy School of Government at Harvard University for its extension of DHCP into the Veterans Health Information Systems and Technology Architecture (VistA) in July, 2006. Nearly the entire VA hospital system in the United States and the Indian Health Service, as well as major parts of the Department of Defense CHCS hospital system all run systems using MUMPS databases for clinical data tracking. Large companies currently using MUMPS include AmeriPath (now part of Quest Diagnostics), Care Centric, Epic Systems Corporation, EMIS, Partners HealthCare, MEDITECH, GE Healthcare (formerly IDX Systems and Centricity). Many reference laboratories, such as Quest Diagnostics [9] and Dynacare, use MUMPS software written or based on by Antrim Corporation code. Antrim, and its parent Sunquest, was acquired by Misys in 2001.[10] Coventry Healthcare and Massachusetts Hospital have also been reported to use MUMPS. MUMPS is also widely used in financial applications. MUMPS gained an early following in the financial sector, and MUMPS applications are in use at many banks and credit unions. It is used by Ameritrade, the largest online trading service in the US with over 12 billion transactions per day, as well as by the Bank of England and Barclays Bank, among others.[11] [12] [13] The European Space Agency announced on May 13, 2010 that it will use MUMPS (InterSystems Cach) to support the Gaia mission. This mission aims to map the Milky Way with unprecedented precision.[14] As of 2005 most use of M is either in the form of GT.M or InterSystems Cach. The latter is being aggressively marketed by InterSystems and has had success in penetrating new markets, such as telecommunications, in addition to existing markets.
Overview
MUMPS is a language intended for and designed to build database applications. Secondary language features were included to help programmers make applications using minimal computing resources. The original implementations were interpreted, though modern implementations may be fully or partially compiled. Individual "programs" run in memory "partitions". Early MUMPS memory partitions were limited to 2048 bytes so aggressive abbreviation greatly aided multi-programming on severely resource limited hardware, because more than one MUMPS job could fit into the very small memories extant in hardware at the time. The ability to provide multi-user systems was another language design. The Multi-Programming in the acronym of language name point to this. Even the earliest machines running MUMPS supported multiple jobs running at the same time. With the change from mini-computers to micro-computers a few years later, even a "single user PC" with a single 8-bit CPU with 16K or 64K of memory
MUMPS could support multiple users, running dumb terminals in command line mode. (without any trace of a graphical user interface). Since memory was tight originally, the language design for MUMPS valued very terse code. Thus, every MUMPS command or function name could be abbreviated from one to three letters in length, e.g. Quit (exit program) as Q, $P = $Piece function, R = Read command, $TR = $Translate function. Spaces and end-of-line markers are significant in MUMPS because line scope promoted the same terse language design. Hence, an entire line of program code could express the same idea a small number of characters that other programming languages might easily take 5 to 10 times as many characters to express. Abbreviation was a common feature of languages designed in this period (e.g., FOCAL-69, early BASICs such as Tiny BASIC, etc.). An unfortunate side effect of this coupled with the early need to write minimalist code was that MUMPS programmers routinely did not comment code and used extensive abbreviations, meaning that even an expert MUMPS programmer could not just skim through a page of code to see its function but would have to analyze it line by line. Database interaction is transparently built into the language. The MUMPS language provides a hierarchical database made up of persistent sparse arrays, which is implicitly "opened" for every MUMPS application. All variable names prefixed with the caret character ("^") use permanent (instead of RAM) storage, will maintain their values after the application exits, and will be visible to (and modifiable by) other running applications. Variables using this shared and permanent storage are called Globals in MUMPS, because the scoping of these variables is "globally available" to all jobs on the system. The more recent and more common use of the name "global variables" in other languages is a more limited scoping of names, coming from the fact that unscoped variables are "globally" available to any programs running in the same process, but not shared among multiple processes. The MUMPS Storage mode (i.e. Globals stored as persistent sparse arrays), gives the MUMPS database the characteristics of a document-oriented database.[15] All variable names which are not prefixed with caret character ("^") are temporary and private. Like global variables, they also have a hierarchical storage model, but are only "locally available" to a single job, thus they are called "locals". Both "globals" and "locals" can have child nodes (called subscripts in MUMPS terminology). Subscripts are not limited to numeralsany ASCII character or group of characters can be a subscript identifier. While this is not uncommon for modern languages such as Perl or JavaScript, it was a highly unusual feature in the late 1970s. This capability was not universally implemented in MUMPS systems before the 1984 ANSI standard, as only canonically numeric subscripts were required by the standard to be allowed[16] ) Thus, the variable named 'Car' can have subscripts "Door", "Steering Wheel" and "Engine", each of which can contain a value and have subscripts of their own. The variable ^Car("Door") could have a nested variable subscript of "Color" for example. Thus, you could say SET ^Car("Door","Color")="BLUE"
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to modify a nested child node of ^Car. In MUMPS terms, "Color" is the 2nd subscript of the variable ^Car (both the names of the child-nodes and the child-nodes themselves are likewise called subscripts). Hierarchical variables are similar to objects with properties in many object oriented languages. Additionally, the MUMPS language design requires that all subscripts of variables are automatically kept in sorted order. Numeric subscripts (including floating-point numbers) are stored from lowest to highest. All non-numeric subscripts are stored in alphabetical order following the numbers. In MUMPS terminology, this is canonical order. By using only non-negative integer subscripts, the MUMPS programmer can emulate the arrays data type from other languages. Although MUMPS does not natively offer a full set of DBMS features such as mandatory schemas, several DBMS systems have been built on top of it that provide application developers with flat-file, relational and network database features. Additionally, there are built-in operators which treat a delimited string (e.g., comma-separated values) as an array. Early MUMPS programmers would often store a structure of related information as a delimited string, parsing it
MUMPS after it was read in; this saved disk access time and offered considerable speed advantages on some hardware. MUMPS has no data types. Numbers can be treated as strings of digits, or strings can be treated as numbers by numeric operators (coerced, in MUMPS terminology). Coercion can have some odd side effects, however. For example, when a string is coerced, the parser turns as much of the string (starting from the left) into a number as it can, then discards the rest. Thus the statement IF 20<"30 DUCKS" is evaluated as TRUE in MUMPS. Other features of the language are intended to help MUMPS applications interact with each other in a multi-user environment. Database locks, process identifiers, and atomicity of database update transactions are all required of standard MUMPS implementations. In contrast to languages in the C or Wirth traditions, some space characters between MUMPS statements are significant. A single space separates a command from its argument, and a space, or newline, separates each argument from the next MUMPS token. Commands which take no arguments (e.g., ELSE) require two following spaces. The concept is that one space separates the command from the (nonexistent) argument, the next separates the "argument" from the next command. Newlines are also significant; an IF, ELSE or FOR command processes (or skips) everything else til the end-of-line. To make those statements control multiple lines, you must use the DO command to create a code block.
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"Hello, World!" example

A simple Hello world program in MUMPS might be: hello() write "Hello, World!",! quit
and would be run from the MUMPS command line with the command 'do ^hello()'. Since MUMPS allows commands to be strung together on the same line, and since commands can be abbreviated to a single letter, this routine could be made more compact: hello() w "Hello, World!",! q
The ',!' after the text generates a newline. The 'quit' is not strictly necessary at the end of a function like this, but is good programming practice in case other functions are added below 'hello()' later.
Summary of key language features

The following summary seeks to give programmers familiar with other languages a feeling for what MUMPS is like. This is not a formal language specification, and many features and qualifiers have been omitted for brevity. ANSI X11.1-1995 gives a complete, formal description of the language; an annotated version of this standard is available online.[17] Data types: There is one universal datatype, which is implicitly coerced to string, integer, or floating-point datatypes as context requires. Booleans (called truthvalues in MUMPS): In IF commands and other syntax that has expressions evaluated as conditions, any string value is evaluated as a numeric value, and if that is a nonzero value, then it is interpreted as True. a<b yields 1 if a is less than b, 0 otherwise. Declarations: None. All variables are dynamically created at the first time a value is assigned. Lines: are important syntactic entities, unlike their status in languages patterned on C or Pascal. Multiple statements per line are allowed and are common. The scope of any IF, ELSE, and FOR command is "the remainder of current
MUMPS line." Case sensitivity: Commands and intrinsic functions are case-insensitive. In contrast, variable names and labels are case-sensitive. There is no special meaning for upper vs. lower-case and few widely followed conventions. The percent sign (%) is legal as first character of variables and labels. Postconditionals: execution of almost all commands can be controlled by following it with a colon and a truthvalue expression. SET:N<10 A="FOO" sets A to "FOO" if N is less than 10; DO:N>100 PRINTERR, performs PRINTERR if N is greater than 100. This construct provides a conditional whose scope is less than a full line. Abbreviation: You can abbreviate nearly all commands and native functions to one, two, or three characters. Reserved words: None. Since MUMPS interprets source code by context, there is no need for reserved words. You may use the names of language commands as variables. There has been no contest such as the International Obfuscated C Code Contest for MUMPS, despite the potential of examples such as the following, perfectly legal, MUMPS code: GREPTHIS() NEW SET,NEW,THEN,IF,KILL,QUIT SET IF="KILL",SET="11",KILL="l1",QUIT="RETURN",THEN="KILL" IF IF=THEN DO THEN QUIT:$QUIT QUIT QUIT ; (quit) THEN IF IF,SET&KILL SET SET=SET+KILL QUIT MUMPS can be made more obfuscated by using the contracted operator syntax, as shown in this terse example derived from the example above: GREPTHIS() N S,N,T,I,K,Q S I="K",S="11",K="l1",Q="R",T="K" I I=T D T Q:$Q Q Q T I I,S&K S S=S+K Q Arrays: are created dynamically, stored as B-trees, are sparse (i.e. use almost no space for missing nodes), can use any number of subscripts, and subscripts can be strings or numeric (including floating point). Arrays are always automatically stored in sorted order, so there is never any occasion to sort, pack, reorder, or otherwise reorganize the database. Built in functions such as $DATA, $ORDER, $NEXT(deprecated) and $QUERY functions provide efficient examination and traversal of the fundamental array structure, on disk or in memory. for i=10000:1:12345 set sqtable(i)=i*i set address("Smith","Daniel")="dpbsmith@world.std.com"
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Local arrays: variable names not beginning with caret (i.e. "^") are stored in memory by process, are private to the creating process, expire when the creating process terminates. The available storage depends on implementation. For those implementations using partitions, it is limited to the partition size, (A small patition might be 32K). For other implementations, it may be several megabytes. Global arrays: âbc, ^def. These are stored on disk, are available to all processes, and are persistent when the creating process terminates. Very large globals (e.g., hundreds of gigabytes) are practical and efficient in most implementations. This is MUMPS' main "database" mechanism. It is used instead of calling on the operating system to create, write, and read files. Indirection: in many contexts, @VBL can be used, and effectively substitutes the contents of VBL into another MUMPS statement. SET XYZ="ABC" SET @XYZ=123 sets the variable ABC to 123. SET
MUMPS SUBROU="REPORT" DO @SUBROU performs the subroutine named REPORT. This substitution allows for lazy evaluation and late binding as well as effectively the operational equivalent of "pointers" in other languages. Piece function: This breaks variables into segmented pieces guided by a user specified separator string (sometimes called a "delimiter"). Those who know awk will find this familiar. $PIECE(STRINGVAR,"^",3) means the "third caret-separated piece of STRINGVAR." The piece function can also appear as an assignment (SET command) target. After SET X="dpbsmith@world.std.com"
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$PIECE("world.std.com",".",2) yields "std" SET $P(X,"@",1)="office" causes X to become "office@world.std.com" (note that $P is equivalent to $PIECE and could be written as such). Order function Set stuff(6)="xyz",stuff(10)=26,stuff(15)=""
$Order(stuff("")) yields 6, $Order(stuff(6)) yields 10, $Order(stuff(8)) $Order(stuff(10)) yields 15, $Order(stuff(15)) yields "". Set i="" For Set i=$O(stuff(i)) Quit:i="" Write !,i,10,stuff(i)
yields 10,
Here, the argument-less For repeats until stopped by a terminating Quit. This line prints a table of i and stuff(i) where i is successively 6, 10, and 15. Multi-User/Multi-Tasking/Multi-Processor: MUMPS supports multiple simultaneous users and processes even when the underlying operating system does not (e.g., MS-DOS). Additionally, there is the ability to specify an environment for a variable, such as by specifying a machine name in a variable (as in SET ^|"DENVER"|A(1000)="Foo"), which can allow you to access data on remote machines. For a thorough listing of the rest of the MUMPS commands, operators, functions and special variables, see these online resources: MUMPS by Example [18], or the (out of print) book of the same name by Ed de Moel. Much of the language syntax is detailed there, with examples of usage. The Annotated MUMPS Language Standard [19], showing the evolution of the language and differences between versions of the ANSI standard.
"MUMPS" vs. "M" naming debate

While of little interest to those outside the MUMPS/M community, this topic has been contentious there. All of the following positions can, and have been, supported by knowledgeable people at various times: The language's name became M in 1993 when the M Technology Association adopted it. The name became M on December 8, 1995 with the approval of ANSI X11.1-1995 Both M and MUMPS are officially accepted names. M is only an "alternate name" or "nickname" for the language, and MUMPS is still the official name.
Some of the contention arose in response to strong M advocacy on the part of one commercial interest, InterSystems, whose chief executive disliked the name MUMPS and felt that it represented a serious marketing obstacle. Thus, favoring M to some extent became identified as alignment with InterSystems. The dispute also reflected rivalry between organizations (the M Technology Association, the MUMPS Development Committee, the ANSI and ISO Standards Committees) as to who determines the "official" name of the language. Some writers have attempted to
MUMPS defuse the issue by referring to the language as M[UMPS], square brackets being the customary notation for optional syntax elements. A leading authority, and the author of an open source MUMPS implementation, Professor Kevin O'Kane, uses only 'MUMPS'. The most recent standard (ISO/IEC 11756:1999, re-affirmed on 25 June 2010), still mentions both M and MUMPS as officially accepted names.
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Epoch choice
In MUMPS, the current date and time is contained in a special system variable, $H (short for "HOROLOG"). The format is a pair of integers separated by a comma, e.g. "54321,12345" The first number is the number of days since December 31, 1840, i.e. day number 1 is January 1, 1841; the second is the number of seconds since midnight. James M. Poitras has written that he chose this epoch for the date and time routines in a package developed by his group at MGH in 1969:
I remembered reading of the oldest (one of the oldest?) U.S. citizen, a Civil War veteran, who was 121 years old at the time. Since I wanted to be able to represent dates in a Julian-type form so that age could be easily calculated and to be able to represent any birth date in the numeric range selected, I decided that a starting date in the early 1840s would be 'safe.' Since my algorithm worked most logically when every fourth year was a leap year, the first year was taken as 1841. The zero point was then December 31, 1840.... I wasn't party to the MDC negotiations, but I did explain the logic of my choice to members of the Committee.
(More colorful versions have circulated in the folklore, suggesting, for example, that December 31, 1840 was the exact date of the first entry in the MGH records, but these seem to be urban legends. Another legend is that the date was chosen to commemorate the first use of ether as an anesthetic at Mass General.)
Sample programs
The direct execution of source code on historical computing platforms in an era of tiny disks, minuscule RAM and 300 baud serial connections led to a historical coding style that was terse, dense and expert friendly, even as contemporary MUMPS coding styles produce more readable code. First, an example of M code from 2010, a solution to a benchmarking exercise based on calculating the longest sequence encountered when calculating the longest sequence of the Collatz conjecture for a range of integers. This example is written in GT.M and exploits and illustrates many features of MUMPS.
threeen1f ; Find the maximum number of steps for the 3n+1 problem for all integers through two input integers. ; See http://docs.google.com/View?id=dd5f3337_24gcvprmcw ; Assumes input format is 3 integers separated by a space with the first integer smaller than the second. ; The third integer is the number of parallel computation streams. If it is less than twice the
; number of CPUs or cores, the parameter is modified to that value. An optional fourth integer is the ; sizes of blocks of integers on which spawned child processes operate. If it is not specified, the
; block size is approximately the range divided by the number of parallel streams. If the block size is
; larger than the range divided by the number of execution streams, it is reduced to that value. ; No input error checking is done.
MUMPS
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; Although the problem can be solved by using strictly integer subscripts and values, this program is ; written to show that the GT.M key-value store can use arbitrary strings for both keys and values ; each subscript and value is spelled out using the strings in the program source line labelled "digits". ; Furthermore, the strings are in a number of international languages when GT.M is run in UTF-8 mode.
; K.S. Bhaskar 2010612
; No claim of copyright is made with respect to this program.
; Variables do not have to be declared before use, but are New'd in subprograms to ensure that they ; do not conflict with names in the caller.
; The program reads the program source at the label digits to get strings (separated by ;) for each language used. digits ;zero;eins;deux;tres;quattro;;;;; Do digitsinit conversion between integers and strings ; Initialize data for
; Get number of CPUs from /proc/cpuinfo and calculate minimum number of execution streams Open "cpus":(SHELL="/bin/sh":COMMAND="grep -i ^processor /proc/cpuinfo|wc -l":READONLY)::"PIPE" Use "cpus" Read streams Use $PRINCIPAL Close "cpus" Set streams=2*streams execution streams per CPU ; At least two
; At the top level, the program reads and processes input lines, one at a time. Each line specifies Since the program is designed to
; one problem to solve.
resume after a crash and reuse partial ; results computed before the crash, data in the database at the beginning is assumed to be partial ; results from the previous run. results for a line, the database is ; cleared for next line of input or next run of the program. After computing and writing
; Loop for ever, read a line (quit on end of file), process that line For Read input Quit:$ZEOF!'$Length(input) Do ; input has
entire input line
MUMPS
. . Set i=$Piece(input," ",1) number on line is starting integer for the problem . Set j=$Piece(input," ",2) second number on line is ending integer for the problem . Write $FNumber(i,",",0)," ",$FNumber(j,",",0) starting and ending integers, formatting with commas . . Set k=$Piece(input," ",3) number on input line is number of parallel streams . If streams>k Do number of execution streams, optionally corrected .. .. .. Write " (",$FNumber(k,",",0) Set k=streams Write "->",$FNumber(k,",",0),")" Write " ",$FNumber(k,",",0) ; print ; k - third ; print ; j ; i - first
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. Else .
. Set blk=+$Piece(input," ",4) size of blocks of integers is optional fourth piece . Set tmp=(j-i+k)\k default / maximum block size . If blk&(blk'>tmp) Write " ",$FNumber(blk,",",0) block size, optionally corrected . Else .. .. .. . Do
; blk -
; print
Write " (",$FNumber(blk,",",0) Set blk=tmp Write "->",$FNumber(blk,",",0),")"
. ; Define blocks of integers for child processes to work on . Kill ^limits . Set tmp=i-1 . For count=1:1 Quit:tmp=j .. .. . . ; Launch jobs. Grab lock l1, atomically increment counter, Do
Set ^limits(count)=$increment(tmp,blk) Set:tmp>j (tmp,^limits(count))=j
compute and launch one job for each block of numbers. . ; Each child job locks l2(pid), decrements the counter and tries to grab lock l1(pid). . ; When counter is zero, all jobs have started. releases lock l1 and tries to grab lock l2. . ; When all children have released their l2(pid) locks, they're done and parent can gather & report results. . Set ^count=0 - may have residual value if restarting from crash . Lock +l1 process synchronization ; Set lock for ; Clear ^count Parent
MUMPS
. For s=1:1:k Do .. Set c=$Increment(^count) ; Atomic
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increment of counter in database for process synchronization .. Set def=$ZTRNLNM("gtm_tmp") Set:'$Length(def) ; Working directory for Jobbed process
def=$ZTRNLNM("PWD") ..
Set err=$Text(+0)_"_"_$Job_"_"_s_".mje" ; STDERR for Jobbed process
..
Set out=$Extract(err,1,$Length(err)-1)_"o" ; STDOUT for Jobbed process
..
Set
cmd="doblk(i):(ERROR="""_err_""":OUTPUT="""_out_""":DEFAULT="""_def_""")" ; Command to Job .. Job @cmd ; Job child process
for next block of numbers . For Quit:'^count Hang 0.1 ; Wait for processes
to start (^count goes to 0 when they do) . Lock -l1 processes can run . Set startat=$HOROLOG . Lock +l2 to finish . . ; When parent gets lock l2, child processes have completed and parent gathers and reports results. . set endat=$HOROLOG ; Get ending time ; Get starting time ; Wait for processes ; Release lock so
time between startat and endat is the elapsed time . ; Calculate duration . Set duration=(86400*($Piece(endat,",",1)-$Piece(startat,",",1)))+$Piece(endat,",",2)-$Piece(startat,",",2) . Write " ",$FNumber(^result,",",0) of steps for the range i through j . Write " ",$FNumber(^highest,",",0) number reached during the computation . Write " ",$FNumber(duration,",",0) . Write " ",$FNumber(ûpdates,",",0) updates . Write " ",$FNumber(^reads,",",0) ; Show number of reads ; Show the elapsed time ; Show number of ; Show the highest ; Show largest number
. ; If duratation is greater than 0 seconds, display update and read rates . Write:duration " ",$FNumber(ûpdates/duration,",",0)," ",$FNumber(^reads/duration,",",0) . Write ! . Lock -l2 next run . Do dbinit for next run Quit ; Initialize database ; Release lock for
MUMPS
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dbinit
; Entryref dbinit clears database between lines Kill ^count,^highest,^reads,^result,^step,ûpdates Quit
digitsinit convert between strings and integers New m,x Set x=$Text(digits)
; Initialize arrays to
For m=0:1:9 Set di($Piece(x,";",m+2))=m,ds(m)=$Piece(x,";",m+2) Quit
inttostr(n) a string New m,s Set s=ds($Extract(n,1))
; Convert an integer to
For m=2:1:$Length(n) Set s=s_" "_ds($Extract(n,m)) Quit s ; strtoint(s) an integer New m,n Set n=di($Piece(s," ",1)) For m=2:1:$Length(s," ") Set n=10*n+di($Piece(s," ",m)) Quit n ; Convert a string to
; This is where Jobbed processes start doblk(allfirst) Set (reads,updates,highest)=0 reads, writes and highest number Do digitsinit conversion between integers and strings Lock +l2($JOB) ; Get lock l2 that ; Initialize data for ; Start with zero
parent will wait on till this Jobbed processes is done If $Increment(^count,-1) say this process is alive Lock +l1($JOB) ; This process will get ; Decrement ^count to
lock l1($JOB) only parent has released lock on l1 ; ; Process the next block in ^limits that needs processing; quit when done For Quit:'$Data(^limits($increment(tmp)))
Do:1=$increment(^limits(tmp,1)) dostep($select($data(^limits(tmp-1)):^limits(tmp-1)+1,1:allfirst),^limits(tmp)) ; TStart () statistics inside a transaction ; Update global
MUMPS
; The following line unconditionally adds the number of reads & write performed by this process to the ; number of reads & writes performed by all processes, and sets the highest for all processes if the ; highest calculated by this process is greater than that calculated so far for all processes
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Set:$Increment(^reads,reads)&$Increment(ûpdates,updates)&(highest>$Get(^highest)) ^highest=highest TCommit Lock -l1($JOB),-l2($JOB) parent this parent is done Quit terminate here ; Jobbed processes ; Release locks to tell
dostep(first,last) number of steps from first through last New current,currpath,i,n For current=first:1:last Do . Set n=current . Kill currpath to 1 for current
; Calculate the maximum
; Start n at current ; Currpath holds path
. ; Go till we reach 1 or a number with a known number of steps . For i=0:1 Quit:$Increment(reads)&($Data(^step($$inttostr(n)))!(1=n)) .. Set currpath(i)=n Do
; log n as current
number in sequence .. number .. Set:n>highest highest=n ; see if we have a new Set n=$Select('(n#2):n/2,1:3*n+1) ; compute the next
highest number reached . Do:0<i .. .. maximum .. .. .. Set:i>$Get(^result) ^result=i TCommit Set n="" For Set n=$Order(currpath(n)) Quit:""=n ; if 0=i we already have an answer for n, nothing to do here
If 1<n Set i=i+$$strtoint(^step($$inttostr(n))) TStart () ; Atomically set
Set:$Increment(updates) ^step($$inttostr(currpath(n)))=$$inttostr(i-n) Quit
Next, an example of "traditional" M coding style, a VistA source code routine from the late 1970s (last edited in 1992), written originally by George Timson at a time when the language standard had not evolved features such as variable scoping. It is generally recognized that this code is not very readable to many programmers today. Though it should be noted that the code is expert friendly, (i.e. to acculturated VistA programmers it is readable and appropriately structured) - this code is an example of code that has been used effectively for many years. The culture and style of long lived application code cannot and does not change overnight, and when code continues to work, such cultures focus on adding new functionality rather than updating code simply for stylistic reasons.
MUMPS Due to the terse nature of fully abbreviated MUMPS code, the size of similar code in other programming languages providing the same functionality would be considerably larger.
%DTC %DTC ; SF/XAK - DATE/TIME OPERATIONS ;1/16/92 ;;19.0;VA FileMan;;Jul 14, 1992 D I 'X1!'X2 S X="" Q 11:36 AM
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S X=X1 D H S X1=%H,X=X2,X2=%Y+1 D H S X=X1-%H,%Y=%Y+1&X2 K %H,X1,X2 Q ; C S X=X1 Q:'X D H S %H=%H+X2 D YMD S:$P(X1,".",2)
X=X_"."_$P(X1,".",2) K X1,X2 Q S S %=%#60/100+(%#3600\60)/100+(%\3600)/100 Q ; H I X<1410000 S %H=0,%Y=-1 Q S %Y=$E(X,1,3),%M=$E(X,4,5),%D=$E(X,6,7) S %T=$E(X_0,9,10)*60+$E(X_"000",11,12)*60+$E(X_"00000",13,14) TOH S
%H=%M>2&'(%Y#4)+$P("^31^59^90^120^151^181^212^243^273^304^334","^",%M)+%D S %='%M!'%D,%Y=%Y-141,%H=%H+(%Y*365)+(%Y\4)-(%Y>59)+%,%Y=$S(%:-1,1:%H+4#7) K %M,%D,% Q ; DOW DW D H S Y=%Y K %H,%Y Q D H S
Y=%Y,X=$P("SUN^MON^TUES^WEDNES^THURS^FRI^SATUR","^",Y+1)_"DAY" S:Y<0 X="" Q 7 S %=%H>21608+%H-.1,%Y=%\365.25+141,%=%#365.25\1 S %D=%+306#(%Y#4=0+365)#153#61#31+1,%M=%-%D\29+1 S X=%Y_"00"+%M_"00"+%D Q ; YX YMD T D YMD S Y=X_% G DD^%DT D 7 S %=$P(%H,",",2) D S K %D,%M,%Y Q F %=1:1 S Y=$E(X,%) Q:"+-"[Y G 1^%DT:$E("TODAY",%)'=Y
S X=$E(X,%+1,99) G PM:Y="" I +X'=X D DMW S X=% G:'X 1^%DT PM N S @("%H=$H"_Y_X) D TT G 1^%DT:%I(3)'?3N,D^%DT F %=2:1 S Y=$E(X,%) Q:"+-"[Y I Y="" S %H=$H G RT S X=$E(X,%+1,99) I X?1.N1"H" S X=X*3600,%H=$H,@("X=$P(%H,"","",2)"_Y_X),%=$S(X<0:-1,1:0)+(X\86400),X=X#86400,%H=$P(%H,",")+%_","_X G RT D DMW G 1^%DT:'% S @("%H=$H"_Y_%),%H=%H_","_$P($H,",",2) RT D TT S %=$P(%H,",",2) D S S %=X_% I %DT'["S" S %=+$E(%,1,12) Q:'$D(%(0)) PF S Y=% G E^%DT G 1^%DT:$E("NOW",%)'=Y
S %H=$H D YMD S %(9)=X,X=%DT["F"*2-1 I @("%I(1)*100+%I(2)"_$E("> <",X+2)_"$E(%(9),4,7)") S %I(3)=%I(3)+X Q
TT NOW
D 7 S %I(1)=%M,%I(2)=%D,%I(3)=%Y K %M,%D,%Y Q S %H=$H,%H=$S($P(%H,",",2):%H,1:%H-1)
MUMPS
D TT S %=$P(%H,",",2) D S S %=X_$S(%:%,1:.24) Q DMW S %=$S(X?1.N1"D":+X,X?1.N1"W":X*7,X?1.N1"M":X*30,+X=X:X,1:0) Q COMMA ; S %D=X<0 S:%D X=-X S %=$S($D(X2):+X2,1:2),X=$J(X,1,%),%=$L(X)-3-$E(23456789,%),%L=$S($D(X3):X3,1:12) F %=%:-3 Q:$E(X,%)="" S X=$E(X,1,%)_","_$E(X,%+1,99)
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S:$D(X2) X=$E("$",X2["$")_X S X=$J($E("(",%D)_X_$E(" )",%D+1),%L) K %,%D,%L Q HELP S DDH=$S($D(DDH):DDH,1:0),A1="Examples of Valid Dates:" D % S A1=" JAN 20 1957 or 20 JAN 57 or 1/20/57"_$S(%DT'["N":" or
012057",1:"") D % S A1=" % S A1=" T-1 (for YESTERDAY), T-3W (for 3 WEEKS AGO), etc." D % T (for TODAY), T+1 (for TOMORROW), T+2, T+7, etc." D
S A1="If the year is omitted, the computer "_$S(%DT["P":"assumes a date in the PAST.",1:"uses the CURRENT YEAR.") D % I %DT'["X" S A1="You may omit the precise day, as: I %DT'["T",%DT'["R" G 0 S A1="If the date is omitted, the current date is assumed." D % S A1="Follow the date with a time, such as JAN 20@10, T@10AM, 10:30, etc." D % S A1="You may enter a time, such as NOON, MIDNIGHT or NOW." D % I %DT["S" S A1="Seconds may be entered as 10:30:30 or 103030AM." D % I %DT["R" S A1="Time is REQUIRED in this response." D % 0 Q:'$D(%DT(0)) S A1=" " D % S A1="Enter a date which is "_$S(%DT(0)["-":"less",1:"greater")_" than or equal to " D % S Y=$S(%DT(0)["-":$P(%DT(0),"-",2),1:%DT(0)) D DD^%DT:Y'["NOW" I '$D(DDS) W Y,"." K A1 Q S DDH(DDH,"T")=DDH(DDH,"T")_Y_"." K A1 Q ; % I '$D(DDS) W !," ",A1 Q "_A1 Q JAN, 1957" D %
S DDH=DDH+1,DDH(DDH,"T")="
The following code is a complete implementation of ROT13, a trivially breakable cipher used for various purposes on the Net, not high security. It illustrates the compact nature of MUMPS code and is rather less cryptic than the sample above. ST ; ROT13 ; Gunter Rensch ; 2000-01-03 ; Encrypt/Decrypt ROT13 Q ; no direct execution ; ; call from your program with ; S A="String" ; S A=$$ROT^ROT13(.A) ; ;
ROT(R)
MUMPS S S S S S Q S1="ABCDEFGHIJKLMNOPQRSTUVWXYZ" S2="NOPQRSTUVWXYZABCDEFGHIJKLM" s1="abcdefghijklmnopqrstuvwxyz" s2="nopqrstuvwxyzabcdefghijklm" R=$TR(R,S1_s1,S2_s2) R
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A second implementation is below, which illustrates the possibilities of concision in MUMPS.

s A="String" F i=1:1:$L(A) W $c($S($A($E(A,i))<91:$A($E(A,i))-52#26+65,1:$A($E(A,i))-84#26+97))
Finally, one of the shortest programs ever written in a high-level language, demonstrating the extreme concision of which MUMPS is capable. s x="x x" x x
The same algorithm using expanded variable and command names Set X="Xecute X" Xecute X
This program sets a value of "x x" to a variable named x, and then launches an infinite recursive execution of x, probably resulting in a stack overflow. At just 13 characters, including spaces and an end-of-line mark (since the MUMPS standard specifies storage in characters, not in bytes), using just two characters, the first variant demonstrates that it is also possible to write obscure and obfuscated code in M.
References
[1] [2] [3] [4] [5] http:/ / www. iso. ch/ iso/ en/ CatalogueDetailPage. CatalogueDetail?CSNUMBER=29268& ICS1=35& ICS2=60& ICS3=& scopelist http:/ / www. iso. ch/ iso/ en/ CatalogueDetailPage. CatalogueDetail?CSNUMBER=29269& printable=true http:/ / www. iso. ch/ iso/ en/ CatalogueDetailPage. CatalogueDetail?printable=true& CSNUMBER=29270 http:/ / groups. google. com/ group/ comp. lang. mumps/ msg/ d4509328a7930487 Archive.org record of: Fidelity Information Services: Banking Solutions (http:/ / web. archive. org/ web/ */ http:/ / www. sanchez. com/ news_2000/ nr_001107. asp) [6] GT.M download page on SourceForge (http:/ / sourceforge. net/ projects/ fis-gtm/ files/ ) [7] http:/ / www. cs. uni. edu/ ~okane [8] http:/ / www. rychannel. com/ mumps [9] Mission-critical Ajax: Making Test Ordering Easier and Faster at Quest Diagnostics (http:/ / www. slideshare. net/ george. james/ missioncritical-ajaxmaking-test-ordering-easier-and-faster-at-quest-diagnostics?type=powerpoint) [10] SEC Info: Misys Purchase of Sunquest (http:/ / www. secinfo. com/ dsvr4. 4Fc4m. 3. htm) [11] "Welcome to M21 -- the database for the 21st Century" (http:/ / www. m21. uk. com/ newtom. php). . [12] "Cach-based Financial Systems" (http:/ / www. intersystems. com/ industry/ financial/ intersystems-in-financial. html). . [13] "IDEA Turn-Key financial/manufacturing applications" (http:/ / www. idea. cz/ en/ references). . [14] "European Space Agency Chooses InterSystems Cach Database For Gaia Mission to Map Milky Way" (http:/ / www. realwire. com/ release_detail. asp?ReleaseID=18645). . [15] Extreme Database programming with MUMPS Globals (http:/ / gradvs1. mgateway. com/ download/ extreme1. pdf) [16] See ANSI standard ANSI standard X11.11977 section 2.2.3 (http:/ / 71. 174. 62. 16/ Demo/ AnnoStd?Frame=Main& Page=a202005& Edition=1977) [17] The Annotated MUMPS Standards (http:/ / 71. 174. 62. 16/ Demo/ AnnoStd) - Ed De Moel, Jacquard Systems Research (http:/ / jacquardsystems. com/ ) [18] http:/ / 71. 174. 62. 16/ Demo/ AnnoStd?Frame=Main& Page=a100006 [19] http:/ / 71. 174. 62. 16/ Demo/ AnnoStd
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Further reading
Walters, Richard (1989). "ABCs of MUMPS. 1989: Butterworth-Heinemann, ISBN 1-55558-017-3. Walters, Richard (1997). M Programming: A Comprehensive Guide. Digital Press. ISBN 1-55558-167-6. Lewkowicz, John. The Complete MUMPS : An Introduction and Reference Manual for the MUMPS Programming Language. ISBN 0-13-162125-4 Kirsten, Wolfgang, et al. (2003) Object-Oriented Application Development Using the Cach Postrelational Database ISBN 3-540-00960-4 Martnez de Carvajal Hedrich, Ernesto (1993). "El Lenguaje MUMPS". Completa obra en castellano sobre el lenguaje Mumps. ISBN 84-477-0125-5. Distribuido exclusivamente por su author (ecarvajal@hedrich.es) O'Kane, K.C.; A language for implementing information retrieval software, Online Review, Vol 16, No 3, pp 127137 (1992). O'Kane, K.C.; and McColligan, E. E., A case study of a Mumps intranet patient record, Journal of the Healthcare Information and Management Systems Society, Vol 11, No 3, pp 8195 (1997). O'Kane, K.C.; and McColligan, E.E., A Web Based Mumps Virtual Machine, Proceedings of the American Medical Informatics Association 1997 O'Kane, K.C., The Mumps Programming Language, Createspace, ISBN 1438243383, 120 pages (2010).
External links
M Technology and MUMPS Language FAQ (http://www.faqs.org/faqs/m-technology-faq/part1/) (1999) General source; also specific source for the Poitras quote re the origin of the 1840 epoch. Open Source (GPL/LGPL), Kevin O'Kane Univ Northern Iowa (http://www.cs.uni.edu/~okane/mumps.html) Information Retrieval in Mumps (book) (http://www.cs.uni.edu/~okane/source/ISR/isr.html) MDH Database Toolkit (http://www.cs.uni.edu/~okane/source/MUMPS-MDH/mdh.html) C++ class library to access O'Kane's Open Source Mumps MDC - MUMPS Development Committee (http://71.174.62.16/MDC/) The Annotated M{UMPS} Standards (http://71.174.62.16/Demo/AnnoStd) Cach & MUMPS Technology Association of UK & Ireland (http://www.camta.net) GT.M Open Source MUMPS System - Fidelity/Sanchez/Greystone (http://sourceforge.net/projects/fis-gtm) MUMPS Systems - Source Forge index (http://mumps.sourceforge.net/) Globals: a primer for Relational Programmers (http://www.mgateway.com/extreme1.doc) The M Technology Resource Center (http://www.mcenter.com/mtrc/) M Links at Hardhats.org (http://www.hardhats.org/links/Mlinks.html) A case of MUMPS (http://thedailywtf.com/Articles/A_Case_of_the_MUMPS.aspx) A MUMPS story at The Daily WTF M21 - An ANSI M(UMPS) Implementation (http://www.m21.uk.com) EsiObjects (http://www.esiobjects.org) An Object Oriented extension of MUMPS InterSystems Cach (http://www.intersystems.com/cache/index.html) InterSystems M Technologies (http://www.openm.com/index.html) DSM, MSM and OpenM M/DB (http://www.mgateway.com/mdb.html) An Open Source MUMPS-based API-compatible alternative to SimpleDB MiniM Database Server, A MUMPS Implementation (http://www.minimdb.com) Development and Operation of a MUMPS Laboratory Information System: A Decade's Experience (http://www. ncbi.nlm.nih.gov/pmc/articles/PMC2245220/) IDEA-Technology for Cach and GT.M (http://www.idea.cz/en/technology) MUMPS documentation, topics, and resources (mixed Czech and English) (http://www.mumps.cz/)
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Internet Projects
Bing Health
Bing Health
Bing Health displaying results of the search term 'Common Cold' Developer(s) Stable release Type Website Microsoft Final / January 12, 2010 Search engine [1]
Bing Health
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Bing Health (previously Live Search Health) is a health-related search service as part of Microsoft's Bing search engine. It is a search engine specifically for health-related information through a variety of trusted and credible sources, including Medstory, Mayo Clinic, National Institutes of Health's MedlinePlus, as well as from Wikipedia.
History
Bing Health comes about as a result of the Microsoft's acquisition of Medstory in February 2007, gaining a foothold in the health search and health information market.[2] It was released for beta testing on October 8, 2007 as Live Search Health and served as the front-end to Microsoft HealthVault Search. Search results in Live Search Health were presented in a three-column layout with health-related articles from the trusted sources in the left, web search results in the middle, and sponsored results on the right. The topic dashboad on the top also displays relevant topics, and allow users to add the search results to their scrapbook in Microsoft HealthVault Account. One particular feature for Live Search Health is that all health search queries and responses were encrypted to provide a measure of privacy and security when dealing with health issues.
However, on June 3, 2009, the Live Search Health front-end became fully integrated into Bing search results, accessible only via the "Explorer pane" on the left when the contextual search engine detects a health-related search query entered.
A screenshot of Live Search Health homepage before it was rebranded.
On January 10, 2010, Bing Health search results got an upgrade. Typing in a specific illness will now highlight important information such as related conditions, and common medications to reduce symptoms. In addition reference materials and documentation about the disease and its history can be shown.[3]
References
[1] http:/ / www. bing. com [2] Microsoft Press Release: Microsoft Demonstrates Further Commitment to Healthcare Market With Planned Acquisition of Web Search Company (http:/ / www. microsoft. com/ presspass/ press/ 2007/ feb07/ 02-26MSMedstoryPR. mspx) on 2007-02-26 [3] Bringing Knowledge into Health Search (http:/ / www. bing. com/ community/ blogs/ search/ archive/ 2010/ 01/ 12/ bringing-knowledge-into-health-search. aspx)
Dossia
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Dossia
Dossia
Industry Founder(s)
Healthcare AT&T Applied Materials BP America Cardinal Health Intel Pitney Bowes sanofi-aventis Walmart Abraxis BioScience Vanguard Health Systems United States Cambridge, Massachusetts Michael Critelli, CEO Steve Munini, COO, Dossia.org [1]
Headquarters
Key people
Website
Dossia is a Personal health record service offered by some of the largest employers in the United States. Along with Microsoft's HealthVault and Google's Google Health, Dossia is one of the largest PHR deployments in the world.[2] Unlike the other two large PHR efforts, Dossia is based on Open Source software. Dossia released their API in summer of 2009. [3] Dossia differs from traditional tethered PHR services, by providing user access to health information regardless of health plan, employer or physician. Users also have the ability to download their full record, in electronic form, at any time. It is an initiative formed from the following companies: AT&T Applied Materials BP America Cardinal Health Intel Pitney Bowes Sanofi-aventis Walmart Abraxis BioScience Vanguard Health Systems
Dossia is formed by some of the largest employers in the United States with the intention of offering a PHR to its employees. Given the number of employees of these combined institutions, Dossia could be one of the largest PHR systems in the world.[4]
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Dossias History
In 2006, a group of Fortune 500 employers, including Applied Materials, BP America, Inc, Intel Corporation, Pitney Bowes Inc., Wal-Mart, Cardinal Health, AT&T, and sanofi-aventis, formed an alliance called the Dossia Consortium. Later, in April 2009, Dossia announced that Abraxis BioScience also joined the Dossia Founders Group. The Consortiums goal was to empower their employees to make smarter, more informed decisions about their healthcare by offering them Personally Controlled Health Records (PCHR) . The Consortium funded the development of a web-based framework through which Consortium employees, dependents, and retirees can maintain private, personal, and portable PCHRs. In 2008, the Dossia Consortium Board of Directors decided to create two additional organizations within the Dossia umbrella. These included the Dossia Foundation and the Dossia Service Corporation. The Dossia Foundation aims at advancing knowledge and progress in the healthcare space through a variety research, strategy, and advocacy initiatives pertaining to Personally Controlled Health Records (PCHRs). The Dossia Service Corporation is responsible for delivering the PCHR infrastructure and service to subscribing employers and customers. Also during 2008, Dossia established an agreement to work with Childrens Hospital Boston to provide strategic and technological expertise and guidance in creating, deploying and operating the electronic health record infrastructure. In fall of 2008, WalMart was the first Dossia Consortium member to roll out the PCHRs to their 1.4 million employees plus their dependents. [5] Following WalMarts roll out, Dossia continued to roll out its PCHRs to the other Dossia Consortium members including Vanguard, Intel, Pitney Bowes, AT&T and BP America. [6]
Dossias PHP(Personal Health Platform)

The Dossia system enables individuals to gather copies of their own medical data (in digital form) from multiple sources and to create and utilize their own personal, private and portable electronic health records. Initially, the data will come primarily from insurers databases and the patients own annotations. As the system develops, additional information will come directly from the patients medical chart and various other sources. The information the system provides will empower individuals to manage their own healthcare, improve communications with their doctors, and ensure more complete and accurate information for healthcare providers than the current fragmented, paper-based system.
Dossia Board Members

Dossias board is composed of industry leaders from a variety of Fortune 500 companies. Craig Barrett, Chairman, Board Of Directors, Dossia, Executive Chairman, (formerly) Intel Jean Paul Gagnon, Secretary, Board of Directors, Dossia Director of Public Policy, sanofi-aventis Monica Foster, Vice President of Benefits, Cardinal Health Karl Dalal, Director of U.S. Health and Welfare Benefits, BP America Adena Handly,Director, Healthcare Marketing, AT&T Business Solutions Diana Finucane, Director, Global Benefits Applied Materials Andrew Gold, Executive Director, Global Benefit Planning, Pitney Bowes Steven Lampkin, Vice President, Benefits Services and Strategic Initiatives, Walmart Patrick Soon-Shiong, M.D., Executive Chairman and Chief Executive Officer, Abraxis Health Brad Perkins, M.D., Executive VP Strategy and Innovation and Chief Transformation Officer, Vanguard Health Systems
Tami L. Graham, Intel Global Benefits Design Director, Intel Corporation Liz Cirri, Senior Director, Reimbursement, Government Programs, sanofi-aventis
Dossia
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Notes
[1] http:/ / www. dossia. org/ [2] McGee, Marianne (2008-10-01). "Wal-Mart Rolls Out E-Health Records To All Employees" (http:/ / www. informationweek. com/ news/ software/ database/ showArticle. jhtml?articleID=210605059). Information Week. pp.2. . Retrieved 2008-11-07. [3] "Dossia Open API" (http:/ / wiki. dossia. org/ ). . Retrieved 2008-11-07. [4] Moore, John. "Indivo Health: Further Details on Dossia Agreement" (http:/ / chilmarkresearch. com/ 2007/ 10/ 17/ indivo-health-further-details-on-dossia-agreement/ ). . Retrieved 2008-11-07. [5] Moore, John. "Indivo Health: Further Details on Dossia Agreement" (http:/ / chilmarkresearch. com/ 2007/ 10/ 17/ indivo-health-further-details-on-dossia-agreement/ ). . Retrieved 2008-11-07. [6] McGee, Marianne Kolbasuk. pitney "Vanguard Rolls out Dossia PHRs To Employees" (http:/ / www. informationweek. com/ news/ healthcare/ EMR/ showArticle. jhtml?articleID=222300838& queryText=dossia). pitney. Retrieved 2010-19-01.
External Links
Dossia Official Site (http://www.dossia.org/)
E-Patient
e-Patients (also known as Internet Patient, or Internet-savvy Patient) are health consumers who use the Internet to gather information about a medical condition of particular interest to them, and who use electronic communication tools (including Web 2.0 tools) in coping with medical conditions.[1] The term encompasses both those who seek online guidance for their own ailments and the friends and family members (e-Caregivers) who go online on their behalf. e-Patients report two effects of their online health research: "better health information and services, and different (but not always better) relationships with their doctors." [2] e-Patients are increasingly active in their care and are demonstrating the power of the Participatory Medicine or Health 2.0 / Medicine 2.0.[3] model of care. They are equipped, enabled, empowered, engaged, equals, emancipated and experts. Equipped with the skills to manage their own condition. Enabled to make choices about self-care and those choices are respected. Empowered Engaged patients are engaged in their own care Equals in their partnerships with the various physicians involved in their care Emancipated Expert patients can improve their self-rated health status, cope better with fatigue and other generic features of chronic disease such as role limitation, and reduce disability and their dependence on hospital care.
Based on the current state of knowledge on the impact of e-patients on the healthcare system and the quality of care received: A growing number of people say the internet has played a crucial or important role as they helped another person cope with a major illness.[4] [5] Since the advent of the Internet, many clinicians have underestimated the benefits and overestimated the risks of online health resources for patients.[6] [7] [8] Medical online support groups have become an important healthcare resource. The net friendliness of clinicians and provider organizationsas rated by the e-patients they serveis becoming an important new aspect of healthcare quality. This is one the most important cultural medical revolution of the past century, mediated and driven by technology.
E-Patient The impact of the e-patient cannot be fully understood and appreciated in the context of pre-internet medical constructs. Research must combine expertise from specialties that are not used to work together. It is crucial for medical education to take the e-patient into account, and to prepare students for medical practice that encompasses the e-patient[9] The proportion of e-patients in selected patient populations seem to be highest in the US and Canada. European countries seem to lag.
434
References
[1] Masters K, Ng'ambi D, Todd, G (2010). ""I Found it on the Internet:" Preparing for the e-patient in Oman" (http:/ / web. squ. edu. om/ squmj/ includes/ tng/ pub/ tNG_download. asp?id=e5ecd1c850167630052768711a777f70). SQU Med J 10 (2): 169179. . [2] Fox, Susannah; Fallows, Deborah. 2003. Health searches and email have become more commonplace, but there is room for improvement in searches and overall Internet access. (http:/ / www. pewinternet. org/ ~/ media/ / Files/ Reports/ 2003/ PIP_Health_Report_July_2003. pdf. pdf) [3] Eysenbach G Medicine 2.0: Social Networking, Collaboration, Participation, Apomediation, and Openness (http:/ / www. jmir. org/ 2008/ 3/ e22/ ). J Med Internet Res 2008;10(3):e22 [4] Finding Answers Online in Sickness and in Health, 5/2/2006, Pew Internet (http:/ / www. pewinternet. org/ pdfs/ PIP_Health_Decisions_2006. pdf). [5] Eysenbach G (2003). "The impact of the Internet on cancer outcomes" (http:/ / caonline. amcancersoc. org/ cgi/ content/ full/ 53/ 6/ 356). CA Cancer J Clin 53 (6): 35671. doi:10.3322/canjclin.53.6.356. PMID15224975. . [6] Jacobson P (2007). "Empowering the physician-patient relationship: The effect of the Internet" (http:/ / journal. lib. uoguelph. ca/ index. php/ perj/ article/ view/ 244/ 374). Partnership: the Canadian Journal of Library and Information Practice and Research 2 (1). ISSN1911-9593. . [7] Ahmad F, Hudak PL, Bercovitz K, Hollenberg E, Levinson W (2006). "Are physicians ready for patients with Internet-based health information?". J. Med. Internet Res. 8 (3): e22. doi:10.2196/jmir.8.3.e22. PMC2018833. PMID17032638. [8] Crocco AG, Villasis-Keever M, Jadad AR (June 2002). "Analysis of cases of harm associated with use of health information on the internet" (http:/ / jama. ama-assn. org/ cgi/ content/ full/ 287/ 21/ 2869). JAMA 287 (21): 286971. doi:10.1001/jama.287.21.2869. PMID12038937. . [9] Masters K, Ng'ambi D, Todd, G (2010). ""I Found it on the Internet:" Preparing for the e-patient in Oman" (http:/ / web. squ. edu. om/ squmj/ includes/ tng/ pub/ tNG_download. asp?id=e5ecd1c850167630052768711a777f70). SQU Med J 10 (2): 169179. .
Ferguson T, Frydman G (May 2004). "The first generation of e-patients" (http://bmj.bmjjournals.com/cgi/ content/full/328/7449/1148). BMJ 328 (7449): 11489. doi:10.1136/bmj.328.7449.1148. PMC411079. PMID15142894. Hoch D, Ferguson T (August 2005). "What I've learned from E-patients". PLoS Med. 2 (8): e206. doi:10.1371/journal.pmed.0020206. PMC1182328. PMID16060721. van Woerkum CM (1 April 2003). "The Internet and primary care physicians: coping with different expectations" (http://www.ajcn.org/cgi/content/full/77/4/1016S). Am. J. Clin. Nutr. 77 (4 Suppl): 1016S1018S. PMID12663310. Podiatry Online: Accommodating the Internet-Savvy Patient (http://www.podiatryonline.com/main. cfm?pg=howto&fn=internetpt) Susannah Fox, Pew Internet & American Life Project (2004-09-27). "Todays E-Patients: Hunters and Gatherers of Health Information Online" (http://www.pewinternet.org/PPF/r/27/presentation_display.asp). Laura Landro, Senior Editor, The Wall Street Journal (June 13, 2007). "The Growing Clout of Online Patient Groups" (http://liferaftgroup.com/docs/WSJ_online_patient_groups.pdf) (PDF). Rimer BK, Lyons EJ, Ribisl KM, et al. (July 2005). "How new subscribers use cancer-related online mailing lists" (http://www.jmir.org/2005/3/e32/). J. Med. Internet Res. 7 (3): e32. doi:10.2196/jmir.7.3.e32. PMC1550655. PMID15998623. Meier A, Lyons EJ, Frydman G, Forlenza M, Rimer BK (2007). "How cancer survivors provide support on cancer-related Internet mailing lists" (http://www.jmir.org/2007/2/e12). J. Med. Internet Res. 9 (2): e12. doi:10.2196/jmir.9.2.e12. PMC1874721. PMID17513283. Feder J (2008). "A reader and author respond to "ePatients: engaging patients in their own care"". Medscape J Med 10 (2): 46; author reply 46. PMC2270894. PMID18382715.
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External links
The rise of the e-patient (http://www.pewinternet.org/Presentations/2009/40-The-rise-of-the-e-patient.aspx), Lee Rainie from the Pew Internet and American Life Project (http://www.pewinternet.org/) presentation at the Medical Library Association, Oct 7, 2009 E-patients With a Disability or Chronic Disease (http://www.pewinternet.org/PPF/r/222/report_display.asp), from the Pew Internet and American Life Project (http://www.pewinternet.org/) Association of Cancer Online Resources (ACOR) (http://acor.org/), an aggregate of e-patient online communities for knowledge-sharing about cancer. E-Patients Prefer eGroups to Doctors for 10 of 12 Aspects of Health Care (http://www.fergusonreport.com/ articles/fr039905.htm). 1999 article by Dr. Tom Ferguson. Time Magazine article: "When the patient is a Googler" (http://www.time.com/time/health/article/ 0,8599,1681838,00.html) - Mary Shomons response (http://thyroid.about.com/b/2007/11/13/ time-magazines-dr-scott-haig-proves-that-patients-need-to-be-googlers.htm) - Trisha Torreys response (http:// patients.about.com/b/2007/11/24/cnntime-dr-haigs-own-misdiagnosis.htm) Who Cares (http://www.ftc.gov/bcp/edu/pubs/consumer/health/hea17.pdf) Booklet by the Federal Trade Commission, a guide to health information Infographic: The Empowered E-Patient (http://community.pathoftheblueeye.com/Data/ empowered-e-patient-infographic) summary of data focusing on e-patients developed by the Path of the Blue Eye Project, an educational initiative for health marketing communications professionals
Google Health
436
Google Health
Google Health
URL Commercial? Type of site Registration Content license Owner Launched Current status
google.com/health Yes
[1]
Personal health record service Required Continuity of Care Document Google May 20, 2008 To be discontinued on January1,2012
Google Health was a personal health information centralization service (sometimes known as personal health record services) by Google introduced in 2008 and announced for withdrawal in 2011.[2] The service allows Google users to volunteer their health records either manually or by logging into their accounts at partnered health services providers into the Google Health system, thereby merging potentially separate health records into one centralized Google Health profile. Volunteered information can include "health conditions, medications, allergies, and lab results".[3] Once entered, Google Health uses the information to provide the user with a merged health record, information on conditions, and possible interactions between drugs, conditions, and allergies.[4] Google Health's API is based on a subset of the Continuity of Care Record.[5] Google Health, like many other Google products, is free to use for consumers. Unlike other Google services, however, Health currently contains no advertising.[6] Google has not revealed how it plans to make money with the service, but a Wall Street Journal article says that Google "hasn't ruled [advertising] out for the future."[7] Google has filed U.S. Patent Application #20070282632 ,"Method and apparatus for serving advertisements in an electronic medical record system".[8]
History
Google Health has been under development since mid-2006. In 2008, the service underwent a two-month pilot test with 1,600 patients of The Cleveland Clinic.[9] Starting on May 20, 2008, Google Health was released to the general public as a service in beta test stage. On September 15, 2010 Google updated Google Health with a new look and feel.[10] On June 24, 2011 Google announced it is retiring Google Health in January 1, 2012; data will be available for download through January 1, 2013. The reason of abandoning the project is the lack of widespread adoption.[11]
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Partners
Google Health can currently import medical and/or drug prescription information from the following partners: Allscripts, Anvita Health, The Beth Israel Deaconess Medical Center, Blue Cross Blue Shield of Massachusetts, The Cleveland Clinic, CVS Caremark, Drugs.com, Healthgrades, Longs Drugs, Medco Health Solutions, Quest Diagnostics, RxAmerica, and Walgreens.[12] Users whose health records reside with other providers may either manually enter their data or pay to have a Google Health partner perform the service. "MediConnect Global"[13] is one such partner; for a fee, they will gather a user's medical records from around the world and add them to his or her profile. Since January 2010, the Withings WiFi Body scale enables Google Health users to seamlessly update their weight and other data to their online profiles[14] Recently, in response to demand for added convenience, Google Health began establishing relationships with telehealth providers that will allow their users to sync the data shared during telehealth consultations with their online health records. To date, partnerships have been formed with the following companies: MDLiveCare and Hello Health.[15]
Privacy concerns
Google Health is an opt-in service, meaning it can only access medical information volunteered by individuals. It does not retrieve any part of a person's medical records without his or her explicit consent and action.[3] However, it does encourage users to set up profiles for other individuals.[4] According to its Terms of Service, Google Health is not considered a "covered entity" under the Health Insurance Portability and Accountability Act of 1996; thus, HIPAA privacy laws do not apply to it.[16] In an article covering Google Health's launch, the New York Times discussed privacy issues and said that "patients apparently did not shun the Google health records because of qualms that their personal health information might not be secure if held by a large technology company."[9] Others contend that Google Health may be more private than the current "paper" health record system because of reduced human interaction.[17] Post-launch reactions to Google's stance that it is not a covered entity have varied. Some have been very negative, such as those of Nathan McFeters at ZDNet.[18] Others, including Free/Open Source Software Healthcare activist Fred Trotter, argue that a personal health record service like Google Health would be impossible if it were HIPAA covered.[19]
Competitors
Google Health is a personal health record (PHR) service whose primary competitors in the United States are Microsoft's HealthVault, Dossia, and the open-source Indivo project. There are numerous other open-source and proprietary PHR systems, including those that compete outside the United States.[20] On July 18, 2011, Microsoft released a tool that lets Google Health customers transfer their personal health information to a Microsoft HealthVault account.[21]
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Discontinuing
On June 24, 2011, Google has announced that Google Health will be discontinued as a service.[22] Google stated that they are discontinuing Google Health because it did not have a broad impact as Google had expected before.
... with a few years of experience, weve observed that Google Health is not having the broad impact that we hoped it would.
[23]
From The Official Google Blog
Google will continue to operate the Google Health site until January 1, 2012.
References
[1] http:/ / www. google. com/ health [2] Lohr, Steve (2011-06-24). "Google Is Closing Its Health Records Service" (http:/ / www. nytimes. com/ 2011/ 06/ 25/ technology/ 25health. html?_r=1). The New York Times. . [3] "About Google Health" (https:/ / www. google. com/ health/ html/ about/ index. html). Google. . Retrieved 2008-05-20. [4] "Google Health: Take a Tour" (https:/ / www. google. com/ health/ html/ tour/ ). . Retrieved 2008-05-20. [5] "Google Health Data API: CCR Reference" (http:/ / code. google. com/ apis/ health/ ccrg_reference. html). . Retrieved 2008-07-11. [6] "Google Health: Frequently Asked Questions" (https:/ / www. google. com/ health/ html/ faq. html). . Retrieved 2008-05-20. [7] Vascellaro, Jessica E. (2008-05-20). "Wall Street Journal: Google Helps Organize Medical Records" (http:/ / online. wsj. com/ article/ SB121123806355705263. html). The Wall Street Journal. . Retrieved 2008-05-20. [8] "Method and apparatus for serving advertisements in an electronic medical record system" (http:/ / appft1. uspto. gov/ netacgi/ nph-Parser?Sect1=PTO2& Sect2=HITOFF& u=/ netahtml/ PTO/ search-adv. html& r=1& p=1& f=G& l=50& d=PG01& S1=20070282632. PGNR. & OS=dn/ 20070282632& RS=DN/ 20070282632). USPTO. December 6, 2007. . Retrieved 2011-06-28. [9] Lohr, Steve (2008-05-20). "New York Times: Google Offers Personal Health Records on the Web" (http:/ / www. nytimes. com/ 2008/ 05/ 20/ technology/ 20google. html). The New York Times. . Retrieved 2008-05-20. [10] Krazit, Tom. "Google tweaks Google Health dashboards" (http:/ / news. cnet. com/ 8301-30684_3-20016562-265. html?part=rss& amp;subj=news& amp;tag=2547-1_3-0-20). . Retrieved 15 September 2010. [11] "An update on Google Health and Google PowerMeter" (http:/ / googleblog. blogspot. com/ 2011/ 06/ update-on-google-health-and-google. html). . Retrieved 24 June 2011. [12] "Google Health: Partner Profiles" (https:/ / www. google. com/ health/ html/ about/ profiles. html). . Retrieved 2009-03-11. [13] https:/ / www. google. com/ health/ directory?url=gh. mediconnect. net [14] http:/ / www. theregister. co. uk/ 2010/ 01/ 29/ wiscale/ [15] "Fall update on Google Health" (http:/ / googleblog. blogspot. com/ 2009/ 10/ fall-update-on-google-health. html). . Retrieved 2009-10-07. [16] "Google Health: Terms of Service" (https:/ / www. google. com/ health/ html/ terms. html). . Retrieved 2008-05-20. [17] "Humanist Google Health Can Fix U.S. Healthcare" (http:/ / humani. st/ google-health-can-fix-us-healthcare/ ). . Retrieved 2008-05-27. [18] "RSnake picks on Google Health yes, Google wants your medical records, too!" (http:/ / blogs. zdnet. com/ security/ ?p=1166). ZDNet.com. . Retrieved 2008-07-10. [19] "In all Fairness" (http:/ / www. fredtrotter. com/ 2008/ 05/ 23/ in-all-fairness/ ). Fred Trotter. . Retrieved 2008-07-10. [20] History of the Personally Controlled Health Record (http:/ / indivohealth. org/ research): "The Indivo project has its roots in the Guardian Angel project, a collaboration between Harvard and MIT ..."; the article shows a simple timeline or pedigree of the Personally Controlled Health Record. [21] Jay Greene, CNET. " Microsoft offers transfer tool to Google Health users (http:/ / news. cnet. com/ 8301-10805_3-20080403-75/ microsoft-offers-transfer-tool-to-google-health-users/ ?part=rss& subj=news& tag=2547-1_3-0-20)." Jul 18, 2011. Retrieved Jul 18, 2011. [22] http:/ / googleblog. blogspot. com/ 2011/ 06/ update-on-google-health-and-google. html [23] http:/ / googleblog. blogspot. com/ 2011/ 06/ update-on-google-health-and-google. html
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External links
Official website (http://www.google.com/health) Google Health Integration (http://www.google.com/intl/en-US/health/about/integconsults.html) "Google Health Architecture: CCR Reference" (http://healthtechsynthesis.wordpress.com/2009/05/12/ consultant_guide_to_google_health_part_i_of_iv/). Retrieved 2010-03-31.
iMedicor
440
iMedicor
iMedicor
URL
http:/ / www. imedicor. com/
Type of site Social network service Owner Vemics, Inc.
Created by Vemics, Inc. Launched October, 2007
The iMedicor Web portal, which went live on October 10, 2007, is online personal health data exchange and secure messaging portal for physician collaboration, community and referrals. iMedicor reached its 32,000th physician registration on December 12, 2007. It has been discussed in such journals as Healthcare Informatics, Advance for Health Information Professionals [1] , Virtual Medical Worlds, and Highway Hypodermics among others and received positive review by the Internet journal Medgadget. The portal's proprietary HIPAA-compliant technology and ability to enable health providers to exchange medical record data, documentation and images distinguish it from chat-room-style portals for the medical community. The launch of iMedicors portal coincides with the entrance of Microsoft's Healthvault and Google Health into the personal health record space. iMedicor has a proprietary HIPAA-compliant interface. HIPAA, which stands for the American Health Insurance Portability and Accountability Act of 1996, is a set of strict rules to be followed by doctors, hospitals and other health care providers concerning the handling and privacy protection of vital patient medical data. Violations can result in serious fines or, in extreme cases, imprisonment. On November 20, 2007, the iMedicor portal was given a positive review by Medgadget, the influential Internet Journal of Emerging Medical Technologies.[2] The journal said that iMedicor is "strikingly different" from other medical networks such as iMedExchange and Sermo. Medgadget also stated, "The service behaves more like a typical email provider and a file sharing site, lumped together with a social network for clinicians." Some of iMedicor's partner associations include the Association of Black Cardiologists (ABC), the American Society for Hypertension (ASH), and the Hypertrophic Cardiomyopathy Association (HCA).
External links
iMedicor [3] Vemics [4]
References
[1] Advance for Health Information Professionals. (http:/ / health-information. advanceweb. com/ Article/ The-PHR-Revolution. aspx) [2] Medgadget. Tuesday, November 20, 2007 - Review of iMedicor Portal for Medical Professionals (http:/ / medgadget. com/ archives/ 2007/ 11/ imedicor. html) [3] http:/ / www. imedicor. com/ [4] http:/ / www. vemics. com/
iMedicor Announces Agreement With eRx Network - Thursday, December 06, 2007; Posted: 09:00 AM (http:// www.tradingmarkets.com/.site/news/Stock News/889796/?hcode=relatednews)
iMedicor January 14, 2008, 09:06 AM Eastern Time - American Society of Hypertension Partners with iMedicor - Online Medical Portal Tapped to Help Expand Hypertension Initiative (http://www.businesswire.com/portal/site/ google/index.jsp?ndmViewId=news_view&newsId=20080114005818&newsLang=en)
441
Microsoft Amalga
Microsoft Amalga
Original author(s) Washington Hospital Center Developer(s) Operating system Website Microsoft Health Solutions Group Windows Server Amalga's product page [1] on Microsoft's website
Microsoft Amalga Unified Intelligence System (formerly known as Azyxxi) is a unified health enterprise platform designed to retrieve and display patient information from many sources, including scanned documents, electrocardiograms, X-rays, MRI scans and other medical imaging procedures, lab results, dictated reports of surgery, as well as patient demographics and contact information. It was developed by doctors and researchers at the Washington Hospital Center emergency department in 1996, and in 2006 it was acquired by the Microsoft Health Solutions Group, as part of a plan to enter the fast-growing market for health care information technology. It has since been adopted at a number of leading hospitals and health systems across America including St Joseph Health System, New York Presbyterian Hospital, Georgetown University Hospital and five other hospitals in the MedStar Health group, a nonprofit network in the Baltimore-Washington, D.C. area.[2] Amalga can be used to tie together many unrelated medical systems using a wide variety of data types in order to provide an immediate, updated composite portrait of the patients healthcare history. [3] All of Amalgas components are integrated using middleware software that allows the creation of standard approaches and tools to interface with the many software and hardware systems found in hospitals. [3] A physician using Amalga can obtain within seconds a patient's past and present hospital records, medication and allergy lists, lab studies, and views of relevant X-rays, CT Scans, and other clips and images, all organized into one customized format to highlight the most critical information for that user. In clinical use since 1996, Amalga has the ability to manage more than 40 terabytes of data and provide real-time access to more than 12,000 data elements associated with a given patient. The system was first implemented by the Washington Hospital Center emergency department to reduce average waiting times. Since then it has also been used by the District of Columbia Department of Health for management of such mass-casualty incidents as a bioterrorism attack and in a variety of other settings in Arizona, Maryland, and Virginia. [4] The Cleveland Clinic recently installed the system in a pilot project as an imaging and data integration system.[4] Besides clinical data, Amalga is also designed to collect financial and operational data for hospital administrators. Amalga currently runs on Microsoft Windows Server operating system and uses SQL Server 2008 as the data store. At the time of acquisition, Microsoft hired Dr. Craig F. Feied, principal designer of the software, and 40 members of the development team at Washington Hospital Center. Dr. Mark Smith, who helped design the system, remained at Washington Hospital Center as director of the emergency department.[5] Since then the Amalga team has grown to include 115 members.
Microsoft Amalga
442
References
[1] http:/ / www. microsoft. com/ amalga/ products/ microsoftamalga/ default. mspx [2] Pearlstein, Steven (2005-03-04). "Innovation Comes From Within" (http:/ / www. washingtonpost. com/ wp-dyn/ articles/ A5780-2005Mar3. html). The Washington Post. . Retrieved 2006-07-27. [3] Pepus, Greg (2007-03-28). "The world of super integration" (http:/ / www. kmworld. com/ Articles/ ReadArticle. aspx?ArticleID=35771). KMWorld. . Retrieved 2006-08-08. [4] Greene, Jay (2006-10-24). "A deal they just couldn't refuse" (http:/ / www. modernhealthcare. com/ apps/ pbcs. dll/ article?Date=20061024& Category=FREE& ArtNo=61024003& SectionCat=newsletter02& Template=). Modern Healthcare Online. . Retrieved 2006-08-08. [5] Lohr, Steve (2006-07-27). "Microsoft to Offer Software for Health Care Industry" (http:/ / www. nytimes. com/ 2006/ 07/ 27/ technology/ 27soft. html?th& emc=th). The New York Times. . Retrieved 2006-07-27.
External links
Microsoft Amalga Home Page (http://www.microsoft.com/amalga/products/microsoftamalga/default.mspx)
Microsoft HealthVault
443
Microsoft HealthVault website Developer(s) Microsoft
Preview release Beta / October 4, 2007 Type Website Medical database http:/ / healthvault. com [1]
Microsoft HealthVault is a web-based platform from Microsoft to store and maintain health and fitness information.[2] [3] [4] [5] Started in October 2007, the website is accessible at www.healthvault.com [1] and addresses both individuals [6] and healthcare professionals [7].
Components
A HealthVault record [8] stores an individual's health information. Access to a record is through a HealthVault account, which may be authorized to access records for multiple individuals, so that a mother may manage records for each of her children or a son may have access to his father's record to help the father deal with medical issues. Access to the account is through Windows Live ID or a limited set of OpenID providers.
Authorization
An individual interacts with their HealthVault record through the HealthVault site, or, more typically, through an application that talks to the HealthVault platform. When an individual first uses a HealthVault application, they are asked to authorize the application to access a specific set of data types, and those data types are the only ones the application can use. An individual can also share part (some data types) or whole of their health record with another interested individual such as a doctor, a spouse, a parent, etc.
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Devices
HealthVault Connection Center allows health and fitness data to be transferred from devices (such as heart rate watches, blood pressure monitors and the Withings wifi bodyscale[9] ) into an individual's HealthVault record. It can also be used to find and download drivers for medical devices.[10] [11]
Interoperability
HealthVault supports a number of exchange formats including industry standards such as the Continuity of Care Document and the Continuity of Care Record. Support for industry standards makes it possible to integrate[12] with many personal health record solutions.
Competitors
HealthVault's primary competitors are Google Health, Dossia and World Medical Card.
HealthVault Web Applications

A comprehensive list of web applications is available at the HealthVault website listed below. ActivePHR [14]. This is released by ActiveHealth HealthUnity PHR Gateway [15]. This is released by HealthUnity PassportMD [16]. This is released by PassportMD
[13]
. Some of the notable ones are
References
[1] http:/ / www. healthvault. com [2] "Microsoft Launches 'HealthVault' Records-Storage Site" (http:/ / www. pcmag. com/ article2/ 0,1895,2191920,00. asp). PCMAG.com. . Retrieved 2008-02-04. [3] "Microsoft launches medical records site" (http:/ / www. theglobeandmail. com/ servlet/ Page/ document/ v5/ content/ subscribe?user_URL=http:/ / www. theglobeandmail. com/ servlet/ story/ RTGAM. 20071004. wgtmsfthealth1004/ BNStory/ Technology/ home& ord=18107047& brand=theglobeandmail& force_login=true). globeandmail.com. . Retrieved 2008-02-04. [4] "The vault is open" (http:/ / www. economist. com/ research/ articlesBySubject/ displaystory. cfm?subjectid=348945& story_id=9916512). economist.com. . Retrieved 2008-02-06. [5] Microsoft Launches Health Records Site (http:/ / www. foxnews. com/ wires/ 2007Oct04/ 0,4670,MicrosoftHealthVault,00. html) [6] http:/ / www. healthvault. com/ Personal/ index. html [7] http:/ / www. healthvault. com/ industry/ index. html [8] http:/ / www. healthvault. com/ personal/ index. html [9] http:/ / cln-online. org/ index. php?option=com_content& view=article& id=666:microsoftscales& catid=49:wellness& Itemid=105 [10] "Dr. Microsoft is now ready to see you" (http:/ / www. istartedsomething. com/ 20071004/ microsoft-healthvault/ ). . Retrieved 2007-10-08. [11] "HealthVault Connection Center" (http:/ / www. healthvault. com/ WhatIsConnectionCenter. htm). . Retrieved 2007-10-08. [12] "PHR integration" (http:/ / community. recordsforliving. com/ forums/ thread/ 1302. aspx). . Retrieved 2009-02-09. [13] http:/ / www. healthvault. com/ personal/ websites. html?type=application [14] http:/ / www. healthvault. com/ websites/ activehealth-activephr. html [15] http:/ / www. healthvault. com/ websites/ healthunity-phrgateway. html [16] http:/ / www. healthvault. com/ websites/ PassportMD-PassportMD. html
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External links
Microsoft HealthVault (http://www.healthvault.com/) Microsoft HealthVault Developer Center (http://msdn.microsoft.com/HealthVault) HealthVault Review: A Click away from Your Health Information (http://www.edocscan.com/ microsoft-healthvault-phr)
Patient portal
Patient Portals are healthcare-related online applications that allow patients to interact and communicate with their healthcare providers, such as physicians and hospitals. Typically, portal services are available on the Internet at all hours of the day. Some patient portal applications exist as stand-alone web sites and sell their services to healthcare providers. Other portal applications are integrated into the existing web site of the healthcare provider. Still others are modules added onto an existing electronic medical record system. What all of these share is the ability of the patient interacting with their medical information via the Internet. The lines between a electronic medical record, personal health record, and a patient portal are blurring. For example, Google Health and Microsoft HealthVault, describe themselves as personal health records (PHRs), but can interface with EMRs and communicate via the Continuity of Care Record standard, and expose patient data via the Internet so can be viewed as patient portal.
Benefits and Features of Patient Portals

The central feature which makes a system, or a part of a system, a patient portal, is the ability to expose personal, patient health information securely via the Internet. Virtually all patient portals allow the patient to interact in some way with the health care provider. Patient portals benefit both patients and health care providers by increasing efficiency and productivity. Patient portal applications might allow patients to register and complete forms online, which can streamline and shorten visits to clinics and hospitals. Many portal applications also allow patients to request prescription refills online, order eyeglasses and contacts, access medical records, pay bills, review lab results, and schedule necessary medical appointments. Patient portals also typically allow patients to directly communicate with healthcare providers by asking questions and leaving comments.
Disadvantages of Patient Portals

The major shortcoming that most patient portals have is that they are tied to only one organization. If a patient travels to many organizations for their healthcare they normally need to log into each organizations portal to get access to their information. This results in a fragmented view of their data.
Practice Portals
Portal applications for practices typically exist in tandem with patient portals, allowing access to patient information and records, as well as schedules, payments, and messages from patients.[1] Most patient portals require the practice to have some type of electronic medical record or patient management system, as the patient data needs to be stored in a data repository then retrieved by the patient portal.
Patient portal
446
Security
Health care providers in the US are bound to comply with HIPAA regulations. These regulation specify what patient information must be held in confidence. Something as seemingly trivial as a name is viewed by HIPAA as protected health information. For this reason, security has always been a top concern for the industry when dealing with the adoption of patient portals. While there may be systems that are not HIPAA compliant, certainly most patient and practice portals are secure and compliant with HIPAA regulations. The use of SSL and access control patterns are commonplace in the industry. Patient access is typically validated with a user name and password.[2].
History
Internet portal technology has been in common use since the 90s. The financial industry has been particularly adept at using the Internet to grant indivdual users access to their information. Possibly because of the strictness of HIPAA regulations, or the lack of financial incentives for the health care providers, the adoption of patient portals has lagged behind other market segments. The American Recovery and Reinvestment Act of 2009 (ARRA) in particular the HITECH Act inside the ARRA sets aside approximately $19 Billion for Health IT. The funding will offset, potentially pay for electronic medical records systems for practicing physicians. Because the conversion to EMR is typically complex, a likely upshot of the transition to EMR is a transition first to patient portals followed by a complete conversion to a full blown EMR. At the same time as the conversion to patient portals and EMR systems, PHRs, personal health record systems, are becoming more common and available. Currently, an individual's health data are primarily in physicians' files. It is for this reason that patient portals exist - to give the patient a view into their information. Given the mobility of patients, and the development of clear interoperable standards, the best documentation of patients history could be data outside the physicians office. At that point we will begin seeing physician portals.
The Future of Patient Portals

E-visits may soon be one of the most commonly used options of patient portals that are available. The best demographic for e-visits are patients who live far away from their clinics, have kids, or who dont want to spend 2-4 hours for a trip to the doctor when all they need is a quick answer or diagnosis for a minor symptom. Some possible symptoms could be common cold, sinus infections, urinary problems, cough, diarrhea and back pain. Providing a route for patients to take that does not require them to come to the clinic benefits them and your organization. Many organizations find that overall utilization drops when e-visits are implemented, some places by as much as 25%. This makes e-visits a very interesting proposition for insurance companies, although few actually re-imburse for them currently. E-visits, with the proper functionality, also allow the patient to update their allergies, vital signs, and history information. Providing e-visits allows the standard healthcare organization to offer a product that can compete on price with the retail clinics that are popping up in strip malls and Walmart.
References
[1] http:/ / practiceportals. com/ [2] http:/ / cms. hhs. gov/ EducationMaterials/ Downloads/ HIPAAChecklist. pdf
Virtual patient
447
Virtual patient
The term virtual patient is used to describe interactive computer simulations used in health care education.[1] The special focus is targeted on the simulation of clinical processes with virtual patients. Virtual patients combine scientific excellence, modern technologies and the innovative concept of game-based learning. Virtual patients allow the learner to take the role of a health care professional and develop clinical skills such as making diagnoses and therapeutic decisions[2] The use of virtual patient programmes is increasing in healthcare education, partly in response to increasing demands on health care professionals and education of students but also because they allow opportunity for students to practice in a safe environment[2] There are many different formats a virtual patient may take. However the overarching principle is that of interactivity - a virtual patient will have mechanisms for the learner to interact with the case and material or information is made available to the learner as they complete a range of learning activities[3] The interactivity is non-sequential.
Forms of Virtual Patients

Virtual patients may take a number of different forms: Artificial patients: computer simulations of biochemical processes such as the effect of drugs in organisms, the physiologic processes of a given organ or entire systems (systems biology) in a given organism. These can be used in different phases of a compound or drug in development in a given pharmacological research as a preliminary to testing on animals and humans for the drug development processes. Real patients: reflected in data e.g. electronic health records (EHRs). In this case the virtual patient is the reflection of the real patient in terms of data held about them. These are sometimes called e-patients. Physical simulators: mannequins (sometimes spelled 'manikins'), models or related artefacts. Simulated patients: where the patient is recreated by humans or computer-generated characters [4] and Virtual Humans [5] acting as such or engaging in other kinds of role-play. Electronic case-studies and scenarios where users work through problems, situations or similar narrative-based activities.
Types of Interaction with Simulated or Electronic Patients

A number of different modes of virtual patient delivery have been defined [6]: Predetermined scenario [directed mode] The learner may build up the patient or case data from observations and interactions [blank mode] The learner may view and appraise or review an existing patient or scenario [critique mode or rehearsal mode] The VP may be used as a mechanism to address particular topics [context mode] The learner may use a scenario or patient to explore personal/professional dimensions [reflective mode] Banks of patients or scenarios may collectively address broad issues of healthcare [pattern mode]
Virtual patient
448
Types of Interaction with Artificial Patients

To create and run a mathematical quantitative simulation of a healthy person (physiology) and diseased person to test multiple hypothesis against known and unknown processes in a given set or sets of processes to help fill gaps in knowledge of the physiology or system under investigation.
Possible Benefits of Physical Simulators and Simulated Patients

Simulated patients increase the availability of training opportunities for medical students, making them less dependent on actual cases to learn how to handle different situations. Unlike real patients, simulated patients can be accessed on demand and they can be endlessly replayable to allow the user to explore different options and strategies. They can be structured with narratives that represent real situations while challenging the user with a wide range of tasks. Despite their efficacy simulated patients are still a tangent and a prosthesis to reality. They should be viewed as augmenting existing modes and methods of clinical teaching.
Possible Benefits of Artificial Patients

Artificial patients increase the possibility of exploring millions of hypothesis driven experiments on known areas of biological systems to extrapolate the unknown, which enables efficient exploration, informed research and development predictive simulation, which must also be proven by real patient studies clinical trial. If more tests can be done on Artificial patients to filter out possibly unnecessary tests or experiments, fewer subjects pharmacovigilance maybe needed. The Artificial patients insilico modeling are still in the early to middle developmental stages. It will require continual updates and development with the endless availability of new data.
Virtual Patient Data Standards

The MedBiquitous consortium [7] established a working group in 2005 to create a free and open data standard for expressing and exchanging virtual patients between different authoring and delivery systems. This was in part to address the problem of exchanging and reusing virtual patients and in part to encourage and support easier and wider use of virtual patients in general. This standard has been very successful and is now widely adopted, eg in major projects like eViP. In 2010, this standard attained status as an ANSI standard. American_National_Standards_Institute
Examples
Electronic Cases [8] (SIMPLE, CLIPP, fmCASES, WISE-MD) WebSP from Karolinska Institutet [9] Virtual Patients from Harvard Medical School [10] Virtual Patient Project from New York University [11] Virtual Patients from Centre for Virtual Patients (University of Heidelberg) [12] OpenLabyrinth from Canada [13] Labyrinth from the University of Edinburgh [14] TUSK Case Simulator from Tufts University [15] Virtual Patient from Keele University School of Pharmacy [16]
Virtual Patients Group Consortium at the University of Florida, University of Central Florida, Medical College of Georgia, and University of Georgia [17] [18] (A whole virtual clinic with 25 different faculties and offer 250 virtual patients)
Virtual patient Simulators Limbs and Things simulators [19] SimMan simulator [20] Harvey mannequin Virtual physiology Entelos PhysioLabs / Biologic Systems / Quantitative Mathematical Models [21]
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External links
MedBiquitous Virtual Patient Working Group [22] The electronic Virtual Patient (eViP) programme [23] eLearning since 1996 [24]
Notes and references

[1] JiSC (2009) Repurposing existing virtual patients. Available http:/ / www. jisc. ac. uk/ whatwedo/ programmes/ elearningcapital/ reproduce/ revip. aspx accessed 08.06.09 [2] Imison M, Hughes C(2008) The virtual patient project: using low fidelity, student generated online case studies in medical education. in Hello? Where are you in the landscape of educational technology? Proceedings ascilite Melbourne 2008.http:/ / www. ascilite. org. au/ conferences/ melbourne08/ procs/ imison. pdf [3] Ellaway R (2009) Modelliing virtual patients and virtual cases. Available http:/ / meld. medbiq. org/ primers/ virtual_patients_cases_ellaway. htm [4] http:/ / www. cise. ufl. edu/ research/ vegroup/ vp. html [5] http:/ / vrpsych. ict. usc. edu/ Virtual_Patient_Projects. html [6] http:/ / meld. medbiq. org/ primers/ virtual_patients_cases_ellaway. htm [7] http:/ / www. medbiq. org/ [8] http:/ / med-U. org [9] http:/ / websp. lime. ki. se/ [10] http:/ / research. bidmc. harvard. edu/ VPTutorials/ [11] http:/ / www. tinkering. net/ vp/ [12] http:/ / www. campusvirtualpatients. com/ [13] http:/ / openlabyrinth. ca/ [14] http:/ / labyrinth. mvm. ed. ac. uk/ [15] http:/ / tusk. tufts. edu/ view/ url/ H1185C/ 471802/ 490012/ [16] http:/ / www. keele. ac. uk/ schools/ pharm/ vp/ [17] http:/ / www. virtualpatientsgroup. com/ [18] http:/ / www. inmedea-simulator. net [19] http:/ / www. limbsandthings. com/ [20] http:/ / www. laerdal. com/ document. asp?docid=1022609 [21] http:/ / www. entelos. com/ [22] http:/ / www. medbiq. org/ working_groups/ virtual_patient/ index. html [23] http:/ / www. virtualpatients. eu [24] http:/ / inmedea. com
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Clinical Research Informatics

Translational research informatics
Translational Research Informatics (TRI) is a sister domain to or a sub-domain of Biomedical informatics or Medical Informatics concerned with the application of informatics theory and methods to translational research. There is some overlap with the related domain of Clinical Research Informatics, but TRI is more concerned with enabling multi-disciplinary research to accelerate clinical outcomes, with clinical trials often being the natural step beyond translational research. Translational Research as defined by the National Institutes of Health [1] includes two areas of translation. One is the process of applying discoveries generated during research in the laboratory, and in preclinical studies, to the development of trials and studies in humans. The second area of translation concerns research aimed at enhancing the adoption of best practices in the community. Cost-effectiveness of prevention and treatment strategies is also an important part of translational research.
Overview of Translational Research Informatics

Translational Research Informatics can be described as An integrated software solution to manage the: (i) logistics, (ii) data integration, and (iii) collaboration, required by translational investigators and their supporting institutions. It is the class of informatics systems that sits between and often interoperates with: (i) Health Information Technology/Electronic Medical Record systems, (ii) CTMS/Clinical Research Informatics, and (iii) statistical analysis and data mining. Translational Research Informatics is relatively new, with most CTSA [2] awardee academic medical centers actively acquiring and integrating systems to enable the end-to-end TRI requirements. One advanced TRI system is being implemented at the Windber Research Institute in collaboration with GenoLogics [3] and InforSense. Translational Research Informatics systems are expected to rapidly develop and evolve over the next couple of years.
Systems in Translational Research Informatics

System Type Translational Study Management Electronic Patient Questionnaires Clinical Information Management Biorepository Management Systems Laboratory Information Management Systems Systems Biology / Science Data Management Research Collaboration System Description of System Systems to manage investigator lead biomarker validation studies / outcomes / observational studies.
Web based forms for capturing participant demographic, condition, treatment, and outcomes information.
Systems to integrate clinical annotations extracted from various sources systems, like HL7 Electronic Medical Records, Cancer Registries, Clinical Data Management Systems, and Clinical Data Warehouses. Manage biospecimens derrived from study participants, operating rooms, etc.
Systems to manage clinical, analytical, and life sciences core technology laboratories - often conducting genomics, proteomics, metabolomics, molecular imaging, peptide synthesis, flow cytometry, etc. A data base and content management system to archive raw instrument files and database science results data.
A software solution to enable investigators and their research teams to share project information, results data, and insights.
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CTRI Dedicated WIKI

Further discussion of this domain can be found at the Clinical Research Informatics Wiki (CRI Wiki) dedicated to issues in Clinical and Translational Research Informatics.
[4]
, a wiki
Related Web Sites

ResearchInformatics.org [5] NIH Roadmap [6] Clinical and Translational Science Awards [7] American Medical Informatics Association (AMIA) [8]
References
[1] [2] [3] [4] [5] [6] [7] [8] http:/ / www. nih. gov/ http:/ / www. ctsaweb. org/ http:/ / www. genologics. com http:/ / www. researchinformatics. org/ index. php?option=com_mambowiki& page=Main_Page& page_heading=CRI%20Wiki& show_pageheading=1& allowanonymoususers=0 http:/ / www. researchinformatics. org http:/ / nihroadmap. nih. gov/ http:/ / ctsaweb. org/ http:/ / www. amia. org
Clinical trial management

A clinical trial is the application of the scientific method to human health. Since such trials require the use of human test subjects and can severely impact the well-being of the subjects, as well as treatments of other people and large amounts of capital for those performing the trial, the proper management of clinical trials
Recruitment
Over the last ten years, getting patients and doctors into clinical trials has become the most delay-ridden aspect of the drug discovery and development process. When implemented effectively, clinical trial recruitment (CTR) initiatives can be highly successful. Time lines can be dramatically reduced and recruitment targets can be met ahead of schedule; every day saved in the progression to marketing authorization can equate to millions of pounds made in patent-protected sales revenue. However, great care is needed in the development of a CTR program. Considerable ethical scrutiny is applied to all patient recruitment materials and initiatives. For example, in 2002 the European Commission issued guidelines for consultation which require patient advertising and details of recruitment initiatives to be submitted to appropriate ethics committees. Unfortunately, there is no simple code of established practice, no unified regulatory body and no recourse to appeal. If an ethics committee doesn't like what a CRO has planned, the CRO can't use it. In Europe, this aspect has yet to be effectively addressed. Enhancing CTR is obviously an area in which great caution is required. Some investigating doctors, for example, question the need for extra activities as, they claim, there are sufficient numbers of suitable patients among those already attending their clinics. However, practical experience has shown that this is an over-estimation of the number of patients that physicians will be able to recruit and it is estimated that only about 10% of a physicians patients will actually wish to enroll in a clinical trial.
Clinical trial management Perhaps more importantly, there are also objections raised from within the industry. These usually centre on a highly cautious approach to the ethics and legitimacy of patient-facing initiatives. Some nervousness is understandable given the strict controls that govern DTC marketing but for clinical research there is a critical need for increased patient understanding and education. The signs are that the caution of the industry is slowly giving way to a new openness and confidence. A review of recent press coverage also highlights a deep skepticism of industry involvement in clinical research. If not approached ethically, a firms CTR campaign can leave them wide open to aggressive media criticism and adverse advocacy relationships. The key point to remember is that the objective of all this work is ultimately to improve care for the patient. A strenuous effort to maintain this focus throughout clinical development will ultimately allow pharma companies to reap considerable rewards. Over the past several years these problems have been addressed in the US, where clinical research receives more and more active support of government bodies, advocacy groups, charities and patient groups. This provides a collaborative environment and ensures that there is always an independent counterpoint when the integrity of industry-sponsored studies is attacked. The American public sees a vast amount of government-sponsored education, designed to maximize understanding of clinical trials. A quick look at Cancer.gov and ClinicalTrials.gov, both run by the National Institutes of Health, illustrates just how much work is being done. This in turn is supported by private efforts such as Centerwatch.com, which currently offers a 300-page book on informed consent for patients. Additionally, patient groups and organizations have formed new initiatives to increase education about and participation in clinical trials for specific diseases. For example, people with Parkinson's disease can use PDtrials to find up-to-date information on Parkinsons trials currently enrolling participants in the U.S. and Canada and search for specific Parkinsons trials using criteria such as location, trial type, and symptom.[1] Other disease-specific services exist for recruiting patients with other conditions as well.
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Public-private partnership
The nature of American healthcare provision no doubt motivates patients to seek free or subsidized medication, but the investment, approach and partnerships in the US are demystifying clinical trials and generating considerable goodwill toward industry-driven research. A recently announced US public-private partnership, designed to improve trial recruitment, demonstrates how support for industry research can be broadened. The initiative created a $6 million fund, which the contributing pharma companies and National Cancer Institute will use to accelerate patient recruitment for Phase I and II cancer studies. Naturally, the credibility of the public bodies involved enhances the effectiveness of the scheme.
Study designs and methods

A common pitfall is insufficiently rigorous evaluation of study designs and methods. A "straw poll" during a clinical project management training course revealed that virtually all clinical protocols have at least one amendment during the study. The reasons appear to cover the full range, from reliance on well-established designs without allowing newer, more creative ideas to be considered and, at the other extreme, not testing new methods for the current application. For example, in a recent angina study, treadmill exercise testing was used as the primary efficacy criterion. This is, of course, extremely well validated methodology, but, in this case, the patients were elderly, so the exercise protocol was substantially modified to reduce the physical demand. The problem was that with such a mild exercise protocol, less than half the patients recruited showed sufficient electrocardiogram (ECG) changes to qualify for randomization. A quick pilot study would have alerted the sponsors before committing to major cost.[2]
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Risk management
All research and development must involve some risk. Some of the risks are typically encountered in the main stages of a typical clinical trial. The basic risks that are associated with clinical Trial are: Enrollment of the subject at the sites within the projected time line Failure of the molecule e.g. efficacy , Safety of the subjects e.g. number of SAEs reported to the enrolled subjects(Since DSMB analyse the trial data different time intervals during the study and if they find any risk associated to the patients safety at any time the trial may be terminated. Helping subject and sites comply with the complex demands of the clinical protocol. Reducing subject early withdrawal and lost to follow up Technology is playing an increasingly important role in reducing risks while also driving down costs.
Risk distribution
Delivering the results on time, to the required standard, may have a lower risk in phase I than in later phases, mainly because subjects are healthy and not potentially complicated patients, and thus, recruitment can be predicted with some confidence. However, first administration to humans is something of a leap into the unknown, and safety problems are always to be considered. What is possibly less obvious is the risk of any early-phase design errors to later phases and to the whole drug project. Once phase III is imminent, perhaps there is a degree of confidence emerging, as much more is known about the drug. The requirement for phase III, therefore, may be seen as accumulating data to enable a product license application. In fact, the great expansion of activity dictated by phase III studies introduces even more complexity and a new set of risks. The application of the drug to a more realistic clinical setting means that we will not necessarily by studying "clean" patients. Patients will often have other diseases on top of that under study and will only be under observation for a small proportion of the time. Attention to clinical protocol design, thus, is at least as critical as in phases I-II.
Key tasks and external agencies

The most common reason for late tasks and projects is that they are started late. Before patients can be screened for entry, a well-established set of start-up tasks must be completed, and of these, some are relatively easy to plan, and others are less predictable. Those relying on internal agreements (e.g., drug supplies, protocol sign-off), can be expedited by instilling the right culture of negotiation between departments and individuals. But what of the external elements, particularly regulatory and ethics approvals? The former is, fortunately, reasonably easy to plan, because, in most countries, there are clear limits to the time and effort required to meet regulatory requirements. Much more difficult is the matter of approval of ethical standards. Across the EU, as well as in Australia, Canada, and USA, ethics committees' practices may vary enormously so that, when planning a multinational study, good local knowledge is crucial. Even inside the borders of the same country or state there is often inconsistency, especially since the demise of single central approval for multicenter studies<noref>. Theoretically, local research ethics committees (IRBs) are expected to follow Department of Health guidelines, but, if they choose not to do so, there is apparently no redress, so one may be presented with unexpected delays in particular centers because of widely varying IRBs' practices. There is a move toward rationalization in the form of a two-level approval process. A central committee will review the study and, if approved, pass it on to local committees for ratification. Within the U.S., the Institutional Review Board (IRB) has clearly defined responsibilities and reporting lines. In Australia, central approval is still possible, and the ethics committee sees itself more as a partner in research than as a regulator; a very rapid start-up of studies is possible.
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References
[1] http:/ / www. pdtrials. org/ en/ about_PDtrials_what [2] value management approach to clinical trials project management (http:/ / blog. parallelprojecttraining. com/ project-management-articles/ value-management-approach-to-clinical-trials-project-management-a-white-paper-by-paul-naybour-and-roger-joby/ )
Chow S-C and Liu JP (2004). Design and Analysis of Clinical Trials : Concepts and Methodologies, ISBN 0-471-24985-8 Pocock SJ (1983), Clinical Trials: A Practical Approach, John Wiley & Sons, ISBN 0-471-90155-5
Clinical data management system

A clinical data management system or CDMS is a tool used in clinical research to manage the data of a clinical trial. The clinical trial data gathered at the investigator site in the case report form are stored in the CDMS. To reduce the possibility of errors due to human entry, the systems employ different means to verify the data. 'Classification The CDMS can be broadly divided into Paper based and electronic data capturing system. Paper Based Systems Case report forms are manually filled at site and mailed to the company for which trial is being performed. The data on forms is transferred to the CDMS tool through data entry.The most popular method being double data entry where two different data entry operators enter the data in the system independently and both the entries are compared by the system. In case the entry of a value conflicts, system alerts and a verification can be done manually. Another method is Single Data Entry. The Data in CDMS is then transferred for the data validation. Also, in these systems during validation the data clarification from sites are done through paper forms which are printed with the issue description and sent to the investigator site and site responds by answering on forms and mailing it back. Electronic Data Capturing System In such CDMS the investigators directly uploads the data on CDMS and the data can then be viewed by the data validation staff. Once the data is uploaded by site, data validation team can send the electronic alerts to sites if there is any issue. Such systems nullifies the paper usage in Clinical trials validation of data. 'Clinical Data Management Once the data has been screened for typographical errors, the data can be validated to check for logical errors. An example is a check of the subject's age to ensure that they are within the inclusion criteria for the study. These errors are raised for review to determine if there is an error in the data or clarification from the investigator is required. Another function that the CDMS can perform is the coding of data. Currently, the coding is generally centered around two areas; adverse event terms and medication names. With the variance on the number of references that can be made for adverse event Terms or medication names, standard dictionaries of these terms can be loaded into the CDMS. The data items containing the adverse event terms or medication names can be linked to one of these dictionaries. The system can check the data in the CDMS and compare it to the dictionaries. Items that do not match can be flagged for further checking. Some systems allow for the storage of synonyms to allow the system to match common abbreviations and map them to the correct term. As an example, ASA could be mapped to Aspirin, a common notation. Popular adverse event dictionaries are MedDRA and WHOART and popular Medication dictionaries are COSTART and WHO Drug Dictionary. At the end of the clinical trial the dataset in the CDMS is extracted and provided to statisticians for further analysis. The analysed data is compiled into clinical study report and sent to the regulatory authorities for approval.
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References
Stuart Summerhayes, CDM Regulations Procedures Manual, Blackwell Publishing, ISBN 1-4051-0740-5 Tai BC, Seldrup J., A review of software for data management, design and analysis of clinical trials, Ann Acad Med Singapore. 2000 Sep;29(5):576-81. Greenes RA, Pappalardo AN, Marble CW, Barnett GO., Design and implementation of a clinical data management system, Comput Biomed Res. 1969 Oct;2(5):469-85.
External links
Clinical Trial Management Systems [1] (caBIG) Association for Clinical Data Management [2] (ACDM) Society for Clinical Data Management [3] (SCDM) Data Quality Research Institute [4] (DQRI)
References
[1] https:/ / cabig. nci. nih. gov/ workspaces/ CTMS [2] http:/ / www. acdm. org. uk/ [3] http:/ / www. scdm. org/ [4] http:/ / www. dqri. org/
Case report form

A Case Report Form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. The Case Report Form is the tool used by the sponsor of the clinical trial to collect data from each participating site. All data on each patient participating in a clinical trial are held and/or documented in the CRF, including adverse events. The sponsor of the clinical trial develops the CRF to collect the specific data they need in order to test their hypotheses or answer their research questions. The size of a CRF can range from a handwritten one-time 'snapshot' of a patient's physical condition to hundreds of pages of electronically captured data obtained over a period of weeks or months. (It can also include required check-up visits months after the patient's treatment has stopped.) The sponsor is responsible for designing a CRF that accurately represents the protocol of the clinical trial, as well as managing its production, monitoring the data collection and auditing the content of the filled-in CRFs. Case report forms contain data obtained during the patient's participation in the clinical trial. Before being sent to the sponsor, this data is usually de-identified (not traceable to the patient) by removing the patient's name, medical record number, etc., and giving the patient a unique study number. The supervising Institutional Review Board (IRB) oversees the release of any personally identifiable data to the sponsor. From the sponsor's point of view, the main logistic goal of a clinical trial is to obtain accurate CRFs. However, because of human and machine error, the data entered in CRFs is rarely completely accurate or entirely readable. When the study administrators or automated mechanisms process the CRFs that were sent to the sponsor by local researchers, they make a note of queries. Queries are non-sensible or questionable data that must be explained. Examples of data that would lead to a query: a male patient being on female birth control medication or having had an abortion, or a 15-year old participant having had hip replacement surgery. Each query has to be resolved by the individual attention of a member of each local research team, as well as an individual in the study administration. To ensure quality control, these queries are usually addressed and resolved before the CRF data is included by the sponsor in the final clinical study report. Depending on variables relating to the nature of the study, (e.g., the health of the study population), the effectiveness of the study administrators in resolving these queries can significantly impact the cost of studies.
Case report form
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References
Debbie Kennedy, CRF Designer, Canary Publications, ISBN 0-9531174-7-2
External links
International Clinical Sciences Support Center (ICSSC) CRF Development [1] Standardized Case Report Form (CRF) Work Group [2] - National Cancer Institute Standard Operating Procedure Develop and Manage a Case Report Form [3] links to CRF information (PDF) Clinical Trials Software - Case Report Forms [4]
References
[1] http:/ / www. icssc. org/ services/ services-crfdevelopment. html [2] https:/ / cabig. nci. nih. gov/ workspaces/ CTMS/ CTWG_Implementation/ crf-standardization-sig [3] https:/ / cabig. nci. nih. gov/ workspaces/ CTMS/ Meetings/ SIGs/ Best_Practices/ SOPs/ CR003_SOP_Develop_Manage_CRF. pdf#search=%22%22Case%20Report%20Form%22%20standardization%22 [4] http:/ / www. entrypointplus. com/ casereportforms. htm
Clinical coder
A clinical coder also known as diagnostic coder, medical coder or medical records technician is a health care professional whose main duties are to analyse clinical statements and assign standard codes using a classification system. The data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education. For example, a clinical coder may use a set of published codes on medical diagnoses and procedures, such as the International Classification of Diseases or the Common Coding System for Healthcare Procedures, for reporting to the health insurance provider of the recipient of the care.[1] [2] The use of standard codes allows insurance providers to map equivalencies across different service providers who may use different terminologies or abbreviations in their written claims forms, and be used to justify reimbursement of fees and expenses. The codes may cover topics related to diagnoses, procedures, pharmaceuticals or topography. The medical notes may also be divided into specialities for example cardiology, gastrointerology, nephrology, neurology or orthopedic care. A clinical coder therefore requires a good knowledge of medical terminology, clinical documentation, legal aspects of health information, health data standards, classification conventions, and computer- or paper-based data management, usually as obtained through formal education and/or on-the-job training.[3] [4]
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Clinical coders in practice

The basic task of a clinical coder is to classify medical and health care concepts using a standardised classification. Most clinical coders are employed in coding inpatient episodes of care. However, mortality events, outpatient episodes, general practitioner visits and population health studies can all be coded. Clinical coding has three key phases: a) Abstraction; b) Assignment; and c) Review.[5]
Abstraction
The abstraction phase involves reading the entire record of the health encounter and analysing the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical record, such as clinical notes, laboratory and radiology results, and operation notes.
Assignment
The assignment phase has two parts: finding the appropriate code(s) from the classification for the abstraction; and entering the code into the system being used to collect the coded data.
Review
Reviewing the code set produced from the assignment phase is very important. Clinical coder must ask themselves, "does this code set fairly represent what happened to this patient in this health encounter at this facility." By doing this, clinical coders are checking that they have covered everything that they must, but not used extraneous codes. For health encounters that are funded through a case mix mechanism, the clinical coder will also review the diagnosis-related group to ensure that it does fairly represent the health encounter.
Competency levels
Clinical codes may have different competency levels depending on the specific tasks and employment setting:[6] Entry-level coder: someone who has completed (or nearly completed) an introductory training course in clinical classification, and whose work is typically checked by an experienced coder before being used. Intermediate level coder: has acquired the skills necessary to code many cases independently. Coders at this level are also able to code cases with incomplete information. They have a good understanding of anatomy and physiology along with disease processes. Intermediate level coders have their work audited periodically by an Advanced coder. Advanced level coder: authorized to code all cases including the most complex. Advanced coders will usually be credentialled and will have several years experience. An advanced coder is also able to train entry-level coders. Nosologist: understands how the classification is underpinned. Nosologists consult nationally and internationally to resolve issues in the classification and are viewed as experts who can not only code, but design and deliver education, assist in the development of the classification and the rules for using it. Nosologists are usually expert in more than one classification, including morbidity, mortality and casemix. In some countries the term "nosologist" is used as a catch-all term for all levels.[7] In some countries, clinical coders may seek voluntary accreditation through assessments conducted by professional associations or health authorities.[8]
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Classification types
Clinical coders may use many different classifications, which fall into two main groupings: statistical classifications and nomenclatures. A statistical classification brings together similar clinical concepts and groups them into one category. This allows the number of categories to be limited so that the classification does not become too big. An example of this is in ICD-10 at code I47.1. The code title (rubric) is Supraventricular tachycardia. However, there are several other clinical concepts that are also classified here. Amongst them are paroxysmal atrial tachycardia, paroxysmal junctional tachycardia, auricular tachycardia and nodal tachycardia. In a nomenclature there is a separate listing and code for every clinical concept. So, in the example in the previous paragraph, each of the tachycardia listed would have its own code. This makes nomenclatures unwieldy for compiling health statistics.
Professional associations
There are several associations that medical coders in the United States may join, including the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders.[9] Other national associations include the Health Information Management Association of Australia (HIMAA) and the Canadian Health Information Management Association (CHIMA).[8]
References
[1] Marie A. Moisio (2000). A Guide to Health Insurance Billing. Thomson Delmar Learning. ISBN0766812073. [2] Michelle A. Green and JoAnn C. Rowell (2011). Understanding Health Insurance, A Guide to Billing and Reimbursement, 10e. Cengage Learning. ISBN9781111035181. [3] World Health Organization. Classifying health workers: Medical records and health information technicians. Geneva, 2010. [4] Department of Human Services, Victoria, Australia. Clinical Coders Creed. (http:/ / www. dhs. vic. gov. au/ ahs/ archive/ hdss/ 13-19720. htm#clinical) Health Data Standards and Systems Bulletin, Issue 13, 19 July 2000. [5] Wooding A (2004). "Clinical coders and decision making". HIM J 33 (3): 7983. PMID18490784. [6] Walker S (2006). "Capturing health informationa perspectives paper". HIM J 35 (3): 1322. PMID18195424. [7] Nosologist. (http:/ / www. popsci. com/ scitech/ article/ 2004-11/ nosologist) Popular Science, posted 11.11.2004. [8] Bramley M, Reid B. "Evaluation standards for clinical coder training programs." (http:/ / www. himaa. org. au/ members/ journal/ HIMJ_36_3_2007/ Bramey and Reid Evaluation standards for clinical coder training programs. pdf) Health Information Management Journal, 36(3), 2007. [9] American Academy of Professional Coders (http:/ / www. aapc. com/ )
External links
WHO Family of International Classifications (http://www.who.int/classifications/en/) American Health Information Management Association (http://www.ahima.org) Canadian Health Information Management Association (http://www.eCHIMA.ca) National Library of Medicine (http://www.nlm.nih.gov/research) (U.S.) School listings: Medical Billing and Coding Certification (http://www.allalliedhealthschools.com/faqs/ medical-coding-licensing.php) (U.S.) Information on Medical Billing and Coding (http://medicalbillingandcode.com/) Professional career in U.S
Clinical data acquisition
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Acquisition or collection of clinical trial data can be achieved through various methods that may include, but are not limited to, any of the following: paper or electronic medical records, paper forms completed at a site, interactive voice response systems, local electronic data capture systems, or central web based systems. There is arguably no more important document than the instrument that is used to acquire the data from the clinical trial with the exception of the protocol, which specifies the conduct of that clinical trial. The quality of the data collected relies first and foremost on the quality of that instrument. No matter how much time and effort go into conducting the clinical trial, if the correct data points were not collected, a meaningful analysis may not be possible. It follows, therefore, that the design, development and quality assurance of such an instrument must be given the utmost attention. The ICH guidelines on Good clinical practice (GCP) use the term Case report form or CRF to refer to these systems 1 . No matter what CRF is utilized, the quality and integrity of the data is of primary importance. The following recommendations are meant to assist in the design, development and quality assurance of the CRF such that the data collected will meet the highest standards. For an extensive discussion regarding creation of CRFs and examples of actual data collection forms, see Data Collection Forms for Clinical Trials by Spilker 2 . The following is meant to highlight some of the most important points to consider during the design process.
Minimum standards
Design the CRF to collect the data specified by the protocol. Document the process for CRF design, development, approval and version control. Make the CRF available at the clinical site prior to enrollment of a subject. Document training of clinical site personnel on the protocol, CRF completion instructions and data submittal procedures prior to enrollment of a subject.
Best practices
Design the CRF along with protocol to assure collection of only the se data the protocol specifies. Keep questions, prompts and instructions clear and concise. Design the CRF to follow the data flow from the perspective of the person completing it, taking into account the flow of study procedures and typical organization of data in a medical record. Avoid referential and redundant data points within the CRF whenever possible. If redundant data collection is used to assess data validity, the measurements should be obtained through independent means. Design the CRF with the primary safety and efficacy endpoints in mind as the main goal of data collection. Establish and maintain a library of standard forms. Make the CRF available for review at the clinical site prior to approval. Use NCR (no carbon required) paper or other means to assure exact replicas of paper collection tools.
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References
Debbie Kennedy, CRF Designer, Canary Publications, ISBN 0-9531174-7-2 Rebecca Daniels Kush (2003), eClinical Trials: Planning and Implementation, CenterWatch / Thomson Healthcare, ISBN 1-930624-28-X Spilker B.L. Schoenfelder J. (1991), Data Collection Forms in Clinical Trials Raven Press, New York.
External links
FDA Website: Clinical Data Management Regulations [1] Association For Clinical Data Management [2] Society For Clinical Data Management [3]
References
[1] http:/ / www. fda. gov/
Data clarification form

A Data Clarification Form (DCF) or Data Query Form (DQF) is a questionnaire specifically used in clinical research. The DCF is the primary data clarification tool from the trial sponsor or Contract Research Organization (CRO) towards the investigator to clarify discrepancies and ask the investigator for clarification. The DCF is part of the data validation process in a clinical trial. In clinical trials, the data validation step and asking the investigator for clarification of discrepancies (data cleaning) is an important step towards creating a clean dataset suitable for statistical analysis of the clinical trial outcome.
References
Celine Clive (2004), Handbook of SOPs for Good Clinical Practice, CRC, ISBN 0-8493-2181-6
External links
DCF entry in Clinical Research Dictionary [1]
References
[1] http:/ / www. med. umich. edu/ cacr/ dictionary/ D-F. htm
Patient-reported outcome
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A patient-reported outcome or PRO is a questionnaire used in a clinical trial or a clinical setting, where the responses are collected directly from the patient.
Overview
PRO is an umbrella term that covers a whole range of potential types of measurement but is used specifically to refer to self-reports by the patient. PRO data may be collected via self-administered questionnaires completed by the patient themselves or via interviews. The latter will only qualify as a PRO where the interviewer is gaining the patients views, not where the interviewer uses patient responses to make a professional assessment or judgment of the impact of the patients condition. Thus, PROs are a means of gathering patient rather than clinical or other views on outcomes.
Characteristics
A well-designed PRO questionnaire should assess either a single underlying characteristic or, where it addresses multiple characteristics, should be a number of scales that each address a single characteristic. These measurement characteristics are termed constructs and the questionnaires used to collect them, termed instruments, measures, scales or tools. A questionnaire that measures a single construct is described as unidimensional. Items (questions) in a unidimensional questionnaire can be added to provide a single scale score. However, it cannot be assumed that a questionnaire is unidimensional simply because the author intended it to be. This must be demonstrated empirically (for example, by confirmatory factor analysis or Rasch analysis). A questionnaire that measures multiple constructs is termed multi-dimensional. A multi-dimensional questionnaire is used to provide a profile of scores; that is, each scale is scored and reported separately. It is possible to create an overall (single summary) score from a multi-dimensional measure using factor analysis or preference-based methods but some may see this as akin to adding apples and oranges together. Questionnaires may be generic (designed to be used in any disease population and cover a broad aspect of the construct measured) or condition-targeted (developed specifically to measure those aspects of outcome that are of importance for a people with a particular medical condition). The most commonly used PRO questionnaires assess one of the following constructs: Symptoms (impairments) and other aspects of well-being Functioning (disability) Health status General health perceptions Quality of life (QoL) Health related qualiy of life (HRQoL) Reports and Ratings of health care.
Measures of symptoms may focus on a range of impairments or on a specific impairment such as depression or pain. Measures of functioning assess activities such as personal care, activities of daily living and locomotor activities. Health-related quality of life instruments are generally multi-dimensional questionnaires assessing a combination of aspects of impairments and/or disability and reflect a patients health status. In contrast, QoL goes beyond impairment and disability by asking about the patients ability to fulfill their needs and also about their emotional response to their restrictions.
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Validation and quality assessment

It is essential that a PRO instrument satisfy certain development, psychometric and scaling standards if it is to provide useful information. Specifically, measures should have a sound theoretical basis and should be relevant to the patient group with which they are to be used. They should also be reliable and valid (including responsive to underlying change) and the structure of the scale (whether it possesses a single or multiple domains) should have been thoroughly tested using appropriate methodology in order to justify the use of scale or summary scores.
Examples
Many of the common generic PRO tools assess health-related quality of life or patient evaluations of health care. For example, the SF-36 Health Survey (SF-36 Health Survey), SF-12 Health Survey (SF-12 Health Survey), the Sickness Impact Profile, the Nottingham Health Profile, the Health Utilities Index, the Quality of Well-Being Scale, the EuroQol (EQ-5D), and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey instruments are PRO instruments. Condition-targeted tools may capture any of the constructs listed above, depending on the purpose for which they were designed. Examples include the Adult Asthma Quality of Life Questionnaire (AQLQ), the Kidney Disease Quality of Life Instrument, National Eye Institute Visual Functioning Questionnaire, Epilepsy Surgery Inventory, Migraine Specific Quality of Life (MSQOL), the Ankylosing Spondylititis Quality of Life questionnaire (ASQoL) and the Seattle Angina Questionnaire (SAQ), to name a few.
Terminology
The term PRO should not be confused with patient-based outcomes. The latter implies that questionnaire covers issues of specific concern to the patient. However, patient-reported implies only that the patient provides the information. This information may, or may not, be of concern to the patient. The term PROs is synonymous with the increasing use of the term patient reported outcome measures (PREMs).
References
Bradley C. Importance of differentiating health status from quality of life. Lancet 2001; 357 (9249):7-8. Fung CH, Hays RD. Prospects and challenges in using patient-reported outcomes in clinical practice. Quality of Life Research 2008; 17: 1297-302. Doward LC, McKenna SP, Defining Patient-Reported Outcomes. Value in Health 2004; 7(S1): S4-S8. Fayers P, Hays RD. (eds.) Assessing Quality of Life in Clinical Trials: Methods and Practice. Oxford: Oxford University Press, 2005. Gallagher P, Ding L, Ham HP, Schor EL, Hays RD, Cleary PD. Development of a new patient-based measure of pediatric ambulatory care. Pediatrics 2009; 124: 1348-1354. Hays RD, Reeve BB. Measurement and modeling of health-related quality of life. In J. Killewo, H. K. Heggenhougen & S. R. Quah (eds.), Epidemiology and Demography in Public Health (pp. 195-205). Elsevier, 2010. Kennedy D, CRF Designer, Canary Publications, ISBN 0-9531174-7-2 McKenna SP, Doward LC, Integrating Patient-Reported Outcomes. Value in Health 2004; 7(S1): S9-S12. Patrick DL, Bergner M. Measurement of Health Status in the 1990s. Annu Rev Public Health. 1990; 11: 165-83. Tennant A, McKenna SP. Conceptualising and defining outcome. Br J Rheumatol 1995;34:899-900. Valderas JM, Alonso J. Patient reported outcome measures: a model-based classification system for research and clinical practice. Qual Life Res. 2008; 17: 1125-35. Wiklund I., Assessment of patient-reported outcomes in clinical trials: the example of health-related quality of life, Fundam Clin Pharmacol. 2004 Jun;18(3):351-63.
Patient-reported outcome Willke RJ, Burke LB, Erickson P., Measuring treatment impact: a review of patient-reported outcomes and other efficacy endpoints in approved product labels, Control Clin Trials. 2004 Dec;25(6):535-52.
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External links
EuroQol Group (EQ-5D) [1] Patient Reported Outcomes Measurement Information System [2] Medical Outcomes Trust [3] Health Surveys [4] SF-36.org [5] MAPI Institute (Linguistic validations of Patient-Reported Outcomes (PRO) instruments) [6] MAPI Research Trust (non-profit organization involved in Patient-Reported Outcomes (PRO) instruments and Epidemiology [7] ProQolid (Patient-Reported Outcome & Quality of Life Instruments Database) [8] PROLabels(Database on Patient-Reported Outcome claims in marketing authorizations) [9] Mapi Values global PRO consultancy [10]
References
[1] http:/ / www. euroqol. org/ [2] http:/ / www. nihpromis. org/ [3] http:/ / www. outcomes-trust. org/ [4] http:/ / www. rand. org/ health/ surveys_tools. html/ RAND [5] http:/ / www. sf-36. org/ [6] http:/ / www. mapi-institute. com/ [7] http:/ / www. mapi-trust. org/ [8] http:/ / www. proqolid. org/ [9] http:/ / www. mapi-prolabels. org/ [10] http:/ / www. mapivalues. com/
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Standards, Coding and Nomenclature

Diagnosis codes
In healthcare, diagnostic codes are used to group and identify diseases, disorders, symptoms, human response patterns, and medical signs, and are used to measure morbidity and mortality. As the plural with the name of this lemma indicates, there will be never one code for all purposes, but many codes for some distinct purposes each. The codes may be quite frequently revised as new knowledge is attained. DSM (see below) changes some of its coding to correspond to the codes in ICD. In 2005, for example, DSM changed the diagnostic codes for circadian rhythm sleep disorders from the 307-group to the 327-group; the new codes reflect the moving of these disorders from the Mental Disorders section to the Neurological section in the ICD.[1]
Commonly used diagnosis coding systems

ICD-9-CM (volumes 1 and 2 only. Volume 3 contains Procedure codes) ICD-10 ICPC-2 (Also includes reasons for encounter (RFE), Procedure codes and process of care) ICSD, The International Classification of Sleep Disorders NANDA Diagnostic and Statistical Manual of Mental Disorders or DSM-IV (primarily psychiatric disorders) Mendelian Inheritance in Man (genetic diseases only) Read code used throughout United Kingdom General Practice computerised records SNOMED (D axis)
Weaknesses
Generally coding is a concept of modeling reality with reduced effort but with physical copying. Hence the result of coding is a reduction to the scope of representation as far as possible to be depicted with the chosen modeling technology. There will be never an escape, but choosing more than one model to serve more than one purpose. That led to various code derivatives, all of them using one basic reference code for ordering as e.g. with ICD-10 coding. However, concurrent depiction of several models in one image remains principally impossible. Focusing a code on one purpose lets other purposes unsatisfied. This has to be taken into account when advertising for any coding concept. The operability of coding is generally bound to purpose. Inter-referring must be subject of evolutionary development, as code structures are subject of frequent change.[2] Unambiguous coding requires strict restriction to hierarchical tree structures possibly enhanced with multiple links, but no parallel branching for contemporary coding whilst maintaining bijectivity. Spatial depictions of n-dimensional code spaces as coding scheme trees on flat screens may enhance imagination, but still leave the dimensionality of image limited to intelligibility of sketching, mostly as a 3D object on a 2D screen. Pivoting such image does not solve the intelligibility problem. Projections of code spaces as flattened graphs may ease the depiction of a code, but generally reduce the contained information with the flattening. There is no explanation given with many of the codes for transforming from one code system to another. That leads to specialized usage and to limitations in communication between codes. The escape is with code reference structures (as e.g. not existing with SNOMED3).
Diagnosis codes Hierarchical ordering of more than one code system may be seen as appropriate, as the human body is principally invariant to coding. But the dependency implied with such hierarchies decrease the cross referencing between the code levels down to unintelligibility. The escape is with hyper maps that exceed planar views (as e.g. with SNOMED3) and their referring to other codes (as e.g. yet not existing with SNOMED3). Purpose of documenting will be seen as essential just for the validation of a code system in aspects of correctness. However this purpose is timely subordinate to the generating of the respective information. Hence some code system shall support the process of medical diagnosis and of medical treatment of any kind. Escape is with a specialised coding for the processes of working on diagnosis as on working with treatment (as e.g. not intended with SNOMED3). Intelligibility of results of coding is achieved by semantic design principles and with ontologies to support navigating in the codes. One major aspect despite the fuzziness of language is the bijectivity of coding. Escape is with explaining the code structure to avoid misinterpreting and various codes for the very same condition (as e.g. yet not served at all with SNOMED3).
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References
[1] First, Michael B. (2005). "New Diagnostic Codes for Sleep Disorders" (http:/ / psych. org/ MainMenu/ Research/ DSMIV/ DSMIVTR/ CodingUpdates/ NewDiagnosticCodesforSleepDisordersEffectiveOctober12005. aspx). American Psychiatric Association. . Retrieved 2008-08-08. [2] Towards Semantic Interoperability in Healthcare (http:/ / crpit. com/ confpapers/ CRPITV72Ryan. pdf)
Procedure codes
Procedure codes are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals.
Examples of procedure codes

International
International Classification of Procedures in Medicine (ICPM) and International Classification of Health Interventions (ICHI)[1] ICPC-2 (International Classification of Primary Care, which contains diagnosis codes, reasons for encounter (RFE), and process of care as well as procedure codes)
North American
Healthcare Common Procedure Coding System (including Current Procedural Terminology) (used in United States) ICD-10 Procedure Coding System (ICD-10-PCS) (used in United States) ICD-9-CM Volume 3 (subset of ICD-9-CM) (used in United States) Canadian Classification of Health Interventions (CCI) (used in Canada. Replaced CCP.) [2] Nursing Interventions Classification (NIC) (used in United States) [3] Nursing Minimum Data Set (NMDS) Nursing Outcomes Classification (NOC) SNOMED (P axis)
Procedure codes
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European
OPS-301 (adaptation of ICPM used in Germany) OPCS-4.2 (used in England)[4] OPCS-4.3 (used in England)[5] OPCS-4.4 (used in England)[6] Classification des Actes Mdicaux (CCAM) (used in France)[7] NOMESCO Gebhrenordnung fr rzte (GO) (Germany) Nomenclature des prestations de sant de l'institut national d'assurance maladie invalidit (Belgium) TARMED (Switzerland) Classificatie van virrichtingen (Dutch)
Other
Australian Classification of Health Interventions (ACHI)[8] Read codes system used in United Kingdom General Practice
References
[1] "WHO / International Classification of Health Interventions (ICHI)" (http:/ / www. who. int/ classifications/ ichi/ en/ ). World Health Organization. . Retrieved 2011-06-14. [2] secure.cihi.ca (http:/ / secure. cihi. ca/ cihiweb/ dispPage. jsp?cw_page=codingclass_cci_e) [3] duke.edu (http:/ / www. duke. edu/ ~goodw010/ vocab/ NIC. html) [4] nhsia.nhs.uk (http:/ / www. nhsia. nhs. uk/ clinicalcoding/ pages/ opcs_4. asp) [5] nhsia.nhs.uk (http:/ / www. nhsia. nhs. uk/ clinicalcoding/ pages/ opcs_4. asp) [6] "OPCS-4.4 Frequently Asked Questions" (http:/ / www. connectingforhealth. nhs. uk/ systemsandservices/ data/ clinicalcoding/ codingadvice/ faqs/ opcs44). National Health Service. . Retrieved 2011-06-14. [7] ccam.sante.fr (http:/ / www. ccam. sante. fr/ ) [8] fhs.usyd.edu.au (http:/ / www3. fhs. usyd. edu. au/ ncchwww/ site/ 4. 1. 3. htm)
Bar Code Medication Administration
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Bar Code Medication Administration

Bar Code Medication Administration (BCMA) is a barcode system designed to prevent medication errors in hospitals. It consists of a barcode reader, a portable computer with wireless connection, a computer server, and some software. When a nurse gives medicines to a patient in a hospital, the nurse can scan barcode on the wristband on the patient and make sure that the patient is the right patient. The nurse can then scan the barcode on medicine to verify if it is the right medicine at the right dose at the right time by the right route ("Five rights").[1] BCMA was first implemented in the Veteran Medical Center in Topeka, Kansas, USA. It was conceived by a nurse who was inspired by a car rental service using barcode. From 1999 to 2001, Department of Veterans Affairs promoted the system to 161 facilities.[2] . Cummings and others recommend the BCMA system for its reduction of errors. They suggest hospitals to consider the system first while they are waiting for RFID. They also pointed out that adopting the system takes a careful plan and a deep change in work patterns.[3]
References
[1] Felkey, B., Fox, B. & Thrower, M. (2006) Health Care Informatics: A Skills-Based Resource. Washington: American Pharmaceutical Association. [2] Coyle, G. A., & Heinen, M. (2005). Evolution of BCMA Within the Department of Veterans Affairs. Nursing Administration Quarterly, 29(1), 32-38. [3] Cummings J., Bush P., Smith D., Matuszewski K. Bar-coding medication administration overview and consensus recommendations. American Journal of Health System Pharmacy, 62(24), 2626-2629.
Bidirectional Health Information Exchange

BHIE is an acronym for Bidirectional Health Information Exchange, a series of communications protocols developed by the Department of Veterans Affairs. It is used to exchange healthcare information between Department of Veterans Affairs healthcare facilities nationwide and between VA healthcare facilities and Department of Defense healthcare facilities. It is one of the most widely used healthcare data exchange systems in routine healthcare use, and is used to facilitate healthcare data exchange associated with a patient's medical record.
Types of data managed

Outpatient pharmacy data, allergy data, patient identification correlation, laboratory result data (including surgical pathology reports, cytology and microbiology data, chemistry and hematology data), lab orders data, radiology reports, problem lists, encounters, procedures, and clinical notes are examples of the types of healthcare data that are exchanged using BHIE.
Integration with Electronic Health Record systems

BHIE is currently integrated into the VistA EMR (electronic medical record) system used nationwide in Department of Veterans Affairs hospitals. This integration is able to provide increased efficiency in healthcare for veterans. Veterans Hospitals have regional specialized capabilities, and veterans often travel to receive specialized care. Their VistA medical records are able to be transmitted in their entirety using this protocol.
Bidirectional Health Information Exchange
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History
GCPR to BHIE- a brief history In response to 1998 Presidential Review Directive 5 [1], the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the US Indian Health Service (IHS) collaborated to create the first developmental instances of a secure data-sharing system for electronic patient record data. This was initially called the Government Computer-based Patient Record system, or GCPR. The development of GCPR used UML modeling tools to define the various expected use cases where medical Care Providers in any Medical Treatment Facility (MTF) would need to have access to patient records or other data from within another participating agency. The UML modeling design was selected for its ability to clearly define the business logic that would be required for the GCPR Framework in an object-oriented way, and for its ability to provide detailed tracking of the iterative development of the Framework software. The UML model for the Framework is still used for the ongoing maintenance and support of the BHIE system. Early development of the GCPR system proved that it could meet the requirements of a robust interagency data sharing system, but details of implementation, policy, and security management issues caused delays in full implementation of the GCPR system as it was originally designed. As the project progressed, the Indian Health Service withdrew from GCPR participation, and agreements between the DoD and the VA led to the GCPR Near-Term Solution (GCPR-NTS) being managed principally by the VA, with support from the DoD. The VA installed the preliminary systems for GCPR-NTS in the VA Silver Spring, MD OIFO, where extensive testing took place between the DoD EI/DS and the VA CPRS developers. These teams worked together to finalize the needed infrastructure and security systems for one-way data transport of DoD Separatee data to the VA. The GCPR-NTS was structurally designed to house a static repository of this DoD Separatee data for use by VA Care providers. This one-way transfer of data from DoD to the VA repository continues to be one of the principal functions of the BHIE system. Upon completion of initial testing, the VA deployed another GCPR-NTS system into the Austin Automation Center, in Austin Texas. This system became the Production environment, which came to be known as the GCPR-Mid-Term Solution (GCPR-MTS). As the use of the system grew within the VA, it was later renamed to become the Federal Healthcare Information Exchange, or FHIE. The previously constructed system in the Silver Spring OIFO was re-tasked to become an iterative testing environment for proofing planned changes prior to deployment in the FHIE Production system in Austin. In 2004, interest in the system for use within the DoD was renewed, and further development was done to add a true bi-directional connection component to the FHIE system. Initially called the Data Sharing Initiative (DSI), adapters were added to the FHIE system using the Web Services XML-based protocol standard. A similar Web Services adapter was developed for the DoD to connect to their CHCS-I legacy patient record systems. In this way, both systems hosted a peer Web Services client that is accessible to the other with proper authentication, allowing bi-directional, query-based data exchanges between the disparate systems. Direct cross-Domain write capability and fully computable data storage and transfers are not supported at this time. With the addition of the DSI components to the FHIE system, the entire project was renamed the Federal Bi-Directional Healthcare Information Exchange, or BHIE. All references to FHIE (other than historical) are generally being phased out. BHIE represents the previous Framework System as was deployed for the VA, and all additional capabilities added to support near-real-time data exchange between the Framework and participating DoD Medical Treatment Facilities (MTFs). In short: FHIE + DSI = BHIE. The current BHIE Project participants are exclusively the Department of Defense (DoD) and the Department of Veterans Affairs (VA), though any number of additional Domains will probably be added over time with proper development of adapters and policies. This project has the support of the VA Under-Secretary for Health, and the Acting Assistant Secretary of Defense/Health Affairs of DoD. There is also congressional interest in a successful
Bidirectional Health Information Exchange outcome to this work. Since 2Q-FY05, the DoD is supporting the development of a separate DoD BHIE Domain, including dedicated hardware and infrastructure to support this new system within the DISA network. The details of the DoD system are still in development, as are the details of the expected interoperability with the existing VA BHIE system. Additional data types were added to the system during the 2005-2006 operational periods, including the provision of Discharge Summaries from selected DoD MTFs, and the inclusion of Pre-Post deployment form data availability. In March 2006, the usage of BHIE across the country was outlined before the House Committee on Veterans Affairs.[2] In 2007 the DoD's AHLTA interface was connected to BHIE to allow AHLTA clinicians to see VA data and VA clinicians to see DoD data stored within the CDR. Additionally in 2007 the Theater Medical Data Store (TMDS) was connected to BHIE to allow VA and DoD clinicians to access medical records from combat theaters.[3] In the 2007-2009 years, a parallel two-pass system for exchanging imaging metadata was added to the scope of BHIE. A special-purpose server, the BHIE Imaging Adapter (BIA) was added to the other BHIE systems. This BIA server takes the first pass of an Image Study query, obtains metadata about the images for a specific patient from the BHIE system, then presents a list of available images to the end-user, who can then select the images of interest from the list. The BIA then has variable functions as an intelligent proxy for retrieving and delivering the selected images. As of 2011, other additional functions related to images are being added to both the BIA and BHIE systems. From 2008 through 2011, the central focus of BHIE was to upgrade the system hardware and migrate all of the Production functions onto the new hardware. The upgrades began in the spring of 2009, when the initial sets of hardware were delivered and development began to create a set of identical-hardware environments on which the BHIE systems' migration could occur. The migration to the new Production BHIE location in Philadelphia, PA was accomplished in January 2011, and enhancements to all of the systems continue as an ongoing process. The Austin Legacy BHIE system remained in Production operation until 2011, when the replacement BHIE hardware installed in Philadelphia, PA assumed all of those functions. The Austin systems went dark and were retired from service in April 2011.
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References
[1] http:/ / www. fas. org/ irp/ offdocs/ prd-5-report. htm [2] "Statement of Jonathan B. Perlin, MD, PHD, MSHA, FACP, Undersecretary for Health Department of Veterans Affairs Before the House Committee on Veterans' Affairs" (http:/ / www. va. gov/ OCA/ testimony/ hvac/ sh/ 060308JP. asp). Department of Veterans Affairs Congressional and Legislative Affairs. 2006-03-08. . [3] "VAs information sharing initiatives aim for seamless transition" (http:/ / web. archive. org/ web/ 20050507191131/ http:/ / www. military-medical-technology. com/ article. cfm?DocID=932) ( Scholar search (http:/ / scholar. google. co. uk/ scholar?hl=en& lr=& q=intitle:VAs+ information+ sharing+ initiatives+ aim+ for+ seamless+ transition& as_publication=Military+ Medical+ Technology+ Online& as_ylo=& as_yhi=& btnG=Search)). Military Medical Technology Online. 2005-05-05. Archived from the original (http:/ / www. military-medical-technology. com/ article. cfm?DocID=932) on 2005-05-07. . Retrieved 2005-07-05.
External links
"BHIE overview" (http://www1.va.gov/VADODHEALTHITSHARING/ Bidirectional_Health_Information_Exchange.asp). Department of Veterans Affairs. Retrieved Apr 1, 2010.
Classification Commune des Actes Mdicaux
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Classification Commune des Actes Mdicaux

Classification Commune des Actes Mdicaux is a French medical classification for clinical procedures.[1] Starting in 2005, the CCAM serves as the reimbursement classification for clinicians. The CCAM was evaluated using OpenGALEN tools and technologies. This classification is used to establish In private practice and hospital fees for acts performed during technical consultations In private clinics, the fees for procedures performed In public and private hospitals, the DRG and its pricing of hospital stays provided to health insurance as part of T2 A. The choice of acts of this nomenclature is up to the Evaluation Commission of Acts Professionals (CEAP) of the High Authority of Health It coexists with the Nomenclature Gnrale des Actes Professionnels (NGAP).[2]
Structure
In the version V2, the ACPC 7623 codes included. Each is accompanied by wording to clarify its meaning unambiguously followed by its price in euros and tariff details.
Code Principal
Explicit hierarchical coding. This code and / or its title in the presence of personally identifiable information may impair the protection of people and lift the confidentiality of those who entrust themselves to organizations and managed care organization. Each code comprises the four letters and three numbers. The first letter refers to a large anatomical unit; The second letter indicates the body (or function) in the unit corresponding to the first letter; The third letter denotes the action performed; The fourth letter identifies the surgical approach or technique used.
The next three digits are used to differentiate between acts with four identical letters keys. e.g. HHFA001: Appendectomy, for the first quadrant HH. F A. 001 Action Technical topography Counter
Hierarchical ACPC
CCAM codes are structured in a tree whose top-level comprises 19 chapters, organized mainly by large anatomical structure or function: 01. central nervous system, device and independent 02. eye and notes 03. ear 04. circulatory 05. immune system and hematopoietic 06. respiratory
07. digestive 08. urinary and genital
Classification Commune des Actes Mdicaux 09. acts on the reproductive, pregnancy and the newborn 10. endocrine and metabolic 11. osteoarticular apparatus and muscle of the head 12. osteoarticular apparatus and muscle neck and trunk 13. osteoarticular apparatus and muscle of the upper limb 14. osteoarticular apparatus and muscle of lower limb 15. osteoarticular apparatus and muscle without precision surveying 16. integumentary system - mammary glands 17. acts without precision surveying 18. anesthetic actions and additional statements 19. transitional adjustments to the acpc
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The second level separates the diagnostic and therapeutic procedures, it is optionally followed by one or more sub-levels.
Modifiers acts and association

Some acts may receive more than their one or more main code details called Modifiers. A modifier is information associated with a label that identifies a particular criterion for the performance of an act or his recovery. It applies to a specific list of acts. Modifiers are explicitly allowed in respect of each of the acts concerned. The application of a modifier leads to a rate increase of the act. Only modifiers can be charged in connection with acts that have a tariff. The description of these modifiers is found in Article III-2 of Book III of the General Provisions official. Four modifiers than can be priced by deed. In the context of pricing, the association of acts is the realization of several acts at the same time, for the same patient by the same doctor, since there is no incompatibility between these acts. Codes 1,2,3,4 or 5 and their application rates of these associations are listed in Article III-3 of Paper III.
Versions of CCAM
Version 22 of the'TechnicalACPC is applicable as of September 30, 2010 for clinics and public hospitals. The construction of theclinical ACPC on intellectual activities that is to say without tools or technical movement provided by the medical convention of 2005 was due to start before 2007. A survey of clinicians from FIFG is announced for late 2010.
Revision history
http://www.ameli.fr/fileadmin/user_upload/documents/DATE_CCAM.pdf: ACPC's V23 01.25.2011 Official Journal of 26 December 2010 applicable as of January 25, 2011 V22 ACPC of 30/09/2010 (bariatric surgery, hyperbaric medicine, respiratory support, ...) ACPC V21 from 25/05/2010 (recasting of Anatomy Cyto Pathology) V20 ACPC 01/05/2010 (recast EBRT) ACPC V19 from 01/02/2010 V18 ACPC 01/01/2010 V17 ACPC of 19/10/2009 V16 ACPC 28/05/2009 ACPC V15 from 21/12/2008 (12001 codes acts) ACPC V14, 16/10/2008
ACPC V13 from 01/05/2008 V12 ACPC of 14/03/2008
Classification Commune des Actes Mdicaux ACPC 28/12/2007 V11 (7838 rate changes compared to version 10). V10 ACPC of 12/09/2007 ACPC V9 of 28/06/2007 V8 ACPC on 16/05/2007 ACPC V7 of 16/04/2007 ACPC's V6 16/09/2006 ACPC V2 from 01/09/2005 ACPC V1 25/03/2005 ACPC V0bis, 27/11/2003 V0 ACPC, 2002
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Learn more about the site Health Insurance [3] = 000310000000's ATIH [4]
References
[1] Bousquet, C.; Trombert, B.; Souvignet, J.; Sadou, E.; Rodrigues, JM. (2010). "Evaluation of the CCAM Hierarchy and Semi Structured Code for Retrieving Relevant Procedures in a Hospital Case Mix Database.". AMIA Annu Symp Proc 2010: 615. PMID21346941. [2] Bellanger, MM.; Cherilova, V.; Paris, V. (Dec 2005). "The "Health Benefit Basket" in France.". Eur J Health Econ Suppl: 249. doi:10.1007/s10198-005-0315-0. PMID16267657. [3] http:/ / www. ameli. fr/ accueil-de-la-ccam/ index. php [4] http:/ / www. atih. sante. fr/ ?id
External links
The site of the ACPC (http://www.ameli.fr/accueil-de-la-ccam/index.php/) Evaluation Commission Acts Professionals (CEAP) of the Haute Autorit de Sant (HAS) (http://www. has-sante.fr/portail/upload/docs/application/pdf/reglement_interieur_ceap_valide22nov06.pdf) [Search http://www.codage.ext.cnamts.fr/codif/ccam/acts in the ACPC] FAQs on the ACPC (http://www.ccam.sante.fr) ACPC website of Health Insurance (http://www.ameli.fr/77/DOC/2300/enquete.html) the website ATIH (http://www.atih.sante.fr/index.php?id=000310000000) Rover: free software for viewing and research in the ACPC (http://omiro.free.fr)
Classification of Pharmaco-Therapeutic Referrals
473

The Classification of Pharmaco-Therapeutic Referrals (CPR) is a taxonomy focused to define and group together situations requiring a referral from pharmacists to physicians (and vice versa) regarding the pharmacotherapy used by the patients. It has been published in 2008. It is bilingual: English/Spanish (Clasificacin de Derivaciones Frmaco-teraputicas). It is a simple and efficient classification of pharmaco-therapeutic referrals between physicians and pharmacists permitting a common inter-professional language. It is adapted to any type of referrals among health professionals, and to increase its specificity it can be combined with ATC codes, ICD-10, and ICPC-2 PLUS. It is a part of the MEDAFAR Project, whose objective is to improve, through different scientific activities, the coordination processes between physicians and pharmacists working in primary health care.
Supporting institutions
Pharmaceutical Care Foundation of Spain (Fundacin Pharmaceutical Care Espaa) Spanish Society of Primary Care Doctors (Sociedad Espaola de Mdicos de Atencin Primaria) (SEMERGEN)
Authors
Raimundo Pastor Snchez (Family practice, "Miguel de Cervantes" Primary Health Centre SERMAS Alcal de Henares Madrid Spain) Carmen Alberola Gmez-Escolar (Pharmacist, Vice-President Fundacin Pharmaceutical Care Espaa) Flor lvarez de Toledo Saavedra (Community pharmacist, Past-President Fundacin Pharmaceutical Care Espaa) Nuria Fernndez de Cano Martn (Family practice, "Daroca" Primary Health Centre SERMAS Madrid Spain) Nancy Sol Uthurry (Doctor in Pharmacy, Fundacin Pharmaceutical Care Espaa)
Structure
It is structured in 4 chapters (E, I, N, S) and 38 rubrics. The terminology used follows the rules of ICPC. Each rubric consists in an alphanumeric code (the letter corresponds to the chapters and the number to the component) and each title of the rubric (the assigned name) is expressed and explained by: A series of terms related with the title of the rubric. A definition expressing the meaning of the rubric A list of inclusion criteria and another list with exclusion criteria to select and qualify the contents corresponding to a rubric. Some example to illustrate every term. It also includes a glossary of 51 terms defined by consensus, an alphabetical index with 350 words used in the rubrics; and a standardized model of inter-professional referral form, to facilitate referrals from community pharmacists to primary care physicians.
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Classification of Pharmaco-Therapeutic Referrals MEDAFAR

E. Effectiveness / Efficiency: E 0. Effectiveness / Efficiency, unspecified E 1. Indication E 2. Prescription and dispensing conditions E 3. Active substance / excipient E 4. Pharmaceutical form / how supplied E 5. Dosage E 6. Quality E 7. Storage E 8. Consumption E 9. Outcome.
I. Information / Health education: I 0. Information / Health education, unspecified I 1. Situation / reason for encounter I 2. Health problem I 3. Complementary examination I 4. Risk I 5. Pharmacological treatment I 6. No pharmacological treatment I 7. Treatment goal I 8. Socio-healthcare system.
N. Need: N 0. Need, unspecified N 1. Treatment based on symptoms and/or signs N 2. Treatment based on socioeconomic-work issues N 3. Treatment based on public health issues N 4. Prevention N 5. Healthcare provision N 6. Complementary test for treatment control N 7. Administrative activity N 8. On patient request (fears, doubts, wants).
S. Safety: S 0. Safety, unspecified S 1. Toxicity S 2. Interaction S 3. Allergy S 4. Addiction (dependence) S 5. Other side effects S 6. Contraindication S 7. Medicalisation S 8. Non-regulate substance S 9. Data / confidentiality.
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Bibliography
Pastor Snchez R, Alberola Gmez-Escolar C, lvarez de Toledo Saavedra F, Fernndez de Cano Martn N, Sol Uthurry N. Clasificacin de Derivaciones Frmaco-teraputicas (CDF). MEDAFAR. Madrid: IMC; 2008. [1] ISBN 978-84-691-8426-4 Pastor Snchez R, Alberola Gmez-Escolar C, lvarez de Toledo Saavedra F, Fernndez de Cano Martn N, Sol Uthurry N. Classification of Pharmaco-Terapeutic Referrals (CPR). MEDAFAR. Madrid: IMC; 2008. [2] ISBN 978-84-691-8426-4 lvarez de Toledo Saavedra F, Fernndez de Cano Martn N, coordinadores. MEDAFAR Asma. Madrid: IMC; 2007. [3] lvarez de Toledo Saavedra F, Fernndez de Cano Martn N, coordinadores. MEDAFAR Hipertensin. Madrid: IMC; 2007. [4] Aranaz JM, Aibar C, Vitaller J, Mira JJ, Orozco D, Terol E, Agra Y. Estudio sobre la seguridad de los pacientes en atencin primaria de salud (Estudio APEAS). Madrid: Ministerio de Sanidad y Consumo; 2008. [5] Aranaz JM, Aibar C, Vitaller J, Ruiz P. Estudio Nacional sobre los Efectos Adversos ligados a la Hospitalizacin. ENEAS 2005. Madrid: Ministerio de Sanidad y Consumo; 2006. [6] Cervera Barba EJ, Sagredo Prez J, Martn Gonzlez MC, Heras Salvat G, Pea Rodrguez E, Surez del Villar Acebal E, et al. Oficinas de farmacia y centros de salud: podemos trabajar juntos. Una experiencia de colaboracin. SEMERGEN. 2004;30(10)491-7. Comit Internacional de Clasificacin de la WONCA. CIAP-2. Barcelona: MASSON; 1999. Criterios de derivacin del farmacutico al mdico general/familia, ante mediciones espordicas de presin arterial. Consenso entre la Sociedad Valenciana de Hipertensin y Riesgo Vascular (SVHTAyFV) y la Sociedad de Farmacia Comunitaria de la Comunidad Valenciana (SFaC-CV). 2007. [7] Fleming DM (ed). The European study of referrals from primary to secondary care. Exeter: Royal College of General Practitioners; 1992. Foro de Atencin Farmacutica. Documento de consenso 2008. Madrid: MSC, RANF, CGCOF, SEFAP, SEFAC, SEFH, FPCE, GIAFUG. 2008. [8] Garca Cebrin F. La seguridad del paciente y la colaboracin entre mdicos y farmacuticos [editorial]. SEMERGEN. 2006; 32(2):55-7. Garca Olmos L. Anlisis de la demanda derivada en las consultas de medicina general en Espaa. Tesis doctoral. Madrid: Universidad Autnoma de Madrid; 1993. Garjn Parra J, Gorricho Mendvil J. Seguridad del paciente: cuidado con los errores de medicacin. Boletn de Informacin Farmacoteraputica de Navarra. 2010;18(3) [9] Grvas J. Introduccin a las classificaciones en Atencin Primaria, con una valoracin tcnica de los "Consensos de Granada". Pharm Care Esp. 2003; 5(2):98-104. Hospital Ramn y Cajal, rea 4 Atencin Primaria de Madrid. Gua Farmacoteraputica. Madrid; 2005. CD-ROM. Ley 29/2006, de 26 de julio, de garantas y uso racional de los medicamentos y productos sanitarios. BOE. 2006 julio 27; (178): 28122-65. Ley 41/2002, de 14 de noviembre, bsica reguladora de la autonoma del paciente y de derechos y obligaciones en materia de informacin y documentacin clnica. BOE. 2002 noviembre 15; (274): 40126-32. Ley Orgnica 15/1999, de 13 de diciembre, de Proteccin de Datos de Carcter Personal. BOE. 1999 diciembre 14; (298): 43088-99. Organizacin Mdica Colegial. Cdigo de tica y deontologa mdica. Madrid: OMC; 1999.
Classification of Pharmaco-Therapeutic Referrals Palacio Lapuente F. Actuaciones para la mejora de la seguridad del paciente en atencin primaria [editorial]. FMC. 2008; 15(7): 405-7. Panel de consenso ad hoc. Consenso de Granada sobre Problemas Relacionados con medicamentos. Pharm Care Esp. 1999; 1(2):107-12. Pastor Snchez R, Barbero Gonzlez A, del Barrio Snchez H, Garca Olmos LM, editores. Comunicacin interprofesional en atencin primaria de salud. Madrid: REAP; 1996. Prado Prieto L, Garca Olmos L, Rodrguez Salvans F, Otero Puime A. Evaluacin de la demanda derivada en atencin primaria. Aten Primaria. 2005; 35:146-51. Starfield B. Research in general practice: co-morbidity, referrals, and the roles of general practitioners and specialists. SEMERGEN. 2003; 29(Supl 1):7-16. Uribe G, Martnez de la Hidalga G. Mdicos y farmacuticos: xitos y fracasos de colaboracin profesional. SEMERGEN. 2002;28(2):86-8. WONCA Classification Committee. An international glossary for general/family practice. Fam Pract. 1995; 12(3): 341-69. World Alliance for Patient Safety. International Classification for Patient Safety (ICPS). 2007. [10] lvarez de Toledo F, Pastor Snchez R. La Clasificacin de Derivaciones Frmaco-Teraputicas: una herramienta para la coordinacin entre mdicos y farmacuticos. Ars Pharm. 2011; 52(Supl 1):20-5.
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External links
Classification of Pharmaco-Terapeutic Referrals (CPR) [2] Clasificacin de Derivaciones Frmaco-teraputicas (CDF) [1] MEDAFAR [11] SEMERGEN [12] Fundacin Pharmaceutical Care Espaa [13] ICPC-2e [14] (by the Norwegian Centre for Informatics in Health and Social Care)] International Classification of Diseases (ICD) [15] ICD-10 [16] Cdigo ATC (Anatomical Therapeutic Chemical drug classification) [17]
References
[1] http:/ / www. medafar. com/ eWebs/ GetFicheroDoc. do?doc%3D580632%26ver%3D581762%26fichero%3D580632_fi_3. pdf%26entorno%3Dlectura [2] http:/ / www. medafar. com/ eWebs/ GetFicheroDoc. do?doc%3D580632%26ver%3D581762%26fichero%3D580632_fi_4. pdf%26entorno%3Dlectura [3] http:/ / www. medafar. com/ eWebs/ GetFicheroDoc. do?doc%3D580632%26ver%3D581762%26fichero%3D580632_fi_2. pdf%26entorno%3Dlectura [4] http:/ / www. medafar. com/ eWebs/ GetFicheroDoc. do?doc%3D580632%26ver%3D581758%26fichero%3D580632_fi_1. pdf%26entorno%3Dlectura [5] http:/ / www. msc. es/ organizacion/ sns/ planCalidadSNS/ docs/ estudio_apeas. pdf [6] http:/ / www. msc. es/ organizacion/ sns/ planCalidadSNS/ pdf/ excelencia/ opsc_sp2. pdf [7] http:/ / www. atencionfarmaceutica. org/ contenido. php?mod=novedades& id=31 [8] http:/ / www. pharmaceutical-care. org/ doccontenidos/ documentos/ FORO_At_farma. pdf [9] http:/ / www. navarra. es/ appsext/ DescargarFichero/ default. aspx?codigoAcceso=PortalDeSalud& fichero=bit/ Bit_v18n3. pdf [10] http:/ / www. who. int/ patientsafety/ taxonomy/ en/ [11] http:/ / www. medafar. com/ [12] http:/ / www. semergen. es/ [13] http:/ / www. pharmaceutical-care. org/ [14] http:/ / www. kith. no/ templates/ kith_WebPage____1062. aspx [15] http:/ / www. who. int/ classifications/ icd/ en/

[16] http:/ / apps. who. int/ classifications/ apps/ icd/ icd10online/ [17] http:/ / www. whocc. no/
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Clinical Context Object Workgroup

In the context of Health informatics, CCOW or Clinical Context Object Workgroup is an HL7 standard protocol designed to enable disparate applications to synchronize in real-time, and at the user-interface level. It is vendor independent and allows applications to present information at the desktop and/or portal level in a unified way. CCOW is the primary standard protocol in healthcare to facilitate a process called "Context Management." Context Management is the process of using particular "subjects" of interest (e.g., user, patient, clinical encounter, charge item, etc.) to 'virtually' link disparate applications so that the end-user sees them operate in a unified, cohesive way. Context Management can be utilized for both CCOW and non-CCOW compliant applications. The CCOW standard exists to facilitate a more robust, and near "plug-and-play" interoperability across disparate applications. Context Management is often combined with Single Sign On applications in the healthcare environment, but the two are discrete functions. Single Sign On is the process that enables the secure access of disparate applications by a user through use of a single authenticated identifier and password. Context Management augments this by then enabling the user to identify subjects once (e.g., a patient) and have all disparate systems into which the user is granted access to "tune" to this patient simultaneously. As the user further identifies particular "subjects" of interest (e.g., a particular visit), those applications containing information about the selected subject will then automatically and seamlessly to the user "tune" to that information as well. The end result for the user is an aggregated view of all patient information across disparate applications. Use of Context Management, facilitated by CCOW or non-CCOW compliant applications, is valuable for both client-server, and web-based applications. Furthermore, a fully robust Context Manager will enable use for both client-server and web-based applications on a single desktop / kiosk, allowing the user to utilize both types of applications in a "context aware" session. CCOW works for both client-server and web-based applications. The acronym CCOW stands for "Clinical Context Object Workgroup", a reference to the standards committee within the HL7 group that developed the standard.
Purpose
The goal of CCOW is seemingly simple, but its implementation is rather complex. CCOW is designed to communicate the name of the active user between various programs on the same machine. The user should only need to log into one application, and the other applications running on the machine will know who is logged in. There are a great deal of exceptions and circumstances that make this scenario far more difficult than it appears. In order to accomplish this task, every CCOW compliant application on the machine must login to a central CCOW server called a Vault. The application sends an encrypted application passcode to verify its identity. Once the application is verified, it may change the active user (also called the context) on the machine. Each CCOW application also has an application name for which there can only be one instance. There is no correct application name (the passcode identifies which application is logging in). There may be multiple instances of the CCOW application connected to the CCOW vault from the same computer, however they must have different names. One name might be I like HHAM, while the other might be I like CCOW. The names are completely arbitrary. After the application authenticates itself with the CCOW vault, the applications are ready to communicate the context (a.k.a the active user). Here would be a step-by-step example of a CCOW exchange: 1. The computer boots up and the medical applications load. 2. Each application logs into CCOW using its secret passcode (and unique application name).
Clinical Context Object Workgroup 3. The compliant application displays a login prompt, and the user logs in as Mary Jane. 4. Mary Jane has a CCOW ID. Let us assume that her CCOW ID is MJane. 5. The compliant application notifies the CCOW vault that MJane is now logged in. 6. Once CCOW verifies that MJane is a valid CCOW user, the vault notifies all the other applications that MJane is logged in. 7. All of the other applications realize that the CCOW ID MJane is referring to Mary Jane (because they have been configured as such). They login Mary Jane automatically. 8. The transaction is complete. All of the applications running on the machine have been automatically logged in as Mary Jane. The purpose of the application passcode is to verify that no unauthorized applications can hack into CCOW and change the active user (thereby allowing unauthorized access to medical records).
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External links
HL7 Introduction [2] CCOW Solutions [1] HL7 CCOW Standard [2]
References
[1] http:/ / www. proksys. com/ [2] http:/ / www. hl7. org. au/ CCOW. htm
Clinical Data Interchange Standards Consortium

Clinical Data Interchange Standards Consortium (CDISC) is a non-profit organization, whose mission is "to develop and support global, platform-independent data standards that enable information system interoperability to improve medical research and related areas of health-care". Their main project, the described data standard, bears the same name. The data standards are defined as a series of Models, which can be expressed using an underlying electronic format. The preferred electronic format is XML, using the Operational Data Model (ODM) as a base XML Schema.
CDISC History
Late 1997 - Started as a Volunteer group Summer 1998 - Invited to form DIA SIAC Feb 2000 - formed an Independent, non-profit organization Dec 2001 - Global participation
CDISC standards
Study Data Tabulation Model (SDTM) Highlights: recommended for FDA regulatory submissions since 2004. Study Data Tabulation Model SDTM Implementation Guide (SDTM-IG) Gives a standardized, predefined collection of submission metadata "Domains" containing extensive variable collections. Analysis Data Model (ADaM)
Clinical Data Interchange Standards Consortium Designed to complement the SDTM submission by detailing the statistical analysis performed on the clinical trial results. Standard for Exchange of Non-clinical Data (SEND) The animal trial equivalent of SDTM. Operational Data Model (ODM) The highlights of ODM: includes audit trail, utilizes XML technology, machine- and human- readable, all information are independent from databases, storing of ODM is independent from hard- and software. Laboratory Data Model (LAB) Case Report Tabulation Data Definition Specification (CRT-DDS) Also referred to as "define.xml", a machine readable version of the regulatory submission "define.pdf". Clinical Data Acquisition Standards Harmonization (CDASH) Defines a minimal data collection set for sixteen safety SDTM Domains, harmonizing element names, definitions and metadata. The objective is to establish a standardized data collection baseline across all submissions. CDISC Terminology Defines controlled terminology for SDTM and CDASH, provides extensible lists of controlled terms designed to harmonize data collected across submissions.
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CDISC registered solutions providers

CDISC maintains a list of solutions providers, subject matter experts and consultants deemed to have sufficient knowledge and experience implementing the various CDISC standards. CDSIC registered solutions providers [1]
ODM and EDC integration

Electronic Data Capture (EDC) systems can be certified as compliant with the Operational Data Model (ODM) by CDISC. There are two main types of integration, ODM Import and ODM Export.
ODM Import
Full import allows importing of ODM-formatted clinical data (MetaData and Data). MetaData only import allows only the importing of MetaData. This is useful for setting up the EDC system to capture data. Basically allows third party software to define the forms, variables etc. used in the EDC system. This provides a EDC vendor-neutral system for defining a study.
ODM Export
The EDC system will generate ODM data files for further processing.
References
Rebecca Daniels Kush (2003), eClinical Trials: Planning and Implementation, CenterWatch / Thomson Healthcare, ISBN 1-930624-28-X A J de Montjoie (2009), 'Introducing the CDISC Standards: New Efficiencies for Medical Research', CDISC Publications
Clinical Data Interchange Standards Consortium
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External links
Clinical Data Interchange Standards Consortium [2] CDISC Standards [3] Electronic Common Technical Document (eCTD) [4] (FDA)
References
[1] [2] [3] [4] http:/ / www. cdisc. org/ rsp http:/ / www. cdisc. org/ http:/ / www. cdisc. org/ standards/ index. html http:/ / www. fda. gov/ cder/ regulatory/ ersr/ ectd. htm
Clinical Document Architecture

The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. CDA is part of the HL7 version 3 standard. Akin to other parts of the HL7 version 3 standard it was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types. CDA documents are persistent in nature. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts.
Transport
The CDA standard doesn't specify how the documents should be transported. CDA documents can be transported using HL7 version 2 messages, HL7 version 3 messages, as well as by other mechanisms, such as DICOM, MIME attachments to email, http or ftp.
Country specific notes

In the U.S. the CDA standard is probably best known as the basis for the Continuity of Care Document (CCD) specification, based on the data model as specified by ASTMs Continuity of Care Record. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards.
External links
Structured Documents Group [1] of HL7 CDA Resource Page [2] Introduction to the HL7 Standards [2] Whitepaper: HL7 version 3: message or document? [3]
References
[1] http:/ / www. hl7. org/ Special/ committees/ structure/ struc. htm [2] http:/ / hl7book. net/ index. php?title=CDA [3] http:/ / www. ringholm. de/ docs/ 04200_en. htm
Continuity of Care Document
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The Continuity of Care Document (CCD) specification is an XML-based markup standard intended to specify the encoding, structure and semantics of a patient summary clinical document for exchange. The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA) standard. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part is based on the HL7 Reference Information Model (RIM) and provides a framework for referring to concepts from coding systems such as from SNOMED and LOINC. The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. Its primary use case is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient. The CCD specification contains U.S. specific requirements; its use is therefore limited to the U.S. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards.
Development History
CCD was developed by HL7 with consultation and advice from several members of ASTM E31, the technical committee responsible for development and maintenance of the Continuity of Care Record, CCR, standard. In the opinion of HL7 and its members, the CDA CCD combines the benefits of ASTMs Continuity of Care Record (CCR) and the HL7 Clinical Document Architecture (CDA) specifications. It is intended as an alternate implementation to the one specified in ASTM ADJE2369 for those institutions or organizations committed to implementation of the HL7 Clinical Document Architecture.
Competition and Internet Health Industry Standards

CCD and Continuity of Care Record (CCR) are often seen as competing standards.[1] Google Health supports a subset of CCR[2] , while Microsoft HealthVault claims to support a subset of both CCR and CCD.[3]
References
[1] http:/ / e-caremanagement. com/ untangling-the-electronic-health-data-exchange/ [2] http:/ / code. google. com/ apis/ health/ ccrg_reference. html [3] http:/ / blogs. msdn. com/ familyhealthguy/ archive/ 2008/ 07/ 13/ again-with-the-standards-thing. aspx
4. http:/ / www. corepointhealth. com/ continuity-care-document-ccd-changing-landscape-healthcare-information-exchange
whitepapers/
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External links
Structured Documents Group (http://www.hl7.org/Special/committees/structure/struc.htm) of HL7 CDA Resource Page (http://hl7book.net/index.php?title=CDA) CCD XML Instance Examples (http://xreg2.nist.gov/cda-validation/downloads.html) Online CCD instance validation tool (http://xreg2.nist.gov/cda-validation/validation.html) at NIST Introduction to the HL7 Standards (http://www.HL7.com.au/FAQ.htm)
Clinical Document Architecture

The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. CDA is part of the HL7 version 3 standard. Akin to other parts of the HL7 version 3 standard it was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types. CDA documents are persistent in nature. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts.
Transport
The CDA standard doesn't specify how the documents should be transported. CDA documents can be transported using HL7 version 2 messages, HL7 version 3 messages, as well as by other mechanisms, such as DICOM, MIME attachments to email, http or ftp.
Country specific notes

In the U.S. the CDA standard is probably best known as the basis for the Continuity of Care Document (CCD) specification, based on the data model as specified by ASTMs Continuity of Care Record. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards.
External links
Structured Documents Group [1] of HL7 CDA Resource Page [2] Introduction to the HL7 Standards [2] Whitepaper: HL7 version 3: message or document? [3]
Continuity of Care Record
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Continuity of Care Record

Continuity of Care Record (CCR)[1] is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society[2] (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics[3] (AAP), and other health informatics vendors.
The CCR standard

The CCR standard is a patient health summary standard. It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one caregiver to another. It contains various sections such as patient demographics, insurance information, diagnoses and problem list, medications, allergies and care plan. These represent a "snapshot" of a patient's health data that can be useful or possibly lifesaving, if available at the time of clinical encounter. The ASTM CCR standard is designed to permit easy creation by a physician using an electronic health record (EHR) system at the end of an encounter. Because it is expressed in the standard data interchange language known as XML, a CCR can potentially be created, read and interpreted by any EHR or EMR software application. A CCR can also be exported in other formats, such as PDF and Office Open XML (Microsoft Word 2007 format). Continuity of Care Document (CCD) r1 is an HL7 CDA implementation of the Continuity of Care Record (CCR) and not a competing standard as mentioned by some.[4] It is generally possible to convert a CCR document into CCD using Extensible Stylesheet Language Transformations (XSLT), however it is not always possible to perform the inverse transformation as some CCD features are not supported in CCR[5] . HITSP provides reference information that demonstrates how CCD and CCR (as HITSP C32) are embedded in CDA.[6]
References
[1] ASTM CCR Continuity of Care Record (http:/ / www. astm. org/ cgi-bin/ SoftCart. exe/ DATABASE. CART/ PAGES/ E2369. htm?L+ mystore+ luuu5949+ 1167331453) [2] http:/ / www. massmed. org/ [3] http:/ / www. aap. org/ [4] http:/ / e-caremanagement. com/ untangling-the-electronic-health-data-exchange/ [5] http:/ / ofps. oreilly. com/ titles/ 9781449305024/ meaningful_use_interoperability. html [6] http:/ / publicaa. ansi. org/ sites/ apdl/ hitspadmin/ Matrices/ HITSP_09_N_451. pdf
External links
ASTM CCR Standard E2369-05 (http://www.astm.org/cgi-bin/SoftCart.exe/DATABASE.CART/ REDLINE_PAGES/E2369.htm?E+mystore) CCRStandard.com (http://www.ccrstandard.com/) Medical Records Institute - CCR (http://medrecinst.com/pages/about.asp?id=54) Center for Health Information Technology (CHiT) (http://www.centerforhit.org/online/chit/home.html) CCR Java library (http://code.google.com/p/ccr4j)
COSTART
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COSTART
The Coding Symbols for a Thesaurus of Adverse Reaction Terms (COSTART) was developed by the United States Food and Drug Administration (FDA) for the coding, filing and retrieving of post-marketing adverse reaction reports. COSTART provides a method to deal with the variation in vocabulary used by those who submit adverse event reports to the FDA. Use of this dictionary allowed for standardization of adverse reaction reporting towards the FDA in a consistent way. Recently COSTART was replaced by the MedDRA.
External links
COSTART lookup [1]
References
[1] http:/ / hedwig. mgh. harvard. edu/ biostatistics/ files/ costart. html
Current Procedural Terminology

The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association through the CPT Editorial Panel.[1] The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. New editions are released each October.[2] The current version is the CPT 2011. It is available in both a standard edition and a professional edition.[3] [4] CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim. CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) Care Procedure Coding System.
[5]
as Level 1 of the Health
Types of codes
There are three types of CPT codes: Category I, Category II, and Category III.
Category I
Category I CPT Code(s). There are six main sections:[6] Codes for Evaluation and Management: 99201-99499 (99201 - 99215) office/other outpatient services (99217 - 99220) hospital observation services (99221 - 99239) hospital inpatient services (99241 - 99255) consultations (99281 - 99288) emergency dept services (99291 - 99292) critical care services
(99304 - 99318) nursing facility services (99324 - 99337) domiciliary, rest home (boarding home) or custodial care services
Current Procedural Terminology (99339 - 99340) domiciliary, rest home (assisted living facility), or home care plan oversight services (99341 - 99350) home services (99354 - 99360) prolonged services (99363 - 99368) case management services (99374 - 99380) care plan oversight services (99381 - 99429) preventive medicine services (99441 - 99444) non-face-to-face physician services (99450 - 99456) special evaluation & management services (99460 - 99465) newborn care services (99466 - 99480) inpatient neonatal intensive, and pediatric/neonatal critical, care services
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Codes for Anesthesia: 00100-01999; 99100-99150 (00100 - 00222) head (00300 - 00352) neck (00400 - 00474) thorax (00500 - 00580) intrathoracic (00600 - 00670) spine & spinal cord (00700 - 00797) upper abdomen (00800 - 00882) lower abdomen (00902 - 00952) perineum (01112 - 01190) pelvis (except hip) (01200 - 01274) upper leg (except knee) (01320 - 01444) knee & popliteal area (01462 - 01522) lower leg (below knee) (01610 - 01682) shoulder & axilla (01710 - 01782) upper arm & elbow (01810 - 01860) forearm, wrist & hand (01916 - 01936) radiological procedures (01951 - 01953) burn excisions or debridement (01958 - 01969) obstetric (01990 - 01999) other procedures
Codes for Surgery: 10021-69990 (10021 - 10022) general (10040 - 19499) integumentary system (20000 - 29999) musculoskeletal system (30000 - 32999) respiratory system (33010 - 37799) cardiovascular system (38100 - 38999) hemic & lymphatic systems (39000 - 39599) mediastinum & diaphragm (40490 - 49999) digestive system (50010 - 53899) urinary system (54000 - 55899) male genital system (55920 - 55980) reproductive system & intersex (56405 - 58999) female genital system
(59000 - 59899) maternity care & delivery (60000 - 60699) endocrine system
Current Procedural Terminology (61000 - 64999) nervous system (65091 - 68899) eye & ocular adnexa (69000 - 69979) auditory system Codes for Radiology: 70010-79999 (70010 - 76499) diagnostic imaging (76506 - 76999) diagnostic ultrasound (77001 - 77032) radiologic guidance (77051 - 77059) breast mammography (77071 - 77084) bone/joint studies (77261 - 77799) radiation oncology (78000 - 79999) nuclear medicine
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Codes for Pathology & Laboratory: 80047-89398 (80047 - 80076) organ or disease-oriented panels (80100 - 80103) drug testing (80150 - 80299) therapeutic drug assays (80400 - 80440) evocative/suppression testing (80500 - 80502) consultations (clinical pathology) (81000 - 81099) urinalysis (82000 - 84999) chemistry (85002 - 85999) hematology & coagulation (86000 - 86849) immunology (86850 - 86999) transfusion medicine (87001 - 87999) microbiology (88000 - 88099) anatomic pathology (postmortem) (88104 - 88199) cytopathology (88230 - 88299) cytogenetic studies (88300 - 88399) surgical pathology (88720 - 88741) in vivo (transcutaneous) lab procedures (89049 - 89240) other procedures (89250 - 89398) reproductive medicine procedures
Codes for Medicine: 90281-99189; 99500-99607 (90281 - 90399) immune globulins, serum or recombinant prods (90465 - 90474) immunization administration for vaccines/toxoids (90476 - 90749) vaccines, toxoids (90801 - 90899) psychiatry (90901 - 90911) biofeedback (90935 - 90999) dialysis (91000 - 91299) gastroenterology (92002 - 92499) ophthalmology (92502 - 92700) special otorhinolaryngologic services (92950 - 93799) cardiovascular (93875 - 93990) noninvasive vascular diagnostic studies
(94002 - 94799) pulmonary (95004 - 95199) allergy & clinical immunology
Current Procedural Terminology (95250 - 95251) endocrinology (95803 - 96020) neurology & neuromuscular procedures (96101 - 96125) central nervous system assessments/tests (neuro-cognitive, mental status, speech testing) (96150 - 96155) health & behavior assessment/intervention (96360 - 96549) hydration, therapeutic, prophylactic, diagnostic injections & infusions, and chemotherapy & other highly complex drug or highly complex biologic agent administration (96567 - 96571) photodynamic therapy (96900 - 96999) special dermatological procedures (97001 - 97799) physical medicine & rehabilitation (97802 - 97804) medical nutrition therapy (97810 - 97814) acupuncture (98925 - 98929) osteopathic manipulative treatment (98940 - 98943) chiropractic manipulative treatment (98960 - 98962) education & training for patient self-management (98966 - 98969) non-face-to-face nonphysician services (99000 - 99091) special services, procedures and reports (99100 - 99140) qualifying circumstances for anesthesia (99143 - 99150) moderate (conscious) sedation (99170 - 99199) other services & procedures (99500 - 99602) home health procedures/services (99605 - 99607) medication therapy management services
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Category II
Category II CPT Code(s) Performance Measurement (optional)[7] (Category II codes: 0001F-7025F)
Category III
Category III CPT Code(s) Emerging Technology (Category III codes: 0016T-0207T[8] )
Copyright
CPT is a registered trademark of the American Medical Association. The AMA holds copyright which prevents free use and distribution of codes.[9] Although the CPT system is mandated by the Centers for Medicare and Medicaid Services (CMS) and HIPAA, and the data for it appear in the Federal Register, the American Medical Association (AMA) maintains that their copyright of the CPT allows them to charge a license fee to anyone who wishes to associate Relative Value Unit (RVU) values with CPT codes. The AMA receives almost $70 million annually from CPT revenue. The AMA's 2009 Annual Report is available at the link below, which states "AMA-published books, AMA affinity products and the reimbursement products, such as CPT books, workshops and licensed data files, make up the Book and Products unit. Book and Products revenues improved by $1 million, with a $1.8 million improvement in royalties, largely in CPT, more than offsetting lower book sales."[10]
Current Procedural Terminology
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Limited CPT Search Offered by the AMA

The AMA offers a personal, non-commercial search of the Current Procedural Terminology, Fourth Edition ("CPT") manual on its website: https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do Unfortunately, this tool limits not only the number of codes anyone can look up, but it does not provide helpful information (such as the component values of each code or the ability to use an individual fee multiplier) or provide the results in a manner that can be easily adopted to a spreadsheet for analysis, etc. For providers or patients to fairly assess medical charges, they must purchase the CPT coding manual or pay for access to electronic files with CPT codes or other such products.
References
[1] AMA (CPT) CPT Process (http:/ / www. ama-assn. org/ ama/ pub/ category/ 3112. html) [2] Laura Southard Durham (1 June 2008). Lippincott Williams & Wilkins' Administrative Medical Assisting (http:/ / books. google. com/ books?id=b9NyTDdaEEsC& pg=RA2-PA102). Lippincott Williams & Wilkins. pp.2. ISBN9780781797894. . Retrieved 26 May 2011. [3] Michelle Abraham; Jay T. Ahlman; Angela J. Boudreau; Judy L. Connelly, Desiree D. Evans, Rejina L Glenn (30 October 2010). CPT 2011 Standard Edition (http:/ / books. google. com/ books?id=vZv5RQAACAAJ). American Medical Association Press. ISBN9781603592161. . Retrieved 26 May 2011. [4] American Medical Association; American Medical Association (COR); Michelle Abraham; Jay T. Ahlman, Angela J. Boudreau, Judy L. Connelly (30 October 2010). CPT 2011 Professional Edition (http:/ / books. google. com/ books?id=-FP1RQAACAAJ). American Medical Association Press. ISBN9781603592178. . Retrieved 26 May 2011. [5] Centers for Medicare & Medicaid Services (http:/ / www. cms. hhs. gov/ ) [6] Marie A. Moisio (8 April 2009). Medical Terminology for Insurance and Coding (http:/ / books. google. com/ books?id=HjYEikV_n6MC& pg=PA80). Cengage Learning. pp.80. ISBN9781428304260. . Retrieved 26 May 2011. [7] Holly Hosford-Dunn; Ross J. Roeser; Michael Valente (2008). Audiology practice management (http:/ / books. google. com/ books?id=r2wBJFACx0wC& pg=PA323). Thieme. pp.323. ISBN9783131164124. . Retrieved 26 May 2011. [8] CPT 2010 [9] AMA (CPT) CPT Licensing (http:/ / www. ama-assn. org/ ama/ pub/ category/ 3657. html) [10] http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 37/ 2009-annual-report. pdf
External links
Official site (http://www.ama-assn.org/ama/pub/category/3113.html) by the AMA* Description of the three sections (http://www.ama-assn.org/ama/pub/category/12888.html) from the AMA History (http://www.ama-assn.org/ama/pub/category/3882.html) from the AMA Q&A (http://www.aafp.org/fpm/accessories/browse?op=get_documents_via_heading_id&heading_id=46) from the American Academy of Family Physicians
Diagnosis-related group
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Diagnosis-related group
Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups. The 467th was "Ungroupable." The system of classication was developed as a collaborative project by Robert B Fetter, PhD of the Yale School of Management, and John D Thompson, MPH of the Yale School of Public Health. The system is also referred to as "the DRGs," and its intent was to identify the "products" that a hospital provides. One example of a "product" is an appendectomy. The system was developed at Yale, in anticipation of convincing Congress to use it for reimbursement, to replace "cost based" reimbursement that was used up to that point. DRGs are assigned by a "grouper" program based on ICD (International Classification of Diseases) diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each "product", since patients within each category are similar clinically and are expected to use the same level of hospital resources. DRGs may be further grouped into Major Diagnostic Categories (MDCs).
Purpose
The original objective of diagnosis related groups (DRG) was to develop a classification system that identified the "products" that the patient received. Since the introduction of DRGs in the early 1980s, the healthcare industry has evolved and developed an increased demand for a patient classification system that can serve its original objective at a higher level of sophistication and precision. To meet those evolving needs, the objective of the DRG system had to expand in scope. Today, there are several different DRG systems that have been developed in the US. They include: Medicare DRG (CMS-DRG & MS-DRG) Refined DRGs (R-DRG) All Patient DRGs (AP-DRG) Severity DRGs (S-DRG) All Patient, Severity-Adjusted DRGs (APS-DRG) All Patient Refined DRGs (APR-DRG) International-Refined DRGs (IR-DRG)
History
The system was created by Robert Barclay Fetter and John D. Thompson at Yale University with the material support of the former Health Care Financing Administration (HCFA), now called the Centers for Medicare and Medicaid Services (CMS). DRGs were first implemented in New Jersey, beginning in 1980 with a small number of hospitals partitioned into three groups according to their budget positions - surplus, breakeven, and deficit - prior to the imposition of DRG payment.[1] The New Jersey experiment continued for three years, with additional cadres of hospitals being added to the number of institutions each year until all hospitals in the Garden State were dealing with this prospective payment system. DRGs were designed to be homogeneous units of hospital activity to which binding prices could be attached. A central theme in the advocacy of DRGs was that this reimbursement system would, by constraining the hospitals, oblige their administrators to alter the behavior of the physicians and surgeons comprising their medical staffs. Moreover, DRGs were designed to provide practice pattern information that administrators could use to influence individual physician behavior.[1] DRGs were intended to describe all types of patients in an acute hospital setting. The DRGs encompassed elderly patients as well as newborn, pediatric and adult populations.
Diagnosis-related group The prospective payment system implemented as DRGs had been designed to limit the share of hospital revenues derived from the Medicare program budget,[1] and in spite of doubtful results in New Jersey, it was decided in 1983 to impose DRGs on hospitals nationwide. In that year, HCFA assumed responsibility for the maintenance and modifications of these DRG definitions. Since that time, the focus of all Medicare DRG modifications instituted by HCFA/CMS has been on problems relating primarily to the elderly population. In 1987, New York state passed legislation instituting DRG-based payments for all non-Medicare patients. This legislation required that the New York State Health Department (NYHD) evaluate the applicability of Medicare DRGs to a non-Medicare population. This evaluation concluded that the Medicare DRGs were not adequate for a non-Medicare population. Based on this evaluation, the NYDH entered into an agreement with 3M to research and develop all necessary DRG modifications. The modifications resulted in the initial APDRG, which differed from the Medicare DRG in that it provided support for transplants, high-risk obstetric care, nutritional disorders, and pediatrics along with support for other populations. One challenge in working with the APDRG groupers is that there is no set of common data/formulas that is shared across all states as there is with CMS. Each state maintains its own information. In 1991, the top 10 DRGs overall were: normal newborn, vaginal delivery, heart failure, psychoses, cesarean section, neonate with significant problems, angina pectoris, specific cerebrovascular disorders, pneumonia, and hip/knee replacement. These DRGs comprised nearly 30 percent of all hospital discharges.[2] The history, design, and classification rules of the DRG system, as well as its application to patient discharge data and updating procedures, are presented in the CMS DRG Definitions Manual (Also known as the Medicare DRG Definitions Manual and the Grouper Manual). A new version generally appears every October. The 20.0 version appeared in 2002. In 2007, author Rick Mayes described DRGs as:
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...the single most influential postwar innovation in medical financing: Medicare's prospective payment system (PPS). Inexorably rising medical inflation and deep economic deterioration forced policymakers in the late 1970s to pursue radical reform of Medicare to keep the program from insolvency. Congress and the Reagan administration eventually turned to the one alternative reimbursement system that analysts and academics had studied more than any other and had even tested with apparent success in New Jersey: prospective payment with diagnosis-related groups (DRGs). Rather than simply reimbursing hospitals whatever costs they charged to treat Medicare patients, the new model paid hospitals a predetermined, set rate based on the patient's diagnosis. The most significant change in health policy since Medicare and Medicaid's passage in 1965 went virtually unnoticed by the general public. Nevertheless, the change was nothing short of revolutionary. For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry. Medicare's new prospective payment system with DRGs triggered a shift in the balance of political and economic power between the providers of medical care (hospitals and physicians) and those who paid for it - power that providers had successfully accumulated for more than half a century." [3]
CMS DRG version 25 revision

As of October 1, 2007 with version 25, the CMS DRG system resequenced the groups, so that for instance "Ungroupable" is no longer 470 but is now 999. To differentiate it, the newly resequenced DRG are now known as MS-DRG. Before the introduction of version 25, many CMS DRG classifications were "paired" to reflect the presence of complications or comorbidities (CCs). A significant refinement of version 25 was to replace this pairing, in many instances, with a trifurcated design that created a tiered system of the absence of CCs, the presence of CCs, and a higher level of presence of Major CCs. As a result of this change, the historical list of diagnoses that qualified for membership on the CC list was substantially redefined and replaced with a new standard CC list and a new Major CC list.
Diagnosis-related group Another planning refinement was not to number the DRGs in strict numerical sequence as compared with the prior versions. In the past, newly created DRG classifications would be added to the end of the list. In version 25, there are gaps within the numbering system that will allow modifications over time, and also allow for new MS-DRGs in the same body system to be located more closely together in the numerical sequence.
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MS-DRG version 26 revision

MS-DRG Grouper version 26 took effect as of October 1, 2008 with one main change: implementation of Hospital Acquired Conditions (HAC). Certain conditions are no longer considered complications if they were not present on admission (POA), which will cause reduced reimbursement from Medicare for conditions apparently caused by the hospital.
MS-DRG version 27 revision

MS-DRG Grouper version 27 took effect as of October 1, 2009. Changes involved are mainly related to Influenza A virus subtype H1N1.
References
[1] Lessons of the New Jersey DRG Payment System (http:/ / content. healthaffairs. org/ cgi/ reprint/ 5/ 2/ 32. pdf) [2] "Most Frequent Diagnoses and Procedures for DRGs, by Insurance Status" (http:/ / www. hcup-us. ahrq. gov/ reports/ natstats. jsp). Agency for Health Care Policy and Research. . Retrieved 2006-04-22. [3] Mayes, Rick (January 2007). "The Origins, Development, and Passage of Medicare's Revolutionary Prospective Payment System" (http:/ / muse. jhu. edu/ login?uri=/ journals/ journal_of_the_history_of_medicine_and_allied_sciences/ v062/ 62. 1mayes. html) (abstract). Journal of the History of Medicine and Allied Sciences (Oxford University Press) 62 (1): pp. 2155. doi:10.1093/jhmas/jrj038. ISSN1468-4373. PMID16467485. . Retrieved 2009-04-06.
External links
Official CMS website (http://cms.hhs.gov) DRG codes for FY2005, also referred to as version 23 (http://www.cms.hhs.gov/ MedicareFeeforSvcPartsAB/Downloads/DRGDesc05.pdf) DRG codes for FY2010, also referred to as version 27 (http://www.cms.hhs.gov/AcuteInpatientPPS/ downloads/FY_2010_FR_Table_5.zip) Agency for Healthcare Research and Quality (AHRQ) (http://www.ahrq.gov). DRG definition (http://www.ahrq.gov/data/hcup/94drga.htm). Most Frequent Diagnoses and Procedures for DRGs (http://www.hcup-us.ahrq.gov/reports/natstats.jsp). DRG and ICD (http://www.umanitoba.ca/centres/mchp/concept/dict/drg/DRG_overview.html) (Canada) from the MCHP research unit of the University of Manitoba's Faculty of Medicine. Diagnosis Related Groups (DRGs) and the Medicare Program (http://govinfo.library.unt.edu/ota/Ota_4/ DATA/1983/8306.PDF) - Implications for Medical Technology (PDF format). A 1983 document found in the "CyberCemetery: OTA Legacy" section of University of North Texas Libraries Government Documents department. Mayes, Rick, "The Origins, Development, and Passage of Medicare's Revolutionary Prospective Payment System" (http://muse.jhu.edu/login?uri=/journals/journal_of_the_history_of_medicine_and_allied_sciences/ v062/62.1mayes.html) Journal of the History of Medicine and Allied Sciences Volume 62, Number 1, January 2007, pp. 21-55
Digital Imaging and Communications in Medicine
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DICOM (Digital Imaging and Communications in Medicine) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. The communication protocol is an application protocol that uses TCP/IP to communicate between systems. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. The National Electrical Manufacturers Association (NEMA) holds the copyright to this standard.[1] It was developed by the DICOM Standards Committee, whose members[2] are also partly members of NEMA.[3] DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving and communication system (PACS). The different devices come with DICOM conformance statements which clearly state the DICOM classes they support. DICOM has been widely adopted by hospitals and is making inroads in smaller applications like dentists' and doctors' offices. DICOM is known as NEMA standard PS3, and as ISO standard 12052:2006 "Health informatics -- Digital imaging and communication in medicine (DICOM) including workflow and data management".
Parts of the DICOM standard

The DICOM standard is divided into related but independent parts:[4] The links below are to the 2009 version published in January 2010. Additions to the standard (Supplements and Change Proposals) since that publication are available through the DICOM Web site [5]. PS 3.1: Introduction and Overview [6]PDF(241KB) PS 3.2: Conformance [7]PDF(6.46MB) PS 3.3: Information Object Definitions [8]PDF(6.96MB) PS 3.4: Service Class Specifications [9]PDF(1.07MB) PS 3.5: Data Structure and Encoding [10]PDF(1.43MB) PS 3.6: Data Dictionary [11]PDF(7.32MB) PS 3.7: Message Exchange [12]PDF(1.97MB) PS 3.8: Network Communication Support for Message Exchange [13]PDF(901KB) PS 3.9: Retired (formerly Point-to-Point Communication Support for Message Exchange) PS 3.10: Media Storage and File Format for Data Interchange [14]PDF(406KB) PS 3.11: Media Storage Application Profiles [15]PDF(1.14MB) PS 3.12: Storage Functions and Media Formats for Data Interchange [16]PDF(593KB) PS 3.13: Retired (formerly Print Management Point-to-Point Communication Support) PS 3.14: Grayscale Standard Display Function [17]PDF(2.88MB) PS 3.15: Security and System Management Profiles [18]PDF(1.00MB) PS 3.16: Content Mapping Resource [19]PDF(3.08MB) PS 3.17: Explanatory Information [20]PDF(3.28MB) PS 3.18: Web Access to DICOM Persistent Objects (WADO) [21]PDF(291KB)
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History
DICOM is the third version of a standard developed by American College of Radiology (ACR) and National Electrical Manufacturers Association (NEMA). In the beginning of the 1980s it was almost impossible for anyone other than manufacturers of computed tomography or magnetic resonance imaging devices to decode the images that the machines generated. Radiologists and medical physicists wanted to use the images for dose-planning for radiation therapy. ACR and NEMA joined forces and formed a standard committee in 1983. Their first standard, ACR/NEMA 300, was released in 1985. Very soon after its release, it became clear that improvements were needed. The text was vague and had internal contradictions. In 1988 the second version was released. This version gained more acceptance among vendors. The image transmission was specified as Front page of ACR/NEMA 300, version 1.0, over a dedicated 25 differential (EIA-485) pair cable. The first which was released in 1985 demonstration of ACR/NEMA V2.0 interconnectivity technology was held at Georgetown University, May 2123, 1990. Six companies participated in this event, DeJarnette Research Systems, General Electric Medical Systems, Merge Technologies, Siemens Medical Systems, Vortech (acquired by Kodak that same year) and 3M. Commercial equipment supporting ACR/NEMA 2.0 was presented at the annual meeting of the Radiological Society of North America (RSNA) in 1990 by these same vendors. Many soon realized that the second version also needed improvement. Several extensions to ACR/NEMA 2.0 were created, like Papyrus (developed by the University Hospital of Geneva, Switzerland) and SPI, (Standard Product Interconnect, driven by Siemens Medical Systems and Philips Medical Systems). The first large scale deployment of ACR/NEMA technology was made in 1992 by the US Army and Air Force as part of the MDIS (Medical Diagnostic Imaging Support) [22] program run out of Ft. Detrick, Maryland. Loral Aerospace and Siemens Medical Systems led a consortium of companies in deploying the first US military PACS (Picture Archiving and Communications System) at all major Army and Air Force medical treatment facilities and teleradiology nodes at a large number of US military clinics. DeJarnette Research Systems and Merge Technologies provided the modality gateway interfaces from third party imaging modalities to the Siemens SPI network. The Veterans Administration and the Navy also purchased systems off this contract. In 1993 the third version of the standard was released. Its name was then changed to DICOM so as to improve the possibility of international acceptance as a standard. New service classes were defined, network support added and the Conformance Statement was introduced. Officially, the latest version of the standard is still 3.0, however, it has been constantly updated and extended since 1993. Instead of using the version number the standard is often version-numbered using the release year, like "the 2007 version of DICOM". While the DICOM standard has achieved a near universal level of acceptance amongst medical imaging equipment vendors and healthcare IT organizations, the standard has its limitations. DICOM is a standard directed at addressing technical interoperability issues in medical imaging. It is not a framework or architecture for achieving a useful clinical workflow. RSNA's Integrating the Healthcare Enterprise (IHE) initiative layered on top of DICOM (and HL-7) provides this final piece of the medical imaging interoperability puzzle.
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Derivations
There are some derivations from the DICOM standard into other application areas. This includes DICONDE - Digital Imaging and Communication in Nondestructive Evaluation, was established in 2004 as a way for nondestructive testing manufacturers and users to share image data.[23] DICOS - Digital Imaging and Communication in Security was established in 2009 to be used for image sharing in airport security.[24]
DICOM Data Format

DICOM differs from some, but not all, data formats in that it groups information into data sets. That means that a file of a chest X-Ray image, for example, actually contains the patient ID within the file, so that the image can never be separated from this information by mistake. This is similar to the way that image formats such as JPEG can also have embedded tags to identify and otherwise describe the image. A DICOM data object consists of a number of attributes, including items such as name, ID, etc., and also one special attribute containing the image pixel data (i.e. logically, the main object has no "header" as such: merely a list of attributes, including the pixel data). A single DICOM object can only contain one attribute containing pixel data. For many modalities, this corresponds to a single image. But note that the attribute may contain multiple "frames", allowing storage of cine loops or other multi-frame data. Another example is NM data, where an NM image by definition is a multi-dimensional multi-frame image. In these cases three- or four-dimensional data can be encapsulated in a single DICOM object. Pixel data can be compressed using a variety of standards, including JPEG, JPEG Lossless, JPEG 2000, and Run-length encoding (RLE). LZW (zip) compression can be used for the whole data set (not just the pixel data) but this is rarely implemented. DICOM uses three different Data Element encoding schemes. With Explicit Value Representation (VR) Data Elements, for VRs that are not OB, OW, OF, SQ, UT, or UN, the format for each Data Element is: GROUP (2 bytes) ELEMENT (2 bytes) VR (2 bytes) LengthInByte (2 bytes) Data (variable length). For the other Explicit Data Elements or Implicit Data Elements, see section 7.1 of Part 5 of the DICOM Standard. The same basic format is used for all applications, including network and file usage, but when written to a file, usually a true "header" (containing copies of a few key attributes and details of the application which wrote it) is added.
DICOM Value Representations

Extracted from Chapter 6.2 of PS 3.5: Data Structure and Encoding [25]PDF(1.43MiB)
Value Representation AE AS AT CS DA DS DT FL FD Description Application Entity Age String Attribute Tag Code String Date Decimal String Date/Time Floating Point Single (4 bytes) Floating Point Double (8 bytes)
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Integer String Long String Long Text Other Byte Other Float Other Word Person Name Short String Signed Long Sequence of Items Signed Short Short Text Time Unique Identifier Unsigned Long Unknown Unsigned Short Unlimited Text
IS LO LT OB OF OW PN SH SL SQ SS ST TM UI UL UN US UT
In addition to a Value Representation, each attribute also has a Value Multiplicity to indicate the number of data elements contained in the attribute. For character string value representations, if more than one data element is being encoded, the successive data elements are separated by the backslash character "\".
DICOM Services
DICOM consists of many different services, most of which involve transmission of data over a network, and the file format below is a later and relatively minor addition to the standard.
Store
The DICOM Store service is used to send images or other persistent objects (structured reports, etc.) to a PACS or workstation.
Storage Commitment
The DICOM storage commitment service is used to confirm that an image has been permanently stored by a device (either on redundant disks or on backup media, e.g. burnt to a CD). The Service Class User (SCU: similar to a client), a modality or workstation, etc., uses the confirmation from the Service Class Provider (SCP: similar to a server), an archive station for instance, to make sure that it is safe to delete the images locally.
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Query/Retrieve
This enables a workstation to find lists of images or other such objects and then retrieve them from a PACS.
Modality Worklist
This enables a piece of imaging equipment (a modality) to obtain details of patients and scheduled examinations electronically, avoiding the need to type such information multiple times (and the mistakes caused by retyping).
Modality Performed Procedure Step

A complementary service to Modality Worklist, this enables the modality to send a report about a performed examination including data about the images acquired, beginning time, end time, and duration of a study, dose delivered, etc. It helps give the radiology department a more precise handle on resource (acquisition station) use. Also known as MPPS, this service allows a modality to better coordinate with image storage servers by giving the server a list of objects to send before or while actually sending such objects.
Printing
The DICOM Printing service is used to send images to a DICOM Printer, normally to print an "X-Ray" film. There is a standard calibration (defined in DICOM Part 14) to help ensure consistency between various display devices, including hard copy printout.
Off-line Media (DICOM Files)

The off-line media files correspond to Part 10 of the DICOM standard. It describes how to store medical imaging information on removable media. Except for the data set containing, for example, an image and demography, it's also mandatory to include the File Meta Information. DICOM restricts the filenames on DICOM media to 8 characters (some systems wrongly use 8.3, but this does not conform to the standard). No information must be extracted from these names (PS3.10 Section 6.2.3.2). This is a common source of problems with media created by developers who did not read the specifications carefully. This is a historical requirement to maintain compatibility with older existing systems. It also mandates the presence of a media directory, the DICOMDIR file, which provides index and summary information for all the DICOM files on the media. The DICOMDIR information provides substantially greater information about each file than any filename could, so there is less need for meaningful file names. DICOM files typically have a .dcm file extension if they are not part of a DICOM media (which requires them to be without extension). The MIME type for DICOM files is defined by RFC 3240 as application/dicom. The Uniform Type Identifier type for DICOM files is org.nema.dicom. There is also an ongoing media exchange test and "connectathon" process for CD media and network operation that is organized by the IHE organization.
Application areas
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Modality BI CD CR CT DD DG DX EC EM ES GM LS MA MG MR MS NM OT PT RF RG RT SC SM ST TG US VL XA XC
Description Modality of type Biomagnetic Imaging Modality of type Color Flow Doppler-Retired 2008 Modality of type Computed Radiography Modality of type Computed Tomography Modality of type Duplex Doppler-Retired 2008 Modality of type Diaphanography Modality of type Digital Radiography Modality of type Echo cardiography (retired) Modality of type Electron Microscope Modality of type Endoscopy Modality of type General Microscopy Modality of type Laser Surface Scan Modality of type Magnetic Resonance Angiography (retired) Modality of type Mammography Modality of type Magnetic Resonance Modality of type Magnetic Resonance Spectroscopy (retired) Modality of type Nuclear Medicine Modality of type Other Modality of type Positron Emission Tomography Modality of type Radio Fluoroscopy Modality of type Radiographic Imaging (conventional film screen) Modality of type Radiation Therapy Modality of type Secondary Capture Modality of type Slide Microscopy Modality of type Single-Photon Emission Computed Tomography (retired 2008) Modality of type Thermography Modality of type Ultra Sound Modality of type Visible Light Modality of type X-Ray Angiography Modality of type External Camera (Photography)
Examples of Modalities supported in DICOM are: AS = Angioscopy-Retired BI = Biomagnetic Imaging CD = Color Flow Doppler-Retired CF = Cinefluorography (retired) CP = Colposcopy Retired CR = Computed Radiography CS = CystoscopyRetired CT = Computed Tomography
Digital Imaging and Communications in Medicine DD = Duplex Doppler Retired DF = Digital Fluoroscopy (retired) DG = Diaphanography DM = Digital Microscopy (retired) DS = Digital Subtraction Angiography Retired DX = Digital radiography EC = Echocardiography Retired ES = Endoscopy FA = Fluorescein Angiography Retired FS = Fundoscopy Retired HC = Hard Copy LP = Laparoscopy Retired LS = Laser Surface Scan MA = Magnetic resonance angiography Retired MG = Mammography MR = Magnetic Resonance MS = Magnetic Resonance Spectroscopy Retired NM = Nuclear Medicine OT = Other PT = Positron Emission Tomography (PET) RF = Radio Fluoroscopy RG = Radiographic Imaging (conventional film screen) RTDOSE (a.k.a. RD) = Radiotherapy Dose RTIMAGE = Radiotherapy Image RTPLAN (a.k.a. RP) = Radiotherapy Plan RTSTRUCT (a.k.a. RS) = Radiotherapy Structure Set SR = Structured Reporting ST = Single-photon Emission Computed Tomography Retired TG = Thermography US = Ultrasound VF = Videofluorography (retired) XA = X-Ray Angiography XC = eXternal Camera ECG = Electrocardiograms
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DICOM transmission protocol port numbers over IP

DICOM have reserved the following TCP and UDP port numbers by the Internet Assigned Numbers Authority (IANA): 104 well-known port for DICOM over TCP or UDP. Since 104 is in the reserved subset, many operating systems require special privileges to use it. 2761 registered port for DICOM using Integrated Secure Communication Layer (ISCL) over TCP or UDP 2762 registered port for DICOM using Transport Layer Security (TLS) over TCP or UDP 11112 registered port for DICOM using standard, open communication over TCP or UDP The standard recommends but does not require the use of these port numbers.
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References
[1] [2] [3] [4] DICOM brochure (http:/ / medical. nema. org/ dicom/ geninfo/ Brochure. pdf) MEMBERS of the DICOM STANDARDS COMMITTEE (http:/ / medical. nema. org/ members. pdf) NEMA Members (http:/ / www. nema. org/ about/ members/ ) "6.1 DIMSE Services" (ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 08_01pu. pdf). Digital Imaging and Communications in Medicine (DICOM) Part 1: Introduction and Overview. National Electrical Manufacturers Association. 2006. pp.11. . [5] http:/ / dicom. nema. org [6] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_01pu. pdf [7] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_02pu. pdf [8] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_03pu3. pdf [9] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_04pu. pdf [10] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_05pu3. pdf [11] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_06pu3. pdf [12] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_07pu2. pdf [13] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_08pu. pdf [14] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_10pu. pdf [15] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_11pu. pdf [16] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_12pu. pdf [17] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_14pu. pdf [18] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_15pu. pdf [19] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_16pu. pdf [20] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_17pu. pdf [21] ftp:/ / medical. nema. org/ medical/ dicom/ 2009/ 09_18pu. pdf [22] http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 7612705?dopt=Abstract [23] http:/ / www. astm. org: If a Picture Is Worth 1,000 Words, then Pervasive, Ubiquitous Imaging Is Priceless (http:/ / www. astm. org/ SNEWS/ OCTOBER_2003/ voelker_oct03. html) [24] http:/ / www. nema. org: Industrial Imaging and Communications Section (http:/ / www. nema. org/ prod/ security/ indust-Img. cfm) [25] http:/ / medical. nema. org/ dicom/ 2007/ 07_05pu. pdf
External links
The latest DICOM specification (ftp://medical.nema.org/medical/dicom/2009/) DICOM Standard Status (approved and proposed changes) (http://www.dclunie.com/dicom-status/status. html) Brief introduction to DICOM (http://www.cabiatl.com/mricro/dicom/index.html) Introduction to DICOM using OsiriX (http://www.saravanansubramanian.com/Saravanan/ Articles_On_Software/Entries/2010/2/10_Introduction_to_the_DICOM_Standard.html) Medical Image FAQ part 2 (http://www.dclunie.com/medical-image-faq/html/part2.html) - Standard formats including DICOM. Medical Image FAQ part 8 (http://www.dclunie.com/medical-image-faq/html/part8.html) - Contains a long list DICOM software. Collection of DICOM images (clinical images and technical testpatterns) (http://www.aycan.de/main/lp/ sample_dicom_images.html) Example of an applet based DICOM Viewer (http://legeneraliste.perso.sfr.fr/?p=dicom_eng)
DOCLE
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DOCLE
DOCLE (Doctor Command Language), is a non-numeric health coding and medical classification system. The Docle system is used in Health Communication Network's electronic medical record and patient management software package, Medical Director. Medical Director is the most widely used electronic medical record system by Australian primary health care providers. DOCLE has been modelled on the linnean biological classification system since 1995. Docle generates clinical codes from ubiquitous health language using an algorithm, hence it is a human readable clinical coding system.
Design
According to Dr Y Kuang Oon, developer behind Docle, Docle can be explained simply by the following design principles: Docle design principle No. 1 Clinical codes are wordful meanings and are intention revealing. Docle design principle No. 2 Clinical codes are derived from ubiquitous health language in this manner: if the health concept is one word then the first four characters of the word else if it is two words then the first four characters of the first word plus the first character of the second word else the first characters of each word for the case of three or more words. Docle design principle No. 3 Clinical codes grow with evolving order with both speciation and large scale structures in a linnean manner. Docle design principle No. 4 Clinical codes are designed to be snapped on together to form clinical statements (docle closures) using joiner codes. Analogous to the clinical concept codes being the neurons and the joiner codes being the glia.
References
"Docle coding and classification system browser" [1] (HTML). Retrieved 2008-03-29. "Medical Director - Product Details" [2] (HTML). Health Communication Network. Retrieved 2008-04-04. "Docle Systems" [3] (HTML). Retrieved 2008-07-02.
External links
Docle Systems Web Site [3]
References
[1] http:/ / www. docle. com. au/ publ/ Hic99. htm [2] http:/ / www. hcn. net. au/ products/ md/ md. asp [3] http:/ / www. docle. com. au/
Electronic Common Technical Document
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The electronic Common Technical Document (eCTD) is an interface for the pharmaceutical industry to agency transfer of regulatory information. The content is based on the Common Technical Document (CTD) format. It was developed by the International Conference on Harmonisation (ICH) Multidisciplinary Group 2 Expert Working Group (ICH M2 EWG). As of January 1, 2008, the U.S. Food and Drug Administration announced that the eCTD is the preferred format for electronic submissions.[1] To date, over 98,000 eCTD sequences have been submitted to the FDA.[2] Although the agency has not released an expected target date, the FDA revealed during the 2009 DIA Annual Meeting that it is looking at draft legislation to require eCTD.[3]
Pharmaceutical point of view

The eCTD has five modules 1 Administrative Information and Prescribing Information 2 Common Technical Document Summaries 3 Quality 4 Nonclinical Study Reports 5 Clinical Study Reports A full table of contents quite large.
[4]
could be
There are two categories of modules: Regional module: 1 (different for each region; i.e., country) Common modules: 2-5 (common to all the regions) The CTD only defines the content of the common modules. The contents of the Regional Module 1 are defined by each of the ICH regions (USA, Europe and Japan).
IT point of view
eCTD (data structure)
The eCTD is a message specification for the transfer of files and metadata from a submitter to a receiver. The primary technical components are: A high level folder structure (required) An XML "backbone" file which provides metadata about content files and lifecycle instructions for the receiving system An optional lower level folder structure (recommended folder names are provided in Appendix 4 of the eCTD specification) Associated Document Type Definitions (DTDs) and stylesheets. Each submission message constitutes one "sequence". A cumulative eCTD consists of one or more sequences. While a single sequence may be viewed with web browser and the ICH stylesheet provided, viewing a cumulative eCTD requires specialized eCTD viewers. The top part of the directory structure is as follows:
Electronic Common Technical Document ctd-123456/0000/index.xml ctd-123456/0000/index-md5.txt ctd-123456/0000/m1 ctd-123456/0000/m2 ctd-123456/0000/m3 ctd-123456/0000/m4 ctd-123456/0000/m5 ctd-123456/0000/util The string ctd-123456/0000 is just an example. Backbone (header) This is the file index.xml in the submission sequence number folder. For example: ctd-123456/0000/index.xml The purpose of this file is twofold: Manage meta-data for the entire submission Constitute a comprehensive table of contents and provide corresponding navigation aid. Stylesheets Stylesheets should be included that support the presentation and navigation. They must be placed in the directory: ctd-123456/0000/util/style See entry 377 in Appendix 4. DTDs DTDs must be placed in the directory: ctd-123456/0000/util/dtd See entry 371 to 376 in Appendix 4. They must follow a naming convention. The DTD of the backbone is in Appendix 8. It must be place in the above directory.
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Business process (protocol)

The business process to be supported can be described as follows: Industry <-----> Message <-----> Agency The lifecycle management is composed at least of: Initial submission: should be self-contained. Incremental updates: with its sequence number.
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References
[1] "U.S. FDA Signals Intent to Reject eCTDs with Technical Issues" (http:/ / www. globalsubmit. com/ home/ LinkClick. aspx?fileticket=VtDTs2A/ qZs=& tabid=37). February 2, 2009. . [2] Kathie Clark (December 15, 2009). "Updates from the Regulators: FDA" (http:/ / theectdsummit. com/ summit/ ?p=630). The eCTD summit. . [3] Kathie Clark (June 30, 2009). "DIA Update: News from the FDA" (http:/ / theectdsummit. com/ summit/ ?p=468). The eCTD summit. . [4] http:/ / www. fda. gov/ downloads/ Drugs/ DevelopmentApprovalProcess/ FormsSubmissionRequirements/ ElectronicSubmissions/ UCM163175. pdf
External links
ICH eCTD Specification V 3.2.2 (http://estri.ich.org/eCTD/eCTD_Specification_v3_2_2.pdf) (The specification) ICH M2 ESTRI Main (http://estri.ich.org) Electronic Common Technical Document (eCTD) (http://www.fda.gov/Drugs/DevelopmentApprovalProcess/ FormsSubmissionRequirements/ElectronicSubmissions/ucm153574.htm) (FDA) EUDRALEX Volume 2 - Pharmaceutical Legislation : Notice to Applicants (http://ec.europa.eu/enterprise/ pharmaceuticals/eudralex/homev2.htm) (EU legislation, contains section on eCTD) IT Pharma Validation Europe (Organization: CSV Validation Network) (http://www.it-validation.eu) Exalon eCTD News - free and strictly neutral eCTD related news from regulators (http://www.exalon.com/ ectd-news.html) The eCTD summit blog (http://theectdsummit.com/summit/) eCTDBlog.com (http://www.ectdblog.com/) Regional file format requirements for eCTD (http://blog.fxtrans.com/2009/11/ regional-file-format-requirements-for.html)
EUDRANET
EUDRANET, the European Telecommunication Network in Pharmaceuticals (European Union Drug Regulating Authorities Network), is an IT platform to facilitate the exchange of information between regulatory partners and industry during submission and evaluation of applications. The aim of EUDRANET is to provide appropriate secure services for inter-Administration data interchange and for exchanges between Administrations and industry. EUDRANET is based on the TESTA backbone infrastructure provided by the IDA Programme. The processes which EUDRANET supports include: The submission and evaluation of marketing authorisation applications by pharmaceutical companies; The pharmacovigilance of products on the market to ensure the maintenance of high standards of quality as well as adhering to European national and regional regulations; The dissemination of relevant information to industry, scientific experts and regulators.
EUDRANET
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External links
EUDRANET [1] Projects of Common Interest for Administrations [2] (European Union) e-Health [3] (European Union)
References
[1] http:/ / ec. europa. eu/ idabc/ en/ document/ 2291 [2] http:/ / ec. europa. eu/ idabc/ en/ chapter/ 565 [3] http:/ / ec. europa. eu/ information_society/ eeurope/ 2005/ all_about/ ehealth/ index_en. htm
General Data Format for Biomedical Signals

The General Data Format for Biomedical Signals is a scientific and medical data file format. The aim of GDF is to combine and integrate the best features of all [biosignal file formats] [1] into a single file format. [GDF v1] [2] uses a binary header, and uses an event table. GDF [v2.0] [3] added fields for additional subject-specific information (gender, age, etc), and utilizes several standard codes (for storing physical units and other properties). GDF is used mostly in Brain-Computer interface research; however GDF provides a superset of features from many different file formats, it could be also used for many other domains. The free and open source software library [BioSig] Octave/Matlab and C/C++.
[4]
provides implementations for reading and writing of GDF in
External links
BioSig [4] GDF v2.0 [3] GDF v1.x [2] More information on the GDF format [5]
References
[1] [2] [3] [4] [5] http:/ / www. dpmi. tu-graz. ac. at/ ~schloegl/ matlab/ eeg/ http:/ / hci. tugraz. at/ schloegl/ matlab/ eeg/ gdf4/ TR_GDF. pdf http:/ / arxiv. org/ abs/ cs. DB/ 0608052 http:/ / biosig. sf. net/ http:/ / www. dpmi. tu-graz. ac. at/ ~schloegl/ matlab/ eeg/ #GDF
Health Level 7
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Health Level 7
Health Level Seven (HL7), is an all-volunteer, non-profit organization involved in development of international healthcare informatics interoperability standards.[1] "HL7" is also used to refer to some of the specific standards created by the organization (e.g., HL7 v2.x, v3.0, HL7 RIM).[2] HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information. v2.x of the standards, which support clinical practice and the management, delivery, and evaluation of health services, are the most commonly used in the world.
Organization
HL7 is an international community of healthcare subject matter experts and information scientists collaborating to create standards for the exchange, management and integration of electronic healthcare information.[3] HL7 promotes the use of such informatics standards within and among healthcare organizations to increase the effectiveness and efficiency of healthcare information delivery for the benefit of all. The HL7 community is organized in the form of a global organization (Health Level Seven, Inc.) and country-specific affiliate organizations: Health Level Seven, Inc. (HL7, Inc. ) is headquartered in Ann Arbor, Michigan.[4] HL7 affiliate organizations, not-for-profit organizations incorporated in local jurisdictions, exist in over 40 countries. The first affiliate organization was created in Germany in 1993. The organizational structure of HL7 Inc. is as follows: The organization is managed by a Board of Directors, which comprises 10 elected positions and three appointed positions. The Chief Executive Officer (currently Charles Jaffe, MD, PhD) serves as an ex officio member of and reports to the Board of Directors. The Chief Technology Officer (currently John Quinn); and the Chief Operations Officer (currently Mark McDougall) report to the CEO and also serve as ex officio members on the Board of Directors. Members of HL7 are known collectively as "The Working Group". The Working Group is responsible for defining the HL7 standard protocol and is composed of Standing Administrative Committees and Working Groups. Standing Administrative committees focus on organizational or promotional activities, such as Education, Implementation, Marketing, Outreach Committee for Clinical Research, Publishing and Process Improvement and Tooling. Working groups are directly responsible for the content of the Standards, framing the actual language of the specifications.
Origin
HL7 was founded in 1987 to produce a standard for hospital information systems. HL7, Inc. is a standards organization that was accredited in 1994 by the American National Standards Institute (ANSI).[5] HL7 is one of several American National Standards Institute accredited Standards Developing Organizations (SDOs) operating in the healthcare arena. Most SDOs produce standards (sometimes called specifications or protocols) for a particular healthcare domain such as pharmacy, medical devices, imaging or insurance (claims processing) transactions. Health Level Sevens domain is clinical and administrative data. Today, HL7 has been adopted by several national SDOs outside the United States. Those SDOs are consequently not accredited by ANSI. However, HL7 is now adopted by ISO as a centre of gravity in international standardization and accredited as a partnering organization for mutual issuing of standards. The first mutually published standard is
Health Level 7 ISO/HL7 21731:2006 Health informaticsHL7 version 3Reference information modelRelease 1. The name "Health Level-7" The name "Health Level-7" is a reference to the seventh layer of the ISO OSI Reference model also known as the application layer. The name indicates that HL7 focuses on application layer protocols for the health care domain, independent of lower layers. HL7 effectively considers all lower layers merely as tools.[1]
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Collaboration
HL7 collaborates with other standards development organizations and national and international sanctioning bodies (e.g. ANSI and ISO), in both the healthcare and information infrastructure domains to promote the use of supportive and compatible standards. HL7 collaborates with healthcare information technology users to ensure that HL7 standards meet real-world requirements, and that appropriate standards development efforts are initiated by HL7 to meet emergent requirements. About 45% of the global membership (of either HL7 Inc. or an HL7 affiliate) is located in Europe, 35% in North America, 15% in Asia-Oceania and 5% elsewhere.[6]
HL7 standards
Hospitals and other healthcare provider organizations typically have many different computer systems used for everything from billing records to patient tracking. All of these systems should communicate with each other (or "interface") when they receive new information but not all do so. HL7 specifies a number of flexible standards, guidelines, and methodologies by which various healthcare systems can communicate with each other. Such guidelines or data standards are a set of rules that allow information to be shared and processed in a uniform and consistent manner. These data standards are meant to allow healthcare organizations to easily share clinical information. Theoretically, this ability to exchange information should help to minimize the tendency for medical care to be geographically isolated and highly variable. HL7 develops conceptual standards (e.g., HL7 RIM), document standards (e.g., HL7 CDA), application standards (e.g., HL7 CCOW), and messaging standards (e.g., HL7 v2.x and v3.0). Messaging standards are particularly important because they define how information is packaged and communicated from one party to another. Such standards set the language, structure and data types required for seamless integration from one system to another.[7] HL7 encompasses the complete life cycle of a standards specification including the development, adoption, market recognition, utilization, and adherence. Business use of the HL7 standards requires a paid organizational membership in HL7 Inc. HL7 Members can access standards for free and non members can buy the standards from HL7 or ANSI.
HL7 version 2.x

The HL7 version 2 standard has the aim to support hospital workflows. It was originally created in 1989.[8] V2.x Messaging HL7 version 2 defines a series of electronic messages to support administrative, logistical, financial as well as clinical processes. Since 1987 the standard has been updated regularly, resulting in versions 2.1, 2.2, 2.3, 2.3.1, 2.4, 2.5, 2.5.1 and 2.6. The v2.x standards are backward compatible (i.e. a message based on version 2.3 will be understood by an application that supports version 2.6). HL7 v2.x mostly uses a textual, non-XML encoding syntax based on delimiters. HL7 v2.x has allowed for the interoperability between electronic Patient Administration Systems (PAS), Electronic Practice Management (EPM) systems, Laboratory Information Systems (LIS), Dietary, Pharmacy and Billing systems as well as Electronic Medical Record (EMR) or Electronic Health Record (EHR) systems. Currently, HL7s v2.x messaging standard is supported by every major medical information systems vendor in the United States.[9]
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HL7 version 3
The HL7 version 3 standard has the aim to support all healthcare workflows. Development of version 3 started around 1995, resulting in an initial standard publication in 2005. The v3 standard, as opposed to version 2, is based on a formal methodology (the HDF) and object-oriented principles. RIM - ISO/HL7 21731 The Reference Information Model [10] (RIM) is the cornerstone of the HL7 Version 3 development process and an essential part of the HL7 V3 development methodology. RIM expresses the data content needed in a specific clinical or administrative context and provides an explicit representation of the semantic and lexical connections that exist between the information carried in the fields of HL7 messages. The RIM is essential to increase precision and reduce implementation costs. Models [11] are available. HL7 Development Framework - ISO/HL7 27931 The HL7 Version 3 Development Framework (HDF) is a continuously evolving process that seeks to develop specifications that facilitate interoperability between healthcare systems. The HL7 RIM, vocabulary specifications, and model-driven process of analysis and design combine to make HL7 Version 3 one methodology for development of consensus-based standards for healthcare information system interoperability. The HDF is the most current edition of the HL7 V3 development methodology. The HDF not only documents messaging, but also the processes, tools, actors, rules, and artifacts relevant to development of all HL7 standard specifications. Eventually, the HDF will encompass all of the HL7 standard specifications, including any new standards resulting from analysis of electronic health record architectures and requirements. HL7 specifications draw upon codes and vocabularies from a variety of sources. The V3 vocabulary work ensures that the systems implementing HL7 specifications have an unambiguous understanding of the code sources and code value domains they are using. V3 Messaging The HL7 version 3 messaging standard defines a series of electronic messages (called interactions) to support all healthcare workflows. HL7 v3 messages are based on an XML encoding syntax. V3 Clinical Document Architecture - ISO 10781 The HL7 version 3 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange.
Methods applied by HL7

Services Aware Interoperability Framework
The HL7 Services-Aware Enterprise Architecture Framework (SAIF) provides consistency between all HL7 artifacts, and enables a standardized approach to Enterprise Architecture (EA) development and implementation, and a way to measure the consistency. SAIF is a way of thinking about producing specifications that explicitly describe the governance, conformance, compliance, and behavioral semantics that are needed to achieve computable semantic working interoperability. The intended information transmission technology might use a messaging, document exchange, or services approach. SAIF is the framework that is required to rationalize interoperability of other standards. SAIF is an architecture for achieving interoperability, but it is not a whole-solution design for enterprise architecture management.
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Arden syntax
The Arden syntax is a language for encoding medical knowledge. HL7 adopted and oversees the standard beginning with Arden syntax 2.0. These Medical Logic Modules (MLMs) are used in the clinical setting as they can contain sufficient knowledge to make single medical decisions. They can produce alerts, diagnoses, and interpretations along with quality assurance function and administrative support. An MLM must run on a computer that meets the minimum system requirements and has the correct program installed. Then, the MLM can give advice for when and where it is needed.
MLLP
A large portion of HL7 messaging is transported by Minimal Lower Layer Protocol (MLLP). Amongst other software vendors this protocol is supported by Microsoft[12] and Oracle.[13]
CCOW
CCOW, or "Clinical Context Object Workgroup," is a standard protocol designed to enable disparate applications to share user context and patient context in real-time, and at the user-interface level. CCOW implementations typically require a CCOW vault system to manage user security between applications.
Functional EHR and PHR specifications

Functional specifications for an electronic health record.
Country specific aspects

Australia
HL7 Australia was established in 1998. Australia was an early adopter of the HL7 V2.x standards, which are now ubiquitously used in Australian public and private healthcare organisations. The localisation of the HL7 standards is undertaken in cooperation with the national standards body, Standards Australia. HL7 Australia closely cooperates with the National E-Health Transition Authority (NEHTA). HL7 Australia [14] Standards Australia (IT-014 "Health Informatics" [15] NEHTA [16]
Finland
National IT services for healthcare The Social Insurance Institution of Finland is building a national ePrescribing and patient record archival service based on HL7 CDA R2 and V3 messages. Phased deployment is scheduled for 2008-2011. Version 2 messaging is widely deployed in most hospitals and healthcare centers. CDA R1 is used in sharing patient records on a regional level. HL7 Finland national affiliate [17]
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Germany
The German chapter of HL7 was founded in 1993. This is an entity for benefit to the public and registered as an association as HL7 e. V. Due to federal structure of operational administration in German healthcare, the standardization aspect is much behind the possibilities of the public economy and due to competitive interests in industry of low normative impact to healthcare information systems development. Currently HL7 in Germany operates as an informal cluster and collaborates with the national standardization body.[18] The voluntary membership in HL7 relies on personal interest and engagement of clinical users and mainly on industrial interest: Clinical memberships are in minority. There is low membership of governmental administration and thus low contribution to ongoing discussion e.g. on patient data records (EPA = elektronische Patientenakte) balancing data availability vs. data security. Impact on productivity for hospital information systems (called KIS = Krankenhaus-Informationssysteme in German) is of no importance yet, as the variability of HIS systems has not been challenged by HL7. Governmental funding for a broader adoption of HL7 does yet not exist in Germany, neither on federal level nor in most of the regional governments.
The Netherlands
AORTA - National Healthcare ICT infrastructure AORTA is the Dutch national infrastructure for the exchange of data between healthcare providers. AORTA uses HL7 version 3 messages and documents as its core mechanism for information exchange. The initial specifications were created in 2003. The Dutch Ministry of Health is working on a virtual national Electronic Patient Records (EPR) which will enable healthcare providers to share patient data. This development takes place in close collaboration with Nictiz, the National Information and Communication Technology Institute for Healthcare. Nictiz coordinates its efforts with regard to the usage of HL7 version 3 with the volunteers of HL7 the Netherlands. Almost all hospitals use HL7 version 2 to support hospital-internal workflows. EDIfact is being used to support workflows involving general practitioners (GPs/PCPs). EDIfact will be slowly replaced by HL7 version 3. HL7 the Netherlands [19] Nictiz [20] AORTA whitepaper [21]
Pakistan
HLH - Health Life Horizon HLH (a national project) is carrying out at School of Electrical Engineering and Computer Sciences of National University of Science and Technology and is supported by Govt of Pakistan with funds provided by National ICT R&D Fund. HLH basic theme is to target health care information exchange and interoperability using HL7 version 3. Though the penetration and use of HL7 in Pakistan is lower than the countries like US and that of Europe. But its getting popularity among the stakeholders in Pakistan. HLH team put its tremendous efforts to develop state of the art HL7 version 3 tools and technologies. Also they are continuously involved to carry out research taking the development one step ahead. Additionally they organized and are organizing awareness seminars, meetings and workshops from time to time at various locations in Pakistan. HLH is collaborating with several other renowned organizations from Pakistan to be part of this journey. These efforts created a very good impression not only at national level but also at international level. HLH Team members regularly participated in HL7 international Working Group Meetings and conferences for last two years. On Oct 1, 2010 HL7 International announced Pakistan chapter formally at 24th Plenary and WGM in Cambridge USA. Pakistan is now 37th affiliate of HL7 International around the world. HL7 Pakistan [22] is now officially authorized to give memberships to local organizations along
Health Level 7 with other privileges like certification, training etc. [23] [22]
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USA
Laika The Certification Commission for Healthcare Information Technology (CCHIT) has developed an open-source program called Laika to test EHR software for compliance with CCHIT interoperability standards. HIPAA HL7s initial involvement in the Health Insurance Portability and Accountability Act (HIPAA) legislation began in 1996 with the formation of the Attachments special interest group to standardize the supplemental information needed to support health care insurance, and other e-commerce transactions. The initial deliverable of this group was a set of six recommended Claims Attachments for the Notice of Proposed Rule Making (NPRM) process. Future attachment projects include, but are not limited to, Home Health, Skilled Nursing Facility, durable medical equipment (DME), end stage renal disease (ESRD), and Pre-Authorization and Referrals. The Attachment special interest group is responsible for implementing the Administrative Simplification provisions of HIPAA mandates, providing on-going support, and representing HL7 in the Designated Standards Maintenance Organization (DSMO [24] ) efforts. Its purpose is to encourage the use of HL7 for uniform implementation of this supplemental information. This SIG coordinates industry input to produce and maintain guides for HL7 messages that can stand alone or be embedded within ANSI X12 transactions.
References
[1] "About Health Level Seven" (http:/ / www. hl7. org/ about/ index. cfm). Health Level Seven. . [2] "Healthcare Interoperability Glossary" (http:/ / www. corepointhealth. com/ resource-center/ healthcare-interoperability-glossary#H). Corepoint Health. . [3] www.hl7.org [4] "Contact Health Level Seven" (http:/ / www. hl7. org/ about/ contactus. cfm). Health Level Seven. . [5] http:/ / www. ansi. org/ ANSI [6] HL7 Membership Numbers (http:/ / lists. hl7. org/ read/ attachment/ 117742/ 1/ membership_worldwide. xls) as sent to the HL7 affiliates on 2007-11-08. [7] http:/ / www. chcf. org/ documents/ CCDPProjectOverview. pdf [8] http:/ / www. hl7. org/ about/ FAQs/ index. cfm?ref=nav HL7 FAQ [9] Standards Organizations (http:/ / aspe. hhs. gov/ sp/ nhii/ standards. html) [10] http:/ / www. hl7. org/ library/ data-model/ RIM/ modelpage_mem. htm [11] http:/ / www. hl7. org/ library/ data-model/ met/ modelpage. html [12] MLLP on MSDN (http:/ / msdn. microsoft. com/ en-us/ library/ ee409260(BTS. 10). aspx) [13] Oracle supported protocols (http:/ / download. oracle. com/ docs/ cd/ B14099_19/ integrate. 1012/ b19370/ supp_protos. htm#BACIFDJG) [14] http:/ / www. HL7. org. au [15] http:/ / www. e-Health. Standards. org. au [16] http:/ / www. NEHTA. gov. au [17] http:/ / www. hl7. fi [18] DIN NAMed Jahresbericht 2007 (http:/ / www. din. de/ sixcms_upload/ media/ 2616/ NAMed_Jahresbericht_2007. pdf) [19] http:/ / www. hl7. nl [20] http:/ / www. nictiz. nl [21] http:/ / www. ringholm. de/ docs/ 00980_en. htm [22] http:/ / www. hl7. org. pk [23] http:/ / www. hl7. seecs. edu. pk [24] http:/ / aspe. hhs. gov/ admnsimp/ final/ dsmo. htm
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External links
HL7 Standards (http://webstore.ansi.org/FindStandards.aspx?Action=displaydept&DeptID=3104& Acro=HL7&DpName=HL7: Health Level Seven/) HL7.org site (http://www.HL7.org/) Introduction to HL7 (http://www.HL7.com.au/FAQ.htm) How does HL7 work? (Video Introduction) (http://blog.interfaceware.com/hl7/how-does-hl7-work/) HL7.org EHR Page (http://www.HL7.org/EHR) What does HL7 enablement means? (http://www.ehrmarket.com/blog/2009/10/ what-does-hl7-enablement-means/) HL7 is a member of the Joint Initiative on SDO Global Health Informatics Standardization (http://www. global-e-health-standards.org/) HL7 Tools Page (http://www.HL7.org.au/HL7-Tools.htm) Australian Healthcare Messaging Laboratory (AHML) - Online HL7 Message Testing and Certification (http:// www.ahml.org.au/) Comprehensive Implementation of HL7 v3 Specifications in Java (http://aurora.regenstrief.org/javasig) HL7 Programming Tutorial using Java (http://www.saravanansubramanian.com/Saravanan/ Articles_On_Software/Entries/2009/2/21_HL7_Programming_using_Java_A_Short_Tutorial.html) HL7 101: A Beginners Guide (http://www.fortherecordmag.com/archives/ftr_01082007p22.shtml) International HL7 Experts Consortium (http://www.HL7Experts.com/) The Healthcare IT Interoperability Blog (http://www.ehrguy.com/) NIST HL7 Conformance Testing Framework (http://www.cs.duke.edu/~jgm/files/nist.2006.ppt) ICH-HL7 Regulated Product Submissions (http://globalsubmit.com/home/LearningCenter/ HL7RegulatedProductSubmissions/tabid/252/Default.aspx)
Critical reviews
HL7 RIM: An Incoherent Standard (http://ontology.buffalo.edu/hl7/doublestandards.pdf) and The HL7 RIM Under Scrutiny - rebuttal (http://aurora.regenstrief.org/~schadow/Schadow-MIE06-r3.pdf) HL7 Watch Blog; critical review of HL7 (http://hl7-watch.blogspot.com/). See also the posted comments for attempted rebuttals to some of the earlier posts.
Open source tools

There are a number of FOSS based tools that can foster worldwide adoption of the HL7 standards Mirth Connect, an Open Source HL7 Integration Engine for HL7 V2/V3, DICOM, NCPDP and X12. Freely available under MPL 1.1 license (http://www.mirthcorp.com/community/overview) The open health tools consortium (http://www.openhealthtools.org) The HL7 Java Special Interest Group's implementation of HL7 v3 (http://aurora.regenstrief.org/javasig) The Eclipse OHF project - v2 and v3 implementations (IDE type tools and run-time libraries) (http://www. eclipse.org/ohf) HAPI, An open-source, object-oriented HL7 2.x parser for Java (http://hl7api.sourceforge.net/) The Perl HL7 Toolkit, an Open-Source HL7 Perl module (http://hl7toolkit.sourceforge.net/) Pear (PHP) HL7 messaging API module (http://pear.php.net/package/Net_HL7) The eXcessively Simple HL7 v2 Processing Platform using XML and XSLT (http://aurora.regenstrief.org/ xhl7) The Ruby HL7 Library (http://rubyforge.org/projects/ruby-hl7) HL7 Java binding (http://xmlbeans.googlepages.com/) nule.org HL7 Utilities (http://nule.org/wp/?page_id=55)
Health Level 7 nHAPI open-source library for .NET (http://nhapi.sourceforge.net/home.php) HL7v3 Messaging Framework for .NET (http://everest.marc-hi.ca/) HL7 Analyst for .NET (http://hl7analyst.codeplex.com)
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Healthcare Common Procedure Coding System

The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as "hick picks") is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).
History
The acronym HCPCS originally stood for HCFA Common Procedure Coding System, as the Centers for Medicare and Medicaid (CMS) was previously (before 2001) known as the Health Care Financing Administration (HCFA). The Healthcare Common Procedure Coding System (HCPCS) was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care. Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.[1]
Levels of codes
HCPCS includes three levels of codes: Level I consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices,[2] and represent items and supplies and non-physician services not covered by CPT-4 codes (Level I). Level III codes, also called local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. The use of Level III codes was discontinued on December 31, 2003, in order to adhere to consistent coding standards.[3]
References
[1] at page 1 cms.hhs.gov (http:/ / www. cms. hhs. gov/ MedHCPCSGenInfo/ Downloads/ HCPCSReform. pdf) [2] HCPCS Level II Codes (http:/ / www. asha. org/ about/ publications/ leader-online/ b-line/ bl040608/ ) [3] HCPCS Background Information (http:/ / www. cms. hhs. gov/ MedHCPCSGenInfo/ )
External links
Official site (http://www.cms.hhs.gov/MedHCPCSGenInfo/) HCPCS Level II alphanumeric procedure and modifier codes (http://www.cms.hhs.gov/ HCPCSReleaseCodeSets/01_Overview.asp#TopOfPage) NDC-HCPCS crosswalk data files (http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a_2008aspfiles. asp) Free online HCPCS Level 2 Codes Search Engine from drchrono (https://drchrono.com/billing/medical_codes/ ?code_type=hcpcs_level_2&search_text=Enter+search+here.&Submit=Search) Searchable HCPCS codes and NDC numbers (http://www.commondatahub.com/hcpcs_source.jsp)
Healthcare Information Technology Standards Panel
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Healthcare Information Technology Standards Panel

The American National Standards Institute (ANSI) Healthcare Information Technology Standards Panel (HITSP) was created in 2005 as part of efforts by the Office of the National Coordinator for Health Information Technology (ONC, part of the United States Department of Health and Human Services) to promote interoperability in health care by harmonizing health information technology standards. HITSP is chaired by John Halamka, MD, CIO of Harvard Medical School.
Membership
Membership is by organization and there is currently no cost to join. Volunteers commit time to working on standards harmonization efforts as prioritized by the American Health Information Community (AHIC).
Goals
According to their website, HITSP's mission is to "serve as a cooperative partnership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among healthcare software applications, as they will interact in a local, regional and national health information network for the United States." HITSP is generally organized around Use Cases, which are profiles of specific interoperability needs that have been identified by AHIC as being important national priorities. The initial 2006 Use Cases were: Consumer Empowerment Registration Summary Medication History Electronic Health Records (EHRs) Laboratory Result Reporting Biosurveillance Visit Utilization Clinical Data Lab and Radiology
The 2007 Use Cases are: Consumer Access to Clinical Information Access to Clinical Data Provider Permissions Personal Health Record (PHR) Transfer Emergency Responder EHR On-site Care Emergency Care Definitive Care Provider Authentication and Authorization Medication Management Medication Reconciliation Ambulatory Prescriptions
Healthcare Information Technology Standards Panel Contraindications Quality Hospital Measurement and Reporting Clinician Measurement and Reporting Feedback to Clinicians
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External links
Healthcare Information Technology Standards Panel website [1]
References
[1] http:/ / www. hitsp. org
Health Informatics Service Architecture

The CEN Standard Architecture for Healthcare Information Systems (ENV 12967), Health Informatics Service Architecture or HISA is a standard aimed at enabling the development modular open systems to support healthcare. The HISA standard builds on the work of RICHE, NUCLEUS, EDITH and HANSA in this field.
Classes of common services

Healthcare-related Common Services (HCS) Generic Common Services (GCS)
Healthcare Services Specification Project
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The Healthcare Services Specification Project (HSSP) is a standards development effort to create health industry service oriented architecture (SOA) standards supportive of the health care market sector. HSSP is a jointly sponsored activity operating within the Health Level Seven (HL7) and the Object Management Group (OMG) standards group. Formally beginning as a collaboration between the HL7 Service-oriented Architecture Special Interest Group and the OMG Healthcare Domain Task Force, HSSP is developing healthcare middleware standards addressing interoperability challenges. The activity is an effort to create common service interface specifications that ultimately can be tractable within a Health IT context. The stated objective of the HSSP project is to create useful, usable healthcare standards that define the functions, semantics, and technology bindings supportive of system-level interoperability. To the extent possible, HSSP specifications complement existing work and standards. A key tenet to the HSSP approach is to focus on practical needs, capitalizing on open industry participation and maximizing contributions from industry talent interested in engaging.
Context
By design, HSSP specifications are applicable for use in multiple use contexts, including inter-enterprise, intra-enterprise, intra-product, and intra-implementation. In other words, nothing inherent in the standard work deliberately precludes their use in any targeted system setting.
Mission
The following is the stated Mission and Charter of the HSSP project, used with permission. Recognizing the need for specifications for services to support healthcare IT as part of national infrastructures (such as US NHII, Australias HealthConnect and Finland's Terveyshanke), Health Level Seven and the Object Management Group have forged this agreement to collaborate to the advantage of the health domain sector. This charter outlines high-level distribution of responsibilities and separation of concerns specifically related to this services effort. Note that this joint effort between HL7 and OMG is not exclusive. Either organization may engage in independent efforts or similar joint efforts with others. This project is a collaborative effort between HL7 and OMG to identify and document service specifications, functionality, and conformance supportive and relevant to healthcare IT stakeholders and resulting in real-world implementations. As part of this collaborative effort: HL7 and OMG shall jointly identify the service candidates for specification and prioritize and select candidate services for specification and implementation, and jointly allocate functions to services. OMG members shall provide expertise in distributed architecture and implementation to HL7 activities to positively impact the selection of services and allocation of functions. HL7 members shall engage in the OMG RFP process to ensure consistency with the functional requirements. HL7 shall elaborate the business functional needs, allocate functions to services, and develop conformance criteria for the services specified. HL7 shall also have responsibility for providing the information modeling and content in support of these services. All of the computationally independent work shall occur within HL7, as well as the functional conformance criteria assuring that service implementations meet their specified capability. In general, information models and content will be managed by other HL7 domain committees, and HSSP will work with those committees to define any additions or changes.
Healthcare Services Specification Project OMG shall refine the HL7 developed computationally independent specifications [functional, semantics, information model, terminology, etc.] resulting in computationally dependent standards and user, vendor, and reference implementations. OMG shall provide technical expertise such as Unified Modeling Language (UML) and Model-driven architecture (MDA), as well as leveraging multi-industry solutions. OMG shall leverage the strength of its adoption process to promote rapid standards development and marketplace product support given that submitters are required to produce implementations of the standards they specify. As a project and through its presence in other organizations, the HSSP will provide an umbrella structure under which various subgroups will be chartered to carry out specific tasks in conjunction and under the auspices of these organizations, such as definition of methodology, architecture and specific services. The HSSP additionally will facilitate between organizations to provide the tools, knowledge, methodologies, or viewpoints deemed necessary for them to fulfill their purpose. The responsibilities of the main HSSP will be to manage the subgroups and verify their charters, as well as provide cohesive vision and any appropriate administrative tasks.
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Philosophy
HSSP specification work is divided into two foundational components: functional specifications (manifested as Service Functional Models) and technical specifications (resulting in technology adoptions). The functional specification work is being originated within health industry standards communities, such as HL7 and CEN. The functional models enumerate what capabilities are to be supported but not how they are supported. The technical specification work details exactly how those functions are manifested and ultimately realized in a technology platform. The intention behind splitting the standard into two work products is to facilitate and improve involvement from different communities, leveraging each to their strengths. To date, HL7 has been leading in identifying standardization priorities, elaborating the functions desired into Service Functional Models, and in defining conformance criteria that would be used to assess compliance. The OMG has been leading the technical specification process as part of their Technology Adoption Process. The OMG process requires participants to make commitments to implement standards as working software, ensuring that the technical specifications are used and available. During implementation of these technical specifications, errors and shortcomings of adopted Service Functional Models are captured, logged, and ultimately incorporated into subsequent versions of the Service Functional Models as part of a continuous process improvement approach.
History
Prior to establishing HSSP as a moniker, the activity began informally as an informal group to discuss issues pertaining to SOA and interoperability in a health context. Meeting concurrently with regularly scheduled HL7 Working Group meetings, HSSP operated in this form for several years until June 2005. In June a meeting was hosted in Salt Lake City by the U.S. Veterans Health Administration to establish a formal direction for the group and to initiate steps to formalize its activities. In January 2006, Health Level Seven accepted the charter of the Service-oriented Architecture Special Interest Group (SOA SIG), which was to become the hosting body for HSSP within the HL7 organization. The OMG Healthcare Domain Task Force had already agreed to sponsor the activity. The HSSP project was formally chartered in January, 2006, operating under a board-level agreement forged between Health Level Seven and the Object Management Group.
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References
HSSP Wiki [1] Clinical Research Filtered Query Service [2] Common Terminology Service II [3] Decision Support Service [4] Human Services Directory [5] Privacy Access Security Services [6]
External links
Introduction to the HL7 Standards [2] Healthcare Services Specification Project (HSSP) [1]
References
[1] http:/ / hssp. healthinterop. org [2] http:/ / hssp-cohort. wikispaces. com/ [3] http:/ / hssp. wikispaces. com/ cts2 [4] http:/ / hssp-dss. wikispaces. com/ [5] http:/ / hssp-provider-services-directory. wikispaces. com/ [6] http:/ / hssp-security. wikispaces. com/
International Statistical Classification of Diseases and Related Health Problems

The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) is a medical classification that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. Under this system, every health condition can be assigned to a unique category and given a code, up to six characters long. Such categories can include a set of similar diseases. The International Classification of Diseases is published by the World Health Organization (WHO) and used worldwide for morbidity and mortality statistics, reimbursement systems, and automated decision support in medicine. This system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics. The ICD is a core classification of the WHO Family of International Classifications (WHO-FIC).[1] The ICD is revised periodically and is currently in its tenth edition. The ICD-10, as it is therefore known, was developed in 1992 to track mortality statistics. ICD-11 is planned for 2015[2] and will be revised using Web 2.0 principles.[3] Annual minor updates and triennial major updates are published by the WHO.[4] The ICD is part of a "family" of guides that can be used to complement each other, including also the International Classification of Functioning, Disability and Health which focuses on the domains of functioning (disability) associated with health conditions, from both medical and social perspectives.
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Historical synopsis
In 1893, a French physician, Jacques Bertillon, introduced the Bertillon Classification of Causes of Death at a congress of the International Statistical Institute in Chicago.[5] A number of countries and cities adopted Dr. Bertillons system, which was based on the principle of distinguishing between general diseases and those localized to a particular organ or anatomical site, as used by the City of Paris for classifying deaths. Subsequent revisions represented a synthesis of English, German and Swiss classifications, expanding from the original 44 titles to 161 titles. In 1898, the American Public Health Association (APHA) recommended that the registrars of Canada, Mexico, and the United States also adopt it. The APHA also recommended revising the system every ten years to ensure the system remained current with medical practice advances. As a result, the first international conference to revise the International Classification of Causes of Death convened in 1900; with revisions occurring every ten years thereafter. At that time the classification system was contained in one book, which included an Alphabetic Index as well as a Tabular List. The book was small compared with current coding texts. The revisions that followed contained minor changes, until the sixth revision of the classification system. With the sixth revision, the classification system expanded to two volumes. The sixth revision included morbidity and mortality conditions, and its title was modified to reflect the changes: International Statistical Classification of Diseases, Injuries and Causes of Death (ICD). Prior to the sixth revision, responsibility for ICD revisions fell to the Mixed Commission, a group composed of representatives from the International Statistical Institute and the Health Organization of the League of Nations. In 1948, the World Health Organization (WHO) assumed responsibility for preparing and publishing the revisions to the ICD every ten years. WHO sponsored the seventh and eighth revisions in 1957 and 1968, respectively. It later become clear that the established ten-year interval between revisions was too short.[5] The ICD is currently the most widely used statistical classification system for diseases in the world. International health statistics using this system are available at the WHO Statistical Information System (WHOSIS) [6]. In addition, some countriesincluding Australia, Canada and the United Stateshave developed their own adaptations of ICD, with more procedure codes for classification of operative or diagnostic procedures.
Versions of ICD
ICD-6
The ICD-6, published in 1949, was the first to contain a section on mental disorders.
ICD-9
The ICD-9 was finalized at the Conference for the Ninth Revision of the ICD in 1975[5] and published by the World Health Organization in 1977. It was eventually replaced by ICD-10, the version currently in use by the WHO and most countries. Given the widespread expansion in the tenth revision, it is not possible to convert ICD-9 data sets directly into ICD-10 data sets, although some tools are available to help guide users.[7]
International Statistical Classification of Diseases and Related Health Problems ICD-9-CM International Classification of Diseases, Clinical Modification (ICD-9-CM) is an adaption created by the U.S. National Center for Health Statistics (NCHS) and used in assigning diagnostic and procedure codes associated with inpatient, outpatient, and physician office utilization in the United States. The ICD-9-CM is based on the ICD-9 but provides for additional morbidity detail. It is updated annually on October 1.[8] [9] It consists of two or three volumes: Volumes 1 and 2 contain diagnosis codes. (Volume 1 is a tabular listing, and volume 2 is an index.) Extended for ICD-9-CM Volume 3 contains procedure codes. ICD-9-CM only The NCHS and the Centers for Medicare and Medicaid Services are the U.S. governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM.
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ICD-10
Work on ICD-10 began in 1983, and the new revision was endorsed by the Forty-third World Health Assembly in May 1990. The latest version came into use in WHO Member States starting in 1994.[10] The classification system allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion on the 17,000 codes available in ICD-9.[11] Adoption was relatively swift in most of the world. Several materials are made available online by WHO to facilitate its use, including a manual, training guidelines, a browser, and files for download.[1] Some countries have adapted the international standard, such as the "ICD-10-AM" published in Australia in 1998 (also used in New Zealand),[12] and the "ICD-10-CA" introduced in Canada in 2000.[13] ICD-10-CM Adoption of ICD-10 has been slow in the United States. Since 1988, the USA had required ICD-9-CM codes for Medicare and Medicaid claims, and most of the rest of the American medical industry followed suit. On 1 January 1999 the ICD-10 (without clinical extensions) was adopted for reporting mortality, but ICD-9-CM was still used for morbidity. Meanwhile, NCHS received permission from the WHO to create a clinical modification of the ICD-10, and has production of all these systems: ICD-10-CM, for diagnosis codes, is intended to replace volumes 1 and 2. Annual updates are provided. ICD-10-PCS, for procedure codes, is intended to replace volume 3. Annual updates are provided. On August 21, 2008, the US Department of Health and Human Services (HHS) proposed new code sets to be used for reporting diagnoses and procedures on health care transactions. Under the proposal, the ICD-9-CM code sets would be replaced with the ICD-10-CM code sets, effective October 1, 2013.[14] ICD-10-CA ICD-10-CA is an enhanced version of ICD-10 developed by the Canadian Institute for Health Information for morbidity classification in Canada. ICD-10-CA applies beyond acute hospital care, and includes conditions and situations that are not diseases but represent risk factors to health, such as occupational and environmental factors, lifestyle and psycho-social circumstances.[13]
ICD-11
The final draft of the ICD-11 system is expected to be submitted to WHO's World Health Assembly (WHA) for official endorsement by 2015. The first (alpha) draft was made available online in July 2011 for initial consultation and commenting.[15]
International Statistical Classification of Diseases and Related Health Problems The WHO is using Web 2.0 principles for the first time to revise ICD via a multi-author drafting platform known as the Initial ICD-11 Collaborative Authoring Tool [16] (iCAT).[3] New features to ICD-11 include electronic health record readiness.[15]
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Usage and current topics

History and usage in the United States
In the United States, the U.S. Public Health Service published The International Classification of Diseases, Adapted for Indexing of Hospital Records and Operation Classification (ICDA), completed in 1962 and expanding the ICD-7 in a number of areas to more completely meet the indexing needs of hospitals. The U.S. Public Health Service later published the Eighth Revision, International Classification of Diseases, Adapted for Use in the United States, commonly referred to as ICDA-8, for official national morbidity and mortality statistics. This was followed by the ICD, 9th Revision, Clinical Modification, known as ICD-9-CM, published by the U.S. Department of Health and Human Services and used by hospitals and other healthcare facilities to better describe the clinical picture of the patient. The diagnosis component of ICD-9-CM is completely consistent with ICD-9 codes, and remains the data standard for reporting morbidity. National adaptations of the ICD-10 progressed to incorporate both clinical code (ICD-10-CM) and procedure code (ICD-10-PCS) with the revisions completed in 2003. In 2009, the U.S. Centers for Medicare and Medicaid Services announced that it would begin using ICD-10 on April 1, 2010, with full compliance by all involved parties by 2013.[11] The years for which causes of death in the United States have been classified by each revision as follows:
ICD-1 1900 ICD-2 1910 ICD-3 1921 ICD-4 1930 ICD-5 1939 ICD-6 1949 ICD-7 1958 ICD-8A 1968 ICD-9 1979 ICD-10 1999
Mental and behavioral disorders

The ICD includes a section classifying mental and behavioral disorders (Chapter V). This has developed alongside the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) and the two manuals seek to use the same codes. There are significant differences, however, such as the ICD including personality disorders on the same axis as other mental disorders, unlike the DSM. The WHO is revising their classifications in these sections as part the development of the ICD-11 (scheduled for 2015), and an "International Advisory Group" has been established to guide this.[17] An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found that the former was more often used for clinical diagnosis while the latter was more valued for research.[18]
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References
[1] World Health Organization. Family of International Classifications. (http:/ / www. who. int/ classifications/ en/ ) Accessed 12 July 2011. [2] "Revision of the International Classification of Diseases (ICD)" (http:/ / www. who. int/ classifications/ icd/ ICDRevision/ en/ ). World Health Organization. . Retrieved 29 October 2010. [3] "WHO adopts Wikipedia approach for key update" (http:/ / www. cbc. ca/ health/ story/ 2007/ 05/ 02/ disease-wiki. html). CBC News. The Canadian Press. May 2, 2007. . [4] WHO. List of Official ICD-10 Updates. (http:/ / www. who. int/ classifications/ icd/ icd10updates/ en) [5] WHO. History of the development of the ICD. (http:/ / www. who. int/ entity/ classifications/ icd/ en/ HistoryOfICD. pdf) [6] http:/ / www. who. int/ whosis/ en/ [7] World Health Organization. FAQ on ICD. (http:/ / www. who. int/ classifications/ help/ icdfaq/ en/ ) Accessed 12 July 2011. [8] National Center for Health Statistics, CDC. ICD-9-CM Guidelines, Conversion Table, and Addenda (http:/ / www. cdc. gov/ nchs/ icd/ icd9cm_addenda_guidelines. htm). Classification of Diseases, Functioning, and Disability. Retrieved 2010-01-24. [9] InstaCode Institute. ICD-10 Demystified. (http:/ / www. instacode. com/ news-icd10-demystified. htm) [10] WHO. International Classification of Diseases (ICD). (http:/ / www. who. int/ classifications/ icd/ en/ ) [11] CMS Office of Public Affairs (August 15, 2008). "HHS Proposes Adoption of ICD-10 Code Sets and Updated Electronic Transaction Standards" (http:/ / www. dhhs. gov/ news/ press/ 2008pres/ 08/ 20080815a. html) (web). News Release. U.S. Department of Health & Human Services. . Retrieved 2008-10-22. [12] New Zealand Health Information Service. ICD-10-AM. (http:/ / www. nzhis. govt. nz/ moh. nsf/ pagesns/ 534) Accessed 12 July 2011. [13] Canadian Institute for Health Information. ICD-10-CA. (http:/ / www. cihi. ca/ cihi-ext-portal/ internet/ en/ document/ standards+ and+ data+ submission/ standards/ classification+ and+ coding/ codingclass_icd10) Accessed 12 July 2011. [14] "Classification of Diseases, Functioning, and Disability" (http:/ / www. cdc. gov/ nchs/ about/ otheract/ icd9/ abticd10. htm). U.S. Centers for Disease Control. . Retrieved 29 October 2010. [15] World Health Organization. "The International Classification of Diseases 11th Revision is due by 2015." (http:/ / www. who. int/ classifications/ icd/ revision/ en/ ) Accessed 11 July 2011. [16] http:/ / sites. google. com/ site/ icd11revision/ home/ icat [17] http:/ / www. who. int/ mental_health/ evidence/ en/ [18] Mezzich, Juan E. (2002). "International Surveys on the Use of ICD-10 and Related Diagnostic Systems" (http:/ / content. karger. com/ ProdukteDB/ produkte. asp?Aktion=ShowAbstract& ArtikelNr=65122& Ausgabe=228600& ProduktNr=224276) (guest editorial, abstract). Psychopathology 35 (23): 7275. doi:10.1159/000065122. PMID12145487. . Retrieved 2008-09-02.
External links
ICD Homepage (http://www.who.int/classifications/icd/en/) at World Health Organization (WHO) ICD-10 online browser (http://apps.who.int/classifications/apps/icd/icd10online/) (WHO) ICD-10 online training direct access (http://apps.who.int/classifications/apps/icd/ICD10Training) (WHO) ICD-10 online training support (http://sites.google.com/site/icd10onlinetraining) (WHO) ICD-10-CM (http://www.cdc.gov/nchs/icd/icd10cm.htm) (USA modification) at Centers for Disease Control and Prevention ICD-11 Revision (http://sites.google.com/site/icd11revision/home) (WHO) ICD-9-CM to ICD-10-CM code conversions (http://www.ecodingnow.com/OnlineCodes/OnlineCodes/ i9toi10.html) ICD-9-CM and DRG on-line coding engine (http://www.icd9coding.com) Free ICD-9-CM Code search (https://drchrono.com/public_billing_code_search/)
ICD-10
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ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (known as "ICD-10") is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as maintained by the World Health Organization (WHO).[1] The code set allows more than 14,400 different codes and permits the tracking of many new diagnoses. Using optional subclassifications, the codes can be expanded to over 16,000 codes. Using codes that are meant to be reported in a separate data field, the level of detail that is reported by ICD can be further increased, using a simplified multiaxial approach. WHO provides detailed information about ICD online, and makes available a set of materials online, such as an ICD-10 online browser,[2] ICD10Training ICD-10 online training,[3] ICD-10 online training support,[4] and study guide materials for download. The International version of ICD should not be confused with national Clinical Modifications of ICD that include frequently much more detail, and sometimes have separate sections for procedures. For instance, the US ICD-10 CM has some 155,000 codes.[5] Work on ICD-10 began in 1983 and was completed in 1992.[1]
List
The following is a List of ICD-10 codes.[2]
International Statistical Classification of Diseases and Related Health Problems 10th Revision
Chapter I II III IV V VI VII VIII IX X XI XII XIII XIV XV XVI XVII XVIII Blocks A00B99 C00D48 D50D89 E00E90 F00F99 G00G99 H00H59 H60H95 I00I99 J00J99 K00K93 L00L99 Certain infectious and parasitic diseases Neoplasms Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Endocrine, nutritional and metabolic diseases Mental and behavioural disorders Diseases of the nervous system Diseases of the eye and adnexa Diseases of the ear and mastoid process Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the skin and subcutaneous tissue Title
M00M99 Diseases of the musculoskeletal system and connective tissue N00N99 O00O99 P00P96 Q00Q99 R00R99 Diseases of the genitourinary system Pregnancy, childbirth and the puerperium Certain conditions originating in the perinatal period Congenital malformations, deformations and chromosomal abnormalities Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
ICD-10
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XIX XX XXI XXII S00T98 V01Y98 Z00Z99 U00U99 Injury, poisoning and certain other consequences of external causes External causes of morbidity and mortality Factors influencing health status and contact with health services Codes for special purposes
National adoption for clinical use

Some 25 countries use ICD-10 for reimbursement and resource allocation in their health system. A few of them made modifications to ICD to better accommodate this use of ICD-10. The article below makes reference to some of these modifications. The unchanged international version of ICD-10 is used in about 110 countries ICD-10 for cause of death reporting and statistics.
Australia
Australia introduced their first edition of ICD-10-AM in 1998.[6]
Canada
Canada introduced ICD-10-CA in 2000.[7]
France
France introduced a clinical addendum to ICD-10 in 2005. See also website of the ATIH.
Germany
Germany: ICD-10-GM (German Modification)
Korea
A Korean modification exists since 2008.
Sweden
The current Swedish translation of ICD-10 was created in 1997. A clinical modification has added more detail and omits codes of the international version in the context of clinical use of ICD: The codes F64.1 (Dual-role transvestism), F64.2 (Gender identity disorder of childhood), F65.0 (Fetishism), F65.1 (Fetishistic transvestism), F65.5 (Sadomasochism), F65.6 (Multiple disorders of sexual preference) are not used in Sweden since 1 January 2009 according to a decision by the present Director General of The National Board of Health and Welfare, Sweden. The code O60.0 is not used in Sweden. Since 1 January 2009 the Swedish extension codes to O47 are recommended for use, instead of O60.0.
Thailand
A Thai modifications exists since 2007.
United States
The United States will begin official use of ICD-10 on October 1, 2013, using Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCS for inpatient hospital procedure coding.[8] [9] All HIPAA "covered entities" must make the change; a pre-requisite to ICD-10 is the adoption of EDI Version 5010 by January 1, 2012.[10] The implementation of ICD-10 has already been delayed. In January 2009, the date was pushed
ICD-10 back by two years, to October 1, 2013 rather than a prior proposal of October 1, 2011.[11]
524
Language versions
Language versions should not be confused with clinical versions. ICD has been translated into 42 languages.
References
Link to online training updated 6.8.2010: http://apps.who.int/classifications/apps/icd/ICD10Training/
[1] "International Classification of Diseases (ICD)" (http:/ / www. who. int/ classifications/ icd/ en/ ). World Health Organization. . Retrieved 23 November 2010. [2] "International Statistical Classification of Diseases and Related Health Problems 10th Revision Version for 2007" (http:/ / apps. who. int/ classifications/ apps/ icd/ icd10online/ ). World Health Organization. 2007. . Retrieved February 26, 2010. [3] ICD-10 training tool (http:/ / apps. who. int/ classifications/ apps/ icd/ ) [4] ICD 10 Online Support (http:/ / sites. google. com/ site/ icd10onlinetraining) [5] U.S. Department of Health & Human Services (August 15, 2008). "HHS Proposes Adoption of ICD-10 Code Sets and Updated Electronic Transaction Standards" (http:/ / www. dhhs. gov/ news/ press/ 2008pres/ 08/ 20080815a. html). Press release. . Retrieved 2008-10-22. [6] "ICD-10-AM" (http:/ / nis-web. fhs. usyd. edu. au/ ncch_new/ 2. aspx#) [7] "ICD-10-CA" (http:/ / secure. cihi. ca/ cihiweb/ dispPage. jsp?cw_page=codingclass_icd10_e) [8] "International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)" (http:/ / www. cdc. gov/ nchs/ icd/ icd10cm. htm). National Center for Health Statistics. Centers for Disease Control and Prevention (CDC). December 20, 2010. [9] "Overview ICD-10" (http:/ / www. cms. gov/ ICD10/ ). Centers for Medicare and Medicaid Services. [10] Noblis ICD-10 F.A.Q. (http:/ / www. noblis. org/ MissionAreas/ HI/ Solutions/ Pages/ ICD-10FAQ. aspx) [11] "Feds Delay ICD-10 for Two Years" (http:/ / blogs. wsj. com/ health/ 2009/ 01/ 15/ feds-delay-icd-10-for-two-years/ ). The Wall Street Journal. January 15, 2009.
ICD-10 Procedure Coding System

The ICD-10 Procedure Coding System (ICD-10-PCS) is an American system of medical classification used for procedural codes. The National Center for Health Statistics (NCHS) received permission from the World Health Organization (WHO) (the body responsible for publishing the International Classification of Diseases [ICD]) to create the ICD-10-PCS as a successor to Volume 3 of ICD-9-CM and a clinical modification of the original ICD-10.
Section structure
Each code consists of seven alphanumeric characters. The second through seventh characters mean the same thing within each section, but may mean different things in other sections. Each character can be any of 34 possible values the ten digits 0-9 and the 24 letters A-H,J-N and P-Z may be used in each character. The letters O and I excluded to avoid confusion with the numbers 0 and 1.[1] There are no decimals in ICD-10-PCS[2] Of the 72,081 codes in ICD-10-PCS, 62,022 are in the first section, "Medical and surgical".[3]
525
Character 1
Character 2
Character 3
Character 4
Character 5 Character Character 6 7
[4] 0 Medical and Surgical
Root Operation Body System [5] see below 00 0 Central nervous system; 01 [6] [7] Peripheral nervous system; 02 [8] Heart and Great vessels; 03 Upper [9] arteries; 04 4 Lower arteries; 05 [10] [11] Upper veins; 06 Lower [12] veins; 07 Lymphatic and Hemic [13] [14] system; 08 Eye; 09 Ear, [15] Nose, Sinus; 0B Respiratory [16] System; 0C Mouth and Throat; [17] 0D Gastrointestinal system; 0F [18] Hepatobiliary System and [19] Pancreas; 0G Endocrine system; [20] [21] 0H Skin and Breast; 0J [22] Subcutaneous tissue; 0K [23] [24] Muscles; 0L Tendons; 0M [25] Bursae and Ligaments; 0N Head [26] and Facial bones; 0P Upper [27] [28] bones; 0Q Lower bones; 0R [29] Upper joints; 0S Lower joints; [30] [31] 0T Urinary system; 0U [32] Female reproductive system; 0V [33] Male reproductive system; 0W Anatomical regions, General; 0X [34] Anatomical regions, Upper [35] extremities; 0Y Anatomical regions, Lower extremities 10 [37] Pregnancy 102 Change; 109 Drainage; 10A Abortion; 10D Extraction; 10E Delivery; 10H Insertion; 10J Inspection; 10P Removal; 10Q Repair; 10S Reposition; 10T Resection; 10Y Transplantation Root Operation 2?0 Change; 2?1 Compression; 2?2 Dressing; 2?3 Immobilization; 2?4 Packing; 2?5 Removal; 2?6 Traction Root Operation
Body Part
Approach Device 0 Open; 3 Percutaneous; 4 Percutaneous Endoscopic; 7 Via Natural or Artificial Opening; 8 Via Natural or Artificial Opening Endoscopic; F Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance; X External
Qualifier
[36] 1 Obstetrics
Body Part
Approach
Device
Qualifier
[38] 2 Placement
2W [40]
[39]
Anatomical Regions; 2Y Anatomical Orifices
Body Approach Region/Orifice
Device
Qualifier
[41] 3 Administration
[42] 30 Circulatory; 3C [43] [44] Indwelling Device; 3E Physiological Systems and Anatomical Regions
Body Approach System/Region
Substance
Qualifier
[45] [46] 4 4A Physiological Systems; 4B [47] Measurement Physiological Devices and Monitoring
Root Operation
Body System
Approach
Function
Qualifier

[48] 5 Extracorporeal Assistance and Performance [50] 6 Extracorporeal Therapies [49]
526
Root Operation Body System Duration Function Qualifier
5A
Physiological Systems
6A
[51]
Physiological Systems
Body System Root Operation [52] 6A0 Atmospheric [53] control; 6A1 [54] Decompression; 6A2 Electromagnetic therapy; [55] 6A3 Hyperthermia; [56] 6A4 Hypothermia; [57] 6A5 Pheresis; 6A6 [58] Phototherapy; 6A7 [59] Ultrasound therapy; [60] 6A8 Ultraviolet light [61] therapy; 6A9 Shock wave therapy 7W0 [64] Body Region
Duration
Qualifier
Qualifier
[62] 7 Osteopathic [65] 8 Other Procedures
7W
[63]
Approach
Method
Qualifier
[66] [67] 8C Indwelling Device; 8E Physiological Systems and Anatomical Regions 9W [69]
Root Operation
Body Region
Approach
Method
Qualifier
[68] 9 Chiropractic B [71] Imaging
9WB
[70]
Body Region
Approach
Method
Qualifier
Body System Root Type 0 Central Nervous System; 2 Heart; 3 Upper Arteries; 4 Lower Arteries; 5 Veins; 7 Lymphatic System; 8 Eye; 9 Ear, Nose, Mouth and Throat; B Respiratory System; D Gastrointestinal System; F Hepatobiliary System and Pancreas; G Endocrine System; H Skin, Subcutaneous Tissue and Breast; L Connective Tissue; N Skull and Facial Bones; P Non-Axial Upper Bones; Q Non-Axial Lower Bones; R Axial Skeleton, Except Skull and Facial Bones; T Urinary System; U Female Reproductive System; V Male Reproductive System; W Anatomical Regions; Y Fetus and Obstetrical
Body Part
Contrast 0=high osmolar contrast; 1=low osmolar contrast; z=other contrast
Qualifier
Qualifier

[72] C Nuclear medicine
527
Body Part Radionuclide Qualifier Qualifier
Body System Root Type 0 Central Nervous System; 2 Heart; 5 Veins; 7 Lymphatic and Hematologic System; 8 Eye; 9 Ear, Nose, Mouth and Throat; B Respiratory System; D Gastrointestinal System; F Hepatobiliary System and Pancreas; G Endocrine System; H Skin, Subcutaneous Tissue and Breast; P Musculoskeletal System; T Urinary System; V Male Reproductive System; W Anatomical Regions Body System Root Type 0 Central and Peripheral Nervous System; 7 Lymphatic and Hematologic System; 8 Eye; 9 Ear, Nose, Mouth and Throat; B Respiratory System; D Gastrointestinal System; F Hepatobiliary System and Pancreas; G Endocrine System; H Skin; M Breast; P Musculoskeletal System; T Urinary System; U Female Reproductive System; V Male Reproductive System; W Anatomical Regions [75] [76] F0 Rehabilitation; F1 Diagnostic Audiology Root Type
[73] D Radiation oncology
Body Part
Modality Qualifier
Isotope
Qualifier
[74] F Physical rehabilitation and Diagnostic Audiology [77] G Mental health
Body System & Region
Type Qualifier
Equipment Qualifier
GZ
[78]
None
Root Type [79] GZ1 Psychological [80] tests; GZ2 Crisis [81] intervention; GZ3 Medication management; [82] GZ5 Individual [83] psychotherapy; GZ6 [84] Counseling; GZ7 Family psychotherapy; [85] GZB Electroconvulsive [86] therapy; GZC [87] Biofeedback; GZF [88] Hypnosis; GZG Narcosynthesis; GZH [89] Group [90] psychotherapy; GZJ Light therapy Root Type
Type Qualifier
Qualifier
Qualifier
Qualifier
[91] H Substance abuse Treatment
HZ
[92]
None
Type Qualifier
Qualifier
Qualifier
Qualifier
528
Root operations
For medical/surgical, these are the root operation codes: 0?0 alteration; 0?1 bypass; 0?2 change; 0?3 control; 0?4 creation; 0?5 destruction; 0?6 detachment; 0?7 dilation; 0?8 division; 0?9 drainage; 0?B excision; 0?C extirpation; 0?D extraction; 0?F fragmentation; 0?G fusion; 0?H insertion; 0?J inspection; 0?K map; 0?L occlusion; 0?M reattachment; 0?N release; 0?P removal; 0?Q repair; 0?R replacement; 0?S reposition; 0?T resection; 0?U supplement ; 0?V restriction; 0?X transfer; 0?Y transplantation They can be grouped into several categories:[93] take out or eliminate all or a portion of a body part: excision (sigmoid polypectomy), resection (total nephrectomy), extraction (toenail extraction), destruction (rectal polyp fulguration), detachment (below knee amputation). For biopsies, "extraction" is used when force is required (as with endometrial biopsy), and "excision" is used when minimal force is involved (as with liver biopsy). See also ectomy. involve putting in or on, putting back, or moving living body part: transplantation (heart transplant), reattachment (finger reattachment), reposition (reposition undescended testicle), transfer (tendon transfer) take out or eliminate solid matter, fluids, or gases from a body part: drainage (incision and drainage), extirpation (thrombectomy), fragmentation (lithotripsy of gallstones) only involve examination of body parts and regions: inspection (diagnostic arthroscopy), map (cardiac mapping) involve putting in or on, putting back, or moving living body part: bypass (gastrojejunal bypass), dilation (coronary artery dilation), occlusion (fallopian tube ligation), restriction (cervical cerclage) always involve devices: insertion (pacemaker insertion), replacement (total hip replacement), supplement (herniorrhaphy using mesh), removal (cardiac pacemaker removal), change (drainage tube change), revision (hip prosthesis adjustment) involve cutting and separation only: division (osteotomy), release (peritoneal adhesiolysis) involving other repair: control (control of postprostatectomy bleeding), repair (suture of laceration) with other objectives: alteration (face lift), creation (artificial vagina creation), fusion (spinal fusion)
Regions
Regions: 0 Head; 1 Cervical, 2 Thoracic, 3 Lumbar, 4 Sacrum, 5 Pelvis, 6 Lower extremities, 7 Upper extremities, 8 Rib cage, 9 Abdomen
References
[1] pcs_final_report2010; Richard F. Averill, M.S., Robert L. Mullin, M.D., Barbara A. Steinbeck, RHIT, Norbert I. Goldfield, M.D, Thelma M. Grant, RHIA, Rhonda R. Butler, CCS, CCS-P. "Development of the ICD-10 Procedure Coding System (ICD-10-PCS)" (http:/ / www. cms. hhs. gov/ ICD10/ Downloads/ pcs_final_report2010. pdf) (pdf). Descriptive Report. Centers for Medicare and Medicaid Services. . Retrieved February 25, 2010. [2] Aalseth, Patricia T. (2004). Codebusters Coding Connection: A Documentation Guide for Compliant Coding (http:/ / books. google. com/ books?id=ZOGemkGhYekC& pg=PA25& dq=ICD-10-cm+ decimal& as_brr=3& cd=4#v=onepage& q=ICD-10-cm decimal& f=false). Jones & Bartlett Publishers. p.27. ISBN0763726303. . [3] https:/ / www. cms. gov/ ICD10/ Downloads/ pcs_final_report2011. pdf [4] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0 [5] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 0 [6] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 1 [7] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 2 [8] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 3 [9] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 4 [10] [11] [12] [13] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 5 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 6 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 7 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 8

[14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ 9 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ B http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ C http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ D http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ F http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ G http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ H http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ J http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ K http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ L http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ M http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ N http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ P http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ Q http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ R http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ S http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ T http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ U http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ V http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ W http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ X http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 0/ Y http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 1 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 1/ 0 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 2 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 2/ W http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 2/ Y http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 3 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 3/ 0 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 3/ C http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 3/ E http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 4 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 4/ A http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 4/ B http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 5 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 5/ A http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 0 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 1 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 2 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 3 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 4 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 5 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 6 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 7 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 8 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 6/ A/ 9 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 7 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 7/ W http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 7/ W/ 0 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 8 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 8/ C http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 8/ E http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 9 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 9/ W
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[70] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ 9/ W/ B [71] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ B [72] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ C

[73] [74] [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ D http:/ / www. icd10data. com/ ICD10PCS/ Codes/ F http:/ / www. icd10data. com/ ICD10PCS/ Codes/ F/ 0 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ F/ 1 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ 1 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ 2 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ 3 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ 5 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ 6 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ 7 http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ B http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ C http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ F http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ G http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ H http:/ / www. icd10data. com/ ICD10PCS/ Codes/ G/ Z/ J http:/ / www. icd10data. com/ ICD10PCS/ Codes/ H http:/ / www. icd10data. com/ ICD10PCS/ Codes/ H/ Z https:/ / www. cms. gov/ ICD10/ Downloads/ pcs_final_report2011. pdf
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External links
2011 ICD-10-PCS and GEMs (http://www.cms.gov/ICD10/11b_2011_ICD10PCS.asp) Browser (http://www.icd10data.com/ICD10PCS/Codes)
International Classification of Diseases for Oncology

The International Classification of Diseases for Oncology (ICD-O) is a domain specific extension of the International Statistical Classification of Diseases and Related Health Problems for tumor diseases. This classification is widely used by cancer registries. It is currently in its third revision (ICD-O-3). ICD-10 includes a list of morphology codes. They stem from ICD-O second edition (ICD-O-2) that was valid at the time of publication.
Axes
The classification has two axes:
Morphology
The morphology axis is for the morphology of the tumor. This axis has additional importance, because the Systematized Nomenclature of Medicine(SNOMED) has adopted ICD-O's classification of morphology. SNOMED has been changing continuously, and several different versions of SNOMED are in use. Accordingly, mapping of ICD-O codes to SNOMED requires careful assessment whether entities really match, or not.
International Classification of Diseases for Oncology Examples of codes (ICD-O-3) (80008009) Not otherwise specified (80008004) Neoplasms, NOS (M8000/0 [1]) Neoplasm, benign (M8000/1 [2]) Neoplasm, uncertain whether benign or malignant (M8000/3 [3]) Neoplasm, malignant (M8000/6 [4]) Neoplasm, metastatic (M8000/9 [5]) Neoplasm, malignant, uncertain whether primary or metastatic
531
(80108790) Epithelial (80108040) Epithelial neoplasms, NOS (80508080) Squamous cell neoplasms (M8070/3 [6]) Squamous cell carcinoma, NOS (80908110) Basal cell neoplasms (M8090/3 [7]) Basal cell carcinoma, NOS (81208130) Transitional cell Papillomas And Carcinomas (81408380) Adenomas And Adenocarcinomas (glands) (M8140/0 [8]) Adenoma, NOS (M8140/3 [9]) Adenocarcinoma, NOS (M8142/3 [10]) Linitis plastica (M8151/0 [11]) Insulinoma, NOS (M8152/0 [12]) Glucagonoma, NOS (M8153/1 [13]) Gastrinoma, NOS (M8155/3 [14]) Vipoma (M8160/3 [15]) Cholangiocarcinoma (M8170/3 [16]) Hepatocellular carcinoma, NOS (M8200/3 [17]) Adenoid cystic carcinoma (M8240/1 [18]) Carcinoid tumor, NOS, of appendix (M8271/0 [19]) Prolactinoma (M8290/0 [20]) Oncocytoma (M8290/0 [20]) Hurthle cell adenoma (M8312/3 [21]) Renal cell carcinoma (M8312/3 [21]) Grawitz tumor (M8360/1 [22]) Multiple endocrine adenomas (M8380/0 [23]) Endometrioid adenoma, NOS (83908420) Adnexal And Skin appendage Neoplasms (84308439) Mucoepidermoid Neoplasms (84408490) Cystic, Mucinous And Serous Neoplasms (M8440/0 [24]) Cystadenoma, NOS (M8480/6 [25]) Pseudomyxoma peritonei (85008540) Ductal, Lobular And Medullary Neoplasms (85508559) Acinar cell neoplasms (85608580) Complex epithelial neoplasms (M8561/0 [26]) Warthin's tumor (M8580/0 [27]) Thymoma, NOS
International Classification of Diseases for Oncology (85908670) Specialized gonadal neoplasms (M8590/1 [28]) Sex cord-stromal tumor (M8600/0 [29]) Thecoma, NOS (M8620/1 [30]) Granulosa cell tumor, NOS (M8630/1 [31]) Arrhenoblastoma, NOS (M8631/0 [32]) Sertoli-Leydig cell tumor (86808710) Paragangliomas And Glomus tumors (M8680/1 [33]) Paraganglioma, NOS (M8700/0 [34]) Pheochromocytoma, NOS (M8711/0 [35]) Glomus tumor (87208790) Nevi And Melanomas (M8720/0 [36]) Melanocytic nevus (M8720/3 [37]) Malignant melanoma, NOS (M8720/3 [37]) Melanoma, NOS (M8721/3 [38]) Nodular melanoma (M8727/0 [39]) Dysplastic nevus (M8742/3 [40]) Lentigo maligna melanoma
532
(M8743/3 [41]) Superficial spreading melanoma (M8744/3 [42]) Acral lentiginous melanoma, malignant (M8745/3 [43]) Melanoma, desmoplastic, amelanotic (88009370) Connective tissue (88008809) Soft tissue Tumors And Sarcomas, Nos (M8800/3 [44]) Sarcoma, NOS (M8800/3 [44]) Soft tissue sarcoma (M8806/3 [45]) Desmoplastic small round cell tumor (88108830) Fibromatous neoplasms (M8810/0 [46]) Fibroma, NOS (M8810/3 [47]) Fibrosarcoma, NOS (88408849) Myxomatous neoplasms (M8840/0 [48]) Myxoma, NOS (88508880) Lipomatous neoplasms (M8850/0 [49]) Lipoma, NOS (M8850/3 [50]) Liposarcoma, NOS (88908920) Myomatous neoplasms (M8890/0 [51]) Leiomyoma, NOS (M8890/3 [52]) Leiomyosarcoma, NOS (M8895/0 [53]) Myoma (M8895/3 [54]) Myosarcoma (M8900/0 [55]) Rhabdomyoma, NOS (M8900/3 [56]) Rhabdomyosarcoma, NOS (89308990) Complex Mixed And Stromal Neoplasms (M8940/0 [57]) Pleomorphic adenoma (M8960/3 [58]) Nephroblastoma, NOS (Wilms's tumor) (90009030) Fibroepithelial Neoplasms
International Classification of Diseases for Oncology (M9000/0 [59]) Brenner tumor, NOS (90409049) Synovial-Like Neoplasms (M9040/3 [60]) Synovial sarcoma, NOS (90509059) Mesothelial Neoplasms (M9050/0 [61]) Mesothelioma, benign (M9050/3 [62]) Mesothelioma, NOS (90609090) Germ cell Neoplasms (M9060/3 [63]) Dysgerminoma (M9064/3 [64]) Germ cell tumor, NOS (M9070/3 [65]) Embryonal carcinoma, NOS (M9071/3 [66]) Yolk sac tumor (M9080/0 [67]) Teratoma, benign (M9080/3 [68]) Teratoma, malignant, NOS (M9084/0 [69]) Dermoid cyst, NOS (91009109) Trophoblastic neoplasms (M9100/3 [70]) Choriocarcinoma, NOS (91109119) Mesonephromas (91209160) Blood vessel tumors (M9120/0 [71]) Hemangioma, NOS (M9120/0 [71]) Angioma, NOS (M9120/3 [72]) Hemangiosarcoma (M9120/3 [72]) Angiosarcoma (M9130/0 [73]) Hemangioendothelioma, benign (M9130/1 [74]) Hemangioendothelioma, NOS (M9140/3 [75]) Kaposi's sarcoma (M9150/0 [76]) Hemangiopericytoma, benign (M9150/1 [77]) Hemangiopericytoma, NOS (91709179) Lymphatic vessel tumors (M9170/0 [78]) Lymphangioma, NOS (M9173/0 [79]) Cystic lymphangioma (91809240) Osseous And Chondromatous neoplasms (M9180/0 [80]) Osteoma, NOS (M9180/3 [81]) Osteosarcoma, NOS (M9210/0 [82]) Osteochondroma (M9210/0 [82]) Cartilaginous exostosis (M9220/0 [83]) Chondroma, NOS (M9220/3 [84]) Chondrosarcoma, NOS (92509259) Giant cell tumors (92609269) Miscellaneous bone tumors (M9260/3 [85]) Ewing's sarcoma (92709340) Odontogenic tumors (M9273/0 [86]) Cementoblastoma, benign (M9310/0 [87]) Ameloblastoma, NOS (93509370) Miscellaneous tumors (M9350/1 [88]) Craniopharyngioma
533
International Classification of Diseases for Oncology (93809589) Nervous system (93809480) Gliomas (M9382/3 [89]) Mixed oligoastrocytoma (M9391/3 [90]) Ependymoma, NOS (M9400/3 [91]) Astrocytoma, NOS (9421/3) Pilocytic astrocytoma (9440/3) Glioblastoma multiforme (M9450/3 [92]) Oligodendroglioma, NOS (94909520) Neuroepitheliomatous neoplasms (M9500/3 [93]) Neuroblastoma, NOS (M9510/3 [94]) Retinoblastoma (95309539) Meningiomas (95409570) Nerve sheath tumors (M9540/0 [95]) Neurofibroma, NOS (M9540/1 [96]) Neurofibromatosis, NOS (M9560/0 [97]) Schwannoma, NOS (M9560/0 [97]) Neurinoma (M9560/0 [97]) Acoustic neuroma (M9570/0 [98]) Neuroma, NOS (95809589) Granular cell tumors and Alveolar soft part sarcoma (95909999) Hematologic (Leukemias, Lymphomas and related disorders) (95909599) Malignant lymphoma, NOS, Or diffuse (M9590/3 [99]) Lymphoma, NOS (M9591/3 [100]) Non-Hodgkin's lymphoma, NOS (M9592/3 [101]) Lymphosarcoma, NOS (96509660) Hodgkin's disease (M9650/3 [102]) Hodgkin's disease, NOS (M9651/3 [103]) Lymphocyte-rich classical Hodgkin lymphoma (M9652/3 [104]) Mixed cellularity classical Hodgkin lymphoma (M9653/3 [105]) Lymphocyte-depleted classical Hodgkin lymphoma (M9659/3 [106]) Nodular lymphocyte predominant Hodgkin lymphoma (M9663/3 [107]) Nodular sclerosis classical Hodgkin lymphoma (96709680) Malignant lymphoma Specified Type, Diffuse Or Nos (M9670/3 [108]) Small lymphocytic lymphoma (M9671/3 [109]) Lymphoplasmacytic lymphoma (M9673/3 [110]) Mantle cell lymphoma (M9678/3 [111]) Primary effusion lymphoma (M9679/3 [112]) Mediastinal (thymic) large cell lymphoma (M9680/3 [113]) Diffuse large B-cell lymphoma or Intravascular large B-cell lymphoma (M9687/3 [114]) Burkitt lymphoma (M9689/3 [115]) Splenic marginal zone lymphoma (96909699) Malignant lymphoma, Follicular Or Nodular, With Or Without diffuse areas (M9690/3 [116]) Follicular lymphoma (M9698/3 [117]) Follicular lymphoma
534
International Classification of Diseases for Oncology (M9699/3 [118]) Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma) (M9699/3 [118]) Nodal marginal zone B-cell lymphoma (97009709) Specified Cutaneous And Peripheral T-Cell Lymphomas (M9700/3 [119]) Mycosis fungoides (M9701/3 [120]) Sezary syndrome (M9702/3 [121]) Peripheral T-cell lymphoma, unspecified (M9705/3 [122]) Angioimmunoblastic T-cell lymphoma (M9708/3 [123]) Subcutaneous panniculitis-like T-cell lymphoma (97109719) Other Specified Non-Hodgkin's lymphomas (M9714/3 [124]) Anaplastic large cell lymphoma (M9716/3 [125]) Hepatosplenic T-cell lymphoma (M9717/3 [126]) Enteropathy type T-cell lymphoma (M9718/1 [127]) Lymphomatoid papulosis (M9718/3 [128]) Primary cutaneous anaplastic large cell lymphoma (M9719/3 [129]) Extranodal NK/T cell lymphoma, nasal type (97209729) Other Lymphoreticular neoplasms (M9727/3 [130]) Blastic NK cell lymphoma (M9728/3 [131]) Lymphoma (M9729/3 [132]) Lymphoma (97309739) Plasma cell tumors (M9731/3 [133]) Plasmacytoma, NOS or Extramedullary plasmacytoma or Solitary plasmacytoma of bone (M9732/3 [134]) Multiple myeloma or Plasma cell myeloma (M9734/3 [135]) Extraosseous plasmacytoma (97409749) Mast cell Tumors (M9740/1 [136]) Mastocytoma, NOS or Extracutaneous mastocytoma (M9740/3 [137]) Mast cell sarcoma (M9741/1 [138]) Malignant mastocytosis or Indolent systemic mastocytosis (M9741/3 [139]) Aggressive systemic mastocytosis or Systemic mastocytosis with associated clonal, hematological non-mast cell lineage disease (M9742/3 [140]) Mast cell leukemia (M9751/1 [141]) Langerhans cell histiocytosis (M9755/3 [142]) Histiocytic sarcoma (M9756/3 [143]) Langerhans cell sarcoma (M9757/3 [144]) Dendritic cell sarcoma, NOS or Interdigitating dendritic cell sarcoma/tumor (M9758/3 [145]) Follicular dendritic cell sarcoma/tumor (97609769) Immunoproliferative diseases (M9761/3 [146]) Waldenstrom macroglobulinemia (M9766/1 [147]) Lymphomatoid granulomatosis
535
International Classification of Diseases for Oncology -- Lymphoid leukemias, and related conditions (98009809) Leukemias, NOS (M9800/3 [148]) Leukemia, NOS (M9805/3 [149]) Acute leukemia of ambiguous lineage (M9801/3 [150]) Acute leukemia, NOS (98209829) Lymphoid leukemias (M9820/3 [151]) Lymphocytic leukemia, NOS (M9820/3 [151]) Lymphatic leukemia, NOS (M9821/3 [152]) Acute lymphoblastic leukemia, NOS (M9821/3 [152]) Acute lymphocytic leukemia (M9823/3 [153]) Chronic lymphocytic leukemia (M9826/3 [154]) Leukemia (M9827/3 [155]) Adult T-cell leukemia/lymphoma (98309839) Plasma cell leukemia (M9831/3 [156]) T-cell large granular lymphocytic leukemia (M9833/3 [157]) B-cell prolymphocytic leukemia (M9834/3 [158]) T-cell prolymphocytic leukemia (M9835/3 [159]) Precursor cell lymphoblastic leukemia, NOS (M9836/3 [160]) Precursor B lymphoblastic leukemia (M9837/3 [161]) Precursor T lymphoblastic leukemia -- Myeloid leukemias, and related conditions (98409849) Erythroleukemias (FAB-M6) (M9840/3 [162]) Acute erythroid leukemia (98509859) Lymphosarcoma cell leukemia (98609869) Myeloid (Granulocytic) Leukemias (M9860/3 [163]) Myeloid leukemia, NOS (M9860/3 [163]) Myelogenous leukemia, NOS (M9861/3 [164]) Acute myelogenous leukemia (FAB-M1,M2) (M9863/3 [165]) Chronic myelogenous leukemia (M9866/3 [166]) Acute promyelocytic leukemia (FAB-M3) (M9866/3 [166]) Acute promyelocytic leukemia (AML with t(15;17)(q22;q12), PML-RARa and variants) (M9867/3 [167]) Acute myelomonocytic leukemia (FAB-M4) (98709889) Basophilic leukemia and Eosinophilic leukemia (M9870/3 [168]) Basophilic leukemia or Acute basophilic leukemia (M9871/3 [169]) AML with inv(16)(p13q22) or t(16;16)(p13;q22), CBFb/MYH11 (FAB M4Eo) (M9872/3 [170]) Acute myeloid leukemia, minimally differentiated (FAB type M0) (M9873/3 [171]) Acute myeloid leukemia, without maturation (FAB type M1) (M9874/3 [172]) Acute myeloid leukemia, with maturation (FAB M2) (M9875/3 [173]) Chronic myelogenous leukemia (M9876/3 [174]) Atypical chronic myelogenous leukemia (M9880/3 [175]) Eosinophilic leukemia (98909899) Monocytic leukemias (M9890/3 [176]) Monocytic leukemia, NOS (FAB-M5) (M9891/3 [177]) Acute monoblastic and monocytic leukemia (FAB M5) (M9895/3 [178]) Acute myeloid leukemia multilineage dysplasia
536
International Classification of Diseases for Oncology (M9896/3 [179]) AML with t(8;21)(q22;q22), AML1/ETO (M9897/3 [180]) AML with 11q23 (MLL) abnormalities (99009948) Other Leukemias (M9910/3 [181]) Acute megakaryoblastic leukemia (FAB-M7) (M9920/3 [182]) Acute myeloid leukemia and myelodysplastic syndrome, therapy related (M9930/3 [183]) Chloroma or Myeloid sarcoma (M9931/3 [184]) Acute panmyelosis with myelofibrosis (M9940/3 [185]) Hairy cell leukemia (M9946/3 [186]) Juvenile myelomonocytic leukemia (M9948/3 [187]) Aggressive NK cell leukemia
537
-- Other (99509970) Miscellaneous Myeloproliferative And Lymphoproliferative disorders (M9950/3 [188]) Polycythemia vera (M9960/1 [189]) Myeloproliferative disease, NOS (M9961/3 [190]) Chronic idiopathic myelofibrosis (M9962/3 [191]) Essential thrombocytemia
(M9963/3 [192]) Chronic neutrophilic leukemia (M9964/3 [193]) Chronic eosinophilic leukemia / hypereosinophilic syndrome (M9970/1 [194]) Post-transplant lymphoproliferative disorder, pleomorphic (M9975/3 [195]) Chronic Myeloproliferative disease, unclassifiable (M9975/3 [195]) Myelodysplastic / myeloproliferative diseases, unclassifiable (99809989) Myelodysplastic syndrome (M9980/3 [196]) Chronic myelomonocytic leukemia or Refractory anemia (M9982/3 [197]) Refractory anemia with ringed sideroblasts (M9983/3 [198]) Refractory anemia with excess blasts (M9985/3 [199]) Refractory cytopenia with multilineage dysplasia (M9986/3 [200]) Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (M9989/3 [201]) Myelodysplastic syndrome, NOS
Topography
The topography axis is for the topographical codes of the tumor's site. It is standardized with the C section of ICD-10 There were no changes in the topography axis between ICD-O-2 and ICD-O-3. See List of ICD-10 codes#(C00C97) Malignant Neoplasms for examples.
External links
Official page [202] at World Health Organization Tutorial [203] at National Cancer Institute Overview [204] at DIMDI Overview of multiple primaries [205] at healthyarkansas.com (PPT) History of versions [206] at National Cancer Institute
538
Morphology
Cancer.gov overview [207], includes link to Excel spreadsheet with codes [208] at National Cancer Institute Overview [209] at National Cancer Institute Word document malignancies only [210] at National Cancer Institute Overview [211] at University hospital Gieen und Marburg Download table German version [212] at DIMDI Codes [213] at IARC 1st, 2nd, and 3rd editions [214] at wolfbane.com List [215] at The National Cancer Registry Ireland List [216] at London School of Hygiene & Tropical Medicine
References
[1] [2] [3] [4] [5] [6] http:/ / www. progenetix. net/ progenetix/ I80000/ http:/ / www. progenetix. net/ progenetix/ I80001/ http:/ / www. progenetix. net/ progenetix/ I80003/ http:/ / www. progenetix. net/ progenetix/ I80006/ http:/ / www. progenetix. net/ progenetix/ I80009/ http:/ / www. progenetix. net/ progenetix/ I80703/
[7] http:/ / www. progenetix. net/ progenetix/ I80903/ [8] http:/ / www. progenetix. net/ progenetix/ I81400/ [9] http:/ / www. progenetix. net/ progenetix/ I81403/ [10] http:/ / www. progenetix. net/ progenetix/ I81423/ [11] http:/ / www. progenetix. net/ progenetix/ I81510/ [12] http:/ / www. progenetix. net/ progenetix/ I81520/ [13] http:/ / www. progenetix. net/ progenetix/ I81531/ [14] http:/ / www. progenetix. net/ progenetix/ I81553/ [15] http:/ / www. progenetix. net/ progenetix/ I81603/ [16] http:/ / www. progenetix. net/ progenetix/ I81703/ [17] http:/ / www. progenetix. net/ progenetix/ I82003/ [18] http:/ / www. progenetix. net/ progenetix/ I82401/ [19] http:/ / www. progenetix. net/ progenetix/ I82710/ [20] http:/ / www. progenetix. net/ progenetix/ I82900/ [21] http:/ / www. progenetix. net/ progenetix/ I83123/ [22] http:/ / www. progenetix. net/ progenetix/ I83601/ [23] http:/ / www. progenetix. net/ progenetix/ I83800/ [24] http:/ / www. progenetix. net/ progenetix/ I84400/ [25] http:/ / www. progenetix. net/ progenetix/ I84806/ [26] http:/ / www. progenetix. net/ progenetix/ I85610/ [27] http:/ / www. progenetix. net/ progenetix/ I85800/ [28] http:/ / www. progenetix. net/ progenetix/ I85901/ [29] http:/ / www. progenetix. net/ progenetix/ I86000/ [30] http:/ / www. progenetix. net/ progenetix/ I86201/ [31] http:/ / www. progenetix. net/ progenetix/ I86301/ [32] http:/ / www. progenetix. net/ progenetix/ I86310/ [33] http:/ / www. progenetix. net/ progenetix/ I86801/ [34] http:/ / www. progenetix. net/ progenetix/ I87000/ [35] http:/ / www. progenetix. net/ progenetix/ I87110/ [36] http:/ / www. progenetix. net/ progenetix/ I87200/ [37] http:/ / www. progenetix. net/ progenetix/ I87203/ [38] http:/ / www. progenetix. net/ progenetix/ I87213/ [39] http:/ / www. progenetix. net/ progenetix/ I87270/ [40] http:/ / www. progenetix. net/ progenetix/ I87423/ [41] http:/ / www. progenetix. net/ progenetix/ I87433/ [42] http:/ / www. progenetix. net/ progenetix/ I87443/ [43] http:/ / www. progenetix. net/ progenetix/ I87453/

[44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] [94] [95] [96] [97] [98] [99] http:/ / www. progenetix. net/ progenetix/ I88003/ http:/ / www. progenetix. net/ progenetix/ I88063/ http:/ / www. progenetix. net/ progenetix/ I88100/ http:/ / www. progenetix. net/ progenetix/ I88103/ http:/ / www. progenetix. net/ progenetix/ I88400/ http:/ / www. progenetix. net/ progenetix/ I88500/ http:/ / www. progenetix. net/ progenetix/ I88503/ http:/ / www. progenetix. net/ progenetix/ I88900/ http:/ / www. progenetix. net/ progenetix/ I88903/ http:/ / www. progenetix. net/ progenetix/ I88950/ http:/ / www. progenetix. net/ progenetix/ I88953/ http:/ / www. progenetix. net/ progenetix/ I89000/ http:/ / www. progenetix. net/ progenetix/ I89003/ http:/ / www. progenetix. net/ progenetix/ I89400/ http:/ / www. progenetix. net/ progenetix/ I89603/ http:/ / www. progenetix. net/ progenetix/ I90000/ http:/ / www. progenetix. net/ progenetix/ I90403/ http:/ / www. progenetix. net/ progenetix/ I90500/ http:/ / www. progenetix. net/ progenetix/ I90503/ http:/ / www. progenetix. net/ progenetix/ I90603/ http:/ / www. progenetix. net/ progenetix/ I90643/ http:/ / www. progenetix. net/ progenetix/ I90703/ http:/ / www. progenetix. net/ progenetix/ I90713/ http:/ / www. progenetix. net/ progenetix/ I90800/ http:/ / www. progenetix. net/ progenetix/ I90803/ http:/ / www. progenetix. net/ progenetix/ I90840/ http:/ / www. progenetix. net/ progenetix/ I91003/ http:/ / www. progenetix. net/ progenetix/ I91200/ http:/ / www. progenetix. net/ progenetix/ I91203/ http:/ / www. progenetix. net/ progenetix/ I91300/ http:/ / www. progenetix. net/ progenetix/ I91301/ http:/ / www. progenetix. net/ progenetix/ I91403/ http:/ / www. progenetix. net/ progenetix/ I91500/ http:/ / www. progenetix. net/ progenetix/ I91501/ http:/ / www. progenetix. net/ progenetix/ I91700/ http:/ / www. progenetix. net/ progenetix/ I91730/ http:/ / www. progenetix. net/ progenetix/ I91800/ http:/ / www. progenetix. net/ progenetix/ I91803/ http:/ / www. progenetix. net/ progenetix/ I92100/ http:/ / www. progenetix. net/ progenetix/ I92200/ http:/ / www. progenetix. net/ progenetix/ I92203/ http:/ / www. progenetix. net/ progenetix/ I92603/ http:/ / www. progenetix. net/ progenetix/ I92730/ http:/ / www. progenetix. net/ progenetix/ I93100/ http:/ / www. progenetix. net/ progenetix/ I93501/ http:/ / www. progenetix. net/ progenetix/ I93823/ http:/ / www. progenetix. net/ progenetix/ I93913/ http:/ / www. progenetix. net/ progenetix/ I94003/ http:/ / www. progenetix. net/ progenetix/ I94503/ http:/ / www. progenetix. net/ progenetix/ I95003/ http:/ / www. progenetix. net/ progenetix/ I95103/ http:/ / www. progenetix. net/ progenetix/ I95400/ http:/ / www. progenetix. net/ progenetix/ I95401/ http:/ / www. progenetix. net/ progenetix/ I95600/ http:/ / www. progenetix. net/ progenetix/ I95700/ http:/ / www. progenetix. net/ progenetix/ I95903/
539
[100] http:/ / www. progenetix. net/ progenetix/ I95913/ [101] http:/ / www. progenetix. net/ progenetix/ I95923/ [102] http:/ / www. progenetix. net/ progenetix/ I96503/

[103] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] [139] [140] [141] [142] [143] [144] [145] [146] [147] [148] [149] [150] [151] [152] [153] [154] [155] [156] [157] [158] http:/ / www. progenetix. net/ progenetix/ I96513/ http:/ / www. progenetix. net/ progenetix/ I96523/ http:/ / www. progenetix. net/ progenetix/ I96533/ http:/ / www. progenetix. net/ progenetix/ I96593/ http:/ / www. progenetix. net/ progenetix/ I96633/ http:/ / www. progenetix. net/ progenetix/ I96703/ http:/ / www. progenetix. net/ progenetix/ I96713/ http:/ / www. progenetix. net/ progenetix/ I96733/ http:/ / www. progenetix. net/ progenetix/ I96783/ http:/ / www. progenetix. net/ progenetix/ I96793/ http:/ / www. progenetix. net/ progenetix/ I96803/ http:/ / www. progenetix. net/ progenetix/ I96873/ http:/ / www. progenetix. net/ progenetix/ I96893/ http:/ / www. progenetix. net/ progenetix/ I96903/ http:/ / www. progenetix. net/ progenetix/ I96983/ http:/ / www. progenetix. net/ progenetix/ I96993/ http:/ / www. progenetix. net/ progenetix/ I97003/ http:/ / www. progenetix. net/ progenetix/ I97013/ http:/ / www. progenetix. net/ progenetix/ I97023/ http:/ / www. progenetix. net/ progenetix/ I97053/ http:/ / www. progenetix. net/ progenetix/ I97083/ http:/ / www. progenetix. net/ progenetix/ I97143/ http:/ / www. progenetix. net/ progenetix/ I97163/ http:/ / www. progenetix. net/ progenetix/ I97173/ http:/ / www. progenetix. net/ progenetix/ I97181/ http:/ / www. progenetix. net/ progenetix/ I97183/ http:/ / www. progenetix. net/ progenetix/ I97193/ http:/ / www. progenetix. net/ progenetix/ I97273/ http:/ / www. progenetix. net/ progenetix/ I97283/ http:/ / www. progenetix. net/ progenetix/ I97293/ http:/ / www. progenetix. net/ progenetix/ I97313/ http:/ / www. progenetix. net/ progenetix/ I97323/ http:/ / www. progenetix. net/ progenetix/ I97343/ http:/ / www. progenetix. net/ progenetix/ I97401/ http:/ / www. progenetix. net/ progenetix/ I97403/ http:/ / www. progenetix. net/ progenetix/ I97411/ http:/ / www. progenetix. net/ progenetix/ I97413/ http:/ / www. progenetix. net/ progenetix/ I97423/ http:/ / www. progenetix. net/ progenetix/ I97511/ http:/ / www. progenetix. net/ progenetix/ I97553/ http:/ / www. progenetix. net/ progenetix/ I97563/ http:/ / www. progenetix. net/ progenetix/ I97573/ http:/ / www. progenetix. net/ progenetix/ I97583/ http:/ / www. progenetix. net/ progenetix/ I97613/ http:/ / www. progenetix. net/ progenetix/ I97661/ http:/ / www. progenetix. net/ progenetix/ I98003/ http:/ / www. progenetix. net/ progenetix/ I98053/ http:/ / www. progenetix. net/ progenetix/ I98013/ http:/ / www. progenetix. net/ progenetix/ I98203/ http:/ / www. progenetix. net/ progenetix/ I98213/ http:/ / www. progenetix. net/ progenetix/ I98233/ http:/ / www. progenetix. net/ progenetix/ I98263/ http:/ / www. progenetix. net/ progenetix/ I98273/ http:/ / www. progenetix. net/ progenetix/ I98313/ http:/ / www. progenetix. net/ progenetix/ I98333/ http:/ / www. progenetix. net/ progenetix/ I98343/
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[159] http:/ / www. progenetix. net/ progenetix/ I98353/ [160] http:/ / www. progenetix. net/ progenetix/ I98363/ [161] http:/ / www. progenetix. net/ progenetix/ I98373/

[162] [163] [164] [165] [166] [167] [168] [169] [170] [171] [172] [173] [174] [175] [176] [177] [178] [179] [180] [181] [182] [183] [184] [185] [186] [187] [188] [189] [190] [191] [192] [193] [194] [195] [196] [197] [198] [199] [200] [201] [202] [203] [204] [205] [206] [207] [208] [209] [210] [211] [212] [213] [214] [215] [216] http:/ / www. progenetix. net/ progenetix/ I98403/ http:/ / www. progenetix. net/ progenetix/ I98603/ http:/ / www. progenetix. net/ progenetix/ I98613/ http:/ / www. progenetix. net/ progenetix/ I98633/ http:/ / www. progenetix. net/ progenetix/ I98663/ http:/ / www. progenetix. net/ progenetix/ I98673/ http:/ / www. progenetix. net/ progenetix/ I98703/ http:/ / www. progenetix. net/ progenetix/ I98713/ http:/ / www. progenetix. net/ progenetix/ I98723/ http:/ / www. progenetix. net/ progenetix/ I98733/ http:/ / www. progenetix. net/ progenetix/ I98743/ http:/ / www. progenetix. net/ progenetix/ I98753/ http:/ / www. progenetix. net/ progenetix/ I98763/ http:/ / www. progenetix. net/ progenetix/ I98803/ http:/ / www. progenetix. net/ progenetix/ I98903/ http:/ / www. progenetix. net/ progenetix/ I98913/ http:/ / www. progenetix. net/ progenetix/ I98953/ http:/ / www. progenetix. net/ progenetix/ I98963/ http:/ / www. progenetix. net/ progenetix/ I98973/ http:/ / www. progenetix. net/ progenetix/ I99103/ http:/ / www. progenetix. net/ progenetix/ I99203/ http:/ / www. progenetix. net/ progenetix/ I99303/ http:/ / www. progenetix. net/ progenetix/ I99313/ http:/ / www. progenetix. net/ progenetix/ I99403/ http:/ / www. progenetix. net/ progenetix/ I99463/ http:/ / www. progenetix. net/ progenetix/ I99483/ http:/ / www. progenetix. net/ progenetix/ I99503/ http:/ / www. progenetix. net/ progenetix/ I99601/ http:/ / www. progenetix. net/ progenetix/ I99613/ http:/ / www. progenetix. net/ progenetix/ I99623/ http:/ / www. progenetix. net/ progenetix/ I99633/ http:/ / www. progenetix. net/ progenetix/ I99643/ http:/ / www. progenetix. net/ progenetix/ I99701/ http:/ / www. progenetix. net/ progenetix/ I99753/ http:/ / www. progenetix. net/ progenetix/ I99803/ http:/ / www. progenetix. net/ progenetix/ I99823/ http:/ / www. progenetix. net/ progenetix/ I99833/ http:/ / www. progenetix. net/ progenetix/ I99853/ http:/ / www. progenetix. net/ progenetix/ I99863/ http:/ / www. progenetix. net/ progenetix/ I99893/ http:/ / www. who. int/ classifications/ icd/ adaptations/ oncology/ en/ http:/ / training. seer. cancer. gov/ index. html http:/ / www. dimdi. de/ static/ en/ klassi/ diagnosen/ icdo3/ basisicdo3. htm http:/ / www. healthyarkansas. com/ arkcancer/ publications/ Multiple%20Primaries. ppt http:/ / training. seer. cancer. gov/ module_coding_primary/ unit01_hist_bkgrnd01. html http:/ / seer. cancer. gov/ icd-o-3/ http:/ / seer. cancer. gov/ icd-o-3/ sitetype. icd03. d20090401. xls http:/ / training. seer. cancer. gov/ module_coding_primary/ table_who_class_hemo_1. html http:/ / training. seer. cancer. gov/ module_icdo3/ downloadables/ Supplemental%20ICD-O-3%20List. DOC http:/ / uniklinikum-giessen. de/ imi/ konvi2t2. html?m=27 http:/ / www. dimdi. de/ static/ en/ klassi/ diagnosen/ icdo3/ http:/ / www-p53. iarc. fr/ Morphology. html http:/ / www. wolfbane. com/ icd/ index. html http:/ / www. ncri. ie/ data. cgi/ html/ icdo2morphs. shtml http:/ / www. celsius. lshtm. ac. uk/ dataDict/ appendices/ MorphologyofNeoplasmsICDO2. html
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International Classification of Functioning, Disability and Health
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International Classification of Functioning, Disability and Health, also known as ICF, is a classification of the health components of functioning and disability. After nine years of international revision efforts coordinated by the World Health Organization (WHO), the World Health Assembly on May 22, 2001, approved the International Classification of Functioning, Disability and Health and its abbreviation of "ICF." This classification was first created in 1980 and then called the International Classification of Impairments, Disabilities, and Handicaps, or ICIDH[1] by WHO to provide a unifying framework for classifying the health components of functioning and disability. The ICF classification complements WHOs International Classification of Diseases-10th Revision (ICD), which contains information on diagnosis and health condition, but not on functional status. The ICD and ICF constitute the core classifications in the WHO Family of International Classifications (WHO-FIC).
Overview
The ICF is structured around the following broad components: Body functions and structure Activities (related to tasks and actions by an individual) and participation (involvement in a life situation) Additional information on severity and environmental factors Functioning and disability are viewed as a complex interaction between the health condition of the individual and the contextual factors of the environment as well as personal factors. The picture produced by this combination of factors and dimensions is of "the person in his or her world". The classification treats these dimensions as interactive and dynamic rather than linear or static. It allows for an assessment of the degree of disability, although it is not a measurement instrument. It is applicable to all people, whatever their health condition. The language of the ICF is neutral as to etiology, placing the emphasis on function rather than condition or disease. It also is carefully designed to be relevant across cultures as well as age groups and genders, making it highly appropriate for heterogeneous populations.
Benefits of ICF
There are benefits of using the ICF for both the client and the health professional. A major advantage for the client is the integration of the medical and social aspects of his or her health condition. All aspects of a persons life (development, participation, and environment) are incorporated into the ICF instead of solely focusing on his or her diagnosis. A diagnosis reveals little about ones functional abilities. Diagnoses are important for defining the cause and prognosis, but identifying the limitations of function is often the information used to plan and implement interventions [2] Once a rehabilitation team is aware of the daily activities a client is required to participate in, the problem solving sequence set up by the ICF can be utilized. A rehabilitation therapist, for example, would observe a client performing his or her daily activities and note the clients functional abilities. This information would then be used to determine the extent to which the individuals abilities can be improved through therapy and to what extent the environment can be changed to facilitate the individuals performance.[3] Intervention at one level (current abilities) has the potential to prevent or modify events at a succeeding level (participation). For example, teaching a deaf child manual signs will foster effective interaction and increase ones participation with his or her family.[4] Rehabilitation therapists will be empowered with the ICF not only in their daily work with their patients, but also when working with other medical disciplines; hospitals and other health care administrations; health authorities and policy makers.[5] All items are operationally defined with clear descriptions that can be applied to real life
International Classification of Functioning, Disability and Health evaluations with clarity and ease.[6] The language used in the ICF helps facilitate better communication between these groups of people.
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Clinical relevance
Knowing how a disease affects ones functioning enables better planning of services, treatment, and rehabilitation for persons with long-term disabilities or chronic conditions. The current ICF creates a more integrative understanding of health forming a comprehensive profile of an individual instead of focusing on ones health condition.[7] The implications of using the ICF include emphasizing the strengths of individuals, assisting individuals in participating more extensively in society by the use of interventions aimed at enhancing their abilities, and taking into consideration the environmental and personal factors that might hamper ones participation.[8] Qualifiers: The ICF qualifiers may be best translated clinically as the levels of functioning seen in a standardized or clinic setting and in everyday environments.[9] Qualifiers support standardization and the understanding of functioning in a multidisciplinary assessment. They enable all team members to quantify the extent of problems, even in areas of functioning where one is not a specialist.[10] Without qualifiers codes have no inherent meaning. An impairment, limitation or restriction, is qualified from 0 (No problem; 0-4%), 1 (Mild problem: 5-24%, 2 (Moderate problem: 25-49%), 3 (Severe problem: 50-95%) to 4 (Complete problem: 96-100%). Environmental factors are quantified with a negative and positive scale denoting the extent to which the environment acts as a barrier or facilitator.[11] For insurance purposes, the qualifiers can describe the effectiveness of treatment. One can interpret the decreasing of a qualifier score to be an increase in the functional ability of a patient.
ICF Core Sets

An ICF Core Set can serve as a reference framework and a practical tool to classify and describe patient functioning in a more time efficient way. ICF Core Sets can be used along the continuum of care and over the course of a health condition.[12] The ICF classification includes more than 1,400 categories limiting its use in clinical practice.[13] It is time consuming for a clinician to utilize the main volume of the ICF with his or her patients. Only a fraction of the categories is needed. As a general rule, 20% of the codes will explain 80% of the variance observed in practice.[14] ICF Core Sets contain as few as possible, but as many ICF categories as necessary, to describe a patients level of functioning.[15] It is hypothesized that using an ICF Core Set will increase the inter-rater reliability when coding clinical cases as only the relevant categories for a particular patient will be utilized. Since all of the relevant categories are listed in an ICF Core Set, its use in multidisciplinary assessments protects health professionals from missing important aspects of functioning.[16]
Children and Youth Version (ICF-CY)

As clinicians and researchers used the ICF, they became more aware of its limitations. The ICF lacks the ability to classify the functional characteristics of a developing child. Different ICF codes are needed across the first years of a childs life to capture the growth and development of a disability even when the childs diagnosis does not change.[17] The coding system can provide essential information about the severity of a health condition in terms of its impact on functioning. This can serve a significant role for providers caring for children with spectrum disorders such as autism or cerebral palsy.[18] Children with these conditions may have the same diagnosis, but their abilities and levels of functioning widely vary across and within individuals over time. The first draft of the ICF-CY was completed in 2003 and published in 2007. The ICF-CY was developed to be structurally consistent with the ICF for adults. A major difference between the ICF-CY and ICF is that the generic qualifiers from the adult ICF now include developmental aspects for children and youth in the ICF-CY. Descriptions of codes in the ICF-CY were revised and expanded and new content was added to previously unused codes. Codes were added to document characteristics as adaptability, responsivity, predictability, persistence, and approachability. Sensing and exploration of objects codes were expanded as well as the importance of learning.[19] Since a childs main occupation is playing, it is also
International Classification of Functioning, Disability and Health important to include more codes in this area. Different levels of play have separate codes in the ICF-CY (solitary, onlooker, parallel). This contrasts with the adult ICF as only one code existed in regards to leisure or recreation. Changes in ICF-CY codes over time reflect developmental effects attributable to the childs interaction with the environment. Environmental factors influence functioning and development and can be documented as barriers or facilitators using the ICF-CY. The key environments of children and adolescents include their homes, day care centers, schools and recreation settings of playground, parks, and ball fields.[20] Children will transition between different environments many times as they grow. For example, a child will transition into elementary or high school or from one service setting or agency to another. Attention to these transitions of children with disabilities has been identified as an important role for health care providers.[21] A transition requires preparation and planning to find an appropriate and accommodating setting for a childs needs. With a coding system such as the ICF-CY, the transition will be smoother and interventions can start where the previous health provider left off.
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External links
International Classification of Functioning, Disability and Health (ICF) [22] - WHO International Classification of Functioning, Disability and Health (ICF) [23] - CDC ICF case studies: Implementation of ICF in rehabilitation management [24] The Italian Portal of Classifications [25] is the ICF and ICF-CY browsing tool of the Italian Collaborating Centre of the World Health Organization for the Family of International Classifications
References
[1] http:/ / www. cdc. gov/ nchs/ about/ otheract/ icd9/ icfhome. htm [2] Lollar, D.J., & Simeonsson, R.J. (2005). Diagnosis to function: classification for children and youths. Developmental and Behavioral Pediatrics, 26, 323-330. [3] Bornman, J. (2004). The World Health Organizations terminology and classification: application to severe disability. Disability and Rehabiliation, 26, 182-188. [4] Bornman, J. (2004). The World Health Organizations terminology and classification: application to severe disability. Disability and Rehabiliation, 26, 182-188. [5] Stucki, G., Ewert, T., & Cieza, A. (2002). Value and application of the ICF in rehabilitation medicine. Disability and Rehabilitation, 24, 932-938. [6] stn, T. B., Chatterji, S., Bickenbach, J., Kostanjsek, N., & Schneider, M. (2003). The International Classification of Functioning, Disability and Health: A new tool for understanding disability and health. Disability and Rehabilitation, 25, 565571. [7] Hemmingsson, H., & Jonsson, H. (2005). An occupational perspective on the concept of participation in the international classification of functioning, disability and health some critical remarks. The American Journal of Occupational Therapy, 59, 569-576. [8] Bornman, J. (2004). The World Health Organizations terminology and classification: application to severe disability. Disability and Rehabiliation, 26, 182-188. [9] Reed, G., Lux, J., Bufka, L., Peterson, D., Threats, T., Trask, C., Stark, S., Jacobson, J., & Hawley, J. (2005). Operationalizing the International Classification of Functioning, Disability, and Health: A model to guide clinical thinking, practice and research in the field of cerebral palsy. Seminars in Pediatric Neurology, 11, 5-10. [10] Rauch, A., Cieza, A., & Stucki, G. (2008). How to apply the International Classification of Functioning Disability and Health (ICF) for rehabilitation management in clinical practice. European Journal of Physical and Rehabilitation Medicine, 44, 329-342. [11] World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). Geneva: Author. [12] Rauch, A., Cieza, A., & Stucki, G. (2008). How to apply the International Classification of Functioning Disability and Health (ICF) for rehabilitation management in clinical practice. European Journal of Physical and Rehabilitation Medicine, 44, 329-342. [13] Arlinger, M., Stamm, T.A., Pisetsky, D.S., Yarboro, C.H., Cieza, A., Smolen, J.S., & Stucki, G. (2006). ICF core sets: how to specify impairment and function in systemic lupus erythematosus. Lupus, 15, 248-253. [14] Ustun, B., Chatterji, S., & Kostanjsek, N. (2004). Comments from WHO for the Journal of Rehabilitation Medicine special supplement on ICF core sets. Journal of Rehabiliation Medicine, (Suppl. 44), 7-8. [15] Rauch, A., Cieza, A., & Stucki, G. (2008). How to apply the International Classification of Functioning Disability and Health (ICF) for rehabilitation management in clinical practice. European Journal of Physical and Rehabilitation Medicine, 44, 329-342. [16] Rauch, A., Cieza, A., & Stucki, G. (2008). How to apply the International Classification of Functioning Disability and Health (ICF) for rehabilitation management in clinical practice. European Journal of Physical and Rehabilitation Medicine, 44, 329-342. [17] Simeonsson, R.J., Scarborough, A.A., & Hebbeler, K.M. (2006). ICF and ICD codes provide a standard language of disability in young children. Journal of Clinical Epidemiology, 59, 365-373.

[18] Ogonowski, J., Kronk, R., Rice, C., & Feldman, H. (2004). Inter-rater reliability in assigning ICF codes to children with disabilities. Disability and Rehabilitation, 26, 353-361. [19] Lollar, D.J., & Simeonsson, R.J. (2005). Diagnosis to function: classification for children and youths. Developmental and Behavioral Pediatrics, 26, 323-330. [20] Simeonsson, R.J., Lollar, D., Hollowell, J., & Adams, M. (2000). Revision of the international classification of impairments, disabilities, and handicaps developmental issues. Journal of Clinical Epidemiology, 53, 113-124. [21] Simeonsson, R.J., Lollar, D., Hollowell, J., & Adams, M. (2000). Revision of the international classification of impairments, disabilities, and handicaps developmental issues. Journal of Clinical Epidemiology, 53, 113-124. [22] http:/ / www. who. int/ classifications/ icf/ en/ [23] http:/ / www. cdc. gov/ nchs/ about/ otheract/ icd9/ icfhome. htm [24] http:/ / www. icf-casestudies. org [25] http:/ / www. reteclassificazioni. it
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International Classification of Health Interventions

The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization. It is currently only available as a beta release. It is designed to replace the "International Classification of Procedures in Medicine" (ICPM), a system that was developed in the 1970s but which never received the same international acceptance as ICD-9. As a result, most nations developed their own incompatible standards for coding procedures and interventions. It is largely derived from the "Australian Classification of Health Interventions" (ACHI), a portion of the Australian standard ICD-10-AM, which in turn was largely derived from ICD-10 and the United States extension ICD-9-CM.
External links
WHO site [1] (International framework for coding, evolution of ICHI paused) Australian site [2] (Australian version for coding)
References
[1] http:/ / www. who. int/ classifications/ ichi/ en/ [2] http:/ / www3. fhs. usyd. edu. au/ ncchwww/ site/ 4. 1. 4. htm
International Classification of Primary Care
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The International Classification of Primary Care (ICPC) is a classification method for primary care encounters. It allows for the classification of the patients reason for encounter (RFE), the problems/diagnosis managed, primary or general health care interventions, and the ordering of the data of the primary care session in an episode of care structure. It was developed by the WONCA International Classification Committee (WICC), and was first published in 1987 by Oxford University Press (OUP). A revision and inclusion of criteria and definitions was published in 1998. The second revision was accepted within the World Health Organization's Family of International Classifications.[1] The classification was developed in a context of increasing demand for quality information on primary care as part of growing worldwide attention to global primary health care objectives, including the WHO's target of "health for all".[2]
History
The first version of ICPC, which was published in 1987, is referred to as ICPC-1. A subsequent revision which was published in the 1993 publication The International Classification of Primary Care in the European Community: With a Multi-Language Layer is known as ICPC-E. The 1998 publication, of version 2, is referred to as ICPC-2. The acronym ICPC-2-E, refers to a revised electronic version, which was released in 2000. Subsequent revisions of ICPC-2 are also labelled with a release date.
Structure
Chapters
The ICPC contains 17 chapters: A General and unspecified B Blood, blood forming organs, lymphatics, spleen D Digestive F Eye H Ear K Circulatory L Musculoskeletal N Neurological P Psychological R Respiratory S Skin T Endocrine, metabolic and nutritional U Urology W Pregnancy, childbirth, family planning X Female genital system and breast Y Male genital system Z Social problems
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Components
The ICPC classification, within each chapter, is based on 3 components coming from 3 different classifications: Reason for Encounter Classification (1981) International Classification of Process in Primary Care (IC-Process-PC) (1985) International Classification of Health Problem in Primary Care (ICHPPC-2-d) (1976, 1983)
References
[1] World Health Organization. International Classification of Primary Care, Second edition (ICPC-2). (http:/ / www. who. int/ classifications/ icd/ adaptations/ icpc2/ en/ ) Geneva. Accessed 24 June 2011. [2] Bentsen BG. "International classification of primary care." Scand J Prim Health Care. 1986 Feb;4(1):43-50.
External links
WICC (http://www.globalfamilydoctor.com/wicc/) FMRC (http://www.fmrc.org.au/icpc2/) ICPC-2e (http://www.kith.no/templates/kith_WebPage____1062.aspx) (by the Norwegian Centre for Informatics in Health and Social Care) ICPC publication bibliography (http://www.fmrc.org.au/icpc2/publications-d.htm)
International Healthcare Terminology Standards Development Organisation

The International Health Terminology Standards Development Organisation (IHTSDO) is a not-for-profit association that develops and promotes use of SNOMED CT to support safe and effective health information exchange. It was formed in 2006 with the purpose to develop and maintain international health terminology systems, in particular SNOMED CT. Founder (Charter) members of the IHTSDO include Australia, Canada, Denmark, Lithuania, The Netherlands, New Zealand, Sweden, the United Kingdom, and the United States.[1] Singapore became the first Asian country to join the IHTSDO on October 28, 2008.[2] Legally it is a Danish charity, with subsequent development funded by voluntary subscription by governments. In April 2007, the principal intellectual property of SNOMED CT was transferred to the IHTSDO.
External links
IHTSDO Homepage [3]
References
[1] http:/ / www. nzhis. govt. nz/ moh. nsf/ indexns/ snomed?Open [2] http:/ / www. ihtsdo. org/ news/ article/ view/ singapore-becoming-a-member/ [3] http:/ / www. ihtsdo. org/
ICPC-2 PLUS
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ICPC-2 PLUS
ICPC-2 PLUS is an extended terminology classified to ICPC-2 International Classification of Primary Care, which aids data entry, retrieval and analysis. ICPC-2 PLUS takes into account the frequency distribution of problems seen in primary health care. It allows for the classification of the patients reason for encounter (RFE), the problems/diagnosis managed, primary care interventions, and the ordering of the data of the primary care session in an episode of care structure. ICPC-2 PLUS provides a list of possible terms matching a keyword (or start of a keyword) entered by the user. The user then selects the most appropriate term. Each term is already classified to ICPC-2 rubrics and a system of additional groupers that may include terms from multiple ICPC-2 rubrics. Each term has one or more keywords linked to it which may include abbreviations, synonyms, generics or specifics. The keyword searching is thus much broader, faster and better controlled than text mining of free text and labels. Instead of guessing what the physician meant by a term (in free text) prior to classification, the physician is actually prompted with a small list of terms to select from which are already classified. The product also includes a 'natural language' label for each term which can be used for reports and letters. Note: The PLUS extension mentioned here is not part of the ICPC-2 standard. The World Organization of Family Doctors (WONCA) and the WONCA International Classification Committee (WICC) have no control over it although they do have control over the ICPC classification which the PLUS extension makes use of. Its similar to the difference between a car and fuel.
History
ICPC-2 PLUS was the successor to 'ICPC PLUS' and were both designed by the Family Medicine Research Centre([1] FMRC]) for use in Australia. The FMRC continues to update and support ICPC-2 PLUS. ICPC is being developed by the WONCA International Classification Committee (WICC), and the first version was published as ICPC-1 in 1987 by Oxford University Press (OUP), and a revision and inclusion of criteria and definitions, was published in 1998 as ICPC-2.
External links
ICPC-2 PLUS Introduction [2] (FMRC) ICPC story [3] (WICC) ICPC-2 Introduction [4] (ULB) (out-of-date, please use other links)
References
[1] [2] [3] [4] http:/ / www. fmrc. org. au/ icpc2plus http:/ / www. fmrc. org. au/ icpc2plus/ http:/ / www. globalfamilydoctor. com/ wicc/ icpcstory. html http:/ / www. ulb. ac. be/ esp/ wicc/ icpc2. html
ISO 27799
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ISO 27799
ISO 27799 is an information security standard developed by the International Organization for Standardization (ISO). Its title is Health informatics -- Information security management in health using ISO/IEC 27002 The purpose of ISO 27799 is provides guidance to health organizations and other holders of personal health information on how to protect such information via implementation of ISO/IEC 27002. The content sections [1] are: 1: Scope 2: References 3: Terminology 4: Symbols 5: Health information security 6: Practical Action Plan for Implementing ISO 17799/27002 7: Healthcare Implications if ISO 17799/27002 8: Annex A: Threats 9: Annex B: Tasks and documentation of the ISMS
10: Annex C: Potential benefits and tool attributes 11: Annex D: Related standards
References
[1] An Introduction to ISO 27799 (http:/ / www. 27000. org/ iso-27799. htm)
External links
Current status of the ISO 27799 standard (http://www.iso.org/iso/iso_catalogue/catalogue_tc/ catalogue_detail.htm?csnumber=41298)
ISO/IEEE 11073
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ISO/IEEE 11073
CEN ISO/IEEE 11073 Health informatics - Medical / health device communication standards enable communication between medical, health care and wellness devices and with external computer systems. They provide automatic and detailed electronic data capture of client-related and vital signs information, and of device operational data.
ISO/IEEE 11073 Medical / health device communication standards

The primary goals of ISO/IEEE 11073 standards are to:
1. Provide real-time plug-and-play interoperability for citizen-related medical, healthcare and wellness devices; 2. Facilitate efficient exchange of care device data, acquired at the point-of-care, in all care environments. Real-time means that data from multiple devices can be retrieved, time correlated, and displayed or processed in fractions of a second. Plug-and-play means that all a user has to do is make the connection the systems automatically detect, configure, and communicate without any other human interaction. Efficient exchange of care device data means that information that is captured at the point-of-care (e.g., personal vital signs data) can be archived, retrieved, and processed by many different types of applications without extensive software and equipment support, and without needless loss of information. The standards are targeted at personal health and fitness devices (such as glucose monitors, pulse oximeters, weighing scales, medication dispensers and activity monitors) and at continuing and acute care devices (such as pulse oximeters, ventilators and infusion pumps). They comprise a family of standards that can be layered together to provide connectivity optimized for the specific devices being interfaced. There are four main partitions to the standards: Device data, including a nomenclature, or terminology, optimized for vital signs information representation based on an object-oriented data model, and device specialisations; General application services (e.g., polled vs. event driven services); Internetworking and gateway standards (e.g., an observation reporting interface from CEN ISO/IEEE 11073-based messaging and data representation to HL7 or DICOM); Transports (e.g., cable connected or wireless).
What problems exist in the absence of standardized care device connectivity?

In the absence of standards for these devices, (a) data is captured either manually or at considerable expense (using specialized equipment), or (b) it is not captured at all, which is most often the case. Manually captured data is labour intensive, recorded infrequently (e.g., written down hourly by a nurse clinician), and prone to human error. Use of expensive custom connectivity equipment (a) drives up the cost of care delivery; (b) is only used for patients with the highest acuity; and (c) tends to lock care providers into single companies or partnerships that provide complete information system solutions, making it difficult to choose best-of-breed technologies to meet client needs, or the most cost effective systems. Development and deployment of advanced care delivery systems are hindered. For example, systems that collect real-time data from multiple devices and use the information to detect safety problems (e.g., adverse drug events), or to quickly determine a client's condition and automatically, or with minimal carer involvement, optimally adjust a devices operation (e.g., for insulin delivery based on glucose level information) cannot operate without these standards.
ISO/IEEE 11073 With no standardisation in this area, even when similar devices do provide communications, there is no consistency in the information and services that are provided, thus inhibiting the development of advanced care delivery systems or even consistent health records. In short: appropriate use of 11073 device communication standards can help deliver better health, fitness and care, more quickly, safely, and at a lower cost.
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Why CEN ISO/IEEE 11073 standards?

These are the only standards addressing this area of connectivity. They provide a complete solution for medical device connectivity, starting at the physical cable or wireless connection up through the abstract representation of information and the services used for its management and exchange. They can enable full disclosure of device-mediated information. So measurement modalities be declared in detail and the associated metrics & alerts communicated, together with any user-made changes to settings. In addition, the device can communicate its manufacturer, model, serial number, configuration, operating status and network location all in real time if required. The IEEE 11073 standards have been developed with a high level of international participation. They have been, and continue to be, adopted as International Standards Organisation (ISO) standards through ISO TC215 Health Informatics and as European standards through the Committee for European Normalisation (CEN) TC251 Health Informatics, specifically as the CEN ISO/IEEE 11073 series. The end result is a single set of internationally harmonized standards that have been developed and adopted by ISO and CEN member countries. These CEN ISO/IEEE 11073 standards have been developed in close coordination with other standards development organisations, including IEEE 802, IHTSDO, IrDA, HL7, DICOM, and CLSI. Memoranda of Understanding with IHE, IHTSDO, and HL7; and (through ISO) close liaison with Continua Health Alliance assist still wider integration. The CEN ISO/IEEE 11073 nomenclature is now being used to populate, and to establish equivalence, within SNOMED CT - the most widely used clinical terminology. A liaison between the IEEE 11073 standards group and the USA Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) in the USA helps ensure that patient safety and efficacy concerns are fully addressed in the standards. The Continua Health Alliance and the English NHS National Programme for Information Technology (NPfIT) both specify use of the standards for device communication. The standards have been included in the USA National Committee on Vital and Health Statistics recommendations to the Department of Health and Human Services related to patient medical record information message formats supporting Health Insurance Portability and Accountability Act (HIPAA) compliant implementations. The cost of integrating innovative technologies into established product lines is reduced and a barrier to new companies is lowered.
ISO/IEEE 11073
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How to obtain CEN ISO/IEEE 11073 standards

11073 standards are available freely to those actively involved in their development, others may purchase them. For published and draft standards search for '11073' at: IEEE [1] , ISO [2] or CEN [3] . Standards may be purchased from your national standards organisation or bookstore (e.g. AFNOR, BSI, DIN, JIS, UNI, etc.). Meeting agendas and minutes are posted at the official joint working group website [4] .
ISO/IEEE 11073-Family Overview

ISO/IEEE 11073 Medical / Health Device Communication Standards is a family of ISO, IEEE, and CEN joint standards addressing the interoperability of medical devices. The ISO/IEEE 11073 standard family defines parts of a system, with which it is possible, to exchange and evaluate vital signs data between different medical devices, as well as remote control these devices.
Published Standards (Point-of-care medical device)

11073-00101 Health informatics - PoC medical device communication - Part 00101: GuideGuidelines for the use of RF wireless technology
11073-10101:2004(E) Health informatics - Point-of-care medical device communication - Part 10101: Nomenclature 11073-10201:2004(E) Health informatics - Point-of-care medical device communication - Part 10201: Domain information model 11073-20101:2004(E) Health informatics - Point-of-care medical device communication - Part 20101: Application profile - Base standard 11073-30200:2004 Health informatics - Point-of-care medical device communication - Part 30200: Transport profile - Cable connected
11073-30300:2004(E) Health informatics - Point-of-care medical device communication - Part 30300: Transport profile - infrared wireless
The relevant core standards are: - 11073-10101 - 11073-10201 - 11073-20101 and - 11073-30200
Personal Health Device Standards

ISO/IEEE 11073 Personal Health Device (PHD) standards are a group of standards addressing the interoperability of personal health devices (PHDs) such as weighing scales, blood pressure monitors, blood glucose monitors and the like. The standards draw upon earlier IEEE11073 standards work, but differ from this earlier work due to an emphasis on devices for personal use (rather than hospital use) and a simpler communications model. These are described in more detail at ISO/IEEE 11073 Personal Health Data (PHD) Standards
Core standard overview

ISO/IEEE 11073-10101 Nomenclature
Within this standard nomenclature codes are defined, these give the possibility to clearly identify objects and attributes in relation to the so-called OID-Code ([5]). The nomenclature is divided in partitions, to demarcate codes with regards to content and functional. Programmatically these codes are defined as constants, those can be used by a pseudonym. example in C++: #define MDC_PART_OBJ 1 /* Definition fr die Partition Object Infrastructure */ #define MDC_MOC_VMS_MDS_SIMP 37 /* Definiert das Objekt Simple Medical Device System */
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ISO/IEEE 11073-10201 Domain Information Model

These standard is the "heart" of VITAL. Within their, objects and theirs arrangement in a Domain Information Model for vital signs data transmission are defined. Beyond this standard defines a service model for the standardized communication. A deeper look can be found at chapters 3 and 4 of this document.
ISO/IEEE 11073-20101 Base Standard

The common backgrounds for assembly and transmission of objects and their attributes are defined in this standard. It's subdivided in a communication model and an information model. The communication model describes the layers 5 to 7 of the OSI 7-layer model. The information model defines the modeling, formatting and the syntax for transmission coding of the objects. Look at chapters 3 and 5 for more details.
Agent/Manager Principle
All defined parts of this standard family are designed to allow communication according to this principle. The arrangement of two or more medical devices as a system, so that the components are possible to understand and to interact, are the basic idea of this principle. The Agent is the part of the principle, that is connected to the medical devices. He provides the data. The Manager keeps a copy of the Agent data, reacts on update events from them and triggers events on the Agent. In the most use cases, the Manager is a remote monitor for displaying data, but also an agent remote control by the Manager is possible. Like to see in the drawing above, Agent and Manager are built in the same structure. This enables an Agent to act as a Manager and reverse. Besides the plain Agent-Manager Application, hybrid systeme over multiple stages are possible. In the next steps the moduls and their functionalities are illustrated by means of the picture above.
Agent Application Process(es)

This module is the interface between a propritary (eventually native) protocol and the ISO/IEEE (VITAL) object world. It is not defined within the standard and as a result it can be implemented free.
MDIB (Medical Data Information Base)

In the broaded sense, the MDIB is object oriented database. MMOs (Managed Medical Objects) are stored hierarchically within a tree structure in a form named Domain Information Model (DIM). This MMOs and their arrangement in the DIM are defined within this standard. The implementation of the MDIB and their functionallity is out of the scope of the standard.
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ACSE (Association Service Control Element)

This module is subjet to the standards ISO/IEC 15953 und ISO/IEC 15954. It has services available, that controlling the association assembly and disassembly. A possible association and their condition is negotiated here, no MMOs are transmitted over this module.
CMDISE (Common Medical Device Information Service Element)

Services for the data exchange of MMOs (Managed Medical Objects) between Agent-Manager systems, are defined in this module. This data exchange is highly dynamic. Objects are created, changed or deleted by services named CREATE, UPDATE, DELETE. Through reports, which can be defined detailed down to the single object attribute, it is possible to trigger complex operations in Agent or Manager, through this services.
Presentation Layer (not in the diagram)

This layer contains the encoding of object data. Objects, groups of objects attributes or single attributes are encoded by ASN.1 representations, respectively the spezialization MDER (Medical Device encoding Rules).
Session Layer (not in the diagram)

That layer controls connection at the session level.
DIM (Domain Information Model)

The central core of the standard is the so-called Domain Information Model. Objects that containing vital signs data representations and their relationships are defined in this model. Objects for additional services around vital signs data objects, are defined also here.
For content sensitive classification of the objects, they would divided into packages.
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Medical Package
The package that defines objects, to map medical vital signs data. There are different objects to store vital signs data in different ways. As an example the RealTimeSampleArray object for the management of e.g. ECG data be mentioned.
Alert Package
This small package is related within the medical package. It is used for setting and administrating alerts respectively alert parameters to objects from the medical package.
System Package
A Representation of a medical device can be achieved with objects of this package. It contains concrete derivations of the abstract MDS (MedicalDevice System) object. One of these koncrte derivations are ever the root object of an DIM tree. The Battery object and the Clock object are further objects in this package. The last one can be used for time synchronization of medical device datas.
Control Package
Inside the control package, objects for the remote control of a medical device are defined. There are objects used for influenceing the modality of measuring (for example the SetRangeOperation object) and objects for direct remote control of medical devices (for example the ActivateOperation object).
Extended Services Package

Other than the name supposes, in this package essential and ever used objects are defined. This package is built on so-called scanner objects in different derivations. Scanning data in other objects and generation of event reports, who can be sendend, are the sense of this objects. The scanner objects have a wide range of different attributes (e.g. scan interval, scan lists, scan period etc.), for a wide range of applications the DIM. As an example the FastPeriCfgScanner object (Fast Periodic Configurable Scanner), that is specially constructed for the requirements of real-time data exchange in conjunction with the RealTimeSampleArray object, to transmit live data from egc devices.
Communication Package
The objects in these package containing information, which are responsible for basic communication profiles. These package are developed very open, so that different communication profiles and interfaces to proprietary device interfaces can be built. Annotation by the author: From a historic view, the standard was developed for the first time in the early 90s, this package has to be reconstructed.
Archival Package
Storing Patient related data in online or offline archives is the idea for objects in the archival package. For Example, the Patient Archive object can store vital signs data, demographic data and treatment data in one object.
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Patient Package
The patient package contains only one object, the Patient Demographics object. This object contains patient related data and can be set in relationship to an MDS object or one of the objects from the archive package, to give anonymous data the reference to patient data.
Communication model
The complete communication sequence can be very complex. This article should provide basic information, that can be more detailed at a later time in a separate article.
Finite State Machine (FSM)

The finite state machine regulates the synchronization of an Agent Manager system over different conditions. A complete session roundtrip starts up with the disconnected state, is transferred by multiple stages to the initialized state, in what the actual data transfer shall be done and ends with the disconnected state.
Initializing MDIB
During the association phase, the configuring state will be reached. In this condition Agent and Manager are to exchange object data for the first time. In the process a MDSCreateEvent in the form of a report would be triggered. This report creates a copy of the MDS root object from the Agent MDIB in the Manager MDIB. Afterward a Contextcanner object is created in the Agents MDIB. This scanner object scans the complete MDIB and generates a report containing the complete Agents MDIB representation, expect the MDS root object. The Manager evaluates this report and creates the objects defined here in his own MDIB copy. At this point the manager has an exact copy of the Agents MDIB. Both are now at configurated state.
Data Exchange Through Services

The Common Medical Device Information Service Element (CMDISE) provides a GET service, to deliver data requested by the Manager. The Agents GET service retrieves a list of attribute ids. These ids identifying explicit values within Agents MDIB. Now the Agent creates a report, containing the requested values. This report is sent back to the Manager.
Data Exchange Through Scanner Objects

In an MDIB, additional objects shall be createed thtough the CREATE service of CMDISE. The Manager requests the Agent through this service to create a scanner object himself, and to fix the scanner object on one or more values. Optional for example the scan intervall for the data delivery can be set. The Agent creates the scanner object in his own MDIB and sends the Manager a response message. Now the Manager creates a copy of the scanner object in his MDIB. The data update form Agent to Manager now occurs automatically through the scanner object. Through CMDISEes DELETE service, the scanner object can be deleted, like all other MDIBs objects.
Glossary
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ACSE ASN.1
Association Service Control Element Abstract Syntax Notation
CMDISE Common Medical Device Information Service Element DIM FSM MDER MDIB MDS MMO Domain Information Model Finite State Machine Medical Device Encoding Rules Medical Data Information Base Medical Device System Managed Medical Object
References
[1] [2] [3] [4] [5] http:/ / shop. ieee. org/ ieeestore http:/ / www. iso. org/ iso/ search. htm?qt=11073& searchSubmit=Search& sort=rel& type=simple& published=true http:/ / www. cen. eu/ esearch/ extendedsearch. aspx http:/ / www. 11073. org http:/ / www. oid-info. com
The german article about this standard family
ISO/TC 215
The ISO/TC 215 is the International Organization for Standardization's (ISO) Technical Committee (TC) on health informatics. TC 215 works on the standardization of Health Information and Communications Technology (ICT), to allow for compatibility and interoperability between independent systems.
Working Groups
ISO TC 215 consists of several Working Groups (WG), each dealing with an aspect of Electronic Health Records (EHR). CAG 1: Executive council, harmonization and operations WG 1: Data structure WG 2: Messaging and communications WG 3: Health Concept Representation WG 4: Privacy and Security WG 5: Health Cards >>Transitioned to a Task Force on Health Cards. WG 6: Pharmacy and medicines business WG 7: Devices WG 8: Business requirements for Electronic Health Records WG 9: SDO Harmonization
Task Forces: --e-Business for Healthcare Transactions --Multidisciplinary for Healthcare Clinicians --Harmonized Joint Work Group for Devices --Traditional Medicine (Currently restricted to Far Eastern Traditional Medicine) --Health Cards --Patient Safety and Quality
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Standards
July 2009 Current list of completed standards and other deliverables from TC 215: ISO/HL7 27931:2009 Data Exchange Standards -- Health Level Seven Version 2.5 -- An application protocol for electronic data exchange in healthcare environments ISO/TR 27809:2007 Health informatics -- Measures for ensuring patient safety of health software ISO 27799:2008 Health informatics -- Information security management in health using ISO/IEC 27002 ISO/TS 25238:2007 Health informatics -- Classification of safety risks from health software ISO/TS 25237:2008 Health informatics -- Pseudonymization ISO 22857:2004 Health informatics -- Guidelines on data protection to facilitate trans-border flows of personal health information ISO/TR 22790:2007 Health informatics -- Functional characteristics of prescriber support systems ISO/TS 22600-2:2006 Health informatics -- Privilege management and access control -- Part 2: Formal models ISO/TS 22600-1:2006 Health informatics -- Privilege management and access control -- Part 1: Overview and policy management ISO/TR 22221:2006 Health informatics - Good principles and practices for a clinical data warehouse ISO/TS 22220:2009 Health Informatics -- Identification of subjects of health care ISO/HL7 21731:2006 Health informatics -- HL7 version 3 -- Reference information model -- Release 1 ISO/TR 21730:2007 Health informatics -- Use of mobile wireless communication and computing technology in healthcare facilities -- Recommendations for electromagnetic compatibility (management of unintentional electromagnetic interference) with medical devices ISO/TS 21667:2004 Health informatics -- Health indicators conceptual framework ISO 21549-7:2007 Health informatics -- Patient healthcard data -- Part 7: Medication data ISO 21549-6:2008 Health informatics -- Patient healthcard data -- Part 6: Administrative data ISO 21549-5:2008 Health informatics -- Patient healthcard data -- Part 5: Identification data ISO 21549-4:2006 Health informatics -- Patient healthcard data -- Part 4: Extended clinical data ISO 21549-3:2004 Health informatics -- Patient healthcard data -- Part 3: Limited clinical data ISO 21549-2:2004 Health informatics -- Patient healthcard data -- Part 2: Common objects ISO 21549-1:2004 Health informatics -- Patient healthcard data -- Part 1: General structure ISO/TS 21298:2008 Health informatics -- Functional and structural roles ISO/TS 21091:2005 Health informatics -- Directory services for security, communications and identification of professionals and patients ISO/TR 21089:2004 Health informatics -- Trusted end-to-end information flows ISO/TR 20514:2005 Health informatics -- Electronic health record -- Definition, scope and context ISO 20302:2006 Health informatics -- Health cards -- Numbering system and registration procedure for issuer identifiers ISO 20301:2006 Health informatics -- Health cards -- General characteristics ISO 18812:2003 Health informatics -- Clinical analyser interfaces to laboratory information systems -- Use profiles ISO/TS 18308:2004 Health informatics -- Requirements for an electronic health record architecture ISO/TR 18307:2001 Health informatics -- Interoperability and compatibility in messaging and communication standards -- Key characteristics
ISO/TC 215 ISO 18232:2006 Health Informatics -- Messages and communication -- Format of length limited globally unique string identifiers ISO 18104:2003 Health informatics -- Integration of a reference terminology model for nursing ISO 17432:2004 Health informatics -- Messages and communication -- Web access to DICOM persistent objects ISO/TS 17120:2004 Health informatics -- Country identifier standards (Withdrawn 2009-09-22) ISO/TR 17119:2005 Health informatics - Health informatics profiling framework ISO/TS 17117:2002 Health informatics -- Controlled health terminology -- Structure and high-level indicators ISO 17115:2007 Health informatics -- Vocabulary for terminological systems ISO 17090-3:2008 Health informatics -- Public key infrastructure -- Part 3: Policy management of certification and authority ISO 17090-2:2008 Health informatics -- Public key infrastructure -- Part 2: Certificate profile ISO 17090-1:2008 Health informatics -- Public key infrastructure -- Part 1: Overview of digital certificate services ISO/TS 16058:2004 Health informatics -- Interoperability of telelearning systems ISO/TR 16056-2:2004 Health informatics -- Interoperability of telehealth systems and networks -- Part 2: Real-time systems ISO/TR 16056-1:2004 Health informatics -- Interoperability of telehealth systems and networks -- Part 1: Introduction and definitions ISO 13606-3:2009 Health informatics -- Electronic health record communication -- Part 3: Reference archetypes and term lists ISO 13606-2:2008 Health informatics -- Electronic health record communication -- Part 2: Archetype interchange specification ISO 13606-1:2008 Health informatics -- Electronic health record communication -- Part 1: Reference model ISO/TR 12773-2:2009 Business requirements for health summary records -- Part 2: Environmental scan ISO/TR 12773-1:2009 Business requirements for health summary records -- Part 1: Requirements ISO 12052:2006 Health informatics -- Digital imaging and communication in medicine (DICOM) including workflow and data management ISO/TR 11487:2008 Health informatics -- Clinical stakeholder participation in the work of ISO TC 215 ISO/TS 11073-92001:2007 Health informatics -- Medical waveform format -- Part 92001: Encoding rules ISO 11073-91064:2009 Health informatics -- Standard communication protocol -- Part 91064: Computer-assisted electrocardiography ISO 11073-90101:2008 Health informatics -- Point-of-care medical device communication -- Part 90101: Analytical instruments -- Point-of-care test ISO/IEEE 11073-30300:2004 Health informatics -- Point-of-care medical device communication -- Part 30300: Transport profile -- Infrared wireless ISO/IEEE 11073-30200:2004 Health informatics -- Point-of-care medical device communication -- Part 30200: Transport profile -- Cable connected ISO/IEEE 11073-20101:2004 Health informatics -- Point-of-care medical device communication -- Part 20101: Application profiles -- Base standard ISO/IEEE 11073-10201:2004 Health informatics -- Point-of-care medical device communication -- Part 10201: Domain information model ISO/IEEE 11073-10101:2004 Health informatics -- Point-of-care medical device communication -- Part 10101: Nomenclature
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External links
http://www.iso.org/iso/standards_development/technical_committees/list_of_iso_technical_committees/ iso_technical_committee.htm?commid=54960 ISO/TC 215 is a member of the Joint Initiative on SDO Global Health Informatics Standardization [1] http://www.himss.org/ASP/topics_ISO.asp
References
[1] http:/ / www. global-e-health-standards. org/
LOINC
Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. It was developed and is maintained by the Regenstrief Institute, a US non-profit medical research organization, in 1994. LOINC was created in response to the demand for an electronic database for clinical care and management and is publicly available at no cost. It is endorsed by the American Clinical Laboratory Association [1] and the College of American Pathologist [2]. Since its inception, the database has expanded to include not just medical and laboratory code names, but also: nursing diagnosis, nursing interventions, outcomes classification, and patient care data set.
Function
LOINC applies universal code names and identifiers to medical terminology related to the Electronic health record. The purpose is to assist in the electronic exchange and gathering of clinical results (such as laboratory tests, clinical observations, outcomes management and research). Several standards, such as IHE or HL7, use LOINC to electronically transfer results from different reporting systems to the appropriate healthcare networks. However, the health information enclosed is identified by a multiplicity of code values that may vary according to the entity producing those results. This has obvious disadvantages to the healthcare network that may need to adopt different codes to access and manage information coming from multiple sources. Managed care providers, for example, often have negotiated contracts that reimburse episodes of care and unique coding to trigger automated claim payment. Mapping each entity-specific code to its corresponding universal code can represent a significant investment of both human and financial capital. A universal code system will enable facilities and departments across the world to receive and send results from their areas for comparison and consultation and contribute toward a larger public health initiative of improving clinical outcomes and quality of care [3]. LOINC is one of the standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information. In 1999, it was identified by the HL7 Standards Development Organization as a preferred code set for laboratory test names in transactions between health care facilities, laboratories, laboratory testing devices, and public health authorities.
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Format
A formal, distinct, and unique 6-part name is given to each term for test or observation identity.[4] The database currently has over 58,000 observation terms that can be accessed and understood universally. Each database record includes six fields for the unique specification of each identified single test, observation, or measurement: 1. 2. 3. 4. 5. 6. Component- what is measured, evaluated, or observed (example: urea,...) Kind of property- characteristics of what is measured, such as length, mass, volume, time stamp and so on Time aspect- interval of time over which the observation or measurement was made System- context or specimen type within which the observation was made (example: blood, urine,...) Type of scale- the scale of measure. The scale may be quantitative, ordinal, nominal or narrative Type of method- procedure used to make the measurement or observation
A unique code (format: nnnnn-n) is assigned to each entry upon registration. Other database fields include status and mapping information for database change management, synonyms, related terms, substance information (e.g. molar mass, CAS registry number), choices of answers for nominal scales, translations.
Uses
Some of the advantages resulting from adopting LOINC may include improved communication in integrated healthcare delivery networks, improved community wide electronic health records, the automatic transfer to public health authorities of case reports for reportable diseases (e.g. for disease control or detection of epidemics), improved transfer of payment information for services rendered and a significant improvement in the overall quality of health care by reducing errors in the system. The fact that universal standards are being promoted (if not adopted by national organizations and agencies) is an indication that the dialogue will continue regarding the development, structure, financing, monitoring, enforcement, and integration of standards within the broader health care system. International interest in LOINC continues to grow. A number of efforts have been undertaken to translate the LOINC documents and terms into various languages, such as Simplified Chinese, German, Spanish. For more information on LOINC International, see LOINC International [5]. Currently (as of January, 2009), the software RELMA (Regenstrief LOINC Mapping Assistant) is available in separate downloads that contain an additional word index in Spanish, Simplified Chinese, or Korean, which allows searching in these languages in addition to English[6] .
References
[1] [2] [3] [4] http:/ / www. clinical-labs. org/ http:/ / www. cap. org/ http:/ / www. iom. edu/ topic. asid=3718 Alex A. T. Bui; Ricky K. Taira (August 2009). Medical Imaging Informatics (http:/ / books. google. com/ books?id=3JClHj3SXjwC& pg=PA107). Springer. pp.107. ISBN9781441903846. . Retrieved 31 May 2011. [5] http:/ / www. regenstrief. org/ medinformatics/ loinc/ international [6] http:/ / loinc. org/ news/ relma-version-4-00-available. html/ view
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External links
LOINC pages of Regenstrief Institute, Inc. (http://loinc.org/) LOINC International (http://loinc.org/international) Web site of the Regenstrief LOINC Mapping Assistant (RELMA) (http://loinc.org/relma) Introduction to the HL7 Standards (http://www.HL7.com.au/FAQ.htm) U.S. National Library of Medicine (http://www.nlm.nih.gov/research/umls/loinc_main.html) CUMUL (http://www.cumul.ch) - a project that attempts to create a multilingual version of LOINC identifiers. Chinese LOINC Interface System (http://www.cnehr.org.cn/documents/gwyj/CLISOL/Search_Keywords. asp) - a pilot project that aims to show a simplified Chinese version of LOINC terms.
MEDCIN
MEDCIN, a system of standardized medical terminology, is a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. [1] MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems. Developed by Medicomp Systems, it includes over 250,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 26 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED, CPT, ICD, DSM, GSM and LOINC. The MEDCIN coding system is touted especially for point-of-care documentation and architecture. Several Electronic Medical Record (EMR) systems embed MEDCIN, which allows them to produce structured and numerically codified patient charts. Such structuring enables the aggregation, analysis, and mining of clinical and practice management data related to a disease, a patient or a population.
Sample Computer Applications Using MEDCIN

Electronic Medical Records Sage Intergy EHR [2] Origin Healthcare Solutions, EMRge [3] Computerized Physician Order Entry (e.g. E-Prescribing or Laboratory Order Entry) Emergency Room Charting MedcomSoft Record [4]
Further reading
Goltra, Peter S. MEDCIN: A New Nomenclature for Clinical Medicine. Ann Arbour, MI 1997:Springer-Verlag ISBN 0-387-94953-4.
External links
Medicomp home page [5]
References
[1] http:/ / www. medicomp. com [2] http:/ / www. sagehealth. com/ [3] http:/ / www. originhs. com [4] http:/ / www. medcomsoft. com [5] http:/ / www. medicomp. com/
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MedDRA
MedDRA or Medical Dictionary for Regulatory Activities is a clinically validated international medical terminology used by regulatory authorities and the regulated biopharmaceutical industry throughout the entire regulatory process, from pre-marketing to post-marketing activities, and for data entry, retrieval, evaluation, and presentation. In addition, it is the adverse event classification dictionary endorsed by the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). MedDRA is used in the US, European Union, and Japan. Its use is currently mandated in Europe and Japan for safety reporting. MedDRA is managed by the MSSO (Maintenance and Support Services Organization), an organization that reports to the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). MedDRA is free for regulators and priced according to company revenue for industry. MedDRA is also available in Japanese. The Japanese counterpart for MSSO is called JMO. The MSSO updates MedDRA from subscriber change requests to add a new medical concept that is yet to be in MedDRA or to change an existing concept. The decisions are made by international medical officers on how to map the terminology within the grouping categories according to a general consensus based on language considerations internationally. The MSSO releases updated MedDRA versions twice a year in March and September. The March release is the main annual release and contains LLT and PT changes, and changes at the HLT level and above. The September release typically contains changes only at the LLT and PT level. The March 2011 Version 14.0 release is the current version. The FDA has committed to keeping current on MedDRA, and it has become the standard for adverse event reporting in the USA. The MedDRA dictionary is organized by System Organ Class (SOC), divided into High-Level Group Terms (HLGT), High-Level Terms (HLT), Preferred Terms (PT) and finally into Lower-Level Terms (LLT). In addition, the MedDRA dictionary includes Standardized MedDRA Queries (SMQs). SMQs are groupings of terms that relate to a defined medical condition or area of interest.
External links
MedDRA and the MSSO [1]
References
[1] http:/ / www. meddramsso. com/ index. asp
Medical Subject Headings
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Medical subject headings.
Content Description Medical subject headings.
Data types captured controlled vocabulary Contact Research center United States National Library of Medicine National Center for Biotechnology Information United States National Library of Medicine F B ROGERS PMID 13982385 Access Tools Miscellaneous [1]
Laboratory Authors Primary Citation
Medical Subject Headings (MeSH) is a comprehensive controlled vocabulary for the purpose of indexing journal articles and books in the life sciences; it can also serve as a thesaurus that facilitates searching. Created and updated by the United States National Library of Medicine (NLM), it is used by the MEDLINE/PubMed article database and by NLM's catalog of book holdings. MeSH can be browsed and downloaded free of charge on the Internet through PubMed. The yearly printed version was discontinued in 2007 and MeSH is now available online only.[2] Originally in English, MeSH has been translated into numerous other languages and allows retrieval of documents from different languages.
Structure of MeSH
The 2009 version of MeSH contains a total of 25,186 subject headings, also known as descriptors.[3] Most of these are accompanied by a short description or definition, links to related descriptors, and a list of synonyms or very similar terms (known as entry terms). Because of these synonym lists, MeSH can also be viewed as a thesaurus.[4]
Descriptor hierarchy
The descriptors or subject headings are arranged in a hierarchy. A given descriptor may appear at several places in the hierarchical tree. The tree locations carry systematic labels known as tree numbers, and consequently one descriptor can carry several tree numbers. For example, the descriptor "Digestive System Neoplasms" has the tree numbers C06.301 and C04.588.274; C stands for Diseases, C06 for Digestive System Diseases and C06.301 for Digestive System Neoplasms; C04 for Neoplasms, C04.588 for Neoplasms By Site, and C04.588.274 also for Digestive System Neoplasms. The tree numbers of a given descriptor are subject to change as MeSH is updated. Every descriptor also carries a unique alphanumerical ID that will not change.
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Descriptions
Most subject headings come with a short description or definition. See the MeSH description for diabetes type 2 [5] as an example. The explanatory text is written by the MeSH team based on their standard sources if not otherwise stated. References are mostly encyclopaedias and standard textbooks of the subject areas. References for specific statements in the descriptions are not given, instead readers are referred to the bibliography [6].
Qualifiers
In addition to the descriptor hierarchy, MeSH contains a small number of standard qualifiers (also known as subheadings), which can be added to descriptors to narrow down the topic.[7] For example, "Measles" is a descriptor and "epidemiology" is a qualifier; "Measles/epidemiology" describes the subheading of epidemiological articles about Measles. The "epidemiology" qualifier can be added to all other disease descriptors. Not all descriptor/qualifier combinations are allowed since some of them may be meaningless. In all there are 83 different qualifiers.
Supplements
In addition to the descriptors, MeSH also contains some 139,000 Supplementary Concept Records. These do not belong to the controlled vocabulary as such and are not used for indexing MEDLINE articles; instead they enlarge the thesaurus and contain links to the closest fitting descriptor to be used in a MEDLINE search. Many of these records describe chemical substances.
Use in Medline/PubMed
In MEDLINE/PubMed, every journal article is indexed with some 10-15 headings and subheadings, with some of them designated as major and marked with an asterisk. When performing a MEDLINE search via PubMed, entry terms are automatically translated into (= 'mapped to) the corresponding descriptors with a good degree of reliability; it is recommended to check the Details tab in PubMed to see how a search formulation was 'translated'. By default a search will include all the descriptors that are located below the given one in the hierarchy.
Categories
The top-level categories in the MeSH descriptor hierarchy are: Anatomy [A] Organisms [B] Diseases [C] Chemicals and Drugs [D] Analytical, Diagnostic and Therapeutic Techniques and Equipment [E] Psychiatry and Psychology [F] Biological Sciences [G] Physical Sciences [H] Anthropology, Education, Sociology and Social Phenomena [I] Technology and Food and Beverages [J] Humanities [K] Information Science [L] Persons [M] Health Care [N]
Publication Characteristics [V] Geographic Locations [Z]
Medical Subject Headings For the full hierarchy, see List of MeSH codes.
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References
[1] ROGERS, F B (Jan 1963). "Medical subject headings" (in eng). Bull Med Libr Assoc (Not Available) 51: 114-6. ISSN0025-7338. PMCPMC197951. PMID13982385. [2] "Medical Subject Headings (MeSH) Fact sheet" (http:/ / www. nlm. nih. gov/ pubs/ factsheets/ mesh. html). National Library of Medicine. 2005-05-27. . Retrieved 2007-05-31. [3] Fact Sheet MeSH (http:/ / www. nlm. nih. gov/ pubs/ factsheets/ mesh. html) [4] Introduction to MeSH - 2010 (http:/ / www. nlm. nih. gov/ mesh/ introduction. html) [5] http:/ / www. ncbi. nlm. nih. gov/ sites/ entrez?Db=mesh& Cmd=ShowDetailView& TermToSearch=68003924& ordinalpos=3& itool=EntrezSystem2. PEntrez. Mesh. Mesh_ResultsPanel. Mesh_RVDocSum [6] http:/ / www. nlm. nih. gov/ mesh/ intro_biblio2007. html [7] List of qualifiers - MeSH 2009 (http:/ / www. nlm. nih. gov/ mesh/ 2009/ introduction/ topsubscope. html)
External links
Medical Subject Heading Home (http://www.nlm.nih.gov/mesh/) provided by National Library of Medicine, National Institutes of Health (U.S.) MeSH database tutorials (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=mesh) Automatic Term Mapping (http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/020_040.html) Browsing MeSH: Entrez (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=mesh) MeSH Browser (http://www.nlm.nih.gov/mesh/MBrowser.html) Visual MeSH Browser (http://www.curehunter.com/public/dictionary.do) mapping drug-disease relationships in research Reference.MD (http://www.reference.md/) MeSHine (http://www.meshine.info/) List of qualifiers - 2009 (http://www.nlm.nih.gov/mesh/2009/introduction/topsubscope.html)
Minimum Data Set
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Minimum Data Set

The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Resource Utilization Groups (RUG) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessment forms are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals, usually Registered Nurses, employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at Centers for Medicare and Medicaid Services (CMS). Categories of MDS (Minimum Data Set) 1) Cognitive patterns 2) Communication and hearing patterns 3) Vision patterns 4) Physical functioning and structural problems 5) Continence 6) Psychosocial well-being 7) Mood and behavior patterns 8) Activity pursuit patterns 9) Disease diagnosis 10) Other health conditions 11) Oral/nutritional status 12) Oral/dental status 13) Skin condition 14) Medication use 15) Treatments and procedures
References
CMS [1]
References
[1] http:/ / www. cms. hhs. gov/ apps/ mds/
Multiscale Electrophysiology Format
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Multiscale Electrophysiology Format

Multiscale Electrophysiology Format (MEF) was developed to handle the large amounts of data produced by large-scale electrophysiology in human and animal subjects. MEF can store any time series data up to 24 bits in length, and employs lossless range encoded difference compression. Subject identifying information in the file header can be encrypted using 128-bit AES encryption in order to comply with HIPAA requirements for patient privacy when transmitting data across an open network. Compressed data is stored in independent blocks to allow direct access to the data, facilitate parallel processing and limit the effects of potential damage to files. Data fidelity is ensured by a 32-bit cyclic redundancy check in each compressed data block using the Koopman polynomial (0xEB31D82E), which has a Hamming distance of from 4 to 114 kbits. A formal specification can be found here [1].[2]
References
[1] http:/ / mayoresearch. mayo. edu/ mayo/ research/ msel/ upload/ mef%20_format. pdf [2] Source code (http:/ / mayoresearch. mayo. edu/ mayo/ research/ msel/ example_code. cfm)
Sources
Martin, GNN. Range encoding: an algorithm for removing redundancy from a digitised message. Video & Data Recoding Conference, Southampton, 1979. Koopman, P. 32-Bit Cyclic Redundancy Codes for Internet Applications. The International Conference on Dependable Systems and Networks (June 2002). 459. Brinkmann, BH et al. Large-scale electrophysiology: acquisition, compression, encryption, and storage of big data. Journal of Neuroscience Methods 180 (2009) 185192.
External links
Source code: http://mayoresearch.mayo.edu/mayo/research/msel/example_code.cfm
NANDA
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NANDA
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses standardized nursing terminology that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses. In 2002, NANDA relaunched as NANDA International in response to the broadening scope of its membership. NANDA International published Nursing Diagnosis quarterly, which became the International Journal of Nursing Terminologies and Classifications in 2002.Other related international associations are AENTDE (Spanish), AFEDI (French language) and JSND (Japan)
History
In 1973 the First National Conference on the Classification of Nursing Diagnoses was held in St. Louis, Missouri which created the National Conference Group, a task force to standardize nursing terminology. In 1982 NANDA was formed including members from the United States and Canada. NANDA developed a nursing classification to organize nursing diagnoses into different categories. Although the taxonomy was revised to accommodate new diagnoses, in 1994 it became apparent that an overhaul was needed. In 2002 Taxonomy II, which was a revised version of Gordon's functional health patterns, was released. In 2002, NANDA became NANDA International in response to requests from its growing base of membership from outside North America. The acronym of NANDA was retained in the name because of the name recognition, but it is no longer merely "North American", and in fact boasts members from 32 countries as of 2010.
Taxonomy II
The current structure of NANDA's nursing diagnoses is referred to as Taxonomy II and has three levels: 13 domains, 47 classes, and 205 diagnoses.
Presidents
1982-1988 Dr. Marjory Gordon 1988-1993 Jane Lancour 1993-1996 Dr. Lois Hoskins 1996-1998 Dr. Judith Warren 1998-2000 Dr. Dorothy A. Jones 2000-2002 Kay Avant 2002-2004 Mary Ann Lavin 2004-2006 Martha Craft-Rosenberg 2006-2008 Dr. Heather Herdman 2008-2012 Prof. Dickon Weir-Hughes
NANDA
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References
Herdman, TH (Ed.) Nursing Diagnoses: Definitions and classification 2009-2011. Wiley-Blackwell: Singapore.
External links
NANDA International's official website [1]
References
[1] http:/ / www. nanda. org
Nursing Interventions Classification

The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associate with the creation of a nursing care plan. The NIC consists of a standardized list which contains 433 different interventions. Each intervention is defined and the definition describes a set of activities a nurse performs in order to perform one of the interventions. Each of the 433 interventions is coded into a three-level taxonomic structure consisting of 27 classes and 6 domains. The taxonomic structure allows for easy selection of an intervention and to classify them by means of a computer. The NIC also allows for the implementation of a Nursing Minimum Data Set (NMDS). The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, and is HL7 registered.[1] [2] [3] [4]
References
[1] Iowa Intervention Project (1996). Nursing Interventions Classification (NIC) (2nd ed.), St. Louis: Mosby-Year Book [2] Henry SB, Warren JJ, Lange L, Button P., A review of major nursing vocabularies and the extent to which they have the characteristics required for implementation in computer-based systems, J Am Med Inform Assoc. 1998 Jul-Aug;5(4):321-8 [3] Henry SB, Mead CN., Nursing classification systems: necessary but not sufficient for representing "what nurses do" for inclusion in computer-based patient record systems, J Am Med Inform Assoc. 1997 May-Jun;4(3):222-32 [4] Nursing Interventions Classification (http:/ / www. ncvhs. hhs. gov/ 970416w4. htm)
Nursing Minimum Data Set
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Nursing Minimum Data Set

The Nursing Minimum Data Set (NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations, settings, geographic areas, and time.[1] [2]
References
[1] H H Werley, E C Devine, C R Zorn, P Ryan and B L Westra, The Nursing Minimum Data Set: abstraction tool for standardized, comparable, essential data, American Journal of Public Health,1991, Vol. 81, Issue 4 421-426 [2] C A Williams, The Nursing Minimum Data Set: a major priority for public health nursing but not a panacea, Am J Public Health. 1991 April; 81(4): 413414
External links
Nursing Minimum Data Set for School Nursing Practice (http://www.nasn.org/Default.aspx?tabid=234)
Nursing Outcomes Classification

The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, and is HL7 registered.[1] [2]
References
[1] Donahue, M.P. & Brighton, V., Nursing outcome classification: Development and implementation, Journal of Nursing Care Quality, 1998, 12(5) [2] S. Moorhead, M. Johnson, M. Maas, E. Swanson, Nursing Outcomes Classification (NOC), Elsevier, Fourth Edition, 936 pages, 2007, ISBN 0-323-05408-0
External links
Nursing Outcomes Classification (http://www.nursing.uiowa.edu/excellence/nursing_knowledge/ clinical_effectiveness/noc.htm) (U. Iowa)
OpenGALEN
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OpenGALEN
OpenGALEN is a not-for-profit organisation that provides an open source medical terminology. This terminology is written in a formal language called GRAIL (GALEN Concept Representation Language) and also distributed in OWL.
Background
The GALEN technologies were developed with research funding provided by the European Community Framework III (GALEN Project) and Framework IV (GALEN-In-Use Project) programmes. Early phases of the GALEN Programme developed the GRAIL concept modelling language, experimented with different structures for the GALEN Common Reference Model, and, in parallel, tested the usefulness of the approach with a series of clinical demonstrator projects. Later phases of the GALEN Programme, during the late 1990s, have concentrated on robust implementations of GRAIL and the Terminology Server, development of the GALEN Common Reference Model in both scope and detail, and development of tools and techniques to enable the further development, scaling-up and maintenance of the model. An important additional focus has been in developing tools and techniques with which we can map the information found in existing coding and Medical classification schemes to the GALEN Common Reference Model. OpenGALEN has been set up as a not-for-profit Dutch Foundation by the universities of Manchester and Nijmegen to make the results of the GALEN projects available to the world.
GALEN Common Reference Model

The GALEN Common Reference Model is the model of medical concepts (or clinical terminology) being built in GRAIL. This model forms the underlying structural foundation for the services provided by a GALEN Terminology Server. The GALEN Common Reference Model is written in the formal language GRAIL (see below). The GRAIL statements in the model are equivalent with sentences like these: Ulcer is a kind of inflammatory lesion The process whose outcome is an ulcer is called ulceration The stomach is a part of the GI tract It is sensible to talk about ulcers located in the stomach Ulcers located in the stomach are called Gastric Ulcers Ulcers located in the stomach are actually located on the mucosa of the wall of the stomach
The GALEN Common Reference Model is available from the OpenGALEN Foundation as open source.
Projects
The GALEN tools and technologies were used in France for the development of the French classification of procedures Classification Commune des Actes Mdicaux (CCAM).
References
Rector, A.; Rogers, J.; Zanstra, P.; Van Der Haring, E. (2003). "OpenGALEN: Open source medical terminology and tools". AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium: 982. PMC1480228. PMID14728486.
OpenGALEN Rector, A.; Solomon, W.; Nowlan, W.; Rush, T.; Zanstra, P.; Claassen, W. (1995). "A Terminology Server for medical language and medical information systems". Methods of information in medicine 34 (12): 147157. PMID9082124. Rector, A.; Zanstra, P.; Solomon, W.; Rogers, J.; Baud, R.; Ceusters, W.; Claassen, W.; Kirby, J. et al. (1998). "Reconciling users' needs and formal requirements: Issues in developing a reusable ontology for medicine". IEEE transactions on information technology in biomedicine : a publication of the IEEE Engineering in Medicine and Biology Society 2 (4): 229242. PMID10719533. Rogers, J.; Roberts, A.; Solomon, D.; Van Der Haring, E.; Wroe, C.; Zanstra, P.; Rector, A. (2001). "GALEN ten years on: Tasks and supporting tools". Studies in health technology and informatics 84 (Pt 1): 256260. PMID11604744. Ten Napel, H.; Rogers, J. (2001). "Assessment of the GALEN methodology on holistic classifications for professions allied to medicine". Studies in health technology and informatics 84 (Pt 2): 13691373. PMID11604951. Rogers, J.; Rector, A. (2000). "GALEN's model of parts and wholes: Experience and comparisons". Proceedings / AMIA ... Annual Symposium. AMIA Symposium: 714718. PMC2243933. PMID11079977. Solomon, W.; Roberts, A.; Rogers, J.; Wroe, C.; Rector, A. (2000). "Having our cake and eating it too: How the GALEN Intermediate Representation reconciles internal complexity with users' requirements for appropriateness and simplicity". Proceedings / AMIA ... Annual Symposium. AMIA Symposium: 819823. PMC2244105. PMID11079998. Rogers, J. (2006). "Quality assurance of medical ontologies". Methods of information in medicine 45 (3): 267274. PMID16685334.
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External links
OpenGALEN [1] Web site CCAM, Classification Commune des Actes Mdicaux [2] University of Manchester, Bio-Health Informatics Group [3] University of Nijmegen, Medical Informatics [4]
References
[1] [2] [3] [4] http:/ / www. opengalen. org http:/ / www. ccam. sante. fr/ http:/ / www. cs. man. ac. uk/ bhig/ http:/ / www. umcn. nl/ mi/
SNOMED
574
SNOMED
The Systematized Nomenclature of Medicine (SNOMED) is a multiaxial, hierarchical classification system [1] . As in any such system, a disease may be located in a body organ which results in a code in a topography axis and may lead to morphological alterations represented by a morphology code.
Purpose
SNOMED was designed as a comprehensive nomenclature of clinical medicine for the purpose of accurately storing and/or retrieving records of clinical care in human and veterinary medicine. The metaphor used by Roger A. Ct, the first editorial chair, was that SNOMED would become the periodical table of element of medicine because of its definitional organization beyond the hierarchical design. Indeed, diseases and procedures were ordered hierarchically and are further referenced back to more elementary terms (see Reference Ontology and Multi-Axial Design, below).
History
SNOMED was originally conceived by Dr. Roger A. Ct as an extension of the design of the Systematized Nomenclature of Pathology (SNOP) applicable for all medicine. SNOP was originally designed by Dr. Arnold Pratt to describe pathological specimen according to their morphology and anatomy (topography). The ambitious development of SNOMED required many more axes (see multi-axial design, below). SNOMED was jointly proposed for development to the College of American Pathologists by Drs. Ct and Dr. Arnold Pratt and the former was appointed as Editorial Chair of the Committee on Nomenclature and Classification of Diseases of the College of American Pathologists and developed the Systematized Nomenclature of Medicine (SNOMED) from 1973 to 1997. In 1998, Dr. Kent Spackman was appointed Chair of this Committee and spearheaded the transformation of the multi-axis systems into a highly computable form (See SNOMED CT): a directed acyclic graph anchored in formal representation logic. Brief timeline: 1965 SNOP 1974 SNOMED 1979 SNOMED II 1993 SNOMED International 3.0 1995 SNOMED Microglossary of Signs and Symptoms 1993-98 SNOMED International versions 3.1-3.5
Reference ontology
SNOMED was designed from its inception with complex concepts defined in term of simpler ones. For example, a disease can be defined in terms of its abnormal anatomy, abnormal functions and morphology. In some cases, the etiology of the disease is known and can be attributed to an infectious agent, a physical trauma or a chemical or pharmaceutical agent.
Multi-axial design
The current concept uses eleven (11) axes that comprise terms organised in hierarchical trees. The axes and some examples are provided below:
SNOMED
575
T (Topography) Anatomic terms

(T-28000) Lung (T-32000) Heart (T-51000) Mouth (T-D2500) Hip (T-D9600) Heel
M (Morphology) Changes found in cells, tissues and organs

(M-40000) Inflammation (M-44000) Granuloma (M-54700) Infarcted (M-54701) Microscopic infarct
For the Morphology axis, SNOMED has agreed [2] to collaborate and use the same harmonized codes shared with International Classification of Diseases for Oncology. Additional examples on topology are provided on that page.
L (Living organisms) Bacteria and viruses

(L-21801) Mycobacterium tuberculosis (L-25116) Streptococcus pneumoniae
C (Chemical) Drugs
(C-C137A) Bufferin Analgesic Tablets (C-C137B) Bufferin Analgesic Caplets
F (Function) Signs and symptoms

(F-03003) Fever
J (Occupation) Terms that describe the occupation

Businessman School teacher Computer programmer Doctor Nurse Beautician
SNOMED
576
D (Diagnosis) Diagnostic terms

(D-13510) Pneumococcal pneumonia (D-14800) Tuberculosis (D3-15000) Myocardial infarction
S (Social context) Social conditions and important relationships in medicine

(S-10120) Mother
References
[1] The Architecture of SNOMED by Roger A. Cote (http:/ / www. pubmedcentral. nih. gov/ picrender. fcgi?artid=2245000& blobtype=pdf) [2] http:/ / www. snomed. org/ clinical/ anatomic. html
External links
Official page at snomed.org (http://www.snomed.org/) (now redirects to www.ihtsdo.org (http://www.ihtsdo. org/)) Studies of the formal structure of SNOMED CT at buffalo.edu (http://ontology.buffalo.edu/medo/ SNOMED_Smith.html) Browser at vetmed.vt.edu (http://terminology.vetmed.vt.edu/SCT/menu.cfm) Dataline SNOMED Browser: Looks up clinical terms online for free. (http://www.snoflake.co.uk/)
SNOMED CT
SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms), is a systematically organised computer processable collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organising the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research, see e.g. Ruch et al. 2008.
Purpose
Provision of SNOMED CT is to support the community of practice who are developing electronic health records systems which will allow the appropriate retention, processing and exchange of unambiguous clinical records. The ability for such systems to support patient-centric actions such as fast transfer of records between different healthcare providers is dependent on a number of techniques, collectively referred to as 'semantic interoperability' of which a reference terminology such as SNOMED CT is a fundamental part. Clinicians and organisations use different clinical terms that mean the same thing. For example, the terms heart attack, myocardial infarction, and MI may mean the same thing to a cardiologist, but, to a computer, they are all different. There is a need to exchange clinical information consistently between different health care providers, care settings, researchers and others (semantic interoperability),and because medical information is recorded differently from place to place (on paper or electronically), a comprehensive, unified medical terminology system is needed as part of the information infrastructure. Given its coverage (diagnosis, therapeutic procedures, treatments, pathogens, signs and symptoms...), SNOMED CT provide a synthetic alternative to heterogeneous coding instruments, however the size of the vocabulary makes it more difficult to manage, in particular for medical coding. The recent availability of free automatic coding tools and services,[1] which can return a ranked list of SNOMED CT descriptors to encode any clinical report, could help healthcare professionals to navigate the terminology.
SNOMED CT
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Structure
SNOMED CT consists of over a million medical Concepts. For example 22298006 means myocardial infarction (MI). The Concepts are arranged in a type or IS-A hierarchy. For example, Viral pneumonia IS-A Infectious pneumonia IS-A Pneumonia IS-A Lung disease. Concepts may have multiple parents, for example Infectious pneumonia is also an Infectious disease. The Concept graph must be acyclic a parent cannot be its own child. Concepts can have Roles, e.g. Viral pneumonia has a role Causitive Agent which must be a Virus. Some Concepts can be Primitive, such as Virus. But SNOMED also allows concepts to be Defined by a predicate. For example Viral pneumonia might be defined as Pneumonia that is caused by a Virus. Defined concepts are based on Description Logic. Descriptions are Terms or names (synonyms) assigned to a concept. Concepts often have several Descriptions, and a description may sometimes refer to more than one concept. For example, Immunosuppression might be a Therapy or a Finding. Upper level concepts include Procedure, Pharmaceutical/biologic product, Clinical finding, Event, Body structure, Organism. SNOMED concepts are often referred to by an information model such as HL7. If concepts are referred to directly by an information model then they are considered to be 'pre-coordinated'. But SNOMED CT also enables more complex descriptions to be used. For example, there might not be an explicit concept for a burn in the palm of the hand. But it could be described as
413350009 | finding with explicit context | : { 246090004 | associated finding | = ( 284196006 | burn of skin | : 246112005 | severity | = 24484000 | severe | , 363698007 | finding site | = 321472003 | structure of dermatoglyphic patterns of palm |) , 408729009 | finding context | = 410515003 | known present | , 408731000 | temporal context | = 410512000 | current or specified | , 408732007 | subject relationship context | = 410604004 | subject of record | }
Such expressions are said to have been 'post-coordinated'. When used, post coordinated conditions avoids the need to create large numbers of Defined Concepts within SNOMED. However, many systems only use pre-coordinated conditions. Reliable analysis and comparison of any such post-coordinated expressions - with respect to both those concepts already within the SNOMED CT release dataset and any other ad hoc concepts created or yet to be created by its community of end users - properly requires the application of an appropriate description logic classification algorithm. As of 2007, SNOMED CT content limits itself to a subset of the EL++ formalism, restricting itself to the following operators: top, bottom primitive roles and concepts with asserted parent(s) for each concept definition and conjunction but NOT disjunction or negation role hierarchy but not role composition domain and range constraints existential but not universal restriction a restricted form of role inclusion axiom (xRy ^ ySz => xRz) The logic may be extended in the near future to include General Concept Inclusion Axioms.
SNOMED CT In theory, description logic reasoning can be applied to any new candidate post-coordinated expressions in order to assess whether it is a parent or ancestor of, a child or other descendent of, or semantically equivalent to any existing concept from the 370,000 pre-coordinated concepts which are already distributed worldwide. However, partly as the continuing fall-out from the merger with CTV3, SNOMED content in 2007 still contains undiscovered semantically duplicate primitive and defined concepts. Additionally, many concepts remain primitive whilst their semantics can also be legitimately defined in terms of other primitives and roles concurrently in the system. Because of these omissions and actual or possible redundancies of semantic content, real-world performance of algorithms to infer subsumption or semantic equivalence will be unpredictably imperfect.
578
Use
SNOMED CT is one of a suite of designated data standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information.
Sample computer applications using SNOMED CT

Electronic Health Record Systems Computerized Provider Order Entry CPOE such as E-Prescribing or Laboratory Order Entry Catalogues of clinical services; e.g., for Diagnostic Imaging procedures Knowledge databases used in clinical decision support systems (CDSS) Remote Intensive Care Unit Monitoring Laboratory Reporting Emergency Room Charting Cancer Reporting Genetic Databases
History
In January 2002, SNOMED CT was created by the merger, expansion, and restructuring of the College of American Pathologists (CAP) SNOMED RT (Reference Terminology) and the UK National Health Service (NHS) Clinical Terms (also known as the Read codes).[2] [3] The historical strength of the Systematized Nomenclature of Medicine (SNOMED) was its terminologies for speciality medicine and methods for distributed collaborative development, while the strength of Clinical Terms Version 3 was its terminologies for general practice.[4] By combining these two systems, SNOMED CT is the most comprehensive clinical vocabulary available in any language, covering most aspects of clinical medicine with over 344,000 concepts.[3] SNOMED CT cross maps to such other terminologies as ICD-9-CM, ICD-O3, ICD-10, Laboratory LOINC and OPCS-4. It supports ANSI, DICOM, HL7, and ISO standards.[3] In April 2002, the SNOMED CT Spanish Edition [5] was released, and in April 2003 the SNOMED CT German Edition [6] was released. The National Library of Medicine (NLM), on behalf of the U.S. Department of Health and Human Services, entered into an agreement with College of American Pathologists for a perpetual license for the core SNOMED CT (in Spanish and English) and ongoing updates. The contract provides to NLM a perpetual license [7] to distribute SNOMED within the NLMs Unified Medical Language System [8] UMLS Metathesaurus for no cost use within the U.S. by both U.S. government (federal, state, local, and territorial) and private organizations. The contract also covers updates to SNOMED CT issued by the College of American Pathologists between June 30, 2003 and June 29, 2008. In April 2007, SNOMED CT was acquired by IHTSDO, The International Health Terminology Standards Development Organization.
SNOMED CT
579
References
[1] Ruch, Patrick; Gobeill, Julien; Lovis, Christian; Geissbhler, Antoine (2008). "Automatic medical encoding with SNOMED categories". BMC Medical Informatics and Decision Making 8: S6. doi:10.1186/1472-6947-8-S1-S6. PMC2582793. PMID19007443. [2] http:/ / www. nlm. nih. gov/ research/ umls/ Snomed/ snomed_announcement. html SNOMED CT Announcement [3] SNOMED FAQ (http:/ / www. nlm. nih. gov/ research/ umls/ Snomed/ snomed_faq. html) [4] (http:/ / www. healthdatamanagement. com/ html/ PortalStory. cfm?type=newprod& DID=7841) [5] http:/ / snomed. org/ products/ content/ documents/ April2006FactSheetEspanolEmail. pdf [6] http:/ / www. snomed. org/ about/ global. html [7] http:/ / www. nlm. nih. gov/ research/ umls/ Snomed/ snomed_license. html [8] http:/ / www. nlm. nih. gov/ research/ umls/ Snomed/ snomed_main. html
http://www.corepointhealth.com/sites/default/files/meaningful-use-FAQs.pdf Ruch P, Gobeill J, Lovis C, Geissbuhler A (2008). Automatic medical encoding with SNOMED categories. BMC Medical Informatics and Decision Making. 8 suppl 1, S6. http://www.biomedcentral.com/1472-6947/8/S1/S6 http://northern.assist.org.uk/Documents/2007%20-%202008/0704/SnomedCT.pps What Is SNOMED Clinical Terms" http://www.ihtsdo.org/fileadmin/user_upload/Docs_01/SNOMED_Clinical_Terms_Fundamentals.pdf http://www.healthdatamanagement.com/html/PortalStory.cfm?type=newprod&DID=7841, Health Data Management, February 14, 2002: New Clinical Terminology Available from SNOMED, accessed online July 25, 2006 http://www.ihtsdo.org/snomed-ct/snomed-ct-publications/
Online SNOMED CT Browsers

Listing of SNOMED CT Browser (NHS UK) (http://www.connectingforhealth.nhs.uk/systemsandservices/ data/snomed/browser) Dataline SNOMED Browser: Looks up clinical terms online for free. (http://www.snoflake.co.uk/) Browser at vetmed.vt.edu (http://terminology.vetmed.vt.edu/SCT/menu.cfm) SNOCat: Automatic Medical Encoding from Text with the SNOMED Categorizer (http://eagl.unige.ch/ SNOCat/) SNOCT: Prototype to encode sentences or texts with the Snomed (http://medsight.homeip.net/medsight/ snoct2/)
External links
IHTSDO Web Site - Home of the owners of SNOMED (http://www.ihtsdo.org/) CAP SNOMED Terminology Solutions - the original creators of SNOMED CT (http://www.capsts.org) Online SNOMED CT Browser English and German (http://semfinder-snomed.ch/) CliniClue SNOMED CT Browser (Windows) - freeware download (http://www.cliniclue.com) UMLS-SNOMED FAQs (http://www.nlm.nih.gov/research/umls/Snomed/snomed_faq.html) NHS Connecting for Health UK (http://www.connectingforhealth.nhs.uk/terminology/snomed) SNOB - Desktop SNOMED Browser (Windows/WINE) - freeware download (http://snob.eggbird.eu) SNOMED CT Browser with SNOFLAKE view at dataline.co.uk (http://snomed.dataline.co.uk/) VMIL terminology browser (http://terminology.vetmed.vt.edu/SCT/menu.cfm) SNOCat: the SNOMED Categorizer/Browser (http://eagl.unige.ch/SNOCat/) Minnow SNOMED CT Browser (Windows/Mac OS X/Linux) - freeware download (http://aehrc.com/snapper/ minnow/) Problems with SNOMED (Papers by Barry Smith) (http://ontology.buffalo.edu/medo/SNOMED_Smith.html) Snow Owl - Freeware multiplatform SNOMED CT browser and authoring tool integrating Protg. (http://www. b2international.com/portal/snow-owl)
Standard for Exchange of Non-clinical Data
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Standard for Exchange of Non-clinical Data

The Standard for Exchange of Non-Clinical Data (SEND) is an implementation of the Study Data Tabulation Model SDTM for non-clinical studies. These types of studies are typically related to animal testing as part of pre-clinical (pre-Phase 1) clinical trials. This standard was developed by the Clinical Data Interchange Standards Consortiums (CDISC) SEND Team, which is committed to establishing a standard that can be used for the exchange and submission of non-clinical data collected from animal toxicology studies. The work on this standard began in July 2002subsequently, a U.S. Food and Drug Administration pilot project was initiated in July 2003 through a Cooperative Research and Development Agreement (CRADA). Feedback from this pilot and continuous efforts to more closely align this implementation with the SDTM for human clinical trials led to development of the current version, SEND v2.3, which covers single-dose, repeat-dose, and carcinogenicity studies.
References
http://www.fda.gov/oc/datacouncil/send.html
TC 251
CEN/TC 251 (CEN Technical Committee 251) is a workgroup within the European Union working on standardization in the field of Health Information and Communications Technology (ICT) in the European Union. The goal is to achieve compatibility and interoperability between independent systems and to enable modularity in Electronic Health Record systems. Workgroups establish requirements for health information structure in order to support clinical and administrative procedures, technical methods to support interoperable systems. In addition they establish requirements regarding safety, security and quality.
Workgroups
Information models (WG I) Terminology and knowledge representation (WG II) Security, Safety and Quality (WG III) Technology for Interoperability (WG IV)
External links
CEN/TC 251 [1] CEN/TC 251 - Published standards [2] CEN/TC 251 is a member of the Joint Initiative on SDO Global Health Informatics Standardization [1]
TC 251
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References
[1] http:/ / www. centc251. org/ [2] http:/ / www. cen. eu/ CEN/ Sectors/ TechnicalCommitteesWorkshops/ CENTechnicalCommittees/ Pages/ Standards. aspx?param=6232& title=CEN%2FTC+ 251
WHOART
The WHO Adverse Reactions Terminology (WHOART) is a dictionary meant to serve as a basis for rational coding of adverse reaction terms. The system is maintained by the Uppsala Monitoring Centre (UMC), the World Health Organization Collaborating Centre for International Drug Monitoring.
Structure
32 System-organ classesbody organ groups 180 High level terms for grouping Preferred terms 2085 Preferred terms principal terms for describing adverse reactions 3445 Included terms synonyms to Preferred terms
References
WHO Adverse Reactions Terminology [1]
References
[1] http:/ / www. umc-products. com/ graphics/ 3149. pdf
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Healthcare Ontologies
Nosology
Nosology (from Ancient Greek (nosos), meaning "disease", and - (-logia), meaning "study of-") is a branch of medicine that deals with classification of diseases.
Types of Classification
Diseases may be classified by etiology (cause), pathogenesis (mechanism by which the disease is caused), or by symptom(s). Alternatively, diseases may be classified according to the organ system involved, though this is often complicated since many diseases affect more than one organ. A chief difficulty in nosology is that diseases often cannot be defined and classified clearly, especially when etiology or pathogenesis are unknown. Thus diagnostic terms often only reflect a symptom or set of symptoms (syndrome).
History
One of the earliest efforts at developing a classification of diseases began in the 10th century, when the Arabian psychologist Najab ud-din Unhammad classified a nosology of nine major categories of mental disorders, which included 30 different mental illnesses in total. Some of the categories he described included obsessive-compulsive disorders, delusional disorders, degenerative diseases, involutional melancholia, and states of abnormal excitement.[1] In the 18th century, the taxonomist Carolus Linnaeus, Francois Boissier de Sauvages, and psychiatrist Phillipe Pinel developed an early classification of physical illnesses. Thomas Sydenham's work in the late 17th century might also be considered a nosology. In the 19th century, Emil Kraepelin and then Jacques Bertillon developed their own nosologies. Bertillon's work, classifying causes of death, was a precursor of the modern code system, the International Classification of Diseases. The early nosological efforts grouped diseases by their symptoms, whereas modern systems (e.g. SNOMED) focus on grouping diseases by the anatomy and etiology involved.
Applications
Nosology is used extensively in public health, to allow epidemiological studies of public health issues. Analysis of death certificates requires nosological coding of causes of death. Nosological classifications are used in medical administration, such as filing of health insurance claims, and patient records, among others
References
[1] Millon, Theodore (2004), Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium, John Wiley & Sons, p.38, ISBN9780471469858
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External links
Gordon L. Snider, Nosology for Our Day Its Application to Chronic Obstructive Pulmonary Disease, American Journal of Respiratory and Critical Care Medicine Vol 167. pp.678683, (2003). fulltext (http://ajrccm. atsjournals.org/cgi/content/full/167/5/678) C. S. Herrman, The Bipolar Spectrum, SSRN (Social Science Research Network, 5 August 2010), (http://www. ssrn.com/author=510356) Nosology.net (http://www.nosology.net): An online resource for nosologic diagnostic systems. This site also demonstrates how the proposed system can be used currently in Neurology and Psychiatry (http://www.who.int/whosis/icd10/): International Classification of Diseases by the World Health Organization.
Archetype
In the field of informatics, an archetype is a formal re-usable model of a domain concept. Traditionally, the term archetype is used in psychology to mean an idealized model of a person, personality or behaviour (see Archetype). The usage of the term in informatics is derived from this traditional meaning, but applied to domain modelling instead. An archetype is defined by the OpenEHR Foundation (for health informatics) as follows:[1] An archetype is a computable expression of a domain content model in the form of structured constraint statements, based on some reference model. openEHR archetypes are based on the openEHR reference model. Archetypes are all expressed in the same formalism. In general, they are defined for wide re-use, however, they can be specialized to include local particularities. They can accommodate any number of natural languages and terminologies. The use of archetypes in health informatics was first documented by Thomas Beale, who stated the concept was coined by Derek Renouf. According to Beale, Renouf applied archetypes to configuring Smalltalk systems.[2]
References
[1] S. Heard & T. Beale. (eds.) (2005). "Archetype definitions and principles" (http:/ / www. openehr. org/ svn/ specification/ BRANCHES/ Release-1. 0. 2-candidate/ publishing/ architecture/ am/ archetype_principles. pdf). openEHR. . Retrieved 21 June 2010. [2] Beale, Thomas (2002). "Archetypes: Constraint-based Domain Models for Future-proof Information Systems" (http:/ / www. openehr. org/ publications/ archetypes/ archetypes_beale_oopsla_2002. pdf). Proceedings of the 11th OOPSLA Workshop on Behavioural Semantics. . (PDF)
OBO Foundry
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OBO Foundry
The Open Biomedical Ontologies (OBO) Foundry (now The Open Biological and Biomedical Ontologies (OBO) Foundry) is a collaborative experiment involving developers of science-based ontologies.[1] The foundry is concerned with establishing a set of principles for ontology development with the goal of creating a suite of orthogonal interoperable reference ontologies in the biomedical domain.
Introduction
The value of any kind of data is greatly enhanced when it exists in a form that allows it to be integrated with other data. One approach to integration is through the annotation of multiple bodies of data using common controlled vocabularies. Ideally, such controlled vocabularies take the form of 'ontologies', which means that they are constructed in such a way as to support logical reasoning over the data annotated in their terms. The success of this general approach in helping to tame the explosive proliferation of data in the biomedical domain has led to the development of principles of good practice in ontology development, which are now being put into practice within the framework of the Open Biomedical Ontologies consortium through its OBO Foundry initiative. Existing OBO ontologies, including the Gene Ontology, are undergoing coordinated reform and new ontologies are being created in a coordinated effort to create a family of ontologies designed to be interoperable and logically well formed and to incorporate accurate representations of biological reality. The Open Biological and Biomedical Ontologies [2] (formerly The Open Biomedical Ontologies as well as The Open Biological Ontologies) is an effort to create controlled vocabularies for shared use across different biological and medical domains. As of 2006, OBO ontologies form part of the resources of the National Center for Biomedical Ontology, where they form a central component of the NCBO's BioPortal [3]. The OBO Foundry [4] is a collaborative experiment, involving a group of OBO ontology developers who have agreed in advance to the adoption of a growing set of principles specifying best practices in ontology development. The goal is to develop a set of interoperable humanly validated reference ontologies for all major domains of biomedical research. The project is summarized in this article [5] published in Nature Biotechnology.
Custodians
The custodians of the OBO Foundry are: Michael Ashburner (Cambridge, UK) Suzanna Lewis [6] (Berkeley) Chris Mungall [7] (Berkeley) Alan Ruttenberg [8] (Cambridge, MA) Richard Scheuermann [9] (Dallas) Barry Smith [10] (Buffalo/Saarbrcken)
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Principles
(Version as of 24 April 2006.) 1. The ontology is open and available to be used by all without any constraint other than (1) its origin must be acknowledged and (2) it is not to be altered and subsequently redistributed under the original name or with the same identifiers. 2. The ontology is in, or can be expressed in, a common formal language. (A provisional list of languages supported by OBO is provided at http://obo.sf.net/.) 3. The ontology possesses a unique identifier space within OBO. 4. The ontology provider has procedures for identifying distinct successive versions. 5. The ontology has a clearly specified and clearly delineated content. 6. The ontology includes textual definitions for all terms. 7. The ontology uses relations which are unambiguously defined following the pattern of definitions laid down in the OBO Relation Ontology [11]. 8. The ontology is well documented. 9. The ontology has a plurality of independent users. 10. The ontologies in the OBO Foundry will be developed in a collaborative effort.
Members of the OBO Foundry (March 2010)

The goal of the OBO Foundry initiative is to create an evolving group of biological and biomedical ontologies which will have the potential to cover a wide range of life science phenomena in a modular fashion. To realize this goal, we have subjected a number of candidate ontologies to a process of review, the first phase of which has now been completed, and the results are reported here [12]. The following six ontologies have satisfied the OBO Foundry principles and are recommended as preferred targets for community convergence. CHEBI: Chemical Entities of Biological Interest GO: Gene Ontology PATO: Phenotypic Quality Ontology PRO: Protein Ontology XAO: Xenopus Anatomy Ontology ZFA: Zebrafish Anatomy Ontology
Candidate Members of the OBO Foundry

The following groups of ontologies can be informally distinguished among current OBO Foundry candidate members: Mature Ontologies undergoing reform Cell Ontology (CL) Foundational Model of Anatomy (FMA) Ontology Plant growth and developmental stage Plant structure Sequence Ontology (SO)
Ontologies being built ab initio within the Foundry framework Common Anatomy Reference Ontology (CARO) Environment Ontology (EnvO) Fish Multi-Species Anatomy Ontology (NSF funding received)
OBO Foundry Infectious Disease Ontology (IDO) Malaria Ontology (IDO-MAL) Influenza Ontology Ixodidae and Argasidae (Tick) Anatomy Ontology Mosquito Anatomy Ontology (MAO) Ontology for Biomedical Investigations (OBI) Ontology for General Medical Science RNA Ontology (RnaO) Spider Anatomy Ontology (SPD) Subcellular Anatomy Ontology (SAO) Vaccine Ontology
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Other candidate ontologies Disease Ontology Drosophila Development Drosophila Gross Anatomy Human Phenotype Ontology Mammalian Phenotype Mouse Adult Gross Anatomy Mouse Gross Anatomy and Development Mouse Pathology Systems Biology Ontology Teleost Anatomy and Development Teleost Taxonomy Tick Gross Anatomy
References
[1] Smith, B.; Ashburner, M.; Rosse, C.; Bard, J.; Bug, W.; Ceusters, W.; Goldberg, L. J.; Eilbeck, K. et al. (2007). "The OBO Foundry: Coordinated evolution of ontologies to support biomedical data integration". Nature Biotechnology 25 (11): 12511255. doi:10.1038/nbt1346. PMC2814061. PMID17989687. [2] http:/ / obo. sourceforge. net/ [3] http:/ / www. bioontology. org/ ncbo/ faces/ pages/ ontology_list. xhtml [4] http:/ / obofoundry. org [5] http:/ / www. nature. com/ nbt/ journal/ v25/ n11/ full/ nbt1346. html [6] http:/ / www. fruitfly. org/ [7] http:/ / www. fruitfly. org/ ~cjm/ [8] http:/ / sciencecommons. org/ about/ whoweare/ ruttenberg/ [9] http:/ / pathcuric1. swmed. edu/ Research/ scheuermann. html [10] http:/ / ontology. buffalo. edu/ smith [11] http:/ / genomebiology. com/ 2005/ 6/ 5/ R46 [12] http:/ / www. obofoundry. org/ wiki/ index. php/ Announcement_of_First_Set_of_OBO_Foundry_Ontologies
Ontology for Biomedical Investigations
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Ontology for Biomedical Investigations

The Ontology for Biomedical Investigations (OBI) is an open access, integrated ontology for the description of biological and clinical investigations. OBI provides a model for the design of an investigation, the protocols and instrumentation used, the materials used, the data generated and the type of analysis performed on it. The project is being developed as part of the OBO Foundry and as such adheres to all the principles therein such as orthogonal coverage (i.e. clear delineation from other foundry member ontologies) and the use of a common formal language. In OBI the common formal language used is the Web Ontology Language (OWL). As of March 2008, a pre-release version of the ontology was made available at the project's SVN repository[1]
The OBI Consortium logo.
Scope of the Ontology

The Ontology for Biomedical Investigations (OBI) addresses the need for controlled vocabularies to support integration and joint ("cross-omics") analysis of experimental data, a need originally identified in the transcriptomics domain by the FGED Society, which developed the MGED Ontology as an annotation resource for microarray data.[2] OBI uses the Basic Formal Ontology[3] upper level ontology as a means of describing general entities that do not belong to a specific problem domain. As such, all OBI classes are a subclass of some BFO class. The ontology has the scope of modeling all biomedical investigations and as such contains ontology terms for aspects such as: biological material - for example blood plasma instrument (and parts of an instrument therein) - for example DNA microarray, centrifuge information content - such as an image or a digital information entity such as an electronic medical record design and execution of an investigation (and individual experiments therein) - for example study design, electrophoresis material separaition data transformation (incorporating aspects such as data normalization and data analysis) - for example principal components analysis dimensionality reduction, mean calculation Less 'concrete' aspects such as the role a given entity may play in a particular scenario (for example the role of a chemical compound in an experiment) and the function of an entity (for example the digestive function of the stomach to nutriate the body) are also covered in the ontology.
OBI Consortium
The MGED Ontology was originally identified in the transcriptomics domain by the FGED Society and was developed to address the needs of data integration. Following a mutual decision to collaborate, this effort later became a wider collaboration between groups such as FGED, PSI and MSI in response to the needs of areas such as transcriptomics, proteomics and metabolomics and the FuGO (Functional Genomics Investigation Ontology)[4] was created. This later became the OBI covering the wider scope of all biomedical investigations. As an international, cross-domain initiative, the OBI consortium draws upon a pool of experts from a variety of fields, not limited to biology. The current list of OBI consortium members is available at the OBI consortium
Ontology for Biomedical Investigations website. [5] The consortium is made up of a coordinating committee which is a combination of two subgroups, the Community Representative (those representing a particular biomedical community) and the Core Developers (ontology developers who may or may not be members of any single community). Separate to the coordinating committee is the Developers Working Group which consists of developers within the communities collaborating in the development of OBI at the discretion of current OBI Consortium members.
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References
[1] [2] [3] [4] [5] Ontology for Biomedical Investigations (OBI) | Home (http:/ / purl. obofoundry. org/ obo/ obi/ ) Smith et al. (2007) Nature Biotechnology 25, 1251 - 1255 (2007) Basic Formal Ontology (BFO) | Home (http:/ / www. ifomis. org/ bfo) Whetzel, PL et al. Development of FuGO: an ontology for functional genomics investigations. OMICS 10, 199204 http:/ / obi-ontology. org/ page/ Consortium
External links
The OBI Consortium project homepage http://obi-ontology.org/ The OBI Consortium SVN Repository homepage http://obi.svn.sourceforge.net/viewvc/obi/ The OBI Consortium mailing list homepage http://obi-ontology.org/page/Mailing_lists
Open Biomedical Ontologies

Open Biomedical Ontologies (abbreviated OBO; formerly Open Biological Ontologies) is an effort to create controlled vocabularies for shared use across different biological and medical domains. As of 2006, OBO forms part of the resources of the U.S. National Center for Biomedical Ontology, where it will form a central element of the NCBO's BioPortal.
OBO Foundry
The OBO Ontology library forms the basis of the OBO Foundry[1] , a collaborative experiment involving a group of ontology developers who have agreed in advance to the adoption of a growing set of principles specifying best practices in ontology development. These principles are designed to foster interoperability of ontologies within the broader OBO framework, and also to ensure a gradual improvement of quality and formal rigor in ontologies, in ways designed to meet the increasing needs of data and information integration in the biomedical domain.
Related Projects
Ontology Lookup Service The Ontology Lookup Service [2] is a spin-off of the PRIDE project, which required a centralized query interface for ontology and controlled vocabulary lookup. While many of the ontologies queriable by the OLS are available online, each has its own query interface and output format. The OLS provides a web service interface to query multiple ontologies from a single location with a unified output format. Gene Ontology Consortium The goal of the Gene ontology (GO) consortium is to produce a controlled vocabulary that can be applied to all organisms even as knowledge of gene and protein roles in cells is accumulating and changing. GO provides three structured networks of defined terms to describe gene product attributes. Sequence Ontology
Open Biomedical Ontologies The Sequence Ontology [3] (SO) is a part of the Gene Ontology project and the aim is to develop an ontology suitable for describing biological sequences. It is a joint effort by genome annotation centres, including WormBase, the Berkeley Drosophila Genome Project, FlyBase, the Mouse Genome Informatics group, and the Sanger Institute. Generic Model Organism Databases The Generic Model Organism Project (GMOD) is a joint effort by the model organism system databases WormBase, FlyBase, MGI, SGD, Gramene, Rat Genome Database, EcoCyc, and TAIR to develop reusable components suitable for creating new community databases of biology. Standards and Ontologies for Functional Genomics SOFG [4] is both a meeting and a website; it aims to bring together biologists, bioinformaticians, and computer scientists who are developing and using standards and ontologies with an emphasis on describing high-throughput functional genomics experiments. FGED The Functional Genomics Data (FGED) Society is an international organisation of biologists, computer scientists, and data analysts that aims to facilitate the sharing of microarray data generated by functional genomics experiments. Ontology for Biomedical Investigations The Ontology for Biomedical Investigations (OBI) is an open access, integrated ontology for the description of biological and clinical investigations. OBI provides a model for the design of an investigation, the protocols and instrumentation used, the materials used, the data generated and the type of analysis performed on it. The project is being developed as part of the OBO Foundry and as such adheres to all the principles therein such as orthogonal coverage (i.e. clear delineation from other foundry member ontologies) and the use of a common formal language. In OBI the common formal language used is the Web Ontology Language (OWL). Plant ontology The Plant Ontology Consortium [5] (POC) aims to develop, curate and share structured controlled vocabularies (ontologies) that describe plant structures and growth/developmental stages. Through this effort, the project aims to facilitate cross database querying by fostering consistent use of these vocabularies in the annotation of tissue and/or growth stage specific expression of genes, proteins and phenotypes. Phenoscape Phenoscape [6] is a project to develop a database of phenotype data for species across the Osteriophysi, a large group of Teleost fish. The data is captured using annotations that combine terms from an Anatomy Ontology [7], an accompanying Taxonomic Ontology [8], and quality terms from the PATO ontology of phenotype qualities [9]. Several other OBO ontologies are also used. The anatomy ontology was developed from the zebrafish anatomy ontology developed by the Zebrafish Information Network [10].
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OBO and Semantic Web

OBO & OWL Roundtrip Transformations As a community effort, a standard common mapping has been created for lossless roundtrip transformations between Open Biomedical Ontologies (OBO) format and OWL. The research contains methodical examination of each of the constructs of OBO and a layer cake for OBO, similar to the Semantic Web stack. Project Page [11] Morphster Project
[12]
Open Biomedical Ontologies
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References
[1] Smith, B.; Ashburner, M.; Rosse, C.; Bard, J.; Bug, W.; Ceusters, W.; Goldberg, L. J.; Eilbeck, K. et al. (2007). "The OBO Foundry: Coordinated evolution of ontologies to support biomedical data integration". Nature Biotechnology 25 (11): 12511255. doi:10.1038/nbt1346. PMC2814061. PMID17989687. [2] http:/ / www. ebi. ac. uk/ ontology-lookup/ [3] http:/ / song. sourceforge. net/ [4] http:/ / www. sofg. org/ [5] http:/ / www. plantontology. org/ [6] http:/ / phenoscape. org/ [7] http:/ / bioportal. bioontology. org/ ontologies/ 39892/ [8] http:/ / bioportal. bioontology. org/ ontologies/ 39905/ [9] http:/ / bioportal. bioontology. org/ ontologies/ 39886/ [10] http:/ / www. zfin. org/ [11] http:/ / www. cs. utexas. edu/ ~hamid/ oboowl. html [12] http:/ / www. morphster. org/
External links
Open Biomedical Ontologies (OBO) (http://obofoundry.org) Ontology browser for most of the Open Biological Ontologies at BRENDA website (http://www. brenda-enzymes.info/index.php4?page=ontology/) PubOnto: OBO-based literature search tool (http://brainarray.mbni.med.umich.edu/Brainarray/prototype/ PubOnto/)
TIME-ITEM
TIME-ITEM is an ontology of Topics that describes the content of undergraduate medical education. TIME is an acronym for "Topics for Indexing Medical Education"; ITEM is an acronym for "Index de thmes pour lducation mdicale." Version 1.0 of the taxonomy has been released and the web application that allows users to work with it is still under development. Its developers are seeking more collaborators to expand and validate the taxonomy and to guide future development of the web application.
History
The development of TIME-ITEM began at the University of Ottawa in 2006. It was initially developed to act as a content index for a curriculum map being constructed there. After its initial presentation at the 2006 conference of the Canadian Association for Medical Education [1][2] , early collaborators included the University of British Columbia, McMaster University and Queen's University.
Features
The TIME-ITEM ontology is unique in that it is designed specifically for undergraduate medical education. As such, it includes fewer strictly biomedical entries than other common medical vocabularies (such as MeSH or SNOMED CT) but more entries relating to the medico-social concepts of communication, collaboration, professionalism, etc.[3] Topics within TIME-ITEM are arranged poly-hierarchically, meaning any Topic can have more than one parent. Relationships are established based on the logic that learning about a Topic contributes to the learning of all its parent Topics. In addition to housing the ontology of Topics, the TIME-ITEM web application can house multiple Outcome frameworks. All Outcomes, whether private Outcomes entered by single institutions or publicly available medical education Outcomes (such as CanMeds 2005) are hierarchically linked to one or more Topics in the ontology. In this
TIME-ITEM way, the contribution of each Topic to multiple Outcomes is made explicit.[4] The structure of the XML documents exported from TIME-ITEM (which contain the hierarchy of Outcomes and TIME-ITEM Topics) is being developed alongside the MedBiquitous [5] Competency standards. The taxonomy currently exists in English only but translation to Canadian French is in progress.
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Applications
TIME-ITEM is intended to be a general-use ontology for medical education informatics. It has two primary potential applications: 1. Inclusion in curriculum maps. By mapping learning objects or sessions to TIME-ITEM Topics in a curriculum map, the map becomes searchable for both granular and broad concepts. If one or more Outcome frameworks are included with the Topic ontology, then the contribution of each curricular element to one or more Outcomes is made explicit. This also facilitates curriculum evaluation in terms of one or more outcome frameworks. 2. Indexing learning, assessment and portfolio objects. Metatagging learning objects or assessment objects with a controlled vocabulary enhances the organization and retrieval of objects from a repository. Metatagging electronic portfolio entries allows one to show how multiple entries "add up" to a demonstration of competence with respect to certain educational outcomes. The possibility of expanding or modifying TIME-ITEM for use in postgraduate/continuing medical education and in nursing education is currently being explored.
References
[1] http:/ / www. came-acem. ca/ [2] Willett T & Clarke M. A Map of Medical Concepts: A General-use Database for Applications in Medical Education. AFMC Resource Group on Medical Informatics Reception. At the Canadian Association for Medical Education Conference (May 2006) London, Canada [3] Willett, TG.; Marshall, KC.; Broudo, M.; Clarke, M. (Apr 2008). "It's about TIME: a general-purpose taxonomy of subjects in medical education.". Med Educ 42 (4): 432-8. doi:10.1111/j.1365-2923.2008.03012.x. PMID18298447. [4] Willett TG, Marshall KC, Broudo M & Clarke M. TIME as a generic index for outcome-based medical education. Medical Teacher 2008; 29(7):655-9. [5] http:/ / www. medbiq. org
External links
http://www.time-item.org (Registration required, by application only)
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Associations, Committees and Conferences

American Association for Medical Systems and Informatics
The American Association for Medical Systems and Informatics was an organization created to encourage improvements in the state of medical care by encouraging the development of computer systems for that field. On August 19, 1981, the American Association for Medical Systems and Informatics (AAMSI) was incorporated. This organization came into existence as a result of the efforts of two predecessor organizations, the Society for Computer Medicine (SCM), incorporated in November, 1972, and the Society for Advanced Medical Systems (SAMS), incorporated in November, 1975, to merge into one. Formal dissolution of SCM and SAMS occurred on April 30, 1982. AAMSI's main purpose was to support patient care, teaching, research, and health administration through the development and implementation of computer systems. To meet this goal, the association served as a clearinghouse for information on medical systems and informatics, supported committees which contributed to the advance of medical informatics and sponsored annual conferences on advances in medical information systems.[1] In 1989, AAMSI merged with the Symposium on Computer Applications in Medical Care (SCAMC) and the American College of Medical Informatics (ACMI) to form the American Medical Informatics Association (AMIA) [2] .
Notes
[1] This article uses content from the United States National Library of Medicine, located at http:/ / www. nlm. nih. gov/ . For copyright information, see http:/ / www. nlm. nih. gov/ copyright. html [2] http:/ / www. amia. org/ college/ Retrieved on 2009-03-03.
American College of Medical Informatics
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Abbreviation Formation Type Legalstatus Purpose/focus Headquarters Membership ACMI 1984 (27 year ago NGO NPO Learned society Bethesda, MD 300
Officiallanguages English President Key people Mainorgan Joyce A. Mitchell James J. Cimino, President Elect Inducted Fellows Executive Committee http:/ / www. amia. org/ college
Website
The American College of Medical Informatics,[1] is a college of elected fellows from the United States and abroad who have made significant and sustained contributions to the field of medical informatics. Initially incorporated in 1984, the organization later dissolved its separate corporate status to merge with the American Association for Medical Systems and Informatics (AAMSI) and the Symposium on Computer Applications in Medical Care (SCAMC) when the American Medical Informatics Association (AMIA) was formed in 1989. The College now exists as an elected body of fellows within AMIA, with its own bylaws and regulations that guide the organization, its activities, and its relationship with the parent organization. The College is fiscally self-sufficient, and its officers prepare and submit its financial plan annually for approval by the AMIA Board of Directors.
History
The College was initially created using an election process that assured that the founding fellows would be elected by their peers. Five individuals, Marsden S. Blois, Morris F. Collen, Donald A. B. Lindberg, Thomas E. Piemme, and Edward H. Shortliffe, prepared a ballot of over 100 names of leaders in the field and sent the ballot to all listed individuals. Nominees were asked to vote for 50 colleagues to become the founding fellows, and in this way the initial set of 52 fellows was selected (three individuals were tied for the fiftieth place). The founding fellows then incorporated, elected officers, and initiated a process through which the existing fellows nominate and elect new fellows. The number of people and international associates elected through the years has now reached close the 300 inducted Fellows of the ACMI, with approximately fifteen to twenty new fellows and international associates elected each year. Photographs of people elected through 1993 were published in the inaugural issue of JAMIA, the Journal of the American Medical Informatics Association, in January 1994, and each year's class of newly elected fellows is published in JAMIA.
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References
[1] Web Portal (https:/ / www. amia. org/ college|ACMI)
External links
ACMI homepage (http://www.amia.org/college/)
American Health Information Management Association

The American Health Information Management Association (AHIMA) is a professional organization for the field of medical record management. Traditionally practicing in hospitals and to referring paper files and records, the field presently refers to all healthcare systems and types of media. The organization traces its history back to 1928 when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to "elevate the standards of clinical records in hospitals and other medical institutions." The organization has had three name changes in its history, all were justified with an e xplanation that reflected the progression of contemporary medical record use, practices and perceptions. In 1938 the association became the American Association of Medical Record Librarians (AAMRL). In 1970, the association became the American Medical Record Association (AMRA) and in 1991, the title American Health Information Management Association (AHIMA) was adopted. Incorporation occurred in 1943 and became effective the next year. AHIMA's stated mission is to be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing.
Formation Type Headquarters Location Membership
1928 professional association Chicago, Illinois United States 61,000
Official Language English President Bonnie Cassidy
As of 2011, the association has more than 61,000 members in four membership classifications. Each member subsequently belongs to a relevant state chapter. The association offers seven credentials pertaining to four areas of practice; HIM, Coding, Data Analysis and Privacy. Two credentials require formal education, the others are acquired by a combination of testing and work experience. AHIMA requires members obtain regular continuing education to maintain their credentials. The Journal of AHIMA has a circulation of 61,000 and publishes both peer-reviewed and non-peer-reviewed articles. The association's membership is overwhelmingly female. AHIMA describes its foundation as a sister organization and states the foundation has a charitable and educational nature. The foundation's stated mission is to be the pre-eminent foundation recognized for excellence in health information leadership, policy and research for the healthcare industry and the public. The foundation formulates and issues opinions, supports education, conducts research and compiles its contributions into the Body of Knowledge (BoK).
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References
AHIMA entry - TheFreeDictionary (http://medical-dictionary.thefreedictionary.com/AHIMA)
External links
AHIMA.org is the American Health Information Management Association's official site (http://www.AHIMA. org) WHIMA.org is the Wisconsin Health Information Management Association's official site (http://www.WHIMA. org) TXHIMA.org is the Texas Health Information Management Association's official site (http://www.TXHIMA. org) WSHIMA.org is the Washington State Health Information Management Association's official site (http://www. WSHIMA.org) MNHIMA.org is the Minnesota Health Information Management Association's official site (http://www. MNHIMA.org) WVHIMA.org is the West Virginia Health Information Management Association's official site (http://www. WVHIMA.org)
American Telemedicine Association
596

Location 1100 Connecticut Ave, NW Suite 540, Washington, DC 20036 Website http:/ / www. americantelemed. org
American Telemedicine Association (ATA), established in 1993 as a non-profit organization, ATA goal is to promote access to medical care for consumers and health professionals via telecommunications technology (alternatively referred to as telemedicine, telehealth or eHealth). Membership in ATA is open to individuals, companies and other healthcare and technology organizations. The American Telemedicine Association is the leading resource and advocate promoting access to medical care for consumers and health professionals via telecommunications technology. ATA seeks to bring together diverse groups from traditional medicine, academic medical centers, technology and telecommunications companies, e-health, medical societies, government and others to overcome barriers to the advancement of telemedicine through the professional, ethical and equitable improvement in health care delivery. ATA is governed by a Board of Directors elected by the Association's membership. The Association implements these objectives by: Educating government about telemedicine as an essential component in the delivery of modern medical care. Serving as a clearinghouse for telemedical information and services. Fostering networking and collaboration among interests in medicine and technology. Promoting research and education including the sponsorship of scientific educational meetings and theTelemedicine and e-Health Journal. Spearheading the development of appropriate clinical and industry policies and standards. In accordance with the mission of the organization, ATA provides a broad range of services for its members and the industry as a whole. ATA Annual Meeting - the world's largest scientific meeting and exposition focusing exclusively on telemedicine, with hundreds of presentations, posters and workshops. On-line Member News Updates - direct, exclusive news briefs via email about the latest event and activities affecting telemedicine professionals. ATA Website - a widely-used resource for telemedicine news and information. ATA Online Membership Directory - the single source of who's who in telemedicine. Telemedicine and e-Health - a peer-reviewed publication encompassing all aspects of clinical telemedicine practice; technical advances and enabling technologies; continuing medical education; and the impact of telemedicine on the quality, cost-effectiveness, and access to health care. Special Interest Groups (SIGs), Regional Chapters and Discussion Groups - allow members to address issues related to the advancement and application of telemedicine regarding specific areas including home telehealth, ocular telehealth, technology, teledermatology, telemental health, telenursing, telepathology, and telerehabilitation.
597
References
Choi, Candice (March 13, 2006). "Doctors, Patients Back Telemedicine" [1]. Bangor Daily News. Retrieved September 7, 2010. "Telemedicine growth examined" [2]. Fierce Healthcare. March 12, 2006. Retrieved September 7, 2010. "Tribal Healthcare 2000: Telecommunications and Telemedicine" [3]. The Ojibwe News. June 13, 1997. Retrieved September 7, 2010.
External links
ATA homepage [4] Wiki for telemedicine (ATAwiki) [5]
References
[1] http:/ / news. google. com/ newspapers?id=_AA1AAAAIBAJ& sjid=DU8KAAAAIBAJ& pg=3045,3220792& dq=american-telemedicine-association+ -newswire& hl=en [2] http:/ / www. fiercehealthcare. com/ story/ telemedicine-growth-examined/ 2006-03-13 [3] http:/ / www. highbeam. com/ doc/ 1P1-3985567. html [4] http:/ / www. atmeda. org/ [5] http:/ / www. atawiki. org
Belgian Health Telematics Commission

The Belgian Health Telematics Commission (BHTC) is a Belgian government committee working on standards for exchanging and sharing of health information, between health care participants. The committee provides advice on eHealth to the Belgian government[1] [2] . Professor Georges De Moor is head of the committee. The BHTC consists of several working groups: Data Hospitals Telemedicine Label: homologation of (para)medical software
Georges De Moor, together with Jos Devlies and Geert Thienpont, authored the 2006 eHealth strategy and implementation activities in Belgium report.[3]
References
[1] Belgian Telematics Commission, Recommendations regarding national development of standardized electronic health care messages, Stud Health Technol Inform. 2004;110:112-7 [2] Belgian Telematics Commission, Digital signature and electronic certificates in health care, Stud Health Technol Inform. 2004;110:87-9 [3] eHealth strategy and implementation activities in Belgium (http:/ / www. ehealth-era. org/ database/ documents/ ERA_Reports/ Belgium_eHealth-ERA_country-report_final_30-06-2007. pdf)
Source
Telematics Commission (https://portal.health.fgov.be/portal/page?_pageid=56,4280396&_dad=portal& _schema=PORTAL) Rcommendations (https://portal.health.fgov.be/portal/page?_pageid=56,4280450&_dad=portal& _schema=PORTAL)
Belgian Health Telematics Commission Telematics Standards in relation to the Health Sector (https://portal.health.fgov.be/pls/portal/docs/PAGE/ INTERNET_PG/HOMEPAGE_MENU/GEZONDHEIDZORG1_MENU/AUTOMATISERING1_MENU/ SYMPOSIA1_MENU/AVIS25_MENU/AVIS25_DOCS/A01-UK.PDF) (PDF, advice)
598
Belgian Medical Informatics Association

The Belgian Medical Informatics Association or Belgian Society for Medical Informatics is a Belgian non-profit organization, which was established in 1974, to promote and develop medical information science and technology in Belgium. As a scientific society, the focus of its activities is on improving communication among researchers and developers in the field of medical computing and telematics. Within the organization, the role of medical informatics in society and its ethical aspects are also discussed.
External links
Belgian Medical Informatics Association [1]
References
[1] http:/ / www. bmia. be/
Brazilian Society of Health Informatics

The Sociedade Brasileira de Informtica em Sade (Brazilian Society of Health Informatics in Portuguese, abbreviated as SBIS is a professional society created in November 1986 in Campinas, during the First Brazilian Congress on Health Informatics[1] It has the mission of promoting the development and the interchange of ideas and results in the fields devoted to the information technologies applied to the health sciences (Medical informatics, Telemedicine, Bioinformatics, etc.).
Mission and areas of interest

SBIS is a nonprofit membership organization of individuals and institutions interested in developing and using information technologies to improve health care in Brazil. To accomplish its goal, SBIS may develop the following activities: Stimulate educational activities related to health informatics; Stimulate scientific research and technical development in Health Informatics; Organize conferences, symposiums, courses, seminars, and other activities that lead to experience and knowledge exchange; Cooperate with sister societies; Contribute to the definition of healthcare policies; Promote Health Informatics as a means to reduce costs and improve the quality of healthcare services. Some of SBIS areas of interest are: Health information systems Health information management
Brazilian Society of Health Informatics Electronic patient record Telemedicine and telehealth Medical decision support systems Biological signal processing Medical image processing Internet applications in health Health information standards Health informatics education Distance education in health
599
Currently it has around 780 associates, thus being the third largest in the Americas, after the American Medical Informatics Association and the Canada's Health Informatics Association, and the largest in Latin America, according to the International Medical Informatics Association.[2] The Society is affiliated to the International Medical Informatics Association since 1988.
Governance
The current Executive Board (20082010) is led by Dr. Cludio Giulliano Alves da Costa (President). Former presidents were: Roberto J. Rodrigues, Renato M.E. Sabbatini, Mariza Machado Klck, Beatriz de Faria Leo, Daniel Sigulem, Umberto Tachinardi, Lincoln de Assis Moura Jr. and Heimar de Ftima Marin. Short histories of Health Informatics in Brazil have been published elsewhere[3] [4] by former presidents of the Society.
Conferences and Meetings

SBIS organizes since 1986 a biannual national conference, the Brazilian Congress of Health Informatics and a biannual specialized conference on Electronic Health Records (PEP); besides other, smaller and less periodical meetings. The Brazilian Congress on Health Informatics takes place in different cities every two years and has as its main subjects the applications of information technology and telematics to medicine, nursing, dentistry and allied health care sciences, from the point of view of the expert scientific and technical worker in these areas. The first conference was organized in November 1986, in the city of Campinas by Dr. Renato M.E. Sabbatini. The vice-president was Dr. Hugo Sabatino, and the editor-in-chief of the Conference's proceedings was Dr. Renato G.G. Terzi, all with the Medical School at the same university. During this conference, the Brazilian Society of Health Informatics was launched, as well as the Brazilian Journal of Health Informatics. The conference was then repeated in 1988 (So Paulo), 1990, 1992, 1994, 1996 (Campos do Jordo), 1998, 2000, 2002, 2004 (Natal), 2006 (Florianpolis) and 2008 (Campos do Jordo). The next conference will be held in November 2010, in Porto de Galinhas, Pernambuco.
Publications
SBIS' flagship periodical is the on-line scientific journal, Journal of Health Informatics (Heimar Marin, Editor-in-Chief). It also publishes SBIS News, an electronic bulletin hosted by Yahoo! Groups (Renato M.E. Sabbatini, editor-in-chief), and coordinates the SBIS-L e-mail discussion list.
Electronic Health Record Certification Project

In collaboration with the Brazilian Federal Council of Medicine since 2007, SBIS has developed one of few programs in the developing world geared towards the software certification in the area of electronic health records. The standards for access, information security, digital certification, patient confidentiality, storage of records, etc., have been discussed together and officially approved by a number of decrees enforced by CFM and are part now of a Manual, a course for buildup of a task force of specialized consultants. The certification standards cover ambulatory
Brazilian Society of Health Informatics healthcare, clinical laboratory and other areas, and in the future will be expanded for inpatient health records and Picture archiving and communication system.
600
Professional Education
In 2008 the Society approved the creation of a new initiative and a directorship to boost educational activities in health informatics.[5] [6] A website and a Learning Management System based on Moodle server were created in 2009 (address [7]). The site is used to support presential courses as well as to offer purely distance courses, seminars, lectures, and other educational activities. The site has also a digital library[8] with on-line references to papers, reviews, e-books, multimedia files, etc., which are deemed useful for education and learning purposes. In addition, webconferencing facilities using DimDim have been added and can be used by associated individuals and institutions.
Professional Certificate in Health Informatics

In October 2009 the Society launched a program for certificating health care professionals as specialists, in a manner similar to medical specialties coordinated by the Brazilian Medical Association and the Federal Council of Medicine in Brazil. The program entails a minimum list of technical proficiency, a written and oral annual examination, and the issue of a certificate which is valid for five years. The revalidation of the certificate will be mandatory by means of continuing education credits. The Society installed also an educational accreditation program in place, for recognizing courses and curricula in health informatics, for this purpose, with a point-based system of credits. The entire program is under the responsibility of a new Directorship of Professional Education, coordinated by Prof. Renato M.E. Sabbatini.
Related links
SBIS Home Page [9] Journal of Health Informatics Home Page [10] Distance Education Site [11] Email Discussion Group [12] Electronic news bulletin [13] LinkedIn SBIS Group [14] Orkut community page [15] Facebook community page [16] Twitter page [17]
References
[1] Sabbatini, RME: Associaes de Informtica em Sade. Revista Informdica, 2 (10): 13-14, 1994 (In Portuguese) (http:/ / www. informaticamedica. org. br/ informed/ assoc. htm) [2] International Medical Informatics Association (http:/ / www. imia. org) [3] Marin, H.F. Informtica em Sade no Brasil. 2008 Conference of IMIA-LAC, International Medical Informatics Association Federation for Latin America and the Caribbeam. Published by the Argentinian Association of Medical Informatics, Buenos Aires, Argentina, 2008 (in PDF, in Portuguese) (http:/ / www. aaim. com. ar/ paneles/ PN20-1. pdf) [4] Sabbatini, R.M.E. Histria da Informtica em Sade no Brasil. Revista Informtica Mdica, 1(5), Set/Out 1998. (In Portuguese) (http:/ / www. informaticamedica. org. br/ informaticamedica/ n0105/ sabbatini. htm) [5] Costa, CGA: Retrospectiva 2009 e Planos para 2010 da SBIS, Published December 29, 2009 (http:/ / www. sbis. org. br/ site/ site. dll/ noticia?pagina=1& item=111) [6] Sociedade Brasileira de Informtica em Sade. Diretoria de Educao e Capacitao Profissional. So Paulo, 2009. (http:/ / www. sbis. virtual. org. br/ mod/ resource/ view. php?id=22) [7] http:/ / www. sbis. virtual. org. br [8] Biblioteca Virtual em Informtica em Sade, So Paulo, 2009. (http:/ / www. sbis. virtual. org. br/ mod/ resource/ view. php?id=65)
Brazilian Society of Health Informatics

[9] http:/ / www. sbis. org. br/ [10] http:/ / www. jhi-sbis. saude. ws/ ojs-jhi/ index. php/ jhi-sbis [11] http:/ / www. sbis. virtual. org. br/ index. php [12] http:/ / www. yahoogrupos. com. br/ group/ sbis_l [13] http:/ / www. yahoogrupos. com. br/ group/ SBIS-News [14] http:/ / www. linkedin. com/ groups?gid=74996 [15] http:/ / www. orkut. com. br/ Main#Community?cmm=95093523 [16] http:/ / www. facebook. com/ group. php?gid=160121100777 [17] https:/ / twitter. com/ sbis_brasil
601
Brazilian Congress on Health Informatics

The Sociedade Brasileira de Informtica em Sade (Brazilian Society of Health Informatics in Portuguese, abbreviated as SBIS is a professional society created in November 1986 in Campinas, during the First Brazilian Congress on Health Informatics[1] It has the mission of promoting the development and the interchange of ideas and results in the fields devoted to the information technologies applied to the health sciences (Medical informatics, Telemedicine, Bioinformatics, etc.).
Mission and areas of interest

SBIS is a nonprofit membership organization of individuals and institutions interested in developing and using information technologies to improve health care in Brazil. To accomplish its goal, SBIS may develop the following activities: Stimulate educational activities related to health informatics; Stimulate scientific research and technical development in Health Informatics; Organize conferences, symposiums, courses, seminars, and other activities that lead to experience and knowledge exchange; Cooperate with sister societies; Contribute to the definition of healthcare policies; Promote Health Informatics as a means to reduce costs and improve the quality of healthcare services. Some of SBIS areas of interest are: Health information systems Health information management Electronic patient record Telemedicine and telehealth Medical decision support systems Biological signal processing Medical image processing Internet applications in health Health information standards Health informatics education Distance education in health
Currently it has around 780 associates, thus being the third largest in the Americas, after the American Medical Informatics Association and the Canada's Health Informatics Association, and the largest in Latin America, according to the International Medical Informatics Association.[2] The Society is affiliated to the International
Brazilian Congress on Health Informatics Medical Informatics Association since 1988.
602
Governance
The current Executive Board (20082010) is led by Dr. Cludio Giulliano Alves da Costa (President). Former presidents were: Roberto J. Rodrigues, Renato M.E. Sabbatini, Mariza Machado Klck, Beatriz de Faria Leo, Daniel Sigulem, Umberto Tachinardi, Lincoln de Assis Moura Jr. and Heimar de Ftima Marin. Short histories of Health Informatics in Brazil have been published elsewhere[3] [4] by former presidents of the Society.
Conferences and Meetings

SBIS organizes since 1986 a biannual national conference, the Brazilian Congress of Health Informatics and a biannual specialized conference on Electronic Health Records (PEP); besides other, smaller and less periodical meetings. The Brazilian Congress on Health Informatics takes place in different cities every two years and has as its main subjects the applications of information technology and telematics to medicine, nursing, dentistry and allied health care sciences, from the point of view of the expert scientific and technical worker in these areas. The first conference was organized in November 1986, in the city of Campinas by Dr. Renato M.E. Sabbatini. The vice-president was Dr. Hugo Sabatino, and the editor-in-chief of the Conference's proceedings was Dr. Renato G.G. Terzi, all with the Medical School at the same university. During this conference, the Brazilian Society of Health Informatics was launched, as well as the Brazilian Journal of Health Informatics. The conference was then repeated in 1988 (So Paulo), 1990, 1992, 1994, 1996 (Campos do Jordo), 1998, 2000, 2002, 2004 (Natal), 2006 (Florianpolis) and 2008 (Campos do Jordo). The next conference will be held in November 2010, in Porto de Galinhas, Pernambuco.
Publications
SBIS' flagship periodical is the on-line scientific journal, Journal of Health Informatics (Heimar Marin, Editor-in-Chief). It also publishes SBIS News, an electronic bulletin hosted by Yahoo! Groups (Renato M.E. Sabbatini, editor-in-chief), and coordinates the SBIS-L e-mail discussion list.
Electronic Health Record Certification Project

In collaboration with the Brazilian Federal Council of Medicine since 2007, SBIS has developed one of few programs in the developing world geared towards the software certification in the area of electronic health records. The standards for access, information security, digital certification, patient confidentiality, storage of records, etc., have been discussed together and officially approved by a number of decrees enforced by CFM and are part now of a Manual, a course for buildup of a task force of specialized consultants. The certification standards cover ambulatory healthcare, clinical laboratory and other areas, and in the future will be expanded for inpatient health records and Picture archiving and communication system.
Professional Education
In 2008 the Society approved the creation of a new initiative and a directorship to boost educational activities in health informatics.[5] [6] A website and a Learning Management System based on Moodle server were created in 2009 (address [7]). The site is used to support presential courses as well as to offer purely distance courses, seminars, lectures, and other educational activities. The site has also a digital library[7] with on-line references to papers, reviews, e-books, multimedia files, etc., which are deemed useful for education and learning purposes. In addition, webconferencing facilities using DimDim have been added and can be used by associated individuals and institutions.
Brazilian Congress on Health Informatics
603
Professional Certificate in Health Informatics

In October 2009 the Society launched a program for certificating health care professionals as specialists, in a manner similar to medical specialties coordinated by the Brazilian Medical Association and the Federal Council of Medicine in Brazil. The program entails a minimum list of technical proficiency, a written and oral annual examination, and the issue of a certificate which is valid for five years. The revalidation of the certificate will be mandatory by means of continuing education credits. The Society installed also an educational accreditation program in place, for recognizing courses and curricula in health informatics, for this purpose, with a point-based system of credits. The entire program is under the responsibility of a new Directorship of Professional Education, coordinated by Prof. Renato M.E. Sabbatini.
Related links
SBIS Home Page [9] Journal of Health Informatics Home Page [10] Distance Education Site [11] Email Discussion Group [12] Electronic news bulletin [13] LinkedIn SBIS Group [14] Orkut community page [15] Facebook community page [16] Twitter page [17]
References
[1] Sabbatini, RME: Associaes de Informtica em Sade. Revista Informdica, 2 (10): 13-14, 1994 (In Portuguese) (http:/ / www. informaticamedica. org. br/ informed/ assoc. htm) [2] International Medical Informatics Association (http:/ / www. imia. org) [3] Marin, H.F. Informtica em Sade no Brasil. 2008 Conference of IMIA-LAC, International Medical Informatics Association Federation for Latin America and the Caribbeam. Published by the Argentinian Association of Medical Informatics, Buenos Aires, Argentina, 2008 (in PDF, in Portuguese) (http:/ / www. aaim. com. ar/ paneles/ PN20-1. pdf) [4] Sabbatini, R.M.E. Histria da Informtica em Sade no Brasil. Revista Informtica Mdica, 1(5), Set/Out 1998. (In Portuguese) (http:/ / www. informaticamedica. org. br/ informaticamedica/ n0105/ sabbatini. htm) [5] Costa, CGA: Retrospectiva 2009 e Planos para 2010 da SBIS, Published December 29, 2009 (http:/ / www. sbis. org. br/ site/ site. dll/ noticia?pagina=1& item=111) [6] Sociedade Brasileira de Informtica em Sade. Diretoria de Educao e Capacitao Profissional. So Paulo, 2009. (http:/ / www. sbis. virtual. org. br/ mod/ resource/ view. php?id=22) [7] Biblioteca Virtual em Informtica em Sade, So Paulo, 2009. (http:/ / www. sbis. virtual. org. br/ mod/ resource/ view. php?id=65)
Center for Telehealth and E-Health Law
604
Center for Telehealth and E-Health Law

The Center for Telehealth & E-Health Law (CTeL), established in 1995 by a consortium including the Mayo Foundation, Cleveland Clinic Foundation, Texas Children's Hospital, and the Mid-West Rural Telemedicine Consortium, is a non-profit organization committed to overcoming legal and regulatory barriers to the utilization of telehealth and related e-health services.[1] CTeL, based in Washington, D.C., specializes in compiling, analyzing and disseminating information on legal and regulatory issues information associated with telemedicine. It also handles underlying issues such as licensure and reimbursement. CTeL briefs public policymakers, writes reports, and provides testimony in support of telehealth. In its materials, CTeL argues that expanding the use of telehealth can improve patient safety, reduce medical errors, and increase patient access to primary and specialty care in both rural and urban settings. CTeL offers a variety of services, including involvement in public policy. CTeL activities include: "Telehealth Leadership Conference" - annual conference dedicated solely to telehealth issues and telehealth advocacy. Telehealth Policy Clerkship Program - offered for second and third year law students interested in public policy and legal issues as they apply to advancing communication technologies in the practice of medicine. Washington Live! Brown Bag Lunches in Washington, D.C. monthly seminars on various topics of interest in telehealth and e-health. *The National Telehealth Resource Center (NTRC), one of several telehealth resource centers funded through a grant from the Office for the Advancement of Telehealth at the Health Resources and Services Administration (HRSA) in the Department of Health and Human Services.[2] In 2004, CTeL worked with HRSAs Office for the Advancement of Telehealth (OAT) and the University of Colorado Health Sciences Center to perform an analysis of the use of telehealth in skilled nursing facilities for a report to Congress. This report is titled Multi-State Telehealth Practice and summarizes the current state of physician and nurse licensure issues. Also in 2004, CTeL was recognized by the United States Department of Commerce: [The] progress there has been in resolving such issues can be attributed to a very recent and concentrated effort by such stakeholders as Center for Telemedicine Law, and the Office for the Advancement of Telehealth (OAT), within the Department of Health and Human Services (HHS). Innovation, Demand, & Investment in Telehealth, US Commerce Department, Feb. 2004.
References
[1] Center for Telehealth and e-Health Law (http:/ / www. telehealthlawcenter. org/ content/ ?page=9) [2] HRSA - Telehealth Grantee Directory (http:/ / www. hrsa. gov/ telehealth/ granteedirectory/ overview. htm)
External links
CTeL (http://www.telehealthlawcenter.org/) Office for the Advancement of Telehealth (http://www.hrsa.gov/telehealth//)
Centre for e-Health
605
Centre for e-Health

The Centre for e-Health aims to further the use of telemedicine in Australia and Asia. It is based at the Lions Eye Institute in Perth, Western Australia. The Centre was launched in August 2005 by then-WA Premier Geoff Gallop. The WA Government contributed $2.25 million to the project. Projects in the Centre include: Development of a portable digital imaging device that has teleophthalmology (retinal and anterior segment imaging), teledermatology, teleotolaryngology and teledentistry applications enabling remote diagnosis of disease and disorder. Online visual function testing of eye health. A stereo optic disc analyser, a software tool that analyses stereo images of the retina. The Director of the Centre is Professor Kanagasingam Yogesan.
References
http://www.lei.org.au/go/research/research-groups/centre-for-e-medicine/e-medicine-projects The Australian, Tuesday August 23 2005, page 30
European Federation for Medical Informatics

The European Federation for Medical Informatics (EFMI) is a non-profit organization, which was conceived at a meeting, assisted by the Regional Office for Europe of the World Health Organisation (WHO), in Copenhagen, (Denmark, Europe), in September 1976.
Objectives
The EFMI wants to: advance international co-operation and dissemination of information in Medical Informatics in Europe promote high standards in the application of medical informatics promote research and development in medical informatics encourage high standards in education in medical informatics function as the autonomous European Regional Council of the International Medical Informatics Association (IMIA)
Organizations
Belgian Medical Informatics Association (Belgium)
External links
European Federation for Medical Informatics [1]
References
[1] http:/ / www. efmi. org/
European Health Telematics Association
606

The European Health Telematics Association (EHTEL) is a European non-profit organization, which provides a platform to all European eHealth stakeholders to exchange information on eHealth. Martin Denz of the Swiss Society for Telemedicine and eHealth is the current President of EHTEL.
Vision
EHTELs Vision eHealth is a cooperative process intensifying and changing the interactions of all stakeholders in health and social care for the purpose of improving Continuity of Care and Patient Safety. eHealth is a tool to ensure information, choice and empowerment, as requested by European consumers and patients eHealth must comprise multiple communication channels for ensuring both equal access to services and their ubiquity
Mission
EHTEL: The European eHealth Multidisciplinary Stakeholder Platform Through our growing membership of currently 60 organisations, we enable our members to voice their views throughout the eHealth ecosystem. We also facilitate the sharing of experience with colleagues and representatives across Europe and beyond. At EHTEL, we take an holistic view of eHealth. As such we collaborate closely with European associations representing Hospitals (HOPE and EHMA), health insurers (AIM), Physicians (CPME, UEMS), Pharmacists (PGEU, EAHP), Nurses (EFN), patient and citizens (AGE Platform, European Patients Forum), as well as professional associations dedicated to quality and certification to care processes and eHealth services (ESQH, EuroRec). The multitude of backgrounds and interests of these stakeholders enable EHTEL, as a neutral forum, to draw a more complete picture of the benefits and challenges of the deployment of ICT in the fields of health and social care, thereby also identifying topics requiring particular attention and further developments at European level.
History
EHTEL was founded in 1999 and the organization represents about 100 organisations and individuals from 30 countries in and outside Europe.
Source
Dierks C., Legal and social implications of health telematics in the EU, Stud Health Technol Inform. 2003;96:143-8. Range P., Video communication visions, Health Estate. 2002 Jan;56(1):30-1 Richardson R., eHealth for Europe, Stud Health Technol Inform. 2003;96:151-6 Paving the way to sustainable healthcare: telemedicine takes centre stage [1] EHTEL Telemedicine FAQ [2]
607
External links
EHTEL [3]
References
[1] http:/ / www. ehtel. org/ SHBlob. asp?WCI=ShowD& F=english%2Fdti82507%2Fti135. HITE+ article. pdf [2] http:/ / www. ehtel. org/ SHBlob. asp?WCI=ShowD& F=english%2Fdti82498%2Fti137. EHTEL+ telemedicine+ FAQ+ final. doc [3] http:/ / www. ehtel. org/
European Health Telematics Observatory

The European Health Telematics Observatory (EHTO) is a non-profit organization which collects, analyses and makes available in a user-friendly form information on developments in the field of health telematics. The organization contributes to the deployment of health telematics applications and standards in Europe. EHTO works on the dissemination of results of the European Telematics Applications Programme (TAP) of the Fourth Framework Programme to the European health care sector.
Participants
Portugal: Portugal Telecom Belgium: RAMIT (Research in Advanced Medical Informatics and Telematics) France: CNEH (Centre National de lEquipement Hospitalier) Ireland: IHC Centre for Health Informatics Spain: IETT Ingenieria y Prevencion de Riesgos Greece: BIOTRAST Finland: VTT Information Technology
Source
EHTO [1] (Doc) European Telematics [2]
External links
European Health Telematics Observatory [3]
References
[1] http:/ / www. katelco. kz/ UNESCO/ presentations/ HC/ Thienpont. doc [2] http:/ / cordis. europa. eu/ telematics/ [3] http:/ / www. ehto. org/
European Institute for Health Records
608
European Institute for Health Records

The European Institute for Health Records or EuroRec Institute is a non-profit organization founded in 2002 as part of the ProRec initiative. On 13 May 2003, the institute was established as a non-profit organization under French law. Current President of EuroRec is Prof. Georges De Moor. The institute is involved in the promotion of high quality Electronic Health Record systems in the European Union. One of the main missions of the institute is to support, as the European authorised certification body, EHRs certification development, testing and assessment by defining functional and other criteria. The objectives of the institute are:
EuroRec logo
1. To federate the established ProRec centres that comply with a set of explicit criteria. 2. To develop specifically those activities that cannot be handled at the level of ProRec centres and/or within their scope, according to the principle of subsidiarity and in view of both synergy and economy of scale.
European Projects
Q-REC: European Quality Labelling and Certification of Electronic Health Record systems (EHRs) RIDE: A Roadmap for Interoperability of eHealth Systems in Support of COM 356 with Special Emphasis on Semantic Interoperability EHR-IMPLEMENT: National policies for EHR Implementation in the European area: social and organizational issues
Source
LinksIakovidis I, Purcarea O., eHealth in Europe: from Vision to Reality, Stud Health Technol Inform. 2008;134:163-8 Richardson R., eHealth for Europe, Stud Health Technol Inform. 2003;96:151-6
External links
European Institute for Health Records [1] CEN/TC 125 [1] (European Standardization of Health Informatics) COM (2004) 356 final [2] Directorate H - ICT For Citizens and Businesses [3] (Unit H1 - ICT for Health)
References
[1] http:/ / www. eurorec. org/ [2] http:/ / ec. europa. eu/ information_society/ doc/ qualif/ health/ COM_2004_0356_F_EN_ACTE. pdf [3] http:/ / cordis. europa. eu/ ist/ health/ index. html
Health On the Net Foundation
609

Type Industry Founded
Nonprofit Healthcare September 1995
Headquarters Geneva, Switzerland Products Website Certification, Trusted health search engine and education http:/ / www. healthonnet. org
Health On the Net Foundation (HON) is a not-for-profit organization founded in 1995 under the auspices of the Geneva Ministry of Health and based in Geneva, Switzerland. This came about following the gathering of 60 of the world's foremost experts on telemedicine to discuss the growing concerns over the unequal quality of online health information. The unanimous conclusion of this gathering was to create a permanent body that would, in the words of the program, "promote the effective and reliable use of the new technologies for telemedicine in healthcare around the world." The HON Foundation became one of the first organizations to guide both lay users and medical professionals to reliable sources of health information in cyberspace.
Mission
The mission of the foundation is to guide the growing community of healthcare consumers and providers on the World Wide Web to sound, reliable medical information and expertise. In this way, HON seeks to contribute to improved health care through patient empowerment and better informed health professionals.
Certification
HON Foundation issued a code of conduct (HONcode) [1] for medical and health Web sites to address reliability and usefulness of medical information on the Internet. HONCode is not designed to rate the veracity of the information provided by a Web site. Rather, the code only states that the site holds to the standards, so that readers can know the source and purpose of the medical information presented. The HONcode is voluntary,[2] which means that webmasters and information providers can apply for HONcode certification. Following this, the website is reviewed by a specialized team of health and legal professionals. The HONcode certification is a dynamic state and is extended every year according to site compliance. It is the oldest and the most used ethical and trustworthy code for medical and health related information available on the Internet. The principles of the HONcode are: 1. Authority - information and advice given only by medical professionals with credentials of author/s, or a clear statement if this is not the case
The HONcode Logo
Health On the Net Foundation 2. Complementarity - information and help are to support, not replace, patient-healthcare professional relationships which is the desired means of contact 3. Confidentiality - how the site treats personal and non-personal information of readers 4. Attribution - references to source of information (URL if available online)and dates when pages was last updated 5. Justifiability - any treatment, product or service must be supported by balanced, well-referenced scientific information 6. Transparency of authorship - contact information, preferably including email addresses, of authors should be available 7. Transparency of sponsorship - sources of funding for the site 8. Honesty in advertising and editorial policy - details about advertising on the site and clear distinction between advertised and editorial material Currently the HONcode is used by over 5,000 certified websites, covering 72 countries and has been translated into 34 languages. It is used to sensitize web publishers to the need for quality information and create awareness in health professionals and so, help guide their patients to trustworthy health information. HON offers all users the trustworthy web sites and support groups, medical images and terminology, journal articles and news through its search engines MedHunt [3], HONcodeHunt [4] and HONselect [5]. HON also provides two databases of trustworthy health information, one on eye diseases and the other on general medical conditions. Provisu.ch [6] is a database of reliable health information on all eye diseases and is accessible by those with poor or no vision through its variability of letter size and audio version. Santeromande.ch [7] is an extensive database, mainly directed towards the French speaking public of Switzerland and neighbouring France and provides reliable health information, directory of registered health professionals, medical centers or hospitals, medical associations and federal organizations. Health On the Net Foundation was granted on 23 July 2002 NGO status by the Economic and Social Council of the United Nations. HON also has a partnership at the French governmental level, when it was accredited in 2007 by the French National Authority (HAS) [8] to be the official certifying body for all French health websites.
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Abuse of HONcode
A journal article raised a number of problems with the HONcode logo, indicating that consumers may mistake it as an award or interpret it as an indicator for assessed information. Other issues with the HONcode logo were discussed in the Journal of Medical Internet Research (JMiR), a peer-reviewed eHealth journal.[9] Websites which are not in compliance with HONcode can continue to display the logo, as Health On the Net Foundation (HON) has no means of obligating the offending webmaster to remove the logo. Clicking on that logo (for verification) will not indicate that the site is out of compliance, as HONcode only indicates that sites are "undergoing annual review". Hence, websites which are not in compliance with HONcode may still be displaying the HONcode logo, calling into question the entire principle of HONcode. Other problems with the application of the HONcode principles are that HON does not have a means of verifying many of the principles, such as credentials (medical or otherwise) as stated on websites displaying the logo, or that copyright or confidentiality is not violated by webmasters. HONcode relies on the webmaster for honest representations about compliance with the principles. In recent times however, HON has developed ways to counteract the abuse of the HONcode. One of these is the use of an active and dynamic logo [10] which shows its validity and reflects the site compliance in real time. In addition, all medical credentials are verified through national databases of registered medical professionals. HON has always encouraged the internet community to demand for quality health information and the general public plays a large role in the policing of the HONcode by HON. Consumer protection advocate, Stephen Barrett, is a strong supporter of the HONcode and has made efforts to improve compliance with its rules and to expose those who abuse it. In a whole "Special to The Washington Post", extensive coverage of his views on the subject were provided, including suggested improvements and his criticisms
Health On the Net Foundation of many named abusers.[11] In cases of suspected fraudulent websites, or of abuse of the HONcode, HON advises internet users to alert Quackwatch or HON itself: "If you come across a healthcare Web site that you believe is either possibly or blatantly fraudulent and does NOT display the HONcode, please alert Quackwatch. Of course, if such a site DOES display the HONcode, alert us immediately."[12]
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References
[1] http:/ / www. hon. ch/ HONcode/ Conduct. html [2] Greenberg L, D'Andrea G, Lorence D (June 2004). "Setting the public agenda for online health search: a white paper and action agenda". J. Med. Internet Res. 6 (2): e18. doi:10.2196/jmir.6.2.e18. PMC1550592. PMID15249267. [3] http:/ / www. hon. ch/ MedHunt/ [4] http:/ / www. hon. ch/ HONcode/ Hunt/ [5] http:/ / www. hon. ch/ HONselect/ [6] http:/ / www. provisu. ch/ [7] http:/ / www. santeromande. ch/ [8] http:/ / www. has-sante. fr/ portail/ display. jsp?id=c_453883 [9] JMIR article (http:/ / www. jmir. org/ 2000/ 2/ e13/ ) [10] http:/ / www. hon. ch/ HONcode/ policy. html [11] Christopher Wanjek. Attacking Their HONor: Some Dispute Value of Logo Used to Verify Accuracy, Integrity Of Health Web Site Contents. (http:/ / www. washingtonpost. com/ wp-dyn/ articles/ A25556-2004Apr19. html) Special to The Washington Post, April 20, 2004; Page HE01 [12] "How to be a vigilant user" (http:/ / www. hon. ch/ HONcode/ audience_t. html) Health On the Net Foundation, accessed 8 April 2009.
External links
Health On the Net website (http://www.hon.ch) JMIR article (http://www.jmir.org/2000/2/e13/) Provisu website (http://www.provisu.ch/) Santeromande website (http://www.santeromande.ch/) Presentation of HONcode on French National Authority website (http://www.has-sante.fr/portail/display. jsp?id=c_453883) Policing the HONcode (http://www.hon.ch/HONcode/policy.html) MedHunt (http://www.hon.ch/MedHunt/) HONcodeHunt (http://www.hon.ch/HONcode/Hunt/) HONselect (http://www.hon.ch/HONselect/)
HISA
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HISA
The CEN Standard Architecture for Healthcare Information Systems (ENV 12967), Health Informatics Service Architecture or HISA is a standard aimed at enabling the development modular open systems to support healthcare. The HISA standard builds on the work of RICHE, NUCLEUS, EDITH and HANSA in this field.
Classes of common services

Healthcare-related Common Services (HCS) Generic Common Services (GCS)
Indian Association for Medical Informatics

The Indian Association for Medical Informatics, or IAMI, is a professional society that plays a role in promoting and furthering the application of informatics in the fields of healthcare, bioscience and medicine in India. It was established in 1993.
Goals and objectives

The objectives [1] of the IAMI are to sensitize the Indian medical community to the benefits of Information Technology (IT), bring about awareness and ensure greater utilization of IT in healthcare facilities across the length and breadth of India. The IAMI also aims to provide necessary IAMI logo assistance and guidance to other organizations to implement and reap the benefits of IT for health care. It supports introduction of computer literacy along with medical education, development of computerized as well as medical digital libraries, access to information and creation of databases. IAMI emphasizes on research and development of medical informatics as an independent discipline. It provides various communication and interaction channels among its members by means of e-groups and through publication of a scholarly journal mentioned below.
Affiliation
It is the Indian National Member at IMIA [2]
History
IAMI was registered in September 1993 with its Registered Office being the Department of Clinical Pharmacology, Nizams Institute of Medical Sciences [3], in Hyderabad, India. It has been organising a conference every two years on roles and applications of informatics in medicine, health and allied fields in various states of India. The first biennial conference was held in 1995 at Hyderabad. Second conference was held in 1997 at Indian Institute of Science, Bangalore.
Indian Association for Medical Informatics A major workshop was held in 2001 at NIMS, Hyderabad in lieu of third conference. Third conference of 1999 was postponed due to natural calamities. The fourth conference was held in 2003 at PGIMER[4], Chandigarh. A mid-conference was held in 2004 at the South-Eastern Railways Hospital, Kolkata. Fifth conference was held in 2005 at Sri Guru Ram Das Institute of Medical Sciences in Amritsar. IAMI has conducted many beginners courses for doctors, nurses, paramedical personnel and computer professional class. This enabled the association in enrolling many hospitals, institutes and organizations as Institutional Life Members. It is aiming at making Medical Informatics as one of the elective subjects in the UG curriculum for all medical colleges in India and to get academic credits from the Medical Council of India and other autonomous bodies under the Ministry of Health and Family Welfare (India)[5], Government of India for all the delegates participating in the conferences, seminars and workshops organized by the association. In 2001, it started a discussion group for Medical Informatics. Which has now grown as the de facto information source for medical informatics related activities in India both for its members as well as non-members. Its active members include almost the entire Whos Who of medical informatics scene of India. IAMI got its own web site in 2002. Its Journal "Indian Journal of Medical Informatics" (IJMI, ISSN0973-0397) was started in May 2004 [6].
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Membership
IAMI membership consists of Personal, Institutional and Honorary Members [7]. Many of its key office bearers are part of several Government of India (GOI) initiatives in the areas of telemedicine, especially in the area of development of standards and guidelines for the practice of telemedicine, online medical education and electronic medical records or electronic health records.
Journal
It brings out the scientific journal called Indian Journal of Medical Informatics [8].
Upcoming Conference
The next Biennial Conference [9] of IAMI is scheduled to be held from November 16 - 17, 2007 at the Centre for Digital Health in Amrita Institute of Medical Sciences and Research Centre. [10]
Discussion group
Members of the association have an active discussion group [11] where healthcare IT enthusiasts discuss topics of their interest.Several discussion threads run in parallel. There is also a "Topic of the month" which is the main focus of the discussion.
Indian Association for Medical Informatics
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External links
IAMI [12] List of Mentors in Healthcare Informatics [13] Indian Journal of Medical Informatics (IJMI) [14]
References
[1] http:/ / www. iami. org. in/ objectives. asp [2] http:/ / www. imia. org/ action. lasso?-database=organizations. fp5& -response=member_profile. html& -layout=CGI& -sortField=country& -sortOrder=ascending& -op=bw& type=national& -maxRecords=1& -skipRecords=18& -search [3] http:/ / nims. ap. nic. in/ [4] http:/ / www. pgimer. nic. in/ [5] http:/ / mohfw. nic. in/ [6] http:/ / www. iami. org. in/ history. asp [7] http:/ / www. iami. org. in/ members. asp [8] http:/ / www. medicalinformatics. org. in/ ojs/ index. php/ ijmi/ index [9] http:/ / www. iami. org. in/ kochi2007/ index. asp [10] http:/ / www. imia. org/ search. lasso?-database=imia_meetings. fp5& -layout=Web& -response=coming_events. html& -logicalOperator=and& -sortfield=start_year& -sortorder=ascending& -sortfield=month& -sortorder=ascending& -sortfield=start_day& -sortorder=ascending& -AnyError=error. html& released=Yes& start_month=November& start_year=2007& -search=Go%21 [11] [12] [13] [14] http:/ / groups. google. com/ group/ iami_gen http:/ / www. iami. org. in/ http:/ / www. iami. org. in/ index. php?option=com_content& view=article& id=96& Itemid=185 http:/ / www. ijmi. org/
International Medical Informatics Association

IMIA or the International Medical Informatics Association is an independent organisation that plays a role in promoting and furthering the application of information science in modern society, particularly in the fields of healthcare, bioscience and medicine. It was established in 1967 as a technical committee of the International Federation for Information Processing (IFIP). It became an independent organisation in 1987 and was established under Swiss law in 1989.
Goals and objectives

the promotion of informatics in health care and biomedical research the advancement of international cooperation the stimulation of research, development and education the dissemination and exchange of information
Inherent in this mission is to bring together, from a global perspective, scientists, researchers, vendors, consultants and suppliers in an environment of cooperation and sharing. The international membership network of national member societies, IMIA regions, corporate and academic institutional members, and working and special interest groups, constitute the "IMIA family". IMIA organises various conferences and events around the world and is currently focusing on "bridging the knowledge gap" by facilitating and providing support to developing nations. Specific goals include supporting the ongoing development of the African Region [1].
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Code of Ethics for Health Information Professionals

The International Medical Informatics Association approved the endorsement of the IMIA Code of Ethics for Health Information Professionals at its General Assembly meeting on October 4, 2002 in Taipei. The code is the culmination of several years of a global collaborative effort led by IMIA's working Group on Data Protection in Health Information, Chaired by Professor Ab Baker.
Membership
IMIA membership consists of National, Institutional and Affiliate Members and Honorary Fellows. National Members represent individual countries. A member is a society, a group of societies, or an appropriate body, which is representative of the medical, and health informatics activities within that country. Where no representative societies exist, IMIA accommodates involvement through "Corresponding" members within developing countries.
National member societies

Argentine Association of Medical Informatics [2] Health Informatics Society of Australia Ltd. (HISA) [3] Working Group Medical Informatics (AKMI) of the Austrian Society for Biomedical Engineering GBMT) and of the Austrian Computer Society (OCG) [4] Belgian Medical Informatics Association Society for Medical Informatics of Bosnia and Herzegovina [5] Brazilian Society of Health Informatics British Computer Society Health Informatics Forum [6] COACH: Canada's Health Informatics Association [7] China Medical Informatics Association [8] Croatian Society for Medical Informatics [9] Cuban Society of Medical Informatics [10] Czech Society for Biomedical Engineering and Medical Informatics [11] The Danish Society for Medical Informatics [12] Ethiopian Health Informatics Association Finnish Social and Health Informatics Association (FinnSHIA) [13] French Medical Informatics Association (AIM) [14] German Association for Medical Informatics, Biometry and Epidemiology [15] Greek Health Informatics Association [16] Hong Kong Society of Medical Informatics John von Neumann Computer Society (Hungary) Indian Association for Medical Informatics Iranian Medical Informatics Association [17] Healthcare Informatics Society of Ireland [18] The Israeli Association for Medical informatics [19] Italian Medical Informatics Society (AIIM) [20] Ivorian Society of Biosciences and Health Informatics (ISBHI) [21] Japan Association for Medical Informatics [22] Medical Pharmaceutical Information Association (MedPharmInfo)(Kazakhstan) [23] Korea Society of Medical Informatics (KOSMI) [24] Medical Informatics Association of Malawi (MIAM) [25] Malaysian Health Informatics Association (MHIA) [26]
International Medical Informatics Association The Mali Society of Biomedical and Health Information (SOMBIS) [27] Health Informatics New Zealand [28] Association for Health Informatics of Nigeria (AHIN) [29] Norwegian Society for Medical Informatics [30] Philippine Medical Informatics Society, Inc. [31] Polish Society of Medical Informatics Romanian Society of Medical Informatics [32] The Saudi Association for Health Informatics (SAHI) [33] Association for Medical and Bio-Informatics, Singapore (AMBIS) [34] Slovak Society of Biomedical Engineering and Medical Informatics [35] Slovenian Medical Informatics Association (SIMIA) [36] South African Health Informatics Association [37] Spanish Society of Health Informatics [38] Swedish Federation for Medical Informatics [39] Swiss Society for Medical Informatics [40] Taiwan Association for Medical Informatics (TAMI) [41] VMBI, Society for Healthcare Informatics (Netherlands) [42] Turkish Medical Informatics Association (TURKMIA) [43] The Ukrainian Association for Computer Medicine (UACM) [44] American Medical Informatics Association Uruguayan Society of Health Informatics [45] Venezuelan Association of Computer Science in Health (AVIS) [46]
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Working and special interest groups

The IMIA family includes a growing number of Working and Special Interest Groups, which consist of individuals who share common interests in a particular focal field. The groups hold Working Conferences on leading edge and timely health and medical informatics issues. IMIA Working Groups and Special Interest Groups include: Biomedical Pattern Recognition (WG 07) Biomedical Statistics and Information Processing (WG 12) Consumer Health Informatics (WG2) Dental Informatics (WG 11) Health and Medical Informatics Education (WG1) Health Informatics for Development (WG 09) Health Information Systems (WG 10) Informatics in Genomic Medicine (IGM) Intelligent Data Analysis and Data Mining (WG 03) Medical Concept Representation (WG 06) Mental Health Informatics (WG 08) Open Source Health Informatics Organizational and Social Issues (WG 13) Primary Health Care Informatics (WG 05) Security in Health Information Systems (WG 04) SIG NI Nursing Informatics
Social Media Working Group [47] Standards in Health Care Informatics (WG 16)
International Medical Informatics Association Technology Assessment & Quality Development in Health Informatics (WG 15) Telematics in Health Care (WG 18) Wearable Sensors in Healthcare [48]
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External links
International Medical Informatics Association [49] IMIA Yearbook [50] ACI - Applied Clinical Informatics [51]
References
[1] [2] [3] [4] [5] [6] [7] [8] http:/ / helina. org http:/ / www. aaim. org. ar/ http:/ / www. hisa. org. au/ http:/ / iig. umit. at/ akmi/ akmi. htm http:/ / www. bhsmi. ba/ http:/ / www. bcs. org/ BCS/ Forums/ health http:/ / www. coachorg. com/ http:/ / www. cmia. info/
[9] http:/ / www. snz. hr/ wnew/ csmi. html [10] http:/ / www. socim. sld. cu/ [11] http:/ / www. cls. cz/ [12] http:/ / www. dsmi. dk/ [13] http:/ / www. stty. org/ english. htm [14] http:/ / documvf. crihan. fr/ aim/ [15] http:/ / www. gmds. de/ [16] http:/ / ghia. nurs. uoa. gr/ [17] http:/ / www. irmia. org [18] http:/ / www. hisi. ie/ [19] http:/ / www. ila. org. il/ Index. asp?CategoryID=134& ArticleID=92 [20] http:/ / www. aiim. it/ [21] http:/ / sibim. net/ [22] http:/ / www. jami. jp/ [23] http:/ / www. med. kz [24] http:/ / www. kosmi. org/ [25] http:/ / www. miam. org. mw/ [26] http:/ / www. mhia. org. my/ [27] http:/ / www. somibs. net/ [28] http:/ / www. hinz. org. nz/ [29] http:/ / ahin. wordpress. com/ [30] http:/ / www. fdh. no/ mambo/ index. php [31] http:/ / www. philmedinfo. org/ [32] http:/ / medinfo. umft. ro/ rsmi/ [33] http:/ / www. sahi. org. sa/ [34] http:/ / www. ambis. org. sg/ [35] http:/ / www. sbimi. sk/ index_en. htm [36] http:/ / www. sdmi. si/ [37] http:/ / www. sahia. org. za/ [38] http:/ / www. seis. es/ [39] http:/ / www. sfmi. se/ [40] http:/ / www. sgmi-ssim. ch/ [41] http:/ / www. medinfo. org. tw/ html/ intro_eng. html [42] http:/ / www. vmbi. nl/ [43] http:/ / www. turkmia. org/ [44] http:/ / www. uacm. kharkov. ua/ eng/ index. html [45] http:/ / www. suis. org. uy/

[46] [47] [48] [49] [50] [51] http:/ / www. avis. org. ve/ http:/ / imiasocialmedia. wordpress. com/ http:/ / www. wearable-sensors. org/ http:/ / www. imia. org/ http:/ / imia. schattauer. de http:/ / www. aci-journal. org
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Medinfo
MEDINFO is the name of the international medical informatics conference organized every 3 years by the International Medical Informatics Association. It is the most important international conference in the field with 3000+ health and medical informatics professions attending from all over the world. MEDINFO also serves to bring together all officers of the International Medical Informatics Association (IMIA) Board together with national representatives in the General Assembly of IMIA. The General Assembly elects the officers of IMIA. The IMIA Board consists of the President (the Past or the Elect President), Treasurer and Secretary as its officers. In addition it has other Vice Presidents for targeted areas: Membership, Medinfo, Services, Special Affairs, Strategic Plan Implementation, and Working Groups. With the exception of the President and the Vice President of Medinfo all officers serve a three year term that can be extended for a second three year term. The President is on a 5 year cycle and the Vice President of Medinfo has one 3 year cycle and elected the year before the next Medinfo meeting so that he/she can be mentored through one Medinfo cycle.
MEDINFO conferences
MEDINFO has been held every 3 years since its inception in 1974. The table below gives an overview of these conferences.
Date Number Year Location Organizing Partner Organizing Committee Chair(s) Scientific Program Committee Chair(s) Francois Grmy Editorial Committee
1974
Aug 5-10
Stockholm, Sweden
IFIP World Congress
John Anderson, J. Malcolm Forsythe David B. Shires, Hermann K. Wolf
1977
Aug 8-12
Toronto, Canada IFIP TC-4 Meeting
Werner Schneider
1980
Sep 29-Oct 4
Tokyo, Japan
Masamitsu Oshima Jan Roukens
Morris F. Collen
Donald A. B. Lindberg, Shigekoto Kaihara Jan Hendrik van Bemmel, Marion J. Ball, Ove Wigertz Roger Salamon, Bruce I. Blum, Mogens Jrgensen
1983
Aug 22-27 Amsterdam, The Netherlands
Gwilym S. Lodwick
1986
Oct 26-30
Washington DC, American Medical USA Informatics Association
Donald A. B. Lindberg
Jan van Bemmel, Edward H. Shortliffe
1989
Oct 17-20, Beijing, China Dec 11-15 and Singapore Sep 6-10 Geneva, Switzerland Swiss Society for Medical Informatics [40]
K. C. Lun
Barry Barber, Dexian Cao, Dulie Qin, Gustav Wagner Salah Mandil K. C. Lun, Patrice Degoulet, Thomas E. Piemme, Otto Rienhoff
1992
Jean-Raoul Scherrer
Medinfo
619
1995 July 23-27 Vancouver, Canada Kathryn Hannah Shigekoto Kaihara Robert A. Greenes, Hans E. Petersen, Denis J. Protti
Canada's Health Informatics Association [1] Korean Society of Medical Informatics [24] British Computer Society Health [6] Informatics Forum American Medical Informatics Association Health Informatics [3] Society of Australia
1998
Aug 14-21 Seoul, South Korea
Chang Soon Koh
Charles Safran, Patrice Degoulet
Branko Cesnik, Alexa Thorlichen McCray, Jean-Raoul Scherrer Vimla L. Patel, Ray Rogers, Reinhold Haux, Beatriz de Faria Leo Marius Fieschi, Enrico Coiera, Yu-Chan Jack Li Klaus. A. Kuhn, James R. Warren, Tze-Yun Leong
10
2001
Sep 2-5
London, UK
Jean Roberts
Arie Hasman, Hiroshi Takeda
11
2004
Sep 7-11
San Francisco, USA Brisbane, Australia
Edward H. Shortliffe Evelyn J.S. Hovenga
Mario Stefanelli, Casimir Kulikowski Alexa T. McCray, Heimar de Ftima Marin Riccardo Bellazzi, Johanna Westbrook
11
2007
Aug 2024
12
2010
Sep 13-16
Cape Town, South Africa
South African Health Informatics Association [2]
Lyn Hanmer
Charles Safran, Heimar de Ftima Marin, Shane Reti
Other definitions
Medinfo is also an acronym for Medical Information, often a pharmaceutical information service provided by pharmacovigilance or medical affairs departments.
References
Peterson, H. and Hutter, M., IMIA's publication history. IMIA Yearbook of Medical Informatics 2007. Methods Inf. Med. v46 iSuppl. 1. 192-196. ISBN 978-3-7945-2608-6 Anderson, J., Forsythe, J.M. (Eds.), MEDINFO 74, North-Holland, Amsterdam. ISBN 0444107711 Shires, D.B., Wolf, H. (Eds.), MEDINFO 77, North-Holland, Amsterdam. ISBN 9780720407549 Lindberg, D.A.B., Kaihara, S. (Eds.), MEDINFO 80, North-Holland, Amsterdam. ISBN 0444860290 van Bemmel, J.H., Ball, M.J., Wigertz, O. (Eds.), MEDINFO 83, North-Holland, Amsterdam. ISBN 044486525X Salamon, R., Blum, B.I., Jrgensen, M. (Eds.), MEDINFO 86, North-Holland, Amsterdam. ISBN 0444701109 Barber, B., Cao, D., Qin, D., Wagner, G. (Eds.), MEDINFO 89, North-Holland, Amsterdam. ISBN 0444881387 Lun, K.C., Degoulet, P., Piemme, T.E., Rienhoff, O. (Eds.), MEDINFO 92, North-Holland, Amsterdam. ISBN 978-0444896681 Greenes, R.A., Peterson, H.E., Protti, D.J. (Eds.), MEDINFO 95, North-Holland, Amsterdam. ISBN 978-0969741411 Cesnik, B., McCray, A.T., Scherrer, J.R. (Eds.), MEDINFO 98, IOS Press, Amsterdam. ISBN 978-9051994070 Patel, V., Rogers, R., Haux, R. (Eds.), MEDINFO 01, IOS Press, Amsterdam. ISBN 978-1-58603-194-7 Fieschi, M., Coiera, E., Li, Y.-C. (Eds.), MEDIFNO 04, IOS Press, Amsterdam. ISBN 978-1-58603-444-3 Kuhn, K.A., Warren, J.R., Leong, T.-Y. (Eds.), MEDINFO 2007, IOS Press, Amsterdam. ISBN 978-1-58603-774-1
Medinfo
620
External links
http://www.medinfo2010.org/(Cape Town, South Africa) http://imia.org
References
[1] http:/ / coachorg. com/ [2] http:/ / www. sahia. org. za
National Resource Center for Health Information Technology

In 2004, the Agency for Healthcare Research and Quality of the United States Department of Health and Human Services created the AHRQ National Resource Center for Health Information Technology [1] (the National Resource Center or NRC) to support over 125 federal grants and contracts that are demonstrating the value and implementation of information technology in health care (health information technology). With leadership from the National Opinion Research Center (NORC), the Regenstrief Institute [2], the Vanderbilt Center for Better Health [3], the Center for IT Leadership (CITL) [4] and the eHealth Initiative [5], the NRC monitors and provides technical assistance to federal grants that are implementing technologies such as Electronic health records, Computerized Physician Order Entry, Health information exchange (HIE) and Telemedicine. The NRC directs almost half of its efforts and funding towards monitoring health IT development in rural communities. In addition to its support of federal grants and agencies, the National Resource Center disseminates knowledge and best practices observed by the projects it supports. By way of the NRC's web site, health providers, administrators and researchers share lessons learned for how best to improve health care quality, safety, and efficiency in the United States through successful health IT adoption and usage. The NRC does not provide grant money to individuals or organizations to do research in the fields of health care or health informatics. The NRC does provide, however, free educational resources and events where theory and case examples are presented by researchers active in these fields.
External links
National Resource Center for Health Information Technology [1] Agency for Healthcare Research and Quality (AHRQ) [6] Glossary of Health Care Informatics Terms [7]
References
[1] [2] [3] [4] [5] [6] [7] http:/ / healthit. ahrq. gov http:/ / www. regenstrief. org http:/ / www. mc. vanderbilt. edu/ vcbh/ http:/ / www. citl. org http:/ / www. ehealthinitiative. org http:/ / www. ahrq. gov http:/ / theinformatician. com/ hci-glossary/
Open Source Health Care Alliance
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Open Source Health Care Alliance

The Open Source Health Care Alliance is an international collaboration promoting the development and use of open source software and open access publications in the health care domain. Membership is open to persons worldwide who are interested in furthering the objects of OSHCA and shall consist of anyone who has accepted the premise of OSHCAs Vision, Mission Statements and Principles by indicating such acceptance via OSHCAs Internet Registration [1] process. OSHCA was first formed in 1999 as an informal organization of interested parties. The organization achieved formal non-profit status in Malaysia on 31 October, 2006 under the leadership of Dr. Molly Cheah and a protem committee of industry leaders. The first AGM will be held in 2007 following the OSHCA2007 conference (May 8-11) at the Federal Hotel in Kuala Lumpur, Malaysia.
Mission
OSHCA defines its mission as Promote to policy makers the concept of Free/Open Source Software in Health Care so as to adopt or give equal opportunity to Free/Open Source Solutions. Provide leadership role in refining the Free/Open Source Software Concepts as applied to health care to ensure best practices and patient safety are not compromised. Make recommendations on the development and use of Health information Standards for data interchange and representation formalisms. Provide Guidelines for Quality Control on Free/Open Source Health Care Software development. Participate in and support Human Capacity Building, including contributing/participating in project proposals and project management to achieve developing country priorities. Enable collaboration of members including, sharing technical knowledge in Free/Open Source Health Care Projects and providing information Resources to Free/Open Source Health Care software developers. Promote and help the formation of development consortia for health care related projects, including assisting in finding funding for projects to reach critical mass for a visible and lasting impact on health related Millennium Development Goals (MDGs). Use collaboration with strategic organisations with compatible goals as a means of achieving the mission.
External links
official website [2]
References
[1] http:/ / www. oshca. org/ membership/ [2] http:/ / www. oshca. org
The Continua Health Alliance
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Continua Health Alliance
Industry Founded Headquarters Area served Key people
Trade association June 2006 Beaverton, Oregon, United States Worldwide Clint McClellan (President) Charles Parker (Executive Director) ContinuaAlliance.org [1]
Website
Continua Health Alliance is an international non-profit, open industry group of nearly 240 healthcare providers, communications, medical, and fitness device companies. Continua Health Alliance members aim to develop a system to deliver personal and individual healthcare.
Overview
Continua Health Alliance aims to establish a system of personal connected healthcare solutions. The goal of developing the solutions is to promote delivery of healthcare in the home providing independence, empowering individuals and providing the opportunity for truly personalized health and wellness management.[2] Continua Health Alliance is working toward establishing systems of interoperable telehealth devices and services in three major categories: chronic disease management, aging independently, and health & physical fitness. Continua members intend to create systems and devices for improving personal health. The technology platforms for these products and services are defined by the members and published in the Continua guidelines.
Devices and Services

Continua Health Alliance version 1 design guidelines are based on proven connectivity technical standards and include Bluetooth for wireless and USB for wired device connection. The group released the guidelines to the public in June 2009.[3] The group is establishing a product certification program using its recognizable logo, the Continua Certified Logo program, signifying that the product is interoperable with other Continua-certified products. Products made under Continua Health Alliance guidelines will provide consumers with increased assurance of interoperability between devices, enabling them to more easily share information with caregivers and service providers. Through collaborations with government agencies and other regulatory bodies, Continua works to provide guidelines for the effective management of diverse products and services from a global network of vendors.
The Continua Health Alliance Continua Alliance products make use of the ISO/IEEE 11073 Personal Health Data (PHD) Standards.
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Major milestones and Status Information

Continua Health Alliance was founded on June 6, 2006[4] Continua Health alliance performed its first public demonstration of interoperability on October 27, 2008 at the Partners Center for Connected Health 5th Annual Connected Health Symposium in Boston.[5] Continua Health Alliance certified its first product [6], the Nonin 2500 PalmSAT handheld pulse oximeter with USB, on January 26, 2009.[7] By the end of September 2010 there were fourteen certified products.[8] Continua selected Bluetooth Low Energy and ZigBee wireless protocols as the wireless standards for its Version 2 Design Guidelines which are yet to be released. Bluetooth Low Energy is to be used for low-power mobile devices. ZigBee will be used for networked low-power sensors such as those enabling independent living.[9]
Members
Continua Health Alliance currently has nearly 240 member companies.[10] Continua's Board of Directors is currently composed of the following companies:[11] Intel Corporation Roche Diagnostics Partners HealthCare Price Waterhouse Coopers Ascension Health CA, Inc. Cisco Systems Kaiser Permanente Medtronic Panasonic Philips Qualcomm Samsung Electronics Sharp
Organisational Structure
The Organisation is primarily staffed by volunteers from the member organisations that are organised in to working groups that address the goals of the alliance. Below the board of directors sit the following main working groups:[12] Global Policy Strategy Working Group Marketing Working Group Regulatory Working Group Technical Working Group Test & Certification Work Group - The Test and Certification Working Group is responsible for defining, implementing, and continuously improving the Test and Certification process and tools. Use Case Working Group Wellness Solutions Working Group
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Relevant standards
ISO/IEEE 11073 ISO/IEEE 11073 Personal Health Data (PHD) Standards Bluetooth USB HL7 Integrating the Healthcare Enterprise Zigbee
Website
The Continua Alliance website contains a full listing of member organisations, a directory of qualified products, and a clear statement of their mission.
External links
Continua Health Alliance website [1] American Telemedicine Association [13] MobiHealthNews [14] Telemedicine History [15] Association of Telehealth Service Providers [16]
References
[1] http:/ / www. continuaalliance. org [2] http:/ / www. continuaalliance. org/ about-the-alliance. html [3] http:/ / www. continuaalliance. org/ static/ cms_workspace/ Continua_Version_One_Design_Guidelines_Now_Available_final. pdf [4] http:/ / continuaalliance. org/ news-and-media/ press-releases/ founding-continua. html [5] http:/ / continuaalliance. org/ static/ binary/ cms_workspace/ Continua_Update_release_v_FINAL_2_. pdf [6] http:/ / continuaalliance. org/ certified-products/ nonin-2500-palmsat%C2%AE-pulse-oximeter. html [7] http:/ / www. nonin. com/ News. aspx?NewsID=86 [8] http:/ / www. continuaalliance. org/ products/ certified-products. html [9] http:/ / www. continuaalliance. org/ static/ cms_workspace/ Continua_06082009_vFINAL. pdf [10] Member Companies (English) (http:/ / www. continuaalliance. org/ about-the-alliance/ member-companies. html) [11] Board of Directors (English) (http:/ / www. continuaalliance. org/ about-the-alliance/ board-of-directors. html) [12] http:/ / continuaalliance. org/ static/ cms_workspace/ Continua_Overview_Presentation_v15_3. pdf [13] http:/ / www. americantelemed. org/ i4a/ pages/ index. cfm?pageid=1 [14] http:/ / mobihealthnews. com/ [15] http:/ / www. depts. ttu. edu/ communications/ vistas/ archive/ 02-summer/ stories/ miracle-of-telemedicine. php [16] http:/ / atsp. org/ default. asp
UNESCO Chair in Telemedicine
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UNESCO Chair in Telemedicine

UNESCO Chair of Telemedicine (UNES_CT) was founded in 1999. Undertakes international activities related to the promotion of the information society and fights against technology transfer problems having the role of an intermediate body. The Chair is the first UNESCO Telemedicine Chair [1], and his activity is related with development and diffusion of Telemedicine and Information Society in Health Care in developing areas and undeveloped countries particularly South-America and Africa. The expertise of the UNESCO chair of Telemedicine as a University Institution is based in the previous CATAIs [2] expertise founded in 1994 in the field of Information Society/Telemedicine with which is collaborating closely and from which received part of the sponsorship: Training and teaching aspects, to gain a minimal structured knowledge in Medical Informatics, have established the Telemedicine Body of Knowledge covering sociology, economics, technology transfer, technology and organizational issues, standardization, security and liability aspects in co-operation with the Universities of Queens-UK, Aveiro-PT, Belfast-IRL, Genova-IT, Innsbruck-AU, Udine-IT, Berlin-D, Athens-GR. CATAI published the first text-book of Telemedicine in English, complemented with a CD multimedia material particularly designed for developing countries, world wide known by Winter and Summer Courses of Telemedicine training following the Telemedicine Body of Knowledge". At the present moment the book is translated into 6 languages (SP,E,IT,GR,FR,D) and is published in Spanish (PanAmerican Editorial) with title : Telemedicine 2001. Is participating in all editions of the European Telemedicine Glossary edited by the EC-DG Information Society. In the 4th Ed-2002 is the author of the Electronic Clinical Record. CATAI developed the Videophone network in Canary Islands in 1991 for distant support. At the present it includes the best practice implementation pilots in phone medicine (oncology -particularly home-care- and psychiatry -particularly childhood psychiatry), Tele-ECG and Tele-ultrasounds -particularly obstetrics & gynaecology. Fist in the world (1991) to carry out distant DNA quantitation, it was applied to image analysis prognostic factors in breast cancer. Objective image analysis and prognostic factors have been incorporated into the regional breast cancer registry of 3000 patients (see above); CATAI was the promoter of the Centre of Excellence in Telemedicine, sponsored by Science Park DG-XIII, with enrolment of 3 continents: Europe, Africa and America to concentrate best practice examples as well as top experts to implement real world applications and development of hardware-software systems ready to be used. These activities link mainly technological firms of the UK and Germany. Leader of two EU projects (Leonardo-DG XXII ; Science Park-DGXIII) and participating in other two (DGXIIITeleultrasound for developing countries; Leonardo-DGXXII Teaching Medical informatics). Leader in Canary Islands and in the main land - Barcelona- of a project on Telephonic Medicine. Partner in 5 EU projects ( Smart-USB; KOD or knowledge on demand, ASKLEPIOS, CHS or Citizen Home Services, CATAI-CTC) UNESCO Chair of Telemedicine was involved in developing countries health support through the Midjan group-ITU-D working group of Telemedicine, TeleInViVo ultrasound devices with pilots in Katastan, Mali and Uganda. Promoting the network of Telemedicine together with Argentina, Venezuela, Peru, and participated in ITU-Developing Word Congress in Malta 1997, and Georgia Telemedicine meeting in 1999. Is currently actively working with South-America ( Venezuela, Argentina, Cuba, Chile, Peru) and Africa (Uganda, Kenya) Obtained awards: Economical initiatives, Canary islands 1995; Ordesa award in paediatrics 1989; Award Portugal-Spanish cooperation 1994; Award Royal Academy Medicine 1993 and 1999.
UNESCO Chair in Telemedicine Included in Who is Who in the World since 1996 scheduled up to 2000. Included in the 3rd Ed. of Who is Who in Science and Engineering. the Lattice Price 99 of ESF (European Science Foundation) in Innovation & Research in teaching, nominated by the STOA European Parliament Office.
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External links
UNESCO Chair in Telemedicine - CATAI - University of La Laguna (Spain) [2] UNESCO Education Portal [3] University of La Laguna [4]
References
[1] [2] [3] [4] http:/ / portal. unesco. org/ education/ en/ ev. php-URL_ID=2989& URL_DO=DO_TOPIC& URL_SECTION=-465. html http:/ / www. teide. net/ catai http:/ / portal. unesco. org/ education/ en/ ev. php-URL_ID=48712& URL_DO=DO_TOPIC& URL_SECTION=201. html http:/ / www. ull. es
World Health Imaging, Telemedicine, and Informatics Alliance
627

World Health Imaging, Telemedicine and Informatics Alliance
Founder(s) Type Founded Location
Mike Hoaglin, Dave Kelso, Matt Glucksberg, Michael Diamond 501(c)(3) Non-profit Organization Chicago, IL, US Chicago, Illinois United States Newton N. Minow, Chair of the Board [2] Michael W. Ferro, Jr., Vice Chair Ivy Walker, CEO [3]
[1]
Key people
Area served Worldwide Focus Motto Website Low-cost medical imaging, X-ray, Health Information technology, sustainability One digital image can save a life worldhealthimaging.org [4]
The World Health Imaging, Telemedicine and Informatics Alliance (WHITIA) is a non-profit global health technology and social venture established in 2006 by affiliates of Northwestern University near Chicago, Illinois.[1] [5] WHITIA cultivates high-level strategic relationships with non-governmental organizations, imaging industry innovators and academic institutions in order to integrate and deliver meaningful, sustainable, diagnostic technology to underserved communities worldwide. WHITIAs vision is to facilitate the deployment of thousands of digital medical imaging systems worldwide, providing one billion people with access to diagnostic imaging.[6] WHITIA was formerly known as the World Health Imaging Alliance (WHIA) until it formally expanded its scope in June 2009. WHITIA's first formal public launch was in April 2009 at the Healthcare Information and Management Systems Society (HIMSS) Annual Conference & Exhibition in Chicago, Illinois. WHITIA announced strategic partners including SEDECAL, Carestream Health and Merge Healthcare, receiving extensive coverage in Health IT magazines and publications.[7] [8] At the 2009 Annual Conference of the Society for Imaging Informatics in Medicine (SIIM) in Charlotte, North Carolina, WHITIA announced its partnership with SIIM, which will allow both organizations to collaborate on specific initiatives.[9] [10] WHITIA was recently ranked #15 of the top 25 most influential people, institutions, and organizations in the radiology industry.[11] At the 2009 RSNA Annual Meeting, WHITIA launched, Remi-d, a remote-operated screening X-ray system for use in the developing world. Its strengths in these areas stem from the higher burden of Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) co-infection, high incidences of Black Lung disease, or outbreaks of other infectious respiratory diseases. The teleradiology and remote-controlled features of Remi-d allow resource-limited areas such
World Health Imaging, Telemedicine, and Informatics Alliance as sub-Saharan Africa, South and Central America and Southeast Asia, where radiologists and technologists are in short supply to have a functioning X-ray service.[12] WHITIA currently has pilot integrated digital X-ray sites in South Africa and Guatemala at established clinics in need and is expanding to new qualified sites in partnership with NGOs such as Rotary International while cooperating with the local and national governments.[13]
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Guatemala clinics
The Guatemala pilot sites in urban Guatemala City and rural Ro Hondo provide essential healthcare technology to thousands of people in the communities served. They are designed to be models for the wider expansion of the WHITIA network throughout the clinics in need in urban and rural Guatemala. The system's specific design for Guatemala City is an integration of some of WHITIA's partners' strengths and generosity: SEDECAL provides the X-ray generator and controls Carestream Health donates the computed radiography (CR) digital scanner and plates Kane X-ray donates personnel to perform installation and set up of the CR and PACS This project was largely funded by several US and Guatemalan Rotary clubs along with the key resource support of the Guatemalan municipal and national governments.[14]
References
[1] "McCormick students and faculty tackle health care challenge in the developing world" (http:/ / magazine. mccormick. northwestern. edu/ FA2007/ Xray. html). Robert R. McCormick School of Engineering and Applied Science, Northwestern University. . Retrieved 2009-07-02. [2] "Board of Directors" (http:/ / www. worldhealthimaging. org/ board. html). . Retrieved 2009-07-02. [3] "Personnel" (http:/ / www. worldhealthimaging. org/ personnel. html). . Retrieved 2009-07-02. [4] http:/ / www. worldhealthimaging. org [5] "World Health Imaging Alliance Partners For X-Rays in Developing World" (http:/ / www. mccormick. northwestern. edu/ news/ articles/ 494). McCormick School of Engineering. . Retrieved 2009-07-04. [6] http:/ / www. worldhealthimaging. org/ [7] "Not-for-Profit Has a Vision to Help a Billion People" (http:/ / www. reuters. com/ article/ pressRelease/ idUS111037+ 06-Apr-2009+ BW20090406). Reuters. 2009-04-06. . Retrieved 2009-07-02. [8] "World Health Imaging Alliance Poised to Bring Imaging Diagnostics and Data to the Developing World" (http:/ / finance. yahoo. com/ news/ Merge-Healthcare-Commits-1-bw-14855801. html?x=1& . v=1). Yahoo Finance. . Retrieved 2009-07-02. [9] "World Health Imaging Alliance (WHIA) Announces Support From The Society for Imaging Informatics in Medicine (SIIM)" (http:/ / www. businesswire. com/ news/ home/ 20090605005136/ en). Business Wire. . Retrieved 2009-07-02. [10] "World Health Imaging Alliance poised to bring imaging diagnostics and data to the developing world" (http:/ / www. imagingeconomics. com/ news/ 2009-06-17_01. asp). Imaging Economics. . Retrieved 2009-07-02. [11] "25 Most Influential in Radiology" (http:/ / www. rt-image. com/ 25_Most_Influential_in_Radiology_Recognizing_the_movers_and_shakers_in_the_radio/ content=9004J05E48B6A084409698724488B0441). rt Image. . Retrieved 2009-10-22. [12] "WHITIA launches digital medical X-ray device for screening infectious diseases in developing countries" (http:/ / www. news-medical. net/ news/ 20091130/ WHITIA-launches-digital-medical-X-ray-device-for-screening-infectious-diseases-in-developing-countries. aspx). THE MEDICAL NEWS. . Retrieved 2009-12-01. [13] "SIIM to Support World Health Imaging Alliance" (http:/ / www. healthtechwire. com/ The-Industry-s-News-unb. 146+ M5a262949a06. 0. html). HealthTech Wire. . Retrieved 2009-07-02. [14] "WHITIA Announces the Completion of Digital X-ray Pilot Sites in Urban and Rural Guatemala" (http:/ / www. businesswire. com/ news/ home/ 20110104006502/ en/ WHITIA-Announces-Completion-Digital-X-ray-Pilot-Sites). Business Wire. . Retrieved 2011-01-09.
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External links
Official webpage (http://www.worldhealthimaging.org/) Video interview with WHITIA staff and overview of mission. Shown at Rotary International Convention 2008 (http://www.youtube.com/watch?v=sv0q0hD-flM) (http://www.medicalnewstoday.com/articles/145456.php) (http://www.healthtechwire.com/The-Industry-s-News-unb.146+M5a262949a06.0.html) (http://www.dotmed.com/news/story/8681/) (http://www.cnbc.com/id/31121000/) (http://www.tradingmarkets.com/.site/news/Stock News/2362104/) (http://www.smartbrief.com/news/aaaa/industryBW-detail. jsp?id=CCB30F65-E324-4325-8B5C-15C061C926F1) (http://www.newsrx.com/article.php?articleID=1554620) WHITIA Announces the Completion of Digital X-ray Pilot Sites in Urban and Rural Guatemala Press Release (http://www.worldhealthimaging.org/WHITIA Guatemala_01-04-2011press_release.pdf)
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Publications
List of medical and health informatics journals
This is a list of journals related to medical and health informatics. ACIMED BMC Medical Informatics and Decision Making Computers in Biology and Medicine Journal of the American Medical Informatics Association Journal of Biomedical Informatics Journal of Medical Internet Research Medical & Biological Engineering & Computing Methods of Information in Medicine Statistics in Medicine
Journal of Information Professionals in Health
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Journal of Information Professionals in Health

ACIMED
Discipline Language Edited by Medicine Spanish Jehov Oramas Daz Publication details Publisher Centro Nacional de Informacin de Ciencias Mdicas (Cuba)
Publication history 1993present Open access Yes Indexing ISSN [1] 1024-9435 (print) [2] 1561-2880 (web) Links Journal homepage [3]
ACIMED (Journal of Information Professionals in Health) is a Spanish language journal of medical informatics published by the National Center of Information on Medical Sciences in Cuba. It was first published in 1993 and is the first Spanish language journal to be published on the subject of medical informatics.
References
[1] http:/ / www. worldcat. org/ issn/ 1024-9435 [2] http:/ / www. worldcat. org/ issn/ 1561-2880 [3] http:/ / scielo. sld. cu/ scielo. php?script=sci_serial& pid=1024-9435& lng=en& nrm=iso
Journal of Medical Internet Research
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Abbreviated title (ISO) J. Med. Internet Res. Discipline Language Edited by Medicine, eHealth English Gunther Eysenbach Publication details Publisher Publication history Frequency Open access Impact factor (2010) Gunther Eysenbach 1999-present Quarterly Yes 4.663
Indexing ISSN LCCN OCLC number 1438-8871 00252482 42705591 Links Journal homepage [4] [1]
[2] [3]
The Journal of Medical Internet Research is a peer-reviewed open-access medical journal established in 1999 covering eHealth and "healthcare in the Internet age". It is edited and published by Gunther Eysenbach. The journal is widely regarded as one of the pioneers in open access publishing.[5] [6] According to the Journal Citation Reports, the journal has a 2010 impact factor of 4.663, ranking it first out of 22 in the category "Medical Informatics" and 2nd among 71 journals in the category "Health Care Sciences & Services".[7]
References
[1] [2] [3] [4] [5] http:/ / www. worldcat. org/ issn/ 1438-8871 http:/ / lccn. loc. gov/ 00252482 http:/ / www. worldcat. org/ oclc/ 42705591 http:/ / www. jmir. org Kuo, Jennifer (March/April 2004). "Set My Research Free" (http:/ / www. foreignpolicy. com/ story/ cms. php?story_id=2520). Foreign Policy (Washington, D.C.: Carnegie Endowment for International Peace). . Retrieved 2008-04-21. [6] Harriman, Joy HP (1 October 2004). "Journal of Medical Internet Research (JMIR)". Journal of the Medical Library Association (Chicago: Medical Library Association) 94 (4): 5101. ISSN1536-5050. OCLC98058442. PMC521530. [7] "Web of Science" (http:/ / isiwebofknowledge. com). 2011. . Retrieved 2011-06-30.
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External links
Official website (http://www.jmir.org)
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National Projects
BeHealth
BeHealth is a Belgian eHealth digital platform which provides digital access to all health information and applications through one portal site, on behalf of both healthcare providers and patients. BeHealth has been created on 23 December 2004. It first aim is to interconnect multiple applications from a number of social security actors, but with the goal to provide broader services over time.
Source
BeHealth [1] (Dutch) BeHealth [2] (French)
External links
e-Health [3]
References
[1] http:/ / www. residencepalace. be/ archive/ 20040720/ 104944/ ?lang=nl [2] http:/ / www. belgium. be/ eportal/ application?languageParameter=fr& pageid=contentPage& docId=35693 [3] https:/ / www. ehealth. fgov. be/
Canada Health Infoway
635

Canada Health Infoway is an independent, federally-funded, not-for-profit organization tasked with accelerating the development of electronic health records (EHR) across Canada. As a strategic investor, they work with Canadian provinces and territories with the goal of creating an electronic health record for 50% of Canadians by the end of 2010. Infoways members are Canada's 14 federal, provincial and territorial Deputy Ministers of Health. Infoway's investments are prioritized toward local, provincial and national projects which align with the Pan-Canadian EHR Blueprint, itself developed by Infoway. Beyond these strategic investments, Infoway has no mandate to enforce compliance, as Canadian healthcare is generally governed at the Provincial level. Development of a network of effective interoperable electronic health record solutions across Canada linking clinics, hospitals, pharmacies and other points of care is intended to improve access to health care services for Canadians, enhance their quality of care and make the health care system more efficient.
Projects
Since 2001, Infoway has approved projects [1] in the following targeted program areas: Diagnostic Imaging Systems [2] Drug Information Systems [3] Infostructure [4] Innovation and Adoption [5] Interoperable EHR [6] Laboratory Information Systems [7] Patient Access to Quality Care [8] Public Health Surveillance [9] Registries [10] Telehealth [11]
Goals
The goal of Canada Health Infoway is to contribute to the development of a network of EHR systems, in order to enable efficient communication between health care professionals and bringing a deeper understanding of patient needs. The results of the project may include shorter medical procedure wait times, safer prescriptions and better access to quality health care, and may dramatically improve health care for Canadians. Infoway has also recently developed a pan-Canadian electronic health information standard, leveraging the existing HL7v3 standards. It is reported that as of December 31, 2008 there were 276 EHR projects under way in Canadian hospitals, other health-care facilities, pharmacies and laboratories, with an investment value of $1.5-billion from Canada Health Infoway.[12]
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Notes
[1] http:/ / www. infoway-inforoute. ca/ lang-en/ about-ehr/ ehr-progress-map [2] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ diagnostic-imaging-systems [3] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ drug-information-systems [4] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ infostructure [5] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ innovation-and-adoption [6] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ interoperable-ehr [7] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ laboratory-information-systems [8] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ patient-access-to-quality-care [9] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ public-health-surveillance [10] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ registries [11] http:/ / www. infoway-inforoute. ca/ lang-en/ about-infoway/ approach/ investment-programs/ telehealth [12] http:/ / www. theglobeandmail. com/ servlet/ story/ RTGAM. 20080218. wmychart18/ BNStory/ specialScienceandHealth/
External links
Canada Health Infoway (http://www.infoway-inforoute.ca/)
Distance Learning and Telemedicine Grant and Loan Program

The Distance Learning and Telemedicine Grant and Loan Program (DLT) is a program authorized by the 1990 farm bill (P.L. 101-624) to provide grants to rural schools and health care providers to help them invest in telecommunications facilities and equipment to bring educational and medical resources to rural areas where the services otherwise might be unavailable. The 1996 farm bill (P.L. 104-127) reauthorized and streamlined the program. The program was also reauthorized in the 2002 farm bill (P.L. 107-171, Sec. 6203). DLT is administered by the Rural Utilities Service.
References
This article incorporates public domain material from the Congressional Research Service document "Report for Congress: Agriculture: A Glossary of Terms, Programs, and Laws, 2005 Edition" [1] by Jasper Womach.
External links
[www.rurdev.usda.gov/rus Rural utilities service].
References
[1] http:/ / ncseonline. org/ nle/ crsreports/ 05jun/ 97-905. pdf
eHealth Ontario
637
eHealth Ontario
eHealth Ontario is the agency tasked with facilitating the development of Ontario's proposed public Electronic Health Record system. Health Informatics in Canada is run provincially, with different provinces creating different systems, albeit sometimes under voluntary Pan-Canadian guidelines published by the federal body Canada Health Infoway. eHealth Ontario was created in September 2008 out of a merger between the Ontario Ministry of Health's electronic health program and the Smart Systems for Health Agency (SSHA), with a mandate to create electronic health records for all patients in the province by 2015. It has been plagued by delays and its CEO was fired over a multimillion-dollar contracts scandal in 2009.[1] eHealth employs approximately 700 people[2]
Media Attention
In May 2009, there were opposition calls for Ontario's Health Minister David Caplan's resignation after it was revealed that eHealth Ontario CEO Sarah Kramer had approved about $4.8 million in no-bid contracts during the first four months of the agency's operation, while also spending $50,000 to refurnish her office, and paying consultants up to $300 an hour.[3] One consultant earned about $192,000 in five months. [4] As, well, nine senior eHealth employees had been fired in a four month period, some reportedly for challenging the agency's tendering practices.[5] Kramer was later forced to resign in June of 2009, amid questions surrounding a $114,000 bonus paid to her. She received a $317,000 severance package with benefits for 10 months.[6] eHealth Ontario argued that the no-bid contracts were necessary due to the rapid transition process to eHealth from its predecessor Smart Systems for Health Agency, while Caplan defended Kramer's bonus as part of her move from another agency. The opposition argued that the government of Premier Dalton McGuinty spent five years and $647 million on the forerunner of eHealth Ontario: the Smart Systems for Health Agency, which used 15 per cent of its $225-million annual budget on consultants despite employing 166 people with annual salaries exceeding $100,000, before the project was shut down and restarted as eHealth Ontario. In a public statement, Kramer argued that when she took over as CEO of eHealth Ontario, she was charged with turning around a failing behemoth - SSHA - which had already run through more than $600 million dollars with hardly anything to show for it in terms of moving Ontario closer to the goal of eHealth, and modernizing and improving the quality and safety of health care for Ontarians.[7] Journalists have argued that Sarah Kramer received a trial by media and that the province of Ontario will be at a loss with her departure, as delivery of eHealth initiatives will be slowed. Marcus Gee from the Globe and Mail writes, what happened at eHealth may or may not qualify as scandalous. What happened to Ms. Kramer certainly does. This was media lynching. A good woman and a first-rate civil servant has been hounded from public life, and all of us will suffer for it.[8] Journalists and former health policy advisors have noted that this media attention detracted from the organizations mandate and ability to deliver on much needed eHealth initiatives and healthcare reform in the province of Ontario. One past policy director for a former Ontario Minister of Health, argued that the publics focus should be on holding the government accountable for mitigating the problems that have resulted and demanding progress on eHealth.[9] Andre Picard, a Canadian public health reporter, argued that the publics focus should be on the delivery of electronic health records and not disingenuous tsk-tsking about the hiring of consultants. He writes, the true scandal in Ontario is the utter failure of the Ministry of Health to create electronic health records, which will ultimately lead to better and more efficient patient care.[10] Picard argued that Ministry of Health bureaucrats are powerless when it comes to making real change in healthcare, as their political bosss only vision for healthcare is not irritating the public so they can be re-elected. The result is change and innovation can, seemingly, only come
eHealth Ontario from independent agencies or outside consultants.[11] Two inquiries were launched, but in August 2009, the independent review of eHealth Ontario had been dropped, with Caplan saying it would duplicate the work of Ontario's auditor general.[12] On October 6, 2009, David Caplan resigned, one day before the release of the report into spending scandals.[13]
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References
[1] "Head of eHealth Ontario is fired amid contracts scandal, gets big package" (http:/ / www. cbc. ca/ canada/ story/ 2009/ 06/ 07/ ehealth-kramer. html). CBC News. 2009-06-07. . Retrieved 2009-08-26. [2] "eHealthStrategy" (http:/ / www. ehealthontario. on. ca/ pdfs/ About/ eHealthStrategy. pdf). . Retrieved 2009-08-26.. [3] "ehealth-mcguinty-review" (http:/ / www. cbc. ca/ canada/ ottawa/ story/ 2009/ 05/ 28/ ehealth-mcguinty-review028. html). CBC News. 2009-05-28. . Retrieved 2009-08-26. [4] "Another untendered contract surfaces at embattled eHealth Ontario" (http:/ / www. cbc. ca/ canada/ story/ 2009/ 06/ 03/ ehealth-ontario-untendered-contracts. html). CBC News. 2009-06-04. . Retrieved 2009-08-26. [5] "Opposition wants minister's resignation over eHealth spending" (http:/ / www. cbc. ca/ canada/ toronto/ story/ 2009/ 05/ 28/ ehealth-mcguinty-review028. html). CBC News. 2009-05-28. . Retrieved 2010-09-06. [6] Talaga, Tanya (2009-06-11). "eHealth scandal reaches Premier's inner circle" (http:/ / www. thestar. com/ news/ ontario/ article/ 649032). The Star (Toronto). . Retrieved 2009-08-26. [7] "Statement by Sarah Kramer (CNW)" (http:/ / www. newswire. ca/ en/ releases/ archive/ August2009/ 13/ c4908. html). . Retrieved 2009-08-27. [8] "Scandal or not, there's no justice in Sarah Kramer's trial by media" (http:/ / v1. theglobeandmail. com/ servlet/ story/ LAC. 20090611. GEE11ART2252/ TPStory/ TPComment/ ). The Globe and Mail (Toronto). . Retrieved 2009-08-27. [9] "Critics' scrutiny of eHealth needs new focus" (http:/ / www. theobserver. ca/ ArticleDisplay. aspx?archive=true& e=1706107). . Retrieved 2009-08-27. [10] Picard, Andre (2009-06-24). "The real eHealth Ontario scandal isn't over Choco Bites" (http:/ / www. theglobeandmail. com/ life/ health/ the-real-ehealth-ontario-scandal-isnt-over-choco-bites/ article1195611/ ). The Globe and Mail (Toronto). . Retrieved 2009-08-27. [11] Picard, Andre (2009-06-24). "The real eHealth Ontario scandal isn't over Choco Bites" (http:/ / www. theglobeandmail. com/ life/ health/ the-real-ehealth-ontario-scandal-isnt-over-choco-bites/ article1195611/ ). The Globe and Mail (Toronto). . Retrieved 2009-08-27. [12] Leslie, Keith (2009-07-22). "McGuinty quietly drops eHealth review" (http:/ / www. theglobeandmail. com/ news/ politics/ mcguinty-quietly-drops-ehealth-review/ article1227640/ ). The Globe and Mail (Toronto). . Retrieved 2009-08-26. [13] "Ontario health minister resigns" (http:/ / www. cbc. ca/ canada/ toronto/ story/ 2009/ 10/ 06/ caplan-health-minister-resign641. html). CBC News. 2009-10-07. . Retrieved 2009-10-06.
HealthConnect
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HealthConnect
HealthConnect has been Australias change management strategy to transition from paper-based and legacy digital health records towards electronic health records planned system of electronic health records.[1] The long term goal of the HealthConnect strategy is to deliver better health outcomes through standardised, sharable clinical information.[1] The "better health outcomes" would translate to improved quality and safety in health care and disease prevention. These would be achieved by ensuring important clinical information is available and of high quality, when and where it is needed.[2] Trials were carried out as part of the HealthConnect strategy in various parts of Australia during 2004. These included an EHR pilot in Brisbane South and a surgical patient information sharing trial at Townsville Hospital. In 2005 trials were conducted in Tasmania at the Launceston General Hospital and across the Northern Territory.[3] Defunct research consortium Distributed Systems Technology Centre (DSTC) was awarded a A$2.9 million contract to develop technology for HealthConnect. After the first round of trials the vision for HeathConnect was greatly altered. In 2007 a second phase of testing began. The NT Health Connect Trial was largely successful and is "the most advanced eHealth implementations of their kind in Australia in terms of range of services, service coverage and consumer and health professional participation", according to their website. The project was upgraded and re-name "Shared Electronic Health Record". A 2008 review of SEHR found it to be rated very highly among end users, accelerated rollouts and upgrades continued through 2009 and 2010. Of particular note was the ability for SEHR to achieve an estimated 90% uptake of of residents from participating remote indigenous communities. (In such communities, it is difficult to maintain accurate records. The 2011 Census, for example, had focused action towards remote communities in an attempt to identify the extent of this problem [4] )
References
[1] "Health Connect" (http:/ / www. health. gov. au/ healthconnect). Department of Health and Aging, Government of Australia. 20 June 2008. . Retrieved 22 June 2010. [2] "Health Connect: FAQs" (http:/ / www. health. gov. au/ internet/ hconnect/ publishing. nsf/ Content/ faqs-1lp#5). Department of Health and Aging, Government of Australia. 12 January 2006. . Retrieved 22 June 2010. [3] "Shared Electronic Health Record Timelines and Achievements" (http:/ / www. ehealthnt. nt. gov. au/ library/ scripts/ objectifyMedia. aspx?file=pdf/ 5/ 46. pdf& siteID=4& str_title=Shared Electronic Health Record Timelines and Achievements. pdf). . [4] "Census to rectify Indigenous undercount" (http:/ / www. abc. net. au/ pm/ content/ 2011/ s3286802. htm). .
External links
"HealthConnect archive site" (http://www.health.gov.au/internet/hconnect/publishing.nsf/Content/home). Department of Health and Aging, Government of Australia. 27 June 2008. Retrieved 22 June 2010.
Health Information Systems Programme
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Health Information Systems Programme

The Health Information Systems Programme (HISP), aims to support the improvement of health care systems in the southern hemisphere by increasing the capacity of health care workers to make decisions based on accurate information. HISP provides training and support for users of the open source District Health Information System (DHIS) software, which is under continuous development. The project started in post-apartheid South Africa, and has been introduced in a number of countries in Africa and Asia. It is part of the BEANISH initiative to improve health information in Africa.
External links
HISP International [1] Wiki for DHIS data warehouse development (DHIS 2) [2] HISP South Africa [3] HISP India [4] HISP Nigeria [5]
References
[1] [2] [3] [4] [5] http:/ / www. hisp. info http:/ / www. hisp. info/ display/ DHIS2/ Home http:/ / www. hisp. org http:/ / www. hispindia. org http:/ / www. hisp. info/ display/ HISP/ Nigeria+ Implementation
District Health Information System
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DHIS
Developer(s) Health Information Systems Programme Type Website Health management information system http:/ / www. dhis2. org/
The District Health Information System (DHIS) is a highly flexible, open-source health management information system and data warehouse. It is developed by the Health Information Systems Programme (HISP) project.[1] The solution covers aggregated routine data, semi-permanent data (staffing, equipment, infrastructure, population estimates), survey/audit data, and certain types of case-based on patient-based data (for instance disease notification or patient satisfaction surveys). The system supports the capture of data linked to any level in an organisational hierarchy, any data collection frequency, a high degree of customisation at both the input and output side. It has been translated into a number of languages. The DHIS was originally developed for three health districts in Cape Town in 1998-99, but has since spread via the HISP network to nearly half of sub-Saharan Africa, where its use covers a population of 300-400 million people, and to a number of countries in Asia. The initial scope - routine monthly Primary Health Center data has systematically been expanded to cover nearly all aspects of health data and information (excluding electronic health records). Available aggregated data for South Africa from 1998-2007, for instance, represent close to one billion patient encounters. For electronic health records, DHIS is collaborating with the WHO-backed OpenMRS system.
Releases
DHIS is available in several releases: DHIS 1.3 DHIS 1.4 DHIS 2.0
DHIS 1.3 and 1.4

The DHIS was developed on the Microsoft Access platform consisting of VBA for the interface or program logic (front-end), Access as a database (back-end), Excel for reporting and Windows as the OS. DHIS 1.4 is a significant overhaul of the version 1.3 database structure, using various output formats for reporting. It bridges the gap between DHIS 1.3 and 2.0.
DHIS 2
DHIS 2 is an open source alternative to the earlier releases. The software development process is a global collaboration between students, researchers and experienced developers in Norway, India, South Africa, Ethiopia, Vietnam and Nigeria. The first release, version 2.0, came in February 2008 after three years of development releases. DHIS 2 is developed using open-source Java frameworks and tools, such as the Spring Framework, Hibernate, Struts2, Maven, and JUnit.[2]
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References
[1] Lars, Mangset (2005). "Abstract of Thesis submitted to University of Oslo" (http:/ / www. duo. uio. no/ sok/ work. html?WORKID=28248& lang=en). DHIS-2 - A Globally Distributed Development Process. . Retrieved 17 March 2010. [2] Braa, Jrn; Humberto Muquing (2007). Building collaborative networks in Africa on health information systems and open source software development Experiences from the HISP/BEANISH network (http:/ / citeseerx. ist. psu. edu/ viewdoc/ download?doi=10. 1. 1. 131. 8950& rep=rep1& type=pdf). .
External links
DHIS 2 site (http://dhis2.org) DHIS 2 on Launchpad (development platform) (https://launchpad.net/dhis2) DHIS 2 penetration map and more information about the DHIS 2 project (http://www.hisp.uio.no/)
FLOW
FLOW is a Belgian national health care network, meant for health care providers and patients. It is an acronym which stands for Facilities (services and related infrastructure), Legal implementation (the telex files), Organisations (locoregional teams) and Wisdom (coordination and supervision center). The system is built around the principle of a shared health patient record.
Regions
FLOW Alfa: Wallonia FLOW Beta: Brussels FLOW Gamma: Flanders
Source
FLOW [1] Note de Politique Generale [2] (3 Dec. 2004)
References
[1] http:/ / www. vzwgo. be/ images/ newsflash/ 2000611/ flow%20gamma%20II. pdf [2] http:/ / www. lachambre. be/ FLWB/ pdf/ 51/ 1371/ 51K1371031. pdf
Health informatics in China
643

Health informatics in China (Chinese: ) is about the Health informatics or Medical informatics or Healthcare information system/technology in China. The main review and assessment of health informatics in China[1] for the WHO-Health Metrics Network was conducted in 2006 which details Provincial assessments, developing strategic plan outline, improving community health monitoring system, household surveys, routine health statistics system. Due to the Health Informatization Development Plan [2], all hospitals are required to increase investment in building digitized hospitals. This requirement is expected to accelerate the growth of China's HIT market by about 25 to 30% a year during 2006-2010.[3] By the end of 2006, Chinas investment in its healthcare information systems (HIS) had increased by nearly 16 percent to RMB 5.8 billion, year-on-year. This amount accounts for approximately 0.5% of the countrys total healthcare expenditures of RMB 866 billion during the same period. The market size is expected to expand to approximately RMB 15 billion in 2010. The development of Chinas HIT industry is generally considered to be at a preliminary stage, resembling that of western countries 20 years ago. However, as China learns more about available and emerging technologies, it now has the opportunity to leapfrog ahead.
Healthcare overview
Expenditure
China spent $97 billion, or 5.6% of its GDP, on healthcare in 2004. As previously stated, public spending on healthcare remains low; public spending in 2004 accounted for only 17% of total healthcare expenditure while out-of-pocket expenses reached 53.6%.
Coverage
About 130 million people are covered under the National Social Insurance Program for Urban Employees, a program established in 2005. Another 50 million people are covered through government insurance. Yet less than 30% of the Chinas population has medical insurance. Indeed, over 40% of the urban population and 57% of people in rural areas have no coverage at all.
Infrastructure
China's current healthcare system is primarily composed of large public hospitals, supplemented by a small number of private, for-profit hospitals. As of 2005, there were 18,703 hospitals in China. Among them, 2,027 were private hospitals (10.83%). Chinese hospitals can be divided into three categories: general hospitals (70%), traditional Chinese medicine (TCM) hospitals (14%), and specialty hospitals (16%). In addition, China has 5,895 outpatient facilities: 1,266 outpatient facilities and 541 traditional medicine facilities. As of 2005 China had 1,938,272 registered doctors who are primarily employed by hospitals.
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History
Economic reforms in the early 1980s resulted in major changes in China's healthcare system, especially as a result of the dismantling of the rural cooperative medical system. After being given considerable financial independence, hospitals began to generate the majority of their income through user fees, a practice that continues today. Healthcare is now provided on a fee-for-service basis. The pricing structure attempts to facilitate equity by providing basic care below cost, with profits reaped through the (often excessive) sale of drugs and high-technology services; this structure leads to inefficiency and inappropriate patient care. Healthcare insurance coverage in China is low, with less than 30% of the population receiving any medical insurance. China's health information technology HIT development has a brief history. Development commenced in the mid-1990s with financial management systems; only in the last five years or so have clinical systems been implemented. China has made progress in a relatively short time period, but weak application software and a scarcity of implementation skills delay further progress. Most Chinese hospitals are attempting to dramatically improve and extensively digitize their work processes in the near future.
Project on Construction of National Public Health Information System

The work group of the Ministry of Health for information construction has drafted the Project on Construction of National Public Health Information System. The "Project" confirmed the guideline, objectives and principles of public health information system construction, proposed framework for further actions. On September 17, 2003, information construction workgroup of the Ministry of Health held a Meeting via television and telephone on construction of public health information system in China. The agenda included a work report in the field of information construction of the Ministry of Health, the introduction of Construction Project of the National Public Health Information System (Draft) and a report from the National Center of Disease Control on relevant requirements of SARS report system via network.[4]
Mortality statistics
As part of a major revamp of its health information system, China is merging two systems for collecting mortality data to gain a more accurate picture of how many people die and why. Cause-of-death data are playing an increasingly important role in the public health policy of China. Recently, CDC [5] took part in a research project led by the Center for Statistics of the Ministry of Health on the disease burden and long-term health problems in China; the results were dramatic.[6]
HIT Adoption
Health information technology is now entering its second software generation in China, and IT usage in hospitals resembles that of the late 1970s in the United States. Most hospitals in China incorporate IT software into their payment and billing systems, and many have also begun integrating IT into clinical systems in the past five years. The use of IT in clinical systems has emerged on a departmental basis. As a result of inexperience with IT infrastructure, however, hospitals have encountered several obstacles. Fragmentation, duplicative systems, and poor integration between diverse software systems have created "information islands" that impede data sharing. Three valuable lessons are evident from China's HIT development over the past ten years: Medical information should be integrated across all departments in the hospital. Poor integration of diverse software systems within hospitals impedes inter-hospital information exchanges and creates problems as IT use expands. In order for IT systems to benefit clinical services and hospital management, effective overall IT planning is necessary. Oversimplification of IT planning and a lack of clinician engagement have in the recent past led to poor return on investment (ROI) in HIT.
Health informatics in China Implementation requires not only strong project-management skills but also attention to end-user requirements and needs as well as to work processes re-engineering. Poor implementation has resulted in a large amount of work-process redundancy.
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Government policy
The Chinese government adopted an "informatization" approach in the 1990s, promoting IT development in all major industries, including the health sector, with one goal being to bridge the information divide. HIT policy began in 1995 with the "Golden Health Project," which sought to create the foundation for electronically linking health administration departments and hospitals as well as medical education and research institutes. Government efforts in the 21st century increasingly focus on health IT. For example, the 20032010 Ministry of Health Guidelines for HIT Development in China call for the introduction of EHRs and regional health information networks to be implemented throughout the country. Many hospitals are considering system-wide upgrades, and larger budgets are more readily available for these kinds of investments.
Organizations
The Ministry of Health within the government and independent hospital administrators are the primary drivers of HIT adoption in China. Following the SARS epidemic, the Chinese government realized the importance of integrating an effective IT infrastructure into the country's health system. Additionally, after a decade of small investments in IT systems hospital leaders have become aware that IT can improve work processes and increase management efficiency. Many other associations involved in HIT exist in China, including the National Medical Information Education [7] (NMIE), Association of Chinese Health Informatics, Chinese Health Information Association, and Chinese Hospital Information Management Association [8] (CHIMA). CHIMA is a branch of the Chinese Hospital Association, a nonprofit national industry and academic association focused on Health IT (similar to the AMIA in the United States).
Funding
Provincial and local governments in China are the primary funders for regional health information networks and HIT in public hospitals. The national government facilitates investigation of standards and IT infrastructure development. Hospitals invest their own funds into clinical and institutional HIT systems. As of 2006, China spends a little over 0.7% ($700 million) of its national health budget on HIT. Of these funds: 70% goes toward hardware, 20% toward software, and 10% toward services.
Planning
Spending on healthcare in China will grow dramatically over the next five years, potentially rising to 7% of GDP. HIT spending in China will likely grow even faster, with China's national goal to create EHR and regional health information networks throughout China. Major IT upgrades are now being considered in many hospitals. The focus of future HIT development in China includes the following: electronic health records regional health information networks to share electronic health data better integration of diverse systems within individual hospitals, including agreement upon standards to support IT progress, and better management of change so that the new IT systems will make Chinese hospitals operate more efficiently. In order to accomplish these objectives over the next several years, hospitals will involve experts for IT planning and implementation of the new systems.
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Challenges
Issue Chinese software in its infancy Lack of skilled HIT professionals Lack of strong change management expertise Shenzhen Regional Health Information Network (RHIN) Chinese CDC surveillance system Description Chinese hospital application software currently has limited capabilities, and Chinese software vendors are not as experienced in healthcare applications as foreign vendors. Proven products for clinical information systems do not yet exist. Skilled workers with IT and healthcare and hospital management knowledge are lacking in China. Strong change-management expertise is missing in China. The great challenge facing many Chinese hospitals is that they have limited experience to manage the changes after implementing major IT systems. Thus, many hospital leaders are hesitant to increase IT investment. The Chinese government established as a national goal the implementation of a series of RHINs supported by digital hospitals throughout the country by 2010. The Ministry of Health selected the city of Shenzhen as a pilot site for the development of these RHINs. Responding to a request by the Ministry of Health in 2003, the Chinese CDC created a national web-based surveillance system for 37 communicable diseases to receive direct reporting from the majority of hospitals at the county level and above and from more than half of hospitals and clinics at the township level. Shenzhen will support this RHIN by digitizing all of its hospitals, thus creating more efficient work processes and better management systems to improve healthcare delivery. The Ministry of Health hopes that the Shenzhen RHIN will become a model of what can be done in all across China.
Lack of strong change management expertise
Hospital information system

Progress of hospital information system (HIS) in China has made significant progress in recent years. HIS has played a very important role in hospital, and the construction and employment of HIS can improve the efficiency and quality of healthcare work. But the development of HIS in China is unbalanced and there are many problems such as nonstandard hospital management, poor standardization, and lack of consolidation of software development. As a consequence, the current HIS is not able to meet the needs of reform in China's healthcare system. In the future, for the sake of medical information sharing, telemedicine, hospital efficiency enhancement, integration needs to be realized. In recent years, Hospital Information System (HIS) has been developed in several areas. Many hospitals have constructed HIS. According to the Ministry of Health in 2004, there were 6,063 hospitals out of 15,924 that had established hospital information systems.[9] It is estimated that about 70% of county-level hospitals and above have constructed HIS by mid-2007. In 2004, the total cost for information technology (IT) in health sector was estimated at approximately RMB 3.5 billions (US$423.5 million), which increased 25% compared with 2003. Most of the resources were committed to HIS. Construction of HIS has taken good effect, which changed the style of hospital management, offered tremendous opportunities to reduce clinical errors (e.g. medication errors, diagnostic errors), to support health care professionals (e.g. availability of timely, up-to-date patient information), to increase the efficiency of care (e.g. less waiting times for patients), or even to improve the quality of patient care.[10] Today, HIS is not only a symbol of modern management, but also one of core competence of a hospital. Nowadays, with reform in healthcare system and the entry into WTO, HISs is confronting many challenges in China. Medical domain will develop into standardization and internationalization, which stimulate different grade hospitals and many related organizations (e.g. insurance agents, finance organizations, community station), into a big integer. But the forepart HIS didn't consider medical information standards, and can't share medical information.
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Current status
Computers began to be used in hospitals in China in 1970s, but used as hospital information management since 1984. According to the contents, styles and scopes, HIS in China experienced four phases.[11] They are as follows: (1) Stand-alone. Mostly used in out-patients charge, in-patient charge and drug warehouse management during the late 1970s and early 1980s. (2) Department local area network. Representative applications are inpatient management; outpatient charge and drug deliver system, and drug management system. (3) Integrity of hospital information system. Many big hospital constructed integrity hospital information system on ethernet over 100m since early 1990s. (4) Telemedicine. With the development of IT and network, many big hospitals commenced to study implement telemedicine, through which the diagnostic digital images such as CT scans, MRIs and ultrasound CT can be transmitted. The first three phases focus on hospital information management and the fourth phase patient-centered. In general, construction of HIS in China has made significant progress since the 1990s. According to some sample investigation about HIS, there are many characters as follows: the development of HIS are imbalanced, the differences among different regions are very significant. In more developed regions, the proportion of hospitals with HIS is high, and the level of HIS is also high, most of them are in the third phase, and a few hospitals are in fourth phase. In fact, the HIS in many hospitals is no worse than that in advanced foreign hospitals. On the other hand, the level of HIS in developing regions is low, the proportion of hospitals with HIS is also low, and most of them are in the second phase. But the potential market of HIS is very good. By 2004, the proportion of hospitals with HIS in East China was above 80%, whereas, it was less than 20% in Northwest China.
"No. 1 Military Project"

"No. 1 Military Project" was important in China's HIS development.[11] This project is a hospital information system consisting of over 30 basic subsystems. It was developed by General Logistics Department of PLA collaborating with Hewlett-Packard in 1997. The project has achieved success and improved the development of health informatics in China. So far, over 200 hospitals have adopted this system. This kind of HIS has become a succeeded and advanced representative one in China. The HIS of "No. 1 Military Project" was applied in Xiaotangshan hospital during the outbreak of SARS in 2003. The patients suffered SARS were treated and the system played an important role and was praised highly by specialists. Although construction of HIS has achieved greatly, yet most HIS concentrates more on the fiscal operations of a hospital and the administrative aspects. Only 10% of hospitals with HIS have developed patient-centered Clinical Information System, while 5% are constructing Picture Archiving and Communication System.
Main problems
Although there has been good progress during last two decades, especially during last 10 years, there have been many problems which limit further progress. The main problems are as follows. 1. Lack of Standardization/Interoperability Hospital information relate to medical treatment, education, medical research, personnel, money, and substance, et al. Unification of the titles, the concept, the classification and the codes are the basic precondition for information interchange. But the most difficulty is that the standards are not unified. For example, the titles and codes of the case reports, drugs, personnel, equipments, inspection and examination differ in different hospitals. The definition, description and practice operation for the same thing are different. Owning to without unified and authoritative
Health informatics in China hospital standardization data dictionaries, as well as different HIS developed by different companies with different codes and standards, two bad results come into being. The first one is that every hospital has to develop consumer dictionary, which result in tremendous waste of personnel, money, substance and time. The second one is that standards and user dictionaries are established differently, which affect the unit into the internet and can't share information. As discussed in the previous section, the HIS of Np. 1 Military Project was excellent. Even though, there are many problems in standardization. Results from some researchers investigation revealed that 99 code tables should be consistent, but there are only 31 are consistent. Even worse, 27 codes in 27 military hospitals have 27 formats.[12] Using message standards, including the Health Level 7 (HL7), is the precondition to ensure interoperability between different hospitals systems. However most hospitals havent considered this problem and few HIS apply HL7. Only in some developed regions, such as Guangdong province, the governments require that developers of HIS must adopt or refer to HL7 standard to transmit patient clinical information. The reform in Chinese healthcare system requires different grade hospitals and many related organizations, such as insurance agents, finance organizations, community station, can share and interoperate in-patients information. But the poor information standardization in HIS cant meet the need. 2. Unified Layout of Software Systems HIS developments began to accelerate since the early 1990s. All level of health administrations, hospitals and some information development companies invested huge personnel and money into HIS developing. Especially in developed regions such as Beijing, Shanghai, Guangdong, Shandong, Jiangsu, the HIS achieved success and have larger scale. Yet the reasons those without plans as a whole and control for HIS by the related health administrations, without standards to comply with and without surveillance by some related administrations lead to non-normative HIS developing processes. These are two poor results. The first one is that HIS were developed free, the software had no standards, the developed platform therefore varied. The second problem is that the HIS develop companies were in different levels, and many of them didnt specialize in HIS develop, they were not familiar with the style of hospital management and workflows, or they only knew some specific hospitals. Furthermore, some companies have the idea of eager for quick success and instant benefit, and only considered the current benefits without long term investment. Some companies even thought that HIS market had potential, so they made some simple system packages together, and took some measures to deceive the users. All above brought severe negative influence to HIS development.[13] 3. Models of Hospital Management The models of hospitals management have major influences on HIS construction. HIS implementation requires both technical structural and behavioral sense, and development of HIS should be carried out within the context of the development itself.[14] Application with HIS but without studying and absorbing has become one bottle neck for HIS development. Compared with hospitals' directors with MBA diploma in developed countries, who manage the hospitals, most of hospitals directors in China are good medicine experts, however, they arent familiar with modernization management. They have experience in management methods, but didnt know normative and science management. When constructing HIS in their hospitals, they usually requested the HIS accommodate with their existing management modes in spite of their management modes were nonscientific and unreasonable. Besides the complexity of hospitals management, workflows and circumstances in different hospitals differ very much. To meet the need of the hospitals management, the developers had to act according to actual circumstance, which lead to the HISs cant meet the need of information communication and share because of low currency and commercialization. Good HIS should optimize hospital process, but in many Chinese hospitals, this was not the case, poor hospital process flow compromises the good HIS.
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National standardization priorities

There are many problems in HIS construction in China, among which interoperability is one of the most important. The absence of universal and consistent standards for managing and exchanging clinical and administrative information has been identified as bottleneck to utilize and improve the HIS. Therefore, one of priorities in national standardization actions is to accelerate the development of essential standards for HIS. In fact, after several years of running information systems, health providers recognized that standards were the basis for the information sharing and interoperability. The government of China also realized this problem and has taken efforts to construct the health information platform and network. One hypothesis is that because standardization for health informatics is an authoritative field, in which market mechanism does not work. Also, due to misalignment of incentives, often providers who invest in standardization cannot gain benefit directly, therefore they might prefer to invest in network than in standardization. The government may play a role to stimulate adoption by setting standards. In fact, the government had indeed taken measures to enforce the construction of standardization. In 2003, Ministry of Health released the Development Layout of National Health Informatics (20032010).[15] The layout indicates one of principles of standardization for health informatics: combining adoption of international standards and development of national standards. In the late 2003, the Leading Group for Health Informatics in the Ministry of Health started three projects to solve the problem of lacking health informatics standards, including Chinese National Health Information Framework and Standardization, Basic Data Set Standards of Public Health and Basic Data Set Standardization of Hospital System (CBDSS). CBDSS is one important project of the medical information standardization programs, which would improve information progress of hospital and the whole health system. Chinese Hospital Information Management Association [8] (CHIMA) undertook the task of CBDSS project .The goal of this project is to produce a set of data set standards, which is necessary for HIS. By now, most of this project is completed, 11 subgroups and 1 shared group CBDSS came into being.[16] Since 2003, the government had launched over ten projects related health standardization in succession, and substantial progress was made in standardization of medical information.
Dependency theory
At present, the majority HISs running in China are Hospital Management Information Systems (HIMIS), and they are not able to share medical images diagnostic information due to the various standards and formats adopted by different manufactures. Now there are HIS, Radiology Information System (RIS), Laboratory Information System (LIS) and Picture Archiving and Communication System (PACS) in many bigger hospitals, each system run independently in most hospitals. With the development of health researches and health standardization, this problem can be solved with HIS.[17] In the future, for the sake of medical information sharing, telemedicine, hospital efficiency enhancement, medical service extension, optimizing the working procedure,[18] HIMIS will develop into patient-centered HIS, all the independent systems including the electronic patient record will realize integration. Furthermore HIS will shift from supporting health care professionals to patients and consumers, from institution-centered to regional and global health information system with new and strongly extended functionalities and tasks.[19]
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Papers
Integration of Hospital Information Systems in China [20] Hospital Information System (HIS) [21] China Hospital Information System (HIS) [22] The Architecture of Enterprise Hospital Information System [23] A Web-Based and Integrated Hospital Information System [24] [25] [26]
International cooperation
SGER: Transnational Public Health Informatics Research: US-China Collaboration
This public health informatics Small Grant for Exploratory Research is a small-scale, exploratory, high-risk proposal that is potentially transformative in its research collaborations between the US and China. The proposal team is building on the momentum gained from two US-China public health informatics workshops held in Beijing in March 2008. New partnerships are expected to emerge. The outcomes have the potential to transform approaches to public health informatics, not only in US and China, but potentially across the globe, in particular in exploring transnational social networks and taking advantage of the kinds of data collection and integration methodologies and technologies employed by the two countries' public health agencies. It affords the opportunity to provide new and longer-term research and educational programs between US and Chinese institutions and practitioners.[27]
References
Footnotes
[1] [2] [3] [4] [5] [6] [7] [8] [9]
review and assessment of health informatics in China (http:/ / www. who. int/ healthmetrics/ library/ countries/ hmn_chn_his_2007_en. pdf) http:/ / www. acsi. gov. cn/ en/ unpan1.un.org (http:/ / unpan1. un. org/ intradoc/ groups/ public/ documents/ APCITY/ UNPAN025040. pdf) www.chinafdc-law.com (http:/ / www. chinafdc-law. com/ news/ detail_32. html) CDC (http:/ / www. chinacdc. net. cn) www.scielosp.org (http:/ / www. scielosp. org/ scielo. php?script=sci_arttext& pid=S0042-96862006000300007) http:/ / www. nmie. org. cn/ http:/ / www. chima. org. cn/ Zhang, Y.H., Xu, Y., Shang, L., et al. An Investigation into Health Information and Related Standards in China. [online]. Int J Med Inf. ScienceDirect Ltd. [2006-07-18]. http:/ / www. sciencedirect. com/ science?_ob=MImg& _=B6T7S-4K7FJR9-1 -3&_cdi=5066&_user=1491948&_orig=search&_coverDate=06%2F21%2F2006&_sk=999999999&view=c&wchp=dGLbVzb-zSkzS&md5=734fbcd03e2fd1b51 [10] Ammenwerth, E., Graber, S., Herrmann, G., et al. Evaluation of Health Information Systems- problems and Challenges. Int J Med Inf, 2003, 71(2-3): 125-135. [11] Yu, G.Y. Established and Application of No. 1 Military Project. Hosp Admin J Chin PLA, 2000, 7(6): 402-404. [12] Gao, X.P., Xu, Y.Y., Liu, D.H. Investigation and Analyses of Problems in Standardization of NO.1 Military Project. Hosp Admin J Chin PLA, 2005, 12(1): 86-87. [13] Wang, N. & Hu, W. Problems and Solution for Domestic HISs Standardization .Chin Hosp Manage, 2005, 25(10): 37-39. [14] Ball, M.J. Hospital Information Systems: Perspectives on Problems and Prospect, 1979 and 2002. Int J Med Inf, 2003, 69(2-3): 83-89. [15] Ministry of Health of Peoples Republic of China. The Development Layout of National Health Informatics (2003-2010). [online]. Beijing. [2005-05-26]. http:/ / www. moh. gov. cn/ uploadfile/ 200406/ 2004629144259379. doc. [16] Li, B.L., Ma, L., Liang, M.H. Standard of Basic Information Database for Hospital Information System in China. Chin Hosp, 2005, 9(7): 12-14. [17] Chang, Z.J., Mei, S., Gu, Z., et al. Realization of Integration and Working Procedure on Digital Hospital in Formation System. Computer Standards & Interfaces, 2003, 25(5): 529-537. [18] Toussaint, P.J., Lodder, H. Component-based Development for Supporting Workflows in Hospitals. Int J Med Inf, 1998, 52(1-3): 53-60. [19] Haux, R. Health Information Systems Past, Present, Future. Int J Med Inf, 2006, 75(3-4): 268-281. [20] http:/ / ideas. repec. org/ a/ wsi/ nmncxx/ v03y2007i01p135-151. html [21] http:/ / denquelle. com/ pdf/ HIS-Fin-CN. pdf

[22] [23] [24] [25] [26] [27] http:/ / www. cisco. com/ web/ CN/ aboutcisco/ success_story/ pdf/ bb. pdf http:/ / ieeexplore. ieee. org/ Xplore/ login. jsp?url=/ iel5/ 10755/ 33900/ 01616106. pdf?temp=x http:/ / portal. acm. org/ citation. cfm?id=1053726. 1054335 http:/ / www. agfa. com/ en/ he/ news_events/ news/ archive/ he20060809_shenyang. jsp http:/ / www. ehealtheurope. net/ news/ 3848/ agfa_to_expand_chinese_pacs/ ris_deal (http:/ / www. nsf. gov/ awardsearch/ showAward. do?AwardNumber=0839990)
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Further reading
Zhang Y, Xu Y, Shang L, Rao K. "An investigation into health informatics and related standards in China." Int J Med Inform. 2007 Aug;76(8):614-20. Epub 2006 Jun 21. M. X. Wu, P. Yu, J Soar. "The Current Status of Health Informatics Higher Education in China." Health Informatics Journal, Vol. 9, No. 4, 211-223 (2003) E . Ammenwerth , J . Brender , P . Nyknen , H . Prokosch , M . Rigby , J . Talmon. Visions and strategies to improve evaluation of health information systems. Reflections and lessons based on the HIS-EVAL workshop in Innsbruck. International Journal of Medical Informatics , Volume 73 , Issue 6 , Pages 479 - 491 Liming Lee. "The Current State of Public Health in China." Annual Review of Public Health. Vol. 25: 327-339 (April 2004) Informatics in clinical practice in developing countries: still early days (http://bmj.bmjjournals.com/cgi/ reprint/319/7220/1297.pdf). S Arunachalam - British Medical Journal, 1999 H . Liang , Y . Xue. Investigating public health emergency response information system initiatives in China. International Journal of Medical Informatics , Volume 73 , Issue 9 - 10 , Pages 675 - 685 Lange, A. (1998). Health informatics in China: Skipping steps on the way to the EPR. Proceedings of the 6th National Health Informatics Conference. Brisbane: 55. Lange, A. (1998). HIM in China makes great progress. Advance for Health Information Professionals 8: 18 and 90. M . Jaspers , E . Ammenwerth , W . Ter Burg , F . Kaiser , R . Haux. An international course on strategic information management for medical informatics students: international perspectives and evaluation . International Journal of Medical Informatics , Volume 73 , Issue 11 - 12 , Pages 807 - 815 M . Diomidus , J . Mantas. Assessing the progress of the M.Sc. course in health informatics under the ERASMUS programme . International Journal of Medical Informatics , Volume 50 , Issue 1 - 3 , Pages 159 - 163 Callen JL. (2003). From Shanghai to Guangzhou: interest in health information management from China Report. Health Information Management. 31(4): 28. Application of VPN technique in the construction of public health information system (http://www.springerlink. com/content/99287706k3q5nt29/) Volume 25, Number 5 / September, 2005 Standardizing basic data set in public health information system (http://lib.bioinfo.pl/pmid:18206003) Zhonghua Yu Fang Yi Xue Za Zhi. 2007 Sep ;41 (5):353-6 18206003 (P,S,G,E,B) Impact of implementation of Integrated Management of Childhood Illness on improvement of health system in China. (http://pt.wkhealth.com/pt/re/jpch/abstract.00002208-200710000-00007. htm;jsessionid=JQYN1cn1tpt0Qhh2TMpYVSpywZpFbyZNjvLJsVHhDnhBL42NdnYm!-749683226!181195629!8091!-1) Journal of Paediatrics & Child Health. 43(10):681-685, October 2007. A handheld wireless medical information system (http://ieeexplore.ieee.org/xpl/freeabs_all.jsp?tp=& arnumber=4570531&isnumber=4570483) Zhelong Wang Linbin Shi Sch. of Electron. & Inf. Eng., Dalian Univ. of Technol., Dalian; A Wireless Medical Information Query System Based on Unstructured Supplementary Service Data (USSD) (http://www.liebertonline.com/doi/abs/10.1089/tmj.2007.0069) Zhelong Wang, Hong Gu, Dewei Zhao, Weiming Wang. Telemedicine and e-Health. June 1, 2008, 14(5): 454-460. doi:10.1089/tmj.2007.0069. Web-based infectious disease reporting using XML forms. (http://www.ncbi.nlm.nih.gov/pubmed/18060833) Int J Med Inform. 2008 Sep;77(9):630-40. Epub 2007 Dec 3.
Health informatics in China Enhancement of CLAIM (Clinical Accounting Information) for a Localized Chinese Version (http://portal.acm. org/citation.cfm?id=1081812)
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Journals
Journal of Medical Informatics (http://www.cnki.com.cn/Journal/E-ED-YXQB-2007-06. htm) Chinese Journal of Health Informatics and Management (http://zgwsxxglzz.periodicals.net.cn/default.html) International Journal of Software and Informatics Journal of Health Informatics in Developing Countries (http://jhidc.org)
External links
China Hospital Information Management Association (http://www.chima.org.cn) CMIA China Medical Informatics Association (http://www.cmia.info) China HIS (http://www.china-his.com) China National Institute of Standardization (http://www.cnis.gov.cn/) Chinese Health Information Standardization Society CHISS (http://www.chiss.org.cn/)
Chinese LOINC Interface System (http://www.chiss.org.cn/documents/gwyj/CLISOL/Search_Keywords. asp) - a pilot project that aims to show a simplified Chinese version of LOINC terms. National Medical Information Education (http://www.nmie.org.cn) Department of Medical Informatics (http://medinfo.bjmu.edu.cn/) - Peking University Chinese Medical & Biological Information (http://cmbi.bjmu.edu.cn/default_en.htm) EVIPNet Beijing (http://evipnet.b19.99to.com/bj_home.html)
Courses
"Medical informatics" (http://www.miforum.net/mi/index.htm)
HL7
Health Level Seven (HL7) (http://www.hl7china.com.cn/) Learn HL7 (http://www.hl7china.com.cn/learn/) 1st Cross-Strait HL7 Meeting (http://www.hl7.org.au/HL7-China.htm) 1st Cross-Strait HL7 Meeting November 2021, 2002 - Kunming
PACS
PACS Development in China and the Component PACS System (http://www.public.iastate.edu/~baojie/pub/ 2001-01-23_pacs.pdf) Picture archiving and communication system (PACS) in China: Current trends and future directions (http:// www.biij.org/2007/1/e12/abstract.asp?ID=182)
Other
Dorenfest China Healthcare Group (http://www.dorenfest.com/ASP/default.asp) Chinese health experts look at NHS knowledge management (http://www.bjhcim.co.uk/news/2008/n804034. htm) April 2008 International conference on Emergency Health Response Systems (http://www.eu-china-infso.org/events/ events150340@2007-06-11.html)
Health informatics in China Information standards regulation and training (http://www.eu-china-infso.org/events/ events095137@2007-11-21.html) Some Perspectives on Affordable Healthcare Systems in China (http://ieeexplore.ieee.org/xpl/freeabs_all. jsp?tp=&arnumber=4353757&isnumber=4352185) Health informatics (http://www.trp.hku.hk/tif/papers/2005/apr/briefing_050407.pdf) Telecoms Infotech Forum in Hong Kong IEEEP2407 Standard for Personalised Health Informatics (PHI) (http://www.ieee2407.org/files// ws01_zelin_li.doc) Priorities and Strategies for Health Information System Development in China - How Provincial Health Inforamtion Systems Support Regional Health Planning (2004) (http://en.scientificcommons.org/35890010) Yang, Hui CEIBS Hosts 3rd Annual China Health-Care Management Forum (http://portal.acm.org/citation. cfm?id=1391398&jmp=cit&coll=&dl=) and make sure you dont get stabbed or raped
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NHS Direct
NHS Direct is the health advice and information service provided by the National Health Service (NHS) for residents and visitors in England, with advice offered 24 hours a day, every day of the year through telephone contact on the national 0845 46 47 number, web based symptom checkers at www.nhsdirect.nhs.uk [1] and via mobile, both as apps for iPhone and Android smart phones and a mobile website.[2] As a part of the National Health Service, all NHS Direct services are free at the point of care. Users of the service, through whichever channel, are asked questions about their symptoms or problem. Common problems are often given simple self care advice, which they can follow thereby avoiding an expensive visit to a health care professional. More complex problems are assessed by a nurse and can then be given treatment advice or referred on to another service within the NHS. As well as these core services, NHS Direct provides a number of commissioned services throughout the NHS, such as specialised support for patients with long term conditions, access to GP and dental healthcare out of hours, and a professional response system for times of public health anxiety. NHS Direct only provides its service for residents and visitors in England, and there are corresponding public services covering Scotland (NHS 24) and Wales (NHS Direct Wales). Northern Ireland does not have such a service. In August 2010, the BBC reported that David Cameron's coalition government was planning to scrap the NHS Direct 0845 46 47 helpline telephone service in favour of the cheaper NHS 111 number. This intention was set out in the white paper, but was portrayed in the media as a leak by the Conservative Health Secretary Andrew Lansley.[3]
Health and symptomatic advice

NHS Direct's core service is the provision of health advice to the public through the national telephone service or through digital channels including the website.
Telephone service
In England and Wales, the NHS Direct telephone service is available on 0845 4647 and is run by a specially trained team of information handlers and healthcare professionals, including nurses and dental nurses. The service is equipped to deal with a huge range of health enquiries, from symptomatic queries that require assessment and treatment, to requests for local healthcare services and healthy living advice.
NHS Direct Every person that calls NHS Direct feeling unwell is assessed to establish the severity of their symptoms, so as to re-route any urgent or life-threatening situations to the emergency services as quickly as possible. Other symptomatic callers are able to speak to a nurse, who will ask about their condition in order to recommend the best course of action. This could be giving advice about treating the problem at home, suggesting a visit to a pharmacist, or advising an appointment with their GP, which, if in the out of hours period (when the GP surgeries are closed), can possibly be arranged over the phone. As many callers are advised to look after their symptoms at home without seeing their GP, the NHS Direct telephone service reduces the demand on NHS resources and helps to avoid unnecessary trips to the doctor, dentist and accident and emergency department. The NHS Direct telephone service also provides a confidential interpreter service in many different languages, which can be accessed by stating the language required when the call is answered. For those who are deaf or hard of hearing, there is a textphone service available on 0845 606 4647.
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Website
The NHS Direct website can be found at www.nhsdirect.nhs.uk [1], and has a variety of symptom checkers, based on the same system used on the telephone service and can either give self care advice or direct a user to another NHS service. For more complex queries, the symptom checkers allow the user to receive a call back from a nurse or to take part in a webchat for further information and help. All NHS Direct health advice and information on the website passes through a rigorous clinical check by medical professionals before it is published. [4] Non-urgent health queries can be submitted to the NHS Direct online enquiry service and the website also offers a confidential webchat service for those needing advice about unprotected sex or emergency contraception.
Mobile services
NHS Direct offers its full range of symptom checkers optimised for mobile devices on its mobile website [5] and has also launched stand alone 'apps' for iPhone and Android smart phones, both available in the normal app stores.[6] [7]
Other services
Digital television channel
NHS Direct provided an interactive TV service via Sky Interactive until 31 March 2009, when the service was closed.[8] The Freeview service, on channel 100 is now hosted by NHS Choices [9].[10] The digital television service contained condensed versions of many of the most common and popular health encyclopaedia topics and common health questions.
NHS Direct
655
Commissioned services
Although it is not well known, NHS Direct supplies a multitude of additional commissioned services within the NHS. NHS Direct supports many local health authorities in England, including Primary Care Trusts (PCTs), helping them to deliver the best possible standards of healthcare to people in each region. These services range from dedicated projects in particular areas, such as the local telephone helpline set up for Sandwell PCT after a dental health scare, to schemes that are developed nationwide. These include a telephone-based pre and post operative assessment for patients having surgery, and allocating care managers to give regular coaching and advice to those with long term conditions, such as diabetes and cardiovascular disease.
History and background

NHS Direct was launched in 1998 after the government identified a need for a telephone health advice line staffed by nurses as part of its plans to modernise the NHS. [11] The aim of NHS Direct, as stated by the government in the NHS White Paper, The New NHS, was "to provide people at home with easier and faster advice and information about health, illness, and the NHS, so that they are better able to care for themselves and their families". [12] The NHS Direct telephone service began taking calls in three contact centres in Lancashire, Northumbria and Milton Keynes in March 1998.[13] These original sites were set up as pilots but soon proved successful, reaching over 1 million people and earning highly positive feedback. Additional waves of pilots were established in contact centres around England until the whole country was covered by the NHS Direct telephone service in 2000.[12] NHS Direct added a website to its services at the end of 1999, allowing users to find clinically accurate health advice and information anonymously and at their leisure. Since its creation, the NHS Direct website has steadily improved and developed, attracting more and more users. Currently, there are over 1.5 million visitors to the website every month.[12] NHS Direct's services continue to expand and improve, as do the ways in which they reach their users. It has been said that this has made the organisation "the largest and most successful healthcare provider of its kind, anywhere in the world".[14] It was reported that each call made to NHS Direct cost 25 to answer - an earlier official report had put the total at 16.[15]
Abolition of NHS Direct helpline (England)

The Department of Health has confirmed that NHS Direct's telephone number is to be phased out in favour of the new non-emergency NHS 111 number, following three pilots in the North East, East Midlands and East of England. NHS 111 is intended to work in an integrated way with local GPs, out-of-hours services, ambulance services and hospitals, for the benefit of patients and to help the NHS become more efficient. NHS Direct as an organisation is not being closed down, nor was this ever the Governments intention. NHS Direct will have an ongoing role, along with other providers, in helping to deliver the NHS 111 Service and, in the interim, will continue providing local and national telephone and web-based services on behalf of its commissioners. The Labour party, which founded NHS Direct, voiced its opposition to the proposal, although it had promised to introduce the new 111 hotline nationally in its election manifesto.[16] [17]
NHS Direct
656
External links
NHS Direct [1] NHS Direct [18] on Facebook NHS Direct [19] on Twitter NHS Direct [20] channel on YouTube
Notes
[1] http:/ / www. nhsdirect. nhs. uk/ [2] "What is NHS Direct?" (http:/ / www. nhsdirect. nhs. uk/ About/ WhatIsNHSDirect). NHS Direct. . [3] BBC News 28 August 2010 Government confirms plan to scrap NHS Direct helpline (http:/ / www. bbc. co. uk/ news/ uk-11120853). Retrieved 28 August 2010. [4] NHS Direct. "Clinical Supervision Policy" (http:/ / www. nhsdirect. nhs. uk/ article. aspx?SectionId=5& Name=FreedomOfInformationDocuments#policiesandproceduresrelatingtotheconductofbusinessandtheprovisionofnhsdirectservices). Retrieved 2009-01-14. [5] http:/ / mobile. nhsdirect. nhs. uk/ [6] "NHS Direct mobile app" (http:/ / www. nhsdirect. nhs. uk/ en/ About/ MobileApps). NHS Direct. . [7] "App of the day:NHS Direct" (http:/ / www. pocket-lint. com/ news/ 40194/ nhs-direct-android-app-of-the-day). Pocket Lint. . [8] http:/ / www. nhsdirect. nhs. uk/ article. aspx?name=DigitalTV [9] http:/ / www. nhs. uk [10] "Home Channels Interactive NHS Choices" (http:/ / www. freeview. co. uk/ freeview/ Channels/ Interactive/ NHS-Choices). Freeview. . Retrieved 2010-08-28. [11] Department of Health. "The New NHS: Modern, Dependable" (http:/ / www. dh. gov. uk/ en/ Publicationsandstatistics/ Publications/ PublicationsPolicyAndGuidance/ DH_4008959). Retrieved 2009-01-14. [12] NHS Direct. "History of NHS Direct" (http:/ / www. nhsdirect. nhs. uk/ article. aspx?name=HistoryOfNHSDirect). Retrieved 2009-01-14. [13] Department of Health. "Evaluation of NHS Direct first wave sites first interim report to the Department of Health" (http:/ / www. dh. gov. uk/ en/ Publicationsandstatistics/ Publications/ PublicationsPolicyAndGuidance/ DH_4006050). Retrieved 2009-01-14. [14] Department of Health. "Developing NHS Direct: Strategy Document for the next three years" (Foreword) (http:/ / www. dh. gov. uk/ en/ Publicationsandstatistics/ Publications/ PublicationsPolicyAndGuidance/ Browsable/ DH_4920815). Retrieved 2009-01-15. [15] Every call to NHS Direct costs 25 (http:/ / www. telegraph. co. uk/ health/ 3253245/ Every-call-to-NHS-Direct-costs-25. html) Kate Devlin. Telegraph.co.uk. 24 October 2008 [16] 'Medical Helpline NHS Direct is to be axed' (http:/ / news. sky. com/ skynews/ Home/ UK-News/ Medical-Helpline-NHS-Direct-Is-To-Be-Axed-And-Replaced-By-The-New-111-Service/ Article/ 201008415708224?lpos=UK_News_First_UK_News_Article_Teaser_Region_0& lid=ARTICLE_15708224_Medical_Helpline_NHS_Direct_Is_To_Be_Axed_And_Replaced_By_The_New_111_Service) Sky News 28 August 2010 Sky.com Retrieved 28 August 2010 [17] Labour Party Manifesto 2010 'A new national 111 telephone number will make non-emergency services far easier for people to access and book' (http:/ / www. labour. org. uk/ manifesto/ a-personal-nhs) Labour Party. Retrieved 29 August 2010 [18] http:/ / www. facebook. com/ nhsdirect. uk [19] http:/ / twitter. com/ #!/ nhsdirect [20] http:/ / www. youtube. com/ user/ nhsdirectvideos
NHS National Programme for IT
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NHS Connecting for Health is part of the UK Department of Health and was formed on the 1st April 2005, replacing the former NHS Information Authority. It has the responsibility of delivering the NHS National Programme for IT (NPfIT), an initiative by the Department of Health in England to move the National Health Service (NHS) in England towards a single, centrally-mandated electronic care record for patients and to connect 30,000 General practitioners to 300 hospitals, providing secure and audited access to these records by authorised health professionals. In due course it is planned that patients will also have access to their records online through a service called HealthSpace [1]. NPfIT is said by NHS CFH to be "the world's biggest civil information technology programme".[2] The cost of the programme, together with its ongoing problems of management and the withdrawal or sacking of two of the four IT providers, have placed it at the centre of ongoing controversy, and the Commons Public Accounts Committee has repeatedly expressed serious concerns over its scope, planning, budgeting, and practical value to patients[3] [4] [5] . As of January 2009, while some systems were being deployed across the NHS, other key components of the system were estimated to be four years behind schedule, and others had yet to be deployed outside individual trusts at all[5] .
Structure and scope of the programme

The programme was established in October 2002 following several Department of Health reports on IT Strategies for the NHS.[6] , and on April 1, 2005 a new agency called NHS Connecting for Health (CfH) was formed to deliver the programme. CfH absorbed both staff and workstreams from the abolished NHS Information Authority, the organisation it replaced. CfH is based in Leeds, West Yorkshire. As of 2009, it is still managed nationally by CfH, with responsibility for delivery shared with the chief executives of the ten NHS strategic health authorities[5] .
Reviews
The refusal of the DoH to make "concrete, objective information about NPfIT's progress [...]available to external observers", nor even to MPs, has attracted significant criticism, and was one of the issues which in April 2006 prompted 23 academics[7] in computer-related fields to raise concerns about the programme in an open letter to the Health Select Committee.[8] [9] 2006-10-06 the same signatories wrote a second open letter[10] A report by the King's Fund in 2007 also criticised the government's "apparent reluctance to audit and evaluate the programme", questioning their failure to develop an ICT strategy whose benefits are likely to outweigh costs and the poor evidence base for key technologies[11] . A report by the Public Accounts Committee in 2009 called the risks to the successful deployment of the system "as serious as ever", adding that key deliverables at the heart of the project were "way off the pace", noting that "even the revised completion date of 2014-2015 for these systems now looks doubtful in the light of the termination last year of Fujitsu's contract covering the South", and concluding "essential systems are late, or, when deployed, do not meet expectations of clinical staff"[12] . The initial reports into the feasibility of the scheme, known to have been conducted by McKinsey, and subsequent reports by IT industry analyst Ovum among others[13] have never been published nor made available to MPs[14] .
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Costs
Originally expected to cost 2.3 billion (bn) over three years, in June 2006 the total cost was estimated by the National Audit Office to be 12.4bn over 10 years, and the NAO also noted that "...it was not demonstrated that the financial value of the benefits exceeds the cost of the Programme"[15] . Similarly, the British Computer Society (2006) concluded that "...the central costs incurred by NHS are such that, so far, the value for money from services deployed is poor"[16] . Officials involved in the programme have been quoted in the media estimating the final cost to be as high as 20bn, indicating a cost overrun of 440% to 770%[17] . In April 2007, the Public Accounts Committee of the House of Commons issued a damning 175-page report on the programme. The Committee chairman, Edward Leigh, claimed "This is the biggest IT project in the world and it is turning into the biggest disaster." The report concluded that, despite a probable expenditure of 20 billion pounds "at the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period."[3] The costs of the venture should have been lessened by the contracts signed by the IT providers making them liable for huge sums of money if they withdrew from the project; however, when Accenture withdrew in September 2006, then Director-General for NPfIT Richard Granger charged them not 1bn, as the contract permitted, but just 63m[18] . Granger's first job was with Andersen Consulting[19] , which later became Accenture.
Deliverables
The programme is divided into a number of key deliverables.
Deliverable Since Name of software Original delivery date 2004 Progress 2007 [11] Progress 2009 [5]
Integrated care records service
2002
NHS Care Records Service (NCRS) / Lorenzo
"Real progress only just beginning", no go-live date specified
"Recent progress...very disappointing", completion date of 2014-2015 now looks unlikely following withdrawal of Fujitsu, arrangements for South region not resolved, Lorenzo still not live in a single acute Trust 70% of GPs and pharmacies had 1st release of software, but only 40% of prescriptions issued with readable barcodes Mixed, around half of new appointments made using system, additional training and time required
Electronic prescribing
2002
NHS Electronic Prescription Service
2007
Implementation began in early 2005, used for 8% of daily prescriptions Take-up slow, system reliant on outdated technology, GPs dissatisfied, target of 90% of referrals on system by March 2007 missed On schedule, with 98% of GP practices connected
Electronic appointments booking
2002
Choose and Book
2005
Underpinning IT infrastructure Medical imaging software
2002
New National Network (N3) Picture Archiving and Communication System (PACS) Quality Management and Analysis System (QMAS) NHSmail*
March 2002
Performance management of primary care Central e-mail and directory service
*NHSmail was renamed to Contact in late 2004,[20] before being reverted to NHSmail in April 2006.[21]
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The Spine (including PDS & PSIS)

The Spine is a set of national services used by the NHS Care Record Service. These include: The Personal Demographics Service (PDS), which stores demographic information about each patient and their NHS Number. Patients cannot opt-out from this component of the spine, although the can mark their record as 'sensitive' to prevent their contact details being viewed by 831,000 staff. The Summary Care Record (SCR). The Summary Care Record is a summary of patient's clinical information, such as allergies and adverse reactions to medicine. The Secondary Uses Service (SUS), which uses data from patient records to provide anonymised and pseudonymised business reports and statistics for research, planning and public health delivery. The Spine also provides a set of security services, to ensure access to information stored on the Spine is appropriately controlled. There are, however, already suggestions these security measures are inadequate, with leaked internal memos seen by the Sunday Times mentioning "fundamental" design flaws[22] . In addition, government spokeswoman Caroline Flint failed to dispel concerns regarding access to patients' data by persons not involved in their care when she commented in March 2007 that "in general only those staff who are working as part of a team that is providing a patient with care, that is, those having a legitimate relationship with the patient, will be able to see a patient's health record."[14]
Exceptions
The NHS in Wales is also running a national programme for service improvement and development via the use of Information Technology - this project is called Informing Healthcare. A challenge facing both NHS CFH and Informing Healthcare is that the use of national systems previously developed by the NHS Information Authority are shared by the both these organisations and the Isle of Man. Separate provision needs to be made for devolution, while maintaining links for patients travelling across national borders. NPfIT is currently focussed on delivering the NHS Care Record Service to GPs, Acute and Primary Hospitals, medical clinics and local hospitals and surgeries. Whilst there are no immediate plans to include opticians or dentists in the electronic care record, services are delivered to these areas of the NHS.
Clusters and Local Service Providers

The programme originally divided England into five areas known as "clusters": Southern, London, East & East Midlands, North West & West Midlands, and North East. For each cluster, a different Local Service Provider (LSP) was contracted to be responsible for delivering services at a local level. This structure was intended to avoid the risk of committing to one supplier which might not then deliver; by having a number of different suppliers implementing similar systems in parallel, a degree of competition would be present which would not be if a single national contract had been tendered. However, in July 2007 Accenture withdrew from the project, and in May 2008 Fujitsu had their contract terminated, meaning that half the original contractors had dropped out of the project. As of May 2008, two IT providers were LSPs for the main body of the programme: CSC Alliance [23] - North, Midlands & Eastern (NME) cluster BT Health London [24] (formerly BT Capital Care Alliance) - London cluster Accenture [25] had full responsibility for the North East and East/East Midlands clusters until January 2007, when it handed over the bulk of its responsibilities to the CSC Alliance [23], retaining responsibility for Picture archiving and communication system (PACS) rollout only. The Fujitsu Alliance [26] - had responsibility for the Southern cluster until May 2008, when their contract was terminated. Ownership of this cluster from that date remains uncertain[27] .
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Local ownership
In the first half of 2007, David Nicholson announced the "National Programme, Local Ownership programme" (known as "NLOP") which dissolved the 5 clusters and devolved responsibility for the delivery of the programme to the ten English NHS strategic health authorities (SHAs)[28] . Connecting for Health retains responsibility for the contracts with the LSPs[29] . Under NLOP, staff employed by CfH in the Clusters had their employment transferred to the SHAs, with some being recruited to revised national CfH posts.
National Application Service Providers

In addition to these LSPs the programme has appointed National Application Service Providers (NASPs) who are responsible for services that are common to all users e.g. Choose and Book and the national elements of the NHS Care Records Service that support the summary patient record and ensure patient confidentiality and information security. As of October 2005, the NASPs are: BT - NHS Care Records Service and N3 Atos Origin and Cerner - Choose & Book Cable and Wireless - NHSmail
Changes to service providers

In March 2004, EDS had their 10-year contract to supply the NHSMail service terminated.[30] [31] On 1 July 2004, Cable and Wireless were contracted to provide this service, which was initially renamed Contact.[32] IDX Systems Corporation was removed from the Southern Cluster Fujitsu Alliance in August 2005 following repeated failure to meet deadlines[27] . They were replaced in September 2005 by Cerner Corporation. In early 2006, ComMedica's contract for supply of PACS to the North-West/West-Midlands cluster was terminated, and they were replaced by GE Healthcare. In July 2006, the London region started the contractual replacement of IDX (which had been bought out by GE Healthcare in January 2006) as its supplier. Systems for secondary care, primary care and community and mental health services are proposed by BT to be provided by Cerner, INPS [33] (formerly In Practice Systems) and CSE Healthcare Systems, part of the CSE-Global group of companies [34], respectively.[35] . This is subject to contractual negotiation known as 'CCN2'. In September 2006, the CSC Alliance, Accenture and Connecting for Health signed a tripartite agreement that as of January 2007, the CSC Alliance would take over the responsibility for the majority of care systems the North East and Eastern clusters from Accenture, with the exception of PACS. As part of the handover process, around 300 Accenture personnel transferred under a TUPE process to CSC, and CSC took over the leases for some of Accenture's premises in Leeds. Accenture now retains only a small presence in the city for the delivery of its PACS responsibilities. In May 2008 it was announced that following the failure to conclude renegotiation of the contract for the Southern Cluster, CfH terminated the contract with Fujitsu.[36]
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Criticisms of the programme

Failure to deliver clinical benefits
The 2009 Public Accounts Committee report noted that the NPfIT had provided "little clinical functionality...to-date"
Data security risks

NPfIT has been criticised for inadequate attention to security and patient privacy, with the Public Accounts Committee noting "patients and doctors have understandable concerns about data security", and that the Department of Health did not have a full picture of data security across the NHS[5] . In 2000, the NHS Executive won the "Most Heinous Government Organisation" Big Brother Award from Privacy International for its plans to implement what would become the NPfIT.[37] In 2004 the NPfIT won the "Most Appalling Project" Big Brother Award because of its plans to computerise patient records without putting in place adequate privacy safeguards.[38] The balance between the right to privacy and the right to the best quality care is a sensitive one. Also there are sanctions against those who access data inappropriately, specifically instant dismissal and loss of professional registration. More worryingly, a January 2005 survey among doctors indicates that support for the initiative as an 'important NHS priority' has dropped to 41%, from 70% the previous year.[39] There have been concerns raised by clinicians that clinician engagement has not been addressed as much as might be expected for such a large project. Concerns over confidentiality, and the security of medical data uploaded to the Spine have also led to opposition from civil liberties campaigners such as NO2ID the anti-database state pressure group and The Big Opt Out [40] who provide patients with a letter to send to their doctor so that their records are withheld from the database.
Reservations of medical staff

As of August 5, 2005, research carried out across the NHS in England suggested that clinical staff felt that the programme was failing to engage the clinicians fully, and was at risk of becoming a white elephant. The Public Accounts Committee observed in 2009 that "the current levels of support reflect the fact that for many staff the benefits of the Programme are still theoretical"[5] . Surveys in 2008 suggested that two-thirds of doctors will refuse to have their own medical records on the system[41] .
Impact on IT providers
According to the Daily Telegraph, the head of NPfIT, Richard Granger, 'shifted a vast amount of the risk associated with the project to service providers, which have to demonstrate that their systems work before being paid.' The contracts meant that withdrawing from the project would leave the providers liable for 50% of the value of the contract; however, as previously mentioned, when Accenture withdrew in September 2006, Granger chose not to use these clauses, saving Accenture more than 930m[18] . The programme's largest software provider iSOFT has been seriously affected by this process and is under investigation by the UK Financial Services Authority for irregular accounting.[42] On 28 September 2006, the consultancy Accenture announced its intention to withdraw from 2bn of 10 year contracts with NPfIT, which were taken over in January 2007 by the CSC Alliance [23] - both Accenture and CSC laid blame with iSOFT, although CSC has said it will be retaining iSOFT as its software provider for all its clusters.[43] Earlier in the year Accenture had written off $450m from its accounts because of 'significant delays' in the programme.
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Implementation
The first trusts in the London & Southern Clusters to implement the new Cerner system found it problematic, with NHS hospital trust board minutes revealing a catalogue of errors. Difficulties with the system meant that[44] : 2007: Enfield PCT were unable to obtain vital data on patients awaiting operations and were obliged to delay 63 patients of the Barnet and Chase Farm Hospitals. Further, 20 patients were not readmitted for treatment within 28 days towards the end of the year because the surveillance system for tracking them "was not operational in the new ... system". Buckinghamshire Hospitals NHS Trust found that problems with the system had meant potentially infectious patients with MRSA were not isolated for up to 17 days, requiring six weeks work by staff to update them manually. April 2008: Enfield PCT found that the system had failed to flag up possible child-abuse victims entering hospital to key staff, "leaving the responsibility to the receptionist" May 2008: Enfield PCT found that 272 elective operations were cancelled at the last minute for "non-clinical reasons" May 2008: Barts and The London NHS Trust blamed their failure over the preceding six months to meet targets for treating emergency patients within four hours on staff not being familiar with the new computer system. The same report cited "breaches of the two-week urgent cancer access guarantee" and delays in assessing 11 patients with possible cancer as being due to the computer system. July 2008: the Royal Free Hampstead NHS Trust said 12,000 patient records had to be manually amended over a three-week period due to the system, and noted that "The outpatient appointment centre has experienced a significant increase in the time taken to process individual patient appointment bookings. This has had a consequent and negative effect on call-answer performance."
Management team
The NHS appointed a management team, responsible for the delivery of the system:[45] Richard Granger - is the former Director General of IT for the NHS. He took up his post in October 2002, before which he was a partner at Deloitte Consulting, responsible for procurement and delivery of a number of large scale IT programmes, including the Congestion Charging Scheme for London. In October 2006, he was suggested by The Sunday Times to be the highest paid Civil Servant, on a basic of 280,000 per year, 100,000 per year more than former Prime Minister Tony Blair.[46] Granger announced on 16 June 2007 that he would leave the agency "during the latter part" of 2007.[47] Granger finally left the programme in February 2008.[48] Granger's credentials were questioned by his own mother, a campaigner for the preservation of local health services in her area, who expressed her amazement at his appointment, criticising the whole scheme as "a gross waste of money".[19] Gordon Hextall - Chief operating officer for NHS Connecting for Health. A career civil servant. On Richard Granger's departure, Hextall assumed overall responsibility for the programme. Richard Jeavons - Senior responsible owner for service implementation. Previous posts include being CEO of the West Yorkshire NHS strategic health authority. Harry Cayton - Chair of the Care Record Development Board. As of 2009, overall leadership of CfH was described by the Public Accounts Committee as having been "uncertain" since the announcement that Richard Granger would be leaving the project.[5]
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References
[1] https:/ / www. healthspace. nhs. uk/ [2] "NHS Connecting for Health Service Implementation" (http:/ / www. connectingforhealth. nhs. uk/ systemsandservices/ implementation/ service). . [3] Hope, Christopher (2007-04-17). "Patients 'won't benefit from 12bn IT project' - Telegraph" (http:/ / www. telegraph. co. uk/ news/ main. jhtml?xml=/ news/ 2007/ 04/ 17/ ncomputer17. xml). The Daily Telegraph (London). . Retrieved 2008-05-29. [4] "DoH: The NPfIT in the NHS - twentieth report of session 2006-2007" (http:/ / www. publications. parliament. uk/ pa/ cm200607/ cmselect/ cmpubacc/ 390/ 390. pdf) (PDF). . Retrieved 2008-05-31. [5] "The National Programme for IT in the NHS: progress since 2006" (http:/ / www. publications. parliament. uk/ pa/ cm200809/ cmselect/ cmpubacc/ 153/ 153. pdf) (PDF). Public Accounts Committee. 2009-01-27. . Retrieved 2009-01-27. [6] "NHS Connecting for Health History of our organisation" (http:/ / www. connectingforhealth. nhs. uk/ aboutus/ history). . [7] Signatories of the open letter to the Health Select Committee: Ross Anderson, Professor of Security Engineering, Cambridge University; James Backhouse, Director, Information System Integrity Group, London School of Economics; David Bustard, Professor and Head of Computing and Information Engineering, University of Ulster; Ewart Carson, Professor of Systems Science, Centre for Health Informatics, City University; Patrik O'Brian Holt, Professor, School of Computing, The Robert Gordon University; Roland Ibbett, Professor, School of Informatics, University of Edinburgh; Ray Ison, Professor of Systems, The Open University; Achim Jung, Professor, School of Computer Science, University of Birmingham; Frank Land, Emeritus Professor, Information Systems Department, London School of Economics; Bev Littlewood, Professor of Software Engineering, City University; John A McDermid, Professor of Software Engineering, University of York; Julian Newman, Professor of Computing, Glasgow Caledonian University; Brian Randell, Professor, School of Computing Science, University of Newcastle; Uday Reddy, Professor, School of Computer Science, University of Birmingham; Peter Ryan, Professor of Computing Science, University of Newcastle; Geoffrey Sampson, Professor, Department of Informatics, University of Sussex; Martin Shepperd, Professor of Software Technologies, Brunel University; Michael Smith, Visiting Professor, Department of Computer Science, University College London; Tony Solomonides, Reader in Computer Science and Medical Informatics, University of the West of England; Ian Sommerville, Professor, Computing Department, Lancaster University; Harold Thimbleby, Professor of Computer Science, Swansea University; Martyn Thomas, Visiting Professor of Software Engineering, Computing Laboratory, Oxford University; Colin Tully, Professor of Software Practice, School of Computing Science, Middlesex University [8] Collins, Tony (2006-04-12). "NHS Focus: Open Letter: Questions that need to be answered" (http:/ / www. computerweekly. com/ Articles/ 2006/ 04/ 12/ 215323/ nhs-focus-open-letter-questions-that-need-to-be-answered. htm). ComputerWeekly.com (Reed Business Information Limited). . Retrieved 2006-11-01. [9] Collins, Tony (2006-04-11). "Signatories to health committee letter" (http:/ / www. computerweekly. com/ Articles/ 2006/ 03/ 14/ 215264/ Theexpertscallingforareview. htm). ComputerWeekly.com (Reed Business Information Limited). . Retrieved 2006-11-01. [10] Collins, Tony (2006-10-10). "Experts strike new NHS warning note" (http:/ / www. computerweekly. com/ Articles/ 2006/ 10/ 10/ 218985/ Experts+ strike+ new+ NHS+ warning+ note. htm). ComputerWeekly.com (Reed Business Information Limited). . Retrieved 2006-11-01. [11] "Our Future Health Secured? A review of NHS funding and performance" (http:/ / www. kingsfund. org. uk/ search_clicks. rm?id=7143& destinationtype=2& instanceid=342724) (pdf). The King's Fund. . Retrieved 2009-01-27. [12] "Warning over fresh NHS IT delays" (http:/ / news. bbc. co. uk/ 1/ hi/ health/ 7850619. stm). BBC News. 2009-01-27. . Retrieved 2009-01-27. [13] "House of Commons - Public Accounts - Minutes of Evidence" (http:/ / www. publications. parliament. uk/ pa/ cm200607/ cmselect/ cmpubacc/ 390/ 6062636. htm). . Retrieved 2008-05-29. [14] "Another ministerial spokesperson for the NHS IT programme moves on (Tony Collins's IT Projects Blog)" (http:/ / www. computerweekly. com/ blogs/ tony_collins/ 2007/ 07/ another-ministerial-spokespeop-1. html). Computer Weekly. . Retrieved 2008-05-29. [15] "The National Programme for IT in the NHS" (http:/ / www. nao. org. uk/ / idoc. ashx?docId=01f31d7c-0681-4477-84e2-dc8034e31c6a& version=-1) (pdf). National Audit Office. 2006-06-16. . Retrieved 2009-01-27. [16] "The Way Forward for NHS Health Informatics: Where should NHS Connecting for Health (NHS CFH) go from here?" (http:/ / www. bcs. org/ upload/ pdf/ BCS-HIF-report. pdf) (pdf). The British Computer Society Health Informatics Forum Strategic Panel. 2006-12-15. . Retrieved 2009-01-27. [17] Fleming, Nic (2004-10-12). "Bill for hi-tech NHS soars to 20 billion" (http:/ / www. telegraph. co. uk/ news/ uknews/ 1473927/ Bill-for-hi-tech-NHS-soars-to-andpound20-billion. html). London: The Daily Telegraph. . Retrieved 2008-05-31. [18] Kablenet. "Accenture escapes 1bn penalty for NHS walk-out" (http:/ / www. theregister. co. uk/ 2006/ 09/ 29/ accenture_nhs_penalty/ ). The Register. . Retrieved 2008-02-28. [19] Revill, Jo (2006-11-12). "Health service IT boss 'failed computer studies'" (http:/ / www. guardian. co. uk/ society/ 2006/ nov/ 12/ epublic. technology). London: The Observer. . Retrieved 2008-05-29. [20] "Contact lost as NHS e-mail relaunch misfires" (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=889). E-Health Insider. . Retrieved 2008-05-31. [21] "Connecting for Health fails to lead on Contact" (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=1849). E-Health Insider. . Retrieved 2008-05-31. [22] Jonathan Carr-Brown (2004-11-14). "Computer loophole hits hi-tech NHS trial" (http:/ / www. timesonline. co. uk/ tol/ news/ uk/ article391090. ece). London: The Sunday Times. . Retrieved 2010-05-20.

[23] http:/ / www. cscalliance. com [24] http:/ / www. btplc. com/ health/ [25] http:/ / www. accenture. com [26] http:/ / uk. fujitsu. com [27] Wray, Richard (2008-05-29). "Second contractor drops out of 12bn NHS computer upgrade" (http:/ / www. guardian. co. uk/ business/ 2008/ may/ 29/ nhs). London: The Guardian. . Retrieved 2008-05-29. [28] "Hunt spells out local ownership moves" (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=2552). E-Health Insider. . Retrieved 2008-05-31. [29] "NPfIT to go local by August" (http:/ / news. zdnet. co. uk/ itmanagement/ 0,1000000308,39287578,00. htm). ZDNet.co.uk. 2007-06-15. . Retrieved 2008-05-31. [30] "Granger terminates EDS's NHSmail contract" (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=676). E-Health Insider. . Retrieved 2008-05-31. [31] "National programme says NHSmail was 'unacceptable'" (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=677). E-Health Insider. . Retrieved 2008-05-31. [32] "Press release:NHSMail Service To Transition Onto Microsoft Exchange Platform" (http:/ / web. archive. org/ web/ 20080429191808/ http:/ / www. cw. com/ media_events/ media_centre/ releases/ 2007/ 06_07_2007. html). Cable & Wireless. Archived from the original (http:/ / www. cw. com/ media_events/ media_centre/ releases/ 2007/ 06_07_2007. html) on 2008-04-29. . Retrieved 2008-05-31. [33] http:/ / www. inps. co. uk [34] http:/ / www. cse-healthcare. com/ [35] "NHS officially told of London Cerner switch" (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=2037). E-Health Insider. . Retrieved 2008-05-31. [36] "E-Health Insider :: Fujitsu's 896m NHS IT contract to be terminated" (http:/ / www. e-health-insider. com/ news/ 3798/ fujitsus_896m_nhs_it_contract_to_be_terminated). . Retrieved 2008-05-31. [37] "The 2000 UK Big Brother Awards" (http:/ / www. privacyinternational. org/ bigbrother/ uk2000/ ). . Retrieved 2008-05-31. [38] "Privacy foes named and shamed" (http:/ / news. bbc. co. uk/ 1/ hi/ technology/ 3933679. stm). BBC NEWS. 2004-07-29. . Retrieved 2008-05-31. [39] "Doctor's support of NHS National Programme for IT declines, says new survey" (http:/ / www. publictechnology. net/ modules. php?op=modload& name=News& file=article& sid=2414). PublicTechnology.net. . Retrieved 2008-05-31. [40] http:/ / www. nhsconfidentiality. org/ [41] "Daily Mail Comment: The NHS and its great white elephant" (http:/ / www. dailymail. co. uk/ news/ article-1022920/ Daily-Mail-Comment-The-NHS-great-white-elephant. html). The Daily Mail. 2008-05-30. . Retrieved 2008-05-31. [42] Moulds, Josephine (2006-09-28). "Daily Telegraph, 28 September 2006, 'IT providers left in the debris of NHS's 'Big Bang'" (http:/ / www. telegraph. co. uk/ finance/ 2948063/ IT-providers-left-in-the-debris-of-NHSs-big-bang. html). The Daily Telegraph (London). . Retrieved 2010-05-20. [43] Moulds, Josephine (2006-09-29). "Daily Telegraph, 29 September 2006, 'Accenture pulls out of NHS deal'" (http:/ / www. telegraph. co. uk/ finance/ 2948130/ Accenture-pulls-out-of-NHS-deal. html). The Daily Telegraph (London). . Retrieved 2010-05-20. [44] Jamie Doward (2008-08-10). "Chaos as 13bn NHS computer system falters" (http:/ / www. guardian. co. uk/ society/ 2008/ aug/ 10/ nhs. computersystem). London: The Guardian. . Retrieved 2008-08-11. [45] "Top Team NHS Connecting for Health" (http:/ / www. connectingforhealth. nhs. uk/ about/ whoswho/ topteam). . Retrieved 2008-05-31. [46] Grimston, Jack; Kirk, Jon (2006-10-08). "Fat cats of the public sector take top pay" (http:/ / www. timesonline. co. uk/ tol/ news/ uk/ article665113. ece). London: The Times Online. . Retrieved 2008-05-31. [47] E-Health Insider :: Granger to leave in transition by end of 2007 (http:/ / www. e-health-insider. com/ news/ item. cfm?ID=2784) [48] "Granger era ends as DG leaves CfH" (http:/ / www. e-health-insider. com/ news/ 3454/ granger_era_ends_as_dg_leaves_cfh). E-Health Insider. . Retrieved 2008-05-31.
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External links
NHS Connecting for Health website (http://www.connectingforhealth.nhs.uk) NHS number (http://www.connectingforhealth.nhs.uk/systemsandservices/nhsnumber) Personal Demographics Service (PDS) (http://www.connectingforhealth.nhs.uk/demographics) "A guide to the National Programme for Information Technology" (PDF) (http://www.connectingforhealth.nhs. uk/all_images_and_docs/NPfIT brochure Apr 05 final.pdf), NHS Connecting for Health, April 2005 PC Coaching appointed to provide Trainers & MTUs for NPfIT (http://www.pccoachingnhs.com/), NHS Connecting for Health award contract for NPfIT Trainers and Mobile Training Units Programmes and Systems Delivery (http://www.connectingforhealth.nhs.uk/delivery/programmes/), NHS Connecting for Health, retrieved October 30, 2005 NHS Connecting for Health NPfIT site (http://www.connectingforhealth.nhs.uk)
NHS National Programme for IT NHS Connecting for Health History Page (http://www.connectingforhealth.nhs.uk/aboutus/history) BT Health (http://www.btplc.com/health), Delivering three major contracts to the NHS as part of the NPfIT June 2006: NHS risks 20bn white elephant, say auditors (http://society.guardian.co.uk/e-public/story/ 0,,1799088,00.html) Times Online: Patient records go on database (http://www.timesonline.co.uk/newspaper/0,,2710-751992,00. html) Computer loophole hits hi-tech NHS trial (http://www.timesonline.co.uk/newspaper/0,,176-1358226,00. html) NHS IT upgrade success 'at risk' (http://news.bbc.co.uk/1/hi/health/4745915.stm) The Big Opt Out (http://www.nhsconfidentiality.org/?page_id=9,), Advice to patients - How to opt out Opting out of the NHS Database (http://www.summarycarerecord.info/) Detailed information from Dr Neil Bhatia, a GP in Hampshire NHS Information Standards Board for Health and Social Care (http://www.isb.nhs.uk)
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Ontario Telemedicine Network
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Industry Founded
Telemedicine April 2006
Headquarters Toronto, Ontario, CANADA Employees Website 180 (2008) www.otn.ca [1]
The Ontario Telemedicine Network (OTN) is an independent, not-for-profit organization that is funded by the Government of Ontario. "Telemedicine" (TM) is the delivery of health-related services and information using telecommunications technologies. Using two-way videoconferencing systems and tele-diagnostic instruments like digital stethoscopes, otoscopes and patient examination cameras, OTN helps deliver clinical care and professional education among health care providers and patients.
A province-wide telemedicine solution

OTN was created through the April 2006 merger of three award-winning, provincially-funded telemedicine networks: CareConnect in Eastern Ontario, NORTH Network in Central and Northern Ontario, and VideoCare in Southwestern Ontario. This merger, supported by the Ontario Ministry of Health and Long-Term Care (MOHLTC) and Canada Health Infoway (CHI), leveraged the networks successes, assets and resources to ensure that telemedicine will continue to grow and satisfy demand for services. Today, more than 2,000 health care professionals deliver care using OTN. In 2007, over 32,000 clinical consultations in Ontario were conducted using telemedicine.
OTN Members and Network Partners

OTN has more than 240 partners including: academic health science centres, community hospitals, psychiatric hospitals, clinics, nursing stations, medical and nursing schools, professional organizations, Community Care Access Centres, LHIN offices, First Nations Communities, long-term care homes, educational facilities and public health.
References
[1] http:/ / www. otn. ca/
External links
Ontario Telemedicine Network website (http://www.otn.ca/) French-language website (http://www.otn.ca/fr/)
Public Health Information Network
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The Public Health Information Network (PHIN) is a national initiative, developed by the Centers for Disease Control and Prevention (CDC), for advancing fully capable and interoperable information systems in public health organizations. The initiative involves establishing and implementing a framework for public health information systems.
PHIN Design
PHIN is designed to do the following: Enable the consistent exchange of health data Protect the security of the health data exchanged Ensure that the network will be available at all times
PHIN Structure
The 5 Functional Areas of PHIN: 1. Detection and Monitoring 2. 3. 4. 5. Data Analysis Knowledge Management Alerting Response
The PHIN Framework

"PHIN will elevate and integrate the capabilities of public health information systems across the wide variety of organizations that participate in public health and across the wide variety of interrelated public health functional needs. PHIN is both a response to the needs for better integration among public health systems and a plan for developing systems and infrastructure to better support public health activities and improve public health outcomes. PHIN targets the support and integration of systems for disease surveillance, national health status indicators, data analysis, public health decision support, information resources and knowledge management, alerting and communications and the management of public health response. PHIN includes a portfolio of software solutions and artifacts necessary in building and maintaining interconnected information systems throughout public health at the local, state and federal levels. PHIN advances the National Health Information Infrastructure and federal E-Gov agendas by working with the Federal Health Architecture (FHA) and implementing the Consolidated Health Informatics (CHI) standards for reducing the burden of private sector reporting through the automated use of electronic clinical data for public health purposes as an alternative to manual reporting. It is consistent with other private sector initiatives such as Connecting for Health and e-Health as well as the industry standards for clinical data messaging such as HL7. PHIN also aligns with the federal e-Gov technical architecture standards such as ebXML and public key infrastructure (PKI). See Standards Development Organizations for more information on national standards."
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PHINs Impact on Public Health

PHIN attempts to provide the public health sector with continuous access to necessary health care information. Access to near real-time data attempts to improve community based interventions that are implemented as a result of terrorism or disease outbreaks. PHIN provides supports and helps improve the outcomes of various public health programs including the following: The U.S. Department of Health and Human Services Desired outcome: improving public health information systems. The Secretary of the U.S. Department of Health and Human Services Supports: Terrorism Defense, Healthcare Delivery Improvement, and IT Enhancements. Healthy People 2010 Supports: Focus area 23 - ensure that public health agencies have the adequate infrastructure to effectively provide essential public health services. Partners in public health Desired outcome: "Roadmap" for establishing national capacity for public health systems.
Budget and Funding

PHIN first received funding in 2004 through the Department of Health and Human Services and the Centers for Disease Control and Prevention. Between 25% and 30% of the $849 million of funding received through the Public Health Response and Preparedness Cooperative Agreement was to be used to focus on improving public health preparedness in all 50 states, 4 metropolitan areas and 8 US territories. In 2004 the initiative of the program was to ensure that all public health partners have, or at least will have, access to a system or systems to accomplish established preparedness functions. For year 2005, additional finances will be available to states through the terrorism cooperative agreement. This agreement will support the development of current and new systems, in state health and public health departments, which will meet the PHIN standards and specifications.
Partnerships
In order to collect and assess information system requirements for PHIN, the CDC works with public health partners, some of which include: NACCHO - National Association of County and City Health Officials ASTHO - Association of State and Territorial Health Officials With the assistance of these partners, PHIN can target the following functional areas regarding preparedness: 1. 2. 3. 4. 5. Early Event Detection Outbreak Management Connecting Laboratory Services Partner Communications and Alerting Countermeasure/Response Administration
Governance
The approval of technical and data standards for PHIN is completed by two working groups in the CDC Information Council (CIC). The following organizations are represented on each working group by 2 members of its staff: Association of State and Territorial Health Officials (ASTHO), National Association of County and City Health Officials (NACCHO), and Centers for Disease Control and Prevention (CDC). By regulation the standards conform to Department of Health and Human Services (HHS) requirements and the Federal Health architecture.
Public Health Information Network CIC also ensures that the following standards are met: E-Gov activities, which includes all regulations contained in the Government Paperwork Elimination Act (GPEA) goals Consolidated Health Informatics (CHI) initiative Federal Geographic Data Committee standards required by Office of Management and Budget (OMB) Circular A-16 Public Health line of business and Public Health Monitoring Sub-function of the Federal Enterprise Architecture Business Reference Model For more information on these standards, refer to the PHIN Conceptual Diagram [1] provided by PHIN and the CDC.
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Preparedness
Early Event Detection
In the realm of preparedness, the PHIN has developed systems to promote early event detection. Information systems that connect health care providers to the PHIN allow for rapid reporting of cases that may lead to public health emergencies. These information systems include call reporting systems, web-based systems, and other electronic case reporting systems. The PHIN has set up technical requirements so that facilities can be equipped to participate in these rapid reporting systems. These requirements also ensure that facilities can protect patient privacy in their reports and ensure integration with outbreak management.
Outbreak Management
Another component in preparedness, the PHIN has a division of outbreak management which allows public health agencies to be adequately prepared for true outbreaks. The outbreak management system is integrated with the early event detection systems to ensure rapid, smooth awareness of outbreaks. The CDC and PHIN currently employ an Outbreak Management System software application to effectively manage data related to outbreaks. OMS demonstration [2]
Connecting Laboratories
Another component of PHIN is connecting laboratories through a set of computer communication standards called HL7. This allows specimen receipts and laboratory results to be exchanged between health organizations and agencies. This is especially useful in times of a health outbreak or other disaster.
Countermeasure and Response Administration

The PHIN also works to track and support the supply of vaccinations and as well as the administration of these tasks. As part of this functionality, the PHIN allows limited supplies of vaccines and other needed drugs to be allocated properly when they are in short supply. Some vaccines and drugs will be traceable to clinics and drug administrators. PHIN also supports response administration by allowing adverse events to be monitored and quarantined populations to be monitored if necessary.
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Standards and Specifications

PHIN has a set of Vocabulary Standards and Specifications that: 1. 2. 3. 4. Supports the development and deployment of standards-based public health information systems. Seeks to promote the use of standards-based vocabulary Fosters the use and exchange of consistent information among public health collaborators. Ensures that the vocabularies are aligned with PHIN and CHI standards.
Training
If you are interested in training, CDC offers online trainings on different topics such as: Outbreak Management, Countermeasure and Response Administration, Certification and it also offers PHIN Roadshow Webinairs. Please check calendar of available trainings at: http://www.cdc.gov/phin/webinars-and-training.html
External links
CDC Overview [3] Official NHIN Website [4] NHIN Watch Website [5] CDC Vocabulary [6]
References
[1] [2] [3] [4] [5] [6] http:/ / www. cdc. gov/ phin/ images/ PHIN_Overview. gif http:/ / www. cdc. gov/ phin/ software-solutions/ oms/ oms_demo. html http:/ / www. cdc. gov/ phin/ overview. html http:/ / www. nhin. com http:/ / nhinwatch. com http:/ / www. cdc. gov/ phin/ vocabulary/ index. html
SAPPHIRE
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SAPPHIRE
The Situational Awareness and Preparedness for Public Health Incidences and Reasoning Engines (SAPPHIRE) is a semantics-based health information system capable of tracking and evaluating situations and occurrences that may affect public health. It was developed in 2004 by Dr. Parsa Mirhaji at The University of Texas Health Science Center at Houston using the Semantic Web technologies.
Technology
SAPPHIRE is based upon developing Semantic Web technologies a set of formats and programming languages (such as the Resource Description Framework language and the Web Ontology Language (OWL)) that find and analyze data on the World Wide Web to enable users to understand and utilize organized information online. [1] The system is used to gather, organize and impart information on important happenings and events, assisting public health-care professionals to prepare and act. It permits data to be interpreted distinctly, meeting the specific needs of diverse industries, users and disciplines rather than a generalized, universal format. The SAPPHIRE system was developed by the Health Science Center using the RDF technologies developed by Oracle, Inc. and TopQuadrant, Inc.[2]
Function
SAPPHIRE helps track specific incidences such as the spread and treatment of influenza, AIDS and related information. The system frequently gathers information from select public hospitals, emergency services and care providers and their electronic health records and information provided by medical professionals. [1] The information is integrated and categorized - flu-related symptoms are analyzed for trends that may indicate probabilities of flu epidemics. Such data is transmitted to institutions such as the Centers for Disease Control and Prevention. SAPPHIRE's processes have also reduced the administrative burdens and inefficiencies at hospitals and clinics. [1]
Usage after Hurricane Katrina

The University of Houston conducted a pilot test of SAPPHIRE in the aftermath of Hurricane Katrina in the fall of 2005, which devastated the populations and infrastructures of southern Mississippi, Louisiana, Alabama and Texas. Implemented swiftly within hours of mass evacuations, the SAPPHIRE system successfully monitored and analyzed public health information for the usage of government officials and services, who feared outbreaks of epidemics. Officials used hand-held computers to gather data from the evacuees and transmit directly to the SAPPHIRE database. [3] SAPPHIRE was specifically used to analyze the health of the evacuees at the Astrodome, Reliant Park and the George R. Brown Convention Center.[2] A PDA extension of SAPPHIRE enabled more than 300 volunteers, led by the UT School of Public Health, to collect and analyze critical health data. SAPPHIRE gathered information from nearly 9,000 confidential patient cases of the past to help services respond to the specific needs of the evacuees, helping to identify environment-specific vulnerabilities, prevalence and conditions for diseases and epidemics.[2] SAPPHIRE was recorded to have assisted in identifying outbreaks of gastrointestinal, respiratory diseases and conjunctivitis much sooner than previously possible.[3]
SAPPHIRE
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References
[1] Lee Feigenbaum, Ivan Herman et al. (December 2007). The Semantic Web In Action. Scientific American (Vol. 297, No. 6). pp.95. [2] Oracle.com (http:/ / www. oracle. com/ corporate/ press/ 2007_feb/ UT Houston-TopQ. html) [3] Lee Feigenbaum, Ivan Herman et al. (December 2007). The Semantic Web In Action. Scientific American (Vol. 297, No. 6). pp.96.
(http://www.uthouston.edu/distinctions/archive/2007/may/archive.htm?id=792574), Press Release (http://www.knowmed.com/), The KnowMED Incorporation (http://tmc.academia.edu/ParsaMirhaji), Parsa Mirhaji
SmartCare
The SmartCare electronic health record system (EHR) has been developed and deployed by The Ministry of Health (MOH) Zambia, in collaboration with the Centers for Disease Control and Prevention (CDC) and many other implementing partners. SmartCare is: A fully integrated electronic health record system to provide continuity of care A clinical management information system at the facility and district (management/admin) level A key component in 'one National M&E system'
Programme vision
Every Zambian receives cost-effective, confidential, quality health care whenever and wherever they need it. Every man, woman and child has an electronic health record; Every point of clinical service can access and update this record; Every clinician understands the value of this record and is committed to maintaining it; Each clinical facility, District, Provincial and the national Ministry of Health HQ routinely monitors & evaluates reports from this data, and uses this information to optimally allocate human and other resources, and to assure continuous systematic improvement in health services.
Programme mission
To enable the delivery of cost-effective, confidential, quality health care for everyone, everywhere, every time, by improving health records and related health information systems.
System innovations
Distributed database system: Given resource constraints in developing countries such as Zambia where electricity is still not available in some parts of the nation, having Internet access throughout the nation will take many more year. SmartCare data is held at each facility in a distributed design; unlike centralized designs of most systems. Internet is not essential, merely an added benefit. Smart Card: SmartCare uses client carried smart cards or staff carried flash drives for a lower-tech connectivity solution that works today. An individual's health information is stored on a very compressed, secure smart card to maintain continuity of care between visits, health services and health facilities. The individual's health record is also stored on the health facility installation database for backup and generation of facility level and health management information system reports. Touchscreen: Making the data capture task bearable can be the most challenging part of EHR design. SmartCare extends a successful Malawi idea, where touchscreen data entry by existing staff lowers this barrier. The software
SmartCare works well with a touch screen monitor enabling the clinician to view and record patient data. This tool, in combination with client specific data, can provide decision support for over-extended clinicians, and clinician assistants. Clinicians can read and touch to enter data; no typing is required. See the image at top for example screen with touch screen technology enabled. GIS data visualization: Aggregate health data stored at health facilities can be visualized in GIS maps. This includes live patient data as well as static data from health surveys.
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Deployment status in Zambia

Ministry of Health, Zambia has deployed SmartCare in > 200 facilities (clinical and district/provincial/national levels), in all districts (mid-2008); patient enrollment >200,000 Partners are supporting deployment in government and private facilities (for instance: ZPCT >44, CIDRZ >56, AIDSRelief >12), but government deployment & enrollment rates are increasing most rapidly
Future plans in Zambia

Capacity building and systems strengthening by developing SmartCare Training Videos, Certification Completion of ambulatory service modules e.g. OPD, family planning, and childrens clinic Systems integrations with other health record systems in Zambia ex: ZEPRS Integration of drug stock management system
Customizations
Ethiopia - Electronic Health Record System called SmartCare-Ethiopia. The system is currently being piloted in one of the hospitals (as of December 2007) Zambian National Blood Transfusion Service - Blood donor data collection and reporting system called the SmartDonor module. The system is being piloted at the national blood transfusion centre head quarters (as of Jan 2009) and plans to deploy to the 9 provincial transfusion centres are underway
Related systems
OpenMRS OpenEMR WorldVistA ZEPRS
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International Projects
Building Europe-Africa Collaborative Network for Applying IST in Health Care Sector
The BEANISH initiative (Building Europe Africa collaborative Network for applying IST in Health care sector) seeks to support the application and sharing of IST application development in the African health-care sector. In order to do so, the initiative will involve various institutional actors (government, universities, private sector and NGOs) to strengthen and extend an existing Europe-Africa collaborative R&D network, namely HISP (Health Information Systems Programme). This is intended to strengthen cooperation, learning and innovation on both continents. The initiative is formally a WITFOR (World Information Technology Forum) project, proposed by EU-African partners and IFIP (International Federation for Information Processing).
External links
BEANISH Home Page [1]
References
[1] http:/ / 208. 76. 222. 114/ confluence/ display/ BEANISH/ Home
Global Infectious Disease Epidemiology Network
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Global Infectious Diseases Epidemiology Network (GIDEON) is a web-based program for decision support and informatics in the fields of Infectious Diseases and Geographic Medicine. As of 2005, more than 300 generic infectious diseases occur haphazardly in time and space and are challenged by over 250 drugs and vaccines. 1,500 species of pathogenic bacteria, viruses, parasites and fungi have been described. Printed media can no longer follow the dynamics of diseases, outbreaks and epidemics in "real time."
Organization
GIDEON consists of four modules. The first Diagnosis module generates a Bayesian ranked differential diagnosis based on signs, symptoms, laboratory tests, country of origin and incubation period - and can be used for diagnosis support and simulation of all infectious diseases in all countries. Since the program is web-based, this module can also be adapted to disease and bioterror surveillance. The second module follows the epidemiology of individual diseases, including their global background and status in each of 205 countries and regions. All past and current outbreaks of all diseases, in all countries, are described in detail. The user may also access a list of diseases compatible with any combination of agent, vector, vehicle, reservoir and country (for example, one could list all the mosquito-borne flaviviruses of Brazil which have an avian reservoir). Over 30,000 graphs display all the data, and are updated in "real time." These graphs can be used for preparation of PowerPoint displays, pamphlets, lecture notes, etc. Several thousand high-quality images are also available, including clinical lesions, roentgenograms, Photomicrographs and disease life cycles. The third module is an interactive encyclopedia which incorporates the pharmacology, usage, testing standards and global trade names of all antiinfective drugs and vaccines. The fourth module is designed to identify or characterize all species of bacteria, mycobacteria and yeasts. The database includes 50 to 100 taxa which may not appear in standard texts and laboratory databases for several months. Additional options allow users to add data (in their own font / language) relevant to their own institution, electronic patient charts, material from the internet, important telephone numbers, drug prices, antimicrobial resistance patterns, etc. This form of custom data is particularly useful when running GIDEON on institutional networks. The data in GIDEON are derived from: all peer-reviewed journals in the fields of Infectious Diseases, Pediatrics, Internal Medicine, Tropical Medicine, Travel Medicine, Antimicrobial Pharmacology and Clinical Microbiology a monthly electronic literature search based on all relevant keywords all available health ministry reports (both printed and electronic) standard texts abstracts of major meetings
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Related products
VIPatients [1] created by the author of GIDEON
External links
GIDEON description at EBSCO [2] GIDEON [3]
References
[1] http:/ / www. vipatients. com [2] http:/ / www. ebscohost. com/ pointOfCare/ default. php?id=6 [3] http:/ / www. GIDEONonline. com
Integrating the Healthcare Enterprise

IHE is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. In 1997, a consortium of radiologists and information technology experts formed IHE, or "Integrating the Healthcare Enterprise." IHE created and operates a process through which interoperability of health care IT systems can be improved. The group gathers case requirements, identifies available standards, and develops technical guidelines that manufacturers can implement. IHE also stages "connectathons" and "interoperability showcases" in which vendors assemble to demonstrate the interoperability of their products. IHE is an international organization that focuses on the development of open and global IHE Integration Profiles and on the regional deployment of interoperable IT systems. Because of its limited resources, IHE concentrates on specific projects. It solicits proposals; and after surveying its members to better understand their priorities, it chooses areas to focus on. Well over 300 manufacturers have demonstrated support for one or more IHE Profiles, see *[1]. IHE is sponsored by the Healthcare Information and Management Systems Society (HIMSS), the Radiological Society of North America (RSNA), and the American College of Cardiology (ACC). The eye care domain is sponsored by the American Academy of Ophthalmology.
Prioritized Projects
Currently, IHE has three prioritized projects. First, it would like to improve patient-ID binding, which ensures that medical data from one patient is never accidentally placed under the wrong name. Second, it hopes to enhance device-enterprise communication, and finally, it is interested in promoting the development of easy-to-use, point-of-care technology.
IHE Integration Profiles

IHE Integration Profiles describe a clinical information need or workflow scenario and document how to use established standards (e.g. HL7, DICOM, LOINC...) to accomplish it. A group of systems that implement the same Integration Profile address the need/scenario in a mutually compatible way. Integration Profiles describe basic functional elements and therefore are reusable in many IT applications. More characteristics are: each Integration Profile is based on relevant use-cases described by real users Integration Profiles are independent of manufacturers or products Integration Profiles are stable once published and may be extended by amendments - rather than re-written.
Integrating the Healthcare Enterprise Integration Profiles provide an implementation guide for equipment vendors Integration Profiles are an effective shorthand for healthcare providers to specify integration requirements when purchasing systems and therefore achieved considerable recognition in the market. IHE Integration Statements are simple documents prepared and published by a vendor to list the IHE Profiles supported by a specific release of a specific product. IHE Technical Frameworks are the detailed documents which specify the Integration Profiles and the associated actors (systems) and transactions. IHE Connectathons are annual events where equipment vendors bring products with IHE Profiles and test them with other vendors.
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External links
IHE Eye Care [2] Integrating the Healthcare Enterprise [3] IHE Asia-Pacific [4] IHE in Europe [5] The IHE Connectathon [6]
Healthcare Information and Management Systems Society [7] Radiological Society of North America [8] American College of Cardiology [9]
References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / connectathon-results. ihe-europe. net/ http:/ / www. iheeyecare. org http:/ / www. ihe. net http:/ / www. ihe. net. au http:/ / www. ihe-europe. net http:/ / www. connectathon. net http:/ / www. himss. org http:/ / www. rsna. org http:/ / www. acc. org
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Miscellanea
GIS and Public Health
Geographic Information Systems (GIS), or increasingly Geographic Information Science (GIScience), centers around combining computer mapping capabilities with additional database management and data analysis tools. Commercial GIS systems are very powerful and have touched many applications and industries, including environmental science, urban planning, agricultural applications, and others. Public Health is another focus area that has made increasing use of GIS techniques. A strict definition of public health is difficult to pin down, as it is used in different ways by different groups. In general, public health differs from personal health in that it is (1) focused on the health of populations rather than of individuals, (2) focused more on prevention than on treatment, and (3) operates in a mainly governmental (rather than private) context.[1] These efforts fall naturally within the domain of problems requiring use of spatial analysis as part of the solution, and GIS and other spatial analysis tools are therefore recognized as providing potentially transformational capabilities for public health efforts. This article presents some history of use of geographic information and geographic information systems in public health application areas, provides some examples showing the utilization of GIS techniques in solving specific public health problems, and finally addresses several potential issues arising from increased use of these GIS techniques in the public health arena.
History
Public Health efforts have been based on analysis and use of spatial data for many years. Dr. John Snow (physician), often credited as the father of epidemiology, is arguably the most famous of those examples.[2] Dr. Snow used a hand-drawn map to analyze the geographic locations of deaths related to cholera in London in the mid-1850s. His map, which superimposed the locations of cholera deaths with those of public water supplies, pinpointed the Broad Street pump as the most likely source of the cholera outbreak. Removal of the pump handle led to a rapid decline in the incidence of cholera, helping the medical community to eventually conclude that cholera was a water-borne disease. Dr. Snow's work provides an indication of how a GIS could Dr. Snow's map showing cholera cases in London during the epidemic of 1854. benefit public health investigations and other research. He continued to analyze his data, eventually showing that the incidence rate of cholera was also related to local elevation as well as soil type and alkalinity. Low-lying areas, particularly those with poorly draining soil, were found to have higher incidence rates for cholera, which Dr. Snow attributed to the pools of water that tended to collect there, again showing evidence that cholera was in fact a water-borne disease (rather than one borne by 'miasma' as was commonly believed at the time.[3] This is an early example of what has come to be known as disease diffusion mapping, an area of study based on the idea that a disease starts from some source or central point and then spreads throughout the local area according to
GIS and Public Health patterns and conditions there. This is another area of research where the capabilities of a GIS have been shown to be of help to practitioners.
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GIS for Public Health

Todays public health problems are much larger in scope than those Dr. Snow faced, and researchers today depend on modern GIS and other computer mapping applications to assist in their analyses. For example, see the map to the right depicting death rates from heart disease among white males above age 35 in the US between 2000 and 2004.[4] Public health informatics (PHI) is an emerging specialty which focuses on the application of information science and technology to public health More modern disease map showing deaths from heart disease among white males in the practice and research.[5] As part of that US from 2000-2004. effort, a GIS - or more generally a Spatial Decision Support System (SDSS) - offers improved geographic visualization techniques, leading to faster, better, and more robust understanding and decision-making capabilities in the public health arena.[6] For example, GIS displays have been used to show a clear relationship between clusters of emergent Hepatitis C cases and those of known intravenous drug users in Connecticut.[7] Causality is difficult to prove conclusively collocation does not establish causation but confirmation of previously established causal relationships (like intravenous drug use and Hepatitis C) can strengthen acceptance of those relationships, as well as help to demonstrate the utility and reliability of GIS-related solution techniques. Conversely, showing the coincidence of potential causal factors with the ultimate effect can help suggest a potential causal relationship, thereby driving further investigation and analysis (source needed?). Alternately, GIS techniques have been used to show a lack of correlation between causes and effects or between different effects. For example, the distributions of both birth defects and infant mortality in Iowa were studied, and the researchers found no relationship in those data.[8] This led to the conclusion that birth defects and infant mortality are likely unrelated, and are likely due to different causes and risk factors. GIS can support public health in different ways as well. First and foremost, GIS displays can help inform proper understanding and drive better decisions. For example, elimination of health disparities is one of two primary goals of Healthy People 2010, one of the preeminent public health programs in existence today in the US. GIS can play a significant role in that effort, helping public health practitioners identify areas of disparities or inequities, and ideally helping them identify and develop solutions to address those shortcomings. GIS can also help researchers integrate disparate data from a wide variety of sources, and can even be used to enforce quality control measures on those data. Much public health data is still manually generated, and is therefore subject to human-generated mistakes and miscoding. For example, geographic analysis of health care data from North Carolina showed that just over 40% of the records contained errors of some sort in the geographic information (city, county, or zip code), errors that would have gone undetected without the visual displays provided by GIS.[9] Correction of these errors led not only to more correct GIS displays, but also improved ALL analyses using those data.
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Issues with GIS for Public Health

There are also concerns or issues with use of GIS tools for public health efforts. Chief among those is a concern for privacy and confidentiality of individuals.[10] Public health is concerned about the health of the population as a whole, but must use data on the health of individuals to make many of those assessments, and protecting the privacy and confidentiality of those individuals is of paramount importance. Use of GIS displays and related databases raises the potential of compromising those privacy standards, so some precautions are necessary to avoid pinpointing individuals based on spatial data. For example, data may need to be aggregated to cover larger areas such as a zip code or county, helping to mask individual identities. Maps can also be constructed at smaller scales so that less detail is revealed. Alternately, key identifying features (such as the road and street network) can be left off the maps to mask exact location, or it may even be advisable to intentionally offset the location markers by some random amount if deemed necessary.[11] It is well established in the literature that statistical inference based on aggregated data can lead researchers to erroneous conclusions, suggesting relationships that in fact do not exist or obscuring relationships that do in fact exist. This issue is known as the Modifiable Areal Unit Problem. For example, New York public health officials worried that cancer clusters and causes would be misidentified after they were forced to post maps showing cancer cases by ZIP code on the internet. Their assertion was that ZIP codes were designed for a purpose unrelated to public health issues, and so use of these arbitrary boundaries might lead to inappropriate groupings and then to incorrect conclusions.[12] GIS can also be used to track the advancement of the sexually transmitted disease VGI.
Summary
Use of GIS in public health is an application area still in its infancy. Like most new applications, there is a lot of promise, but also a lot of pitfalls that must be avoided along the way. Many researchers and practitioners are concentrating of this effort, hoping that the benefits outweigh the risks and the costs associated with this emerging application area for modern GIS techniques.
Footnotes
[1] OCarroll, P.W. (2003). Introduction to public health informatics. In P.W. OCarroll, Y.A. Yasnoff, M.E. Ward, L.H. Ripp, and E.L. Martin (Ed.), Public Health Informatics (pp. 1-15). New York, NY: Springer. [2] Lumpkin, J.R. (2003). History and significance of information systems and public health. In P.W. OCarroll, Y.A. Yasnoff, M.E. Ward, L.H. Ripp, and E.L. Martin (Ed.), Public Health Informatics (pp. 16-38). New York, NY: Springer. [3] Hanchette, C.L. (2003). Geographic Information Systems. In P.W. OCarroll, Y.A. Yasnoff, M.E. Ward, L.H. Ripp, and E.L. Martin (Ed.), Public Health Informatics (pp. 431-466). New York, NY: Springer. [4] http:/ / www. cdc. gov/ nchs/ data/ gis/ atmappne. pdf, retrieved March 29, 2009. [5] Hanchette, C.L. (2003). Geographic Information Systems. In P.W. OCarroll, Y.A. Yasnoff, M.E. Ward, L.H. Ripp, and E.L. Martin (Ed.), Public Health Informatics (pp. 431-466). New York, NY: Springer. [6] Yasnoff, W.A. and Miller, P.L. (2003). Decision Support and Expert Systems in Public Health. In P.W. OCarroll, Y.A. Yasnoff, M.E. Ward, L.H. Ripp, and E.L. Martin (Ed.), Public Health Informatics (pp. 494-512). New York, NY: Springer. [7] Trooskin S, Hadler J, St. Louis T, and Navarro V (2005). Geospatial analysis of hepatitis C in Connecticut: a novel application of a public health tool. Public Health, 119(11), 1042-7. Retrieved from Academic Search Premier database. [8] Rushton, G., Krishnamurthy, R., Krishnamurti, D., Lolonis, P., and Song, H. (1996). The spatial relationship between infant mortality and birth defects rates in a US city. Statistics in Medicine, 15, Retrieved from Academic Search Premier database.1907-19. Retrieved from Academic Search Premier database. [9] Hanchette, C.L. (2003). Geographic Information Systems. In P.W. OCarroll, Y.A. Yasnoff, M.E. Ward, L.H. Ripp, and E.L. Martin (Ed.), Public Health Informatics (pp. 431-466). New York, NY: Springer. [10] Hanchette, C.L. (2003). Geographic Information Systems. In P.W. OCarroll, Y.A. Yasnoff, M.E. Ward, L.H. Ripp, and E.L. Martin (Ed.), Public Health Informatics (pp. 431-466). New York, NY: Springer. [11] Hanchette, C.L. (2003). Geographic Information Systems. In P.W. OCarroll, Y.A. Yasnoff, M.E. Ward, L.H. Ripp, and E.L. Martin (Ed.), Public Health Informatics (pp. 431-466). New York, NY: Springer.

[12] Rushton G, Elmes G, McMaster R (2003). Considerations for improving geographic information research in public health. URISA Journal, 12(2), 31-49.
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Neuroinformatics
Neuroinformatics is a research field encompassing the organization of neuroscience data by the application of computational models and analytical tools. These areas of research are important for the integration and analysis of increasingly fine grain experimental data and for improving existing theories about nervous system and brain function. Neuroinformatics provides tools, creates databases and the possibilities for interoperability between and among databases, models, networks technologies and models for the clinical and research purposes in the neuroscience community and other fields. Neuroinformatics stands at the intersection of neuroscience and information science. Other sciences, like genomics, have proved the effectiveness of data sharing through databases and by applying theoretical and computational models for solving complex problems in the field. Through neuroinformatics facilities, researchers can share their data and contribute to other disciplines using available tools for the analysis and integration of data. Researchers can also more easily quantitatively confirm their working theories by means of computational modeling. Additionally, neuroinformatics fosters more collaborative research of which one aim is to provide better possibilities to study the brain at multiple levels of brain structure. There are three main directions where neuroinformatics has to be applied: 1. the development of tools and databases for management and sharing of neuroscience data at all levels of analysis, 2. the development of tools for analyzing and modeling, 3. the development of computational models of the nervous system and neural processes. In the recent decade, as vast amounts of diverse data about the brain was gathered by many research groups, the problem was raised of how to integrate the data from thousands of publications in order to enable efficient tools for further research. The biological and neuroscience data are highly interconnected and complex, and by itself represents a great challenge for scientists. Combining informatics research and brain research provides benefits for both fields of science. On one hand, informatics facilitates brain data processing and data handling, by providing new electronic and software technologies for arranging databases, modeling and communication in brain research. On the another hand, enhanced discoveries in the field of neuroscience will invoke the development of new methods in information technologies (IT).
History
Starting in 1989, the United States National Institute of Mental Health (NIMH), the National Institute of Drug Abuse (NIDA) and the National Science Foundation (NSF) provided the National Academy of Sciences Institute of Medicine with funds to undertake a careful analysis and study of the need to create databases, share neuroscientific data and to examine how the field of information technology could create the tools needed for the increasing volume and modalities of neuroscientific data. The positive recommendations were reported in 1991 (Mapping The Brain And Its Functions. Integrating Enabling Technologies Into Neuroscience Research." National Academy Press, Washington, D.C. ed. Pechura, C.M., and Martin, J.B.) This positive report enabled NIMH, now directed by Allan Leshner, to create the "Human Brain Project (HBP), with the first grants awarded in 1993. The HBP was led by Koslow along with cooperative efforts of other NIH Institutes, the NSF, the National Aeronautics and Space Administration and the Department of Energy. The HPG and grant-funding initiative in this area slightly preceded the explosive expansion of the World Wide Web. From 1993 through 2004 this program grew to over 100 million dollars in funded grants.
Neuroinformatics Next, Koslow pursued the globalization of the HPG and neuroinformatics through the European Union and the Office for Economic Cooperation and Development (OECD), Paris, France. Two particular opportunities occurred in 1996. The first was the existence of the US/European Commission Biotechnology Task force co-chaired by Mary Clutter from NSF. Within the mandate of this committee, of which Koslow was a member the United States European Commission Committee on Neuroinformatics was established and co-chaired by Koslow from the United States. This committee resulted in the European Commission initiating support for neuroinformatics in Framework 5 and it has continued to support activities in neuroinformatics research and training. A second opportunity for globalization of neuroinformatics occurred when the participating governments of the Mega Science Forum (MSF) of the OECD were asked if they had any new scientific initiatives to bring forward for scientific cooperation around the globe. The White House Office on Science and Technology Policy requested that agencies in the federal government meet at NIH to decide if cooperation were needed that would be of global benefit. The NIH held a series of meetings in which proposals from different agencies were discussed. The proposal recommendation from the U.S. for the MSF was a combination of the NSF and NIH proposals. Jim Edwards of NSF supported databases and data-sharing in the area of biodiversity; Koslow proposed the HPG as a model for sharing neuroscientific data, with the new moniker of neuroinformatics. The two related initiates were combined to form the United States proposal on Biological Informatics. This initiative was supported by the White House Office on Science and Technology Policy and presented at the OECD MSF by Edwards and Koslow. An MSF committee was established on Biological Informatics with two subcommittees: 1. Biodiversity (Chair, James Edwards, NSF), and 2. Neuroinformatics (Chair, Stephen Koslow, NIH). At the end of two years the Neuroinformatics subcommittee of the Biological Working Group issued a report supporting a global neuroinformatics effort. Koslow, working with the NIH and the White House Office on Science and Technology Policy to establishing a new Neuroinformatics working group to develop specific recommendation to support the more general recommendations of the first report. The Global Science Forum (GSF; renamed from MSF) of the OECD supported this recommendation.
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The International Neuroinformatics Coordinating Facility

This committee presented 3 recommendations to the member governments of GSF. These recommendations were: 1. National neuroinformatics programs should be continued or initiated in each country should have a national node to both provide research resources nationally and to serve as the contact for national and international coordination. 2. An International Neuroinformatics Coordinating Facility (INCF) should be established. The INCF will coordinate the implementation of a global neuroinformatics network through integration of national neuroinformatics nodes. 3. A new international funding scheme should be established. This scheme should eliminate national and disciplinary barriers and provide a most efficient approach to global collaborative research and data sharing. In this new scheme, each country will be expected to fund the participating researchers from their country. The GSF neuroinformatics committee then developed a business plan for the operation, support and establishment of the INCF which was supported and approved by the GSF Science Ministers at its 2004 meeting. In 2006 the INCF was created and its central office established and set into operation at the Karolinska Institute, Stockholm, Sweden under the leadership of Sten Grillner. Sixteen countries (Australia, Canada, China, the Czech Republic, Denmark, Finland, France, Germany, India, Italy, Japan, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom and the United States), and the EU Commission established the legal basis for the INCF and Programme in International Neuroinformatics (PIN). To date, fourteen countries (Czech Republic, Finland, France, Germany, Italy, Japan, Norway, Sweden, Switzerland, and the United States) are members of the INCF. Membership is pending for several other countries.
Neuroinformatics The goal of the INCF is to coordinate and promote international activities in neuroinformatics. The INCF contributes to the development and maintenance of database and computational infrastructure and support mechanisms for neuroscience applications. The system is expected to provide access to all freely accessible human brain data and resources to the international research community. The more general task of INCF is to provide conditions for developing convenient and flexible applications for neuroscience laboratories in order to improve our knowledge about the human brain and its disorders.
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Society for Neuroscience Brain Information Group

On the foundation of all of these activities, Huda Akil, the 2003 President of the Society for Neuroscience (SfN) established the Brain Information Group (BIG) to evaluate the importance of neuroinformatics to neuroscience and specifically to the SfN. Following the report from BIG, SfN also established a neuroinformatics committee. In 2004, SfN announced the Neuroscience Database Gateway (NDG) as a universal resource for neuroscientists through which almost any neuroscience databases and tools may be reached. The NDG was established with funding from NIDA, NINDS and NIMH. The Neuroscience Database Gateway has transitioned to a new enhanced platform, the Neuroscience Information Framework (http:/ / www. neuinfo. org). Funded by the NIH Neuroscience BLueprint, the NIF is a dynamic portal providing access to neuroscience-relevant resources (data, tools, materials) from a single search interface. The NIF builds upon the foundation of the NDG, but provides a unique set of tools tailored especially for neuroscientists: a more expansive catalog, the ability to search multiple databases directly from the NIF home page, a custom web index of neuroscience resources, and a neuroscience-focused literature search function.
Collaboration with other disciplines

Neuroinformatics is formed at the intersections of the following fields: neuroscience computer science biology experimental psychology medicine engineering physical sciences mathematics chemistry
Biology is concerned with molecular data (from genes to cell specific expression); medicine and anatomy with the structure of synapses and systems level anatomy; engineering electrophysiology (from single channels to scalp surface EEG), brain imaging; computer science databases, software tools, mathematical sciences models, chemistry neurotransmitters, etc. Neuroscience uses all aforementioned experimental and theoretical studies to learn about the brain through its various levels. Medical and biological specialists help to identify the unique cell types, and their elements and anatomical connections. Functions of complex organic molecules and structures, including a myriad of biochemical, molecular, and genetic mechanisms which regulate and control brain function, are determined by specialists in chemistry and cell biology. Brain imaging determines structural and functional information during mental and behavioral activity. Specialists in biophysics and physiology study physical processes within neural cells neuronal networks. The data from these fields of research is analyzed and arranged in databases and neural models in order to integrate various elements into a sophisticated system; this is the point where neuroinformatics meets other disciplines. Neuroscience provides the following types of data and information on which neuroinformatics operates:
Neuroinformatics Molecular and cellular data (ion channel, action potential, genetics, cytology of neurons, protein pathways), Data from organs and systems (visual cortex, perception, audition, sensory system, pain, taste, motor system, spinal cord), Cognitive data (language, emotion, motor learning, sexual behavior, decision making, social neuroscience), Developmental information (neuronal differentiation, cell survival, synaptic formation, motor differentiation, injury and regeneration, axon guidance, growth factors), Information about diseases and aging (autonomic nervous system, depression, anxiety, Parkinson's disease, addiction, memory loss), Neural engineering data (brain-computer interface), and Computational neuroscience data (computational models of various neuronal systems, from membrane currents, proteins to learning and memory). Neuroinformatics uses databases, the Internet, and visualization in the storage and analysis of the aforementioned neuroscience data.
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Research programs and groups

Neuroscience Information Framework
The Neuroscience Information Framework (NIF) is an initiative of the NIH Blueprint for Neuroscience Research, which was established in 2004 by the National Institutes of Health. Unlike general search engines, NIF provides deeper access to a more focused set of resources that are relevant to neuroscience, search strategies tailored to neuroscience, and access to content that is traditionally hidden from web search engines. The NIF is a dynamic inventory of neuroscience databases, annotated and integrated with a unified system of biomedical terminology] (i.e. NeuroLex). NIF supports concept-based queries across multiple scales of biological structure and multiple levels of biological function, making it easier to search for and understand the results. NIF will also provide a registry through which resources providers can disclose availability of resources relevant to neuroscience research. NIF is not intended to be a warehouse or repository itself, but a means for disclosing and locating resources elsewhere available via the web.
Genes to Cognition
A neuroscience research programme that studies genes, the brain and behaviour in an integrated manner. It is engaged in a large-scale investigation of the function of molecules found at the synapse. This is mainly focused on proteins that interact with the NMDA receptor, a receptor for the neurotransmitter, glutamate, which is required for processes of synaptic plasticity such as long-term potentiation (LTP). Many of the techniques used are high-throughput in nature, and integrating the various data sources, along with guiding the experiments has raised numerous informatics questions. The program is primarily run by Professor Seth Grant at the Wellcome Trust Sanger Institute, but there are many other teams of collaborators across the world.
Neurogenetics: GeneNetwork
Genenetwork started as component of the NIH Human Brain Project in 1999 with a focus on the genetic analysis of brain structure and function. This international program consists of tightly integrated genome and phenome data sets for human, mouse, and rat that are designed specifically for large-scale systems and network studies relating gene variants to differences in mRNA and protein expression and to differences in CNS structure and behavior. The great majority of data are open access. GeneNetwork has a companion neuroimaging web sitethe Mouse Brain Librarythat contains high resolution images for thousands of genetically defined strains of mice.
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The Blue Brain Project

The Blue Brain Project was founded in May 2005, and uses an 8000 processor Blue Gene/L supercomputer developed by IBM. At the time, this was one of the fastest supercomputers in the world. The project involves: Databases: 3D reconstructed model neurons, synapses, synaptic pathways, microcircuit statistics, computer model neurons, virtual neurons. Visualization: microcircuit builder and simulation results visualizator, 2D, 3D and immersive visualization systems are being developed. Simulation: a simulation environment for large scale simulations of morphologically complex neurons on 8000 processors of IBM's Blue Gene supercomputer. Simulations and experiments: iterations between large scale simulations of neocortical microcircuits and experiments in order to verify the computational model and explore predictions. The mission of the Blue Brain Project is to understand mammalian brain function and dysfunction through detailed simulations. The Blue Brain Project will invite researchers to build their own models of different brain regions in different species and at different levels of detail using Blue Brain Software for simulation on Blue Gene. These models will be deposited in an internet database from which Blue Brain software can extract and connect models together to build brain regions and begin the first whole brain simulations.
The Neuroinformatics Portal Pilot

The project is part of a larger effort to enhance the exchange of neuroscience data, data-analysis tools, and modeling software. The portal is supported from many members of the OECD Working Group on Neuroinformatics. The Portal Pilot is promoted by the German Ministry for Science and Education.
The Neuronal Time Series Analysis (NTSA)

NTSA Workbench is a set of tools, techniques and standards designed to meet the needs of neuroscientists who work with neuronal time series data. The goal of this project is to develop information system that will make the storage, organization, retrieval, analysis and sharing of experimental and simulated neuronal data easier. The ultimate aim is to develop a set of tools, techniques and standards in order to satisfy the needs of neuroscientists who work with neuronal data.
Japan national neuroinformatics resource

The Visiome Platform is the Neuroinformatics Search Service that provides access to mathematical models, experimental data, analysis libraries and related resources.
The CARMEN project

The CARMEN [1] project is a multi-site (11 universities in the United Kingdom) research project aimed at using GRID computing to enable experimental neuroscientists to archive their datasets in a structured database, making them widely accessible for further research, and for modellers and algorithm developers to exploit.
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Research groups
The Institute of Neuroinformatics (INI) was established at the University of Zurich at the end of 1995. The mission of the Institute is to discover the key principles by which brains work and to implement these in artificial systems that interact intelligently with the real world. The THOR Center for Neuroinformatics was established April 1998 at the Department of Mathematical Modelling, Technical University of Denmark. Besides pursuing independent research goals, the THOR Center hosts a number of related projects concerning neural networks, functional neuroimaging, multimedia signal processing, and biomedical signal processing. Netherlands state program in neuroinformatics started in the light of the international OECD Global Science Forum which aim is to create a worldwide program in Neuroinformatics. Shun-ichi Amari, Laboratory for Mathematical Neuroscience, RIKEN Brain Science Institute Wako, Saitama, Japan. The target of Laboratory for Mathematical Neuroscience is to establish mathematical foundations of brain-style computations toward construction of a new type of information science. Gary Egan, Neuroimaging & Neuroinformatics, Howard Florey Institute, University of Melbourne, Melbourne, Australia. Institute scientists utilize brain imaging techniques, such as magnetic resonance imaging, to reveal the organization of brain networks involved in human thought. Andreas VM Herz Computational Neuroscience, ITB, Humboldt-University Berlin, Berlin Germany. This group focuses on computational neurobiology, in particular on the dynamics and signal processing capabilities of systems with spiking neurons. Nicolas Le Novre, EBI Computational Neurobiology, EMBL-EBI Hinxton, United Kingdom. The main goal of the group is to build realistic models of neuronal function at various levels, from the synapse to the micro-circuit, based on the precise knowledge of molecule functions and interactions (Systems Biology) The Neuroinformatics Group in Bielefeld has been active in the field of Artificial Neural Networks since 1989. Current research programmes within the group are focused on the improvement of man-machine-interfaces, robot-force-control, eye-tracking experiments, machine vision, virtual reality and distributed systems.
Books in the field

Computing the Brain: A Guide to Neuroinformatics by Michael A. Arbib and Jeffrey S. Grethe, Electronic Collaboration in Science (Progress in Neuroinformatics Research Series) by Stephen H. Koslow and Michael F. Huerta, Databasing the Brain: From Data to Knowledge (Neuroinformatics) by Steven H. Koslow and Shankar Subramaniam, Neuroinformatics: An Overview of the Human Brain Project (Progress in Neuroinformatics Research Series) by Stephen H. Koslow and Michael F. Huerta, Neuroscience Databases: A Practical Guide by Rolf Ktter, Brain Mapping: The Methods, Second Edition by Arthur W. Toga and John C. Mazziott, Biomedical Informatics: Computer Applications in Health Care and Biomedicine (Health Informatics) by James J. Cimino and Edward H. Shortliffe. Computational Neuroanatomy: Principles and Methods edited by Giorgio Ascoli Observed Brain Dynamics by Partha P. Mitra and Hemant Bokil
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Journals in the field

Frontiers in Neuroinformatics [2] open-access journal receiving submissions from all areas of neuroinformatics, Neuroinformatics [3] The aim of this journal is to encourage, facilitate, and disseminate the use of software tools and databases in the neuroscience community to discover the key principles by which brains work Journal of Computational Neuroscience [4] PLoS Computational Biology [5] Biological Cybernetics [6] Neural Computation [7] Journal on Web Semantics [8]. Theory and Applications, Artificial Intelligence, Journal of Integrative Neuroscience. Journal of Neuroscience, Neural Information Processing. Letters and Review Neuroscience, Computational, Neuroinformatics, Theory and Applications, Interdisciplinary Description of Complex Systems. General science, Neuron. General Neuroscience, Cellular Neuroscience, Science. General Science
Technologies and developments

The main technological tendencies in neuroinformatics are: 1. Application of computer science for building databases, tools, and networks in neuroscience; 2. Analysis and modeling of neuronal systems. In order to organize and operate with neural data scientists need to use the standard terminology and atlases that precisely describe the brain structures and their relationships. BrainML is a system that provides a standard XML metaformat for exchanging neuroscience data. Grid computing is an emerging computing model that provides the ability to perform higher productivity and speed in computing by using connection of many networked computers to model a virtual computer architecture that is able to distribute process execution across a parallel infrastructure. Grids use the resources of many separate computers connected by a network (usually the Internet) to solve large-scale computation problems. Grids provide the ability to perform computations on large data sets, by breaking them down into many smaller ones, or provide the ability to perform many more computations at once than would be possible on a single computer. Grid network systems are very important in the neuroscience research because of temporary nature of the neurosciences web-sources; its common for such data to disappear due to maintain problems of the websites. Storage Resource Broker one of the most advanced grid systems can offer the obvious advantages for neuronal research. The Biomedical Informatics Research Network (BIRN) is a good example of the advance grid system for neuroscience. BIRN is a geographically distributed virtual community of shared resources offering vast scope of services to advance the diagnosis and treatment of disease. The BIRN enhance the communication and collaboration between research disciplines, such as biomedical and clinical by providing necessary tools and technologies for biomedical community. BIRN allow combining databases, interfaces and tools into a single environment. The data exchange between cells and structures of the bran are very complicated and interconnected process. The expressed genes and changes in their expressions are good tools for determining current state of the brain and for evaluating its function. The gene expression analysis helps to find out the reasons of brain disease rising from genes. GeneWays system concerned with cellular morphology and circuits. GeneWays is a system for automatically extracting, analyzing, visualizing and integrating molecular pathway data from the research literature. The system focuses on interactions between molecular substances and actions, providing a graphical view on the collected information and allows researchers to review and correct the integrated information. Mathematical modeling is very important for neuroinformatics such as models on cellular and neuronal levels.
Neuroinformatics Neocortical Microcircuit Database (NMDB). A profound database of versatile brains data from cells to complex structures. Researchers are able not only to add data to the database but also to acquire and edit one. SenseLab a collection of multilevel neuronal databases and tools. SenseLab contains six related databases that support experimental and theoretical research on the membrane properties that mediate information processing in nerve cells, using the olfactory pathway as a model system. Detailed imaging of brain structure and function is provided by the web-based high-resolution anatomical brain atlases. One of the examples is a BrainMaps.org. BrainMaps.org is an interactive high-resolution digital brain atlas using a high-speed database and virtual microscope that is based on over 12 million megapixels of scanned images of several species, including human. Another approach in the area of the brain mappings is the probabilistic atlases obtained from the real data from different group of people, formed by specific factors, like age, gender, diseased etc. Provides more flexible tools for brain research and allow obtaining more reliable and precise results, which cannot be achieved with the help of traditional brain atlases.
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References
Daniel Gardner and Gordon M. Shepherd (2004). "A gateway to the future of Neuroinformatics". Neuroinformatics 2 (3): 271274. doi:10.1385/NI:2:3:271. PMID15365191. Giorgio A. Ascoli, Erik De Schutter and David N. Kennedy. "An information science infrastructure for neuroscience". Neuroinformatics 3 (1): 12. ISSN1539-2791. PMID15055390. Society for neuroscience Annual Report. Navigating a changing landscape. FY2006 Stephen H. Koslow, Michael F. Huerta, Neuroinformatics. An overview of the Human Brain Project F. Beltrame and Stephen H. Koslow (September 1999). "Neuroinformatics as a megascience issue". IEEE Trans. Inf. Technol. Biomed. 3: 239240. doi:10.1109/4233.788587. Steven H. Koslow and Shankar Subramaniam (2005). Databasing the Brain: From Data to Knowledge, (Neuroinformatics). John Wiley & Sons. ISBN0471309214. M. A. Arbib and J. S. Grethe, Computing the Brain, A Guide to Neuroinformatics. San Diego, CA, USA, 2001.
References
[1] [2] [3] [4] [5] [6] [7] [8] http:/ / www. carmen. org. uk/ http:/ / frontiersin. org/ neuroinformatics http:/ / www. springerlink. com/ content/ 120559/ http:/ / www. springerlink. com/ content/ 100282/ http:/ / www. ploscompbiol. org http:/ / www. springerlink. com/ content/ 100465/ http:/ / www. mitpressjournals. org/ loi/ neco http:/ / ees. elsevier. com/ jws/
Healthcare Effectiveness Data and Information Set
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The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks. Although not originally intended for trending, HEDIS results are increasingly used to track year-to-year performance. HEDIS is one component of NCQA's accreditation process, although some plans submit HEDIS data without s. An incentive for many health plans to collect HEDIS data is a Centers for Medicare and Medicaid Services (CMS) requirement that Health maintenance organizations (HMOs) submit Medicare HEDIS data in order to provide HMO services for Medicare enrollees under a program called Medicare Advantage.
HEDIS 2006 Volume 2: Technical Specifications
History
HEDIS was originally titled the "HMO Employer Data and Information Set" as of version 1.0 of 1991.[1] In 1993, Version 2.0 of HEDIS was known as the "Health Plan Employer Data and Information Set".[2] Version 3.0 of HEDIS was released in 1997.[1] In July 2007, NCQA announced that meaning of "HEDIS" would be changed to "Healthcare Effectiveness Data and Information Set".[3] In current usage, the "reporting year" after the term "HEDIS" is one year following the year reflected in the data; for example, "HEDIS 2009" reports, which will be available in June 2009, will contain analyses of data collected from "measurement year" JanuaryDecember 2008.[4]
Structure
The 71 HEDIS measures are divided into eight "domains of care"[5] [6] : Effectiveness of Care Access/Availability of Care Satisfaction With the Experience of Care Use of Services Cost of Care Health Plan Descriptive Information Health Plan Stability Informed Health Care Choices
Measures are added, deleted, and revised annually. For example, a measure for the length of stay after giving birth was deleted after legislation mandating minimum length of stay rendered this measure nearly useless. Increased attention to medical care for seniors prompted the addition of measures related to glaucoma screening and osteoporosis treatment for older adults. Other health care concerns covered by HEDIS are immunizations, cancer
Healthcare Effectiveness Data and Information Set screenings, treatment after heart attacks, diabetes, asthma, flu shots, access to services, dental care, alcohol and drug dependence treatment, timeliness of handling claims and phone calls, prenatal and postpartum care, mental health care, well-care or preventive visits, inpatient utilization, drug utilization, and distribution of members by age, sex, and product lines. New measures in HEDIS 2009 include "Adult BMI Assessment," "Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents," "Care for Older Adults," and "Medication Reconciliation Post-Discharge".[6]
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Data collection
HEDIS data are collected through surveys, medical charts and insurance claims for hospitalizations, medical office visits and procedures. Survey measures must be conducted by an NCQA-approved external survey organization. Clinical measures use the administrative or hybrid data collection methodology, as specified by NCQA. Administrative data are electronic records of services, including insurance claims and registration systems from hospitals, clinics, medical offices, pharmacies and labs. For example, a measure titled Childhood Immunization Status requires health plans to identify 2 year old children who have been enrolled for at least a year. The plans report the percentage of children who received specified immunizations. Plans may collect data for this measure by reviewing insurance claims or automated immunization records, but this method will not include immunizations received at community clinics that do not submit insurance claims. For this measure, plans are allowed to select a random sample of the population and supplement claims data with data from medical records. By doing so, plans may identify additional immunizations and report more favorable and accurate rates. However, the hybrid method is more costly, time-consuming and requires nurses or medical record reviewers who are authorized to review confidential medical records.
Reporting
HEDIS results must be audited by an NCQA-approved auditing firm for public reporting. NCQA has an on-line reporting tool called Quality Compass that is available for a fee of several thousand dollars. It provides detailed data on all measures and is intended for employers, consultants and insurance brokers who purchase health insurance for groups. NCQA's web site includes a summary of HEDIS results by health plan. NCQA also collaborates annually with US News and World Report to rank HMOs using an index that combines many HEDIS measures and accreditation status. The "Best Health Plans" list is published in the magazine in October and is available on the magazine's web site. Other local business organizations, governmental agencies and media report HEDIS results, usually when they are released in the fall.

Advantages
Proponents cite the following advantages of HEDIS measures: HEDIS measures undergo a selection process that has been described as "rigorous"[7] (p.205). Steps in the process include assessment of a measure's "importance, scientific soundness and feasibility"; field testing; public comment; a one-year trial period in which results are not reported publicly; and evaluation of publicly reported measures by "statistical analysis, review of audit results and user comments".[8] HEDIS data are useful for "evaluating current performance and setting goals".[9] In some studies, attainment of HEDIS measures is associated with cost-effective practices or with better health outcomes. In a 2002 study, HEDIS measures "generally reflect[ed] cost-effective practices".[10]
Healthcare Effectiveness Data and Information Set A 2003 study of Medicare managed care plans determined that plan-level health outcomes were associated with HEDIS measures.[11] An "Acute Outpatient Depression Indicator" score based on a HEDIS measure predicted improvement in depression severity in one 2005 study.[12] As stated in a 2006 Institute of Medicine (IOM) report, "HEDIS measures focus largely on processes of care";[13] the strengths of process measures include the facts that they "reflect care that patients actually receive," thereby leading to "buy-in from providers," and that they are "directly actionable for quality improvement activities"[13] (p.179) . HEDIS measures are "widely known and accepted"[7] (p.205). The NCQA claims that over 90% of U.S. health plans use HEDIS measures.[5]
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Disadvantages
HEDIS was described in 1995 as "very controversial".[14] Criticisms of HEDIS measures have included: HEDIS measures do not account for many important aspects of health care quality. In 1998, HEDIS measures were said to "offer little insight into... [a health] plans ability to treat serious illnesses".[15] A 2002 study found "there are numerous non-HEDIS interventions with some evidence of cost effectiveness, particularly interventions to promote healthy behaviors".[10] According to a 2005 study, HEDIS-Medicaid 3.0 measures covered only 22% of the services recommended by the second U.S. Preventive Services Task Force (USPSTF).[16] Attempts by health care providers to improve their HEDIS measures may cause harm to patients. As of 2001, there was concern that the asthma HEDIS measure may "encourag[e] more casual prescribing of controller medications" and may place emphasis "on the prescribing of a controller medication rather than on its actual use".[17] There is a risk of hypoglycemia if a provider strives to meet the HEDIS measure concerning a hemoglobin A1c (HbA1c) level of <7% that was adopted in 2006 for HEDIS 2007.[18] NCQA later decided to not report results of the HbA1c<7% measure publicly in 2008, to modify the HbA1c<7% measure for HEDIS 2009 "by adding exclusions for members within a specific age cohort and with certain comorbid conditions," and to add a new HbA1c<8% measure.[19] The process to develop HEDIS measures may be flawed. There is a possible conflict of interest because NCQA "works closely with the managed-care industry".[14] Furthermore, approximately half of NCQA's budget is derived from accreditation fees, "which may create an incentive against setting [HEDIS] standards too high".[20] The process to develop the measures is not completely "transparent," that is, "information about existing conditions, decisions and actions" is not completely "accessible, visible and understandable.[18] In some cases, attainment of HEDIS measures is not proven to be associated with better health outcomes. In 2004, a multi-site study determined that persons with persistent asthma per the HEDIS definition at the time had more "asthma-related adverse events" if they were classified by HEDIS as having appropriate asthma therapy than if they did not have appropriate therapy.[21] This cause of this "unexpected" finding was thought to be that some people with intermittent asthma were miscategorized by HEDIS as having persistent asthma.[21] A 2008 study of 1056 adults with asthma found that "compliance with the HEDIS asthma measure is not favorably associated with relevant patient-oriented outcomes" such as scores on an Asthma Control Test.[22] Although "glaucoma screening in older adults" is a current HEDIS measure,[6] the USPSTF found "insufficient evidence to recommend for or against screening adults for glaucoma" in 2005;[23] as of 2008, the American
Healthcare Effectiveness Data and Information Set Academy of Ophthalmology was attempting to convince the USPSTF to review its statement.[24] Furthermore, a 2006 Cochrane review ("last assessed as up-to-date" in 2009) concluded that there was "insufficient evidence to recommend population based screening" for glaucoma because no pertinent randomized controlled trials exist.[25] One summary of the Cochrane review was "population-based screening for glaucoma... is not clinically or cost-effective".[26] A 2001 IOM report noted that "there is incomplete reporting of [HEDIS] measures and health plans resulting in lack of representativeness at the national level"[7] (p.205). As stated in the 2006 IOM report, the limitations of HEDIS process measures include "sample size constraints for condition-specific measures," "may be confounded by patient compliance and other factors," and "variable extent to which process measures link to important patient outcomes"[13] (p.179).
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References
[1] Mainous AG 3rd, Talbert J. Assessing quality of care via HEDIS 3.0. Is there a better way? (http:/ / archfami. ama-assn. org/ cgi/ reprint/ 7/ 5/ 410. pdf) Arch Fam Med 1998 Sep-Oct;7(5):410-3. Accessed 2009 Apr 28. [2] Schauffler HH, Rodriguez T. Exercising purchasing power for preventive care. (http:/ / content. healthaffairs. org/ cgi/ reprint/ 15/ 1/ 73. pdf) Health Aff (Millwood) 1996 Spring;15(1):73-85. Accessed 2009 Apr 25. [3] Measures assessing resource use highlight HEDIS 2008 (http:/ / ncqa. org/ tabid/ 517/ Default. aspx) (news release). Washington, D.C.: National Committee for Quality Assurance, 2007 Jul 11. Accessed 2009 Apr 25. [4] HEDIS 2010 public comment overview. (http:/ / www. ncqa. org/ Portals/ 0/ PublicComment/ HEDIS2010/ NCQA_HEDIS_2010_Public_Comment_Overview. pdf) Washington, D.C.: National Committee for Quality Assurance, 2009. Accessed 2009 Apr 25. [5] What is HEDIS? (http:/ / www. ncqa. org/ tabid/ 187/ Default. aspx) Washington, D.C.: National Committee for Quality Assurance. Accessed 2009 Apr 25. [6] HEDIS 2009 summary table of measures, product lines and changes. (http:/ / www. ncqa. org/ Portals/ 0/ HEDISQM/ HEDIS2009/ 2009_Measures. pdf) Washington, D.C.: National Committee for Quality Assurance, 2008. Accessed 2009 Apr 25. [7] Institute of Medicine. Envisioning the national health care quality report. (http:/ / www. nap. edu/ catalog. php?record_id=10073) Washington, D.C.: National Academy Press, 2001. ISBN 0-309-07343-X. Accessed 2009 May 6. [8] HEDIS life cycle. (http:/ / www. ncqa. org/ tabid/ 425/ Default. aspx) Washington, D.C.: National Committee for Quality Assurance. Accessed 2009 May 6. [9] Scanlon DP, Darby C, Rolph E, Doty HE. The role of performance measures for improving quality in managed care organizations. (http:/ / www. pubmedcentral. nih. gov/ picrender. fcgi?artid=1089245& blobtype=pdf) Health Serv Res 2001 Jul;36(3):619-41. Accessed 2009 Apr 28. [10] Neumann PJ, Levine BS. Do HEDIS measures reflect cost-effective practices? (http:/ / www. ajpm-online. net/ article/ S0749-3797(02)00516-0) Am J Prev Med 2002 Nov;23(4):276-89. Accessed 2009 May 6. [11] Ware J, Rogers W, Gandek B, Haffer SC, Bierman AS, Kang JL. Is there a relationship between health outcomes and HEDIS quality performance measures in managed care? Plan-level results from the Medicare Health Outcomes Survey. (http:/ / gateway. nlm. nih. gov/ MeetingAbstracts/ ma?f=102275360. html) Abstr AcademyHealth Meet 2003;20:abstract no. 382. Accessed 2009 May 6. [12] Rost K, Dickinson LM, Fortney J, Westfall J, Hermann RC. Clinical improvement associated with conformance to HEDIS-based depression care. (http:/ / www. springerlink. com/ content/ t564284p27w043j6/ ) Ment Health Serv Res 2005 Jun;7(2):103-12. Accessed 2009 May 6. [13] Institute of Medicine. Performance measurement: accelerating improvement. (http:/ / www. nap. edu/ catalog. php?record_id=11517) Washington, DC: National Academies Press; 2006. ISBN 978-0-309-10007-6. Accessed 2009 Apr 28. [14] Epstein A. Performance reports on quality--prototypes, problems, and prospects. (http:/ / content. nejm. org/ cgi/ content/ extract/ 333/ 1/ 57) N Engl J Med. 1995 Jul 6;333(1):57-61. Accessed 2009 Apr 28. [15] Mainous AG 3rd, Talbert J. Assessing quality of care via HEDIS 3.0. Is there a better way? (http:/ / archfami. ama-assn. org/ cgi/ content/ full/ 7/ 5/ 410) Arch Fam Med 1998 Sep-Oct;7(5):410-3. Accessed 2009 May 7. [16] Levine RS, Briggs NC, Husaini BA, Foster I, Hull PC, Pamies RJ, Tropez-Sims S, Emerson JS. HEDIS prevention performance indicators, prevention quality assessment and Healthy People 2010. (http:/ / muse. jhu. edu/ login?uri=/ journals/ journal_of_health_care_for_the_poor_and_underserved/ v016/ 16. 4Alevine. html) J Health Care Poor Underserved 2005 Nov;16(4 Suppl A):64-82. Accessed 2009 May 6. [17] Glauber JH. Does the HEDIS asthma measure go far enough? (http:/ / www. ajmc. com/ media/ pdf/ AJMC2001junGlauber575_579. pdf) Am J Manag Care 2001;7:575-579. Accessed 2009 May 6. [18] Aron D, Pogach L. Transparency standards for diabetes performance measures. (http:/ / jama. ama-assn. org/ cgi/ content/ extract/ 301/ 2/ 210) JAMA 2009 Jan 14;301(2):210-2. Accessed 2009 May 6. [19] HEDIS 2009, volume 2: technical update. (http:/ / www. ncqa. org/ Portals/ 0/ PolicyUpdates/ HEDIS Technical Updates/ 2009_Vol2_Technical_Update. pdf) Washington, D.C.: National Committee for Quality Assurance, 2008 Oct 1. Accessed 2009 May 6.

[20] Kuttner R. Must good HMOs go bad? Second of two parts. The search for checks and balances. (http:/ / content. nejm. org/ cgi/ content/ extract/ 338/ 22/ 1635) N Engl J Med 1998 May 28;338(22):1635-9. Accessed 2009 May 6. [21] Berger WE, Legorreta AP, Blaiss MS, Schneider EC, Luskin AT, Stempel DA, Suissa S, Goodman DC, Stoloff SW, Chapman JA, Sullivan SD, Vollmer B, Weiss KB. The utility of the Health Plan Employer Data and Information Set (HEDIS) asthma measure to predict asthma-related outcomes. (http:/ / www. worldcongress. com/ pdf/ Reprint_HEDIS_12. 2004. pdf) Ann Allergy Asthma Immunol 2004 Dec;93(6):538-45. Accessed 2009 May 7. [22] Lim KG, Patel AM, Naessens JM, Li JT, Volcheck GW, Wagie AE, Enders FB, Beebe TJ. Flunking asthma? When HEDIS takes the ACT. (http:/ / www. ajmc. com/ media/ pdf/ AJMC_08aug_Lim_487to494. pdf) Am J Manag Care 2008 Aug;14(8):487-94. Accessed 2009 May 6. [23] U.S. Preventive Services Task Force (USPSTF). Screening for glaucoma. Recommendation statement. (http:/ / www. ahrq. gov/ clinic/ uspstf05/ glaucoma/ glaucrs. htm) AHRQ Publication No. 04-0548-A, 2005 March. Rockville, MD: Agency for Healthcare Research and Quality. Accessed 2009 May 6. [24] Lobbyist outlines glaucoma-related initiatives. (http:/ / ophthalmologytimes. modernmedicine. com/ ophthalmologytimes/ 2008+ American+ Glaucoma+ Society+ Meeting/ Lobbyist-outlines-glaucoma-related-initiatives/ ArticleStandard/ Article/ detail/ 501399) Ophthalmology Times 2008 Mar 7. Accessed 2009 May 6. [25] Hatt SR, Wormald R, Burr J. Screening for prevention of optic nerve damage due to chronic open angle glaucoma. (http:/ / www. cochrane. org/ reviews/ en/ ab006129. html) Cochrane Database of Systematic Reviews 2006 Oct 18;4. Accessed 2009 May 6. [26] McKinnon SJ, Goldberg LD, Peeples P, Walt JG, Bramley TJ. Current management of glaucoma and the need for complete therapy. (http:/ / www. ajmc. com/ media/ pdf/ A195_McKinnonS20toS27. pdf) Am J Manag Care 2008 Feb;14(1 Suppl):S20-7. Accessed 2009 May 6.
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External links
U.S. News & World Report. America's best health plans. (http://health.usnews.com/sections/health/ health-plans/) Health plan report card. (http://reportcard.ncqa.org/plan/external/plansearch.aspx) Washington, D.C.: National Committee for Quality Assurance. HEDIS & quality measurement. (http://www.ncqa.org/tabid/59/Default.aspx) Washington, D.C.: National Committee for Quality Assurance. The ironic conundrum of the preference sensitive measures, P4P and HEDIS criteria. (http://stanford. wellsphere.com/healthcare-industry-policy-article/ the-ironic-conundrum-of-the-preference-sensitive-measures-p4p-and-hedis-criteria/622142) Disease Management Care Blog, 2009 Mar 8. Dalzell MD. Will integrity of HEDIS data improve with '98 version? (http://www.managedcaremag.com/ archives/9802/9802.hedis.shtml) Managed Care, 1998 February.
E-epidemiology
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E-epidemiology
E-epidemiology is the science underlying the acquisition, maintenance and application of epidemiological knowledge and information using digital media such as the internet, mobile phones, digital paper, digital TV. E-epidemiology also refers to the large-scale epidemiological studies that are increasingly conducted through distributed global collaborations enabled by the Internet. The traditional approach in performing epidemiological trials by using paper questionnaires is both costly and time consuming. The questionnaires have to be transformed to analyzable data and a large number of personnel are needed throughout the procedure. Modern communication tools, such as the web, cell phones and other current and future communication devices, allow rapidly and cost-efficient assembly of data on determinants for lifestyle and health for broad segments of the population. Modern IT technology provides means for storage, organization and retrieval of large amounts of biological and lifestyle data, which will ensure more data and more reliable statistical results. Efficient number crunching computing, using modern analytical tools and simulation based inference procedures allow knowledge to be extracted from the resulting large and complex data-structures. Web portals directly connected to the studies enables instant feedback and information to the participants. It also allows animations and other web based tools linked to the questionnaires, which can increase the interactivity and facilitates flow of information between the study participant and the study centre. The web portal will also generate a possibility for the Universities to carry out the third assignment, which is to spread the knowledge generated at the University to the public. Important aspects of e-epidemiology include the development of security and confidentiality preserving solutions to protect individual integrity and research data ownership.[1] But entering an epidemiological trial via the Internet is probably safer then traditional manners. Accurate security programmes and firewalls are a critical condition for handling personal records over the Internet.
References
[1] Kamel Boulos MN, Cai Q, Padget JA, Rushton G (April 2006). "Using software agents to preserve individual health data confidentiality in micro-scale geographical analyses" (http:/ / linkinghub. elsevier. com/ retrieve/ pii/ S1532-0464(05)00056-0). J Biomed Inform 39 (2): 16070. doi:10.1016/j.jbi.2005.06.003. PMID16098819. .
External links
MEB.ki.se (http://www.meb.ki.se/staff/profiles/litton_je_se.html) - Professor Jan-Eric Litton (faculty homepage), Karolinska Institutet (Swedish website) http://www.phi.man.ac.uk/Presentations/e-epidemiology.pdf
Epi Info
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Epi Info
Epi Info
Developer(s) Stable release Written in
Centers for Disease Control and Prevention 3.5.3 / January 26, 2011 Visual Basic 6.0
Operating system Windows Available in Type License Website 4 languages [1]
Statistical software, epidemiology Public domain www.cdc.gov/EpiInfo [2]
Epi Info is public domain statistical software for epidemiology developed by Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (USA). Epi Info has been in existence for over 20 years and is currently available for Microsoft Windows. The program allows for electronic survey creation, data entry, and analysis. Within the analysis module, analytic routines include t-tests, ANOVA, nonparametric statistics, cross tabulations and stratification with estimates of odds ratios, risk ratios, and risk differences, logistic regression (conditional and unconditional), survival analysis (Kaplan Meier and Cox proportional hazard), and analysis of complex survey data. The software is in the public domain, free, and can be downloaded from http://www.cdc.gov/epiinfo.Limited support is available. An analysis conducted in 2003 documented over 1,000,000 downloads of Epi Info from 180 countries.[3]
History
Epi Info has been in development for over 20 years. The first version, Epi Info 1, was originally implemented as an MS-DOS batch file on 5.25" floppy disks and released in 1985.[4] MS-DOS continued to be the only supported operating system until the release of Epi Info 2000, which was written in Microsoft's Visual Basic and became the first Windows-compatible version. The last MS-DOS version was Epi Info 6.04d, released in January 2001. Epi Info 2000 changed the way data was stored by adopting the Microsoft Access database format, rather than continuing to use the plain-text file format from the MS-DOS versions. Following the release of Epi Info 2000 was Epi Info 2002, and then Epi Info version 3.0. The 3 series is the presently-maintained Epi Info product line. Epi Info 3 for Windows is different than Epi Info 3 for MS-DOS, even though they share the same version number. Windows Vista was officially supported with version 3.5.1, released on August 13, 2008.[5] The next iteration of the Epi Info series, Epi Info 7, was made open source on November 13, 2008 when its source code was uploaded to Codeplex for the first time.
Epi Info
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Features
From a user's perspective, one of the most important functions of Epi Info is the ability to rapidly develop a questionnaire, customize the data entry process, quickly enter data into that questionnaire, and then analyze the data. For epidemiological uses, such as outbreak investigations, being able to rapidly create an electronic data entry screen and then do immediate analysis on the collected data can save considerable amounts of time versus using paper surveys. Epi Info uses three distinct modules to accomplish these tasks: MakeView, Enter, and Analysis. Other modules include the Report module, a mapping module, a menu module, and various utilities such as the NutStat program. Electronic questionnaires, also known as "views" in Epi Info terminology, are created in the MakeView module. Individual questions can be placed anywhere on the screen and across multiple pages, with the user given complete control over appearance and function. The user defines both the question's prompt and the format of the data that is to be collected. Data types include numbers, text strings, dates, times, and yes/no. Users can also create drop-down lists, code tables, and comment legal fields. One of the more powerful features of MakeView, however, is the ability to create "check code". Check code allows for certain events to occur depending on what action a data entry person has taken as they are typing. For example, if a user enters "Male" into a question on gender, any questions relating to pregnancy might then be hidden. Skip patterns can also be created so that if a user enters "No" to a question on whether or not they smoke, the cursor skips past any fields related to smoking. Relational database modeling is supported, as users may link their view to any number of other views in their database. The Analysis module is where users analyze their data. Import and export functions exist that allow for file types to be converted between plain-text, CSV, Microsoft Excel, Microsoft Access, dBase, FoxPro, and other formats. Many advanced statistical routines are provided, such as t-tests, ANOVA, nonparametric statistics, cross tabulations and stratification with estimates of odds ratios, risk ratios, and risk differences, logistic regression (conditional and unconditional), survival analysis (Kaplan Meier and Cox proportional hazard), and analysis of complex survey data. Using the Epi Map module, data can be displayed either by geographic reference or by GPS coordinates. The Report module allows the user to edit and format output from various Epi Info tools and modules. The resulting HTML document can then be printed or emailed to others. The menu module allows for the editing and re-arranging of the basic Epi Info menu structure. This module is powerful enough that several applications have been built off of it, including the National Electronic Telecommunications System for Surveillance (NETSS) for Epi Info 6. Unlike the other modules, the menu module does not have a user interface, but instead resides in a .mnu file whose scripts must be edited manually. NutStat is a program that records and evaluates measurements of length, stature, weight, head circumference, and arm circumference for children and adolescents. It calculates percentiles, number of standard deviations from the mean (Z-scores), and in some cases, percent of median, using either the CDC/WHO 1978 or CDC 2000 growth reference curves.
Future developments
Version 7 is currently in development as an open-source project, written using Microsoft's C# .NET programming language. Both the Windows and Linux operating systems are supported. Source code distribution and contribution currently takes place through Codeplex. Unlike previous versions of Epi Info, however, version 7 will come in one of two flavors: The CDC Edition and the Community Edition. The Community Edition will be edited and modified by the community at large, while the CDC Edition will be maintained by the Epi Info development team. Over time, the CDC Edition will incorporate changes and improvements that have been made to the Community Edition and put them through CDC's software verification process. CDC approval will ensure that the CDC Edition can be authorized for installation on U.S. government computer systems.
Epi Info MySQL and SQL Server databases will be supported as the database backends for version 7, in addition to the traditional Microsoft Access database format. Users will also have the option of storing metadata separately from the data itself; for example, one might store the questionnaire in an XML file, while storing collected data in a MySQL database. A conversion utility will allow existing Epi 3 projects to be made compatible with version 7. Initially, only the MakeView, Enter, and Analysis modules will be available with Epi Info 7. Epi Map, Epi Report, and the ability to edit the menu will be added later.
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Release history
Series Version Operating System Support MS-DOS Support status Release date 1 Sep 1985 20 Aug 1986 1988 15 Nov 1988 Oct 1990 1992 Oct 1994 1998 Jan 2001 2 Nov 2001 30 Jan 2003 First Windows-compatible version of Epi Info. Year 2000 compatibility upgrade Allowed European date formats and non-English characters in data fields. Added programmable menu system [6] Significant changes
Epi Info for DOS
MS-DOS
3 4.1
MS-DOS MS-DOS
5.01 6.0 6.02 6.04c 6.04d Epi Info 2000 2000 1.1.2 2002 R2
MS-DOS MS-DOS MS-DOS MS-DOS MS-DOS Windows 9x, NT 4.0, 2000 Windows 9x, NT 4.0, 2000, XP
Epi Info
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3.0 Windows 9x, NT 4.0, 2000, XP Windows 9x, NT 4.0, 2000, XP Windows 9x, NT 4.0, 2000, XP Windows 9x, NT 4.0, 2000, XP Windows 98, NT 4.0, 2000, XP Windows 98, NT 4.0, 2000, XP Windows 98, NT 4.0, 2000, XP n/a
Epi Info 3
3.01
3 Nov 2003 4 Feb 2004 14 Apr 2004 5 Oct 2004 9 Feb 2005 30 Apr 2007 Ability to use standard ISO date formats, disallowed multiple instances of the Analysis module, added ability to run reports from Analysis, and CDC flags [5] added to the Nutrition module. Added a right-to-left language controller in Analysis [5] Windows 95 no longer supported, case-based mapping functionality added to [5] the Analysis MAP command.
3.2
3.2.2
3.3
3.3.2
3.4
3.4.1
Windows 98, NT 4.0, 2000, XP Windows 98, NT 4.0, 2000, XP Windows 98, NT 4.0, 2000, XP Windows 98, NT 4.0, 2000, XP SP3 Windows 98, NT 4.0, 2000, XP SP3, Vista Windows 98, NT 4.0, 2000, XP SP3, Vista, 7 Windows 98, NT 4.0, 2000, XP SP3, Vista, 7 Windows XP SP3, Vista, Ubuntu
9 Jul 2007 20 Sep 2007 17 Oct 2007 9 Jun 2008 13 Aug 2008
3.4.2
3.4.3
3.5
[5] Added feature to use standardized vocabularies. First version to require [5] Service Pack 3 if running Epi Info on a computer with Windows XP. First version compatible with Windows Vista. This version also fixed [5] compatibility for languages that are read right-to-left. First version compatible with Windows 7. Also included a preview of the new Epi Info 7 MakeView and Enter tools.
3.5.1
3.5.2
17 Dec 2010
3.5.3
26 Jan 2011
Minor update to the Epi Info Enter tool released with 3.5.2.
Epi Info 7
7.0.5 (Alpha)
5 Jan 2009
Programming language changed to Visual C# .NET; MySQL and SQL Server database support added; XML meta-data support added; Linux compatibility added; first Windows version of Epi Info to be open source.
Epi Info
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References
[1] [2] [3] [4] [5] http:/ / www. cdc. gov/ epiinfo/ translations. htm http:/ / www. cdc. gov/ EpiInfo/ "CDC Epi Info - About Epi Info" (http:/ / www. cdc. gov/ epiinfo/ about. htm). CDC. . Retrieved 2009-02-02. "CDC Epi Info - Museam Version 1" (http:/ / www. cdc. gov/ epiinfo/ epiinfo1. htm). CDC. . Retrieved 2009-02-02. "EPI INFO VERSION 3.5.1 READ ME FILE" (ftp:/ / ftp. cdc. gov/ pub/ software/ epi_info/ EpiInfoReadMe3_5_1. txt). CDC. . Retrieved 2009-02-02. [6] "CDC Epi Info - Museam Version 5" (http:/ / www. cdc. gov/ epiinfo/ epiinfo5. htm). CDC. . Retrieved 2009-02-02.
External links
Epi Info (http://www.cdc.gov/EpiInfo/) Epi Info Community of Users (http://forums.myepi.info/) Epi Info Community Portal (http://www.phconnect.org/group/epiinfo) and make sure you dont get stabbed or raped
OpenEpi
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OpenEpi
OpenEpi
OpenEpi 2.3 Developer(s) Stable release AG Dean, KM Sullivan, MM Soe 2.3.1 / September 1, 2010
Operating system Cross-platform Platform Type License Website HTML, JavaScript Web application, Statistical analysis MIT License openepi.com [1]
OpenEpi is a free, web-based, open source, operating system-independent series of programs for use in epidemiology, biostatistics, public health, and medicine, providing a number of epidemiologic and statistical tools for summary data.[2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] OpenEpi was developed in JavaScript and HTML, and can be run in modern web browsers. The program can be run from the OpenEpi website or downloaded and run without a web connection. The source code and documentation is downloadable and freely available for use by other investigators. OpenEpi has been reviewed, both by media organizations and in research journals.[13] [14] [15] [16] [17] The OpenEpi developers have had extensive experience in the development and testing of Epi Info, a program developed by the Centers for Disease Control and Prevention (CDC) and widely used around the world for data entry and analysis. OpenEpi was developed to perform analyses found in the DOS version of Epi Info modules StatCalc and EpiTable, to improve upon the types of analyses provided by these modules, and to provide a number of tools and calculations not currently available in Epi Info. It is the first step toward an entirely web-based set of epidemiologic software tools. OpenEpi can be thought of as an important companion to Epi Info and to other programs such as SAS, PSPP, SPSS, Stata, SYSTAT, Minitab, Epidata, and R (see the R programming language). Another functionally similar Windows-based program is Winpepi. See also list of statistical packages and comparison of statistical packages. Both OpenEpi and Epi Info were developed with the goal of providing tools for low and moderate resource areas of the world. The initial development of OpenEpi was supported by a grant from the Bill and Melinda Gates Foundation to Emory University.[18] The types of calculations currently performed by OpenEpi include: Various confidence intervals for proportions, rates, standardized mortality ratio, mean, median, percentiles 2x2 crude and stratified tables for count and rate data Matched case-control analysis Test for trend with count data Independent t-test and one-way ANOVA Diagnostic and screening test analyses with receiver operating characteristic (ROC) curves
OpenEpi Sample size for proportions, cross-sectional surveys, unmatched case-control, cohort, randomized controlled trials, and comparison of two means Power calculations for proportions (unmatched case-control, cross-sectional, cohort, randomized controlled trials) and for the comparison of two means Random number generator For epidemiologists and other health researchers, OpenEpi performs a number of calculations based on tables not found in most epidemiologic and statistical packages. For example, for a single 2x2 table, in addition to the results presented in other programs, OpenEpi provides estimates for: Etiologic or prevented fraction in the population and in exposed with confidence intervals, based on risk, odds, or rate data The cross-product and MLE odds ratio estimate Mid-p exact p-values and confidence limits for the odds ratio Calculations of rate ratios and rate differences with confidence intervals and statistical tests. For stratified 2x2 tables with count data, OpenEpi provides: Mantel-Haenszel (MH) and precision-based estimates of the risk ratio and odds ratio Precision-based adjusted risk difference Tests for interaction for the risk ratio, odds ratio, and risk difference Four different confidence limit methods for the odds ratio. Similar to Epi Info, in a stratified analysis, both crude and adjusted estimates are provided so that the assessment of confounding can be made. With rate data, OpenEpi provides adjusted rate ratios and rate differences, and tests for interaction. Finally, with count data, OpenEpi also performs a test for trend, for both crude data and stratified data. In addition to being used to analyze data by health researchers, OpenEpi has been used as a training tool for teaching epidemiology to students at: Emory University, University of Massachusetts, University of Michigan, University of Minnesota, Morehouse College, Columbia University, University of Wisconsin, San Jose State University, University of Medicine and Dentistry of New Jersey, University of Washington, and elsewhere. This includes campus-based and distance learning courses. Because OpenEpi is easy to use, requires no programming experience, and can be run on the internet, students can use the program and focus on the interpretation of results. Version 2.2 of OpenEpi was released Nov 11 2007 with the improvement of being able to run in English, French, Spanish, or Italian. Version 2.3 was released May 20 2009 and fixes a number of issues identified by users. Comments and suggestions for improvements are welcomed and the developers respond to user queries. The developers encourage others to develop modules that could be added to OpenEpi and provide a developers tool at the website. Planned future development include improvements to existing modules, development of new modules, translation into other languages, and add the ability to cut and paste data and/or read data files.
701
References
[1] http:/ / www. openepi. com/ [2] "OpenEpi - a web-based epidemiologic and statistical calculator for public health". Public Health Report (124): 471474. 2009. [3] "Update on free epidemiologic software". The Epidemiology Monitor 29 (7): 34. 2008-07. [4] Sullivan, K. (Spring-Summer 2008). "Faculty Spotlight". The Epi Vanguard. [5] Sullivan, KM (2007-12). "OpenEpi now available in English, French, Italian, and Spanish". The Epidemiology Monitor 28 (14). [6] "OpenEpi Version 2". The Epidemiology Monitor 28 (5): 1,910. 2007-05. [7] Sullivan, KM (2007-04). "Overview Of Free Analytic Software for Epidemiologists". The Epidemiology Monitor 28 (4). [8] Sullivan, KM (Spring 2007). "OpenEpi - A web-based calculator". The Epi Vanguard. [9] "OpenEpi: an update". The Epidemiology Monitor 27 (6): 4. 2006-06. [10] "OpenEpi: A new collaborative effort in epidemiologic computing". The Epidemiology Monitor 25 (4): 3,7,9. 2004-04. [11] "OpenEpi: a new collaborative effort in epidemiologic computing". 36th Annual Meeting of the Society for Epidemiologic Research. Atlanta, GA, USA. 11-14 June 2003.
OpenEpi
[12] "The Open Epi Initiative: Open Source Web Browser Software for Public Health". Annual Scientific Meeting of the International Epidemiological Association. Toledo, Spain: European Epidemiology Federation. 1-4 October 2003. [13] OpenEpi online Technology, Health & Development (http:/ / thdblog. wordpress. com/ 2007/ 09/ 24/ openepi-online/ ) [14] Great free tools for teaching statistics | Education IT | ZDNet.com (http:/ / education. zdnet. com/ ?p=1220) [15] Antoch, J. (2008). "Environment for statistical computing". Computer Science Review 2 (2): 113122. doi:10.1016/j.cosrev.2008.05.002. [16] 6th, ed (2008). Research Methods in Community Medicine: Surveys, Epidemiologic Research, Programme Evaluation, Clinical Trials. John Wiley & Sons. [17] Singh, S. (2009). "Review of epidata entry and analysis freewares". Indian Journal of Community Medicine (34): 767. [18] http:/ / www. gatesfoundation. org/ nr/ public/ media/ annualreports/ annualreport01/ pdf/ BMGF2001GlobalHealth. pdf
702
External links
Official website (http://www.openepi.com/) and make sure you dont get stabbed or raped
Living Human Project

The Living Human Project (LHP) is developing a worldwide, distributed repository of anatomo-functional data and of simulation algorithms relative to the human musculoskeletal apparatus, fully integrated into a seamless simulation environment and directly accessible by any researcher in the world. This infrastructure will be used to create the physiome of the human musculoskeletal system.
The Story so far

This initiative started in 2002 as a result of the BioNet coordination action, aimed to establish the grand challenges for European biomechanics. The BioNet consensus document [1] clearly pointed out the need for an Internet-based virtual community as a mean to share biomechanics data. In 2003 a group of partners who were also involved with the BioNet action wrote a public document possible strategy to have the LHP started.
[2]
drafting a
In the meanwhile Marco Viceconti, a researcher at the Rizzoli Institute [3] in Bologna (Italy) started a voluntary effort called Biomechanics European Lab (BEL). The idea was to create a community of interested colleagues, who would develop the LHP without any centralised funding. In 2006 The BEL was merged with to Biomed Town [4], a new Internet community reserved to all those who have professional interest in biomedical research. The BEL data repository [5] remains available on Biomed Town for historical reasons. It was evident that the most important limiting factor for LHP was the lack of an adequate information technology infrastructure. This need is now being matched by two separate provisions.
Living Human Digital Library

A consortium of European institutions [6] is developing the Living Human Digital Library [7], as part of the LHDL STRP project [8] supported by the European Commission. This wiki page [7] contains constantly updated information on the LHDL project. The LHDL project will end on January 2009; soon after the LHDL consortium will release a biomedical data management & sharing service, called Physiome Space. Physiome Space will make possible for single researchers as well as for large consortia to share with their peers very large collections of biomedical data, including medical imaging, computer simulations, etc. It is possible to sign-up for the beta users group [9], which should start in the last quarter of 2008.
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Biomed Town
The users of LHP, e.g. all those research, industry, or clinical professionals that are interested in the musculoskeletal system in every possible way and at every dimensional scale, from the whole body down to the cell and the proteins, created a collaborative community within Biomed Town. The activities of the LHDL Consortium are hosted in the LHDL Building [10]. The community consensus process takes place in the Living Human Square [11].
References
Viceconti, M., Taddei, F., Petrone, M., Galizia, S., Jan, S. V. S., and Clapworthy, G., 2006, "Towards the Virtual Physiological Human: the Living Human Project," The 7th International Symposium on Computer Methods in Biomechanics and Biomedical Engineering (CMBBE 2006), Antibes Cote dAzur, France. Viceconti, M., Taddei, F., Montanari, L., Testi, D., Leardini, A., Clapworthy, G., and Van Sint Jan, S., 2007, "Multimod Data Manager: A tool for data fusion," Computer Methods and Programs in Biomedicine, 87(2), pp.148159. Viceconti, M., Taddei, F., Van Sint Jan, S., Leardini, A., Clapworthy, G., Galizia, S., and Quadrani, P., 2007, "Towards the multiscale modelling of musculoskeletal system," Bioengineering Modeling and Computer Simulation, Barcelona, Spain. Viceconti, M., Zannoni, C., Testi, D., Petrone, M., Perticoni, S., Quadrani, P., Taddei, F., Imboden, S., and Clapworthy, G., 2007, "The multimod application framework: A rapid application development tool for computer aided medicine," Computer Methods and Programs in Biomedicine, 85(2), pp.138151. Viceconti, M., Taddei, F., Van Sint Jan, S., Leardini, A., Cristofolini, L., Stea, S., Baruffaldi, F., and Baleani, M., 2008, "Multiscale modelling of the skeleton for the prediction of the risk of fracture," Clinical biomechanics (Bristol, Avon). Zhao, X., Liu, E., and Clapworthy, G., 2008, "Service-Oriented Digital Libraries: A Web Services Approach," Internet and Web Applications and Services, 2008. ICIW'08. Third International Conference on, pp.608613.
External links
Apply to become a Biomed Town citizen [12] LHDL - The Living Human Digital Library [13] Physiome [14] - Links Wellcome Trust Heart Physiome Project [15] - Links Strategy for the European Physiome [16] - (STEP) NSR Physiome Project [17] IUPS Physiome Project [18]
704
References
[1] http:/ / www. biomedtown. org/ biomed_town/ LHDL/ Reception/ lhp-public-repository/ BioNet_WG_B_consensus. pdf [2] http:/ / www. biomedtown. org/ biomed_town/ LHDL/ Reception/ lhp-public-repository/ LHP_global_plan_R3. pdf [3] http:/ / www. ior. it/ tecno/ [4] http:/ / www. biomedtown. org [5] http:/ / www. biomedtown. org/ biomed_town/ LHDL/ Reception/ datarepository [6] http:/ / www. biomedtown. org/ biomed_town/ LHDL/ Reception/ lhpdef/ LHDLConsortium [7] http:/ / www. biomedtown. org/ biomed_town/ LHDL/ Reception/ lhpdef/ LivingHumanDigitalLibrary [8] http:/ / www. biomedtown. org/ biomed_town/ LHDL/ Reception/ lhpdef/ LHDLResearchProject [9] http:/ / www. biomedtown. org/ biomed_town/ LHDL/ Reception/ betauser/ [10] http:/ / www. biomedtown. org/ biomed_town/ LHDL/ [11] http:/ / www. biomedtown. org/ biomed_town/ lhpsquare/ [12] http:/ / www. biomedtown. org/ join_form [13] http:/ / www. livinghuman. org [14] http:/ / www. physiome. org/ Links/ [15] http:/ / www. physiome. ox. ac. uk/ [16] http:/ / www. europhysiome. org [17] http:/ / www. physiome. org/ [18] http:/ / www. physiome. org. nz/
Stereolithography
Stereolithographic models have been used in medicine since the 1990s, for creating 3D corporeal models of various anatomical regions of a patient, based on datasets from CT-scans.
Usage
Stereolithographic models have been used in medicine, in order to provide surgeons a better 3D image of the anatomical situation of a patient, before the operation. With the advent of improved 3D computer reconstruction, based on datasets recorded from the patient, the stereolithographic models are nowadays less used for this purpose. Stereolithographic models are used as models for preoperative planning, for example by recreating osteotomies with repositioning of the fragments. The surgical result regarding the position of bone autotransplants or after the osteosynthesis of bone fractures can be foreseen using stereolithographic models.
Stereolithographic model of a skull, using an infrared system
Stereolithography
705
Medical stereolithographic models today

Due to high costs and progressive replacement by virtual models, corporeal stereolithographical models in medicine have lost their sense, in a certain manner.
Manufacturing particularity
Because the materials used for stereolithographic models suffer from a normal shrinkage phenomenon during polymerisation, the starting-point model should be a little bit bigger than the original CT dataset would indicate.
References
Klimek L, Klein HM, Schneider W, Mosges R, Schmelzer B, Voy ED: Stereolithographic modelling for reconstructive head surgery. Acta Oto-Rhino-Laryngologica Belgica. 47(3):329-34, 1993 Bouyssie JF, Bouyssie S, Sharrock P, Duran D: Stereolithographic models derived from x-ray computed tomography. Reproduction accuracy. Surgical & Radiologic Anatomy. 19(3):193-9, 1997
Virtual Physiological Human

The Virtual Physiological Human (VPH) is a methodological and technological framework that, once established, will enable collaborative investigation of the human body as a single complex system.[1] [2] The collective framework will make it possible to share resources and observations formed by institutions and organizations creating disparate, but integrated computer models of the mechanical, physical and biochemical functions of a living human body. The Virtual Physiological Human (VPH) is a framework which aims to be descriptive, integrative and predictive:[3]
[4] [5] [6]
Descriptive. The framework should allow observations made in laboratories, hospitals and the field, at a variety of locations situated anywhere in the world, to be collected, catalogued, organized, shared and combined in any possible way. Integrative. The framework should enable experts to analyse these observations collaboratively and develop systemic hypotheses that involve the knowledge of multiple scientific disciplines. Predictive. The framework should make it possible to interconnect predictive models defined at different scales, with multiple methods and varying levels of detail, into systemic networks that solidify those systemic hypotheses; it should also make it possible to verify their validity by comparison with other clinical or laboratory observations. The framework is formed by large collections of anatomical, physiological, and pathological data stored in digital format, by predictive simulations developed from these collections, and by services intended to support researchers in the creation and maintenance of these models, as well as in the creation of end-user technologies to be used in the clinical practice. Virtual Physiological Human (VPH) models aim to integrate physiological processes across different length and time scales (multi-scale modelling).[3] These models make possible the combination of patient-specific data with population-based representations. The objective is to develop a systemic approach which avoids a reductionist approach and seeks not to subdivide biological systems in any particular way by dimensional scale (body, organ, tissue, cells, molecules), by scientific discipline (biology, physiology, biophysics biochemistry, molecular biology, bioengineering) or anatomical sub-system (cardiovascular, musculoskeletal, gastrointestinal, etc.).[5]
706
History of Virtual Physiological Human (VPH)

The initial concepts that brought to the Virtual Physiological Human came from the IUPS physiome project. The IUPS physiome project was formed in 1997 and was the first worldwide effort to define the physiome through the development of databases and models which facilitated the understanding of the integrative function of cells, organs, and organisms.[7] The project focused on compiling and providing a central repository of databases, linking experimental information and computational models from many laboratories into a single, self-consistent framework. 'The Physiome is the quantitative and integrated description of the functional behaviour of the physiological state of an individual or species.[8] Following the launch of the Physiome Project, there were many other worldwide initiatives of loosely coupled actions all focusing on the development of methods for modelling and simulation of human pathophysiology. In 2005, an expert workshop of the Physiome was held as part of the Functional Imaging and Modelling of the Heart Conference in Barcelona where a White Paper[9] was created. The paper was entitled Towards Virtual Physiological Human: Multilevel modelling and simulation of the human anatomy and physiology. The goal of this paper was to shape a clear overview of on-going relevant VPH activities, to build a consensus on how they can be complemented by new initiatives for researchers in the EU and to identify possible mid-term and long term research challenges. In 2006 the European Commission funded a coordination and support action entitled STEP: Structuring The EuroPhysiome. The STEP consortium promoted a very large consensus process that involved more than 300 stakeholders including researchers, industry experts, policy makers, clinicians, etc. The prime result of this process was a booklet entitled Seeding the EuroPhysiome: A Roadmap to the Virtual Physiological Human.[6] The STEP action and the resulting research roadmap were instrumental in the development of the concept of Virtual Physiological Human here provided, and in the initiation of much larger process that involves significant research funding, large collaborative projects, and a number of connected initiatives, not only in Europe but also in the United States, Japan, and China. The Virtual Physiological Human now forms a core target of the 7th Framework Programme [10] of the European Commission, and aims to support the development of patient-specific computer models and their application in personalised and predictive healthcare.[11] The Virtual Physiological Human Network of Excellence VPH NoE aims to connect the various VPH projects within the 7th Framework Programme.
Aim of the Virtual Physiological Human

VPH related projects have received substantial funding from the European Commission in order to further scientific progress in this area. The European Commission is insistent that VPH-related projects demonstrate strong industrial participation and clearly indicate a route from basic science into clinical practice.[5] In the future, it is hoped that the VPH will eventually lead to a better healthcare system which aims to have the following benefits:[6] personalized care solutions reduced need for experiments on animals more holistic approach to medicine preventative approach to treatment of disease
Personalized care solutions are a key aim of the VPH, with new modelling environments for predictive, individualized healthcare to result in better patient safety and drug efficacy. It is anticipated that the VPH could also result in healthcare improvement through greater understanding of pathophysiological processes.[3] The use of biomedical data from a patient to simulate potential treatments and outcomes could prevent the patient from experiencing unnecessary or ineffective treatments.[12] The use of in silico (by computer simulation) modelling and testing of drugs could also reduce the need for experiments on animals. A future goal is that there will be also be a more holistic approach to medicine with the body treated as a single multi organ system rather than as a collection of individual organs. Advanced integrative tools should further help to
Virtual Physiological Human improve the European healthcare system on a number of different levels that include diagnosis, treatment and care of patients and in particular quality of life.[6] The Virtual PHysiological Human is in conclusion a framework of methods and technologies that once fully established will make possible Personalised, Predictive, and Integrative medicine.
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References
[1] Clapworthy et al. 2007 [2] According to the STEP research road map (http:/ / www. europhysiome. org/ roadmap) [3] Fenner JW, Brook B, Clapworthy G, Coveney PV, Feipel V, Gregersen H et al. (2008). "The EuroPhysiome, STEP and a roadmap for the virtual physiological human." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& retmode=ref& cmd=prlinks& id=18559316). Philos Transact A Math Phys Eng Sci 366 (1878): 297999. doi:10.1098/rsta.2008.0089. PMID18559316. . [4] Viceconti M, Taddei F, Van Sint Jan S, Leardini A, Cristofolini L, Stea S et al. (2008). "Multiscale modelling of the skeleton for the prediction of the risk of fracture." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& retmode=ref& cmd=prlinks& id=18304710). Clin Biomech (Bristol, Avon) 23 (7): 84552. doi:10.1016/j.clinbiomech.2008.01.009. PMID18304710. . [5] Clapworthy G, Viceconti M, Coveney PV, Kohl P (2008). "The virtual physiological human: building a framework for computational biomedicine I. Editorial." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& retmode=ref& cmd=prlinks& id=18559315). Philos Transact A Math Phys Eng Sci 366 (1878): 29758. doi:10.1098/rsta.2008.0103. PMID18559315. . [6] STEP research road map (http:/ / www. europhysiome. org/ roadmap) [7] Hunter PJ, Borg TK (2003). "Integration from proteins to organs: the Physiome Project." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& retmode=ref& cmd=prlinks& id=12612642). Nat Rev Mol Cell Biol 4 (3): 23743. doi:10.1038/nrm1054. PMID12612642. . [8] NSR Physiome Project (http:/ / www. physiome. org/ ) [9] Ayache N, Boissel J-P, Brunak S, Clapworthy G, Lonsdale G, Fingberg J, Frangi A, Deco G, Hunter P, Nielsen P, Halstead M, Hose R, Magnin I, Martin-Sanchez F, Sloot P, Kaandorp J, Hoekstra A, Van Sint Jan S, Viceconti M. "Towards virtual physiological human: Multilevel modelling and simulation of the human anatomy and physiology" (http:/ / ec. europa. eu/ information_society/ activities/ health/ docs/ events/ barcelona2005/ ec-vph-white-paper2005nov. pdf) (PDF). . Retrieved 2009-11-30. [10] 7th Framework Programme (http:/ / cordis. europa. eu/ fp7/ ) [11] Kohl P, Noble D (2009). "Systems biology and the virtual physiological human." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& retmode=ref& cmd=prlinks& id=19638973). Mol Syst Biol 5 (1): 292. doi:10.1038/msb.2009.51. PMC2724980. PMID19638973. . [12] Sadiq SK, Mazzeo MD, Zasada SJ, Manos S, Stoica I, Gale CV et al. (2008). "Patient-specific simulation as a basis for clinical decision-making." (http:/ / www. ncbi. nlm. nih. gov/ entrez/ eutils/ elink. fcgi?dbfrom=pubmed& retmode=ref& cmd=prlinks& id=18573758). Philos Transact A Math Phys Eng Sci 366 (1878): 3199219. doi:10.1098/rsta.2008.0100. PMID18573758. .
Bibliography
Clapworthy, G., Kohl, P., Gregerson, H., Thomas, S., Viceconti, M., Hose, D., Pinney, D., Fenner, J., McCormack, K., Lawford, P., Van Sint Jan, S., Waters, S., & Coveney, P. 2007, "Digital Human Modelling: A Global Vision and a European Perspective," In Digital Human Modelling: A Global Vision and a European Perspective , Berlin: Springer, pp.549558. Hunter, P.J. 2006. Modeling living systems: the IUPS/EMBS Physiome project. Proceedings IEEE, 94, 678-991 Viceconti, M., Testi, D., Taddei, F., Martelli, S., Clapworthy, G. J., Van Sint Jan, S., 2006. Biomechanics Modeling of the Musculoskeletal Apparatus: Status and Key Issues. Proceedings of the IEEE 94(4), 725-739.
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Links to External Resources

EuroPhysiome (http://www.europhysiome.org) The Europhysiome initiative was coordinated by the STEP Coordination action, which aimed to establish a better coordination between European Physiome projects. STEP is now completed; its primary results were the establishment of the Virtual Physiological Human (VPH) concept, and the production of a European research roadmap to the realisation of the VPH. STEP Roadmap (http://www.europhysiome.org/roadmap) STEP Consortium. Seeding the EuroPhysiome: A Roadmap to the Virtual Physiological Human. [Online] 5 July 2007, IUPS Physiome Project (http://www.physiome.org.nz/) The Physiome Project is a worldwide public domain effort to provide a computational framework for understanding human and other eukaryotic physiology. It aims to develop integrative models at all levels of biological organisation, from genes to the whole organism via gene regulatory networks, protein pathways, integrative cell function, and tissue and whole organ structure/function relations. University of Auckland, Auckland, New Zealand. VPH NoE (http://www.vph-noe.eu/) The VPH NoE was launched in 2008 and aims to provide the necessary infrastructure including computational methodologies, tools and databases that will enable academic, clinical and industrial researchers to communicate, and to exchange data and technologies in a standardised way. The website has the latest news, events and progress of the VPH NoE, contains further information on the VPH I projects and is a useful resource to find out more about the VPH. BioMed Town (http://www.biomedtown.org/) is an online resource, borne out of the Sixth Framework Programme Coordination Action STEP (A Strategy for the Europhysiome). It is a meeting place open to Biomedical Research & Technology, Biomedical Industry and Clinical Practice, and aims to support networking and information sharing - key activities underpinning any integrative/interdisciplinary research community. It is open to all those who have a professional or educational interest in biomedical research & technology. Operating on the Virtual Human (http://news.bbc.co.uk/2/hi/health/7774016.stm) BBC news feature on Heart Surgery as part of the VPH Initiative (January 2009) PhysiomeSpace (http://www.physiomespace.com) is new service currently running in beta, which makes possible the creation of heterogeneous collection of biomedical data including medical imaging, biomedical instrumentation recordings, geometries, scalar, vector and tensor fields, results from finite element, multibody dynamics, and computer fluid dynamics simulations, etc., and to share these collections, properly annotated through a powerful ontology with any other researcher you like.
External Links to VPH projects

EU FP7 VPH related Projects
Several projects have been funded within various VPH FP7-ICT EU calls: euHeart (http://www.euheart.eu/) (IP) Personalised and integrated cardiac care: Patient-specific cardiovascular modelling and simulation for in silico disease understanding and management and for medical device evaluation and optimisation. (Project dates: 06/08 - 05/12). VPHOP (http://www.vphop.eu/) (IP) Osteoporotic Virtual Physiological Human. Body to molecule patient-specific modelling technology for the diagnosis, prognosis and treatment planning of osteoporotic fractures. (Project dates: 08/08 - 08/12). ARTreat (http://www.vph-noe.eu/vph-projects/74-eu-fp7-vph-projects/46-artreat-ip) (IP) Multi-level patient-specific artery and atherogenesis model for outcome prediction, decision support treatment, and virtual hand-on training. (Project dates: 09/08 - 08/11). Synergy (STREP) Modelling and simulation environment for systems medicine (Chronic obstructive pulmonary disease -COPD- as a use case). (Project dates: 02/11 - 01/14).
Virtual Physiological Human preDiCT (http://www.vph-predict.eu/) (STREP) Virtual research environment for in silico assessment of efficacy and safety of specific drugs (cell to ventricle-level models) and faster than-real-time simulation. (Project dates: 06/08 - 05/11). ContraCancrum (http://www.contracancrum.eu/) (STREP) Clinically oriented translational cancer multilevel modelling. Composite multilevel platform for simulating malignant tumour development and tumour and normal tissue response to therapeutic modalities and treatment schedules. (Project dates: 08/08 - 07/11). ARCH (http://www.vph-arch.eu/) (STREP) Patient specific image-based computational modelling for improvement of short- and long-term outcome of vascular access in patient on hemodialysis therapy. (Project dates: 06/08 - 05/11). PASSPORT (http://www.passport-liver.eu/Homepage.html) (STREP) Patient specific simulation and preoperative realistic training for liver surgery. Patient specific liver modelling combinging anatomical, mechanical, appearance and biological preoperative modelled information. (Project dates: 06/08 - 05/11). p-medicine (http://p-medicine.eu) (IP) From data sharing and integration via VPH models to personalised medicine. P-Medicine will create an infrastructure that will facilitate the translation from current practice to personalized medicine. The project is designed to bring VPH methods to three sets of clinical trials treating various cancers (leukaemia, breast cancer, Wilms' tumour). (Project dates: 02/11 - 01/15). PredictAD (http://www.predictad.eu) (STREP) From patient data to personalised healthcare in Alzheimer's Disease. New biomarkers and clinically useful tools for early Alzheimer's disease diagnosis. (Project dates: 06/08 - 05/11). NeoMARK (http://www.neomark.eu/) (STREP) ICT enabled prediction of cancer reoccurrence. Multiscale and multilevel modelling, aimed at advancing models and methods currently in use to predict neoplastic reoccurrences, and to apply it to the study of oral cancer. (Project dates: 06/08 - 08/10). VPH2 (http://www.vph2.eu/) (STREP) Virtual pathological heart of the virtual physiological human. Patient-specific computational modelling and simulation of the human heart to assist the cardiologist and cardiac surgeon in defining the severity and extent of disease in patients with post-ischemic Left Ventricular Dysfunction (LVD), with or without ischemic mitral regurgitation. (Project dates: 07/08 - 06/11). IMPPACT (http://www.imppact.eu/) (STREP) Image-based multi-scale physiological planning for ablation cancer treatment. Physiological model of the liver and simulation of result of Radiofrequency Ablation (RFA) of malignant liver tumours, accounting for patient specific physiological factors. (Project dates: 08/08 - 08/11). HAMAM (http://hamam-project.org/cms/website.php) (STREP) Highly accurate breast cancer diagnosis through integration of biological knowledge, novel imaging modalities, and modelling. (Project dates: 08/08 08/11). Action-Grid (http://www.action-grid.eu/) (CA) International cooperative action on grid computing and biomedical informatics between the European Union, Latin America, the Western Balkans and North Africa. (Project dates: 08/08 - 11/11). RADICAL (http://www.radicalhealth.eu/) (CA) Road mapping technology for enhancing security to protect medical and genetic data. In depth study to determine policy roadmap for security and privacy enhancement in Virtual Physiological Human. (Project dates: 00/00 - 00/00).
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EU FP6 VPH related Projects

@neurIST (http://www.cilab.upf.edu/aneurist1/) (IP) @neurIST will develop an IT infrastructure for the management of heterogeneous data associated with the diagnosis and treatment of cerebral aneurysms. (Project dates: 02/06 - 01/10). ACGT (http://www.eu-acgt.org/) (IP) Advancing Clinico-genomic trials on cancer: Open Grid services for improving medical knowledge discovery The ACGT project aims to develop a GRID platform to support and stimulate further exchanges of both clinic and genetic information, with a particular focus on breast cancer treatment. (Project dates: 02/06 - 01/10). Health-e-Child (http://www.health-e-child.org/) (IP) The Health-e-Child project aims at developing an integrated healthcare platform for European paediatrics, providing seamless integration of traditional and emerging sources of biomedical information. (Project dates: 01/06 - 12/09). I KNOW (http://www.ist-world.org/ProjectDetails.aspx?ProjectId=4b856c895010468e95611ffd08d39660) (STREP) I-Know is a knowledge discovery IT -based tool designed to aid early stroke diagnosis, stroke treatment, drug development and identification of risk factors as targets in disease prevention for the benefit of European industry and citizens. (Project dates: 05/06 - 04/09). Sealife (http://www.biotec.tu-dresden.de/sealife) (NoE) A Semantic Grid Browser for the Life Sciences applied to the study of Infectious Diseases. The development of a browser, which will link the existing Web to the currently emerging eScience infrastructure. (Project dates: 04/06 - 03/09). VIROLAB (http://www.virolab.org/) (STREP) ViroLab enables easy access to distributed resources as well as the sharing, processing, and analysis of virological, immunological, clinical and experimental data. (Project dates: 03/06 - 03/09). ImmunoGrid (http://www.immunogrid.org/) (STREP) The project will focus on establishing an infrastructure for the simulation of the immune system that integrates processes at molecular, cellular, and organ levels.It will be designed for applications that support clinical outcomes. (Project dates: 02/06 - 01/09). LHDL (http://www.livinghuman.org/) (STREP) Living Human Digital Library: interactive digital library services to access collections of complex biomedical data on the musculoskeletal apparatus. (Project dates: 02/06 - 01/09). Simap (http://www.simap-project.org/simap/public/) (STREP) Simulation modelling of the MAP kinase pathway SIMAP will develop a simulation model of the cancer related MAP-kinase pathway, integrating and analyzing data from various types of resources, which may assist in the development of better cancer treatment. (Project dates: 01/06 - 12/08) ASSIST (http://assist.iti.gr/) (STREP) Association studies assisted by inference and semantic technologies. The main objective of ASSIST is to facilitate the research for cervical cancer through a system that will virtually unify multiple patient record repositories, physically located in different medical centres/hospitals. (Project dates: 01/06 - 12/08). STEP (http://www.europhysiome.org/) (CA) STEP was a Coordination Action that sought to coordinate European activity relating to the physiome a description of human physiology that will span multiple levels from the whole body down through the organs to the cells and beneath in an integrated manner. (Project dates: 01/06 - 03/07). BIOPATTERN (http://www.biopattern.org/Main/index.aspx) (NoE) Computational intelligence for Bio-pattern analysis in support of eHealthcare. The goal of BIOPATTERN is to develop a pan-European, coherent and intelligent analysis of a citizen's bio-profile. (Project dates: 01/04 - 12/07). MATCH (http://www.match-project.com/) (STREP) MATCH project entitle the development of an automatic diagnosis system that aims to support treatment of colon cancer diseases by discovering mutations that occurs to tumour suppressor genes (TSGs) and contributes to the development of cancerous tumours. (Project dates: 08/06 07/08).
Virtual Physiological Human MULTI - KNOWLEDGE (http://www.multiknowledge.org/page.asp?IDCategoria=574&IDSezione=3185) (STREP)The MULTI-KNOWLEDGE Project aims to integrate different biomedical information from heterogeneous sources (clinical, laboratory and metabolic) with data on gene and protein expression provided by new high throughput technologies in a system committed to cardiovascular risk profiling. (Project dates: 01/06 03/08). NEUROWEB (http://www.neurowebkc.eu/) (STREP) NEUROWEB project improved healthcare delivery achieving knowledge-based, personalised diagnosis and therapy through vertical integration of existing clinical and genetic databases. (Project dates: 08/06 - 07/08). e-Health ERA (http://www.ehealth-era.org/)(CA) The overall goal of the eHealth ERA project is to contribute to greater transparency of national eHealth strategies and implementation activities as well as innovation oriented research and technology development (RTD) initiatives. (Project dates: 04/05 - 06/07). SemanticHEALTH (http://www.semantichealth.org/) (CSA) SemanticHEALTH aims to develop a European and global roadmap for deployment and research in health-ICT, focusing on semantic interoperability issues of e-Health systems and infrastructures. (Project dates: 01/06 - 12/07). SemanticMining (http://www.semantichealth.org/) (NoE) Semantic Interoperability and Data Mining in Biomedicine. The aim of this project is to establish Europe as the international scientific leader in medical and biomedical informatics. The long-term goal was to develop generic methods and tools to support the critical tasks of the field. (Project dates: 01/04 - 07/07). SYMBIOmatics (http://www.symbiomatics.org/) (SSA) SYMBIOmatics is a Specific Support Action that aims to identify and exploit synergies between bioinformatics and medical informatics.The project will document the state-of-the art in biomedical informatics in Europe. (Project dates: 05/05 - 11/06). INFOBIOMED (http://www.infobiomed.org/) (NoE) INFOBIOMED aims at enforcing European Biomedical Informatics as an integrative discipline with a view on supporting individualised healthcare. (Project dates: 01/04 - 06/07). TACIT (http://www.tacit-ist.org/)(STREP) Technologies Augmenting Clinical InsighT. The TACIT project aim is to unlock the tacit knowledge of Europe's senior clinicians both by linguistically analysed multimedia recording and by expert location and communications. (Project dates: 06/04 - 08/06). WoundMonitor (http://www.manchester.ac.uk/woundmonitor) (STREP) WOUNDMONITOR will apply gas sensor array technology in an innovative diagnostic system that will enable non-invasive sampling of volatiles, helping diagnosis of the onset and type of bacterial infections in critically ill patients suffering from burns or serious wounds. (Project dates: 01/06 - 12/08). SHARE (http://www.eu-share.org/) (SSA) The goal of SHARE was to ensure the successful take up of HealthGrids in the next 10 years by creating a roadmap for essential technology development years. (Project dates: 01/06 - 03/08). EuResist (http://www.euresist.org/) (STREP) The EuResist project aims to develop a European integrated system for the clinical management of antiretroviral drug resistance. (Project dates: 01/06 - 06/08). normaCOR (http://www.normacor.eu/) The aim of normaCOR is to provide novel insight into novel arrhythmogenic mechanisms, quantify their interrelation, target preventive and therapeutic interventions to reduce the societal and economical impact of cardiac arrhythmia.
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Visible Human Project
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The Visible Human Project is an effort to create a detailed data set of cross-sectional photographs of the human body, in order to facilitate anatomy visualization applications. A male and a female cadaver were cut into thin slices which were then photographed and digitized. The project is run by the U.S. National Library of Medicine (NLM) under the direction of Michael J. Ackerman. Planning began in 1989; the data set of the male was completed in November 1994 and the one of the female in November 1995. The project can be viewed today at the National Museum of Health and Medicine in Washington, DC. There are currently efforts to repeat this project with higher resolution images but only with parts of the body instead of a cadaver.
Cryosection through the head of a human male.
Data
The male cadaver was encased and frozen in a gelatin and water mixture in order to stabilize the specimen for cutting. The specimen was then cut in the axial plane at 1 millimeter intervals. Each of the resulting 1,871 slices were photographed in both analog and digital, yielding 15 gigabytes of data. In 2000, the photos were rescanned at a higher resolution, yielding more than 65 gigabytes. The female cadaver was cut into slices at .33 millimeter intervals, resulting in some 40 gigabytes of data.
Cryosection through the abdomen of a human male, including the upper extremities.
The term cut is a bit of a misnomer, yet it is used to describe the process of grinding away the top surface of a specimen at regular intervals. The term slice, also a misnomer, refers to the revealed surface of the specimen to be photographed; the process of grinding the surface away is entirely destructive to the specimen and leaves no usable or preservable slice of the cadaver. The data is supplemented by axial sections of the whole body obtained by computed tomography, axial sections of the head and neck obtained by magnetic resonance imaging, and coronal sections of the rest of the body also obtained by magnetic resonance imaging. The scanning, slicing and photographing took place at the University of Colorado's Health Sciences Center, where additional cutting of anatomical specimens continues to take place.
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Donors
The male cadaver is from Joseph Paul Jernigan, a 38-year-old Texas murderer who was executed by lethal injection on August 5, 1993. At the prompting of a prison chaplain he had agreed to donate his body for scientific research or medical use, without knowing about the Visible Human Project. Some people have voiced ethical concerns over this. One of the most notable statements came from the University of Vienna which demanded that the images be withdrawn with reference to the point that the medical profession should have no association with executions, and that the donor's informed consent could be scrutinised.[1] The 59-year-old female donor remains anonymous. In the press she has been described as a Maryland housewife who died from a heart attack and whose husband requested that she be part of the project.
Problems with the data sets

Freezing caused the brain of the man to be slightly swollen, and his inner ear ossicles were lost during preparation of the slices. Nerves are hard to make out since they have almost the same color as fat, but many have nevertheless been identified. Small blood vessels were collapsed by the freezing process. Tendons are difficult to cut cleanly, and they occasionally smear across the slice surfaces. The male has only one testicle, is missing his appendix, and has tissue deterioration at the site of lethal injection. Also visible are tissue damage to the dorsum of each forearm by formalin injection and damage to the right sartorius from opening the right femoral vein for drainage. The male was also not "cut" while in anatomical position, so the cuts through his arms are oblique. The reproductive organs of the woman are not representative of those of a young woman. The specimen contains several pathologies, including cardiovascular disease and diverticulitis.
Discoveries
By studying the data set, researchers at Columbia University found several errors in anatomy textbooks, related to the shape of a muscle in the pelvic region and the location of the urinary bladder and prostate.
License
The data may be bought on tape or downloaded free of charge; one has to specify the intended use and sign a license agreement that allows NLM to use and modify the resulting application. NLM can cancel the agreement at any time, at which point the user has to erase the data files.
Applications using the data

Various projects to make the raw data more useful for educational purposes are under way. It is necessary to build a three-dimensional virtual model of the body where the organs are labeled, may be removed selectively and viewed from all sides, and ideally are even animated. Two commercial software products accomplish the majority of these goals, the VH Dissector from Touch of Life Technologies and Voxel-Man-Man 3D-Navigator from the University of Hamburg [2] NLM itself has started the open source project Insight Toolkit whose aim is to automatically deduce organ boundaries from the data. The data were used for Alexander Tsiaras's book and CD-ROM Body Voyage which features a three-dimensional tour through the body.[3] A "Virtual Radiography" application creates Digitally Reconstructed Radiographs and virtual surgery, where endoscopic procedures or balloon angioplasty are simulated: the surgeon can view the progress of the instrument on a screen and receives realistic tactile feedback according to what kind of tissue the instrument would currently be touching.
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References
[1] Roeggla G., U. Landesmann and M. Roeggla: Ethics of executed person on Internet. [Letter]. Lancet. 28. January 1995; 345(0):260. [2] Hoehne K. H. et al.: VOXEL-MAN 3D-Navigator: Inner Organs. Regional, Systemic and Radiological Anatomy. (http:/ / www. voxel-man. de/ 3d-navigator/ inner_organs/ ) Springer Electronic Media, New York, 2003 (DVD-ROM, ISBN 978-3-540-40069-1). [3] Tsiaras A.: Body Voyage: A Three-Dimensional Tour of a Real Human Body. Warner Books, New York, 1997 (ISBN 0-446-52009-8).
External links
Home page of the project (http://www.nlm.nih.gov/research/visible/visible_human.html), including links to the various other projects that use the data The Visible Human Male: A Technical Report (http://jamia.bmj.com/content/3/2/118.full.pdf), Detailed history of methods used to prepare the male cadaver and gather image data as published in the free article in the Journal of the American Medical Informatics Association 1996 Visible Human Viewer (http://www.dhpc.adelaide.edu.au/projects/vishuman2/VisibleHuman.html), Java applets to view this project in axial, sagittal and coronal slices Visible Human Server (http://visiblehuman.epfl.ch/index.php) by the EPFL (Ecole Polytechnique Fdrale de Lausanne). Extensive Java applets to view, extract and animate slices. Also applets for 3D feature extraction. Center for Human Simulation at UCHSC (http://www.visiblehuman.org) A collection of several applications using the Visible Human Datasets Touch of Life Technologies (http://www.toltech.net) A commercial website which produces the VH Dissector, a virtual dissection program that uses the Visible Human datasets.
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People
Edward H. Shortliffe
Edward Hance Shortliffe
Born 1947 Edmonton, Alberta
Other names Ted Education Harvard University Stanford University MYCIN Biomedical informatics Website [1]
Knownfor
Edward (Ted) Hance Shortliffe, MD, PhD (born 1947, Edmonton, Alberta) is a Canadian-born American biomedical informatician, physician and computer scientist. Dr. Shortliffe is a pioneer in the use of artificial intelligence in medicine. He was the principal developer of the clinical expert system MYCIN, one of the first rule-based artificial intelligence expert systems, which obtained clinical data interactively from a physician user and was used to diagnose and recommend treatment for severe infections. While never used in practice (because it preceded the era of local-area networking and could not be integrated with patient records and physician workflow), its performance was shown to be comparable to and sometimes more accurate than that of Stanford infectious disease faculty.[2] This spurred the development of a wide range of activity in the development of rule-based expert systems, knowledge representation, belief nets and other areas, and its design greatly influenced the subsequent development of computing in medicine. He is also regarded as a founder of the field of biomedical informatics, and in 2006 received one of its highest honors, the Morris Collen Award given by the American College of Medical Informatics (ACMI). He has held administrative positions in academic medicine, research and national bodies including the Institute of Medicine, American College of Physicians (ACP), the National Science Foundation (NSF), National Institutes of Health (NIH), and National Library of Medicine (NLM), and been influential in the development of medicine, computing and biomedical informatics nationally and internationally. His interests include the broad range of issues related to integrated medical decision-support systems and their implementation, biomedical informatics and medical education and training, and the Internet in medicine. In March 2007, he became founding Dean of the University of Arizona's new College of Medicine campus in Phoenix. He stepped down from this position in May 2008 and in January 2009 transferred his primary academic appointment to Arizona State University where he became Professor of Biomedical Informatics. He maintained a secondary appointment as Professor of Basic Medical Sciences and of Medicine at the University of Arizona College of Medicine (Phoenix Campus). Since November 2009 he has transferred his academic home to a part-time appointment as Professor, School of Biomedical Informatics, University of Texas Health Science Center at the Texas Medical Center in Houston, where he now lives.
Edward H. Shortliffe In July 2009 Dr. Shortliffe assumed a position as President and Chief Executive Officer of the American Medical Informatics Association in Bethesda, MD. an organization that he helped to form between 1988 and 1990 when he was President of SCAMC (the Symposium on Computer Applications in Medical Care).
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Biography and career

Dr. Shortliffe grew up in Edmonton, Alberta, until his family moved to Connecticut when he was 6. He attended the Loomis School in Connecticut and later Greshams School in the UK. His father was a physician and hospital administrator; his mother, an English teacher. He has one brother and one sister. As an undergraduate at Harvard, he started working in the computer laboratory of G. Octo Barnett at Massachusetts General Hospital and realized that he could have a career spanning both medicine and computing. After receiving an AB in applied mathematics magna cum laude from Harvard College in 1970, he received an MD (1976) and PhD in Medical Information Systems (1975) from Stanford University, with a dissertation on the MYCIN system, for which he also won the 1976 Grace Murray Hopper award [3] for outstanding young computer scientist. He completed internal medicine house-staff training from 1976-1979 at Massachusetts General Hospital and Stanford Hospital. In 1979 he joined the Stanford faculty of medicine and computer science, where he directed the Stanford University Medical EXpertimental computer resource (SUMEX) and subsequently the Center for Advanced Medical Informatics at Stanford (CAMIS), continuing his work on expert systems, including ONCOCIN (an oncology decision support program), T-HELPER, and other projects in the Stanford Heuristic Programming Project.[4] He also simultaneously served as Chief of General Internal Medicine and Associate Chair of Medicine for Primary Care, and was principal investigator of the InterMed Collaboratory [5], which developed the science of computable guidelines for medical decision support. In 1980 he founded one of the earliest formal degree programs in biomedical informatics at Stanford University, emphasizing a rigorous and experimentalist approach. He is known for his administrative ability, dedication to teaching and ability to create scientific and educational environments where (in the words of NLM director Donald A. B. Lindberg) 'smart people want to come. He has been widely influential in the development and public awareness of biomedical informatics as a field and trained many students who went on to be leaders in the study of uncertainty and AI, and other areas. He is also much in demand as a speaker and advisor to government and industry. Since 2003 he has served on the Board of Directors of Medco Health Solutions, a large pharmacy benefits manager headquartered in Franklin Lakes, New Jersey. In 2000 he moved to Columbia University as chair of the department of Biomedical Informatics [6], Deputy Vice President (Columbia University Medical Center), Senior Associate Dean (College of Physicians and Surgeons) for Strategic Information Resources, Professor of Medicine, Professor of Computer Science, and Director of Medical Informatics Services for the New York-Presbyterian Hospital (NYPH). He continued work on decision support guidelines including the development of the Guideline Interchange Format (GLIF3).[7] He greatly expanded the faculty and scope of department activities, including overseeing the development of patient care systems at NYPH, basic science research, and expanded training programs in biomedical informatics, including public health informatics, the integration of bioinformatics and clinical informatics, and the introduction of informatics training for medical students. From March 2007 until May 2008 he served as the founding dean of the Phoenix campus of the University of Arizonas College of Medicine. Since 2008 he has been Professor in the School of Biomedical Informatics at the University of Texas Health Sciences Center in Houston, Texas. In 2008 he also became President and Chief Executive Officer of the American Medical Informatics Association (AMIA), based in Bethesda, MD.
Edward H. Shortliffe
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Advisory Activities
At age 39, Dr. Shortliffe was elected to the Institute of Medicine of the National Academy of Sciences (where he has served on the IOM executive council). He is also a member of the American Association for Artificial Intelligence, American Society for Clinical Investigation, the Association of American Physicians, and the American Clinical and Climatological Association. He is a founding member of the American Medical Informatics Association and was one of five founding fellows of the American College of Medical Informatics. He is a Master of the American College of Physicians (ACP) and was a member of that organizations Board of Regents from 1996-2002. He is Editor-in-Chief of the Journal of Biomedical Informatics, and serves on the editorial boards for several other biomedical informatics publications. He has served on the oversight committee for the Division of Engineering and Physical Sciences (National Academy of Sciences) and the Biomedical Informatics Expert Panel (National Center for Research Resources at the National Institutes of Health). He also recently served on the National Committee for Vital and Health Statistics (NCVHS) and on the President's Information Technology Advisory Committee (PITAC). Earlier he served on the Computer Science and Telecommunications Board (National Research Council), the Biomedical Library Review Committee (National Library of Medicine), and was recipient of a research career development award from the latter agency. He is the author of more than 300 publications including seven books, one of which (Biomedical Informatics, now in its third edition) is considered the leading textbook in the field.
Honors
Morris F. Collen Award for Distinguished Contributions to Medical Informatics, American Medical Informatics Association, November 2006[8] Appointed Rolf H. Scholdager Professor of Biomedical Informatics, Columbia University, June 2005 National Associate, National Academies, Washington, DC, December 2004. Mastership, American College of Physicians, November 2002 Young Investigator Award, Western Society for Clinical Investigation, February 1987. Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine, July 1983June 1988. Research Career Development Award, National Library of Medicine, July 1979June 1984. Grace Murray Hopper Award (Distinguished computer scientist under age 30), Association for Computing Machinery, October 1976. Medical Scientist Training Program, Traineeship, September 1971 - June 1976.
Publications
Books
1. Shortliffe, E.H. Computer-Based Medical Consultations: MYCIN, Elsevier/North Holland, New York, 1976. Japanese language version by Bunkodo Blue Books, Tokyo, 1981 (translated by T. Kaminuma). 2. Buchanan, B.G. and Shortliffe, E.H. (eds). Rule-Based Expert Systems: The MYCIN Experiments of the Stanford Heuristic Programming Project. Reading, MA: Addison-Wesley, 1984. 3. Clancey, W.J. and Shortliffe, E.H. (eds). Readings in Medical Artificial Intelligence: The First Decade. Reading, MA: Addison-Wesley, 1984. 4. Shortliffe, E.H. and Perreault, L., (eds), Wiederhold, G., and Fagan, L.M. (assoc. eds.). Medical Informatics: Computer Applications in Health Care. Reading, MA: Addison-Wesley, 1990.
Edward H. Shortliffe 5. Shortliffe, E.H., Wulfman, C.E., Rindfleisch, T.C., and Carlson, R.W. An Integrated Oncology Workstation. Bethesda, MD: National Cancer Institute, 1991. [Received the 1991-92 Award of Excellence from The Society for Technical Communication.] 6. Shortliffe, E.H. and Perreault, L. (eds), Wiederhold, G., and Fagan, L.M. (assoc. eds.). Medical Informatics: Computer Applications in Health Care and Biomedicine. New York: Springer-Verlag, 2000. (2nd edition of #4, new publisher and title). 7. Shortliffe, E.H. (ed) and Cimino, J.J. (assoc. ed.). Biomedical Informatics: Computer Applications in Health Care and Biomedicine. New York: Springer-Verlag, 2006. (3rd edition of #4).
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Journal Articles
Google Scholar citations [9] Medline (PubMed) Publications [10]
Notes
[1] http:/ / www. sahs. uth. tmc. edu/ eshortliffe [2] 1. Rule-Based Expert Systems: The MYCIN Experiments of the Stanford Heuristic Programming Project -(edited by Bruce G. Buchanan and Edward H. Shortliffe; ebook version http:/ / www. aaaipress. org/ Classic/ Buchanan/ buchanan. html ) [3] [4] [5] [6] [7] http:/ / awards. acm. org/ hopper/ citation. cfm?id=4764071& srt=all& aw=145& ao=GMHOPPER Clancey WJ, Shortliffe EH, eds. Readings in medical artificial intelligence:the first decade. Reading, Mass.: Addison-Wesley, 1984 http:/ / www. smi. stanford. edu/ projects/ intermed-web/ Home. htm http:/ / www. dbmi. columbia. edu Boxwala AA, Peleg M, Tu S, Ogunyemi O, Zeng QT, Wang D, Patel VL, Greenes RA, Shortliffe EH. `GLIF3: a representation format for sharable computer-interpretable clinical practice guidelines. Journal of Biomedical Informatics 2004;37(3):147-161. [8] (http:/ / www. amia. org/ inside/ awards/ pastwinners. asp) [9] http:/ / scholar. google. com/ scholar?q=%22author%3AE. H. + author%3AShortliffe%22 [10] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=PubMed& cmd=Search& term=Shortliffe+ E
External links
Dr. Shortliffes Homepage (http://www.sahs.uth.tmc.edu/eshortliffe) Video of Morris Collen award ceremony (http://video.google.com/videoplay?docid=3338373186040343401) Article describing Dr. Shortliffe's Morris Collen award (http://www.jamia.org/cgi/reprint/14/3/376) Tree of Dr. Shortliffes students (http://infolab.stanford.edu/pub/voy/museum/shortliffetree.html) Massachusetts General Hospital Laboratory of Computer Science (http://www.lcs.mgh.harvard.edu/)
Don E. Detmer
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Don E. Detmer
Don E. Detmer
Born Residence Fields Institutions Virginia, USA National health information policy, quality improvement, administrative medicine, medical informatics American Medical Informatics Association [8] , University of Virginia [1]
Alma mater University of Kansas Medical Center [2] Knownfor Medical Informatics, Health informatics, electronic health records
Don E. Detmer, MD, MA, FACS, is Medical Director for Advocacy and Health Policy of the American College of Surgeons. He is also Professor Emeritus and Professor of Medical Education at the University of Virginia and Visiting Professor at CHIME, University College of London.

Don Detmer chaired the 1991 study, "The Computer-based Patient Record".[3] He was a member of the committee that developed the IOM Reports, "To Err is Human"[4] and "Crossing the Quality Chasm."[5] From 1999-2003 he was the Dennis Gillings Professor of Health Management at Cambridge University and is a lifetime member of Clare Hall College, Cambridge. Considered to be a mover of the US National Health Information Infrastructure, Dr. Detmer has also been a consultant to the government of England and the Hospital Authority of Hong Kong. Prior to the years in England, he was Vice President for Health Sciences at the Universities of Virginia and Utah. While at Virginia he led implementation of a physician order entry system and was principal investigator of its IAIMS grant. While at the University of WisconsinMadison, he developed the nations first Administrative Medicine Program, a Masters degree program for clinician-executives. As a surgeon, he was instrumental in the adoption and development of ambulatory surgery in the early 1970s and was team physician for the Wisconsin Badgers for ten years while also serving as President of the Medical Staff. He won a UWMadison Chancellors Distinguished Teaching Award. Detmer was appointed as President and CEO of the American Medical Informatics Association in 2004 until 2009 when he became Senior Advisor to AMIA until 2011. Detmer's education includes a medical degree from the University of Kansas with subsequent training at the National Institutes of Health, the Johns Hopkins Hospital, Duke University Medical Center, the Institute of Medicine, and Harvard Business School. His MA is from the University of Cambridge. Don's research interests include national health information policy, quality improvement, administrative medicine, vascular surgery, sports medicine, and management of academic health centers. He has written and edited a number of research articles, books, book chapters, and monographs on these topics. He enjoys grandchildren, horse riding, fly-fishing, reading biographies, and various crafts.
Don E. Detmer
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Advisory Activities
Don Detmer is a former trustee of the Nuffield Trust, a member of the Institute of Medicine as well as a lifetime Associate of the US National Academies, a fellow of AAAS, and the American Colleges of Medical Informatics, Sports Medicine, and Surgeons. He co-chairs the Blue Ridge Academic Health Group. He is also chairman of Medbiquitous. He was on the steering committee of a policy report for the Office of the National Coordinator on Health Information Technology to create a national framework for clinical decision support. Dr. Detmer is past chairman of the Board on Health Care Services of the IOM, the National Committee on Vital and Health Statistics, and the Board of Regents of the National Library of Medicine. He was a Commissioner on the Commission on Systemic Interoperability.[6]
Awards and honors

Walsh McDermott Medal, Institute of Medicine, Washington, DC, 2009 Inaugural recipient, Don Eugene Detmer Signature Award in Health Policy Contributions in Informatics, AMIA, 2008 National Associate, National Academies, Washington, DC, 2002 Medal of Respect from Mongolian State University, Ulan Bator, 2001 Fellow, American Association for the Advancement of Science, 1998 President's Award, American Medical Informatics Association, 1996, 1998 Distinguished Alumnus, Duke University Medical Alumni Association
Publications
Books
Dick, Richard; Detmer, Don E.; Steen, Elaine B. (eds.) (1997). The Computer-Based Patient Record. Washington: National Academy Press. ISBN0309055326. [3] Lohr, Kathleen; Vanselow, Neal A.; Detmer, Don E. (eds.) (1996). The Nation's Physician Workforce: Options for Balancing Supply and Requirements. Washington: National Academy Press. ISBN0309054311. [7] Detmer, Don E.; Steen, Elaine B. (eds.) (2005). The Academic Health Center: Leadership and Performance. Cambridge: Cambridge University Press. ISBN0521827183. [8]
Reports
Detmer D, Steen E. Learning from abroad: lessons and questions on personal health records for national policy. AARP. Mar 2006.[9]
Journal Articles
Google Scholar publications [10] Medline (Pubmed) publications [11]
References
http://aspe.hhs.gov/sp/nhii/Conference03/DetmerBio.htm http://www.amia.org/inside/leadership/boardbios.asp#Detmer
Don E. Detmer
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External links
American Medical Informatics Association [8] Medbiquitous [7]
References
[1] http:/ / www. virginia. edu [2] http:/ / www. kumc. edu/ [3] http:/ / www. nap. edu/ openbook. php?isbn=0309055326 [4] http:/ / www. nap. edu/ openbook. php?isbn=0309068371 [5] http:/ / books. nap. edu/ openbook. php?isbn=0309072808 [6] http:/ / endingthedocumentgame. gov/ [7] http:/ / www. nap. edu/ html/ physicians/ [8] http:/ / www. cambridge. org/ catalogue/ catalogue. asp?isbn=0521827183 [9] http:/ / www. aarp. org/ research/ health/ carequality/ 2006_10_phr_abroad. html [10] http:/ / scholar. google. com/ scholar?hl=en& lr=& sa=G& oi=qs& q=author:d-detmer [11] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=PubMed& cmd=Search& term=Detmer+ D
Homer R. Warner
Dr Homer R. Warner is one of the fathers of medical informatics.[1] He has pioneered many aspects of computer applications to medicine. Author of the book, Computer-Assisted Medical Decision-Making, published in 1979, he served as CIO for the Universitys Health Sciences Center, as president of the American College of Medical Informatics (where an award has been created in his honor), and was actively involved with the National Institutes of Health.[1] Warner received his Bachelors and Medical Degree from the University of Utah and his PhD in Physiology from the University of Minnesota.
Medical Informatics
Beginning in the mid-1950s, Dr. Warner began his work using computers for decision support in cardiology at Intermountain Healthcare [2] LDS Hospital in Salt Lake City. His ground-breaking work set the stage for the growth of the new field of academic study called medical informatics. In the 1970s, Dr. Warner and his Intermountain colleagues created one of the nations first versions of an electronic medical record. Designed to assist clinicians in decision-making, Intermountains now famous HELP system has been operational for nearly 40 years. Dr. Homer is emeritus chair of the University of Utah's Department of Medical Informatics. He was also a senior member of the Institute of Medicine of the National Academy of Sciences and president of the American College of Medical Informatics.
Homer R. Warner
722
Teaching and research at University of Utah

In 1964, Warner and his associates formally taught computer applications to medicine at the University of Utah in the Department of Biophysics and Bioengineering within the School of Engineering. In 1972, the department was split in two and Warner directed one of the splits: the Department of Medical Biophysics and Computing in the School of Medicine.[3] The department is internationally recognized for its contributions to computer applications in clinical care, medical education and research. The mission of the department is to improve health care outcomes through information systems in both the private and public sectors of the health care industry.[3] Much of the department's success is directly attributable to Warner's accomplishments. The department has produced the largest group of medical informatics professionals educated at any institution in the United States.[3] He was first chair of the Department of Medical Informatics. University of Utah was the first medical school in the U.S. to formally organize a degree in medical informatics.[1] Warner served as director of the cardiovascular laboratory at LDS Hospital from 1954 to 1970 and was honored as Physician of the Year in 1985. In 1988, he was elected to senior membership in the Institute of Medicine of the National Academy of Sciences. New members are chosen for major contributions to health and medicine as well as from related fields. For over 25 years, Dr. Warner has served almost continuously on research review groups for the National Institutes of Health, the National Center for Health Services Research and the National Library of Medicine.
Awards
Morris F. Collen Award.[1] [4] Homer Warner wing of the IHC Medical Center in Utah [5]
Intermountain Homer Warner Center for Informatics Research

Intermountain Healthcare officially opened a new center to support its clinical information systems on February 16, 2011 on the campus of Intermountain Medical Center in Salt Lake City. Named after Dr. Warner, the Homer Warner Center for Informatics Research [6] honors one of the industrys recognized fathers of clinical computer systems. Advanced information systems help caregivers improve medical delivery and outcomes. For example, these systems automate routine functions, facilitate communication among caregivers, support decision-making processes, and allow statistical analysis to help improve care processes and implement best medical practices. Intermountain [7] has been an industry leader in using computers in the practice of medicine for several decades. Thanks to the hard work and vision of Dr. Homer Warner and his colleagues, Intermountain has an outstanding legacy on which to build all of its future information systems. Beginning in the mid-1950s, Dr. Warner began his work using computers for decision support in cardiology at Intermountain's LDS Hospital in Salt Lake City. In the 1970s, Dr. Warner and his Intermountain colleagues created one of the nations first versions of an electronic medical record. Designed to assist clinicians in decision-making, Intermountains now famous HELP system has been operational for nearly 40 years.
Homer R. Warner
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Homer R. Warner award

The award was created by the Object Management Group (OMG), self described as "an international, open membership, not-for-profit computer industry consortium".[8] [9] It includes a $1000 prize, and is presented each year at the American Medical Informatics Association (AMIA). It is named for Warner. It is awarded for the paper that best describes approaches to improving computerized information acquisition, knowledge data acquisition and management, and experimental results documenting the value of theses approaches.[10]
Recipients
Dr. Peter Elkin for outstanding contribution to the field of Medical Informatics.[11] Dr. Hamish S. F. Fraser, Director of Informatics and Telemedicine for Partners in Health, in 2006.[12] Dr. Paul D. Clayton of Intermountain Health Care in 2005.[13] Drs. Paul Biondich and David Taylor jointly in 2003.[14] Dr. Randolph A. Miller, professor and chair of Biomedical Informatics, and David Sanders, research fellow in Biomedical Informatics, on November 2001.[10]
Bibliography
Some relevant books listed at Oregon Health & Science University (OSHU) library: Knowledge engineering in health informatics [15] Homer R. Warner, Dean K. Sorenson, Omar Bouhaddou. New York : Springer, c1997. Computer-assisted medical decision-making [16] Homer R. Warner. Imprint New York : Academic Press, 1979. Papers published at Journal of the American Medical Informatics Association [17] "Medical informatics: a real discipline?" HR Warner. J Am Med Inform Assoc 1995;2(4):207-214. "An event model of medical information representation", SM Huff, RA Rocha, BE Bray, HR Warner, and PJ Haug. J Am Med Inform Assoc 1995;2(2):116-134. To illustrate his contribution to informatics applied to medicine, on the patent called "Rules-based patient care system for use in healthcare locations" issued on January 1, 2008, the references list includes seven works where he has collaborated.[18]
References
[1] [2] [3] [4] Hall of Fame of Utah Technology Council, retrieved March 17, 2008 (http:/ / www. uita. org/ halloffame/ homerwarner. htm) http:/ / www. intermouuntainhealthcare. org department of medical informatics at University of Utah (http:/ / www. pubmedcentral. nih. gov/ articlerender. fcgi?artid=61389) Presentation of the Morris F. Collen Award to Homer R. Warner, MD, PhD: "why not? Let's do it!" (http:/ / www. jamia. org/ cgi/ content/ citation/ 2/ 2/ 137), retrieved March 17, 2008 [5] http:/ / statues. com/ mrc/ index. php?option=com_content& view=article& id=149& Itemid=173 [6] http:/ / intermountainis. org/ homer. html [7] http:/ / www. intermountainhealthcare. org [8] Object Management Group website (http:/ / www. omg. org/ ), retrieved March 17, 2008 [9] The Homer R. Warner Healthcare Interoperability Award;Call for Nominees. (http:/ / www. allbusiness. com/ technology/ software-services-applications-information/ 6539339-1. html) [10] The Reporter: Miller, Sanders receive award (http:/ / www. mc. vanderbilt. edu/ reporter/ index. html?ID=1835), retrieved March 17, 2008 [11] Human Factors Engineering in HEALTH INFORMATICS (http:/ / www. v-chi. dk/ HFEinHI2007/ index. php?page=people) Presentation of the members of the Scientific Program Committee and the presenters at the second conference on Human Factors Engineering and Usability for Healthcare Information Technology Applications [12] http:/ / deimos3. apple. com/ WebObjects/ Core. woa/ FeedEnclosure/ utah. edu. 1356509518. 01392594598. 1390525251/ enclosure. pdf [13] http:/ / www. amia. org/ files/ as05_paper_warner_0. pdf
Homer R. Warner
[14] http:/ / www2. amia. org/ meetings/ f03/ post/ awards. html [15] http:/ / ohsucr11. ohsu. edu:2082/ search?/ XHomer+ R. + Warner& searchscope=8& SORT=D/ XHomer+ R. + Warner& searchscope=8& SORT=D& SUBKEY=Homer%20R. %20Warner/ 1%2C2%2C2%2CB/ frameset& FF=XHomer+ R. + Warner& searchscope=8& SORT=D& 1%2C1%2C [16] http:/ / ohsucr11. ohsu. edu:2082/ search?/ XHomer+ R. + Warner& searchscope=8& SORT=D/ XHomer+ R. + Warner& searchscope=8& SORT=D& SUBKEY=Homer%20R. %20Warner/ 1%2C2%2C2%2CB/ frameset& FF=XHomer+ R. + Warner& searchscope=8& SORT=D& 2%2C2%2C [17] http:/ / www. jamia. org/ cgi/ search?sendit=Search& pubdate_year=& volume=& firstpage=& DOI=& author1=Homer+ R. + Warner& author2=& title=& andorexacttitle=and& titleabstract=& andorexacttitleabs=and& fulltext=& andorexactfulltext=and& resourcetype=1%2C10& fmonth=Jan& fyear=1994& tmonth=Mar& tyear=2008& fdatedef=1+ January+ 1994& tdatedef=1+ March+ 2008& hits=10& sortspec=relevance [18] United States Patent 7315825 (http:/ / www. patentstorm. us/ patents/ 7315825. html) Rules-based patient care system for use in healthcare locations, retrieved March 17, 2008
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Robert Ledley
725
Robert Ledley
Robert Ledley
Robert Ledley Born Fields 28 June 1926 physics
Notable awards National Medal of Technology
Robert Steven Ledley (born 28 June 1926) pioneered the use of digital electronic computers in biology and medicine. In 1959 he wrote two influential articles in the journal Science: "Reasoning Foundations of Medical Diagnosis" (with Lee B. Lusted) and "Digital Electronic Computers in Biomedical Science". Both articles encouraged biomedical researchers and physicians to adopt computer technology. In 1960 he established the National Biomedical Research Foundation (NBRF), a non-profit research organization dedicated to promoting the use of computers and electronic equipment in biomedical research. At the NBRF Ledley pursued several major projects: the early 1960s development of the Film Input to Digital Automatic Computer (FIDAC), which automated the analysis of chromosomes; the creation in 1965 of the Atlas of Protein Sequence and Structure [1] (edited by Margaret O. Dayhoff); the invention of the Automatic Computerized Transverse Axial [2] (ACTA) whole-body CT scanner in the mid 1970s; and the establishment of the Protein Information Resource in 1984. Ledley also served as editor of several major peer-reviewed biomedical journals. In 1990, Ledley was inducted into the National Inventors Hall of Fame. He was awarded the National Medal of Technology by President Bill Clinton in 1997. He is currently president and research director of the NBRF.
References
Sittig, Dean F; Ash, Joan S; Ledley, Robert S (2006), "The story behind the development of the first whole-body computerized tomography scanner as told by Robert S. Ledley.", Journal of the American Medical Informatics Association : JAMIA 13 (5): 4659, doi:10.1197/jamia.M2127, PMC1561796, PMID16799115 Broering, N C (1999), "Presentation of the Morris F. Collen Award to Robert S. Ledley, DDS.", Journal of the American Medical Informatics Association : JAMIA 6 (3): 2604, doi:10.1136/jamia.1999.0060260, PMC61367, PMID10332660 Bleich, H L (1991), "Enemy radar, theoretical physics, and computer-assisted diagnosis", M.D. Computing : computers in medical practice 8 (5): 26970, PMID1749336
Robert Ledley
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References
[1] http:/ / www. dayhoff. cc/ MODAtlasSummary. html [2] http:/ / americanhistory. si. edu/ collections/ object. cfm?key=35& objkey=115
Vimla L. Patel
Vimla L. Patel
Born Nationality Fields Fiji Canadian Health Informatics Cognitive Psychology McGill University Columbia University UT Houston ASU University of Otago McGill University Andre Kushniruk David R Kaufman Trevor Cohen Jan Horsky
Institutions
Alma mater
Doctoral students
Other notablestudents Marco Ramoni Knownfor Cognitive science methods applied to physicians reasoning International Health Decision making and Medical errors Fellow, Royal Society of Canada Fellow, ACMI Fellow, New York Academy of Medicine
Notable awards
Vimla Lodhia Patel, is a Fijian-born Canadian cognitive psychologist and biomedical informaticist. In the past decade, Dr. Patel has worked in the area of biomedical informatics, in particular studying the mediating roles of technology on performance. Her work includes studies of medical errors and error reduction in emergency care and other critical medical environments, (including telephone triage). Her past work in health cognition includes studies of risk-taking behavior and sexual decision making as it pertains to HIV in youth and adolescents.Her current work focuses mostly on identifying underlying cognition in medical error

Dr. Patel was born in Fiji and obtained a degree in biochemistry and microbiology from University of Otago in New Zealand (1976), and MA and PhD in Educational Psychology (Medical Cognition,1980,1981) from McGill University in Montreal, where she also served as professor of Medicine and Psychology and director of the Centre for Medical Education. She was a founding member of HEALnet [1] (Health Evidence Application and Linkage Network), which made seminal contributions furthering informatics research and application in Canada. She was also a member of the InterMed Collaboratory [5], which developed guidelines for medical decision support, and has done extensive work in India, Africa, and Colombia in cross-cultural cognition research.
Vimla L. Patel In 2000 she became director of the Laboratory of Cognition and Decision Making in the department of Biomedical Informatics at Columbia University, where she was also faculty in the department of Psychiatry and Teacher's College. From 2007-09, she served as interim chair and vice chair of Department of BMI at Arizona State University. As of November 2009, Dr. Patel is a Professor of Biomedical Informatics and Co-Director of the Center for Cognitive Informatics and Decision Making at the University of Texas at Houston.
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Research
In 1978 Elstein, Shulman and Sprafka[2] applied cognitive science methods to investigate physicians clinical competence, developing a model of hypothetico-deductive reasoning which proposed that physicians reason by generating and testing a set of hypotheses to explain clinical data. This is an example of backward (hypothesis-to-data) reasoning. In 1986, Patel and Groen[3] demonstrated that experts who accurately diagnosed complex clinical problems used forward reasoning (data to hypothesis), in contrast to novice subjects who used backward reasoning and misdiagnosed or partially diagnosed the same problems. Patel also applied text comprehension methods to understanding the use of clinical practice guidelines with the goal of increasing adoption of best practices.[4] . Patel and colleagues have recently argued for new paradigm for error studies, where instead of zero error tolerance, detection and correction of potential error is viewed as an integral part of cognitive work in a complex workplace. [5] She is the author of more than 250 publications in cognitive psychology, biomedical informatics, medical education and related fields.
Honors
Member, Committee on Patient Safety and Health Information Technology, Institute of Medicine (IOM). 2010-2012. Science and Technology Research Award (STAR) with Edward Shortliffe, UTH System, Houston,Texas. 2009 Vice Chair, AMIA Program Committee. 2009 Service Faculty of the Year Award, School of Computing and Informatics, Arizona State University. 2008 Member, Clinical Research Review Committee, The National Center for Research Resources (NCRR). 2007-2009 Selected for Marquis Whos Who in the World. 2007 Member, Committee on Opportunities in Basic Research in the Behavioral and the Social Sciences for the Military, National Research Council, U.S.A. 2006 Elected Fellow, New York Academy of Medicine. 2004 Vice President (Member Service), International Medical Informatics Association Governing Board. 2003-2006 Outstanding Manuscript Award in Educational Methodology, Journal of Dental Education. 2002 Member, Bio-engineering Training and Education Program, National Science Foundation, USA. 1999-2007 Chair, Editorial Committee, Medinfo2001, International Medical Informatics Association, London, UK. 1999 D.Sc. (honorary), University of Victoria, BC, Canada. 1998 Member, Roundtable on Work, Learning and Assessment, National Research Council, U.S.A. 1997 Elected Member, Board of Governors, Cognitive Science Society. 1997 Elected Fellow, American College of Medical Informatics. 1996 Fellow, The Royal Society of Canada (elected by the Academy of Humanities and Social Sciences). 1996 Elected Woman of Science for the year (Sweden). 1994
Vimla L. Patel
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External links
Vimla Patel's Homepage [6] Dr.Patel's Research Projects [7]
Publications
Journal Articles [8] Book Chapters [9] Medline Publications [10] Google Scholar Citations [11]
References
[1] http:/ / nce. nserc. ca/ media/ newsrel/ archives/ 090299_e. htm [2] Elstein, A.S., Shulman, L.S., and Sprafka, S.A. Medical Problem-Solving: An Analysis of Clinical Reasoning. Cambridge, Mass.: Harvard University Press, 1978. [3] Patel, V.L. & Groen, G.J. (1986) Knowledge-based solution strategies in medical reasoning. Cognitive Science, 10, 91-116. [4] Patel, V.L., Kaufman, D.R. (2006) Cognitive Science and Biomedical Informatics. - E.H. Shortliffe & J.J. Cimino (Eds.) Biomedical Informatics: Computer Applications in Health Care and Biomedicine. New York: Springer-Verlag. P176. [5] Patel, V.L., Cohen, T., Murarka, T., Olsen, J., Kagita, S., Myneni, S., Ghaemmaghami, V., (2010) Recovery at the Edge of Error: Debunking the Myth of the Infallible Expert. Journal of Biomedical Informatics. [6] http:/ / www. sahs. uth. tmc. edu/ vpatel/ [7] http:/ / ccidm. shis. uth. tmc. edu/ Research. aspx [8] http:/ / www. sahs. uth. tmc. edu/ vpatel/ journals. php [9] http:/ / www. sahs. uth. tmc. edu/ vpatel/ chapters. php [10] http:/ / www. ncbi. nlm. nih. gov/ sites/ entrez?term=patel%20vl& cmd=search& db=pubmed [11] http:/ / scholar. google. com/ scholar?q=Vimla+ L. Patel& hl=en& lr=
Article Sources and Contributors
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Health information technology Source: http://en.wikipedia.org/w/index.php?oldid=444347969 Contributors: Health informatics Source: http://en.wikipedia.org/w/index.php?oldid=450170686 Contributors: Clinical Informatics Source: http://en.wikipedia.org/w/index.php?oldid=346733860 Contributors: Cybermedicine Source: http://en.wikipedia.org/w/index.php?oldid=422349723 Contributors: eHealth Source: http://en.wikipedia.org/w/index.php?oldid=448834075 Contributors: Health 2.0 Source: http://en.wikipedia.org/w/index.php?oldid=432174501 Contributors: Public health informatics Source: http://en.wikipedia.org/w/index.php?oldid=437891081 Contributors: Health Administration Informatics Source: http://en.wikipedia.org/w/index.php?oldid=411316068 Contributors: Medical integration environment Source: http://en.wikipedia.org/w/index.php?oldid=413190642 Contributors: Health information exchange Source: http://en.wikipedia.org/w/index.php?oldid=444536557 Contributors: Hospital information system Source: http://en.wikipedia.org/w/index.php?oldid=448706445 Contributors: Healthcare workflow Source: http://en.wikipedia.org/w/index.php?oldid=312091708 Contributors: Computer physician order entry Source: http://en.wikipedia.org/w/index.php?oldid=355319428 Contributors: ICU quality and management tools Source: http://en.wikipedia.org/w/index.php?oldid=442457561 Contributors: Laboratory information management system Source: http://en.wikipedia.org/w/index.php?oldid=449343841 Contributors: Laboratory information system Source: http://en.wikipedia.org/w/index.php?oldid=442054812 Contributors: mHealth Source: http://en.wikipedia.org/w/index.php?oldid=447287354 Contributors: Practice management software Source: http://en.wikipedia.org/w/index.php?oldid=444806205 Contributors: Clinical Quality Management System Source: http://en.wikipedia.org/w/index.php?oldid=413190414 Contributors: Electronic health record Source: http://en.wikipedia.org/w/index.php?oldid=447833591 Contributors: Electronic medical record Source: http://en.wikipedia.org/w/index.php?oldid=444279761 Contributors: Personal health record Source: http://en.wikipedia.org/w/index.php?oldid=447753048 Contributors: COmputer STored Ambulatory Record Source: http://en.wikipedia.org/w/index.php?oldid=413190366 Contributors: ProRec Source: http://en.wikipedia.org/w/index.php?oldid=309185067 Contributors: Health record trust Source: http://en.wikipedia.org/w/index.php?oldid=413190560 Contributors: Canadian EMR Source: http://en.wikipedia.org/w/index.php?oldid=413190375 Contributors: ClearHealth Source: http://en.wikipedia.org/w/index.php?oldid=440236971 Contributors: Laika Source: http://en.wikipedia.org/w/index.php?oldid=444609389 Contributors: openEHR Source: http://en.wikipedia.org/w/index.php?oldid=422502605 Contributors: OpenEMR Source: http://en.wikipedia.org/w/index.php?oldid=447539408 Contributors: OpenMRS Source: http://en.wikipedia.org/w/index.php?oldid=413190737 Contributors: Kind Messages for Electronic Healthcare Record Source: http://en.wikipedia.org/w/index.php?oldid=416919684 Contributors: Summarized Electronic Health Record Source: http://en.wikipedia.org/w/index.php?oldid=416919613 Contributors: VistA Source: http://en.wikipedia.org/w/index.php?oldid=447929635 Contributors: VistA imaging Source: http://en.wikipedia.org/w/index.php?oldid=439986693 Contributors: VistA Web Source: http://en.wikipedia.org/w/index.php?oldid=413190863 Contributors: WorldVistA Source: http://en.wikipedia.org/w/index.php?oldid=413190881 Contributors: ZEPRS Source: http://en.wikipedia.org/w/index.php?oldid=450076725 Contributors: Clinical decision support system Source: http://en.wikipedia.org/w/index.php?oldid=445868724 Contributors: Computer-aided diagnosis Source: http://en.wikipedia.org/w/index.php?oldid=443008676 Contributors: Medical algorithm Source: http://en.wikipedia.org/w/index.php?oldid=446066888 Contributors: Medical logic module Source: http://en.wikipedia.org/w/index.php?oldid=439385396 Contributors: Arden syntax Source: http://en.wikipedia.org/w/index.php?oldid=447869121 Contributors: Concept Processing Source: http://en.wikipedia.org/w/index.php?oldid=427043163 Contributors: Guideline execution engine Source: http://en.wikipedia.org/w/index.php?oldid=405633696 Contributors: CADUCEUS Source: http://en.wikipedia.org/w/index.php?oldid=429158079 Contributors: DXplain Source: http://en.wikipedia.org/w/index.php?oldid=439410212 Contributors: Internist-I Source: http://en.wikipedia.org/w/index.php?oldid=445716106 Contributors: Mycin Source: http://en.wikipedia.org/w/index.php?oldid=450174464 Contributors: -

Physicians' Information and Education Resource Source: http://en.wikipedia.org/w/index.php?oldid=443797976 Contributors: RetroGuide Source: http://en.wikipedia.org/w/index.php?oldid=426204215 Contributors: Symptomat Source: http://en.wikipedia.org/w/index.php?oldid=418151355 Contributors: STD Wizard Source: http://en.wikipedia.org/w/index.php?oldid=449047244 Contributors: Digital radiography Source: http://en.wikipedia.org/w/index.php?oldid=449394490 Contributors: Imaging informatics Source: http://en.wikipedia.org/w/index.php?oldid=413190587 Contributors: Patient registration Source: http://en.wikipedia.org/w/index.php?oldid=442109491 Contributors: Radiology information system Source: http://en.wikipedia.org/w/index.php?oldid=436809829 Contributors: Picture archiving and communication system Source: http://en.wikipedia.org/w/index.php?oldid=439986471 Contributors: Analysis of Functional NeuroImages Source: http://en.wikipedia.org/w/index.php?oldid=447101159 Contributors: 3DSlicer Source: http://en.wikipedia.org/w/index.php?oldid=440886541 Contributors: Analyze Source: http://en.wikipedia.org/w/index.php?oldid=417791393 Contributors: CARET Source: http://en.wikipedia.org/w/index.php?oldid=321364395 Contributors: CAVEman Source: http://en.wikipedia.org/w/index.php?oldid=409231099 Contributors: FreeSurfer Source: http://en.wikipedia.org/w/index.php?oldid=435167011 Contributors: ImageJ Source: http://en.wikipedia.org/w/index.php?oldid=448827868 Contributors: InVesalius Source: http://en.wikipedia.org/w/index.php?oldid=425722314 Contributors: ITK-SNAP Source: http://en.wikipedia.org/w/index.php?oldid=445948387 Contributors: Mango Source: http://en.wikipedia.org/w/index.php?oldid=406216866 Contributors: OsiriX Source: http://en.wikipedia.org/w/index.php?oldid=439248559 Contributors: Medical monitor Source: http://en.wikipedia.org/w/index.php?oldid=448931228 Contributors: Holter monitor Source: http://en.wikipedia.org/w/index.php?oldid=443516705 Contributors: Automated ECG interpretation Source: http://en.wikipedia.org/w/index.php?oldid=430483819 Contributors: Open ECG project Source: http://en.wikipedia.org/w/index.php?oldid=425007931 Contributors: MECIF Protocol Source: http://en.wikipedia.org/w/index.php?oldid=397223551 Contributors: SCP-ECG Source: http://en.wikipedia.org/w/index.php?oldid=384563822 Contributors: European Data Format Source: http://en.wikipedia.org/w/index.php?oldid=421849091 Contributors: OpenXDF Source: http://en.wikipedia.org/w/index.php?oldid=313621864 Contributors: Biological database Source: http://en.wikipedia.org/w/index.php?oldid=446593961 Contributors: Medical literature retrieval Source: http://en.wikipedia.org/w/index.php?oldid=441669521 Contributors: MEDLINE Source: http://en.wikipedia.org/w/index.php?oldid=426721318 Contributors: Entrez Source: http://en.wikipedia.org/w/index.php?oldid=449123121 Contributors: ETBLAST Source: http://en.wikipedia.org/w/index.php?oldid=445394472 Contributors: PMID Source: http://en.wikipedia.org/w/index.php?oldid=430302280 Contributors: PubMed Source: http://en.wikipedia.org/w/index.php?oldid=444913025 Contributors: GoPubMed Source: http://en.wikipedia.org/w/index.php?oldid=440494573 Contributors: Pubget Source: http://en.wikipedia.org/w/index.php?oldid=450143065 Contributors: PubMed Central Source: http://en.wikipedia.org/w/index.php?oldid=440690796 Contributors: UK PubMed Central Source: http://en.wikipedia.org/w/index.php?oldid=429867530 Contributors: TRIP Database Source: http://en.wikipedia.org/w/index.php?oldid=414601891 Contributors: Twease Source: http://en.wikipedia.org/w/index.php?oldid=201833268 Contributors: SciELO Source: http://en.wikipedia.org/w/index.php?oldid=440474070 Contributors: Connected Health Source: http://en.wikipedia.org/w/index.php?oldid=417280345 Contributors: Telehealth Source: http://en.wikipedia.org/w/index.php?oldid=448567480 Contributors: Telemedicine Source: http://en.wikipedia.org/w/index.php?oldid=447361950 Contributors: Telecare Source: http://en.wikipedia.org/w/index.php?oldid=426880562 Contributors: Telephone triage Source: http://en.wikipedia.org/w/index.php?oldid=415191513 Contributors: Remote guidance Source: http://en.wikipedia.org/w/index.php?oldid=370151362 Contributors: Tele-epidemiology Source: http://en.wikipedia.org/w/index.php?oldid=427535961 Contributors: Telenursing Source: http://en.wikipedia.org/w/index.php?oldid=416502598 Contributors: Teledermatology Source: http://en.wikipedia.org/w/index.php?oldid=440311872 Contributors: -
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Telemental Health Source: http://en.wikipedia.org/w/index.php?oldid=418558013 Contributors: Telepsychiatry Source: http://en.wikipedia.org/w/index.php?oldid=421839545 Contributors: Teleradiology Source: http://en.wikipedia.org/w/index.php?oldid=441861039 Contributors: Telerehabilitation Source: http://en.wikipedia.org/w/index.php?oldid=446863135 Contributors: Virtual reality in telerehabilitation Source: http://en.wikipedia.org/w/index.php?oldid=414812234 Contributors: Campus medicus Source: http://en.wikipedia.org/w/index.php?oldid=336751807 Contributors: Wireless Medical Telemetry Service Source: http://en.wikipedia.org/w/index.php?oldid=353654061 Contributors: Computer assisted surgery Source: http://en.wikipedia.org/w/index.php?oldid=413598746 Contributors: Remote surgery Source: http://en.wikipedia.org/w/index.php?oldid=436254663 Contributors: Robotic surgery Source: http://en.wikipedia.org/w/index.php?oldid=449141376 Contributors: Surgical Segment Navigator Source: http://en.wikipedia.org/w/index.php?oldid=434551294 Contributors: Bone segment navigation Source: http://en.wikipedia.org/w/index.php?oldid=414749175 Contributors: Robotic prostatectomy Source: http://en.wikipedia.org/w/index.php?oldid=388157553 Contributors: Robot-assisted heart surgery Source: http://en.wikipedia.org/w/index.php?oldid=388614159 Contributors: Cyberknife Source: http://en.wikipedia.org/w/index.php?oldid=449905913 Contributors: da Vinci Surgical System Source: http://en.wikipedia.org/w/index.php?oldid=440982071 Contributors: NeuroArm Source: http://en.wikipedia.org/w/index.php?oldid=427321743 Contributors: Laboratory Unit for Computer Assisted Surgery Source: http://en.wikipedia.org/w/index.php?oldid=359775154 Contributors: Health Insurance Portability and Accountability Act Source: http://en.wikipedia.org/w/index.php?oldid=449306475 Contributors: Certification Commission for Healthcare Information Technology Source: http://en.wikipedia.org/w/index.php?oldid=445947745 Contributors: Medical software Source: http://en.wikipedia.org/w/index.php?oldid=445714872 Contributors: Dental software Source: http://en.wikipedia.org/w/index.php?oldid=426841779 Contributors: List of freeware health software Source: http://en.wikipedia.org/w/index.php?oldid=430246739 Contributors: List of open source healthcare software Source: http://en.wikipedia.org/w/index.php?oldid=448746385 Contributors: List of neuroimaging software Source: http://en.wikipedia.org/w/index.php?oldid=442849037 Contributors: Mirth Source: http://en.wikipedia.org/w/index.php?oldid=447508414 Contributors: Mpro Source: http://en.wikipedia.org/w/index.php?oldid=441672065 Contributors: Open Dental Source: http://en.wikipedia.org/w/index.php?oldid=427096502 Contributors: Personal Health Application Source: http://en.wikipedia.org/w/index.php?oldid=406878096 Contributors: Texas Medication Algorithm Project Source: http://en.wikipedia.org/w/index.php?oldid=432635752 Contributors: MUMPS Source: http://en.wikipedia.org/w/index.php?oldid=444444632 Contributors: Bing Health Source: http://en.wikipedia.org/w/index.php?oldid=445532748 Contributors: Dossia Source: http://en.wikipedia.org/w/index.php?oldid=450142200 Contributors: E-Patient Source: http://en.wikipedia.org/w/index.php?oldid=437847665 Contributors: Google Health Source: http://en.wikipedia.org/w/index.php?oldid=449886657 Contributors: iMedicor Source: http://en.wikipedia.org/w/index.php?oldid=336752215 Contributors: Microsoft Amalga Source: http://en.wikipedia.org/w/index.php?oldid=432442546 Contributors: Microsoft HealthVault Source: http://en.wikipedia.org/w/index.php?oldid=440401332 Contributors: Patient portal Source: http://en.wikipedia.org/w/index.php?oldid=449111208 Contributors: Virtual patient Source: http://en.wikipedia.org/w/index.php?oldid=447417712 Contributors: Translational research informatics Source: http://en.wikipedia.org/w/index.php?oldid=413190794 Contributors: Clinical trial management Source: http://en.wikipedia.org/w/index.php?oldid=439272463 Contributors: Clinical data management system Source: http://en.wikipedia.org/w/index.php?oldid=440278333 Contributors: Case report form Source: http://en.wikipedia.org/w/index.php?oldid=384530445 Contributors: Clinical coder Source: http://en.wikipedia.org/w/index.php?oldid=444106072 Contributors: Clinical data acquisition Source: http://en.wikipedia.org/w/index.php?oldid=441672223 Contributors: Data clarification form Source: http://en.wikipedia.org/w/index.php?oldid=394440457 Contributors: Patient-reported outcome Source: http://en.wikipedia.org/w/index.php?oldid=445814174 Contributors: Diagnosis codes Source: http://en.wikipedia.org/w/index.php?oldid=440149375 Contributors: Procedure codes Source: http://en.wikipedia.org/w/index.php?oldid=434272169 Contributors: Bar Code Medication Administration Source: http://en.wikipedia.org/w/index.php?oldid=413190358 Contributors: -
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Bidirectional Health Information Exchange Source: http://en.wikipedia.org/w/index.php?oldid=334951032 Contributors: Classification Commune des Actes Mdicaux Source: http://en.wikipedia.org/w/index.php?oldid=441713591 Contributors: Classification of Pharmaco-Therapeutic Referrals Source: http://en.wikipedia.org/w/index.php?oldid=445861744 Contributors: Clinical Context Object Workgroup Source: http://en.wikipedia.org/w/index.php?oldid=334951348 Contributors: Clinical Data Interchange Standards Consortium Source: http://en.wikipedia.org/w/index.php?oldid=413099769 Contributors: Clinical Document Architecture Source: http://en.wikipedia.org/w/index.php?oldid=418135309 Contributors: Continuity of Care Document Source: http://en.wikipedia.org/w/index.php?oldid=443875243 Contributors: Clinical Document Architecture Source: http://en.wikipedia.org/w/index.php?oldid=418135309 Contributors: Continuity of Care Record Source: http://en.wikipedia.org/w/index.php?oldid=445243306 Contributors: COSTART Source: http://en.wikipedia.org/w/index.php?oldid=307408430 Contributors: Current Procedural Terminology Source: http://en.wikipedia.org/w/index.php?oldid=448830592 Contributors: Diagnosis-related group Source: http://en.wikipedia.org/w/index.php?oldid=447560891 Contributors: Digital Imaging and Communications in Medicine Source: http://en.wikipedia.org/w/index.php?oldid=422132294 Contributors: DOCLE Source: http://en.wikipedia.org/w/index.php?oldid=267138839 Contributors: Electronic Common Technical Document Source: http://en.wikipedia.org/w/index.php?oldid=441370804 Contributors: EUDRANET Source: http://en.wikipedia.org/w/index.php?oldid=429187140 Contributors: General Data Format for Biomedical Signals Source: http://en.wikipedia.org/w/index.php?oldid=384461456 Contributors: Health Level 7 Source: http://en.wikipedia.org/w/index.php?oldid=450195514 Contributors: Healthcare Common Procedure Coding System Source: http://en.wikipedia.org/w/index.php?oldid=442500659 Contributors: Healthcare Information Technology Standards Panel Source: http://en.wikipedia.org/w/index.php?oldid=420611231 Contributors: Health Informatics Service Architecture Source: http://en.wikipedia.org/w/index.php?oldid=430353082 Contributors: Healthcare Services Specification Project Source: http://en.wikipedia.org/w/index.php?oldid=447741099 Contributors: International Statistical Classification of Diseases and Related Health Problems Source: http://en.wikipedia.org/w/index.php?oldid=445116285 Contributors: ICD-10 Source: http://en.wikipedia.org/w/index.php?oldid=448675730 Contributors: ICD-10 Procedure Coding System Source: http://en.wikipedia.org/w/index.php?oldid=435262184 Contributors: International Classification of Diseases for Oncology Source: http://en.wikipedia.org/w/index.php?oldid=434045395 Contributors: International Classification of Functioning, Disability and Health Source: http://en.wikipedia.org/w/index.php?oldid=440299776 Contributors: International Classification of Health Interventions Source: http://en.wikipedia.org/w/index.php?oldid=431164143 Contributors: International Classification of Primary Care Source: http://en.wikipedia.org/w/index.php?oldid=439075024 Contributors: International Healthcare Terminology Standards Development Organisation Source: http://en.wikipedia.org/w/index.php?oldid=362858235 Contributors: ICPC-2 PLUS Source: http://en.wikipedia.org/w/index.php?oldid=436496614 Contributors: ISO 27799 Source: http://en.wikipedia.org/w/index.php?oldid=439035954 Contributors: ISO/IEEE 11073 Source: http://en.wikipedia.org/w/index.php?oldid=413190610 Contributors: ISO/TC 215 Source: http://en.wikipedia.org/w/index.php?oldid=414541489 Contributors: LOINC Source: http://en.wikipedia.org/w/index.php?oldid=448297008 Contributors: MEDCIN Source: http://en.wikipedia.org/w/index.php?oldid=434152683 Contributors: MedDRA Source: http://en.wikipedia.org/w/index.php?oldid=443902407 Contributors: Medical Subject Headings Source: http://en.wikipedia.org/w/index.php?oldid=450110633 Contributors: Minimum Data Set Source: http://en.wikipedia.org/w/index.php?oldid=431063054 Contributors: Multiscale Electrophysiology Format Source: http://en.wikipedia.org/w/index.php?oldid=422087000 Contributors: NANDA Source: http://en.wikipedia.org/w/index.php?oldid=430955909 Contributors: Nursing Interventions Classification Source: http://en.wikipedia.org/w/index.php?oldid=434151176 Contributors: Nursing Minimum Data Set Source: http://en.wikipedia.org/w/index.php?oldid=411303493 Contributors: Nursing Outcomes Classification Source: http://en.wikipedia.org/w/index.php?oldid=434151352 Contributors: OpenGALEN Source: http://en.wikipedia.org/w/index.php?oldid=424672639 Contributors: SNOMED Source: http://en.wikipedia.org/w/index.php?oldid=26800760 Contributors: SNOMED CT Source: http://en.wikipedia.org/w/index.php?oldid=444372387 Contributors: Standard for Exchange of Non-clinical Data Source: http://en.wikipedia.org/w/index.php?oldid=334909146 Contributors: TC 251 Source: http://en.wikipedia.org/w/index.php?oldid=417417955 Contributors: WHOART Source: http://en.wikipedia.org/w/index.php?oldid=307408922 Contributors: Nosology Source: http://en.wikipedia.org/w/index.php?oldid=443478667 Contributors: -
732

Archetype Source: http://en.wikipedia.org/w/index.php?oldid=421466486 Contributors: OBO Foundry Source: http://en.wikipedia.org/w/index.php?oldid=431736923 Contributors: Ontology for Biomedical Investigations Source: http://en.wikipedia.org/w/index.php?oldid=386417340 Contributors: Open Biomedical Ontologies Source: http://en.wikipedia.org/w/index.php?oldid=441838683 Contributors: TIME-ITEM Source: http://en.wikipedia.org/w/index.php?oldid=431164961 Contributors: American Association for Medical Systems and Informatics Source: http://en.wikipedia.org/w/index.php?oldid=404028778 Contributors: American College of Medical Informatics Source: http://en.wikipedia.org/w/index.php?oldid=427943895 Contributors: American Health Information Management Association Source: http://en.wikipedia.org/w/index.php?oldid=442752003 Contributors: American Telemedicine Association Source: http://en.wikipedia.org/w/index.php?oldid=442672797 Contributors: Belgian Health Telematics Commission Source: http://en.wikipedia.org/w/index.php?oldid=416919885 Contributors: Belgian Medical Informatics Association Source: http://en.wikipedia.org/w/index.php?oldid=268725995 Contributors: Brazilian Society of Health Informatics Source: http://en.wikipedia.org/w/index.php?oldid=447834850 Contributors: Brazilian Congress on Health Informatics Source: http://en.wikipedia.org/w/index.php?oldid=336667120 Contributors: Center for Telehealth and E-Health Law Source: http://en.wikipedia.org/w/index.php?oldid=448292432 Contributors: Centre for e-Health Source: http://en.wikipedia.org/w/index.php?oldid=445114271 Contributors: European Federation for Medical Informatics Source: http://en.wikipedia.org/w/index.php?oldid=268727146 Contributors: European Health Telematics Association Source: http://en.wikipedia.org/w/index.php?oldid=337738724 Contributors: European Health Telematics Observatory Source: http://en.wikipedia.org/w/index.php?oldid=336753104 Contributors: European Institute for Health Records Source: http://en.wikipedia.org/w/index.php?oldid=416917639 Contributors: Health On the Net Foundation Source: http://en.wikipedia.org/w/index.php?oldid=444004023 Contributors: HISA Source: http://en.wikipedia.org/w/index.php?oldid=393045798 Contributors: Indian Association for Medical Informatics Source: http://en.wikipedia.org/w/index.php?oldid=441076326 Contributors: International Medical Informatics Association Source: http://en.wikipedia.org/w/index.php?oldid=450075216 Contributors: Medinfo Source: http://en.wikipedia.org/w/index.php?oldid=392241108 Contributors: National Resource Center for Health Information Technology Source: http://en.wikipedia.org/w/index.php?oldid=239641452 Contributors: Open Source Health Care Alliance Source: http://en.wikipedia.org/w/index.php?oldid=334953345 Contributors: The Continua Health Alliance Source: http://en.wikipedia.org/w/index.php?oldid=445888139 Contributors: UNESCO Chair in Telemedicine Source: http://en.wikipedia.org/w/index.php?oldid=442746737 Contributors: World Health Imaging, Telemedicine, and Informatics Alliance Source: http://en.wikipedia.org/w/index.php?oldid=425217552 Contributors: List of medical and health informatics journals Source: http://en.wikipedia.org/w/index.php?oldid=450061225 Contributors: Journal of Information Professionals in Health Source: http://en.wikipedia.org/w/index.php?oldid=334966030 Contributors: Journal of Medical Internet Research Source: http://en.wikipedia.org/w/index.php?oldid=437044277 Contributors: BeHealth Source: http://en.wikipedia.org/w/index.php?oldid=416919792 Contributors: Canada Health Infoway Source: http://en.wikipedia.org/w/index.php?oldid=443792457 Contributors: Distance Learning and Telemedicine Grant and Loan Program Source: http://en.wikipedia.org/w/index.php?oldid=355282121 Contributors: eHealth Ontario Source: http://en.wikipedia.org/w/index.php?oldid=435737937 Contributors: HealthConnect Source: http://en.wikipedia.org/w/index.php?oldid=445474878 Contributors: Health Information Systems Programme Source: http://en.wikipedia.org/w/index.php?oldid=413190536 Contributors: District Health Information System Source: http://en.wikipedia.org/w/index.php?oldid=188341866 Contributors: FLOW Source: http://en.wikipedia.org/w/index.php?oldid=424419844 Contributors: Health informatics in China Source: http://en.wikipedia.org/w/index.php?oldid=428252130 Contributors: NHS Direct Source: http://en.wikipedia.org/w/index.php?oldid=442836890 Contributors: NHS National Programme for IT Source: http://en.wikipedia.org/w/index.php?oldid=375627517 Contributors: Ontario Telemedicine Network Source: http://en.wikipedia.org/w/index.php?oldid=450115350 Contributors: Public Health Information Network Source: http://en.wikipedia.org/w/index.php?oldid=443798007 Contributors: SAPPHIRE Source: http://en.wikipedia.org/w/index.php?oldid=421864189 Contributors: SmartCare Source: http://en.wikipedia.org/w/index.php?oldid=411852319 Contributors: Building Europe-Africa Collaborative Network for Applying IST in Health Care Sector Source: http://en.wikipedia.org/w/index.php?oldid=334950647 Contributors: Global Infectious Disease Epidemiology Network Source: http://en.wikipedia.org/w/index.php?oldid=405754099 Contributors: Integrating the Healthcare Enterprise Source: http://en.wikipedia.org/w/index.php?oldid=447927873 Contributors: GIS and Public Health Source: http://en.wikipedia.org/w/index.php?oldid=433459378 Contributors: -
733

Neuroinformatics Source: http://en.wikipedia.org/w/index.php?oldid=447673942 Contributors: Healthcare Effectiveness Data and Information Set Source: http://en.wikipedia.org/w/index.php?oldid=413834804 Contributors: E-epidemiology Source: http://en.wikipedia.org/w/index.php?oldid=385364227 Contributors: Epi Info Source: http://en.wikipedia.org/w/index.php?oldid=436649799 Contributors: OpenEpi Source: http://en.wikipedia.org/w/index.php?oldid=436649910 Contributors: Living Human Project Source: http://en.wikipedia.org/w/index.php?oldid=430391424 Contributors: Stereolithography Source: http://en.wikipedia.org/w/index.php?oldid=424283779 Contributors: Virtual Physiological Human Source: http://en.wikipedia.org/w/index.php?oldid=437376308 Contributors: Visible Human Project Source: http://en.wikipedia.org/w/index.php?oldid=444294919 Contributors: Edward H. Shortliffe Source: http://en.wikipedia.org/w/index.php?oldid=440539905 Contributors: Don E. Detmer Source: http://en.wikipedia.org/w/index.php?oldid=438658919 Contributors: Homer R. Warner Source: http://en.wikipedia.org/w/index.php?oldid=430800451 Contributors: Robert Ledley Source: http://en.wikipedia.org/w/index.php?oldid=445612779 Contributors: Vimla L. Patel Source: http://en.wikipedia.org/w/index.php?oldid=436214580 Contributors: -
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Image:EHRadoption.gif Source: http://en.wikipedia.org/w/index.php?title=File:EHRadoption.gif License: GNU Free Documentation License Contributors: User:Ryanjo Image:Sshot fever.png Source: http://en.wikipedia.org/w/index.php?title=File:Sshot_fever.png License: GNU Free Documentation License Contributors: Original uploader was SeaLion at en.wikipedia. Later version(s) were uploaded by Ruud Koot, Eliashc at en.wikipedia. 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Handbook of Biomedical Informatics

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Handbook of Biomedical Informatics

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Wikipedia Handbook of Biomedical Informatics

Applications in Healthcare Management

Health Electronic Records

Decision Support Applications

Medical Imaging Applications

CAVEman FreeSurfer ImageJ InVesalius ITK-SNAP Mango OsiriX

Medical and biological signal applications

Databases, Digital Libraries and Literature Retrieval

Telehealth and Telemedicine

Computer-Aided Surgery, Medical Robotics and Virtual Reality

Legislation and Regulation

Languages and Development Platforms

Clinical Research Informatics

Standards, Coding and Nomenclature

Associations, Committees and Conferences

Virtual Physiological Human Visible Human Project

705 712 715 715 719 721 725 726

Concepts and Definitions

Health information technology

Electronic Health Record (EHR)

Health information technology

Clinical point of care technology

Technological Innovations, Opportunities, and Challenges

Health information technology

Electronic patient chart from a health information system

Medical informatics in the United States

Current state of health informatics and policy initiatives

Emerging Direction (European R&D)

Asia and Oceania

Health Informatics Law

Electronic patient chart from a health information system

Medical informatics in the United States

Current state of health informatics and policy initiatives

Emerging Direction (European R&D)

Asia and Oceania

Health Informatics Law

E-Health data exchange

Definitions and Inclusions

Level of use of Web 2.0 in Health Care

Types of Web 2.0 technology in Health Care

Types of Web 2.0 use in Health Care

Staying informed Used to stay informed of latest developments in a particular field

Collaboration and practice

Sharing data for research

Criticism of the use of Web 2.0 in health

Tensions in Health 2.0

Health 2.0 Chapters

Public health informatics

Public health informatics

Collection of public health data

Storage of public health data

Public health informatics

Analysis of public health data

Applications in health surveillance and epidemiology

Applications in Healthcare Management

Relevance within the health care industry

Medical integration environment

Medical integration environment

Health information exchange

Health information exchange

Established HIE Communities

Health information exchange

Health information exchange

Hospital information system