Abstract:
This deliverable 1.1 presents the work performed for Workpackage 1 of the TripleC project titled System installation and technical adaptation of workstations. It focuses on description of system installation and technical adaptation of workstations of the TripleC project. Further basic user requirements are discussed from two views. The first view concerns documentation of user requirements using ORCA in hospital cardiology units and compatibility with the national data environment, the second one concerns physicians comments and experiences.

Keyword list:
Cardiology, Electronic Patient Record, Multimedia Cardiac Workstation

Introduction

HIS in the Czech Republic and basic requirements on ORCA functioning in hospital cardiology units

Requirements on compatibility with the national data environment for information system ORCA applied in an independent ambulatory care in cardiology

ORCA installation

User requirements and experiences with ORCA

The most important meetings of the project TripleC during the first six months of its duration

This report is the first deliverable for the project I4C-TripleC. It focuses on description of system installation and technical adaptation of workstations of the TripleC project and gives the basic user requirements of the practical functioning of the multimedia computer-based patient record system ORCA in the Czech Republic. The basic user requirements are discussed from two views.

The first view is based on description of the hospital information systems in the Czech republic. For practical functioning of the ORCA in this environment it is necessary to satisfy standards further described in more details and Czech legislation rules. Documentation of user requirements using ORCA in hospital cardiology units and compatibility with the national data environment, applied to an independent ambulatory care in cardiology is described in chapter 3 and chapter 4.

The second view is the view of physicians. These are functional requirements specified on the basis of scenarios and inventories of physicians and on their practical experience with ORCA, Physicians’ comments and experiences are described in chapter 5 as well as the experience with the installation of Czech environment to ORCA.

A Hospital Information System is a system, which covers all areas of systematic entering, storing and processing of the data in a hospital. Creation of a Health Information System demands challenging labor of specialized teams (physicians), analysts, programmers and other professions. Introduction and operation of such a complex system is expensive (hundreds of thousands of millions of USD) and its lifetime is 6-12 years. The environment of the system often rapidly changes (hospital infrastructure, legislation), the data volume increases and the quality of processed data improves, due to new diagnostic technologies. That is why the selection of an appropriate HIS is so important.

In the Czech Republic there are 207 hospitals (including 23 large regional or teaching hospitals with more than 1000 beds), directly managed by the Ministry of Health. Most of the other ones are small hospitals, which are part of governmental property. Only 12 hospitals are private ones belonging to church or companies. Nowadays there are about 40 hospitals with full Hospital Information Systems (HIS) consisting of following modules: patient management system, patient care system, hospital management system, clinical information and research system. Unfortunately in the rest of hospitals there are only parts of HIS, mainly concerned with hospital accounting system. Just several hospitals (about sixty) are running isolated modules of HIS without interaction. Here are some examples: finance & billing payment from insurance companies, laboratory information system, and resource management & staff scheduling, catering, transport and pharmacy. In several hospitals there are also clinical modules for patient management systems but only for isolated units, e.g., surgery, hematology, stomatology, gynecology.

A great problem to introduce HIS in the Czech Republic is the great deficit of financial resources for investment. For example, purchasing HIS hardware and software for a large hospital with ten departments means an investment of about 8 million USD. The investment is not possible without state financial support. Also the choice of HIS for large hospitals is difficult because of the small number of competitive offers. The main difficulties concern following issues: language, law, accounting system, interface system of insurance companies, interface system for statistics, national standards for health informatics, and traditions of Czech physicians. Most foreign companies seek for the first HIS contract with the aim to test their software under national conditions. By this way the large hospitals are in fact test centers for new software with as consequence that a final solution and HIS implementation is postponed to infinity. Nowadays 8 large Czech hospitals are in such a situation and none of those hospitals have a complete HIS.

A typical specification for a HIS in the Czech Republic is:
Database environment:
ORACLE (the most frequent), INFORMIX, PROGRESS (for small applications), MUMPS (rare).
Trading names of HIS software in the Czech Republic are:
SMS (USA), AMIS, SA&S, LOGIS, STAPRO, SIEMENS NIXDORF (Germany), PCS, APP, SYSTEMA (Austria).

A typical type of HIS built in a teaching hospital has the following specification:

Health care provider Teaching hospital Ostrava-Poruba
Number of beds 1403
Number of employees 3255
Company providing software and hardware SMS s.r.o., Brno
Server and operating system 2xHP 9000/800 G50, OS HP UX
Database MUMPS: open M/SQL UNIX M Database
Number of modules 12
Number of users 220 terminals, 60 PC

The first experience with a HIS showed difficulties in training of health personnel, problems with national differences lasting 3 years, and finally the transfer to Czech laboratory information system from Ostrasoft company.

Smaller regional hospitals with hundreds of beds are in better situation. Here the investment for HIS is about 1 million USD and there is better choice of software. The above stated number of local and foreign companies can be enlarged with 10 companies, HiComp Systems Brno, STEINER, DIALOG Brno etc. Removal of national differences of HIS is easier and more successful for a small hospital.  There are 40 small hospitals with working HIS in the following cities, e.g. Breclav, Uherske Hradiste, Ceska Lipa.

Building a HIS in the Czech Republic is a local problem. First of all, to finance a HIS is a difficult task because of insufficient payments from insurance companies. On the other side, a working HIS is the main condition for a high rentability of a hospital due to possible savings of one third of expenses. From the point of view of the Ministry of Health, the main problem is a chaotic development of HIS without considering basic principles of HIS unification in the Czech Republic. All HIS should satisfy the following rules:

• support of methods and standards of the National Information System that is guaranteed by the Institute of Health Information and Statistics of the Czech Republic (data for health yearbooks, OECD and WHO);
• support of data standards for patient data transfer among information systems of health care providers;
• national codes of laboratory items for sharing of the results of measurements between physicians and other users;
• obligatory interface for statistics;
• obligatory interface for health insurance;
• obligatory interface for Financial Offices;
• recommendation of the Ministry of Health on data protection;
• data standards for communication with governmental offices.

Another problem is connecting a HIS to the national health data network, in fact to their virtual private networks for running health registers like waiting lists for organ transplantation, registers of cardiovascular interventions, national oncological registers, and registers of unwanted blood donors. A further problem is the monitoring of cost and budgets of large hospitals directly managed by the Ministry of Health. Pilot projects are conducted on the implementation of electronic (chip) health cards for citizens in Litomerice. These cards are also part of a HIS in these projects. However, this is nowadays the concept of the Ministry of Health in the Czech Republic.

Information system ORCA is based on the knowledge database with a great amount of professional information and predefined descriptive optionsthat are dynamically presented during its use. The system concept is suitable especially for physicians and their way of thinking during the health care about ambulatory patients.

In the Czech republic the work of physicians involves duties to satisfy the legal procedures in administrative routines connected with health care provided to citizens. It also covers duties to use standards from the field of healthcare, economics, statistics and public administration.

Ambulatory healthcare is provided:
a) in the healthcare facilities (policlinics, hospital, medical institution) with a superior information system working for all institution, e.g. hospital information system;
b) in an independent ambulance of a general practitioner or medical specialist or by a specialist with a proper independent information system of the ambulance.

In the following part the duties of any provider of the healthcare in an independent ambulance of a specialist are stated.

3.1 STANDARDS

1. Solely the Czech unique identification number makes personal identification of a citizen: YYMMDD/XXXX. The number is used in all health institutions, pharmacies, health insurance companies and public administration.
2. For the purpose of health documentation and health insurance accounting the coding described in the List of healthcare (services) procedures according to the law 134 / 1998 of digest. There are approximately 8000 health (services) procedures accomplished not only with point values used for calculation of payments to health insurance companies, but also by time limits for running of services, that are used in special calculations (e.g. available at the server of Czech Ministry of Health). Therefore it is necessary to make a selection for running the system ORCA in ambulatory care in cardiology.
3. To state diagnosis by a healthcare provider in a healthcare documentation the 4digit code of the International Classification of Diseases ICD10.XXX (see e.g. http://www.uzis.cz). Therefore it is necessary to make a selection of codes for running the system ORCA in ambulatory care in cardiology.
4. To prescribe drugs by a healthcare provider the list of produced drugs paid fully or partially by General Health Insurance Company of the Czech Republic (actualized quarterly) is used. Therefore it is necessary to make a selection of drugs for running the system ORCA in ambulatory care in cardiology. Apart from the list described, there is the list of drugs approved for application in the Czech Republic, that is available in the AISLP ( Automated Information System of Curative Drugs).
5. To transfer data from laboratory examinations there are used Data standard for transferring of data on patients among healthcare institutions and National classification of laboratory items to communicate laboratory results to physicians. Both standards are available on http://www.mzcr.cz. Therefore it is necessary to make a selection of laboratory standards for running the system ORCA in ambulatory care in cardiology.

3.2 METHODS AND DATA INTERFACE

1. To transfer data between General Health Insurance Company and healthcare providers there are data interfaces for the following parts: I – coding systems, II - individual documents, III.- special interface. Other insurance companies accepted stated interfaces too. Therefore it is necessary to make a selection of laboratory standards to run the system ORCA in ambulatory care in cardiology.
2. To issue documents by health care providers it is obligatory to use Methods to acquire and transfer documents of the General Health Insurance Company, that is valid also for other health insurance companies. The part of these method are electronic versions of documents, e.g. for accounting of ambulance healthcare, to provide patient with healthcare benefits, prescriptions, order for examination, order for laboratory examination. Therefore it is necessary to make a selection of electronic versions of documents to run the system ORCA in ambulatory care in cardiology.
3. Any ambulance has the duty to provide the following health statistics documentation:                                                                                                 Disciplinary document on ambulatory activities per year (number of examinations, patients etc.)

Document on economics of healthcare institution per year (payments of insurance companies, costs of working activities etc. )
Document on health workers and components of wages in health care sector per half of the year according to the law no.1 / 1992 of digest.                   Reports for the Register of Healthcare Institutions (establishment, changes, end ).
4. There exist a tax declaration of healthcare institution operator that requires collecting data during all the year activities. Therefore it is necessary to assure collecting all required data run the system ORCA in ambulatory care in cardiology.

Currently, there are three workplaces in the Czech Republic, where the Orca system has been installed, i.e. University Hospital Prague, Hospital Caslav and EuroMISE Center.

Technical components in all workplaces consist of one SQL server, network infrastructure and several workstations. Servers as the main part of the system were selected from broad choice of offers. The winning offer - server Dell PowerEdge2300 - was then installed at all the three places. Servers have the following specification: Pentium II 400 MHz, 128 MB RAM, 9 GB RAID level 5, DAT DDS-3. The servers are running Microsoft Windows NT 4.0 and MS SQL server 6.5. The network infrastructure in all the three places is based on Ethernet 10Base-T or 100Base-T.

University Hospital Prague has installed Orca with workstations in the following departments, where Orca will be used: ECG, ambulatory care in cardiology, ergometry, department of radioisotopes, consultation and presentation room and physician’s rooms. The ECG equipment is planned to be the ECG device from CardioControl.

Hospital Caslav is using four workstations, acute ambulance of department of internal medicine – working 24 hours per day, intensive care unit, bed division, where are patients moved after stabilization in intensive care unit and ambulatory care in cardiology.

EuroMISE Center is using two workstations for data collection in a preventive cardiology research unit, one Pentium II/350MHz, 64MB RAM with Czech Windows 98, second with paneuropean Windows 95. Other workstations are used by researchers for further data processing software development and ORCA management. These workstations are running either Czech Windows98 or paneuropean Windows95. The last part of computer equipment, which is partly used for TRIPLEC project is the computer laboratory, where 12 computers for training of health personal and one computer for ORCA presentation.

Fig. 3.1. – Installation in Teaching Hospital, Prague

Fig. 3.2. – Installation at EuroMISE Center

Fig. 3.3. – Installation in Caslav

5.1 Physicians’ comments and experiences
 

• When prescribing the medication the physician is forced to fill in the duration of the drug therapy. In many cases it is not possible to estimate the therapy duration.
• When filling in the patient data the physician also can state the date of the patient’s birth. When the physician clicks with the mouse in the appropriate field, the text cursor appears at the end of the birth date input box. The physician has to move the cursor at the beginning to be able to fill in the box.
• Czech physicians also would welcome if the data from the previous visit of the patient could be copied simply to the current visit and physicians only might change these data. It means to use a copy of contents of the previous clinical narrative as a basis to enter the current findings.
• When filling the patient data in patient administration, there should be the possibility to write the occupation by hand (not only to choose one of ten offered).
• The diagnosis description allows only 50 characters. This is not much for detailed description.
• Generation of reports – physicians need report generation for test requests, report generation with previous history, new diagnoses, and current clinical narrative. In general, the best way is to have a possibility to generate report with custom selection of items from ORCA database
• We would like to extend medication definitions with an "Add-to-list" button so fields can be edited to enter the next medication.
• In family history we need to specify the relationship to which the disease applies (father, mother…)
• In Czech Republic, each person has a national ID. ORCA is designed to use institution specific identification numbers. The possible solution is to enter a virtual institution named “National identification number” and use it for identification purpose.
• When creating a new event, it is desirable to choose the specialization and the department via a listbox.
• The drug prescription field where the medication definition is selected should not be case-sensitive.
• In chapter Medication – in drug prescription physicians are not happy to fill the time of the application and number of repeated applications. What means total number of prescriptions? Is it the number of receipts or number of drug packages? It is not possible to open window with previous medications.
• Sometimes, certain drugs are removed from the market. Although it is not possible to delete a medication definition that has been applied in a drug prescription, it must be possible in the overview window to mark certain definitions as obsolete, so they no longer appear in the drug prescription window.
• It is very important to have the WHO-list of diseases in Orca. This could be an extra listbox in Diagnosis.
• It is necessary to add the Czech Republic and Slovakia to the list of countries offered by the ORCA. Obviously the best solution is to state all countries in ORCA.
• The list of professions is not complete and it is not possible to add a new profession not implemented in the offered list. The list of clinics and specializations should have possibility to be enlarged or modified. This is valid for every list, where adaptation to local conditions is necessary. In real situations all these lists should be centrally supervised to prevent misunderstandings of data from different workplaces.
• Laboratory data in the cells are shown in red when the data are abnormal. It would be very helpful if values above normal appear in red and values below normal in a different color.
• What does it take to import text files of a certain event type. Is it possible to import radiology reports as free text with an event type like ‘chest X-ray.
• If you do not have laboratory equipment connected to ORCA, you are not able to enter the data manually. Therefore it is very important to make a module for manual laboratory data entry.
• Will physicians be allowed to use the ORCA system after they master the system and the project will be over? It is necessary to answer their question to motivate their effort to study the new ways of data collecting.
• Previous history allows only 255 symbols of the free text. It is not sufficient to describe patient history.
• Patient history - physicians need to enlarge the incorporated text with other possibilities and make their own databases of questions on patients. For example concerning the nervous systems there are no offered items.
• In part Intoxication, there is a question about the time (day or week), but there is no possibility to choose measurement scale and type of alcohol.

• The ORCA version 1.3 is currently very unstable when using Czech translated knowledge base. The client program gives the error messages when running the program randomly (e.g. when browsing the database, when prescribing medication etc.). Sometimes the error message causes abnormal termination of the client program and therefore maybe the loss of the data. For practical use we have had to uninstall the Czech terminology database and switched back to the original database in English, so we use temporarily Orca with Czech menus (which are working perfectly) and English knowledge base.
• During ORCA installation we had severe problems when installing ODBC3.5 on some machines – Pentium HP Vectra and K6/200 with Octek Rhino12+ motherboard, with paneuropean Windows95. On these machines we had to configure ORCA via BDE database interface instead of suggested ODBC. It is probable that this problem can appear again on some other machines.
• When choosing language in the main menu, the language is changed in all but the currently active window with clinical narrative.
• ORCA is connected to an MS SQL server. In principle, it is also possible to interconnect with other databases (e.g. Sybase), which we should prefer.
• At this moment the Czech and Slovak hospitals and EuroMISE center are able to enter only data derived from the knowledge tree to ORCA database. There is no tool for extracting the entered data from knowledge tree to some tabular form for further processing. Due to importance of such tools for research purposes EuroMISE Center is working on development of a set of tools for manual entering of laboratory data into ORCA and extraction of them into a relational database or text file.

6.1 Bratislava 23.10.1998

Main organizer : J.Hatala, Slovak Cardiovascular Institute
Participants: Erasmus Univ. Rotterdam, Cardio Control, EuroMISE Center, Caslav hospital, University hospital Prague, Slovak Cardiovascular Institute.

After the ORCA presentation and discussion about the program the timetable was prepared. The most important tasks to be solved are:
 

• The knowledge base translation and the translation of the screens – will be done by the Czech and Slovak side and will be implemented to ORCA by the Dutch side.
• Slovak and Czech partners will prepare networks, PCs and server.
• The parameters of the server  (minimum configuration: 64 MB RAM, 10 GB SCSI HDD, Ethernet card 32 bits, CD-ROM, SCSI DAT backup tape unit) and software (NT server 4.0, MS SQL server 6.5). Server will be A brand (Dell, HP, …). Preferably Win95 clients will also be A brand.

6.2 Caslav 24.11.1998

Main organizer: H. Grunfeldova, Caslav hospital
Participants: EuroMISE Center, Caslav hospital

 Programme: a guided tour through the hospital, with special attention to the places, where ORCA will be used (there will be 5 ORCA clients – cardiology, intensive care unit, admission room, internal department, biochemistry department); discussion about the ORCA hardware and data processing

Discussion:

• Discussion about the translation of medical terms into Czech (was done by the Faculty hospital Prague).
• Discussion about the server, its configuration. EuroMISE contacted several suppliers, they have sent their offers. The best offer seems to be from DELL Computer Prague. Two more weeks for collecting information about the servers until the final decision.
• Preparation of the workshop in Prague in December.

6.3 Prague, Faculty hospital 19.10.1998 and 12.11.1998

Main organizer : J. Peleska, University hospital Prague
Participants: EuroMISE Center, University hospital Prague

 The participants evaluated the network in the hospital and discussed the connections for ORCA clients. Two possibilities were suggested. The accepted one contains seven connections (ECG/ECHO, cardiostimulation, cardiology emergency department, ergometry, isotope department, computer center, and physician office).  The server will be behind an alarm.

6.4 Prague, EuroMISE Center 14.12.1998

Main organizer : J. Zvarova, EuroMISE Center Prague
Participants: EuroMISE Center, University hospital Prague, Caslav hospital

During the workshop the main features of  ORCA were presented in a lecture and a movie. A discussion about the possible use in the future, about the data processing and hardware followed.