Modelling health care processes for eliciting user requirements: a way to link a quality paradigm and clinical information system design.

Healthcare institutions are looking at ways to increase their efficiency by reducing costs while providing care services with a high level of safety. Thus, hospital information systems have to support quality improvement objectives. The elicitation of the requirements has to meet users' needs in relation to both the quality (efficacy, safety) and the monitoring of all health care activities (traceability). Information analysts need methods to conceptualise clinical information systems that provide actors with individual benefits and guide behavioural changes. A methodology is proposed to elicit and structure users' requirements using a process-oriented analysis, and it is applied to the blood transfusion process. An object-oriented data model of a process has been defined in order to organise the data dictionary. Although some aspects of activity, such as 'where', 'what else', and 'why' are poorly represented by the data model alone, this method of requirement elicitation fits the dynamic of data input for the process to be traced. A hierarchical representation of hospital activities has to be found for the processes to be interrelated, and for their characteristics to be shared, in order to avoid data redundancy and to fit the gathering of data with the provision of care.

ARIANE: a mediation framework with health information sources.

OBJECTIVES: to design and implement mediators dedicated to access heterogeneous information sources in a homogeneous way. METHOD: processes translate a query into the syntax of a target source built thanks to the UMLS knowledge sources and a catalog of information sources. Communication services connect users with information sources at the point they deliver results. RESULTS: examples show the benefits healthcare professionals may found in searching information in this way. DISCUSSION: improvements on the current developments may be done according to the current architecture of ARIANE. Specially, the user interface should be easier to use than the present one.

Guideline development: focus on breast cancer screening in the EsPeR project.

We describe in this paper, the implementation of a clinical practice guideline focused on breast cancer screening. Our aim in conceiving such a computerized guideline was first to help general practitioners in appreciating the risks their female patients might develop breast cancer and secondly to suggest them the screening measures adapted to each particular case. This implementation enables us to present our general methodology to elaborated and promulgate guidelines within the EsPeR project. This methodology aims at providing guidelines based on knowledge validated according to the EBM principles, that can be used in real time and updated according to current knowledge.

An adaptive medical e-learning environment: the MEDIDACTE project.

Most e-learning systems offer the same tools and resource materials to students who are different in terms of motivations, training backgrounds, technical skills and learning objectives. Adaptive systems development is a challenge intended to improve the efficiency of these systems. This communication presents the design and implementation of an adaptive medical e-learning environment. The authors describe the MEDIDACTE architecture developed in three levels namely, the educational resource, educational project and user level. Current MEDIDACTE implementation and integration in Marseille Medical University curriculum are presented.

Towards health care process description framework: an XML DTD design.

The development of health care and hospital information systems has to meet users needs as well as requirements such as the tracking of all care activities and the support of quality improvement. The use of process-oriented analysis is of-value to provide analysts with: (i) a systematic description of activities; (ii) the elicitation of the useful data to perform and record care tasks; (iii) the selection of relevant decision-making support. But paper-based tools are not a very suitable way to manage and share the documentation produced during this step. The purpose of this work is to propose a method to implement the results of process analysis according to XML techniques (eXtensible Markup Language). It is based on the IDEF0 activity modeling language (Integration DEfinition for Function modeling). A hierarchical description of a process and its components has been defined through a flat XML file with a grammar of proper metadata tags. Perspectives of this method are discussed.

Mediation services with health information sources.

OBJECTIVES: To design and implement mediators dedicated to access various kinds of information sources in the framework of the project ARIANE. METHOD: Mediators are dynamically built thanks to three components: pieces of knowledge issued from the UMLS knowledge sources and from a catalog of information sources, processes that translate a query into the syntax of a target source, and communication services provided by operating systems. RESULTS: A scenario details the complete mediation process with an indexed web site. CONCLUSION: This approach mixes knowledge and software engineering. It benefits from services provided by operating systems and allows scalability and reusability of software components.

Integration of health care process analysis in the design of a clinical information system: applying to the blood transfusion process.

Hospital information systems have to support quality improvement objectives. The requirements of the system have to meet users' needs in relation to both the quality (efficacy, conformity, safety) and the monitoring of all health care activities (traceability). Information analysts need complementary methods to conceptualize clinical information systems that provide actors with immediate individual benefits and guide collective behavioral changes. A methodology is proposed to elicit users' needs using a process-oriented analysis, and it is applied to the field of blood transfusion. We defined a process data model, the main components of which are: activities, resources, constrains, guidelines and indicators. Although some aspects of activity, such as "where", "what else", and "why" are poorly represented by the data model alone, this method of requirement elicitation fits the dynamic of data input for the process to be traced. A hierarchical representation of hospital activities has to be found for this approach to be generalised within the organisation, for the processes to be interrelated, and for their characteristics to be assessed.

Modelling health care processes for eliciting user requirements: a way to link a quality paradigm and clinical information system design.

Hospital information systems have to support quality improvement objectives. The design issues of health care information system can be classified into three categories: 1) time-oriented and event-labelled storage of patient data; 2) contextual support of decision-making; 3) capabilities for modular upgrading. The elicitation of the requirements has to meet users' needs in relation to both the quality (efficacy, safety) and the monitoring of all health care activities (traceability). Information analysts need methods to conceptualize clinical information systems that provide actors with individual benefits and guide behavioural changes. A methodology is proposed to elicit and structure users' requirements using a process-oriented analysis, and it is applied to the field of blood transfusion. An object-oriented data model of a process has been defined in order to identify its main components: activity, sub-process, resources, constrains, guidelines, parameters and indicators. Although some aspects of activity, such as "where", "what else", and "why" are poorly represented by the data model alone, this method of requirement elicitation fits the dynamic of data input for the process to be traced. A hierarchical representation of hospital activities has to be found for this approach to be generalised within the organisation, for the processes to be interrelated, and for their characteristics to be shared.

Quality criteria and access characteristics of Web sites: proposal for the design of a health Internet directory.

The increasing volume of information available on the Internet today is a problem for health care professionals who want to access rapidly data of high quality. Usual search engines and directories are not sufficient to satisfy their needs. Moreover, the information published by Web sites is not always guaranteed. Some institutions around the word deal with the definition of a set of criteria for the evaluation of medical Web sites. We base our current work on the technologies we developed previously in order to integrate sources of information of various kinds using the "Unified Medical Language System" knowledge bases. This paper focuses on quality criteria and access characteristics Web sites should satisfy to be registered in a "Health Internet Directory". The design of such a system is proposed and discussed.

Confidentiality issues within a clinical information system: moving from data-driven to event-driven design.

Within a hospital, the moving of medical information systems from retrospective data-gathering methods to prospective clinical information systems raises the question of the confidentiality of patient data. A method of improving the traditional matrix model usually used to achieve access controls is described. The event-driven model refers to the way a security system ensures that a given user has a valid "need-to" relationship to a given patient. Events are defined as the occurrence of specific data that trigger the creation or the updating of the relationship between the identity of a user and the identity of a patient (e.g., admission, discharge, transfer, prescription, and report). The creation and the deletion of the relationships between users and patients are based on numerous repositories and working lists of patients. This implementation requires an organization of the hospital activities which is able to manage, in a real-time manner, those repositories as closely as possible to the steps occurring during the patient's care process. Although this approach seems to reasonably fit the dynamic of the care process, it adds significant organizational constraints.

Modeling and implementing a database on drugs into a hospital intranet.

Our objective was to develop a drug information service, implementing a database on drugs in our university hospitals information system. Thériaque is a database, maintained by a group of pharmacists and physicians, on all the drugs available in France. Before its implementation we modeled its content (chemical classes, active components, excipients, indications, contra-indications, side effects, and so on) according to an object-oriented method. Then we designed HTML pages whose appearance translates the structure of classes of objects of the model. Fields in pages are dynamically fulfilled by the results of queries to a relational database in which information on drugs is stored. This allowed a fast implementation and did not imply to port a client application on the thousands of workstations over the network. The interface provides end-users with an easy-to-use and natural way to access information related to drugs in an internet environment.

ARIANE: integration of information databases within a hospital intranet.

Large information systems handle massive volume of data stored in heterogeneous sources. Each server has its own model of representation of concepts with regard to its aims. One of the main problems end-users encounter when accessing different servers is to match their own viewpoint on biomedical concepts with the various representations that are made in the databases servers. The aim of the project ARIANE is to provide end-users with easy-to-use and natural means to access and query heterogeneous information databases. The objectives of this research work consist in building a conceptual interface by means of the Internet technology inside an enterprise Intranet and to propose a method to realize it. This method is based on the knowledge sources provided by the Unified Medical Language System (UMLS) project of the US National Library of Medicine. Experiments concern queries to three different information servers: PubMed, a Medline server of the NLM; Thériaque, a French database on drugs implemented in the Hospital Intranet; and a Web site dedicated to Internet resources in gastroenterology and nutrition, located at the Faculty of Medicine of Nice (France). Accessing to each of these servers is different according to the kind of information delivered and according to the technology used to query it. Dealing with health care professional workstation, the authors introduced in the ARIANE project quality criteria in order to attempt a homogeneous and efficient way to build a query system able to be integrated in existing information systems and to integrate existing and new information sources.

UMLS-based conceptual queries to biomedical information databases: an overview of the project ARIANE. Unified Medical Language System.

OBJECTIVE: The aim of the project ARIANE is to model and implement seamless, natural, and easy-to-use interfaces with various kinds of heterogeneous biomedical information databases. DESIGN: A conceptual model of some of the Unified Medical Language System (UMLS) knowledge sources has been developed to help end users to query information databases. A query is represented by a conceptual graph that translates the deep structure of an end-user's interest in a topic. A computational model exploits this conceptual model to build a query interactively represented as query graph. A query graph is then matched to the data graph built with data issued from each record of a database by means of a pattern-matching (projection) rule that applies to conceptual graphs. RESULTS: Prototypes have been implemented to test the feasibility of the model with different kinds of information databases. Three cases are studied: 1) information in records is structured according to the UMLS knowledge sources; 2) information is able to be structured without error in the frame of the UMLS knowledge; 3) information cannot be structured. In each case the pattern-matching is processed by the projection rule according to the structure of information that has been implemented in the databases. CONCLUSION: The conceptual graphs theory provides with a homogeneous and powerful formalism able to represent both concepts, instances of concepts in medical contexts, and associations by means of relationships, and to represent data at different levels of details. The conceptual-graphs formalism allows powerful capabilities to operate a semantic integration of information databases using the UMLS knowledge sources.

Towards interoperability of information sources within a hospital Intranet.

Information is usually available in heterogeneous data format and various legacy sources. Interoperability appears to be a major approach for applications to access information. The project ARIANE is devoted to provide end-users with an easy to use and natural access to information databases. In this frame we defined actors able to operate the mediation between end-users and information servers: a "broker" which selects appropriate resources and "mediators" which access data suppliers. We have implemented a web-oriented stand-alone prototype accessing three types of information sources: a bibliographical server, a SQL database server and a hypertext server. Both broker and mediators exploit the Unified Medical Language System knowledge sources, especially the Information Sources Map which allows a way to identify information servers.

Implementation of a database on drugs into a university hospital Intranet.

Several databases on drugs have been developed worldwide for drug information functions whose sources are now electronically available. Our objective was to implement one of them in our University hospitals information system. Thériaque is a database which contains information on all the drugs available in France. Before its implementation we modeled its content (chemical classes, active components, excipients, indications, contra-indications, side effects, and so on) following an object-oriented method. From this model we designed dynamic HTML pages according to the Microsoft's Internet Database Connector (IDC) technics. This allowed a fast implementation and does not imply to port a client application on the thousands of workstations over the network of the University hospitals. This interface provides end-users with an easy-to-use and natural way to access information related to drugs in an Intranet environment.

Conceptual integration of information databases into an Intranet.

Large information systems handle massive volume of data stored in heterogeneous sources of information. Each server has its own model of concepts representation with regard to its aims. One of the main problems encountered by end-users when accessing different servers is to match their own viewpoint on biomedical concepts with their various representations that are made in the database servers. The aim of the project ARIANE is to provide end-users with easy-to-use and natural means to access and query heterogeneous information databases. The objectives of this research work consist in building a conceptual interface by means of the Internet technology inside an enterprise Intranet, and to propose a method to realize it. Moreover, this method provides designers of web sites with a powerful tool to manage them on the basis of an ontology of the biomedical domain. This method is based on the knowledge sources provided by the Unified Medical Language System project of the U.S. National Library of Medicine and exploits intensively the conceptual graphs theory.

Impact of the TOP-FORUM hypermedia system in a pediatric oncology care unit.

This paper describes our approach in analyzing the impact of the TOP-FORUM hypermedia in a pediatric oncology care unit. The impact of this technology is realized through the study of accommodation and assimilation adoption. Accommodation refers to the technological adoption and Assimilation refers to the professional adoption. Results show that accommodation depends on information and formation of the users. Assimilation is more difficult to evaluate because it depends on human, social and organizational problems.

Towards semantic integration within an existing medical information system.

Talking about the problems of integration in medical information systems, the necessity to provide end users with a consistent and coherent view of patient's data, has been largely reported. In order to attempt this goal, systems need to perform semantic integration. We propose a pragmatic way to describe the semantics of the elements of a database, based on a bottom-up three steps process: 1. a back documentation of the elements of the system from their description contained in the data catalog of the database 2. a first semantic extension to transform a data catalog into a data dictionary 3. a second semantic extension to create a dictionary of the medical concepts from a data dictionary. This dictionary of concepts can be considered as the final result of "semantic integration". It contains a set of entities directly understandable by the end users. These entities are deduced or built from the elements collected and characterized in the data dictionary. This work reports the conceptual analysis and the implementation of such a data dictionary.

A UMLS-based method for integrating information databases into an Intranet.

The Internet and the World Wide Web provide today end-users with capabilities to access universally to information in various and heterogeneous databases. The biomedical domain benefits from this new technology, specially for information retrieval by searching and browsing various sites. Nevertheless, end-users may be disoriented by specific ways to access information on different servers. In the framework of an Intranet design and development, we present a method for integrating information databases based on knowledge sources of the UMLS. The method provides designers of a Web site with facilities to implement an easy and homogeneous access to information. The pages are built dynamically and displayed according to a style sheet and their content stored in a database during the design phase. The database also describes the links between pages. Moreover, this organization provides administrators with powerful capabilities to manage Web sites.