Practical examples of universal design for health care applications demonstrated in IS4ALL Seminar

Brussels 13 December 2001The second part of the second IS4ALL "Universal Access in Health Telematics" Seminar was dedicated to the demonstration of practical health care scenarios in which universal access plays a key role. MediBRIDGE CEO, Louis Schilders, highlighted the concrete use of EPRs in the C-CARE project, and Dr. Akoumianakis described the difficult road to a universal health data access code of practice using four existing scenario-based examples.


The Belgium-based company MediBRIDGE has been active in the health care market since quite some time. Already in 1989, their first project EUCLIDES was launched and now the EC-funded project C-Care, which stands for Continuous Care, is running. MediBRIDGE representative Mr. Schilders explained the three basic concepts in this initiative which are co-responsibility in shared care; seamless care by transferring information from one doctor to another; and continuous care through the use of permanent referral letters. The C-Care project focuses on two possible intervention situations: the emergency scenario and the home visit of a general practitioner (GP) on duty.

In Belgium, a particular situation exists in which clinical laboratories are sending information to GPs. This scenario has been taken over by all the C-Care partners in Italy, Spain, and Greece. More than 12.000 GPs are using the system to send 3 million messages a month. The GP integrates the obtained information in his patient records where it stays locked up in the GP's PC. MediBRIDGE tries to convince the GP to export the data that is considered important for emergency situations. This is the basic idea of C-Care, as described by Mr. Schilders. A part of the patient record containing risk factors, allergies, etc. is being transported, put on a server, and made available to authorised persons. As such, preventive medicine, pharmacy, and home care can be integrated as alternative scenarios.

In the C-Care environment, a configuration of the user's profile is made and the access is controlled. The source of information has to be identifiable, next to a unique patient identification. The system includes a voice and Web interface, as well as a tracing mechanism and tracing procedures. The patient's ID is being transferred to the emergency department in case of an accident. The physician on duty has access to the electronic patient record (EPR). He clicks on the C-Care logo, enters his user name and password and receives the available patient data, according to his access rights. The EPR contains items such as administrative information, medication, allergies, medical antecedents, medical evaluation, vaccinations, etc. Their availability depends on whether the user is a doctor, a pharmacist or a nurse, as Mr. Schilders explained.

All this data arrives before the patient enters the emergency department. The doctor may want to receive confirmation of the data from the server and this is transferred in a secured and encrypted manner. There is also automatic feedback to the author of the data. At the emergency department, all is known about the patient and the procedure can start without losing any time. The nurse verifies the patient identification data but only has access to the administrative data. In a second scenario, the GP on duty receives an SMS message from the home base to go to a patient who is not one of his. The doctor calls the server by mobile phone and enters the patient ID. The doctor gets mobile style sheets and via button-push navigation, he can select the required information. Today, 8000 EPRs are hosted on the C-Care server and in the Belgian region of Heist-op-den-Berg, 20 GPs are working with the system, Mr. Schilders concluded.

Dr. Akoumianakis outlined the plan to explore nine or ten scenarios within the IS4ALL project in order to develop a universal access code of practice. The scenarios have to respond to four conditions. They have to be relevant to the concept of universal access for different user communities and platforms; they should be expressed in a narrative form or in a semi-formal or formal notation; they have to provide content to describe; and they have to generate meaningful situations and contexts of use. Sources are existing practices or systems, and national or European projects, next to envisioned situations.

The scenario consists of three phases: agreement with the user community in which type, nature, and scope of the scenario are explained; the narrative description where mock-ups and prototypes are being used; and the revision and confirmation stage performed by real users. The ultimate goal is to recommend a number of techniques which have been thoroughly tested and assessed to obtain evidence of practicability. Currently, IS4ALL is working on general purpose techniques for universal access in four scenarios, being Ward-in-Hand; Medical Information Islands in Italy; C-Care in Belgium; and HYGEIAnet, a regional health telematics network in Crete, as Dr. Akoumianakis told the seminar audience.

For Ward-in-Hand, IS4ALL met the project co-ordinator, drafted the scenario, and established a collaboration agreement with the end-users. The aim is to built a PDA-IPAQ based interface for services and applications in the hospital ward that allows the doctor to log in into the hospital system to consult the clinical record or work flow when he arrives in the ward. All the activities should be displayed on the IPAQ, on the Web, and on the PC. The doctor has to be able to consult or update them in the ward, at home, and in the office, as Dr. Akoumianakis showed.

The Medical Information Islands, as they have been organised in the operational IFC Information System, are autonomous but a Web system is linking the islands. The information that feeds the system uses a specific platform but may come from totally different kinds of software, and is united into the Electronic Patient Record. IS4ALL wants to engineer the application so that the users can exploit the diversity of technology in such a way that it is universally accessible. The W3C-WAI guidelines to assess accessibility are tested in this project in order to evaluate them in a health telematics scenario, noted Dr. Akoumianakis.

HYGEIAnet is a ten-year old health telematics network in Crete. The objectives of the IS4ALL demo are to illustrate an approach to universal access based on re-engineering artifacts. Dr. Akoumianakis described how the initiative assumes the availability of a tentative mock-up and also makes use of a technique called screening or filtering. The question is to identify features which are suitable to universal access but how does one derive suitable filters for this purpose? Screening is an old technique used by engineers and may be informal, based on intuition, or semi-formal informed by empirical evidence and analytical insight, as long as the process follows a protocol.

There are different types of filters for universal access. They can be user category specific, envisioning various situations of use; terminal specific, such as card systems, keypads, touch screens, tools with operating instruction, etc.; and usage context specific, taking into account the usage pattern and ubiquity. Within HYGEIAnet, IS4ALL has focused on the presentation of the EPRs and the tasks performed with them via the desktop, the Web, the IPAQ, and the WAP phone. Designs have been re-engineered to facilitate universal access via these four different tools. Dr. Akoumianakis concluded that design approaches for universal access do not rely on state-of-the-art solutions but on thorough analysis of user contexts.

More news about the IS4ALL Seminar is available in this VMW issue's article IS4ALL highlights electronic health record in second seminar on Universal Access in Health Telematics.

Leslie Versweyveld

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