Abstract

This paper describes the results obtained by using the HEALTH.one Electronic Healthcare Record(EHR) software at Greek Primary Care institutions. It was found that the use of HEALTH.one greatly facilitates every day practise. The features of the software used and the customisation made for the Greek Primary Care institutes are also described. The results of the statistical analysis of the EHR database of Amorgos island (in Cyclades) are presented as an example.

Objectives

The Medical Physics Laboratory of the School of Medicine of the University of Athens has installed an Electronic Healthcare Record (EHR)Software package at the island of Amorgos, in order to facilitate the extensive study of the local population and help the local doctors in enhancing the quality of the provided services.

Methods and Materials

The HEALTH.one ( ¹ EHR software package has been used. HEALTH.one is a general purpose package, which can be customised to meet the needs of individual doctors or institutions. The records are structured and stored according to the GEHR architecture ^{2 3}. Each record may contain multimedia objects (still or moving images, EKGs etc.). HEALTH.one allows the analysis of both individual Healthcare records and the entire population recorded. Each record is stored in an individual file, which allows its easy exporting and further processing (e.g. transferring it to remote sites). HEALTH.one also allows the construction of drugs’ database from which prescribed drugs from the physician can automatically be entered in the Healthcare record and printed.

The Medical Physics Laboratory (MPL) of the School of Medicine in the framework of its Telemedicine Services activities [1], in co-operation with the A’ Internal Medicine University Clinic at the Laikon General Hospital and the A’ Paediatric University Clinic at the Aghia Sofia Paediatric General Hospital have customised HEALTH.one in order to meet the needs of primary care physicians. Prototype records (sequences) have been created for General Practice, Paediatrics and Cardiology. Each prototype record is composed of the following parts:

1. Basic Medical Information. This parts holds information related to the family history, the personal history, the way of life and possible allergies of the patient. Lists containing the most important values have been created for each of the above fields (containing, for example, the most important diseases that might be found in the personal history of the patient).
2. History. This part holds the history of the current disease of the patient, in free text from.
3. Systems’ review. This parts holds the results of the systems’ review. Associated lists with the most important values exists for every system.
4. Physical Examination. The findings of the physical examination are stored here. Associated lists with the most important values exists for every system.
5. Basic Laboratory Tests: The results of basic laboratory tests, available in primary care institutions are stored here.
6. Paraclinical examinations. This part holds ECGs and X-rays attached to the record.
7. Follow up. The follow up plan of the patient is stored here.
8. Prescriptions. Prescribed drugs are stored in this part. HEALTH.one maintains a database of the drugs that are most frequently used in primary care. The database has been created by MPL in cooperation with the Health Care Centres participating in the VSAT Project.
9. Telemedicine. This part holds information exchanged during Telemedicine sessions (questions of the local doctor, answers of the consulting doctor, etc.)

In order to facilitate the follow-up of chronic patient, sequences have been created for patients suffering from hypertension and diabetes mellitus, in co-operation with doctors of the Health Care Centre of Aliveri. Sequences concerning bronchic asthma, psychiatric diseases and injuries are under development.

Although basic laboratory tests results have been included in the prototype records, the recording of the results of more specific examinations has been made possible, via a special software module created by HDMP.

MPL, in co-operation with HDMP, has modified HEALTH.one in order to allow the attachment of EKGs to the EHRs [2]. The Cardio Control( EKG machine and Cardio Perfect( software package are used to acquire, view and process EKGs.

MPL has extended HEALTH.one, in order to allow exporting and importing of Healthcare records together with selected attached objects (X-rays, EKGs, etc.). Proper modifications have been made in order to allow the transfer of exported records via PSTN lines with the use of modems and via VSAT and Internet links from rural sites to tertiary hospitals of support, in the context of the VSAT [3] Project.

MPL has also created a ‘summary’ software module, which processes Healthcare records and displays only the positive signs, and other significant information and data concerning a patient. This has been insistently requested by doctors participating in the VSAT project and has been proved to be a very useful feature.

Concerning the analysis of the Healthcare records, HEALTH.one provides a script language, which allows the creation of multi-purpose analysis scripts. Every item contained in an EHR can be processed in multiple ways, in order to extract the required information. MPL has created analysis a large number of analysis scripts that allow the selection of certain categories of patients which can be used in every day practise, facilitating the management of patients. Examples include children or adults that need to follow a vaccination programme, women that need to undergo a mammography examination, women that need to undergo a smear Pap test. Persons falling into the above categories are identified and invitation notes for examinations are printed automatically by the software and then mailed.

Finally, a Decision Support System (DSS) is under development at MPL implementing the client/server architecture. The Decision Support Server uses the Dynamic Data Exchange protocol to communicate with the client (i.e. the EHR software). The latter provides the server with information related to the patient and uses the results of the processing of the DSS to intelligently guide the physician during the data entry procedure ⁴. The initial application to interpret spirometry data, has been accomplished with the guidance of expert Pneumologists ⁵. of the DSS software uses an Expert System specialised in the interpretation of Spirometry data.

Results and Discussion

Server versions of HEALTH.one have been installed in the Health Care Centres in the island of Naxos and Milos in Cyclades in Central Aegean and of Plomari in the island of Lesvos in Eastern Aegean. A standalone version of HEALTH.one has been installed in the island of Amorgos, also in Cyclades, as well as in the three supporting hospitals that participate in the VSAT Project (Laikon General, Onassis Cardiac Surgery Centre, Aghia Sofia Paediatric). The installation of server versions of HEALTH.one at the regional hospital of Syros and the Health Care Centre of Mykonos is currently being negotiated. In the context of the Telecardiology Programme TALOS ⁶ [4][5], HEALTH.one is expected to be used in the second phase due to start by fall 1996, in all the participating five Health Care Centres.

As an example of the HEALTH.one capabilities, the results obtained in the island of Amorgos, is presented. The Healthcare records of all the 291 inhabitants of the municipalities of Arkessini and Vroutsi on the Amorgos island have been recorded. The creation of the records of all the 1600 inhabitants of the island is estimated to be completed by the end of summer 1996. The preliminary analysis of the population (based mainly on the family and personal history of the inhabitants) gave the following results:

The population studied consists of 291 persons, (248 adults and 44 children). 145 are men and 146 women.

Figure 1 - Distribution of ages

40 persons were found to suffer from hypertension (13,4% of the population). 14 of them are men (4,8% of the population) and 26 women (8.9% of the population). Hypertension was found in the family history of 14 women and 4 men.

Figure 2 - Age distribution of persons suffering from hypertension

20 persons were found to suffer from hypercholesterolaemia (6,9% of the population. 8 of them are men (2,7% of the population) and 12 women (4,1% of the population).

Figure 3 - Age distribution of persons suffering from hypercholesterolaemia

Diabetes mellitus was found in 9 persons (3,1% of the population), 2 men (0,7% of the population) and 7 women (2,4% of the population).

HEALTH.one analysis scripts were used to detect the co-existence of the above diseases with other. The results of the analysis were the following:

4 persons were found to suffers from coronary disease (1,4% of the population). All of them are women, older than 60. Three of them suffer from hypertension, while two of them also suffer from hypercholesterolaemia.

5 persons have had a stroke (1,7% of the population). Two of them are men (0,7% of the population) and 3 women (1% of the population). All of those persons are older than 60. Two of them suffer from hypercholesterolaemia or diabetes mellitus.

Finally, cancers of various types were found in 7 persons (2,4% of the population). Epilepsy was found in 3 persons and high occurrence of bronchic asthma was found in members of 3 families.

Primary physicians find that HEALTH.one facilitates their work significantly, as well as the follow-up of the patients. The management of patients suffering from hypertension, diabetes mellitus and bronchic asthma has been significantly facilitated.

As a general conclusion, the introduction of the EHR technology in the rural areas of Greece has proved to be very beneficial. It facilitates the follow up of chronic patients and allows better processing of the patient data, which may lead, to interesting conclusions about the Healthcare conditions of the local population. Furthermore, it can facilitate the implementation of proper Telemedicine services, which can be seen as the only real opportunity for improving locally offered primary Healthcare services of assured quality.

References

1. D. Sotiriou, Telemedicine on Greek Islands, 9th Microgravity Summer School on Space and Telemedicine, Schnellenberg Castle, Germany, July 4-7, 1995
2. S. Mavrogeni et al., Tele-cardiology Services in the Aegean Islands, paper presented in the International Conference on Telemedicine and Telecare via videoconference satellite link from the Sismanoglion General Hospital, in Athens, November 8-9, 1995, London
3. Project ‘VSAT Network for Telematics and Healthcare’, 4nd Progress Report, April 1996
4. D. Sotiriou ‘Telemedicine Services in Greece’, invited presentation in the the World Congress of Telemedicine, Toulouse, November 30 - December 1, 1995
5. A. Kontaratos et al., TALOS: A system providing Tele-cardiology Services in the Aegean Islands, paper presented in the World Congress of Telemedicine, Toulouse, November 30 - December 1, 1995
6. A. Ginis, S. Deftereos, D. Sotiriou, “Creation of Electronic Healthcare Record of the Inhabitants of the Municipalities of Arkessini and Vroutsi”, paper presented in the 8th Panhellenic conference of Greek General Practitioners, April 17-21, 1996, Greece (original title, “Δημιουργία Ηλεκτρονικών ιατρικών Φακέλων των κατοικών των κοινοτήτων Αρκεσίνης και Βρουτσίου Αμοργού”). The paper has won the Honorable Mention of the committee of the "Professor D. Ikkos award"
7. A. Aessopos, E. Arampatzi, S. Deftereos, K. Stoumpos, D. Sotiriou, “Electronic Healthcare Record Sequences for Primary Care”, paper presented in the 8th Panhellenic conference of Greek General Practitioners, April 17-21, 1996, Greece (original title, “Ακολουθίες Ηλεκτρονικών Ιατρικών Φακέλων για την Πρωτοβάθμια Φροντίδα Υγείας”)

¹HEALTH.one is a copyright of HDMP SA, Brussels

²The current version of HEALTH.one is not fully compatible with GEHR. A full GEHR compatible version is scheduled for beginning of March 1996

³The GEHR project, CEU 3rd Framework Programme Project (A2014), 1992-94

⁴The DSS system is based onn the Expert System tool “FuzzyCLIPS” (CLIPS is a copyright of NASA, FuzzyCLIPS is a copyright of the National Research Council of Canada)

⁵Ch. Melissionos, Asst. Prof. of Pneumonology, private communication

⁶TALOS a Project providing Telecardiolgoy services from the Onassis Cardiac Surgery Centre in Athens to the Aegean islands of Naxos, Milos, Santorini, Mykonos ans Skiathos

A. Ginis, Public Surgery of Arkessini, Amorgos Island
S. Deftereos and D. Sotiriou, Medical Physics Laboratory, School of Medicine, University of Athens
Τελευταία αναθεώρηση : 1/1/2006