The Danish EHR Observatory has monitored Danish EHR projects for several years with respect to a number of parameters such as diffusion, diffusion rate, barriers and limitations, and experience gained. The results of the 2002 monitoring reveal that investment in IT is relatively low and the diffusion rate is below the estimated level. The EHR projects gain a lot of valuable experience, but the coordination of evaluation results should be improved.

The Danish Health IT strategy [Danish Ministry of Interior and Health, National Strategy for IT in the Health Sector 2003-2007, Copenhagen, 2003 (in Danish). http://www.im.dk/publikationer/itstrategi/itstrategi.pdf. notes that integration between electronic health records (EHR) systems has a high priority. A prerequisite for real integration and semantic interoperability is agreement of the data content and the information models. The National Board of Health is working on a common model for EHR, and its adoption is now being promoted through pilot projects. At the same time, several development and implementation projects are taking place at a regional level. These EHRs are built on information models from different vendors and are based on different integration platforms. The Danish EHR observatory, which has been monitoring the development of EHRs in Denmark since 1998, has analysed the challenges of using different information models and integration platforms. This paper also maps the development in Denmark to the new paradigms in modelling techniques and integration technology.

The EPR-Observatory - a public funded project organization - has monitored Danish EPR-projects with respect to various parameters such as diffusion and diffusion rate, barriers and limitations, experience gained. Furthermore, the Observatory has aggregated and disseminated the results and has established a constructive dialogue between the Danish EPR projects. The Observatory has also focused in the later years on analysis of common frames of reference for EPR systems. The National Board of Health and some of the larger counties have developed such frames. First generation systems have been implemented in a few counties with moderate coverage, but a number of projects developing second generation systems are making progress, and the market situation is quickly maturing. There are still, however, major problems in the practical implementation of the systems.

In 1996 a national strategy for the development of electronic patient records (EPR) for the Danish hospitals and primary care was launched. An element in the strategy was to support a number of regional EPR development projects. The EPR-Observatory has in the two recent years collected data from the regional projects, dealing with the expectations in four areas: 1) Impact on organisational issues, 2) Benefits of EPR, 3) Integration of EPR with other information systems and 4) security aspects of EPR. Among the observations an increasing teamwork and im-proved knowledge about the patient was found. What was expected, but not found, was resistance to EPR, as a result of changes in skills and power. The most obvious benefits are increased data accessibility and improved decision ma-king. The most considerable disadvantage is an enormous growth in discontent with the systems performance and the fact, that all the projects are delayed. Many different types of integration solutions are chosen, because of a lack of a common model for integration. Generally the projects find, that EPJ yields increased security, but logistical problems arise in having the systems running 24 hours 7 days a week. Economical benefits cannot be documented. This relates to the fact, that the regional projects are stand-alone projects. The ongoing growth in discontent with the EPR-systems and the fact, that all the projects are delayed must be subject to further exploration.

Health informatics is a true interdisciplinary research discipline combining computer engineering, health science and fields dealing with organisation and communication issues. Much of the research published within the area has a common goal: to develop optimal information systems for better access to relevant data, information, and knowledge in the health care sector. As a respond to existing discontinuity between research and practical use, we present an architecture for an interdisciplinary virtual organisation promoting synergy across health informatics environments including research, industry, clinical, and educational settings. A set of key lessons learned from a practical implementation of the architecture are reported.

The quality of the EMG examination might be improved by standardization. However, knowledge about interlaboratory differences in the performance of the EMG examination is a prerequisite for standardization. The aim of this study was to describe differences in EMG techniques used and number of muscles and nerves examined per patient at 6 European EMG laboratories. The EMG results of 595 patients were prospectively sampled. The average number of muscles examined per patient in different disorders varied from laboratory to laboratory, for example from 3.0 to 10.8 muscles in anterior horn cell disorders and from 2.0 to 5.5 muscles in myopathies. The average number of muscles examined by quantitative EMG varied from 0 to 4.3 in anterior horn cell disorders and from 0.0 to 4.5 in myopathies. Also the average number of nerve segments examined per patient varied from laboratory to laboratory for example from 2.7 to 17.7 for motor segments and from 3.1 to 9.0 for sensory segments in polyneuropathies. The laboratories that used needle electrodes for nerve conduction studies and quantitative analysis of individual motor unit potentials examined a smaller number of muscles and nerves than laboratories using surface electrodes for nerve conduction studies and qualitative EMG studies. The results of this study may have impact on guidelines and examination protocols as well as on quality assurance.

The first step for quality development is identification of the quality problem. This should be followed by a set up of criteria and standards and relevant data should be collected to perform quality assessment. The quality-level is evaluated and in cases with non-satisfying results, the problem(s) should be identified and the process repeated [1]. Identification of the best results for continuous quality improvement and professional self-assessment is part of the process [1]. Decentralization of the whole quality development process is an aim. The Ministry of Health is politically responsible for the process and the National Board of Health is responsible for the implementation of the process at the national level. To support continuous quality development, three bills were passed in the government in 1992: 1) Free choice of hospital for the patients; 2) Appropriate local and regional distribution of specialized functions, to ensure optimal treatment of rare and complicated diseases; 3) Coordinated planning and organization of the health services. The strategy for quality development illustrated by four cases. Four projects were identified to illustrate steps in the national strategy for quality development. PROBLEM IDENTIFICATION. ESTEEM [2,3]: Using knowledge-based systems for interpretation of EMG (electromyography) in different laboratories disclosed great variations in clinical usability. The variations could be explained by different examination techniques, test planning protocols, and diagnostic criteria. It was concluded that the use of a EMG-knowledge based system disclosed great problems for standardization of procedures dependent on EMG measurements. QUALITY ASSESSMENT. Hip fracture quality project [unpublished data]: The assumption for the study was that early and active rehabilitation after hip fracture would promote the ability of the patients to cope with activities of daily living (ADL) and prevent development of complications. About 85% of the patients were expected to be able to go home on the 12th day, but this was the case for only 56% of the patients. It was concluded that the pre-set standard was not achieved and that the post-operative care was carried out in an ineffective way. QUALITY IMPROVEMENT. Laboratory quality project [4]: Quality control assessment procedures have been implemented for years in hospital laboratories. The aim of the study was to evaluate the size of analytical bias between two local hospital laboratories using the same reference intervals. The results showed that only a few of the routine analyses meet the goals for acceptance of general reference intervals in a geographical area. The problems were reflected in the quality assessment results but, nevertheless, no action seems to have been taken to minimize the bias. It is concluded that interpretation of quality control data is a great problem. QUALITY MONITORING AND EVALUATION. National databases for health care quality [5]: Principles for development, implementation, and use of national databases has been worked out by The National Board of Health. Clinical departments will get a tool to monitor and improve the daily working routines. National databases for clinical monitoring exist for vascular surgery, laparoscopic surgery, treatment of breast cancer, and surgery for hip fractures.

From the prospective multi-center evaluation study of the decision support system KANDID, significant variations were revealed in local epidemiology, local examination techniques, local preferred examination protocols, and local diagnostic criteria among seven European EMG laboratories. A clinical network of eight Electromyographic (EMG) centers has, due to this study, harmonized terminology and the interpretation of EMG examinations. The ESTEEM project has, based on these specifications, developed the EMG-Platform for the local data acquisition, storage, interpretation, and telecommunication between the clinical ESTEEM centers. On this basis, a medical audit and consensus process across Europe is being carried out on a daily basis. This process has shown an impact on diagnostic criteria within the clinical group. This study has illustrates informatics as a necessary prerequisite for the quality assurance of clinical EMG practice.

This study was undertaken with the aim of evaluating inter- and intraobserver variation on the pathophysiological interpretation of individual electromyographic (EMG) tests on muscles and nerve segments. Seven physicians from 6 European EMG laboratories independently interpreted 81 EMG studies comprising 735 muscle tests and 726 tests on nerve segments. Pathophysiological conclusions were inferred from findings of these tests without considering clinical information. For most combinations of findings, both the inter- and intraobserver variations on the interpretation were low, suggesting that common criteria for pathophysiological interpretations were used and that these were used consistently. For some combinations of findings, however, there was disagreement on whether these indicated specific or unspecific pathophysiological changes. In particular disagreement on whether findings indicated demyelination may be of clinical significance. A large part of the intraobserver variation may be explained by a change towards more cautious interpretations during the study for most of the physicians. It is concluded that there is a need to seek for consensus on the pathophysiological interpretation of individual findings and for incentives to ensure consistency in interpretations. The fact that experienced physicians changed their ways to interpret findings during the study suggests that agreement may be improved globally.

This paper describes the current status of the utilisation of clinical practice guidelines (protocols) in the ESTEEM project as one form of the clinical quality assurance procedures considered in the project. The performance of electrodiagnostic studies, in terms of which types of conclusions need to be inferred during the examination plan, is briefly described. The main focus of the paper is a description of an European multicentre clinical audit in the field of Clinical Neurophysiology, using a common data-entry protocol for prospective EMG case collection and assessment with the ultimate objective of building up a multicentre reference database of EMG cases.

This study was undertaken to analyse epidemiological and methodological differences in referral pattern, examination techniques and distribution of diagnoses among different European EMG laboratories. Seven European EMG laboratories filled in questionnaires and sampled 700 cases retrospectively. The use of needle or surface electrodes for nerve studies and the selection of quantitative techniques for muscle studies exhibited considerable variation. The pattern of referral varied with respect to the type of referral source and the neurological expertise of the referring physician. The proportion of patients without any neurophysiological abnormality ranged from 16 to 33%. The 3 most common diagnostic groups were mononeuropathies, polyneuropathies and radiculopathies although a great inter-laboratory variation was found. The proportion of patients with multiple diagnoses varied from 0 to 23% and most of these diagnoses were from a few known combinations. The presence of an inter-laboratory variation suggests that the quality of the EMG examination may be improved by focussing on the use of techniques, strategies and diagnostic criteria.

ESTEEM is an AIM project which is primarily concerned with how to develop, integrate and clinically test knowledge-based systems for electromyography (EMG) in order to get them generally acceptable, useful and applicable into disseminated clinical routines. A medical workstation entitled the 'EMG-Platform' on which different kinds of application modules including KBSs can be interfaced to a kernel is being developed. Accordingly, an EMG communication protocol is being developed. The ESTEEM consortium is composed of a technical specialist group and a group of clinical experts in EMG from seven European countries. The last group has, besides extensive data collection for building up a multicentre EMG database, agreed on a common EMG terminology and a subsequent general EMG data set specification which covers the informatic needs for describing an EMG examination of different 'EMG schools'.

KANDID is an advanced EMG decision support system dedicated to the support of the clinical neurophysiologist during EMG examinations. It has facilities for test planning, automatized and structured data interpretation, EMG diagnosis, explanation, and reporting. In a prospective European multicenter field trial, the agreement levels between clinical neurophysiologists and KANDID's diagnostic statements were measured under ordinary clinical EMG practice. KANDID was assessed in 159 individual patient EMG examinations by nine clinical neurophysiologists at seven different EMG laboratories. The reasoning of KANDID was considered understandable for the examiners in 80-90% of cases. The agreement level for the electrophysiological states of muscles and nerves between KANDID and the individual examiners was, on average, 81%. The corresponding diagnostic agreement with KANDID was, on average, 61%. A pronounced interexaminer variation in the agreement level related to the different EMG centers was observed. All Danish and Belgian examiners agreed with KANDID in more than 50% of their cases with regard to the EMG diagnosis, while the English examiners were in agreement with KANDID in 50% or less of their cases. These differences were possibly due to differences in epidemiology, examination techniques, control material, and examination planning strategies. It is concluded that it is possible to transfer systems like KANDID out of their development sites and apply them successfully if they can be locally customized by the clinical end users via editors.

This study analyses the spatial distribution of individual motor unit potentials (MUPs) over the skin surface and the influence of motor unit depth and recording configuration on this distribution. Multichannel surface (13 × 5 electrode grid) and intramuscular (wire electrodes inserted with needles of lengths 15 and 25 mm) electromyographic (EMG) signals were concurrently recorded with monopolar derivations from the biceps brachii muscle of 10 healthy subjects during 60-s isometric contractions at 20% of the maximum torque. Multichannel monopolar MUPs of the target motor unit were obtained by spike-triggered averaging of the surface EMG. Amplitude and frequency characteristics of monopolar and bipolar MUPs were calculated for locations along the fibers’ direction (longitudinal), and along the direction perpendicular (transverse) to the fibers. In the longitudinal direction, monopolar and bipolar MUPs exhibited marked amplitude changes that extended for 16–32 mm and 16–24 mm over the innervation and tendon zones, respectively. The variation of monopolar and bipolar MUP characteristics was not symmetrical about the innervation zone. Motor unit depth had a considerable influence on the relative longitudinal variation of amplitude for monopolar MUPs, but not for bipolar MUPs. The transverse extension of bipolar MUPs ranged between 24 and 32 mm, whereas that of monopolar MUPs ranged between 72 and 96 mm. The mean power spectral frequency of surface MUPs was highly dependent on the transverse electrode location but not on depth. This study provides a basis for the interpretation of the contribution of individual motor units to the interference surface EMG signal.