The Health Record: Kernel of a Medical Memory Sandra Bringay1 and Catherine Barry1 and Jean Charlet2

Abstract. For a few years, the growth of the Medical Information Systems was important. Treating essentially of administrative data, these ones become more and more based on the medical data and based on the patient. The place of the Electronic Health Record3 has to be specified in those systems. In this publication, our aim is to define the Health Record that we consider as the kernel of a medical memory. Indeed, although a lot of studies have been carried out on this subject, the professionals of health still do not have at their disposal tools allowing them to reproduce all the practices they realise with Health Records on paper. We will show the difficulties of the design of such a tool according to data-based approaches and documents-based approaches. We will also focus our attention on one practice realised by the professionals of health: annotations. We will show the interest of numerical annotations through an application managing the documents of Electronic Health Records.

1 INTRODUCTION

1.1 Medical knowledge management in the context of Information Systems The evolution of the Information Systems is one of the stakes of the system of health. According to [71;23;1] and GMSIH4, the mutualisation of the patients’ medical data became one of the main objectives of the medical authorities. They want to simplify the knowledge exchanges in a hospital unit, between several hospitals and others medical organizations (connection between the hospital and the city with the networks of care), at a regional and a national level. Indeed, the more the number of professionals of health around the patient increases, the more the flow of data, information and knowledge must be fast and coherent. [12] defines the hospital Information Systems as “all the computerized artefacts used in the hospital (computers, networks and software) and by metonymy, all the data handled by the hospital data processing”. The Electronic Health Record is one of those artefacts.

Traditionally, the professionals of health use paper documents, the Health Record, to convey the medical knowledge. This record shows now its limits [12;63;9;6] (automatic handling of data, transmission and sharing of medical information, etc). Since the eighties, many research teams worked on its computerization. They

1 LaRIA, Université de Picardie Jules Vernes, 5 rue du Moulin Neuf 80000 Amiens, {bringay,barry}@laria.u-picardie.fr 2 STIM - DPA/DSI/AP-HP, 91, bd Hôpital 75634 Paris Cedex 13, jc@biomath.jussieu.fr 3 In the literature we find a lot of terms to designate the record allocated to a patient. The term “Medical Record” is used by the professionals of health to designate the record written by the physicians, in opposition to the record written by the nurses for example. We find also the term “Computerized Patient Record”. In this publication, we will prefer the term “Electronic Health Record”. 4 http://www.gmsih.fr

were confronted with various problems (technological, design, use, etc). The design of those computerized systems was local. The teams provided solutions adapted to the hospital units.

For a few years, hospitals have worked on the economical and organisational piloting [45;46;48]. They are now conscious of the stake of knowledge management. They thought about the design of a new Health Record, which belongs to the hospital Information System. Their aim is to place at the disposal of the professionals of health, the knowledge they need, when they need it, by encouraging the knowledge sharing. According to [53], they evolved from the design of medico-economic-based applications focus on the management of the medical data to make statistics (epidemiologic research, evaluation of the care quality), to the design of medical-data-based applications focus on the management of all the knowledge produced about the patients.

In 2003, the DocPatient project was launched at the University of Amiens to computerize Hospital Health Record5. It is carried out in collaboration with two pilot sites6 and an industrial partner7. We wonder how share, in the hospital organizations, the important data, the necessary information, the strategic knowledge and the key competences. How make these ones circulate between those who create them and those who need them?

The installation of an Information System in the hospital of Amiens by the Medasys8 company, during the last year, modified our initial objective. We now take up position on the development of the Speciality Record, interacting with a Shared Record included in a new Information System.

1.2 The DocPatient project The DocPatient project is based on the results of the Hospitexte project9. We want to create an Electronic Health Record according to a documentary approach. At the end of this latter, authors built a document-based application to transform the record into a hypertext. They considered the document as the central object of the system. That is the reason why we are particularly interested in documents as knowledge support.

During the first year, we studied the existing Health Record in one of our two pilot sites, the Paediatric Unit. In this unit, knowledge is distributed in numerous geographical sources, on various mediums. They use a Paper Health Record, an Electronic Health Record and many others sources: videos, signals, X-ray, etc

5 This project is financed by HTSC program (Man, Technologies and Complex Systems), which belongs to the State-Region Contract in the Picardy region (2000-2006). It gathers a multi-field team composed of sciences for the engineer (computer sciences) and social sciences (law, management, psychology). Project site: http://www.laria.u-picardie.fr/EQUIPES/ic/htsc 6 The Paediatric Unit II of Amiens hospital (directed by Doctor G. Krim) and the Cardiovascular Pole of the Picardy region. 7 UNI-MEDICINE : http://www.uni-medecine.com/ 8 Medasys: http://www.medasys.com/company/index.htm 9 This project was carried out with the DIAM (Artificial Intelligence and Medicine Department) which become the STIM (Laboratory of Sciences and Medical Information Technologies). It was completed in 1999 by V. Brunie’s PHD [12], with the collaboration of B. Bachimont and J. Charlet.

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In this publication, we limit our study to the documents produced by the professionals of health in a linguistic form. Such a document is generally produced to describe an event and the context (circumstances) in which this event takes place. For example, a physician meets a patient. He carries out an act (interview, examination) and in order to preserve a trace of the knowledge produced during this act, he writes a document.

We studied paper documents and tried to identify their content and how there are created and used. This study enabled us to determine the practices carried out on documents by the professionals of health. We want to reproduce those practices with a data-processing tool. Most of documents are forms, designed by the hospital authorities (often the heads of department) and imposed to the professionals of health who write them. Of course, others documents exist. There are designed and written by the professionals of health themselves. Moreover, we realized that the paper forms are often annotated because the professionals of health cannot write all the information they want. We want to preserve in the Electronic Health Record the knowledge included in the annotations.

In parallel, we worked on the data-processing application currently use in the unit. Its objective is to make statistics. This application is data-based, i.e. data capture through documents, data storage in a database and presentation of the captured or calculated data in documents. The professionals of health, who handle this application, use the term “document” to describe the screen enabling them to capture or visualize data. Even with a data-based application, users see documents on the screen.

In this publication, we clarify three points: (1) We focus our attention on the Health Record that we consider as the kernel of the Medical Memory, used by various stakeholders, for numerous tasks. It includes different types of knowledge. We show how to distribute knowledge in various records.

(2) Traditionally, two types of medical applications exist: the document-based applications as in the Hospitexte project and the data-based applications as in the Paediatric Unit. In those two types of applications, documents are used as an interface between users and the system. We describe the numerical documents handled by the professionals of health as a support of knowledge.

(3) The paper documents are annotated. We affirm that it is impossible to create numerical forms to store all the knowledge produced about a patient. To our mind, it is necessary to transpose the practice of annotation from paper to numeric, in order to preserve the knowledge currently included in the paper annotations.

2 MEDICAL KNOWLEDGE We wonder in this section why and how share medical knowledge. Indeed, a lot of categories of professionals of health have interest to dispose of an access to the medical knowledge, but their objectives are very different. So it is difficult to give them the data and information they need, on the format they need, when they need them.

In DocPatient project, the managers team carried out interviews to analyse the needs in the Paediatric Unit. The interviews deal with the following topics: description of the occupation, current

and wished transformations in the unit, description of the use made of the current Paper Record, etc. Those interviews were carried out with various categories of the professionals of health: physicians, interns, nurses and administrative staff. These ones allow us to identify the place of the Health Record in the French system of care and the motivations related to its computerisation. This study was concluded by the document [21]. We use in this section the results of this study.

In a first part, we present the evolution of the medical knowledge management, before evoking their current sharing. We describe the various kinds of medical knowledge and give a synthesis.

2.1 Evolution of knowledge management in the medical area As explain by [59], the first tools built for managing knowledge in hospitals were dedicated to the administrative piloting of the establishments. A lot of products were developed in the seventieth to manage the pay, the accountancy, etc.

After a few years, the desire of managing knowledge arrived in the technical units (laboratories, radiography units, etc). These ones were equipped with computerized tools. As those tools did not communicate, the knowledge exchanges between technical units and care units were realised with paper documents or by phone.

Since the eighties, in front of the growth of the financial constraints in medicine, the control of the cost became essential. The publics authorities decided to finance the establishments of care according to their real medical activities, rather than a global budget. The PMSI8 was created in order to force the establishments to evaluate their activities. The aim of the PMSI is to associate to each hospitalization of the patients a RSS9 including medical, economic and administrative data. The RSS allows organising the patients in groups: the GHM10. A cost is associated to each GHM and allows attributing a budget to each establishment.

With the PMSI, hospitals took an interest in the computerization of their care units and developed tools to permit a systematic capture of the medical data. Now, the medical units themselves want to manage their knowledge to improve the hospitalizations of the patients in their activities of care and to make easier their activities of research.

Moreover, the need of knowledge sharing increases with the creation of care networks about pathologies which force the professionals of health to exchange knowledge between all the members of the network (unit of care, city physician, etc.).

2.2 Current sharing of the medical knowledge Although the aim of the medical knowledge sharing is to improve care, we can distinguish three types of needs:

(1) The need for all the organisations of care (hospitals) to share not-nominative knowledge in order to improve the organisational and economic piloting of the establishments.

8 PMSI (Programme de Médicalisation des Systèmes d'Information): Program of provision of medical care for the information systems http://www.le-pmsi.org/index.html 9 RSS (Résumé de Sortie Standardisé): Standardized summary when a patient achieves a hospitalization. 10 GHM (Groupement Homogène de maladies): The homogeneous group of patients corresponds to the “diagnostic related group” in the USA.

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(2) The needs for the medical authorities (professionals of health for their missions of research, education, etc.) to share not-nominative knowledge in order to improve techniques of the care.

(3) The needs for hospital units and networks of care (professionals of health for their mission of care) to share nominative knowledge in order to give better medical care to the patients.

2.2.1 Not-nominatives knowledge sharing for organisational and economic management of the system of care The organisations of care need to dispose of not-nominatives knowledge in order to take organisational and economic decisions concerning the system of care. For example, these ones need reliable, homogenous, representative and structured data to evaluate the quality and the trajectory of the care, to realise the analytic accountancy, to control the costs, etc.

Since the first January 2004, a new pricing policy of the medical acts was created. The establishments of care are now paid for each act. That is the reason why the medical unit are now forced to describe the acts with a best precision. Those descriptions are based on a new version of the CCAM11. So, more and more, the medical units need to computerize this capture of this acts descriptions to relieve the professionals of health who are the sources of this data. So it is possible to make statistics on this structured data to have indications to evaluate the establishments.

2.2.2 Not-nominatives knowledge sharing for the professionals of health in their activities of researches Medicine is front of the requirements of quality and optimality of the care. Not-nominatives knowledge sharing offers a visibility in term of epidemiology which helps researchers to develop new practices, new protocols, etc.

With the development of the evidence-based medicine12, the professionals of health must share and apply collective knowledge, which have been collectively validated. For example, to make easier the diffusion of better practices, they use protocols of care, RMO13, or GBP14 developed in a lot of disciplines. The professionals of health must also acquire knowledge and know-how, which enable them to adapt the general knowledge to the context, always particular, of a patient.

Consequently, the professionals of health must memorize more and more new data, information and knowledge. This memorizing 11 CCAM (Classification commune des actes médicaux): The common classification of the medical acts is based on GALEN ontology (http://www.univ-st-etienne.fr/dspim/galen.html) 12 Factual medicine or evidence-based medicine (EBM) appears in 1992 in Canada. It proposes a new way to practice medicine based on scientific studies and evidences. 13 RMO (Références Médicales Opposables) : Medical opposable references. Their aim is to avoid superfluity or dangerous in the care of certain diseases and in the doctor’s instructions of certain examinations or medicines. RMO examples: In most of the cases, it is useless to repeat the tracking of Cholesterol, if it appeared normal the first time, before 3 or 5 years according to the case and in the absence of pathology, treatment or increase of the weight. 14 GBP (Guides de bonnes pratiques): Medical guidelines are standard means for dissemination of medical knowledge and for setting forth healthcare standards.

becomes cognitively impossible. So, computerised tools should help the professionals of health in their daily work of memorizing. For example, it is possible to associate the prescriptions to computerized decision-making systems based on the GBP [53;64;34].

To produce those documents, generally semi-structured, the professionals of health use structured data.

2.2.3 Nominatives knowledge sharing for the professionals of health in their activities of care According to [1], encouraging the continuity and the coordination of the care increases their quality because better information of the professionals of health makes easier the diagnoses and the observations. At the present time, the only tool used by the professionals of health to share knowledge is the Health Record. Paper and Electronic Health Record exist. Normally, these records must include all the knowledge relative to a patient but we will see that it is rarely the case.

Paper Health Record with all the medical information about the patient does not exist. Indeed, the units in charge of prescriptions keep documents for medico-legal reasons. So, all the medical information relative to a patient cannot be gathered in a single record in the same time. To communicate them to another unit, it is necessary to duplicate documents. It is long, expensive and impossible for some documents such as radiographies15. This problem of information transmission involves the production of redundant examinations or medical complications.

The medical units, which already have a data-processing tool, cannot easily share information because their systems are often commercial systems. For example, in the hospital of Amiens, maternity use a tool which cannot communicate with the Paediatric Unit tool. During the transfer of a child between the two units, a paper document is printed in the maternity. Information is captured twice numerically in Paediatric Unit. Not to repeat the capture in all medical units, a common tool must lay the foundations for a communication between the various units.

An electronic memory is the solution to diffuse knowledge. Thanks to the numerical medium, it is possible to exceed the medico-legal constraints and to build a dematerialized record, including all the knowledge relative to a patient. Data, information and knowledge are so "singles and ubiquitous" [1]. With a distributed record, information remains physically where there is created and in their original format, but there become accessible from everywhere. So, the professionals of health can retrieve the totality of the medical knowledge, currently represented in semi-structured documents.

2.3 Nature of the medical knowledge In this section, we describe the various types of medical knowledge and their contextual and textual nature.

2.3.1 Various types of medical knowledge It is possible to distinguish three kinds of medical memories. Their gathering corresponds to all the medical data, information and knowledge:

15 The transmission of all the documents produced about a patient is a French problem. In the Anglo-Saxon countries, only the hospitalisation report is transmitted.

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(1) The professional memory includes all the not-nominative medical knowledge related to the medical practices (protocols, GBP, RMO, Thesaurus, etc. and the knowledge used to produce this documents) and all the not-nominative medical knowledge related to the organisational and economic management of the care system (payslip, yearbook, organization chart, etc.).

(2) The patient memory (or Health Record) includes all the nominative medical knowledge relative to a patient as administrative documents, laboratory results, hospitalisation report, etc.

(3) The individual memory (or Personal Record) includes all the nominative and not-nominative medical knowledge of a professional of health as his personals notes, his annotations, etc.

2.3.2 From contextual knowledge to textual knowledge On a day-to-day basis, medicine is not a rigid science but a practice realised by the professionals of health in various contexts. Traditionally, in the hospital units, they use documents to convey medical knowledge with their context. This is the reason why, they learn how to read and write medical documents during their training of medicine. Indeed, each document provides the context of the information it contains. [18] take the following example: If the sentence “the symptoms are attributed to an overdose of Phenobarbital” appears in a clinical examination report, it is a hypothesis balancing several clinical observations. If it appears in the conclusion of a blood barbiturate measure result, it is the confirmation of a hypothesis. In conclusion, we can say that the medical knowledge is contextual and it is textual because it belongs to documents. This requirement explains the failure of a lot of Electronic Health Record using databases, because these ones are based on a unique and structured data encoding of the

patient. This kind of system does not allow various contextual interpretations of the medical knowledge.

So, difficulties appear to link the tools used by the professionals of health in their mission of care, who handle contextual and nominative knowledge through documents (semi-structured data) (see §2.2.3), with the tools of management (see § 2.2.1) and the tools of the medical researches (see §2.2.2) which handle not-nominative and structured data. Indeed, in spite of the use of semantic thesaurus to assume the transformation of this knowledge, it is not obvious to provide management and research tools from the tools used by the medical units.

2.4 Synthesis The Figure 1 is adapted from [19]. It represents all the medical knowledge, in all its forms (structured data, semi-structured documents, semantic thesaurus). In this Figure, we have place the Health Record as the kernel of the life cycle of the medical knowledge. This record, a collection of semi-structured documents, includes all the nominative knowledge, produced by the professionals of health in their mission of care, about a patient. Thanks to semantic thesaurus, not-nominative and structured data are extracted from this record and are used by the physicians in their mission of research, to produce epidemiological studies which are behind protocols, guidelines and RMO. These ones are then used by the professionals of health during the care. Not-nominative and structured data are also extracted from the Health Record, thanks to semantic thesaurus, to be used by the medical authorities for the medico-economic piloting of establishments. The nominative knowledge included in the Health Record could also be presented to others actors (patients, networks of care, etc.) in different ways (as a structured document, as an hypertext, as a structured document associated to an envelope).

Figure 1. Medical knowledge life cycle

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Thanks to the work of the managers of our project, we can affirm that most of the professionals of health are rather in favour of the computerization of their practices. The difficulties they complain often result from the conditions under wprocessing tools are placed at their disposal (e.g. computers are not enough powerful for software) rather than the technologies themselves. However, some professionals of health were reticent because computerization produces new constraints, in particular the time-consuming information capture and the possible control by administrations. In addition, they have the recall of the expert systems failure. During interviews, the term "time" was often used when we asked them what an Electronic Health Record could bring to them. They do not want to become "data capturer". Their main expectation is that the tool does them some favours in order to win time they will devote to the relational with the patients. “Physicians are by nature somewhat cautious and tend to adopt new strategies and technologies only when there is proven benefit” [38].

3 HEALTH RECORD In this section we pay attention to the Health Record that we have place in the previous section as the kernel of the medical memory, and which is the object of our research in the DocPatient Project.

We first give a definition of the Health Record and explain the difficulties encountered to computerize such a tool. Then, we present the expectations linked to its computerisation and we present the various records which can exist.

3.1 Health Record: definition We give the definition of a corporate memory [62]:

“A corporate memory is an explicit and persistent representation of knowledge and information in an organization, in order to facilitate their access, their reuse by the members of the organization for their tasks”

"The term of record is used (…) to indicate all the health information relative to a given person." [41] The Health Record is a memory which represents data, information and medical knowledge, relative to a patient and which is produced and used by a medical organization. The representation of this information must be persistent i.e. constant and durable in time, and explicit i.e. sufficiently clear and comprehensible not to be ambiguous for professionals of health interpretation. Thanks to this memory, the various categories of the professionals of health must store and find all the relevant information during their activities.

3.2 Difficulties for building an Electronic Health Record Concerning the organization of the health system and the relations between the various professionals of health and the patients, the design of such a memory is complex. Besides, the hospital organizations are particular organizations, since there are manufacturing units of services (the care) which must be in conformity with the expectations of the patients, under the best conditions of effectiveness, cost and time. But they are also manufacturing units of knowledge.

The stakeholders are all the "persons who have an interest or a stake which can be affected by the system" [27]. They are not inevitably the users of the memory. In a hospital organization, many stakeholders have activities relative to the Health Record: medical units (physicians, interns, nurses, etc.), technical units (pharmacy, laboratories, etc), administrative staffs, researchers, patients, etc. For all those actors, the Health Record plays a key

role. It is necessary to associate them to the design of the memory [29].

Those actors use the Health Record for very varied tasks which l activities (diagnoses, therapeutic decisions,

preparations of the interventions, hospitalization syntheses, etc.) or others (data retrieval for the care evaluation or for epidemiologic studies, education, etc.).

The Health Record must represent very varied data, information and knowledge, as the value of the weight the nurse notes daily, or the hospitalization reports, the images as radios, scanners, etc.

This knowledge is currently stored on varied mediums, the paper documents, the electronic documents existing in various formats (p. ex. doc, pdf), images (p. ex. scanner, radio), databases, etc.

The memory, its users and its managers are distributed in various geographical places and are heterogeneous. So, it is difficult to build such a tool. More than a technical problem, the difficulty is related to the organization itself. Indeed, the technical necessary meadows reached a certain level of maturity making it possible the equipment of the professionals of health. The company [1] lists what can curb the construction of such a memory:

(1) The problems of data capture, time-consuming, resulting from a lack of availability of the professionals of health require the development of adapted interfaces.

(2) The lack of maturity of the culture and the practice of computerized tools requires personalized helps.

(3) The fear of the transparency requires a communication about the deontology of the computerized medical practice.

3.3 Expectations associated to the Electronic Health Record Sharing of the medical knowledge can only be effective with a computerized tool. The use of such a tool has a lot of consequences for the medical units because it is possible to do the professionals of health some favours as the information research, the data and information processing, the storage, the access of the patient to his record, etc.

3.3.1 Information research The professionals of health often look for information in the Health Record. However, these one becomes quickly bulky due to the multiplication of documents (reports of examination, radio, etc.). Consequently, it becomes difficult for the users to retrieve information in it.

With the numerical medium, it is possible to envisage the use of the knowledge management techniques to place at the disposal of the professionals of health, the methods and the tools making easier information research. A lot of teams work on this subject. We can quote the documents indexing by content [39;40], the seamless integration and intelligent processing of distributed and heterogeneous clinical information [58], the appearance of automatic reminders thanks to guidelines [17], the research in a large amount of clinical and genome-based information stored in big warehouse [37], the query and the visualisation of a distributed Health Record [55], etc.

However, as [12] explains, it is not obvious that the numerical medium allows reproducing all the practices of information research carried out with the paper record and described by [54] (First reading, others readings, fact search, problems resolution, etc.). Indeed, the paper documents’ physical characteristics give indications to the readers. For example, if a set of documents is yellowing, the professional of health suspects that documents correspond to an old hospitalization. A lot of work still to be done

hich new data- can be medica

5

to

al documents must be preserved 50 years (70 years for the Paediatric data) for traceability reasons. However, paper is not

erical medium, although it implies

3.3

ative to this access tient education on his

[47;38]. The searches better

inf hes mo

alth Re ilities ab

e patients [2].

is section that a lot of teams work on the

3.

y of financings. produce interfaces adapted to the practices of the professionals

of health.

3.3.2 Data and information processing The professionals of health expect associate the Electronic Health Record with tools which help them to treat data and information in a reliable way. For example, it is possible to associate the prescriptions with helps to calculate the proportioning of the perfusions and others preparations, to locate critical parts in cardiac signals. The physicians expect also find tools for synthesize the data and the information belonging to the Health Record, for example summarize in a graphical forms the status of a patient [57], produce automatically documents syntheses [30], to exploit the experience of over hospitalizations and others physicians by looking for cases [7], etc.

3.3.3 Storage Medic

eternal. The storage on numproblems of durability (it is necessary to preserve the numerical medium with the software to read the records), is the only way of preserving medical knowledge.

.4 Access of the patient and the law to the Health Record According to the last laws [41], the patient must get an access to his Health Record, but all the procedures relhave to be specified. The impact of pasatisfaction with health care has been studied bypatient improves his level of medical culture. He re

ormation on his health. He aspires to more knowledge, wisre and more to be associated to his decisions of care. Consequently, the access of the patient and the law to the Hecord gives the professionals of health a sense of responsibout their content. Computerization allows a greater control and a

certain homogeneity and validity of the data. These ones must still representative of the medical activity and be also understandable for the patient. With numerical techniques it is possible to offer to the patient a new visibility of his record. It is also possible to add to the access of the patient to his record some functionality. For example, [33;28] have shown the interest of fostering ongoing communication with the patient, by sending him reminders by phone or two-way pager. A similar effort is made about the health care web sites to provide relevant information to th

3.3.5 Synthesis We have shown in thElectronic Health Record in order to provide tools which help the professionals of health in their daily practice of the medicine. Consequently, the Electronic Health Record becomes a partner in the therapeutic relationship which links the patient and the professionals of health [38]. We position our work on two axes: the management of the textual documents produced by the professionals of health and the practice of annotation. We will develop these two points in section 5 and 6 of this publication.

4 Various kinds of Health Records The medical world has been for a few years buzzing with excitement and a multitude of Health Records were created. All the establishments of care are currently in the search of powerful tools for medico-economic piloting. There are either implied in projects

of Electronic Health Record, or in analysis of the needs, or on standb

(1) Most of the hospital units have at their disposal tools created to manage the Health Record as the Health Record of anaesthesia of the hospital of Lille [8], the Health Record of cardiology, aXi-Cardio, proposed by the company Axicare16, etc.

(2) Hospitals try to set up the Shared Health Record as the Information System created in the hospital of Amiens or in the hospital George Pompidou in Paris by the company Medasys17 with the DxCare component which manages a certain Health Record.

(3) The networks of care also work on Health Record shared between all the members of the network. We can quote the network ONCORANET with the project DPPR18, the company Uni-Medicine19 invested in the management of more than thirty networks of care as the network on the Diabetes disease in Picardy (http://www.diabete-picardie.org/), or the network on the Diabetes disease in Essonne (http://www.medcost.fr/html/intranets_re/re_180200.htm). How make the professionals of health not to be lost in such a

multitude of Health Records? All data, information and knowledge are not relevant for the fessionals of health for their tasks. We wonder how there can be ributed in various records to make easi

prodist er an access adapted to the

name, marital statcome ose

expressed with the same linguistic terms. For

riori a common minimum record to be appropriate for h a record is based on information

red the term “shared record”. [31] defines it as the

professionals of health (cf. Figure 2). Some data as the administrative data (name, firstus, etc.) or some medical data (weight, temperature, etc.) are

mmon to all the specialities and have same semantics, i.e. all the dical units associate the same signification to those data. Th

data can be captured only once and shared without problem. On the contrary, some data do not have the same signification in all the specialities or are not example, the French abbreviation IVG is used for “Interruption Volontaire de Grossesse20” in a gynaecological unit and as “Insuffisance Ventriculaire Gauche”21 in a cardiologic unit. For those data, it is not possible to build a common semantics and to share them easily.

Since twenties years, there were many attempts aiming at defining a pall the medical specialities. Sucformatting, which encourage a global vision of the record. Those projects were failures because "semantics shared of the medical data is difficult to specify and share" [31]. Due to the specificity of the medical specialities, the professionals of health cannot work with such records. In front of those failures, the medical community prefer

common reserve of data, which "aims at gathering all the medical data concerning a patient". The professionals of health don’t have to agree anymore on a common semantics. They just have to provide the shared record with the data and information they consider useful to share. We specify this definition in the following way:

The Shared Record is a Health Record which represents all the medical information, relative to a patient, that the various hospital units wish to share.

16 Axicare: http://www.axicare.com/applications2.htm 17 Medasys: http://www.medasys.com/company/index.htm 18 DPPR (Dossier Patient Partagé et Réparti) : Shared and Distributed Patient Record http://oncoranet.lyon.fnclcc.fr/ 19 List of Uni-Medicine networks of care: http://www.uni-medecine.com/page2872.asp 20 Translation : termination of pregnancy 21 Translation : left ventricular insufficiency

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The record can be shared in a hospital between several medical units or in a network of care between several establishments.

r disposal their own ge a certain Health

is accessible from Speciality Record and he Shared Record establishes the link between all

medical information, relative to a patient, identified by a professional of health as important for his

ore in such a record all the personal notes of the

Most of the hospital units have at theicomputerized tool enabling them to manaRecord. Those tools adapted to their practices, represent data and information with semantics relative to their speciality. Those records used for the medical practice can be fed by the shared record and can feed the shared record.

The Speciality Record is a Health Record which represents all the specific medical information, relative to a patient, produced in a hospital unit taking part in a certain speciality.

The hospital units do not want to share all the information. Moreover, as we said before, all of the information is not relevant to share. This information is so only accessible from Speciality Record. On the contrary, there is information which is useful to several specialities. There Shared Record. Tthe Speciality Records.

Moreover, it becomes very important to preserve a space in the Health Record for the professional of health in order to help him to organize his own knowledge and create his own vision of the record.

The Personal Record of the professional of health is a Health Record which represents all the

activity. We st

professionals of health, the annotated documents, etc. We do not affirm in this section that data and information must

be duplicated in all those records but that those records must give access to those documents.

Maybe others records exist, as an Educational Record built by a physician teacher, a record intended to the patient or a record intended for the payments departments, partners of the hospital organization, as the social security for example.

Figure 2. Various Health Records

3.5 Conclusion In this section we have defined the object of our works: the Health Record. Presenting the difficulties related to its computerization, and the various scientific works realised on this subject, we wanted to position our researches on two particular points: the use of

usetextual documents to store medical knowledge and theannotations to complete those documents. To fin

of ish, we have

BEPRThElectroapareprokn Studying the paper and numerical documents of the Paforba

thefor

4.

le and the nature of each segment (part), as well as all

btitle, paragraph, etc) are used. Describing the structure of the data included in the segments of

a document consists in describing the organization of data, their role and their nature, as well as the hierarchical and/or logics

of structure , to describe

is composed of a street,

orm

describe the various records and we affirm that in our project we work on one of those records: the Speciality Record.

4 NUMERICAL DOCUMENTS: INTERFACE TWEEN THE USER AND THE INFORMATION OCESSING SYSTEM

e objective of the DocPatient project consists in building an nic Speciality Record according to a document-based

proach. We consider this one as a collection of documents. We particularly interested in the textual documents created by the fessionals of health, in which they leave traces of their

owledge. ediatric Unit, we realized that documents are, for the most part, ms, which have evolved because of their use in the document-sed and data-based applications. In the first part, we define the notion of form. Then, we describe se ones in the two types of applications. Finally, we describe the ms of the future Electronic Health Record.

1 Forms In this first part, we define the notion of forms and describe its characteristics which will be useful in the following sections.

4.1.1 Forms: definition A form is a document created by a designer (e.g. the head of department) in order to be completed by a writer (e.g. health professionals). Forms standardize data, information and knowledge capture and make easier their search and their communication. They are built for typical needs and situations. A part of the medicine training consists in the acquisition of know-how about forms writing and reading. Others kinds of documents exist in the Health Record, designed and written by health professionals themselves. For example, a surgeon draws a diagram to explain his operation to the patient. He is the designer and the writer of the document, which could not be re-used in another context of data capture. To some extent, he "improvises" the document according to the information he wants to communicate and the context of production of this information. A numerical form is a form whose medium is numeric.

4.1.2 Physical structure of the document, logic structure of the document and logic structure of data We now point out the concepts of logic structure of the document, logic structure of data, as well as the concept of physical structure of the document. We use those concepts in the following section.

Describing the physical structure of a document consists in describing its presentation, its page-setting. If the document contains text, we describe its typographical characteristics: font, colour, size, etc.

Describing the logic structure of a document consists in describing the ro

the hierarchical and/or logics relations which link them in the entire document. To describe this structure, concepts resulting from edition (title, su

relations which link them in a segment. This level corresponds to a model of the natural world. Indeedthis structure, concepts resulting from the description of the world about us are used. For example, an address a postal code, a locality, etc.

4.1.3 Structured/semi-structured f

7

When a writer considers a form, he perceives its organization, its structure.

The form of the Figure 3 is semi-structured. The designer organizes the document in parts. The titles of the paragraphs give information to the writer on their content but there is no precise information on which data must appear in it.

Figure 3. Semi-structured form

The form of the Figure 4 is structured. The designer organizes the

locate data during data capture and the reader can easily ide

document in parts as well as data in the paragraphs. Data are already identified and the writer just has to complete the fields with values. The interest of the structured documents is that the writer can easily

ntify and interpret these ones a posteriori.

Figure 4. Structured form

A medical form can be composed of structured and semi-structured parts. In the document of the Figure 5, the first paragraph relating to the childbirth is structured (date, place), whereas the second paragraph is semi-structured (course of the childbirth).

Figure 5. Mixed form

4.1.4 Fixed and not-fixed form The form of the Figure 6 is fixed. The writer can choose neither

the linguistic formulation nor the organization of

Figure 6. Fixed form

The form of the Figure 7 is noch

t fixed. In the field "Previous

"Oct. 20. 2004"or"

ildbirth", the writer can write "First childbirth of the mother (2000) without problem" or "the mother gave birth once in 2000, without particular problem". In the same way, in the field “dates” in the paragraph "Childbirth", he can write20/10/04 ".

Figure 7. Not-fixed form

The interest of a fixed document is that it is in general more readable. All the writers fill in it in the same way and under the same form. Besides, it is fast and simple to complete. A medical form can be composed of fixed and not-fixed parts. In document 5, the first paragraph relating to the childbirth is fixed (date, place), whereas the second paragraph is not fixed (course of the childbirth).

In a semi-structured form, the order of the paragraphs can be fixed or not. On the other hand, the organization of data is not fixed because the writer is free to write in paragraphs. A structured document can be fixed or not. For example, in documents 6 and 7,

t 6 (fixed), whereas

pplications and data-based applications.

s.

tions

the data concerning the childbirth are structured (date and place). The writer is not free of his capture in documenin document 7 (not-fixed), he can add information to the date (e.g. 20/10/2000 in the morning).

4.2 Forms in document-based applications and in data-based applications Traditionally, two types of applications are distinguished: document-based a

1. The aim of the document-based applications is to manage documents. These ones permit to place and find a document in a collection (surf from a numerical document to another and move in a document), in order to produce and consult data and information which are traces of authors’ knowledge.

2. The aim of the document-based applications (built with a database) is to manage data and information, traces of users’ knowledge. These ones permit to capture data and information, to place and find them in a database and to make calculations on them. In those two types of applications, the capture and the

consultation are done through documents. We describe forms in those two types of application

data in the paragraphs. In the field "Previous childbirth", he can only specify the number of childbirth and the years. The format of the date in the paragraph “Childbirth” is also imposed to him (20/10/2000). 4.2.1 Forms in document-based applica

8

In a document-based application, editors are generally used to produce the numerical documents. To treat those documents a po

the headings in the models of documents or in the lists of mark-up is carried out by the designer in order to be used by the writer.

In the segments, we find data and information, which are traces of writers’ knowledge. According to the handling wished of data and information, the structure can be limited to the logic structure in segments of the form (production of a semi-structured document) or go until the logic structure of data and information in the segments (production of a structured document).

To update the existing documents, it is possible either to modify documents directly, or to create a new document and preserve (or not) the old document.

In a document-based application, the Health Record is a collection of docum it seems to be in conformity with th cal units. Indeed, the

In a data-based application, data and information are represented according to a model. There are linked by relations used to control the redundancy, to carry out calculations on data, to manage the access authorizations, to add constraints of integrity, etc.

As it is difficult for a user to work directly on data and information, an interface is added to this mean of storage (tables of the database), linking the system and the user and allowing the capture and the consultation of data and information. Forms are generally structured and fixed.

Forms are structu n identify and treat data and information ke calculations. This is

database. The capture is very simple and fast. It is limited to some clicks, thanks to the interface elements, as buttons, lists of predefined values, check-boxes, etc. Generally, data are also associated with constraints of integrity, which ensure the validity of the data captured.

To update data, it is possible either to replace in the table the old value with the new one, or to preserve all the values.

In a data-based application, the Health Record is seen as a set of data and information, that seems to be adapted to make statistics on medical data, for example to manage not-nominative knowledge for economic and organizational management of the establishments (see §2.2.1) or for medical researches (see §2.2.2).

When we examine the medical documents, we realize that not only data are captured in structured and fixed fi ds. All information useful to m s is also captured in su h fields. For example, a "diagn ormation, physician’s interpretation, which is a trace of his knowledge of the state of the

o make statistics on diagnosis, it i

a

given situation. This is the reason why the designer adds text fields (memos) in which the writer can add data and information.

4.2.3 Synthesis

4.2.3.1 From documents to data If the user wants to retrieve data or information in a collection of paper (or numerical) documents, he flips (or surfs) through documents and identifies data or information in the segments. Indeed, in the author’s mind, decomposing his document in segments has a signification, perceived by the reader who visualizes the document. The physical structure (perceptible presentation) marks im cture of the document and

osal an explicit representation of the logic structure of the document, there can be treated (finding the titles of segments and building a synopsis to help the reader to find the required segment). In the same way, if the system has at its disposal an explicit representation of the logic structure of data and information in a segment, data and information can be treated (placed in a certain structure, the system knows that the integer 0683247933 represents a telephone number and not the number of Health Records).

There is here a sliding of the document-based approach the data-based approach. If em to help m to ha

ugh n, it

a representation of

Thnodoweofshbepethe

se the two approaches merge into data wished,

steriori, the application must have at its disposal a representation of its logic structure. The user marks out portions of text and/or load models of documents in which he completes segments. Those documents are forms because the choice of

ents. This way of representinge practices of care in the medi

professionals of health traditionally use documents to write nominative information relative to a patient in semi-structured documents (see §2.2.3). In order to make easier the capture during standard meetings, they use forms which give indications on the writing context and on the conditions of its interpretation.

4.2.2 Forms in data-based applications

red so that the system caon which we want to ma

the reason why it is necessary that the system has at its disposal an explicit logic structure of data. Forms are fixed and the writer only has a little freedom of capture. He can only complete the fields predefined by the designer in order to correspond to the tables of the

elcake statistic

ostic" field contains inf

patient. If the medical unit decides ts necessary to capture such information in a structured and fixed

field. As forms are structured and fixed, the professional of health

cannot capture all the data and information he would like because the designer cannot envisage all the relevant medical facts for

plicitly the logic stru the logic structure of the data included in the segments. The

reader can localise the segment which contains the required data and information and identify these ones in it.

The aim of a document-based approach is not to look for data and information automatically or to help the reader to find these ones in documents. However, it is possible. Indeed, if the system has at its disp

tohi the user wants the syst

ndle data and information in a collection of documents, it must have at its disposal an explicit representation of the logic structure of the document and a representation of the logic structure of the of data and information. To make the representation of data and information coherent in all documents (e.g. to identify the same data in several documents), the designer must build a data and information model, which consist in coming close the data-based approach.

4.2.3.2 From data to documents We decide to build an application in order to manage a collection of data and information. Data and information model is conceived. From this model, forms are built. These ones are often similar with the original documents which having been used to build the data model.

If the user wants the application to help him to flip throdocuments and to have an overall vision on data and informatiois necessary that the system has at its disposalthe logic structure of forms, to make calculations on the documents themselves. In the Health Record, the creation of new documents can be envisaged to make easier the data appropriation by a reader.

e Health Record contains numerous numerical values which are t easily interpretable. For example, a nurse daily notes on a cument the child’s weight. This document corresponds to one ek of observation and if someone wants to know the evolution

the weight during a most important duration, several documents ould be consulted. A new way of representation of those data can created, as a graph, which makes easier immediate human rception. So, there is here a sliding of the data-based approach to document-based approach.

4.2.3.3 Conclusion It is not relevant of speaking about data-based approach and document-based approach becauthemselves. According to the exploitation of the

9

structured or semi-structured documents can be built. The more the system has a fine logic data structure and the more treatments on data will be done. The more the system has a fine logic documents structure and the more treatment on documents can be done. Whereas a weak structure of documents makes easier a daily use, it is impossible without a strong structure to integrate into the Health Record tools with a strong value added as helps for prescriptions or diagnosis. The solution comes from a compromise resulting from the

by the user and the machine. This ev

of

more afraid of the

of mentalities

rofessionals of he

current Paper Health Record, we find:

calculations (storage in a database). The professionals of health,

gments of sentences in structured forms.

itten a posteriori of the medical act (e.g. s are semi-structured forms

for speeding the capture. They are similar to

data, information and documents determines the way of zing the medical documents.

ri by the professional of health to create knowledge useful fo

are very often annotated and that annotations include a lot of data h are traces of the knowledge elaborated by

and the reader in the distribution of knowledge between forms and

study of the documents use.

4.3 Numerical forms in the Electronic Health Record From our study on the paper and numerical documents of the Paediatric unit, we deduced that most of forms have evolved during the last years to become documents perceived as semi-structured or structured

olution is due to two factors: fear of medico-legal consequences of medical acts and a certain evolution of the mentalities. To finish, we give the characteristics of the documents used in Electronic Health Record.

4.3.1 Medical forms evolution

4.3.1.1 Fear from medico-legal consequencesphysician’s acts The professionals of health are more and medico-legal consequences of their acts. Indeed, the patients and law can ask to access to the Health Record. The more they have this access and the less the Health Record contains interpretations of the raw data, except for final interpretations (e.g. Diagnoses). On the contrary, the number of raw data increases but, they are less rich in signification because the professionals of health cannot add comments, without being completely sure of their assertions. As [66] explains, the last laws about the inclusion of those interpretations in the Health Record are contradictory. As the professionals of health always need to note the evolution of their conclusions, they write this information in their personal notes. Consequently, documents only contain the obligatory data during the transmission of documents to the patients. The hospital authorities impose the use of forms by choosing models of documents so that the capture is the most uniform possible. They fix what must appear in documents segments, transforming these ones into documents more and more structured.

4.3.1.2 A certain evolutionLet us take the example of the Paediatric Unit. There is more than ten years that this unit use a database to make statistics. The professionals of health are used to capture the same data in the paper and numerical forms. As the numerical forms of the base are structured, the paper forms have evolved to structured forms in order to make easier this double capture. The p

alth became are conscious of the interest of a data-processing tool in spite of the time-consuming capture. They generally prefer to use helps as much as possible (check-boxes, drop-down lists) and to type the minimum of text to have more time with the patient.

4.3.2 Medical numerical forms In the

(1) Forms written in real time, in the room of the patient (e.g. examination of the respiratory functions): these forms contain primarily raw data on which the hospital units want to make

who have in front of them the patients, do not want to waste time in data capture. This capture is limited to some se

(2) Forms wrhospitalization report): these formand contain primarily information (e.g. interpretations) on which the hospital units cannot define calculations a priori. These forms leave more freedom to the writer than the previous category of forms because the designer cannot envisage all the information to be preserved. Indeed, such information has no sense extracted from their context of creation, i.e. the professionals of health cannot use them a posteriori to produce knowledge, except in documents. The writers interpret then the title of the paragraphs and express medical information in natural language.

(3) Mixed forms composed of parts belonging to the two first identified categories. For example, in the form corresponding to the examination realised at the entry of the patient in the unit, two parts are found. The first part corresponds to the raw data of the examination captured in real time (first category). The second part corresponds to the conclusions of this examination, that a physician writes a posteriori (second category). Now, let’s consider the question of the interface between the

numerical system and the user. Form use determines the type of the numerical forms which could be presented on the screen of the Electronic Health Record.

(1) For the first category of forms, electronic, structured and fixed documents will be used (no freedom of capture for the writer) with helps the forms in data-based applications.

(2) For the second category of forms, electronic, semi-structured and not-fixed documents will be used (freedom of capture for the writer) because the conservation of the context of writing is the essential criterion. These documents allow the addition of information not envisaged by the designer. They are similar to the forms in document-based applications.

4.4. Conclusion The use ofrepresentation selected for computeriAll the data and information which can be transferred in a database to make calculations (for epidemiological studies, or organisational and economic management) are captured in structured and fixed forms. On the contrary, when data and information are used a posterio

r the patient care, there are captured in semi-structured forms, to keep data and information with their context of creation.

Whereas the writing and the reading device becomes more and more complex because a machine is now needed to write and consult the numerical documents, the possible numerical treatments on documents and data, make easier the perception that the professionals of health have of the Health Record and make easier its handling.

5 ANNOTATIONS: ANOTHER SUPPORT OF KNOWLEDGE IN THE HEALTH RECORD As we have said in introduction of this publication, when we study the documents of the Paper Health Record, we realized that they

and information, whicvarious types of actors who are handling those documents.

After having briefly pointed out what we understand by annotation, we describe the part played by the designer, the writer

10

annotations, before evoking a particular kind of annotations used as mean of communication.

5.1 Annotation definition According to our readings [24;25;26;68], we define an annotation as follow:

An annotation is a particular note linked to a target. The target can be a collection of documents, a document, a segment of document (paragraph, group of words, image,

ace of the mental representation elaborated by the

n the second image, a physician reads a bjective of reading, highlights, ents.

part of image, etc), and another annotation. Each annotation has a content, materialized by an inscription. It is the trannotator about the target. The content of the annotation can be interpreted by another reader. The anchor is what links the annotation to the target (a line, a surrounded sentence, etc).

On Figure 8, we give two examples of annotations. On the first image, a nurse leaves a post-it on a document. This annotation includes information intended for her colleague who also works with the patient. Odocument and, according to his osurrounds and comments some segm

Figure 8. Annotations example

5.2 Knowledge distribution by the designer, the writer and the reader in forms and annotations

5.2.1 Designer’s form As we saw in section 4, create a document is a way of representing

ent, designer of a

ument. Following

"quA im

is aphos

freforsegwainfsig

colinHe enough freedom to write the data and infin usearranenthe

Wleareatreausein Howrrea not have

se new comments. For example, a head of ndex all documents which can be used for

Figure 9 so

his social comprehension. The head of departmhospitalization report, expects that the physician (writer) will fill in the fields with certain data and information. This intention appears in the descriptive headings used to structure the document. Due to these ones, the designer gives instructions to the writer, by indicating him how to complete the form and to the reader, by indicating him how to read the form. It is a trace of the context in which the designer wants the document to be read and interpreted. "The kinds of text allow the reading of content in new contexts, distant in time and space of the context of creation" [3].

The designer leaves traces of his knowledge by structuring the form and by adding descriptive headings.

5.2.2 Writer’s form The writer perceives the organization of the dochis interpretation of the headings, he answers designer’s

estions" by filling in the paragraphs with data and information. physician writes a hospitalization report according to the model posed by his head of department. He knows that this document

addressed to one of his colleagues and that he has to make pear a history of the medical events occurred during the pitalization of the patient. When the writer uses a not-fixed and semi-structured form, he is e to write as he wants in the segments. He chooses a linguistic mulation and a logical structure of data and information in the ments, in conformity with his own model of the world. In this y, he leaves traces of the context of writing, by adding data and ormation not envisaged by the designer and which are nificant of the event at the origin of the document writing. On the contrary, in a fixed form, we lose information about the

ntext of writing. The writer must adapt data capture to the guistic formulation and to data structure chosen by the designer. does not have ormation not envisaged by the designer of the document, except text fields (memos). In paper documents, a professional of health s annotations rather than memos. Thanks to the anchor (an ow, a surrounded part, etc), he preserves a trace of the context of notation creation, because we know which part of the document couraged the writer to inscribe a new information. In this way, writer appropriates the annotated document. The writer leaves traces of this knowledge by filling in the fields

with data and information if these ones are envisaged by the designer and in the annotations if not.

5.2.3 Reader’s form hen the professionals of health consult paper documents, they ve traces in annotations which are significant of their documents ding. For example, a physician prepares a course on the X tments. He wants to find real examples of this treatment he will to illustrate his lecture. He makes a research of Health Records which this treatment was used and annotates documents. wever, the forms of the Health Record are designed to be itten and read in a certain context. If a professional of health ds a document in another context, the designer did

envisaged a field for thodepartment can hardly iteaching and he will not leave in each document a dedicated paragraph which would be rarely filled in. However, for this kind of reading, it is possible with a good analysis to envisage the most part of the information to add and so the fields. For example, we can allow the teacher to add in forms a new part containing the fields relating to the lesson (cf. Figure 9 solution 1). However without the anchor, added information would not be in relation with the part of the document having caused the comment, and one once again we lose a part of the context of creation (cf.

lution 2). The annotations allow the reader to add data and information

corresponding to an original vision on the document.

Solution 1: part added to the form

11

Solution 2: annotation added to the form

Figure 9. New part in the form or annotation

ument, by trying to understand it, he leaves traces of his interpretation in annotations, according to his reading objective. Annotations make easier the comprehension of the document because the fact of paraphrasing, adding information (extensive annotation) or synthesizing (intensive annotation) takes part in the design by the annotator of knowledge, during the interiorization of the information consulted in the document. Annotations are in general easier to read a posteriori by the annotator than the document because there are formulated with his own words. However, when the acts of annotation and consultation of the annotations are distant in time, the annotator has sometimes difficulties to understand himself. Indeed, we often forget our objective of reading when we annotate. When a document is read, if the objective of reading is not t e same one, we interpret it differently and annotations are different.

With those ann new documents that [19] calls "documents of reading" and who correspond to

cument all the segments of sentences highlighted has a sense. Annotations are a good solution to give to the

means of building their own reading and

ted form. As

e and knowledge + reader’s knowledge

traces of the knowledge elaborated

er to co

g and reading rules. With hey need an intermediary, the processing

w working on the construction of an application to ma

we hope that our experimentations will confirm our hypotheses of research. In parallel, we are developing a model of the different annotations it is possible to encounter in the Health Record.

7 REFERENCES [1] Accenture, L’innovation devient réalité, Presentation for the

Pharmaceutical Summer Schools, 2003. www.pharmaceutiques.com/phq/colloques/univ_2003/20030913_ou

The annotator has an additional role. When he decides to add in an annotation, information not envisaged by the designer, he can give it a type (information for lecture, urgent information, information intended for X, etc.). He can also decide to place the annotation in such or such record (see §3.4).

In addition, when a reader consults a doc

h

otations, it is possible to build

reader’s points of view on a document. For example, a professional of health reads the Health Record in order to find the possible causes of a complication and highlights some information. To gather in a new do

professionals of health thegenerating their own vision of the Health Record. By adding his own mark, the reader becomes the author of his own reading insofar as he reformulates in his own terms what he sees: to some extent, he writes the document that he would have liked to consult if he had been the author [3]

The reader leaves traces of his interpretation of the form by writing data and information in the annotations which can be used to constitute his Personal Record (cf. §3.4).

5.2.4 Synthesis In this section, we have showed how the designers, the writers and the readers leave traces of their knowledge in an annota

[56], we propose a definition as an equation:

Annotated form = designer’s structurwriter’s knowledge +

This equation, which shows the insertion of the reader in the construction of the document, makes this reader to be an author himself. The form is created by the designer who structures it and leaves traces of his knowledge in the descriptive headings. The form is filled in by the writer who leaves traces of his

comprehension in the different fields of the form and in the annotations, if data and information have not been envisaged by the designer. The reader leavesduring the reading of the document in the annotations. As explains by [3], annotation practice is a manner, for the reader, to appropriate the document, to rewrite it according to the wished use (to prepare a course, a summary, etc). He becomes the "author of his reading".

In conclusion, we think that an annotation tool is essential in addition to a management system of Health Records, in ord

ntextualise the information not envisaged by the designers and which is produced during the writing and the reading of the Health Record.

6 CONCLUSIONS AND OUTLINES In this publication, we have defined the position of the Health record that we consider as the kernel of the medical memory. Partner of the medical practice, its computerization will have consequences on a lot of actors and their organization (section 3).

After this first work, we have considered special documents: medical documents (section 4). With paper documents, the professionals of health have a direct perception of the content of the record, if they know the writinnumerical documents, tsystem, to perceive their content. Although the reading device become more complex, with the numerical medium, it is possible to put at the disposal of the professionals of health varied perceptible forms of the documents, which make easier the reading. Indeed, if the system has at its disposal an explicit representation of the logical structure of documents and data, the tool can provide to the users, varied views on the record, by reorganizing documents and data in various ways.

In the last section (section 5), we have shown why the annotations are part of the reading contract which link authors and readers. We thought that an annotation tool is essential in complement of a Health Record management tool, to contextualise information not envisaged by the designers of the documents and which are produced during the writing and the reading of the record.

On a theoretical point of view, this first works underlined two needs: the first one consists in defining the sense of the various documents created thanks to all the resources of the record (need of a hypertextual semantics as [12]). The second one consists in defining the sense of the annotations added to the documents of the record by the writer or the reader to construct their own vision of the record (need of an annotational semantics).

We are nonage the documents and the annotations of the Health Record.

This application will be use in the Paediatric Unit and

ziel.ppt [2] L. Adams, Notions of Reliability: Considering the Importance of

Difference in Guiding Patients to Health Care Web Sites, in Methods of Information in Medicine, Special Topic on ICT, in Health Care: Socio-technical Approaches, Guest Editors M. Berg, J. Aarts, J. Van Der Lei, Ed. Schattauer, ISSN 0026-1270 3146F, 2003.

E

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[3] B. Bachimont, Dossier et lecture hypertextuelle : problématique et discussion : Exemple autour du dossier patient, in Les cahiers du numérique, numéro spécial sur l’information médicale numérique, Vol. 2/2, P. Le Beux et D. Boullier, 105-123, 2001.

[4] Y. Badr, F. Laforest and A. Flory, DRUID: coupling user written documents and databases, Proceedings of the ICEIS 6th International Conference on Enterprise Information Systems, Angers, France, 1st Avril, (2003). http://lisi.insa-lyon.fr/~flafores/articles/iceis03_16-01-2003.pdf

[5] M. Baldonado, S. Cousins, J. Gwizdka and A. Paepeke, Notable : at the Intersection of Annotations and Handheld Technologies, in Proceedings of the HUC Handheld and Ubiquitous Computing, Bristol, LNCS 1927, Springer Verlag, Berlin, 100-113, September 25-27, (2000). http://www.imedia.mie.utoronto.ca/~jacekg/pubs/HUC2K_notable.pdf

[6] E. Balka ro-Politics of Informati n a Canadian Hospita cial Topic on ICT in t Editors M.

7, (2003). [8]

, Getting the Big Picture: The Macon System Development (and Failure) i

l, in Methods of Information in Medicine, SpeHealth Care: Sociotechnical Approaches, Gues

Berg, J. Aarts, J. Van Der Lei, Ed. Schattauer, ISSN 0026-1270 E 3146 F, 2003.

[7] C. Barth, M. Tobman, C. Natscher, H. Sussmann and A. Horsch, Fusing a Systematic and a Case-based Information Pool for Medical Decision Support, in Proceedings of MIE Medical Informatics Europe, St Malo, France, May 4-

M-C. Beuscart-Zéphir, Anaesthesiology: Quality management, Usability, and Performances, Presentation for MIE Medical Informatics Europe, St Malo, France, May 4-7, (2003). http://www.univ-lille2.fr/evalab/documents/diap-mie2003.pdf

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