Envisioning patient safety in Telehealth: a research perspective.

This article explores the need for research into patient safety in large-scale Telehealth systems faced with the perspective of its development extended to healthcare systems. Telehealth systems give rise to significant advantages in improving the quality of healthcare services as well as bringing about the possibility of new types of risk. A theoretical framework is proposed for patient safety for its approach as an emerging property in complex socio-technical systems (CSTS) and their modelling in layers. As regards this framework, the differential characteristic Telehealth elements of the system have been identified, with a greater emphasis on the level of Telehealth system and its typical subsystems. The bases of the analysis are based on references in the literature and the experience accumulated by the researchers in the area. In particular, a case describing an example of Telehealth to control patients undergoing treatment with oral anticoagulants is used. As a result, a series of areas of research into and topics regarding Telehealth patient safety are proposed to cover the detectable gaps. Both the theoretical and practical implications of the study are discussed and future perspectives are reflected on.

ccML, a new mark-up language to improve ISO/EN 13606-based electronic health record extracts practical edition.

OBJECTIVE: The objective of this paper is to introduce a new language called ccML, designed to provide convenient pragmatic information to applications using the ISO/EN13606 reference model (RM), such as electronic health record (EHR) extracts editors. EHR extracts are presently built using the syntactic and semantic information provided in the RM and constrained by archetypes. The ccML extra information enables the automation of the medico-legal context information edition, which is over 70% of the total in an extract, without modifying the RM information. MATERIALS AND METHODS: ccML is defined using a W3C XML schema file. Valid ccML files complement the RM with additional pragmatics information. The ccML language grammar is defined using formal language theory as a single-type tree grammar. The new language is tested using an EHR extracts editor application as proof-of-concept system. RESULTS: Seven ccML PVCodes (predefined value codes) are introduced in this grammar to cope with different realistic EHR edition situations. These seven PVCodes have different interpretation strategies, from direct look up in the ccML file itself, to more complex searches in archetypes or system precomputation. DISCUSSION: The possibility to declare generic types in ccML gives rise to ambiguity during interpretation. The criterion used to overcome ambiguity is that specificity should prevail over generality. The opposite would make the individual specific element declarations useless. CONCLUSION: A new mark-up language ccML is introduced that opens up the possibility of providing applications using the ISO/EN13606 RM with the necessary pragmatics information to be practical and realistic.

Comorbidity patterns in patients with chronic diseases in general practice.

INTRODUCTION: Healthcare management is oriented toward single diseases, yet multimorbidity is nevertheless the rule and there is a tendency for certain diseases to occur in clusters. This study sought to identify comorbidity patterns in patients with chronic diseases, by reference to number of comorbidities, age and sex, in a population receiving medical care from 129 general practitioners in Spain, in 2007. METHODS: A cross-sectional study was conducted in a health-area setting of the Madrid Autonomous Region (Comunidad Autónoma), covering a population of 198,670 individuals aged over 14 years. Multiple correspondences were analyzed to identify the clustering patterns of the conditions targeted. RESULTS: Forty-two percent (95% confidence interval [CI]: 41.8-42.2) of the registered population had at least one chronic condition. In all, 24.5% (95% CI: 24.3-24.6) of the population presented with multimorbidity. In the correspondence analysis, 98.3% of the total information was accounted for by three dimensions. The following four, age- and sex-related comorbidity patterns were identified: pattern B, showing a high comorbidity rate; pattern C, showing a low comorbidity rate; and two patterns, A and D, showing intermediate comorbidity rates. CONCLUSIONS: Four comorbidity patterns could be identified which grouped diseases as follows: one showing diseases with a high comorbidity burden; one showing diseases with a low comorbidity burden; and two showing diseases with an intermediate comorbidity burden.

ICF disability measured by WHO-DAS II in three community diagnostic groups in Madrid, Spain.

OBJECTIVE: The planning, provision and monitoring of medical and support services for patient groups with chronic ailments may require disability assessment and registration. The purpose of this study was to assess disability in three groups of patients with chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) or stroke. METHODS: Convenience samples of consecutive patients diagnosed with COPD (102), CHF (99), and stroke (99) were taken from 1,053 primary care users in the southern area of the autonomous region of Madrid. The patients were informed of the study and were assessed in their homes by trained field workers using the World Health Organization Disability Assessment Schedule II (WHO-DAS II). RESULTS: None of the groups had patients with extreme disability on their global WHO-DAS II scores. The prevalence of severe disability differed among the groups and was highest for stroke and CHF (33.33% and 29.29%, respectively) and lowest for COPD (14.71%). The three groups shared two similar traits, namely, a higher prevalence of disability among women than men, and a specific pattern by domain, with the highest prevalence of severe/extreme limitations being found in household life activities and mobility. Severe restrictions in Social Participation were more frequent in patients with stroke and CHF. The group with moderate disability according to the global WHODAS II score (n=94) showed a high prevalence of severe limitations in mobility, life activities and self-care. CONCLUSIONS: Disability among non-institutionalized persons with COPD, CHF and stroke is frequent and shows gender- and domain-related patterns similar to those described in a population-based study performed using the WHO-DAS II in elderly persons in Spain. ICF-validated disability categories could be useful in epidemiological surveys, individual assessments and primary care data monitoring systems.

ICF disability measured by WHO-DAS II in three community diagnostic groups in Madrid, Spain / Discapacidad CIF, según WHODAS-2, en tres grupos diagnósticos de atención primaria en un Área de Salud del sur de Madrid, España

Objective: The planning, provision and monitoring of medical and support services for patient groups with chronic ailments may require disability assessment and registration. The purpose of this study was to assess disability in three groups of patients with chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) or stroke. Methods: Convenience samples of consecutive patients diagnosed with COPD (102), CHF (99), and stroke (99) were taken from 1,053 primary care users in the southern area of the autonomous region of Madrid. The patients were informed of the study and were assessed in their homes by trained field workers using the World Health Organization Disability Assessment Schedule II (WHO-DAS II). Results: None of the groups had patients with extreme disability on their global WHO-DAS II scores. The prevalence of severe disability differed among the groups and was highest for stroke and CHF (33.33% and 29.29%, respectively) and lowest for COPD (14.71%). The three groups shared two similar traits, namely, a higher prevalence of disability among women than men, and a specific pattern by domain, with the highest prevalence of severe/extreme limitations being found in household life activities and mobility. Severe restrictions in Social Participation were more frequent in patients with stroke and CHF. The group with moderate disability according to the global WHODAS II score (n=94) showed a high prevalence of severe limitations in mobility, life activities and self-care. Conclusions: Disability among non-institutionalized persons with COPD, CHF and stroke is frequent and shows gender- and domain-related patterns similar to those described in a population-based study performed using the WHO-DAS II in elderly persons in Spain. ICF-validated disability categories could be useful in epidemiological surveys, individual assessments and primary care data monitoring systems (AU)

Objetivo: La planificación, prestación y monitorización de servicios sociales y sanitarios a pacientes con trastornos crónicos puede requerir evaluación y registro de su discapacidad. El objetivo de este estudio fue evaluar la discapacidad de tres grupos de pacientes con enfermedad pulmonar obstructiva crónica (EPOC), insuficiencia cardiaca congestiva (ICC) o ictus. Métodos: Pacientes con EPOC (102), ICC (99) e ictus (99), vistos consecutivamente, identificados de una lista de 1053 usuarios de atención primaria en el sur de la Comunidad Autónoma de Madrid, España. Tras ser informados, fueron evaluados en sus casas por entrevistadores entrenados utilizando WHODAS-2. Resultados: No hubo casos de discapacidad extrema, pero las tres poblaciones mostraron prevalencias de discapacidad grave según WHODAS-2 total, más altas en ictus e ICC (33,33% y 29,29%, respectivamente) y menores en EPOC (14,71%). Los grupos compartían un patrón de discapacidad más alta en mujeres y otro específico por dominios, con prevalencias más altas de discapacidad grave/extrema en actividades domésticas y movilidad. La participación social estaba más restringida en ictus e ICC. El grupo con discapacidad moderada en WHODAS-2 global (94 enfermos) mostraba prevalencias altas de discapacidad grave en movilidad, actividades diarias domésticas y autocuidado. Conclusiones: La discapacidad en personas no institucionalizadas con EPOC, ICC e ictus es frecuente, con patrones por sexo y dominio similares a los descritos en España con WHODAS-2 en un estudio poblacional de personas de edad avanzada. Las categorías CIF de discapacidad podrían utilizarse en encuestas epidemiológicas y evaluaciones individuales, así como en sistemas de información orientados a la monitorización de la discapacidad en atención primaria (AU)

A literature review of transmission effectiveness and electromagnetic compatibility in home telemedicine environments to evaluate safety and security.

OBJECTIVE: The objective of this study was to determine already reported cases of transmission/reception failure and interferences to evaluate the safety and security of the new mobile home telemedicine systems. MATERIALS AND METHODS: The literature published in the last 10 years (1998-2009) has been reviewed, by searching in several databases. Searches on transmission effectiveness and electromagnetic compatibility were made manually through journals, conference proceedings, and also the healthcare technology assessment agencies' Web pages. RESULTS: Search strategies developed through electronic databases and manual search identified a total of 886 references, with 44 finally being included in the results. They have been divided by technology in the transmission/reception effectiveness studies, and according to the type of medical device in the case of electromagnetic interferences studies. CONCLUSIONS: The study reveals that there are numerous publications on telemedicine and home-monitoring systems using wireless networks. However, literature on effectiveness in terms of connectivity and transmission problems and electromagnetic interferences is limited. From the collected studies, it can be concluded that there are transmission failures, low-coverage areas, errors in the transmission of packets, and so on. Moreover, cases of serious interferences in medical instruments have also been reported. These facts highlight the lack of studies and specific recommendations to be followed in the implementation of biomonitoring systems in domestic environments using wireless networks.

Proof-of-concept design and development of an EN13606-based electronic health care record service.

OBJECTIVE: The authors present an Electronic Healthcare Record (EHR) server, designed and developed as a proof of concept of the revised prEN13606:2005 European standard concerning EHR communications. METHODS: The development of the server includes five modules: the libraries for the management of the standard reference model, for the demographic package and for the data types; the permanent storage module, built on a relational database; two communication interfaces through which the clients can send information or make queries; the XML (eXtensible Markup Language) process module; and the tools for the validation of the extracts managed, implemented on a defined XML-Schema. RESULTS: The server was subjected to four phases of trials, the first three with ad hoc test data and processes to ensure that each of the modules complied with its specifications and that the interaction between them provided the expected functionalities. The fourth used real extracts generated by other research groups for the additional purpose of testing the validity of the standard in real-world scenarios. CONCLUSION: The acceptable performance of the server has made it possible to include it as a middleware service in a platform for the out-of-hospital follow-up and monitoring of patients with chronic heart disease which, at the present time, supports pilot projects and clinical trials for the evaluation of eHealth services.

Airmed-cardio: a GSM and Internet services-based system for out-of-hospital follow-up of cardiac patients.

A platform built around three information entities (patient, health-care_agent, and central_station) was designed to enable patients with chronic heart disease (in stable condition; emergency situations were excluded deliberately) to complete specifically defined protocols for out-of-hospital follow-up and monitoring. The patients belonged to one of four specific risk groups: arterial hypertension, malignant arrhythmias, heart failure, and postinfarction rehabilitation. They were provided with portable recording equipment and a cellular phone that supported data transmission [electrocardiogram (ECG)] and wireless application protocol (WAP) (remaining parameters and ad hoc questionnaires). The central station was an automatized platform, with no human operator. The information received was organized chronologically in patient folders. The health-care_agents had continuous and secure access to the patient folders, through tools based on the world wide web and WAP, and to short messages sent by their patients. A pilot project was conducted with 89 patients (mean length of participation: 50.1 days). A total of 2168 ECGs (mean duration transmission = 2 min/30 s; network errors < 0.1%) and 4011 short messages (none lost, in 95% of cases 30 s < delay < 1 min) were transmitted; 6083 WAP sessions (mean duration = 3 min 11 s; network failures < 0.1%) were The functionality of the platform was also evaluated, analyzing the subjective component of usability, showing the evolution of patient acceptance over time.

Enfermedad de moyamoya hemoragia intraventricular primaria en paciente adulto. A propósito de un caso / Moyamoya disease and primary intraventricular hemorrhage in adult patients. A propos of a case

La enfermedad de moyamoya es considerada generalmente como una patología cerebrovascular pediátrica pero en algunos casos los sintomas se manifiestan en adultos. Es rara la hemorragia intraventricular primaria (HIVP) como consecuencia de esta enfermedad. Deben tenerse claros los criterios diagnóstico y neuroimaginológico de la enermedad de moyamoya definitiva. Varón de 52 años con antecedentes familiares de dos hermanos fallecidos por accidente cerebrovascular hemorrágico y antecedentes patológicos personales de cefaleas de años de evolución e hipertensión arterial. Es remitido por cuadro de ictus, con cefalea, rigidez nucal+++, desorientación temporospacial y estupor. En la TAC craneal se evidencia pequeño hematoma subependimario paraventricular izquierdo y hemorragia panventricular. La angiografía cerebral muestra un patrón angiográfico moyamoya y circulación arterial en territorio posterior con impotante desarrollo que suple la irrigación del encéfalo. Dada la presentación tan infrecuente de la enfermedad a esta edad, en nuestro medio y como responsable de una HIVP, se revisaron determinadas peculiaridades neurorradiológicas de interés como es la evolución, caracerísticas diagnósticas, clasificaciones angiográficas y diagnóstico diferencial con el síndrome de moyamoya a propósito de este caso(AU)