P. Degoulett, F-C. Jean\ Review Paper C. Safran2 Multimedia : 1Broussais University Hospital and Paris VI University, Paris, France Electronic Assistants for Health­ 2Harvard Medical School, Center for Clinical Computing, Boston MA, USA Care Professionals

Abstract: The increasing costs of health care and the economic reality has produced an interesting paradox for the health professional to perform more clinical work with fewer support personnel. Moreover, an explosion of the knowledge-base that underlies sound clinical care not only makes effective time management critical, but also knowledge management compelling. A multimedia is an electronic assistant for the busy health professional that can help with administrative tasks and give access to clinical information and knowledge networks. The multimedia nature of processed information reflects an evolution of medical technologies that involve more and more complex objects such as video sequences or digitized signals. Analysis of the 445 Medline-indexed publications for the January 1991 to December 1994 period, that included the word "workstation" either in their title or in their abstract, helps in refining objectives and challenges both for health professionals and decision makers. From an engineering perspective, development of a workstation requires the integration into the same environments of tools to localize, access, manipulate and communicate the required information. The long-term goal is to establish an easy access in a collaborative working environment that gives the end-user the feeling of a single virtual health

enterprise, driven by an integrated computer system when the information system relies on a set of heterogeneous and geographically distributed components. Consequences in terms of migration from traditional client/server architectures to more client/network architectures are considered. Keywords: Health-care Professional Workstation, Engineering, Integration, , Intranet

1. Introduction cilities are still not in a position to (physician, nurse, etc.), the worksta­ provide their professionals with trans­ tion can be more than a dataandknowl­ Health-care professionals depend parent access to distributed patient data, edge integrator. Through evolution­ on accurate and timely access to infor­ knowledge sources, and processing ary steps, the workstation will first mation about the patients under their services. The workstation for the serve the information needs for patient care, information contained in the bio­ health-care professional provides both care, support professional and per­ medical literature, and information a short-term solution to the problem of sonal communications, provide deci­ accumulating in databases around the inadequate information infrastructures sion support, and facilitate professional world. However, the promise of the and an evolutionary path toward an and personal task management [4-8]. information age has not been realized integrated information environment [1- The workstation needs to evolve from in health-care because of the technical 3]. The development of such a work­ an information display device into a short-sightedness of closed· systems station involves consideration from work-facilitating device with the goal and sociopolitical boundaries that in­ the viewpoints of the end-user, the of becoming an intelligent electronic hibit collaboration and data sharing. engineer, and the health administra­ assistant. Because of continued purchasing of tor. From the engineer's perspective, closed-end solutions, health-care fa- From the end-user's perspective the workstation is the unique mediator

Yearbook of Medical Informatics 1996 65 between the health-care professional cilitate the collection of the data previous generations. Comments on a and the health network that conceals necessary for executive decision sup­ prototype are different from experi­ the complexity of the underlying in­ port. ments in a real situation. Such experi­ formation system. It is a hardware and ments require mature and secure prod­ software framework that needs to ad­ ucts, and it becomes more difficult at dress interface management, secure 2. Functional Requirements this stage to make drastic changes. communication, processing and con­ Economic pressures impose the need trol, and eventually local storage. 2.1. The Expression of End-users' for a large market to balance the Physically, these processes can be Needs high cost of development. End-us­ combined within the same box or dis­ ers' expectations are likely to be tributed over a network.Their devel­ It is traditional in health care to tempered by the constraint of mini­ opment should benefit from a careful assume thatthe functions of a comput­ mal consensual functions and the evaluation of end-user needs and ap­ erized system should be patient-cen­ need, at the institution level, to fa­ propriate software-engineering tech­ tered and the developments user-en­ cilitate transitions. niques [2,9,10]. tered. Interfaces and accessible func­ Finally, from the health adminis­ tions need to be tailored to the ex­ 2.2. Organizational and trator's perspective, the workstation is pressed needs of individual users or Technological Trends a new technology that needs to be categories of users (e.g., general prac­ integrated into the organization and titioners, radiologists, nurses). Indeed, Requirements must also be based have proved cost/effectiveness [11]. the participati()n of end-users in the on the prospective understanding of This technology, however, is nothing development process and in evalua­ the changes in the delivery of care and less than a radical structural agent of tion teams with designers and external in the technology. Table 1 illustrates, change. The device can enhance pro­ evaluators minimizes the risk of inap­ through the analysis of Medline in­ ductivity, change communication pat­ propriate design and provides the nec­ dexed publications from January 1st, terns and, hence, the ways in which essary feedback on the viability of the 1991 to December 31st, 1994, the professionals and support staff col­ first prototypes [12-15]. growing interest for workstations. A laborate in the care process, provide But end-users' reactions are often total of 445 publications included the the technical ingredients for true con­ conflicting and biased by their per­ term "workstation", either in their title tinuous quality improvement, and fa- sonal experiences with products of or in their abstract. The number of

Period 1991-1992 1993-1994 Total (100%)

Nature of the publication (%) (%) (%) Analysis and design, review papers 15,6 23,7 20,2 Development, derscriptive papers 65,1 57,7 60,9 Evaluation papers 19,3 18,6 18,9 Total no (1) 192 253 445 Main application domain covered Generic 10,4 5,5 7,6 Health-care units 18,8 31,6 26,1 Radiology, PACS, radiotherapy 35,9 31,6 33,5 Biology, genetics, molecular biology 8,9 12,6 11,0 Anatomopathology 8,9 5,1 6,7 Surgical processing 3,1 4,0 3,6 Signal processing . 3,1 2,4 2,7 Education 4,2 1,6 2,7 Access to data and knowledge banks 4,7 0,8 2,5 Table 1. Epidemiology, clinical research 0,5 3,6 2,2 Nature and domain of Workstations for disabled people 1,6 1,2 1,3 publications covered by the 445 Total no (I) 192 253 445 Total number of publications publications from 1991 to 1994, in Medline (2) 752,528 759,666 1,512,194 indexed in Medline and including Ratio (1)/(2) 0,026% 0,033% 0,029% in their title or their summary the term "workstation".

66 Yearbook of Medical Informatics 1996 publications has increased by 32% Table 2. Selected functional requirements. from the period 1991-1992 to the pe­ riod 1993-1994. Application domains 1. Ability to help the medical practice (direct patient care support) cover all medical fields and mainly Computerized patient record update and consultation health-care units, radiology, biology and - data recording (administrative, medical, nursing, investigations) pathology. The number of true evalua­ -multimedia object management (e.g., text, graphics, images, sounds) -data presentation (e.g., summaries, flow sheets, graphics) tion papers is low by comparison with - simultaneous record consultation (group work, staff discussions) design papers, descriptive papers and Decision support literature reviews. -clinical calculations (e.g., drug doses, predictive value of a sign or symptom) However, the recent development - search for similar patient cases of community health-information net­ - access to contextual knowledge (intelligent agents) works (CHIN) and the current explo­ - diagnostic and therapeutic suggestions sion of Internet- and Intranet-based - prognosis evaluation experiences will significantly change - strategy selection support for the years to come the vision of the -follow-up support (e.g., monitoring and alerts, follow-up reminders, functionalities and architecture of a compliance evaluation) workstation [ 16, 17]. 2. Support to the management of the health care professional environment - health-care unit management (resources, planning) . 2.3. A Typology of Functionalities -access to reference information (e.g., protocols, consensus reports) -evaluation of medical prbcedures (e.g., outcome measures) 3. Teaching and research Table 2, derived from the literature -access to literature and the personal experience of the -access to external data and knowledge banks (e.g., drugs, clinical trials) authors, summarizes some key func­ -end user assistance (e.g., on-line help, tutorials) tional requirements of an intelligent - support to continuous education workstation for the health professional 4. Logistic capabilities [1,4-9]. Group 1 and part of group 5 -desktop publishing (e.g., text processing, spreadsheets, presentation tools) functions are clearly patient centered. -communication facilities (e.g., mailing, file/record transmission, Internet Group 3 and 4 indicate that direct help and Intranet tools) to the end users' activity is a necessary -personal data management (e.g., agenda, addresses) 'condition of acceptability and success. - personalization, customization of the workstation Group 2 to 4 functions concern both 5. Protection, security and confidentiality the end-users and their environment -end-user identification and authentication (e.g., professional smart cards) - data integrity and security management (e.g., the institution). - maintenance of patient data privacy and confidentiality Development of CHINs raises the issue of the ubiquitous, rapid and se­ cure management of permanent pa­ office or in the hospital ward, and the patient's case: tient records. A workstation is the key interpretation and selection of impor­ - fmd similar cases to evaluate what tool on which the integration of the tant images by the production sites, hasbeendoneandachieved[24-26], distributed pieces of the patient record such as radiology or pathology depart­ - askadvicefromcolleaguesthrough (from various servers) can be achieved. ments [21]. In the latter case, both the telemedi~ine consultation [ 18-20], Communication between profession­ speed of access to sequences of im­ - find relevant literature and knowl­ als (within or between institutions) ages and the quality of the displays are edge [17,27-29]. and cooperative work (groupware) crucial acceptability factors [22,23]. become essential [18-20]. Simulta­ Decision support can be passive, at neous consultation of the patient record the end,. user's request, or active driven 3. Development Tools and and distance interaction constitute the by the health-care context(e.g., alarms, Strategies foundation of such cooperative work. reminders, automatic diagnosis or Requirements in terms of multime­ therapeutic suggestions). In the con­ 3.1. Analysis and Design Tools dia object management are highly de­ text of widely available networks, sev­ pendent on the context; for example, eral decision-support strategies have Design and implementation of an the display and simple manipulation to be balanced within the limited time intelligent workstation are growing of selected images at the physician's frame that a physician can devote to a processes in which new functions are

Yearbook of Medical Informatics 1996 67 gradually added to existing ones. such methods. cate transparently across different lan­ Changeability and adaptability are es­ guages and platforms. Using such an sential. For the workstation developer, 3.2. Medical Object Modeling and approach, workstation development the long-term objective is to conceive Management environments can deal both with com­ a virtual environment that gives the ponents specifically designed and end-user the illusion of a single and Medical information must be trans­ implemented for use in a medical work­ unique application, despite the fact parently accessible whatever its na­ station, and with the encapsulation of that the functions rely on a set of ture or location. Thus, objects to be external components that were not ini­ distributed and heterogeneous pieces handled by a workstation include local tially designed to cooperate (e.g., a of hardware and software. Develop­ (on the workstation) or foreign objects text editor, a spreadsheet, a decision­ ment is facilitated if the workstation (within the institution, such as those support system) [36]. software is initially conceived in a found in hospital information system With the globalization of health modular client/server design in which databases, or outside the institution, networks, sources for relevant medi­ each component conforms to a nor­ such as those accessible through the cal objects will be more and more malized interface protocol [9,10,30]. Internet). Those objects may be simple located outside the hospital. Manage­ The Domain-Specific Software Ar­ or complex objects (e.g., multimedia), ment of foreign objects will thus be­ chitecture (DSSA) methodology is an static or dynamic (e.g., actions and come a key issue that will involve both example of producing specifications procedures, such as protocols or deci­ data management and communication that permit the assembly of special­ sion-making processes). tools. Object-oriented techniques can ized components for a particular do­ If the communication aspects (i.e., facilitate the constitution of main [31]. how to reach and to interact with the metamodels of accessible data struc­ The main goal of an analysis and desired objects) have to be handled at tures [9,30,37,38]. In that respect, the design tool is clearly to increase both run time, development time is deeply design and implementation of a "for­ productivity and quality in worksta­ concerned with object modeling. At eign objects cache" together with the tion developments. One way to reach that time, two complementary aspects necessary "intelligent agents" to feed this goal is to provide analysis and must be considered: how the worksta­ the cache asynchronously with the design tools supporting re-use. Re­ tion functions and processes will be workstation use of the retrieved ob­ usability, which can be fostered by able to interact uniformly with hetero­ jects have to be considered [39]. Be­

encapsulation and information hiding, geneous objects, and how the neces­ sides performing the necessary trans­ together with the need of a uniform sary semantic integration between lation between differenttypes of infor­ method able to cover all the modeling objects originating from various places mation presentation (e.g., different aspects quoted before, highlights the will be achieved at the workstation. medical data-encoding schemes), the interest of using object-oriented analy­ The first point can take advantage of communication tools, together with sis and design methods [32]. These the emergence of standards such as the data management tools, have to methods ensure that the same ideas OMG' s CORBA. Thanks to its nor­ guarantee the semantic mapping be­ and concepts are manipulated from malized object-interface description tween objects that may have been the requirements phase down to the (through the use of the Interface De­ modeled differently [40,41]. implementation phase (i.e., there is no scription Language, IDL), the avail­ paradigm shift between the different ability ofcompatible Interface Reposi­ 3.3. Interface Management stages of the life cycle), that the sys­ tories implemented by most of the tem dynamics (i.e., how the objects Object Request Brokers (ORB), the Graphic user-interface management interact with one another) can be eas­ CORBA approach allows objects of systems must allow medical applica­ ily handled, and that the potential de­ different origins to interact with one tion developers to create end-user in­ centralized architecture is carefully another and thus improve software terfaces that are adapted to their pro­ taken into account (i.e., through mes­ modularity [35]. The repositol1: stores fessional habits and comply with medi­ sage sending interaction modelling) the location of the foreign objects as cal style guides [42]. Indeed, end-us­ [33,34]. In addition, spiral models of well as the operations available for a ers must be able to move between development enhance changeability given object an4 the means to access components that share a common look and adaptability. For these reasons, them. Indeed, as long as an object can and feel, in order to minimize the com­ the analysis and design tool of a work­ issue a request in a standard format, ponent-training period and enhance station development environment called for by a standardized object­ acceptance of the workstation. Ethno­ should benefit from being based on request broker, objects can communi- graphic studies of end-users' work

68 Yearbook of Medical Informatics 1996 practices (e.g., through video record­ Internet and Intranet information serv­ amounts to a multimedia computer ing) might provide a better understand­ ers (through additional built-in (PC or Macintosh, workstation, ing of the cognitive processes involved functionalities such as E-mail or news or adapted X terminal). This standard in human-machine interaction, the handling, helper applications located hardware that always includes a high­ barriers encountered, and the effect of at the workstation side, dedicated plug­ resolution color display (to visualize education and training [ 14,43]. Health ins, or the ability to load applets from still and live pictures) and a network professionals are frequently interrupted the network) could provide a valuable connection (generally Ethernet based) in their activities.lt is thus very impor­ example of what should be the user can be enhanced with various input/ tant to be able to interrupt a transaction, interface of tomorrow's medical work­ output devices depending on the spe­ to record the state of the interface when station. From the development stand­ cific needs (e.g., microphone and digi­ the interruption occurred, and then to be point, such an approach will lead to tal video camera, speakers, fast mo­ able to resume the stored configuration. lighter (since most of the Input/Output dems or ISDN connections, ATM From a technical point of view, the will be borrowed from the browser) switches). A smart-card reader could interface manager must comprise all and more portable code (through the be a convenient way to ensure identi­ the basic building blocks necessary to use of the Java™ abstract windowing· fications of users (both health-care give life to multimedia objects (e.g., toolkit for instance). Moreover, when professionals and their patients) if they texts, charts, images) and to benefit in the past respect of style guides was want to access sensitive information. from audio and video extensions (voice left to the programmer's opinion, the This kind of sedentary workstation is commanding, input or production of use of a unique interaction metaphor generally seen in hospital wards, staff audio documents, synchronizing au­ (i.e., through a browser) enhanced by meeting rooms, and medical personal dio with video).It is commonly stated the use of a common implementation offices. that developing a convenient user in­ language and framework will favor the Nomadic workstations, through terface for a software product can cur­ appearance of medical applications re­ their data-input modes (stylus on a rently represent more than half of the ally sharing a common look and feel. sensitive screen, coupled with an effi­ programming-efforts. User Interface In a prospective view, the availabil­ cient manual writing OCR) mimics an Management Systems (UIMS) have ity of development tools to build electronic writing pad and is generally then evolved from programming in­ Internet sites, able to deal with 3-D implemented in a palmtop such as the tensive systems limited to part of the applications and virtual reality (through Apple Newton. It allows the input and software life cycle, to highly interac­ the use of the VRML language), could consultation of basic information to be tive tools that can be used throughout open the way to anew evolution in man­ connected to the network through wire­ all the phases of this cycle [44]. Rapid machine interaction and to the appear­ less (radio or infrared) connections. prototyping capabilities become par­ anceof anew interaction metaphor more But with the rapid spread of Internet ticularly important. Traditional UIMS adapted for clinical use than the tradi­ and Intranet technologies, health-care give priority to multi-windowing, di­ tional2-D desktop metaphor . . enterprises seem ready to change their rect object manipulation, complex "computer model". The ever and ever­ graphical and multimedia management more powerful workstations (gener­ facilities and re-usability of interface 4. Components of the ally PC based) could decline due to components. Generally, these prod­ Multimedia Workstation their inherent costs and difficulties to ucts offer convenient features to rap­ be managed and updated for the ben­ idly build "static" interfaces, but 4.1. Hardware Environment efitof"network-likecomputers" (NC). prototypingthe dynamic behavior (i.e., In the latter approach, all the power is the link between the interface and the Physically, components of the work­ transferred to the network and the con­ application) remains difficult to handle station can be gathered within the same nected servers, and the NC amounts to correctly (even through the use of call­ box (i.e., machine) or distributed among an Internet browser, probably a PC back editors), because most tools im­ several machines linked by a network without storage, which is externally pose to bind application control at (e.g., combination of graphic terminal, maintained via the Net. compilation time. data and information-processing serv­ Internet-based applications open ers). The need for ubiquitous access to 4.2. Software Components new opportunities for building inte­ information allows for different catego­ grated interfaces [16,26,45,46]. The ries of workstations (i.e., sedentary or From the study of health-care pro­ increasing use of Web browsers as nomadic). fessionals' needs, it is possible to de­ unique client interfaces to access all A sedentary workstation generally fine the functional architecture and the

Yearbook of Medical Informatics 1996 69 software components needed for its thorization (the user is allowed to biosignal processing, decision-sup­ implementation. do what he or she is requesting to port tools or a natural-language pro­ In a "traditional" client/server ap­ do), confidentiality (the right in­ cessor for automatic text indexing. proach (i.e., the workstation is in turn formation is only transmitted to the a client for different dedicated serv­ right person), data integrity (re­ In a different an~ newer approach, ers), five software components could corded data are valid), and action where the network is the system ("cli­ be considered as generic, and should tracking (every manipulation is ent/network approach"), those com­ be integrated: an interface manager, a signed and recorded in case of ponents (at least those functions) are local data and knowledge manager, a conflict) are of paramount im­ retrieved in a particular server, that communication manager, a security portance. acts as a unique front-end for the net­ manager and a control (or supervisor) 5. The control component (the con- · work computer. Depending on the in­ component [9,51]. Of course, the pre­ ductor) allows to optimize task formation willing to be accessed, the cise interrelationships of these com­ management and to eventually dis­ server serves its client or forwards the ponents will depend on the chosen tribute the requests on different in­ request to another server (either local hardware infrastructure. formation servers. In that particu­ or remote). In the second case, when 1. The interface mana&er, considered lar domain, emphasis is currently the requested information is made · as a mediator between the user and put on the development of intelli­ available, the front-end server is re­ the workstation, must allow for easy gent agents, which task is to re­ sponsible for formatting the retrieved interaction with any modality of trieve relevant information on the information in a common standard­ medical information, either mono­ Net from the various servers that ized way. This architecture, which is or multimedia. In addition, this might reference it. In such an envi­ the foundation of Intranet develop­ component must be in phase with ronment, parallel requests are is­ ments, allows the client workstation to the work environment. In particu­ sued asynchronously with the user be as simple as possible since it has lar, it must ease the sharing of a work [39], being prompted only only to deal with a single server pre­ workstation between several users, when the answer is made available. sentin~ information in a single formal­ while guaranteeing confidentiality 6. Other components are more spe­ ism, and has no more to be able to of the accessed data and memori­ cific of a domain or ofcategories of "speak" with a collection ofheteroge­ zation of user preferences. users. This concerns statistical neous servers (Fig.1). 2. The data mana&er should allow for packages, local image processing, storage and local management of user data, while facilitating access to local and remote servers for Figure 1. Network computer-based architecture. downloading relevant data (e.g., parts of a medical record or knowl­ ! edge elements such as a protocol). Network C++ plug-in I 3. Communication functions must Computer groupware or I news client mail client I enforce access to relevant informa­ Based tion, whatever its nature or loca­ Workstation · ' ' Applet interpreter tion, and ease groupware (e.g., ac­ Network connection I cess to remote data, tele-expertise, W . -- simultaneous consultation from I various locations of the same Internet TCPIIP Servers ~Frrewall J record). Workstation communication _, tools must then be designed to inte­ L ~ grate current and upcoming mes­ / sage-handling standards [47-48]. http Servers nntp" Servers ftp----- Servers CGI - 4. Security management is of particu- . HTMLpages applets News File systems

lar concern with objects scattered 1 in wide-area networks [49 ,50]. The Database servers functions should address the prob­ relational, object-oriented, Intranet lems of authentication (the user is multimedia, WAfS Servers really who he declares to be), au-

70 Yearbook of Medical Informatics 1996 5. Integration Aspects nication, control and semantics. work of the health-care professionals, 1. Presentation integration tries to increase quality and performances and From previous discussions, it ap­ guarantee that the different tools enable evolution and changes at the pears that the concept of a workstation accessed by the workstation have a institutional level. Installation of an can be instantiated in some flexible common appearance and behav­ intelligent workstation should, there­ presentation (i.e., from a notepad to a ior. Presentation integration is fore, be part of the general strategy of powerful multimedia workstation or a achieved through the use of local the enterprise. At an institutional level, network computer) and eventually and/or institutional style guides. this implies [2,57]: complex to implement and maintain 2. Data integration means the capa­ - the clear definition of a migration (i.e., largely determined by the under­ bility, for the end-user, to perceive strategy; lying architecture of the information the information as ifit was stored in the selection of an appropriate net­ system). Indeed, at least three aspects a single database, when there are in work infrastructure supporting of integration of a workstation can be fact distributed databases on mul­ wide-area connectivity; considered [9]. tiple servers. This is particularly the installation of applications that true for the patient's record. support standardized application­ 5.1. Functional Integration 3. Communication integration relies programming interfaces (API) and on the standardization of the mes­ system-independent repositories Functional integration is of imme­ sages exchanged between the sta­ (client/server applications); diate concern for the end-users of the tion and the different servers. an institutional commitmentto pro­ workstation. The objective is the clear 4. Objective ofcontrol integration is to mote and respect standards [47]; definition, for each category of users allow interworking of the different procedures to check the confor­ of the required functionalities (i.e., applications on the workstation (i.e., mity of the application to selected what the workstation should provide), in sequence or in parallel) [51]. norms and standards, and to insure and they shouldbe made accessible (i.e., 5. Semantic integration still represents quality; and how the workstation shouldpresentfunc­ the critical issue. Meaning of medi­ the organizational and financial tions and their dynamic binding). A cal concepts should be imified for investments needed to provide for typical example is the integration of enabling the applications to ex­ the necessary training of the end­ desktop publishing functions with more change information. A metathe­ users, to promote collaborative traditional HIS functions (e.g., appoint­ saurus such as the UMLS is useful work, and to create a dynamic en­ ment and scheduling, act management, to establish links between a con­ vironment for change. medical-record management). For ex­ cept extracted from a given no­ ample, a summary report, directly ac­ menclature (e.g., MESH, ICDlO, cessible through a spreadsheet or a SNOMED International) and entry 6. Evaluation Criteria text editor can be produced from the points to data and knowledge banks. integration of answers to queries on However, no metathesaurus will Establishment of a reference list of distributed servers. If some error is exactly match the precise needs of evaluation criteria might be relevant found, the end-user should be able to any institution in terms of concept­ in different si~ations [58,59]. During update transparently both the report and object-modeling. Within an the development process, a list of cri­ and the original· data on the servers. institution, semantic integration is teria can serve as internal validation, This problem is particularly relevant facilitated by the constitution of a for example, to avoid deviations from in Intranet-based applications where global data dictionary and the de­ intended objectives. In this case, the information can be generated as HTML velopment of a vocabulary/termi­ list should be defmed a priori and pages from the servers without easy nology server that allows for map­ internal validation should be completed feedback on the source data. ping between the information com­ by independent evaluators. ing from various sources [54-56). At a management level, evaluation 5.2. Technical Integration can help with the selection of the most 5.3. Organizational Integration appropriate workstation strategy (from Technical integration relates to the a comparative study of scenarios) and way the different components of the Organizational integration refers to with determining the impact of the workstation constitute a coherent envi­ the way the workstation can become installation of workstations in a given ronment.lt can be considered from five part of the enterprise-information sys­ organization (e.g., cost-effectiveness dimensions: presentation, data, commu- . tem, can facilitate the collaborative evaluation). Intuitive perceptions of

Yearbook of Medical Informatics 1996 71 · increased productivity, as claimed by record coding and data/knowledge more be considered as an economic vendors or perceived by end-users, query systems facilitates the search barrier. The situation is not the same at have to be balanced with direct mea­ for contextual knowledge and these­ a single mid-sized facility, such as a surements. This is particularly diffi­ lection of similar patient cases already 500-bed teaching or city hospital where cult since counterproductivity may be stored in databases. their might be 5000 desktops. Rapid expected with the introduction of a Part of the difficulty in the develop­ developments in software .and hard­ new tool, and the learning curve may ment of an intelligent workstation is ware make each instance of the work­ differ with different workstations or related to the management of multi­ station obsolete if not at the time of categories of users. media medical objects that are ex­ deployment, then certainly within three Table 3, from [53], gives some ex­ pressed with multiple formalisms and years. Considering that workstations amples of criteria relevant to the evalu­ reside on heterogeneous machines. currently cost about $2500 to pur­ ation of a workstation for the health This requires the use of collections of chase and some have estimated that professional. The extent to which func­ dedicated tools and their integration in each workstations costs over $5000 tions are covered (what the worksta­ the common workstation platform. Re­ per year to support, the current ap­ tion does) and integrated (functional use of existing software components proach to hardware deployment in a integration) is of immediate concern is essential, since major elements al­ mid-sized facility is over $4 million for end-users. ready exist in the marketplace and annually for purchase and replacement At a technical level (i.e., how the cannot be rebuilt from scratch. But and up to $25 million annually for workstation functions are implemented), integration and re-use might be con­ support before considering the costs conforming with software-engineering flicting goals [10]. For example, the of any applications. In this case, the principles (e.g., modularity, re-usabil­ success of office-integrated products emergence of Intranet technology ity, modularity) are important to guaran­ (e.g., combination of a word proces­ along with programming techniques, tee accepted and perennial applications. sor, a worksheet, a graphics system, such as Java that allow the desktop Organizational criteria should be and a database) is in contradiction client to remain simple, raise the prom­ distinguished when one is analysing with modularity, which is a condition ise ofless expensive and less complex the result of a workstation experience for re-use. Constitution of a meta-da­ hardware to support the workstation and what can be attributed to the tool tabase (e.g., through an object-oriented enterprise functionality. and to its environment. Similar com­ model} facilitates the transparent ac­ A major difficulty remains in the

plex interrelationships obviously appear cess to heterogeneous information re­ fact that an intelligent workstation (ei­ for medical, cultural or ethical criteria. positories and semantic integration ther a PC or a NC) is something to add [40,41], but limits the dynamic inclu­ to an existing information system, act­ sion of new components (i.e., new ing as a mediator between the end-user 7. Discussion and data structures have to be declared in and the underlying information sys­ Conclusion the meta-database to be transparently tem. For an institution, installation of accessed). Security issues have still intelligent workstations is different The multimedia workstation for not been solved [50]. from the purchase of a set of micro­ health-care professionals, integrated Networks of care delivery are dy­ computers or graphics stations. Deci­ in a network architecture, is the natural namically evolving and are geographi­ sion makers should be convinced about bridge to distributed and integrated cally dispersed. These forces are caus­ the necessity of a clear migration strat­ health-information systems and offers ing the facility-centric view of care to egy and conscious of the importance the support for telemedicine and col­ change and, hence, our strategies for of the educational and organizational laborative work in the health area managing the clinician's desktop must investments that are required. Experi­ through exchange with other profes­ change. In our past environment, we ences with collaborative development sionals of the domain. Medical deci­ defined the workstation not only by its of workstation components and pro­ sions rely on consultation of the pa­ functionality, but also by its hardware. motion of re-usable software libraries tient record, analysis of similar cases, When a society accepts to spend 2000 are two areas where substantial and access to contextual knowledge. to 3000 US$ per year and per inhabit­ progress might be expected. The workstation allows the end-user ant for health care, investment of a Increasingly, sophisticated techno­ to view the patient record as a single single workstation for the cabinet of­ logical solutions for socio-political entity when the information is distrib­ fice of a physician that provides both problems are unlikely to be successful uted among different servers. Auto­ local processing capabilities and com­ unless the underlying socio-political matic coupling between medical- munication capabilities cannot any problems themselves are addressed

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Table 3. Categories of criteria.

Categories of criteria Main actors Questions

1. Functional End users What? - Functional coverage -Functional adaptability, etc. 2. Technical Engineers How? Architectural -Extensibility, evolutivity, maintainability, etc. -Modularity, distributivity, portability, openness (e.g., standards), interoperability, reusability, etc. - Degree of integration (presentation, communication, data/knowledge, control), etc. Quality and performances -Acceptability, ease of use, time response, reliability, security, etc. 3. Organizational Decision makers Which consequences? -End-users' participation, - Support for group decisions, - Changes in the relationships between actors, etc. 4.Medical Patients, Improved quality - Quality of care, health professionals of care? -Medical efficacy, effectiveness, etc. 5. Cultural and ethical Society Which values? - Educational and research value, - Auditability, patients' /professionals' privacy, etc. 6. Economic Decision makers Which resources? - Direct and indirect costs, - Return on investments, etc. 7. Industrial and commercial Industrials Which perspectives? - Industrial commitment, investments, -Market identification, market share, etc.

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