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Sistema de Información Científica
Red de Revistas Científicas de América Latina y el Caribe, España y Portugal
Revista Colombiana de Psiquiatría, Suplemento, vol. XXXV / 2006
Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
Adaptation of a Psychosomatic Medicine Computer Record
System for Multi-Language Support: Making Psychiatric
Computer Software Regionally Functional in Spanish-
Speaking Countries
Jay J. Strain
James J. Strain
Luis G. Ruiz-Flores
Murali K. Aela
Electronic medical record (EMR) systems are becoming a standard for patient care, but
are difficult to customize for local, regional, or international use. Particularly in the
case of psychosomatic medicine, where diverse sociological, economical, cultural,
and political influences may contribute to a patient’s disease state, EMRs have diffi-
culty in being economically implemented.
Careful, flexible computer program design,
special editing systems to customize graphic user interfaces, and identifying local-
regional physician experts to assist in translation are keys to making a working
We discuss the Micro-Cares™ CISCL Clinical Information System and the programming
and customization decisions which have gone into adapting it for multi-language sup-
Discussed are the EMR design, adaptation for multiple hardware platforms (desk-
top, laptop and tablet computers, and on hand-held PDA systems), multi-tiered data
storage, and customizable language manager, and questionnaire designer. Concepts of
flexibly “scaling” CISCL to support the single user, or multiple user, or extensive depart-
ment/division personnel are discussed.
Experience with regional testing and use are described, including modifications to
the CISCL program that have been extensively user-guided. Finally, we examine stand-
ards of approach to multi-language support that have arisen from adapting CISCL to
non-Romance-based languages, e.g., Mandarin.
Our current experiences are summa-
rized with description of on-going research efforts.
Key words:
Software, microcare, computerized medical records systems,
matic medicine, Latin American.
* See comment, p. 38-43.
M. D. Albert Einstein Medical Center, Albert Einstein Medical Center.
M. D. Mount Sinai – NYU Medical Center/Health Service.
M. D. Centro Médico Nacional, Ciudad de México.
M. S. DocOptions, Inc., Tracy, California.
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Revista Colombiana de Psiquiatría, Suplemento vol. XXXV / 2006
Strain J.J., Strain J.J., Ruiz-Florez L.G., Aela M.K.
La historia clínica sistematizada
en medicina psicosomática.
Los sistemas de registro médico electró-
nico (RME) se están convirtiendo en el
estándar en cuanto al cuidado clínico del
paciente se refiere, pero son difíciles de
diseñar a medida para uso local, regional
o internacional. Ésto es particularmente
cierto en el caso de la medicina psicoso-
mática, en la que diversas influencias de
tipo sociológico, económico, cultural y
político influyen en el estado del pacien-
te, haciendo que los RME sean difíciles
de implementar de manera económica. Un
programa de computador diseñado de
cuidadoso y flexible con sistemas
de edición para personalizar gráficas, e
identificar médicos expertos en el medio
local-regional para que asistan en la tra-
ducción son las claves para hacer que una
aplicación funcione.
Presentamos el Micro-Cares™ CISCL Sis-
tema de Información Clínica y discutimos
la programación y las decisiones tomadas
para adaptar el sistema a un soporte multi-
lingüístico. Se discuten el diseño del RME,
su adaptación para múltiples plataformas
de hardware (computadores de escritorio,
portátiles y
y sistemas PDA Palm™),
sistemas de almacenamiento multinivel,
administrador de idioma personalizado y
diseñador de cuestionarios. También se
discuten los conceptos de “escalonar” el
CISCL de manera flexible para soportar un
usuario único o múltiples usuarios, o per-
sonal numeroso de un departamento o di-
Se presenta una descripción de las prue-
bas y uso a nivel regional, incluyendo mo-
dificaciones en el programa del CISCL que
han sido guiados por los usuarios. Para
finalizar, examinamos estándares de apro-
ximación en soporte multilingüístico que
han surgido al adaptar el CISCL a otros
idiomas no basados en las lenguas roman-
ce, por ejemplo, el mandarín. Nuestras
experiencias actuales se resumen con una
descripción de nuestras investigaciones en
Palabras clave:
, sistemas de re-
gistros médicos computarizados, medicina
psicosomática, Latinoamérica.
Electronic medical records have
become mandatory in a modern
hospital setting.
They have been
shown to optimize communication
between physicians and help limit
errors with medication prescribing
The electronic systems pro-
vide not only a method to assure
and optimize completion of patient
records, but also a mechanism for
tracking resource use.
nately, most computer information
systems are expensive, and diffi-
cult to install and maintain. Most
are originally designed for use in
large, multi-disciplinary institu-
tions or wealthy private practices in
English-speaking North America.
Such electronic record systems are
difficult to implement in Central
and South America.
Multiple paradigms exist for the
creation of electronic medical record
(EMR) systems, but making any sys-
tem useful internationally requires
careful system design, protocols for
identifying local-regional experts to
assist in customization, and provi-
sion for a system for rapid editing
for regional dialect display.
We de-
scribe a psychosomatic medical
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Revista Colombiana de Psiquiatría, Suplemento, vol. XXXV / 2006
Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
records system, Micro-Cares™
CISCL, and efforts to optimize the
program for use towards document-
ing psychosomatic disease and care
at diverse international locations.
We further discuss specifics related
to patient care tracking in Central
and South America, and experi-
ences with customizing computer
systems to communicate in Span-
ish, Portuguese, and additional non-
English languages.
Micro-Cares™ CISCL began as
a project based on US National In-
stitutes of Health medical records
standards available in the 1970’s
(e.g., Clinical Information [CLINFO]
system, Research Data Entry[RDE]
system, etc.) [4,5]. The data struc-
tures designed were excellent for
capturing data, but confined the
user to documenting text or nu-
meric data in a limited “line-by-
line” fashion.
Later graphic user
interfaces (GUIs) provided more
flexibility in data entry (e.g.,
Microsoft Windows™-style inter-
faces, etc.) with ability to pre-define
data “forms”. This ongoing develop-
ment is well documented in previ-
ous investigations [6-8].
Figure 1.Computer Modeling Regional Care Practices [9]
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Strain J.J., Strain, J.J., Ruiz-Florez L.G., Aela M.K.
While language translation of a
“form” can be simple to provide, the
nature and complexity of conveying
medical information made auto-
matic translation problematic.
ditionally, the medical data acquired
and the medical decision making
performed have been found to be
dramatically tied to regional infor-
mation sources, care practices, and
customs [see Figure 1].
teaching and training institutions
impart to the trainee standards and
approaches to medical care that are
regionally appropriate but not al-
ways universal.
Furthermore, psy-
chosomatic medicine is further
constrained by an integration of
social, economic, cultural, reli-
gious, and even political forces that
are difficult to model, especially as
a generic approach for all psychia-
For these reasons, no inter-
national standard psychosomatic
medical record is in use.
Micro-Cares™ CISCL attempts
to address these issues through a
flexible, customizable medical
record system with 1) a knowledge
of consultation psychiatric work
practices, 2) custom mechanisms
for editing the user interface, 3) a
customizable, language-independ-
ent report writing system, 4) pre-
defined templates based on
and-true”, standardized psychiatric
forms, 5) a “Language Manager”
which allows the user to view all
languages supported in a side-by-
side fashion, and 6) a custom ques-
tionnaire designer which allows the
regional user to adapt the CISCL
system to specific user needs.
A Knowledge of Consultation
Psychiatry Work Practices
Acknowledging that a flexible
computer program should “adapt” to
its user, Micro-Cares™ CISCL be-
gins with the assumption that each
physician may have a work setting
that is unique.
Some physicians
may have desktop computers in
every room of their clinic; some
may have a laptop that is shared
among a group of physicians.
users may have access to a central
computer at the main psychiatric
division headquarters, but use only
handheld personal data assistants
(PDAs) during their “rounds” during
the day.
CISCL provides a network-
based program that can support all
three of these approaches via mul-
tiple desktops or laptop units simul-
taneously linked to a central data-
base [10].
There is also support for
remote capture of data via Palm
Operating System (OS)-based
handhelds. Information is bi-
directionally shared to all users of
the office or division or department
to allow continuity of care. CISCL
can be used independently on a sin-
gle laptop for a single user, or as a
more complex, networked, multi-
user or even multi-department
data collection system, and auto-
matically scales itself to either of
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Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
these models.
This flexibility was
believed to be necessary given
evaluation of the nomadic nature
of psychosomatic medicine consul-
tation services and parallels the
workflow requirements of the con-
sultation psychiatrist.
Customized Editing of the
CISCL Interface
CISCL has an architecture
where the main supporting data-
base is maintained concurrently for
each language being supported. It
is maintained along side additional
secondary databases “tables” (tech-
nically called “relational tables”) for
each language so that regional and
local customization are directly
linked to the master database for a
particular user.
In this fashion,
each institution, with local prefer-
ences, opens a master database
dedicated to their own pre-defined
preferences and to their specific
Inherent to the structure
is a core 100 item database that
has thirty years of optimization to-
wards general hospital and consul-
tation psychiatry [11].
Display pref-
erences, local research variables,
and additional custom-designed
questionnaires are linked to this
central data core and are main-
tained in a fashion transparent to
the user.
Traditionally, graphic user in-
terfaces (GUIs) in computer pro-
grams were “hardwired” to text
descriptors that could not be
changed by the user [12]. Because
data in a particular field was “pre-
defined”, translation of a program
into new languages required chang-
ing every display, user item, and
supporting text individually. Al-
though some aspects of this older
approach are still necessary, more
flexible data storage methods exist.
CISCL is designed with separated
database layers and communica-
tion layers. Language customiza-
tion information can be maintained
in separate relational tables or spe-
cialized data “resources.”
Using this architecture, multi-
ple levels of customized data pres-
entation are supported.
Through the use of “code
groups”, reusable data
(e.g., city names, state codes, de-
partment types, patient types, in-
surance providers, etc.) can be que-
ried for values, and any user can
quickly add, edit, or modify them
to reflect the local practice envi-
And while certain stand-
ard code groups may be common to
every language, the ability to cus-
tom generate new ones is particu-
larly useful where regional-specific
data need to be codified for user
To customize the CISCL inter-
face, a native-speaking psychiatry
expert or group of experts is identi-
fied to assist in translation.
ing with these physician-psychia-
trist experts, who live in the areas
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Strain J.J., Strain, J.J., Ruiz-Florez L.G., Aela M.K.
to where the CISCL program is to
be employed, attention to local race
categorization, specific marital sta-
tus descriptors, local expected re-
ferral centers, treatment option
trends, health insurance plans, and
many other factors are codified and
further optimized for guided data
In addition to the coding groups,
individual data entry screens are
similarly customized. Where this is
particularly important is in “laying
out” the display for the user to en-
ter data.
The graphic user inter-
face (GUI) screens are limited in
space or “real estate” and need to
have language phrases translated
to fit accordingly.
For instance, the
translation for “Patient Episode Se-
lection” in Spanish is “Selección del
Episodio del Paciente”.
Since the
length of the phrase is significantly
longer, a truncated expression may
need to be created.
translation programs are unable to
determine the importance of a par-
ticular phase or what can be re-
moved from the phrase and still
maintain readability.
For these
reasons, a knowledgeable regional
expert is mandatory.
Structured data entry is pro-
vided in CISCL along expected prac-
tice work-flow (e.g. demographic,
administrative, medication, labora-
tory, progress notes, etc.) and leads
to a selection of custom question-
This provides a standard-
ized “style” to data entry for the in-
dividual user.
But it also allows
institutions to use the CISCL pro-
gram in the fashion or custom of
their current office.
For instance,
in an environment where a secre-
tary may be available to take the
call, a nursing coordinator can be
used to enter “intake” or “telephone
consultation” data.
This allows the
physician to then focus on medi-
cally-relevant data. The data entry
forms that are to be used by a sec-
retary can be customized separately
to support non-medical terminology
to assist with non-physician data
entry of demographic and adminis-
trative information. This data is
again shared bi-directionally to all
users in that department so that
when they go to see the patient for
whom the consult was called, they
can directly proceed with the pa-
tient evaluation.
A Language-Independent,
Customizable Report System
Custom Reports can be gener-
ated “ad hoc” or from predefined
templates, customized for each lan-
guage, and supplied in standardized
Microsoft™ Word format.
While use
of Word™ templates is perhaps not
the most economical way to provide
reports (instead of using a built-in
Crystal Reports, or other reporting
packages), the advantage is that
Microsoft™ Word is supported in
multiple languages, and users are
intimately familiar with this form
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Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
of documentation.
For instance, if
one chooses to edit the Word docu-
ment from CISCL, they can add
their hospital or personal logo and
have it printed automatically with
all reports.
Translation of data sent
to the report is performed intrinsi-
cally by the CISCL program. Simi-
larly, if one chooses to use hospital
or other custom stationary, one can
simply edit the Word™ document to
support this change.
In addition,
Word™ was found to be the most fle-
xible mechanism to support com-
plex Asian characters and extended
character sets automatically.
Using Standardized Metrics for
Psychiatric Care
There are many standard
methods for evaluating the psychi-
atric patient.
Many reliable scales
for evaluation include the abbrevi-
ated Mini Mental State Examina-
tion (MMSE), Hamilton Depression
score, Glasgow coma score, and
Beck Depression or Anxiety Scale.
Other standardized examinations
are used routinely as part of hospi-
tal inpatient admissions. And many
are repeated during therapy to as-
certain whether the patient has
made progress.
CISCL supports input of ques-
tionnaires such as these in multi-
ple languages, and is particularly
helpful at guiding the system ad-
ministrator through creation of new
scales for patient testing.
scales are inserted into the regional
database with all the custom code
group and language preferences.
Since the code groups are defined
in the regional language, the elec-
tronic exam automatically has ac-
cess to the custom standards of that
user and their department. As seen
in the Mexican version of CISCL,
the Escala de Experiencia Sexual de
Arizona (ASEX) scale is one that
was of particular use for the HE
Centro Medico National, and it was
added to their version of the data-
base. This questionnaire is not
found in English CISCL, but can
easily be imported directly.
The nature of medical care is
also changing. With automated sys-
tems, patients can be expected to
enter data into an electronic ques-
tionnaire on their own.
This can
occur while the physician is en-
gaged in other patient care tasks.
Standardized test data can even be
automatically collected via laptop in
the waiting room or at the patient’s
bedside under the guide of secre-
tarial or nursing teams.
Regional versions of many
standardized exams already exist.
The important emphasis of the
CISCL approach is that since the
data is linked to a language-inde-
pendent matrix, it is often extremely
easy to directly compare survey data
from multiple regions. For instance,
the underlying coding scheme for
the Mini Mental State Examination
is the same whether it has been
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Strain J.J., Strain, J.J., Ruiz-Florez L.G., Aela M.K.
modified to support spelling “WORLD”
or “MUNDO” backwards.
language databases can have differ-
ent collections of questionnaires or
scales, but more importantly can
continue to
research can be performed across
different institutions and different
languages by creating custom sur-
vey that has been entered using the
“Survey Wizard” module in CISCL
(See below).
Language Manager
The CISCL program can be ini-
tiated in a “Developer Mode” where
any text item on the GUI can iden-
tified and update via the “Language
As shown in the Figure
3, the cursor when held on the item
on the screen will show the corre-
sponding “resource key” and the
language manager then allows the
user to search and replace this with
any description the user’s request.
The CISCL program can also
dynamically change to another sup-
ported language via the Language
Options menu.
Why this is so use-
ful is that Spanish-speaking users
can examine the CISCL data from
any other CISCL user in any of the
other languages and compare their
datasets directly.
The linking of the
data allows us also to merge multi-
Figure 2. Customized Questionnaires in Regional Language
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Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
language datasets for advanced
comparison and analysis.
The language modifications
can even be used to match the
needs of country-specific, regional
translation issues, such as modi-
fying the Portuguese database for
costal or mountain Portugal or Bra-
zilian regional dialects.
Custom “Survey Wizard”
Questionnaire Designer
Survey Wizard
is a unique
CISCL tool of particular use to re-
gional customization.
One of the
most useful and flexible features of
CISCL, it is a pro-
prietary system which allows a user
to efficiently generate a survey (or
scale), create an individualized col-
lection tool, and integrate and
standardize the data entry across
multiple data sources within the
CISCL database.
Actually, this
, due to its
ability to provide flexible modeling
and revision of underlying data
structures, was used to create the
main Psychiatric Consultation data
entry form used by CISCL.
larly, the
Survey Wizard
can be used
for all of the following:
Create and review public do-
main and private surveys:
Figure 3. Editing the Graphic User Interface for Language Preferences
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Strain J.J., Strain, J.J., Ruiz-Florez L.G., Aela M.K.
II. Modify existing surveys:
III. Create new surveys for out-
comes tracking at the point of
IV. Create new surveys for the pa-
tient to enter data into while
waiting for an appointment.
V. Create patient information
data collection tools such as
customized History and Physi-
cals, Consultation Forms and
Flow Sheets.
Survey Wizard’s
ity is adaptable to native language
needs by allowing direct access to
“code groups” or even creation of
temporary custom variables that
can be accessed by any question-
naire. For instance, the cities or
states can be stored in code groups
for use by all portions of CISCL and
are predefined.
But how does such
a system support complex data col-
For example, what if it is
necessary to generate a new scale
where Answer#1 is worth 10 points,
Answer #2 is worth 15, Answer #3
is worth 25, etc.
These re-usable
data elements can be created for a
current survey, edited for different
languages, or even shared as data
collections with new surveys or
These flexible data-struc-
tures help transform the efforts by
the physician in collection and
CISCL data entry into an opportu-
nity for “ad hoc” clinical data analy-
The underlying master data-
base acts a foundation with links
directly to additional surveys.
this way, CISCL provides a signifi-
cant platform for research and pa-
tient care optimization. In addition,
sponsorship for regional studies
can be obtained by implementing
data collection for national, inter-
national, and disease-targeted re-
search efforts such as depression
in HIV.
Engineering Multi-Language Support
Modelling psychiatry work-flow
has been a twenty-year project
where recent technological ad-
vances have allowed expansion of
functionality to match the require-
ments of psychosomatic care.
tial attempts focused on collecting
over 300 data items on all patients
for all physicians [13].
were made that a secretary or group
of data entry assistants were avail-
able to enter consultation informa-
tion into the computer system.
the CISCL program has undergone
evolution into a multi-language sup-
porting system, there have been
major issues in adapting it to sup-
port cultural and language diversity.
Initially, all CISCL screens were
designed specifically to handle the
length of English text.
As we quickly
discovered, each language has dif-
ferent physical length require-
ments. For example, a general
guideline in translating English ap-
plications into German dialects is
that the German text is expected to
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Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
be 25% longer [14]. This length char-
acteristic is a phenomenon we have
seen in translating CISCL into Por-
tuguese and Spanish as well as
other languages.
All CISCL forms
were adjusted to permit additional
text length with added space to sup-
port these expectations.
Originally, automated transla-
tion systems such as Whipple Ware
and SysTrans [15] were used to di-
rectly translate screens from Eng-
lish into Spanish.
Early attempts
with automated translation led to
accurate translation in 87% of the
general text [16]. Some of the diffi-
culty involved translation of trun-
cated text and deciphering ana-
And while this created
“Spanish-appearing” screens, the
specific language conversion was
only about 50% correct in our expe-
rience for medical/psychiatric con-
tent. This was due to the inability
of such translators (language trans-
lation systems) to place emphasis
or understand nuances of the psy-
chiatric medical description.
example, automated translation
protocols fail to understand that
“pen” can be either a writing im-
plement or a fenced-in yard for ani-
mals; it is impossible for current
automated translators to interpret
the context [17].
Secondarily, “screen shots”
were obtained of each screen in the
graphic user interface, and paper-
versions of these were sent to local
psychiatrist experts for translation.
This was extremely time consuming
and made updating the CISCL sys-
tem difficult since each change to the
GUI had to be copied, sent, translated,
and re-entered into the system.
often required multiple iterations,
with creation of the complete func-
tioning program, sending it to the
testing physicians, and then having
them relay further changes.
In an attempt to increase the
speed of translation, we then tried
obtaining a local human translator
to aid the programmers, in addition
to distant regional experts for sup-
port. As in the case of the Portuguese
translation, a Harvard University
language expert was used.
But since
it was impossible to find a regionally-
knowledgeable, medically-trained,
psychiatrically-trained, Portuguese-
speaking expert, many of our trans-
lations were unacceptable.
many iterations were required and
this led to a frustrating, extended
cycle to completion.
Next, we arranged for a regional
expert to sit alongside the program-
mer and guide translation.
was extremely successful, but
hugely resource expensive, and was
only able to provide translation of
the currently existing program.
Additional features and continuous
updates required waiting for peri-
ods when the psychiatrist experts
and programmers were both avail-
able to provide translation.
translation process had to be re-
peated for every language, and
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Strain J.J., Strain J.J., Ruiz-Florez L.G., Aela M.K.
every additional screen that was
added. As we quickly discovered,
translation efforts could not be gen-
For example, a Portugal
Portuguese translation was not a
substitution for a Brazilian version;
each had to be modified for local
Given the above difficulties, two
new approaches were tested to pro-
vide flexibility to language transla-
tion: 1) “Resource Files” — upgrade-
able language files that could be
quickly updated for each screen ele-
ment, and 2) a custom language da-
tabase built within each CISCL sys-
The resource file approach has
been recently supported by Micro-
soft™ Windows as a recognized stand-
ard for translation.
It allows the user
to compare “side-by-side” multiple
languages and translate them ac-
A “resource module” was
added that allowed us to send to the
regional expert a Microsoft Excel™
comparison file of the languages for
While this first ap-
proach, combined with e-mail, was
more rapid than the use of “screen-
shots”, it continued to make adapt-
ing CISCL for regional language dia-
lects (e.g., Mexico vs. Spain, etc.)
extremely time-consuming and dif-
ficult to maintain.
Also, updated re-
source modules had to be manually
re-integrated into the CISCL pro-
gram, and this required ongoing de-
velopment time.
Our current model was devel-
oped based on limitations and diffi-
culties experienced with the re-
source file approach.
It provides a
specialized “Language Editor” [Fig-
ure 3] which shows the user the
current screen and the translation
in any language of choice.
Now the
user can start with a routine lan-
guage translation (e.g., Mexican
Spanish), and modify
items on
the screen, and any menus or mes-
sages that CISCL displays for the
users, to provide regional, personal,
and context-appropriate translation.
This builds on previous language
versions, and gives the user an
unparalleled ability to create either
a modified regional dialect, or even
enter a completely new language
with any of the character sets pro-
vided on their computer.
It is our
belief that this provides the most
flexible option for medical users in
diverse language and cultural en-
Suggestions for Multi-language Appli-
cation Development
Support of Languages – Intelligent
System Design
In the programming world,
there are general approaches which
support a multi-lingual model, but
none of these are easy to imple-
ment or simple to maintain.
new techniques have of necessity
been proposed to support complex
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Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
web-based and database applica-
tions. These are concurrently uti-
lized in many countries, and three
major architectures have become
the most popular.
They include
namic Content Generation
Site Repli-
, and
Selective Replication
As shown in Table 1, Dy-
namic Content Generation most
closely approximates the schema
utilized by CISCL.
CISCL supports
low-level access to all descriptors,
and each is loaded dynamically as
a language is called upon to be dis-
We performed extensive
testing with our optimized language
module and found essentially no
performance differences with use of
this approach over previous “re-
source” standards.
An additional
advantage is that we are able to
automatically provide accurate
translation for our web-based appli-
cation, and also handheld informa-
tion systems, since the multi-lan-
guage data support files are directly
accessible for all hardware systems
connected to CISCL.
Type of
Example of Structure
Database has stored in it
“tables” of images and
The database is
queried for translation
and display of items on
the screen
Complicated data
storage structure, hard
to maintain
Load on database can be
performance issues
Need administrator
control of editing
Site Replication
Multiple, duplicate
versions of the program
are stored, each in a
separate language
One error needs to be
changed on many
duplicate sites
Need to update
functionality at all sites
Main display references
language directories or
folders for content,
graphics, buttons, etc, to
support display
Harder to set up initially
Overall maintenance is
Can be supported in
Table 1. Multi-language Program Support [18]
Integrating Culture into Program Design
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Strain J.J., Strain, J.J., Ruiz-Florez L.G., Aela M.K.
Based on the experience of
many design teams who work for
complex web-based and cell phone-
based systems, there have been
guidelines developed for optimizing
computer applications for cultural
diversity: 1) Identify target cultures
you will be programming for, 2) De-
sign and develop a global model that
takes common designs into ac-
count, 3) Bring in a culture-specific
interface designers and utilize lo-
cal physicians to revise the design,
and 4) conduct usability tests of cul-
turally-targeted versions using re-
gional subjects [21].
1. Targeting Cultures
In our experience, text language
cannot be translated “word-for-word”.
Comprehension of Western or Eng-
lish-based icons, symbols, clichés,
slang, acronyms, and abbreviations
may be difficult for local user groups.
Local language and practice conven-
tions need to be taken into account.
Word wrapping and hyphenation
need to be considered as well, since
improper hyphenation of a word may
change its meaning. And as de-
scribed above, words written in one
language differ in length from words
in another language, and this must
be taken into account in the inter-
face design [20].
Each portion of the GUI must
support the “regional settings” of the
local user.
Multiple numeric, cur-
rency, time, and distance formats
can be manipulated by the underly-
ing operating system.
As an exam-
ple, numeric formats differ in cer-
tain Scandinavian countries, where
“123.123” is expressed as “123,123”.
The first representation is treated
as a number, and the second is
treated a text because of the pres-
ence of the comma symbol, and
causes a failure in data analysis.
Images and color form the
“visual language of a culture” [21].
The developer must choose under-
standable images and pictures, and
avoid taboos and offensive icons:
Symbolism must be respected, as
in using pictures of animals which
can have different cultural impor-
tance. Colors as well have culture-
dependent meanings. The color red,
for example, may be used to repre-
sent a warning or an error mes-
sage, but in another culture it may
be used to promote a positive expe-
rience. Generally colors in user
interfaces are used for grouping,
verifying, or distinguishing objects
from one another, but the target
users must be able to comprehend
their importance [21].
2. Global Model
Psychiatry as yet does not have
a global model.
Ideally, an applica-
tion can be designed to meet the
needs of every international user.
Even with multiple internationally
users, and continuous updates
based on user feedback, this is a
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Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
difficult task. With the dual goals of
a) capturing psychiatric data and b)
achieving a better user experience,
we have used the actual, retrieved
data to determine what we should
collect. Beginning with a complex,
all-inclusive psychiatric dataset,
multiple years of data on tens of
thousands of patients was analyzed
to create a core dataset that is ap-
plicable to a majority of psychiatric
An architecture based on
the core data, with the ability to add
additional items as necessary, ap-
pears to be an effective way to de-
sign a globally-applicable model.
seen in Figure 4, it does allow for
capture of a diverse, cultural
dataset even in non-European ven-
ues [22].
3. Interface Design using “Cultural
Acknowledged regional psychia-
try experts with fluent language
abilities have been necessary at all
phases of GUI development.
nically, these are referred to as “cul-
tural representatives” [21] The use
of psychiatric cultural representa-
tives in testing is particularly criti-
cal because without them it is of-
ten impossible to anticipate the
user’s reaction to a program. These
experts benefit program develop-
ment in many ways: 1) it involves
potential real users, 2) it allows us
to have them do real tasks, and 3)
it allows us to track where errors
occur or the programmer’s percep-
Figure 4. CISCL as optimized for Chinese at hospitals in Taiwan
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tions do not match the user’s needs
4. Usability Testing
Ideally, every user would have
the benefit of the programmer at
their side, customizing the com-
puter program to meet their needs.
Workflow practices and situational
language preferences in this fash-
ion could be documented. Unfortu-
nately, this is usually not possi-
However, there are several
established techniques that we
have used to revise CISCL closer
to what is acceptable for users at
each locale.
In some cases, many hours
have been spent with “cultural rep-
resentative” experts to review lan-
guage translation and GUI charac-
In addition, helpful
suggestions have been provided by
users via e-mail “screen-shots” of
where corrections/additions can be
We have also traveled to lo-
cal regions for psychiatric confer-
ences (such as the Asociacion
Psychiatria Mexicana in Mexico)
where group sessions have given us
insight into local practices, and the
CISCL system has been adapted
Some research com-
panies having language test groups
utilize “usability diaries” to have
their users log functional issues
that they encounter.
A newer tech-
nology has been the ability to re-
motely “login” to a user’s computer
(with their permission) to track how
they use the system and assist
them in local/regional changes di-
We have been utilizing
“GoToMeeting” as one of these tech-
nologies [23].
In summary, our current user-
accessible resource definition has
significant benefits. Built-in to
CISCL, the “Language Manager”
has special search modes to iden-
tify code or description, and dy-
namically changes the display
screens, allowing trial of different
words or anagrams, or even more
descriptive truncated sentences.
This information is supported sepa-
rately in a communication layer
which does not affect the underly-
ing patient database architecture.
New languages or dialects can also
be quickly developed based on cur-
rently available language modules.
And with this design, the user can
edit the GUI concurrent with data
entry, e.g. change the description
of the demographic interface while
performing data collection on pa-
Language descriptors are reus-
able for new programming, and as
new features are added, the previ-
ously approved language code can
be called upon for translation.
standardized protocol for addition of
new codes means that with mini-
mal work, a program can be updated
for all languages currently sup-
Overall, this approach
speeds up the deployment cycle in
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Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Languaje Support
that there is no more need for cre-
ating the GUI, then translating,
then sending to programmers, then
verifying that works, then creating
a final “distribution version” for
CISCL provides concurrent
use and language optimization, and
is structured according to the prin-
ciples which are believed to be es-
sential to providing a good multi-
cultural graphic user interface (see
Table 2) [21].
Electronic Medical Record (EMR)
systems cannot be converted to a
regional language effectively with-
out identification of a regional ex-
pert to assist in the translation.
Early effort must be placed into
identifying regional customs and
practice standards.
Multiple iterations of translation
will need to be undertaken because
adaptation may require use of idi-
oms, anagrams, or custom trunca-
tion of definitions/descriptions.
A method must be provided with
continuous editing of the program
at the “local” level – generation of
user “language dictionaries.”
Link to universal standards
(e.g., International Classification of
Disease [ICD], Current Procedural
Terminology [CPT], Diagnostic and
Statistical Manual of Mental Disor-
ders [DSM IV], etc) with well-codi-
fied translations may assist in
making a program more universally
and regionally acceptable.
Ultimately, program customiza-
tion and translation may even re-
quire a new graphic user interface,
or use of a new technology platform,
to be accepted.
Overall Goals for the Multi-cultural Graphic Users Interface:
Communicate in the country’s native language and or dialects.
Support natural writing symbols and punctuation
Support native dates, currency, weight scales, numbers, and addresses.
Support natural activities/environments (e.g., local psychiatric consultation
models, etc.).
Communicate in an efficient, effective, and inoffensive manner.
Table 2: Goals in Multi-Cultural, Multi-Language Design
Recibido para evaluación
: 22 de abril de 2006
Aceptado para publicación
: 2 de mayo de 2006
Jay J. Strain
Albert Einstein Medical Center
5501 Old York Road, Klein Suite 510
Philadelphia, PA 19141
Correo electrónico:
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