Ebook: Achievements, Milestones and Challenges in Biomedical and Health Informatics

This volume contains the accepted papers of the International Symposium on Achievements, Milestones, and Challenges in Biomedical and Health Informatics (BMHI) to be held in Athens on October 29, 2022. This is an International Summit event, organised by invitation and attended by the most distinguished colleagues in the field, presenting original review papers in their respective domains with an in-depth, bird’s eye, critical view which also looks in breadth across the timeline of an entire career. It spans an almost forty or even fifty year period that stretches back to the beginnings of the application of computers in health and healthcare, but from a more humble perspective, it can also be seen as just a droplet in the ocean of the scientific history of humanity.

We know that scientific progress is not always linear, and we also understand that, in a similar way, the progress of BMHI may have encountered a few mishaps, delays, failures and enthusiastic expectations, as well as some successes. Each distinguished author in this volume has, from his or her perspective, expertise, region, and background and with humility, attempted to describe the achievements attained, the milestones reached, and the challenges which have been overcome or which we failed to conquer. The Scientific Programme Committee followed all the accepted standards of organising such a Summit event, and each submitted paper was peer reviewed by 3 independent reviewers before being thoroughly revised and submitted to editing and proofreading procedures to maximise the scientific effort of the authors, but also to ensure the high quality of the accepted papers.

I would like to thank my fellow co-editors, Professor Emeritus Arie Hasman and Professor Emeritus Reinhold Haux, for their support during the entire process of organising this Summit event. Without them this event may never have come about. I would also like to thank all reviewers for their challenging work in improving the quality of the papers of the distinguished authors. Finally, I thank Dr. Emmanouil Zoulias for his support in the demanding process of editing the files of the proceedings preparatory to their acceptance by IOS Press.

It should be noted that these Proceedings are published as Open Access, with e-access for ease of use and browsing without the loss of any of the advantages of indexing and citation in the biggest Scientific Literature Databases, such as Medline and Scopus, which the series of Studies in Health Technology and Informatics (HTI) of IOS Press provides. This volume contains 17 high-impact papers in the field of Biomedical and Health Informatics and is dedicated to the entire community of our domain, as well as to the current and the forthcoming students of the discipline wishing to fathom the depth and the timeline of the evolution of BMHI.

The Editor would like to thank the Members of the Scientific Programme Committee, the Organising Committee, and all reviewers, who have performed a very professional, thorough and objective refereeing of the scientific work in order to achieve a high-quality publishing achievement for a remarkable and unique scientific event.

Athens, 18.09.2022

John Mantas, Editor

Biomedical and Health Informatics (BMHI) have been essential catalysts for achievements in medical research and healthcare applications over the past 50 years. These include increasingly sophisticated information systems and data bases for documentation and processing, standardization of biomedical data, nomenclatures, and vocabularies to assist with large scale literature indexing and text analysis for information retrieval, and methods for computationally modeling and analyzing research and clinical data. Statistical and AI techniques for decision support, instrumentation integration, and workflow aids with improved data/information management tools are critical for scientific discoveries in the - omics revolutions with their related drug and vaccine breakthroughs and their translation to clinical and preventive healthcare. Early work on biomedical image and pattern recognition, knowledge-based expert systems, innovative database, software and simulation techniques, natural language processing and computational ontologies have all been invaluable for basic research and education. However, these methods are still in their infancy and many fundamental open scientific problems abound. Scientifically this is due to persistent limitations in understanding biological processes within complex living environments and ecologies. In clinical practice the modeling of fluid practitioner roles and methods as they adjust to novel cybernetic technologies present great opportunities but also the potential of unintended e-iatrogenic harms which must be constrained in order to adhere to ethical Hippocratic norms of responsible behavior. Balancing the art, science, and technologies of BMHI has been a hallmark of debates about the field’s historical evolution. The present article reviews selected milestones, achievements, and challenges in BMHI education mainly, from a historical perspective, including some commentaries from leaders and pioneers in the field, a selection of which have been published online recently by the International Medical Informatics Association (IMIA) as the first volume of an IMIA History WG eBook. The focus of this chapter is primarily on the development of BMHI in terms of those of its educational activities which have been most significant during the first half century of IMIA, and it concentrates mainly on the leadership and contributions of John Mantas who is being honored on his retirement by the Symposia in Athens for which this chapter has been written.

In this essay we will discuss capacity development in health informatics research and application, which to us is among the major contributions of Professor John Mantas scholarship. Specifically, driven by the inspiration of his scholarship we will elaborate on advancing new applications areas, additional actors and geographical uptake of health informatics and eHealth solutions over time. We will illustrate capacity development in health informatics and address challenges that systematically foster digital health literacy, engagement and empowerment, and building health informatics capacities regionally, in Europe and globally.

The role of the field of informatics in medical imaging is vital; novel or adapted informatics’ core methods can be employed to realise innovative information processing and engineering of medical images. As such, imaging informatics can assist in the interpretation of image-based, clinically recorded evidence. This, in turn, leads to the generation of associated actionable knowledge to achieve precision medicine practice. The discipline of informatics has the power to transform data to useful clinical information patterns of observable evidence and, subsequently to generate actionable knowledge in terms of diagnosis, prognosis, and disease management. This paper presents the author’s personal viewpoint and distinct contributions to innovations in the acquisition and collection of imaging data; storage, retrieval, and management of imaging information objects; quantitative analysis, classification, and dissemination of imaging observable evidence.

As an indigenous scientist, I have dedicated all my professional life to protecting people using informatics for public policy to the privacy of users, patients, clients, and citizens as a human right and obligation as part of the United Nations international development goals. I am reflecting on my earliest knowledge of the impact of data and information privacy on my journey as scientist. I was just a number out of many other numbers as a indigenous child. The aim of this paper is to share my own personal experience together with one of my students. Now working with data as a scientific task within the data modeling to measure poverty. As a datum with human value, I was a 1) Female child with young parents, 2) Low socioeconomic status & 3) Identified as an indigenous person within a minor language group. These three data descriptions described me as a person who needed protection of my human dignity and identity as a child, based on all the protocols of social services for providing help. In conclusion, as scientists, we need to remember when using client data in vulnerable contexts and protection of their privacy, due to the potential risk of active discrimination. Thanks to my extensive education in Australia, I became an outlying datum that deviated from the data modeling applied to me. Today, I work for Privacy digital standards to impact real life with respect to human dignity and obtain accurate scientific interpretations of human beings’ realities.

In this contribution some achievements and milestones in the field of medical informatics, especially concerning decision support, as perceived by the author, are presented. The author focuses on those topics with respect to decision support that during his career in medical informatics impressed him and triggered him to convince his PhD students to start research on related topics. Both some of these achievements and the related research of some of his PhD students will be presented. The contribution starts with signal classification. Both ECG classification and sleep EEG classification are discussed. Then the use of Bayes’ theorem for diagnostic purposes is discussed and some early applications pass review, among which the AAPHelp system developed by de Dombal and colleagues. Attention is subsequently paid to the advent of expert systems and other knowledge-based systems such as MYCIN and INTERNIST and to guideline-based decision support systems. Finally, the author presents his ideas about challenges for the field.

Technological advancements have introduced wearable and passive monitoring tools that can capture aspects of daily living, health and well-being in homes and communities. Personal Health Informatics is the study of any information system, tool or platform designed for individuals and their families/ communities with the goal to facilitate decision making, access to information, education, managing health, prevent disease, and improve communication whereby the individual patient or consumer is the end user whose needs and preferences inform the design and implementation of the system. Examples of such tools include digital phenotyping, consumer genomics and smart homes. Such platforms capture patient generated health data and allow for proactive models of care, whereby patterns or trends are analyzed to identify opportunities for tailored interventions. Future research needs to address the impact of personal health informatics systems on health outcomes, shared decision making and patient empowerment. We discuss new roles and opportunities that arise with the growth of this field, including the role of the personal health data navigator who can guide and assist patients and families in navigating the complex digital landscape in order to most effectively utilize inclusive personal health informatics tools.

This paper highlights some of the challenges, achievements and collaborations using health informatics education and research as a change agent in which I have been involved over the last 40 years. The Open Software Library (OSL) was a specialist publisher of Computer-Based Training materials (CBT) mainly authored by nurses and medics. The “Rainbow” series of distance learning materials, “Using Information in Managing the Nursing Resource” sold over 55,000 copies. It was utilized as the basis for seven Universities’ Certificate and Diploma programmes and in-house training by the NHS to encourage organisational change. Workshops at Manchester University’s HSMU focusing on evaluation studies highlighted that most NHS IT projects failed because of human and organisational issues rather than IT. This led to the development of a master’s degree in Health Informatics shared between four European Universities. IMIA conferences, Working Groups and the development of the IMIA approved Education Recommendations and the IMIA Knowledge Base are effectively used worldwide.

This chapter describes the milestones and outcomes of Health and Human Services Informatics (HHSI) education programmes at master and doctoral degree level. In Finland, since the year 2000 the programmes have been based on the International Medical Informatics Association (IMIA) recommendations on biomedical and health informatics and the master’s degree programme has been twice accredited by the IMIA Accreditation Committee. The paradigm created to advance and support both education and research in the health and human services fields is used to analyse and synthesize the research focuses of students’ theses and evaluate milestones. The outcomes of HHSI programmes are described using quantitative and qualitative data from a student administrative database and student theses. The research focuses and research methods were coded for master’s and doctoral theses based on the HHSI paradigm. Experiences from the accreditations and feedback are summarized to provide insights for future development. Based on the results, recommendations for further development of the programmes are provided.

The field of biomedical and health informatics has taken its rightful place in the development and evaluation of methods and systems that aim to help those working in health, healthcare, public health, and biomedical research fields to optimally use data, information, and knowledge to improve human health. In the current century, competencies and curricula have been developed and have matured not only for informaticians but also clinicians, researchers, and patients/consumers. This paper provides an overview of the history and evolution of efforts around the world, interspersing history from the field with the author’s own personal journey.

Background:

Health information systems (HIS) represent an essential part of the infrastructure for the delivery of good health care.

Objectives:

To present the author’s personal views on HIS developments over the last decades and on the opportunities and priorities for future HIS developments.

Methods:

Reflecting on his views, the author identified relevant semantic dimensions, which are denoted as development paths, and searched for appropriate periods to characterize HIS development leaps.

Results:

HIS developments were divided into the periods past (1961–2016), present (2017–2022), and future (the next decades). Eight development paths for HIS were considered as being relevant to presenting the author’s views: life situations related to health care, entities for health care, health care facilities, settings of health care, data to be processed, features for functions, architectures of HIS, and management of HIS. For each of these paths, the past and present states as well as challenges and opportunities for future HIS developments were outlined.

Discussion and Conclusions:

The presented views on HIS developments and the selected development paths and periods are by nature subjective ‘avant la lettre‘. The views were, however, formed over almost half a century during which the author has been engaged with HIS developments, and thus may be worth reporting and discussion. If past is prologue, the tremendous HIS developments in the past and in the present may predict a similar development intensity in the future. Present HIS are significantly better than HIS of the past, however they leave room for continued improvement with an end of HIS developments far from sight.

Objectives:

To clarify the views of the general population of two countries (US and Japan), concerning handling of their medical records electronically, disclosure of the name of disease, secondary usage of information, compiling their records into a lifelong medical record, access to their medical records on the internet, questionnaire filling for delicate history, comprehensive consent for laboratory results, chart and genome profile, and AI use in diagnosis and explanation.

Methods:

The authors contacted people nationwide in the United States at random via Random Digit Dialing (RDD) in 2008. Same questionnaire plus some new items were surveyed in 2022 by mail invited web entry. The authors had also surveyed people in Japan in 2007 and 2017 using same questionnaires sent by mail.

Results:

In US, accessing own chart by internet became accepted (positive 52% to 61%) and popular in these 14 years. Japan showed small change, as regional medical record sharing is yet to come. About medical records in un-identifiable manner to be used for the purpose of medical error precautions, infectious disease measures and device/drug developments, in US, positive answers are constantly low, even for infectious disease prevention like CoVID-19. About preference to compile medical record into one file as a lifelong medical record, sharp contrast was observed. US people became favor of lifelong record (46% to 71%), while Japanese people decreased (76% to 57%). As for comprehensive consent, Japan positive answers are more than US for all situations, except if genome profile is included. US answers are almost same, even genome profile is included. About AI (artificial intelligence) application to healthcare, both US and Japan survey showed best preferred is “Doctor may use AI and everything, and explains in person”. Japanese people largely prefer explanation in person, while US showed small preference.

Nursing Informatics emerged in Australia during the early 1980s and drove the Professional development and acceptance of Health Informatics. Milestones achieved include the development of a national journal, the establishment of the Health Informatics Society of Australia and the Australasian College of Health Informatics (now collectively the Australasian Institute of Digital Health), nursing participation in Health Informatics standards development activities, adoption of the HL7 messaging standard, the delivery of numerous workshops, an annual national health informatics conference since 1993, hosting international conferences, the development and delivery of Health Informatics post graduate programs and establishing a research centre where the first prototype for an archetype repository was developed. This became the openEHR Clinical Knowledge Manager. The most recent milestone was the establishment of a private company that became a Registered Training Organisation. Continuing challenges include workforce capacity building to address the poor understanding of the need for improved data and IT governance at every level, the need to comply with proven scientific and technical principles and a need to transform national and international traditional infrastructures no longer fit for purpose to enable adequately support for global sustainable digital health ecosystems. Desired personal and aggregate data supply chains must be taken seriously and be supported by the best available technologies. Our collective biggest challenge is to improve multidisciplinary and intersectoral collaboration, semantic interoperability and optimum digital support to maintain global public health.

The whole healthcare system is evolving fast due to environmental pressure related to pandemics, climate change, personnel shortages, and financial limitations, to name but a few. Nurses are central actors in the sustainability of healthcare systems. Rapid technological development can support innovative means for holistic and applied critical thinking to improve healthcare delivery based on the uniqueness of nursing. Nurses need to develop adaptive and scientific skills regarding technologies and develop and apply these for better use of “smart” systems in care delivery. The paradigm shift in nursing roles will impact all levels of care, from primary to specialized care, all age groups, from newborn to elderly care, as well as all domains, such as preventive, reparative, rehabilitation, and palliative care. The impact of technologies on human behavior addresses human- factors interaction, computer interaction, and other effects of technologies on wellbeing, including but not limited to robots and artificial intelligence -based assisting nursing deliveries. Nursing competencies need to be developed at all levels of education to prepare a mindset and culture of the healthcare workforce in a digital health system. Gamification and simulation as educational tools help prepare educators to educate healthcare clinicians and researchers who become key mediators between technologies and practice.

The resurgence of machine learning AI has triggered the importance of collecting “personal big data” over a long period of time from wearable devices and EHRs. Collecting data from this large number of variables over a significant period of time has further induced the study on “Temporal Phenomics”, which can be a powerful approach to achieve pre-emptive and “earlier medicine”. The paper presents a methodology to make studying “Temporal Phenomics” more feasible and convenient without limitations on the number of variables and the length of time periods.

The history of medicine is punctuated by conquests, discoveries and revolutions. It is also marked by questioning. It is made of doubts and certainties. In this thousand years old history, certain recent battles bear witness to these questionings, such as quality, refocusing on the patient, medical errors, antibiotic resistance and the importance of gender, which has been neglected for so long in medicine. Digitalization is one of these many revolutions, and it is not immune to questioning. Building evidence and trust, equity of access for neglected populations, and training are among these issues. More specifically, in the field of decision support, the first enthusiastic hours of computing were followed by unexpected observations, such as the identification of human factors, such as alert fatigue. Today, immense hopes rest on the development of deep learning, and it is up to us to accelerate its development by investing energy, time and resources to build on evidence, trust, and a strong integration of health professionals and patients.

Cyber security attacks evidence has shown that many sectors and industries are still at an insufficient level of readiness to counter these threats, including healthcare organizations and the entire healthcare industry. The COVID-19 pandemic has additionally launched the issue of cyber protection of healthcare systems and connected medical and other devices as well as modern IT components, which are often the entry point for attackers against healthcare organizations. With the aim of a systematic approach to cyber security in healthcare organizations, this article comprehensively presents cyber risks and possible consequences of attacks in the context of healthcare organization services, as well as identifies the five most important cyber security challenges and provides recommendations for establishing protection mechanisms in line with best practices.

The aim of this paper is to share knowledge and experiences of a professional lifetime in the field of Biomedical and Health Informatics (BMHI), almost from the time of the initiation of the domain until today. The achievements and the milestones reached are not personal, but they just indicate the progress of the field as it was experienced by the observer. The challenges are still there waiting to be tackled for the benefit of healthcare. The paper is based on a systematic review of the author’s published contributions across the professional timeline. For organizing the presentation of the results, the timeline is subdivided into five phases. In the discussion an aggregation of the achievements, milestones, and the challenges is presented.