An economic evaluation of a telehealth network in British Columbia.

We carried out an economic evaluation of the northernmost five sites of the British Columbia telehealth network. The videoconferencing network links health-care facilities in 12 communities with Vancouver, for clinical consultations, administrative meetings and educational sessions. The economic evaluation was based on the netcost criterion (i.e. cost of telehealth minus travel costs avoided). Cost and utilization data were obtained from client interviews and log data compiled between September 2001 and January 2003. The results showed that the subnetwork of five sites was not only cost reducing, but also cost-effective. Travel costs for administrative meetings were reduced by $724,457/annum and were greater than the annual fixed and variable costs of all the telehealth sessions ($553,740). A sensitivity analysis was conducted on six parameters: amortization period, opportunity cost of capital, operating cost of a telehealth session (by type of session), number of telehealth sessions, travel time and the opportunity cost of travel time. The study suggests that the cost-effectiveness of telehealth to remote areas will increase over time as the cost of equipment continues to fall, as network connections become cheaper and as utilization rates rise.

The usability axiom of medical information systems.

INTRODUCTION: In this article we begin by connecting the concept of simplicity of user interfaces of information systems with that of usability, and the concept of complexity of the problem-solving in information systems with the concept of usefulness. We continue by stating "the usability axiom" of medical information technology: information systems must be, at the same time, usable and useful. We then try to show why, given existing technology, the axiom is a paradox and we continue with analysing and reformulating it several times, from more fundamental information processing perspectives. DISCUSSION: We underline the importance of the concept of representation and demonstrate the need for context-dependent representations. By means of thought experiments and examples, we advocate the need for context-dependent information processing and argue for the relevance of algorithmic information theory and case-based reasoning in this context. Further, we introduce the notion of concept spaces and offer a pragmatic perspective on context-dependent representations. We conclude that the efficient management of concept spaces may help with the solution to the medical information technology paradox. Finally, we propose a view of informatics centred on the concepts of context-dependent information processing and management of concept spaces that aligns well with existing knowledge centric definitions of informatics in general and medical informatics in particular. In effect, our view extends M. Musen's proposal and proposes a definition of Medical Informatics as context-dependent medical information processing. SUMMARY: The axiom that medical information systems must be, at the same time, useful and usable, is a paradox and its investigation by means of examples and thought experiments leads to the recognition of the crucial importance of context-dependent information processing. On the premise that context-dependent information processing equates to knowledge processing, this view defines Medical Informatics as a context-dependent medical information processing which aligns well with existing knowledge centric definitions of our field.

Case-based medical informatics.

BACKGROUND: The "applied" nature distinguishes applied sciences from theoretical sciences. To emphasize this distinction, we begin with a general, meta-level overview of the scientific endeavor. We introduce the knowledge spectrum and four interconnected modalities of knowledge. In addition to the traditional differentiation between implicit and explicit knowledge we outline the concepts of general and individual knowledge. We connect general knowledge with the "frame problem," a fundamental issue of artificial intelligence, and individual knowledge with another important paradigm of artificial intelligence, case-based reasoning, a method of individual knowledge processing that aims at solving new problems based on the solutions to similar past problems. We outline the fundamental differences between Medical Informatics and theoretical sciences and propose that Medical Informatics research should advance individual knowledge processing (case-based reasoning) and that natural language processing research is an important step towards this goal that may have ethical implications for patient-centered health medicine. DISCUSSION: We focus on fundamental aspects of decision-making, which connect human expertise with individual knowledge processing. We continue with a knowledge spectrum perspective on biomedical knowledge and conclude that case-based reasoning is the paradigm that can advance towards personalized healthcare and that can enable the education of patients and providers. We center the discussion on formal methods of knowledge representation around the frame problem. We propose a context-dependent view on the notion of "meaning" and advocate the need for case-based reasoning research and natural language processing. In the context of memory based knowledge processing, pattern recognition, comparison and analogy-making, we conclude that while humans seem to naturally support the case-based reasoning paradigm (memory of past experiences of problem-solving and powerful case matching mechanisms), technical solutions are challenging.Finally, we discuss the major challenges for a technical solution: case record comprehensiveness, organization of information on similarity principles, development of pattern recognition and solving ethical issues. SUMMARY: Medical Informatics is an applied science that should be committed to advancing patient-centered medicine through individual knowledge processing. Case-based reasoning is the technical solution that enables a continuous individual knowledge processing and could be applied providing that challenges and ethical issues arising are addressed appropriately.

Introducing a conceptual information retrieval (IR) framework.

This is the third in the series of the articles on an application of the systems analytic approach to evaluation of information retrieval (IR). Previously terminological and evaluation problems associated with IR were identified, and it was proposed that the systems analytic approach can provide solutions to these problems. Here, after the general discussion of a systems approach, different attempts to introduce this approach into IR are presented and critiqued: modelling of IR, identifying boundaries of a system under evaluation, identifying variables under investigation; and creating evaluation frameworks. On the basis of the critique of this work, the authors present their proposal for a solution: first the IR components, their boundaries and relationships are identified, and then the two models of IR are introduced. One of the models addresses components of the IR process and relationships between them, the second one is the process model of IR.

Project based experiential distance education: an oxymoron?

In the context of a program in Health Information Science at the University of Victoria in Victoria, BC, Canada, we have over the past 20 years made progress and gained experience in delivering a number of courses in a project-based experiential learning mode which links professionals and students in real world projects. As we are moving towards distance education, we are facing the challenge of translating these achievements into distance mode. The paper reviews the principles which make project-based educational mode involving collaboration with professionals desirable. We then review the experience with two specific courses, in which local students work with distant and local representatives of health institutions, respectively, on projects defined in the professional environment. This experience showed that the approach is of mutual interest and benefit to both the students and the professionals involved, but that a long lead time, and considerable detail in the preparation are required to lead such endeavors to success. We then discuss three alternatives to translating the principles of these approaches into distance mode. Among the alternatives, conducting a local project, closely affiliated with the teaching institution, or relying on a mock project which is based on recorded examples from previous projects, seem to be the most promising options. The alternative of having every student pursuing a different project, which may be local for the student but distant for the educational institution, is less attractive if faculty are expected to assume responsibility for successful project completion. It may, however, be the preferred solution if students are health professionals residing at distant health care institutions. All three alternatives have drawbacks that may limit the feasibility of project-based experiential learning in distance mode.

Introducing a technology-enabled problem-based learning approach into a health informatics curriculum.

PURPOSE: To investigate the effect on learner satisfaction of introducing a technology-enabled problem-based learning (PBL) approach into a health informatics curriculum. Course redesign was undertaken to prepare students for three 4-month work terms and a rapidly changing professional environment upon graduation. METHODS: Twenty-six Canadian undergraduate students of a redesigned course in biomedical fundamentals completed a midterm questionnaire in 2002. Eight of these students participated in a focus group. RESULTS: Students agreed that seven of nine functions provided by the web-based online course management system enhanced their learning: private email (92.3%), calendaring (88.5%), course notes (88.5%), discussion forums (84.5%), online grades (84.5%) assignment descriptions (80.8%) and online quizzes (80.8%). Although students agreed that two PBL activities enhanced learning (learning to present information) (84.5%) and learning to identify information needed (73.1%), the majority of students (69.2%) expressed a preference for the traditional lecture approach over the PBL approach. Students reported feeling uncertain of what was required of them and related anxiety accounted for most of the negative feedback. CONCLUSION: These findings give us clear goals for improvement in the course beginning with a comprehensive, carefully guided introduction to the processes of PBL. The positive trends are encouraging for the use of web-enabled courseware and for the further development of the PBL approach.

Terminological problems in information retrieval.

This is the first in the series of the papers on an application of the systems analytic approach to evaluation of information retrieval (IR). At the beginning, the importance of consistent terminology in information retrieval is discussed, and different definitions of "information retrieval" and "IR system" are presented. The importance of identifying boundaries of the IR system for clarifying terminological differences is discussed. The terminological problems in IR are summarized, and some of the existing approaches to their solution are identified. A historical overview of IR research is presented in order to explain the existing terminological differences and to create a common basis for a discussion of evaluation approaches to IR.

Current status of the evaluation of information retrieval.

This is the second in the series of the articles on an application of the systems analytic approach to evaluation of information retrieval (IR). In the previous article a historical overview of IR was presented and existing terminological problems associated with IR were identified and discussed. In the presented article the current status of IR evaluation is summarized, and different evaluation approaches are discussed. The Cranfield evaluation model and the most often used relevance-based measures of recall and precision are explained, and their problems are presented. Possible evaluation alternatives to the Cranfield model are discussed, and the case for a systems analytic approach to IR is summarized.

Decision support for governing boards of integrated delivery networks: explicating versus eliciting knowledge.

The everyday knowledge work of members of one governing health board was mapped using institutional ethnography. Our objective was to identify opportunities to improve the effective use of information and communication technologies for decision support. The dynamic interplay of work processes, professional discourse, institutional complexes and dominant ideology was explicated, that is, made visible in relation to the actualities of work practices.

Evaluation: salvation or nemesis of medical informatics?

The currently prevailing paradigms of evaluation in medical/health informatics are reviewed. Some problems with application of the objectivist approach to the evaluation of real-rather than simulated-(health) information systems are identified. The rigorous application of the objectivist approach, which was developed for laboratory experiments, is difficult to adapt to the evaluation of information systems in a practical real-world environment because such systems tend to be complex, changing rapidly over time, and often existing in a variety of variants. Practical and epistemological reasons for the consequent shortcomings of the objectivist approach are detailed. It is argued that insistence on the application of the objectivist principles to real information systems may hamper rather than advance insights and progress because of this. Alternatives in the form of the subjectivist approach and extensions to both the objectivist and subjectivist approaches that circumvent the identified problems are summarized. The need to include systems engineering approaches in, and to further extend, the evaluation methodology is pointed out.

A new method for matching a document to potential users' information needs.

This paper explores approach to finding out how the information needs that a document can address can be captured. This is important in order to improve indexing strategies applied to document collections. We propose and implemented a cognitive science approach, the "jeopardy game" method of evaluation combined with "think aloud" analysis. The results of the demonstration study are presented and discussed. Some possible improvements to the method for matching a document to potential users' information needs are identified.

Cluster analysis of Wisconsin Breast Cancer dataset using self-organizing maps.

This work deals with multidimensional data analysis, precisely cluster analysis applied to a very well known dataset, the Wisconsin Breast Cancer dataset. After the introduction of the topics of the paper the cluster analysis concept is shortly explained and different methods of cluster analysis are compared. Further, the Kohonen model of self-organizing maps is briefly described together with an example and with explanations of how the cluster analysis can be performed using the maps. After describing the data set and the methodology used for the analysis we present the findings using textual as well as visual descriptions and conclude that the approach is a useful complement for assessing multidimensional data and that this dataset has been overused for automated decision benchmarking purposes, without a thorough analysis of the data it contains.