Education and training of medical informatics in the medical curriculum.

The teaching of medical informatics is of importance for students in medicine and health care, realizing that they will be the health professionals of the future. Training in medical informatics is also of value for practicing clinicians who are overwhelmed by the avalanche of systems that are available on the market. Some examples of operational systems are presented here to indicate that health care has changed dramatically over the last decades. This paper intends to contribute to the drafting of IMIA guidelines for teaching medical informatics by (1) reporting on the experience at the Faculty of Medicine and Health Sciences of the Erasmus University Rotterdam as part of the curriculum, (2) reporting on the implementation of guidelines for teaching medical informatics in The Netherlands since these guidelines were drafted in 1986, and (3) by introducing the teaching material contained in the new Handbook of Medical Informatics and on its Web site.

Shared care for diabetes: supporting communication between primary and secondary care.

As health care becomes more complex, interest in the benefits of coordination of care has increased. Especially patients that are being treated jointly by more than one physician (shared care), are vulnerable to adverse effects resulting from inadequate coordination and communication. We describe a study in which care providers support shared care by using computer-based patient records for data storage, and structured electronic data interchange (EDI) as a means of communication. The study showed that the electronic communication network for exchanging consultation outcomes significantly increased frequency of communication and the availability of data to the general practitioner on diagnostic procedures performed in the hospital, thus providing more complete information about the care that patients are receiving.

Rotterdam general practitioners report (ROHAPRO): a computerised network of general practices in Rotterdam, The Netherlands. Rotterdam's HuisArtsen Project.

STUDY OBJECTIVE: Dutch public health services are charged with collective preventive care for the population--care that should, by law, be based on epidemiological data. General practices potentially offer important data for this purpose, particularly since more and more use a computer. This study aimed to assess whether it is possible to obtain useful epidemiological data from this source. DESIGN: In 1990, the Rotterdam Municipal Health Service, in collaboration with the Erasmus University Rotterdam, started a computerised sentinel practice network. The main features of this and a specific small investigation are described. SETTING: The following institutions cooperate in the network: Municipal Health Service Rotterdam Area; Departments of General Practice and of Medical Informatics, Erasmus University Rotterdam; Rotterdam District Association of General Practitioners. PATIENTS: Data are currently collected from 20 general practitioners and > 40,000 patients. In a specific project, the distribution of cardiovascular risk factors in different ethnic groups was compared. MAIN RESULTS: It was possible to build up a regional epidemiological registration system in this manner. In the cardiovascular project we found striking differences between ethnic groups. The risk profile for Turkish men, in particular, was less favourable. The health service also uses the system to improve cooperation between public health and primary health care (for example, in cervical screening, influenza vaccination). CONCLUSION: Computerised general practices offer great possibilities for research and for preventive activities in which public health care and general practitioners can cooperate.

Communication in health care.

For routine communication, care providers still mainly rely on paper documents and paper mail. Evidence exists, however, that this communication can be improved, both by a better content of information exchange and by a more timely deliverance of this information. At present, several alternatives to paper-based communication are available, such as the Fax, the Smart Card, electronic mail, and electronic data interchange. This paper describes existing communication problems, and examines the current state of development and research aimed at improving this communication using electronic communication techniques that are gradually replacing paper-based communication. Applicability and shortcomings of these new techniques are also discussed.

A standardized message for supporting shared care.

As health care becomes more complex, interest in the benefits of coordination of care has increased. Especially patients that are being treated jointly by more than one physician (shared care), are vulnerable to adverse effects resulting from inadequate coordination and communication. We describe a study in which care providers support shared care by using computer-based patient records for data storage, and structured electronic data interchange as a means of communication. In this study, we are aiming at the development and implementation of protocols for shared care.

A powerful macro-model for the computer patient record.

Especially in the Netherlands, the introduction of computer patient records (CPRs) in primary care has been relatively successful. Specialists usually maintain more extensive records than general practitioners and it has proven to be a great challenge to design a CPR that is useful and practical for specialized care. In this paper, we present the design of a CPR for use by specialists in an out-patient clinic. The philosophy underlying the design is that specialists may keep record in a relatively conventional way, while, at the same time, the system motivates them to add structure to their data. Data can be presented in various views, each suitable for one or more specific tasks. The potential to benefit from these views depends on the degree of structure in the recorded data. Since a CPR has to be faithful and permanent, explicit representation of observations, insights, and evolution of insight is also supported. The CPR system is in a final stage of implementation and will be evaluated in a clinical setting in summer 1994.

Communication in Health Care.

For routine communication, care providers still rely on paper documents and paper mail. At present, new technologies are emerging that have considerable potential for improving communication in health care. This paper reviews existing communication problems, and discusses electronic communication techniques that are gradually replacing paper-based communication.

The introduction of computer-based patient records in The Netherlands.

Computer-based patient records, although an area of active research, are not in widespread use. In June 1992, 38% of Dutch general practitioners had introduced computer-based patient records. Of these, 70% had replaced the paper patient record with a computer-based record to retrieve and record clinical data during consultations. Possible reasons for the use of computer-based patient records include the nature of Dutch general practice and the early and active role of professional organizations in recognizing the potential of computer-stored patient records. Professional organizations issued guidelines for information systems in general practice, evaluated available systems, and provided postgraduate training that prepares physicians to use the systems. In addition, professional organizations successfully urged the government to reimburse general practitioners part of the expenses related to the introduction of computer-based patient records. Our experience indicates that physicians are willing and able to integrate information technology in their practices and that professional organizations can play an active role in the introduction of information technology.

Electronic communication between providers of primary and secondary care.

OBJECTIVE: To study the effects of the introduction of electronic data interchange between primary and secondary care providers on speed of communication, efficiency of data handling, and satisfaction of general practitioners with communication. DESIGN: Comparison of traditional paper based communication for laboratory reports and admission-discharge reports between hospital and general practitioners and electronic data interchange. SETTING: Twenty-seven general practitioners whose offices were equipped with a practice information system and two general hospitals. OUTCOME MEASURES: Paper based communication was evaluated by questionnaire responses from and interviews with care providers; electronic communication was evaluated by measuring time intervals between generation and delivery of messages and by assessing doctors' satisfaction with electronic data interchange by questionnaire. RESULTS: Via paper mail admission-discharge reports took a median of 2-4 days, and laboratory reports 2 days, to reach general practitioners. With electronic data interchange almost all admission-discharge reports were available to general practitioners within one hour of generation. When samples were analysed on the day of collection (as was the case for 174/542 samples in one hospital and 443/854 in the other) the laboratory reports were also available to the general practitioner the same day via electronic data interchange. Fifteen general practitioners (of the 24 who returned the questionnaire) reported that the use of electronic admission-discharge reports provided more accurate and complete information about the care delivered to their patients. Ten general practitioners reported that electronic laboratory reports lessened the work of processing the data. CONCLUSION: Electronic communication between primary and secondary care providers is a feasible option for improving communication.

Framework for a new generation of medical information systems.

This paper describes the design philosophy underlying an information system for an outpatient specialty department. Flexibility, the ability to adapt the system to a specific hospital situation and to user desired tasks, now and in the future, are the main issues with which the design is dealing. This flexibility is supported in the functional design and in the way communication of data is handled. The use of standards is a key factor in structured data interchange. The system design is independent of any actual standard used. It can incorporate standards that are currently available, and anticipates those that will become available. The open system design is based on data interchange between functional elements within the system, and electronic data interchange with external systems.

Electronic Data Interchange in medical care: an evaluation study.

This paper describes the evaluation of the first phase of the Communication Project Apeldoorn (COPA). The aim of COPA was to investigate the contribution of Electronic Data Interchange (EDI) to quality of care and practice efficiency. In this project over 33 general practitioners (GPs), 12 pharmacists and two hospitals (with one management) participated. In order to limit the number of variables for the evaluation study a limited number of messages was implemented: free-text messages between GPs; admission/discharge reports from hospitals to GPs, laboratory test reports from hospital to GP. The goal of the evaluation of the first phase of the project was to study message flow, the effect of integration with the Electronic Medical Record and the use of those data for patient care. In order to compare the use of EDI with the original situation (i.e. regular mail) a baseline study was performed. In this study the procedure for handling laboratory test reports and admission/discharge reports was also investigated. The results of the baseline study were compared with the evaluation of the use of EDI.

AIDA's fourth-generation software functionality.

Aspects characterizing typical, office-like environments are described and common procedures are extracted. These are used to derive the requirements of fourth-generation software packages. Typical fourth-generation software packages are discussed, and a presentation is given of a fourth-generation software package called AIDA, including all its functional aspects.

Structure and software tools of AIDA.

AIDA consists of a set of software tools to allow for fast development and easy-to-maintain Medical Information Systems. AIDA supports all aspects of such a system both during development and operation. It contains tools to build and maintain forms for interactive data entry and on-line input validation, a database management system including a data dictionary and a set of run-time routines for database access, and routines for querying the database and output formatting. Unlike an application generator, the user of AIDA may select parts of the tools to fulfill his needs and program other subsystems not developed with AIDA. The AIDA software uses as host language the ANSI-standard programming language MUMPS, an interpreted language embedded in an integrated database and programming environment. This greatly facilitates the portability of AIDA applications. The database facilities supported by AIDA are based on a relational data model. This data model is built on top of the MUMPS database, the so-called global structure. This relational model overcomes the restrictions of the global structure regarding string length. The global structure is especially powerful for sorting purposes. Using MUMPS as a host language allows the user an easy interface between user-defined data validation checks or other user-defined code and the AIDA tools. AIDA has been designed primarily for prototyping and for the construction of Medical Information Systems in a research environment which requires a flexible approach. The prototyping facility of AIDA operates terminal independent and is even to a great extent multi-lingual. Most of these features are table-driven; this allows on-line changes in the use of terminal type and language, but also causes overhead. AIDA has a set of optimizing tools by which it is possible to build a faster, but (of course) less flexible code from these table definitions. By separating the AIDA software in a source and a run-time version, one is able to write implementation-specific code which can be selected and loaded by a special source loader, being part of the AIDA software. This feature is also accessible for maintaining software on different sites and on different installations.

Performance of AIDA during development and operation.

A system for hospital pharmacies (CENTRASYS) and a system for primary health care (ELIAS), both developed using prototyping and a fourth-generation tool (AIDA), are introduced. Differences in development strategies are analyzed and conclusions are drawn with respect to the use of AIDA for management, development and operation of the systems. The use of AIDA increases development speed enormously, enabling a productivity of over 40 lines per day, which is more than twice the amount that is accepted as reasonable.

The role of AIDA in a primary care information system.

In this article the development of a computer system for General Practice, ELIAS, is described. The use of the 4th-generation software toolkit AIDA proved to be very helpful in increasing the speed of development as well as the quality of the ELIAS software. The programming support that AIDA offered, not only in increasing the rate of development but also in the flexible way in which parts of the system and the database can be adjusted (in prototyping as well as in the operational system) and its self-documenting functions, contributed to the ease of development. The consistent lay-out of the frames and uniform screen-handling, the opportunity of data validation and the availability of help information at every item in screen frames--all facilitated by AIDA--rendered ELIAS a very user-friendly system.

AIDA for reproductive medicine and the fertility clinic.

A Medical Information System for the Fertility Department has been built (VERGYNIA) using the 4th generation software package AIDA to make the medical data accessible for research and teaching on the one hand and to assist the management of the department in the daily routine of patient care on the other. The system has been implemented on a PDP 11/23 computer with a 20 Mbyte hard disk, a 10 Mbyte removable disk and 128 Kbyte central memory. Three visual display terminals and a small printer are connected to the system. A dedicated line connection between this system and the computer facilities of the Department of Medical Informatics allows easy transfer of data for analysis by statistical packages and the transfer of new programs to the computer of the Fertility Department. The PDP 11/23 contains a production system, a developmental system, and a separate environment for research which can all three run simultaneously on the same computer without interfering with each other. VERGYNIA was predominantly constructed with AIDA; only parts of the output programs have been programmed in MUMPS, due to the fact that the required AIDA tools were not yet available at the time of development. The original version of VERGYNIA was already in operation in 1982 and was built with the tools that form the basis of the current AIDA release. Due to many ad hoc modifications and additions, the system needed a total redesign in order to make it compatible with the new enhancements of the current AIDA release. This redesign was carried out during 1985.

The chance of spontaneous conception for the infertile couple referred to an academic clinic for reproductive endocrinology and fertility in The Netherlands.

892 infertile couples were studied retrospectively over a 4 year and 7 month period for their chance of spontaneous conception after first attendance at the clinic. The Kaplan-Meier method was used for all calculations. Most of the spontaneous conceptions took place within two years. As the age of the female patient increased, beginning at age 30, the cumulative spontaneous conception rate decreased. The same was true for the duration of infertility beginning at 4.5 years. The influence of the latter was more important. The cumulative conception rate was not influenced by whether the infertility was primary or secondary. Patients referred by a general physician had a better chance of achieving spontaneous conception than patients referred by a gynaecologist. It is concluded that time plays a significant role in the achievement of pregnancies in our clinic, but should no longer be relied upon two years after entering the clinic.

MUMPS as a host language for AIDA.

In this contribution, the main characteristics of MUMPS, the host language of AIDA, are briefly discussed. This is basically an introductory text for readers who had had no previous experience with MUMPS, on the programming side. After a short introduction, its history is summarized. Then the language itself is introduced and illustrated with examples; for the sake of brevity not all commands, functions and other features are discussed. In the next section, an introduction to MUMPS' stronghold is given: the database structure. Finally, we give the main reasons why we have chosen MUMPS as AIDA's host language. In the appendices, attention is given to the language standardization process, the visibility of MUMPS and its availability, sources of further information and the most important text books on MUMPS (in English).

The performance of three visual coding procedures and three computer programs in classification of electrocardiograms according to the Minnesota Code.

A test library composed of the ECG's of 228 patients with clinically proven myocardial infarction and 294 subjects without clinical evidence of infarction was used to assess the performance of three visual coding procedures and three computer programs designed to classify ECGs according to the Minnesota Code. The results showed that visual coding performed by one experienced senior coder tended to be more consistent than visual coding relying on two less experienced coders and arbitration of disagreements by a supervisor. There was no significant difference in coding results when only one preprocessed complex was coded in comparison with the more elaborate coding of the whole source ECG using majority rule. The coding performance of the three computer programs was similar to that of the visual coding procedures. It is concluded that computer coding of ECGs according to the Minnesota Code is feasible. Combined optimal use of automated coding and visual verification of selected items may still further improve coding precision. However, when judged against an ECG independent standard, the accuracy of all coding procedures in discriminating infarcts from non-infarcts according to the Minnesota code criteria is rather limited. 'Soft' criteria give a reasonable sensitivity with low specificity whereas the use of 'hard' criteria with adequate specificity results in a substantial drop in sensitivity.