Dr Mario Veloso
CENTIS
Rua da Junqueira, 126
1300 Lisboa
Portugal
Tel +351 1 362 23 10
Fax +351 1 363 34 09
email mario.veloso@individual.puug.pt
Mr Colin Gordon
Information Dept.
Royal Brompton Hospital
Sydney Street
LONDON SW3 6NP
UK
tel +44 171 351 8706
fax +44 171 351 8743
email shjaacg@ucl.ac.uk
There is a wide consensus between healthcare professionals that unacceptable
delays occur in the implementation of new standards for 'best practice'.
This problem is common to the everyday practice of healthcare professionals
throughout Europe and results in poor quality of care and wasted resources.
PRESTIGE addresses this problem by the use of clinical guidelines and
protocols which have been shown to be effective in improving the healthcare
process in terms of quality, efficiency and outcome.
The project will use healthcare telematics technology to assist in
the generation, dissemination and routine application of guidelines, and
thus will bridge the gap between medical research and everyday clinical
practice. To support the use of clinical guidelines and protocols, PRESTIGE
will verify and pilot a set of integrated technologies that build on experience
and expertise gained during the 1991-94 AIM programme together with other
leading European professional, governmental, clinical, industrial and specialist
participants.
PRESTIGE is structured into several actions addressing major healthcare
specialties, including cardiothoracic disease, neurological disease, diabetes
and general practice. Substantial user involvement has been assured through
national and specialist user groups and renowned healthcare centres.
PRESTIGE will make available a common pool of interoperable generic
technologies to these user groups and clinical sites using the following
technologies: architectures for multimedia patient records
· There is a wide consensus, supported by research, that unacceptable delays occur in the implementation of new standards for best practice healthcare that are derived from research evidence. This problem is common to the everyday practice of healthcare professionals throughout Europe.
· It is widely agreed, and has been confirmed by research, that clinical guidelines and protocols developed by sound methods based on evidence are an effective means to improve healthcare process in terms of quality, efficiency and outcome.
· Evidence further indicates that information (telematics) technology can assist the generation, dissemination and routine application of guidelines by providing practitioners with patient-specific advice and alerts. PRESTIGE is a project to address this need within the Fourthamework for Telematics.
PRESTIGE is being proposed as the main effort in this programme to implement health telematics for clinical guidelines and protocols and as such has backing from many European healthcare societies and user groups.
Our analyses have included requirement investigations by projects in the AIM Exploratory and main phases (1990-94), and analyses of the views of professional associations and colleges, consensus specialty associations, health service purchasers and health service research. Investigation within the AIM programme of user needs for telematics for clinical protocols and guidelines was also undertaken through the EPISTOL study [Barahona and Christensen eds., 1994) and a special AIMCOM conference [proceedings published in Gordon and Christensen eds., 1995], many of whose contributors are members of the PRESTIGE consortium. Organisations whose policies and goals have been studied include, among others, the Cochrane Collaboration, The French Federation of Cancer Centres, the Dutch College of General Practitioners, the UK Royal College of General Practitioners, the R&D Directorate of the UK National Health Service, the Canadian Medical Association and the USA Agency for Health Care Policy Research. The key conclusions, in terms, of needs, are summarised in the display box above.
There is convincing evidence that these needs are closely linked to the need for the electronic patient record as a support for effective co-operation in healthcare, continuity of care and efficient use of resources. The functional requirements for the patient record identified during the AIM programme included the development of the record as a basis for co-operative care planning. Both in the hospital and the primary care settings, there is a need for patient-centred records that can be shared by different professionals and can provide, through the services of act management, a basis for the efficient collaborative delivery of care. In all countries and specialities, the ability to implement such patient records is impeded to a greater or lesser extent by the limitations of current clinical terminologies and coding systems, which are poorly adapted for this purpose and mutually incompatible: new terminology services to extend and supplement these resources are therefore going to be urgently required in the next few years.
As the project title (Patient REcords Supporting TelematIcs and GuidelinEs) indicates, PRESTIGE will deliver the technical extensions to existing patient record technology that permit guideline support as a functional extension of the record. In this, specific, sense, the project addresses to Task HC 1.2: Integrated Healthcare Record Architecture.
The following "Recommended Actions" for the 4th Framework were produced by the AIMCOM Conference, Health Telematics for Clinical Guidelines and Protocols (proceedings edited by C Gordon and J P Christensen, IOS Press 1995: p15).
1. Investigation of the healthcare business organisation and re-engineering implications of embedding computer-aided guideline use in clinical practice.
2. Inclusion of guideline support in infrastructure provision requirements for health telematics, in terms of:
the electronic patient record;
medical terminologies and coding systems;
knowledge and data communications.
3. Action to establish consensus on guideline knowledge representation methods and models, with the objective of preparing subsequent standards proposals in this field.
4. Organised collaboration between healthcare telematics and clinical communities on guideline development and dissemination methods, including links with:
Cochrane Collaborations;
Guideline authoring bodies;
Clinical professions.
5. A programme of clinical trials of computerised guidelines, within the context of an overall healthcare telematics quality methodology, and of a total quality management approach to healthcare delivery.
Telematics support is needed for the use of clinical guidelines in many healthcare sectors and specialities. This project is designed to address a representative set of major user groups by means of a shared set of generic technologies. The overall project structure is shown in the diagram below. The activities in cardiology, cancer, diabetes and neurology will implement support for computerised guidelines in both GP and hospital settings, in each case addressing problems of co-operative and shared care between these sectors. The project has particularly strong representation (medical, industrial and technical) in primary healthcare: a specific primary care sub project will manage large-scale user applications in four countries (Italy, Finland, UK, Netherlands), and cover professional needs and dissemination services on a European basis. (In view of other likely major initiatives in the cancer sector, the cancer activity has been limited in PRESTIGE to a technology assessment and requirement study by a major national user group, the Royal College of Radiologist (UK)).
In all implementation settings, the application involves linkage of new technology to existing ("legacy") products and systems. In primary care this integration will be conducted with the involvement as industrial partners of several of the major European systems suppliers, leading to a rapid, large-scale roll-out of the resulting product at the end of the RT&D. In the hospital sector, the technology will be integrated initially into tertiary hospitals with strong internal It resources, with the participation of several HIS product suppliers. These suppliers will then incorporate these results into a set of widely reusable HIS components, subsystems and integration products.
The project will conduct its own internal technology transfer, training, procurement and requirements analysis services. It is anticipated that these services, which are indispensable to the successful application of this technology, will form an additional set of subsequent project results. Interoperability, open system and reusable tools are fundamental to the project design. The standard component interfaces and functional specifications and the data and protocol knowledge models used will be placed in the public domain.
By "telematic support for the support of clinical guidelines and protocols", we mean:
· authoring and dissemination tools, assisted by a terminology server, allowing clinicians to develop structured electronic versions of clinical guidelines and protocols, in a standard format that can be used with telematics tools to assist clinical practice. These tools will also allow national and international guidelines to be tailored and adapted to local organisational and resource contexts.
· Extensions to existing electronic patient records, assisted by a terminology server, to allow fuller use with clinical guidelines to record the application of guidelines as individual patient care plans, and to allow patient-specific computerised prompts and reminders based on guideline knowledge.
· User interfaces to allow selection and inspection of a guideline during the patient consultation, to allow protocol-guided entry of structured clinical data (assisted by a terminology server), and protocol-assisted planning, co-operation and communication (e.g. generation of referral datasets and service requests; creation and communication of multimedia documents).
· Inference services allowing the implications of a guideline to be determined in the specific circumstances of an individual patient record (including event- and data- driven watchdog and reminder services).
· Facilities for both concurrent and retrospective audit, by automatic collection of quality indicator datasets.
· Act management services to permit multidisciplinary co-operative care plan execution, including facilities for inter-departmental service requests and data sharing.
The guidelines that will be implemented (all with the active support and endorsement of responsible research and professional organisations), are summarised, with domain, location and related application features, in the table below. As may be seen, the guidelines cover a large proportion of major acute and chronic health problems affecting the European population.
Clinical problem Sector Implementation Features
sites
(minimum)
Cervical screening PHC NL, IT Nation-wide standard
implementation (NL); regional
implementation (IT)
Influenza PHC NL, IT Nation-wide standard
vaccination implementation (NL);
regional implementation (IT)
Generic prescribing PHC UK, NL, IT .
Diabetes management PHC, UK, PT, DE, Implements world consensus
Hospital NL, SW, IT guidelines of WHO DiabCare.
Angina management PHC, UK, DE Full coverage of referral chain
and co-operative Community, (1/2/3 sectors). Multimedia
care Hospital telematics.
Anticoagulant PHC, DK County-wide national project (DK)
therapy (ACT) Hospital
Asthma diagnosis, PHC, UK+other Full coverage of referral chain
manage-ment and Hospital (1/2/3 sectors). Link to
co-operative care national guideline initiative
(UK) Teleconferencing.
Epilepsy diagnosis, PHC, PT,DK Telediagnosis using multimedia
investigation, care Hospital telematics.
planning
The project applications demand and involve state-of-the-art tools and methods in addition to the runtime technology components. Full consensus exists on these needs and the skills and resources are available within the consortium for their delivery.
· All implementations will be prepared by analysis and modelling of the local healthcare business environment (using modelling methodologies developed in DILEMMA, ISAAC and SHINE), and will investigate business process re-engineering aims, effects and implications of guideline implementation.
· All implementations will use the PRESTIGE tools to create and adapt computerised versions of guidelines appropriate to and acceptable in the target user environment.
· All implementations will develop validation metrics and QA indicator datasets (process and outcome) as frameworks for technology assessment to be carried out in the Validation phase.
Active local user involvement will be obligatory in all these implementation processes.
One partner and site (Nijmegen University and Hospital) will lead an activity to verify methods and tools for adapting and disseminating guideline material within a multi-specialty organisational setting.
An important final stage in implementing telematics for clinical guidelines comprises the services for access and sharing of computerised guideline materials. World Wide Web pages will be implemented making the text and standard model-compliant knowledgebase formats of clinical guidelines available in the public domain. The PRESTIGE dissemination tools will be made freely available to the clinical organisations to allow central updating and local tailoring of the guidelines. The public availability of the DILEMMA/PRESTIGE protocol and Guideline model will permit all telematic systems suppliers' products to exploit the WWW materials - thus creating an important new added-value market for such products.
Partner Main Activities
Egas Moniz/CENTIS, Lisbon Prime Contractor, Technical and Administrative
Management. Leader of neurology sub project
Royal Brompton Hospital Leader of cardiology shared care sub project.
Protocol management technology; technology
integration site
Project management
IIRIAM, Marseille Leader of Generic Technology sub project (WP06).
RICHE-based industrialisation of project technology for protocol
and act management in hospital information systems
Medical Informatics Group, Manchester University
Leader of WP05: Common Services. Integration and
application of GALEN terminology modelling services and servers.
WHO DiabCare (Munich and UK) Leader of diabetes sub project
LHV Leader of primary healthcare sub project. User Groups
manager. Lead Dutch regional/national implementation
validation of telematics for guidelines in primary
care.
Associate partner: NHG.
SAPHIS, Paris Generic technology: architecture and modelling.
RICHE-based industrialisation of project technology for protocol
and act management in hospital information systems
Siemens Nixdorf Information Systems Ltd
Business process re-engineering, exploitation planning and security.
BULL France Enhancement of Act Management server software.
RICHE-based industrialisation of project technology for protocol
and act management in hospital information systems
NHS Information Management Centre
Protocol and guideline modelling, business modelling
and Act Management technology
AAH Meditel Ltd Telematics for clinical guidelines in primary
Cendata healthcare:
VVAA-RAET integration of PRESTIGE technology with commercial
THETA primary care systems
Danish Hospital Institute Implement and verify neurology (EEG telediagnosis)
Gentofte Hospital and cardiology (ACT) telematics applications
Vision Centre,
Rigshospitalet
DANTEC
UNINOVA, Lisbon Medical AI expertise applied to protocol-based
resource management
Sowerby Unit, Newcastle Telematics for primary care guidelines:
requirements, implementation, verification, QA.
Nijmegen University Protocol Authoring Tool (GAUDI) and services; GALEN terminology
modelling services and servers; leader of QA workpackage.
THETA, Florence Application of project technologies in primary care;
product implementation and verification.
Leadre of WP04: technology procurement
Modena Local Health Unit Regional/local implementation and verification of
Funen County, Denmark telematics for guidelines.
Health Regions of Lisbon
and Tejo Valley, Portugal
Linköping University Quality assurance and terminology modelling services
The Mainz Heart Center at Johannes Gutenberg University
Mainz Implementation of PRESTIGE technology within a
cardiology quality management programme
(ECARTE-QUANTUM_STEP)
Royal College of Cancer sub project : technology assessment
Radiologists and requirements analysis for national clinical
oncologists user group.
· PRESTIGE proposes to act as the major - though not only - Healthcare Telematics project in this Framework to address the subject of telematics for clinical guidelines and protocols. The consortium has been constructed to fulfil this role.
· The consortium includes the majority of contributors to the AIMCOM Conference "Health Telematics for Clinical Guidelines" (April 1994; proceedings published, under the same title, C Gordon and J P Christensen eds., IOS Press 1995).
· The consortium includes the authors of a Generic Guideline and Protocol Model, developed in the DILEMMA project of AIM.
· The Consortium includes experts in assessment of clinical guidelines implementation and the application of clinical trials evidence in guideline development (R Grol; J Grimshaw; N Freemantle, Cochrane Centre for Effective Clinical Practice; A Liberati, Italian Cochrane Centre).
· The consortium includes as members, sponsors organisations and associate partners for guideline development (NHG, Netherlands; WHO DiabCare, Munich) as well as leading organisers of clinical trials (A Rickards, cardiology; D Mant, primary care).
· The consortium includes industrial expertise (ICL Ltd.) in issues of Business Process Re-engineering, recognised as important in the effective implementation of clinical guidelines.
· The consortium includes experienced members of the international health telematics standards community (CEN TC251, Arden Syntax, Riche, NHS CBS).
The consortium includes members of the AIM projects AFASIA, DIABCARE, DILEMMA, ESTEEM, GALEN, HELIOS, ISAAC, MARGOT, NUCLEUS and SHINE. It includes the project managers of five of these projects (DIABCARE, DILEMMA, ESTEEM, GALEN, ISAAC). Co-operative relations between these partners were developed in the Concertation process of AIM, notably in project Lines 1 (Standardisation and Coding) and 3 (Knowledge-Based Systems); through the 1993 AIMCOM Conference on the Electronic Patient Record, and through the AIMCOM Conference "Health Telematics for Clinical Guidelines" (cf. above).
The consortium is a balanced, well integrated grouping of clinical, academic and industrial partners with internationally eminent participants in each category. The following is an incomplete summary of the project's strengths:
· Primary Care Informatics Research Centre: Sowerby Unit, Newcastle University (I Purves, I Grimshaw).
· University Medical Informatics and medical KBS research centres: Linköping (O Wigertz), Manchester (A Rector), Nijmegen (P de Vries Robbé, P Zanstra), VTT.
· International European hospital IT suppliers with telematics and security expertise: ICL Ltd (P Cooper), BULL France (Cl. Meyer), IIRIAM (H Kanoui), Saphis (B Frandji).
· Primary Care Informatics Suppliers: Cendata, MicroHis (NL); AAH Meditel Ltd. (UK; G Hayes), THETA (IT: S Bertelli).
· Expertise in healthcare protocol and business modelling: NHS IMC (P Nicklin, I Herbert).
· Tertiary and University Hospitals with R&D expertise: Egas Moniz, Lisbon (M Veloso); Royal Brompton Hospital, London (A Rickards, D Pitty); Gentofte Hospital, Copenhagen, Linköping U.H. ; Nijmegen U.H.
· Knowledge-based Systems and AI: UNINOVA (P Barahona), IIRIAM.(H Kanoui), Royal Brompton Hospital (C Gordon).
· Quality Assurance research: Nijmegen (R Grol).
· National GP user association: LHV (plus other sponsoring bodies: NHG; UK RCGP, UK BCS Primary Health Care Specialist Group ).
· World expert quality and knowledge centres in diabetes: WHO DiabCare (K. Piwernetz); clinical trails review : Cochrane Collaboration (York, Milan); cardiology quality management and imaging: Mainz U. H. (R. Brennecke).
· Health Service Research and IT Management Consultancy: Danish Hospital Institute (S Vingtoft); NHS Information Management Centre
European Health Telematics Observatory
European Telematics Observatory
CONCORD: Your directory to the TELEMATICS Applications Programme