Healthcare Telematic Applications in Cyprus

Summary Objectives: a) To present a review of ongoing health telematic applications in Cyprus. b) To promote the use of these health telematic applications in the Cyprus region. c) To help in the spin off of other health telematic applications thus enabling the offering of a better health service to the citizens. Methods and Results: The health telematics applications include a medical system for emergency telemedicine (AMBULANCE and EMERGENCY-112 projects), a system for the evaluation of the risk of stroke by telemedicine (EROS), a diagnostic telepathology network in gynaecological cancer (TELEGYN), a collaborative virtual medical team for home healthcare of cancer patients (DITIS), and a health telematics training network (HEALTHNET). The paper refers to the set-up and characteristics of these applications and tries to relate them with the health policies that should be applied in Cyprus. Conclusions: It is anticipated that this paper will promote the importance of health telematics applications for Cyprus and increase the awareness on the possibilities that these applications offer for health policies in all levels of health related human resources.


Introduction
Rapid advances in information technology and telecommunications and their convergence (telematics) are leading to the emergence of a new type of information infrastructure that has the potential of supporting an array of advanced services for healthcare. In Europe during the last decade, information technologies had played a decisive role in health care and health prevention. In the constant competition for resources in the health sector, these new so-called telematics technologies and applications would not stand much of a chance if they were not intended to improve the quality of care, directly or indirectly, to help in the cost-containment and better management of the health sector, and to increase competitiveness of the health telematics industry (1). Cyprus, although at its infancy in health telematics, is actively participating in a number of promising applications covering a spectrum of diseases. The objective of this paper is to illustrate the progress carried out in these efforts, to show the potential benefits of these efforts, and most importantly to prompt the spin off of more applications as well as trigger the drawing of a national strategic plan, thus enabling the offering of a better service to the citizen.
Cyprus is situated in the northeastern part of the Mediterranean Sea, and has an area of 9.251 square kilometres. The present population of Cyprus is estimated at 754.800. The population in the Government controlled area is estimated at 666.800 as at the end of 1999. Cyprus has applied to become a member of the European Union in 1990. The capital of the island is Nicosia with a population of 197.800. Throughout the year the number of tourists visiting the island exceeds 2,4 million. There are four general hospitals,

Summary
Objectives: a) To present a review of ongoing health telematic applications in Cyprus. b) To promote the use of these health telematic applications in the Cyprus region. c) To help in the spin off of other health telematic applications thus enabling the offering of a better health service to the citizens. Methods and Results: The health telematics applications include a medical system for emergency telemedicine (AMBULANCE and EMERGENCY-112 projects), a system for the evaluation of the risk of stroke by telemedicine (EROS), a diagnostic telepathology network in gynaecological cancer (TELEGYN), a collaborative virtual medical team for home healthcare of cancer patients (DITIS), and a health telematics training network (HEALTHNET). The paper refers to the set-up and characteristics of these applications and tries to relate them with the health policies that should be applied in Cyprus. Conclusions: It is anticipated that this paper will promote the importance of health telematics applications for Cyprus and increase the awareness on the possibilities that these applications offer for health policies in all levels of health related human resources. systems, as well as lack of a proper health information system infrastructure.

Keywords
The computerisation of the Governmental Health Information Support System (HISS) commenced in 1989 as a co-project between the Ministry of Health and the East Mediterranean Region Office (EMRO) of the World Health Organisation (WHO). Firstly, the Patient Administration System (PAS) module was implemented. The pilot commenced in 1991 at Archbishop Makarios III hospital in Nicosia and was successfully completed in 1993. WHO evaluated the results of the pilot implementation at a regional conference in Limassol in June 1993. Subsequently, the Ministry of Health, in collaboration with the Department of Information Technology Services, proceeded with the PAS implementation in the other three General Hospitals which was completed in March 1999. The PAS module is currently being implemented at the three rural hospitals.
The Ministry of Health decided to proceed with the further implementation of HISS modules at all Government hospitals, outpatient departments and rural health centres. The health information system will be expanded to cover all disciplines, including pharmacy, pathology, radiology, laboratories, theatre management, blood bank, clinical management support, order management, manpower, estate, availability and use of facilities, etc. However, the implementation of this decision is moving very slowly. Moreover, the Ministry of Health, within 2001, will be connected to the Government Data Network that which will facilitate the delivery of high speed ATM/Frame Relay services.
Due to the rising expenditure of the current health services infrastructure (3), the Government is planning the introduction of an effective National Health Insurance Scheme (NHIS). The main points of the proposed NHIS are to offer: (i) medical treatment to the entire population of the Republic irrespective of their financial situation, by compulsorily contributing to a "global budget", (ii) the freedom of the patient to choose his/her doctor and/or medical institution to be treated, and (iii) state-of-the-art medical treatment (4).
In this paper, the following health telematics applications are presented in sections 2 to 6: a medical system for emergency telemedicine (AMBULANCE and EMERGENCY-112 projects), a system for the evaluation of the risk of stroke by telemedicine (EROS), a diagnostic telepathology network in gynaecological cancer (TELEGYN), a collaborative virtual medical team for home healthcare of cancer patients (DITIS), and a health telematics training network (HEALTH-NET). Section 7, covers some additional activities of health telematics, and section 8 covers the concluding remarks.

A Medical Device for Emergency Telemedicine: the Ambulance and Emergency-112 Projects
The objectives of AMBULANCE and EMERGENCY-112 (5, 6), two projects sponsored by the EU and in which Cyprus actively participated, were the development and testing of a portable device allowing emergency telemedicine services between ambulance vehicles and distanced expert physicians via wireless communication. The ultimate goal was to produce a marketable system that will significantly enhance pre-hospital care. The emergency telemedicine system consists of two separate modules (7): (i) the mobile unit (ambulance site), and (ii) the consultation unit (hospital site). Diagnostically important data, like ECG, blood pressure, heart rate, oxymetry, temperature, etc., are collected via a biosignal monitor connected to a portable computer at the mobile site and are transmitted through the GSM mobile telephony network to the hospital site. Images of the patient's position and state are still captured through a small camera and transmitted. The specialist at the hospital site can observe the signals in real-time, view the images of the patient and mark some interesting areas (whiteboardring), a marking that appears simulta-neously on the mobile screen. Thus, he is able to assess the severity of the emergency and through a bidirectional GSM voice communication can instruct the paramedic how to handle the case. The system is supported by a multimedia database, which stores all information available from the time the system is initialized until the arrival of the patient at the hospital. Apart from the GSM communication link, the system supports satellite links, and normal telephone lines communications, as well as operation in Local Area Networks.
The system addresses multiple user needs including: ongoing integration of pre-hospital and in-hospital emergency care systems, new and better therapies available for medical emergencies, demands for cost efficient health programs, integration of emergency handling records into modern computer files, and higher public demands for medical emergency systems. The potential fields of use for the system can be summarised as follows: assessing the severity of multiple trauma, directing handling of major bleeding and life threatening cardiac arrhythmia's, directing on-scene thrombolytic therapy in acute myocardial infarction, directing use of CPAP-ventilation on scene, directing analgesia for stacked victims, and directing priorities in cases of multiple victims.
The system was evaluated and verified in Cyprus, Greece, Italy and Sweden. Each pilot recorded certain time indicators, such as time-to-transportation, time-to-starttreatment, time-to-stabilization, etc., in a total of 100 cases in which the system was used and in another 100 cases without using the system, in order for comparative results to be deduced. It was shown that the system provides significant support to the early and specialized pre-hospital patient management and to emergency case survival. The diagnosis at the scene of an emergency, as well as the handling of the case, was substantially improved through on-line access to medical specialists, which decreased the time to make the first diagnosis and start the appropriate treatment. Severe or multiple trauma patients were better assessed, while the electronic registration of the patient's data freed the ambulance personnel of any paper work and helped

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devoting more time on real emergency care. The system can be further used in directing the management of stacked victims and setting priorities in cases of major incidents (TRIAGE). It can also contribute to directing the transport of victims, thus reducing the time of arrival at the hospital.

EROS: Evaluation of the Risk of Stroke by Telemedicine
Stroke is the third leading cause of death in the Western World and the major cause of disability in adults. The objective of the proposed study is to develop an integrated teleconsultation system for the estimation of the annual incidence of stroke related to carotid atherosclerotic plaque and the detection of high risk and low risk subgroups of patients. The identification of high and low risk subgroups of patients will be a decisive factor for the selection of the therapy, i.e. medical or surgical. Thus, only patients at high risk will be considered for carotid endarterectomy, while patients at low risk will be spared from an unnecessary and expensive surgery that also carries a risk. The knowledge base of the system will be based on a total of 800 cases that have been collected under the EU BIOMED II ACSRS project for the identification of individuals with asymptomatic carotid stenosis at risk of stroke. It is anticipated that the major outcome of this project will be the establishment of a standardised methodology facilitated via the teleconsultation system that can be used to identify patients at high risk of stroke.
The pilot development of a computer aided system that facilitates the automated characterization of carotid plaques for the identification of individuals with asymptomatic carotid stenosis at risk of stroke is briefly presented (8,9). Ultrasound scans of carotid plaques were performed using duplex scanning and color flow imaging. The gray level of the image was then standardised using blood and adventitia as reference, and the plaque was manually outlined. From the segmented plaque images, ten different texture feature sets and shape parameters, a total of 61 features, were extracted. The plaques were classified into two types: (i) symptomatic because of ipsilateral hemispheric symptoms, or (ii) asymptomatic because they were not connected with ipsilateral hemispheric events. For the plaque classification, a modular neural network system composed of self-organizing feature map (SOFM) classifiers, was used. For each feature set, an SOFM classifier was trained and the ten classification results were combined using majority voting.
A total of 166 (76 symptomatic and 90 asymptomatic) ultrasound images of carotid plaques were analysed. The statistics of all features extracted for the two classes indicated a high degree of overlap. The neural network system was trained and evaluated using five different bootstrap sets where in each set 116 different plaques were selected at random for training and 50 different plaques for evaluation. The average diagnostic yield obtained by the ten different feature sets was 62.4%. Combining the ten classification results significantly improved the average diagnostic yield up to 76.4% when combined with weighted averaging (8,9). The results of this study show that it is possible to identify a group of patients at risk of stroke based on texture features extracted from ultrasound images of carotid plaques. This group of patients will benefit from a carotid endarterectomy whereas other patients will be spared from an unnecessary operation.

TELEGYN: Diagnostic Telepathology Network -Application in Gynaecological Cancer
Gynaecological cancer (breast, ovarian, endometrial, cervical) consists of a large number of tumors with variable presentation and often unpredictable malignant potential, making patient management demanding but alsoand challenging.
Surgery plays a significant role in the management of most gynaecological benign and malignant tumours. However, even the most experienced surgeon is totally reliant on intraoperative histopathological evaluation for distinguishing between malignant and benign disease. In practice, expert histopathologists with experience in each human body system cannot be found next to each surgeon. As a result in most cases, therapy is based on postoperative histopathological diagnosis including second opinions, such as consultations from experts at remote sites. The main objective of this initiative is to establish a telepathology network which will offer online dynamic intraoperative and postoperative consultations between a panel of experts using a telepathology network to transmit video (laparoscopic scenes), still images (histopathologic specimen images), and clinical data. Medical experts will also use network resources, in particular data and knowledge repositories, for offline investigations. A typical telepathology system that involves surgery, histopathology, and telepathologic interaction between medical experts is currently being implemented (10). In this system, laparoscopic video sequences may be reviewed by the expert histopathologist who in turn may provide further advice to the surgeon. Depending on the diagnosis, additional specialized biopsy slides may be prepared and assessed. In urgent cases, intraoperative diagnoses will be attempted to help the surgeon optimize first surgery. If the necessary expertise is not locally available or a second opinion is needed, histopathologists may utilize the telepathology network to consult a specialist using available video and clinical data. In addition, there is a digital library module where the biopsy slide image data together with other clinical data and possibly pre-existing patient data are stored and updated.
A Biopsy Analysis Support System, named BASS (11)(12)(13), was developed to enable the automated analysis of breast cancer biopsy slides, as well as, the contentbased image retrieval. A database of cases (DBC) was generated using 47 breast cancer biopsy slides immunolabelled for Methods Inf Med 5/2002 prognostic factors, estrogen or progesterone, where two medical experts selected and digitized up to three regions of interest from each slide. The biopsy analysis module is divided into a standardization stage, an adaptive nuclei detection stage (11,12), and a trainable neural network based classification stage (13). The output of the analysis module describes the content of each biopsy image. All digitized images are transformed from RGB color space to the YIQ color space. In YIQ space, the luminance (Y channel) and the chromaticity (I, Q channel) of a color images are clearly separated. BASS uses the luminance image for the detection of candidate nuclei, while for the classification module utilizes features based on all three channels.
BASS' classification stage (13) uses a widely accepted manual grading scheme for accurately assessing staining intensity and heterogeneity of the nuclei populations in the biopsy slides. According to the grading scheme, nuclei are assigned to one of five staining intensity classes (negative, weak, moderate, strong, very strong). Depending on the proportions of the classified nuclei, one final H-Score out of five possible values (0, 1+, 2+, 3+, 4+) is assigned to the biopsy. The input to the classification stage consists of a six-dimensional feature vector. The feature vectors are based on a fixed number of pixels in a small circular neighborhood of each nuclei candidate center location. The features are optical density, two chromaticity values, a variance based texture measure, and the average optical density and variance of all nuclei candidates in the biopsy image. A 72% correct classifications score was obtained by the neural network based classification stage on the evaluation set of cases (13).

DITIS: Collaborative Virtual Medical Team for Home Healthcare of Cancer Patients
Complex and chronic illnesses, such as cancer demand the use of specialised treatment protocols, administered and monito-red by a co-ordinated team of professionals. Home-based care of chronic illnesses (e.g. cancer patients) by a team of professionals is often a necessity, due to the protracted length of the illness, whereas hospital based treatment is limited, often demand-based for short periods of time. As it is not possible for the health care team to be physically present by the patient at all times, or at any time physically together, whilst the patient is undergoing treatment, a principal aim of the current project is to overcome this problem, through DITIS (⌬⌱⌻⌯⌺, in Greek, stands for: Network for Medical Collaboration) (14,15). DITIS is a system that supports Virtual Medical Teams dealing with the home-healthcare of cancer patients in Cyprus. It aims to support the creation, management and co-ordination of virtual medical teams, for the continuous treatment of the patient at home, and if needed for periodic visits to places of specialised treatment and back home.
The design and development of DITIS tele-cooperation system is based on internet and GSM/WAP connectivity, and includes the following five modules (14,15): (i) Mobile agents e.g. IBM's aglets workbench, Mitsubishi's Concordia, and Voyager, for the implementation of a flexible communication infrastructure for the support of mobile users. The mobile agents may be extended to offer intelligence and cooperation. (ii) Web based database for the storage and processing of the Electronic Medical Record. (iii) Telecooperation system for sharing of information, team communication, coordination of team activities, and (iv) Adaptive intelligent interface for database access from a variety of access units, such as mobile computing units with GSM internet connectivity, and fixed units with internet access supporting tele-cooperation.

HEALTHNET: Health Telematics Training Network
Health care continuous education is a crucial factor that influences the quality of the delivered health care services. The wWorldwide medical research efforts accumulate new medical knowledge, while change and refresh the existing knowledge on a continuous basis. The healthHealth care professionals will become more effective in the delivery of health care only if they are aware of new findings and ongoing research efforts. Tele-education and distancet learning offer new opportunities to the practice of the medical profession and the training of the 800.000 physicians and 1.600.000 nurses practicing in Europe. Furthermore, experience has shown that an inhibiting factor for the widespread introduction of new technologies and services and their adoption in every day clinical practice is the inertia and sometimes resistance of users in accepting these technologies. Health care professionals are increasingly confronted with information technology. However, most of them lack a good understanding of the fundamentals, usefulness, possibilities and limitations of information technology.
In the HEALTHNET project, an attempt was made to compile a complete syllabus to cover all the needs of the physician related to teleworking (16). In this respect, it was decided that for the given resources, and the limited amount of time available by the physicians, to cover the syllabus on networking, internet, and teleworking in the health sector. The project mainly aims at the physicians who form the most important user group in the healthcare delivery. On the other hand, we should not underestimate the contribution of the paramedical and the administrative personnel. While they have well-defined roles concerning the use of the new technology tools, they usually use these tools on behalf of the physicians.
Furthermore, the University of Cyprus, in collaboration with the Cyprus Institute of Neurology and Genetics, and the Nicosia General Hospital, are participating in the following EU Leonardo da Vinci projects related to training in health telematics:

Other Activities
The need for exchange of medical expertise and knowledge and access of information of all Cypriots to centers of medical excellence in hours of need has been hindered by the lack of direct contact between the two communities (Greek Cypriot and Turkish Cypriot). The Neurological and Genetic Networking (NeuroNet) project aims at introducing telemedicine applications through the establishment of an internet networking infrastructure, which will allow easy and fast exchange of medical expertise and data for neurological diseases with high prevalence in both communities. A distributed data bank will be developed that will include clinical, genetic, imaging and laboratory data. The system will be initially applied to multiple sclerosis patients.
In August 1998, a new video conferencing system was installed at the Paraskevaidion Surgical and Transplant Center in Cyprus. The system allows Orthopaedic doctors in Cyprus to efficiently communicate with their colleagues at the Shriners Hospital, U.S.A. Doctors at the Shriners Hospital can assess difficult cases of children with orthopaedic problems examined in Cyprus. Clinical data, together with imaging data (e.g. X-rays), and other important information are transmitted to enable the better management of the patient.
The Clinic of Oncology Radiation Therapy and Radiation Diagnostics of the Bank of Cyprus Oncology Centre is participating in the EU projects TELEPLAN and VIRTUOSO. The TELEPLAN project is focusing in the field of teleconsultation based stereotactic radiation surgery and treatment planning. The following clinics are participating: Goettingen and Berlin, Germany, Florence, Italy, and the Athens Medical Centre, Greece. The VIRTUOSO project is investigating the application of teleconsultation in the planning of treatment of patients for oncology radiation therapy through virtual simulation. The participating clinics include Offenbach, Germany, and Innsbruck, Austria.
A teleconference system equipped with a data camera, and with the option to transmit live video directly from echo equipment has been donated recently to Makarios Hospital in Nicosia.The system is intended for presentations, discussions and getting or giving a second opinion about specific patients, as well as, to familiarize the health professionals with the use and the benefits of the new technologies. This system is operated by the Cyprus Society of Medical Informatics. The Cyprus Society of Medical Informatics was established in 1997, and now has more than 180 members, mainly physicians. It has organized numerous courses about computer basics and health telematics, and is extremely active in the promotion of information technology in the health profession.

Concluding Remarks
Some recommendations that will help the wide spread of medical informatics, incorporating health telematics in Cyprus follow. A number of these recommendations are based on studies carried out for the Ministry of Health by different institutes (17)(18)(19).These recommendations are as follows: 1. High level political decision, commitment and leadership for the immediate promotion and application of medical informatics technology in all operations of the Ministry of Health, incorporating all hospitals and regional health centres. 2. Adoption of electronic patient health records for all Cypriot citizens, to facilitate not only the efficient handling of patient care but also the collection of national health data. 3. Development of a health communications network supporting all the activities of the healthcare sector for the easy access and efficient exchange of medical data.The network should provide secure and confidential internet access to physicians working in both the public and private sectors. 4. Expansion of the health communications network to nearby Mediterranean, and European countries. This effort could be made possible through EMRO WHO and European projects.
5. Training of the physicians, the paramedical and administrative staff on the use and benefits of information technology.
The adoption of the planned National Health Insurance Scheme, linked with EU harmonization reforms required in the health system would enable the fast implementation of the medical informatics and health telematics infrastructure. The above infrastructure, once developed, should be further exploited with the new paradigm of citizen-centred shared care promoted by the European Commission in the (5th) Framework Programme (20)]. This new paradigm builds on health telematics networks and services, linking hospitals, laboratories, pharmacies, primary care and social centres offering to individuals a "virtual healthcare centre" with a single point of entry. The information shared by all care providers is patient health-related information (electronic healthcare records) that is comprehensible, reliable and confidential. These networks will vary in capacity scale and security features all the way from optical fibre networks to simple telephony networks and internet communication. Special emphasis will be given to systems for personal health monitoring and prevention, including advanced sensors and micro-systems. Internet health support services to citizens offering health monitoring and prevention services, or between the health professionals for teleconsultation and collaborative work, are being set up all over the world.
Medical informatics and healthcare telemetics contribute in forming a new basis for the practice of medicine, targeting in the better delivery of healthcare not only in Cyprus but worldwide. Emerging technological trends like pervasive computing (enabling the seamless human-computer interactions with multimedia databases, "smart" cards), intelligent agent technology, electronic commerce applications in the healthcare sector, high-bandwidth Web, mobile computing, and citizen-centred services provide promising solutions for healthcare applications (21). However, more work and efforts are needed in the areas of interoperability, standards, security and legal issues at both, national, and

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international levels to enable the wider application of health telematics in all areas of medicine should not be underestimated (1). Cyprus should accelerate its pace in medical informatics and healthcare telematics for the whole of the health care sector thus enabling the offering of a better service to the citizens.