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Summary report of observations, conclusions and recommendations
ELSEVIER
International Journal of Bio-Medical Computing 39 (1995) I 1~ I5
Summary report of observations, conclusions and recommendations Ab Bakker, Ed Hammond, Marion Ball IMIA
Working
Group
10 Hospital
Information
Systems
Working
1. Scope of HIS
Whereas the preceding IMIA working conferences considered the scope of the Hospital Information Systems (HIS) to be restricted to the information systems within the borders of the institution, this conference was of the opinion that functions outside the hospital also need to be included in the definition, i.e. HIS broadens its definition to mean Health Information System. The relationships between the HIS and the Computer-based Patient Record (CPR) were discussed intensively. 2. HIS and CPR
The CPR system (CPRS) must be designed with the patient as the center piece. In fact, the concept of a person-centered system was suggested to reflect the fact that a person should not have to see a health care provider in order to be in a system, but should need only to reside in a regionally defined area covered by the CPRS. The CPRS must. however, have characteristics of being usercentered for a wide variety of users. The CPR itself is a repository of all data relating to a person ~- both health or wellness data as well as data relating to an illness. The CPR contains data for the lifetime of the person. The CPR, as a conceptual document, includes data relating to a patient regardless of the place or person who is the source of that data. Whether that data is
Group
Conference,
Durham.
North
Caroliru.
-17 J(J Auqusr
1994
collected into a single physical database or is a virtual common database created by a linkage of several databases, was not a dominant consideration, although most participants felt the latter was a more realistic approach. The content of the CPR must be defined, perhaps in the form of a global data model. Levels of implementation, including the definition of a core data set, should be established. What is to be collected at each encounter of various types, both in-patient and outpatient, needs to be defined. The relationship between the HIS and the CPRS was discussed with the following outcome. In some respects the CPRS was a subset of the HIS (the HIS also containing local data), while in other respects, the CPRS encompassed the HIS (data from several institutions). The distributed nature of the CPR and the interoperability of systems, raised many issues which must be addressed. Standards must be in place far the definition of terms (semantics) used in the (:PR and for the interchange of data. A common data model for what is contained within the CPR must be defined and accepted. Issues of confidentiality, security and privacy must be addressed. Access rights must be defined and procedures for enforcing these rights must be deployed. A unique person identifier must be established and maintained. Other questions raised but not answered include: who controls the various parts of the C’PR and how is the consistency of the data originating in other institutions to be verified?
0020-7101/95~$09.50\G 1995 Elsevier Science Ireland Ltd. All rights reserved SSDI 0020-7101(94)01072-Z
12
A. Bakker et al. / ht. J. Biomed. Comput. 39 (1995) I l-15
3. Costs of CPR and HIS The participants felt that it is very difficult to define the cost of a CPRS, or for that matter, of an HIS. The general belief was that the realization and operational use of the CPRS would increase information handling costs, but these costs would be significantly offset by both direct and indirect gains. Current information handling costs for health care facilities were estimated to be between 1.5 and 3% of the total operational costs. This percentage will increase significantly becauseof the CPRS. Few studies have documented the benefits of an information system. However, those benefits need to be substantiated if an increase in expenditure for information systems is to be expected. With the shift to a regional CPRS and the linkage among all health care facilities and organizations, substantial organizational changes must take place. These changes will require an enhanced understanding of the informational system by administrators and clinical personnel alike. 4. Open systems The term ‘open’ is used in various ways which often leads to confusion. The technical facilities required to be able to send a messagefrom one computer to another (interconnectivity) will be made available by the information technology industry. No special action is needed in this respect from the medical informatics side. We should concentrate on the interoperability of systems. Such interoperability can be realized in different gradations, depending on the application choices to be made. Essential ingredients of a policy for openness were identified as: standardization of the exchange messagesyntax; and externalization of the data dictionary of each of the systems as far as communicable data are concerned. To pave the way towards interoperability of modules from different suppliers, it was recommended that the three aspects, namely, database, user interface and logic, be kept separate in the application software. Transportability does not necessarily require the same operating system but does require the same interfaces (e.g. POSIX),
which may be available for non-transportable operating systems as well. 5. The chief information architect The increasing importance of informational systems for health care establishments, led the participants to recommend the creation of the position of Chief Information Architect (CIA) who reports to the Chief Executive Officer (CEO) at the same level as the Chief Financial Officer (CFO) and the Chief Operating Officer (COO). 6. Integration of functions for health care professionals The integrative aspects of the HIS were emphasized. The clinical information system must accommodate the full family of users and suppliers of data including physicians, nurses, technicians, administrators, medical record personnel, and all other personnel involved in the patients’ care. Not only should the users and suppliers of data share some data elements, they should support analysis of the care process that lead to a re-engineering which takes advantage of the opportunities of IT. The point was made, however, that IT investments must be cost-effective in changing health care processes, building human networks, and re-engineering. Access to data should be clearly defined based on the need to know. Displays of data need to be organized depending on the needs of the category of the individual and the circumstances of the encounter. Education of the various users in this integrated approach must be anticipated. 7. Linkages between institutions New linkages must be established among institutions to support the interchange of data. Organizational changes and the development of an information infrastructure must be put in place to permit these linkages to occur. Information networks must be physically established to permit the ubiquitous accessto and collection of health care data. Data dictionaries supporting the CPR and the HIS should be made ‘public’. The group felt
A. Bakker et al. / ht. J. Bionzed. Compu/. 39 /1995) 11 15
that telemedicine, as a project unto itself, was overemphasized. On the other hand, the participants felt that the transmission of data including image, waveforms, sound and text among health care facilities was desirable. 8. Smart cards
Little enthusiasm was shown for the smart card as a form of the CPR. The primary reason was the fact that the smart card could not be kept up to date without an extensive networked system. The existence of such a system precluded the need for the smart card. The one use that was supported was that of patient identity and inclusion of data that did not change or changed slowly over time. Examples include blood type, allergies, date of birth and immunizations. 9. High capacity networks
As long as the CPR is restricted to alpha-numeric data, medium/low speed networks will be sufficient. In the long-run, high speed communication will be necessary to support the transmission of images. Who pays for these systems and who makes their creation happen was discussed. Is it the private sector or is it the government? Is it the same in all countries? How is it financed - by a general tax or by a use tax? What will the required capacity of such networks be and what is the time schedule for that requirement? Obviously, systems must accommodate a variety of communications scenarios which will change over time. 10. Assessment of costs and benefits
We noted that IMIA Working Group 15, under the leadership of Seymour Perry, was established recently to deal with the subject of assessmentof benefits and costs of health care information systems. WGlO should be aware of the activities and recommendations of this working group. I 1. Coordination
of developments
Guidelines and pathways should be developed and promulgated to stimulate both national and international initiatives in new areas of technol-
13
ogy. The coordination of developments in areas such as the CPR, clinical workstations. adoption of careplans, and new technology, can best be accomplished by: l international standards which are the same or compatible; o mutual exchange of drafts and concepts; l common repositories of relevant documents addressing these topics, with IMIA taking the lead in setting up such a repository. 12. Standards
The development of a comprehensive and complete set of standards to support the HIS was identified as one of the top priorities for the next few years. The group was pleased to note an increased interest and productivity in standards development in both Europe and the USA, as well as increased cooperation in the international development of standards. We need to develop a strategic plan which identifies: 0 WHAT standards are necessary; 0 WHO should take the lead in developing standards; 0 HOW standards will be developed; 0 WHEN standards will be developed and available for use. The standards effort requires additional funding, particularly in the USA, if the standards are to be realized in an appropriate time frame. Relying on volunteers who have to fund their own efforts is not productive. Care should be taken to get both vendors and users appropriately involved in these efforts. Governments should be supportive not competitive. The participants identified several barriers to the development of healthcare standards: l lack of funding; 0 lack of qualified people; 0 poorly defined objectives; 0 limited recognition and awards for people developing standards; l poorly defined processes; l lack of a strategic plan. Standards for data interchange have made the most progress and are usable although not complete. Standards for vocabulary (semantics stan-
14
A. Bakker et al. / ht. J. Biomed. Comput. 39 (1995) 11-15
dards or data dictionaries) are non-existent and demand high priority. Suppliers and vendors can be encouraged to adopt and comply with standards by: 0 making the standards usable; 0 clearly describing the purpose of the standard; l educating both suppliers and users; 0 documenting the realizable benefit of the standard; 0 establishing demonstration projects for standards; 0 user pressure appropriately applied; 0 bulletin boards describing experiences with specific vendors and the use of standards; 0 certification.
tem for healthcare should include the person’s home, as well as all the health care delivery facilities and supporting structures. It was felt that the new enterprise systemscould evolve from the present institutional systems, In view of the effort and lead-time required, it was considered unrealistic to start from scratch. An important step in the evolution will be the global sharing of data dictionaries from the various institutions. Another required component is the standardization and structuring of the CPR. Responsibilities and authorization for the use of data is required, to avoid this area becoming a stumbling block. 15. Security
13. HIS reference model The discussions of the preceding working conferences on a reference model for the HIS were extended and led to the proposal that IMIA develop a multi-dimensional model describing: l a preferred technical structure; 0 a functional structure; l a functional decomposition, describing the functions and interfaces for the main modules; l requirements for modules. Participants were asked, as a first step, to provide input for this reference model immediately after the conference and to identify additional sources of input (waterfall model). An analysis of the material received should make clear whether such an approach is feasible. 14. Care plans Broad use of care plans or protocols is anticipated soon. Forces for the development of these care plans are in place. Attention must be paid to developing applications which can incorporate these plans into the process of care. Sharing of care plans/protocols via Internet should be stimulated. The evolution from the HIS to an enterprise system was widely supported, although the term enterprise system itself was misleading and vaguely defined. Suggestions were made to find a better word to describe the new concepts. The point was made strongly that the enterprise sys-
The participants felt that the awareness of security issues by health care providers was improving. By giving patients the right to be informed about who had accessto their record, health care providers may use more effort in preserving the privacy and confidentiality of patient data. Audits of randomly chosen patients’ records pertinent to data accessissues, can further encourage compliance. Protection against intrusion through Internet connections was considered an important issue, and system developers have a responsibility for providing protection against such intrusion. Firewall protection and the use of a security server, such as KERBEROS, were mentioned. Encryption as a protection of confidentiality is strongly suggested for traffic crossing the borders of the institution. Electronic signatures can be expected to become the usual technique for guaranteeing the integrity of the message and the identity of the originator. The key management issue was not discussed in detail but reference was made to the Trusted Health Information System (THIS) within the INFOSEC program of the European Union (EU). This project will make recommendations before the end of 1994. Because IMIA has a dedicated working group (WG4) for security issues, WGlO participants felt the general area of security should be left to that group. WG4 held a recent working conference at
Heemskerk, The Netherlands (IJBMC, February 1994). Certification of software appears to be a desirable goal. A distinction was made between process certification (IS0 9000) and product validation. No government activities in this field were reported. 16. Use of clinical databasesfor research It is clearly desirable to be able to use clinical data for research and to harvest clinical databases for knowledge. Some of the barriers that must be overcome are incompleteness of the clinical databases,inadequate interfaces, legal restrictions, and the lack of integrity and quality of the data. The use of clinical data for real-time queries and as input to clinical algorithms, is likely to require that the data be consolidated into one physical and local databank because of performance problems. In any case, a common data dictionary and a global directory showing the location of data are necessary. To avoid interference with the routine transactional load, one may either restrict the processing of search requests to periods of low activity or have an additional copy of the database on a computer dedicated to queries. Downloads of clinical data to PCs for further analysis is also an acceptable approach with appropriate privacy protection. The user interface for queries must be simple and obvious, and even then, education of the users is important to harvest the potential benefits of the facility. 17. HIS and developing countries Contrary to the conclusions of earlier conferences, the participants felt that no special HIS model was necessary for developing countries. Developing countries should be involved in the model development mentioned earlier and in this way avoid widening the gap. Implementation of systems in those countries might follow different pathways. In support of developing countries, the following recommendations were made. IMIA should:
share its experiences, both successesand failures; maintain a list of experts who are prepared to give personal support, either by receiving visitors/students or by visiting such countries themselves; implement an active policy to stimulate the participation of developing countries in its working conferences. 18. New technologies The participants felt that new data input technologies, such as speech recognition, would not become a major input method over the next few years, except perhaps in some niche applications. Natural language records with free text analysis to understand meaning and content, was not considered to be of practical value before the end of the century. Severe doubt about the value of this approach was expressed. The widespread use of PACS for image transfer was expected by the end of the century, at least for certain categories of images. 19. Future working conferences The participants felt that working conferences, like the Durham conference, are extremely useful to discuss freely the developments in health information systems. They strongly recommended organizing such conferences every 3 years, in non-MEDINFO years. The present formula was considered very close to optimal and should be maintained. This formula includes: l a programme committee which selects subjects and invites speakers; l pre-prints in advance of the meeting: 0 short plenary presentations; 0 emphasis on discussions in small groups (guided by questions from the programme committee); l publication of results in a refereed journal. In addition to broad working group conferences, IMIA WGlO might consider annual working conferences with a specific focus.
International Journal of Bio-Medical Computing 39 (1995) I 1~ I5
Summary report of observations, conclusions and recommendations Ab Bakker, Ed Hammond, Marion Ball IMIA
Working
Group
10 Hospital
Information
Systems
Working
1. Scope of HIS
Whereas the preceding IMIA working conferences considered the scope of the Hospital Information Systems (HIS) to be restricted to the information systems within the borders of the institution, this conference was of the opinion that functions outside the hospital also need to be included in the definition, i.e. HIS broadens its definition to mean Health Information System. The relationships between the HIS and the Computer-based Patient Record (CPR) were discussed intensively. 2. HIS and CPR
The CPR system (CPRS) must be designed with the patient as the center piece. In fact, the concept of a person-centered system was suggested to reflect the fact that a person should not have to see a health care provider in order to be in a system, but should need only to reside in a regionally defined area covered by the CPRS. The CPRS must. however, have characteristics of being usercentered for a wide variety of users. The CPR itself is a repository of all data relating to a person ~- both health or wellness data as well as data relating to an illness. The CPR contains data for the lifetime of the person. The CPR, as a conceptual document, includes data relating to a patient regardless of the place or person who is the source of that data. Whether that data is
Group
Conference,
Durham.
North
Caroliru.
-17 J(J Auqusr
1994
collected into a single physical database or is a virtual common database created by a linkage of several databases, was not a dominant consideration, although most participants felt the latter was a more realistic approach. The content of the CPR must be defined, perhaps in the form of a global data model. Levels of implementation, including the definition of a core data set, should be established. What is to be collected at each encounter of various types, both in-patient and outpatient, needs to be defined. The relationship between the HIS and the CPRS was discussed with the following outcome. In some respects the CPRS was a subset of the HIS (the HIS also containing local data), while in other respects, the CPRS encompassed the HIS (data from several institutions). The distributed nature of the CPR and the interoperability of systems, raised many issues which must be addressed. Standards must be in place far the definition of terms (semantics) used in the (:PR and for the interchange of data. A common data model for what is contained within the CPR must be defined and accepted. Issues of confidentiality, security and privacy must be addressed. Access rights must be defined and procedures for enforcing these rights must be deployed. A unique person identifier must be established and maintained. Other questions raised but not answered include: who controls the various parts of the C’PR and how is the consistency of the data originating in other institutions to be verified?
0020-7101/95~$09.50\G 1995 Elsevier Science Ireland Ltd. All rights reserved SSDI 0020-7101(94)01072-Z
12
A. Bakker et al. / ht. J. Biomed. Comput. 39 (1995) I l-15
3. Costs of CPR and HIS The participants felt that it is very difficult to define the cost of a CPRS, or for that matter, of an HIS. The general belief was that the realization and operational use of the CPRS would increase information handling costs, but these costs would be significantly offset by both direct and indirect gains. Current information handling costs for health care facilities were estimated to be between 1.5 and 3% of the total operational costs. This percentage will increase significantly becauseof the CPRS. Few studies have documented the benefits of an information system. However, those benefits need to be substantiated if an increase in expenditure for information systems is to be expected. With the shift to a regional CPRS and the linkage among all health care facilities and organizations, substantial organizational changes must take place. These changes will require an enhanced understanding of the informational system by administrators and clinical personnel alike. 4. Open systems The term ‘open’ is used in various ways which often leads to confusion. The technical facilities required to be able to send a messagefrom one computer to another (interconnectivity) will be made available by the information technology industry. No special action is needed in this respect from the medical informatics side. We should concentrate on the interoperability of systems. Such interoperability can be realized in different gradations, depending on the application choices to be made. Essential ingredients of a policy for openness were identified as: standardization of the exchange messagesyntax; and externalization of the data dictionary of each of the systems as far as communicable data are concerned. To pave the way towards interoperability of modules from different suppliers, it was recommended that the three aspects, namely, database, user interface and logic, be kept separate in the application software. Transportability does not necessarily require the same operating system but does require the same interfaces (e.g. POSIX),
which may be available for non-transportable operating systems as well. 5. The chief information architect The increasing importance of informational systems for health care establishments, led the participants to recommend the creation of the position of Chief Information Architect (CIA) who reports to the Chief Executive Officer (CEO) at the same level as the Chief Financial Officer (CFO) and the Chief Operating Officer (COO). 6. Integration of functions for health care professionals The integrative aspects of the HIS were emphasized. The clinical information system must accommodate the full family of users and suppliers of data including physicians, nurses, technicians, administrators, medical record personnel, and all other personnel involved in the patients’ care. Not only should the users and suppliers of data share some data elements, they should support analysis of the care process that lead to a re-engineering which takes advantage of the opportunities of IT. The point was made, however, that IT investments must be cost-effective in changing health care processes, building human networks, and re-engineering. Access to data should be clearly defined based on the need to know. Displays of data need to be organized depending on the needs of the category of the individual and the circumstances of the encounter. Education of the various users in this integrated approach must be anticipated. 7. Linkages between institutions New linkages must be established among institutions to support the interchange of data. Organizational changes and the development of an information infrastructure must be put in place to permit these linkages to occur. Information networks must be physically established to permit the ubiquitous accessto and collection of health care data. Data dictionaries supporting the CPR and the HIS should be made ‘public’. The group felt
A. Bakker et al. / ht. J. Bionzed. Compu/. 39 /1995) 11 15
that telemedicine, as a project unto itself, was overemphasized. On the other hand, the participants felt that the transmission of data including image, waveforms, sound and text among health care facilities was desirable. 8. Smart cards
Little enthusiasm was shown for the smart card as a form of the CPR. The primary reason was the fact that the smart card could not be kept up to date without an extensive networked system. The existence of such a system precluded the need for the smart card. The one use that was supported was that of patient identity and inclusion of data that did not change or changed slowly over time. Examples include blood type, allergies, date of birth and immunizations. 9. High capacity networks
As long as the CPR is restricted to alpha-numeric data, medium/low speed networks will be sufficient. In the long-run, high speed communication will be necessary to support the transmission of images. Who pays for these systems and who makes their creation happen was discussed. Is it the private sector or is it the government? Is it the same in all countries? How is it financed - by a general tax or by a use tax? What will the required capacity of such networks be and what is the time schedule for that requirement? Obviously, systems must accommodate a variety of communications scenarios which will change over time. 10. Assessment of costs and benefits
We noted that IMIA Working Group 15, under the leadership of Seymour Perry, was established recently to deal with the subject of assessmentof benefits and costs of health care information systems. WGlO should be aware of the activities and recommendations of this working group. I 1. Coordination
of developments
Guidelines and pathways should be developed and promulgated to stimulate both national and international initiatives in new areas of technol-
13
ogy. The coordination of developments in areas such as the CPR, clinical workstations. adoption of careplans, and new technology, can best be accomplished by: l international standards which are the same or compatible; o mutual exchange of drafts and concepts; l common repositories of relevant documents addressing these topics, with IMIA taking the lead in setting up such a repository. 12. Standards
The development of a comprehensive and complete set of standards to support the HIS was identified as one of the top priorities for the next few years. The group was pleased to note an increased interest and productivity in standards development in both Europe and the USA, as well as increased cooperation in the international development of standards. We need to develop a strategic plan which identifies: 0 WHAT standards are necessary; 0 WHO should take the lead in developing standards; 0 HOW standards will be developed; 0 WHEN standards will be developed and available for use. The standards effort requires additional funding, particularly in the USA, if the standards are to be realized in an appropriate time frame. Relying on volunteers who have to fund their own efforts is not productive. Care should be taken to get both vendors and users appropriately involved in these efforts. Governments should be supportive not competitive. The participants identified several barriers to the development of healthcare standards: l lack of funding; 0 lack of qualified people; 0 poorly defined objectives; 0 limited recognition and awards for people developing standards; l poorly defined processes; l lack of a strategic plan. Standards for data interchange have made the most progress and are usable although not complete. Standards for vocabulary (semantics stan-
14
A. Bakker et al. / ht. J. Biomed. Comput. 39 (1995) 11-15
dards or data dictionaries) are non-existent and demand high priority. Suppliers and vendors can be encouraged to adopt and comply with standards by: 0 making the standards usable; 0 clearly describing the purpose of the standard; l educating both suppliers and users; 0 documenting the realizable benefit of the standard; 0 establishing demonstration projects for standards; 0 user pressure appropriately applied; 0 bulletin boards describing experiences with specific vendors and the use of standards; 0 certification.
tem for healthcare should include the person’s home, as well as all the health care delivery facilities and supporting structures. It was felt that the new enterprise systemscould evolve from the present institutional systems, In view of the effort and lead-time required, it was considered unrealistic to start from scratch. An important step in the evolution will be the global sharing of data dictionaries from the various institutions. Another required component is the standardization and structuring of the CPR. Responsibilities and authorization for the use of data is required, to avoid this area becoming a stumbling block. 15. Security
13. HIS reference model The discussions of the preceding working conferences on a reference model for the HIS were extended and led to the proposal that IMIA develop a multi-dimensional model describing: l a preferred technical structure; 0 a functional structure; l a functional decomposition, describing the functions and interfaces for the main modules; l requirements for modules. Participants were asked, as a first step, to provide input for this reference model immediately after the conference and to identify additional sources of input (waterfall model). An analysis of the material received should make clear whether such an approach is feasible. 14. Care plans Broad use of care plans or protocols is anticipated soon. Forces for the development of these care plans are in place. Attention must be paid to developing applications which can incorporate these plans into the process of care. Sharing of care plans/protocols via Internet should be stimulated. The evolution from the HIS to an enterprise system was widely supported, although the term enterprise system itself was misleading and vaguely defined. Suggestions were made to find a better word to describe the new concepts. The point was made strongly that the enterprise sys-
The participants felt that the awareness of security issues by health care providers was improving. By giving patients the right to be informed about who had accessto their record, health care providers may use more effort in preserving the privacy and confidentiality of patient data. Audits of randomly chosen patients’ records pertinent to data accessissues, can further encourage compliance. Protection against intrusion through Internet connections was considered an important issue, and system developers have a responsibility for providing protection against such intrusion. Firewall protection and the use of a security server, such as KERBEROS, were mentioned. Encryption as a protection of confidentiality is strongly suggested for traffic crossing the borders of the institution. Electronic signatures can be expected to become the usual technique for guaranteeing the integrity of the message and the identity of the originator. The key management issue was not discussed in detail but reference was made to the Trusted Health Information System (THIS) within the INFOSEC program of the European Union (EU). This project will make recommendations before the end of 1994. Because IMIA has a dedicated working group (WG4) for security issues, WGlO participants felt the general area of security should be left to that group. WG4 held a recent working conference at
Heemskerk, The Netherlands (IJBMC, February 1994). Certification of software appears to be a desirable goal. A distinction was made between process certification (IS0 9000) and product validation. No government activities in this field were reported. 16. Use of clinical databasesfor research It is clearly desirable to be able to use clinical data for research and to harvest clinical databases for knowledge. Some of the barriers that must be overcome are incompleteness of the clinical databases,inadequate interfaces, legal restrictions, and the lack of integrity and quality of the data. The use of clinical data for real-time queries and as input to clinical algorithms, is likely to require that the data be consolidated into one physical and local databank because of performance problems. In any case, a common data dictionary and a global directory showing the location of data are necessary. To avoid interference with the routine transactional load, one may either restrict the processing of search requests to periods of low activity or have an additional copy of the database on a computer dedicated to queries. Downloads of clinical data to PCs for further analysis is also an acceptable approach with appropriate privacy protection. The user interface for queries must be simple and obvious, and even then, education of the users is important to harvest the potential benefits of the facility. 17. HIS and developing countries Contrary to the conclusions of earlier conferences, the participants felt that no special HIS model was necessary for developing countries. Developing countries should be involved in the model development mentioned earlier and in this way avoid widening the gap. Implementation of systems in those countries might follow different pathways. In support of developing countries, the following recommendations were made. IMIA should:
share its experiences, both successesand failures; maintain a list of experts who are prepared to give personal support, either by receiving visitors/students or by visiting such countries themselves; implement an active policy to stimulate the participation of developing countries in its working conferences. 18. New technologies The participants felt that new data input technologies, such as speech recognition, would not become a major input method over the next few years, except perhaps in some niche applications. Natural language records with free text analysis to understand meaning and content, was not considered to be of practical value before the end of the century. Severe doubt about the value of this approach was expressed. The widespread use of PACS for image transfer was expected by the end of the century, at least for certain categories of images. 19. Future working conferences The participants felt that working conferences, like the Durham conference, are extremely useful to discuss freely the developments in health information systems. They strongly recommended organizing such conferences every 3 years, in non-MEDINFO years. The present formula was considered very close to optimal and should be maintained. This formula includes: l a programme committee which selects subjects and invites speakers; l pre-prints in advance of the meeting: 0 short plenary presentations; 0 emphasis on discussions in small groups (guided by questions from the programme committee); l publication of results in a refereed journal. In addition to broad working group conferences, IMIA WGlO might consider annual working conferences with a specific focus.