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1.  A Systematic Evaluation of Data Streams for Global Disease Surveillance 
Objective
The overall objective of this project is to provide a robust evaluation of data streams that can be leveraged from existing and developing national and international disease surveillance systems, to create a global disease monitoring system and provide decision makers with timely information to prepare for and mitigate the spread of disease.
Introduction
Living in a closely connected and highly mobile world presents many new mechanisms for rapid disease spread and in recent years, global disease surveillance has become a high priority. In addition, much like the contribution of non-traditional medicine to curing diseases, non-traditional data streams are being considered of value in disease surveillance. Los Alamos National Laboratory (LANL) has been funded by the Defense Threat Reduction Agency to determine the relevance of data streams for an integrated global biosurveillance system through the use of defined metrics and methodologies. Specifically, this project entails the evaluation of data streams either currently in use in surveillance systems or new data streams having the potential to enable early disease detection. An overview of this project will be presented, together with results of data stream evaluation. This project will help gain an understanding of data streams relevant to early warning/monitoring of disease outbreaks.
Methods
Three specific aims were identified to address the overall goal of determining the relevance of data streams for global disease surveillance. First, identify data streams as well as define metrics for the evaluation. Second, evaluate data streams using two different methodologies, decision analysis modeling using a support tool called Logical Decisions® that assigns utility scores to data streams based on weighted metrics and assigned values specific to data stream categories; and a Surveillance Window concept developed at LANL that assigns a window or windows of time specific to a disease within which information coming from various data streams can be determined to have utility. This would obtain a ranked list of useful data streams. Additionally, evaluate data integration algorithms useful for a global disease surveillance system through a review of scientific literature. Finally, validate the top-ranked data streams by application of specific historical outbreaks to determine whether the data streams are capable of providing early warning or detection of the particular disease before it became a large outbreak.
Results
Seventeen categories of data streams were identified that ranged from traditional ones such as clinic/healthcare provider and laboratory records to newly emerging sources of information such as social media and internet search queries. The Logical Decisions® based evaluation of data streams identified 5 data streams that consistently showed utility regardless of the goal of biosurveillance. However, different data streams varied in rank, given different biosurveillance goals, and there is no one top ranked data stream. Surveillance window based evaluation of data streams during disease outbreaks identified data streams that had high utility for early detection and early warning regardless of disease, while others were more disease and operations specific. Additionally, we have built a searchable biosurveillance resource directory that houses information on global disease surveillance systems.
Conclusions
LANL has developed a robust evaluation framework to determine the relevance of various traditional and non-traditional data streams in integrated global disease surveillance. Through the use of defined surveillance goals, metrics and data stream categories, not only have we identified data streams currently in use that have high utility, but also new data streams that could be exploited for the early warning/monitoring of disease outbreaks. Our robust evaluation framework facilitates the identification of a defensible set of options for decision makers to use to prepare for and mitigate the spread of disease.
PMCID: PMC3692853
evaluation; disease surveillance; data streams
2.  Methodological reflections on the evaluation of the implementation and adoption of national electronic health record systems 
Introduction/purpose of presentation
Far-reaching policy commitments to information technology-centered transformations of healthcare systems have now been made in many countries. There is as yet little empirical evidence to justify such decisions, hence the need for rigorous independent evaluation of current implementation efforts. Such evaluations however pose a number of important challenges. This presentation has been designed as a part of a Panel based on our experience of evaluating the National Health Service’s (NHS) implementation of electronic health records (EHR) systems in hospitals throughout England. We discuss the methodological challenges encountered in planning and undertaking an evaluation of a program of this scale and reflect on why and how we adapted our evaluation approach—both conceptually and methodologically—in response to these challenges.
Study design/population studied
Critical reflections on a multi-disciplinary and multi-facet independent evaluation of a national program to implement electronic health record systems into 12 ‘early wave’ NHS hospitals in England.
Findings
Our initial plan was to employ a mixed methods longitudinal ‘before-during-after’ study design. We however found this unsustainable in the light of fluxes in policy, contractual issues and over-optimistic schedules for EHR deployments. More importantly, this research design failed adequately to address the core of multi-faceted evolving EHRs as understood by key stakeholders and as worked out in their distinct work settings. Thus conventional outcomes-centric evaluations may not easily scale-up when evaluating transformational programs and may indeed prove misleading. New assumptions concerning the implementation process of EHR need to be developed that recognize the constantly changing milieu of policy, product, projects and professions that are inherent to such national implementations. The approaches we subsequently developed substitute the positivist view that EHR initiatives are self-evident and self-contained interventions, which are amenable to traditional quantitative evaluations, to one that focuses on how they are understood by various stakeholders and made to work in specific contexts. These assumptions recast the role of evaluation towards an approach that explores and interprets processes of socio-technical change that surround EHR implementation and adoption as seen by multiple stakeholders.
Conclusions and policy implications
There is likely to be an increase in politically-driven national programs of reform of healthcare based on information and communication technologies. Programs on such a scale are inherently complex with extended temporalities and extensive and dynamic sets of stakeholders. They are, in short, different and pose new evaluation challenges that previously formulated evaluation methods for health information systems cannot easily address. This calls for methodological innovation amongst research teams and their supporting bodies. We argue that evaluation of such system-wide transformation programs are likely to demand both breadth and depth of experience within a multidisciplinary research team, constant questioning of what is and what can be evaluated and how, and a particular way of working that emphasizes continuous dialogue and reflexivity. Making this transition is essential to enable evaluations that can usefully inform policy-making. Health policy experts urgently need to reassess the evaluation strategies they employ as they come to address national policies for system-wide transformation based on new electronic health infrastructures.
PMCID: PMC3571157
electronic health record; evaluation; methodology; socio-technical changing
3.  Same organization, same electronic health records (EHRs) system, different use: exploring the linkage between practice member communication patterns and EHR use patterns in an ambulatory care setting 
Objective
Despite efforts made by ambulatory care organizations to standardize the use of electronic health records (EHRs), practices often incorporate these systems into their work differently from each other. One potential factor contributing to these differences is within-practice communication patterns. The authors explore the linkage between within-practice communication patterns and practice-level EHR use patterns.
Design
Qualitative study of six practices operating within the same multi-specialty ambulatory care organization using the same EHR system. Semistructured interviews and direct observation were conducted with all physicians, nurses, medical assistants, practice managers, and non-clinical staff from each practice.
Measurements
An existing model of practice relationships was used to analyze communication patterns within the practices. Practice-level EHR use was defined and analyzed as the ways in which a practice uses an EHR as a collective or a group—including the degree of feature use, level of EHR-enabled communication, and frequency that EHR use changes in a practice. Interview and observation data were analyzed for themes. Based on these themes, within-practice communication patterns were categorized as fragmented or cohesive, and practice-level EHR use patterns were categorized as heterogeneous or homogeneous. Practices where EHR use was uniformly high across all users were further categorized as having standardized EHR use. Communication patterns and EHR use patterns were compared across the six practices.
Results
Within-practice communication patterns were associated with practice-level EHR use patterns. In practices where communication patterns were fragmented, EHR use was heterogeneous. In practices where communication patterns were cohesive, EHR use was homogeneous. Additional analysis revealed that practices that had achieved standardized EHR use (uniformly high EHR use across all users) exhibited high levels of mindfulness and respectful interaction, whereas practices that were furthest from achieving standardized EHR use exhibited low levels of mindfulness and respectful interaction.
Conclusion
Within-practice communication patterns provide a unique perspective for exploring the issue of standardization in EHR use. A major fallacy of setting homogeneous EHR use as the goal for practice-level EHR use is that practices with uniformly low EHR use could be considered successful. Achieving uniformly high EHR use across all users in a practice is more consistent with the goals of current EHR adoption and use efforts. It was found that some communication patterns among practice members may enable more standardized EHR use than others. Understanding the linkage between communication patterns and EHR use can inform understanding of the human element in EHR use and may provide key lessons for the implementation of EHRs and other health information technologies.
doi:10.1136/amiajnl-2011-000263
PMCID: PMC3341779  PMID: 21846780
Electronic health record use; communication patterns; complex adaptive systems; practice-level EHR use patterns; EHR use standardization; organizational behavior; complexity science
4.  Advice for Decision Makers Based on an Electronic Health Record Evaluation at a Program for All-inclusive Care for Elders Site 
Applied Clinical Informatics  2011;2(1):18-38.
Objective
Provide evidence-based advise to “Program of All-inclusive Care for the Elderly” (PACE) decision makers considering implementing an electronic health record (EHR) system, drawing on the results of a mixed methods study to examine: (1) the diffusion of an EHR among clinicians documenting direct patient care in a PACE day care site, (2) the impact of the use of the EHR on the satisfaction levels of clinicians, and (3) the impact of the use of the EHR on patient functional outcomes.
Methods
Embedded mixed methods design with a post-test design quantitative experiment and concurrent qualitative component. Quantitative methods included: (1) the EHR audit log used to determine the frequency and timing during the week of clinicians’ usage of the system; (2) a 22-item clinician satisfaction survey; and (3) a 16-item patient functional outcome questionnaire related to locomotion, mobility, personal hygiene, dressing, feeding as well the use of adaptive devices. Qualitative methods included observations and open-ended, semi-structured follow-up interviews. Qualitative data was merged with the quantitative data by comparing the findings along themes. The setting was a PACE utilizing an EHR in Philadelphia: PACE manages the care of nursing-home eligible members to enable them to avoid nursing home admission and reside in their homes. Participants were 39 clinicians on the multi-disciplinary teams caring for the elders and 338 PACE members.
Results
Clinicians did not use the system as intended, which may help to explain why the benefits related to clinical processes and patient outcomes as expected for an EHR were not reflected in the results. Clinicians were satisfied with the EHR, although there was a non-significant decline between 11 and 17 months post implementation of the EHR. There was no significant difference in patient functional outcome the two time periods. However, the sample size of 48 was too small to allow any conclusive statements to be made. Interpretation of findings underscores the importance of the interaction of workflow and EHR functionality and usability to impact clinician satisfaction, efficiency, and clinician use of the EHR.
Conclusion
This research provides insights into EHR use in the care of the older people in community-based health care settings. This study assessed the adoption of an EHR outside the acute hospital setting and in the community setting to provide evidence-based recommendations to PACE decision makers considering implementing an EHR.
doi:10.4338/ACI-2010-09-RA-0055
PMCID: PMC3631909  PMID: 23616858
Evaluation studies; technology evaluation; clinical information systems; patient care team; aged
5.  The Application of JPEG2000 in Virtual Microscopy 
Virtual microscopy (i.e., the viewing of entire microscope specimens on a computer display) is becoming widely applied in microscopy teaching and clinical laboratory medicine. Despite rapidly increasing use, virtual microscopy currently lacks of a universally accepted image format. A promising candidate is JPEG2000, which has potential advantages for handling gigabyte-sized virtual slides. To date, no JPEG2000-based software has been specifically suited for virtual microscopy. To study the utility of JPEG2000 in virtual microscopy, we first optimized JPEG2000 code-stream parameters for virtual slide viewing (i.e., fast navigation, zooming, and use of an overview window). Compression using ratios 25:1–30:1 with the irreversible wavelet filter were found to provide the best compromise between file size and image quality. Optimal code-stream parameters also consisted of 10 wavelet decomposition levels, progression order Resolution-Position-Component-Layer (RPCL), a precinct size of 128 × 128, and code-block size of 64 × 64. Tiling and the use of multiple quality layers were deemed unnecessary. A compression application (JVScomp) was developed for creating optimally parameterized JPEG2000 virtual slides. A viewing application (JVSview) was developed specifically for virtual microscopy, offering all of the basic viewing functions. JVSview also supports viewing of focus stacks, embedding of textual descriptions, and defining regions of interest as metadata. Combined with our server application (JVSserv), virtual slides can be viewed over networks by employing the JPEG2000 Interactive Protocol (JPIP). The software can be tested using virtual slide examples located on our public JPIP server (http://jvsmicroscope.uta.fi/). The software package is freely downloadable and usable for noncommercial purposes.
doi:10.1007/s10278-007-9090-z
PMCID: PMC3043697  PMID: 17999112
JPEG2000; JPIP; telepathology; digital pathology; virtual slide
6.  Pan-Canadian Evaluation of Irreversible Compression Ratios (“Lossy” Compression) for Development of National Guidelines 
New technological advancements including multislice CT scanners and functional MRI, have dramatically increased the size and number of digital images generated by medical imaging departments. Despite the fact that the cost of storage is dropping, the savings are largely surpassed by the increasing volume of data being generated. While local area network bandwidth within a hospital is adequate for timely access to imaging data, efficiently moving the data between institutions requires wide area network bandwidth, which has a limited availability at a national level. A solution to address those issues is the use of lossy compression as long as there is no loss of relevant information. The goal of this study was to determine levels at which lossy compression can be confidently used in diagnostic imaging applications. In order to provide a fair assessment of existing compression tools, we tested and compared the two most commonly adopted DISCOM compression algorithms: JPEG and JPEG-2000. We conducted an extensive pan-Canadian evaluation of lossy compression applied to seven anatomical areas and five modalities using two recognized techniques: objective methods or diagnostic accuracy and subjective assessment based on Just Noticeable Difference. By incorporating both diagnostic accuracy and subjective evaluation techniques, enabled us to define a range of compression for each modality and body part tested. The results of our study suggest that at low levels of compression, there was no significant difference between the performance of lossy JPEG and lossy JPEG 2000, and that they are both appropriate to use for reporting on medical images. At higher levels, lossy JPEG proved to be more effective than JPEG 2000 in some cases, mainly neuro CT. More evaluation is required to assess the effect of compression on thin slice CT. We provide a table of recommended compression ratios for each modality and anatomical area investigated, to be integrated in the Canadian Association of Radiologists standard for the use of lossy compression in medical imaging.
doi:10.1007/s10278-008-9139-7
PMCID: PMC3043739  PMID: 18931879
Compression; JPEG2000; digital imaging; lossy compression; JPEG
7.  IHE cross-enterprise document sharing for imaging: interoperability testing software 
Background
With the deployments of Electronic Health Records (EHR), interoperability testing in healthcare is becoming crucial. EHR enables access to prior diagnostic information in order to assist in health decisions. It is a virtual system that results from the cooperation of several heterogeneous distributed systems. Interoperability between peers is therefore essential. Achieving interoperability requires various types of testing. Implementations need to be tested using software that simulates communication partners, and that provides test data and test plans.
Results
In this paper we describe a software that is used to test systems that are involved in sharing medical images within the EHR. Our software is used as part of the Integrating the Healthcare Enterprise (IHE) testing process to test the Cross Enterprise Document Sharing for imaging (XDS-I) integration profile. We describe its architecture and functionalities; we also expose the challenges encountered and discuss the elected design solutions.
Conclusions
EHR is being deployed in several countries. The EHR infrastructure will be continuously evolving to embrace advances in the information technology domain. Our software is built on a web framework to allow for an easy evolution with web technology. The testing software is publicly available; it can be used by system implementers to test their implementations. It can also be used by site integrators to verify and test the interoperability of systems, or by developers to understand specifications ambiguities, or to resolve implementations difficulties.
doi:10.1186/1751-0473-5-9
PMCID: PMC2954912  PMID: 20858241
8.  2012 International Society for Disease Surveillance Conference 
The International Society for Disease Surveillance held its eleventh annual conference in San Diego on December 4th and 5th, 2012, under the theme Expanding Collaborations to Chart a New Course in Public Health Surveillance. During these two days, practitioners and researchers across many disciplines gathered to share best practices, lessons learned and cutting edge approaches to timely disease surveillance. A record number of abstracts were received, reviewed and presented – the schedule included 99 orals, 4 panels, 94 posters, 5 roundtables and 12 system demonstrations. Presenters represented 24 different countries from Africa, North and South America, Europe, and Asia. Topics covered included, but were not limited to, statistical methods for outbreak detection, border health, data quality, evaluation of novel data streams, influenza surveillance, best practices and policies for information sharing, social network analysis, data mining techniques, surveillance during weather events and mass gatherings, syndrome development, and novel uses of syndromic surveillance data. There were also discussions on the impact of regulations and standards development on disease surveillance, including Meaningful Use and the International Health Regulations.
The 2012 Conference was also host to several exciting keynote and plenary talks, including those given by James Fowler, Professor of Medical Genetics and Political Science at the University of California, San Diego and Bill Davenhall, Global manager of Esri’s Health and Human Service Solutions Group. Plenary speakers Steve Waterman, Centers for Disease Control and Prevention (CDC); Simon Hay, University of Oxford; and Brian McCloskey, Health Protection Agency in London, reflected on the importance of effective collaborations in their respective topics of migrant and border health, malaria disease epidemiology and mass gathering health. National and international representatives from the CDC, the World Health Organization and the Department of Homeland Security also discussed their respective strategic plans for disease surveillance.
In addition, the 2012 Data Visualization Event enabled conference attendees to collaborate and gain knowledge of visualization tools and techniques applied to a rich, de-identified set of ambulatory electronic health record (EHR) data. Participants developed visualizations of chronic disease events using this common data set and presented their work during the evening poster session. The goals for this event were to demonstrate and share visualization tools and techniques that attendees could learn to apply to their own data and also to provide exposure to data elements available in ambulatory EHR systems and highlight their potential for surveillance and research.
My hope is that attendees of the 2012 ISDS Conference strengthened existing collaborations and fostered new ones, and returned to their places of work or study energized with new ideas and approaches to disease surveillance. The challenge for all of us is to sustain this new energy throughout the coming year and to leverage the tools available to us to share best practices and reach out for assistance when needed. We all want to improve the health of our populations, and collaborations will enable us to achieve that goal.
PMCID: PMC3692742
9.  How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings 
Background
Adoption of EHRs by U.S. ambulatory practices has been slow despite the perceived benefits of their use. Most evaluations of EHR implementations in the literature apply to large practice settings. While there are similarities relating to EHR implementation in large and small practice settings, the authors argue that scale is an important differentiator. Focusing on small ambulatory practices, this paper outlines the benefits and barriers to EHR use in this setting, and provides a "field guide" for these practices to facilitate successful EHR implementation.
Discussion
The benefits of EHRs in ambulatory practices include improved patient care and office efficiency, and potential financial benefits. Barriers to EHRs include costs; lack of standardization of EHR products and the design of vendor systems for large practice environments; resistance to change; initial difficulty of system use leading to productivity reduction; and perceived accrual of benefits to society and payers rather than providers. The authors stress the need for developing a flexible change management strategy when introducing EHRs that is relevant to the small practice environment; the strategy should acknowledge the importance of relationship management and the role of individual staff members in helping the entire staff to manage change. Practice staff must create an actionable vision outlining realistic goals for the implementation, and all staff must buy into the project. The authors detail the process of implementing EHRs through several stages: decision, selection, pre-implementation, implementation, and post-implementation. They stress the importance of identifying a champion to serve as an advocate of the value of EHRs and provide direction and encouragement for the project. Other key activities include assessing and redesigning workflow; understanding financial issues; conducting training that is well-timed and meets the needs of practice staff; and evaluating the implementation process.
Summary
The EHR implementation experience depends on a variety of factors including the technology, training, leadership, the change management process, and the individual character of each ambulatory practice environment. Sound processes must support both technical and personnel-related organizational components. Additional research is needed to further refine recommendations for the small physician practice and the nuances of specific medical specialties.
doi:10.1186/1472-6947-9-15
PMCID: PMC2662829  PMID: 19236705
10.  MED22/401: Hypertext Atlas For Pathology Education 
Introduction
Macro- and microscopic pictures play the key role in the pathology diagnosis and education. Collections of annotated digital histological images are being prepared and an interface offering convenient way of dealing with high resolution images and their descriptions was developed. The atlas will be primary used in pre-graduate course of pathology at the University.
Methods
Leica DMLB microscope equipped with the Leica~S1 scanning camera is used to obtain pictures at the resolution of up to5112*5112 pixels, 3*12~bit color. These pictures are digitally manipulated (esp. contrast enhancement and sharpening), downsized to 3000*3000 pixels, 3*8 bit color and archived. Subsequently, these raw images are compressed using JPEG (JFIF lossy format) to 900*900 and 2000*2000 pixel images used in the actual collection. These pictures are logically glued together and described in the atlas source text prepared using the TeX/LaTeX typesetting system. LaTeX2HTML converter is used to produce the actual hypermedia document, while the same source can be used to obtain a more classical printed version of the atlas. The static character of the HTML hypertext document is made dynamic through JavaScript functions, which add the required interactivity.
Results
The atlas is accessible using standard JavaScript enabled Web browsers. There is always one main window with the text, table of content, index, active section headers and other hypertext links, and links to individual images. All the images are displayed in separate windows. The 900*900 pixels images are used as standard resolution pictures, the higher resolution images (2000*2000) are displayed on demand in a separated ``magnifying glass'' window. This interface can be used to compare several pictures displaying them in the same time and providing also a tool to focus on the most important parts of the large windows. Use of the higher resolution images leads to no information loss through this process. The interface could mimic the fine focusing of the microscope that provided the picture and is a series of images taken in consecutive planes of focus.
Discussion
The atlas was primary produced as a stand-alone package, stored on local disc or CD-ROM. In this form it is suitable for pre-graduate and initial postgraduate education. Currently, it is being converted into very flexible, easily available and expandable diagnostic tool available through Internet. The Internet accessible atlas may be easily updated and expanded with new images and text. Images at different compression levels could be stored, the low resolution one used to fast scan and the highest resolution images used for detailed comparison with unknown specimen. Through the very high speed network (e.g. TEN-155) it will be possible to transfer even the raw data images with resolution above3000*3000 pixels.
doi:10.2196/jmir.1.suppl1.e64
PMCID: PMC1761766
Pathology; Telepathology; Dermatopathology; Educational Technology; Multimedia
11.  “Meaningful use” of electronic health records and its relevance to laboratories and pathologists 
Electronic health records (EHRs) have emerged as a major topic in health care and are central to the federal government’s strategy for transforming healthcare delivery in the United States. Recent federal actions that aim to promote the use of EHRs promise to have significant implications for laboratories and for pathology practices. Under the HITECH (Health Information Technology Economic and Clinical Health) Act, an EHR incentive program has been established through which individual physicians and hospitals can qualify to receive incentive payments if they achieve “meaningful use” of “certified” EHR technology. The rule also establishes payment penalties in future years for eligible providers who have not met the requirements for meaningful use of EHRs. Meaningful use must be achieved using EHR technology that has been certified in accordance with functional and technical criteria that are set forth a regulation that parallels the meaningful use criteria in the incentive program. These actions and regulations are important to laboratories and pathologists for a number of reasons. Several of the criteria and requirements in the meaningful use rules and EHR certification criteria relate directly or indirectly to laboratory testing and laboratory information management, and future stage requirements are expected to impact the laboratory as well. Furthermore, as EHR uptake expands, there will be greater expectations for electronic interchange of laboratory information and laboratory information system (LIS)-EHR interfaces. Laboratories will need to be aware of the technical, operational, and business challenges that they may face as expectations for LIS-EHR increase. This paper reviews the important recent federal efforts aimed at accelerating EHR use, including the incentive program for EHR meaningful use, provider eligibility, and EHR certification criteria, from a perspective of their relevance for laboratories and pathology practices.
doi:10.4103/2153-3539.76733
PMCID: PMC3049251  PMID: 21383931
Electronic health records; federal regulations; laboratory information management; laboratory information systems; meaningful use
12.  An approach for aggregating upstream catchment information to support research and management of fluvial systems across large landscapes 
SpringerPlus  2014;3:589.
The growing quality and availability of spatial map layers (e.g., climate, geology, and land use) allow stream studies, which historically have occurred over small areas like a single watershed or stream reach, to increasingly explore questions from a landscape perspective. This large-scale perspective for fluvial studies depends on the ability to characterize influences on streams resulting from throughout entire upstream networks or catchments. While acquiring upstream information for a single reach is relatively straight-forward, this process becomes demanding when attempting to obtain summaries for all streams throughout a stream network and across large basins. Additionally, the complex nature of stream networks, including braided streams, adds to the challenge of accurately generating upstream summaries. This paper outlines an approach to solve these challenges by building a database and applying an algorithm to gather upstream landscape information for digitized stream networks. This approach avoids the need to directly use spatial data files in computation, and efficiently and accurately acquires various types of upstream summaries of landscape information across large regions using tabular processing. In particular, this approach is not limited to the use of any specific database software or programming language, and its flexibility allows it to be adapted to any digitized stream network as long as it meets a few minimum requirements. This efficient approach facilitates the growing demand of acquiring upstream summaries at large geographic scales and helps to support the use of landscape information in assisting management and decision-making across large regions.
Electronic supplementary material
The online version of this article (doi:10.1186/2193-1801-3-589) contains supplementary material, which is available to authorized users.
doi:10.1186/2193-1801-3-589
PMCID: PMC4210460  PMID: 25392769
Digitized stream network; GIS; Aggregation; Landscape information; Large scale assessment
13.  Linking Whole-Slide Microscope Images with DICOM by Using JPEG2000 Interactive Protocol 
Journal of Digital Imaging  2009;23(4):454-462.
The use of digitized histopathologic specimens (also known as whole-slide images (WSIs)) in clinical medicine requires compatibility with the Digital Imaging and Communications in Medicine (DICOM) standard. Unfortunately, WSIs usually exceed DICOM image object size limit, making it impossible to store and exchange them in a straightforward way. Moreover, transmitting the entire DICOM image for viewing is ineffective for WSIs. With the JPEG2000 Interactive Protocol (JPIP), WSIs can be linked with DICOM by transmitting image data over an auxiliary connection, apart from patient data. In this study, we explored the feasibility of using JPIP to link JPEG2000 WSIs with a DICOM-based Picture Archiving and Communications System (PACS). We first modified an open-source DICOM library by adding support for JPIP as described in the existing DICOM Supplement 106. Second, the modified library was used as a basis for a software package (JVSdicom), which provides a proof-of-concept for a DICOM client–server system that can transmit patient data, conventional DICOM imagery (e.g., radiological), and JPIP-linked JPEG2000 WSIs. The software package consists of a compression application (JVSdicom Compressor) for producing DICOM-compatible JPEG2000 WSIs, a DICOM PACS server application (JVSdicom Server), and a DICOM PACS client application (JVSdicom Workstation). JVSdicom is available for free from our Web site (http://jvsmicroscope.uta.fi/), which also features a public JVSdicom Server, containing example X-ray images and histopathology WSIs of breast cancer cases. The software developed indicates that JPEG2000 and JPIP provide a well-working solution for linking WSIs with DICOM, requiring only minor modifications to current DICOM standard specification.
doi:10.1007/s10278-009-9200-1
PMCID: PMC2896636  PMID: 19415383
Digital pathology; telepathology; DICOM; JPEG2000; JPIP; virtual slide; whole-slide imaging; WSI
14.  Linking Whole-Slide Microscope Images with DICOM by Using JPEG2000 Interactive Protocol 
Journal of Digital Imaging  2009;23(4):454-462.
The use of digitized histopathologic specimens (also known as whole-slide images (WSIs)) in clinical medicine requires compatibility with the Digital Imaging and Communications in Medicine (DICOM) standard. Unfortunately, WSIs usually exceed DICOM image object size limit, making it impossible to store and exchange them in a straightforward way. Moreover, transmitting the entire DICOM image for viewing is ineffective for WSIs. With the JPEG2000 Interactive Protocol (JPIP), WSIs can be linked with DICOM by transmitting image data over an auxiliary connection, apart from patient data. In this study, we explored the feasibility of using JPIP to link JPEG2000 WSIs with a DICOM-based Picture Archiving and Communications System (PACS). We first modified an open-source DICOM library by adding support for JPIP as described in the existing DICOM Supplement 106. Second, the modified library was used as a basis for a software package (JVSdicom), which provides a proof-of-concept for a DICOM client–server system that can transmit patient data, conventional DICOM imagery (e.g., radiological), and JPIP-linked JPEG2000 WSIs. The software package consists of a compression application (JVSdicom Compressor) for producing DICOM-compatible JPEG2000 WSIs, a DICOM PACS server application (JVSdicom Server), and a DICOM PACS client application (JVSdicom Workstation). JVSdicom is available for free from our Web site (http://jvsmicroscope.uta.fi/), which also features a public JVSdicom Server, containing example X-ray images and histopathology WSIs of breast cancer cases. The software developed indicates that JPEG2000 and JPIP provide a well-working solution for linking WSIs with DICOM, requiring only minor modifications to current DICOM standard specification.
doi:10.1007/s10278-009-9200-1
PMCID: PMC2896636  PMID: 19415383
Digital pathology; telepathology; DICOM; JPEG2000; JPIP; virtual slide; whole-slide imaging; WSI
15.  A Mobile App for Securely Capturing and Transferring Clinical Images to the Electronic Health Record: Description and Preliminary Usability Study 
JMIR mHealth and uHealth  2015;3(1):e1.
Background
Photographs are important tools to record, track, and communicate clinical findings. Mobile devices with high-resolution cameras are now ubiquitous, giving clinicians the opportunity to capture and share images from the bedside. However, secure and efficient ways to manage and share digital images are lacking.
Objective
The aim of this study is to describe the implementation of a secure application for capturing and storing clinical images in the electronic health record (EHR), and to describe initial user experiences.
Methods
We developed CliniCam, a secure Apple iOS (iPhone, iPad) application that allows for user authentication, patient selection, image capture, image annotation, and storage of images as a Portable Document Format (PDF) file in the EHR. We leveraged our organization’s enterprise service-oriented architecture to transmit the image file from CliniCam to our enterprise clinical data repository. There is no permanent storage of protected health information on the mobile device. CliniCam also required connection to our organization’s secure WiFi network. Resident physicians from emergency medicine, internal medicine, and dermatology used CliniCam in clinical practice for one month. They were then asked to complete a survey on their experience. We analyzed the survey results using descriptive statistics.
Results
Twenty-eight physicians participated and 19/28 (68%) completed the survey. Of the respondents who used CliniCam, 89% found it useful or very useful for clinical practice and easy to use, and wanted to continue using the app. Respondents provided constructive feedback on location of the photos in the EHR, preferring to have photos embedded in (or linked to) clinical notes instead of storing them as separate PDFs within the EHR. Some users experienced difficulty with WiFi connectivity which was addressed by enhancing CliniCam to check for connectivity on launch.
Conclusions
CliniCam was implemented successfully and found to be easy to use and useful for clinical practice. CliniCam is now available to all clinical users in our hospital, providing a secure and efficient way to capture clinical images and to insert them into the EHR. Future clinical image apps should more closely link clinical images and clinical documentation and consider enabling secure transmission over public WiFi or cellular networks.
doi:10.2196/mhealth.3481
PMCID: PMC4296096  PMID: 25565678
mobile phone; photographs; electronic health records; telemedicine
16.  Users' perspectives of barriers and facilitators to implementing EHR in Canada: A study protocol 
Background
In Canada, federal, provincial, and territorial governments are developing an ambitious project to implement an interoperable electronic health record (EHR). Benefits for patients, healthcare professionals, organizations, and the public in general are expected. However, adoption of an interoperable EHR remains an important issue because many previous EHR projects have failed due to the lack of integration into practices and organizations. Furthermore, perceptions of the EHR vary between end-user groups, adding to the complexity of implementing this technology. Our aim is to produce a comprehensive synthesis of actual knowledge on the barriers and facilitators influencing the adoption of an interoperable EHR among its various users and beneficiaries.
Methods
First, we will conduct a comprehensive review of the scientific literature and other published documentation on the barriers and facilitators to the implementation of the EHR. Standardized literature search and data extraction methods will be used. Studies' quality and relevance to inform decisions on EHR implementation will be assessed. For each group of EHR users identified, barriers and facilitators will be categorized and compiled using narrative synthesis and meta-analytical techniques. The principal factors identified for each group of EHR users will then be validated for its applicability to various Canadian contexts through a two-round Delphi study, involving representatives from each end-user groups. Continuous exchanges with decision makers and periodic knowledge transfer activities are planned to facilitate the dissemination and utilization of research results in policies regarding the implementation of EHR in the Canadian healthcare system.
Discussion
Given the imminence of an interoperable EHR in Canada, knowledge and evidence are urgently needed to prepare this major shift in our healthcare system and to oversee the factors that could affect its adoption and integration by all its potential users. This synthesis will be the first to systematically summarize the barriers and facilitators to EHR adoption perceived by different groups and to consider the local contexts in order to ensure the applicability of this knowledge to the particular realities of various Canadian jurisdictions. This comprehensive and rigorous strategy could be replicated in other settings.
doi:10.1186/1748-5908-4-20
PMCID: PMC2673204  PMID: 19358739
17.  Chapter 13: Mining Electronic Health Records in the Genomics Era 
PLoS Computational Biology  2012;8(12):e1002823.
Abstract: The combination of improved genomic analysis methods, decreasing genotyping costs, and increasing computing resources has led to an explosion of clinical genomic knowledge in the last decade. Similarly, healthcare systems are increasingly adopting robust electronic health record (EHR) systems that not only can improve health care, but also contain a vast repository of disease and treatment data that could be mined for genomic research. Indeed, institutions are creating EHR-linked DNA biobanks to enable genomic and pharmacogenomic research, using EHR data for phenotypic information. However, EHRs are designed primarily for clinical care, not research, so reuse of clinical EHR data for research purposes can be challenging. Difficulties in use of EHR data include: data availability, missing data, incorrect data, and vast quantities of unstructured narrative text data. Structured information includes billing codes, most laboratory reports, and other variables such as physiologic measurements and demographic information. Significant information, however, remains locked within EHR narrative text documents, including clinical notes and certain categories of test results, such as pathology and radiology reports. For relatively rare observations, combinations of simple free-text searches and billing codes may prove adequate when followed by manual chart review. However, to extract the large cohorts necessary for genome-wide association studies, natural language processing methods to process narrative text data may be needed. Combinations of structured and unstructured textual data can be mined to generate high-validity collections of cases and controls for a given condition. Once high-quality cases and controls are identified, EHR-derived cases can be used for genomic discovery and validation. Since EHR data includes a broad sampling of clinically-relevant phenotypic information, it may enable multiple genomic investigations upon a single set of genotyped individuals. This chapter reviews several examples of phenotype extraction and their application to genetic research, demonstrating a viable future for genomic discovery using EHR-linked data.
doi:10.1371/journal.pcbi.1002823
PMCID: PMC3531280  PMID: 23300414
18.  The use of regional platforms for managing electronic health records for the production of regional public health indicators in France 
Background
In France, recent developments in healthcare system organization have aimed at strengthening decision-making and action in public health at the regional level. Firstly, the 2004 Public Health Act, by setting 100 national and regional public health targets, introduced an evaluative approach to public health programs at the national and regional levels. Meanwhile, the implementation of regional platforms for managing electronic health records (EHRs) has also been under assessment to coordinate the deployment of this important instrument of care within each geographic area. In this context, the development and implementation of a regional approach to epidemiological data extracted from EHRs are an opportunity that must be seized as soon as possible. Our article addresses certain design and organizational aspects so that the technical requirements for such use are integrated into regional platforms in France. The article will base itself on organization of the Rhône-Alpes regional health platform.
Discussion
Different tools being deployed in France allow us to consider the potential of these regional platforms for epidemiology and public health (implementation of a national health identification number and a national information system interoperability framework). The deployment of the Rhône-Alpes regional health platform began in the 2000s in France. By August 2011, 2.6 million patients were identified in this platform. A new development step is emerging because regional decision-makers need to measure healthcare efficiency. To pool heterogeneous information contained in various independent databases, the format, norm and content of the metadata have been defined. Two types of databases will be created according to the nature of the data processed, one for extracting structured data, and the second for extracting non-structured and de-identified free-text documents.
Summary
Regional platforms for managing EHRs could constitute an important data source for epidemiological surveillance in the context of epidemic alerts, but also in monitoring a number of indicators of infectious and chronic diseases for which no data are yet available in France.
doi:10.1186/1472-6947-12-28
PMCID: PMC3378443  PMID: 22471902
19.  The Relationship between Electronic Health Record Use and Quality of Care over Time 
Objective
Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability.
Methods
The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care.
Results
The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses.
Conclusions
In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.
doi:10.1197/jamia.M3128
PMCID: PMC2705247  PMID: 19390094
20.  Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: A randomized trial 
Importance
Most evaluations of pay-for-performance (P4P) have focused on large-group practices. Thus, the effect of P4P in small practices, where many Americans receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied.
Objective
To assess the effect of a P4P incentive on quality in EHR-enabled small practices in the context of an established quality improvement initiative.
Design
Cluster-randomized trial
Setting, Participants
Small (<10 clinicians) primary care practices in New York City from April 2009-March 2010. A city program had provided all participating practices with the same EHR with decision support and patient registry functionalities and quality improvement specialists offering technical assistance.
Intervention
Incentivized practices were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities or who had Medicaid or were uninsured (maximum payments: $200/patient; $100,000/clinic). Quality reports were given quarterly to intervention and control groups.
Main outcomes and measures
Differences in performance improvement, from beginning to end of the study, between control and intervention practices on aspirin or anti-thrombotic prescription, blood pressure control, cholesterol control, and smoking cessation. Mixed effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention.
Results
Participating practices (n=42 for each group) had similar baseline characteristics, with a mean (median) of 4592 (2500) patients at the incentive group practices and 3042 (2000) at the control group practices. Intervention practices had greater absolute adjusted improvement in rates of appropriate anti-thrombotic prescription (12.0% improvement vs. 6.0% improvement among controls, difference: 6.0% (2.2–9.7%), p=0.001 for intervention effect), blood pressure control improvement (no comorbidities: 9.7% vs. 4.2%, difference: 5.5% (1.6–9.3%), p=0.01 for intervention effect; with diabetes: 9.0% vs. 1.2%, difference: 7.8% (3.2–12.4%), p=0.007 for intervention effect; with diabetes and/or ischemic vascular disease: 9.5% vs. 1.7%, difference: 7.8% (3.0–12.6%), p=0.01 for intervention effect) and improvement in rates of smoking cessation interventions (12.4% vs. 7.7%, difference: 4.7% (−0.3–9.6%), p=0.02 for intervention effect). Intervention practices performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant.
Conclusion and Relevance
Among small EHR-enabled practices, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Since most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time.
ClinicalTrials.gov registration #
NCT00884013
doi:10.1001/jama.2013.277353
PMCID: PMC4013308  PMID: 24026600
21.  Scalable Decision Support at the Point of Care: A Substitutable Electronic Health Record App for Monitoring Medication Adherence 
Background
Non-adherence to prescribed medications is a serious health problem in the United States, costing an estimated $100 billion per year. While poor adherence should be addressable with point of care health information technology, integrating new solutions with existing electronic health records (EHR) systems require customization within each organization, which is difficult because of the monolithic software design of most EHR products.
Objective
The objective of this study was to create a published algorithm for predicting medication adherence problems easily accessible at the point of care through a Web application that runs on the Substitutable Medical Apps, Reusuable Technologies (SMART) platform. The SMART platform is an emerging framework that enables EHR systems to behave as “iPhone like platforms” by exhibiting an application programming interface for easy addition and deletion of third party apps. The app is presented as a point of care solution to monitoring medication adherence as well as a sufficiently general, modular application that may serve as an example and template for other SMART apps.
Methods
The widely used, open source Django framework was used together with the SMART platform to create the interoperable components of this app. Django uses Python as its core programming language. This allows statistical and mathematical modules to be created from a large array of Python numerical libraries and assembled together with the core app to create flexible and sophisticated EHR functionality. Algorithms that predict individual adherence are derived from a retrospective study of dispensed medication claims from a large private insurance plan. Patients’ prescription fill information is accessed through the SMART framework and the embedded algorithms compute adherence information, including predicted adherence one year after the first prescription fill. Open source graphing software is used to display patient medication information and the results of statistical prediction of future adherence on a clinician-facing Web interface.
Results
The user interface allows the physician to quickly review all medications in a patient record for potential non-adherence problems. A gap-check and current medication possession ratio (MPR) threshold test are applied to all medications in the record to test for current non-adherence. Predictions of 1-year non-adherence are made for certain drug classes for which external data was available. Information is presented graphically to indicate present non-adherence, or predicted non-adherence at one year, based on early prescription fulfillment patterns. The MPR Monitor app is installed in the SMART reference container as the “MPR Monitor”, where it is publically available for use and testing. MPR is an acronym for Medication Possession Ratio, a commonly used measure of adherence to a prescribed medication regime. This app may be used as an example for creating additional functionality by replacing statistical and display algorithms with new code in a cycle of rapid prototyping and implementation or as a framework for a new SMART app.
Conclusions
The MPR Monitor app is a useful pilot project for monitoring medication adherence. It also provides an example that integrates several open source software components, including the Python-based Django Web framework and python-based graphics, to build a SMART app that allows complex decision support methods to be encapsulated to enhance EHR functionality.
doi:10.2196/ijmr.2480
PMCID: PMC3815431  PMID: 23876796
electronic health record; personal electronic health record; hospital information systems; medical informatics applications; accountable care organizations; medication adherence
22.  Screening Mammography for Women Aged 40 to 49 Years at Average Risk for Breast Cancer 
Executive Summary
Objective
The aim of this review was to determine the effectiveness of screening mammography in women aged 40 to 49 years at average risk for breast cancer.
Clinical Need
The effectiveness of screening mammography in women aged over 50 years has been established, yet the issue of screening in women aged 40 to 49 years is still unsettled. The Canadian Task Force of Preventive Services, which sets guidelines for screening mammography for all provinces, supports neither the inclusion nor the exclusion of this screening procedure for 40- to 49-year-old women from the periodic health examination. In addition to this, 2 separate reviews, one conducted in Quebec in 2005 and the other in Alberta in 2000, each concluded that there is an absence of convincing evidence on the effectiveness of screening mammography for women in this age group who are at average risk for breast cancer.
In the United States, there is disagreement among organizations on whether population-based mammography should begin at the age of 40 or 50 years. The National Institutes of Health, the American Association for Cancer Research, and the American Academy of Family Physicians recommend against screening women in their 40s, whereas the United States Preventive Services Task Force, the National Cancer Institute, the American Cancer Society, the American College of Radiology, and the American College of Obstetricians and Gynecologists recommend screening mammograms for women aged 40 to 49 years. Furthermore, in comparing screening guidelines between Canada and the United States, it is also important to recognize that “standard care” within a socialized medical system such as Canada’s differs from that of the United States. The National Breast Screening Study (NBSS-1), a randomized screening trial conducted in multiple centres across Canada, has shown there is no benefit in mortality from breast cancer from annual mammograms in women randomized between the ages of 40 and 49, relative to standard care (i.e. physical exam and teaching of breast-self examination on entry to the study, with usual community care thereafter).
At present, organized screening programs in Canada systematically screen women starting at 50 years of age, although with a physician’s referral, a screening mammogram is an insured service in Ontario for women under 50 years of age.
International estimates of the epidemiology of breast cancer show that the incidence of breast cancer is increasing for all ages combined, whereas mortality is decreasing, though at a slower rate. These decreasing mortality rates may be attributed to screening and advances in breast cancer therapy over time. Decreases in mortality attributable to screening may be a result of the earlier detection and treatment of invasive cancers, in addition to the increased detection of ductal carcinoma in situ (DCIS), of which certain subpathologies are less lethal. Evidence from the SEER cancer registry in the United States indicates that the age-adjusted incidence of DCIS has increased almost 10-fold over a 20-year period (from 2.7 to 25 per 100,000).
The incidence of breast cancer is lower in women aged 40 to 49 years than in women aged 50 to 69 years (about 140 per 100,000 versus 500 per 100,000 women, respectively), as is the sensitivity (about 75% versus 85% for women aged under and over 50, respectively) and specificity of mammography (about 80% versus 90% for women aged under and over 50, respectively). The increased density of breast tissue in younger women is mainly responsible for the lower accuracy of this procedure in this age group. In addition, as the proportion of breast cancers that occur before the age of 50 are more likely to be associated with genetic predisposition as compared with those diagnosed in women after the age of 50, mammography may not be an optimal screening method for younger women.
Treatment options vary with the stage of disease (based on tumor size, involvement of surrounding tissue, and number of affected axillary lymph nodes) and its pathology, and may include a combination of surgery, chemotherapy, and/or radiotherapy.
Surgery is the first-line intervention for biopsy confirmed tumours. The subsequent use of radiation, chemotherapy, or hormonal treatments is dependent on the histopathologic characteristics of the tumor and the type of surgery. There is controversy regarding the optimal treatment of DCIS, which is noninvasive.
With such controversy as to the effectiveness of mammography and the potential risk associated with women being overtreated or actual cancers being missed, and the increased risk of breast cancer associated with exposure to annual mammograms over a 10-year period, the Ontario Health Technology Advisory Committee requested this review of screening mammography in women aged 40 to 49 years at average risk for breast cancer. This review is the first of 2 parts and concentrates on the effectiveness of screening mammography (i.e., film mammography, FM) for women at average risk aged 40 to 49 years. The second part will be an evaluation of screening by either magnetic resonance imaging or digital mammography, with the objective of determining the optimal screening modality in these younger women.
Review Strategy
The following questions were asked:
Does screening mammography for women aged 40 to 49 years who are at average risk for breast cancer reduce breast cancer mortality?
What is the sensitivity and specificity of mammography for this age group?
What are the risks associated with annual screening from ages 40 to 49?
What are the risks associated with false positive and false negative mammography results?
What are the economic considerations if evidence for effectiveness is established?
The Medical Advisory Secretariat followed its standard procedures and searched these electronic databases: Ovid MEDLINE, EMBASE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the International Network of Agencies for Health Technology Assessment.
Keywords used in the search were breast cancer, breast neoplasms, mass screening, and mammography.
In total, the search yielded 6,359 articles specific to breast cancer screening and mammography. This did not include reports on diagnostic mammograms. The search was further restricted to English-language randomized controlled trials (RCTs), systematic reviews, and meta-analyses published between 1995 and 2005. Excluded were case reports, comments, editorials, and letters, which narrowed the results to 516 articles and previous health technology policy assessments.
These were examined against the criteria outlined below. This resulted in the inclusion of 5 health technology assessments, the Canadian Preventive Services Task Force report, the United States Preventive Services Task Force report, 1 Cochrane review, and 8 RCTs.
Inclusion Criteria
English-language articles, and English and French-language health technology policy assessments, conducted by other organizations, from 1995 to 2005
Articles specific to RCTs of screening mammography of women at average risk for breast cancer that included results for women randomized to studies between the ages of 40 and 49 years
Studies in which women were randomized to screening with or without mammography, although women may have had clinical breast examinations and/or may have been conducting breast self-examination.
UK Age Trial results published in December 2006.
Exclusion Criteria
Observational studies, including those nested within RCTs
RCTs that do not include results on women between the ages of 40 and 49 at randomization
Studies in which mammography was compared with other radiologic screening modalities, for example, digital mammography, magnetic resonance imaging or ultrasound.
Studies in which women randomized had a personal history of breast cancer.
Intervention
Film mammography
Comparators
Within RCTs, the comparison group would have been women randomized to not undergo screening mammography, although they may have had clinical breast examinations and/or have been conducting breast self-examination.
Outcomes of Interest
Breast cancer mortality
Summary of Findings
There is Level 1 Canadian evidence that screening women between the ages of 40 and 49 years who are at average risk for breast cancer is not effective, and that the absence of a benefit is sustained over a maximum follow-up period of 16 years.
All remaining studies that reported on women aged under 50 years were based on subset analyses. They provide additional evidence that, when all these RCTs are taken into account, there is no significant reduction in breast cancer mortality associated with screening mammography in women aged 40 to 49 years.
Conclusions
There is Level 1 evidence that screening mammography in women aged 40 to 49 years at average risk for breast cancer is not effective in reducing mortality.
Moreover, risks associated with exposure to mammographic radiation, the increased risk of missed cancers due to lower mammographic sensitivity, and the psychological impact of false positives, are not inconsequential.
The UK Age Trial results published in December 2006 did not change these conclusions.
PMCID: PMC3377515  PMID: 23074501
23.  TME11/385: International Pathology Consultations through Internet E-mail and High Resolution Digital Photomicrography 
Journal of Medical Internet Research  1999;1(Suppl 1):e118.
Introduction
Remote consultation though static telepathology, i.e. based on the delivery of still histology images, is one of the most interesting as well as discussed telemedicine fields, due to its suitability for an email implementation, and to the problem of the preliminary image sampling. Current scanning digital cameras can acquire digital images at very high resolutions that allow the acquisition of microscopic images at low optical magnification, decreasing the number of photographs necessary to represent a histology slide. A small number of images can be thus tiled to represent an entire biopsy, obtaining a visual representation that resembles that of light microscope. In this way, no real sampling is needed. The present paper discusses this approach in conjunction with the Internet Electronic mail.
Methods
The acquisition device: the images were acquired through a photoscanner, which incorporates a linear CCD chip, that slides onto the image field as in flatbed scanners. This allows for very high resolutions (up to 3400x2700 pixels) at a cost considerably lower than equivalent digital cameras, but with higher time for acquisition (1-2 minutes). This allows for the acquisition of low magnification large fields which at the same time contain as much detail as higher magnification fields. 20:1 JPEG compression has been adopted for reducing storage size. E-mail protocols and formats: MIME is a message format for heterogeneous, possibly encrypted and signed, multimedia e-mail still deliverable by the usual protocols, i.e. SMTP and POP. MIME is adequate for representing a static telepathology case composed of text data and a set of histology images. In our study, we used the Netscape Communicator 4.0 mail agent. Material: The study included two steps. The former involved the delivery of 31 cases acquired by a senior pathology resident, the latter 30 cases acquired by a physician with little pathology knowledge, both in Cedars-Sinai Medical Center and e-mailed to Udine University for interpretation.
Results
In the first step, twenty-eight cases (93.5%) were correctly diagnosed by telepathology. In the second step, two cases had insufficient images, and seventeen (60.7%) were correctly diagnosed by telepathology. Experiments in sending digitally signed and encrypted cases have been done, with some interoperability problem.
Discussion
High-resolution digital photomicrography and the Internet offer useful tools for telepathology consultations. Our preliminary results show that the diagnostic accuracy decreases with the knowledge of the image sampler. This makes static telepathology more suitable for remote expert consultation than as a mean for primary diagnosis on material selected by a technician. Furthermore, this technology is probably best suited for the study of small specimens, such as biopsies. However, e-mail protocols provide for a range of features that, when used, makes its use highly valuable in telemedicine and telepathology.
doi:10.2196/jmir.1.suppl1.e118
PMCID: PMC1761731
Telemedicine; Remote Consultation; Telepathology; Internet; Electronic Mail
24.  Electronic Healthcare Record and Clinical Research in Cardiovascular Radiology. HL7 CDA and CDISC ODM Interoperability 
Integrating clinical research data entry with patient care data entry is a challenging issue. At the G. Pompidou European Hospital (HEGP), cardiovascular radiology reports are captured twice, first in the Electronic Health Record (EHR) and then in a national clinical research server. Informatics standards are different for EHR (HL7 CDA) and clinical research (CDISC ODM). The objective of this work is to feed both the EHR and a Clinical Research Data Management System (CDMS) from a single multipurpose form. We adopted and compared two approaches. First approach consists in implementing the single “care-research” form within the EHR and aligning XML structures of HL7 CDA document and CDISC ODM message to export relevant data from EHR to CDMS. Second approach consists in displaying a single “care-research” XForms form within the EHR and generating both HL7 CDA document and CDISC message to feed both EHR and CDMS. The solution based on XForms avoids overloading both EHR and CDMS with irrelevant information. Beyond syntactic interoperability, a perspective is to address the issue of semantic interoperability between both domains.
PMCID: PMC2655824  PMID: 18693829
HL7; CDA; CDISC; ODM; Medical Records Systems; Computerized; Biomedical Research; Clinical trial; Radiology; Interventional; Cardiovascular systems
25.  Pseudonymization of Radiology Data for Research Purposes 
Journal of Digital Imaging  2006;20(3):284-295.
Medical image processing methods and algorithms, developed by researchers, need to be validated and tested. Test data would ideally be real clinical data especially that clinical data is varied and exists in large volumes. Nowadays, clinical data is accessible electronically and has important value for researchers. However, the usage of clinical data for research purposes should respect data confidentiality, patient right to privacy, and patient consent. In fact, clinical data is nominative given that it contains information about the patient such as name, age, and identification number. Evidently, clinical data needs to be de-identified to be exported to research databases. However, the same patient is usually followed during a long period of time. The disease progression and the diagnostic evolution represent extremely valuable information for researchers as well. Our objective is to build a research database from de-identified clinical data while enabling the data set to be easily incremented by exporting new pseudonymous data, acquired over a long period of time. Pseudonymization is data de-identification, such that data belonging to an individual in the clinical environment still belong to the same individual in the de-identified research version. In this paper, we explore various software architectures to enable the implementation of an imaging research database that can be incremented in time. We also evaluate their security and discuss their security pitfalls. As most imaging data accessible electronically is available with the digital imaging and communication in medicine (DICOM) standard, we propose a de-identification scheme that closely follows DICOM recommendations. Our work can be used to enable electronic health record (EHR) secondary usage such as public surveillance and research, while maintaining patient confidentiality.
doi:10.1007/s10278-006-1051-4
PMCID: PMC3043895  PMID: 17191099
Research database; confidentiality; security; privacy; de-identification; pseudonymization; nominative health care data; radiology; medical imaging

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