Health Informatics

An overview of the University of Bath School for Health research portfolio in health informatics (Jun 03 – May 05) Dr Maged N Kamel Boulos M.N.K. Boulos @bath.ac. uk

Agenda
Introduction
Synchronous communication in online distance learning
Readability of Internet-derived patient information
Action and initiatives to promote NHS use of GIS
Health service research using GIS
Interactive Web mapping technologies
Using software agents to preserve disaggregate health GIS confidentiality
Dermatological informatics projects
Journalology research
Semantic Web research
PhD and MSc research projects
Serving our wider research community: peer reviewing activities

Introduction - 1
Established in 2003, health informatics research at the University of Bath School for Health now spans many aspects of medical/health informatics, including:
Telemedicine and e-learning,
Semantic Web applications in health and healthcare (including knowledge representation/management and decision support applications),
Medical and health-related digital libraries,
Consumer health informatics,
Dermatological informatics,
Human-computer interaction in health and healthcare applications, and
GIS (geographic information systems) in health and healthcare (health geographics/geoinformatics).

Introduction - 2
Despite our short history, our research results have been widely covered in the news media, including the BBC, Daily Mail, Daily Express, The Guardian, The Times, The Telegraph, The Bath Chronicle, BMJ News In brief , bjhc&im , Medical News Today, Government Technology (CA, USA), Arab News, Spatial News and others.
Press archive/clippings: http://staff.bath.ac. uk / mpsmnkb /# inthenews

Introduction - 3
This presentation will provide a very quick tour of the University of Bath School for Health research and collaboration portfolio in health informatics (see http://www.bath.ac. uk /health/research/hi/index.html ) , plus few examples of research conducted by our MSc/PhD students.
The viewer is kindly reminded that the paper can only “scratch the surface” of some of our ongoing research activities because of their current confidential/“not yet published” nature.

Research into the use of synchronous communication in online distance learning - 1
MNK Boulos and Andrea Taylor (School for Health) recently collaborated with Alice Breton of the Royal College of Surgeons of Edinburgh to pilot a communications experiment within the online MSc in Healthcare Informatics.
The study aimed to alleviate some of the disadvantages that students face when participating in distance learning programmes, such as isolation, lack of motivation and lower than average completion rates.
The project team used an Internet text and audio facility, PalTalk ( http://www. paltalk .com/ PalTalkSite / ) to conduct live virtual classrooms and increase communications and interaction, with pleasing results.

Technology alone is not enough to ensure the success of synchronous sessions! We also need to develop the e-skills of synchronous classroom teachers to enable them to use the tools productively.

Research into the use of synchronous communication in online distance learning - 2
Our results showed that students felt a pronounced sense of belonging to a more supportive learning community, and this improved educational outcomes.
They appreciated the real-time human contact and interaction and praised the ease of use/voice quality of the PalTalk application.
Publication: Boulos MN, Taylor AD, Breton A . A Synchronous Communication Experiment within an Online Distance Learning Programme : A Pilot Study . Telemedicine Journal and e - Health . 2005 ; 11 - in press .

Research into the readability of Internet-derived patient information - 1
Readability is an attempt to match the reading level of written material to the ‘reading with understanding’ level of the reader.
Readability (or understandability) is a frequently overlooked aspect of health information quality and accessibility.
Sizeable proportions of Western populations have limited language and math skills making it difficult for them to fully and safely understand and act upon online health information.

A study of 15 British Internet health sites conducted in 2004 by this author found that online health advice for people with diabetes is often too complex to understand.
NHS Direct Online ( http://www. nhsdirect . nhs . uk / - selected content as at 7 July 2004) was the hardest to understand, needing a reading age of an educated 16 year old.
But the BMJ Publishing Group’s BestTreatments ( http://www. besttreatments .co. uk / ) scored closer to the reading age of a 9 year old, which is the average reading ability of people in the United Kingdom.

< The BBC Website, Friday 10 September 2004 Findings from our study were widely covered in the news media during September/ October 2004, with a very positive impact on some of the evaluated services, which responded by revising and improving their material.

Publication: Boulos MN . British Internet - derived Patient Information on Diabetes Mellitus : Is it Readable? Diabetes Technology & Therapeutics . 2005 Jun;7 ( 3 ) : 528-35 .
The study provides a very detailed discussion and practical recommendations on how to improve the readability of existing online consumer health information.
We also propose the development of “intelligent”, user-friendly readability software tools and wizards that go beyond the mere computerisation of readability formulae to further assist health information authors and providers in their mission, e.g., by checking their material against domain- and reading level-specific dictionaries.

Action and initiatives to promote the use of GIS within the NHS - 1
Geographic Information Systems (GIS) are still vastly under-utilised within the provision of health services in the UK.
In general, this has been due to a lack of awareness of the value of spatial information in everyday practices and decision making processes. GIS should no longer be seen as tools for simple map production.
Aware of all of this, we have undertaken research and some initiatives to improve the situation.

The International Journal of Health Geographics http://www. ij - healthgeographics .com/ (Founder and Editor-in-Chief: MNK Boulos, Bath Uni, UK with RE Hoskins, USA).
Publishes original and review papers on the application of geographic information systems/science and related technologies in public health, healthcare, health services, and health resources.
Published by BioMed Central and i ndexed in PubMed and fully archived in PubMed central ( US National Library of Medicine ).

We recruited a truly international Editorial Board with members from the WHO and US CDC. Quick stats: 61 published papers by authors from around the world as at mid-June 2005 , with more manuscripts in the pipe (under peer reviewing). Current rejection rate: >20%

Int J Health Geogr – Impact factor We calculated the number of papers and citations for both Int J Health Geogr (IJHG) and Health & Place , its most directly comparable closed-access journal, which is published by Elsevier. IJHG has, already in its 2 nd year (2003), a higher number of citations per paper than the older Health & Place, and already in its 3 rd year (2004) as many papers published annually. The data are still too scarce on citations to articles published in 2004, but the numbers look very good so far. Hence, IJHG is doing great. 0.6 17 30 2004 HealthPlace 2.1 70 34 2003 HealthPlace 3.8 90 24 2002 HealthPlace 0.7 22 30 2004 IJHG 2.7 27 10 2003 IJHG 1.6 8 5 2002 IJHG per Paper Citations Papers Year Journal Citations Scholar Google

This author also edits the NHS Informatics UK Health GIS Special Interest Group (SIG - free registration required) http://www.informatics. nhs . uk /groups/group3/
This SIG has been set up to disseminate information and provide support to users of GIS within the NHS and the wider health industry in the UK.
It is intended to foster an appreciation of GIS as effective analytical tools in many complex health and healthcare processes, and to promote the development of spatial technology within the NHS from maps that simply tell us “Where/when is what?” to powerful decision support systems that help us decide “So what?” .

The SIG forms part of the Specialist Library in Health Informatics of England's National (electronic) Library for Health (NLH/NeLH). The SIG features a document library, a discussion board, and a forum to share news (including news about forthcoming events), maps and other relevant resources and Web links.

Research:
Boulos MN. Towards evidence-based, GIS-driven national spatial health information infrastructure and surveillance services in the United Kingdom . Int J Health Geogr . 2004 Jan 28;3(1):1. (As of June 2005, BMC copy of this article was accessed more than 10,000 times since publication - other mirrors like PubMed Central are not counted.)
Boulos MN. Research protocol: EB-GIS4HEALTH UK - foundation evidence base and ontology-based framework of modular, reusable models for UK/NHS health and healthcare GIS applications . Int J Health Geogr . 2005 Jan 13;4(1):2.

It was proposed that EB-GIS 4 HEALTH UK will use the Protégé Ontology Editor and Knowledge Acquisition System. http:// protege .cim3.net/ cgi -bin/ wiki .pl? ProjectsThatUseProtege

Raising awareness publications: Boulos MN . Finding the best path to take ( towards a national strategy for health GIS applications ). Health Director ( published by GovNet Communications, UK ) . 2004 Nov .
Available from: http://staff.bath.ac. uk / mpsmnkb /MNKB_GIS_HD_Nov04. pdf

Raising awareness publications – Cont’d: Boulos MN . Spatially Enabling the UK National Health Service . [email_address] . 2005 Jun;9(6):38-40.
Unabridged complete version freely available from: http:// gisdevelopment .net/magazine/years/2005/ jun /index. htm

Health service research/healthcare delivery applications of GIS - 1
In a recent study by MNK Boulos and GP Phillipps (2004), ‘traffic light’ maps were used to study the distribution of dentists per 1,000 population in all 304 English Primary Care Trusts (PCTs) and 22 Welsh Local Health Boards (LHBs).
The BBC Website, Monday 10 May 2004

Publication: Boulos MN, Phillipps GP. Is NHS dentistry in crisis? 'Traffic light' maps of dentists distribution in England and Wales . Int J Health Geogr . 2004 May 10;3(1):10.
Online demonstrator: http:// healthcybermap .org/PCT/dentists/
Generated a great deal of interest in the media, with reports appearing in BBC News Online and a number of newspapers, including the Daily Mail , The Guardian , The Times , The Telegraph and The Bath Chronicle among many others (and even Channel 4 news ).

‘ Traffic light’ map of England showing the distribution of dentists per 1,000 people by PCT as at 31 December 2002, classified into four classes: 0-0.2 (red = serious shortage of NHS dentists), 0.2-0.3 (dark orange-yellow = shortage of NHS dentists), 0.3-0.4 (light orange-yellow = some shortage of NHS dentists) and 0.4-1 dentist per 1,000 population (green = low, but acceptable or good number of dentists).
‘ Traffic light ’ maps of dentists distribution in England and Wales

In December 2004, this author was commissioned by Enterprise LSE (London School of Economics) to be the main author of a ‘Cold Review’ of a National Audit Office report on NHS Dentistry.

Research into interactive Web mapping technologies (client-side solutions) - 1
Client-side imagemaps: bitmaps (JPEGs).
Publication: Boulos MN . Web GIS in practice : an interactive geographical interface to English Primary Care Trust performance ratings for 2003 and 2004 . Int J Health Geogr . 2004 Jul 28;3 ( 1 ): 16 .
Online d emonstrator : http:// healthcybermap .org/PCT/ratings/
Related (interactive Web mapping): Boulos MN. Descriptive review of geographic mapping of severe acute respiratory syndrome (SARS) on the Internet . Int J Health Geogr . 2004 Jan;3:2 .

Colour-blind friendly! Developed using

Research into interactive Web mapping technologies (client-side solutions) - 2
Scalable Vector Graphics (SVG), a World Wide Web Consortium non-proprietary, XML-based vector graphics format, and an extremely powerful alternative to Macromedia® Flash and bitmap graphics.
Publication/collaboration: Boulos MN, Russell C, Smith M . Web GIS in practice II : interactive SVG maps of diagnoses of sexually transmitted diseases by Primary Care Trust in London, 1997 - 2003 . Int J Health Geogr . 2005 Jan 18;4 ( 1 ): 4 .
Online d emonstrator : http:// healthcybermap .org/PCT/STDs/

Developed i n collaboration with Graphical Data Capture L td , London, UK

Featured in Government Technology , CA, USA, Friday 25 February 2005 http://www. govtech .net/magazine/channel_story. php ?channel=25&id=93172 "Looking for patterns, trends and comparisons in this kind data is crucial for decision makers seeking to tackle public health issues," said Dr. Maged Boulos, the lecturer in healthcare informatics in the University of Bath's School for Health , who developed the map in collaboration with Chris Russell and Michael Smith from Graphical Data Capture Ltd. "When combined with other data sources and maps, such as demographic, deprivation or social exclusion, transport and existing genito-urinary medicine clinic data sets, the new map could help ministers and public health officials channel their resources and target STD prevention programs to the areas with the most need, or scale such programs according to the magnitude of the problem in different areas."

Using software agents to preserve disaggregate health GIS/surveillance data confidentiality - 1
Confidentiality constraints often preclude the release of disaggregate data about individuals, which limits the types and accuracy of the results of geographical health analyses that could be done.
Access to individually geocoded (disaggregate) data often involves lengthy and cumbersome procedures through review boards and committees for approval (and sometimes is not possible).
Moreover, current data confidentiality-preserving solutions compatible with fine-level spatial analyses either lack flexibility or yield less than optimal results (because of confidentiality-preserving changes they introduce to disaggregate data), or both.

I n collaboration with Professor Gerard Rushton and Qiang Cai ( a PhD candidate ) , both from the University of Iowa Department of Geography in the United States, and Dr Julian Padget from the University of Bath Department of Computer Science, MNK Boulos started exploring a solution based on software agents with the potential of providing flexible, controlled ( software - only ) access to unmodified confidential disaggregate data and returning only results that do not expose any person - identifiable details .
Such a solution would be appropriate for micro - scale geographical analyses where no person - identifiable details are required in the final results ( i . e . , only aggregate results are needed ).
Gerard Julian Maged

Our proposed software agent technique also enables post-coordinated analyses to be designed and carried out on the confidential database(s), as needed, compared to a more conventional solution based on the Web Services model that would only support a rigid, pre-coordinated and rather limited set of analyses.
We have also explored some of the mobility, security, trust and related issues associated with software agents in the context of our proposed solution, as well as possible directions/solutions to address these issues, including the use of virtual organizations.

Publication: Boulos MN, Cai Q, Padget JA, Rushton G. Using Software Agents to Preserve Individual Health Data Confidentiality in Micro-scale Geographical Analyses . Journal of Biomedical Informatics . Accepted on 21/6/2005 - in press.
A grant proposal based on this research is in preparation.

Dermatological informatics projects - 1
Map of Dermatology is a free Web resource developed by this author that enables users to search for images of skin conditions by body region (e.g., feet, legs, pubic regions, anogenital region, buttocks, trunk, axillae and female breast, arms, hands and head) and morphology (e.g., macules, papules, vesicles and bullae, pustules, scales, wheals, nodules and lichenification) rather than by condition name, which is much more useful and natural in answering questions about unknown clinical presentations/diagnoses, especially for non-specialists. Based on regional/ morphological differential diagnosis lists from Fitzpatrick’s “ Color Atlas and Synopsis of Clinical Dermatology ”

Online demonstrator: http:// healthcybermap .org/ dermap / Google Images currently offers access to the largest online dermatology image collection (indexed from multiple sources). However, the raw Google Image Search is not very well suited for regional/morphological dermatology searches, hence the need for such an added-value, special regional/morphological search layer/interface to harness Google.

Map of Dermatology can be thought of as a dermatology-specific “add-on” or special interface to Google Image Search that is intended to answer questions that might be hard to answer by the average user using the basic Google Image Search interface.
A limited user evaluation was conducted late in 2004, and the overall feedback received was very positive.
Currently investigating the use of more sophisticated dermatology differential diagnosis algorithms for the Map, together with the British Association of Dermatologists' (BAD) Diagnostic Index and Codes (BSF grant proposal in preparation with colleagues at Southampton University).

Publication: Boulos MN . Map of Dermatology : A Regional and Morphological Differential Diagnosis Web Image Browser ( submitted to a leading dermatology journal and is currently under peer reviewing ).
Map of Dermatology is also now an OMNI/NMAP-catalogued resource . OMNI and NMAP are British gateways to hand-selected and evaluated, quality Internet resources in health and medicine.

Research collaboration with the Project Team of the Skin Conditions Specialist Library of the National Library for Health (NLH), namely Professor Hywel Williams and Dr Douglas Grindlay, who are based at the University of Nottingham ’s Centre of Evidence Based Dermatology, Queen’s Medical Centre, Nottingham, UK.
This author is also one of the eight members of the Library’s core Editorial Team, which is led by Professor Hywel Williams.

The NLH Skin Conditions Specialist Library can be visited at http://www.library. nhs . uk /skin

Research and related activities undertaken/ explored by this author with the Nottingham Skin Conditions Specialist Library Team involve the following aspects of the Library:
policy and editorial matters,
quality standards and resource selection criteria,
the adoption of robust evidence-based and knowledge management approaches,
the development of an online diagnostic tool for dermatology,
taxonomy/ content indexing, organisation and navigation, and
usability issues.
We currently also have one of our MSc in Healthcare Informatics students (Bruce Taylor) doing a project on the development of quality filters for resource selection for the NLH Skin Conditions Specialist Library.

Publication: Grindlay D, Boulos MN, Williams HC. Introducing the National Library for Health Skin Conditions Specialist Library . BMC Dermatology . 2005 Apr;5:4.

Journalology research into the geographical distribution of Medical Informatics papers - 1
Studying the contribution of individual countries to leading journals in a given discipline can:
highlight which countries have the most impact on that discipline, and also
prove useful in identifying evolving research trends within the discipline worldwide, centres of expertise, existing collaboration nuclei (and potential collaborators) in different research areas from around the world, in addition to
giving some idea about the geographical outreach of the examined journals.

This author examined the number of countries that contributed articles to one leading medical informatics journal, Medical Informatics & the Internet in Medicine , and the amount of their contributions between 1999 and the first half of 2004.
The five-year-and-half corpus of the journal’s abstracts retrieved from PubMed was further explored using MetaCarta Geographic Text Search http://www. metacarta .com/

MetaCarta can prove very useful as a bibliometric research tool.

The examined journal has an international outreach, with authors from 24 countries, spanning four continents, contributing to the journal during the studied period.
The journal is dominated by a very large number of articles from Europe (81.25% of all 128 articles counted in this study).

There were no contributions from Africa or South America.
A detailed discussion and interpretation of these results, and ideas for future/better analyses are provided in the following publication: Boulos MN. On geography and medical journalology: a study of the geographical distribution of articles published in a leading medical informatics journal between 1999 and 2004 . Int J Health Geogr . 2005 Mar 23;4(1):7.

Semantic Web research
Recent Semantic Web publications by this author include: Boulos MN . A first look at HealthCyberMap medical semantic subject search engine . Technol Health Care . 2004;12 ( 1 ): 33-41 .
The medical semantic subject search engine can be tried online at http:// healthcybermap . semanticweb .org/ icd . htm
The author would like to thank Dr David Hunt president of Yaki Technologies, USA , for kindly providing us with their proprietary ICD-9-CM search technology to build HealthCyberMap’s semantic subject search tool.

Explicit concepts in resource metadata map onto a domain ontology (a clinical terminology or classification) allowing a Semantic Web search engine to infer implicit meanings (synonyms and semantic relationships) not directly mentioned in either the resource or its metadata. Similarly, user queries would map to the same ontology allowing the search engine to infer the implicit semantics of user queries and use them to optimise retrieval.

A semantic subject search example. A search for “Borrelia burgdorferi” retrieves resources on “Lyme disease” (ICD-9-CM code: 088.81). Our underlying ICD-9-CM brokering ontology “knows” (or has the relation properly defined or represented in it which says) that “Lyme disease” is-caused-by-> “Borrelia burgdorferi” (an organism).

A semantic subject search example (cont’d). A search for “Borrelia burgdorferi” has retrieved this resource metadata record on “Lyme disease” (among other relevant resource records). Note how the words “Borrelia burgdorferi” do not occur in the retrieved resource metadata record shown in this screenshot.

PhD research projects
H Badredine : Factors affecting the success of information and communication technology adoption and development within the healthcare systems of three developing Middle Eastern countries (MPhil/PhD in Healthcare Informatics - Lead supervisor: Dr MNK Boulos; Second supervisor: Dr Emmanuel Fragniere from Bath Uni School of Management).
P Abdelmalik : Will start his MPhil/PhD research into 'Public Health GIS' in October 2005. Funded by the Public Health Agency of Canada - Government of Canada (Lead supervisor: Dr MNK Boulos).

MSc research projects - 1
AW Steele : The use of encoded guidelines in an electronic medical record system for targeted tuberculin testing of latent tuberculosis (MSc - graduated with distinction in 2004).
E Ibrahim : Accessibility to online information by adult Saudi cancer patients: Analysis of patterns, barriers, and impact on defined outcomes (MSc).
R R aiteri : Use of and attitudes toward a PDA software for antiretroviral drug interactions among HIV-treating clinicians in Piemonte, Italy (MSc).
RS Moore : Assessing attitudinal barriers to the introduction of an electronic patient record in the emergency department (MSc).

MSc research projects - 2
J O’Connor : The cardiac kiosk: A patient–centred technology for collaborative support in the lipid clinic - An output based specification (OBS) (MSc).
DJ Kelley : Computerized Physician Order Entry: identification of barriers and factors critical to successful implementation (MSc).
S-Y Tay : Comparing unstructured data entry templates and free text among emergency department residents (MSc).
B Taylor ’s MSc project mentioned before (a quality filter for the Skin Conditions Library).
And many more…

Serving our wider research community: peer reviewing activities
This author has recently peer reviewed at least one paper for each of the following journals:
BMC Public Health
Drug Discovery Today: BIOSILICO (Elsevier)
Geographical Analysis (The Ohio State University)
International Journal of Health Geographics (BMC): as Editor-in-Chief
ISPRS Journal of Photogrammetry and Remote Sensing (Elsevier)
The Photogrammetric Record (RSPSoc and Blackwell Publishing): Book Review (of GIS in Public Health Practice . CRC Press, Florida, 2004) - will appear in the September 2005 issue of The Photogrammetric Record

And more to come in the future …
For other related past research projects and publications by this author prior to joining the University of Bath School for Health, please refer to the author’s online research profile at http://www.bath.ac. uk /expertise/ showperson . php ? employeenumber =500059
t he future starts today ! Potential collaborations?

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