decision support system for primary health care in an inter/intranet environment
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Computer Methods and Programs in Biomedicine 55 (1998) 3137
Decision support system for primary health care in aninter:intranet environment
Tom af Klercker a,b,c,*, Mans af Klercker d
a Departments of General Practice and Primary Care, Faculty of Health Sciences, S-581 85, Linkoping, Swedenb Department of Otorhino laryngology, Faculty of Health Sciences, S-581 85, Linkoping, Sweden
c Department of Computer science, Uni6ersity of Linkoping, Linkoping, Swedend Department of Computer science, Uni6ersity of Uppsala, Uppsala, Sweden
Received 28 February 1997; received in revised form 25 August 1997; accepted 28 August 1997
The need for easily accessible computerised decision- and documentation-support in primary health care has beenpreviously published. The implementation of such a tool in an intranet environment is described. The use of free-warewhich can be downloaded from the world-wide-web (www) is shown to constitute a very potent and manageablesystem. With the use of innovative scripting, very good log-functions can be added in order to render thoroughstudies of its use possible. In this way, it is possibleunder strict research conditionsto study the potential helpand support provided by case-based decision support software in everyday use on a primary care unit. The ease ofuse of this system, as well as its flexibility, shows promise for the future. 1998 Elsevier Science Ireland Ltd.
Keywords: Case-based; Decision support; Primary health care; HTTP; World-wide-web
The need for support in decision-making anddocumentation in primary health care (PHC) hasalready been reported . The use of an inductivecomputer program for producing such supportsystems from local case files has also been previ-
ously published [2,3]. Most Swedish PHC centresare computerised, with a variety of commerciallyavailable systems. The implementation of a sup-port system that can be easily and widely ex-tended must be platform-independent. In thefuture, the Swedish health-care system is intendedto rely heavily on information technology (IT)and an easy way to be in the front line is to usecommon IT-solutions. One widely available net-work is the world-wide-web (www) in local (in-tranet) or global (internet) versions. As most of
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0169-2607:98:$19.00 1998 Elsevier Science Ireland Ltd. All rights reserved.
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T. af Klercker, M. af Klercker : Computer Methods and Programs in Biomedicine 55 (1998) 313732
the software is free of charge and easy to down-load from the www, such a solution is cheap,relatively simple to structure for various tasks andeasy to use in an everyday working environment,since the same technique is used in routine infor-mation-searches on the intra-:internet.
Our aim was to implement and study the use ofa decision-support system in PHC for the ear noseand throat (ENT) section of a local PHC unit,running a local network. The idea was to use acommonly available, free net-browser and aneasy-to-handle server run on an existing computeralready connected to the Internet. The basis forthe system was a decision-tree generated fromcase-notes, using an inductive technique describedelsewhere .
The implementation of a decision and docu-mentation supporting system from a decision treegenerated by inductive computer software hasbeen previously carried out by the authors on avery small scale. The inductive programXpertRule Professional by Attar software, runon a Microsoft DOS based machine, produced apruned and edited decision-tree  that was im-plemented on an Apple Macintosh using Hyper-Card. The program ran well but lacked much ofthe functionality required for clinical and researchpurposes. The Apple Macintosh platform couldnot be used, as nearly all computer programs usedin Swedish PHC are based on IBM compatiblepersonal computers (PCs). There are a variety ofoperating systems involved and an even greatervariety of commercially available software used.Thus, a system that could be easily implementedon any platform and with all necessary function-ality was required.
3. Design considerations
A decision- and documentation support pro-gram for PHC should be easy to run and veryquick, e.g. short answering-times. It must, forresearch reasons, have a couple of easily accessi-
ble functions behind the interface to facilitatefollow up and studies into user related facts. Thismeans easy access to the different screens and alog function that can measure almost everythingrelated to the use of the program. As money is alimiting factor in Swedish PHC, the system shouldbe cheap. It should be possible to run the pro-gram on almost any computer on any net in anyPHC-centre. As the system will hold patient re-lated information, it must be safe and complywith all laws and regulations within the Swedishhealth care system. Patient related and patientspecific information should only be stored tempo-rarily within the local system, while the operatoris actually dealing with the patient. When theoperator exits the patient interview, the researchand processing components of the system shouldonly store depersonalised information. Thus, thesystem log files should contain only informationnecessary for research purposes, without the pos-sibility of tracing back to any individual patient.
The program must be only suggestive, ratherthan dictative, as the responsibility rests with theuser and not with the system. It is important thatthis is made clear when using the system, leavingno doubt as to who is responsible for the patient.As treatment is often guided by local traditions,the system should not give suggestions regardingtreatment unless the local users assume responsi-bility for this. Therefore, local adjustments mustbe easily carried out on the program. It must bepossible to perform test runs with systems that areeasily discernible from a real patient-related run.
Local traditions and changes in the disease-panorama should be mirrored in the decisionsupport system as soon as the change is stable andaccepted by the users. This means that the pro-gram should include every new case tried in con-junction with the system and that the rules changeas the underlying database changes.
As connection to the internet leads to a risk ofinfecting the computer with viruses, an effectiveanti-virus environment is an absolute necessity.Some operating systems used in PHC are veryweak with regard to virus defence. To permit theuse of the standard protection system for theintranet, it was necessary for the www-program torun in its own operating system. Therefore, in the
T. af Klercker, M. af Klercker : Computer Methods and Programs in Biomedicine 55 (1998) 3137 33
test PHC-centre both IBM OS:2 and MicrosoftWindows were run.
4. System description
The decision support system prototype is builtusing a client:server solution. The protocol used isHyperText Transport Protocol (HTTP) which isthe protocol used by the www . This choice wasmade for the following reasons.
4.1.1. Platform compatibilityRecent years have seen tremendous growth of
the www. This has encouraged software develop-ment by clients and servers using the HTTP pro-tocol. Today, there are servers and browsers (aHTTP client is most often called a browser) onevery major computer platform. This enables thesystem to be used in basically any computer envi-ronment. It further enables the server and clientto run on different platforms, which is of greatadvantage.
Most computer networks already use Ether-net technology, making it very easy to create aTCP:IP network (the networking standard of theinternet) on a network already in place, greatlyreducing installation costs. All the major operat-ing systems (OSs), Windows 95, Windows NT,OS:2, MacOS and UNIX, also come with TCP:IPinstalled.
4.1.2. Ease of installationIf a TCP:IP-ready network is already installed
at the testing site, installation of the client:serversystem is easy. A ready-configured server is con-nected to the network and www-browsers areinstalled on each work-station. This is all that isneeded to get the system up and running.
4.1.3. PriceMany applications of both www-servers and
browsers are available free of charge on the inter-net, of which many are in widespread usetheApache server used in this prototype is said to berunning at over 200 000 www sites. A smooth
working system of bug reporting and user testinghas squashed existing bugs in the software in thepast. Consequently, the server software is alreadyrobust. The browsers are also of good qualityNetscape Navigator is actually commerciallyavailable software, but is distributed free ofcharge to non-commercial users.
In larger installations one might opt for usingcommercially available software, in order tobenefit from technical support. In this prototypehowever, software provided free of charge hasbeen to our complete satisfaction.
4.2.1. The ser6erOur choice of a HTTP-server was the Apache
www-server. It has a large number of uses andstems from one of the original www-servers on theinternet (the NCSA www-server). It is availableon UNIX-systems and on Windows NT. It has allthe usual features of a modern HTTP-server, suchas: ability to handle HyperText Mark-up Lan-guage-forms (HTML-forms), multi-level securityetc. Its world-wide use ensured us of its reliability.The choice of a HTTP-server was not critical inthis prototype; any server with the ability to han-dle common gateway interface (CGI)  externalscripts would have sufficed and this includes virtu-ally any server on any computer s