Wednesday, September 15, 2010

Medinfo Day 3

The first session I got to on the third full day of the conference, was the nursing informatics (NI) session. As I walked in (a couple of minutes late) a picture of Florence Nightingale was on the screen & I wondered how much we had moved on? Heimar Marin gave a history and overview of IMIA’s WG 8 Nursing Informatics Specialist Interest Group. She called for more countries to join. Panellists spoke about developments in their own areas of the world. Hyeoun-Ae Park described Korea, Japan and Taiwan including their population, life expectancy and health care systems along with the development of NI and their use of ICT in the country. She described the education of nurses in Korea country and how the use of ICT had developed over the last 20 years, until its current state “Ubiquitous healthcare” which uses telemedicine and telecare approaches. She also presented, on behalf of others, the situation in Japan which is now moving from a vocation based system towards a more science based system. In a similar way to Korea and Japan the use of technology is moving from educational to clinical uses with standardised languages as part of the EHR. Taiwan will be hosting the NI conference in 2015.

Patrick Weber spoke for Europe on current practice and education. He plugged a recent book and then moved on to look at EU approaches to IT underpinning strategic policy in eHealth to promote empowerment of the individual via electronic systems. He used the developments in Switzerland to illustrate national approaches before looking at them likely effects of demographic change and the increase in chronic diseases in Europe. The next speaker was Sue Newbold from the USA who talked about the NI history group which is hosted by AMIA on their web site. Interviews with various pioneers in the field have been recorded and transcribed. These are made available on the web site and Sue showed some screen shots and speculated about common themes. Graham Wright was not able to attend & his place was taken by South African representatives talking about their experiences. The use of ICT is increasing but there is no formal recognition of the role and there is a lack of appropriate education at various levels. Much of healthcare in sub Saharan Africa is nurse led and delivered and is competing for resources.

The next session I attended was exploring organisational issues. The first paper was about the MEDAL project measuring emergency department’s adaptive load in an Israeli hospital. He described waiting times and overcrowding in ED as being a major problem and the development of a tool to try to identify the best use of resources, highlighting where the major bottlenecks occur. Current approaches use statistical calculations to produce load factors, however this project argued there is no average and the issues for nurses, doctors & patients are different and any system needed to take into account the “gut feelings” of the people involved, based on a neural network approach. Their new system enables staff to disagree with the score and update the weights by clicking a button on the workload dashboard. Alarm can be set to trigger local problems.

The next paper was “Theories. Models and frameworks for diagnosing technology induced errors” presented by Andre Kushniruka. It started with definitions and examples of medication and other unintended consequences and reported on a systematic review of papers in the field. At the lowest level software engineering and programming problems, working up to human factors and ultimately organisational approaches. Examples of the application of the models were given followed by discussion of certification of technology and processes and tracking adverse events. A good and interesting presentation. e-iatrogensis seems be an emerging and important growth area!

The next paper, by Charles Webster, looked at process aware EHR BPM systems – two prototypes and a conceptual framework. The Business Process Management models and diagrams were very busy and seemed to see cost and efficiency as being the ultimate goals. I lost the plot around the “patient class event hierarchy” and “closed loop process improvement” and diagrams and language which didn’t help to explain anything to me. “Process mining” might be the way to go – but after this talk I have less idea than I did at the start.

The next paper with two speakers (“to prevent it being deadly boring” ;-) looking at virtual autopsies in forensic science in Sweden. The technology examines cold human bodies to determine cause of death, using MRI & CT. The virtual autopsy table is available on You Tube. From the look of the video this is the ultimate coffee table!! This paper focused on the real introduction of the technology into real world workflow environments, not just for the police and forensic science services but also to prevent the information in court. (see and soon at

The final paper of the morning, by Mirjam Ekstedt and colleagues from Oslo, Norway, asked why people want a paper copy of their Electronic Patient Record (EPR)? Patients n ow have the right to see their records, but few actually do this. The study looked at why people want to see the records and any conflicts between confidentiality, trust and control with a focus on the transmission of one’s own information. The risks of delay, information overload because of poorly organised records and lower quality discharge summaries were considered. A summary care record was seen as a way forward, however the value of this was challenged during the Q&A session.

After lunch I attended a panel session entitled “The need to develop Health Informatics to become an Evidence-based Health Science, and the Role of the Global ACE (alliance for clinical excellence) Initiative.” The chair and 1st speaker was Michael Rigby from the UK, followed by Jan Talmon from the Netherlands and finally Mehdi Khaled from Oracle. They have been working on evaluation guideline for health informatics. Michael suggested that many health informatics implementations had received an “easy ride” in scientific terms and that this has been abused by policy makers. He started with some frequently made assumptions highlighting some of the risks when the assumptions are not challenged. He followed this with some “facts” about problems in health informatics which may have made uncomfortable reading for many advocates. He suggested that any other change in medicine/healthcare requires evidence to support it but major changes brought by health information systems don’t need the same level of evidence.

Jan Talmon moved on to examine evidence and evaluation. The complexity of the human factors in healthcare make the generation of methodologically robust studies more difficult. Changes to the EU directive earlier this year to include software as medical devices may require much more detailed evaluation before it becomes licensed. The declaration of Innsbruck provides guidelines for evaluation systems. See GEP-HI & STARE-HI.

Mehdi Khaled started with a historical story about a trail showing the role of citrus fruit in scurvy in 1747, and then went on to look at recent evaluation projects on CPOE and other systems. The conclusion was around the need for standardised evaluation tools contained within the Global alliance for Clinical Excellence – a not for profit company, which is currently looking for partners. An interesting discussion about the potential benefits (and some of the hurdles) tried to explore where this sort of approach may be going.

Final session

The final session was a plenary session with the awards. Chaired by Enrico Coiera it included a final report by Reinhold Haux as the outgoing president and the handover to Antoine Geissbuhler the incoming president. The Scientific Programme Committee awarded prizes for the best posters and papers and IMIA awards for excellence were presented. There were also thanks to the many many people who have been instrumental in putting the conference together and the ceremony concluded with a presentation by the winning bid team who will be running the next Medinfo in 2013 in Copenhagen.

Final thoughts.

At the end of a major conference like this it is useful to reflect on all aspects from the scientific papers, panels and demonstrations to the venue, organisation, catering etc
Cape Town is a nice friendly city, and makes a good base for tourism – although the weather was changeable with the initial days sunny but by Wednesday becoming grey and damp. The venue itself was adequate although the provision of the wireless network and power outlets was poor and the requirement to have a ticket to get a cup of coffee was over the top. There appeared to less exhibitors than at previous events. I didn’t get a chance to see many of the posters as these were only up for a short period of time while the “tours” were going on and when then removed – they could have been left up for longer so that others who were not able to attend the tour could see them – there was certainly enough space in the hall. It was good to meet up with many old friends and meet new ones – and often the informal and social networking is one of the real benefits of this sort of event.
As often occurs with these meetings, the programme tried together related topics, however this sometimes meant that 3 or 4 presentations which were of interest occurred simultaneously and then the next couple of hours had little of direct interest. Because of the meeting being in Africa there has, rightly, been a focus on the developing world , which has given it a different flavour. Some of the work was very practical and others on a more esoteric theoretical levels. There were some good papers and one or two really innovative ideas but many were not that inspiring – both in terms of the content and the quality of presentations.
On the selection of presentations I was able to attend I did not feel that health informatics has moved on very much over the last 3 years and I didn’t really get a feel for where the work may be going over the next few years – possibly apart from the growth in the study of e-iatrogenesis and/or telecare/remote monitoring.
I now have a few hours to explore Cape Town and hopefully Table Mountain before getting back to the airport for my flight back to the UK.



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