Critical success factors for establishing a multidisciplinary health community knowledge management system using internet-based ICTs: the cardiology paradigm

Int. J. Healthcare Technology and Management, Vol. 7, Nos. 3/4, 2006 283

Critical success factors for establishing a multidisciplinary health community knowledge management system using internet-based ICTs: the cardiology paradigm

Yiannis Koumpouros* D. Gounari 31, 12131–Peristeri, Greece Fax: +30–210–5735222 E-mail: [email protected] *Corresponding author

Gian Luigi Nicolosi Chief Cardiology Department, Ospedale Civile, Via Monterale 24, 33170 Pordenone, Italy E-mail: [email protected]

Manuel Martínez-Sellés Hospital Universitario Gregorio Maranon Dr. Esquerdo, 46, 28007 – Madrid, Spain E-mail: [email protected]

Abstract: The current paper concerns the development of an internet-based Health Community Knowledge Management System in the field of Cardiology. The research conducted covers a wide range of state-of-the-art technologies (ontologies, knowledge management techniques, etc.). The objectives of the final system are: to create an ontology for the modelling of the knowledge base around cardiology, while facilitating every day working needs of the various intended end users. Pharmaceutical companies, healthcare professionals, and biomedical companies are all interested and are participating in the formation of the virtual community for disseminating valuable knowledge in cardiology. The technological challenges of applying such an internet-based system, as well as the sociocultural and political factors affecting the application of similar internet-based ICTs and the integration with existing processes and systems in healthcare are examined. The research was conducted in three countries/pilot sites (Greece, Spain and Italy) and two experiences for testing purposes are being considered. The work concludes that some of the major success factors are:

• knowledge critical mass

• political commitment and endorsement

• well-structured ontology

• multilinguality of the content and the system

• timeless processes

• multipartnership participation

• patient- and problem-oriented knowledge management system.

Copyright © 2006 Inderscience Enterprises Ltd

284 Y. Koumpouros, G.L. Nicolosi and M. Martínez-Sellés

Keywords: knowledge management; ontology; cardiology; internet.

Reference to this paper should be made as follows: Koumpouros, Y., Nicolosi, G.L. and Martínez-Sellés, M. (2006) ‘Critical success factors for establishing a multidisciplinary health community knowledge management system using internet-based ICTs: the cardiology paradigm’, Int. J. Healthcare Technology and Management, Vol. 7, Nos. 3/4, pp.283–302.

Biographical notes: Dr Yiannis Koumpouros received his degree in Electrical Engineering from the Technological Educational Institute of Piraeus, Greece, in 1993. He continued his studies at the National Technical University of Athens (NTUA), Greece, obtaining an MSc in Electrical and Computer Engineering (1997) and a PhD in Biomedical Engineering (2000). He received his MBA from the NTUA, the University of Athens and the University of Piraeus (2004). He was R&D Manager in several private Greek companies. He was General Manager of ATAC-Innovative Applications. He has participated in various R&D projects at a National and a European level. He was adjunct Professor at the University of the Aegean and the Technological Educational Institute of Piraeus, Department of Automation, Laboratory of Telematics Applications. He is Vice-President of the Hellenic Society for Medical Informatics and Technology. He was adjunct Professor at the Greek Open University and lecturer in the Technological Educational Institute of Athens, Department of Informatics. He worked as evaluator and peer-reviewer for several EU-funded projects. He has published more than 30 scientific papers in conferences, journals, and peer-reviewed magazines. He is the author of several books in the fields of health, telematics and informatics. He is currently the President of the General Panarkadian Hospital of Tripolis.

Dr Gian Luigi Nicolosi, MD obtained his medical degree and his specialty in Cardiovascular Diseases at the University of Padova (Italy) in 1972 and 1975, respectively. He is chief of the Cardiology Unit of Pordenone Hospital (Italy) since 1999 and chief of the Cardiology Interhospital Department of the Pordenone Province. He is fellow of the Italian National Association of Hospital Cardiologist (ANMCO), fellow of the European Society of Cardiology, and fellow of the American College of Cardiology. He was President of the ANMCO from 2000 to 2002. He is incoming editor of the Italian Heart Journal. He is the author or co-author of more than 800 papers or abstracts in Italian and International Scientific Journals.

Dr. Manuel Martínez-Sellés is an Associate Clinician in the Hospital General Universitario Gregorio Marañón from Madrid. His major research interests are heart failure and acute coronary syndromes. He has 15 international publications in international peer-review journals and more than 50 abstracts in international congresses. His doctoral thesis, cum laude, obtained the Highest Distinction in the University Completeness from Madrid in the year 2001 and he has been Associated Honorific Professor in that university since 2002.

Critical success factors 285

1 Introduction

Medicine and healthcare in general have known an impressive growth and improvement in the last century and this acceleration was even greater during the last decades. Medical research, clinical evidence and case studies enormously increased (and will continue to increase) medical knowledge. On the other hand, the progressive specialisation of Medical Doctors (MDs) and Healthcare (HC) professionals gives way to the creation of specialised and often very technical knowledge domains, dedicated to elites of specialists, difficult to be shared with medical doctors and healthcare professionals in general, outside these restricted circles. So we might say that the increase of medical knowledge conflicts with the diffusion and usage of it in the ‘usual’ daily medical practice of General Practitioners (GPs) and MDs operating on the territory, who are generally lightly linked to the research networks and to the scientific community. This paradox (wider and wider medical knowledge practically used by less and less segments of HC professionals on individual basis) drives the idea on which the presented system is based, that is ‘making effective knowledge available and immediately usable by any MD and other HC professional operating in the territory’. A number of researches on the effectiveness of healthcare systems in different countries show that the role of GPs is losing relevance, while patients ask more and more for visits and medical consultations by specialists and for laboratory and radiological exams. The effects of this behaviour are contributing to the increase of the healthcare costs and to the increased load to the hospitals, where patients are referred to for diagnosis and therapy. While life expectancy increases, illnesses and comorbidity also increases and usually creates a complex personal health burden with the need of several different medical competencies and knowledge, to define a correct and personalised clinico-therapeutic pathway. A Knowledge Management (KM) system would help HC professionals to manage and organise the incredible amount of knowledge and experience required to address the health problems brought daily to the attention of GPs and specialists, and to make this knowledge available even to the most peripherally located MD or hospital.

The purpose of the presented system was to set up an intelligent collaborative network environment for the management of a new Community of Health Knowledge and Competence in the Cardiology domain. The final IT platform is designed to facilitate the transactions of knowledge and competence between healthcare experts and on site operators and to support the professionals in taking evidence-based decisions at the point of need. In an ‘Ambient Intelligence’ vision, the current system works on the development of metacontent services to improve information handling and knowledge management, to support new forms of health organisations based upon learning environments and community memory. The healthcare professional is placed at the centre of this ‘ambient intelligence’, as the key for future developments of an all-inclusive knowledge-based health system.

The following sections demarcate some basic terms and concepts in a health KM system, while presenting the adoption and diffusion of ICTs in health organisations. The interaction of the several stakeholders in eHealth is also discussed in order to reveal the need for a KM system. Following, the specific needs of the Cardiology domain (social factors, factors internal to the healthcare system, economical factors) are presented supporting the initiative of building the current system. After the description of the technological solution, the major results and conclusions are discussed.


2 Materials and methods

2.1 Background information

The core of any Knowledge Management system is the knowledge itself. It is critical therefore, prior to building any such system, to be able to define the knowledge in the addressed domain.

2.1.1 What is ‘medical knowledge’?

Medical knowledge includes any medical evidence from the scientific literature, trials and research, case studies, statistical data, guidelines and best practices from the different health domains. But knowledge also comprises more ‘volatile’ matters, such as personal considerations based on one’s medical experience gained through personal practice, results from discussions and consultations between different specialists, results and presentations from workshops or scientific congresses or round tables that might not be recorded or published. In some cases, such ‘non-structured’ knowledge may constitute the key for solving specific health problems. And last but not least a huge amount of medical knowledge comes from the pharmaceutical and biomedical industry that heavily invests on trials and research and of course in the dissemination of information and marketing of their products. This too constitutes potential knowledge, part of which is obviously protected by Intellectual Property Rights (IPR), and which may not be immediately usable unless previously evaluated and integrated in a correct knowledge framework. On the other hand, pharmaceutical and biomedical business companies are eager for medical evidence based on real case studies and on the direct contact with patients to better direct their business strategies towards real needs. In that perspective the current platform constitutes an important support system. So we might consider it as an instrument which implements the idea of knowledge management (used for example in large business organisations) inside an ‘ethical’ framework designed to improve the efficacy of the therapeutic and diagnostic intervention in healthcare.

Knowledge management has been adopted in the industry environment to enhance productivity, avoid information and knowledge loss and improve communications between different actors working for the same final goal (product or service). Although knowledge management systems implemented in large industrial context (large industries and/or industries with strong subcontracting links with providers) can count on a strong managerial push, nonetheless it requires drastic organisation changes and personnel education and motivation actions taking long time. The application of such a model in such a different context as healthcare rises many issues and concerns, mostly deriving from the feebleness of managerial push towards the adoption of new organisational models and innovative technologies among national and regional HC systems and from the difficulty of convincing the medical community to change their individual approach towards knowledge acquisition and communication. However, the availability of fast communication technologies and of large medical data banks in the past years and continuously fed by the medical and research community, is now pushing towards the adoption of more productive tools and systems for knowledge sharing even in healthcare.

Portals on health and on cardiology and Cardiovascular Disease (CVD) specialisations are many, and many of them are very qualified, but knowledge is dispersed and MDs have to navigate among different knowledge sources to find a complete picture of diagnosis and treatment cases attaining their specific request. Chat


lines (specific and specialised, used by elites of MD professionals) and Databases (DB) on diagnosis results, and online medical journals may be found on the internet (Silber, 2003; Gunther et al., 1999). Medical knowledge resources such as Medline or the Cochrane Collaboration offer a wide knowledge DB, but even such knowledge resources lack one important content: the daily experience of cardiologists and MD professionals, expressed in non-formal reports and usually transferred among restricted groups of MD professionals who strictly cooperate or who get in touch during their daily practice. Knowledge management internet or online services for health are not common. A few examples have been found, in USA, Canada and Australia.1–5

In EU many initiatives have been established to implement coordinated efforts for CVD prevention, most of them devoted to optimise the care (network for defibrillators, network for emergency and ambulance CVD care, network for aemodynamics, network for cardiac catheterisation facilities) and the efficiency of service (pharmacy network for one-stop-shop care reservation, remote ECG reading) or to establish a diffused knowledge and application of specific guidelines for cardiology and of phone consultations for GPs on CVD problems.6 At the European level wider initiatives exist such as the European Heart Health Initiative (EHHI), a project of the European Heart Network with contributory funding from the European Commission, which aims to raise awareness and promote action against cardiovascular disease across Europe. One of the goals of this initiative is to establish alliances of organisations in each member state to coordinate action on heart disease prevention. Other initiatives like the mentioned European Heart Health Initiative aim at addressing specific operational objectives and are not devoted to knowledge diffusion and sharing among the medical community. The UK first experienced a network for teleconsultations involving more than 200 GPs. The experience led to a 30% reduction of hospital interventions (non-acute patients were cured at home by GPs or other MD specialists). This experience led to further projects for KM which are distributed in UK, under the endorsement and promotion of the UK National Health Service (NHS).7–9

2.1.2 Online technologies diffusion in health organisations

Apart from its social significance in terms of protecting people’s health, healthcare is also important economically. Total expenditure on healthcare across Europe represents more than 8% of GDP and it employs between 5% and 11% of the workforce in member states (James, 2002). As is the case with most other major industrial, commercial and public sectors in advanced economies, healthcare is beginning to be transformed through the application of new information and communication technologies. This is the foundation of eHealth which, in principle at least, mirrors eCommerce developments in using internet and related technologies to integrate B2B and B2C activities, processes and communications. In the same way that consumers have access to a wide variety of banking services without ever going inside a bank building, so they may eventually receive an increasing percentage of their healthcare through online links rather than making personal visits to GPs or hospitals. Unlike some other sectors of the economy, however, many of the items of information and processes involved in healthcare delivery are complex and not readily ‘systematised’. This has led to healthcare being perceived as lagging behind other aspects of consumer relations in terms of its use of informatics. It is generally true to say that, until now, the use of electronic systems in health has been oriented towards the internal administration and efficiency of health providers,


i.e., hospitals and primary care. New developments, however, have produced widely available technologies with common standards suitable both for large enterprises and for consumers in the form of internet and new network techniques. The advantage of such development is that the same technology can be used in different ways. Healthcare institutions, for example, can disseminate information to drive more common standards, e.g., in public health; health professionals can increase convenience; and citizens can get information about diagnoses, treatments and facilities.

2.2 Stakeholders in eHealth

The healthcare sector incorporates a huge variety of organisations: public-sector providers, governmental departments, private healthcare systems, not-for-profit bodies and charities – the list goes on. It is also incredibly knowledge-intensive, and the complexity of healthcare provision only increases as the industry’s knowledge base broadens. In addition, heightened levels of public expectation and media scrutiny add to the pressure to perform as efficiently and effectively as possible while maintaining an acceptable degree of transparency and accountability. Pressure to make increasing use of new technologies in healthcare is therefore mounting, not only because of the availability of suitable hardware and software but also from each of the stakeholders in health:

• Institutions (health policy makers and payers) are encouraging use of informatics for all public sector services (eGovernment) to improve convenience, shift costs and increase efficiency. This has led to a number of initiatives at both national and international level.

• Businesses (those who supply goods and services to the healthcare sector) are making available more eCommerce and supply chain management solutions that are readily applicable to many healthcare delivery processes at affordable prices.

• Citizens have raised expectations through increasing consumerism in terms of getting the same level of timely information and quick, reliable response from healthcare as from other services.

• Healthcare professionals are increasingly aware of the need for higher quality and reduced risk of litigation but also of the explosion of information needed and the increasing complexity of healthcare processes, neither of which can be managed satisfactorily through traditional manual methods.

As shown in Figure 1, each of these interested parties has their own agenda and motivations. Developments such as eHealth (Silber, 2003), however, require an integrated approach within which all aspects of healthcare delivery can make best use of the technology to improve effectiveness and efficiency. This means creating a constructive dialogue between all parties involved to agree on a common aim and strategy: i.e., a community of knowledge among the involved HC professionals of a defined territory. In recent years, the number of people accessing the World Wide Web has increased beyond expectation. All manner of users, from the casual surfer to the professional can avail themselves of this vast information resource, with health information and health promotion resources being prominent. The internet is seen as a new medium for the dissemination of health-related information having the potential to reach a global audience. Previous studies have demonstrated that much of the health


information on the web is of variable and inconsistent quality, difficult to understand (Zylinski et al., 1998; Smith, 1992; Impicciatore et al., 1997) and difficult for medical professionals to make direct contributions (Wyatt, 1997; Ribbons, 1998). While the internet has the capability of transforming the future of online health information systems, the potential for misinformation and confusion is also there on the web. A significant pitfall with many systems is that they lack the endorsement of medical professionals and verification of the medical information provided. In addition, the demand by the public for faster and better access to information, and the untapped potential of the Information Highway, is leading European Healthcare into quite a few knowledge and information initiatives.

Figure 1 Stakeholders in eHealth

supply

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Patientfunding

Clinicalprocess &

medical info

Clinical process and medical info

Lifestyle &healthcare

options

Lifestyle and healthcare

options

Policy&

Policy and funding

rofessional ViewProfessional view

InstitutionView

Institution view

Citizen ViewCitizen view

BusinessView

Business view

Procurement&

Procurement and supply

A more strategic approach to managing knowledge and information is critical to support current and future initiatives. We cannot create knowledge helter-skelter without clear means to capture it, classify it and make it accessible. There is no doubt that a wealth of talent and an untapped treasure of experience and knowledge exist in the public sector. Yet it is crucial that every organisation recognises the value of the intellectual capital at its disposal if it is to truly fulfill its potential, and this is particularly important to those public sector bodies that have thus far been guilty of neglecting what is in effect their greatest asset. In this context, the core of the presented system is a portal website that comprises many services concerning transactions of knowledge. Among the technical objectives of the system was to exploit state-of-the-art technologies thus reducing and minimising potential development risks. The final platform supports the establishment of a dynamic network of expertise. Knowledge Management can be a strategy for ensuring that health knowledge and information are identified, captured, created, shared, analysed, used and disseminated to improve and maintain the health of citizens.


2.2.1 Establishing a health community knowledge management system

The creation of a Knowledge Management (KM) system is a complex process, that requires a strong commitment by the participant actors and that involves important resources. Knowledge sharing in healthcare is currently performed following unwritten rules, based on common behaviour and on consolidated habits. The scientific community (researchers, medical specialists), most of whom are based in hospitals and universities, are grouped in restricted elites of ‘experts’ among whom share their knowledge and exchange experiences. Also publications and research or clinical studies are managed in a consolidated way, that privileges and advantages specific groups of specialists. The increased specialisation, both medical/clinical and technical, in the usage of specific diagnostic and curing techniques generates very specialised branches of medicine, even inside specific medical fields such as cardiology, where medical professionals specialise in specific techniques. This extreme specialisation process increases the specific knowledge on each particular therapy or technology, but at the same time contributes to losing the entire picture, where different therapies might be compared and evaluated when addressing a specific patient’s case. This situation originates some amazing paradoxes, where one patient might receive very different therapeutic advice from different medical specialists. But patients are becoming more and more attentive to their health, most of them trying to get information from different sources (and the internet is one of such sources) before asking advice from a MD, and even then patients will ask different MD specialists before trusting one of them. In this changing environment it is evident that GPs feel lonely and excluded from the knowledge derived from clinical results of research and specialised excellence centres. Despite the heterogeneity of the types (limited or not to the gatekeeping role of GPs) of healthcare systems that can be observed in most EU countries, it has often been argued that a system in which GPs act as gatekeepers to specialist care leads to lower healthcare costs (Franks et al., 1992; Martin et al., 1989; Starfield, 1994).

The above considerations give the rationale to invest on KM systems and services for healthcare, and justify the efforts required to establish such systems. In particular the main contributions of the current system to the Community Social and Health Objectives are expected to be the following:

• Continuous improvement of quality of life and health and safety for citizens, as a result of a good decision support system for MDs.

• Continuous promotion of health knowledge and competence of health professionals to support appropriate evidence-based decisions, as a result of the availability of knowledge and of the possibility to increase this knowledge by adding each individual interesting experience and by submitting problems and questions to a network of medical specialists.

• Optimised problem-oriented distribution health strategies in a network-based learning environment and community memory, achieved by the sharing of best practice of evidence-based medicine results.


2.3 Why a KM system for cardiology?

Medicine is facing a deep social change that affects the entire healthcare approach: people live more and more and develop chronic diseases; people move from one continent to another and the recent case of SARS, like HIV was in the past decade, shows how medical knowledge must be fast available to all the medical community, and not restricted to delimited regional areas and to the scientific and research medical community. Knowledge is currently distributed among the medical community and the traditional communication means do not completely fill the gap between different medical schools and approaches (cultural or territorial gap) and often discriminate medical specialists in categories (i.e., cardiologists attend different workshops and read different magazines from pneumologists or internal medicine doctors or neurologists) and leave the GPs at the border of specific knowledge. But knowledge should be usable, trustworthy, and immediately effective for medical doctors and healthcare professionals who are in front of real persons (and not medical cases) and must give answers that might save lives. Of course a KM system for Health is a complex objective, and some delimited experiences might help to address the issue and drawbacks arising when establishing a KM system and fostering the development of a knowledge medical network.

A knowledge management system for Cardiology addresses the need to establish a virtuous cycle for knowledge sharing between different healthcare professionals facing heart diseases.

2.3.1 There is a need for interaction between different healthcare professionals in the cardiology field?

The reasons are many and depend on different factors, some of them social, some internal to the healthcare system and some economic, that are characteristic of the new trends of the healthcare system.

Social factors pertain to the higher age of patients, due to the increase of life expectancy and to the wider medical information available to patients. The elderly are subject to develop chronic diseases, many of them related with the cardiovascular system that are frequently combined with other illnesses; so GPs and medical specialists other than cardiologists may encounter hybrid situations where the diagnosis of cardiovascular diseases are important but not so easy. Comorbidities (the presence of different combined diseases) are increasing in older age and heart disease is highly prevalent among them. Here the knowledge accumulated by the scientific community might be the fundamental factor to support MDs other than cardiologists in their decisional process. Cardiologists facing particular situations might also be supported in the diagnosis and treatment of a specific patient’s disease by the available experience of other professionals, who have possibly treated similar cases. But knowledge should also be complete and correct to address specific requests and demands from patients: more and more often patients go to the doctor already informed (even though this information could be incorrect or incomplete) on their possible or specific disease and of the available treatments and cure. Media, internet and direct communication between patients contribute to increased patients’ awareness and in consequence, patients’ expectations. The first level of the healthcare system attained by this social behaviour is the primary care level, where GPs operate: a KM system will therefore enable also GPs to address specific heart diseases.


Factors internal to the healthcare system pertain mainly to the high specialisation characterising the medical profession. This is more true in hospitals where surgeons and medical specialists become better experts in the adoption of particular diagnostic tools and treatments. From this situation arises the risk of diminished criticism when addressing one patient’s illness or heart disease: different cardiologists might take different decisions based on their particular expertise. The cardiology departments in hospitals address different and complex problems, some of which are detected and first addressed in other hospital departments, such as the intensive care department of the emergency department where acute patients arrive. The detection and care of such patients hospitalised outside the cardiology unit requires a shared knowledge at least at the admission of a patient. More specifically, healthcare personnel in ambulances and GPs who address patients to a hospital should be enabled to decide to which hospital and to which hospital department the patients should be taken or addressed for advice. And finally, the improvement of therapy for cardiovascular diseases and the secondary prevention actions usually performed create the new need to organise the continuity of care for patients with chronic heart diseases, usually at home, but who should be continuously followed up by competent healthcare professionals.

Finally the economic factors highly affect the organisation of the overall healthcare system: the cost of health is dramatically increasing in western countries and governements are drastically controlling and monitoring the expenses for health. Cardiovascular diseases are already the main cause of death in the world and their importance will continue to increase until, at least, the year 2020 (Murray and Lopez, 1997). Heart diseases affect more then 20% of the world population and is the first cause of death in Europe10 (four million deaths per year) and the USA (over 58 million US suffer from some sort of heart disease and about one million die per year). The care and treatment of cardiovascular diseases constitute therefore a significant expenditure for the healthcare system of EU countries. Even though preventive actions have been promoted and implemented, the number of CVD-affected people is increasing. As health costs absorb an average of 8% of GDP in EU countries, we can estimate that costs related to CVD care and treatment constitute more than 2% of the GDP of EU countries. This gives a dimension of the economic factor pushing towards the rationalisation of resources. Hospitals are first requested to reorganise their health programmes and to optimise their resources. This fact leads to the reorganisation of departments on the basis of economic savings, so concentrating medical competence in specific departments but at the same time dispersing patients in different hospital units depending on the prevalent disease or on the patient’s illness and health status severity. On the other hand expenses derived from prescriptions by GPs and specialists for lab exams and other costly medical investigations are also under strict monitoring by national health security systems due to the enormous increase of such costs. So GPs and medical specialists are requested to limit prescriptions and to correctly evaluate each patient’s real needs for in-depth medical analysis and for specific and often expensive treatments.

In summary we can identify the following reasons to implement a KM system for cardiology:

• Chronic heart diseases are highly prevalent.

• Comorbidities are ubiquitous.

• Cardiology Departments take care of complex problems.


• Organisation of continuity of care is required for continuous quality improvement

between prevention and rehabilitation.

• In homogeneity of competence and expertise on CVD of management, nurses, hospital and clinical cardiologists, GPs, emergency MDs, internal and other medicine specialists.

• Reduction of cost for diagnosis support exams and treatments for CVD.

• Continuous education of MDs and HC professionals at all levels.

Taking into consideration the above points, the purpose of the KM system is to develop an intelligent collaborative network environment for the management of Health Knowledge and Competence. The focus is the integration of Knowledge Management Technologies into the everyday working environment of healthcare professionals where the HC professional is placed at the centre of this ‘ambient intelligence’ as the key for future developments of an all-inclusive knowledge-based health system.

3 Technological approach

The core of the system is a website portal that comprises many services concerning transactions of knowledge. Transactions are implemented using JAVA and the technology of Intelligent Agents. An ontology is used to semantically empower the process of knowledge search as well as to make knowledge classification easier. A document repository contains the required scientific documentation. Every scientific term in the ontology and every published document in the website portal is related to the name of the source (expert) and the names of the experts in the Advisory Board for IPR and validation purposes. Consequently, the end user is adequately informed about the source of knowledge in order to establish a direct relationship with the expert that provided him with the specific information. So, the experts are able to establish a direct network of expertise by exchanging information on specific aspects of their discipline. An Advisory Board (AB) is formed in order to validate sensible contributions (clinical guidelines and recommendations). AB members are also responsible for the ontology update according to the knowledge classification needs demanded by users’ contributions to the system. The validation of knowledge and the maintenance of the knowledge repository are two vital tasks, because the information in the knowledge repository is highly critical for the society. A brief architecture of the final system is presented in Figure 2.


Figure 2 System architecture

ProfilingDB

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As the users access the system, the following information flow happens among the modules, as depicted in the schema:

• User gets authenticated by the security module.

• User interface is provided by the presentation modules, which first connects to:

a The profiling module to retrieve user’s profile.

b The multilingualism module to get the user’s specific language content.

c The user accesses information via the presentation module, and is capable of searching, knowledge sending and communication with other users of the system.

• To perform a search the system initiates the search agent module. The user has two options, as far as the knowledge sources to be searched are concerned:

a Perform a conceptual search using the ontology and the internal knowledge repositories, providing ranking to search results via the ranking module.

b Search external knowledge bases, with which the system may have established a link.

• Documents and knowledge are inserted into the system from users and external sources. Each inserted document is passed through the keyword extraction module in order to facilitate the process of associating the document with specific keywords. In case the keywords proposed by the system automatically are not considered adequate by the user, he/she may propose new ones. These will be added to the system after having been reviewed by the appropriate experts, who will be notified by the alerting module.


• The user may also communicate with other users of the created community, using

the collaboration tools, chat, forum and alerts.

The different modules of the system can be further categorised in three main types: Data Repositories (Experience Database and Documents Repository, Profiling Base, Users DB, Collaboration DB), Information Management (Ontology Engine, Ontology Maintenance Tool, Search Engine, Ranking Module, Keyword Extraction Module), and User Services (Profiling and Personalisation, Presentation Module, Collaboration Module).

The Ontology Data are represented and stored in the standard RDF (Resource Description Framework) Format. The information is divided in two main categories, classes and relations. The categorisation of these classes is depicted in Figure 3.

Figure 3 Categorisation of classes

The classes’ terminology follows the Medical Subject Headings (MESH) medical vocabulary as much as possible, focusing mainly in the Cardiology sector. The relations defined for the ontology in the frame of the current work are presented in Figure 4.

Therefore knowledge may not only be categorised, but also intelligently linked and related, in order to provide a meaningful service to the healthcare community using the platform.

The Ontology Engine module is the core knowledge ‘storage point’ of the system and can be accessed from the following modules:

• Ontology Maintenance tool to provide administrative access to information.

• Search Engine to provide conceptual information search.

• Keyword Extraction module to link documents to knowledge.

The Ontology Engine Module depends also on the security module and the users’ database to authenticate users and authorise content.


Figure 4 Relations of the ontology

One of the main advantages of the presented Ontology Model is the fact that it can be continuously updated and maintained so as to contain more terms and concepts. The maintainability of the Domain Ontology of Cardiology is of major importance in the scope of the project since it constitutes the core mechanism that will be used for the distribution of knowledge among experts. Furthermore, the maintenance of the ontology will help the doctors and the other experts to associate more precisely their documents/knowledge assuring the better results during the search of knowledge inside the system.

4 Results

The final system, described in the previous section, was applied under real working conditions in two pilot areas in Spain and Italy. All the mentioned actors (cardiologists, cardio-surgeons, GPs, pharmaceutical companies, etc.) were involved during the pilot testing in order to acquire the desired feedback, improve the system’s functionalities and maximise its effectiveness. The end users were constantly providing feedback by filling appropriate quality assurance forms or by simply emailing their comments. The major findings are discussed in this section, by categorising them into ‘success factors’.

A KM system is only effective when users find it useful, usable, rich in information, trustworthy, interactive enough to allow fast information and knowledge exchange between health professional of recognised experience. MDs are often reluctant in using IT and communication technologies for their daily work: they are face-to-face with a


patient and cannot wait for a remote answer or a teleconsultation with other specialists before answering patient’s questions or making their diagnosis. Also MDs find the consultation of internet-based literature and specific knowledge more and more difficult and time-consuming, even when they know where to search for information, than reading specialised press. The reasons for this behaviour are many and different and range from the lack of practice and habit to IT to the difficulty in finding the exact knowledge and information pertinent to one’s specific scientific needs or patients case.

The ontology formed and used in the current project proved to be the best way to overcome the above problems. It was necessary to have an ‘ontology-expert’ (technical person) to continuously communicate with expert end users and revise the ontology in order to adopt it to the users’ expectations. The final structure of the ontology should represent as much as possible the thinking of different health professionals. Thus, many changes were performed before the last version of our ontology which finally proved to satisfy the users (relevant results to the anticipated ones using our searching mechanisms).

4.1 Success factors

The users’ feedback and the comments collected during the several meetings held and the operation of the system under real working conditions in the pilot period can form some critical success factors that should satisfy several specific conditions. As already mentioned earlier, a KM system would be successful only if widely used and if it results in an increased efficacy of care and support to a large segment of healthcare professionals. To start a virtual circle where knowledge increases gradually also through the contributions of all HC professionals using it, a KM system should ensure the following conditions:

• Environmental conditions:

a It should be a patient- and problem-oriented knowledge management system, focused into the everyday clinical decision-making environment of different health professionals.

b Specific groups of interests with cardiologists as leaders, coordinating different complementary specialties and expertise should be delineated.

c Multipartnership participation should be ensured (i.e., different HC organisations plus business companies interested in health).

• Operational and technical conditions:

a It should ensure flexibility to continuous needs (self-adjusted and self-maintained reengineering).

b It should perform strategic integration of information and knowledge, to develop Continuous Medical Education (CME) and to achieve professional accreditation and credits.

c It should ensure usability to enable easy, fast and secure knowledge exchange (submission, retrieval, search) and interaction.

d It should ensure authorship and authority, security and privacy to users and to encourage them in using it.


• Political and institutional conditions:

a Official commitment and endorsement by regional or departmental governments of the test sites (Agency for Health Services) should be ensured.

b It should be exploited from pilots to diffuse experience through Institutional Commitments of regional and national agencies for health services: it should be part of an institutional strategy.

4.2 Other critical factors

The prerequisites elicited above during the pilot usage of the system well anticipate the main critical factors that should be overcome to make a KM system, as the presented one, successful. Some other factors, which are critical now but could become less important in the future, when e-health support and tools will be widely diffused and adopted by the medical community, are the following.

The first critical factor is the diffusion and usage of IT in hospitals and among MDs. Even though the basic IT technologies (PC and PC networks) are well diffused in HC centres and hospitals and among MDs and GPs, their usage is often limited to ‘internal’ activities, such as the management of patient’s data or the personal computing activities related to HC professional work. Internet connections in hospitals are often restricted to part of hospital staff; GPs and MDs are not used to consult other specialists through the internet, preferring more traditional communication ways such as the phone. Also the diffusion of portable communication devices other than GPRS phones (Palm PCs, PDAs) is rather low between MDs and even when such devices are available, they are seldom used for ‘medical’ and e-health purposes.

Then we should mention the resistance of MDs in using IT tools for consultation, and in particular when they are face-to-face with a patient.

Another important critical factor is the language. The availability of epidemiological and medical knowledge in each MD’s mother language is fundamental for at least two reasons:

1 comprehension, communication and interaction easiness

2 epidemiological affinity (for knowledge derived from the same area or country) which could be determinant for some specificities in care.

All the users pointed out that the multilinguality of the system was critical. Thus, both the system’s interfaces and the ontology came in three languages (English, Italian, and Spanish).

An important critical factor is the constitution of a ‘knowledge critical mass’ that makes a KM system attractive. This aspect has been evaluated as one of the most critical for the success of a specific test site by the end users.

Much more critical is the description and the qualification of the available knowledge, that should be well categorised into specific medical voices, to ease the association of different knowledge, the search for specific knowledge and to avoid the overload of information that so often discourages the usage of internet-based information services. This factor is both technical (establishing the more adapted tools) and medical (defining the more adapted content and knowledge description), and should be addressed by a joint team of medical and technical professionals.


And finally the ‘quality’ of the offered knowledge is to be considered as a critical

factor. Even though an ‘accreditation’ procedure was not envisaged (the idea is that any accredited HC professional behaves ethically and that any such ‘ethical’ knowledge should be useful), some mechanisms were made available to identify at least the knowledge source and provider identity and especially keep the knowledge up-to-date. The institution of an ‘Advisory Board’ in the long term may be a key factor for adequate system maintenance. Hospitals and HC centres accredited by each national health ministry usually have an internal ‘quality’ commission that ensures that services offered are correct, complete and ethically evaluated. The participation in a KM system for cardiology should be considered a service provided by excellence centres, reference hospitals and research centres to the regional medical community. In this respect they should be submitted to the same evaluation and quality assurance process as all other more institutional services offered by HC centres and hospitals. Regional health agencies could also play an important role in this task, by instituting dedicated task forces or by including similar systems among their institutional services, so ensuring the verification of all ethical and medical prerequisites and verifying the update and overall quality of the service.

The main ethical issues related to the provision of web-based systems for e-health that were mentioned are:

• Good practice: ‘primum non nocere’ and then correctly and completely inform.

• Qualification: selection of information, information sources, service and products providers by cluster projects, certification codes and seals, regulations and best practices, localisation of information (importance of a regional information/service network).

• Clearness: putting medical and scientific information in simple words, harmonisation of different sources of information, easy to understand scope and contents of the e-health portal, transparency of information source, identification of relevance of information, clear description of services, informed consent for the treatment of medical data, different languages.

Moreover, even if the adoption of an ethics code is voluntary, a formal legislation or regulation may be near. Concluding, web-based systems for e-health should provide users with:

• clear identification of the information/service target

• clear identification of the information/service source

• clear identification of experiences (from real use cases)

• updated information

• consultation and telesupport tools to build a common knowledge community.

As far as the specific test sites are concerned, a commitment has been given by several Italian organisation such as:


• Regional government of Friuli Venezia-Giulia Region (Agency for Health Services).

• Public Health System Cardiologists organised by The National Association of Hospital Cardiologists: ANMCO (Associazione Nazionale Medici Cardiologi Ospedalieri).

• University Cardiologists, organised by The Italian Society of Cardiology: S.I.C. (Società Italiana di Cardiologia).

In Spain, this was the first knowledge sharing experience which improves the professional interaction among different levels of the healthcare system (GPs, area specialists and reference specialists), and that could be considered an important and valuable cooperation from the medical technology industry. Possible future collaborators could be: the Spanish Cardiology Society (Sociedad Española de Cardiología – SEC) or the Madrid Regional Government Health Council. Currently, the work is supported by the Hospital General Universitario Gregorio Marañón, and Medtronic Iberica SA which operates in Spain distributing medical technology, performing clinical research and delivering educational programmes for medical professionals. Medtronic Ibérica is also a company leader in many health areas – neurostimulation, spinal, cardiac surgery, vascular, diabetes, etc. – working in products and therapies to restore health, extend life and alleviate pain.

5 Conclusion

The thorough testing of the system drove the technical teams to revise it in an early stage according to the success factors noticed in the previous pages. As described at the beginning of the paper, the current work aimed at providing a KM system for exchanging valuable knowledge in the domain of cardiology.

The current system main asset is therefore the provision of an integrated knowledge management system, gathering knowledge currently not directly available through the usual communication methods. Individual experiences are currently the patrimony of each individual HC professional or hospital division/department where the knowledge was originated either by direct experience or by personal knowledge and previous medical and professional background. Such knowledge, often deeply linked to the territory health situation, to population habits and lifestyle, is the most valuable asset offered by the system.

Of course such knowledge would not be sufficient, so the next asset of the final system is the integration of such particular knowledge into a wider amount of available knowledge and information, that is currently dispersed in different sources and that requires time-consuming search by MDs and HC professionals willing to reach it. The organisation and description of the available knowledge by means of medical ontologies, as structured in the current system, ensures a good performance of the system’s search tools. The security requirements of the system were mainly referred to the protection of the system users’ data and to the assurance of the stored knowledge integrity.

As noticed in the results section, the most important aspect that should be considered for the correct establishment of any similar system is the process of building up a ‘knowledge critical mass’ from which users can start working with the system. The building up process of that ‘critical mass’ should take place before the start of the specific


test experiences both in Spain and Italy and should come from the collaboration of professionals from the three involved health sectors: medical, pharmaceutical and technological. This task was considered both critical and difficult to be accomplished by the consortium. In the frame of the project the end users forced to work in order to achieve the desired amount of knowledge into the system. However, for the sustainability of the system, it was necessary to find the required incentives for new users in order to continue this ‘enrichment’ of knowledge with their own specific experiences. Some initial thoughts are pay-per-contribution or official credits for using the system, etc.

The GPs involved in this pilot testing phase declared that the system can contribute to minimise the feeling of GPs who feel lonely and far from the ‘excellence medicine’ and feel to be kept apart from the progress of medical research. This feeling could be overcome by the provision of an on-site, efficient and usable knowledge management system, supporting the decision process of GPs and MD specialists who may face CVD affected people. This psychological factor could play a fundamental role for establishing similar systems as a reference service for knowledge in cardiology, at least in the Pilots area.

As in any web-based and KM system, a significant success factor is how many users are using it (hits performed). To this direction, the commitment given by the Italian organisations can be considered as a very good first step in supporting the presented work. The emphasis and support given by the national health ministries and regional health agencies and care systems to projects dedicated to optimise resources for HC and to improve efficacy of care constitutes the main political opportunity of our system.

Acknowledgment

The current project was funded by the EC, under the IST programme.

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Notes 1 Health Canadas Knowledge Management, http://www.hc-sc.gc.ca/iacb-dgiac/km-cs/english/

kmhome.htm

2 SAMHSA’s Mental health Information service (initiative of the US Department of Mental health and human services), http://www.mentalhealth.org/

3 Knowledge Management Standing Committee (University of Tasmania-Australia), http://www.healthsci.utas.edu.au/partnersinhealth/knowledge.html

4 Knowledge Management Tool (business experience), http://www.kmtool.net/healthcare.htm

5 The Center for Mental Health Services (CMHS) Knowledge Exchange Network (KEN), www.mentalhealth.org

6 T.Ri.P.S.S. II project, http://www.ceformed.it/rivista/scompenso.htm

7 UK National Knowledge Service (initiative of NHS), www.nks.nhs.uk

8 CHAIN project (NHS initiative), http://chain.ulcc.ac.uk/chain/chain.htm

9 ATTRACT project (experience in South Wales, UK), http://www.attract.wales.nhs.uk/

10 American Heart Association, www.americanheart.org