A Survey of Robotic Systems for Nursing Care.

An increase of the aging population with a decrease in the available nursing staff has been seen in recent years. These two factors combined present a challenging problem for the future and has since become a political issue in many countries. Technological advances in robotics have made its use possible in new application fields like care and thus it appears to be a viable technological avenue to address the projected nursing labor shortage. The introduction of robots in nursing care creates an active triangular collaboration between the patient, nurse, and robot, which makes this area significantly different from traditional human-robot interaction (HRI) settings. In this review, we identify 133 robotic systems addressing nursing. We classify them according to two schemes: 1) a technical classification extended to include both patient and nurse and 2) a novel data-derived hierarchical classification based on use cases. We then analyze their intersection and build a multidimensional view of the state of technology. With this analytical tool, we describe an observed skew of the distribution of systems and identify gaps for future research. We also describe a link between the novel hierarchical use case classification and the typical phases of nursing care from admission to recovery.

A Novel Digital Nutrition Diary for Geriatric Patients at High Risk of Frailty Syndrome.

Due to the physical, psychological, or socioeconomic changes that accompany aging, many people will be affected by geriatric frailty syndrome, which can lead to multimorbidity and premature death. Nutrition counseling is often used to prevent and intervene in frailty syndrome, especially in geriatric rehabilitation. To this end, the consumption behavior of geriatric patients is recorded using paper-based, as well as retrospective memory logs in face-to-face interviews between patients and nutritionists. To simplify this procedure, a digital nutrition diary was developed that is specially adapted to the needs of geriatric patients (>=70 years), enabling them to record their consumption behavior themselves. In an initial study (Study 1), conducted in a geriatric rehabilitation division with twelve subjects (ten male, two female, mean age 79.2 ±5.9 years), feedback about the usability of the digital nutrition diary, and how to improve it, was surveyed. In addition, the usability of an activity tracker and a body composition scale was surveyed to determine whether geriatric patients are generally able to use these devices. In a second study (Study 2), also conducted in the geriatric rehabilitation division, this time with sixteen subjects (ten male, six female, mean age 79.3 ±3.9 years), the usability of the digital nutrition diary was surveyed again to evaluate its modifications based on the feedback from Study 1. In Study 1, the usability rating of the system (0−100) was 82.5 for the activity tracker, 29.71 for the body composition scale, and 51.66 initially for the digital nutrition diary, which increased to 76.41 in Study 2.

Cybersecurity Protection for PACS and Medical Imaging: Deployment Considerations and Practical Problems.

Cybersecurity is increasingly affecting the healthcare sector. In a recent article, the authors analyzed specific attacks against picture archiving and communications systems (PACS) and medical imaging networks and proposed security measures. This article discusses issues that require consideration when deploying these proposed measures and provides recommendations on how to implement them. Hospitals should deploy virus scanners on systems where permitted, with high priority on devices that are part of the central IT infrastructure of the hospital. They should introduce a systematic management of software updates on operating system, application software and virus scanner level and clarify the provision of security updates for the intended duration of use when purchasing a new device. They should agree with the PACS vendor on a long-term strategy for implementing access rights, and enable encrypted network communication where possible. This requires an agreement on the encryption algorithms to be used, and a public-key infrastructure. For most of these tasks, standards and profiles exist today. There are, however, some gaps: Implementation of cybersecurity measures would be facilitated by integration profiles on certificate and signature management, and access rights in a PACS environment.

Cybersecurity in PACS and Medical Imaging: an Overview.

This article provides an overview on the literature published on the topic of cybersecurity for PACS (Picture Archiving and Communications Systems) and medical imaging. From a practical perspective, PACS specific security measures must be implemented together with the measures applicable to the IT infrastructure as a whole, in order to prevent incidents such as PACS systems exposed to access from the Internet. Therefore, the article first offers an overview of the physical, technical and organizational mitigation measures that are proposed in literature on cybersecurity in healthcare information technology in general, followed by an overview on publications discussing specific cybersecurity topics that apply to PACS and medical imaging and present the "building blocks" for a secure PACS environment available in the literature. These include image de-identification, transport security, the selective encryption of the DICOM (Digital Imaging and Communications in Medicine) header, encrypted DICOM files, digital signatures and watermarking techniques. The article concludes with a discussion of gaps in the body of published literature and a summary.

Cybersecurity Challenges for PACS and Medical Imaging.

Cybersecurity issues have been on the rise for years, increasingly affecting the healthcare sector. In 2019, several attacks have been published that specifically aim at medical network protocols and file formats, in particular digital imaging and communications in medicine. This article describes five attack scenarios on picture archiving and communications systems (PACS) and medical imaging networks: the import of patient data from storage media containing malware, a compromise of the hospital network, malware embedded in digital imaging and communications in medicine images or reports, a malicious manipulation of medical images and a network infiltration of malicious health level seven messages. Prevention and mitigation measures for each of these attacks exist, some of which can be implemented by the system user (e.g., hospital), while others require implementation in the PACS and medical imaging devices by the vendors. In practice, however, many of these are not in common use. What is missing today are PACS network security guidelines for practitioners that support users in keeping their network secure. Furthermore, integrating the healthcare enterprise integration profiles and test tools might be needed to address the deployment of public key infrastructure and digital signatures in the PACS environment.

Large Scale eHealth Deployment in Europe: Insights from Concurrent Use of Standards.

Large-scale eHealth deployment projects face a major challenge when called to select the right set of standards and tools to achieve sustainable interoperability in an ecosystem including both legacy systems and new systems reflecting technological trends and progress. There is not a single standard that would cover all needs of an eHealth project, and there is a multitude of overlapping and perhaps competing standards that can be employed to define document formats, terminology, communication protocols mirroring alternative technical approaches and schools of thought. eHealth projects need to respond to the important question of how alternative or inconsistently implemented standards and specifications can be used to ensure practical interoperability and long-term sustainability in large scale eHealth deployment. In the eStandards project, 19 European case studies reporting from R&D and large-scale eHealth deployment and policy projects were analyzed. Although this study is not exhaustive, reflecting on the concepts, standards, and tools for concurrent use and the successes, failures, and lessons learned, this paper offers practical insights on how eHealth deployment projects can make the most of the available eHealth standards and tools and how standards and profile developing organizations can serve the users embracing sustainability and technical innovation.

Dynamic DICOM configuration in a service-oriented medical device architecture.

A surgical intervention raises additional requirements to a medical device network, be it security concerns or the demand for just-in-time integration of an additional devices. The German national flagship project OR.NET aims to satisfy these requirements by defining, implementing and validating an integration solution for safe and dynamic networking. This work presents an approach to incorporate imaging related medical devices into a dynamic plug and play operating room (OR) network utilizing the existing Digital Imaging and Communications in Medicine (DICOM) protocol. The presented approach was created as part of the OR.NET project to realize the integration of DICOM devices into the developed infrastructure, both in regard to newly created DICOM devices with direct support of the OR.NET protocol and the integration of existing DICOM devices (e.g. image archives) employing a gateway. Preliminary evaluation results indicate that the approach is viable and that no critical transmission delays are introduced by the prototypical gateway implementation.

Five years of interdisciplinary research on ageing and technology: Outcomes of the Lower Saxony Research Network Design of Environments for Ageing (GAL)--an introduction to this Special Issue on Ageing and Technology.

This Special Issue of Informatics for Health and Social Care is presenting outcomes of the Lower Saxony Research Network Design of Environments for Ageing (abbreviated as GAL), probably one of the largest inter- and multidisciplinary research projects on aging and technology. In order to investigate and provide answers on whether new information and communication technologies can contribute to keeping, or even improving quality of life, health and self-sufficiency in ageing societies through new ways of living and new forms of care, GAL had been established as a five-year research project, running from 2008 to 2013. Ambient-assisted living technologies in personal and home environments were especially important. During the five years of research in GAL, more than seventy researchers from computer science, economics, engineering, geriatrics, gerontology, informatics, medicine, nursing science and rehabilitation pedagogy intensively collaborated in finding answers.

Information and communication technologies for promoting and sustaining quality of life, health and self-sufficiency in ageing societies--outcomes of the Lower Saxony Research Network Design of Environments for Ageing (GAL).

Many societies across the world are confronted with demographic changes, usually related to increased life expectancy and, often, relatively low birth rates. Information and communication technologies (ICT) may contribute to adequately support senior citizens in aging societies with respect to quality of life and quality and efficiency of health care processes. For investigating and for providing answers on whether new information and communication technologies can contribute to keeping, or even improving quality of life, health and self-sufficiency in ageing societies through new ways of living and new forms of care, the Lower Saxony Research Network Design of Environments for Ageing (GAL) had been established as a five years research project, running from 2008 to 2013. Ambient-assisted living (AAL) technologies in personal and home environments were especially important. In this article we report on the GAL project, and present some of its major outcomes after five years of research. We report on major challenges and lessons learned in running and organizing such a large, inter- and multidisciplinary project and discuss GAL in the context of related research projects. With respect to research outcomes, we have, for example, learned new knowledge about multimodal and speech-based human-machine-interaction mechanisms for persons with functional restrictions, and identified new methods and developed new algorithms for identifying activities of daily life and detecting acute events, particularly falls. A total of 79 apartments of senior citizens had been equipped with specific "GAL technology", providing new insights into the use of sensor data for smart homes. Major challenges we had to face were to deal constructively with GAL's highly inter- and multidisciplinary aspects, with respect to research into GAL's application scenarios, shifting from theory and lab experimentation to field tests, and the complexity of organizing and, in our view, successfully managing such a large project. Overall it can be stated that, from our point of view, the GAL research network has been run successfully and has achieved its major research objectives. Since we now know much more on how and where to use AAL technologies for new environments of living and new forms of care, a future focus for research can now be outlined for systematically planned studies, scientifically exploring the benefits of AAL technologies for senior citizens, in particular with respect to quality of life and the quality and efficiency of health care.

A technical platform for environments for ageing--lessons learned from three field studies.

The Lower Saxony Research Network "Design of Environments for Ageing" (GAL) studied possible applications of assistive technology for enabling older adults to live longer and independent in their own home. As part of this work, a technical platform was developed as a common technical basis for all assistive systems in the project. This article presents an overview of the architecture and core functionality of the technical platform, which in the first generation was developed for use in a laboratory setting, and in a second generation was extended for use in the project's field studies, i.e. prototype installations in end-users homes. The field studies' primary objective was the evaluation of the assistive technologies, that were developed within the overall project. However, these studies also confirmed that the fundamental concept of the technical platform is valid, and the prototypes continuously worked 24 h a day for several months. However, there were some problems related to lack of infrastructure in the older adults' homes and human factors such as inadvertent placement of objects across sensors' field of view, acceptance problems due to aesthetical reasons or simply communication problems, which show that making complex technologies work for users with little technical experience is well possible, but requires a careful consideration of the complete service chain and related "soft factors".

Adverse drug event notification on a semantic interoperability framework.

Adverse drug events (ADEs) are common, costly and one of the most important issues in contemporary pharmacotherapy. Current drug safety surveillance methods are largely based on spontaneous reports. However, this is known to be rather ineffective. There is a lack of automated systems checking potential ADEs on routine data captured in electronic health records (EHRs); present systems are usually built directly on top of specific clinical information systems through proprietary interfaces. In the context of the European project "SALUS", we aim to provide an infrastructure as well as a tool-set for accessing and analyzing clinical patient data of heterogeneous clinical information systems utilizing standard methods. This paper focuses on two components of the SALUS architecture: The "Semantic Interoperability Layer" (SIL) enables an access to disparate EHR sources in order to provide the patient data in a common data model for ADE detection within the "ADE Detection and Notification Tool" (ANT). The SIL in combination with the ANT can be used in different clinical environments to increase ADE detection and reporting rates. Thus, our approach promises a profound impact in the domain of pharmacovigilance.

Guideline-driven telemonitoring and follow-up of cardiovascular implantable electronic devices using IEEE 11073, HL7 & IHE profiles.

For patients with Cardiovascular Implantable Electronic Devices (CIEDs), telemonitoring promises improved quality of life and safety, since events recorded by the device or observed by the patient can alert a health professional. Taking into account the latest clinical guidelines when responding to such alerts, is a topic of active research addressed by the iCARDEA project. A key technical challenge is correlating telemonitoring CIED report data in a vendor-independent format with Electronic Health Record (EHR) data collected in the hospital and Personal Health Record (PHR) data entered by the patient, in guideline-driven care processes. The iCARDEA CIED exposure service component presented in this paper employs standards specifications from ISO/IEEE 11073 (Health Informatics, Point-of-care Medical Device Communication) and HL7v2.x in the context of Integrating the Healthcare Enterprise (IHE) profiles to deliver telemonitoring CIED report data from two different CIED vendors to the adaptive care planner that implements guideline-driven care plans. Experience gained with implementation and initial component testing is discussed, while challenges and expectations for future health information standards to effectively support EHR-integrated guide-line-driven telemonitoring services are highlighted.

The Lower Saxony research network design of environments for ageing: towards interdisciplinary research on information and communication technologies in ageing societies.

Worldwide, ageing societies are bringing challenges for independent living and healthcare. Health-enabling technologies for pervasive healthcare and sensor-enhanced health information systems offer new opportunities for care. In order to identify, implement and assess such new information and communication technologies (ICT) the 'Lower Saxony Research Network Design of Environments for Ageing' (GAL) has been launched in 2008 as interdisciplinary research project. In this publication, we inform about the goals and structure of GAL, including first outcomes, as well as to discuss the potentials and possible barriers of such highly interdisciplinary research projects in the field of health-enabling technologies for pervasive healthcare. Although GAL's high interdisciplinarity at the beginning slowed down the speed of research progress, we can now work on problems, which can hardly be solved by one or few disciplines alone. Interdisciplinary research projects on ICT in ageing societies are needed and recommended.

Monitoring systems for the support of home care.

In this article, the design of a system for the ambient, unobtrusive and automatic monitoring of Activities of Daily Living (ADL) is described. In the context of the growing imbalance between (potentially young) caregivers and (most often older) people receiving care, technical monitoring systems may help to organise care more efficiently and to identify degrading abilities very early to trigger preventive measures. To improve the acceptance of the system described in this article, the selection process of the sensors to be integrated into the flat or to be worn by the older people has been steered by the results of focus group interviews with older people, their relatives and professional caregivers. The interviews revealed that these people would in general accept such systems, but security, mobility and communication aspects have to be clearly and appropriately addressed. In an experimental study the recognition rate of the activity 'preparation and intake of food or beverages' has been measured with two age groups (6 subjects, age between 25 and 40/mean 30 years and 5 subjects, age between 72 and 84/mean 75.3 years). The food preparation was detected with a sensitivity of 74.7% and a specificity of 84.2% using a vision sensor.

Providing interoperability of eHealth communities through peer-to-peer networks.

Providing an interoperability infrastructure for Electronic Healthcare Records (EHRs) is on the agenda of many national and regional eHealth initiatives. Two important integration profiles have been specified for this purpose, namely, the "Integrating the Healthcare Enterprise (IHE) Cross-enterprise Document Sharing (XDS)" and the "IHE Cross Community Access (XCA)." IHE XDS describes how to share EHRs in a community of healthcare enterprises and IHE XCA describes how EHRs are shared across communities. However, the current version of the IHE XCA integration profile does not address some of the important challenges of cross-community exchange environments. The first challenge is scalability. If every community that joins the network needs to connect to every other community, i.e., a pure peer-to-peer network, this solution will not scale. Furthermore, each community may use a different coding vocabulary for the same metadata attribute, in which case, the target community cannot interpret the query involving such an attribute. Yet another important challenge is that each community may (and typically will) have a different patient identifier domain. Querying for the patient identifiers in the target community using patient demographic data may create patient privacy concerns. In this paper, we address each of these challenges and show how they can be handled effectively in a superpeer-based peer-to-peer architecture.

Enhancing IHE XDS for federated clinical affinity domain support.

One of the key problems in healthcare informatics is the inability to share patient records across enterprises. To address this problem, an important industry initiative called "integrating the healthcare enterprise (IHE)" specified the "cross enterprise document sharing (XDS)" profile. In the IHE XDS, healthcare enterprises that agree to work together form a "clinical affinity domain" and store healthcare documents in an ebXML registry/repository architecture to facilitate their sharing. The affinity domains also agree on a common set of policies such as coding lists to be used to annotate clinical documents in the registry/repository and the common schemes for patient identification. However, since patients expect their records to follow them as they move from one clinical affinity domain to another, there is a need for affinity domains to be federated to enable information exchange. In this paper, we describe how IHE XDS can be enhanced to support federated clinical affinity domains. We demonstrate that federation of affinity domains are facilitated when ontologies, rather than coding term lists, are used to annotate clinical documents. Furthermore, we describe a patient identification protocol that eliminates the need to keep a master patient index file for the federation.

A secure semantic interoperability infrastructure for inter-enterprise sharing of electronic healthcare records.

Healthcare professionals need access to accurate and complete healthcare records for effective assessment, diagnosis and treatment of patients. The non-interoperability of healthcare information systems means that interenterprise access to a patient's history over many distributed encounters is difficult to achieve. The ARTEMIS project has developed a secure semantic web service infrastructure for the interoperability of healthcare information systems. Healthcare professionals share services and medical information using a web service annotation and mediation environment based on functional and clinical semantics derived from healthcare standards. Healthcare professionals discover medical information about individuals using a patient identification protocol based on pseudonymous information. The management of care pathways and access to medical information is based on a well-defined business process allowing healthcare providers to negotiate collaboration and data access agreements within the context of strict legislative frameworks.

Experiences with a workstation prototype for softcopy reading within the Bavarian mammography recertification program: workstations and education.

RATIONALE AND OBJECTIVES: In January 2002, the Bavarian Statutory Health Care Administration ("Kassenärztliche Vereinigung Bayerns", KVB) started a recertification program for quality assurance and quality improvement in mammography reading. MATERIALS AND METHODS: All accredited radiologists and gynecologists are asked to prove their qualification every 1-2 years. The recertification program requires the physicians to read 50 cases randomly selected from a larger collection of high-quality test cases. The portion of malignant and benign cases corresponds to the requirements of the German National Association of Statutory Health Insurance Physicians ("Kassenäztliche Bundesvereinig ung", KBV). In order to perform the recertification in a manageable manner a decentralized approach (test at different locations in parallel) was preferred over a centralized one. Therefore, the X-ray films were digitized and converted to DICOM Digital Mammography format to be read on a softcopy device. To verify the applicability of digitized mammograms for recertification purposes, a comparative study with 32 trained radiologists and gynecologists was performed. RESULTS: A system of two high-resolution/high-contrast monitors (2048 X 2560 pixels, > or = 350 cd/m2) in combination with a 5 mega-pixel dual-head graphics adapter with calibrated output was chosen for the mammography workstation. The software was implemented according to the particular requirements of this program. As a result, the comparative study showed that there was no significant difference in the error rate of the reported findings between conventional film and softcopy reading. CONCLUSION: The first intermediate results of this quality initiative are promising. As of 2003, the test is mandatory for all mammography-reading physicians in Bavaria.

Introduction to the DICOM standard.

Digital Imaging and Communication in Medicine (DICOM) has become one of the most popular standards in medicine. In the beginning, DICOM was used for communication of image data between different systems. Actual developments of the standardisation enables increasingly more DICOM-based services for the integration of modalities and information systems (e.g. RIS, PACS). In this article a review of the historical background, the technological concept, the organizational structure and current developments is given.