Cultural aspects of information technology implementation.

Culture sets our values and norms. It is a way of thinking that determines our behaviours, decisions, actions and knowledge. Technology transfer and integration are basically the exchange of the knowledge, know-how and skills through which technology was created and on which its use depends. Culture is deeply rooted in ourselves. We are usually unaware of its influence on our professional activity. Cultures are diverse, and their encounter through technology exchange triggers conflicts that are expressed in objective terms. We need to detect and resolve those conflicts at the right level, i.e. at the cultural level instead of only focusing on the visible 'obstacles' to the deployment of telematics applications. This paper summarises the basic concepts on which we ground a practical approach to detecting and resolving culture-based conflicts in technology transfer and integration. It investigates the relation between cultural preferences and actions. Culture is translated and reduced to a seven dimensions framework. Cultural preferences influence the decision-making process that leads to tangible actions. The structure and dynamics of that process are described as a Change Governance Framework. It considers the control aspects of decision making that are sensitive to cultural preferences, i.e. the way decisions are taken, why, by whom.

The future is no longer what it used to be. Managing health telematics projects.

Future used to mean global progress and convergence of science and technology and society. Today, we observe the decoupling of the two poles of knowledge formation and application (i.e. science and technology, and culture and society, respectively) and also fierce confrontation between them. The key issue to reconcile the two poles is to re-invent the link between them. The new future lies in the development of mental and technical capacities for change and the creation of new forms of solidarity. We propose, as a general attitude, to reactivate and develop the four principles of efficacy-effectiveness-efficiency, hospitality, responsibility and pertinence. Translated into driving forces for the development of health care telematic projects, they amount to the acceptance of and capacity for enterprise-wide solutions, hospitality and capacity to acquire outside knowledge, self-managed, multi-functional team work spirit, reengineering mentality to achieve pertinent technico-cultural solutions.

Healthcare Information Framework.

CEN committee TC 251 Medical Informatics, has set up a project team charged with producing a European pre-standard ENV on Healthcare Information Framework (HIF). The HIF is based on abstraction from a specific information system architecture to a reference architecture and further to a conceptual architectural framework based on serving open, distributed and heterogeneous healthcare enterprises. To specify the suitable healthcare information system architecture modelling of the healthcare enterprise is required. As there is no one method serving all needs, the HIF gives guidance on what aspects to look at in selecting a suitable modelling method. It is expected that the work will be completed by early 1995.

Integration architecture: the ISAR project.

ISAR (Integration System Architecture) will integrate six AIM Projects on the HIS platform at the University Hospital (CHRU) of LILLE. These Projects were elicited from six European consortiums that provided prototypes or pre-competitive products. These consortia are: ESTEEM (storage and analysis of electromyograms), EURIPACS (picture archiving and communication system), MENELAS (analysis of the natural language for medical applications), OEDIPE (storage and serial analysis of electrocardiograms), OPADE (help with drug prescription), and TANIT (mobile system for anaesthesia). When introducing an information system to a medical department and running it, two issues arise. First, how can the Information system be anchored to the Clinical processes in order to support them in an effective and efficient way, and, second, how can the Information system adapt to the changes in the Clinical processes?

KAVAS-2: Knowledge Acquisition, Visualization and Assessment System.

The objective of KAVAS-2 is the development of a tool, named KAVIAR, with which domain experts can make their knowledge explicit. It contains components for (computer assisted) knowledge elicitation and for machine learning. A key issue in KAVAS is the assessment of the quality of the classification and domain models built. Various quality measures are available and implemented in KAVIAR to assess the quality of models, specifically those developed from data bases by machine learning techniques.

Information transfer in high dependency environments: an ergonomic analysis.

We have studied the information flow in HDE (with special focus on the information transfer process) using data provided by a group of experienced health care professionals. A model of the information flow in HDE was built up. It postulates the existence of quanta of information (due to the artificial fragmentation of the information flow produced by the clinical working processes: organization in shifts, demand of simultaneous activities from different staff members, etc.). This fragmentation is described by using the so-called Clinical Information Process Units (CIPUs), which correspond to patient care activities going on in parallely and serially linked blocks, performed by the staff in the specific environments. Due to a transfer in responsibility over the patient the CIPUs are linked by information transfer events which are described using transfer modules (TraMs). We exemplified 32 CIPUs related to the clinical environments (PreOp, Surgery, Recovery Intensive Care, Ward, Diagnostics, Outpatient) and the health care professional groups (Anesthesiologist/Intensivist, Surgeon, Nurse, Physician, Diagnostic Physician, Physical Therapist). A matrix was established providing the transfer situations among the CIPUs enabling a systematic classification of the TraMs. The contents of the TraMs are built up of information link elements, which are assembled according to the specific settings of the transfer situation given by the emitter, receiver and purpose. In summary we modelled the process of information transfer in HDE through CIPUs, TraMs and information links in a way, which may be useful to design information technology applications or to reorganize the information management in HDE.

Turning the mass-spectrometer into an easy to handle clinical instrument for routine multipatient surveillance of respiratory and anesthetic gases during anesthesia.

Although most authors use it as the reference instrument for respiratory gases measurement, the use of mass-spectrometer in clinical routine in ICU and in anesthesia remains quite limited. We developed a fully automatically controlled system, carrying on a twinned goal: The ACS-2000 (Automatic Calibration System) turns the Airspec MGA-2000 mass-spectrometer into a true clinical instrument, as easy to use as any routine monitoring instrument, and lets the clinician and the anesthetist benefit from its uncomparable metrological performances. PAMS-M, multibed monitoring system, shares the mass-spectrometer time among 4 to 8 rooms, providing each anesthetist with full composition of inspired and end tidal gases composition, trend evolution of those data, as with the display of capnogram. Each room is equipped with an IBM PC compatible intelligent terminal, abling the user to select the nature of the displayed information and enter into an easy menu driven dialog with the system. As a subproduct, the informatic infrastructure on which the system is based allowed, beyond the standard monitoring function, to set the bases of a computerized patient's anesthesia or respiratory monitoring report.

Assessment of the performance of electrocardiographic computer programs with the use of a reference data base.

To allow an exchange of measurements and criteria between different electrocardiographic (ECG) computer programs, an international cooperative project has been initiated aimed at standardization of computer-derived ECG measurements. To this end an ECG reference library of 250 ECGs with selected abnormalities was established and a comprehensive reviewing scheme was devised for the visual determination of the onsets and offsets of P, QRS, and T waves. This task was performed by a group of cardiologists on highly amplified, selected complexes from the library of ECGs. With use of a modified Delphi approach, individual outlying point estimates were eliminated in four successive rounds. In this way final referee estimates were obtained that proved to be highly reproducible and precise. This reference data base was used to study measurement results obtained with nine vectorcardiographic and 10 standard 12-lead ECG analysis programs. The medians of program determinations of P, QRS, and T wave onsets and offsets were close to the final referee estimates. However, an important variability could be demonstrated between measurements from individual programs and mean differences from the referee estimates amounted to 10 msec for QRS for certain programs. In addition, the variances of all programs with respect to the referee point estimates were variable. Some programs proved to be more accurate and stable when the data from high- vs low-noise recordings were analyzed. Average Q wave durations calculated from ECGs for which programs agreed on the presence of a Q or QS wave differed by more than 8 msec in several program-to-program comparisons. Such differences may have important consequences with respect to diagnostic performance. Various factors that might explain these differences have been determined. The present study demonstrates that to allow an exchange of results and diagnostic criteria between different ECG computer programs, definitions, minimum wave requirements, and measurement procedures urgently need to be standardized.

Real time mathematical analysis of instantaneous respiratory signals at the bedside by a multiprocessor system (PAMS).

The authors address the following problems: How to turn a mass spectrometer, or a set of individual gas sensors, into a real and useful medical instrument? In other words, how to transform the instantaneous gas composition signals into meaningful physiological variables? The parameters that can be computed breath by breath from the real time processing of gas concentration signals, combined with flow and pressure signals at the mouth are first described. Particularly, we point out the theoretical and practical importance of alveolo-capillary gas exchange parameters, as opposed to gas exchange parameters estimated at the mouth level: A-c exchange parameters are a more sensitive and more specific indicator of any physiological change and they are less sensitive to breath by breath fluctuations of ventilation. We discuss the clinical usefulness of breath by breath computations, as a more sensitive way to monitor the patient as well as the anesthesia circuit, and to generate all the information required for on line analysis of functional tests. We describe a system for the real time processing of the respiratory signals. Based on three microprocessors it takes over the calibration, the offset correction of each signal ... It also corrects for the dynamics of each sensor and resynchronizes all the signals. It computes breath by breath more than 50 physiological variables that can be either recorded analogically, either printed, either acquired by a general monitoring system of the patient, which then combines respiratory data with other physiological. therapeutical and medical data from the patient.

Continuous monitoring by microprocessor from the operating room to the intensive care unit.

The "Chronicler" is made up of a microcomputer (the CPU is a Motorola 6809), an alphanumeric-graphic display with keyboard and a printer. The system is connected to several physiological signal monitors and in our application to a mechanical ventilator under electronic control. It collects every 5 seconds - or at each breathing cycle if required - all the data supplied by the various measuring devices including those in the mechanical ventilator. The time basis for displaying and storing the data is a multiple of the data acquisition time basis; it is selected interactively by the user during operation. Up to five raw analog curves (f.i. capnogram, pulmonary artery pressure curve) can be displayed and their morphology can then be examined. Manual data are entered or retrieved at any time. The system was designed by Dr. Demeester's team in order to help the anesthesiologist during and after anesthesia. Clinical use of the system by our staff has convinced us that indeed it is of great help in the control of general anesthesia: this results from the very clear and efficient presentation of the data both as numbers and curves; an alarm program under interactive control of the user makes surveillance still easier; furthermore the use of the system is simple and convenient. Finally, when surgery is over, a standard report is automatically printed; it is equivalent to a manually written anesthesia report. The data are stored on floppy disks and can be processed later for retrospective analysis in order to investigate, for instance, the influence of surgical maneuvers and of drugs on physiological parameters. The "Chronicler" is thus a tool for dynamic monitoring during anesthesia; it is also a powerful tool for clinical and physiological research.

Ventilation in dogs on cardiopulmonary bypass with and without lungs.

In 13 anesthetized or awake dogs, on cardiopulmonary bypass, we varied PaO2 and PaCO2 while continuously monitoring ventilatory responses and mechanics, to assess the dog's ability to maintain eupneic ventilation for any chemical drive. In a second group of 13 dogs on cardiopulmonary bypass we repeated the tests after removal of both lungs, to assess the importance of pulmonary feedback and mechanics. The VE/PO2 plot formed two hyperbolas, asymptotic to 39 Torr PO2 with lungs, and to 27 without; both intercepted zero ventilation near 200 Torr. Hyperoxic apnea occurred at, or below, PCO2 30 +/- 7 Torr under barbiturate and 20 +/- 4 Torr under morphine. Steady-state low PCO2 (10 Torr) turned off hypoxic drives as low as 20 Torr PO2. Empty-chest dogs had a low respiratory frequency (18 vs. 40), and near zero dynamic elastance; ventilatory work per minute and airway resistance were the same with and without lungs. Chest wall ventilatory responses are grossly independent of the presence of absence of lungs.

A multi-sensor support for in vivo monitoring of blood parameters with in situ sensor calibration.

An apparatus permitting continuous simultaneous in vivo monitoring of human arterial blood parameters is described. Sensors are held firmly in position in arterial blood flowing through an extracorporeal shunt. The system is reliable, rugged and inexpensive. Installation and manipulation are easy, and the sensors can be calibrated in situ. The system seems well suited for computer-aided monitoring of intensive care patients.