e-HealthExpert.org - Primum non nocere

The World Health Organization (WHO) published a list of errors to avoid when designing, installing or supporting an Healthcare Information System / Hospital Information System / HIS:

1. Don't depend too much on one pioneering innovator, and do not leave any such innovator in charge - they will become too rigid and narrow-minded in their views, and stifle change and development.
2. Don't spend a large amount of time creating a detailed, rigid specification - it will be out of date before being designed, built, and implemented; rather, specify core principles and functionality together with a design-and-build or prototyping methodology.
3. Don't leave performance criteria, both in terms of functions provided and maximum percentage downtime to chance, but include them in the procurement contract.
4. Don't forget error correction and maintenance - write minimum standards into supply contracts, and ensure that there are sanctions, e.g., part of procurement payment held back until satisfactory functioning over a specified period; maintenance payments paid partly at the end of each period with reductions for loss of service.
5. Don't let the supplier determine needs or performance; instead, ensure that the customer remains in control.
6. Don't exploit your supplier - whilst the customer should lead, an aggrieved supplier provides a poor service and a bankrupted supplier disappears and leaves the customer stranded.
7. Don't impose "solutions" on end users and data suppliers; rather, ensure that they feel they are valued and want the system.
8. Don't automate today's paper processes - look at what new functions and methods automated Information Systems can undertake.
9. Don't specify too futuristically - there is a limit to how much people or an organization can change in one move; instead allow an evolutionary path.
10. Don't treat the organization or the specification as rigid structure, but instead allow for organizational and end-user learning, as well as technological and environmental change.
11. Don't stop evaluation at the point of installation testing - there will be ongoing organizational and personal behavioral change that must be identified and appropriate adjustments made.
12. Don't stop investing in a "successful" system - it will soon become out-of-date, and disillusionment will set in thus, to the dismay of users and paying parties, the "success" will soon evaporate.
13. Don't be complacent with a "successful" system - the very word of its success will increase usage, overload access, and degrade performance — this applies to all elements, including data networks and communications.
14. Don't confuse Education (concerned with changing professional practice and performance) with Training (about how to operate a system).
15. Don't change practice and switch on a system in one activity, but also don't computerize old practice - separate the two change processes, even though this will mean a short period of dysfunctional working, so as to ensure that the different changes are fully understood, and any problems can be traced to the correct source to facilitate rapid adjustment.
16. Don't rely on memory or suppliers - persons can forget, become ill, or leave; suppliers can go out of business or be taken over. Ensure that everything is properly documented, including performance agreements, and all systems specifications, functionalities, applications, and operational routines — the constant test must be "Could a new person take over that task tomorrow?".
17. Don't overlook the need for convincing answers on confidentiality - it will be a prime question from all health professionals before they use a system.
18. Don't think that removing names from records creates confidentiality - other factual combinations in records can effectively identify indirectly by implication or circumstance.
19. Don't assume that any types of data item are of low confidentiality - for some individuals any specific item may be very confidential because of personal circumstances, e.g., address or blood group.
20. Don't touch anything which does not run on open standards, is of a closed proprietary nature, or cannot accommodate modern recognized data and other standards - any short-term gain will be minimal compared with the cost of the dead end up which you are committing your organization.
21. Don't think that any Information System project is ever finished - if it successful, people will want more of it; if it unsuccessful, adjustments are clearly needed; and in any eventuality circumstances will change.

This list, named "A Don't List in Setting Up an Healthcare Information System", first appeared in the manual Setting up Healthcare Services Information Systems: A Guide for Requirement Analysis, Application Specification, and Procurement, edited in 1999 by PAHO (Pan American Health Organization) - a branch of the World Health Organization (WHO).

Choosing the best manual to help someone else on the difficult journey of setting up an Healthcare Information System / Hospital Information / HIS is, by itself, no simple endeavor. But, if we had to pick a single book on the subject, it would certainly be the World Health Organization's time proven manual:

Setting up Healthcare Services Information Systems: A Guide for Requirement Analysis, Application Specification, and Procurement, ISBN 9275122660, edited in 1999 by PAHO (Pan American Health Organization) - a branch of the World Health Organization (WHO).

This manual was assembled from the contributions of dozens of knowledgeable and experienced collaborators and according to its editors:

"This book discusses the implementation of information systems and the application of information technology in terms of the requirements in health care services, and provides a comprehensive review of information systems and information technology solutions."

"contains practical guidelines and suggestions to be used by healthcare and systems professionals when embarking in the initial stages of planning and developing healthcare services information systems and information technology (IS&T) applications."

From the manual:

• "A successful implementation is one that promotes and supports the institution's ability to execute its plans and meet its goals."
• "Organizations are discovering that successful information systems implementation in the health services institution requires a firm understanding of the organization's overall strategic plan."
• "A health services information system has the purpose of improving the overall performance of the institution."
• "The system being implemented must be recognized as a strategic tool and corporate asset that represents an investment in the organization's viability. "
• "A technology that is appropriate to an advanced, sophisticated user such as a large teaching institution in an urban area may not be appropriate for an emerging health services organization in a rural setting."
• "The social and economic context must always be considered along with issues related to availability of resources and personnel, health information infrastructure, sustainability and continuity of the decisions, and appropriate flow of financial resources."

We couldn't agree more.

Squid is a caching Web proxy supporting HTTP, HTTPS, FTP, and other protocols.
It reduces bandwidth and improves response times by caching and reusing frequently-requested web pages.
It runs on Unix and Windows and is licensed under the GNU GPL.

This page describes howto install and configure Squid to run in a Ubuntu Linux platform.

Install Squid:

sudo apt-get install squid

Configure Squid:

sudo cp /etc/squid/squid.conf /etc/squid/squid.conf.orig

sudo nano /etc/squid/squid.conf

• Inside the file /etc/squid/squid.conf find the http_access section, uncomment the following 2 lines and add your network (lets assume that your network is 10.10.10.0/24):

acl our_networks src 192.168.1.0/24 192.168.2.0/24 10.10.10.0/24
http_access allow our_networks

• Find the visible_hostname section and after the lines:

#Default:
# none

• add:

visible_hostname localhost

Restart Squid:

sudo /etc/init.d/squid start

Done. You should now be able to use Squid to speed up repetitive web connections.

Howto's, Manuals and Documents about Software installation, setup and configuration

This is the archive of software packages known by the e-HealthExpert.org members.

All entries should at least include:

1. Software name and version,
2. An abstract of what it does,
3. The type of license under which it is released,
4. The software homepage address,
5. A rating value from 1 to 5 [1 (lousy), 2 (mediocre), 3 (average), 4 (good), 5 (very good)],
6. Submission author's name.

This new area of e-HealthExpert.org site is also meant to be a repository of the most relevant software that appears at our [sw-hw] mailing list.

The [sw-hw] mailing list is an open forum in which any member can freely review, evaluate and talk about any subject related to systems architecture, software, hardware and, more in general the usage of IT technology to support all the activities of a Healthcare Organization. List guidelines and subscription application forms are available from: [sw-hw] mailing list usage guidelines.

In this manual we will be collecting the things that our members feel that may increase the probabilities of success of a given Clinical IT or Hospital Information System project.

At first it may not look like the most beautifully thing about HIS building, but we fell that with time it will evolve into something useful.

So, please feel free to comment or add your own ideas about the subject.

Your support, help of any kind, or just your interest, are all very welcome.

We always welcome new contributors - especially bright people with previous experience in e-Health, Health IT/Clinical IT, Healthcare Information Systems, or in any related fields. But, no matter what your skills and interests are, there is a place here for you.

Here are some areas where you can contribute:

a) Let other people know about e-HealthExpert.org;

b) Contributing contents (news, personal stories, comments, etc.), editing other people contents, or helping managing the e-HealthExpert.org organization;

c) Contributing hardware, software, site hosting resources, or money (we accept donations through all major credit cards. The email contact is at the bottom of this page).


The e-HealthExpert.org team.

Richard Heeks from the University of Manchester (UK), has an article on how to evaluate a eHealth, Heath IT or HIS project risk. The assessment (success and failure) factors are described. A hospital worked example is given.
The full article is available at: eHealth Project Risk Assessment

Another interesting work from the same author is How can I make my e-health project more likely to succeed and/or less likely to fail?

There is also a downloadable .pdf named: Why health care information systems succeed or fail

One of the most insightful articles about the reasons why Clinical IT projects succeed or fail must be Angelina Kouroubali's article: "Structuration Theory and Conception-Reality Gaps: Addressing Cause and Effect of Implementation Outcomes in Health Care Information Systems". In a clever way she connected Heeks work with the Giddens structuration concepts to create a single framework:

"...To facilitate the introduction of IS [Information Systems] in health care, research should investigate the way IS affects human actions and organizational structures and the reasons it affects them...
[Giddens] Structuration theory introduces the notion of the interdependency between human actions and organizational structures. Heeks theory of conception-reality gaps helps illuminate the causes of an implementation outcome...
The paper describes the two theories and how they may help healthcare information systems research. It illustrates its points using examples from the field."

The article was part of the Proceedings of the 35th Conference in Information Sciences (2002) and is available in .pdf format from: Structuration Theory and Conception-Reality Gaps: Addressing Cause and Effect of Implementation Outcomes in Health Care Information Systems

The European Interoperability Framework (EIF) is the reference interoperability document for the development and delivery of e-government services (including e-Health and Health IT related services) at pan-European level. The EIF provides:

• a set of guidelines and recommendations to enable interoperability of government systems and processes with a view to delivering pan-European e-Government services (PEGS),
• identifies a number of general principles that should be considered for any e-government service to be set up at a pan-European level: accessibility, multilingualism, security, privacy, subsidiarity, use of open standards (adopted and maintained by an open not-for-profit organization and freely available on a royalty-free basis), assessing the benefits of Open Source Software, and use of multilateral (or 'many-to-many') solutions.

Based on these principles, the EIF addresses three distinct interoperability levels that need to be considered: organisational interoperability, semantic interoperability, and technical interoperability.
For each of these levels, the EIF provides a number of recommendations.

You may download the full specification at: European Interoperability Framework