ICT ARCHITECTURE FOR A COMMUNITY MEDICINE

NURSE PROJECT

Thomas Karopka, Ilvio Bruder

IT Science Center Rügen gGmbH, Circus 14, 18581 Putbus, Germany

Neeltje van den Berg, Wolfgang Hoffmann

Section Epidemiology of Health Care and Community Health, University of Greifswald, Greifswald, Germany

Andreas Heuer

Institute of Computer Science, University of Rostock, Rostock, Germany

Keywords: Telemedicine, Tele-homecare, Community medicine nurse, ICT.

Abstract: In the Federal State of Mecklenburg-West Pomerania 35-40% of the general practitioners (GPs) will retire

within the next 5-7 years. In rural regions, it is difficult to find successors for the vacant practices. Thus a

problem of supplying primary health care to the elderly population in rural regions is foreseeable. An

efficient way to lower the workload for the remaining GPs is the implementation of a special trained

community medicine nurse (cm-nurse). The cm-nurses are supported by telemedical devices, a video

conference system and a mobile data management system. In this paper we report on the information and

communication technology (ICT) architecture of the project.

1 INTRODUCTION

Society's demographic change and structural

changes in the German health-care system are

nationwide challenges. In the Federal State of

Mecklenburg-West Pomerania, demographic

changes are developing more dynamically than in

many other regions in Germany. At the end of 2005,

25.4% of the population was more than 60 years old

- a percentage which will climb to 34.8% by the year

2020. One of the consequences of an ageing

population is the increase of age-specific diseases.

On the other hand, 35-40% of the general

practitioners (GPs) will retire within the next 5-7

years.

In rural regions, it is difficult to find successors for

the vacant practices. Thus a problem of supplying

primary health care to the elderly population in rural

regions is foreseeable. The Institute of Community

Medicine of the University of Greifswald and the

Institute of Computer Science of the University of

Rostock have started an interdisciplinary research

project between the faculties of medicine, health

economics, pharmaceutics and informatics to

develop a model project for a cm-nurse that supports

GPs in the primary health care for elderly patients in

rural areas (Terschüren, 2007). One of the main

goals of the project is to develop a model that

disburdens the GPs in rural areas in the task of

serving an ever increasing area and therefore

spending a lot of time travelling from the patients for

home visits. The idea is that a part of the home visits

can be carried out by a special trained cm-nurse,

supported by telecare equipment. Modern mobile

technologies, a carefully designed information flow

between the cm-nurse, GP and the participating

pharmacists as well as a central data store for

epidemiological and health economic evaluation are

the prerequisites for the development of a new

model that is unprecedented in the German health

care system.

A key role for the success of a project of this kind

plays the underlying ICT infrastructure. While the

different devices and techniques needed already exist,

Karopka T., Bruder I., van den Berg N., Hoffmann W. and Heuer A. (2008).

ICT ARCHITECTURE FOR A COMMUNITY MEDICINE NURSE PROJECT.

In Proceedings of the First International Conference on Health Informatics, pages 26-30

 SciTePress

Figure 1: System Architecture.

the integration of these into a working system is still

a challenge. In this paper we focus on the

technological aspects and challenges for the ICT

infrastructure needed to allow the project to work.

2 DESIGN OF THE SYSTEM

Several requirements had to be fulfilled and

influenced the design of the system. The main

requirement was that the system should work in

rural areas with no guarantee of internet access.

Further, the system should be open for different

clients and operating systems. Another requirement

was the usability of the system. The software should

be designed in a way that reflects the workflow that

the nurse is accustomed to.

Figure 1 gives an overview of the system. The

central part is a tablet-PC that is used by the cm-

nurse during the home visits. The Institute for

Community Medicine has developed standardised

questionnaires to support the cm-nurse in the daily

work and to collect data for research. At the end of a

working day the cm-nurse transmits the data to the

central database. To support the research in the

project, a central database with pseudonymized

patient data was installed in the Institute of

Community Medicine. The database consists of a

MySQL database currently running on a Windows

2003 server behind the university firewall. The cm-

nurses use a VPN client to log into the university

network to access this central database. Several

other interfaces exist in the system. To support the

drug anamnesis module data is exchanged between

cooperating pharmacies the GP and the cm-nurse.

The data that the nurse collects can be sent to the

electronic patient record (EPR) system in the GP

office. Several telecare devices are also used in the

system. This interface is currently not integrated into

the system and is not considered here.

3 IMPLEMENTATION

Whenever possible we used open source software

for the system. The system was implemented as a

client server system. We used the model-view-

controller (MVC) design pattern for the

development of the system. This allows for easy

implementation of different clients. Figure 2

illustrates the software design. Currently the only

clients used are tablet PCs. But it is also possible to

use PDAs or UMPCs. Apache Struts is used as the

framework. Tomcat 5.5 is used as servlet container.

The recorded data is stored in a local object database

(DB4O) on the tablet PC. At the end of a working

day the cm-nurse transmits the data to the server in

the Institute for Community Medicine using a VPN

connection. On the server the data is inserted in a

MySQL database. This is done using Hibernate for the

ICT ARCHITECTURE FOR A COMMUNITY MEDICINE NURSE PROJECT

Figure 2: Software Design.

object-relational mapping. The software was

designed in a way that it is possible to add other

mobile clients in a later phase of the project.

4 DISCUSSION

The constraint with the highest impact on system

design was the requirement for the system to work in

rural areas. This is a contradiction to the need of a

broadband wireless infrastructure. In the first pilot

project we experimented with WIMAX but it was

not possible to serve the area needed. An alternative

is GSM/GPRS or broadband UMTS. Both system

were not available in all of our test regions. We also

noticed problems with unstable connections.

Therefore we decided to implement a system that

allows the nurse to work offline. The nurse selects

the patients she wants to visit. All the data is copied

to a local database on the tablet-PC. Once the nurse

is back in her office, she connects the tablet-PC to

the internet and transmits the data to the central

server.

Another process was the selection of the client. We

proposed three clients: A tablet-PC, a PDA and a

UMPC. PDAs are already in use in different clinical

settings and also in home care (Hsu, 2007; Alonso,

2004). Although the PDA is small, light and has a

long battery runtime, we opted against the PDA

because the display is too small for our application.

The modules are designed to guide the cm-nurse

through her visit with standardised questionnaires.

On a PDA the handling was judged to be too

complicated. The UMPC was ruled out due to the

low battery runtime. We finally choose the tablet PC

as a compromise. It has a good battery runtime,

allows a good visualisation of the questionnaires and

is easy to handle with the pen.

Table 1 shows the kind of data and the number of

measurements in the monitoring module in one of

the projects.

Table 1: Type and frequency of data in the monitoring

module.

Module # of Measurements

Monitoring 1822

Blood pressure 1696

Pulse 1241

Drink monitoring 1142

Blood sugar 839

Weight 486

Blood sample 364

Nutrition advice 382

Medical advice 273

Conversation 126

Vaccination 125

Wound examination 112

Dressing 101

The decision to use the Apache Struts Framework

was partly due to time constraints in the project. We

DSL

HEALTHINF 2008 - International Conference on Health Informatics

only had one month to develop the core of the

system. The Apache Struts framework with the

validation support and the supplied libraries was an

ideal starting point for a prototype. Later on it was

very easy to add new modules to the software and it

was decided to keep the web application instead of

developing a native client. A disadvantage of the

servlet technology is the response time that the

servlet container needs to build the page and the

stateless interface. The advantage, however, is the

easy to use interface and the maintainability of the

software. Currently the software is used in four

different field trials by 27 cm-nurses.

To the authors knowledge the model of a community

medicine nurse supported by ICT as described here

is new. However, the participation of nurses in

primary care or the support of GPs by nurses is

already considered in several countries. In the

systematic review of (Laurant, 2005) the authors

come to the conclusion that appropriately trained

nurses can produce as high quality care as primary

care doctors and achieve as good health outcomes

for patients. The report of (Bourgueil, 2005)

compares the situation in six European countries as

well as in Quebec and Ontario. However, there is

few information of the ICT used by nurses to

communicate with the GP. Most of the published

literature is concerned with telenursing or

telehomecare. Telenursing refers to the use of

telecommunications technology in nursing where the

nurse either does a “virtual visit” using a video

conference system or a telephone to provide home

care services. Studies in Europe suggest that a large

number of patients could benefit from in-home

telecommunication services (Valero, 1999).

Telehomecare means the delivery of health services

over distances into the home care setting where

home health nurses use technology to provide

services in the home which enhance the efficiency

and the quality of care (Milholland, 1995). In these

use cases ICT is used to support a home health nurse

in providing her service, usually over a distance.

Although we also use telemedical devices the

primary use case of our software is the standardised

communication of a cm-nurse with the GP. The cm-

nurse works in delegation of the GP i.e. a task

formerly carried out by the GP is now transferred to

the cm-nurse. However, the GP needs to have the

overview of the health state of the patient and

therefore needs the measurements as well as the

standardised questionnaires to get an impression of

the patients' current health state. Table 2 gives an

overview of the currently implemented modules.

Table 2: Overview of implemented modules.

Module Description

First Interview General questions.

Carried out during first

patient contact

Standard monitoring Module that is carried

out during every home

visit

Training for

telemedical devices

Used to document the

training in the use of the

telemedical devices

Fall prevention Standardised

questionnaire for the

detection of fall risks in

the domesticity of the

patient

Drug anamnesis Registration and

check of all drugs in the

domesticity of the patient

(including interaction

check in cooperation

with local pharmacist)

Geriatric assessment Test for signs of

possible dementia: clock

drawing test (Shulman,

1986), DemTect

(Kessler, 2000)

Palliative care Management of pain and

provision of

psychological and social

support

SF-12 Short form of the SF-36

health survey for

assessment of the health

related quality of life of

patients (Bullinger, 1995)

A project that uses very similar technology is from

the Luleå University of Technology in Sweden

(Andersson, 2007). The project is called SARAH

and is run by the Center for Distance spanning

healthcare at Luleå University of Technology,

Norrbotton County council and the municipalities in

Luleå and Boden. In this project a district nurse is

supplied with a field rucksack with a laptop

facilitating mobile access to the electronic patient

record and videoconferencing between the GP and

the district nurse, an electronic stethoscope, a digital

camera and other telecare equipment.

For future work an interface for the cooperating

pharmacies is planned where the pharmacist can

ICT ARCHITECTURE FOR A COMMUNITY MEDICINE NURSE PROJECT

access the questionnaire for the drug anamnesis

module.

5 CONCLUSIONS

An ageing population, fewer GPs in rural areas and

high costs in the healthcare system challenge the

development of new models in home healthcare.

ICT offers numerous potential benefits in terms of

improvements for patients, professionals and cost

savings in the healthcare system. We have

implemented a complex ICT infrastructure to

support a community medicine nurse that carries out

home visits in delegation of a GP. The ICT

infrastructure supports the cm-nurses in their daily

work as well as providing data for the health-

economical and epidemiological evaluation of the

project.

ACKNOWLEDGEMENTS

The authors would like to thank Andreas Holtz who

designed and implemented the original system.

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