Ayder Referral Hospital - Medicen

 



Medicine

 
For chemical substances, see Medication. For other uses, see Medicine (disambiguation).
The ancient Greek symbol today associated with medicine the world over: the rod of Asclepius with its encoiled serpent. The World Health Organization, the Royal Society of Medicine, the American Medical and Osteopathic Associations, the British and the Australian Medical Associations are some of the bodies that incorporate it in their insignia
Medicine is the art and science of healing. It encompasses a range of health care practices evolved to maintain and restore health by the prevention and treatment of illness.
Contemporary medicine applies health science, biomedical research, and medical technology to diagnose and treat injury and disease, typically through medication, surgery, or some other form of therapy. The word medicine is derived from the Latin ars medicina, meaning the art of healing.[1][2]
Though medical technology and clinical expertise are pivotal to contemporary medicine, successful face-to-face relief of actual suffering continues to require the application of ordinary human feeling and compassion, known in English as bedside manner.[3]
Contents
History
 
Prehistoric medicine incorporated plants (herbalism), animal parts and minerals. In many cases these materials were used ritually as magical substances by priests, shamans, or medicine men. Well-known spiritual systems include animism (the notion of inanimate objects having spirits), spiritualism (an appeal to gods or communion with ancestor spirits); shamanism (the vesting of an individual with mystic powers); and divination (magically obtaining the truth). The field of medical anthropology studies the various prehistoric medical systems and their interaction with society.
Early records on medicine have been discovered from early Ayurvedic medicine in the Indian subcontinent, ancient Egyptian medicine, traditional Chinese medicine and ancient Greek medicine. Early Greek doctor Hippocrates, who is also called the Father of Medicine,[4][5] and Galen laid a foundation for later developments in a rational approach to medicine. After the fall of Rome and the onset of the Dark Ages in Western Europe, the Greek tradition of medicine went into decline. After 750, the Muslim Arab world had Galen and Aristotle's works translated into Arabic, and Islamic physicians engaged in some significant medical research. Notable Islamic medical pioneers include polymath Avicenna, who, along with Hippocrates, has also been called the Father of Medicine,[6][7] Abulcasis, the father of surgery, Avenzoar, the father of experimental surgery, Ibn al-Nafis, the father of circulatory physiology, and Averroes.[8] Rhazes, who is called the father of pediatrics, was one of first to question the Greek theory of humorism, which nevertheless remained influential in both Western and Islamic medieval medicine. During the Crusades, one Muslim observer famously expressed a dim view of contemporary Western medicine. [9] However, overall mortality and mordibity levels in the medieval Middle East and medieval Europe did not significantly differ one from the other, which indicates that there was no major medical "breakthrough" to modern medicine in either region in this period. The fourteenth and fifteenth Black Death was just as devastating to the Middle East as to Europe, and it has even been argued that Western Europe was generally more effective in recovering from the pandemic than the Midddle East. [10] As the medieval ages ended, important early figures in medicine emerged in Europe, including Gabriele Falloppio and William Harvey.
An ancient Greek patient gets medical treatment: this aryballos (circa 480-470 BCE, now in Paris's Louvre Museum, probably contained healing oil
The major shift in medical thinking was the gradual rejection, especially during the Black Death in the 14th and 15th centuries, of what may be called the 'traditional authority' approach to science and medicine. This was the notion that because some prominent person in the past said something must be so, then that was the way it was, and anything one observed to the contrary was an anomaly (which was paralleled by a similar shift in European society in general - see Copernicus's rejection of Ptolemy's theories on astronomy). Physicians like Ibn al-Nafis and Vesalius led the way in improving upon or indeed rejecting the theories of great authorities from the past (such as Hippocrates, and Galen), many of whose theories were in time discredited.
Modern scientific biomedical research (where results are testable and reproducible) began to replace early Western traditions based on herbalism, the Greek "four humours" and other such pre-modern notions. The modern era really began with Robert Koch's discoveries around 1880 of the transmission of disease by bacteria, and then the discovery of antibiotics around 1900. The post-18th century modernity period brought more groundbreaking researchers from Europe. From Germany and Austrian doctors such as Rudolf Virchow, Wilhelm Conrad Röntgen, Karl Landsteiner, and Otto Loewi) made contributions. In the United Kingdom Alexander Fleming, Joseph Lister, Francis Crick, and Florence Nightingale are considered important. From New Zealand and Australia came Maurice Wilkins, Howard Florey, and Frank Macfarlane Burnet). In the United States William Williams Keen, Harvey Cushing, William Coley, James D. Watson, Italy (Salvador Luria), Switzerland (Alexandre Yersin), Japan (Kitasato Shibasaburo), and France (Jean-Martin Charcot, Claude Bernard, Paul Broca and others did significant work. Russian (Nikolai Korotkov also did significant work, as did Sir William Osler and Harvey Cushing.
The Persian philosopher Avicenna, sometimes called the Father of Modern Medicine. His Canon of Medicine, written during the Islamic Golden Age, probed the nature of contagious disease, identified anaesthetics and medicinal drugs, introduced quarantine and experimental medicine, and even the idea of clinical trials
As science and technology developed, medicine became more reliant upon medications. Pharmacology developed from herbalism and many drugs are still derived from plants (atropine, ephedrine, warfarin, aspirin, digoxin, vinca alkaloids, taxol, hyoscine, etc). The first of these was arsphenamine / Salvarsan discovered by Paul Ehrlich in 1908 after he observed that bacteria took up toxic dyes that human cells did not. Vaccines were discovered by Edward Jenner and Louis Pasteur. The first major class of antibiotics was the sulfa drugs, derived by French chemists originally from azo dyes. This has become increasingly sophisticated; modern biotechnology allows drugs targeted towards specific physiological processes to be developed, sometimes designed for compatibility with the body to reduce side-effects. Genomics and knowledge of human genetics is having some influence on medicine, as the causative genes of most monogenic genetic disorders have now been identified, and the development of techniques in molecular biology and genetics are influencing medical technology, practice and decision-making.
Evidence-based medicine is a contemporary movement to establish the most effective algorithms of practice (ways of doing things) through the use of systematic reviews and meta-analysis. The movement is facilitated by the modern global information science, which allows all evidence to be collected and analyzed according to standard protocols which are then disseminated to healthcare providers. One problem with this 'best practice' approach is that it could be seen to stifle novel approaches to treatment. The Cochrane Collaboration leads this movement. A 2001 review of 160 Cochrane systematic reviews revealed that, according to two readers, 21.3% of the reviews concluded insufficient evidence, 20% concluded evidence of no effect, and 22.5% concluded positive effect.[11]
Clinical practice
Girl having her head bandaged, as depicted by the portraitist Henriette Browne (1829-1901)
In clinical practice doctors personally assess patients in order to diagnose, treat, and prevent disease using clinical judgment. The doctor-patient relationship typically begins an interaction with an examination of the patient's medical history and medical record, followed a medical interview[12] and a physical examination. Basic diagnostic medical devices (e.g. stethoscope, tongue depressor) are typically used. After examination for signs and interviewing for symptoms, the doctor may order medical tests (e.g. blood tests), take a biopsy, or prescribe pharmaceutical drugs or other therapies. Differential diagnosis methods help to rule out conditions based on the information provided. During the encounter, properly informing the patient of all relevant facts is an important part of the relationship and the development of trust. The medical encounter is then documented in the medical record, which is a legal document in many jurisdictions.[13] Followups may be shorter but follow the same general procedure.
The components of the medical interview[12] and encounter are:
  • Chief complaint (cc): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'presenting complaint.'
  • History of present illness / complaint (HPI): the chronological order of events of symptoms and further clarification of each symptom.
  • Current activity: occupation, hobbies, what the patient actually does.
  • Medications (Rx): what drugs the patient takes including prescribed, over-the-counter, and home remedies, as well as alternative and herbal medicines/herbal remedies. Allergies are also recorded.
  • Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.
  • Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).
  • Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.
  • Review of systems (ROS) or systems inquiry: a set of additional questions to ask which may be missed on HPI: a general enquiry (have you noticed any weight loss, change in sleep quality, fevers, lumps and bumps? etc), followed by questions on the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc).
The physical examination is the examination of the patient looking for signs of disease ('Symptoms' are what the patient volunteers, 'Signs' are what the healthcare provider detects by examination). The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (taste has been made redundant by the availability of modern lab tests). Four chief methods are used: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen); smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis). The clinical examination involves study of:
Laboratory and imaging studies results may be obtained, if necessary.
The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.
The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.
This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.
On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results or specialist consultations.
Institutions
Contemporary medicine is in general conducted within health care systems. Legal, credentialing and financing frameworks are established by individual governments, augmented on occasion by international organizations. The characteristics of any given health care system have significant impact on the way medical care is provided.
Advanced industrial countries (with the exception of the United States) [14][15] and many developing countries provide medical services though a system of universal health care which aims to guarantee care for all through a single-payer health care system, or compulsory private or co-operative health insurance. This is intended to ensure that the entire population has access to medical care on the basis of need rather than ability to pay. Delivery may be via private medical practices or by state-owned hospitals and clinics, or by charities; most commonly by a combination of all three.
Most tribal societies, but also some communist countries (e.g. China) and the United States,[14][15] provide no guarantee of health care for the population as a whole. In such societies, health care is available to those that can afford to pay for it or have self insured it (either directly or as part of an employment contract) or who may be covered by care financed by the government or tribe directly.
Modern drug ampoules
Transparency of information is another factor defining a delivery system. Access to information on conditions, treatments, quality and pricing greatly affects the choice by patients / consumers and therefore the incentives of medical professionals. While the US health care system has come under fire for lack of openness,[16] new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other.
Delivery
See also: clinic, hospital, and hospice
Provision of medical care is classified into primary, secondary and tertiary care categories.
Primary care medical services are provided by physicians, physician assistants, or other health professionals who have first contact with a patient seeking medical treatment or care. These occur in physician offices, clinics, nursing homes, schools, home visits and other places close to patients. About 90% of medical visits can be treated by the primary care provider. These include treatment of acute and chronic illnesses, preventive care and health education for all ages and both sexes.
Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists. These include both ambulatory care and inpatient services, emergency rooms, intensive care medicine, surgery services, physical therapy, labor and delivery, endoscopy units, diagnostic laboratory and medical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting.
Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals. These include trauma centers, burn treatment centers, advanced neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology, etc.
Modern medical care also depends on information - still delivered in many health care settings on paper records, but increasingly nowadays by electronic means.
Branches
Working together as an interdisciplinary team, many highly-trained health professionals besides medical practitioners are involved in the delivery of modern health care. Examples include: nurses, emergency medical technicians and paramedics, laboratory scientists, (pharmacy, pharmacists), (physiotherapy,physiotherapists), respiratory therapists, speech therapists, occupational therapists, radiographers, dietitians and bioengineers.
The scope and sciences underpinning human medicine overlap many other fields. Dentistry, while a separate discipline from medicine, is considered a medical field.
A patient admitted to hospital is usually under the care of a specific team based on their main presenting problem, e.g. the Cardiology team, who then may interact with other specialties, e.g. surgical, radiology, to help diagnose or treat the main problem or any subsequent complications / developments.
Physicians have many specializations and subspecializations into certain branches of medicine, which are listed below. There are variations from country to country regarding which specialties certain subspecialties are in.
The main branches of medicine used in Wikipedia are:
Basic sciences
 
 
Specialties
Main article: Medical specialty
In the broadest meaning of "medicine", there are many different specialties. However, within medical circles, there are two broad categories: "Medicine" and "Surgery." "Medicine" refers to the practice of non-operative medicine, and most subspecialties in this area require preliminary training in "Internal Medicine". "Surgery" refers to the practice of operative medicine, and most subspecialties in this area require preliminary training in "General Surgery." There are some specialties of medicine that do not fit into either of these categories, such as radiology, pathology, or anesthesia, and those are also discussed further below.
Surgery
Main article: Surgery
Surgical specialties employ operative treatment. In addition, surgeons must decide when an operation is necessary, and also treat many non-surgical issues, particularly in the surgical intensive care unit (SICU), where a variety of critical issues arise. Surgery has many subspecialties, e.g. general surgery,Transplant surgery, trauma surgery, cardiovascular surgery, neurosurgery, maxillofacial surgery, orthopedic surgery, otolaryngology, plastic surgery, oncologic surgery, vascular surgery, and pediatric surgery. In some centers, anesthesiology is part of the division of surgery (for logistical and planning purposes), although it is not a surgical discipline.
Surgical training in the U.S. requires a minimum of five years of residency after medical school. Sub-specialties of surgery often require seven or more years. In addition, fellowships can last an additional one to three years. Because post-residency fellowships can be competitive, many trainees devote two additional years to research. Thus in some cases surgical training will not finish until more than a decade after medical school. Furthermore, surgical training can be very difficult and time consuming.
'Medicine' as a specialty
Main article: Internal Medicine
Internal medicine is the medical specialty concerned with the diagnosis, management and nonsurgical treatment of unusual or serious diseases, either of one particular organ system or of the body as a whole. According to some sources, an emphasis on internal structures is implied.[17] In North America, specialists in internal medicine are commonly called "internists". Elsewhere, especially in Commonwealth nations, such specialists are often called physicians.[18] These terms, internist or physician (in the narrow sense, common outside North America), generally exclude practitioners of gynecology and obstetrics, pathology, psychiatry, and especially surgery and its subspecialities.
Because their patients are often seriously ill or require complex investigations, internists do much of their work in hospitals. Formerly, many internists were not subspecialized; such general physicians would see any complex nonsurgical problem; this style of practice has become much less common. In modern urban practice, most internists are subspecialists: that is, they generally limit their medical practice to problems of one organ system or to one particular area of medical knowledge. For example, gastroenterologists and nephrologists specialize respectively in diseases of the gut and the kidneys.[19]
In Commonwealth and some other countries, specialist pediatricians and geriatricians are also described as specialist physicians (or internists) who have subspecialized by age of patient rather than by organ system. Elsewhere, especially in North America, general pediatrics is often a form of Primary care.
There are many subspecialities (or subdisciplines) of internal medicine:
·         Cardiology
·         Critical care medicine
·         Dermatology
·         Endocrinology
·         Gastroenterology
·         Geriatrics
·         Hematology
·         Hepatology
·         Infectious diseases
·         Nephrology
·         Neurology
·         Oncology
·         Pediatrics
·         Pulmonology
·         Rheumatology
·         Sleep medicine
Training in internal medicine (as opposed to surgical training), varies considerably across the world: see the articles on Medical education and Physician for more details. In North America, it requires at least three years of residency training after medical school, which can then be followed by a one to three year fellowship in the subspecialties listed above. In general, resident work hours in medicine are less than those in surgery, averaging about 60 hours per week in the USA.
Diagnostic specialties
Other
Following are some selected fields of medical specialties that don't directly fit into any of the above mentioned groups.
Interdisciplinary fields
Interdisciplinary sub-specialties of medicine are:
Education
Painted by Toulouse-Lautrec in the year of his own death: an examination in the Paris faculty of medicine, 1901
Medical education and training varies around the world. It typically involves entry level education at a university medical school, followed by a period of supervised practice or internship, and/or residency. This can be followed by postgraduate vocational training. A variety of teaching methods have been employed in medical education, still itself a focus of active research.
Many regulatory authorities require continuing medical education, since knowledge, techniques and medical technology continue to evolve at a rapid rate.
Legal controls
In most countries, it is a legal requirement for a medical doctor to be licensed or registered. In general, this entails a medical degree from a university and accreditation by a medical board or an equivalent national organization, which may ask the applicant to pass exams. This restricts the considerable legal authority of the medical profession to physicians that are trained and qualified by national standards. It is also intended as an assurance to patients and as a safeguard against charlatans that practice inadequate medicine for personal gain. While the laws generally require medical doctors to be trained in "evidence based", Western, or Hippocratic Medicine, they are not intended to discourage different paradigms of health.
Doctors who are negligent or intentionally harmful in their care of patients can face charges of medical malpractice and be subject to civil, criminal, or professional sanctions.
Statute of limitations
There is only a limited time during which a medical malpractice lawsuit can be filed. In the USA and Canada, these statute of limitations laws vary between 1 and 4 years (see Medical malpractice for more information).
Controversy
The Catholic social theorist Ivan Illich subjected contemporary western medicine to detailed attack in his Medical Nemesis, first published in 1975. He argued that the medicalization in recent decades of so many of life's vicissitudes — birth and death, for example — frequently caused more harm than good and rendered many people in effect lifelong patients. He marshalled a body of statistics to show what he considered the shocking extent of post-operative side-effects and drug-induced illness in advanced industrial society. He was the first to introduce to a wider public the notion of iatrogenesis.[20] Others have since voiced similar views, but none so trenchantly, perhaps, as Illich. [21]
Through the course of the twentieth century, healthcare providers focused increasingly on the technology that was enabling them to make dramatic improvements in patients' health. The ensuing development of a more mechanistic, detached practice, with the perception of an attendant loss of patient-focused care, known as the medical model of health, led to criticisms that medicine was neglecting a holistic model.[citation needed] The inability of modern medicine to properly address some common complaints continues to prompt many people to seek support from alternative medicine. Although most alternative approaches lack scientific validation, some, notably acupuncture for some conditions and certain herbs, are backed by evidence.[22]
Medical errors and overmedication are also the focus of complaints and negative coverage. Practitioners of human factors engineering believe that there is much that medicine may usefully gain by emulating concepts in aviation safety, where it is recognized that it is dangerous to place too much responsibility on one "superhuman" individual and expect him or her not to make errors. Reporting systems and checking mechanisms are becoming more common in identifying sources of error and improving practice. Clinical versus statistical, algorithmic diagnostic methods were famously examined in psychiatric practice in a 1954 book by Paul E. Meehl, which controversially found statistical methods superior.[23] A 2000 meta-analysis comparing these methods in both psychology and medicine found that statistical or "mechanical" diagnostic methods were generally, although not always, superior.[23]
Disparities in quality of care given are often an additional cause of controversy.[24] For example, elderly mentally ill patients received poorer care during hospitalization in a 2008 study.[25] Rural poor African-American men were used in a study of syphilis that denied them basic medical care.
 

Ontology-Based Distributed Health Record Management System

Calin Cenan

1

1, Gheorghe Sebestyen1, Gavril Saplacan1, Dan Radulescu2Dept. of Computer Science, Technical University of Cluj Napoca, Calin.Cenan@cs.utcluj.ro

2

Medical Pharmacy University Cluj-Napoca

Abstract

The paper presents the architecture of a distributed

software system that manages patients’ health records

and assures remote and interactive access to medical

services. In order to cover the complex relationships

between different medical concepts (symptoms,

diseases, treatment, medication, etc.) and also to

include “intelligence” in the software system an

ontology-based approach was adopted. This solution

together with the adoption of some widely accepted

medical standards (e.g. HL7, LOINC, etc.) assure

interoperability and transparent data exchange

between various medical applications. The paper

presents a distributed healthcare system model in

which patients, doctors and software components

interact in order to assure better medical services. The

key factor in the implementation of this model is the

extensive use of the domain’s ontology as the bases for

database definition and medical data processing. In

order to show the usefulness of the proposals as well

as their effectiveness in electronic management of

patient’s health records an experimental

implementation of the proposed methodology is in

work in the filed of cardio-vascular diseases.

1. Introduction

All the modern concepts of medical services are

centered on the healthcare consumer, the patient who

receives medical attention or treatment. Recent

developments in information technology and

communication offer new opportunities in the

implementation of high quality healthcare systems.

These technologies assure the support for better

medical data processing, more accurate diagnoses and

easier access to medical services.

Today a major request imposed for medical systems

is the integration of the different medical applications

and services, regardless of their regional distribution,

ownership or specific medical domains. A patient

should access medical services in a uniform and

transparent way anytime and anywhere. His/her

medical records should travel seamlessly between

medical entities (e.g. general practitioner, hospital,

laboratory) as required by his/her treatment path. This

can be achieved with the intensive use of standards and

with the adoption of a generally accepted terminology.

Clearly an ontology-based approach is needed in

order to represent entities, ideas, and events, along with

their properties and relations, as a form of knowledge

representation about the medical world [1]. Unlike

many other disciplines, medicine has a long standing

tradition in structuring its domain knowledge, e. g.

disease taxonomies, medical procedures, anatomical

terms and others, in a wide variety of medical

terminologies, thesauri and classification systems.

A number of international organizations (e.g. HL7

consortium, ISO, CEN, etc.) are involved in a complex

effort towards global classification and coding of

concepts and terms used in medical domain. There are

also a number of international research project focused

on the development of new ITC models and

methodologies for better medical information

management.

This paper present our proposal for a healthcare

information system dedicated for cardio-vascular

diseases. Through the extension of the ontology the

proposed system may be used also for other medical

domains.

The rest of the article is organized as follows: The

second chapter presents the current state of research in

the domain and the third one presents the proposed

distributed, patient-centric healthcare system model.

The next parts of the paper are dedicated to the

principles behind our ontological approach and the way

we built our medical knowledge base.

2. Related Work

Medical informatics standards are critical for design

of terminologies, which are increasingly used to

populate clinical databases. Medical classification, or

medical coding, is the process of transforming

descriptions of medical diagnoses and procedures into

universal values. Some widely recognized medical

coding standards used in our system are:

·

hospital cases

Diagnosis-Related Group (DRG) - system to classify

·

health problems, 10

International Classification of Diseases and relatedth revision (ICD-10) [2]

·

(LOINC) - database and universal standard for

identifying laboratory observations [3]

Logical Observation Identifiers Names and Codes

·

drug establishments provided by U.S. Food and Drug

Administration (FDA) [4]

National Drug Code (NDC) - directory of registered

·

exchange, of electronic health information [5]

The medical community has long been sensitive to

the need of modeling its knowledge and of making its

terminologies explicit. Therefore, there exist several

terminological or ontological resources that model

parts of the medical domain: controlled medical

vocabularies such as the Systematized Nomenclature of

Medicine, Clinical Terms (SNOMED CT) [6], GALEN

[7], MENELAS [8], ONIONS library [9], or the highly

complex UMLS [10] used to allow a standard, accurate

exchange of data content between different systems and

providers.

SNOMED, the Systematized Nomenclature of

Medicine, is a standardized medical vocabulary that

has been accepted internationally. Intended to

completely and logically interrelate groupings of

defined medical terms, SNOMED is a formalized,

information-packed set of more than 300,000 coded

medical terms.

Health Level Seven (HL7) provide standards for the

UMLS, the Unified Medical Language System is an

umbrella system which covers many medical thesauri

and classifications. From a conceptual perspective, the

UMLS can be divided into a Semantic Network (SN)

which forms the upper ontology and consists of

semantic types linked by semantic relations and a

Meta-thesaurus which contains concepts assigned to

one or more types. Given the size, the evolutionary

diversity and inherent heterogeneity of this huge

UMLS semantic network, there is no surprise that the

lack of a formal semantic foundation leads to

inconsistencies and circular definitions [11].

3. Architecture of healthcare system

In order to define the system’s architecture a number

of aspects must be taken into consideration. The first is

the distributed nature of the medical data and services.

Every entity involved in the medical system (general

practitioners, hospitals, laboratories) should administer

their one medical information using an appropriate

application (server). But, a patient treatment may

involve a number of entities, so their corresponding

applications must exchange medical data concerning

the patient. Automatic data transfer must be assured

when a patient goes from his/her general practitioner to

the laboratory or to the hospital and backwards.

Another important aspect taken into consideration is

the possibility for a patient to access medical services

from home, using a terminal (PC, PDA, intelligent

phone). The system must allow off-line or on-line

consultations and remote data acquisition from portable

medical equipments.

The medical data security is another important issue.

All the transfers must be done in accordance with the

privacy rules accepted in medical systems.

Fig1. General view of the Distributed system

Figure 1 shows the general view of the proposed

system, in which the following elements can be

identified:

·

type of medical entity (general practitioner office,

hospital, laboratory application)

medical applications (servers) adapted for every

·

practitioners, specialists (in hospitals), laboratory

analysts

main actors of the system: patients at home, general

·

servers

A medical application (server) has a multi-layer

structure. Figure 2 shows the main software

components organized on the following layers: medical

Internet

interactions between actors and servers and between

Hospital Labs Server

HL7 – Web

Portal Access Access using Client App.

GP Server

knowledge database layer, access control layer, data

processing layer and user and service interface layer

Fig2. Multi layer structure of the Distributed

Healthcare System

The database is structured on 4 components: patient

records, medical documents, knowledge base and

resources database. The patient records part stores all

the medical information concerning patients:

demographic data (recorded once) and periodical

observations (results of consults). The knowledge base

preserves all the concepts and relations defined in the

domain’s ontology and it is the bases for medical

reasoning and decision. The proposed ontology will

support applications both individually and, more

importantly, within an environment of heterogeneous

inter-working clinical information systems. The

resources database is used to administer financial and

medical resources (e.g. treatment costs, drugs,

equipments’ usage, etc.) The medical documents part

preserves all the official documents generated during

the healthcare process.

The access control layer is responsible for the

authorization of users for different operations:

recording, viewing medical data, modifying records,

etc. The business interaction block is managing the

interactions between the actors and the system during a

medical procedure in accordance with rules in the

ontology (based on treatment plans). The diagnosis and

treatment module is the decision support unit for the

medical diagnoses. This module generates suggestions

concerning treatments based on the patient’s medical

data and rules specified in the ontology. The statistical

processing module contains a set of predefined

procedures that allow statistical evaluations on the

medical data repository. The administration module is

used to keep track of the usage of resources, cost and

will export data to other resource management systems.

4. Ontology for the Cardiology Domain

In our approach the ontology has the central role of

knowledge representation. It contains domain concepts

and knowledge about patient characteristics.

The main part of the ontology implemented in our

project is inspired by a knowledge base that should

assist in management of heart failure patients. The

current version of the constructed heart failure

ontology is presented in [12] and it is available at

http://lis.irb.hr/heartfaid/ontology/

heart failure ontology has started from the terms

defined in [13]. In order to connect the ontology

concepts with the terms defined in UMLS appropriate

references were introduced for every concept.

We built the medical ontology encoded in an internal

format of a database, without a representation readable

by a human user. All the ontology’s elements were

properly translated in our database. So we have tables

in our database to store concepts, instances of concepts,

concept hierarchy and relationships between different

concepts and instances, synonyms and UMSL

synonyms. The slots from ontology are a little bit

difficult to store in the database so we need many

tables to store these properties: tables to store slot’s

characteristics like name, tables to store possible

associations, and tables to store the actual values of

these slot. According to this we have for example

tables to store the fact that “

slot connecting instances and also that this slot is a

valid property only for instances of concepts “

characteristics

“

fact that for “

“

super class “

is related to instances like “

“

are instances of concept “

example the instances “

“

“

“

disorder

Medical plans have the goal of indicating the

decisions and tasks most appropriate for optimizing

health outcomes and controlling costs. They are built

either from loose indications of a preferred set of

choices or from normative rules requiring more or less

strict adherence.

. The design of theIndicated” is the name of aPatient”, “Testing”, “CHF risks”,Classification” and “Treatment”. We can store theFelodipine” (which is an instance ofCalcium antagonist” and further an instance of theHeart failure medication group”) this slotDiastolic hypertension”,Unstable angina” and “Systolic hypertension” whichPatient characteristics”. ForDiastolic hypertension” andSystolic hypertension” of concept “Hypertension” arePatient characteristics” via sub classes “Diagnosis”,Cardiovascular system related”, “Artery and blood” and “Blood pressure disorder”.

Business interactions block

Medical knowledge database layer

Access Control Layer

Patient UI

Physician UI App to App

Interface

WEB Portal for human

access interfaces

B2B

web services

Logistic&

Administration

Laboratory UI

Patient

records

Diagnosis&

Treatment

Statistical

Processing

Health

records

Knowledge

database

Resource

database

One of the main theoretical contributions of our work

was the decision to represent in our ontology the

medical plans using Process Specification Language,

PSL [14], merging the PSL ontology and the Heart

Failure ontology in our healthcare system.

The Process Specification Language (PSL) is

developed by the American NIST, National Institute of

Standards and Technology, and defines a neutral

representation for processes that supports automated

reasoning. The initial use of this ontology was for

manufacturing processes.

There are four kinds of entities required for

reasoning about processes: activities, activity

occurrences, timepoints, and objects.

·

reusable behaviors within the domain

(activity ?a) - activities can be considered to be

·

is associated with a unique activity and begins and ends

at specific points in time.

(activity_occurrence ?occ) - an activity occurrence

·

is anything that is not a time point, nor an activity nor

an activity occurrence. Intuitively, an object is a

concrete or abstract thing that can participate in an

activity.

An example taken from our approach can state that

(take_care Patient1 Doctor1)

is an instance of the class of Treatment activities:

(Treatment_activities (take_care Patient1 Doctor1))

There may be multiple distinct occurrences of this

instance which consequently will be recorded in many

episodes from the medical life of the patient:

(occurrence_of Occ1 (take_care Patient1 Doctor1))

(occurrence_of Occ2 (take_care Patient1 Doctor1))

(= (beginof Occ1) t1), (= (endof Occ1) t2)

(= (beginof Occ2) t5), (= (endof Occ2) t8)

(object ?x), (participates_in ?x ?occ ?t) - an object

5. Conclusions

Our research dealt with new ways of delivering

health care in a coordinated approach. We propose

distributes architecture for efficient management of

patients’ health record. The application assures

interactive and real time data exchange between the

main actors of the medical system.

Using ontology and widely accepted medical coding

standards the proposed solution solves the

interoperability issues between medical entities. Rules

and relations embedded in the medical knowledge

based offer support for a better medical decision and in

these ways assure higher quality for medical services.

Also the system assures remote access and patient’s

monitoring reducing time and cost needed for medical

assistance.

Acknowledgment

under the auspices of CARDIONET, national research

grant funded by ANCS, CNMP-PC, 11-01/2007.

: Work on this paper is supported

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