Selected eHealth Applications in Cyprus from the Training Perspective

Summary Objectives: In this paper a review of selected eHealth applications in Cyprus is presented linked with their success or failure based on their training activities. Methods: The eHealth systems presented and their training activities include an update of the health information system (HIS) in the public hospitals, a medical system for emergency telemedicine (AMBULANCE and EMERGENCY-112 projects), a home monitoring system for cancer patients (DITIS), a satellite-based network in healthcare applications (EMISPHER and HEALTHWARE projects), and the training activities of the Cyprus Society of Medical Informatics. Different methodologies for training were used ranging from classical approaches like train the trainers, using demo cases followed by personal training, group training, and workshops, to more recent methodologies based on eLearning sessions including teleconsultations. Results: The training was carried out successfully in all cases. However, not all eHealth systems were put into practice successfully, mainly for reasons not related to training. Conclusions: It is anticipated that this paper will promote the importance of these applications and their training activities as well as help in the spin off of others thus enabling the offering of a better service to the citizen.


Introduction
Rapida dvances in information technology andt elecommunicationsa nd their convergence(telematics) are leading to the emergenceo fanewt ype of information infrastructure that hasthe potential of supporting an arrayo fa dvanced servicesf or healthcare. This is commonly callede Health. In the constant competition forresources in the health sectort hese newe Health technologiesa nd applicationsw ould not stand muchc hancei ft heyw eren ot intendedt o improvethe quality of care, directly or indirectly,t oh elpi nt he cost-containment and better management of the health sector, and to increase competitiveness of the medical informaticsi ndustry, including health telematics [ 1]. Cyprus,a lthougha ti ts early stages in eHealth systems, is activelyp articipating in an umber of promising applicationsc overing as pectrumo fh ealthcare processes andservices. Theobjective of this paperi st op rovide as napshot of selected eHealtha pplications, and to discuss their trainingactivitiesleading to their success or failure.
In Cyprusthere wasamajor efforttointroduceah ealth information system (HIS) in the public hospitals whichi sc onsidered to have been ap artialf ailure. At the same time severalt elematicsp ilot projectsw ere fundeda nd developed buto nlyafewa re currentlyb eing used anda re consideredt o be successful. We will presentthe effortto introducethe HIS (the outcome of thisproject wasnot what it wase xpected), andw e will also discussthe efforts for anew initiativetointroduceanew HISfor the public hospitalswhich is currentlyunderway.Also, three health telematicsp rojectsa re pres-ented relatedt oe mergency telemedicine, home monitoring, andasatellite-based network thatcan be used for healthcareapplications.Thetraining aspectsofall these projects arep resented along with the reasons for their success or failure. Furthermore,the training activitiesofthe Cyprus Societyof Medical Informatics arepresented.

TheHealth Information
Systemofthe Ministry of Health [2] Thei ntroduction of the Governmental Health Information System commenced in 1989 as aco-project between the Ministryof Health of the Republic of Cyprus andt he East Mediterranean Region Office (EMRO) of the Wo rld Health Organization (WHO). Firstly, the Patient Administration System (PAS) module wasi mplemented. The pilot commenced in 1991 at Archbishop Makarios III HospitalinNicosia andwas successfullyc ompleted in 1993.W HO evaluated the results of the piloti mplementation at a regionalc onferencei nL imassoli nJ une 1993. Subsequently, the MinistryofHealth in collaboration with the Department of Information Technology Servicesp roceeded with the PA Si mplementation in the other three district generalh ospitalsw hich was completedinMarch 1999. TheP AS module wass ubsequentlyi ntroduced at three rural hospitals. Otherm odules besidest he patient'sp ersonala nd demographic data that have been introduced at the four hospitals are: i) doctor'sregister, ii) scheduling for the outpatient department, iii) outpatient encounters,and iv)in-patientregister.
Theinitial training of userswas delayed in relation to the deployment of the system at the firsts ite (Makarios Hospital) which delayedt he whole process. Thet raining startedwith the firstgroup of administrative staffa nd the nursing personnelf ollowed. To date 760 employees have been trained from allt he hospitals, 80% of them are nursing personnel, about 20% administrative staffand asmall numberare medical staff.
In June 2003, the MinistryofHealth and the Department of Information Technology Serviceso ft he Ministryo fF inanceh ave published an expression of interest (EOI) document for the establishment of aturnkey solutiono faready-madea pplication software for an Integrated Health Care Information System (IHCIS). The system will covert he clinical,a dministrative andf inanciala ctivitieso fb oth the NewN icosia General Hospitala nd the NewF amagusta GeneralH ospital.T he envisioneds ystem will have the capability forafull electronic patientrecord,beweb-enabled andsupport the vision of the Ministryo fH ealth for paperless andfilmless hospitals. TheIHCIS consists of the following 13 modules: Patient Administration,E lectronic Health Care Record,H ospital OrderE ntry, Clinical Laboratory, Radiology/PACS, Billing, StockC ontrol, PrescriptionM anagement, PersonnelM anagement, Blood Bank, Health SmartC ard, Histopathology, and Coding andClassification of clinical terms. At present the evaluation of the tenders is in progress, andt he deployment of the first phase is expected to be completedb ym id 2007.
Thet enders shallp ropose, design, and implement appropriatet raining packages for each of the modules of the IHCIS listed above andanintroductorycourse regarding the overalls ystem functionality shallb e provided to allu sers. Thet enders hall provide adetailedplanofthe training courses, outlining andj ustifying the sequence and frequencyofthe courses, and shalldescribe the wayand practicetoensure asuccessful training outcome.The tenders hall include detailed information for alloffered training coursesi ncluding the following: course name, duration (hrs), location, aims of the trainingc ourse,c ourse outline, instructors qualifications, and offeredc ertification at the endofthe training course.
Ad etailedl isto fp rospectiveu sers has alreadyb een preparedf or training andi ncludesaround a1000 and250 usersfor the NewNicosia andNew FamagustaHospitals respectively.ATraint he Trainers methodology will be followed, whereagroup of ten expert userswill be traineda nd will be responsible for further endu ser traininga nd firstline supportineach of the hospitals.
Thewhole project is expected to take 12 months.I ts hould be noted that thist ime schedule is consideredt ob eo ptimistic by an umber of officersi nt he Ministryo f Health, based on the rather limited information technology experience of the personnelofthe hospitals. However, the plans at present are to proceed as originally scheduled.
Furthermore,t he University of Cyprus, in collaboration with the MinistryofHealth andthe Pafos General Hospitalhas recently been awardedanewI NTERREGI II B ArchimedP rogram project entitled" A Mediterranean Research andH igher Education Intraneti nM edical andB iological Sciences" [3]. The aimo ft his project is the development of am edical educational/ research intranet between higher education andresearch institutions fromGreece, Italy andC yprus,t os upportt he undergraduate educational program,graduate practiceand residencya nd to promote research collaborationsb y: i) dissemination of web-based lecturesa nd seminars,c overing advanced scientific topicsa nd up-to-date technologies, and ii) promotion of research collaborationst hrough web-based shared workspaces.
Thea im of the AMBULANCE project wasthe development of aportable emergency telemedicine devicet hats upports realtime transmission of critical biosignals as well as still imagesofthe patientusing the GSMlink.This device can be used by paramedicso rn ot specialized personnelt hat handle emergencycases in ordertoprovide telediagnosis, long distances upporta nd directionsf rom expert physicians located at an emergencyc oordination centero ra specialized hospital.
Thesystem can be used for different cardiovascular or severe injuriescases. It comprises of twod ifferent modules: i) the mobile unit, whichislocated in an ambulance vehicle near the patient, andii) the consultation unit,w hich is located at the hospital site andcan be used by the expertsinorder to give directions.
EMERGENCY-112, whichw as the extension of the AMBULANCE project, aimedtoextend the system to an integrated system whichwould be able to operateover severalc ommunication links (Satellite, GSM, POTS,ISDN,LAN,etc.)andfor different cases (ambulanceemergencies, rural health centerorany other remotelylocated health centersupport, navigating ships supportand home monitoring).InEMERGEN-CY-112, emphasiswas giventomaximizing the system's future potentiala pplication, through the utilization of different links (both fixedand wireless),aswellasthrough the increase of the overallsystem'susability, focusing on advanced user-interface and ergonomics. Thes ystem comprises of two different modules: i) The patient unit which is the unit located near the patient. This unit can operate automatically andh as several operating features( depending on the case used). ii) The physician'su nit whichi st he unit located near the expert doctor.This unit can be eitherfixed or mobile depending on the placewhere the expert doctor is located. Diagnostically importantd ata, likeE CG, blood pressure,h eartr ate, oxymetry, temperature, etc., arec ollected via ab iosignal monitor connected to aportable computerat the mobile site andare transmittedthrough the mobile telephonynetwork (i.esatellite, GSM or UMTS) to the hospitalsite.Still images of the patient'sp osition ands tate are captured through asmall cameraand transmitted. The specialistatthe hospital site can observe the signals in real-time, viewt he images of the patienta nd mark some interesting areas (whiteboarding), am arking that appearss imultaneouslya tt he mobile screen.Thus,heisabletoassess the severity of the emergencya nd through ab idirectional voicec ommunication link can instruct the paramedic howtohandle the case. Thes ystem is supported by am ultimedia database, whichstores allinformation available fromthe time the system is initialized untilthe arrivalofthe patientatthe hospital.
Thes ystem wase valuateda nd verified in Cyprus, Greece, Italy andSweden. Each pilot recordedc ertain time indicators, such as time-to-transportation,t ime-tostart-treatment, time-to-stabilization,e tc., in atotal of 100 cases in whichthe system wasused and in another 100 cases without using the system,i no rderf or comparative results to be deduced.Itwas shownthatthe system provides significant supportt ot he early ands pecialized pre-hospital patient management andt oe mergency case survival. The diagnosis at the scene of an emergency, as well as the handling of the case, wass ubstantiallyi mproved through on-lineaccess to medical specialists,which decreased the time to make the firstd iagnosisa nd startt he appropriatet reatment. Severe or multiple trauma patients were better assessed,w hilet he electronic registration of the patient'sdatafreed the ambulancep ersonnelo fa ny paperwork and helped them devote moret ime to real emergencycare.
User trainingwas performed on each site wheret he base stationsa nd clients of the system were installed.The ageofthe users rangedf rom 25 to 50 years. Usersw ere divided intoe xperienced andn on-experienced computerusers. Training wasinitially performed using demo cases. This wase ssentialsincethe system's main purposewas the supportofemergency medical cases. Initial trainingtime foreach experienced user wasabout 30 minutes whereas for inexperienced usersi tw as about one hour.F ur-thermore the useofthe system initiallywas performed in collaboration with the technicalpeople, thus allowing users to continue their training. Au ser manual with instructionsand installation disks wassupplied to the sites.
Theresults fromthe system use(except from the initial evaluation phase) were not at the success levelw ei nitiallye xpected.I n generalthe system wasintroduced andused in dailyr outine in onlyo ne hospital which wase stablishedw hent he system was created.T his is the Interbalkan Hospital in Thessaloniki,G reece. Thee mergency health cared epartment wasc reated at the time when the system wasf inished; the people of the department were trainedfrom the beginning andthe system becamepartof their dailyr outine.T he samed epartment wass upporting twoi solateda reas in the northern part of Greece; av illage called "Zoni" andasmalli sland called "Agios Efstratios". Unfortunately at the other sites in Greece,I taly,a nd Sweden wheret he system wasinstalled,the departments were alreadye stablisheda nd the useo ft he systemwas initiallydelaying the process since many of the usersw eren ot computere xperts. Thef inalr esult wasr areu se of the system.
In Cyprus, althoughthe system wassuccessfullye valuateda tt he Department of Accident andE mergency at the Nicosia General Hospital, connecting aruralhealth centerand an ambulance, it hasnot yetbeen set in routineoperation. However, this project will nowberevitalized based on anew INTERREG III BA rchimedP rogram project entitled"An INTEgrated broadband telecommunication pilott eleservices-platformfor improving health careprovision in the Region of MEDiterranean"w hich has recentlyb een awardedt ot he University of Cyprusand the Pafos General Hospital [7]. Theaim of this project is to develop aplatform thatw ill enhancet he provision of medical servicesf or both citizensa nd travellers in remote/isolatedr egionso ft he southeast Mediterranean,a nd on board of ships travelling acrossit. The platform will supportECG andvitalsignal processing as well as ultrasound imaging andv ideoc onferencing functionality.

DITIS:
HomeHealthcare of Cancer Patients [8][9][10][11] DITIS ( ΔΙΤΗΣ,i nG reek,s tandsf or: Network for HomeH ealthCareC ollaboration) is asystem that supports virtual healthcare teamsdealing with the home-healthcareof cancer patients in Cyprus. DITIS wasoriginallyd evelopedw ith aviewtoaddress the difficultieso fc ommunication andc ontinuityofcarebetween the home-healthcare multidisciplinary team (of the Pancyprian Association of CancerPatients andFriends, PA SYKAF) andb etween the team andt he oncologist often over 100 km away.D ITIS hast hrough itsd atabase andp ossibilityo f access via mobile or wire line (computers) offeredm uchm ore than improvedc ommunication.I ts flexibility of communication anda ccess to the patient'sh istorya nd dailyrecord at alltimesand from anywhere (e.g.h ome, outpatients,o re vend uring emergencyadmission) hasoffered the team acontinuous overallassessment and history of each symptom. DITIS supports the creation,m anagementa nd co-ordination of virtualhealthcareteams, for the continuous treatment of the patient at home. Thus it has offeredi mproved quality of life to the patient, forexamplebyoffering the nurses the possibilityo fi mmediate authorization to change prescription via mobile devicesand the oncologist the possibilityofassessment and symptomc ontrol without necessarily having to see the patient. Amongi ts international successes, DITIS wasafinalistatthe eHealth Ministerialc onferencei n2 003 (ranked among the best 25 eHealth projectsout of 179 EU projects), ranked 7th in the 2003 Wo rld Summit Award( out of 89 entriesi ne -content from 89 countries), andw as the only non-ISTfundedp roject participating in the cluster project MEMO due to itsmobilecollaboration aspect.Currently, DITIS is thesubject of an extensivec ost-benefite valuation by the Association of CharteredC ertifiedAccountants (ACCA), as commissionedbythe EC.The purposeofthe case study is to show economicb enefits froma dopting ICT in healthcare, beyond the undisputables ocial andm edical benefits.T he results were presented during the 2005 eHealth Minis-terialConferenceand at the EU parliament to stir debate in supportfor eHealth.
DITIS is at present being deployed, for its healthcarec ollaboration andp atient management aspects, in the context of two EU fundede -TENm arketv alidation projects(HealthService24 [11] andLinkCare). Bothp rojectsi nvolvet rials for cardiac patient monitoring whicha re in progress at the LITOp olyclinic. They feature the first adaptationsofDITIS to be used in an acute careenvironment (asopposed to the chronic patientenvironment forcancer patients).
The system wass uccessfullyi mplemented, tested,and deployedatP ASYKAF duetothe pragmatic approach thatitfollows in supporting the home-healthcareteam and due to ah ighly motivatedt eam thatp ays special attentiont ot he needso ft he endusers.
Training in supporto fD ITIS wasp rovidedt oa ll the healthcares taff including doctors, nursing personnel, psychologists, social workers, andadministrative staff. The ageofthese personnelrangedfrom 23 to 55 years, andt heyc ould be easily separated into twogroups:i)experienced andii) nonexperienced users. Forexperienced users, a four-hour-long training session wasp repared, covering mainlythe application software (30 minutesa bout the DITIS project, 30 minutes introduction to the useofcomputers in medical applications, one hour about overallD ITIS system functionality andusage, and one hour about the specific functionality fore ach group of users).F or non-experienced users, 16-24 hours of training wasprovided, beginning with basic computers kills training (mouse, keyboard, main Windows applications, and internet) andt henc overing mobile devices andt he application software.
Training wasi nitiallyo rganized for groups of four (for personnelwith the same specialization), andthenwhere needed was followed-up with one-to-one training, targeting each individual's needs. Thei nitial training includedageneralp resentation of the functionalitiesofthe system,aswellas the functionalitiesrelating to each individual's discipline (role).The individual training sessions were about three hours long. They included: • Introduction to the computerb asics, if needed (20 to 30 minutes). • Introduction to the DITIS program.This wasa lsoc overed in the group training, buti tg aveac hancet ob em ore interactiveand specific in this case (about ten minutes). • Ag eneralized presentation of allt he functionalities of the system,w ith emphasisonuser role (about one hour). • Ac omprehensive hands-on useo ft he system,via astructured approach (i.e. by adding an ew patienta nd progressively introducing other functionalitieso ft he system,asfor example the appointments, pain ands ymptom diaries, and so on) (about twohours).
Asystem manualwas preparedand givento the users, supplemented by asupportteam, whichp rovideds upporta sn eeded,d ependent on their availability as there is no dedicated supportp ersonnel( the system designers andd evelopers double up in this role). Basically, within ourconstraints, there wasevery efforttoprovide continuous user supportrelating to the useofthe system. Afew pointsworth noting are: • Users were encouragedtoinstall the systemo nt heir home PCs( the majority have ahome PC), whichhelpedthemto usethe system when it wasmore suitable to them. • Users were givent he option to request anothert raining session if theyf elt uneasy about using the system (this happenedinveryfew cases).
• Language turnedo ut to be ap roblem. PA SYKAF employs al arge number of non-Greek-speaking nurses (permanent residents of Cyprus)a nd an umber of Greek-speaking nurses (some not con-versantinEnglish). This wasparticularly problematic, especially in group training sessions with both Greek-speaking and English-speaking participants.Note that the interface is currentlyavailableonlyin English,b ut plans areu nderway to also offeritinGreek.
In summary,D ITIS is adopted today, mainlybecause so muchw as giventosupporting the endusers in their efforts to learn the technology.The commitment of the entire team hasb een enormous in providing different types of training based on the real needsofusers. DITIS is asuccess not only because it is an innovativeproduct(there are many innovativeproducts thatnever getdeployed), butbecause the time andeffortwas takentotrain the users, andacontinuous effortisstill on-goingtosupportthem. Eventually, we hope to have usersw ithin the adopting organization become trainers themselves.

Concluding Remarks
In this paperareviewo fs elected eHealth applicationsinCyprus waspresented linked with their success or failurebased on their training activities. Differentmethodologies for training were used ranging from classical approaches liketrain the trainers,using demo cases followedb yp ersonalt raining, group training, andw orkshops,tomore recentm ethodologies based on eLearning sessions including teleconsultations. The trainingw as carriedo ut successfullyi na ll cases. However, not alle Health systems were put into practices uccessfully, mainly for reasons not relatedtotraining.
Cypruss hould acceleratei ts pace in eHealth servicesfor the benefitofthe whole healthcaresector.Acritical factor in achieving this is trainingthe physicians,the paramedical anda dministrative staffi ne merging information technologies in healthcare. Training thesep ersonnels hould include concepts likeelectronic patientrecord,webbased systems, security,t eleworking, and other.Linked with the training, there should be 24-hour supportfor the medical staffin the hospital, clinical systems, or home care underoperation. Furthermore,based on the recommendationso ft he WHO reporto n eHealth Tools &S ervices [ 17], Cyprus should invest moreoneLearning methods in health sciences, provide widera ccess to digitall ibrariesa nd information about evidence-based research within the eHealth domain, andhelpinthe establishment of a network to share experiences internationally.These actions should be promoted taking intoc onsideration recentt rends in health informaticse ducation andt raining based on the introduction of newt echnologies, including the electronic patientr ecord andePrescription [18], as well as hitech imaging, robotics, and genomics andp roteomicsapplications [19].
Finally, Cyprus shouldp rescribe itsn ational action plani ne Health, aligned with the recentlya nnounced EU eHealth action plan [ 20]. This nationalp lans hould prescribe the roadm ap leading to the wider spreado fi nformation andc ommunication technologies enabling the faster implementation of electronic health records,p atient identifiers andh ealth cards,a nd the faster rollout of high-speed internet access to enable optimum interactionsa mongh ealth careprofessionals andwith the generalpublic [ 21]. It is hopedt hatt hese efforts will be materialized,t hus enabling the offering of better service to citizens.