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Handbook of Research on
Distributed Medical
Informatics and E-Health
Athina A. Lazakidou
University of Peloponnese, Greece
Konstantinos M. Siassiakos
University of Piraeus, Greece
Hershey • New York
Medical inforMation science reference
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Iordanis Evangelou
National Institutes of Health, USA
Anastasia Kastania
Athens University of Economics & Business,
Greece
Konstantinos Konstantinidis
General Hospital Salzburg, Austria
Melpomeni Lazakidou
Institute of Occupational Medicine, Salzburg,
Austria
List of Contributors
Alamantariotou, Kleopatra / City University London, UK 443
Antunes, Luís / LIACC University of Porto, Portugal 30
Apiletti, Daniele / Politecnico di Torino, Italy 478
Apostolakis, I. / National School of Public Health, Greece 367
Baralis, Elena / Politecnico di Torino, Italy 478
Basu, Ambar / University of South Florida, USA 104
Bodie, Graham D. / Louisiana State University, USA 104
Bountis, Christos / Oxford Radcliffe Hospitals, UK 198
Brisk, Philip / Ecole Polytechnique Federale de Lausanne, Switzerland 228
Bruno, Giulia / Politecnico di Torino, Italy 478
Capilla, Rafael / Universidad Rey Juan Carlos, Spain 282
Ceresa, Mario / Politecnico di Milano, Italy 165
Cerquitelli, Tania / Politecnico di Torino, Italy 478
Chadwick, David / University of Kent, UK 30
Chryssanthou, A. / Greek Data Protection Agency, Greece 367
Coronado, Miguel López / University of Valladolid, Spain 152
Crespo, Jesús Poza / University of Valladolid, Spain 152
Cruz-Correia, Ricardo / CINTESIS, Portugal & University of Porto, Portugal 30
Dabiri, Foad / University of California, USA 228

Moser, L. E. / University of California, Santa Barbara, USA 117
Mucic, Davor / Psychiatric Centre Little Prince, Denmark 129
Mughal, Shazia Yasin / University of Valenciennes et Hainaut de Cambrésis, France 456
Noshadi, Hyduke / University of California, USA 228
Novóa de Manuel, Francisco Javier / Center of Medical Informatics and Radiological Diagnosis &
University of Corunna, Spain 325
Olson, Bradley / SUNY Upstate Medical University, USA 410
Omar, Azizah / Universiti Sains Malaysia, Malaysia 137
Ordóñez, Juan Luis Pérez / UCenter of Medical Informatics and Radiological Diagnosis &
University of Corunna, Spain 325
Perakis, Konstantinos / National Technical University of Athens, Greece 241
Prakash, Nupur / Gura Gobind Singh Indraprastha University, India 1
Rodrigues, Maria Andréia F. / Universidade de Fortaleza, Brazil 399
Sánchez, José Antonio / Universidad Politécnica de Madrid, Spain 282
Sánchez, Roberto Hornero / University of Valladolid, Spain 152
Sarrafzadeh, Majid / University of California, USA 228
Schaefer, Gerald / Aston University, UK 180
Scharcanski, Jacob / Instituto deo Informatica—Universidade Federal do Rio Grande do Sul,
Brazil 338
Schmeida, Mary / The Cleveland Clinic, USA 500
Seoane Fernández, José Antonio / Articial Neural Networks and Adaptative Systems Group &
University of Corunna, Spain 325
Seth, Ankur / Adobe Systems, India 1
Sevdalli, Maria / Higher Technological Institute of Kalamata, Greece 470
Shim, J.P. / Mississippi State University, USA 273
Siassiakos, Konstantinos / University of Piraeus, Greece 382
Sood, Sanjay P. / C-DAC School of Advanced Computing, Mauritius 1
Surján, György / National Institute for Strategic Health Research, Hungary 48
Tafa, Žilbert / University of Montenegro, Montenegro 305
Tait, Roger / Nottingham Trent University, UK 180

Section II
Standardization and Classication Systems in Medicine
Chapter IV
The Cultural History of Medical Classications 48
György Surján, National Institute for Strategic Health Research, Hungary
Table of Contents
Chapter V
Overview and Analysis of Electronic Health Record Standards 84
Spyros Kitsiou, University of Macedonia Economic and Social Science, Greece
Vicky Manthou, University of Macedonia Economic and Social Science, Greece
Maro Vlachopoulou, University of Macedonia Economic and Social Science, Greece
Section III
Distributed E-Health Communication Systems and Applications
Chapter VI
The Integrative Model of E-Health Use 104
Graham D. Bodie, Louisiana State University, USA
Mohan J. Dutta, Purdue University, USA
Ambar Basu, University of South Florida, USA
Chapter VII
A Distributed E-Healthcare System 117

Firat Kart, University of California, Santa Barbara, USA
Gengxin Miao, University of California, Santa Barbara, USA
L. E. Moser, University of California, Santa Barbara, USA
P. M. Melliar-Smith, University of California, Santa Barbara, USA
Chapter VIII
Telepsychiatry Within European E-Health 129
Davor Mucic, Psychiatric Centre Little Prince, Denmark
Chapter IX
Pitfalls and Successes of a Web-Based Wellness Program 137

Tammara Massey, University of California, USA
Foad Dabiri, University of California, USA
Roozbeh Jafari, University of Texas, USA
Hyduke Noshadi, University of California, USA
Philip Brisk, Ecole Polytechnique Federale de Lausanne, Switzerland
Majid Sarrafzadeh, University of California, USA
Chapter XVII
Third Generation (3G) Cellular Networks in Telemedicine: Technological Overview,
Applications and Limitations 241
Konstantinos Perakis, National Technical University of Athens, Greece
Dimitris Koutsouris, National Technical University of Athens, Greece
Chapter XVIII
Telemedicine Consultations in Daily Clinical Practice: Systems, Organisation, Efciency 260
Anton V. Vladzymyrskyy, Association for Ukrainian Telemedicine and eHealth Development &
Donetsk R&D Institute of Traumatology and Orthopedics, Ukraine
Chapter XIX
Ubiquitous Healthcare: Radio Frequency Identication (RFID) in Hospitals 273
Cheon-Pyo Lee, Carson-Newman College, USA
J. P. Shim, Mississippi State University, USA
Section V
Mobile Health Applications and New Home Care Telecare Systems
Chapter XX
Agile Patient Care with Distributed M-Health Applications 282
Rafael Capilla, Universidad Rey Juan Carlos, Spain
Alfonso del Río, Universidad Rey Juan Carlos, Spain
Miguel Ángel Valero, Universidad Politécnica de Madrid, Spain
José Antonio Sánchez, Universidad Politécnica de Madrid, Spain
Chapter XXI
Mobile Health Applications and New Home Care Telecare Systems: Critical Engineering Issues 305
Žilbert Tafa, University of Montenegro, Montenegro

I. Varlamis, University of Peloponnese, Greece
Chapter XXVI
Virtual Learning Environments in Health 382
Stamatia Ilioudi, University of Piraeus, Greece
Christina Ilioudi, University of Piraeus, Greece
Konstantinos Siassiakos, University of Piraeus, Greece
Chapter XXVII
Multimedia Distance Learning Solutions for Surgery 390
Jelena Vucetic, Alpha Mission, Inc., USA
Chapter XXVIII
Collaborative Virtual Environments and Multimedia Communication Technologies in
Healthcare 399
Maria Andréia F. Rodrigues, Universidade de Fortaleza, Brazil
Raimir Holanda Filho, Universidade de Fortaleza, Brazi
Chapter XXIX
Transforming a Pediatrics Lecture Series to Online Instruction 410
Tiffany A. Koszalka, Syracuse University, USA
Bradley Olson, SUNY Upstate Medical University, USA
Chapter XXX
Quality and Reliability Aspects in Telehealth Systems 425
Anastasia Kastania, Athens University of Economics and Business, Greece
Stelios Zimeras, University of the Aegean, Greece
Section IX
Data Evaluation, Validation, and Quality Aspects
Chapter XXXI
Quality of Health Information on the Internet 443
Kleopatra Alamantariotou, City University London, UK
Chapter XXXII
A Practical Approach to Computerized System Validation 456
Kashif Hussain, University of Valenciennes et Hainaut de Cambrésis, France

Medical Informatics: Thirty Six Peer-Reviewed Shades 1
Sanjay P. Sood, C-DAC School of Advanced Computing, Mauritius
Sandhya Keeroo, C-DAC School of Advanced Computing, Mauritius
Victor W.A. Mbarika, Southern University, USA & A&M College, USA
Nupur Prakash, Guru Gobind Singh Indraprastha University, India
Ankur Seth, Adobe Systems, India
Within this opening chapter, the authors explore various perspectives on medical informatics and, to aid
in understanding the evolving meaning of the domain, carry out a systematic review of formal denitions
of medical informatics. Additionally, they use MeSH (medical subject headings) descriptors relevant to
medical informatics to map 36 peer-reviewed denitions. Ultimately, the authors believe that this research
will serve as a handy and an informative resource and may also catalyze further research.
Chapter II
Medical Privacy and the Internet 17
D. John Doyle, Cleveland Clinic Foundation, USA
Ever since the Hippocratic Oath of antiquity, protecting the privacy of patients has been an important
precept of medical ethics. Technological developments, however, have allowed health information to be
used by many organizations and individuals that may be unaware of medical privacy concerns. Within
his research, Doyle contends that the rise of e-Health technology should prompt us to take a closer look
at the issue of medical privacy.
Detailed Table of Contents
Chapter III
Security of Electronic Medical Records 30
Ana Ferreira, University of Kent, UK & LIACC, University of Porto, Portugal
Ricardo Cruz-Correia, CINTESIS, Portugal & University of Porto, Portugal
Luís Antunes, LIACC, University of Porto, Portugal
David Chadwick, University of Kent, UK
This chapter reports the authors’ experiences regarding security of the electronic medical record (EMR).
Although the EMR objectives are to support shared care and healthcare professionals’ workow, there
are some barriers that prevent its successful use. These barriers comprise not only costs, regarding re-
sources and time, but also patient / health professional relations, ICT (information and communication

Spyros Kitsiou, University of Macedonia Economic and Social Science, Greece
Vicky Manthou, University of Macedonia Economic and Social Science, Greece
Maro Vlachopoulou, University of Macedonia Economic and Social Science, Greece
This chapter provides a brief overview of the most relevant electronic healthcare record standards by
examining the level of interoperability and functionality they provide in terms of context, structure, access
services, multimedia support, and security. Such evaluations will provide healthcare decision-makers and
system integrators with a clear perspective regarding the capabilities and limitations of each standard.
Section III
Distributed E-Health Communication Systems and Applications
Chapter VI
The Integrative Model of E-Health Use 104
Graham D. Bodie, Louisiana State University, USA
Mohan J. Dutta, Purdue University, USA
Ambar Basu, University of South Florida, USA
This chapter examines an integrative model of e-health use that connects social disparities at the popu-
lation level with individual characteristics related to the amount and type of online health information
usage, thus providing an account of the ways in which societal disparities play out in individual e-health
usage patterns. Based on an overview of the literature on e-health disparities, the authors suggest that
social-level disparities are manifested in the form of individual-level differences in health information
orientation and health information efcacy, which in turn inuence the amount and type of online health
use. Exploring the underlying social structures that enable individual-level access, motivation, and ability
to utilize the Internet for health and how these structures interact with individual motivation and ability
advances our understanding of the Internet, the digital divide, and health disparities.
Chapter VII
A Distributed E-Healthcare System 117

Firat Kart, University of California, Santa Barbara, USA
Gengxin Miao, University of California, Santa Barbara, USA
L. E. Moser, University of California, Santa Barbara, USA
P. M. Melliar-Smith, University of California, Santa Barbara, USA

Medical Images in Ophthalmology 152
Isabel de la Torre Díez, University of Valladolid, Spain
Roberto Hornero Sánchez, University of Valladolid, Spain
Miguel López Coronado, University of Valladolid, Spain
Jesús Poza Crespo, University of Valladolid, Spain
María Isabel López Gálvez, University of Valladolid, Spain
This chapter describes a Web-based application to store and exchange electronic health records (EHR)
and medical images in ophthalmology: TeleOftalWeb 3.2. The Web-based system has been built on Java
Servlet and Java Server Pages (JSP) technologies. Its architecture is typical, as it contains three-layers
with two databases. The user and authentication information is stored in a relational database: MySQL
5.0. The patient records and fundus images are achieved in an extensible markup language (XML) native
database: dbXML 2.0. The application uses XML-based technologies and Health Level Seven/Clinical
Document Architecture (HL7/CDA) specications. The EHR standardization is carried out. The main ap-
plication object is the universal access to the diabetic patients EHR by physicians wherever they are.
Chapter XI
Clinical and Biomolecular Ontologies for E-Health 165
Mario Ceresa, Politecnico di Milano, Italy
Marco Masseroli, Politecnico di Milano, Italy
This chapter mainly focuses on biomedical knowledge representation and its use in biomedicine. It
rst illustrates the existing resources and explains why they need to be better integrated. Then, the
authors describe the main problems that machines can encounter in processing the factual biomedical
knowledge and explain what terminologies, classications and ontologies are and why they could help
in better organizing and exploiting the bioinformatics resources available online. The authors hope that
a concise perspective of the eld and a list of selected resources may help interested people quickly
understand the main principles of knowledge representation in biomedicine and its high relevance for
modern biomedical research and e-health.
Chapter XII
Distributed Medical Volume Registration 180
Roger Tait, Nottingham Trent University, UK
Gerald Schaefer, Aston University, UK

Section IV
Wireless Telemedicine and Communications Technologies in Healthcare
Chapter XV
An Analysis of a Successful Emergency Telemedicine Venture 215
Jelena Vucetic, Alpha Mission, Inc., USA
This chapter describes business and technological challenges and solutions for a successful emergency
telemedicine venture called MediComm. Its objective is to provide a new generation of integrated
information and communication systems, targeting medical and emergency care organizations. This
system enables multi-directional transfer of information (including voice, data, fax, video) between
the organization’s central information system and its mobile eet of ambulance vehicles. MediComm
enables emergency care personnel to take a patient’s vital measurements and personal information in an
ambulance on the way to the hospital, send the information to the hospital, and receive from the hospital
directions for the patient’s treatment during transportation. When the patient arrives into the hospital,
his/her information will be already updated in the information system, and the medical personnel will be
ready to provide the necessary care immediately. Thus, time will be saved, which for many patients is
of critical importance. The treatment of patients will be more effective and simplied, which will result
in substantially lower cost of medical care.
Chapter XVI
Recongurable Embedded Medical Systems 228
Tammara Massey, University of California, USA
Foad Dabiri, University of California, USA
Roozbeh Jafari, University of Texas, USA
Hyduke Noshadi, University of California, USA
Philip Brisk, Ecole Polytechnique Federale de Lausanne, Switzerland
Majid Sarrafzadeh, University of California, USA
This chapter introduces recongurable design techniques for lightweight medical systems. The research
presented in this chapter demonstrates how the wise use of reconguration in small embedded systems
is an approach that is benecial in heterogeneous medical systems. By shrewdly designing embedded
systems, one can make efcient use of limited resources through efcient and effective reconguration
schemes that balance the tradeoffs between power consumption, memory consumption, and interoper-

Chapter XIX
Ubiquitous Healthcare: Radio Frequency Identication (RFID) in Hospitals 273
Cheon-Pyo Lee, Carson-Newman College, USA
J. P. Shim, Mississippi State University, USA
Ubiquitous healthcare has become possible with rapid advances in information and communication
technologies. Ubiquitous healthcare will bring about an increased accessibility to healthcare providers,
more efcient tasks and processes, and a higher quality of healthcare services. Radio frequency identi-
cation (RFID) is a key technology of ubiquitous healthcare and enables a fully automated solution for
information delivery, thus reducing the potential for human error. This chapter provides an overview
of ubiquitous healthcare and RFID applications. In this chapter, the background of ubiquitous comput-
ing and RFID technologies, current RFID applications in hospitals, and the future trends and privacy
implications of RFID in hospitals are discussed.
Section V
Mobile Health Applications and New Home Care Telecare Systems
Chapter XX
Agile Patient Care with Distributed M-Health Applications 282
Rafael Capilla, Universidad Rey Juan Carlos, Spain
Alfonso del Río, Universidad Rey Juan Carlos, Spain
Miguel Ángel Valero, Universidad Politécnica de Madrid, Spain
José Antonio Sánchez, Universidad Politécnica de Madrid, Spain
This chapter deals with the conceptualization, design and implementation of an m-health solution to
support ubiquitous, integrated and continuous health care in hospitals. Existing technologies from the
computer eld are widely used to improve patient care but new challenges demand the use of new com-
munication, hardware and software technologies as a way to provide the necessary quality, security and
response time at the point of care need. Mobile and distributed developments can clearly help to increase
the quality of healthcare systems as well as reduce the time needed to react to emerging care demands.
In this chapter, the authors discuss important issues related to m-health systems and describe a mobile
application for hospital healthcare and a highly usable application that allows for patient monitoring
with handheld devices.
Chapter XXI

with different computational costs, through a Web browser and in a transparent and user-friendly way.
Chapter XXIII
PACS Based on Open-Source Software Components 338
Daniel Welfer, Instituto de Informatica — Universidade Federal do Rio Grande do Sul, Brazil
Jacob Scharcanski, Instituto de Informatica — Universidade Federal do Rio Grande do Sul, Brazil
This chapter discusses the concept of open-source picture archiving and communication systems (i.e.
PACS), which are low cost, and easy to re-congure and customize for specic users’ needs. Open-source
PACS are based on relatively low cost computational resources and are built by integrating open-source
software components that implement basic services of PACS. These services, as well as how to integrate
them, are described in this chapter. As an example, a PACS based on open-source software components
for angiographic studies is discussed. Using the open-source approach, the authors expect to help diffus-
ing the PACS technology by reducing its development and maintenance costs by using easily available
components (e.g. desktop PCs).
Section VII
Medical Decision Support Systems
Chapter XXIV
Case Based Reasoning for Customizing Treatment Processes 351
Carolin Kaiser, University of Erlangen-Nuremberg, Germany
This chapter introduces a case based reasoning (CBR) system for customizing treatment processes. Ac-
cording to the CBR paradigm, which solves problems based on past experience, the proposed system
uses old treatment processes of similar, former patients and modies them for new patients. In general,
CBR is an established and well suited articial intelligence method to support medical decision making.
However, CBR systems capable of planning treatment processes by adapting old treatment processes
to t new patients are rare. The aim of this system is to increase the treatment quality of the patient
by providing physicians with valuable treatment propositions and to contribute to the development of
medical CBR systems by introducing procedures enabling the formation of new treatment processes by
modifying former treatment processes.
Section VIII
Virtual Environments in Healthcare
Chapter XXV

tions, robotics and telecommunications have enabled new solutions for training and continued education
in various medical disciplines. This chapter presents the most recent developments and future trends in
distance learning for surgeons, focusing on the following goals: (a) Building a comprehensive, world-
wide, virtual knowledge base for various disciplines of surgery and telesurgery; (b) Building a virtual
knowledge base for rare medical cases, conditions and recommended procedures; (c) Interactive mul-
timedia simulators for hands-on training in all surgical disciplines; (d) Building a worldwide surgical
community, which will accelerate the accumulation and sharing of the latest surgical breakthroughs and
technological advances. Above all, the most important goal is to improve patient health and convenience,
and reduce risks of mortality and complications.
Chapter XXVIII
Collaborative Virtual Environments and Multimedia Communication Technologies in
Healthcare 399
Maria Andréia F. Rodrigues, Universidade de Fortaleza, Brazil
Raimir Holanda Filho, Universidade de Fortaleza, Brazi
The authors of this chapter show how recent computing technologies such as collaborative virtual envi-
ronments, high speed networks and mobile devices can be used for training and learning in healthcare
providing an environment with security and quality of service. Though a number of studies have been
conducted in these research areas, the development of integrated care has proven to be a difcult task.
Therefore, we aim also to discuss the promising directions of the current work and growing importance
on these subjects. This includes comparative analysis of the most relevant computer systems and ap-
plications developed so far that integrate modern computing technologies and health care.
Chapter XXIX
Transforming a Pediatrics Lecture Series to Online Instruction 410
Tiffany A. Koszalka, Syracuse University, USA
Bradley Olson, SUNY Upstate Medical University, USA
A major issue facing medical education training programs across the USA is the recent advent of univer-
sal mandatory duty hour limitations and the time pressure it places on formal face-to-face educational
sessions. In response to these mandates, many medical education programs are exploring the use of
online instruction. This chapter describes the instructional development process followed to transform
a classroom-based pediatrics residency lecture series into an on-demand, video-enhanced, online in-

A Practical Approach to Computerized System Validation 456
Kashif Hussain, University of Valenciennes et Hainaut de Cambrésis, France
Shazia Yasin Mughal, University of Valenciennes et Hainaut de Cambrésis, France
Sylvie Leleu-Merviel, University of Valenciennes et Hainaut de Cambrésis, France
This chapter provides a practical approach to computerized system validation (CSV). Any computer
system can be validated utilizing the techniques described. These activities address the organization
commitment to implement the underlying system in order to improve, ensure and maintain the quality
standards. The CSV is described as a reference and an orientation guide to understand the related quality
processes. The activities presented should be useful for initiating and conducting the principal tasks of
validation. This chapter reects a quick guide and addresses one of the “non-technical” aspects of CSV
methodology. A clear approach is presented that denes the CSV activities and provides an efcient means
of validation to new and existing systems, applications, and environments within the organization.