Chapter 3. MEDICAL INFORMATION SYSTEMS
3.1. Implementation of telemedicine in the public health system The modern development of information technologies makes
healthcare more and more dependent on IT solutions. The main goal of healthcare informatization is to help the doctor in treating the patient; to assist the manager of the medical institution in organizing the work of doctors; to help the organizer of health care in creating a system of medical care for the population and ensuring a healthy lifestyle.
The basis of informatization of healthcare in Ukraine is a unified public health information environment in all its aspects, based on modern Internet technologies. An integral part of this process is the automation of health care facilities using medical information systems (MIS).
Medical information system (MIS) can be defined as a complex of hardware and software facilities, designed to automate the work of medical institutions. The main component of this
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system is the patient’s electronic medical record (PEMR), in particular, an outpatient record (at the clinic) or a case history (at the hospital or sanatorium). Quite often, one implies MIS when discussing electronic case histories in general.
The main objectives of MIS can be summarized as follows:
preparation, storage and analysis of information necessary for medical rehabilitation, diagnostic, administrative and managerial processes, research, educational and methodological work, as well as communication with other organizations and world databases.
In the technical aspect, MIS is a local network of personal computers (workstations), and the server on which the databases are stored and the main software is installed – the core of the system.
As for software, this is a set of programs, each of which performs its specific task, but is integrated into a single information environment, that is, it receives data for its work from a common database and puts the results of its work there.
Progress, which touched on absolutely all types of human activities, has led to the development of telemedicine – a new area, which ensures the exchange of skills and experience between the specialists themselves, as well as between the specialist and the patient.
Back in the last century, all discoveries in the field of medicine and medical practice were published in scientific papers, which were not easy to get. Today, you can exchange experience or consult a patient using telecommunications.
By definition of the World Health Organization (WHO), telemedicine is a method of providing health care services where distance is a critical factor.
The draft law “On Telemedicine” (No. 10196 as of March 14, 2012) defines it as a set of organizational, financial and technological measures, ensuring the provision of remote medical consultation services, in which the patient or the doctor directly conducting the examination and / or treatment of the patient receives a remote consultation from another doctor using telecommunications.
With the development of telemedicine, many opportunities
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have appeared. Foreign experts are ready to share their experience with domestic doctors, as well as learn from the knowledge and skills of our specialists. In addition, telemedicine allows obtaining medical advice online, which enables doctors to make the decision and prescribe treatment quickly and correctly. Not every provincial clinic has highly qualified doctors, therefore, the advice from experienced professionals in locations, where it is difficult to get, is worth its weight in gold.
Telemedicine has many advantages, including:
• the opportunity to consult those patients whose transportation is impossible due to a severe disease;
• the opportunity to get advice from another specialist will allow doctors to make the most correct decision when solving a particular problem, relying not only on your own experience, but also on the experience of a colleague;
• telemedicine serves as an indispensable tool for transfer of experience, contributes to the development of world medicine;
• the ability to provide assistance in the event of natural disasters when there is an acute shortage of personnel;
• reduction of time for information transfer in the form of analysis results and laboratory tests.
Telemedicine is a tool that helps to improve the skills of doctors without discontinuing one’s full time work.
Telemedicine is a comprehensive concept. It cannot be considered solely on the one hand. It provides for the interaction of two opponents, which as a result ensures mutual benefits for both parties.
This area of advisory activity prioritizes the solution to the following tasks:
• a significant reduction in the cost of medical services – it is no secret that consulting by world-renowned specialists is not cheap, but this can save a person’s life; expenses for transportation of the patient, temporary accommodation and the consultation itself can be significantly reduced if one holds teleconference bridges and online conferences, which in terms of performance are no worse than a visual contact.
• providing assistance in those remote places where there is no
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way to get there quickly — sometimes help may be needed suddenly, and doctors in villages and towns cannot make their own decisions;
• data exchange in the field of medicine and pharmaceutics;
• collection of data and transfer of personal experience that will help in solving complex problems – instead of acting according to the protocol that was developed decades ago, the doctor gets the opportunity to ask his/her foreign colleagues what they think about a relevant situation.
Telemedicine simplifies life not only for those people who need medical advice, but also for the doctors themselves. Modern means of communication help to quickly resolve issues of treatment and surgical operations, allow real-time assistance to be provided, to share one’s own skills and abilities with colleagues.
The task of telemedicine is expanding every year, which allows us to render the medical care more qualified and effective, thus reducing mortality among the population.
Telemedicine technologies are based on communication tools that help exchange information in real time. There are several ways to exchange information in order to provide significant assistance:
1. Medical consultations in real time is carried out using special computer equipment, it has access to the global network.
Being online, you can monitor the treatment process, the progress of operation, as well as provide advice to patients. Online consultations can be of three directions:
• emergency – when help and advice are urgently needed;
• planned – communication between two opponents is planned for a specific time and date;
• video consultation – help to connect several specialists at once in real time, as well as the patient. Experts estimate that video consultation is by 10, 20, and even 50 times cheaper than the patient going directly to the doctor from remote parts of the planet to more developed clinics.
2. Delayed consultations occur through communication by e- mail, which is convenient for transmitting data and analysis results.
One can also consult a specialist who, with proper organization, will help the doctor with the diagnosis, and the patient himself in
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deciding on further treatment.
3. Telemedicine in the field of training – is used to conduct continuing work-based education, video seminars, conferences and consultations can be held where experienced specialists share their skills and train their colleagues in a particular field of medicine.
This will reduce the time spent on training, as well as funds for travel and temporary residence
It is possible to make a point connection at once to 5, 10, 15 people, therefore lectures and practical skills can be transmitted immediately to a large number of doctors, it saves time and lecturer forces are spent less.
4. Broadcast operations and complex manipulations allow us to evaluate the quality of the doctor’s work, as well as receive practical advice on improving surgical intervention to achieve the highest treatment results.
5. Mobile complexes are communication facilities, installed in emergency rooms, rural medical centers and intensive care vehicles that are forced to work in places of accidents and disasters. Mobile complexes allow us to receive emergency advice from experienced doctors who are in the clinic and cannot leave their place.
6. Biomonitoring systems are effective for remote monitoring of the health for subjects with chronic diseases, or working at a harmful enterprise. This method allows us to identify and timely eliminate the real threat to life, reduce mortality among the active population of the planet.
One of the most technical means of providing advice is home telemedicine. It provides a link between a patient who is being treated at home and a doctor who, for example, is in another country.
Telemedicine consultations, depending on their target audience, can be divided into four groups:
1. Specialist-Patient-Specialist – when one doctor consults with his colleague about the treatment of the patient, where the patient can be present and take an active part in the conversation.
2. Specialist-Patient-Doctor gives recommendations for the treatment of patients who themselves cannot come to the clinic taking into account the circumstances.
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3. Laboratory-Specialist-Doctor – the doctor can get all the data from the test results much faster than if they were transported by a living person.
4. Specialist-Rescuer-Doctor – the doctor advises the rescue teams working in places of accidents and disasters regarding the ways and methods of saving the lives of victims.
At present, telemedicine is one of the most important and highly effective ways to quickly transfer the necessary information using global networks and satellite communications, as well as related technological equipment.
Telecommunication facilities began to serve for the benefit of the development and improvement of medicine not immediately.
The first country that decided to test the effectiveness of such a connection was Norway. This country is characterized by the presence of hard-to-reach ambulances. It was there that telecommunications medical assistance was first provided. The second project was carried out in France for sailors of the civilian and navy.
Telemedicine in France is currently improving healthcare, especially in the rural and mountainous areas. Thus, in remote villages, “medical cabins” are installed to communicate with the doctor via the Internet, which will allow virtual visits by doctors.
Such a medical cabin, developed by H4D enterprise, is able to carry out preventive tests for patients with diabetes, measure heart rate and blood pressure, take an X-ray, diagnose pathological conditions and conduct genetic tests. From a remote location, the patient can directly get a doctor's consultation on the screen.
In the USA, the first telemedicine programs were developed almost 40 years ago, and over the past 10-15 years, technology has stepped far forward. The telemedicine market in the EU is constantly growing – from 4.4 billion euros in 2011. According to the forecast, it should triple by 2019 (up to 11.5 billion euros).
The greatest impetus to the spread of new medical technology is the increase in the number of elderly people, as well as, of course, the increase in the cost of medical services.
In Ukraine, it became possible to unite about 40 medical institutions into one network, including clinics of various levels:
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national medical institutes, highly specialized clinics, regional, district and city hospitals. They include the leading medical centers of the country, such as N.M. Amosov National Institute of Cardiovascular Surgery, Institute of Pediatrics, Obstetrics and Gynecology, Institute of Neurosurgery, Institute of Cancer, Children's Specialized Hospital “Okhmatdet”, as well as regional, city and district hospitals.
• The development of telemedicine is essential for our country, especially given the anti-terrorist operation in the east.
• In military medicine, telemedicine technologies can simplify the work of doctors, perform effective management at the stages of evacuation, systematize and standardize the quality of medical care.
Given the complexity and protracted treatment of gunshot wounds, this allows us to keep a constant and long-term monitoring of the treatment process of each victim.
• Significant work on the introduction of telemedicine in Ukraine has been carried out during the last year since the adoption of the common program of Ukraine and NATO.
The World Health Organization annually makes adjustments and develops new systems that have helped the development of telemedicine worldwide. Among the most successful and progressing international programs, the following are distinguished:
«Planet Heres» is a program whose main task is the exchange of data on medicine, statistics and innovative approaches to the treatment of certain diseases.
«Satellife» allows to share one’s own experience and research in the field of medicine, as well as to conduct online consultations between all program participants, uniting countries and continents.
«Hector» is a European program that allows to advise ambulance specialists quickly and efficiently, which will improve the quality of medical services and reduce the number of fatal cases.
«HOMER-D» is software that helps to get qualified medical advice from the doctor without leaving home.
More than 180 telemedicine programs are known in the world, and have been successfully operating for more than a dozen years.
They are constantly being modernized and simplified, which makes
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it easier for doctors to work and to obtain the necessary information for patients. Every year, WHO allocates billions of dollars to develop and improve various telemedicine areas, choosing optimal and less costly ways to connect the consumer of the medical service and the provider (the doctor).
Telemedicine geolocation projects are divided into such groups as:
• Local – the most common, since the exchange of data occurs at the level of one medical facility. All data is within its scope and is not intended for distribution.
• Regional – information is exchanged at the level of one region.
• Nationwide – data exchange between people within the same state.
• International – information is open to public use, and can be distributed between people from different countries.
Recently, cases of abduction and illegal dissemination of information about medicine have become more frequent. Fraudsters break into telemedicine systems, taking all available data, and illegally dispose of it. Therefore, the key direction in the development of telemedicine is the security of all the transmitted data, and the development of this direction is carried out by European experts.
The era of innovation has long crossed the tangible line, but not every clinic has introduced telecommunications. First of all, this is due to staff. It is difficult to find highly specialized employees responsible for correct operation of the system, as well as to guarantee the safety of all information. The second reason is the lack of funding. At the regional level, it is not possible to allocate funds so that hospitals can use computer equipment and global network. And thirdly, many doctors are not ready to move to a new level of development, preferring to work in “an old fashioned way” through personal consultations of the patient with the doctor, as well as by transferring all information in a handwritten form.
Currently, active work is underway to introduce telemedicine technologies at clinics. This process cannot occur quickly; it takes a
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certain amount of time. However, clinics in large cities can already discuss the introduction of telemedicine, as they have the ability to conduct operations under the guidance of foreign specialists who are online.
Introduction of telemedicine will have the following benefits for each individual category of citizens:
• For the patient – it will be possible to reduce the cost of travel to the doctor’s location, as well as independently choose the most experienced specialist, based on feedback on his/her work.
Queues under the doctors' offices will decrease significantly, since half of all calls to a specialist have a preventive direction, that is, treatment of the disease can be carried out without leaving home.
• For the doctor – the cost of effort and time for consultation will be reduced, and the need for additional medical staff will also be decreased. There will be an opportunity to obtain advice from experienced professionals, which will help in solving complex problems.
• For the hospital – holding consultations with foreign colleagues will allow conducting complex operations, rather than transporting the patient to another country. Furthermore, expenses for advanced training of specialists will be reduced, it can be carried out without discontinuing one’s full time work.
Introducing telemedicine technologies in the modern healthcare system, one can “kill two birds with one stone”.
Telemedicine has become a kind of response to the requirements of the present day, when every minute is important to save the patient’s life. This system helps to win such precious time, establish boundaries between cities and provide quality medical care to those who need it so much.
Chapter 4. BASES OF MEDICAL STATISTICS 1.1. Evidence-based medicine and statistics
Statistical analysis of information is a mandatory procedure of modern medicine and an integral part of evidence-based medicine.
This knowledge is absolutely necessary for planning, conducting
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and analyzing the scientific research in medicine. Effective healthcare management is impossible without processing and analyzing statistical information on the state of health, providing medical care to population, healthcare resources and their use. In their practice, doctors certainly encounter the need for statistical analysis of information they receive, therefore, the knowledge of the basics of medical statistics, as well as the capabilities of computerized statistical packages, is the key to the correct interpretation and use of research results in their work.
The basic concepts and principles of the term “evidence based medicine” (EVM) make up the dominant ideology of modern medicine.
Every patient is an individual, and each disease requires a special approach – so have been said by famous scientists in many countries for decades. The famous winged phrase states that medicine is not a trade, but an art. All this is true. However, evidence-based medicine has forced doctors to take a new look at therapeutic approaches, critically review the known canons, evaluate the effectiveness of therapeutic interventions, determine the most rational tactics in typical cases, and abandon ineffective methods of therapy. By the way, evidence-based medicine does not exclude an individual approach to each patient.
Numerous randomized placebo-controlled clinical trials in evidence-based medicine that clearly reflect effective and ineffective methods of treatment and prevention of diseases of circulation, respiration, digestion, excretion, etc. are conducted at the current stage of therapy development. The results of these studies make it possible to review the outdated views of this problem from the standpoint of evidence-based medicine and to reject ineffective and even dangerous methods of treatment.
Modern methods of therapy should positively influence the prognosis, prolong the life expectancy of the patient, reduce the development of complications and improve the quality of life.
Many of methods that are effective in scientific research have proven to have no effect in clinical practice on endpoints of the disease, and sometimes they are even dangerous.
There are two goals in the treatment of patients: to reduce
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mortality and to improve quality of life. The modern medical practice – evidence-based medicine – is a medicine based on evidence, rather than experimental research, the opinion of scientists, etc. To this end, many multicenter (more than 1000 patients) randomized placebo-controlled clinical trials are conducted to study the effects of pharmacological agents on endpoints of the disease (mortality, development of myocardial infarction, stroke, heart failure, fatal arrhythmias, and the impact on recurrence rates and hospitalization, etc.) To this end, $15.6 billion was invested in the U.S. scientific programs in 1999, $3 billion – in Germany, and $0.75 billion – in France. Therefore, to obtain the results of evidence-based medicine, it is necessary to invest large amounts of money in many countries.
Internal medicine (this name is recommended by the Bologna Process) is discussed in numerous scientific and preventive research works. Fundamental monographs, articles and manuals on these issues have been published. However, we have not come across any textbook in which the diagnosis and treatment of internal diseases would be summarized clearly, using important simple and informative diagnostic, treatment and preventive algorithms from the standpoint of evidence-based medicine.
Evidence-based medicine uses categories of recommendation and such concepts as confidence levels.
Categories of recommendations in evidence-based medicine:
Class I – Еvidence and / or consensus of experts that this diagnostic and treatment method is appropriate, useful and effective.
Class II – Contradictory evidence and / or differences of opinion as to the usefulness and effectiveness of the diagnostic or treatment method:
IIa – Expert evidence and / or opinion of utility and efficiency usefulness;
IIb – Usefulness and effectiveness are not sufficiently substantiated by the evidence and / or opinion of experts.
Class III – Availability of evidence and / or the common opinion of experts that this diagnostic and treatment method is not useful, and in some cases dangerous.