DATABASES FOR CARDIOLOGY

Developments in Cardiovascular Mediane

VOLUME 115

For a list of titles see end of volume.

DATABASES FOR CARDIOLOGY

edited by

GEERT T. MEESTER Interuniversity Institute of Cardiology, Utrecht, The Netherlands

and

FRANCESCO PINCIROLI Department of Bioengineering, Politecnico di Milano, Milan, Italy

SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.

Library of Congress Cataloging-in-Publication Data

Databases f o r c a r d i o l o g y / e d i t e d b y Geer t T . Meester an d Francesc o P i n e i r o ! i .

p. cm . — (Development s i n c a r d i o v a s c u l a r medic in e ; v . 115 )

Inc lude s b i b l i o g r a p h i c a l r e f e r e n c e s .

I nc lude s index .

ISBN 978-94-010-5653-3 ISBN 978-94-011-3720-1 (eBook) DOI 10.1007/978-94-011-3720-1

1. C a r d i o l o g y — D a t a bases . I . Mees te r , G. T . (Geer t T. )

I I . P i n c i r o l i , F r a n c s e c o . I I I . S e r i e s .

[DNLM: 1 . C a r d i o l o g y . 2 . In fo rmat io n Systems . W 1 DE997VME v .

115 / WG 26. 5 D232]

RC682.D35 199 1

616. 1 '2' 0285574—dc20

DfMLM/DLC

f o r L i b r a r y o f Congress 90-500 9

ISBN 978-94-010-5653-3

Printed on acid-free paper

A l l rights reserved © 1991 by Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 1991 Softcover reprint of the hardcover 1st edition 1991 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owners.

Thble of contents

Acknowledgements

Foreword Geert T. Meester and Francesco Pinciroli

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xi

Contributing Authors xv

Part One: Basic approaches 1

1. Introduction to basic concepts on methods and techniques for Databases 3

Richard F. Walters 2. Observational databases: a clinical perspective 41

Suzanne B. Knoebel

Part Two: Tools and services 51

1. Advanced instruments and methods for the development of databases applied to cardiology 53

Francesco Pinciroli and Carlo Combi 2. A query language for medical statistical analysis 77

R. Brennecke, H.J. Rupprecht, R. Erbel and J. Meyer 3. Enhancing relational database management systems by applying

artificial intelligence techniques 87 Willem R.M. Dassen, Rob G.A. Mulleneers and William P.S. van Braam

4. Electronic information in cardiology: review of external databases and services 97

Luciana Libutti 5. Computer-aided clinical problem solving as an educational paradigm

for teaching preclinical cardiac pathophysiology 113 Robert A. Greenes, Bryan P. Bergeron, Mark S. Dichter and John T. Fallon

6. Continuing education of physicians and nurses in the DBMS area 141 G. Invernizzi, C. Combi and G. Pozzi

Part Three: Subject-oriented databases 153

1. The ARTEMIS data and knowledge base for hypertension 155 Partrice Degoulet, Marion Lavril, Pierre-Franfois Plouin, Gilles Chatellier and JoiH Menard

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2. Databases for prevention, pacemaker and postoperative treatment: the charite experience in cardiology 167

K.H. Giinther, R. Bohm, V. Dilba, R.R. Moebes, St. Petzschmann, P. Piorkowski and J. Witte

3. Development of and experience with the coronary angiography and PTCA information systems at Leuven University 179

Jos L. Willems, Stef Renkens, Marcel De Wei and Jan Piessens 4. A database for the follow-up of heart transplant patients 201

Ph. Doublet, P. Rubel, G. Dureau and P. Vuillard 5. The K. U. Leuven Coronary Surgery Data Base: a clinical research

data base 223 P. Sergeant and E. Lesaffre

6. Clinical results with computer support of the decisions (in the cardiosurgical intensive care unit) 239

Vladimir A. Lishchouk 7. A pediatric cardiology diagnostic coding system and database 259

R. W. Brower, E. Harinck and A.C. Gittenberger-de Groot 8. Databases and decision system for diagnosis of congenital heart

disease 273 Ivan Marcic and Darko Ivancevic

9. Practical PC-based data management in paediatric cardiology 289 K.J. Sprenger and M.M.A. de Moor

Part Four: Departmental applications 305

1. Patient documentation for the ultrasound laboratory 307 Riidiger Brennecke, Frank Schon and Raimund Erbel

2. A research-oriented database management system for Holter data 315 Pierfranco Ravizza

3. A database management system of coronary care unit data 335 Marco Tubaro, Carlo Iacoangeli, Enrico Natale, Roberto Ricci and Filippo Milazzotto

4. Information management for decision making by critical care physicians and nurses 343

Thomas W. Rosenal, Margaret White and Kathryn J. Hannah 5. Practical data management in the Cardiology Department of a City

Hospital 357 A. Pizzuti

6. A PC-based implementation of a multi-service software for cardiology 367

F. Pinciroli, C. Combi, G. Pozzi and R. Rossi 7. An out-patient clinical data base management system 381

G. Pinelli, G. Carini, G.L. Manini, S. Urbinati, M. Ruffini and L. Guazzotti

8. Databases for network systems L. Goncalves and R. Domingos

9. CADANS: the nervous system for cardiology Geert T. Meester, O.E.H. Sartorius, D. Panggidaej, M.G.J.M. Gerritsen, J.A. T.G. van Kester and P.M. van Rappard-van der Veen

Index

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393

401

415

Acknowledgements

Bayer AG and Bayer Italia SpA supported in full the second Como Workshop of 'Databases for Cardiology', held in January 1990 at the Centro di Cultura Scientifica 'Alessandro Volta' at Villa Olmo in Como, Italy. The Workshop was promoted by the editors. It was specifically intended for the compilation of this book. Mrs. Chiara De Santis served as general secretary to both the workshop and the book.

FRANCESCO PINCIROLI and GEERT T. MEESTER Editors and Promoters of the Second Como Workshop

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Foreword

A database is in principle just a large collection of related or separate data, systematically stored in a computer. It should be possible for the data to be easily entered into the database-structure and afterwards also easily read, corrected and processed.

The later analysis of data from such a database is greatly enhanced by the availability of special query languages and statistical analysis programs, not only for serial items but also for large combinations of data.

Query languages, such as SQL (Structured Query Language) developed especially for these purposes, make databases easily accessible, also to researchers who may not be very well versed in computer programming.

The cardiological/medical clinician and researcher of today is of necessity confronted more and more with computer-based data storage.

Interest is of course focused primarily on the clinical use of such databases more than on the technical design itself, except for some very specific, personalized applications.

For the latter approach, there are at present many software packages commercially available, especially designed for use in the personal computer environment.

This book is comprised out of a number of contributions by various authors with differing backgrounds and from many different countries.

The editors, being a cardiologist and an information scientist, have strived to achieve an equilibrium between these two fields. The chapters in this book form a cross-section of the many approaches to database design and implementation in the area of cardiology.

The material included herein will assist the reader to make an informed choice when facing the necessity to design or utilise a patient-oriented database. It should also provide the opportunity to familiarise him/herself with the intricacies of computerised databases, as seen from the viewpoint of the practicing cardiologist or researcher in the cardiovascular domain.

Successful data-analysis is an essential condition to database design. Therefore, several chapters are dedicated to the interrogation of existing databases. A survey of query languages would deviate too far into the technical

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xii

aspects, other texts supply abundant information regarding the choice and use of these tools.

During the assembly of the text the editors became aware of the lack of an annotated bibliography in this field. Furthermore, a software catalogue, however useful, could not be constructed within the scope of this book, because it would be almost immediately outdated. For this, the reader is directed to the Cardiovascular Software Directory compiled by the American College of Cardiology [1], the Annual Medical Software Buyers' Guide in the Journal of M.D. Computing [2] and with a broader spectrum with regard to area of application, the Directory of Portable Databases [3].

In addition, the editors stressed the need to include databases used to develop artificial intelligence and confirm testing of expert systems and diagnostic programs and to organize databases for testing purposes, taking into account the experience of the ECG.

One of the authors in this volume, Dr. R. Brennecke (Mainz, Germany) is planning to maintain a catalogue of cardiological databases. Copies are available on request. Readers are recommended to supply additional information on databases not yet covered in this catalogue. As far as the situation in Italy is concerned, workshops for Cardiological Databases were held in 1987 and 1988 and the related proceedings were published [4].

The contents of this book show four main sections, covering basic approaches, tools and services, subject-oriented databases and finally department applications.

The first chapter, written by R. F. Waiters, introduces concepts and methods for the design and use of databases. This chapter serves as an overall introduction to the topics in this book. The following chapter, by Suzanne B. Knoebel, approaches the cardiological database from a clinical point of view. How to extract the optimum information from an available database in a natural course of events. F. Pinciroli and C. Combi cover advanced instrumentation in their chapter, including hypermedia and the MEDIX standard for the exchange of medical data.

Next, R. Brennecke et al. present a special query language enabling large sets of interdependent queries. Suggestions were also made to hire if necessary an information scientist educated in databases, who could help the cardiologist in keeping data consistency, back up and data dictionaries always updated. In the following chapter, Dassen et al. cover the application of artificial intelligence techniques to enhance a relational Database Management System. An increasing number of external databases are available to the cardiologist. Libutti surveys the field and encourages the use of these large sets of data. This topic is continued and approached from another angle in the discussion of problem-solving as an educational tool in teaching cardiac pathophysiology (R.A. Greenes et al.).

In addition, Invernizzi et al. discuss the educational aspects of the use of database systems.

Moving to the field of patient-oriented applications, the following chapters

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describe several different clinical databases and their uses. Firstly, the ARTEMIS database for hypertension (P. Degoulet et 01.) and then the East German 'Charite' experience, described by K.H. Gunther et 01. J.L. Willems et 01., present the coronary and PTCA information systems in use at Leuven University.

Ph. Doublet et 01. explain the use of French videotex system as applied in the follow-up of heart transplant patients.

A large and intricate clinical research database for coronary surgery is summarised by P. Sergeant et 01. (Leuven). It has a follow-up of 3500 patient­years, with more than 1000 variables for each record. Decision support in the intensive care unit is the topic of Lischouk et 01. Standardising a diagnostic coding system for paediatric cardiology with a database as used in the Netherlands, forms the chapter by R. W. Brower et 01. This is followed by a decision system to aid in the diagnosis of congenital heart disease as an attempt to rationalisation, is discussed by I. Maleic et 01.

The data management in paediatric cardiology based on a microcomputer approach is covered by Sprenger et 01. The echocardiography laboratory (R. Brennecke), the Holter tape laboratory (Ravizza et 01.), the coronary care unit (Tubaro et 01. and Th. W. Rosenal et 01.), the out-patient clinic (G. Pinelli et 0/.) are functional units that can greatly benefit from automated database management, particularly in an integrated combination (Pizzuti). A combination of different uses in a single software package as described by F. Pinciroli et 01., is often practical. Finally, databases in a network environment is covered by L. Goncalves et 01. and G. T. Meester et 0/.

The editors also wish to use this opportunity to make a few recommendations both for the design and the usage of medical databases.

With the inevitable progress in telecommunications, the need for data­transportation between databases within one hospital, one country and perhaps even between countries will certainly increase. This can only be effectuated when data-definitions are not only specified, but preferably equal from one site to another. Terms such as 'unstable angina' and 'ejection fraction' should be defined clearly. International standardisation is therefore a must. The major professional organisations in the cardiological field should promote and sponsor these activities, probably most effectively through working committees and consensus-conferences. An initiative of the American College of Cardiology [5] led in October 1989 to the formation of a Database Committee (ACCORD: ACC Outcome and Risk-Stratification Database) under the leadership of Suzanne B. Knoebel, M.D. The goal of this new committee is to develop a national computer database on selected cardiovascular procedures.

Not only in Italy and the Netherlands but also in many other countries, activities in the medical database field are taking place. Many of the chapters in this book form together a major indication of the growing attention to this area.

As far as future initiatives are concerned, the suggestion was made to organize a very specific International Summer School, focusing on the use of

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large databases, to be Europe based but not restricted to Europe. Another initiative could be the creation of a user group, with newsletters to

exchange information and experiences. Finally, it was suggested to hold the Como conference on a regular basis, to

discuss the different topics in the light of the latest breakthroughs. The editors are aware of the fact that this book is not and cannot be a manual

for the construction of medical databases. Its aim is to provide the reader with an extensive overview of the medical cardiological database field, with examples of design, construction and data-analysis, while not omitting possible problems and pitfalls.

G. T. MEESTER F. PINCIROLI

References

1. Cardiovascular Software Directory (1988) Compiled by the American College of Cardiology Computer Applications Committee.

2. The Fifth Annual Medical Software Buyers' Guide (1988) M. D. Computing 5: No.6. 3. Directory of Portable Databases (1990) Published by CuadralElsevier, New York, Vol. I,

No. 1. 4. Milazzotto T, MartinyW, Matta F, Pinciroli F, (eds) 1987 and 1989 Banche di Dati Integrate in

Cardiologia. Published by C.S.T. Torino, Italy. 5. Cardiology (1990) Official Newsletter of the American College of Cardiology 19: No.2.

Contributing Authors

R. Brennecke, II. Medical Clinic, Mainz University, Langenbeckstr. I, D-6500 Mainz, FRG. ch 11.2 H.J. Rupprecht, Raimund Erbel and J. Meyer. ch IV. 1. Frank Schon and Raimund Erbel

R.W. Brower, Medical Computing Consultants, P.O. Box 35010, 3005 DA Rotterdam. E. Harinck and A.C. Gittenberger-de Groot

Willem R.M. Dassen, Department of Cardiology, University of Limburg, P.O. Box 616,6200 MD Maastricht. Rob G.A. Mulleneers and William P.S. van Braam

Patrice Degoulet, Medical Informatics Department Broussais University Hospital, 96 Rue Didot, F-75014 Paris, France. Marion Lavril, Pierre­Fran~ois Plouin, Gilles Chatellier and Joel Menard

Ph. Doublet, INSA, Department of Informatics, F-69621 Lyon Cedex 03, France. P. Rubel, G. Dureau and P. Vuillard

Lino M.M. Goncalves, University Hospital of Coimbra, Av. Bissaya Barrete, 3049 Coimbra Codex, Portugal. R. Domingos

Robert A. Greenes, Dept. of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, U.S.A. Bryan P. Bergeron, Mark S. Dichter and John T. Fallon

K.H. Giinther, Department of Internal Medicine, Humboldt University Hospital, Charite, Schumannstr. 20/21, Berlin, DDR 1040. R. Bohm, V. Dilba, RR Moebes, St. Petzschmann, P. Piorkowski and J. Witte

Giorgio Invernizzi, Cardiology Department, Ospedali Riuniti, L-go Barozzi I, 1-24100 Bergamo, Italy. C. Combi and G. Pozzi

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Suzanne B. Knoebel, Krannert Institute of Cardiology, 1001 West 10th Street, Indianapolis, IN 46202, U.S.A.

Luciana Libutti, Institute of Studies on Research and Scientific Documentation, National Research Council, Via Cesare de Lollis 12, 1-00185 Rome, Italy

Vladimir A. Lishchouk, Bakulev Institue of Cardiovascular, Surgery, Academy of Medical Sciences, Moscow 117031, U.S.S.R.

Geert T. Meester, Interuniversity Institute of Cardiology ICIN, P.O. Box 19258, 3501 DG Utrecht. O.E.H. Sartorius, D. Fanggidaej, M.G.J .M. Gerritsen, J.A.T.G. van Kester and F.M. van Rappard-van der Veen

Francesco Pinciroli, Department of Bioengineering, Politecnico of Milan, Piazza Leonardo da Vinci 32,1-20133 Milan, Italy. ch 11.1. Carlo Combi, ch IV.6. Carlo Combi, G. Pozzi and R. Rossi

G. Pinelli, Cardiology Department, Bellaria Hospital, 1- Bologna, Italy. G. Carini, G.L. Manini, S. Urbinati, M. Ruffini and L. Guazzotti

Alfredo Pizzuti, Department of Cardiology, SS. Annunziata Hospital, 1-12038 Savigliano, Italy

Pierfranco Ravizza, Department of Cardiology, General Hospital, Via Ghislanzoni, 1-22053 Lecco, Italy

Thomas W. Rosenal, Department of Intensive Care, The Calgary General Hospital, 841 Centre Avenue E., Calgary, Alberta, Canada T2E OAL Margaret White and Kathryn J. Hannah

P. Sergeant, Department of Cardiac Surgery, Gasthuisberg University Hospital, Catholic University of Louvain, B-300 Louvain, Belgium. E. Lesaffre

K.J. Sprenger, Paediatric Cardiac Unit, Dept. of Paediatrics & Child Health, Red Cross War Memorial Children's, Hospital, Rondebosch 7700, Cape Town, South Africa. MMA De Moor

Marco Tubaro, Via Val Pellice 53, 1-00141 Rome, Italy. Carlo Jacoangeli, Enrico Natale, Roberto Ricci and Filippo Milazzotto

Ivan Maleic, Department of Paediatric Cardiology, University Hospital REBRO, Yu-41000 Zagreb, Yugoslavia. Darko Ivancevic

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Richard F. Walters, Division of Computer Science &, Department of Family Practice, University of California, Davis, CA 95616, U.S.A.

Jos J. Willems, Division of Medical Informatics, University Hospital Gasthuisberg, Herestr. 49, B-3000 LOllvain, Belgium. Stef Renkens, Marcel De WeI and Jan Piessens