Masic I Historical Background of Medical Informatics Development

PREFACE

The history of Medical/Health/Biomedical informatics had begun between fifties and sixties of the last century. In the wake of the Second World War when a few doctors and researchers were exploring the role of the computers and when they tried to involve their possibilities for improving diagnostic and treatment of health condition of patients and helping to better diagnose of diseases. They used logic and probabilistic reasoning to tackle specific healthcare problems in biology, physiology and a few disciplines in medicine.

Initial step was Lee Lusted's and Robert Ledley's article published in 1959 in the respected journal "Science" in which authors described their idea of using data analysis in medical research and diagnosis. Robert S. Ledley and Lee B. Lusted published "Reasoning Foundations of Medical Diagnosis," a widely read that article which introduced computing, especially operations research techniques to medical professionals. Ledley's and Lusted's article has remained influential for decades, especially within the field of Medical Decision-Making. Guided by Ledley's late 1950s survey of computer use in biology and medicine the National Institute of Health in Bethesda, USA (NIH) undertook the first major effort to introduce computers to biology and medicine. Drs. Lee Lusted and Robert Ledley promoted formalizing statistical approaches for modeling medical decision-making as a way of reducing errors, among other benefits. In that time computers were not yet advanced enough to provide individual care providers and hospital systems with the tools to conduct these analyses.

Medical informatics as a academic and scientific discipline is relatively young if we compared it to other biomedical disciplines. Development of Medical informatics was in direct correlation with the advent and widespread in use of digital computers and the development of information and communication technologies (ICTs) based just on these computers. In previous decades the medicine and health care services have changed significantly thanks to developments of biomedical informatics and its 6 Preface application in medical education and health care protection, especially in medical diagnostics.

In the period after Second World War USA was the leading country in the field of Computer science and the leader in using the first computers in medicine and healthcare services. During the last two decades of 20th century was particularly important for development of Medical informatics, with great influence of Internet by medical professionals at every level of health care system.

Today, we can hardly imagine diagnostic procedures, such as, for example, Magnetic Resonance Imaging (MRI), Computerized Tomography (CT), Positron Emission Tomography (PET scan), etc. MRI is a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in your body. CT of the body uses sophisticated X-ray technology to help detect a variety of diseases and conditions. CT scanning is fast, painless, noninvasive and accurate. In emergency cases, it can reveal internal injuries and bleeding quickly enough to help save lives. A PET-scan is an imaging test that can help reveal the metabolic or biochemical function of your tissues and organs. The PET scan uses a radioactive drug (tracer) to show both normal and abnormal metabolic activity.

Most of these sofisticated mashines contain excellent software for access to medical knowledge without access to numerous databases, or electronic storage of data relating to patients, without information technology in medicine.

At the very beginning of its development, Medical informatics is considered as discipline that could be helpful but not necessary discipline. However, today it is one of the bases in medicine and health care in general. That is why, a lot is expected of Medical informatics, in terms of providing support to health care services in all parts of the world as well as in contributing to its quality and efficiency, and innovation in biomedicine and research in biomedical sciences. The process of its growth continues so that today's work is tomorrow's history. A 'historical' discussion of the area is its history to date, a report rather than a summation.

When talking about the development of Medical informatics, the important place have an international non-profit organization IMIA (International Medical Informatics Association) and its branch associations, especially European Federation for Medical Informatics (EFMI) that their work covers all continents, comprises more than 70 academic institutions and more than 50,000 individuals. In promotion and spreading out of knowledge and experiences of the Medical informatics as scientific and academic discipline both of them have great impact in spreading medico-tecnological knowledge worldwide.

Preface

Its role in this rapid development of Medical informatics presented by its objectives: promotion of ICTs in health care, public health and biomedical research; stimulating research, development and everyday promotion of education and responsible be-havior¸ moving ICT from theory to practice in all areas of health care and stimulation of progress, implementation of new technologies and research.

Everything mentioned above couldn't be realized without contributions of the great scientists and their discoveries and achievements. Thanks to them today we can speak about great improvement of health care protection on every level of the health care systems in almost every country in the world.

Comprehensive and essential contents on Medical informatics, but also the aspects nurtured by the main "schools of Medical informatics" -Anglo-Saxon's (Abbot, Anderson, Barber, etc.), French (Gremy, Remond, etc.), German (Reichhertz, Wagner). et al.), American (Collen, Warner, Greens, Hammond, Ball, Shortliffe, et al.), Middle and East Europe (Dezelic, Masic, Zvarova, Naszlady, Mihalas, etc.), whose terms "Health Informatics" (Abbot) and "Medical Informatics" (Gremy and Reichertz) have entered the European and world medical literature. For those studying the subject or working in the field, the experiences of others who use Information and Communication Technologies (ICTs) for the better of health care can provide a necessary perspective. Finally, Editor of this book shortly described important facts about history of development of Biomedical informatics in the world including South-Eastern Europe countries, pointed facts about biomedical experts contributions during long period of his participation in IMIA General Assembly and EFMI Council.

As well as its successes, the history of Health/Medical/Biomedical Informatics is populated with visionary promises that have failed to materialize despite the best intentions. Some of the chapters in this book already were published in the book "Contri-butions to the History of Medical Informatics" in the First Edition edited and printed in 2014 by Izet Masic and George Mihalas, after organized the Special Topic Conference about History of Medical Informatics, held in Prague in 2013, organized by Professor Jana Zvarova and chaired by George Mihalas, Casimir Kulikowski, and full papers presented at this Conference were published in the journal Acta Informatica Medica and, also, involved in this book.

Development of Medical informatics in other parts of Europe and in the world, including description of contributions of most influential academics, scientists and experts within this field of medicine, author described with 30 co-authors from all parts of the world, in the mentioned book and, also, in other two monographs -"Honorary Fellows of EFMI" and "Honorary Fellows of IMIA" (published in 2017 and 2018). Also, some other authors, most influental medical informatics academics and experts described some important historical facts about development of the Medical informatics in the past.

Editor of this book in his Chapter "The Most Influential Scientists in the Development of Medical Informatics" described Curriculum Vitae and biosketch formats of a few most influential biomedical experts in the scientific and academic field of biomedicine with their important contributions in the biomedical informatics. In this chapter we tryed to describe a short facts about some of the most influential medical informaticians during the history of development of this scientific discipline. The number of 31 published CVs in the biomedical journal "Acta Informatica Medica" (the journal founded by Izet Masic in 1993) were printed in the issues, published from 2014 until 2021 and deposited in PubMed, PubMed Central, Scopus and other databases.

Also, some of the chapters in this book were published as articles in Acta Informatica Medica journal and in the International Journal on Biomedicine and Healthcare, issues printed during 2018-2020 (the journal is founded by Jana Zvarova in 2013, and she was Editor-in-Chief during period 2013-2017, and Izet Masic, who is Editor-in-Chief from 2018 to present). Mentioned published articles are re-published with permission of the authors of the chapters in the book and Publisher "Avicena", Sarajevo and Academy of Medical Sciences of Bosnia and Herzegovina (both journals are official journals of the Academy -AMNuBiH). Acta Informatica Medica journal is, also, official journal of the European Federation for Medical Informatics (EFMI).

Sarajevo, May 2022

10 Influence of Computer Sciences on THE Development of Medical Informatics operation. Malfunctioning was also frequent. The machines required special rooms, and the speed of work was very slow compared to machines we have today. For example, one addition lasted about 0.6 milliseconds, and multiplication took about 15 milliseconds. The price of these machines was relatively high, there were great costs for the qualified personnel and experts, programmers were deficient, which lead that these machines being reserved for bigger and more complex tasks of manipulating with huge amount of data for both scientific and engineering purposes (1).

John von Neumann proposed that operational instructions should be included inside the computer memory, beside the data memory, which lead to the production of EDVAC ("Electronic Discrete Variable Automatic Computer") in 1946, and also the production of UNIVAC ("Universal Automatic Computer") in 1952 as the first computer for the commercial use with UNIVAC II, IBM 704, IBM 705, etc. This was a period of fantastic development of the computers. We emphasize that von Neuman was the first who precisely described all the elements and functions of the computer system, and this project is considered cornerstone for the series of computer systems of different performances in the future generations of computers (1). The first computers of the second generation were built in 1957, and the majority in the period from 1959 till 1964. Their characteristic is that instead of the electronic tubes they used the transistors and semi conductor diodes. The appearances of transistors in the electronics provoked the revolution in the building of widely available computers. This significantly reduced the requests for size, space, costs of electricity and efficiency. The speed of these computers is significantly greater and multiplication took about 20 microseconds. It is specific that the computers of the second generation used a small magnetic core for construction of the primary memory. This was the time of general use of computers, and there were more of those interested in training to become professional programmers. The people who worked on these machines inspired the awe in general public. In this period several programming languages were introduced, such as ALGOL and COBOL. Some of the computers from this generation are RCA 501, IBM 7070, 7090, HONEYWELL 800, IBM 1400, IBM 1600, CDC 160, NCR 500 and others (1).

The computers of the third generation (1964) operated on the principles of monolithic technique and the integrated circuits. The period of the building of these computers lasts to 1971. The new technique led to the further microminiaturization, so that on the tile of small dimensions there was great number of various elements (transistors and diodes). For example, on the tile sized 1-2cm there was around 30 different electronic elements. The velocity of work of these computers is great and they could calculate around 10 million additions in a minute. The computers of this generation use numerous languages for programming and multiprogramming. The basic character-istic is that they could simultaneously perform more jobs at once, using the "divided time" technique for working.

The deficiency of the previous computers is that there is time when the central processors unit ("Control Processing Unit -CPU") is inactive and waiting for some input or output device to finsg its task. This was converted so that the CPU serves more jobs at once. Namely, the CPU, which is the "brain and heart" of every computer, is now divided between concurrent programs serving them, and simultaneously follow-up and manage the work of the more output/input (I/O) units. Difference from the previous generation, where the job had to be transferred on punched paper tape or on punched cards which were previously prepared far from the computer, while the user waited for the results for several hours or days, is also that this generation of computers was more available. They had strength and the capacity to perform the complex tasks, to perform the extensive tasks and made sense of operational systems which enabled much easier performing of the schedule of work. The resources within system could divide without mutual interrupting, and the users had the "direct approach" to the computer through monitor with the option of communicating with the computer from distant locations. This favored the production of various input-output units, different screens and memory devices (disks) on which millions of data was easily available to the user. Some of the computers from this generation are IBM 360, RCA SIE-MENS 4004, UNIVAC 9000, CDC 6600, HONEYWELL 200 and others.

The computers of the fourth generation were built in 1971 on the principle of so called "Large Scale Integration" (LSI). The basis of this technique are tiles sized 3x3 millimeters and similar, with 100-200 different electronic elements placed on 1mm. This allowed even greater miniaturization, are created devices of great possibilities, with the costs being reduced. The computers of this generation operated in nanoseconds with approximately 10-15 millions operations in a second. These computers have a large capacity of central memory, from one to several gigabytes. Regardless of the significant capacity of the large computers, they still could not answer to the increased requests of users. Therefore, the development of the minicomputer systems with hardware and software ("operational systems") was pushed with significant reduction of costs, from the ground change of the conceptions of the development and applications of the informational systems in the sense of their decentralization. The decentralization, which is the distribution into the network terminals and of PC significantly, elevates the management of the computer equipment and transfers the management of organizations to the lower level. The computers from these generations have simplified internal structure, the length of "words" is shorter and it uses simplified logics in "addressing the data" placed in computers memory (1).

The notion of the length of the word reflects the potential possibilities of a computer. The majority of large computers used 32 elements for representing one word ("32-bits computers"), some even 48 bits and longer words. Large computers also have complex operation systems (in fact "the computer programs") that classify and manage different tasks. Mini computers of this generation are constructed for "16-bits words" and could not operate with great numbers in the frame of an instruction cycle (theoretically this requires more time to process the same problem). However "16-bits minicomputers", significantly cheaper and slower, with the operational system adapted for the definite task, can manage it better and quicker than large computers. The greatest producers of minicomputers of the sixties and seventies are (besides IBM), Digital Equipment Corporation, Data General, NCR and others. The typical representatives of these generations of computers are IBM 370, Siemens 7700, Univac 100, Honeywell 66 and others. By the end of the seventies the producers of large computers begin to produce 32-bits minicomputers, and widen the possibilities of their operational systems. The use of the computers becomes cheaper, and the number of the trained skilled people abruptly grows which leads to wider applications of computers.

The progress in the field of the "integrated circuits" (created by Jack Kilby in 1958) leads to the development of micro-processors which use the input/output processors in the frame of the large computers and also in small minicomputers for the management with greater number of local terminals, and for their connection in large networks (3). The significantly perfected microelectronics enables the rise of the mighty logic functions in the frame of the small Silica components -of the integrated circuits or microchips. The logic device which can be programmed and all its components are found on the one and unique Silica chip, called the microprocessor.

The microprocessors are being developed as process units of the simple structure for integration into chapter microcomputers. This provoked the revolution in the development of mini and microcomputer systems, because microprocessors became the central processor units for the new type or the computers intended for individuals. The creator of the first microprocessor is IBM (Intel 8008), and the first personal computer appeared in 1975 (Altair 8800). In 1977 the market offered computers made by Apple Computer inc., Commodores Business Machines, Tandy-Radio Shack and others.

First microcomputers which use microprocessors with 8-bits were available at the market for both professional organizations and inviduals (mainly programmers). In these years we already had mighty machines with the possibilities of managing big libraries. "The characteristic of these machines is that they are projected for more usable use and have the possibilities of the simultaneous performance of several various programs or applications" (1). Among the different products in the domain of microcomputers we differ: "the pocket computer, laptop/notebook, the personal and small general purpose computers" (1). In the literature the term "the personal computer" and "microcomputer" are often used as synonyms (1,3).

The later microcomputer for the multi business application used 16-bits and memory locations could be addressed with 32-bits binary address system. At the time Intel announced detailed information about its first 64-bits processor called Itanium (Marced). Itanium was to work on 800 MHz and was announced to be able to process about 6.4 billions of operations and according to Intel's words was about ten times quicker than the RISC processor and usual 32-bits instructions would perform equally fast as the Pentium III processors. The nucleus itself contained 25.4 million transistors and the integrated 4 MB of the three degree CACHE memory had even 320 millions of transistors. Pentium III processors with its 256 KB CACHE memory had only 28 million transistors. The first chipset which was to support Itanium enabled the parallel work of 512 processors and to 64 GB SDRAM memory. With the corresponding software, they could successfully serve more users. In the basis, we have the structure developed by John von Neuman and is called "von Neumann architecture" (1).

The fifth generation of computers enables even more simple communication between human and computer. The fifth generation has the advantages of computer -the speed and reliability of the counting and memory, and is similar with the advantages of humans when they make decisions and act in new and unpredictable situations.

The computer of the fifth generation work similarly to humans, that is they work as "intelligent". They solve problems by means of the expert systems which support the work of the experts in a field (for example, in the diagnosing of the disease, deciding on the therapy and similar), by which the computer helps that he explains why and on the basis of what he decided for the definite solution (for the given diagnosis or the choice of the definitive therapy). The breakthrough of the computer and information technologies in all the segments of the society, led to the needs for the computer and information technologies. The knowledge of information technology is now part of general literacy. The computer literacy does not require comprehensive and detailed knowledge of the electronics or programming.

The electronic computer is the mean by which we can more successfully solve the problems. The electronic computer is probably one of the most important inventions in the second half of the previous century. The expansive breakthrough of the computer technologies into all spheres of human work, characterizes the new wave of the great changes which often is called 'the computer revolution' (1). The intensive development of the electronic technology in this century enabled the construction of such machines which besides the arithmetic operations can perform also more complex logic operations by means of which it is possible to quickly easily and reliable solve such tasks which up to the invention of the computer was impossible to solve by the standard way of processing. Practically is proved that the computers have extraordinary ability to process a great number of the data in short time period. The personal computers (PC) today are widely used in all the segments of society. They are used into two fields: in the business bookkeeping and household accounting. It is true, that today are much more convent for use in the household bookkeeping, but is very wide also their application in the business bookkeeping, by which the segment of the health care is one from the most significant ('the PC are widely used individually, in network or as the intelligent terminals on the great systems') (1,3).

Some computers are built only for specific tasks such as monitor for vital function of patient in medicine or control satellite in space. It is usually not possible to modify the purpose of computer. According to the type the computers are divided onto 'analogs and digital'. The analog computer 'works on the principle of the analogy of the different physical processes,' and is in the state to memorize the different sizes by means of the different values of the electric current strength in the individual points inside the computer.

WHAT IS THE INFORMATICS?

The answer to this question is neither facile nor unambiguous, as informatics being a young scientific discipline, still has no unique definition. There are at least three reasons; terminological disagreements, various approaches in the comprehension of informatics notion and region wide enough to study informatics problem. Therefore the informatics definition differentiates from one user to another and these differences are most prominent between west and east informatics theoreticians (1,4,5).

The term "Informatics" in the literature was included by Philippe Dreyfus in 1962, combined french words: "information" and "automatique", because in that time automatique was main part of information service (1). The breakthrough of the computer and information technologies in all the segments of the society, led to the needs for the computer and information technologies. The knowledge of information technology is now part of general literacy. The computer literacy does not require comprehensive and detailed knowledge of the electronics or programming.

Although with the electronic computer which is the invention of our age, the attempts of the construction of the first machine for the processing of the information reach far in the history of human civilization. The only and global function of a computer data processing can be naturally separated into the series of the other elementary operations, as for examples are: 'the follow-up of the data, their registration, reproduction, selection, sorting, and comparison' and so on. The computers are being classified according to 'the purpose, type and computer size'. According to the purpose the computers it can be of the general and specific purposes. The computers for the general purpose serve for the commercial applications or any other application that is necessary (1). With the penetration of the contemporary informational technologies the developed human communities have entered in the informational or postindustrial society. In the techno polis or scientific centers, as for example are Tuskuba (by Tokyo) and Sicilian value in USA, by the concentration of knowledge and team work, are being created the new generations of the electronic computers and bio computer. The previous development and the predictions of the new achievements have brought and are bringing to the enormous changes in the structure of the high developed countries, both in the way of the production and changes in the structure of the personnel and in the methodologies and solving the problems and time orientations. The basic characteristics of the informational society is that knowledge and the information achieve the strategic and active resource of the converting and the development of such society, in the same way as are the human work and the capital were for the industrial society. The informatics societies inspected to the future, and not the past. In that sense the new informational technologies become the basic intellectual technology in which the theoretic learning out and new methods ("system analysis theory of the probability theory of the decision" and so on) connected with the possibilities of the computers become the essential factor of the further development of the society. From such a coupling are born the new generations of the computers, "the intelligent robots, the artificial intelligence and expert systems, the automatized production and offices, computer diagnostic and therapeutic systems and new software technologies" (1,6).

As a consequence of the computer revolution and the revolution in the telecommunication came to the political changes worldwide. So, today, the economy in USA in the largest measure is founded on the information's; already by the beginning of the seventieth, about the half of the working strength in USA could be classified into the informational workers employed in the production, processing and the distribution of informatics workers with employment in the production, processing and distribution of information. On the other hand, by the development of information comes to expression also the so called "technologic colonization", which reflects in the dictation of the way of use of the connected technology, engaging the foreign experts, spying and wiretapping and so on. Recently it was recorded the expressive growth of industry of the computers. In the year 1987, is accounted that in the world there was 50 million computers but it is supposed that over 70% of the population use the computers in their work. Only in USA about 43% of the adult inhabitants nowadays use the Internet for their needs. The software industry has in 1980 3 billions dollars turnover, and growth per year step from 30%, while the companies which treat commercial applicative software realized in 1981 year about 2.5 billions dollars of the income for its business. The telecommunication of services realized the turnover about 4.6 billions of dollars, and their annual year increase amounts about 21%. In 1995 in the world was built about 600 million bigger phone power stations, and the value of the market of the telecommunicate equipment amounts about 500 billions of dollars.

Although the electronic computer the invention of our age, the attempts of the construction of the first "machine for accounting" and for the processing of the information's reach far in the history of human civilization. The antecedents to this machine were the different kinds of the documents as carriers of the data. From the beginning the data were inscribed onto stone or on the papyrus, then on the paper, that by the arrival of electronics and informatics completely changed their nature. For the mankind it was the first technological revolution. If medical informatics is regarded as a scientific discipline dealing with theory and practice of information processes in medicine, comprising data communication by information and communication technologies (ICT), with computers as an especially important ICT, then it can be stated that the history medical informatics is connected with the beginnings of computer usage in medicine.

WHAT IS MEDICAL INFORMATICS?

The Medical informatics is the foundation for understanding and practice of the up-to-day medicine. Its basic tool is the computer, subject of studying and the means by which the aspects and achieve the new knowledge in the studying of a man, his health and disease, and functioning of the total health activities (1,3,6,7). The name 'medical informatics' originated in Europe where it was first used by Francois Grémy and Peter Reichertz in 1973. Current network system possesses the limited global performance in the organization of health care, and that is especially expressed in the clinical medicine, where the computer technology has not received the wanted applications yet. In front of us lies the brilliant future of the medical informatics. It should expect that the application of terminal and personal computers with more simple manners of operation will enable routine use of computer technology by all health professionals in the fields of telemedicine, Distance Learning -DL (Web based medical education), application of Information and Communication Technologies (ICT), Medical robotics, Genomics, etc. The development of nature languages for communication with the computers and the identification of input voice will make the work simpler. Regarding the future of medical informatics education there are numerous controversies. New experimental approaches (cell therapy, tissue engineering) raise important issues to be addressed by ICT in health. Informatics can substantially contribute to the advance of these fields. This knowledge must be applied not only at an individual level, in terms of patient care, but also to improve the health of populations, through new public health studies and programs. The aggregation of electronic health records and informatics infrastructures to facilitate longitudinal and bio-bank-based association studies poses new opportunities for health informaticians (8). Everybody agrees that the Medical informatics is very significant for the whole health care and for the needs for personnel. However, there is not yet the general agreement regarding the teaching programs, because the medical informatics is very involved and propulsive, what makes the performance of the stable education programs more difficult.

Facts described in this chapter of the book could be great help for accepting knowledge about development of very propulsive biomedical scientific disciplines -Medical/ Health informatics, which is big part of all medical disciplines and make contents of everyday practice of all medical professionals. Breakthrough of the computer and information technologies in all the segments of the society, led to the needs for the computer and information technologies. The knowledge of information technology is now part of general literacy. During his presentation at MIE 2012 Conference in Pisa prof Edward Ted Shortliffe proposed to use the term Biomedical Informatics in the future, regarding IMIA strategic plan for 2015: "Biomedical informatics is a multi-disciplinary area that involves multiple content areas. It is one of the fastest growing subject/content areas in the world. The use of informatics is expected to enhance research efforts in areas such as genomics and proteomics, for example, and also to change the way medicine is practiced in the 21st century. Research in informatics ranges from the theoretical to applied efforts. The demand for more research in biomedical informatics and for biomedical informatics to support other researchers escalates daily" (8).

presented, followed by a reflection of this evolution in medical informatics education (Arie Hasman). An illustrative example followed about how the actions at a national level (Jana Zvarova) had an echo at European level. Nevertheless, the history of MI in Europe can only be well understood within the global context, which was the focus of the last part of the panel. First, a view of the importance to learn from history for shaping the future (Marion Ball), followed by two independent attempts to define major stages in the evolution of medical informatics with their general characteristics: one mostly oriented on the evolution of concepts and organizational impact (George Mihalas), the other mostly oriented on the evolution of technologies and applications (Izet Masic). The panel ended with a presentation of the History project of IMIA (Casimir A. Kulikowski) ( Figure 1).

Looking Back on Fifty Years of Medical Informatics (Barry Barber and Maureen Scholes)

Based on the materials sent by Barry Barber (included in this volume as a separate article), the chair of the panel presents the story of EFMI foundation, within the context of the enthusiastic 70's development of IT applications in all areas, including health- care. Comments about expectations from medical informatics in those early stages offered a more comprehensive picture of this pioneering era in Europe (1).

Evolution of people and ideas in Medical Informatics (Jan H. van Bemmel)

In the past decades we have seen major changes in medical informatics. Some reasons for it were that nobody was able to predict the advent of the personal computer in the 1970s, the world-wide web in 1991, followed by the rapid rise of the Internet, and the spread of the social media in this century. Foremost, however, nobody expected that it wouldn't be primarily the hardware or the software, but that human factors would become crucial for the successful applications of computers in health care (2,4,5).

In the past, sometimes unrealistic expectations were held, e.g., regarding medical decision-support systems, or the use of electronic patient records. Although the technology was widely available, some applications in health care appeared to be far more complex than expected. Health care processes can seldom be fully standardized. This holds even more for individual patients and their diseases. Humans take part at least in two very different roles in the loop of information processing: as subjects, delivering patient care, and as subjects that are the objects of care -the patients. Besides, medical informatics lacks a specific methodology; all its methods were borrowed from neighboring disciplines such as physics, mathematics and, of course, computer science. Also human factors play a major role in applying computers in health care. Everyone pursuing a career in biomedical informatics needs to be very aware of this.

It is to be expected that patients and their relatives will request an increasing role in using computers for health. There is also a strong demand to use the computer for the assessment of the quality of health care. All this implies that research in medical informatics is much more challenging than thought in the past.

European eHealth Visions (Diane Whitehouse)

When looking back 50 years, it can also be exciting to peer into the future by several decades. Current European policy documents already look ahead, mostly to 2020. All current policy initiatives are firmly embedded in the notion of what a commitment to the EU2020 agenda can offer. Each of the seven flagship initiatives involve a set of coherent, comprehensive, actions that are intended to bring these aspirations to fruition. Several of these flagships can either support or offer a response to the challenges of active and healthy ageing, and enhancing a sense of well-being.

The second variant of Europe's eHealth action plan, published in December 2012, therefore faces forward to 2020. Its content was already indicated in some ways by the ideas of the European Union's 2012 task force on eHealth. Lying ahead are po-tential interpretations of European policy development in 2030, 2040 and even up to the Digital Futures of 2050: they already include visions of healthy lifestyles supported dynamically by information and communication technologies.

In 2013, together with Magda Rosenmoeller (IESE, Spain) and Petra Wilson (CISCO, Belgium), Diane Whitehouse was editing a book aimed at providing an update on eHealth in Europe ( Figure 2).

The volume reviewed the current stateof-the-art in European eHealth developments, yet started by tracing the history of European eHealth and its advances and challenges. It describes best practices as well as challenges, offers a voice to stakeholders, and examines the future eHealth market in the European Union.

It concludes with a vision for the future. The book brings together 25 chapters written by more than thirty leading experts and corporate executives in their respective eHealth fields. All are encouraged to cite past and contemporary case studies. Looking ahead, it provides their insights and visions of eHealth tomorrow.

An abridged history of medical informatics education (Arie Hasman)

Medical informatics education started in the seventies of the last century. Medical informatics was considered by some as applied informatics, others were of the opinion that medical informatics was more than informatics and medicine together and therefore considered it as a discipline separate from informatics. In both cases the 'end product' of these types of education was considered to be a professional not being a medical professional (although these new professionals could initially have been educated as a medical specialists). In 1973 an invitational workshop was held at the Reisensburg near Ulm, Germany where the above noted opinions were expressed. The purpose of the workshop was to define approaches to education in medical informatics. This workshop resulted in the Reisensburger Protocol that pointed out the way in which medical informatics should be taught.

History of Medical Informatics in Europe -a Short Review Using A Different Approach

In addition the idea became more widespread that medical informatics also had to be taught to medical students (e.g. in the USA the GPEP (General Professional Education of the Physician and College Preparation for Medicine) 'Physicians for the Twenty-First Century', or the Dutch approach to medical informatics). In the Netherlands there were even three possible different approaches in teaching informatics: as part of a program in a specific discipline (as was done in medicine where medical informatics was introduced in the curriculum, as a specialization of a discipline with up to 30% informatics in its curriculum and an applied informatics program that focused on a specific discipline, like medical informatics.

In the past a number of conferences were held about experiences in medical informatics education. During these conferences the various programs showed what topics they included in their curricula or the curricula of other disciplines. The IMIA working group on education developed a database in which the characteristics of programs in medical informatics were stored and could be viewed. Also in the European Commission stimulated education in MI by funding the (IT)-EDUCTRA projects and the Nightingale project. It became time to make recommendations about how curricula in medical informatics should be organized (3). In 2000 the first international IMIA Recommendations on education in medical informatics were published. In 2010 the first revision was published. The Recommendations have been widely used.

A last development is the accreditation of programs. This year three programs were accredited by IMIA. In the panel the above mentioned developments will be further discussed.

Medical Decision Support and Medical Informatics Education: Roots, Methods and Applications in Czechoslovakia and the Czech Republic (Jana Zvárová)

The history of medical informatics in Czechoslovakia and the Czech Republic was described, with a focus mainly on the topics of medical informatics education and decision support methods and systems. Several conferences were held in Czechoslovakia and in the Czech Republic, organized in cooperation with IMIA or EFMI. The first IMIA conference held in a socialist country was organized in Prague, Czechoslovakia in 1985. The proceedings covering selected full papers titled Diagnostic Strategies and Expert Systems were published by the Elsevier, North Holland (4). The Velvet Revolution in Czechoslovakia, provoked by a students' strike on November 17 th , 1989, opened the door for cooperation in science and education with a number of countries in the world. In 1990s medical informatics topics were further developed in education and decision support tasks on the national level and in an international cooperation. The second IMIA conference in Prague in 1990 , s focused on medical informatics and medical education. It brought together participants from 18 countries from all over the world and the proceedings Knowledge, Information and Medical Education, published by Elsevier in 1991 (5,6). Support of several European and national projects focused on medical informatics topics also highly contributed to medical informatics development in the Czech Republic. In 1994, two European projects contributed to the foundation of the European Center for Medical Informatics, Statistics and Epidemiology, EUROMISE, as the joint workplace of Charles University in Prague and Academy of Sciences of the Czech Republic that has been further developing the field of medical informatics in the Czech Republic (6).

Back to the Future: What Can We Learn from History (Marion Ball)

The presentation was inspired from the keynote speech at Medinfo 2010 in Capetown (7). For framing the problem, the presentation started, in a critical but realistic view, with some examples, revealing that newer, more sophisticated and more expensive methods are not always better! A deeper view revealed that, while health information technology worked well in clinical applications such as those which involve laboratory and image data, but for primary care or internal medicine or other more complex clinical environments, the introduction of computer technology has often added to the clinician's time and work. A major challenge of HIT, then, is to develop systems that actually save time, and simplify work, rather than the opposite. Other challenges, like a new type of medical error, which frequently arises due to the involvement of computer systems, or the fragmentation of medical care and the intrusion of administrative and bureaucratic managers to deal with billing and insurance, which often contribute to the unsustainable growth in costs of healthcare. The benefit of such a view is the understanding that these problems can be addressed by reengineering health care systems, while recognizing that not all change requires IT for success and that health IT needs to capitalize on innovations by developing intelligent software tools that can help reduce, rather than increase costs.

Evolution of concepts in Medical informatics (George I. Mihalas)

The classical way to present a "history" is to list major events in a chronological order, with more or less detailed comments about the persons, ideas or events. A distinction between periods brings a systematization flavor, easing the comments. We can distinguish the following stages in the development of medical informatics (8):

-Early stage: (up to ~1975): pioneering work of scientists, major work on: signal analysis, laboratory applications, first attempt on decision support, databases, modeling and simulation of biological processes, biostatistics.

-MI "childhood/youth" (~1975-~1990): founding national and international organizations, conferences, attempts to systematize major areas of MI, first specialized schools, development of methodologies, patient records, health information systems (HIS), advanced decision support -expert systems.

-Consolidation period (~1990-~2000): MI consolidates its position as independent discipline, it became clear that the object of study is "medical information" (not computer applications); implementation of hospital information systems, new chapters (imaging, telemedicine); substantial funding for e-health research start, more visible the complexity of EHR, including confidentiality, data protection, standards etc.

-Maturity of MI (~2000-~2010): clearer understanding of e-health potential to address major challenges of present healthcare, internet impact on medical applications; involvement of politicians, extension of regional/national projects, e-health as business, patient-centered MI, new keywords: integration, interoperability, consumer informatics; awareness on difficulties in real implementation of HIS, "failures" reported; analysis of "barriers", quality assessment, clear contour of sub disciplines: bioinformatics, neuroinformatics, VPH (Virtual Physiological Human) etc.

-Full integration of MI in Medicine and Healthcare (~2010-~2020): increased user acceptance, generalization of EHR/EMR, inclusion in HIS, vertical integration data (molecular/cellular/genetic up to organ/system and whole body, horizontal integration (primary care, specialized ambulatory and hospital data), full interoperability, patient empowerment, visible steps towards "personalized medicine", increase patient safety, preventive medicine, use of portable devices, home monitoring systems, tele-assistance, intensive use of web facilities.

Staging medical informatics (Izet Masic)

The Medical informatics is the foundation for understanding and practice of the upto-day medicine. Its basic tool is the computer, subject of studying and the means by which the aspects and achieve the new knowledge in the studying of a man, his health and disease, and functioning of the total health activities (9). For the last fifty years of Medical informatics development the five time period are characteristic:

-First period (1955)(1956)(1957)(1958)(1959)(1960)(1961)(1962)(1963)(1964)(1965): experimenting, and the studying of the new technologies in the medicine, automatic medical decision making, use of computers in biostatistics, automatic analysis of electrocardiograms, health information systems, computerization of clinical laboratories.

-Second period (1965)(1966)(1967)(1968)(1969)(1970)(1971)(1972)(1973)(1974)(1975): solutions for automatized data processing, hospital information systems, medical equipment with built in computers, new biomedical engi-neer disciplines, new diagnostic methods and therapeutic procedures based on microprocessors, the computer tomography, computer assisted medical decision.

-Third period (1975)(1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985): significant progress of computer technique development, the interest for education by health workers grew, important congresses were organized, software packages on market, with significant commercial effects; appearance of personal computers with perfected technical performances, especially memory, intensive application of personal computers.

-Fourth period (1985)(1986)(1987)(1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995): standardization of knowledge; intensive research on improvement of methods and technique of artificial intelligence, expert system in medical diagnostics and therapy; intensive connection of hospitals with private doctor surgeries.

-Fifth period (1995-present): development of medical informatics cannot be separated from development of computer technologies; integration of informatics methods into medical segments in health care work sites, improvements of hardware and software technologies, mostly in the domain of projecting on basis of high quality language of the fourth and fifth generation of computers; expansion of the use of microprocessor technology in the diagnostic systems, informatics methods in doctor surgery, building of informatics equipment, instrumentation and prostheses. IMIA 50th Anniversary History Project and the Prototype Rutgers History Informatics System (Casimir A. Kulikowski) Developing informatics tools to support the writing of the history of biomedical and health informatics is an important endeavour given the approaching 50 th Anniversary of IMIA in 2017. The need is to archive, index, and produce readily accessible recollections from the pioneering days of our field. The Rutgers History Informatics project has developed a MediaWiki to experiment with ways of collecting, indexing and visualizing the materials that related to the evolution of IMIA. The wiki allows access to documents, biosketches and short descriptions of historical events for IMIA, together with timeline summaries which place them in context. The prototype system will be augmented with audio material, and will serve as an archival repository for historical research, including software tools for text analysis and extraction of the information that can be used by authors contributing to the 50 th Anniversary IMIA History, which is planned as an edited volume of contributions from all world regions and societies that are members of IMIA. Contributions to the IMIA History Project are already being published as articles in the IMIA Yearbook (2,10,11,12,13). The analysis of materials on the MediaWiki should help in studying the participation of different researchers and research groups in the activities of IMIA, and the "social networks" of scientists, practitioners, and education specialists that have led the activities of the organization, supplementing conventional citation analyses. The patterns of participation and interaction between different regional and world-wide activities of IMIA will be clearly outlined and visualizable on maps and correlated to summaries of the subfields of specialization of medical informatics, and the main themes that have dominated the discourse and publications in our discipline will also be more clearly analyzable. This represents a novel informatics-based community-building enterprise, very much like Wikipedia content development, but focused on the specific discipline of biomedical and health informatics, and for its specific worldwide association: IMIA ( Figure 3).

PANEL ORGANIZERS AND PARTICIPANTS

• George I Mihalas -president of EFMI 2006EFMI -2008 (1)(2)(3)(4)(5). The decrease of hardware price and wide availability of personal computer (PC), led to the formation of particular application and problem solving under the control of users. Decentralized structure of the contemporary medicine with lots of specialization favors such tendency (6)(7)(8)(9)(10). The computers become more and more the integral parts of the medical equipment (for example: Color Doppler, Computerized tomography (CT), MRI, etc. Also, more and more of PCs are used for physicians dayly work in surgeries for data collecting, processing and storaging on different media about patients for purposes like decision making, research or education. Such peripheral applications do not favor including into central approaches as net nodes or in the peripheral stations of the central systems, so the users collect the fruits from the general field of informatics, they are not getting rich with achievements of the new method of the medical informatics (11)(12)(13)(14)(15)(16)(17)(18) .

The development of own methodology is the characteristics of the new science. However, the medical informatics does not use the unique methodology. Particular applications in the medicine have lead to the mixture of interdisciplinary methodologies and application of formal methods at empiric discipline.

five periods in the development of Medical Informatics

The medical aspects of the methodologies which they consider necessary for the creation of the medical informatics as scientific discipline are as follows (1, 7):

• Tests evaluation data collecting method regarding to the objectivity, sensitivity,confidence and value;

• Analysis of data informational contents;

• Analysis and formal treatment of medical opinion and actions;

• Evaluation of usefulness of medical decisions and actions;

• Regulation of the theoretic concept of causative interrelation between the objects and processes;

• System analysis in health care: modeling and simulations.

By connecting medical science and disciplines with technologies, as well as disciplines in information and computer sciences, creates the methodologies by means of which those technologies and disciplines can contribute to the adequate use of medical knowledge basis and providing better health protection. It should also be noticed that with the use of medical informatics methods, those technologies which get into the composition of wide field of the medical informatics are being reexamined, such as the evaluation of diagnostics technologies (by computer supported or non supported) and the evaluation of the informational system.

Since those years and till today has increased the number of information; came to the exponential growth of knowledge; also the number of scientists and researches has increased, and the science has become the real industry of the modern world which uses the contemporary electronic technology on the market of ideas. On the electronic technology has begun, also, to base the contemporary medical equipment, and in the practice are developing the numerous health care information systems, as well as mighty bases of the bibliographic information of the medical literature. The informatics age has strongly splashed the medicine.

INTRODUCING OF COMPUTERS APPLICATIONS IN THE MEDICINE AND HEALTHCARE PROTECTION

The development of contemporary medical documentation was followed by advancement of data method processing. The real application of informatics on health care activity dated only some decades backwards and appeared in the time of computers devices and electronic computers development (1,4,6,7,16,20). The first expert article in which the idea about application of computer technologies in the medicine was presented by Robert S. ledley and Lee Browning lusted (1959), and that article was considered to be the basic literature from the field of the medical informatics (1,4). In the mentioned article the authors mediate about medical application of the electronic computers in the diagnostics and therapy, establishing theoretic foundations for medical decisions by means of computers. Therefore the beginning of the medical informatics connect for the fifties years of 20 th century, in which is fertilized the appearances of the first commercial electronic computers and their application in the field of medicine.

FIVE PERIODS IN DEVELOPMENT OF MEDICAL INFORMATICS

For the last fifties and some more years of Medical informatics development the five time period are characteristic (1,4,6,7,18):

The first period from 1955 till 1965 mainly is characterized by experimenting, and the studying of the new technologies in the medicine. The pioneers of medical informatics are Joshua lederberg and William Shigeru yamamoto (1924 who early showed interest in automatic calculation in the forties of the 20th century. The important work of Robert S. Ledley (1926Ledley ( -2012, as the first medical professional working with the first computer of the pre-transistor era SEAC on the development of new computing methods in the field of symbolic logics is described, leading later to his famous work with Lee Browning Lusted (1922-2012) in automatic medical decision making. Another important step in medical informatics history was the development of BMDP software (Biomedical Programs) by Wilfrid J. dixon and collaborators, allowing the use of computers in biostatistics. As the first project in the field of computerized diagnostics, resulting from an incentive of Arthur E. "Buck"rikli (1917- , Godfrey N. Hounsfield , Jack D. Myers researchers (ACCR) with significant material investment of money (about 40 million dollars), induced the development in the field of automatization of the medical health care services, of modeling and simulation, equipment and instrumentarium, recognition of samples, training in biomedical of literature. That was the strong stimulus to the rapid development of the medical informatics, first of all in USA, and then in the whole world. In this period appeared also the first prototype of the clinical information system (BIS) in El Camino Hospital in California. For creating of BIS was very important was realizing of documenting patient encounters in the medical record, as integral part of practice workflow -starting with patient appointment scheduling to writing out notes and finishing with medical billing, using a developed method of documentation -SOAP (an acronym for subjective, objective, assessment and plan), and originated from POMR, developed by dr. Lawrence Weed. The second period from 1965 till 1975 characterizes the numerous invention activities of adequate solutions for the automatized data processing. By the end of the sixties West European countries were establishing the numerous hospital information systems (HIS). Firstly, medical equipment with built in computers were applied. The new biomedical engineer disciplines were developed; new diagnostic methods and therapeutic procedures based on the micro processing technology were introduced. The development of medical informatics in Europe was presented, describing the pioneering role of Peter L. Reichertz (1930Reichertz ( -1987 in Hannover, Germany and François Grémy (1929Grémy ( -2014 in Paris, France. First hospital information systems in Europe were implemented during the late sixties in Sweden (Danderyd and Karolinska Hospital), Great Britain (Kings Hospital in London) and Germany (Medizinische System Hannover). In 1979 the first Nobel Prize in physiology and medicine was given for an achievement in medical informatics, the computer tomography -the laureates were Godfrey N. hounsfield and Allan M. cormack . Computer assisted medical decision making started to develop significantly in the seventies in usa with the consultation system help of Homer R. warner (1911-2012) ("A pioneer of Using Computer in Patient Care") and collaborators. In early seventies the development of artificial intelligence methods and expert systems was noted. In this connection, presented were the systems DENDRAL of Edward Albert feigenbaum (1936-), Bruce buchanan (1940-), Joshua lederberg and Carl djerassi (1923-2015-), INTERNIST of Jack D. myers The third period from 1975 till 1985 year is significant with the progress of computer technique development when it became cheaper, which lead to very intensive development of the information system at all the levels of health care system, from the primary to the quaterly level. The interest for education by health workers grew being engaged by medical informatics. The expert and scientific assemblies from the field of the medical informatics become with time more and more numerous and assembled a lot of experts of all profiles, including also the significant number of doctor who began to engage in the medical informatics professionally. Important congresses were organized: twelve world congresses of medical informatics organized by International Medical Informatics Association -IMIA, founded in 1974 and twentyfive European congresses organized by European Federation of Medical Informatics -EFMI, founded in 1976 (21,22). In this period appear the (software) packages on market, becoming the profitable venture with the significant commercial effects. Only in USA, during those years, they had 25 producers for the health care information systems with year turnover between 5 and 7 milliard dollars. This period is characterized also by the appearance of personal computers at the world market with the perfected technical-technologic performances, especially by memory capacities, what enabled the powerful development of informatics in health care system. Besides, the intensive and mass application of personal computers opened the new possibilities -namely connecting computers from home ambulance directly to the informational systems in health care centers. The installation of terminals was being intensified by patient beds (bed side terminal), when medical nurses for their current tasks, and patients -if they are able to -had possibilities of correcting wrongly taken data.

The fourth period from 1985 to 1995 was the new phase of medical informatics development. And further was the development of health care informatics intensified and was meeting high standards through new manner enabling processing and standardization of knowledge. Intensive researches on improvement of methods and technique of artificial intelligence was conducted, and included development and application of expert system in medical diagnostics and therapy. The artifficial intelligence was being introduced as separate discipline of medical informatics, and began to be used by numerous expert systems in practice, about which we will speak later. The hospital information systems, in this period, became more complex, more functional and more qualitative than the previous ones and supported greater number of hospital function. These systems were composed of more independent modules integrated by contemporary communications into unique system which supported all functions of a health care organization regardless to its size and complexity. Formerly built in information systems they Integrated primary health care (ISPHC) and hospital information systems (HIS) into complex systems both on regional and national level. Such approach showed significant advantages in the development of HIS, Especially intensive connection of hospitals with private doctor surgeries by computer technologies was seen in USA. In recent years, the clinical information systems ("Clinical Departmental Systems") with applications into HIS are being developed supporting connection of a patient and definite medical specialization, supporting decisions making in every day medical work.

The fifth period, from 1995 to present, development of medical informatics can not be separated from development of computer technologies. With regard to this, we have to emphasize the fact once again, that the area of the medical informatics significantly grows wider than just the application of electronic computers, although the technical development of microprocessor and telecommunication technologies are significantly influenced by the development of the medical informatics and can not be imagined without electronic computers. At the beginning the technical foundation ("hardware"), is necessary for support of information systems development, and was unimproved and inadequate so that the beginning of applications in this region were modest and limited. In the meantime, however, accounting and computer technologies immensely advanced. For example, the appearance of electronic computers with network of terminals significantly influenced integration of informatics methods into medical segments in health care work sites, which was the basis for development of health care information systems in all segments of health care activities. Investment in huge material means of payment and adequate human potentials in this high specialized development, resulted with significant improvements of hardware and software technologies, mostly in the domain of projecting on basis of high quality language of the fourth and fifth generation of computers. All this brought to the expansion the use of microprocessor technology in the diagnostic systems, and expansion of technology usage brought to wider use of microprocessor technologies and led to so called "information revolution" of our time, resulting in application of informatics methods in doctor surgery, building of informatics equipment, instrumentation and prostheses (1,15).

Behind us is five generations of computers, and already considerably is being done upon the sixth generation, of which hardware basis makes the "biochip" as a foundation of microcomputers. This is completely new technique which, according to many, approaches to physiologic mechanism of neurosynapsis in human brain. The contemporary informatics technology enables current realization of Lusted and other pioneers idea for medical computer application, especially in the domain of medical decisions making. By this the medical informatics becomes the basic discipline of nowadays medical science and practice (15,16).

THE HISTORY OF MEDICAL INFORMATICS DEVELOPMENT -AN OVERVIEW WORLDWIDE MEDICAL INFORMATICS DEVELOPMENT

Medical Informatics as academic and scientific biomedical discipline

Medical/Health/Biomedical informatics is a multi-disciplinary area that involves multiple content areas. It is one of the fastest growing subject/content areas in the world (1)(2)(3). The use of informatics is expected to enhance research efforts in areas such as genomics and proteomics, for example, and also to change the way medicine is practiced in the 21st century (3)(4)(5)(6).

Research in Medical informatics ranges from the theoretical to applied efforts. The demand for more research in Medical informatics and for Biomedical informatics to support other researchers escalates daily (2,5).

The development of Medical informatics began in the 1950's of 20th century, when the earliest reference to applications of electronic digital computers in medicine appeared. Historical facts in this article reflect on the development of the discipline of Medical/Health informatics that is now part of all medical disciplines and part of the medical practice of all health professionals (2). Applications of computer and information technologies in all segments of society and knowledge of information technology is now part of general literacy (1).

c) Consolidation of MI (1990-2000)

: MI consolidates its position as an independent discipline. It becomes clear that the object of study is medical information (not computer applications); implementation of hospital information systems (HIS), and new chapters (imaging, telemedicine). Substantial funding for e-health research is allocated, the complexity of EHR becomes more visible, including confidentiality, data protection, standards etc.;

d) Maturity of MI (2000-2010): a clearer understanding of e-health potential to address major challenges of present healthcare, internet impact on medical applications; involvement of politicians, an extension of regional/national projects, e-health as a business, patient-centered MI, new keywords: integration, interoperability, consumer informatics; awareness on difficulties in the real implementation of HIS, "failures" reported; analysis of "barriers", quality assessment, the clear contour of sub-disciplines: bioinformatics, neuroinformatics, Virtual Physiological Human, etc. e) Full integration of MI in Medicine and Healthcare (2010-2020): focus on user acceptance, a generalization of EHR/EMR, inclusion in HIS, vertical integration data (molecular/cellular/genetic up to organ/system and whole body, horizontal integration (primary care, specialized ambulatory, and hospital data), full interoperability, patient empowerment, visible steps towards "personalized medicine", increase pa-It wasn't until the late 1950s, that the argument was made for computers to be integrated into the healthcare field for the sake of automation, error reduction and perhaps even performance improvement, thanks to Philippe Dreyfus in Paris, France.

After gaining his Master Degree in physics in 1950 from the École supérieure de physique et de chimie industrielles de la ville de Paris (9) he became a professor at the Informatics faculty at Harvard University using Mark I, the first automated computer ever built. In 1958 he was nominated director of the Bull Calculus Centre. In 1962 he coined the new term informatique (9). He established the coined term -Informatics (information + automatique) in 1962 (1,9).

The publication of a highly influential paper, "Reasoning Foundations of Medical Diagnosis," by Ledley and Lusted, helped propel the movement even further. Early names for Health informatics included medical computing, biomedical computing, medical computer science, computer medicine, medical electronic data processing, medical automatic data processing, medical information processing, medical information science, medical software engineering, and medical computer technology (1)(2)(3). Joshua Lederberg and William S. Yamamoto in the forties of 20 th century early showed interest in automatic calculation (1).

Development of Medical informatics started in the fifties of last century. In the postwar period USA was the leading country in the field of computer science and this led to the first uses of computers in medicine (11)(12)(13)(14)(15). In the very beginning, there was Germany's Dr. Gustav Wagner, founder of the German Society for Medical Documentation, Computer Science and Statistics and Peter Leo Reichertz (4,5). It was the world's very first professional organization for informatics (1). The development of information and communication technologies (ICT) during the last two decades of 20th century was particularly important for medical informatics, with Internet and its profound influence on the everyday medical work. It is emphasized that Internet caused a new information revolution since Medical information became available to the public and ceased to be in exclusive control of health professionals. The development and global spreading of ICT brought also new medical fields, interdisciplinary connected to medical informatics: telemedicine and cyber-medicine (16)(17)(18)(19)(20).

According to its name, Medical informatics is connected to the beginnings of electronic computers implementation in medicine. It started in fifties of 20th century when first electronic computers appeared and were implemented in different fields of science and economy.

What is the informatics?

The answer to this question is neither facile nor unambiguous, as informatics being a young scientific discipline, still without unique definition. There are at least three reasons; terminological disagreements, various approaches in the comprehension of informatics notion and region wide enough to study informatics problem. Therefore the informatics definition differentiates from one user to another and these differences are most prominent between west and east informatics theoreticians.

Medical informatics has to do with all aspects of understanding and promoting the effective organization, analysis, management, and use of information in health care. While the field of Medical informatics shares the general scope of these interests with some other health care specialties and disciplines, Medical (Health) informatics has developed its own areas of emphasis and approaches that have set it apart from other disciplines and specialties (1)(2)(3). Being a young scientific discipline the informatics has found exceptionally wide application, not only in every science branch, but also in every economy and non-economy activities of human society. Informatics bacomes practically irreplaceable in all life regions and man work. Especially emphasized interest for the application of informatics is automatized information system, and appears in health activity field. In these efforts emerges and develops new medical discipline under the name "Medical informatics".

Medical informatics has been emerging as a discipline in its own right over the past quarter century with number of notable attempts along the way to define the field in scientific and formal yet succinct terms (1). The Medical informatics is the foundation for understanding and practice of the up-to-day medicine. Its basic tool is the com-

The History of Medical Informatics Development -an Overview puter, subject of studying and the means by which the aspects and achieve the new knowledge in the studying of a man, his health and disease, and functioning of the total health activities (5).

Medical informatics as a multidisciplinary field that uses health information technology (HIT) to improve health care via any combination of higher quality, higher efficiency (spurring lower cost and thus greater availability), and new opportunities, developed differently in USA and Europe (8). Most notably, the UK spearheaded the field forward. The broad history of health informatics in the UK is often described with 'early development of health informatics was unorganized and idiosyncratic'. In the early 1950s, it was prompted by those involved in NHS finance and only in the early 1960s did solutions including those in pathology (1960), radiotherapy (1962), immunization (1963), and primary health care (1968), emergency care, etc. (1,4).

Many of these solutions, even in the early 1970s were developed in-house by pioneers in the field to meet their own requirements. In part this was due to some areas of health services (for example the immunization and vaccination of children) still being provided by Local Authorities. The UK health informatics community has long played a key role in international activity, joining TC4 of the International Federation of Information Processing (1967), which became IMIA (1979). Under the aegis of BCS Health, Cambridge was the host for the first EFMI Medical Informatics Europe (1978) conference and London was the location for IMIA's tenth global congress ( The Medical informatics community is still growing, it is by no means a mature profession, but work in the UK by the voluntary registration body, the UK Council of Health Informatics Professions has suggested eight key constituencies within the domain -information management, knowledge management, portfolio/programme/ project management, ICT, education and research, clinical informatics, health records(service and business-related), health informatics service management. These constituencies accommodate professionals in and for the NHS, in academia and commercial service and solution providers. Since the 1970s the most prominent international coordinating body has been the International Medical Informatics Association (IMIA) (4,5).

In America, the field of Medical informatics unfolded somewhat differently. Even though the idea of using computers in medicine emerged as technology advanced in the early 20th century, it was not until the 1950s that informatics began to have an effect in the United States. The earliest use of electronic digital computers for medicine was for dental projects in the 1950s at the United States National Bureau of Standards by Robert Ledley. During the mid-1950s, the United States Air Force (USAF) carried out several medical projects on its computers while also encouraging civilian agencies such as the National Academy of Sciences -National Research Council (NAS-NRC) and the National Institutes of Health (NIH) to sponsor such work (1,11,12,18).

In 1959, Robert S. Ledley and Lee B. Lusted published "Reasoning Foundations of Medical Diagnosis," a widely read article in Science, which introduced computing (especially operations research) techniques to medical workers. Ledley and Lusted's article has remained influential for decades, especially within the field of Medical Decision-Making (MDM). Guided by Ledley's late 1950s survey of computer use in biology and medicine (carried out for the NAS-NRC), and by his and Lusted's articles, the NIH undertook the first major effort to introduce computers to biology and medicine. (11,12).

This effort, carried out initially by the NIH's Advisory Committee on Computers in Research (ACCR), chaired by Lusted, spent over $40 million between 1960 and 1964 in order to establish dozens of large and small biomedical research centers in the US. One early (1960, non-ACCR) use of computers was to help quantify normal human movement, as a precursor to scientifically measuring deviations from normal, and design of prostheses (1). The use of computers (IBM 650, 1620, and 7040) allowed analysis of a large sample size, and of more measurements and subgroups than had been previously practical with mechanical calculators, thus allowing an objective understanding of how human locomotion varies by age and body characteristics.

The next steps, in the mid-1960s, were the development (sponsored largely by the NIH) of expert systems such as MYCIN, developed by Edward H. "Ted" Shotliffe and collaborators, Internist-I, developed by Jack D. Myers et collaborators.

In 1965, the National Library of Medicine started to use MEDLINE and MEDLARS. Around this time, Neil Pappalardo, Curtis Marble, and Robert A. Greenes developed MUMPS (Massachusetts General Hospital Utility Multi-Programming System) (1,11,18). In the 1970s and 1980s it was the most commonly used programming language for clinical applications. The MUMPS operating system was used to support MUMPS language specifications. As of 2004, a descendent of this system is being used in the United States Veterans Affairs hospital system.

During the 1960s, Morris Collen developed computerized systems to automate many aspects of multiphasic health checkups (1). These systems became the basis the larger medical databases Kaiser Permanente developed during the 1970s and 1980s. The American College of Medical Informatics (ACMI) has since 1993 annually bestowed the Morris F. Collen, MD Medal for Outstanding Contributions to the Field of Medical informatics. In the 1970s a growing number of commercial vendors began to market practice management and electronic medical records systems. Although many products exist, only a small number of health practitioners use fully featured electronic health care records systems.

In 1970, Warner Slack, MD, and Howard Bleich, MD, co-founded the academic division of clincal informatics at Beth Israel Deaconess Medical Center and Harvard Medical School (2). Warner Slack is a pioneer of the development of the electronic patient medical history and in 1977 Dr. Bleich created the first user-friendly search engine for the worlds biomedical literature. In 2002, Dr. Slack and Dr. Bleich were awarded the Morris F. Collen Award for their pioneering contributions to Medical informatics.

Computerized systems involved in patient care have led to a number of changes. Such changes have led to improvements in electronic health records which are now capable of sharing medical information among multiple healthcare stakeholders thereby, supporting the flow of patient information through various modalities of care.

Computer use today involves a broad ability which includes but isn't limited to physician diagnosis and documentation, patient appointment scheduling, and billing (5,8,18). Many researchers in the field have identified an increase in the quality of healthcare systems, decreased errors by healthcare workers, and lastly savings in time and money. The system however is not perfect and will continue to require improvement. Frequently cited factors of concern involve usability, safety, accessibility, and user friendliness.

As leaders in the field of Medical informatics improve upon the aforementioned factors of concern, the overall provision of healthcare will continue to improve. AMIA has named an award after Homer H. Warner, one of the fathers of Medical informatics, who with associates developed consultation system HELP, and who founded the Department of Medical Informatics at the University of Utah in 1968 (2), on application of informatics to medicine (11,12).

Clinical Informatics AMIA's contribution

New medical specialties and subspecialties emerge over time like Anesthesia in the 19th century or Emergency Medicine in the 20th century (1). Medical Informatics and its subspecialties of Biomedical, Clinical, and Public Health informatics have emerged as a new discipline within health and health care in the 21st century -after a gestation period of roughly sixty years (14,18). The formative period coincides with the development of computer science -information and communications technology -and the emergence of electronic health records as essential technology for health care. It also coincides with the development of training programs in biomedical, clinical, and public health informatics. The American Medical Informatics Association (AMIA) is the USA professional home for biomedical and health informaticians. In response to the needs of a growing work force in Clinical Informatics, AMIA developed a professional code of ethics as well as a front ranking scientific research journal -Journal of the American Medical Informatics Association (JAMIA) (1). In 2006, AMIA was elected to full membership in the Council of Medical Specialty Societies, in recognition of its importance as an emerging specialty area in healthcare.

Clinical Informatics is not only one of the first new subspecialties that have emerged in this century, in the authors' opinion; it is fundamentally different from all prior subspecialties. Even though the knowledge and skills of a medical informatician are unique, the need for informatics as an essential component of daily medical care and research cuts across all primary specialties. For example, clinical specialties like surgery, pediatrics, and internal medicine rely on informaticians and to a lesser extent information and communication technologists to implement, manage, and advance electronic health record systems, aid in designing clinical decision support and manage research data. Imaging and laboratory specialties have long had a need for experts in clinical information systems. Expertise in Clinical Informatics has been recognized as crucial for the operation of clinical institutions as demonstrated by the large number of newly created Chief Medical Informatics Officer (CMIO) and Chief Nursing Informatics Officer (CNIO) (1) positions. Because Clinical Informatics is of growing importance and value to all existing medical specialties, at this point it is possible if not probable that it will be incorporated as a subspecialty certification option open to all existing primary specialties.

In 2004, then President George W. Bush called for the widespread use of electronic health records (EHRs) by 2014. This challenge generated an important goal for those in Clinical Informatics but it quickly became apparent that the US health care system was sorely lacking the informatics workforce sufficient in number and knowledge to accomplish this goal.

These work force demands dictated that it was time for Clinical Informatics to evolve from an avocational or part time activity of self-identified informaticians to a fully professional career track with training, standards, codes of ethics and certification (14)(15)(16). Clinical Informatics needed to shed its status as a 'club' sport and become a fully recognized profession within the house of medicine. Knowledge and skills in Clinical Informatics are widely acknowledged as crucial to future success in patient care, research related to biomedicine, and public health, as well as to health policy design and implementation. It is apparent that success in realizing electronic health record systems depends more on knowledge and expertise like needs assessment, organizational leadership, and change management skills than on information technology itself. The core expertise of a medical informatician is thus more strategic than tactical in nature. The training requirements proposed by AMIA incorporate these competencies as a central element of the training for clinical informaticians.

AMIA is the professional home to clinical informaticians representing a variety of health professions including medicine. Clinical Informatics professionals are not the first to develop a professional model: The nursing profession created a certified nurse informatician and as of November 2000, 381 nurses had been certified as nurse informaticians by the American Nurses Credentialing Center. Several years ago, pathologists within AMIA started an unsuccessful effort to create formal informatics specialty training and certification (14)(15)(16).

In 2005, the membership of AMIA concluded at a town hall meeting that AMIA should move forward with creating a formal certification program for health professionals in Clinical Informatics, beginning with physicians. The AMIA Board then formally approved a strategic plan to pursue a Clinical Informatics subspecialty within the structure of the American Board of Medical Special ties. In 2010, AMIA will embark upon an effort to create an Advanced Inter-Professional Informatics Certification process to supplement the existing nurse certification and support professional education for practicing dentists, pharmacists, as well as physicians and others who do not wish to seek certification through ABMS. While options other than the America Board of Medical Specialties (ABMS) for physician certification and the Accreditation Council for Graduate Medical Education (ACGME) for training program accreditation exist, the importance and leadership of these two organizations are so solidly established that essentially, they oversee the approval of new specialties in medicine. The ABMS approves the content of a medical specialty and through their member boards oversees the creation of a competency examination and the certification of physicians, who meet their training standards. The ACGME offers accreditation to training programs that meet the subspecialty's formal training criteria. Before the ACGME would establish the program accreditation process, a new specialty would traditionally first receive approval from the ABMS.

AMIA officers have also communicated with ACGME officials in the past so they are aware that work is moving forward in a timely manner. The establishment of Clinical Informatics as a sub-certification requires that several conditions be met. First, one must convince physician peers within the ABMS governance structure that the emerging discipline is substantive and essential to the health care needs of patients. In short, the specialty must pass the test of being vital to comprehensive care (e.g., the vital importance of the EHR for the 'Medical Home' for the sick and injured as well as being important to preventing illness and maintaining health status. Markers to determine the essential nature of a specialty include the availability of formal educational programs of sufficient rigor and length and the definition of knowledge and skills relevant and critical to working as a professional in the discipline. The presence of one or more scholarly publications in the field that offer peer reviewed articles is another marker. The existence of an organizational home for such professionals like AMIA is a prerequisite, as is a professional code of ethics.

Other criteria include documentation of regular well organized meetings, with a national scale and scope that offer relevant high quality continuing educational programs. It is necessary that the subspecialty demonstrate the existence of a 'population' of practicing medical professionals in the discipline. Both, the American College of Medical Informatics (ACMI -a college of elected fellows who have made significant and sustained contributions to the field of medical informatics) and an active well established Clinical Informatics working group within AMIA, are indicators of stability and permanence.

Further requirements include demonstration of well structured collection of the knowledge and skills that comprise competence in the field and well formulated training requirements. While AMIA as an organization fulfilled several other criteria simply by serving as the professional home for biomedical and health informaticians, and by providing continuing medical education and means to disseminate scholarly activity; the requirements for formal descriptions of the core content and training requirements specifically for Clinical Informatics had not been met until recently. The generation of core content and training requirements involved substantial AMIA efforts supported though funding from the Robert Wood Johnson Foundation (RWJ) under the leadership of RWJ's Vice President John R. Lumpkin, MD.

Two groups were created and empowered by the AMIA Board of Directors to create the core content and training requirements documents to frame the approach to the ABMS. Participants in the groups included clinical informaticians from medicine, nursing, dentistry, and pharmacy in the belief that Clinical Informatics needs to be focused primarily on informatics rather than medicine per se. Close attention was given to assuring that the documentation met the ABMS requirements.

Once the core content and training documents were created and published, attention turned to identifying a specialty board recognized by the ABMS that was willing to serve as the 'parent' for the Clinical Informatics subspecialty through its certification authority. In the summer of 2009, the American Board of Preventive Medicine (ABPM) formally agreed to become the home for the Clinical Informatics certification for physicians. Further, ABPM designated AMIA as the organization of record for issues related to this emerging specialty. Preventive Medicine is a primary specialty that takes a broad systems view of its discipline and focuses both on individual patients and on populations.

This philosophy corresponds well with AMIA's commitment to systems thinking, using informatics to support both individual and population health, and its aim to be the professional home for both clinical and public health informaticians.

The role of academic and scientific associations in development of Medical informatics

Until the creation of IFIP-TC4 (later IMIA) in 1967 and EFMI in 1976, theoretical and practical aspects of Medical informatics developed fast, presenting results in the beginning in scientific and professional journals of a predominantly interdisciplinary character, and later in dedicated Medical informatics (MI) journals (3)(4)(5).

In this period conferences with MI contents were organized mostly either under the umbrella of "parent" societies (e.g. general computer or specialized health documentation and statistics/epidemiology societies) or under organization of particular groups and associations of people engaged in MI, research and development of MI applications. In scientifically and technologically strong countries (e.g. in France, Germany, U.K., U.S.A.), but also in other countries, such conferences were organized predominantly as national events. International interaction at such events was rather sporadic.

First international acceptance came from the International Federation for Information Processing (IFIP), an organization formed under the patronage of UNESCO. In 1967 François Grémy (the first IMIA president) initiated the IFIP-TC4 on MI gathering medical informaticians, especially from Europe and triggered organization of national MI societies. IFIP-TC4 was perceived as a Federation of National Societies, thus reflecting the spirit of international cooperation among nations in education, science and culture. This federative thinking was transfered to EFMI.

By establishing IFIP-TC4 on MI, Grémy was the first to add the adjective "medical" to the new term "informatics". Under his chairmanship several TC4 working groups were initiated, organizing meetings on information processing of medical records, education in MI, decision making and data protection. Earlier, in 1966, Grémy had initiated at the Faculté de Médicine of the Université de Paris, as professor of the Centre de calcul et de statistique, with a curriculum on information processing by computers. (1)(2)(3).

Development of Medical informatics in other parts of Europe and in the world , including description of contributions of most influential academics, scientists and experts within this field of medicine, author described with 30 co-authors from all parts of the world, in the book "Contribution to the History of Medical Informatics" (published in 2015), and two monographs -"Honorary Fellows of EFMI" and "Honorary Fellows of IMIA" (published in 2017 and 2018). Also some other authors, most influental medical informatics academics and experts described some important historical facts about development of Medical informatics in the past (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39).

A short review of important facts about it is written in next two chapters (1-4).

THE ROLE OF IMIA IN THE DEVELOPMENT OF MEDICAL INFORMATICS

Why IMIA was established?

The IMIA is the most important organisation for health and biomedical informatics. IMIA has a key role to play in anticipating new challenges for informatics in the most important trends of future medicine (regenerative, genomic, longevity, patient-centred, preventive). In terms of health care perhaps the most important challenge for biomedical informatics is to facilitate a fast and reliable translation of the biomedical research findings into real-use clinical solutions (3,4).

From this perspective a major goal is to facilitate "translational research", improving the diagnostic arsenal with new imaging systems and micro devices suitable for "point of care" solutions, promoting rational drug design and supporting the development of personalized therapeutic strategies that can guarantee efficacy and patient safety. New experimental approaches (cell therapy, tissue engineering) raise important issues to be addressed by ICT in health. Informatics can substantially contribute to the advance of these fields. This knowledge must be applied not only at an individual level, in terms of patient care, but also to improve the health of populations, through new public health studies and programs.

The aggregation of electronic health records and informatics infrastructures to facilitate longitudinal and bio-bank-based association studies poses new opportunities for health informaticians.

The most important mandate for International Medical Informatics Association (IMIA) is to contribute, through the use of Information and Communication Technology (ICT), to the improvement of biomedical research, clinical practice and public health. In the future a more complete knowledge on the different factors that contribute to the development of disease (genetics, environment) will be increasingly available for developing new preventive, diagnostic and therapeutic solutions.

Knowledge is the core for IMIA's existence. IMIA's role will be to stimulate and connect researchers to enable their research. IMIA has numerous roles to play in providing leadership in the development and delivery of education, and where appropriate through collaborating with other organizations in contributing to the development of education across the entire spectrum of people impacted by informatics.

IMIA's direct role in education relates to education for biomedical informaticians, but it also has important indirect roles in ensuring the highest quality of education for all other groups of individuals who have a direct or indirect interaction with the practice of biomedical informatics. IMIA has a role in developing educational and research opportunities within biomedical informatics, and mechanisms for fostering the development of 'the next generation' and discovering the currently unrecognised and underdeveloped talent of existing biomedical informatics students.

The IMIA acts as a bridging organisation, bringing together the constituent organisations and their members and provides leadership and expertise to the multidisciplinary, health focused community and to policy makers, to enable the transformation of healthcare in accord with the world-wide vision of improving the health of the world population (7).

The role of IMIA

IMIA was originally established in 1967 as Technical Committee 4 of the International Federation for Information Processing (IFIP) (1)(2)(3)(4)(5). IFIP is a non-governmental, non-profit umbrella organization for national societies working in the field of information processing (2). IMIA was established in 1960 under the auspices of UN-ESCO as a result of the first World Computer Congress held in Paris in 1959. In 1979, it evolved from a Special Interest Group of IFIP to its current status as a fully independent organization (1,5).

IMIA continues to maintain its relationship with IFIP as an affiliate organization. IMIA also has close ties with the World Health Organization (WHO) as a NGO (Non Government Organization), and with the International Federation of Health Information Management (IFHIMA). IMIA is constantly striving to further the services it provides to its members and the informatics community in general by promoting free interaction among and between its member network and the bio-medical and health informatics community at large.

The basic goals and objectives of the association are to (1): a) promote informatics in health care and research in health, bio and medical informatics; b) advance and nurture international cooperation; c) to stimulate research, development and routine application; d) move informatics from theory into practice in a full range of health delivery settings, from physician's office to acute and long term care; e) further the dissemination and exchange of knowledge, information and technology; f) promote education and responsible behaviour; g) represent the medical and health informatics field with the World Health Organization and other in-ternational professional and governmental organiza-tions (1).

In its function as a bridge organization, IMIA's goals are (1): a) moving theory into practice by linking academic and research informaticians with care givers, consultants, vendors, and vendor-based researchers; b) leading the international medical and health informatics communities throughout the 21st century; c) promoting the cross-fertilization of health informatics information and knowledge across professional and geographical boundaries; d) serving as the catalyst for ubiquitous worldwide health informati (1) IMIA, from time to time, appoints taskforces to undertake specific, sometimes time-limited, pieces of activity that are not readily amendable to being undertaken by other parts of IMIA. Taskforce members are appointed according to the skills and expertise needed to undertake the mandated activity, and seek to draw on the knowledge and skills of IMIA's members around the world. Figure 6).

Since its inception in 1992, the IMIA Yearbook of Medical Informatics has been one of the most visible and valuable "products" that IMIA provides -not only to its members but to the health and biomedical informatics community at large. It is designed to present an overview of the most original, excellent state-of-the-art research in the area of health and biomedical informatics of the past year; to provide surveys about recent developments, and comprehensive reviews on relevant topics in this field; and to provide information about IMIA.

Beginning in 2014, the IMIA Yearbook had been published in an online open access format and the print version discontinued.

The Objectives of IMIA Yearbook are: a) to present an overview of the most excellent original state-of-the-art research in the area of health and biomedical informatics of the past year; b) to provide surveys about the recent developments, and comprehen-sive reviews on relevant topics in the field of health and biomedical informatics; c) to provide original papers on the history of Medical Informatics as well as Research and Education organized in the field; d) to provide syntheses about the most valuable outputs of IMIA Working Groups activities; e) to provide information about IMIA.

IMIA Honorary Fellows

In the past IMIA General Assembly has been elected 31 Honorary Fellows 4 The goal is to promote the dissemination of knowledge and best practices, foster new ideas, and encourage worldwide collaboration and sharing of expertise and resources. International leadership in biomedical and health informatics has the opportunity to encourage best practices in biomedical sciences and in the practice of health care, as well as in global and population health, education and research. The forming of an Academy in 2017 of international leaders who focus on health sciences informatics can stimulate and guide future directions in the aforementioned areas.

The Academy through its members can advise governmental and non-governmental organizations about the contribution of informatics professionals and the importance of informatics-based knowledge and provide problem solving strategies ( Figure 5) (37)

IMIA awards

In the year 2001 the IMIA approved the establishment of a Medical Informatics Award of Excellence named "Morris Collen Award" to be given every three years to an individual, whose personal commitment and dedication to medical informatics has made a lasting contribution to medicine and healthcare through her or his achieve-

EFMI publications

The most important EFMI publication, indexed in Medline is Studies in Health Technology and Informatics, which publishes papers presented at MIE Conferences. EFMI also publishes several sub-specialty official journals covering the spectrum of medical informatics subdisciplines. Currently, EFMI has three officially endorsed general journals, Methods of Information in Medicine, International Journal of Medical Informatics and Acta Informatica Medica. Until the year 2020 official journal of EFMI was also International Journal of Biomedical Informatics (EJBI), but excluded this year. From the year 2020 EFMI started to pubish EFMI Inside magazine ( Figure 10).

Through its work, EFMI provides leadership and expertise to the multidisciplinary, health IT community and to policy makers, enables the transformation of healthcare in accord with the world-wide vision of improving the health of the world population. EFMI is constantly striving to further the services it provides to its members and the informatics community in general by promoting free interaction among and between its member network and the bio-medical and health informatics community at large.

EFMI Honorary Fellows

During

During past period EFMI Council has been elected 31

EFMI awards

In the year 2015, during MIE conference in Madrid, the EFMI Council approved the establishment of a Medical Informatics Award of Excellence named "Leo Peter Reichertz Young Scientist's Award" and "Rolf Hansen Memorial Award" to be given to an individual, whose personal commitment and dedication to medical informatics has made a lasting contribution to medicine and healthcare through her or his achievements in research, education, development or applications in the field of medical informatics. Also, during MIE conferences Mantas' Prize for Best Paper on Education in Biomedical and Health Informatics is giving to presenter for "Outstanding paper about Education in Biomedical and Health Informatic" (37).

In the year 2015, during MIE conference in Madrid, the EFMI Council approved the establishment of a Medical Informatics Award of Excellence named "Leo Peter Reichertz Young Scientist's Award" and "Rolf Hansen Memorial Award" to be given to an individual, whose personal commitment and dedication to medical informatics has made a lasting contribution to medicine and healthcare through her or his achievements in research, education, development or applications in the field of medical informatics. Also, during MIE conferences Mantas' Prize for Best Paper on Education in Biomedical and Health Informatics is giving to presenter for "Outstanding paper about Education in Biomedical and Health Informatic" (37).

ABOUT THE BEGINNINGS OF MEDICAL INFORMATICS IN EUROPE

The first computer, Mark I, "Bessie" for intimates, is born in 1944 from a collaboration of the US Navy and Harvard University, under the leadership of Howard Aiken. They conceived and realized a machine that could work "automatically" by following programs introduced in advance (1).

The term "Informatics" was created in 1962 (Académie Française) from two words, information and automatic, and covers all techniques, information concepts and applications of computers. Among them, medicine is the field where we will describe some factors of development in Europe since the late sixties.

Francis Roger France

cess was also linked to useful accounting and administrative programs. It was the time of the Hollerith card that everyone had to carry to the computer center. There, each work had to be classified and located like books in a Library, before being processed.

The development of computer applications in medicine followed all over the world industrial and financial projects with some delay. The first applications in Europe after 1965 were clinical laboratories and hospital administrative tasks. Most often existing software had to be adapted locally (2). Other fields were often seen with apprehension. Medical informatics creates a mixture of human and mechanical factors, with a danger of commercial exploitation. Some health professionals had a fear to be replaced by machines.

As postgraduate student in the USA (1970)(1971)(1972) This ambitious and costly project was initiated and supported by a French-German agreement, with the hope that the pharmaceutical industry could contribute also financially, better than any other medical sector.

One of the major results expected was a more unified terminology or an easy access to an equivalent name for a same product in all European countries.

This required a list of each active principle for each drug. The EEC obtained to have access to some data banks from several Ministries of Health like Italy and Belgium. Such possible access blocked the project. The pharmaceutical industry had accepted that Committees of experts get more details in order to register a product for its reimbursement, country by country. It felt jeopardized if anyone, mainly another industrial group could obtain easily through the EEC network secrets of drugs manufacturing. As this project was stopped there was some money left for other EEC projects.

I was approached in the corner of a corridor by Prof. Wolf-Terroine who announced me that there was a new agreement in the BMWG to put the hospital MBDS as one of the main objectives of the group and that I would be charged to do a "feasibility" study.

Use of the MBDS in European countries

Thereafter, I was appointed as Advisor to several governments that implemented the MBDS and had to deliver many explanatory speeches.

Among them, let's quote:

• Portugal that made a special agreement with Bob Fetter to use DRGs, with financial support from the US, provided a NATO base could be installed near Lisbon.

• France, where I was associated to the foundation of the PMSI (Projet de Médicalisation des Systèmes d'Information), under the leadership of François Gremy and Mr.

Stephan.

• Belgium accepted the MBDS in order to change the hospital financing system.

This important reform was initiated by Minister Jean-Luc De Haene.

• Italy and Spain expressed the wish to make this information system uniform in the country, but they were regional variations in implementation.

• UK, Ireland , Denmark, Sweden and the Netherlands modified their hospital statistics in order to correspond to the European standard and used it for hospital care management.

• Luxemburg and Germany took some delay before adopting the system.

• Greece was reluctant to use the MBDS.

THE IMPACT OF EFMI (EUROPEAN FEDERATION FOR MEDICAL INFORMATICS)

Besides these official developments through national policies and international proj- • To promote high standards in the application of medical informatics;

• To promote research and development in medical informatics;

• To encourage high standards in education in medical informatics;

• To function as the autonomous European Regional Council.

We can consider that the European Federation had three main impacts:

• EFMI used the same limits for Europe as WHO . It has to be remembered that in 1976, Western and Eastern Europe were completely separated. This decision allowed to open medical informatics to Eastern countries as well as to assimilated countries like Israêl.

• In order to apply to become a country member, there should be only one scientific society by country. This statement obliged several countries like Italy and Greece to modify their internal structure.

• A major role of EFMI has been the diffusion of scientific information through MIE Conferences (4) as well as MEDINFO, as during many years the majority of members of IFIP-TC4 followed by IMIA was European.

EEC RESEARCH AND DEVELOPMENT PROGRAMS

The European Union (Niels Rossing) initiated research projects in medical informatics called BICEPS-EUROAIM, to which we participated in 1986. However, guidelines had to be provided, taking in account weaknesses as well as strong aspects of medical informatics in Europe.

The AIM Requirements and Strategic Review Board was created by the EEC in 1989.

AIM is an acronym for Advanced Informatics in Medicine. The experts were appointed from the industry and from university research centers. I was chosen as chairman and Gerald Santucci as secretary. We worked during eight months and published the results in a book published by Springer-Verlag (8) entitled Perspectives of Information Processing in Medical Applications in 1991.

We considered challenges and opportunities, dreamed of modernization that could lead to high quality medicine, crossing national frontiers, requiring a collaborative international work and a common infrastructure. Integration, modularity and security were among the key words used. These ideas are still applied, nearly 25 years later, first in the numerous AIM projects and now in eHealth.

OTHER INITIATIVES Education and Training

Apart from the UNESCO one shot session of courses in 1968, the Council of Europe issued recommendations in 1991 for the development of European strategies in health information Systems (16,17).

Hospital Management

PCS-E (Patients Classification Systems-Europe) was created in order to diffuse and to adapt DRGs in European countries. A major impact of all these efforts has been the creation of networks of experts that is practically very useful (18).

THE EARLY HISTORY OF EUROPEAN FEDERATION OF MEDICAL INFORMATICS

• Barry Barber (UK);

• Antonio Perens de Talens, (Italy);

• Francois Gremy (France);

• Rolf Hansen (Norway);

• Mogens Jorgensen (Denmark);

• Hans Peterson (Sweden);

• Peter L. Reichertz (Federal Republic of Germany);

• Jan Roukens (Holland);

• Jan van Egmond (Belgium);

• Ilkka Vaananen (Finland.

In addition two representatives from WHO was invited as they had shown interest for the new Federation and had offered the meeting to be held in the WHO European headquarters premises in Copenhagen and invitation for lunch. They were the head of the headquarters M. Sedeuilh and A. Weber.

REFLECTIONS ON THE DEVELOPMENT OF MEDICAL INFORMATICS

The recording of numbers appears to pre-date the emergence of writing and excavations of the clay tablets of civilisations in the Middle East have shown that clay tablets were used to keep account of activities undertaken in a systematic fashion. Correspondingly, various forms of abacus have been used types of calculation from the Sumerian abacus dating from about 4 ½ thousand years ago to the Chinese abacus (Suanpan) from around 2 thousand years ago. As time passed various forms of writing were developed using animal hides, which were developed as vellum and papyrus which eventually developed into paper. Wood block printing, also, was a very ancient art and movable type printing had been utilised in the far East but the development of movable type page setting in Europe transformed the process of printing. It led to the explosion of printing presses and printed material which transformed the cultural environment by facilitating the transmission of ideas and information. However, paper systems were an essential part of any significant project, accounting or the work performed by individuals.

Caesar Augustus decreed that a census should be taken (1) and there is no doubt that this was part of his system of control. Similarly the Magna Carta (2), commissioned by William the Conqueror of England, was a key component of his system of control and taxation of his conquered land. These activities were expensive and were not undertaken for fun but were active information systems in the modern sense of the term. However, it might be argued that the Jacquard loom (3)] and the use of punched cards in engineering control systems was the next step from paper systems towards modern, computer-based, information systems. Indeed, the fast, 5-hole, paper tape readers and

INITIAL LIMITATIONS OF COMPUTERS

The computer that we purchased had 8k of 39-bit words as immediate access memory with a cycle time of 256μsec and it used three 35mm magnetic film handlers as the backing store. It used 5-hole paper tape as the input and output medium, although we did not know at that time where these facilities had been first developed. The instruction code comprised 6-bit function code operating on an 13-bit address code -which enabled the instruction to thus address the whole store directly. Two machine code instructions could be held in a single word and this allowed for a B-line modifier-bit between them.

The 1000 foot reels of magnetic tape could hold 4096 blocks of 64 39-bit words but all this complicated technology only held just over a megabyte per reel. Data and program input was achieved using a Teletype machine to both print the information on paper as well as on the 5-hole tape. The paper tape reader could input information at 500 char/sec. Correspondingly, the computer printed out paper tape at 100 char/sec which was then run through a printer. Interestingly, we all got quite good at winding up large rolls of paper tape and at deciphering -and sometimes adjusting with a Unipunch -the symbols on the tape!

In purchasing the computer, the Board of Governors of The London Hospital were advised that the financial systems at the heart of the case made out for the computer would only take up half of the computer's time. Accordingly, they decided that the rest of the time should be made available for medical and scientific research as was appropriate for a Teaching Hospital. This directive enabled many projects to be undertaken within both the hospital and the medical college. Thus, computing time was available but the programming, systems development and operating of the non-financial programs was almost exclusively carried out by the users themselves.

The Operational Research Unit, a sister Unit of the Computer Unit, that had developed out of the work carried out in the Medical Physics Department was able to take full advantage of these facilities for the exploration of the use of Operational Research techniques developed during WWII to improve the operation of the hospital. Among the projects it explored were Queueing in Out-Patient clinics, staffing of emergency anaesthetic services, admission and discharge arrangements, planning the haemodialysis programme, running obstetric surveys, examining the nurse training programme, establishing a microfiche nurse record system as well as an assessment of computerised radiotherapy treatment planning systems.

As with much university computing on large batch machines, this work was helped by the availability of "High Level Programming Languages". In the case of the Elliott 803 we had 8o3 Autocode and, at a later stage, we had 8o3 Algol although this was really designed for the Elliott 503, which was about 60 times faster although only twice as expensive!

Although these facilities were an amazing improvement on the use of a mechanical calculator or the punched card equipment of the finance department, a quick comparison with the personal computers now readily available in many homes shows how limited they were in comparison with the tasks that began to be tackled. However, the work undertaken did enable staff to begin to explore the data that was routinely handled in the hospital and in the research work of the Medical College and this expertise formed the basis for subsequent developments in the use of "Real Time" hospital systems.

The three Annual Reports from the Computer and Operational Research Units covering the first three years of use of the Elliott 803 showed how the computer had been used and what the next steps in computerisation of the hospital might be. The average weekly running time grew from 50.7 hours in the first full year to 74.4 and 104.6 hours in the following two years.

The third report outlined the next step in which a "batch processing system" could be used to handle the basic "Patient Administration" of the hospital (5). It should be noted that at this same time Elliott Medical Automation Ltd was established under the direction of Dr L C Payne and he made an arrangement with University College Hospital to install an Elliott 803 on their premises as a means of exploring a wide variety of health computing problems, which included laboratory computing with auto-analysers and radiotherapy treatment planning but his ideas went much further into the areas of medical informatics (6).

CULTURAL LIMITATIONS

Unlike the present day, computers were housed in large airconditioned rooms which could only be accessed by authorised people. Frequently, there was a viewing window for visitors but these were soon discontinued for security reasons. There was little or no public or professional understanding of:

• The uses and limitations of computers;

• How information could be entered into computers;

• How information systems could provide information;

• No teaching about computers in schools.

Culturally, it was thought that typing was a "secretarial skill" beneath the dignity of professional people like doctors and nurses and collating information was a job for clerical staff.

These ideas have only slowly changed as more and more people have had access to more and more powerful computers. Like journalists before them who found that typing was an important skill for their profession, many professional staff, especially at Universities, where there was access to large computer systems, found that they could draft their research papers and reports by typing into computer systems and that errors could be easily corrected as their ideas were developed.

This drift in work patterns was accelerated as many organisations moved away from providing personal secretaries towards typing pools and then to providing computing facilities instead.

Although the culture was changing solutions had to be found to achieve data input to computer systems that did not involve memorising complex systems of codes. As ideas developed different approaches were explored and tested it was found that:

• A tree-branching approach in which the users selected options from short lists enabled them to locate appropriate parts of a record for data entry or inspection.

• More powerful computer systems could assist the data entry process with basic validation checks and spell checking.

• Staff were no longer "afraid" of using computers.

• Some early systems envisaged data entry being handled by a core of individuals like telephone operators but it quickly became apparent that the only way to capture reliable information was for it to be entered directly by those involved in creating it.

• For this to happen, the process had to be made easy and fast. One of the major reasons for the termination of Prof John Anderson's Kings College Hospital Medical Records System was the appearance of a paper by his colleagues claiming that it took longer to enter the medical record into the computer system than when the recording was done by hand (7).

OPPORTUNITIES OFFERED

On the other side of the equation computers offered amazing opportunities for the communication and analysis of information and for improvements in the functioning of organisations. At one go they could overcome the limitations of a single medical record located in one place. In an increasingly distributed health care system up-to-date medical records can be available wherever they are needed crossing whatever organisational boundaries are necessary, subject only to the issues of patient confidentiality. By collecting information about the passage of patients through their care the medical information systems can automatically provide information about the functioning of a hospital or other care system in order to facilitate improvements in the delivery of care both from the patients' perspective of avoiding non-clinical delays and worry as well as from the organisation's perspective in terms of the efficiency of the delivery of care. It should be noted too, that almost every aspect of clinical care has been transformed over the last 50 years with dedicated information systems and devices which assist clinicians in the processes of diagnosis, therapy and recording of clinical findings -quite apart from the larger systems for hospitals as a whole. However, these advances have only been possible as a result of the improvements in the speed and size of computer systems, the ease of computer usage and data input, the the clinical and organisational research that has been incorporated into modern information systems.

SOME KEYS TO SUCCESSFUL INFORMATION SYSTEMS

The early computing systems tended to use a "batch processing" approach in which information was recorded and analysed for later use but the advent of much faster and more powerful computer systems began to enable computers to accept information that has been input and provide an almost instant response. This "Real Time" approach provided opportunities for the direct interaction of doctors and nurses with the computer systems for the first time. However, it was very demanding of the computing facilities because, if the computer's responses were too long in coming, the users would simply walk away and get on with other work -and the system as designed would be an evident failure. The total system of hardware, software and user activity must be fast enough in providing results for the users to complete their tasks without any perceptible delay.

The Management of Change in any organisation requires serious attention and all the key disciplines must be brought into the process at the right organisational level and with experienced individuals. In setting up the Real Time System at The London Hospital, an Executive was established chaired by a senior administrator and which included a senior doctor and nurse as well as the Directors of the Computer and Operational Research Units -which provided the technical input. Although the technical staff were engaged full time, they were often involved in many other activities than the process of building the Hospital's Real Time Computer System. The other staff simply had the routine oversight of the process of building the system added to their other professional activities. At the start, the five initial members of this Executive had, between them, over 100 person years of experience at the hospital. This Executive was responsible for all the decision-making in the project. Once the outline of the project was clear, it established "Training and Consultation" sessions, initially with the senior medical, scientific and nursing staff but then focussing later on user training with more junior staff as various parts of the system were moving towards implementation. The Executive, decided to address the areas of activity that we described as Patient Administration in order to gain experience of these systems before tackling the more life threatening issues of the full medical record.

Although, even then once a part of the system had been introduced and was running routinely, any interruption or failure to deliver results could cause considerable organisational problems -and would have the senior doctor and nurse out on the wards trouble shooting the clinical issues. The whole process was that of exploring an area of systems activity with surveys or Operational Research techniques, developing a feasible computer-based system, testing the users reactions and making changes as needed, establishing an appropriate training programme and then proceeding to full implementation -and reviewing problems and progress some weeks after implementation. During the development of the project, the hospital Chairman, Sir Harry Moore, provided us with a copy of an early paper outlining why computer systems fail (8) and he advised us that he did not expect us to fail for any of the reasons outlined in that early paper! That paper listed many of the reasons why so many computer systems have failed and still continue to fail! An early Figure 1. Poster of MIE 1978 Conference review of the project was given in (9); the basic software developed "in-house" for the system was ported from the initial Univac 418/III fast message-switching hardware to two other platforms before finally being decommissioned after some 36 years a few years ago. The reason for the original choice of computer system was that it was a very fast message switching system with a 750ns cycle time, 80k of 18-bit words of RAM and two fast drums holding 3m 6-bit characters with 4 ¼ms access time backed up with a Fastrand II holding 132m characters with a 90ms access time. The whole scheme was designed to facilitate the fast menu selection process (10). Although the system came with a basic RTOS operating system, it was necessary for the staff to write all the "middleware" to enable the system to function a needed by the designers and the hospital staff.

THE EMERGENCE OF NURSING INFORMATICS

Although the term medical informatics was frequently used, it was inevitable that nurses should become heavily involved in the use and design of health care information systems. Indeed at the foundation of EFMI there was considerable discussion about the name but it was finally decided that the term "medical" should be interpreted as including all aspects of health care -instead of specifically including the words "health" or "health care" in the title.

The issues of nurse allocation were an early interest of mathematicians and some computer solutions followed but a more important issue surfaced in the handling of the records of nurses in training and the development of training programmes. If the allocation programs were somewhat too complex for the early computers, it became clear that as "nurses looked after patients who were visited from time to time by doctors", they would be closely involved in the acceptance or rejection of medical information systems both on the hospital ward and in the community. Successful projects invariably involved nurses who could focus on the systems aspects with their colleagues and ensure that they were designed to help their colleagues carry out their activities. The recording of these activities became integral with the activities themselves rather than an additional task added at the expense of providing care for their patients. As with doctors, the important issue was to find some acceptable means of data capture "in real time" instead of creating additional time-consuming work. It appears to be true today that some systems still absorb far too much nursing time and take nurses away from the basics of patient care.

The first conference of the pre-cursor of the International Medical Informatics Association was MEDINFO 74 (11) and already there were were a number of papers on nursing issues and systems in the first conference raising issues relating to the processes of caring for patients (12), drug administration (13), intensive care (14) and ed-ucation (15). However, following increasing interest in nursing systems at MEDINFO 80 (16) in Tokyo with the Japanese nurses the British Computer Society's medical computing groups agreed to host a special conference on nursing systems that aimed to bring together the first international meeting concerned with Nursing Informatics to pull together what was known and going on in the field. Maureen Scholes co-ordinated and chaired this activity and the resultant conference in London and Harrogate is recorded in reference (17). The success of this effort led to the formation of IMIA WG8 on Nursing Informatics, with Maureen Scholes as the first chairman who was then followed by Prof Kathy Hannah.

BUILDING AN INTERNATIONAL COMMUNITY

Prof François Grémy's initiative from led to the formation of Technical Committee 4 of the International Federation for Information Processing [IFIP]. When we received his invitation to participate in this activity we were surprised that anyone would contemplate "going overseas" for a committee meeting but his insight and forward thinking led to the amazing world-wide series of activities of the International Medical Informatics Association (IMIA). In the process of participating in and contributing to these IMIA and EFMI events, we have all developed a network of friends and colleagues across the world who have helped us sharpen our ideas and helped us find solutions to problems as a result of their different perspectives and types of expertise. This globalisation began long before e-mail and the internet but the Group 4 fax machine did mean that, for the first time, it was possible to contact colleagues where one's poor language skills made it impossible to get past our colleague's telephone operator! This international community who manage happily to turn up at very unlikely locations across the world to attend committee meetings and to participate in conferences is the most precious asset that we have in medical informatics.

The British Computer Society (BCS) had established a Medical Specialist Group in 1967 to explore the growing ways in which computer systems were beginning to be used in a variety of hospitals and health care organisations but we were able to find limited funding that enabled us to participate in the activities of IFIP/TC4 -an obscure designation that lasted for the first 10 years until we were able to gain independence as IMIA. The first major activity was the development of the MEDINFO conference in Stockholm on August 5-10, 1974 (11) which started the three-year series of world-wide conferences. In addition, various working groups were established to explore particular issues in detail -Education was a major issue but so was Data Protection and Security which was initiated as WG4 under Prof Gerd Griesser. Japan into the IMIA orbit and, of course, there were many distinguished Americans who brought the USA into the world-wide activities -Morris Collen, Donald Lindberg, Marion Ball -to name but a few! The MEDINFO congresses continued as the main showcase of medical informatics with the sequence etched in the mind much more clearly than the dates of the kings of England that we learned at school! Each MEDINFO was memorable for different things but many of us remember Jean-Raoul Scherrer riding an elephant into the circus one evening in Geneva at MEDINFO 92. MEDINFO 89 was intended to be held in Beijing and the programme committee were meeting colleagues who had not spoken english for thirty years. It was sad that events outside our control led to a split conference where the main part was moved to Singapore while the mainly Chinese participants met as originally planned in Beijing. However, I succeeded Peter Reichertz as editor and, with Gustav Wagner's help, we produced the proceedings of MEDINFO 89 (19) exactly as the programme committee had planned the meeting rather than as it eventually turned out -it was the meeting as it never was and our Chinese colleagues were very pleased with that result! In addition to the large conferences, IFIP/TC4 established a series of working groups. There was an early interest in the issues of education with the establishment of WG1 and the issues of confidentiality were developed in WG4. Prof Gerd Griesser and then David Kenny, chaired the first activities of WG4 leading to monographs on the issues (20,21). These early working conferences were successfully re-initiated in conjunction with Prof Ab Bakker with follow-up conferences in 1992 every two years with working conferences in Heemskerk (22), Helsinki (23), Osaka/Kobe (24), Victoria (25) and Varenna (26). Ab Bakker, Tervo Pellikka, François-Andre Allaert, Kiyomo Ishikawa, Joechen Mother and Francesco Pinciroli all played their part in making these working conferences happen. Another working conference on Hospital Information Systems held in Cape Town (27) led to another working group but everyone's experience is clouded by their specific interests as the field is so wide and so expanding that no-one can embrace the totality of these developments.

The Journées d'Informatique Médicale were held in Toulouse for some 10 years providing an international meeting place for many interested in Medical Informatics but eventually it became clear to many in Europe that IFIP TC4 and its Working Groups would not be able to address all the needs of the developing European Medical Informatics community and the Toulouse meetings needed to be built upon by an organisation that embraced all European countries. Thought was given to the development of a European Medical Informatics body that would complement the world-wide body -although many of the participants in IFIP TC4 were worried that this might detract from the world-wide activities. A meeting was convened at WHO Headquarters in Copenhagen on 10-11 September 1976 that led to the establishment of the European Federation for Medical Informatics (EFMI). The need for this European dimension was underlined by a very successful Medical Informatics conference, MEDCOMP 77 (28), organised in Berlin by Online Conferences Ltd based at Uxbridge University. Further conferences were considered but when the BCS offered to host the first EFMI conference it firmly put in place a professional organisation providing these events instead of a private commercial but friendly and interested commercial concern. The first EFMI conference took place in Cambridge on 4-8 September 1978 (29). (Figure 1). These, MIE, conferences followed thereafter in the years between MEDINFO conferences. The second conference followed in Berlin and the third in Toulouse. MIE 79 30 (32). As computer systems for holding Personal Data were developed the issues of data protection and privacy became important. The Convention "For the Protection of Individuals with regard to Automatic Processing of Personal Data was developed in 1981 (33) together with a Recommendation on "Automated Medical Data Banks (34) which was developed further in 1997 as a Recommendation "On the Protection of Medical Data" (35). These issues were taken much more seriously in Europe than elsewhere and the European Union based its Directive "On the Protection of Individuals with Regard to the Processing of Personal Data and on the Free Movement of such Data" (36) in 1995 on the previous work of the Council of Europe and the needs of the Single Market. Unfortunately, many of the freedoms established in these documents have been eroded by the significant but often over-exaggerated fear of "terrorism" in a fashion reminiscent of the religious wars of the middle ages.

At the start of the European Union's programme of Advanced Informatics in Medicine (AIM) a conference was organised in Brussels to explore the current issues of data protection within the health care arena (37) which set the scene for how these issues should be handled by the various projects within the programme. Even while these initial projects were running the secretariat established an AIM Requirements Board to explore generic issues for AIM and future programmes in the wider medical area (38) and published this more widely (39). Amongst this work there was developed a series of "Six Safety First Principles" for medical information systems (40,41) which required that systems should be:

• Safe for Patients and Users;

• Secure for Patients, Users and Others;

• Convenient for Users;

• Legally Satisfactory for Users and Suppliers;

• With Legal Protection of Software Products;

• Multi-Lingual.

Perhaps for the first time thought was being given to systems safety inthe light of emerging problems of safety (42) as opposed to simplydata protection and of external systems control (43). The AIM programme and subsequent programmes included a number of medical data protection and security projects such as SEISMED (overview 44 & final Guidelines 45), ISHTAR (46) and MEDSEC (47) among many others. Some of these issues were presented to the annual British Computer Society Healthcare Computing conference in 1992 exploring the "Worst Case Scenarios" or "What happens when it all goes wrong?" (48). These issues were raised again under the heading of "Info Vigilance" at MEDINFO 2001 (49). The issue of safe information systems is a subset of the wider issue of the delivery of safe health care and it needs to be tackled in that context. The AIM programme was looking towards new standards for health information systems as well as new systems. The MEDSEC project was exploring these issues and the European Standards Organisation (CEN) had established a Technical Committee 251 to develop appropriate standards for medical information systems (CEN/TC251) and working group 6 had been addressing information safety and security and a number of draft standards were developed including prENV 12924 which attempted to categorise Healthcare Information Systems and prescribe the protection that each category needed (50). The fundamental conclusion that we reached was that we needed a safety standard developed in the context of IEC 61508 for medical systems and devices (51). Meanwhile, the clinicians were becoming concerned about safety issues in medicine more generally. The British Medical Journal ran an issue specifically on this topic in March 2000 "Reducing Errors; Improving Safety" (52) with 5 editorials on various aspects of these issues, 4 major papers and a clinical review. Sir Brian Jarman raised the these issues in his Harveian Oration at the Royal College of Physicians in London in 1999 (53) and and this had extensive coverage in the British press at the time. In America Kohn et al raised these safety issues in their book with the eye-catching title of "Too Err is Human: Building a Safer Health System" (54).

The Department of Health in London published its approach to these issues in "Building a Safer NHS for Patients" (55) and then established the National Patient Safety Agency to provide a continuing focus for advice and guidance (56). This work developed to the point where the BMA and the Royal College of Physicians set up a major two day conference to address various aspects of the matter on 21-22 October 2004 with the proceedings released later on a CD-ROM (57). The conference included a positively glittering array of medical and legal speakers including experts from other countries and industries. There was even a "mock legal negligence trial" presided over by a retired Lord Justice of Appeal in which the claimant succeeded in her appeal whereas the audience, comprising mostly of medical practitioners, thought that the appeal would fail! The issue of patient safety -and the safety of health information systems -is a cultural one of continual learning and improvement and, if some of the news from our hospitals today is correct, there is still a great deal to rectify and to learn. The adoption by IMIA of the Code of Ethics for Health Informatics Professionals developed by Eike-Henner Kluge in conjunction with IMIA WG4 could be a major step along the way to clarifying some of the issues involved (58).

AN ABRIDGED HISTORY OF MEDICAL INFORMATICS EDUCATION IN EUROPE

The history of medical informatics is relatively short. The field started in the fifties of the last century. EFMI was established in 1976 and educational programs in medical informatics in Europe were not introduced much earlier.

We were asked to sketch the history of medical informatics education in Europe. Different names with sometimes (slightly) different meanings have been suggested for our field of medical informatics. We will use the terms medical informatics, biomedical informatics and health informatics in this contribution interchangeably as umbrella terms.

When we started writing, we realized that we were not fully aware of all educational developments that took place in other European countries other than our own. That is why we called our contribution an abridged history with apologies that we probably do not refer to all important developments. On the other hand, we also realized that writing such a history does not mean that all developments have to be traced back and be mentioned. It is more important to look for trends that can be inferred from the various developments and to provide examples of those trends. That is what we have done in the following where we distinguish five different themes.

The questions whether medical informatics is a discipline separate from informatics or even whether it is a scientific discipline and whether it is necessary to develop specialized curricula for this field have often been posed. Especially in the beginning much of the research carried out by medical informaticians focused on the development of 08 Arie Hasman, John Mantas, Tatyana Zarubina systems, like for example hospital information systems, departmental systems, database systems, signal and image processing systems and expert systems. These systems had as goal to support physicians and nurses in their work. Later on questions about the quality of the systems and the general design principles on which they have to be based became more important. It was also realized that a technically perfect system does not warrant that such a system will be automatically accepted in practice. Since the implementation of an information system is a process of mutual transformation, the organization and the technology transform each other during the implementation process. Therefore, also sociological aspects play an important role and should be taken into account.

Medical informatics was considered by some as computer science applied to medicine, others were of the opinion that medical informatics was more than computer science and medicine together (because the body of knowledge in medical informatics also contained knowledge coming from a number of other disciplines like epidemiology, cognitive psychology, sociology, biostatistics, etc.) and therefore, they considered it as a medical discipline closely linked to but separate from informatics. However, in both views education in medical informatics would lead to graduates that were medical informatics professionals and not medical professionals (although some of these new professionals could initially have been educated as a medical specialist). Also, in order to be accepted by physicians, medical informatics specialists should be educated at an academic level.

Medical informatics is both an engineering discipline (design and development of information systems for example) and an applied science (aspects related to information science). Since medicine and healthcare are the domains of study of medical informatics, studies in medical informatics can lead to new knowledge that is pertinent to these domains. But the research outcomes are always about the computational and informational aspects of medicine and healthcare and therefore, also contribute to the field of medical informatics.

Research in medical informatics gradually changed. The development of information systems for example was increasingly left to industry.

We will not discuss the question about the scientific character of medical informatics further but refer to a panel discussion held during the IMIA working conference in Heidelberg/Heilbronn where it was concluded that medical informatics is a separate discipline with its own methodology (1).

Specialists in medical informatics were needed for a number of reasons. It was realized that because more and more medical knowledge was generated it would become very difficult for medical practitioners to stay well informed about new developments. In order to cope with the increasing knowledge base computers would be helpful.

Also in medical research the use of computer systems became very important. In education computers would be needed to teach medical students how to access knowledge and to become independent life long learners. For computer-aided learning medical informatics specialists would be needed next to medical experts. Computer-aided instruction was used on a larger scale after PCs were introduced that were less costly than the mainframes used before (e.g. in the Plato (Programmed Logic for Automatic Teaching Operations) project of the University of Illinois (2)).

There was another reason that medical students should be taught medical informatics: only with such a background they would become proficient users of information systems.

In several medical faculties academic units for medical informatics were created. These units carried out research and also started education in medical informatics or medical information science as it was then often called, especially in the US. The name 'medical informatics' originated in Europe where it was first used by Francois Grémy and Peter Reichertz. The term informatics was used to distinguish the discipline from computer science as it was called in the US. The hardware was not the distinguishing aspect of this discipline, the processing of data into information was the aim. Later the terms health informatics and biomedical informatics came into use. The first theme we recognized in medical informatics we called the 'initiation stage' with a wink to Nolan's life cycle. In the next section we will discuss the characteristics of a number of early educational programs.

Almost simultaneously with the first endeavours of individual departments to design courses in medical informatics, leaders in the field began reflecting about how to design courses and curricula in medical informatics that would lead to graduates with similar capabilities. Questions about the functions these graduates would take and which subjects they therefore should be taught passed in review. We will present this theme of 'guiding stage' in section 3.

In EFMI and IMIA working groups on Education and Training were established. The Education working group of EFMI organized workshops during MIE conferences. The IMIA Education working group organized a number of conferences. At a later stage, IMIA and EFMI working groups coordinated their activities in a more productive way by organising common workshops or by working together on the educational recommendations.

In the late eighties the European Commission started with financially supporting research and development of ICT applications in medicine. It was soon realized that the products delivered by the funded programs would only be used when the potential users would have enough knowledge and skills with respect to ICT. Therefore, several projects to stimulate education of health professionals were funded. We shall discuss developments of this 'contagion stage' in section 4.

Over the years new medical informatics educational programs were established all over the world. Since not only the technology but also the character of applications was changing, education should take these developments into account. IMIA felt the need to initiate the development of recommendations about the content of curricula in medical informatics. These recommendations should help to establish education in the field, to further develop existing educational activities in the various nations and to support international initiatives concerning education in health informatics. In principle this was a continuation of the efforts described in section 3. The Recommendations were published in the year 2000. Because of new developments in the field an updated version of the Recommendations was published in 2010 (3). This trend of 'consolidation' will be discussed in section 5.

Having recommendations for designing curricula, the next question becomes: how can one monitor the quality of medical informatics programs? IMIA decided to start the process of accrediting medical informatics programs. This theme of 'quality control' will be discussed in section 6. Section 7 contains some conclusions.

THE INITIATION STAGE

Technical Committee Four (TC4) of IFIP was established by Francois Grémy. Under his leadership TC4 became independent from IFIP in 1977 and was then called IMIA.

In 1974 for the first time medical informatics education was discussed at a meeting in Lyon organized by the international working group TC4.1. During this meeting the competences required by health professionals were identified. The meeting set the scene for application-oriented education at different levels of demand ranging from an orientation of users of information systems to the level of contributors to the advancement of system development (4).

At that time there were already some educational curricula in medical informatics. Francois Grémy for example already in 1969 initiated a curriculum in medical applications of computer techniques at Pitié-Salpêtrière. A second conference held in Chamonix followed in 1983. In the remaining part of this section we present some of the educational programs that were reported in Chamonix (5). In France and the United Kingdom some universities provided education and training to medical students and/or physicians. John Anderson at King's College Hospital Medical School reported about his experience with research and education in medical informatics. Learning medical students and doctors to type was one example of a training that enabled them to enter data into the medical record part of the hospital information system. This course was given during six years. Also computer-aided learning programs in several areas of medicine were being developed. However, according to John Anderson, these learning programs were hardly shared between institutions, and the wheel was re-invented regularly (6).

Computer technology was changing very rapidly in those days. First only mainframes were available, restricting the introduction of computing considerably. Then relatively cheap mini-computers came on the market, resulting in systems that could be installed even in individual departments. This situation changed even more after the introduction of micro-computers in the eighties. Now individual physicians could afford to use them. Since computer technology was usually a subject in medical informatics courses, the courses had to be updated regularly. But it was increasingly realized that the principles of computer technology have to be taught only superficially to medical students. Instead the methodology behind applications was important and the benefits but also the limitations of the use of computers should be explained.

The establishment in the Soviet Union of medical informatics as a discipline (called medical cybernetics) began in the late fifties of the twentieth century. Like in other countries in Europe also in the Soviet Union the following questions were posed and discussed:

• Is medical cybernetics a mere combination of medicine and cybernetics or something more -a separate scientific discipline and educational subject?

• Should medical cybernetics education be a separate area of high-level specialty training?

• Should all medical students be trained in medical informatics?

The first attempt in the Soviet Union to establish a medical informatics department in a medical school was undertaken in 1961 by the Leningrad Military Medical Academy. There was a small Medical statistics and cybernetics department led by professor L.E. Polyakov. A year later the department and its course were taken over by the larger Organization and tactics of medical service department.

In Salamon and Dusserre (7) reported that in the seventies and half of the eighties medical informatics was not part of the usual medical curriculum in France. For students who wished to become medical informaticians medical schools offered an optional course (Biologie Humaine) leading to a Master of Science degree. Also a PhD in Medical Informatics could be obtained. The authors mention that relatively many students followed the Master course. They also indicated that there were enough opportunities for graduates to find a job.

In Belgium Roger France introduced a course for medical students in which medical information processing, using an informatics methodology was taught to facilitate decision making (8).

In the Netherlands at the Free University in Amsterdam in 1973 the department of Medical Informatics started under the chairmanship of Jan van Bemmel. Apart from research the department became involved in education in Medical Informatics both for medical and informatics students.

To provide more insight in the character of applications and the way to implement them Jan van Bemmel developed a comprehensive model for ordering computer applications in medicine. It consisted of six levels of complexity with the higher levels being more and more human dependent. He showed that there were many more applications at the lower levels of the model, due to the fact that at these levels the dependence on the human is relatively small and therefore the chance of being able to create a successful application relatively large. Applications on the higher levels are more difficult to develop because usually the processes that these applications have to support are not well understood. One can learn from the model that when human dependence is high interactive applications should be designed. The model was widely used for teaching (9).

At the Free University medical students in the second year of their study followed lectures in medical informatics with a compulsory written examination. In addition elective courses could be followed in the third and fourth year. In the fifth year elective block courses were organized four times a year. The duration of the block course was five days and each day the student was confronted with topics from one of the complexity levels of the earlier mentioned model of van Bemmel. Each topic was introduced by a lecture and then followed by practical work in which the ideas presented in the lectures were further elaborated.

In the following an example of one day of the block course devoted to the level 'recognition and diagnosis making' is presented. In a lecture the students were confronted with concepts like sensitivity, specificity, predictive value, decision trees, Bayes' rule, ROC, etc. In the practical part the student was among others introduced to the differential diagnosis between neonatal hepatitis, biliary atresia and normality. A pre-pro-grammed decision tree was presented to the student. To each node a logical statement was connected, consisting of one or two conditions regarding one or two of four parameters (for example the results of laboratory tests), Each condition contained the name of one parameter followed by one of the operators 'greater than', 'equal to' and 'smaller than' followed by unknown threshold values. In case there were two conditions they were combined with one of the logical operators AND, OR and NOT. The student had to determine the threshold values that optimized the classification performance of the decision tree. A database with patient data was available to determine the thresholds (10).

The student could also work with Bayes' rule to get familiar with the concepts sensitivity, specificity and predictive value by actually calculating them. In addition this rule was used to determine which of seven congenital heart diseases a patient was suffering from. A database was available with the necessary probabilities and the data of a number of patients. Also the students could construct ROC curves to better understand its meaning (11).

Informatics students could also specialize in medical informatics. During their study they had to spend a year specializing in medical informatics. Students had to study basic physiology and anatomy, biostatistics, pattern recognition, signal analysis and image processing, networks and communication and the structure of healthcare. In addition they were confronted with special medical informatics subjects. The informatics study was finished with a thesis in medical informatics (12).

At the University of Leiden students were offered the possibility of obtaining a degree in Medical Informatics. In the beginning of the nineties a separate four year program in Medical Informatics was established by the University of Amsterdam. This program is still in existence and is now the only bachelor/master program in medical informatics in the Netherlands (13).

In Germany a degree in medical informatics could be obtained in several ways: via an application subject Medicine in an informatics study or via a postgraduate course.

Since 1974 several universities offered courses in informatics with application subject Medicine. In total 20-25% of the study was devoted to the application subject. A certificate in Medical Informatics (not issued by a university but by the German Informatics Society and the Association for Medical Documentation, Informatics and Statistics (GMDS)) could be obtained by graduates from different disciplines after 5 years of on-the-job training (comparable to the requirements for becoming a clinical chemist). The requirements for the certificate were specified. The five years of on the job experience for example needed to focus on either or all of the following fields in a medical environment: information management, (computer-aided) management of healthcare delivery and technical informatics and software production. Also, as was the case in The Netherlands, non-physicians could obtain a doctoral degree presented by the Medical Faculty when they completed work and a thesis within the medical environment and with relevance to the theory or practice of medicine. In 1978 medical informatics became compulsory for medical students. Moreover an additional qualification in medical informatics could be obtained by physicians. The qualification required a minimum of 2 years of clinical work and a minimum of 1½ years of work in medical informatics, normally under the supervision and direction of a holder of the certificate for medical informatics (14). The philosophy behind the curriculum was that informatics is a methods-oriented science concerned with applications of computer systems to solve concrete, existing problems rather than with research about and teaching the principles of computer systems. This meant that formalization and modelling of the problem field, selection and implementation of methods for solution and the application of methods in information processes should be part of the curriculum.

Conveyance of skills, attitudes and reliable judgment are of great importance in practical sciences, while knowledge and rational reasoning may suffice in a theoretical discipline. The incorporation of practical training before, during or after university education is a recurring characteristic of curricula for practical disciplines. Since the program was of the opinion that medical informatics was a practical science the practical training was deemed very important (16).

The education took 4.5 years and the program usually had an intake limited to 35 students per semester. Foundations of the natural sciences and technology covered 25% of the curriculum, informatics 40% and medical informatics 35% (15). Theoretical informatics was less emphasized; the focus was on practical informatics. The medical lectures provide the basic concepts of human biology, terminology and medical methodology so that the graduates were able to understand, to analyze and to solve application problems in the medical area. But medicine should not only be presented by the subset of human biology which tended to overload the student with irrelevant detail. Instead of these irrelevant details it should include the healthcare system: or-ganizations and social structures and institutions and methods to analyse, model and modify them.

A key element was the practical course on "Systems engineering in the health care field". Fifteen hours per week in the beginning were allocated to this course which took place in the actual work environment of the healthcare field during the end of the second year.

Students developed scientific concepts via literature seminars and via lectures of invited experts. In 1983 20% of the students graduating from informatics curricula with medicine as application subject worked in the healthcare field as compared to 60% of the graduates from Heidelberg/Heilbronn. The Heidelberg/Heilbronn program now exists for about forty years (17. 18, 19, 20). The curriculum was revised several times during its existence among others to keep up-to-date with the developments in the field (21).

In Greece in the late seventies only a few hospital based seminars and courses were taught on the principles of computer science to a healthcare professionals' audience as part of their continuing education, preparing them for the acceptance of the political decision of the early hospital information systems implementations. At that time no formal academic courses existed. Related formal courses were those included in the traditional Medical Physics courses already implemented a decade ago before that time in most Medical and Nursing Schools.

The programs mentioned in this section were usually not based on existing model curricula. Exception was the medical informatics program of Heidelberg/Heilbronn. During the years several model curricula were proposed in Germany. These model curricula influenced the Heidelberg/Heilbronn curriculum but also the other way around. This will be the subject of the next section.

THE GUIDING STAGE

In May 1969 in Germany a model curriculum for informatics was prepared with support of the then existing learned societies for mathematics and communication technology (the German Informatics Society was founded in the fall of 1969). Three types of informatics were defined: theoretical, technical and practical informatics. About 75% of the curriculum was devoted to these subjects. The remaining 25% was assigned to an application field, like engineering, commerce, mathematics or medicine (22).

In 1973 Peter Reichertz together with the Informatics Society and the GMDS organized a workshop to define a framework for education in medical informatics. This meeting was held at the Reisensburg in Ulm, Germany. Several types of education were defined for medical students, physicians, informatics students and informaticians: medicine as an application subject in an informatics study, informatics education for medical students, an additional qualification Medical Informatics for medical specialists and a certificate Medical Informatician for both informaticians and physicians were the suggested possibilities. From these educational variants it can be concluded that medical informatics was considered a combination of medicine and informatics. Yet a number of topics were included in the curriculum that were not regularly taught in either the core informatics or the core medical education: Methods critique of medical thought and decision processes, Man and environment, Hospital organization and management, Organizational structures in Healthcare and Legal issues. It was expected that these topics had to be taught by medical informaticians because these topics were rarely found in either informatics or medical curricula. According to Möhr the inclusion of these topics proved that medical informatics was more than the union of medicine and informatics and that one of the most important contributions of the conference was the creation of a vision of a new type of professional, the health informatician and the specification of an integrated curriculum which was more than a union of a subset of medicine and informatics. This provided a welcome framework for the Heidelberg/Heilbronn program.

Jochen Moehr reported about this meeting in the IMIA Yearbook of 2004 (23) and also discussed the effects of the Reisensburg meeting, especially for Germany (22).

The symmetry between medical informatics education for informaticians and physicians as expressed in the Reisensburg meeting was put into practice. From 1978 on medical informatics became a compulsory part of medical education. Immediately after the meeting several university programs in informatics started offering medicine as an application subject. The Certificate Medical Informatician was introduced in 1978. Also several institutions started offering courses leading to the additional qualification Medical Informatics.

In 1991 the Recommendations for Education and Training in Medical Informatics of the GMDS appeared (24). It elaborates the Reisensburg framework. The recommendations distinguish an informatics-related approach and a medicine-related approach to medical informatics. But contrary to the Reisensburg framework the recommendations considered medical informatics as a separate medical discipline with specific methodological approaches and with distinguished fields and not as just a combination of informatics and medicine. This shows that the Heidelberg/Heilbronn curriculum influenced the recommendations. Concerning the informatics-based approach the recommendations also mention medical informatics as an 'integrated' applied subject within informatics curricula. This referred among others to the informatics curriculum of the University of Hildesheim together with the medical school of Han-nover: this informatics curriculum started in 1988 with medical informatics as a core part of the curriculum.

The recommendations also stated that an informatics study with an applied subject should be called applied subject medical informatics instead of medicine. A mere educational offering of medical fundamentals was not enough as an applied subject. Also it is stated that the number of hours devoted to medical informatics as recommended by the Informatics Society should be increased. The recommendations explicitly mention the subjects that were regarded as medical informatics subjects: structure of the healthcare system, medical documentation, information systems in healthcare, biosignal processing, image processing, medical linguistics, knowledge based methods and systems in medicine.

In 1981 a report about a model curriculum for doctoral-level programs in what was called health computing was published in the USA by the Association for Computing Machinery (ACM) (25). The health care industry in the United States was a $220 billion a year industry (about 10% of the Gross National Product), with information handling accounting for about 30% of the health care dollar. Although computing could play a major role in facilitating health care information flow to reduce costs and improve the quality of care, the health care industry lagged behind most other major U.S. industries in its utilization of information technology. According to the report this was due to a great extent to the scarcity of adequately trained health computing professionals who can design and develop appropriate uses for the technology. The health computing profession's development and its ability to attract bright and creative young professionals, in turn, was hampered by the poorly specified and diverse career paths, the lack of a well organized peer structure for information exchange, and unspecified goals for the education of health computing professionals.

The authors noticed that there is a need for leadership and that in order to be accepted by the medical profession they should have a comparable preparation as MDs have. Therefore they proposed a model doctoral level curriculum. This acceptance problem was also the reason that in the Reisensburg framework a university level for the graduates was deemed necessary together with five years of on the job training for those who wanted to work as leaders in the healthcare sector.

In the report the subjects that all health computing specialists should master is specified: computer science, health sciences, integrative studies and contributing studies. The remaining part of the curriculum is divided in four tracks: health information systems, health research computing, health educational computing and health computing administration. They suggest that students will be attracted from a diversity of disciplines, ranging from computer science and mathematics to engineering to biology. According to Möhr and Leven a comparison of the Heidelberg/Heilbronn cur-riculum with the ACM curriculum shows that a large set of concepts is covered in both curricula.

In the Netherlands in 1987 recommendations for education and training in medical informatics education and training were formulated by the Subcommittee Medical Informatics of the Committee for Medicine of the Royal Netherlands Academy of Arts and Sciences under the chairmanship of Jan van Bemmel. In the report 'Medical Informatics -Renewal in Medicine' it is noted that professionals in healthcare were increasingly confronted with computer systems (26,27). Since the professional will always be responsible for the consequences of the use of the results of medical information processing, it is important that the student in medicine (or health sciences) will be taught both the fundamentals of medical information processing and the essentials of existing applications. Another reason to introduce students to the field of medical informatics was the fact that medical education requires the students to accumulate a multitude of facts. Because of the explosive growth of biomedical knowledge more and more of this knowledge was crammed into the curriculum. The report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine (GPEP) of the Association of American Medical Colleges entitled 'Physicians for the Twenty-First Century' was taken as starting point (28).

The perception that medical education too much emphasized the acquisition of knowledge was taken as one of the starting points of the GPEP report. The Panel recommended that in the general education of the physician medical faculties should emphasize the acquisition and development by students of skills, values and attitudes at least to the same extent that they do their acquisition of knowledge. Medical faculties should limit the amount of factual information that students are expected to memorize. The Panel realized that the acquired knowledge rapidly would become obsolete by the advances in biomedical knowledge and technology. Moreover students were passive recipients of information rather than active participants in their own intellectual growth. Medical faculties should encourage students to learn independently. The development of skills that support independent self-directed learning should therefore be emphasized. Students who learn independently develop abilities to seek out information and to analyze and apply it to the solution of problems. Computers are powerful tools for education, information management and analysis. The Panel concluded that basic research is needed on the use of electronic information systems in medical education. They therefore recommended that Medical Schools should designate an academic unit for institutional leadership in the application of information sciences and computer technology to the general professional education of physicians and promote their effective use. These latter recommendations were based on the Subgroup report on Medical Information Science Skills, chaired by Nina Matheson and Donald A. B. Lindberg (29). They observed that only a handful of American medical schools have the personnel and computer resources to provide education in the principles and operation of medical information systems.

The subgroup described seven levels of understanding of the principles of information handling: (1) Using basic information handling tools; (2) Independent learning about computers and information management; (3) Using computer systems and accessing databases; (4) Knowledgeably using systems and specialized databases; (5) Perceiving new applications; (6) Building systems for personal applications and 7Tool building.

The Dutch report 'Medical Informatics, Renewal in medicine' proposed the content for the introductory education in Medical informatics, based on levels 1 to 4 of the GPEP report. Also it was stressed that the medical students should get practical experience so that they would understand the possibilities and limitations of information systems. Although the education of medical students was extensively elaborated, the report also mentions the need for educating medical informatics specialists via PhD studies and informatics graduates with a major in medical informatics. The recommendation that all medical faculties should designate an academic unit was taken over in the Dutch report.

The Information for Health programme (IfH) of the NHS had as purpose to put in place the people, resources, culture and processes necessary to ensure that the NHS clinicians and managers had the information needed to support the core purposes of the NHS in caring for individuals and improving public health. To successfully implement IfH at the local level the NHS Information Authority in 2001 developed competency profiles that identified skill and knowledge levels for NHS staff. The profiles provided guidance and baseline data for local staff training (30).

In The medical cybernetics program at the university level comprises the study of several tracks: humanitarian, social and economical, mathematics and natural science, the professional, educational practice and practical training, research and the final state certification, with the main component being the preparation and defence of a diploma thesis. Each track has mandatory and elective parts.

The mathematics and natural science track includes the subjects: differential and integral calculus, mathematical statistics, computer science and medical informatics, morphology (anatomy, histology, and cytology), physiology, general pathology (pathological anatomy and pathological physiology), pharmacology, biochemistry, genetics and immunology.

The professional track consists of clinical and medical cybernetics subjects. The clinical subjects are internal medicine, clinical and experimental surgery, neurology and psychiatry, pediatrics, radiology, radiotherapy and clinical cybernetics. The subjects of medical cybernetics include the theory of cybernetics, medical electronics, physiological cybernetics, systems analysis and health system organization and health information systems.

Learning outcomes of the medical cybernetics program are: the mastery of knowledge of and skills in automation of data entry, physiological signal processing, methods of experimental design and statistical analysis of data, applications of mathematical and heuristic image analysis methods for solving problems of differential diagnosis and prediction of the patient state, methods of model construction and analysis (from the sub cellular level to health care systems), purpose and principles of the design and construction of automated health information systems, mathematical tools of systems analysis, etc. Graduate work is done during the last semester. It is a complete research or design project carried out under the supervision of a medical cybernetics specialist. The knowledge and skills of medical cybernetics graduates are described in the FSHS.

In Russia the term medical cybernetics denotes the specialty, whereas the term medical informatics denotes the discipline that is taught to students majoring in the specialties Clinical Medicine, Pediatrics and Dentistry. Medical informatics education to medical students started in 2000 in Russia. In that year the Russian Ministry of Health approved a program for this discipline, prepared by the Second Pirogov Moscow Medical Institute (now PRNRMU). It was regarded as a separate discipline. The education in medical informatics covered 38 hours, 12 for lectures and 26 for workshops, and was given in the middle of the six years of the medical study. In all workshops the students had to work individually on the computer.

During the first five years of training the first experience with teaching medical informatics was obtained and weak points were detected. To improve the training of the medical informatics discipline the The most common suggestions and proposals mentioned in the returned questionnaires included the need for advanced training of teachers of the medical informatics course, the establishment of a model set of special software (computer programs that will help students to study how to develop medical models, to acquaint themselves with medical information systems in practice or to design, for example, expert systems for medical decision support), the availability of a database of test questions for students to test their knowledge and the necessity to increase of the number of classroom hours.

The third version of the Federal State Higher Educational Standards included the recommendations of the Russian medical information society. For instance, the training of the medical informatics course for students majoring in Clinical Medicine, Pediatrics and Dentistry now equals 3 credits, which corresponds to 72 and 36 academic hours of classroom and self-study, respectively.

Due to this significant increase in training time for the medical informatics course, the range of topics could be extended and the requirements could include skills and abilities that should be developed during the study. It allowed a transition from familiarizing students with the aims of the discipline to being able to pass on a notion of the medical informatics theory and of modern computer technology applications in medicine and health care. After a typical course a student needs to know:

• Types, structure and characteristics of medical information systems;

• Principles of automated medical institution management, using modern information technologies;

• Basic approaches to formalize and structure various medical data types used to find solutions during the diagnostic and treatment process.

A student has to be able to:

• Perform textual and graphical processing of medical data using standard software;

• Use statistical and heuristic algorithms for diagnosis and treatment monitoring;

• Use the modern internet resources to search for professional information as part of self-training and advanced training in specific topics of medical knowledge;

• A student has to master the basic skills of using medical information systems to efficiently carry out physician duties.

In Greece during the early 1980's formal courses started to appear in curricula in the Nursing School of the University of Athens. The lack of computer skills made it appropriate to introduce Introduction to Informatics as a first officially taught course combined with a laboratory practicum. At a later stage a separate course was introduced: that of medical informatics. As there was a strong objection by most of the conservative faculty members to accept new subjects as courses within the official curriculum of a traditional Nursing academic programme, it was difficult to have both above mentioned courses accepted as obligatory within the curriculum, so one course was accepted as obligatory and the other as optional. Due to the lack of computer skills among the fresh students in the first years of this initiation, the obligatory course was the Introduction to Informatics and the optional one was the Medical Informatics course later renamed as Health Informatics. Exactly the opposite occurred in early 1990's when the computer skills of the incoming students were at an appropriate level. Medical informatics education was also covered in EFMI meetings. The education working group organized a workshop at each MIE meeting. In 2005 an EFMI special topic conference on Education in Medical Informatics was held in Athens attracting more than 200 attendees. This conference was also an IMIA meeting as indicated above. These conferences showed the interest that existed in medical informatics education, both to educate specialized professionals but also to educate medical students in the field.

The importance of information systems for healthcare was recognized by the European Community. Large amounts of money were funded to develop information systems of various kinds that could support professionals in their work. The AIM (Advanced Informatics in Medicine) initiative was a research and development activity of the European Community managed through Directorate General XIII of the European Commission. The programme focused on the possibilities of information and telecommunication technologies in the healthcare sector. It was realized that the developed systems would only be accepted and used when physicians and nurses had enough knowledge about and skills in the use of these new tools. The three year Concerted Action Education and training in health informatics (EDUCTRA) therefore started in 1992 as part of the AIM programme. Since the topic Education and Training in health informatics was considered too broad to be covered by one concerted action it was decided to focus on education and training in health informatics of professionals (including physicians, nurses, managers, etc.). The goal of EDUCTRA was to:

• obtain an overview of existing educational and training programmes in the area of health informatics;

• identify potential gaps in the training and education of healthcare professionals and patient groups in the various countries;

• propose, on the basis of this investigation, actions to remedy these gaps; and to

• investigate the potential of transferring existing training programmes to other countries.

Representatives of the member states surveyed the status of training and education in IT in their country. It appeared that in almost all countries health professionals lacked knowledge regarding the possibilities and limitations of information systems. It was concluded that the situation concerning health informatics at the universities was also far from ideal. Only some courses in health informatics were provided in medical and nursing schools. The courses that were offered were frequently devoted to the technical use of computers. In a large number of countries medical faculties did not have health informatics departments. Graduate students entered professional life without having had an introduction to the possibilities and limitations of information systems. Post-graduate level courses in IT and health informatics were of variable content and quality, probably due to the limited number of health informatics teachers (32).

Since hardly any curricula in health informatics existed it was concluded that one of the tasks of EDUCTRA had to be to define guidelines for developing curricula for various groups of professionals. The objective of the guidelines was to provide trainers with a framework according to which they can design their courses. These guidelines were produced and published in 1995 (33,34).

An Erasmus Inter-University Cooperation Programme (also a programme funded by the European Commission) had as target education in Health Informatics at the MSc level. The programme was funded (from 1989 to 1998) by Erasmus in two phases.

The first phase developed a curriculum in the field of Health Informatics at an MSc level after an international workshop organised in Athens, and the second phase was the implementation of the programme by exchanging both professors and students among six European Universities in the beginning of the implementation to 20 European Universities at the mature stage of the programme. The first six European Universities/Institutions were: University of Athens, Polytechnical University of Madrid, University of Gent, City University London, University of Pavia, and the University of Manchester. The programme was coordinated by the University of Athens, was given at the Nursing School, and the overall evaluation merited it as a very successful coordinated effort despite the huge logistical overload and the very little funding support by Erasmus for a programme with no registration fees for the students. The MSc education was given until 1997/1998.The aim of this curriculum that started in 1990 was to give those working or intending to work in the health service a broad advanced postgraduate education in health informatics in order to develop the ability to understand and evaluate in detail the theoretical and practical requirements of informatics in medicine, nursing and healthcare. The course enrolled students from different European countries and also had lecturers from several European countries (35). It should be also mentioned that the official title of the Erasmus programme established in 1989 was MSc in Health Informatics. The term Health Informatics was for the first time used in an official academic programme and academic title to represent our field.

Another Erasmus programme funded the development of an educational self-learning software tool to study the application of the Bayes theorem. This program was developed initially as part of the block course at the Free University in Amsterdam mentioned above. The program was redesigned and translated also into English, German and French in a cooperation of the University of Maastricht, Freiburg and Gent (36). The program consisted of two parts. An instruction part could be used by the student to repeat already learned concepts. With the second part the student can test his/her knowledge in an exploratory way. The computer-aided instruction program was used at several universities as well as at the above mentioned Erasmus MSc in Health Informatics in Athens.

In 1993 the joint European project EuroMISE (European Education in Medical Informatics, Statistics and Epidemiology) started under the umbrella of the European TEMPUS-PHARE programme. The idea was to teach the teachers in among others health informatics. Faculty from various European countries was involved in the programme. The students came from central and eastern European countries (37).

The results of European funded projects like EDUCTRA, the ERASMUS MSc Programme, the EuroMISE, etc. were the starting point of the IT EDUCTRA (Information Technologies EDUCation and TRAining) project that was approved in the Fourth Framework programme of the EU in 1995 (38).

The main goal of the IT EDUCTRA program was to create a training program for healthcare professionals in the basics of information technology and IT medical applications. The final product was a CD-ROM containing the teaching materials and tools and used new information technologies for the dissemination of knowledge and skills required for new health care systems.

The NIGHTINGALE (Nursing Informatics Generic High-level Training in Informatics for Learning & Education) project, again an EU financed project, was also approved in 1995 (39). The project was considered essential for planning and implementing of a strategy to train the nursing profession in using and applying healthcare information systems. The project was based on previous experiences obtained in the Telenursing AIM project and on the EDUCTRA Concerted Action which partially touched the subject of education and training of the nursing profession. The main goal of the project was to bring to the surface, by means of a series of workshops, the user needs of the nursing profession with respect to telematics, to develop a nursing informatics curriculum for European nurses, and to develop educational tools and software assisting the educational process in nursing informatics. A number of European Conferences on Health Telematics education were also organized (40,41,42) and a textbook in health informatics for nurses was compiled (43).

CONSOLIDATION STAGE

Over the years the number of programs in Health Informatics increased steadily. Beginning in 1990 the University of Maryland at Baltimore began to enter information collected on health/medical informatics programs worldwide into a database (44). IMIA's Working Group 1 on Education and Training in Medical Informatics provided guidance on critical issues of policy and purpose. In 1993 the database was revised to improve the quality and quantity of information accessible by remote users. The database was accessible through Gopher. A few years later it was reported that the data were outdated or replaced by links to the Gopher sites of the respective programs. It was then decided to establish a website at the University of Heidelberg. The main goal was to give potential students easy access to a new version of the database (45).

Although there were different opportunities world-wide for obtaining education in health informatics many countries had not, or at least not sufficiently, established such opportunities. Therefore IMIA felt the need to develop international recommendations for health informatics education. The IMIA recommendations that resulted took into account the various existing, mainly national recommendations of which some were mentioned in section 3. The IMIA recommendations were published in 1999 and centred on educational needs for healthcare professionals to acquire knowledge and skills in information processing and information and communication technology as needed and used in medicine and healthcare (3). The educational needs are described as a three-dimensional framework with dimensions 'professional in healthcare', 'type of specialization in health informatics' and 'stage of career progression'. For the various educational needs learning outcomes were suggested. Two types of learning outcomes were documented: learning outcomes for all healthcare professionals in their role as IT users and learning outcomes for health informatics specialists. Three levels of knowledge and skills were distinguished: introductory, intermediate and advanced. The knowledge and skill levels were classified into three domain areas: (1) Methodology and technology for the processing of data, information and knowledge in medicine and healthcare; (2) Medicine, health and biosciences, health system organization;

(3) Informatics/computer science, mathematics, biometry.

The programs that prepare graduates for careers in health informatics were divided into two types: health informatics courses as part of informatics/computer science programs and dedicated educational programs in health informatics.

The recommendations were received positively as can be concluded from the many references to them. Because of the tremendous progress in and the evolution of our field of health informatics, the contents of those recommendations were not fully up-to-date. Therefore a first revision of the Recommendations was published in 2010 (46). The name of the first domain area was changed into Biomedical and Health Informatics Core Knowledge and Skills, doing much more justice to our field than the earlier name: Methodology and technology for the processing of data, information and knowledge in medicine and healthcare.

QUALITY CONTROL

There is an increasing need for health informaticians and an increasing number of health informatics programs deliver health informaticians with different kinds of ex-pertise. The IMIA recommendations define the knowledge and skills necessary for these different types of health informaticians.

In many countries the quality of educational programs is monitored via an accreditation procedure. As a first step the program writes a self-assessment report that serves as a reference for a site visit committee. The site visit committee visits the premises of a program and checks the contents of the curriculum, the adequacy of examinations, lecture rooms, computer facilities, the library, etc. In some countries there are no accreditation requirements for individual graduate programs, only for universities. In this case the university determines the quality of programs that it offers, once it is accredited.

In order to attract the best students, institutions with health informatics programs, be it vocational, bachelor or master programs, may want to convince potential students of the international level of their program. A program may also want to show to their university board that they indeed provide excellent education. The results of national accreditations are not always convincing since not always do the members of national site visit committees have a clear understanding of the level of international health informatics programs or of the international level of health informatics itself. This is especially true when the university itself determines the quality of the program.

IMIA developed an accreditation procedure as a support for institutions that want to prove that their program in health informatics is of an international level (47). Institutions interested in IMIA accreditation have to write a self-assessment report. In the self-assessment report an answer should be given to the following six main questions: The self-assessment report will, in addition to a site visit, provide the members of the site visit committee enough information to judge the program.

The accreditation protocol is now tried out. In the mean time three programs have been accredited and another three are in the process of writing a self-assessment report.

DISCUSSION

In this contribution we have sketched the development of education in Health Informatics in Europe. We recognized a number of themes. Education in health informatics started in several European countries at the end of the sixties, beginning of the seventies. This education concerned health professionals, medical students and also students that wanted to become medical informaticians. In that same period also model curricula were defined as a guide for programs. A change can be observed from a focus on computer science to a focus on informatics.

In this contribution we did not mention the medical informatics educational literature. Several different textbooks on health informatics are available and several scientific journals in medical informatics also cover educational aspects.

The question whether health informatics is a separate discipline should, according to de Vries (philosopher at the University of Amsterdam; personal communication), be answered positively. In the first place in order to be a discipline institutional facilities are required. A discipline should at least have educational programs using its own textbooks. Furthermore, a discipline should consist of a population of researchers whose work has a larger chance to influence the work of others in the discipline than the work of researchers outside the discipline. According to de Vries the term discipline refers more to how education is organized than how the research is organized. Given the above survey of the history of health informatics we conclude that we can at least say that health informatics is a discipline. And in our opinion we can add that it is also an applied science.

Our contribution shows that the field of medical informatics has grown enormously. Medical informatics in itself is a very broad field and this means that there is a need for specialization. Because of the broadness of the field, medical informatics can be considered as an interdisciplinary field. The field is becoming mature as is evident from the last theme of this contribution.

Writing about the history of a domain or idea is a complex work, requiring a sound documentation through an immense volume of literature and other documents and will always be biased by the personal perception, experience and background of the author. The history of medical informatics has already been approached in various angles, as mentioned above. The view here comes from author's background in biophysics and informatics, his experience as an expert of EC, as an EFMI Council member and as a professor to both students in medicine and in computer science, including an experience as a director of a governmental institution.

The intent in this paper was to reveal the topics which raised the highest interest along half a century and link these trends with the specific socio-political and technological context. There are several remarks which should be mentioned here, some of them were discussed during the panel in Prague, and others were added after reading so much literature.

a) The staging proposed by the author has no precise limits. The roots of most characteristic ideas can almost always be found in the preceding period; I have included them in the stage where they proved to arouse a large interest. There are visible developments of some trends even within a stage, making possible to split them into sub-periods.

b) There are some topics which have not been mentioned separately, like nursing informatics, compunetics, emergency e-health, e-prescription, etc, or just mentioned without any comment, like patient safety, ontologies, personal medical record, healthon-the-net, etc. c) A better understanding of a certain event or feature is gained when one also mentions or describes the context in which it is presented. The inter-relations between context and events are strong and offer the best mean to foresee the future developments.

Finally, some comments about the references. The key words for articles and, especially the subject index in books are supposed to be not only helpful, but almost essential for such a historical undertaking. Unfortunately, even there are clear standards in this direction (Medical Subject Headings MeSH (69), they are not always observed, making "improvements": sometimes the granularity is either too low, but most often too high, making them useless. The common search engines make no distinction between normal text and key words. Moreover, most of the times, the classification is uniaxial. Or, in multidisciplinary domains, like medical informatics, one would prefer to classify an item (article, chapter, book etc) from various points of views: technological, methodology, domain of application, etc.

Concerning the references, for papers which are supposed to use a large number of references of various kinds, a classification seems welcome, hence we tried to use here separate lists for articles, books, journals and websites.

Another shortcoming is the limited life of some web addresses. It would be useful to have "archives" managed by the entities (institutions, societies, etc) which organized the events, where to store all the documents connected to them. An attempt to collect such documents is a part of the "IMIA History Project", led by Casimir Kulikowski, which has set up a web page (70) and organized an attractive Workshop at MEDINFO 2013 (71).

Empiric analyses of information scientists' profiles on Scopus, Web of Science, Google Scholar, ResearchGate, specialist databases, and social networking websites revealed that less than 50% of the authors' publication activity is covered (5). Uncovered literature, with the minorization of authors who are not from digital age, and their inadequate assessment with all the disadvantages, and great individual impact, cannot establish Google Scholar as a platform through which important decisions can be made in the academic community, even though it became practice lately. Different Scopus, Web of Science, ResearchGate and Google Scholar results on the work of an author require a further search for an ideal platform and an ideal way to assessment the work of an author. This current type of assessment is not good enough and certainly is not a real indicator of the actual work of an author, and especially impact of one author (6).

EUROPEAN FEDERATION FOR MEDICAL INFORMATICS -THE MOST INFLUENTIAL PROMOTER OF MEDICAL INFORMATICS DEVELOPMENT FOR THE PAST 45 YEARS

Medical informatics, as much as it is a result of evolution as planned philosophy, have its roots in the history of information technology and medicine. Development of medical informatics started in the fifties of the 20th century. In the period after Second World War USA was the leading country in the field of Computer science and the leader in using the first computers in medicine and healthcare services. One year after the MEDINFO Congress in Stockholm (1974) (Chair of SPC was Professor John Anderson, UK), several European Medical informatics societies started with establishing of European Federation for Medical Informatics (EFMI). There were three persons that in 1975 had the first discussions and they were Jan Roukens (Holland), Jan van Egmond (Belgium) and Mogens Jorgensen (Denmark). They started to write Statute and discuss these with a few other interested representatives from other European countries. These persons were called the Preliminary Executive Group (PEG) and they held a meeting in Paris in June, 1976, where they decided to invite all known European societies to be represented at a constituent meeting of the Federation of the European Medical Informatics Societies. It was proposed that one delegate with voting right from each Society be present in Copenhagen on September 10 and 11, 1976.

ESTABLISHMENT OF EFMI

On September 10-11, 1976 e) EFMI publishes scientific papers from its conferences in EFMI official journals.

Today EFMI is the leading nonprofit organization in biomedical and health informatics in Europe. EFMI comprises 28 national societies and includes an exceptional network of experts and stakeholders in health, care, IT and its societal dimensions; supported by 14 topic working groups ranging from human factors, to security and translational health informatics (5)

EFMI MIE AND EFMI STC CONFERENCES

EFMI PUBLICATIONS

The most important EFMI publication, indexed in Medline is Studies in Health Technology and Informatics, which publishes papers presented at MIE Conferences. EFMI also publishes several sub-specialty official journals covering the spectrum of medical informatics subdisciplines. Currently, EFMI has three officially endorsed general journals ( Figure 4), Methods of Information in Medicine, International Journal of Medical Informatics and Acta Informatica Medica. Until the year 2020 official journal of EFMI was also International Journal of Biomedical Informatics (EJBI), but excluded this year. From the year 2020 EFMI started to pubish EFMI Inside magazine. Through its work, EFMI provides leadership and expertise to the multidisciplinary, health IT community and to policy makers, enables the transformation of healthcare in accord with the world-wide vision of improving the health of the world population (9-12). EFMI is constantly striving to further the services it provides to its members and the informatics community in general by promoting free interaction among and between its member network and the bio-medical and health informatics community at large.

EFMI HONORARY FELLOWS

During past period EFMI Council has been elected 31 Fellows as most influential Medical informatics experts for their contribution in development of this academic and scientific field (3).

In alphabetical order EFMI Honorary Fellows are ( pertise to the multidisciplinary, health IT community and to policy makers, enables the transformation of healthcare in accord with the world-wide vision of improving the health of the world population. EFMI is constantly striving to further the services it provides to its members and the informatics community in general by promoting free interaction among and between its member network and the bio-medical and health informatics community at large.

EFMI AWARDS

In the year 2015, during MIE conference in Madrid, the EFMI Council approved the establishment of a Medical Informatics Award of Excellence named "Leo Peter Reichertz Young Scientist's Award" and "Rolf Hansen Memorial Award" to be given to an individual, whose personal commitment and dedication to medical informatics has made a lasting contribution to medicine and healthcare through her or his achievements in research, education, development or applications in the field of medical informatics. Also, during MIE conferences Mantas' Prize for Best Paper on Education in Biomedical and Health Informatics is giving to presenter for "Outstanding paper about Education in Biomedical and Health Informatics".

FORTY FIVE YEARS OF THE DEVELOPMENT OF MEDICAL INFORMATICS IN BOSNIA AND HERZEGOVINA (BIH)

From the 1974 automatic analysis of health data in health care institutions in Bosnia and Herzegovina was introduced gradually thanks to the engagement of Fuad Sacirbegovic director of Department for Statistics of the Federal Public Health Institute, Serstnev, whose heritage is on the same position. From 1977 Institute has published annual reviews and summary health statistics reports in BiH and utilization of health capacities under the title "Network, capacities and services of health institutions in BiH".

Initiation, development and implementation of some informatics activities, such as automatic manipulation of health data and intensive use of information technologies for the need of diagnostics, therapy and patient rehabilitation on the all levels of healthcare in BiH health system started to be solved systematically in the end of seventies and in beginning of eighties. Crucial decision at state level was in 1981, when BiH government brought decision to start with work on the project "Development of BiH Health Information System -HISBiH". Before the project, the study/analysis "Social-economical First, informatics education which should provide general knowl-• edge to users and data analysis on the place of their generation, and on all places of collecting data in health system (physicians of all specializations, nurses and paramedical staff). Second level, informatics education of this level is in regard to med-• ical staff which was directly involved in collection, manipulation, analysis and interpretation of health data. This kind of education was expanded with skills, knowledge and practical applications which are necessary for personnel on this level. The Third level is basically a very wide and highly specialized education for experts in the health sector who would like to be professionally involved in this kind of work. In B&H there has never been an accepted proposal for introducing sub-specialization from medical informatics in spite of the fact that authors of this paper put a lot of effort and energy into making it official. It is a fact that at some universities in European countries there are separate faculties or universities for graduates withthe title of engineers of health informatics.

There The EFMI FOUNDERS electro and mechanical engineers, economists and was chaired by myself). In 1985, after positive assessments, the revisions of the project were adopted and its implementation began after financial funds were ensured. Implementation started in 1986 and it was planned to be Concept of centralization of data manipulation in the architecture proposed in HIS BiH project (central host and analysis in Sarajevo, regional analysis in eight centers in BiH and local in 109 municipalities) but it has never been finalized and failed. The true is that some of designed activities were started on institutional level, but never reached finish as Clinical information system of the University Clinical Center in Sarajevo, which was one of the biggest projects in area of development and construction of of medical data at every level of health care service (collecting, processing, evaluation, storage, using for decision making, etc.) in family practice, out-patients' clinics, general and special hospitals and university clinics. The time from primary collected data at every working place in health care system until final storage at in Department for statistics of WHO in Geneva was less than one year, it means it was very prompt and useful method and way for decision makers. But it was very huge and "paper based oriented" and health professionals were very occupied with data collecting and processing. We need to mention that one of founders of WHO and the first President of General and medical education (the first visit in 1975 and second visit in 1989), when I visited academicians Lisicyn and Gasparyan, recognizable persons in the health informatics and Cybernetics fields in Former Soviet Union. In that time University in Moscow produced "Vrach Kibernetics" (Doctor of Cybernetics), special medical occupation for health care informaticians. Education in Moscow and London defined my interest and occupation with Health informatics in Primary health Care and Family medicine and my Master and Doctoral thesis I earned in that field (Figures 6 and 8).

These are already mentioned facts which I published in interview with Professor Dezelic and explained important events regarding establishing and implementation of Health Informatics in Former Yugoslavia, but also in South-East Europe. I must describe some important points about development of Medical informatics and influence of our influential persons, not only from former Yugoslavia, because in the past very few experts in this field were mentioned as important persons who created strategy, tactic and operational activities in all kinds of Health and Medical informatics, not only in the Europe, even worldwide.

Medical informatics in biomedical education

The need for additional education of health professionals was realised after the first application of electronic data manipulation. For physicians in primary health care and in clinics, in order to perform their duties in a high quality manner, must have been up to date with the latest accomplishments in medicine and health. Since the 60's the development of information technologies has had a quantitative and qualitative growth especially in diagnostics and therapy, and health workers had to follow that. The International Federation for Information Processing (IFIP) in the early 60's organized expert teams whose task was to develop strategy, concepts and content of under and postgraduate medical education. At a Unfortunately, not so many of them became engaged in managing structure of EFMI and IMIA in the past (as presidents of IMIA or EFMI) besides very hard and effective influences od development of those associations. But, readers need to know that our students of Biomedical faculties have possibilities to learn the same subjects and contents of Heath informatics at Universities in former Yugoslavia as in US, UK, Germany, France, etc. because in that time we have had one of the best educational system in the world, also one of the best organized health care system in the world, which produced very qualitative products in all kind of industry, economy, education, etc. especially in Africa and Middle East, educated students from undeveloped countries, because president of former Yugoslavia, Tito chaired more than 100 countries ("The Nonaligned Movement /The Block of Independent Countries"). Interesting fact is that in 1984, Energoinvest Company in Sarajevo produced computers (IRIS 16 and IRIS 32), led by Academician Bozo Matic and his team (he was Director of "Energoinvest" company, also, President of Academy of Sciences and Arts of BiH, and Rector of Sarajevo University) where his team of experts in 1977 worked on projects on biological robotics and produced "biological prosthesis", etc.

One of my projects was creating "Family Registration Card" as "Medical Record Linkage" in Primary healthcare system for collection and depositing "minimal data sets" on electronic cards, as optimum of data processing and storage medical data for quality assessment outcomes of MDs work in Primary Healthcare System protection ("all data about one patient stored at one place" and the stored data must be kept by family practitioner). It was my project to establish the first Local Information System in BiH for Family medicine practice. Unfortunately, war in our country (1992-1995) stopped all those projects.

For education of Medical informatics subject, academician professor Dezelic (1931-), as pioneer of Medical informatics in former South-East Europe, established almost all Cathedras at universities in former Yugoslavia, From such formulations it clearly follows that the terms "Medical informatics" and "Health informatics" were considered synonymous, but in the former Yugoslavia areas (with a socialist society organization, in which there was no private medical practice) the adjective "health" was preferred. With the appearance of the international associations, IMIA and EFMI, the name Medical Informatics finally prevailed in our country (recommendations by IMIA experts of WG for education). At the time of the 1990 MIE Congress in Glasgow at a meeting of the EFMI Council and the IMIA Annual Assembly, YAMI was admitted to the membership of both international medical informatics organizations, but this did not last long. Already at that time, Yugoslavia entered a period of political unrest that led to its disintegration. It should be noted here that after the wars against Slovenia and Croatia in September 1991, both MI associations -Slovenian and Croatian -withdraw from YAMI, followed by the MI association of Bosnia and Herzegovina a few months later. After the Republic of Croatia and other republics of the former Socialist Federative Republic of Yugoslavia (SFRJ) were internationally recognized in January 1992 and became members of the UN in May of the same year, the conditions were met for medical informatics associations of the former three Yugoslav republics -Bosnia and Herzegovina, Croatia and Slovenia -to become members of IMIA and EFMI. This happened during the 1992 MEDINFO Congress in Geneva (7), but oficially accepted Izet Masic as national representative of Bosnia and Herzegovina at EFMI Council in Lisbon, Portugal, during MIE '94 Conference ( Figure 10) .

Gjuro

The worst time was for the Medical Informatics Society of Bosnia and Herzegovina (BHSMI) was, because the armed conflict lasted between March 1992 and November 1995, with the siege of the capital Sarajevo. But even in such a terrible situation, BHSMI, which I led, had a fruitful activity, amazing in such circumstances, managing to organize professional gatherings, produce numerous publications and launch the journal "Acta Informatica Medica" (www.actainformmed.org) (Figure 4). Cooperation with EFMI Medical informatics helped me in organization of these events in Sarajevo: in 1999 the First Congress of Medical Informatics, opened by Attila Naszlady, EFMI President, who helped me during wartime in BiH that BSMI became official member of EFMI (Figure 11 In the post-war period, BHSMI organized national symposia and applied for the MIE Congress, which was held in 2009, and signed from a lot of participants of former MIE Conferences as "the best ever MIE". Much more about these facts described in this part of article could be read in my other articles and several books in the field of Medical Informatics (mentioned in the list of references at the end of the text). A few articles are published in two official EFMI journals: Acta Informatica Medica (indexed in PubMed) and EFMI Inside, both deposited on www.efmi.org) (7). I will finish this small review about history of MI in BiH with words said by Gjuro Dezelic during opening of the MIE 2009 in Sarajevo in his keynote lecture: "We should consider the mandate to organize the MIE 2009 Congress in Sarajevo as the crown of all efforts of professor Masic efforts to get it for a long time… ". I added that the credit should be given to EFMI, which, by choosing Sarajevo, supported the construction of new medical, biomedical and health-information bridges between the western and eastern parts of the European world" and images which illustrates very important activities which helped to improve and use all achievements of Health/Medical/Biomedical informatics as scientific and academic disciplines and also in functioning of all segments of health protection at every level of healthcare systems.

EVOLUTION OF TRENDS IN EUROPEAN MEDICAL INFORMATICS

A comprehensive presentation of history of medical informatics requires a systematic and multiaxial approach, to provide not only a list of events, journals, organizations or people, but also to analyze the characteristics of each epoch, to reveal the trends and to recall both successes and failures. The evolution of ideas and trends in medical informatics had some specific features which deserve a special attention. By offering such a dynamic view, the "history" becomes a tool (1) for a realistic estimation of the impact of medical informatics on various domains -healthcare, computer science, industry and education. Such an approach was used in the Foreword to MEDINFO 86 of the Scientific Program Committee (2), analyzing the trends for a short period of time (3 years), within six major directions.

MATERIAL AND METHODS

One of the best ways to analyze the evolution of trends/ideas/concepts in any domain is to search the literature, starting with its early attempts to present the achievements in the specific field. This was also our approach, having an immense number of references: all congresses of medical informatics organized by EFMI (European Federation for Medical Informatics (3), or by IMIA (International Medical Informatics Association (4), as well as the contents of most representative journals (5)(6)(7)(8)(9) or book series dedicated to this field: Lecture Notes in Medical Informatics (10) for period 1978-1991, followed by Studies in Health Technology and Informatics (SHTI) (11). Nevertheless, some important books (mainly referring the early stages) were also considered. Even the number of materials consulted was large; the references listed here were limited to most relevant ones.

Another important source of information came from the European Commission (12). Several volumes in series (11) refer to projects carried out within successive research frames financed by EC (13)(14)(15)(16). Another source about the evolution of trends in bio-medical/health informatics was to analyze the very content of the courses presented to the students, either medical students/computer science students or future Healthcare Informatics Professionals (HIPs); all teachers tried to be "up-to-date" to the most important topics of interest of the domain at the particular moment (17)(18)(19)(20)(21). We could find here, not only some clear milestones for defining the most representative stages of development of ideas in Medical Informatics, but also some views about potential future development of the domain. A comprehensive view from educational point of view is included in the article of Arie Hasman et al. published in Acta Informatica Medica journal (22).

The present paper intends to systematize the enormous amount of information analyzed. This attempt is not the first one and we can cite here several books and articles on "History of medical informatics" (23)(24)(25)(26), seen from various perspectives: technological development, educational needs, research objectives, etc. Our attempt is to integrate all those views and extract from them the defining lines of trends, tracing the evolution of major topics and concepts of medical informatics within its complex environment, with moving targets, rapid technological advent and provocative societal challenges, by trying to identify the most common topics which raised the interest of the scientific community in (European) medical informatics over almost half a century.

The presentation was organized following the classical chronological way for a "historical" approach. From the point of view of evolution of trends, we can distinguish five major stages in the development of medical informatics, which will be presented here.

MAJOR STAGES OF MEDICAL INFORMATICS HISTORY

Early (pre-organizational/pioneering) stage: 1950 -1975

It might be surprising, but a lot of ideas about future developments have their roots in this period. Visionary scientists have realized the enormous potential behind the "new emerging information technology". Important technological steps took place, with fast transition through first three computer generations; some authors do even split this phase into five distinctive periods (24). Most related work from this stage had a visible pioneering mark but becoming good introduction for the future work in the specific field, under the generic title "computer applications in …" (27). A major characteristics of this stage we can note the absence of coherent research plans, the work was performed mainly in isolated groups, not raising yet the interest of healthcare managers. Worth to mention that, the development of software in parallel with hardware drew the attention upon "information processing" as a key issue and IFIP (International Federation for Information Processing, established in 1960 (28) under the auspices of UNESCO), initiated technical committees for various domains, including medical domain (TC4 since 1974). Even it is difficult to distinguish important revolutionary achievements for the medical domain, this period was quite prolific in ideas, opening the doors for significant future work.

To summarize the major characteristics of this period:

• Pioneering work of scientists who envisioned various applications of IT in medicine and healthcare (M&HC);

• Analog computers still considered;

• Major work on: signal analysis, laboratory applications;

• First attempts on decision support (diagnosis);

• Databases, modeling and simulation of some biological processes.

Medical Informatics -"childhood/youth": 1975 -1990

The work done in the preceding two decades traced the contour of the emerging domain, most often called "Medical informatics" or "Health informatics". It became clearer and clearer that several medical activities will use computer applications in the future; hence a certain preparation of present and future medical staff about computer use became obvious. Thus, the applications in major areas of medical informatics were systematized and first educational programs in medical informatics began (17), including advanced programs for healthcare information professionals. A detailed description about the evolution of medical informatics education is presented by Arie Hasman et al. (22). This is also the period when first national and international professional organizations (associations, societies) were established and specialized conferences started to take place. The object of medical informatics is still mostly perceived as dealing with computer applications in various medical fields. They referred not only clinical applications but also healthcare management, which raised the interest at higher level of healthcare institutions and also the interest of industry -the roots of "e-health as a business". IT offices/compartments in health ministries or health insurance houses have been created in some countries, elaborating strategies for local, regional or even national healthcare information networks (29), but the progress in this line was still limited to a couple of successful networks by the end of this stage (30).

However, the awareness about the potential of these applications to address major challenges of healthcare, accumulated along this period, led to inclusion of ehealth/ medical informatics topics in the research programs of the European Commission at end of this period. Several projects were financed by the EC under the first research frames, led at the beginning by Niels Rossing; for our domain it was the AIM (Advanced Informatics in Medicine) Exploratory Plan (31). An important program of WHO, launched at the beginning of seventies, made also reference to the use of IT for reaching their goals (32).

Most important expectations were from the applications in healthcare system; besides the local health information systems to cover certain regions (counties) mentioned above, a visible interest was paid to the development of clinical/departmental and hospital information systems (33), dragging in also the issue of medical data protection, security and confidentiality (34). The term EHR (Electronic Health/Medical Record) has been introduced also in this period.

For research, the highest attraction was held by artificial intelligence methods (29,35). The work on clinical decision support started to occupy an important place, including the development of medical expert systems, natural language processing, the work on medical terminology and ontologies, specialized high level software etc (36). Actually, research topics and developments showed a marked diversification: mathematical modeling and computer simulation of biological processes (37), advanced techniques for medical imaging (CT, MRI), biological signal processing and medical data analysis etc. Involvement of industry for the development of specialized equipment became evident, moving some of this work from medical informatics groups towards related fields of bioengineering. Actually, the parallel development of medical informatics and bioengineering is a good example of a successful cross-fertilization (38).

A point which has to be mentioned is that Europe was split by an "iron curtain" into West and East, with completely different views, mentalities, laws, etc by common heritage and goals (even not always recognized by the leaders). Communication between the two sides was difficult, facing obstacles which might seem today ridiculous! We should emphasize here that, despite all these obstacles, some people tried to maintain the feeble existing link. And, even this article aimed mainly to trace the trends and not the people, the names of Jana Zvarova and Jan H. van Bemmel should be mentioned for their efforts to offer the chance of two different worlds to meet (36,39).

To summarize the major characteristics of this period:

• Founding most national and international organizations, conferences;

• Attempts to systematize major areas of medical informatics;

• First specialized schools and courses;

• Development of methodologies, EHR;

• Principles of Clinical and Hospital Information Systems;

• Security and medical data protection;

• Advanced decision support systems -expert systems.

Consolidation period: 1990 -2000

The accumulation of knowledge and experience from the previous phase led to an important, maybe the most important conceptual step in the development of medical informatics: it became quite clear that "computer" as a key word in definition of medical informatics should be replaced by "medical information"; computers proved to be just convenient tools for information processing. Coiera made a nice comparison for this: "Medical informatics is about computers as much as cardiology is about stethoscopes" (40). This conceptual shift had a milestoning impact on defining future trends in medical informatics and this is why we proposed the term "consolidation stage" for this period. The new view was best perceived in medical informatics research and education, but it was less felt by the real/practical environment -the major beneficiary -the healthcare system itself. This difference of perception deserves a deeper insight; we will limit ourselves here to just notice it; some of its consequences will be included in the "Discussions" paragraph.

This stage was rich in outstanding achievements: new attractive infrastructure advance -accessibility of computers, extensive use of PC's, performant communications and start of internet applications, all together generating a new chapter -telemedicine (41), (the new term "telematics" was coined to reflect the strong synergy between telecommunication and informatics (42,43).

Basic medical informatics courses have been generalized in most medical schools and several specialized medical/health informatics schools have been created, either at undergraduate or (most often) at master level (22). Doctoral level in medical informatics was also introduced in several European countries.

Technological development of IT&C (Information Technology and Communication), with its penetration into all domains, had an impact on its perception by politicians. Several countries extended the name of their ministries of communication with "information (technology)". Potential medical applications in public health and in the "ever-lasting healthcare reform" (specific to most countries during last decades), determined the creation or development of IT/ITC compartments in health ministries, to elaborate or develop national/regional strategies for implementation of IT in healthcare/medical activities; quite often, health insurance houses were also dragged into this carousel. Even the results of national strategies for this specific stage were -sometimes -below expectations, the interest in the field of governmental institutions became an important fact to be considered for future developments. An important role was also played by the "e-health unit" of DG "Information Society" (they had various names) which became a major financing source for European research in medical informatics within frame programs 3 to 5. The calls for projects were carefully prepared, including endeavoring topics, including also fundamental research, often left aside due to the long duration of "return of investment". The merit of Jean-Claude Healy shall be underlined, who continued his mission even after moving to WHO (49). Several success stories from European projects have been reported (50).

The large palette of applications, with some visible achievements with high potential of extension had also a strong impact on industry; e-health market showed a marked increase.

To summarize the major characteristics of this period:

• Medical Informatics (MI) consolidates its position as independent (stand-alone) discipline, with own object and methods;

• Departments of MI/HI in health units (including ministries);

• Interest at high level, launching of national/regional strategies for implementation of IT in healthcare Hospital Information Systems (HIS) in several hospitals, still mainly for management;

• Start substantial funding for e-health research (e.g. The European Commission);

• More visible importance and complexity of EHR, including confidentiality, data protection, standards etc.;

• Development of MI education (mandatory discipline in most medical schools);

• Contour of new job: HIP -Health Information Professional;

• New chapters: internet applications, telemedicine, virtual reality etc.;

• Notable progress in classical topics -data bases and case mix, medical imaging, knowledge processing and ontologies etc.

Maturity of Medical Informatics: 2000 -2010

The new millennium started in the enthusiastic atmosphere generated by several good achievements, handy technology, some well defined directions for medical informatics research and almost boundless trust in the potential of medical informatics/e-health to address major challenges of healthcare system. However, even a superficial survey over the work done last decades could show a discrepancy between expectations and reality. Reports showed that a high percentage of projects about implementation of information systems failed, others had deviations, either not reaching the parameters or having delays or exceeding the budget (51). Several studies tried to analyze this in detail, revealing potential factors which could contribute to these modest results (besides mismanagement or incompetence): low user acceptance, lack of interoperability, too rapid technological changes, low political support, lack of coordination between teams etc. The importance of quality assessment became evident; actually such studies have been performed even before, but their relevance has not been properly perceived until now (52).

Even successful projects had a lower impact than expected, being used after the end of the projects mainly by the participants in the consortia. Hence, the calls raised the requirements for well prepared exploitation and dissemination plans (15,16). Moreover, the enlargement of European Union, with several new members, imposed actions to engage also the political factors. Thus, starting with 2002, EC organized annually the "E-Health High Level Conferences" (12), where delegations from ministries of health of member states were invited. These conferences usually adopted "Declarations", underlining the engagement of official institutions to support all actions directed to better dissemination and implementation of the results from European projects. Moreover, there were recommendations to attract universities or SMEs from the new member states in the research consortia.

Scientific community realized that the challenges for healthcare systems, including the type of problems around implementation of healthcare information systems, were not specific for Europe, but were general, like many other issues. That is why several actions to extend cooperation beyond Europe took place (53), with a couple of summits EC-USA by the end of the period. An important event of the period was the establishment in 2000 of ERA (European Research Area), which became a reference point for various research programs throughout Europe, including the well-known (first -2004) "eHealth Action Plan" (54). Several actions have been done also within EFMI frame, leading to some successful common projects (55).

The increase of activities connected to e-health generated also an increase of scientific events (conferences, seminars, exhibitions) of medical informatics. EFMI, which used to organize their quasi-annual MIE conferences (Medical Informatics Europe -in each year when there were no MEDINFO's organized by IMIA), added another annual conference -Special Topic Conference, starting with the STC in 2001 in Bucharest (3).

Concerning the research topics, this stage maintained and developed all major topics from previous periods, emphasizing two aspects: interoperability and integration. Fundamental research was strongly stimulated in the 6 th and 7 th Frame Programs of EC. Virtual Physiological Human became an important platform (56), offering an excellent tool for vertical integration of biomedical information, for linking the molecular level (genomic data from bioinformatics, including development of nanotechnologies for data acquisition, like lab-on-chip), to cell and organ level (using modeling and simulation tools as well as visualization procedures), up to whole body, or even to public health (57). Most projects included also the horizontal integration -the availability of data from primary care to ambulatory specialized care or hospital.

Assessment of quality of information systems was also a topic of interest; as it is often associated with standards and certification procedures, such work took place within a couple of European projects, referring mainly to certification of EHR (58).

The high mobility of persons also required an improvement of health information exchange, yielding a new chapter -"travel medical informatics" (59,60).

From a technological point of view one should mention the development of thematic networks (61), use of grid technology (62). It was also the period of general use of internet, and beginning of m-health (mobile phone use) (63) and p-health (use of personal portable devices for health data acquisition) (64).

To summarize the major characteristics of this period:

• Clearer understanding of e-health potential to address major challenges of present healthcare;

• Involvement of politicians, extension of regional/national projects;

• E-health as business, emergence of specialized industry (e.g. HIMSS);

• All big IT companies started to pay interest to M&HI applications;

• Patient-centered MI -development of EHR/EMR;

• New keywords: integration, interoperability, consumer informatics;

• More visible hidden gaps -difficulties in real implementation of Health Information Systems -several "failures" reported; analysis of "barriers", modest rate of user acceptance, quality assessment of HIS;

• Need of larger scale education & training programs (AMIA 10x10);

• Clear contour of sub disciplines: bioinformatics, neuroinformatics, VPH etc.

Full integration of Medical informatics in medicine and healthcare: 2010 -2020

The last period in our staging is the present one, hence we will not insist in a detailed description and we will limit the presentation to emphasizing the new characteristic features.

Maybe the most relevant result of the fretful end of the previous decade was the ascertainment of the strong inter-relation between all factors related to health -life style, environment, culture, social and political factors etc and future e-health projects should integrate these features. This is visible in both "eHealth Governance Initiative (ehgi)" (65) "second eHealth Action Plan (eHAP)" (66). The directions to empowering the patient, well aging, personalized care, interoperability and integration are still in a developing trend.

At national level, most countries would need to rethink and revise their e-health strategies, according to the new trends and requirements, to adopt the developed standards and introduce certification procedures for use of all ITC applications in healthcare.

A new keyword is more and more used in all IT applications -'big data', referring to the huge amount of data collected every day in healthcare (especially from genomic data, but not only from there), which need, of course, appropriate tools for handling and processing (W14). A suitable infrastructure was developed -cloud computing, which will have a strong impact on various ITC applications in healthcare, including the national healthcare plans and strategies (68).

The trend towards personalized healthcare will probably push forward fundamental research. Author's view is that any piece of biological/medical information has a "life" made of two parts: an "internal" life, expressed as molecular structure, transmitted as "cellular signaling", becoming biosignals detectable by laboratory or visualization procedures, thus starting its "external" life, when it is processed and interpreted by physicians; the pattern of all pieces of information represent the health state of an individual. For the present period we are still able to collect just fragments of information, which, most often can be integrated with sufficient accuracy for medical practice. We expect that theoretical development of models will be developed and complex simulations will be built, able to integrate all kind of individual data, from genomic and cellular to physiomic data at tissue and organ level, for building the "digital patient" (also called "e-patient" in (57). Such individual "virtual clones" will be the basic tools for the future of predictive and preventive medicine.

To summarize the major characteristics of this period:

• Big Data approach;

• Cloud computing;

• Social networks on health;

• Restructuring national e-health strategies:

-Involvement of politicians, improvement of legislation;

-Certification of EHR and ITC applications in healthcare;

-Wide adoption of standards;

• Decreasing gaps, increase user acceptance;

• Certification of educational programs in medical informatics;

• Generalization of EHR/EMR, inclusion in Health Information Systems:

-Integration of molecular & genetic data;

-Full interoperability -communication, devices, semantic interoperability;

• Patient empowerment, involvement through PMR (Personal Medical Record);

• Visible steps towards "personalized medicine", with:

-Increase patient safety, reduction of medical accidents and errors;

-Increase preventive medicine, reduction of curative medicine;

-Use of portable/wearable devices for monitoring, prediction & prevention;

-Deployment of home monitoring systems and tele-assistance;

• Attention moves towards:

-Deeper penetration of IT tools in medical research (modeling & simulation, digital patient etc);

-Advanced decision support systems.

HISTORICAL BACKGROUND OF EFMI IN DEVELOPMENT OF MEDICAL INFORMATICS

Historical facts in this article reflect on the development of the discipline of Medical/ Health informatics that is now part of all medical disciplines and part of the medical practice of all health professionals. Applications of computer and information technologies in all segments of society and knowledge of information technology is now part of general literacy (1).

The classical way to present a "history" is to list major events in chronological order, with more or less detailed comments about the persons, ideas or events. A distinction between periods brings a systematization flavor, easing the comments. The development of medical informatics began in the 1950's of 20th century, when the earliest reference to applications of electronic digital computers in medicine appeared.

During that period, new terms were born: medical computer science, computer medicine, medical electronic data processing, medical automatic data processing, medical information processing, medical information science, medical software engineering and medical computer technology. Most of these terms were interchangeable, such as medical computer science for medical information science, etc. e) Full integration of MI in Medicine and Healthcare (2010-2020): focus on user acceptance, a generalization of EHR/EMR, inclusion in HIS, vertical integration data (molecular/cellular/genetic up to organ/system and whole body, horizontal integration (primary care, specialized ambulatory, and hospital data), full interoperability, patient empowerment, visible steps towards "personalized medicine", increase patient safety, preventive medicine, use of portable devices, home monitoring systems, Tele-assistance, intensive use of web facilities.

Until the creation of IFIP-TC4 (later IMIA) in 1967 and EFMI in 1976, theoretical and practical aspects of MI developed fast, presenting results in the beginning in scientific and professional journals of a predominantly interdisciplinary character, and later in dedicated MI journals (3)(4)(5).

In this period conferences with MI contents were organized mostly either under the umbrella of "parent" societies (e.g. general computer or specialized health documentation and statistics/epidemiology societies) or under organization of particular groups and associations of people engaged in MI, research and development of MI applications. In scientifically and technologically strong countries (e.g. in France, Germany, U.K., U.S.A.), but also in other countries, such conferences were organized predominantly as national events. International interaction at such events was rather sporadic.

First international acceptance came from the International Federation for Information Processing (IFIP), an organization formed under the patronage of UNESCO. In 1967 François Grémy (the first IMIA president) initiated the IFIP-TC4 on MI gathering medical informaticians, especially from Europe and triggered organization of national MI societies. IFIP-TC4 was perceived as a Federation of National Societies, thus reflecting the spirit of international cooperation among nations in education, science and culture. This federative thinking was transfered to EFMI. Today EFMI is the leading nonprofit organization in biomedical and health informatics in Europe. EFMI comprises 28 national societies and includes an exceptional network of experts and stakeholders in health, care, IT and its societal dimensions; supported by 14 topic working groups ranging from human factors, to security and translational health informatics. EFMI has two governing bodies: EFMI Executive Board (President, Vice-President WGs, Vice-President IMIA, Secretary, Treasurer, Executive officer, Publication officer, Institutional members officer) and the EFMI Council. Council members represent national societies and WGs. EFMI Publications Currently, EFMI has three officially endorsed general journals, Methods of Information in Medicine, International Journal of Medical Informatics and Acta Informatica Medica. The most important EFMI publication, indexed in Medline, is Studies in Health Technology and Informatics, which publishes papers presented at MIE Conferences. EFMI also publishes several sub-specialty official journals covering the spectrum of medical informatics subdisciplines.

Through its work, EFMI provides leadership and expertise to the multidisciplinary, health IT community and to policy makers, enables the transformation of healthcare in accord with the world-wide vision of improving the health of the world population. EFMI is constantly striving to further the services it provides to its members and the informatics community in general by promoting free interaction among and between its member network and the bio-medical and health informatics community at large. Along the same lines at Opening Ceremony, professor Gjuro Dezelic said "the result of MIE '09 will be a contribution to the advance of human health in Europe streaming to unity".

John Anderson in his welcome noted: "Medical informatics has established itself as an important area of medical activity and its growing application, as this conference illustrates, suggests a very rich potential for the future. Sociological changes have taken place to meet this challenge and developments in the issues of privacy and confidentiality are important, as also are user education, and the teaching of medical informatics to medical students and to doctors. Inevitably these changes illustrate that medical informatics has already had a significant impact on medical teaching and training as well as in the relationship of medicine to society." (3).

Reflecting on the development of MI in former Yugoslav countries and the South-European region, he said that the influence of MIE Congresses has been very strong (3). He recalled that the first opportunity to establish links with EFMI was the MIE '78 Congress in Cambridge. Dezelic was invited to attend the EFMI Council meetings as an unofficial observer from Yugoslavia. Then, he presented on his eight-year experience of teaching MI to medical students on an MIE '79 panel in Berlin, at a time when very few medical schools worldwide included MI in their curriculum. WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO WELCOME TO Saudi Arabia, Serbia, Slovenia, Sweden, Ukraine, United Arab Emirates, USA, and Vietnam). Acceptance rate in 2021 was 42.3% ( Table 1).

The journal in its function and everyday work is following the recommendations and guidelines of ICJME, COPE, EASE, WAME, etc. as well as the recommendations of "Sarajevo Declaration on Integrity and Visibility of Scholarly Journals", accepted by 17 Editors of biomedical journals which are printed in the countries in South-Eastern Europe at "SWEP 2018" Conference held in Sarajevo (5-9).

The journal supports, and had its presentations at conferences held in Bosnia and Herzegovina. The abstract papers presented at "The Mediterranean Seminar on Science Writing, Editing and Publishing" -"SWEP 2016", "SWEP 2018"; "SWEP 2020" and "SWEP 2021", also found its place in the journal, by which we met our goal of promoting science and scientific publication at the area of Bosnia and Herzegovina and other countries in the region, and in the Mediterranean countries (9).

Acta Informatica Medica is one of the six biomedical journals from Bosnia and Herzegovina deposited in databases Pubmed (in addition to the Bosnian Journal of Basic Medical Sciences, Medical Archives, Materia Socio-Medica, Medicinski Glasnik (Zenica), Acta Medica Academica), and Scopus (besides the Bosnian Journal of Basic Medical Sciences, Medical Archives, Acta Medica Academica, Medicinski Glasnik, Acta Medica Saliniana, Folia Medica and Journal of Health Studies) (3). The purpose of the journal is to continue the publishing of both-its online and print edition, four times a year. The journal in its function and everyday work is Importance of Acta Informatica Medica journal in spreading of Biomedical informatics knowledge and experiences in scientific and academic community. The journal began with the practice to publish the articles of PhD students free of charge, and in that manner opened to this population, and began with the practice of populating biomedical information technology, both in Bosnia and Herzegovina and in the region. The journal opened to PhD students, and they embrace it through the official letter to the Editor, presenting their goals and problems. The tendency for the future is to preserve the Open Access model, while enabling funding through the subscription and purchase of printed publications.

INFOMETRICS OF THE JOURNAL IN THE PAST

Acta Informatica Medica is a journal covering the technologies/fields/categories related to Medicine (miscellaneous) (Q3). It is published by Avicena Publishing in Sarajevo. SCImago Journal Rank is an indicator, which measures the scientific influence of journals (10)(11)(12). It considers the number of citations received by a journal and the importance of the journals from where these citations come.

SJR acts as an alternative to the Journal Impact Factor (or an average number of citations received in last 2 years). This journal has an h-index of 24. The best quartile for this journal is Q3. According infometric statistics for the last ten years -2013-2022, we can stated great improvement: Scimagojr.com Index H (for 2017) for Acta Informatica Medica was 12, while scimagojr.com index (SJR) was 0.275 (2). On the aforementioned page, the total number of citations from the journal Acta Informatica Medica was 187 (it should be noted that the number is only from the journals that are covered by Scopus). Self-citation (the number of citations from a journal citing article to articles published by the same journal) was 7.

For the period 2013-2017, the Google Scholar h5 index was 17 and the h5 median was the 28. For the year 2020, the overall rank of Acta Informatica Medica is 15980. According to SCImago Journal Rank (SJR), this journal is ranked 0.267 (Figures 9 and 10). Journal Impact IF Ranking: In the Medicine (all) research field, the Quartile of Acta Informatica Medica is Q2. Acta Informatica Medica has been ranked: Highest Impact Factor for 2011-2022 was 1.496 and Lowest Impact Factor for 2011-2022 was 0.59 (11). During the year 2021 in Acta Informatica Medica journal was published 46 papers. From total amount published papers, 67,39% was original papers, where it was more published original papers in the journal than in the year 2020. In the year 2021 in Acta was published: 1 editorial, 31 original paper, 1 professional paper, 1 systematic review, 5 reviews, 2 case reoports, 1 dilemma, 1 the letter to editor, 2 obituaries, 1 newsletter. (Table 2 and Figure 5).

Acta Informatica Medica journal has next Important Metrics values for 2021 (last updated on November 16, 2021): Impact Score is 1.50, h-Index is 24, Rank is 15980, SJR is 0.267 (Figures 9-10). The impact score shown here is equivalent to the average number of times documents published in a journal/conference in the past two years have been cited in the current year (i.e., Cites / Doc. (2 years)). It is based on Scopus data and can be a little higher or different compared to the impact factor (IF) produced by Journal Citation Report of Thomson Reuters metrics.

The impact score (IS) 2020 of Acta Informatica Medica is 1.50, which is computed in 2021 as per its definition (Figures 9 and 10). Acta Informatica Medica IS is increased by a factor of 0.78 and approximate percentage change is 108.33% when 2.

Figure 1. Distribution of articles according to type in the year 2021

The journal began with the practice to publish the articles of PhD students free of charge, and in that manner opened to this population, and began with the practice of populating biomedical information technology, both in Bosnia and Herzegovina and in the region. The journal opened to PhD students, and they embrace it through the official letter to the Editor, presenting their goals and problems. The purpose of the journal is availability in the future period, to those authors who are not able to pay a publishing fee (because the subscription fee should be secondary and the quality of the work at the first place) to publish their papers free of charge. The tendency for the future is to preserve the Open Access model, while enabling funding through the subscription and purchase of printed publications.

The website of the journal is refreshed in 2018, revised by Editorial Board (new members were included) and regularly updated. The authors of the published articles in 2018 issues are from 11 countries and four continents. Acceptance rate in 2018 was 32.7% (Table 1). Scimagojr.com Index H (for 2017) for Acta Informatica Medica is 12, while scimagojr.com index (SJR) is 0.275 (2). On the aforementioned page, the total number of citations from the journal Acta Informatica Medica was 187 (it should be noted that the number is only from the journals that are covered by Scopus). Self-citation (the number of citations from a journal citing article to articles published by the same journal) was 7. For the period 2013-2017, the Google Scholar h5 index was 17 and the h5 median was the 28. The journal in its function and everyday work is following the recommendations and practices of ICJME, COPE, EASE, WAME, etc. as well as the recommendations of "Sarajevo Declaration on integrity and visibility of scholarly journals" (3).

The journal supports, and had its presentations at conferences held in Bosnia and Herzegovina. The abstract papers presented at "The Mediterranean Seminar on Science Writing, Editing and Publishing" -SWEP 2018; SWEP 2020 and SWEP 2021, also found its place in the journal, by which we met our goal of promoting science and scientific publication at the area of Bosnia and Herzegovina and other countries in the region and in the Mediterranean countries. compared to preceding year 2019, which shows a rising trend. The impact score (IS), also denoted as Journal impact score (JIS), of an academic journal is a measure of the yearly average number of citations to recent articles published in that journal. Acta Informatica Medica has an h-index of 24. It means 20 articles of this journal have more than 20 number of citations. The h-index is a way of measuring the productivity and citation impact of the publications. The h-index is defined as the maximum value of h such that the given journal/author has published h papers that have each been cited at least h number of times (10-12).

Presented facts above are based on Scopus data -Acta Informatica Medica journal coverage history is as following: 2012-2020. Also, on Figures 7 and 8 are shown Impressum of the journal with a few cover pages published in the past and one of ilustrative contents regarding EFMI 45th anniversary in 2021 (13)(14)(15).

ACTA INFORMATICA MEDICA JOURNAL STATISTICS

Journal statistics is calculated for the period of online presence on journal platform ejmanager and scopemed/bibliomed (5,(10)(11)(12) e) Ten years on from the introduction of the method of "Distance learning" in medical curriculum. In December 2002, at the Cathedra for Medical Informatics, Medical Faculty, University of Sarajevo a symposium was organised under the name "Tele-education in Biomedicine" organized to celebrate the ten-year anniversary of the establishment of the above cathedra; participants at the symposium were health infor- It should especially be pointed out that the professionals and experts of health informatics in Bosnia and Herzegovina have given important contributions to the promotion of this medical discipline through several studies and projects, from the building and realization of information systems at certain levels of healthcare to introducing modern education models in biomedicine using contemporary information technologies.

BEGINNINGS OF DEVELOPMENT OF HEALTH INFORMATICS IN B&H

Health (medical) informatics as a separate scientific discipline began to be effective in academic institutions at the end of the 70's by the presentation of actual accomplishments in this area in under and postgraduate education at biomedical faculties. As a specialized discipline, health informatics has its rudiments in Bosnia and Herzegovina (B&H) in the beginning of the past century (20 th ), when experts, mostly graduates from the Vienna Medical Faculty, began their professional careers in our country (6)(7)(8)(9). Those who were more involved in the area of health statistics started to be intensely interested in the application of health technologies in health science.

Officially, health informatics has been used in B&H after the Second World War in Public health institutes on a regional level, special emphasis should go to the contribution of Fuad Secerbegovic, being manager of the Department for health statistics of Public health institute of Bosnia and Herzegovina from 1972 to 1995, after Evgenije Sestnev, the first chief of that Department . From 1977 the automatic analysis of health data in the above institutions was introduced gradually thanks to the engagement of Fuad Secerbegovic, who has published annual reviews and summary health statistics reports in B&H and utilization of health capacities under the title "Network, capacities and services of health institutions in B&H". The first health data was collected and processed by computers by the Company "Energovinvest" Ltd in Sarajevo in 1977 (1).

By the end of the 70's of the previous century, at the University of Sarajevo Health informatics under the subject Social medicine and organization of health care as well as on postgraduate studies of the same faculty was being taught (1,2,3). During 1992, the first year of the War, the Cathedra for Medical Informatics was established at the Medical Faculty, University of Sarajevo, and later on at other medical faculties in Bosnia and Herzegovina with a certain number of hours of theoretical and practical education. Currently, curricula are being adapted using the principles of Bologna process and declaration.

HEALTH INFORMATICS IN PRACTICE IN BOSNIA AND HERZEGOVINA

Initiation, development and implementation of some informatics activities, the automatic manipulation of health data and the intensive use of information technologies for the need of diagnostics, therapy and patient rehabilitation on all levels of care in BiH health system started to be solved systematically by the end of 70's and beginning of the 80's. A crucial decision with a state charter was made in 1981, when the B&H government made a decision to start with work on the project "Development of B&H health information system". Before the project, it was the completed study/analysis "Social-economical position of the health system in B&H"; based on that the B&H parliament approved the preparation of the appropriate project, this should have made modernization of the information system of health care. Basically, this project was to modernize and make automatic, the well developed and functional health statistics system in Bosnia and Herzegovina, which was part of an also well organized (centralized) Yugoslav health statistics system lead by the State Public Health Institute Belgrade. Project "Development of information system of health care B&H in circumstances of electronic data manipulation" was approved by the Executive Board of Association of healthcare communities B&H. On the 8th December 1983, eight companies applied for the tender, a contract was signed with the Intertrade Company from Ljubljana, Slovenia. In 1985 after positively assessed revisions the project was adopted and in the same year began its implementation after financial funds were assured (Table 1).

In 1985 the Electronic calculation centre of Health and retirement insurance fund in Sarajevo (ERC ZIPO) was established . The act itself, culminated in the establishment of a centre, was "Elaborate about social-economic finding of establishing working unit for manipulation of electronic data for health and retirement insurance fund". For a number of years the centre was lead by engineer Mirza Ceric. Unfortunately, this very well designed project, content of activities, as well as part of completed tasks in regard to the procurement of hardware and production of software applications, has never been completed and realized in practice. The concept of centralization of data manipulation in the architecture proposed in the ZIS B&H project (central host and analysis in Sarajevo, regional analysis in eight centres in B&H and local in 109 municipalities) has never been finalized and fell down. It was utopia which has no chance to be realized in practice. It is true that some of the designed activities were started at an institutional level, but never reached their end as Clinical information system of the University clinical centre in Sarajevo, which was one of the biggest projects in area of development and construction of medical information systems. From 23 companies bidding on the tender, IRIS (eminent Company for hardware and software and part of Energoinvest Company, fourth biggest company in former Yugoslavia) was chosen and has spent almost ten years working on the Study, Initiative design and Main project of Clinical information system of the University clinical centre in Sarajevo.

This project was also unfinished due to the War in B&H (1992)(1993)(1994)(1995). Already procured hardware and designed software for some applications from the project (Medical subsystem, Diagnostics-polyclinic subsystem, Administrative-technical subsystem and Financial-economical subsystem) were destroyed or in the meantime lost their usefulness. The biggest progress was made in the development of information system for the pharmaceutical sector (only in Sarajevo the system connected 43 pharmacies in a centralized system of receipt collection and analysis). Besides the University clinical centre in Sarajevo, certain health institutions in Bosnia and Herzegovina started with the development of local and unique health information systems.

The first Local Health Information System was created and used in Sarajevo in the year 1982 when Izet Masic and Arif Agovic tested special designed Health data bases for the supervision of approximately 6.000 citizens -users of health care services at the Community health centre "Visnjik" in Sarajevo. Health data was processed by a specially designed software package ARCHIVE on a Personal Sinclair QL computer, later redesigned in Clipper and DBASE III and FoxBASE. After 3 years of testing those data bases Izet Masic graduated first master thesis within Health informatics. During the war (1992)(1993)(1994)(1995), and after the war, a lack of appropriate financial funds, and many other factors influenced the interruption of the planned activities, especially, having in mind how those activities were recommended in project plans regarding system development and perception.

HEALTH INFORMATICS IN MEDICAL EDUCATION

The need for additional education of health professionals was realised after the first application of electronic data manipulation. For physicians in primary health care and in clinics, in order to perform their duties in a high quality manner, must have been up to date with the latest accomplishments in medicine and health. Since the 60's the development of information technologies has had a quantitative and qualitative growth especially in diagnostics and therapy, and health workers had to follow that. Great role in this field had IMIA and EFMI. Working groups of IMIA and EFMI recommended and defined concepts and methodologies of education for medical informatics on three levels (3,4,5,6).

First, informatics education which should provide general knowledge to users and data analysis on the place of their generation, and on all places of collecting data in health system (physicians of all specializations, nurses and paramedical staff). Second level, informatics education of this level is in regard to medical staff which was directly involved in collection, manipulation, analysis and interpretation of health data. This kind of education was expanded with skills, knowledge and practical applications which are necessary for personnel on this level.

The Third level is basically a very wide and highly specialized education for experts in the health sector who would like to be professionally involved in this kind of work. In B&H there has never been an accepted proposal for introducing sub-specialization from medical informatics in spite of the fact that authors of this paper put a lot of effort and energy into making it official. It is a fact that at some universities in European countries there are separate faculties or universities for graduates with the title of engineers of health informatics.

There are five medical faculties in Bosnia and Herzegovina (Sarajevo, established in 1946;Tuzla, established in 1976;Banja Luka, established in 1986;Foca, established in 1994;and Mostar, established in 1997). At all the faculties, since 1992 and later, cathedras for medical informatics were established and/or introduced as independent subjects: medical informatics or health informatics, bioinformatics, etc. In principle, 60-70% of the curriculum are the same, or very similar; the only difference is that the chiefs of some cathedras are medical doctors and of others are professors, engineers, mathematicians or economists with the title of MSc or PhD in this area. Most of those cathedras have web sites where students can check the number of hours and content to be taught.

Openly speaking in undergraduate education until 1992 when medical informatics was introduced as an independent subject at the Medical Faculty, University of Sarajevo just some lectures were taught; those were methodological units in that time very important for health practice (medical documentary with two teaching hours and health information systems also two teaching hours) under the subject of Social medicine and organization of health care and Professor Izet Masic. from 1979 on Postgraduate education at the Medical Faculty, University of Sarajevo there were subject Health informatics led by the pioneer of health informatics in ex-Yugoslavia Prof Gjuro Dezelic, PhD using concept, content and methodology at the Medical Faculty, University of Zagreb. In the school year 1970-1971 at the Medical Faculty, University of Zagreb was introduced "Basic Informatics" (named Use of electronic computers in health care) as obligatory subject for 6 th semester students with a duration of 15 school hours. A similar programme was at postgraduate studies at the same faculty under the subject "Introduction in scientific work". In 1973 a separate cathedra for "Basics of Informatics" was established since it was obvious to make a distinction between those two areas. Both, under and postgraduate students had the chance to attend "Techniques of programming electronic computers" for a duration of 20 school hours. In 1973 the subject at postgraduate studies "Analysis of health data by methods of informatics and statistics" for a duration of 20 hours it was introduced.

Since 1985, Professor Izet Masic took over the leader position and with the help of Professor Gjuro Dezelic and Professor Arif Smajkic launched a separate course "Informatics and Economics in Health" for a total duration of 30 hours. Numbers of postgraduate students became MSc and PhD in this subject, and some of them became professors and assistants in B&H universities and abroad. Since 1992 at the Medical Faculty, University of Sarajevo there have been Cathedra for Medical Informatics. The content of education is 30 hours of theoretical and 45 hours of practical education for students of the Medical Faculty, 15+15 hours for students of Faculty of Dental medicine and 30+30 hours for students of College of Noursing. From 2002 the subject is split into two parts: Fundamentals of medical informatics with funding of 15+15 hours in the second semester of studies and Applicative medical informatics with funding of 15+45 hours in the eleventh semester. The final exam is due after the 11th semester. Curriculum, teaching materials, application for the exam, the exam itself and checking of results are possible at the web site (www.imasic.org). Also, since 2002 at Cathedra for Medical informatics the project "Distance learning in biomedicine" is in progress which allows students to use an electronic way of learning and to pass their exams in this subject. This method of education was in a pilot phase and waited for official approval from the appropriate institutions in charge for high education.

In total, education from Medical informatics gained 3000 students. At postgraduate students of The Medical Faculty, University of Sarajevo there are subject Medical Informatics with funding of 15+15 hours and this type of education enabled over 800 medical doctors all medical specializations. In progress is the adaptation of curriculum of neighbouring countries in Medical informatics and content of methodological units with the Bologna process.

BOSNIA AND HERZEGOVINA HEALTH INFORMATICS AT INTERNATIONAL LEVEL

All the above mentioned activities could not have been realized in practice without strategies and concepts developed by professionals and experts in the area of medical informatics. In the early 80's, first in Sarajevo, then in other towns within Bosnia and Herzegovina, mostly engineers of electro-technique start to be intensely interested for some segments of health informatics; some of them managed certain projects, besides others they were involved in preparation of design of software applications for the mentioned project ZIS B&H. They have been followed by ambitious physicians who could see in the new information technologies a future and practical help in performing their everyday jobs. Pioneers in this area were: Izet Masic, Zoran Ridjanovic, Benjamin Djulbegovic, Sead Beganovic and others who attended professional meetings and workshops with appropriate topics from medical informatics. They were supported by Professor Abdulah Konjicija who in 1984 started to introduce mathematical models in diagnostics and therapy of certain diseases, and altered with mentioned experts algorithms for curing the phases of a disease.

Later, those experts began to work more closely on some parts of the medical informatics for which they had an affinity. Some of them have prepared papers and presentations for specially organized symposiums "B&H days of informatics" held annually on the mountain of Jahorina near Sarajevo from the year 1976. In October 1987 a group of experts within the field of Medical informatics decided at General Assembly to set up an independent Society for medical informatics of Bosnia and Herzegovina which was joined with similar independent societies from Croatia Herzegovina with regard to SMI BiH and the City of Sarajevo for the organization of MIE2009. At the next meeting of the EFMI Council held in Munich in June 2004, the Board made a positive decision on the application and recommended to SMI BiH the preparation of the BID book for the following EFMI Council. Finally, on the EFMI Council meeting in Athens held on 18 March 2005, an official decision was made that Sa- The War period (1992)(1993)(1994)(1995) in Bosnia and Herzegovina Society for Medical Informatics was spent working very hard and in almost impossible conditions eight scientific and professional events were organized. At those events over 500 papers were presented which were published from the proceedings, which at that time was a real miracle and fantastic achievement having in mind that Sarajevo was under what was to be the longest siege any City has endured in history, added to this a severe lacking in electricity, water supply, gas and food. The siege of Sarajevo was to last for Approx: 1379 days without a break. Those materials found their way across Europe and they were recognized as a Sarajevo miracle at the time.

Serious activities of the Society follow on local and international level. The Society has organized a number of professional symposiums (eight in total so far) on the actual themes of: • History of Health and Social culture in B&H, march 1993;

IZET MASIC HISTORY OF INFORMATICS AND MEDICAL INFORMATICS

• Health information systems, December 1993;

• War medicine and medicine in a war, November 1993;

• War medicine and medicine in a war, November 1994;

• Medical documentation and evidence, November 1996; recommended to SMIBiH the preparation of the BID book for the following EFMI Council. Finally, on the EFMI Council meeting in Athens held on 18 March 2005, an official decision was made that Sarajevo will be the host of the MIE2009 to be held in Sarajevo (1, 2, 3).

The SMIBiH also organized a Special Topic Conference named "eHealth and eEducation" in the premises of the rector of Sarajevo University on 20th December 2005. During the conference Professor Rolf Engelbrecht, as key speaker, held a tele-conference from Munich, Germany on "Tele-medicine in Germany". It was the very first tele-lecture from biomedicine organized by our society. The event was organized with the support of ERICSSON and the International Society for tele-medicine and eHealth having in mind that the SMIBiH becomes an official member of the ISfTeH and Izet Masic a member of the ISfTeH Governing Council.

MEDICAL INFORMATICS IN BOSNIA AND HERZEGOVINA IN SCIENCE AND RESEARCH

SMIBiH after establishing in 1993 launched the professional and scientific journal Acta Informatica Medica (Acta Inform Med) and it has been published continuously for the past 20 years. At first journal was published twice a year, then three times a year, since 2005 quarterly and from this year bimonthly. The Journal has abstracted 68 age files and questions is an attractive way of self-education [3,5].

Very first serious initiative was generated by WUS Austria (World University Service of Austria) in BiH. During 2002 and 2003 WUS Austria, through its programs, Distance learning 2002 and Distance learning 2003 supported the development of the educational processes at BiH universi- and indexed in more than 20 on-line databases (PubMed, PubMed Central, Scopus, Embase, EBSCO, etc. So far, it has published over 1.500 scientific papers, articles, editorials, case studies, and various actualities. Teachers and associates involved in the education of students on post and undergraduate studies on biomedical faculties in Bosnia and Herzegovina during the past 20 years published a number of books, monographies, and other publications, some of which, have been translated into the English language ( Figure 5). Also, BiH experts for medical informatics participate enthusiastically at European and world congresses of medical informatics with oral presentations or poster presentations. This is an opportunity to mention just some of the more important publications: health fields. There are several trends and developments that can be recognized by carefully examining the single contributions to the various topics. First, interoperability and data exchange standards become most important. Systems must be interconnected to each other: locally, nationally, and transnationally. Second, ontologies ("those that is") are being developed in an increasing path. By doing so, medical vocabulary that is used in an application, as well as the semantics of applied items is defined. Third, Web apllications allow to share medical information and knowledge by many users -researchers, staff and patients. Fourth, clinical decision support systems provide huge impact on medical workflow and patient care to the benefit of patient, the caring physician, and the financing health care bodies (6)(7)(8)(9)(10)(11)(12)(13).

The great variety of scientific topics and countries that were presented, made MIE 2009 Conference in Sarajevo a huge success and a fruitful study of proceedings by those interested in Medical Informatics.

FUTURE OF MEDICAL INFORMATICS IN B&H

Teaching staff performed a number of surveys analysing current levels among medical students and health professionals. Key activity of the B&H SMI will be to enhance efforts on reconstructing a high education system in the country in accordance with the Bologna process (14-26). There are two areas which the focus of activities needs to be directed: under and postgraduate education and continuous medical education (CME) for health workers, medical doctors as well as nurses.

MEDICAL INFORMATICS IN CROATIA -A HISTORICAL SURVEY

As in many European countries, medical informatics (MI) began to develop in Croatia in the sixties of the 20th century when medicine was widely recognized as a field in which the use of computers is important and widespread, and will be necessary in the future. This was not much later of the period, when the roots of this discipline were planted all over the world by various working groups and associations engaged in research and development of computer applications in medicine and health care (1).

Let us remember that in the fifties of the last century, i.e. after the 2nd World War, USA was a leading country in the field of computer science, introducing the first uses of computers in medicine (2). But soon, when Europe recovered from the war disasters, the use of computers in medicine and health care began to advance rapidly, especially in the technologically advanced European countries -France, Germany, Sweden and United Kingdom. This was a result of the entrance of the biggest American computer companies, as for example IBM, Univac, Burroughs, Control Data and Honeywell, into European markets with their computer systems, and the beginning of their investments into European computer industry, in which among the known European computer manufacturers were English ICL, In the time of the development of first medical computing projects in the USA and European West, i.e. in the fifties of the 20th century, in Croatia the quantity of data and information in the Croatian healthcare system reached such a high level, that introduction of sophisticated information and communication technologies (ICT) was widely demanded. As elsewhere, most benefits were expected by the use of computers because of their efficiency in information processing. Croatia, in these days a federal republic in the former Yugoslav Federation, had a rather developed healthcare system as a result of the tradition in the public health philosophy and ideas of Andrija Stampar (4). As the healthcare system in a substantial part deals with collecting, storing and processing of data, by several independent studies performed in those days it has been shown that the costs in the information sector amount to at least one-third of total costs in the healthcare system (5). So e.g. Morris F. Collen reported that 25-40% of hospital costs are connected with data handling (6), but in other sources it is estimated that the costs might be even higher. So it became apparent that the Croatian healthcare system should be based on the use of modern ICT, especially by the use of computers.

But in that period it was not easy to introduce computers into Croatian healthcare practice. The installation of computers in the whole country was slow, first computers were installed in state statistical institutions, some of the banks and leading research institutes, as well as in newly established computing centres, serving various users (in whole Yugoslavia in 1962 there were installed 30 computers, and to the end of 1968 the number increased three times, cf. ref. Croatian computerized healthcare. The early beginning of MI education at Croatian medical schools aroused attention elsewhere, including its spreading to other parts of former Yugoslavia and discussions on its first experiences, problems and prospects at international conferences 4,22 .

After more than one decade of broad MI education at the appreciation level, and with several successful research and development projects, trained MI specialists were needed. Following these demands, the School of Medicine, together with the School of Electrical Engineering and the School of Science, all of the University of Zagreb, started a program of postgraduate education in MI in 1984. The program was called "Health Information Systems". More than 120 students enrolled and about 30% finished the program by a M.S. thesis. Most of the students were physicians, but there were also pharmacists, mathematicians, economists, librarian and engineers working in healthcare.

At present the specialized postgraduate program in MI at the University of Zagreb is suspended. However, there are several MI courses in other postgraduate and doctoral programs. These include: Methods in MI, Knowledge discovery in medical domains, Statistical analysis of free text, Health information system management, Simulation modeling, Public health information systems, Biosignal processing, and Medical image processing.

All medical schools, schools of dental medicine and schools of nursing in Croatia have chairs of MI, some linked with medical statistics, led by professors of MI. Several young people are engaged in teaching and research, ensuring good 22 But from the very beginning the aim of this initial education of health professionals in MI (still under the name "medical computing", as Grémy proposed the name for this medical discipline just in the same time in 1967) was to extend it as soon as possible to medical students, in order to prepare them for their future professional work characterized by the use of rapidly developing ICT. It is important to mention that at that time this approach in medical education was extraordinary rare. For example, first report on teaching computers to medical students came from USA in 1965 (8), and further reports of similar attempts were published only a few years later. In addition, these first curricula were concerned only with the narrow area of computer programming, and not with other aspects of MI, so important for future health professionals.

All that was still before the Todd Commission Report on medical education in Great Britain (9) stressed the urgent necessity for medical students to be trained in MI, stating that "computers, with all their implications in terms of equipment, procedures and ways of thinking, will play too large a part in the work of all doctors in the future to be left entirely to the expert (in computing -author´s comment); every doctor should at least learn to understand their basic principles and potentialities."

Soon after these first publications on MI education, and experiencing positive acceptance in teaching MI to postgraduate students, the Andrija Stampar School of Public Health, as a part of the School of Medicine in Zagreb and supported by the Association of Healthcare Institutions of Croatia, proposed to the end of 1969 introduction of special compulsory appreciation courses in MI at the undergraduate and postgraduate levels for all medical students. The School of Medicine in Zagreb accepted it and teaching for undergraduates and

Croatia obtained MI education in the form of appreciation courses for almost three decades and were well prepared for the future challenges of the Croatian computerized healthcare. The early beginning of MI education at Croatian medical schools aroused attention elsewhere, including its spreading to other parts of former Yugoslavia and discussions on its first experiences, problems and prospects at international conferences 4,22 .

After more than one decade of broad MI education at the appreciation level, and with several successful research and development projects, trained MI specialists were needed. Following these demands, the School of Medicine, together with the School of Electrical Engineering and the School of Science, all of the University of Zagreb, started a program of postgraduate education in MI in 1984. The program was called "Health Information Systems". More than 120 students enrolled and about 30% finished the program by a M.S. thesis. Most of the students were physicians, but there were also pharmacists, mathematicians, economists, librarian and engineers working in healthcare.

At present the specialized postgraduate program in MI at the University of Zagreb is suspended. However, there are several MI courses in other postgraduate and doctoral programs. These include: Methods in MI, Knowledge discovery in medical domains, Statistical analysis of free text, Health information system management, Simulation modeling, Public health information systems, Biosignal processing, and Medical image processing.

prospects for future development of MI at th universities and professional schools.

At the beginning teaching materials for MI wer in the form of handouts with lectures and tests i written form. The first Croatian textbook intende for MI teaching was published in 1976, entitle "Fundamentals of Informatics" 23 . The next editio was enlarged and changed the title to "Healt Informatics" (editions in 1986, 1987 and 1989). I 1997 a new textbook was published under the titl "Medical Informatics" 24 . A big innovation i Croatian MI publishing, both for educational an scientific/professional purposes, is the recent new book entitled again "Medical Informatics", but thi time a work of 42 Croatian authors -universit teachers (8 professors, 1 lecturer and 6 assistant from all four Croatian medical schools, professors from other university institutions) scientists and professionals from health institution and firms engaged in MI projects 25 . It is officiall recognized as a university textbook in all medica schools in Croatia, but has also characteristics of MI manual, suitable for other medical practitioner and health professionals interested in MI. clinical postgraduates started in the summer semester of the academic year 1970/71 (10). When in 1972 the University Computing Centre (SRCE) was opened in Zagreb, operating a modern time-sharing UNIVAC 1110 system, a Terminal station, equipped with conversation terminals, was opened at the Andrija Stampar School of Public Health. This Terminal station, apart from its importance for medical research, served as the first MI Laboratory for practical work with computers in the MI education of medical students and healthcare personnel in Croatia. As the terminal network of SRCE spread to other Croatian universities (in Osijek, Rijeka and Split, being in the same time major health centres in Croatia), this gave a strong impetus to the development of MI teaching, as well as to the scientific and professional development of MI in Croatia.

CROATIAN SOCIETY FOR MEDICAL INFORMATICS AND INTERNATIONAL COLLABORA-TION OF CROATIAN MEDICAL INFORMATICIANS

In late sixties of the past century first MI projects in Croatia´s healthcare are noted, mainly concerned with problems in public health. The gathered experience was reported at the First Symposium on Applying Computers in Healthcare (Zagreb, April [21][22][23]1971) and later published in the symposium proceedings as reports on (1) the use of automatic data processing in the healthcare of the City of Zagreb (processing of data from people not being health insured); (2) the processing of health-statistical data in the field of outpatient healthcare and occupational health in the Medical Center Varazdin; and (3) the computerization of the Croatian Cancer Registry (initiated 1967 in the Croatian National Institute of Public Health in collaboration with international institutions, and continued at home in 1969) (1).

In a recent panel discussion on the history of MI in Europe (at the Special Topics Conference of the European Federation for MI, Prague, 2013) there have been two presentations finding it appropriate to divide the whole MI history into five periods (stages). Talking about the evolution of concepts in MI George Mihalas denoted the period until the middle of seventies of the past century as the "Early Stage" in MI concepts evolution (11), and in their presentation of the history of MI education Arie Hasman and John Mantas named it the "initiation stage" (12). These two terms, similar in their meaning, denote well the first period of the development of MI as a new field in biomedical sciences. 29 . YAMI became member of EFMI and IMIA at the MIE 1990 Congress in Glasgow, but was dissolved at the end of 1991 after Yugoslavia fell apart in middle of that year. Consequently, the national societies mentioned above became eligible to join EFMI and IMIA independently. CSMI became member of both associations during the MEDINFO Congress in Geneva in September 1992.

According to its Statutes CSMI´s basic objectives are to advance dissemination of information in the field of MI in Croatia, to promote high standards in MI applications, and to promote research, education and international cooperation in MI. CSMI especially organizes MI conferences and meetings, promotes MI education and its popularization, encourages MI standardization, and struggles for medical informatics dignity and dignity of people involved Further development of MI in Croatia, its appearance on the international scene and the establishment of the CSMI

Development of MI projects

Further development of MI in Croatia, still in its early stage, was mainly related to the administrative and financial applications in healthcare institutions (especially in larger hospitals, such as the University Hospitals in Zagreb) and Croatian health insurance funds. Among the important projects which are introduced in the field of medical documentation it is worth to mention the beginning of computer data processing in the Health Center Remetinec (Novi Zagreb) in 1970, in collaboration with the Computing Centre of the City of Zagreb and continued as a routine after 1973. Following the previously mentioned first successfully computerized health registrythe Croatian Cancer Registry, the Croatian National Institute of Public Health started with computer processing of data in its second registry -the Croatian Psychoses Registry (founded in 1961). Two other computerized health registries followed: the Croatian Registry of Cured Alcoholics (1974) at the University Hospital "Sisters of Mercy" in Zagreb, and the Registry of Diabetes (now National Diabetes Registry CroDiab) at the University Clinic for Diabetes, endocrinology and Metabolic Diseases "Vuk Vrhovac" in Zagreb.

Remembering the introduction and development of these early MI projects it is worth to note the support that came from the Croatian state health authorities, realizing that application of modern ICT in health care is one of the important components in its modernization and future development. This was an important impetus for future development of MI in Croatia.

The development of health information systems in several countries in the mid-sixties of past century induced also such projects in Croatia at the beginning of seventies.

The "Integrated Health Information System" project for the whole healthcare system of the City of Zagreb, was conceived still in 1974 as a comprehensive application of ICT in that field. Its conceptual design started several years later (in the beginning of eighties) (13), but could not be implemented as planned because of the financial problems during the eighties and the later decay of the ex-Yugoslavia at the beginning of nineties. In the late eighties as similar approach was adopted in the Istria County for the needs of primary healthcare (PHC) (14), with the extension to apply the rapidly spreading microcomputer hardware affordable for PHC teams working in territorially distributed offices and to satisfy their information needs by the use of Lawrence Weed´s POMR (Problem Oriented Medical Record) approach (15,16).

Among the first hospital information systems in Croatia one can note the beginning of the implementation of such system at the Clinical Hospital Centre in Zagreb in the eighties (17), oriented under conditions of limited hardware resources to develop a basic data set at the level of an integrated hospital information system covering several hospitals (18).

In the nineties of past century new projects in the field of health information systems appeared, based on new ICT technologies -local computer networks, personal computers and Internet. Several applications were developed, serving needs of special health facilities, like general practitioners offices (Zadar, 1995) and institutions for the prevention and rehabilitation of diseases (Polyclinic for Prevention of Cardiovascular Diseases and Rehabilitation in Zagreb). In the field of image and signal processing, as well as computer assisted modelling, several research groups developed applications in orthopaedics, electroencephalography, dental medicine and other fields. First projects in telemedicine were introduced, starting with telepathology, alergology and teleradiology. They were reviewed (27) and followed in late nineties by a telemedicine project in isolated areas, with a number of Adriatic Sea islands chosen as test sites for first trials (beginning in 1998) (28).

Several new registries were established in the Croatian Institute of Public Health: Registry of health professionals (in 1991), Registry of persons treated for psychoactive drugs (in 1983) with regular annual reports on the epidemiology of addiction (started in 1999), Registry of persons with HIV/AIDS (established in 1985).

MI applications in clinical medicine

As in many clinical disciplines in Croatia in those years significant efforts were made to follow the development of medical science in the world, so the application of diagnostic and therapeutic methods based on electronic computers started early. Besides the methods for the calculation of radiation doses in radiotherapy applied in several Croatian hospitals, applications in nuclear medicine and electroencephalography have been developed, and the computed tomography has been applied in Zagreb very early (1975). A Centre for Tissue Typisation, supporting kidney transplantation, was established 1973 at the University Hospital Centre in Zagreb, and started with computer applications from its very beginnings. The use of medical records designed for computer processing started in psychiatry, diabetology, otolaryngology, maxillofacial surgery, gynaecology and other clinical disciplines. ICT based diagnostic and therapeutic instrumentation (e.g. in the clinical laboratory, intensive care, electrocardiography, etc.) was introduced in daily medical work also in the seventies of the last century.

Start and development of MI research

First published results on MI research in Croatia originate from the Andrija Stampar School of Public Health. After the opening of the Terminal station at the School many biomedical researchers in Croatia wanted to perform their statistical data analysis, so necessary in their work, using the big mainframe in SRCE. At that time such analysis was performed by using computer programs in batch processing mode, with software packages specifically intended for biomedical research (e. g. MEDCOMP from the University of Cincinnati [1963], BMD -from UCLA [1971] and SPSS from Stanford University [1973]). As these packages at that time did not allow the user to work online and to create their own strategies of data analysis during this work, a special conversational statistical data analysis language as well as a special interactive statistical package for biomedical research, CSTAT, were developed (19,20). This was welcomed by the users, because it allowed a narrower contact with their own data and creation of new strategies for their statistical analysis, an approach possible today when using personal computers.

In the beginning of eighties the Croatian funds for scientific work started financing first two MI projects. Let us mention their titles: "Production and flow of information in the health care system" (1981)(1982)(1983)(1984)(1985) and "Creating algorithms and models of information flow on the operational level in the healthcare system" (1981)(1982)(1983). These projects resulted in a number of papers: two on the health information systems, four on databases and one on the role of microcomputer technology in health applications (the IBM PC Model 5150 was released in 1981!) (the citations of these papers can be found in ref. 21). Another project was started in the field of modelling and computer simulation of infectious diseases in the population, with the development of software for continuous simulation with graphics modules, partly in collaboration with the Institute of Medical Cybernetics, University of Vienna. The method of continuous simulation was also applied to other health problems, especially to investigate the dynamics and control of non-communicable diseases in the population, and to study the creation and monitoring genetic diseases. The results of these computer simulation studies were published in nine papers (21).

The project of continuing education in PHC (1985)(1986)(1987)(1988) in collaboration with the Japan International Cooperation Agency (JICA) has gathered researchers from Croatia and Japan in the development of new methods for computer assisted instruction (CAI) in medicine, and this joint work resulted in four papers (21).

Two last projects in the eighties were "Information aspects and ICT basis of health assessment" (1986-1990), and the interdisciplinary project "Connecting the space and health data to assess the health status of the population" (1986)(1987)(1988)(1989)(1990)). In the framework of these projects four papers have been published on information systems, three on databases in PHC, two on linkage of space, households and inhabitants, and one on genealogies handling by computers (21).

To the end of the eighties, inspired by the rapid development of the medical decision-making software and computer-based expert systems, first ideas appeared to start with research in this field. At that time in the Andrija Stampar School of Public Health several research projects disposed with computerized databases, so it appeared suitable to exploit these data for such purposes. It was favourable that during the eighties at the University of Ljubljana a suitable software system was developed (named AS-SISTANT) allowing automatic learning of rules by which physicians make their decisions. In collaboration with the Slovenian colleagues it was possible to acquire the software, so the first pilot study could be carried out on data in the field of perinatology and rheumatology (22), as an introduction for future medical decision-making research in the next decade.

other parts of former Yugoslavia for this, or Croatia where most of MI professionals ctive. first organization of medical informaticians atia was established 1983 in the form of a n for MI at the Croatian Medical Association. embers could be professionals of various s, physicians as well as other people with ic education. From the very beginning it lanned, when the circumstances will allow shing of an independent MI society which acilitate membership to EFMI and IMIA. Zagreb developed during forthcoming years strongest MI center in former Yugoslavia, a of "Conferences on Informatics in care" started there, attracting medical aticians from the whole country and helping arations to establish MI societies and their tion which could become member of EFMI MIA 27 . After more than one year of ations, the Croatian Society for Medical atics (CSMI) was founded on February 16, . It is worth to note that shortly after the tion of CSMI a successful Alps-Adria ence has been organized in According to its Statutes CSMI´s basic objectives are to advance dissemination of information in the field of MI in Croatia, to promote high standards in MI applications, and to promote research, education and international cooperation in MI. CSMI especially organizes MI conferences and meetings, promotes MI education and its popularization, encourages MI standardization, and struggles for medical informatics dignity and dignity of people involved in medical informatics. All projects described in this subchapter were led by professors at the Andrija Stampar School of Public Health, which is a part of the School of Medicine in Zagreb. The first two MI projects described in this subchapter were led by Gjuro Dezelic, professor of MI, and Silvije Vuletic, professor of medical statistics. The project on computer simulation was led by Gj. Dezelic in close cooperation with Prof. Branko Cvjetanovic, a leading Croatian epidemiologist, professor at the School and WHO expert. The project on continuing education in PHC was led jointly by Gj. Dezelic and Takao Akatsuka, professor of information engineering at Yamagata University, Yonezawa, Japan. The project on health assessment was led by Gj. Dezelic, and the interdisciplinary project on connecting space and health data was led by Nada Dezelic, professor of health ecology. Most of the papers cited in this subchapter were published in the proceedings of international conferences (in total 12 papers, 6 of them at EFMI MIE congresses and 3 at IMIA MEDINFO congresses), in the proceedings of domestic conferences there were 9 papers, and the rest was published in journals.

Development in MI education

After the introduction of first MI compulsory courses at the School of Medicine in Zagreb in the academic year 1970/71, other medical schools in Croatia followed this trend. The School of Medicine of the University of Rijeka introduced such education in 1977. As the medical schools in Osijek and Split were in the beginning linked to the School of Medicine in Zagreb, so the first MI education in Split (the medical study was opened in 1974) started in 1976, and in Osijek (the medical study was opened in 1979) in 1981. In the second part of eighties personal computers were gradually introduced into MI laboratories, allowing students to broaden their practical work. In Croatian nursing schools MI education was also introduced in early eighties of the past century. The Zagreb University School of Dental Medicine introduced MI in its postgraduate education in the middle of eighties. As noted earlier, all medical postgraduate studies had MI courses in their curricula. Consequently, medical and health professionals in Croatia obtained MI education in the form of appreciation courses for almost three decades and were well prepared for the future challenges of the Croatian computerized healthcare. The early beginning of MI education at Croatian medical schools aroused attention elsewhere, including its spreading to other parts of ex-Yugoslavia and discussions on its first experiences, problems and prospects at international conferences (10,23).

After more than one decade of MI education at the appreciation level, and with several successful research and development projects, trained MI specialists were needed. Following these demands, the School of Medicine, together with the Faculty of Electrical Engineering and Computing and the Faculty of Science, all of the University of Zagreb, started a program of postgraduate education in MI in 1984. The program was called "Health Information Systems" and lasted about two decades. More than 120 students enrolled and about 30% finished the program by a M.S. thesis. Most of the students were physicians, but there were also pharmacists, mathematicians, economists, librarians and engineers working in healthcare (1).

At the beginning the teaching materials for MI were in the form of handouts with lectures and tests in written form. The first Croatian textbook, intended for MI teaching and accepted by the Zagreb University Publishing board as an official text, was published in 1976 and entitled "Fundamentals of Informatics" (24). The next three enlarged and revised editions under the changed title "Health Informatics" were published in 1986, 1987 and 1989. To the end of the eighties, the teaching materials needed for practical work in MI education were also prepared in the form of handouts, until the first MI laboratory manual was published as a book in 1990 (25).

It is worth mentioning that during the eighties an intensive cooperation in MI teaching has been established by the Andrija Stampar School of Public Health with the Medical School in Sarajevo, in the neighbouring Bosnia and Herzegovina, where Gjuro Dezelic taught MI to their postgraduate students from 1984 to 1990, until Izet Masic, after gaining his PhD, succeeded him in teaching and expanded the MI education in his country to the undergraduate level.

Beginnings of international cooperation and establishment of CSMI

First international contacts of Croatian MI professionals happened already at the first of the EFMI congresses -Medical Informatics Europe MIE 1978 in Cambridge. At this venue Gjuro Dezelic had a chance to contact with leading persons of EFMI, and they invited him to participate at the EFMI Council meetings as an informal observer representing Yugoslavia, in which Croatia was one of the six federal republics. As EFMI then consisted of 11 member countries, the Council was interested to get new members and national representatives. In September 1979, at the Congress MIE Berlin, IMIA held its General Conference, so Dezelic could also participate as an observer. As EFMI and IMIA accepted as regular members only MI societies of individual countries, being members of the World Health Organization, in Ex-Yugoslavia it was necessary to found such societies in particular republics, and then to establish their federal association eligible for membership. As the number of MI professionals in particular parts of Yugoslavia was uneven, and most of them were in Croatia, it took a rather long time until the full membership in EFMI and IMIA could be achieved.

In the meantime, after the successful panel of the Croatian Medical Association entitled "Health Information Systems and Health Informatics Activity in the Development of Modern Medicine and Healthcare" in April 1983 in Zagreb (attended by more than hundred participants), the first association of Croatian MI professionals has been established -the Medical Informatics Section of the Croatian Medical Association, with Marija Strnad elected as chair. The members of the Section were physicians and other professionals interested in MI. Already at this panel it was concluded that, when circumstances permit, to establish in Croatia an autonomous MI society, similarly as in other countries, as an incentive to join EFMI and IMIA.

As MI became a topic of increased interest in the medical community in Croatia, the Croatian Association of Healthcare Institutions, an organizer of traditional international exhibitions "Medicine and Technology" held each May in Zagreb, initiated in 1986 the first of "Meetings of Informatics in Healthcare" (MIH) as a successful accompanying event. At the 2nd MIH in May 1987 the Association founded its Committee for Health Informatics, with Gj. Dezelic serving as chairman. The Committee was specially engaged to organize MI conferences with participants from other parts of Ex-Yugoslavia and abroad (especially MI experts from the so-called "Alpe-Adria Region" [A-A Region], consisting of geographically relevant parts in Austria, Germany, Italy and Ex-Yugoslavia). At this MIH the Committee was entrusted with the mandate of representing Yugoslav MI professionals in EFMI and IMIA, until an association at the federal level was formed. In the same time Gjuro Dezelic, as the chairman of the Committee, became the status of the official observer from Yugoslavia in EFMI and IMIA.

At the 3rd MIH in May 1988 it was agreed that in particular Yugoslav republics, able to gather enough members, autonomous MI societies should be formed. As a result of this agreement the Croatian Society for Medical Informatics (CSMI) was established on February 16, 1989, succeeding the previously mentioned Committee for Health Informatics. Also to the end of 1988 MI societies were established both in Bosnia and Herzegovina (BiH) and Slovenia, and Serbia formed the MI section of the Serbian Medical Association. In that way the prerequisites to establish the Yugoslav Association for Medical Informatics (YAMI) were fulfilled.

Simultaneously in August 1988, at the EFMI Congress MIE 88 in Oslo, several participants from A-A Region agreed to meet yearly by turns in Graz, Trieste and Zagreb. According to that in May 1989, at the occasion of the 4th MIH in Zagreb, the first "Alpe-Adria Round Table Discussion" was organized, and the topics were "Presentation of MI activities in the A-A Region" and "Possibilities of the MI collaboration in the A-A Region" (the organizers on behalf of their countries were Günther Gell The prospects for further successful advancement of MI in Croatia were good. Research was advancing well by pursuing many of the problems of the time and orienting itself to contemporary themes. The development of information systems in healthcare began, and MI education produced a new generation of people interested to work in MI. As an indicator of this it can be noted that CSMI had more than hundred members soon after its foundation in 1989. The regulation of its official links with EFMI and IMIA through YAMI was awaited, but the procedure was long. Although YAMI was founded in the middle of 1989, its registration by the federal authorities of Ex-Yugoslavia was fulfilled at the end of that year, so the official application for admission to EFMI and IMIA could be submitted only at the beginning of 1990.

Although the boards of both international organizations quickly accepted YAMI´s application, one had to wait until August to formalize its membership at MIE 1990 in Glasgow.

Soon after founding, YAMI organized its first MI congress in December 1990 in Belgrade. At YAMI´s first general assembly held at this occasion, it was decided to submit to IMIA the candidacy of CSMI for the MEDINFO congress in 1995 in Zagreb. So the plans for future activities both of CSMI and YAMI were ambitious.

At the same time the Commission of the European Communities (the forerunner of the European Commission), in the endeavour to support common understanding and cooperation in research and basic technological developments in Europe, at the end of 1989 "undertook a number of programmes with the aim of advancing informatics and telecommunications in important application fields. One of these programmes is concerned with medicine and health care. It is called AIM, Advanced Informatics in Medicine." The AIM action supported in the beginning 42 projects, and a special EFMI´s working group was mandated to submit project proposals of its members (26). As CSMI members participated for years at MIE congresses, this was a good possibility for them to participate also in European projects, either by proposing own projects, or to collaborate in AIM meetings. Everything seemed favourable for Croatian MI researchers, especially for the younger generation trained in MI, expecting to increase their international presence in Europe. But future events disturbed these prospects.

Yugoslavia has entered a period of political turmoil, which led to its dissolution. A little more than two years after the founding of CSMI, in mid-1991 began the aggressive war against Croatia (the main aggression ceased at the beginning of January 1992, but the war ended in August 1995). It caused many victims and great destruction, and many members of CSMI were engaged in defending the country and fighting for its freedom and independence. This of course influenced the work and development of CSMI. But difficulties occurred also in international cooperation. As examples let us mention two cases: (1) Due to the war threats, members of CSMI could not travel to Graz to attend the second meeting "AA 91-Alpe Adria-Informatica Medica" in early October 1991, but could be represented by their fellow Miroslav Madjaric (working at that time with Professor Gell); at this meeting participants from four countries-Günther Gell from Graz, Attila Naszlady from Budapest, Mateja Kozuh-Novak from Ljubljana and Miroslav Madjaric from Zagreb -issued a Resolution to the responsible governments "to stop fighting in Croatia and to induce a peaceful solution on the basis of democracy, freedom and respect for human rights"; and (2) Gjuro Dezelic could not travel to deliver his invited lecture at the "Conference on Training Strategies for Health Information Systems" organized by the Council of Europe and EFMI in Strasbourg, which was scheduled for October 31st, 1991 at 10:40 hours; this happened because at the beginning of that month the Commission of the European Communities, after the start of the war in Ex-Yugoslavia, decided to forbid all invitations of participants from that country to European conferences, as well as to cancel those in progress; at this conference Dezelic had to participate also as a member of the Programme Committee.

The war against Croatia, which followed after a short 10-days war against Slovenia at the end of June, led to the dissolution YAMI. In September 1991 the Slovenian and Croatian MI societies withdrew from YAMI, and the MI Society of BiH followed a few months later. After January 15th, 1992, when the Republic of Croatia was diplomatically recognized by the European Community member countries and most other Western countries, CSMI already on January 20th submitted its application for membership to EFMI and IMIA. Both organisations accepted CSMI´s application at their first formal meetings, and at the MEDINFO 1992 in Geneva CSMI became member of IMIA (on September 5th) and EFMI (on September 6th).

The candidacy of CSMI for the MEDINFO 1995 Congress in Zagreb, announced in 1990, was from the very beginning fully supported by the Croatian ministers of health and science as well as by the lord-mayor of Zagreb, but due to the post-war economic problems in the country CSMI could not continue any more to apply for the organization of this big world MI gathering in Croatia.

Advancement of MI research in Croatia, beginning of CSMI biennial symposia and start of the CSMI Bulletin

After Croatia gained international recognition and became a member of the United Nations in May 1992, the opportunities for MI research began to normalize. CSMI could finally revive initial plans, stipulated at its founding, to organize national MI symposia. It was decided to organize them biennially, and the first was scheduled for October [21][22]1993 in Zagreb. Since then, CSMI MI symposia are organized each two years until today. From the very beginning the proceedings to all symposia (published under the title "Medical Informatics") were prepared in advance and available to participants, and this habit important for the success of these scientific gatherings is kept until the present time. The main editors of the symposia proceedings, being a good indicator of MI topics investigated by Croatian MI professionals in this period, were from the beginning Josipa Kern and Mira Hercigonja-Szekeres, with several other CSMI members joining occasionally as co-editors.

The number of submissions at symposia in the nineties of the 20th century was about thirty, mostly in the form of full papers (in average 27), and a significant number of authors wrote their texts in English. The 3rd Symposium in 1997 in Split introduced as a novelty a video conference between Split and Zagreb, provided in cooperation with CARNet -the Croatian Academic and Research Network. The success with video-conferencing has enabled to organize the 4th Symposium in 1999 entirely as a video conference between the four major medical centres in Croatia: Zagreb-Osijek-Rijeka-Split. The submissions covered various MI topics: (1) information systems (IS) in hospitals, (2) IS in primary healthcare and public health, (3) software and databases, (4) data security and classification, (5) standardization in MI, (6) signal and image processing, (7) telemedicine, (8) medical decision support systems, (9) modelling and simulation, (10) temporary, which were investigated by Croatian MI professionals in these days. As the 1st symposium in 1993 was held shortly after the end of war, an extraordinary topic was introduced -MI in emergency conditions. Here an interesting work was presented by Neven Henigsberg and co-authors describing an information system connecting 32 healthcare institutions, based on digital data exchange by using packet-radios (the then available wireless technology), able to communicate large quantity of data collected during disasters (in the pertinent case in besieged areas) and stored in databases, when existing communication infrastructure is disabled.

In parallel to the introduction of MI symposia in 1992 CSMI started to publish its periodical named "Bilten HDMI" (CSMI Bulletin, ISSN 1330-0253). The first editor-in-chief was Josipa Kern, followed in 1996 by Silvije Vuletic, who edited it until 2004. In the same period a change occurred also in the person of the CSMI representative in the EFMI Council and IMIA General Assembly. The CSMI president Gjuro Dezelic, who had the observer status of his country in these bodies since 1978, and continued to serve as the official representative since 1990, after joining the Croatian diplomacy could not fulfil this duty any more asked for a successor, so the CSMI vice-president Josipa Kern overtook the duties of the CSMI representative to EFMI and IMIA in 1994. After the beginning of work in the field of medical decision-making and expert systems at the end of the eighties of the 20th century, despite unfavourable post-war economic conditions in the country, two new research projects were started: (1) "Heuristic decision support systems in healthcare" (led from 1991 to the end of 1992 by Gjuro Dezelic, and from 1993 to 1994 by Josipa Kern), and (2) "Information technologies and decision-making in healthcare" (led from 1996 to 1999 by Josipa Kern). The results were published in more than twenty papers, including a PhD thesis and several Master's theses. The methods applied were: inductive learning, neural networks, pattern recognition and text analysis (21).

Further development of MI education

In the beginning of nineties, the MI laboratory at the School of Public Health has been equipped with a number of personal computers networked to a workstation of the Croatian Academic and Research Network (CARNet), the first Internet Service Provider (ISP) in Croatia (established in 1992). Except that medical students were now able to extensively use common software for text processing, spreadsheets, databases and statistical computing, they were also able to start using Internet and communicate via e-mail. This enabled them to become familiar with examples of the computer applications in doctor´s offices, information on drugs, computer-assisted instruction etc. They could start searching Medline databases and read electronic magazines. The postgraduate students were able to start studying special topics, like simulation modelling, methods of inductive learning, decision making by data mining and by free text analysis. In the year 1999, in collaboration with CARNet, the MI university teachers at all four Croatian medical schools -in Osijek (Vesna Ilakovac), Rijeka (Mladen Petrovecki), Split (Marijan Erceg) and Zagreb (Josipa Kern, Jadranka Bozikov) -organized a teleconference on telemedicine for students of medical schools, a project which provoked much interest among Croatian medical students.

In 1997 a fully revised edition of Dezelic´s MI textbook appeared under the title "Medical Informatics", published by CSMI, and a new chapter on medical decision-making was added (written by J. Kern) as a result of the increased interest for this special MI field among students (29). In this textbook MI is clearly defined as an interdisciplinary "scientific discipline that deals with the theory and practice of information processes, i.e. with data processing in the broadest sense", as well as it "deals with the procedures for handling of medical data, information and knowledge needed to solve medical problems and for decision-making in healthcare".

DEVELOPMENT IN THE 21 ST CENTURY

Development of MI projects-Current status of computerization of the Croatian healthcare system

Since the beginning of the 21st century the Ministry of Health is committed to developing a national health information system in Croatia. The key drivers behind this decision were previous experience with computerized applications and health information systems development, coupled with a growing understanding of the importance of health information for making appropriate decisions in health care. Health information is used to treat individual patients or population groups, to plan health care and estimate health problems requiring intervention, as well as to ensure better use of resources.

In 2001 a group of experts, consisting of health professionals, MI professionals, and jurists was established to start a new project -an integrated national health information system (INHIS). The requirements for this system were that it should be centralized and cover primary health care (PHC, the 'gate keeper' in the Croatian healthcare system), as well as hospitals (the main generator of expenses in health care). The need for centralization derives from the fact that Croatia has a rather small population (< 5 million people), and the Croatian Public Health Institute and the Croatian Health Insurance Institute both require reports on health and health service status as well as surveillance of costs. Security and standardization were sine qua non requirements for the integrated health information system (30).

The first phase of the pilot project was based in general practitioner´s (GP) offices which agreed to participate, and several hospitals (clinical and general hospitals). After the successful evaluation of the pilot results the hospital part of the project was halted, but the primary healthcare component continued to develop (31,32). The PHC project was designed at two levels: central (kernel of the system) and local (individual GP offices). The kernel was run by one vendor, and the local applications were given to several vendors. At the same time a process for certifying local applications was established. The outcome of this process was that several vendors were certified to develop and install their applications in GP offices. All the GP offices holding contracts with the Croatian Health Insurance Institute were obliged to install one of the certified software systems by the end of 2008. By the end of 2007 about 50% had started Figure 6. Participants at the Brijuni STC 2007 the real work by using these applications. The most recent information (end of 2012) indicates that the implementation of these systems was successful. An evaluation procedure ("are the health professionals satisfied with") was completed (33). Recently, development of an integral evaluation instrument for the PHC information system has been under way (34).

Croatia is mindful of the importance of a regulatory framework for the computerization of its healthcare system and several relevant laws have been passed, one of which is the Personal Data Protection Law (35). In addition, an Agency for Personal Data Protection has been established to ensure compliance with this law. Other important legislation covers issues such as the relationship between electronic and paper documents, digital signatures, and standardization.

The ethical aspect of personal data protection is covered by the Code of Ethics for Health Information Professionals, passed by IMIA (36) and translated by CSMI (37). Although the hospital part of the INHIS project was halted, hospital directorates have continued to develop and implement particular ICT applications in their hospitals (38,39,40,41).

In the Croatian Institute of Public Health a new registry was established. It is the Registry of persons with disabilities, established in 2002.

Wanting to direct the process of computerization in Croatia, the Croatian Academy of Medical Sciences (CAMS) established the Committee for e-Health (previously: the Committee on Telemedicine), with a mission to engage all stakeholders in the implementation/improvement of the INHIS in Croatia. The members of the Committee for e-Health are members of CAMS and CSMI. It issued the Declaration on e-Health, organized a debate among the members of both organizations, and finally published it at the CAMS's website (42). The settings of this Declaration entered into the "National Health Care Strategy" issued by the Croatian Ministry of Health. Also, it became a basis for development of the strategic document on e-Health in Croatia.

In the period 2007-2010 the project ACTION Grid (International Cooperative Action on Grid Computing and Biomedical Informatics between the European Union, Latin America, the Western Balkan and North Africa) (43) was established as the initiatives to create a common health information infrastructure in Europe, and extending it to other regions. The Facultad de Informatica, Universidad Politecnica de Madrid (Spain) was the coordinator of the project (Victor Maojo). The University of Zagreb, School of Medicine was a partner institution with Josipa Kern as the project leader from the Croatian side. The aim was to enhance cooperation between research centres, universities, hospitals, small and medium-sized enterprises, public entities and others, and expand the impact of European achievements in grid and biomedical informatics to researchers, educators, and health practitioners world-wide (44,45,46,47,48).

Current development in MI education

The e-Croatia Education Program started in the early years of the 21st century with the introduction of information science into the national curriculum at all levelsfrom elementary schools through to universities. The development of an appropriate ICT infrastructure was the first step. This involved building of computer classrooms and creating broadband access to the Internet via ADSL from 600 libraries, 700 primary schools, all secondary schools and higher education institutions (49).

IMIA recommends that all health professionals should be acquainted with ICT and be able to use technology responsibly in their daily work. All health professionals should be educated in MI, as well as nursing informatics should be a part of the medical/nursing curriculum. Recently there are four medical schools at Croatian universities, and several nursing schools at baccalaureate level. All the university MI education programs are similar, using the same MI textbooks. However, the position in the medical/nursing curriculum is not the same.

Having several computer laboratories at the School of Medicine in Zagreb, students and teachers began to introduce e-learning into several subjects (pathology, brain research, physiology, etc.). However, MI and medical statistics are the subjects which make the greatest use of ICT, not just as an educational tool, but also as a way of solving information problems in medicine and healthcare. Recently, all courses at the School of Medicine in Zagreb have developed e-lectures, put their teaching material to local Intranet, and realized communication with students by using their internal system maintained by the School´s Office for e-learning, and supervised by using the authentication and authorization infrastructure (AAI) of research and high education system implemented in the Republic of Croatia (50).

In 2009 a new comprehensive MI textbook was published, again under the title "Medical Informatics". This was a big innovation in Croatian MI publishing, as it serves both for educational and scientific/professional purposes. It is a work of 42 Croatian authors -university teachers (8 professors, 1 lecturer and 6 assistants from all four Croatian medical schools, 2 professors from other university institutions), scientists and professionals from health institutions and firms engaged in MI projects (51). It is officially recognized as a university textbook in all medical schools in Croatia, but has also characteristics of a MI manual, suitable for other medical practitioners and health professionals interested in MI. Recently, this textbook serves also as a basis for informatics" (1997), documents on the prin and recommendations to personal data prot (2000), as well as translations of the IM Recommendations on MI education (2001Code of Ethics (2003, available at CSMI´s in portal (in operation since 2000) 31 . CSMI´s of served also as guest-editors of other Cr scientific and professional journals 32 . 31 URL address: http://www.hdmi.hr/. Graduate study curricula for medical and nursing students in Croatia

As an example of MI teaching at Croatian universities, the MI curricula at the School of Medicine in Zagreb will be described.

The MI curriculum for medical students begins with basic ICT skills as an elective course at the beginning of the study. MI for students of the fifth year includes topics relevant to acquaint the students with the concept and tasks of medical informatics as an interdisciplinary profession that deals with the theory and practice of information processes in medicine, health care and research.

The nursing informatics curriculum starts in the second year of the graduate study in nursing (52). The course begins with basic ICT skills and continues with the concepts and tasks of nursing informatics and its role in the nursing process, health care and research.

Both curricula are delivered through lectures, seminars and practical work in computer labs.

Postgraduate study curriculum

At present the specialized postgraduate MI program at the School of Medicine in Zagreb is suspended. However, there are several MI courses in other postgraduate and doctoral programs.

ACTIVITIES OF CSMI

The first president of CSMI Gjuro Dezelic was on duty to the year 2004. The next presidents were: Josipa Kern (2004Kern ( -2008, the vice-president until 2004), Mladen Petrovecki (2008 and Vesna Ilakovac (2009 until today).

In THE BIRTH OF MEDICAL INFORMATICS (1970INFORMATICS ( -1989 In the early 1970s, new developments brought first prototypes of decision support systems in medicine and health care to Czechoslovakia. In 1980s, new information and knowledge in the field of medical informatics was acquired by Czechoslovakian researchers mainly through MEDINFO and MIE conferences and through some national conferences with international participation described further in more detail. Figure 1 shows Jan van Bemmel, chair of the Scientific Program Committee (SPC), Jana Zvarova, chair of the Local Organizing Committee (LOC), and Shigekoto Kaihara (then IMIA president) from Japan. The proceedings made of selected full papers, titled Diagnostic Strategies and Expert Systems, were published by Elsevier, North Holland (1). Among 79 published papers in the proceedings, 30 papers were from Czechoslovakian authors.

The 1988 National Conference Computers with International Participation on Medical Education

The conference was organized by Charles University in Prague on their premises in August 29 -31, 1988. The languages used at the conference were Czech, Slovak, English, and Russian. The papers of the conference focused on using computers in teaching biophysics, physiology, and clinical disciplines, on medical informatics education, and on the use of expert systems. The international speakers were F. Gremy (France)

THE CHILDHOOD OF MEDICAL INFORMATICS (1990 -1999)

The Velvet Revolution in Czechoslovakia, initiated by a students' strike on November 17 th , 1989, opened the door for cooperation in science and education with a number of western countries. In 1990s, medical informatics topics were further developed in education and decision support tasks at the national level and through international co-operations.

IMIA Working Conference in Prague 1990

The second IMIA conference held in Prague, 3-7. September 1990, focused on medical informatics and medical education ( Figure 2). It brought together participants from 18 countries from all over the world and the proceedings, titled Knowledge, Information and Medical Education, were published by Elsevier in 1991. The proceedings contained over 60 contributions describing the influence of computers on medical education (in the curriculum and at the postgraduate level) and the education in medical informatics in general (2).

Education in the Methodology Field of Healthcare

Due to political changes in the last decade of the twentieth century, Central and Eastern European countries were able to receive support through selected programs of the European Union. The first European project focused on medical informatics education, titled Education in the Methodology Field of Healthcare -EuroMISE (European education in Medical Informatics, Statistics and Epidemiology) was operational from 1993 to 1995. The key issues of this educational programme were to promote multidisciplinary approaches and to focus on healthcare issues that received insuffi-cient attention in traditional training (3,4). The project developed educational programs and designed courses in a broad European co-operation focusing on teaching teachers and health professionals from Central and Eastern European countries. Eu-roMISE courses given in English consisted of 200 hours of teaching, and more specifically, 160 hours of direct teaching (lectures and practices) and 40 hours devoted to the preparation of the lectures presented by students at EuroMISE workshops and conferences. Moreover, students were given three months to prepare a final thesis on a subject taught during EuroMISE courses.

Czech participants had a sound experience during visits at universities participating in the project. Visits were organized by cooperating EU teachers. In the field of medical informatics, several visits were organized by J. H. van Bemmel and A. Hasman

Managing Uncertainty in Medicine

The second European project entitled Managing Uncertainty in Medicine with the acronym MUM, was operating from 1994 to 1996. The goal was to contribute to the emerging unification theory of managing uncertainty, when both probabilities and logical approaches were applied, and incorporate these methods into diagnostic knowledge-based systems and smart systems for data analysis. Another important part was to gain practical experience in the field of medical data analysis and knowledge processing by introducing software tools in selected medical health care facilities and by developing decision support systems to be used in various health care facilities in order to offer better treatment to patients, especially in situations where clinical experience may be lacking. lowed the extension of the multidisciplinary cooperation of the EuroMISE Center to three more institutions, namely the University of Economic in Prague, the University General Hospital in Prague, and the Municipal Hospital in Caslav. An intensive collaboration between the Faculty of Science and the Second Faculty of Medicine of the Charles University was formalized.

Information Technology for Education and Training

The main goal of the 4th framework program of European countries titled IT EDUCTRA (Information Technology EDUcation and TRAining) operating from 1996 to 1998 was to contribute to the information distribution from of information technology in education and training in medicine. Twenty universities and research workplaces and companies took part in the project, among them the EuroMISE Center. One aim was to develop teaching materials in different European languages (including the Czech language) from research results reached in Spain, Germany, Italy, Denmark, Great Britain or other countries. High priority was given to topics such as electronic communication, patient electronic records, safety and security of data, computer-assisted diagnosis, and management of health care quality. Based on the analysis of educational needs in medicine, ten topics were selected for health care education, each of them covering many incremental subjects and disseminated on a CD (5).

EuroMISE Courses from 1996 to 1999

The financial support given for the EuroMISE project stopped December 31 st 1995. Nevertheless, courses were conducted in Prague until the year 1999 due to the personal support of many teachers from organizations participating in the EuroMISE project and the personal involvement of other medical informatics colleagues, like (6,7). This project led to the creation of the first structured EHR in both Czech and Slovak languages and evidenced the importance of structuring the information to allow systems interoperability in health care.

The knowledge acquired from the TripleC Project was further advanced in the national research centers project EuroMISE-Cardio (2000)(2001)(2002)(2003)(2004), where multidisciplinary research in the field of EHR and decision support systems was conducted with a focus on cardiology and dentistry. The priority was to propose and develop appropriate tools for structured data entry, representation, and processing in order to minimize the effort of users (physicians, nurses) and maximize the clinical relevance of collected data. The suggested Czech solution was implemented in a pilot application named MUDR (MUltimedia Distributed electronic health Record) (8,9). Two cardiology outpatient clinics were involved in gathering patients' data and validating research prototypes. The Minimum Data Model of a Cardiology Patient was proposed and research in formalizing clinical guidelines in cardiology was initiated.

A voice-recognition component of an EHR used in dental medicine, titled DentCross, was developed and semantic interoperability in cardiology was studied. The synergy of both voice recognition and the graphical representation of data made activities in the dental practice easier, quicker, and more comfortable (10,11). Since 2004, a dental EHR with the interactive voice-recognition DentCross component has been in use in dental care at the University Hospital in Prague-Motol.

Medical Guideline Technology

The MGT (Medical Guideline Technology) European project was conducted during the years 1998 to 2000. The project focused on the development of computerized tools providing patient-specific practice guidelines (combining general guidelines for specific medical circumstances and specific conditions with a valid price model). Three main applications were created in the same medical domain of hypertension and cardiology by countries that differed in their health care systems, available resources, and organizational structures.

THE ADOLESCENCE OF MEDICAL INFORMATICS (2000 -2013)

Central In 2011 and 2012, discussions during workshops were enriched by the questions and comments of the foreign chairs of the workshops B. Blobel (2011) on HL7 Standards. Detailed information about EuroMISE 2004 conferences, satellite symposia, and workshops were published in special issues of the International Journal of Medical Informatics (17,18), and Methods of Information in Medicine (19,20). Keynote speeches were given in the Aula Magna of the Charles University in Prague with great impact on the audience (Figure 4).

Information Technology for the Development of Continuous Shared Health Care

The Information Society program of the Academy of Sciences of the Czech Republic was operating from 2004 to 2008. It's theme was the development of methods and tools for providing shared health care continuity in the information society. Research focused on the remote access to information either as data or knowledge from medical records using HL7 standards. It was validated in co-operation with the Municipal Hospital in Caslav.

Center of Biomedical Informatics

The Center for Biomedical Informatics was operated during the period from 1st

MEDICAL INFORMATICS IS GETTING MATURE

The importance of information in medicine continues to rise. Medical research and practice benefit from fast development of information and communication technologies. Challenges that medicine is now facing will not be met without access to even more expansive and higher-quality data. Medical applications based on information technology are sure to have a very strong potential to maintain or lower medical costs, improve quality, and support new medical agenda. Many eHealth applications support the processes of health care. It is expected that an increasing development of eHealth applications will influence also medical informatics education and training. Education is the core of the research and development. It is true for all business branches and the same holds for the health care industry. Since the year 2000, the Czech Society of Biomedical Engineering and Medical Informatics (often in co-op- eration with the EuroMISE Center) organized at least one workshop per year in the House of Physicians dedicated to a selected medical informatics topic. The workshop in 2001 titled International Standard HL7-a Pathway to Better Healthcare chaired by W. Ed Hammond from the Duke University in Durham, USA, introduced the HL7 organization and its activities. This workshop initiated the foundation of the HL7 group of the Czech Republic (22). The workshops in the House of Physicians introduced different topics to a broad audience of Czech physicians, engineers, and other healthcare workers and served also the dissemination of medical informatics knowledge to Ph.D. students. Figure 5 shows the participants of the workshop on Standards and Electronic Healthcare supported by GS1 1 Czech Republic and held in the House of Physicians in October 2011.

Medical informatics education has been incorporated to faculty curricula at several universities in the Czech Republic, e.g. Charles University in Prague, Czech Technical University in Prague, Masaryk University in Brno, and Technical University in Brno. The project MEFANET (MEdical Faculties NETwork) has been operating since 2007 and focuses on the progress in education of medical and health care disciplines using modern information and communication technologies. MEFANET aims at developing and strengthening the cooperation between Czech and Slovak medical faculties. More details about medical informatics education at medical faculties can be found in the web page of MEFANET (23) and in (24,25,26).

FUTURE PLANS

The challenge facing the IMIA History Taskforce and the Editorial Board of the 50 th Anniversary History Project, is how to summarize the international dimensions of the evolution of a highly interdisciplinary scientific and technological field like biomedical and health informatics (14,15). The prototype repository at Rutgers provides a preliminary version of an easily accessible archive for the documents of IMIA, and information about its contributors, events, and organizational evolution. The overview timeline provides a convenient point-of-entry to compile and search for specific dates, periods, and people. The indexing by document-type will enable the writers of the history to access the items of interest by region, country, or working group, and special interest group, as well as the World Congresses on Medical Informatics (Medinfos) and other meetings sponsored by IMIA. In addition to conventional archival media-based approaches, we will be exploring more recent software analytics tools for analyzing the text in the documents and correlating the contents with that in the published literature, so as to develop a detailed picture of the participation of different researchers and research groups in the activities of IMIA throughout its history. This can show how "professional social networks" of scientists, practitioners, and education specialists have led the activities of the organization, complementing conventional citation analyses. The patterns of participation and interaction between different regional and world-wide activities of IMIA will be clearly outlined and displayed on maps and correlated to summaries of the subfields of specialization of medical informatics. In this way, the main themes that have dominated the discourse and publications in our discipline can be more clearly defined, and included in the interpretive historical narratives. The sessions at EFMI-STC in Prague (12) and the Workshop at Medinfo 2013 (11,13) have led to the commissioning of the histories of the different national and regional societies and associations that comprise IMIA so they can be included in the 50 th Anniversary IMIA History volume. By investigating the use and development of new analytical summarization and visualization methods, these activities also contribute to the development of specialized informatics methods in support of historical research. And, they will be doing this to produce comprehensive, interesting narratives about the accomplishments and challenges of a unique international professional organization in informatics itself: IMIA.

• promoting the cross-fertilization of health informatics information and knowledge across professional and geographical boundaries;

• serving as the catalyst for ubiquitous worldwide health information infrastructures for patient care and health research.

With the continued evolution and recent diversification of informatics, IMIA has seen differing generations of professionals join its numbers. As well, with the sharply increasing political interest in the eHealth revolution, IMIA has embraced new and emerging nations into the "family". This is a testament to those early pioneers whose vision of informatics as an integrate component of the health of the word's population has proven to be the "right" direction. As a volunteer organization, IMIA has been shaped by its presidents and their boards in their leadership roles. All have left their mark on the organization. Through the years, IMIA has grown and changed.

MEMBERSHIP

Generally, membership to IMIA is limited to organizations, societies, and corporations. Member Societies: in each country, one society or a group of societies or an appropriate body which is representative of activities within the field of medical informatics may become a Member Society. In an country where no representative societies exist, IMIA accommodates involvement through "Corresponding" members, especially within developing countries. IMIA Member Societies may organize into regional groups. Currently, 54 societies joined the IMIA, and are named as presented on Table 1 . First Presidents of IMIA: Francois Gremy (1968Gremy ( -1975, Jan Roukens (1975Roukens ( -1980, David B. Shiers (1980)(1981)(1982)(1983) the adninistrative and scientific activities such as board meeting and working conferences were held in European countries. At the time, members of IMIA that implicitly believed that medical informatics could only be applied to developed countries.

However, Dr. Salah Mandil, from WHO; always stated that medical informatics should also be applied to developing countries since it has the potencial of tackling their health issues. The organizing committee chaired by Mr. Ouyang worked extremely hard for two and half years in order to make this conference a success. The Tiananmen Square Incident took pace in 1989. Soon after that Shigekoto Kaihara began receiving a hundred lettters from participants stating that they would be unable to attend the MEDINFO in China and that IMIA should hold the meeting in some other city. After considerable deliberation, it was decided that the first part of the conference should be held in Beijing, but the second part will be held in Singapore fot those, who would be unable to participate in the Beijing MEDINFO. The Beijing MEDINFO as well as the Singapore MEDINFO were equally successful. More than 600 participians attended to each conference. After this experience, IMIA has envolved into a strong international organization based on the mutual trust and friendship of all members across the globe (6).

IMIA activities during presidency of Hans Peterson )1986-1989)

Hans Peterson served as President of IMIA from 1983 through 1986. His election as an International Associate of the College recognizes these sustained achievements. In 1983, after three years as president elect, Hans Peterson became president of IMIA. "What I remember best", he says, "is that there was no money." MEDINFO 83 had diminished already limited funds, and money was simply not available for what was needed for MEDINFO 86 and subsequent activities. IMIA's officers ended up providing IMIA with free services, from printing and stationery to mailing and telephones. Grants to working conferences were impossible, and IMIA's officers had to spend almost all their time on finances. The final blow came when IMIA closed its permanent secretariat in Amsterdam and its small remaining treasury vanished. The bottom line was "very little time for accomplishments and achievements. The goal was to survive." IMIA activities during presidency of Marion J. Ball (1992Ball ( -1995 At the conclusion of MEDINFO 92 in Geneva, Marion J. Ball received the gavel from Jos Willems. Soon she faced a crisis when Brasil withdrew as the site for MEDINFO 95. She turned to her colleagues and the IMIA members, and Canada took on the challenge of hosting an international congress with only two years lead time, thanks to Kathryn Hannah and Steve Huesing. With the guidance of the board, IMIA distributed governance to five new vice-presidents and implemented Jos Willems´s vision of a professionally-run organization with a permanent secretariat. To make IMIA a bridge organization across sectors and regions, she worked to create institutional membership, make IMIA more visible in the USA and foster working conferences. She was also able to lend support to the Asia Pacific Association for Medical Informatics (APAMI), newly and succesfully formed by KC Lun. With the support of board, she was able to make a substantive progress in key areas, including strengthening IMIA organizationally and fostering health informatics regionally. As IMIA`s first President from the USA, she was determined to give IMIA more visibility in the USA and the Americans. During her Presidency, IMIA sponsored four working conferences in the USA. One of these focused on organizational issues, one on nursing informatics, and a third on hospital information systems. The fourth, which she co-chaired, focused on health professional workstations; its findings have served as a roadmap for many of the advanced made in the years since then. • Strengthen IMIA as professional organization;

• Build bridges to other organizations;

• Tap the experience of former officersand honorary members;

• Make IMIA better visiable to the outside world;

• Make MEDINFOs still better and MEDINFO 2001 the largest ever.

• During his serving IMIA, they established a true Permanent Office,

The IMIA office was envolved in:

• giving assistance to IMIA`s Board and General Assembly,

• long-range planning; preparation of policy and its execution,

• with member societies, working groups, and affiliated societies,

• facilitation of regional and working conferences, consultation activities, and MEDINFOs, • contants with and giving service to industrial and academic instituional members.

• publications, newsletters, Yearbooks, conference proceedings, etc.,

• promoting medical/health/nursing informatics to industry,

• raising financial resources from IMIA services and activities.

At the end of his presidency, MEDINFO 2001 took place in London at a very new venue in the Docklands. The conference was a great success. In London he handed the gavel to his successor, K.C. Lun from Singapore (6).

IMIA activities during presidency of Kwok Chan (KC) Lun (2001Lun ( -2004 Prof. K.C.

IMIA Publications

The IMIA Yearbook of Medical Informatics, founded in 1992, showcases contributions from the best state-of-the-art research, and has become one of the most visible and valuable IMIA publications, drawing on, and adding to the great and impressive variety of books, proceedings and journal articles produced under IMIA sponsorship (6). It is designed to present an overview of the most original, excellent state-of-the-art research in the area of health and biomedical informatics of the past year; to provide surveys about recent developments, and comprehensive reviews on relevant topics in this field; and to provide information about IMIA. Beginning in 2014, the IMIA Yearbook will be published in an online open access format and the print version will be discontinued. IMIA's three official journals are: a) Applied Clinical Informatics; b) International Journal of Medical Informatics, and c) Methods of Information in Medicine.

Other Initiatives

IMIA continues to develop its communication capabilities through its website, which is undergoing expansion and development, and contains profiles on its members, working groups and activities. IMIA is constantly striving to further the services it provides to its members and the informatics community in general by promoting free interaction among and between its member network and the bio-medical and health informatics community at large. [6] IMIA Visions

IMIA's vision is that there will be a world-wide systems approach for healthcare. Clinicians, researchers, patients and people in general will be supported by informatics tools, processes and behaviors that make it easy to do the right thing, in the right way, at the right time to improve health care for all. (8).

The IMIA Strategic Plan

The IMIA strategic plan is based on three guiding principles. The principles are: a) IMIA will help to ensure a holistic, systems approach to collaboration and networking about biomedical informatics to maximize impact world-wide b) IMIA will uphold an ethical approach to informatics systems as identified by IMIA's seven ethical principles c) IMIA will promote biomedical informatics based on evidence and best practice to ensure impact on health is high quality, safe, efficient and sustainable and that makes it easy to do the right thing, in the right way, at the right time world-wide.

The most important mandate for IMIA is to contribute, through the use of Information and Communication Technology (ICT), to the improvement of biomedical research, clinical practice and public health. It is envisioned that, in the coming years, a more complete knowledge on the different factors that contribute to the development of disease (genetics, environment) will be increasingly available for developing new preventive, diagnostic and therapeutic solutions. IMIA has a key role to play in anticipating new challenges for informatics in the most important trends of future medicine (regenerative, genomic, longevity, patient-centred, preventive).

In terms of health care perhaps the most important challenge for biomedical informatics is to facilitate a fast and reliable translation of the biomedical research findings into real-use clinical solutions. From this perspective a major goal is to facilitate "translational research", improving the diagnostic arsenal with new imaging systems and micro devices suitable for "point of care" solutions, promoting rational drug design and supporting the development of personalized therapeutic strategies that can guarantee efficacy and patient safety.

New experimental approaches (cell therapy, tissue engineering) raise important issues to be addressed by ICT in health. Informatics can substantially contribute to the advance of these fields. This knowledge must be applied not only at an individual level, in terms of patient care, but also to improve the health of populations, through new public health studies and programs. The aggregation of electronic health records and informatics infrastructures to facilitate longitudinal and bio-bank-based association studies poses new opportunities for health informaticians.

Biomedical informatics is a multi-disciplinary area that involves multiple content areas. It is one of the fastest growing subject/content areas in the world. The use of informatics is expected to enhance research efforts in areas such as genomics and proteomics, for example, and also to change the way medicine is practiced in the 21st century. Research in informatics ranges from the theoretical to applied efforts. The demand for more research in biomedical informatics and for biomedical informatics to support other researchers escalates daily.

Knowledge is the core for IMIA's existence. IMIA's role will be to stimulate and connect researchers to enable their research. IMIA has numerous roles to play in providing leadership in the development and delivery of education, and where appropriate through collaborating with other organizations in contributing to the development of education across the entire spectrum of people impacted by informatics.

IMIA's direct role in education relates to education for biomedical informaticians, but it also has important indirect roles in ensuring the highest quality of education for all other groups of individuals who have a direct or indirect interaction with the practice of biomedical informatics.

IMIA has a role in developing educational and research opportunities within biomedical informatics, and mechanisms for fostering the development of 'the next generation' and discovering the currently unrecognised and underdeveloped talent of existing biomedical informatics students.

THE FUTURE OF IMIA

Developing informatics tools to support the writing of the history of biomedical and health informatics is an important endeavour given the approaching 50th Anniversary of IMIA in 2017. The need is to archive, index, and produce readily accessible recollections from the pioneering days of our field. The Rutgers History Informatics project has developed a MediaWiki to experiment with ways of collecting, indexing and visualizing the materials that related to the evolution of IMIA. The wiki allows access to documents, biosketches and short descriptions of historical events for IMIA, together with timeline summaries which place them in context. The prototype system will be augmented with audio material, and will serve as an archival repository for historical research, including software tools for text analysis and extraction of the information that can be used by authors contributing to the 50th Anniversary IMIA History, which is planned as an edited volume of contributions from all world regions and societies that are members of IMIA. Contributions to the IMIA History Project are already being published as articles in the IMIA Yearbook (8). The analysis of materials on the MediaWiki should help in studying the participation of different researchers and research groups in the activities of IMIA, and the "social networks" of scientists, practitioners, and education specialists that have led the activities of the organization, supplementing conventional citation analyses. The patterns of participation and interaction between different regional and world-wide activities of IMIA will be clearly outlined and visualizable on maps and correlated to summaries of the subfields of specialization of medical informatics, and the main themes that have dominated the discourse and publications in our discipline will also be more clearly analyzable. This represents a novel informatics-based community-building enterprise, very much like Wikipedia content development, but focused on the specific discipline of biomedical and health informatics, and for its specific worldwide association: IMIA. EFMI is running another series of meetings: the Special Topic Conferences (STC). Its concept has the following components: Organization by a member society in combination with its annual meeting, EFMI council meeting is integral part, Topic defined to the needs of the member society, Relevant EFMI Working groups are engaged for the content, Contributions mostly on invitation, Small 2-day conference with more than 100 participants. The most important meeting, however is the regular Council Meeting (twice a year) where council members can exchange opinions and have opportunity to discuss problems of medical informatics.

THE EUROPEAN FEDERATION FOR MEDICAL INFORMATICS -EFMI

Through its work, EFMI provides leadership and expertise to the multidisciplinary, health focused community and to policy makers, enables the transformation of healthcare in accord with the worldwide vision of improving the health of the world population (8-10). The scope of all Medical informatics journals covers:

EFMI MEDICAL INFORMATICS JOURNALS

• Information systems, including national or international registration systems, hospital information systems, departmental and/or physician's office systems, document handling systems, electronic medical record systems, standardization, systems integration, etc.;

• Computer-aided medical decision support systems using heuristic, algorithmic and/or statistical methods as exemplified in decision theory, protocol development, artificial intelligence, etc.

• Educational computer based programs pertaining to medical informatics or medicine in general;

• Organizational, economic, social, clinical impact, ethical and cost-benefit aspects of IT applications in health care.

IN CLOSING

Through its work, EFMI provides leadership and expertise to the multidisciplinary, health focused community and to policy makers, enables the transformation of healthcare in accord with the world-wide vision of improving the health of the world population. EFMI is constantly striving to further the services it provides to its members and the informatics community in general by promoting free interaction among and between its member network and the bio-medical and health informatics community at large.

THE MOST INFLUENTIAL SCIENTISTS IN DEVELOPMENT OF MEDICAL INFORMATICS

Medical informatics as a discipline is still relatively young compared to other medical disciplines. Its development could be traced back 70 years in direct correlation with the advent and widespread in use of digital computers and the development of information and communication tools based just on these computers.

In previous decades, society in general terms, and thus the medicine and health care have changed significantly, to great extent thanks to these developments. Today, we can hardly imagine diagnostic procedures, such as, for example, computerized tomography, or access to medical knowledge without access to numerous databases, or electronic storage of data relating to patients, without information technology in medicine. At the very beginning of its development, Mdical informatics is considered as discipline that could be helpful but not necessary discipline.

However, today it is one of the bases in medicine and health care in general. That is why, a lot is expected of Medical informatics, in terms of providing support to health care services in all parts of the world as well as in contributing to its quality and efficiency, and innovation in biomedicine and research in biomedical sciences. health care, public health and biomedical research; stimulating research, development and everyday application; promotion of education and responsible behaviour¸ moving ICT from theory to practice in all areas of health care and stimulation of progress, implementation of new technologies and research.

Everything mentioned above couldn't be realized without contributions of the great scientists and their discoveries and achievements. Thanks to them today we can speak about great improvement of health care protection on every level of the health care systems in almost every country in the world.

In this chapter we will try to describe a short facts about some of the most influential medical informaticians during the history of development of this scientific discipline . Author of this chapter described bioscathces of a few most influential biomedical experts in the scientific and academic field of biomedicine with their important contributions in the biomedical informatics. The number of top 31 published CVs in the biomedical journal "Acta informatica Medica" were printed in the issues published from 2014 until 2021 years and deposited in PubMed Central, Scopus and other databases. Charles Edwin Molnar (1935Molnar ( -1996 was a codeveloper of one of the first minicom-puters and a pioneer in cochlear modeling research (1). As a young researcher at the Lincoln Laboratory of the Massachusetts Institute of Technology in 1962, Molnar with another engineer, Wesley A. Clark -led a team of designers in developing the Laboratory Instrument Computer, or LINC. The machine, which was one of the few unclassified projects a the laboratory in the early 60s, was intended for doctors and medical researchers. Although it would be considered of insignificant power compared to modern personal computers, it was a self-contained machine that had a simple operating system and a small display and stored its programs on a magnetic tape. (1). In 1956 he returned to Durham as first assistant in the Department of medicine. In the same year John obtained his MD with a thesis using a new technique of phosphate clearance by the kidney. Next year he was awarded a Rockefeller travelling fellowship to Harvard University and carried out studies on sodium transport in the isolated toad bladder at Massachusetts General Hospital, which he continued to research throughout his subsequent career. He was present at Harvard when 'real time' was discovered, a concept which revolutionised the development of computer technology, and which he realised could be applied to medical records with enormous advantage. He returned to Durham in 1957 to assume direction of the artificial kidney unit there. In 1959 he went to King's as senior lecturer in medicine and consultant in endocrine and metabolic medicine. He was a key figure in the development of renal medicine at King's during the 1960s when the first acute dialyses were performed. He established and directed the South East region artificial kidney unit at this time, which subsequently became based at Dulwich Hospital. He also set up the first Hypertension clinic in London. In 1964 he published, with Sidney Osbourne, the results of his noteworthy and courageous research, the world's first in-vivo neutron activation analysis. At the Atomic Energy Establishment (Harwell) they had both undergone neutron bombardment and demonstrated that this could be used to calculate the quantities of key elements such as sodium and calcium journals that serves as an indicator of their importance in the field. The more citations in reputable journals, the higher the impact factor. The ISI sold subscriptions to their publication the Science Citation Index (SCI), and over time grew to include the Social Sciences Citation Index (SSCI) and the Arts and Humanities Citation Index (AHCI). These databases now form the foundation of the online research tool called the Web of Knowledge. He is responsible for many innovative bibliographic products, including Current Contents (CC), the Science Citation Index (SCI), and other citation databases, the Journal Citation Reports (JCR), and Index Chemicus (IC). He is the founding editor and publisher of "The Scientist", a news magazine for life scientists. (1986)(1987)(1988)(1989). "What I remember best", he says, "is that there was no money." MEDINFO '83 had diminished already limited funds, and money was simply not available for what was needed for MEDINFO '86 and subsequent activities. IMIA's officers ended up providing IMIA with free services, from printing and stationery to mailing and telephones. Grants to working conferences were impossible, and IMIA's officers had to spend almost all their time on finances. The final blow came when IMIA closed its permanent secretariat in Amsterdam and its small remaining treasury vanished. The bottom line was "very little time for accomplishments and achievements. The goal was to survive." Now, after completing his 18th year as national representative for Sweden in 1993, Peterson continues to work for the recognition and acceptance of Medical Informatics. In his view, growing decen-tralization makes standardization critical.

For Peterson, "an international body free from political and governmental influence is absolutely necessary. In this body we have to cooperate also with the industry and get a mutual understanding that cooperation is the only way out." . She had significant professional participation in national and international initiatives in biomedical informatics and statistics, especially in the field of research, higher education and continuing education using new information technology. She founded two biomedical journals: European Journal for Biomedical Informatics (EJBI) and International Journal on Biomedicine and Healthcare (IJBH), and, also, she has been a member of the editorial boards of several international journals. She has served as the expert in the field for the EC and Czech governmental institutions.

The results of Professor Jana Zvárová's research activities are presented in 10 monographs and more than 300 articles in peer-reviewed journals. The total number of citations of her work is more than 600 and she was the main author of three patents directed to biomedicine.

SPECIAL TRIBUTE ON MORRIS F. COLLEN: CHARISMATIC LEADER OF MEDICAL INFORMATICS

Dr. Morris Collen (Figure 1, 2 (1). He ended his tenure in 1979 when he became director of the Division of Technology Assessment. His greatest influence was his friend, mentor, and colleague Sidney R. Garfield, MD (2). Before engaging in medicine, Dr. Collen had obtained a degree in electrical engineering. Therefore, he had a vision of conjugating two of these by applying computer technology to improve care in medicine. He himself predicted that computers will probably have "the greatest technological impact on medical science since the invention of the microscope."(2) Thereafter, he developed a prototype electronic health record. Collen's early foray into electronic collection and storage of patient data was Kaiser Permanente's first step on the road to becoming a leader in health records technology.

The Journal of the American Medical Informatics Association (JAMIA) and Methods recognized his worth and his greatness describing him as "a world-class scientist, an advisor to American presidents, and a profound humanist, who started out as an exemplary clinician. Dr. Collen's qualities put him, from the start, in the midst of an environment rife with innovation and opportunity, and marked by other giants"(3).

He accomplished much of his work in many capacities with the National Library of Medicine (NLM), the Institute of Medicine of the National Academy of Sciences of the United States, the American Medical Informatics Association and many others.

His scientific publications include over 200 articles and numerous books in the areas of internal medicine, preventive medicine, health services research, multiphasic testing, technology assessment, and medical informatics (4). As an NLM Scholar-in-Residence from 1987-1993, he made a historical review of health care information system published in the book The History of Medical Informatics in the United States, which is considered as classics.

THE TRIBUTES

By reading the tributes of his colleagues, we will get the full sense of the great visionary Morris F. Collen, or Morrie -how was he amid colleagues and friends named.

One of his colleagues, Robert Pearl, MD, Executive Director and CEO of The Kaiser Permanente Medical Group, described Morrie Collen's phenomenal legacy in this way. "When I think of Morrie Collen, I think of two words, pioneer and vision. He was not just a year or two ahead of his time, he was decades ahead of his time.…Morrie understood that to be successful, Kaiser Permanente had to not just practice great medicine; it had to create great medicine. He created a focus on research…He understood that our members would be our members for decades to come. And so, it was essential that we invest in systems and approaches that would make them healthier…" (5) Bruce Sams, MD, second Executive Director of Kaiser Permanente said "One of the things that was most impressive about Morrie is his keen, analytical mind. He sees things very clearly; he analyzes them as a very logical way of approaching a problem. … He had visions of other things that could be done -particularly in the computer world -and he was so far ahead of his time" (5,6,7,8).

JANA ZVAROVA MEMORIAL CONFERENCE 2018, PRAGUE, CZECH REPUBLIC, MAY 4TH, 2015

In Prague on 4th May 2018 was organized Special Topic Conference dedicated to acknowledging and honoring of Prof. Jana Zvárová, founder and Editor in Chief of both this European Journal for Biomedical Informatics and the International Journal on Biomedicine and Healthcare, who suddenly and unexpectedly passed away in July 2017.

Prof. Zvárová was one of pioneers of Biomedical Informatics in former countries of "Eastern block"(former socialistic countries) of the World.

In the Editorial of special issue of the European Journal for Biomedical Informatics edited by professors Bernd Blobel and Arie Hasman, as Guest Editors, published online in this journal on April 30th 2018, Bernd and Arie expressed their opinions and some facts about her, as they said, "unforgettable friend and colleague" Jana Zvarova (EJBI. 2018; 14(2): 1-2):

Jana Zvarova "was an extraordinary personality, who influenced the development and improvement of health and social care by means of medical informatics, biomathematics and biostatistics as well as epidemiology both nationally and globally. She dedicated her excellent work based on a broad education and huge practical experience to the benefit of patients and health professionals, but first of all to teaching undergraduate, PhD and PostDoc students from the Czech Republic as well as other countries, acknowledging the importance of educating and training current and future

Izet Masic

staff for best serving the community. Due to this engagement Jana Zvárová received a big number of awards, fellowships, medals, etc. during her professional life that lasted until her last breath. Frequently in cooperation with the Editors, authors and other colleagues, Jana Zvárová has organized quite a number of conferences and educational events covering such diverse topics as biomathematics, biostatistics, medical informatics, eHealth, mobile health, medical documentation, EHR systems, clinical decision support, interoperability challenges and related standards, but also clinical, social and legal aspects. At EuroMISE and also later at the Center for Biomedical Informatics at Charles University Prague (launched in 2006, based on an agreement between the Charles University Prague and the Czech Academy of Sciences) lecture series on advanced eHealth, knowledge representation and management, medical and clinical guidelines, ontologies, EHR systems and interoperability were organized by Jana. With the establishment of the EuroMISE Mentor Association (EMA) in 2013, mentoring courses addressing regular and PhD students were organized in cooperation and coordination with, and on the topic of, some of those international conferences organized in Prague. Jana Zvárová specifically supported the series of International HL7 Interoperability Conferences (IHIC) by giving them a publication platform at the European Journal for Biomedical Informatics". Mentioned topics from some of the fields Jana was interested has been presented at Special Topic Jana Zvarova Memorial 2018 Conference in Prague, held on May 4th of the 2018. Almost all presented contributions invited speakers, and distinguished Medical Informatics experts and academics, friends of Jana Zvarova, and also some of them, former teachers of Charles University EuroMise center, chaired by professor Jana Zvarova.

Presentations at this STC are printed in Special Issue of the European Journal for Biomedical Informatics and were visible on-line before the day of CTC (www.jbi.org).

This volume starts with an obituary for Jana Zvárová. George Mihalas, Vice-Chair of the History Working Group of the International Medical Informatics Association (IMIA) acknowledges and honors her professional life and achievements. Further contributions in this volume specifically address in more or less detail cooperation with Jana Zvárová in the context of electronic healthcare documentation, EHR systems, interoperability, knowledge management and decision support, educational challenges, but also the role of women in the domain of health informatics. Bernd Blobel discusses requirements, standards and solutions for interoperable EHR systems with some focus on user perspectives, thereby also referring to earlier papers with a more technical focus. Elske Ammenwerth addresses the transformation of the patient into a responsible care manager by assessing the role of patient portals for empowering them. The analysis emphasizes the situation in Austria, but also considers the aspects in general. Jan Kalina discusses the challenges of Big Data analysis in medicine. He illustrates the complexity reduction of highdimensional data with practical research problems such as face recognition and gene analysis. František Och presents the project "Comprehensive assessment of the clinical effect of specifically selected natural remedies on the treatment of knee osteoarthritis" Jana Zvárová was strongly involved in. In that context he presents the interdisciplinary challenge of evidence-based medicine in balneology as initiated by Jana. Lenka Lhotska discusses the evolution of decision support systems in healthcare, specifically highlighting the role of distributed systems and the Internet of Things (IoT). Izet Masic focuses on the field Jana Zvárová was especially engaged in: education in medical informatics, biostatistics and related domains and applications. He specifically highlights the situation in his home country During ICIMTH 2019 Conference were organized two interesting workshops: John Mantas moderated workshop "CrowdHEALTH EU Project" and Reinhold Haux moderated workshop: "On Writing for Publication and on Good Research in Biomedical and Health Informatics".

All keynote lectures and paper and poster presentations were followed by interesting discussions. Participants were able to participate with presentations of full papers and As usual, like in previous years, great job of reviewed and selected papers which were presented at ICIMTH 2019 have done by Professor Arie Hasman (2-4). The Organizing Committee, led by Professor John Mantas and his tream, chaired by Paris Galos, have done also a really great job.

We hope that "ICIMTH 2020" Conference which is now traditional scientific event in the field of Biomedical Informatics in Europe and larger, next year will attract larger number of participants, because event like this certainly deserves it.

THE MOST IMPORTANT GOOGLE SCHOLAR INDEX DISADVANTAGES

AIM

Aim of this article is to present Google Scholar Index disadvantages. Google Scholar is a free of charge accessible web search engine that indexes the full text of literature (1). It is a place where you can evaluate author, see his output or make journal assessment (1, 2, 3). The results obtained through Google Scholar have begun to be used in everyday academic community (1, 2, 4).

METHODS

The work has a descriptive character, and the conclusions are the result of the long-standing work of the author in this area.

RESULTS

The Google Scholar platform is subject to individual content manipulation, has a wide range of searches that includes pages that do not have to be true, takes the focus of papers that are only in digital form, indexes of journals (h5 index, h5 median), and the author's work (h-index. i10-index). These are questionable criteria for the evaluation of the work of the journal or author, the number of quotes of a particular journals is subject to manipulation and poor quality recognition, it does not classify the journals to those who are peer-reviewed and who are not, and the assessment through the index is not adequate, does not recognize the same titles, if there is a quotation error and lists them as a separate work, does not inform the author about adding new work, does not inform the author about the addition of a new quote, sources of references are often incorrect. And finally, criteria for including or not of some of published articles from different kind of scien-tific or professional publications are not enough defined, because authors personally making decisions which publication or some other scientific or professional content will be deposited in databases like ResearchGate or Academia.edu and will be cited on Google Scholar and accounted as author's reference.