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Proceedings of the 28th Annual Hawaii International Conference on System Sciences - 1995

An Intelligent Multimedia Patients Information System: Design Problems and Solutions

Dr. Grace Au’, Dr. Ching Kwong Kwokz and Heung Wing be1

lDepartment of Information and Systems Management, The Hong Kong University of Science and Technology, Hong Kong

2Department of Neurosurgery, Kwong Wah Hospital, Hong Kong

Abstract This paper reports the research findings in the design

of an intelligent multimedia patients information systems (IMPIS). The system is aimed to be used by medical professionals at different organizational levels within a hospital, as well as hospital administrative executives for management support purposes. The data transmitted could be in the form of text, graphics such as electronic diagnostic images, sound such as voice annotation notes, or video such as critical moments during an operative procedure. These data are used for helping practitioners in the diagnostic process, conducting research in medical areas, and archiving of medical information for future references and medical legal purposes. In addition, statistical results can be generated for facilitating resources planning in hospitals. This paper presents an integrated object-interface-scenario modeling approach to designing such a system. The problems found, with the illustration of a prototype, and the proposed solution to the identified problems are discussed.

1: Introduction

Multimedia can be defined as the input, assimilation and output of any combination of text, graphics, animation, video and audio data through one or more communication media. It has opened up a new dimension for people to expand the use of database management systems by including the storage and manipulation of audio-visual data other than traditional text. The need for multimedia in computerization of patients’ medical records were studied because of its diverse requirements on the variety of data types to be archived. Patients information system is a potential multimedia application which if properly implemented, could improve efficiency, completion of documentation, and quality of patients care.

The use of multimedia in the medical industry begins with electronic diagnostic imaging systems [4, 161. The concept of PACS (picture archiving and communication systems) which link all diagnostics imaging devices in a hospital for storing electronic images such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound and computed radiography (CR), has

developed over the past few years [ 11, 14, 181. Another type of imaging systems which can be used in maintaining paper records for patients - document processing systems, are also being investigated [3,7, 101.

Integration of these high-end imaging systems with existing hospital information systems became one of the technology challenges faced by today’s health care and information technology professionals [5]. The On-line Medical Record project [ 133 was aimed to unify the structured clinical database, the point-of-care data collection and diagnostic image management. However, little has been reported on how other types of multimedia data such as graphics, video and audio information can be used and integrated into these systems.

This paper summarizes the preliminary results of the IMPIS project conducted by the Department of Information and Systems Management at the Hong Kong University of Science and Technology in collaboration with the Department of Neurosurgery at Kwong Wah Hospital in Hong Kong. The focus of this research is to design a patients information system which provides meaningful multimedia data about the medical history of a patient. This information can be used for medical practitioners in diagnosis as well as in handling medical legal cases where a more vivid description of the patient’s condition is required.

Since the system has to be integrated with the territory- wide hospital information systems, the existing hospital information systems development is described in section two. Section three presents an integrated object-interface -scenario modeling framework which is used for obtaining user requirements during the design phase. As the concept of multimedia is rather new to the hospital staff, detailed sessions of discussions and interviews were conducted with selective medical practitioners and hospital administrators. A prototype of the system, when applied in the Department of Neurosurgery of Kwong Wah Hospital, is described in section four. The design problems and proposed solutions are discussed in sections five and six respectively. Conclusions and future work are given in section seven in the paper.

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2: Development of hospital information systems in Hong Kmg

Hong Kong’s Hospital Authority (HA) officially took over the management of all 39 hospitals and 56 specialist out-patient clinics in Hong Kong in December 1991 from the Government Hospital Services Department and subverted Health Organization. Prom an organization with almost no co-ordinated computerization implementation, a three-stage IT strategy formed in 1992 will take the HA into the year2000 [ll].

Stage I of the strategy begins in 1992 with the “Hong Kong Health Information Highway” project. The goal of the project was to attain “seamless health care delivery” by linking up 39 general hospitals, 56 specialist outpatient clinics and two HA offices via high-speed networks; Pour fundamental databases - Patients, Staff, Finance and Assets were established. An integrated patient administration system (IPAS) which enabled the centralization of territory-wide patients admission and discharge records were implemented. Other systems systems such as the out-patient appointment system and the drug dispensing labeling system were also implemented. Stage II recently begins with the development of clinical information systems. Stage III will be focusing on the integration of applications in the hospital and clinical environment. The development of management support systems to help hospital administrative in monitoring the existing operation and planning for future services will also be included.

An electronic medical card which contains personal particulars of the patient and some vital data on medical precautions such as the patient’s drug history is currently being evaluated in two bospitals. The objective of the medical card is to enable first-hand information about a patient to be retrieved quickly and easily in case of emergency, during patient registration and processing of patient bills. If proved to be successful, the patient card will be rolled out to all public hospitals. It is also anticipated that the next version of the electronic card will be able to carry the medical case summary of the patients in the form of text and image using the optical media.

Other applications that are under investigation include in-patient and out-patient management systems, patient records management system, and patient billing and revenue collection system. Clinical support applications under development or outsourced by Hospital Authority include radiology information management system, ward order entry and results reporting systems, specialty clinical information systems, operating theater management system, computer-based pharmaceutical procurement and supplies management system, diagnostic imaging system, laboratory management system and nursing management information system. Business support applications such as clinical management system,

human resources and payroll system, financial system, assets management and materials management systems, staff roistering system, library management and text delivery system, electronic mail and office automation systems are also under investigation.

Before the territory-wide hospital information systems can support permanent archival of electronic diagnostic images of patients, most of the diagnosis are still based upon verbal description of the symptoms from the patient or some medical examination results that are generated from other sources. The IPAS data only include patients’ admission and discharge information, but does not contain any information about the diagnosis or operation that a patient has at the hospital. The IMPIS project attempts to go beyond the traditional approach by expanding the patient’s medical history to include graphics, audio and video data. These data may be crucial to the physicians when images and video clips showing critical treatment that a patient has received previously are important in giving a more informed and efficient diagnosis. Inappropriate application of drugs on patients due to the lack of detailed patient’s medical history, especially in emergency cases, can be reduced. Some of the examinations required can be automated so as to support the medical practitioners in the diagnostic process. By entering the results of the examination on-line, instant analysis on the patient’s condition can be obtained.

Currently, the patients admission and discharge data generated by IPAS are downloaded to Kwong Wah Hospital as a “.DBF” tile in a real-time mode. This file is stored at a local hospital server where authorized users with the appropriate level of security access are able to log onto the database through a desktop personal computer. Nevertheless, one of the design challenges of IMPIS was to integrate the information of the patients collected at the hospital with the data stored in IPAS. After studying the data structure of IPAS, an object- interface-scenario approach as described in the following section, was used to investigate the user requirements of multimedia system.

3: The object-interface-scenario framework

Allen and Frieder [2] described PACS and the complications of database design and communications constraints with an examination on both the relational and object-oriented database approaches, as well as the centralized and distributed approaches. These approaches are generally “database table-focus” or “relationship- focus” modeling methodologies. As the design of IMPIS is centered around “patients” and “medical practitioners” as end-users, it is more appropriate to use a user-oriented approach focusing on how data are being manipulated by users An integrated object-interface-scenario modeling framework is therefore applied so as to capture the complex and uncertain requirements of the system.

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Several joint application design sessions were held between systems designers and selective medical staff in order to explore the user requirements. A prototype was built during these sessions for helping the users to visualize how the system will work in reality so that they are able to specify the requirements in more depth.

There are two types of objects in the object-interface- scenario analysis. Physical objects are objects such as patients, doctors, clinics, hospital administrators and examination reports, which retain their own identity either outside or inside the computerized system, Logical objects are objects that are created artificially such as computerized records.

The objective of the IMPIS system is to have “complete” medical data on each patient. This include all the possible incidents that could happen to a “patient”, for example, being diagnosed by a doctor, taking a medical examination or taking an X-ray, etc., with recording of the time, date, place, persons involved and outcome of the event. As different from a text-based transaction processing system, the scope of the data in Ih4PIS include

As there are many events that could happen to a patient through time, possible scenarios were then identified and studied (see figure 1). The two main parameters in formulating a scenario is the purpose of the patient’s visit and the clinic involved. An example of a scenario is “when a patient visits the cardio-pulmonary surgery unit for a post-operation medical check”.

diagnostic images, graphics, voice and vi&o clips.

Figure 1. The Concept of A Scenario

Patient Patient

doctor’s prescription

The scope of this research involves a detailed study based on the scenario matrix as shown in figure 2. All possible events that could happen to a patient in either an in-patient or out-patient case are required to be further broken down for all different types of clinics. For example, a medical examination recommended by a physician or an operation being performed by a surgeon.

Figure 2. The Scenario Matrix

HOSPITAL CLINICS In- Patient Out-Patient Internal Medicine . . Neurology . . Nephrology . . Cardiology . . Endocrinology . . Geriatric . . Urology . . General Surgery . . Other Specialties . . Cardio-pulmonary Surgery l

.

Gastro-enterology . . Neurosurgery . . Ophthalmology . . Ear-Nose-Throat ENT . . Obstetrics and Gynecology l

.

Pediatrics . . Radiology . . Anesthesiology . . Pathology . . Orthopedics . .

As the scope of study is too wide to he covered in the initial investigation, the requirements of the Department of Neurosurgery was selected to be a pilot site for the study to he undertaken.

The “interface” between different objects for example, patient, doctors, nurses, etc., in each scenario event are examined. The modeling of the interface involves the following tasks : l identify the role of different objects involved in the event l identify the means of communication between different

objects l examine what type of information is being generated and in

what format l describe how the information is being used by different

objects and identify the flow of information between these objects

l identify how the information is being stored and retrieved by different objects

Two types of data are being classified in the modeling process. Global data refers to patient data which are shared between different departments in the hospital, and local data which are mainly generated and used within the department. The global data contains a further subset of patients’ demographic data which has the same data structure mapping as that of the IPAS database at Hospital Authority. Hence, whenever there is a change of data structure of IPAS, only this portion of the data file and the associated program will need to be updated.

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4: A prototype system for IMPIS

A prototype based on the above design methodology when applied in the Department of Neurosurgery at Kwong Wah Hospital was built for users to evaluate. The scenario selected was “when a patient was admitted as an in-patient to the department until he or she is discharged from the hospital”. The conceptual structure of the IMPIS prototype and its associated entity-relationship diagram is shown in figures 3 and 4 respectively.

There are two components in the prototype - the patient case record and the medical library. According to figure 4, each component is made up of a group of entities. The case summary entity forms the focal point of the patient case record component. Each case summary record belongs to one patient and may contain one or more operation records. Each operation note may have one or many operation codes and angiogram. Detail description of each entity type is given in the following subsections. In addition, the patient record component integrates with IPAS. It contains a data mapping of IPAS together with other clinical information such as medical officer in charge, diagnostic examination results and operations record. The medical library acts as a supporting unit and data source for the patient case record. An interface of the IMPIS prototype system for the Department of Neurosurgery is shown in figure 5.

4.1: The patient case record component

The Case summary entity (see figure 6) contains summary information on each patient who is admitted to the hospital. A case will be closed when the patient is discharged. All information such as history, progress, disease, operation and outcome are condensed on a case summary form. This is particularly useful in getting all the admission information at a glance during out-patient follow-up. With such means, continuous care of the patient can be ensured. Moreover, this module is integrated with IPAS so that the personal details of the patient are not required to be re-entered in the system. By using the unique “hospital number” assigned by IPAS during patient admission, the corresponding data about a particular patient can be retrieved instantly.

Operation Notes record the details about every operation that is being performed daily. Photos of the injured patient prior to and after the operation are stored (see figure 7). Such records also incorporated the key medical images such as CT scan and video clippings of the critical moments during an actual operation (see figure 8). Surgeons can annotate voice recording notes on important findings for that record. This integration and amalgamation of all these forms of multimedia data are extremely valuable in giving a more informed and vivid description of the operative procedures which cannot be achieved otherwise by using pure text.

Angiogram (see figure 8) contains graphical information such as X-ray images of blood vessels for the patient under examination. It allows users to record the pathological findings of the blood vessels by annotating on a standard anatomical diagram of the organ concerned.

Admission Diagnosis is designed to record the clinical findings of the patient on admission to the ward. In addition, the external injuries such as bruising and laceration can be marked on a graphical representation of the human body on the computer screen (see figure 9). This type of graphics recordings are extremely useful at a later date when there is a medical legal implication such as health insurance claim.

Ward contains a physical layout of the beds in the ward with the occupation details of beds (see figure 10). With the trigger of a button on the selected bed in the diagram, the data of the patient assigned to the bed will be instantly retrieved from the IPAS database. A report can be printed out to show the utilization rate of the beds in the ward over a period of time so that better arrangement of beds can be made.

Prescription module is integrated with the drug formulary database so that data about the drug can be retrieved automatically. The prescription form generated is used in issuing to the patients and transferring to the pharmacy division.

Electromyelogram (EMG) Record keeps the electromagnetic diagnostic information of a patient with an image of the waveform such as electroencephalogram (EEG) and the doctor’s opinion of the diagnosis.

4.2: Tbe medical library component

Disease Code holds a full set of ICD90 standard disease description and codes. The information inside is called by many patient case record modules such as case summary, operation record, etc. Operation Code is similar to the disease code and also follows the ICD90 standard. It is used in a similar manner to disease code. Drug Formuiary contains brief information and coding about all the drugs available in the hospital. The information is well classified and organized so that users can easily access the data. Drug formulary is integrated with the prescription module.

4.3: Other functionality

The prototype generates two types of reports - the admission statistics report that shows the number of patients that are admitted to the hospital within a selected date range and the work load statistics report that shows a summary of work load status of different surgeons within a certain period. These reports are used by hospital executives for supporting management decisions.

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Figure 3. A Conceptual Structure of the IMPIS Prototype

Statistical reports for

I I l Ward record

PATIENTS INFORMATION SYSTEMS

Figure 4. Entity-relationship Diagram of IMPIS Prototype

Patient Case Record Medical Library

EMG Record

Operation Code Disease Code - I : I relationship d I:M relationship

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Figure 5. The Main Menu of IMPIS Figure 6. The Operation Note Module (1)

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Figure 7. The Operation Note Module (2)

Figure 9. The Admission Diagnosis Module Figure 10. The Ward Module

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5: Design problems

An evaluation on the prototype was done by showing the system to a wider group of potential users including doctors, surgeons, nurses and other medical officers in the Department of Neurosurgery. Users were asked to try out the system individually and feedback was collected from the users. The results were further supplement by the observations made during the evaluation process. The type of problems encountered can be categorized into two groups - technical and non-technical problems.

5.1: Non-technical problems

The non-technical problems can be discussed with respect to users, operational and social perspectives.

5.1.1: User-related problems

During the evaluation process, we discovered that most medical professionals generally have a low level of computer literacy. Many do not even know how to type. The ‘learning curve of users are generally very slow. Intensive training and a long period of hands-on support was required to help the users to use the system.

Surgeons, are generally found to resist the use of computer systems in their work firstly because they found it difficult to learn a new technology at their age, and secondly, rejected the additional work load on their job duties, Although they are convinced about the potential benefits of being able to retrieve medical history of a patient very easily, they do not want to get involved with the actual input process of the data.

5.1.2: Operational and cost problems

The input logistics of the data required in the system was addressed seriously by the users. Since there is no computerized radiology system installed in the hospital, these images have to be manually input into the computers system. A scanning or digitizing input workstation is required to capture these electronic diagnostic images onto the computer. This is a tedious process and it is evident that it would not be appropriate for surgeons to input these data into the system. Similarly for video data. Since only critical moments were required to be stored, it means that the video has to be edited before digitized into the computer. At the moment, not all the surgical operations are recorded onto video tapes. The cost of implementing such a system hence became a critical issue to hospital executives interviewed.

5.1.3: Social problems

The security of patients’ data was a major social concern, especially when a user can easily get access to the territory-wide patients data bank once they are log

onto IMPIS. Medical data is as sensitive as criminal records, and should not be accessed by all levels of medical staff. It is a,common practice that all medical data generated from the hospital am considered properties of the hospital and will not be released without consent. Also, another matter noticed by the users were what if the patients refuse for any video to be taken in an operation.

A major problem raised by the surgeons was the use of these computerized records in medical legal cases. In Hong Kong, there is no written law in accepting computer digitized data as legal documents. At the moment, only microfiche and microfilm are accepted in court as medical evidence. Although the use of WORM (write-once-read- many) disks for permanent archive of original data seems to be one possible solution in proving the originality of the document, the legal procedures involved in certifying a WORM diskette as a “true” has to be established.

5.2: Technical problems

The prototype system was implemented using FileMaker Pro running on Microsoft Chinese Windows over a period of two months during the joint application design sessions. A small ethernet network running for two to three users was set up for the testing purpose. There are five main technical concerns discovered throughout the design and prototype evaluation process.

5.2.1: Integration with IPAS

Since IPAS is managed by Hospital Authority, the interface program written for retrieving IPAS data from IMPIS has to be updated whenever there is a change in the IPAS data structure. It is anticipated that more and more of this type of maintainance problems will arise as the territory-wide hospital information systems are being increasingly centralized.

5.2.2: Availability of software development tools

The ideal database management system development environment for developing this type of system should be able to handle multimedia data types, SQL and client- server processing functions. Such pre-requisites limit the choice of database software. On the PC, Filemaker Pro, and FoxPro for Windows for example, are popular database software development tools which can be adopted for such purposes. However, the database engine of these systems are not powerful enough for supporting multimedia applications in a multi-user environment. It was impossible to transfer a video clip of one minute and display the video without crashing the system.

A system that supports both Chinese and English data entry and output is needed for IMPIS. Data such as the patient name is necessary to be stored in both languages in Hong Kong. The commonly used Chinese characters set

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Proceedings of the 28th Annual Hawaii Intemational Conference on System Sciences - I995

for computer is Big 5 code. However, software which can support Big 5 code and co-exists with both a networking software and a database program is very limited. Under the Microsoft Chinese Windows, only Novell network system is compatible.

6: Soiutions

5.2.3: Capacity of data storage required

It is estimated that a huge capacity of data storage is required. There is about 20,000 patients admitted each year in a general hospital. If the average of each patient case file is 20 megabytes, a total of 400 gigabits of storage space will be required per year. Even if the files are compressed to 1:4 of the size, 100 gigabits are still required. With the fastest CPU, tbe delay in retrieval t ime is inevitably slow. Allowance has also to be made for decompression of the file.

There is also a data retention problem of the data downloading from the IPAS database. The database is growing at a rate of 40 megabytes per month. With the current mode of downloading, a detailed capacity plan is required in order to accommodate the data expansion.

For the non-technical problems discussed above, one of the solutions in helping the users in using the system is to adopt a consistent interface in the design. This principle was enforced by using common background buttons between screens, clear field labels and standard typeface. User-friendliness and simplicity is the most critical principle in designing the user interface. A long education process in convincing the users of tbe benefits and teaching the users in using the system cannot be avoided. Also, it is found that features such as the automated admission diagnosis module which enabled instant results to be generated helped to attract users’ interests. More of this type of features that is closely related to their routine tasks will help to better utilize the system. We have also found that most medical practitioners liked the idea of using voice annotation in recording the case notes instead of typing in the text manually. Users indicated that the concept could be applied to other tasks where they have to make notes while carrying out their daily duties.

5.2.4: Hardware confSguration for user workstation

The minimum configuration for supporting multimedia output on a Windows-based PC for a user demands a computer such as a 486DX2 66MHz with at least 16 megabytes of RAM, a high resolution VGA graphic acceleration card and monitor, a pair of speakers with a 16-bit sound card a video compression and display card, a decompression card for images, a SCSI card for a CD- ROM drive or additional hard disk and a network card. With these armamentarium, the slots in the PC are completely filled, even for the most up-to-date hardware architecture design. Moreover, it will be difficult to utilize fully the computer for other purposes other than medical records. The cost of such a machine is inevitable high.

The only solution to the data input problem is to have one or more dedicated operators to carry out the digitizing process. In order to store critical moments of an operation, a new procedure has to be implemented in the hospital and supporting staff have to be appointed to manage the video shooting process. There will also be a need for the surgeon in charge to select the required video clippings.

5.2.5: Networking support

Electronic medical record has to be stored and retrieved on a reliable hospital network system. Such a system might be required to link 50 workstations in a small hospital to as much as 200 workstations in a large general hospital. Heavy traffic within the network is expected during the office hours. Delivery of a large tile including images, sound and video clips requires significant traffic time. When more than 50 users are retrieving or printing data, undue deEay is bound to happen when the network is based on the exist technology. The ethernet system with coaxial wiring system is doom to halt the whole system. More wide band cabling, such as optical fiber, is required. However, such cable is expensive and not economically feasible in the public hospital system with a skeleton budget.

On the social issues concerned by the medical professionals, solutions have yet to be determined. The inclusion of multimedia data has provoked the need for re-thinking about the responsibilities of medical staff in maintaining patients record within a hospital. It is likely that new procedures and policies have to be formulated in order to facilitate the implementation so that all the required data are properly archived into the system. Consensus have to be obtained from the patients if this type of data were to be stored as part of a patient’s case record in the hospital. In addition, patient’s right in accessing the archived information will have to be stated clearly on a signed agreement between the patient involved and the hospital. Data security policies within the hospital have to be carefully established in order to avoid misuse of any sensitive patients data.

Most of the technical problems found in the evaluation process were mainly due to the hardware limitations, networking support and software incompatibility problems. These technological problems will be sorted out in time. Research work in handling these problems have been conducted by others [1, 8, 121. However, what is missing is a conceptual design for illustrating the role of various components, how they could be arranged in such an environment so as to work together cost-effectively. A proposed system architecture design for IMPIS based on the lessons learn from this research is shown in figure 11.


Figure 11. A Proposed System Architecture Design of IMAS

I 3PARlNE)cTAl LOCAL AREA NEWORK 1


SPVTAL WlWORK

A “true” multimedia information system requires the marriage of both a powerful client-server architecture database management system and an efficient electronic multimedia data management system. As the requirements of diagnosis examination support increase in the system, a dedicated medical diagnosis server is recommended.

Database management systems which can handle multimedia data in a multi-user environment are still limited. Most vendors claim that their database systems are able to support multimedia simply because the systems are able to handle one gigabit of data per field and user can define data types such as “picture”, “movie”, “sound”, etc. There is usually no other functionality to facilitate the input, processing and output of multimedia data in these systems. The system architecture of these database management systems are often maximized for on-line text-based data transaction processing instead of geared towards an effective archival and retrieval of multimedia data. An electronic data management system, which is designed specially to archive and retrieve multimedia data, will help to improve the system performance. Input, processing, output and other facilities such as compression/decompression techniques are often built into these systems in order to maximize the quality of the data stored and speed of retrieval, but at the same time minimize the storage cost of the multimedia data.

The design proposed to utilize the on-line transaction processing power of a client-server database by putting all the database tables in the hospital-wide server. Each data file in the electronic multimedia data management system is labeled with a unique identification number. The link between the client-server database management server

and the electronic data management system is established by using a database table maintaining the relationship between the record in the database management system and the associated identification key(s) of the multimedia data. When a user executes a query on a patient, the query will be sent to the database management system for processing. A list of results which fits into the criteria of the user will be returned and displayed on the computer terminal. The user can continue the query process until an option for retrieving further multimedia data is selected. The command will then be sent to the database management system where the associated identification key(s) of the multimedia data is retrieved. The database management system then sends a message to the electronic multimedia data management system and the selected data tile is located. The electronic multimedia data management system then takes over the user request and send the multimedia data file to the user over the high-speed network. In this way, the database management system can continue to serve the usual transaction processing for other users while the electronic multimedia data management system will concentrate on managing the transfer of multimedia data.

In order to reduce the cost of hardware and networking devices, a hybrid model of network design can be used by partitioning the hospital network into high speed network such as FDDI to serve high-end users and an ethernet network to serve normal users. Each department should install a decentralized LAN system linked to a high-speed hospital-wide networking backbone with their own departmental medical diagnostic server and electronic data management system. This will help to reduce the traffic of transmitting multimedia data across the hospital

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network. Only inter-departmental exchange of data is transported through the backbone. Data such as laboratory results which are mostly text-based can be distributed through the ethernet channel. Although the database structure is different for each department, the data inside IPAS are shared by various departments. Data generated from different departmental LAN can be filtered and extracted before exporting back to the central Hospital Authority data bank for generating statistical reports.

With the advent of CD-ROM, bulky multimedia data storage at departmental level is feasible and economical. When the hard disk in the departmental server is full, the data can be spilled over to a CD-ROM. As most of the hospital record is not going to be changed after all the data is verified, it can be stored on a CD-ROM. Sequential CD-ROMs can be loaded onto a jukebox or stack CD players. Many years of record can be read and retrieved simultaneously by this method.

7: Conclusions and future work

The research presented in this paper has demonstrated how multimedia data can be used in real-life applications. However, we have discovered that the inclusion of multimedia data does not simply means installation of an optical fiber network or having powerful multimedia computers. Rather, it often requires more involvement and co-operations with users of the systems in the input stage than traditional text-based database systems. The cost of implementation of this type of system is high and the value of the return has yet to be determined. The success of implementing a system like IMPIS also rely heavily on organization intervention in pursuing these systems to be used effectively. Nevertheless, the advancement in information technologies has given rise to the birth of a new generation of computerized patients records in a format that was not possible ten or twenty years ago. However, the development of this new generation of computerized patients record will not rely only on the continuous growth in technologies, but also on the way how this type of information is accepted in our society.

In spite of the problems which cannot be solved by technologies alone, we will continue the development of another generation of IMPIS based on our proposed design and explore how users response to other new technologies. The scope of study shall include features such as artificial intelligence [ 151, content-based retrieval techniques on multimedia data, video-conferencing in supporting collaboration diagnosis [9] and voice recognition systems [T].

References

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