PIACS: A System for the Automatic Detection, Categorization and Comparison of Scratch-Related Skin Lesions in Dermatology

In the treatment of chronic pruritus-related, scratch-induced skin lesions the categorization, counting and temporal comparison are common methodologies. The observation requires a good memory and expertise in this field to gain comparable findings for this time-consuming process. Digital image processing aims at supporting such manual detections. The objective is to develop a software tool for automatic image detection and comparison. The new photographic setting implies the usage of markers to derive the brightness and size of lesions. MATLAB has been used for the software development. The newly defined setting allows taking standardized images of pruritus-associated cutaneous lesions for detection and comparison. The tool named PIACS (Prurigo Image Analyzing and Comparing System) allows automatically detecting, categorizing and comparing lesions based on digital images.

The need for cost-benefit analyses of eHealth in low and middle-income countries

Cost and benefit analyses are crucial for eHealth interventions, especially in low and middle income countries (LMIC). We performed a scoping review, with goals to acquire an overview of cost-benefit studies and to collect indicators that are being used for costs and savings with respect to eHealth. Of all retrieved articles, 29 were included in our analysis and 21 contained cost/savings indicators which we categorized into outcome measures with respect to providers, patients and other stakeholders. Nearly all authors stated that more evidence from economic analyses by health economists are urgently needed and that pilot projects should collect cost related data for evaluation.

Qualitative and quantitative evaluation of rigid and deformable motion correction algorithms using dual-energy CT images in view of application to CT perfusion measurements in abdominal organs affected by breathing motion

OBJECTIVE

To compare six different scenarios for correcting for breathing motion in abdominal dual-energy CT (DECT) perfusion measurements.

METHODS

Rigid [RRComm(80 kVp)] and non-rigid [NRComm(80 kVp)] registration of commercially available CT perfusion software, custom non-rigid registration [NRCustom(80 kVp], demons algorithm) and a control group [CG(80 kVp)] without motion correction were evaluated using 80 kVp images. Additionally, NRCustom was applied to dual-energy (DE)-blended [NRCustom(DE)] and virtual non-contrast [NRCustom(VNC)] images, yielding six evaluated scenarios. After motion correction, perfusion maps were calculated using a combined maximum slope/Patlak model. For qualitative evaluation, three blinded radiologists independently rated motion correction quality and resulting perfusion maps on a four-point scale (4 = best, 1 = worst). For quantitative evaluation, relative changes in metric values, R(2) and residuals of perfusion model fits were calculated.

RESULTS

For motion-corrected images, mean ratings differed significantly [NRCustom(80 kVp) and NRCustom(DE), 3.3; NRComm(80 kVp), 3.1; NRCustom(VNC), 2.9; RRComm(80 kVp), 2.7; CG(80 kVp), 2.7; all p < 0.05], except when comparing NRCustom(80 kVp) with NRCustom(DE) and RRComm(80 kVp) with CG(80 kVp). NRCustom(80 kVp) and NRCustom(DE) achieved the highest reduction in metric values [NRCustom(80 kVp), 48.5%; NRCustom(DE), 45.6%; NRComm(80 kVp), 29.2%; NRCustom(VNC), 22.8%; RRComm(80 kVp), 0.6%; CG(80 kVp), 0%]. Regarding perfusion maps, NRCustom(80 kVp) and NRCustom(DE) were rated highest [NRCustom(80 kVp), 3.1; NRCustom(DE), 3.0; NRComm(80 kVp), 2.8; NRCustom(VNC), 2.6; CG(80 kVp), 2.5; RRComm(80 kVp), 2.4] and had significantly higher R(2) and lower residuals. Correlation between qualitative and quantitative evaluation was low to moderate.

CONCLUSION

Non-rigid motion correction improves spatial alignment of the target region and fit of CT perfusion models. Using DE-blended and DE-VNC images for deformable registration offers no significant improvement.

ADVANCES IN KNOWLEDGE

Non-rigid algorithms improve the quality of abdominal CT perfusion measurements but do not benefit from DECT post processing.

Design and development of a linked open data-based health information representation and visualization system: potentials and preliminary evaluation

Background

Healthcare organizations around the world are challenged by pressures to reduce cost, improve coordination and outcome, and provide more with less. This requires effective planning and evidence-based practice by generating important information from available data. Thus, flexible and user-friendly ways to represent, query, and visualize health data becomes increasingly important. International organizations such as the World Health Organization (WHO) regularly publish vital data on priority health topics that can be utilized for public health policy and health service development. However, the data in most portals is displayed in either Excel or PDF formats, which makes information discovery and reuse difficult. Linked Open Data (LOD)—a new Semantic Web set of best practice of standards to publish and link heterogeneous data—can be applied to the representation and management of public level health data to alleviate such challenges. However, the technologies behind building LOD systems and their effectiveness for health data are yet to be assessed.

Objective

The objective of this study is to evaluate whether Linked Data technologies are potential options for health information representation, visualization, and retrieval systems development and to identify the available tools and methodologies to build Linked Data-based health information systems.

Methods

We used the Resource Description Framework (RDF) for data representation, Fuseki triple store for data storage, and Sgvizler for information visualization. Additionally, we integrated SPARQL query interface for interacting with the data. We primarily use the WHO health observatory dataset to test the system. All the data were represented using RDF and interlinked with other related datasets on the Web of Data using Silk—a link discovery framework for Web of Data. A preliminary usability assessment was conducted following the System Usability Scale (SUS) method.

Results

We developed an LOD-based health information representation, querying, and visualization system by using Linked Data tools. We imported more than 20,000 HIV-related data elements on mortality, prevalence, incidence, and related variables, which are freely available from the WHO global health observatory database. Additionally, we automatically linked 5312 data elements from DBpedia, Bio2RDF, and LinkedCT using the Silk framework. The system users can retrieve and visualize health information according to their interests. For users who are not familiar with SPARQL queries, we integrated a Linked Data search engine interface to search and browse the data. We used the system to represent and store the data, facilitating flexible queries and different kinds of visualizations. The preliminary user evaluation score by public health data managers and users was 82 on the SUS usability measurement scale. The need to write queries in the interface was the main reported difficulty of LOD-based systems to the end user.

Conclusions

The system introduced in this article shows that current LOD technologies are a promising alternative to represent heterogeneous health data in a flexible and reusable manner so that they can serve intelligent queries, and ultimately support decision-making. However, the development of advanced text-based search engines is necessary to increase its usability especially for nontechnical users. Further research with large datasets is recommended in the future to unfold the potential of Linked Data and Semantic Web for future health information systems development.

Does single-source create an added value? Evaluating the impact of introducing x4T into the clinical routine on workflow modifications, data quality and cost-benefit

OBJECTIVES

The first objective of this study is to evaluate the impact of integrating a single-source system into the routine patient care documentation workflow with respect to process modifications, data quality and execution times in patient care as well as research documentation. The second one is to evaluate whether it is cost-efficient using a single-source system in terms of achieved savings in documentation expenditures.

METHODS

We analyzed the documentation workflow of routine patient care and research documentation in the medical field of pruritus to identify redundant and error-prone process steps. Based on this, we established a novel documentation workflow including the x4T (exchange for Trials) system to connect hospital information systems with electronic data capture systems for the exchange of study data. To evaluate the workflow modifications, we performed a before/after analysis as well as a time-motion study. Data quality was assessed by measuring completeness, correctness and concordance of previously and newly collected data. A cost-benefit analysis was conducted to estimate the savings using x4T per collected data element and the additional costs for introducing x4T.

RESULTS

The documentation workflow of patient care as well as clinical research was modified due to the introduction of the x4T system. After x4T implementation and workflow modifications, half of the redundant and error-prone process steps were eliminated. The generic x4T system allows direct transfer of routinely collected health care data into the x4T research database and avoids manual transcription steps. Since x4T has been introduced in March 2012, the number of included patients has increased by about 1000 per year. The average entire documentation time per patient visit has been significantly decreased by 70.1% (from 1116±185 to 334±83 s). After the introduction of the x4T system and associated workflow changes, the completeness of mandatory data elements raised from 82.2% to 100%. In case of the pruritus research study, the additional costs for introducing the x4T system are €434.01 and the savings are 0.48ct per collected data element. So, with the assumption of a 5-year runtime and 82 collected data elements per patient, the amount of documented patients has to be higher than 1102 to create a benefit.

CONCLUSION

Introduction of the x4T system into the clinical and research documentation workflow can optimize the data collection workflow in both areas. Redundant and cumbersome process steps can be eliminated in the research documentation, with the result of reduced documentation times as well as increased data quality. The usage of the x4T system is especially worthwhile in a study with a large amount of collected data or a high number of included patients.

Piloting the EHR4CR feasibility platform across Europe

BACKGROUND

Pharmaceutical clinical trials are primarily conducted across many countries, yet recruitment numbers are frequently not met in time. Electronic health records store large amounts of potentially useful data that could aid in this process. The EHR4CR project aims at re-using EHR data for clinical research purposes.

OBJECTIVE

To evaluate whether the protocol feasibility platform produced by the Electronic Health Records for Clinical Research (EHR4CR) project can be installed and set up in accordance with local technical and governance requirements to execute protocol feasibility queries uniformly across national borders.

METHODS

We installed specifically engineered software and warehouses at local sites. Approvals for data access and usage of the platform were acquired and terminology mapping of local site codes to central platform codes were performed. A test data set, or real EHR data where approvals were in place, were loaded into data warehouses. Test feasibility queries were created on a central component of the platform and sent to the local components at eleven university hospitals.

RESULTS

To use real, de-identified EHR data we obtained permissions and approvals from 'data controllers' and ethics committees. Through the platform we were able to create feasibility queries, distribute them to eleven university hospitals and retrieve aggregated patient counts of both test data and de-identified EHR data.

CONCLUSION

It is possible to install a uniform piece of software in different university hospitals in five European countries and configure it to the requirements of the local networks, while complying with local data protection regulations. We were also able set up ETL processes and data warehouses, to re-use EHR data for feasibility queries distributed over the EHR4CR platform.

A European inventory of common electronic health record data elements for clinical trial feasibility

Background

Clinical studies are a necessity for new medications and therapies. Many studies, however, struggle to meet their recruitment numbers in time or have problems in meeting them at all. With increasing numbers of electronic health records (EHRs) in hospitals, huge databanks emerge that could be utilized to support research. The Innovative Medicine Initiative (IMI) funded project ‘Electronic Health Records for Clinical Research’ (EHR4CR) created a standardized and homogenous inventory of data elements to support research by utilizing EHRs. Our aim was to develop a Data Inventory that contains elements required for site feasibility analysis.

Methods

The Data Inventory was created in an iterative, consensus driven approach, by a group of up to 30 people consisting of pharmaceutical experts and informatics specialists. An initial list was subsequently expanded by data elements of simplified eligibility criteria from clinical trial protocols. Each element was manually reviewed by pharmaceutical experts and standard definitions were identified and added. To verify their availability, data exports of the source systems at eleven university hospitals throughout Europe were conducted and evaluated.

Results

The Data Inventory consists of 75 data elements that, on the one hand are frequently used in clinical studies, and on the other hand are available in European EHR systems. Rankings of data elements were created from the results of the data exports. In addition a sub-list was created with 21 data elements that were separated from the Data Inventory because of their low usage in routine documentation.

Conclusion

The data elements in the Data Inventory were identified with the knowledge of domain experts from pharmaceutical companies. Currently, not all information that is frequently used in site feasibility is documented in routine patient care.

New bachelors degree program in health informatics in Ethiopia: curriculum content and development approaches

With a widespread use of information technology in healthcare organizations, there is a pressing need for professionals who are both skilled in the use and management of information systems and knowledgeable in the field of healthcare. To fill this need, the department of health informatics at the University of Gondar started a new bachelor's degree in the health informatics program commencing in 2012. The curriculum was developed by a thorough needs assessment and considering the recommendations of the international medical informatics association. The program has duration of 4 years with a total of 249 ECTS. Currently there are 57 students enrolled in the program and 15 full time academic staffs are involved in the teaching and research activity of the department. To share our experience for other countries, in this paper we explain the curriculum development process and its content to the health informatics community.

Towards a trial-ready mobile patient questionnaire system

Gathering patient-reported data enables physicians to know a patient and his/her health-related needs in a more comprehensive way. One method to collect these data is to let the patient fill out electronic questionnaires on a mobile device, e.g. a tablet. Although having successfully implemented a prototype, the mobile questionnaire system at this site has been stretched to its limits within both routine care and clinical trials. By collecting user feedback and analysing the capabilities and limits of the underlying framework, we identified key issues of the prototype. A new implementation addresses these obstacles while keeping the overall application logic and usability. This leads to a trial-ready mobile patient questionnaire system.

Analysis of eligibility criteria from ClinicalTrials.gov

Electronic health care records are being used more and more for patient documentation. This electronic data can be used for secondary purposes, for example through systems that support clinical research. Eligibility criteria have to be processable for such systems to work, but criteria published on ClinicalTrials.gov have been shown to be complex, making them challenging to re-use. We analysed the eligibility criteria on ClinicalTrials.gov using automatic methods to determine whether the criteria definition and number changed over time. From 1998 to 2012 the average number of words used to describe eligibility criteria per year increased by 46%, while the average number of lines used per year only slightly increases until 2000 and stabilizes afterwards. Whether the increase of words resulted in increased criteria complexity or whether more data elements are used to describe eligibility needs further investigation.

Protocol feasibility workflow using an automated multi-country patient cohort system

The Electronic Health Record for Clinical Research (EHR4CR) project aims to improve the current process of clinical trials, providing a technological platform that supports the design and execution of trials. For the protocol feasibility scenario, the system currently allows the user to create a set of in-/exclusion criteria to find patients matching these criteria across sites located in several countries. The automated multi-country patient cohort system developed in EHR4CR implies substantial changes on the current protocol feasibility process, which will be reflected in this study.

Development of best practice principles for simplifying eligibility criteria

Real world data is crucial for clinical research. In hospitals this information is more and more stored in electronic health records (EHR) and could be used for clinical trial feasibility and patient recruitment. On the other side eligibility criteria within study protocols are complex and usually not written in a way that is intuitively understandable or electronically usable. As part of overcoming the gap between eligibility criteria and the data that is available in EHRs we simplified eligibility criteria and created a guideline with best practice principles. The guideline explains how understandable criteria should be formulated and illustrates with examples what 'good' and 'bad' criteria are.

Query engine optimization for the EHR4CR protocol feasibility scenario

An essential step when recruiting patients for a Clinical Trial (CT) is to determine the number of patients that satisfy the Eligibility Criteria (ECs) for that trial. An innovative feature of the Electronic Health Records for Clinical Research (EHR4CR) platform is that when automatically determining patient counts, it also allows the user to view counts for subsets of the ECs. This is helpful because some combinations of ECs may be so restrictive that they yield very few or zero patients. If we wanted to show all possible combinations of ECs, the number of queries we would have to execute would be of 2ⁿ, where n is the total number of ECs. Assuming that an average study has between 20 and 30 ECs, the program would have to execute between 2²⁰ (1,048,576) and 2³⁰ (1,073,741,824) queries. This is not only computationally expensive but also impractical to visualise. The purpose of our research is to reduce possible combinationsto a manageable number.

Are physicians interested in the quality of life of their patients? usage of EHR-integrated patient reported outcomes data

In addition to clinical findings, patient reported outcomes (PRO) are a valuable source of information. However, the available time of a physician per patient is limited. Under these constraints, do physicians look into PRO data? By using an, electronic health record (EHR) integrated system for the documentation of PRO the data is directly available during treatment. To evaluate whether this information is used we analyzed access patterns for two types of PRO forms. 56% and 74% of these forms were accessed within routine care while 74% and 100% were analyzed for clinical research.

[Assessment of pruritus - current standards and implications for clinical practice : consensus paper of the Action Group Pruritus Parameter of the International Working Group on Pruritus Research (AGP)]

With a prevalence of 20%, chronic pruritus is a symptom of many diseases with major impact on healthcare costs. The lack of specific therapeutic measures makes the development of new drugs and their testing in clinical trials urgent. It is not possible to measure pruritus in an objective way. For these reasons, it is necessary to have a series of standardized measures to characterize pruritus in a reliable way. Intensity scales such as the visual analog scale (VAS) are most frequently used to document the course of the symptoms. However, for assessing pruritus intensity, VAS is not an optimal instrument, although it cannot be dispensed with. The VAS should be combined with other scales in clinical studies in order to internally test the consistency of data. Other instruments for assessing intensity and course of pruritus are in the process of development. Presently scratch activity and scratch-associated lesions can be documented in a descriptive fashion. There are some studies that have employed devices to document scratch activity; however, methodological studies are not yet available. The patient-benefit index is an indispensable tool in clinical trials. A questionnaire for gathering data on the history and some pruritus-specific parameters has been developed and published. Questionnaires on patient quality of life, anxiety and depression are helpful in obtaining data on other cost-relevant parameters. A questionnaire on the quality of life, for instance, can provide important help in the assessment of the burden of the disease. The results of these questionnaires can be correlated with data on pruritus intensity scales. The relevant questionnaires have been partially digitalized so that they are available immediately as part of patient care. Additional methodological developments and studies are required in order to define a robust set of instruments for measuring pruritus in daily practice and in clinical studies.

Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus

The most commonly used tool for self-report of pruritus intensity is the visual analogue scale (VAS). Similar tools are the numerical rating scale (NRS) and verbal rating scale (VRS). In the present study, initiated by the International Forum for the Study of Itch assessing reliability of these tools, 471 randomly selected patients with chronic itch (200 males, 271 females, mean age 58.44 years) recorded their pruritus intensity on VAS (100-mm line), NRS (0-10) and VRS (four-point) scales. Re-test reliability was analysed in a subgroup of 250 patients after one hour. Statistical analysis showed a high reliability and concurrent validity (r>0.8; p<0.01) for all tools. Mean values of all scales showed a high correlation. In conclusion, high reliability and concurrent validity was found for VAS, NRS and VRS. On re-test, higher correlation and less missing values were observed. A training session before starting a clinical trial is recommended.

Multilingual Medical Data Models in ODM Format: A Novel Form-based Approach to Semantic Interoperability between Routine Healthcare and Clinical Research

BACKGROUND

Semantic interoperability between routine healthcare and clinical research is an unsolved issue, as information systems in the healthcare domain still use proprietary and site-specific data models. However, information exchange and data harmonization are essential for physicians and scientists if they want to collect and analyze data from different hospitals in order to build up registries and perform multicenter clinical trials. Consequently, there is a need for a standardized metadata exchange based on common data models. Currently this is mainly done by informatics experts instead of medical experts.

OBJECTIVES

We propose to enable physicians to exchange, rate, comment and discuss their own medical data models in a collaborative web-based repository of medical forms in a standardized format.

METHODS

Based on a comprehensive requirement analysis, a web-based portal for medical data models was specified. In this context, a data model is the technical specification (attributes, data types, value lists) of a medical form without any layout information. The CDISC Operational Data Model (ODM) was chosen as the appropriate format for the standardized representation of data models. The system was implemented with Ruby on Rails and applies web 2.0 technologies to provide a community based solution. Forms from different source systems - both routine care and clinical research - were converted into ODM format and uploaded into the portal.

RESULTS

A portal for medical data models based on ODM-files was implemented (http://www.medical-data-models.org). Physicians are able to upload, comment, rate and download medical data models. More than 250 forms with approximately 8000 items are provided in different views (overview and detailed presentation) and in multiple languages. For instance, the portal contains forms from clinical and research information systems.

CONCLUSION

The portal provides a system-independent repository for multilingual data models in ODM format which can be used by physicians. It serves as a platform for discussion and enables the exchange of multilingual medical data models in a standardized way.

Qualitative and quantitative evaluation of EHR-integrated mobile patient questionnaires regarding usability and cost-efficiency

OBJECTIVES

The objective of this evaluation study is to assess a web-based application, currently available on iPad, to document questionnaires regarding patient reported outcomes such as quality of life. Based on the single source approach, the results of these questionnaires are available in the electronic health record to be used for treatment and research purposes. The assessment focuses on the usability and efficiency of the system.

METHODS

The system usability scale questionnaire with seven additional items was used to rate the usability by the patients. It was formally validated by a Cronbach Alpha test. In addition, semi-structured interviews were conducted with patients and medical staff. Time and cost measures, based on official tables of costs, were taken through workflow observations. This study was conducted in the department of dermatology at the University Hospital of Münster, Germany from April to June 2011.

RESULTS

Using the web-based application questionnaire, results about patient reported outcomes like quality of life are immediately available in the electronic health record and can be used for treatment or research purposes. 118 patients and four staff members participated in the study. The usability score reached 80 from 100 points and patients as well as medical staff stated in the interviews that the usability of the web-based system was high, and they preferred it to the previously used paper-based questionnaires. In the setting of our pilot department the mobile devices amortized their costs after 6.7 months. In general, depending on the professional group who are going to post process the paper-based forms, the earliest break-even point to use mobile questionnaires is at 1737 paper sheets per year.

CONCLUSION

The mobile patient questionnaires, integrated into the electronic health record, were well accepted in our pilot setting with high usability scores from patients and medical staff alike. The system has also proved to be cost-efficient compared to the paper-based workflow, given that a certain number of questionnaires is used per year.

Interoperability in clinical research: from metadata registries to semantically annotated CDISC ODM

Planning case report forms for data capture in clinical trials is a labor-insensitive and not formalized process. These CRFs are often neither standardized nor using defined data elements. Metadata registries as the NCI caDSR provide the capability to create forms based on common data elements. However, an exchange of these forms into clinical trial management systems through a standardized format like CDISC ODM is currently not offered. Thus, our objectives were to develop a mapping model between NCI forms and ODM. We analyzed 3012 NCI forms and included common data elements regarding their frequency and uniqueness. In this paper, we have created a mapping model between both formats and identified limitations in the conversion process: Semantic codes requested from the caDSR registry did not allow a proper mapping to ODM items and information like the number of module repetitions got lost. Summarized, it can be stated that our mapping model is feasible. However, mapping of semantic concepts in ODM needs to be specified more precisely.

Mapping turnaround times (TAT) to a generic timeline: a systematic review of TAT definitions in clinical domains

BACKGROUND

Assessing turnaround times can help to analyse workflows in hospital information systems. This paper presents a systematic review of literature concerning different turnaround time definitions. Our objectives were to collect relevant literature with respect to this kind of process times in hospitals and their respective domains. We then analysed the existing definitions and summarised them in an appropriate format.

METHODS

Our search strategy was based on Pubmed queries and manual reviews of the bibliographies of retrieved articles. Studies were included if precise definitions of turnaround times were available. A generic timeline was designed through a consensus process to provide an overview of these definitions.

RESULTS

More than 1000 articles were analysed and resulted in 122 papers. Of those, 162 turnaround time definitions in different clinical domains were identified. Starting and end points vary between these domains. To illustrate those turnaround time definitions, a generic timeline was constructed using preferred terms derived from the identified definitions. The consensus process resulted in the following 15 terms: admission, order, biopsy/examination, receipt of specimen in laboratory, procedure completion, interpretation, dictation, transcription, verification, report available, delivery, physician views report, treatment, discharge and discharge letter sent. Based on this analysis, several standard terms for turnaround time definitions are proposed.

CONCLUSION

Using turnaround times to benchmark clinical workflows is still difficult, because even within the same clinical domain many different definitions exist. Mapping of turnaround time definitions to a generic timeline is feasible.

CIS-based registration of quality of life in a single source approach

Background

Documenting quality of life (QoL) in routine medical care and using it both for treatment and for clinical research is not common, although such information is absolutely valuable for physicians and patients alike. We therefore aimed at developing an efficient method to integrate quality of life information into the clinical information system (CIS) and thus make it available for clinical care and secondary use.

Methods

We piloted our method in three different medical departments, using five different QoL questionnaires. In this setting we used structured interviews and onsite observations to perform workflow and form analyses. The forms and pertinent data reports were implemented using the integrated tools of the local CIS. A web-based application for mobile devices was developed based on XML schemata to facilitate data import into the CIS. Data exports of the CIS were analysed with statistical software to perform an analysis of data quality.

Results

The quality of life questionnaires are now regularly documented by patients and physicians. The resulting data is available in the Electronic Health Record (EHR) and can be used for treatment purposes and communication as well as research functionalities. The completion of questionnaires by the patients themselves using a mobile device (iPad) and the import of the respective data into the CIS forms were successfully tested in a pilot installation. The quality of data is rendered high by the use of automatic score calculations as well as the automatic creation of forms for follow-up documentation. The QoL data was exported to research databases for use in scientific analysis.

Conclusion

The CIS-based QoL is technically feasible, clinically accepted and provides an excellent quality of data for medical treatment and clinical research. Our approach with a commercial CIS and the web-based application is transferable to other sites.

HIS-based Kaplan-Meier plots--a single source approach for documenting and reusing routine survival information

BACKGROUND

Survival or outcome information is important for clinical routine as well as for clinical research and should be collected completely, timely and precisely. This information is relevant for multiple usages including quality control, clinical trials, observational studies and epidemiological registries. However, the local hospital information system (HIS) does not support this documentation and therefore this data has to generated by paper based or spreadsheet methods which can result in redundantly documented data. Therefore we investigated, whether integrating the follow-up documentation of different departments in the HIS and reusing it for survival analysis can enable the physician to obtain survival curves in a timely manner and to avoid redundant documentation.

METHODS

We analysed the current follow-up process of oncological patients in two departments (urology, haematology) with respect to different documentation forms. We developed a concept for comprehensive survival documentation based on a generic data model and implemented a follow-up form within the HIS of the University Hospital Muenster which is suitable for a secondary use of these data. We designed a query to extract the relevant data from the HIS and implemented Kaplan-Meier plots based on these data. To re-use this data sufficient data quality is needed. We measured completeness of forms with respect to all tumour cases in the clinic and completeness of documented items per form as incomplete information can bias results of the survival analysis.

RESULTS

Based on the form analysis we discovered differences and concordances between both departments. We identified 52 attributes from which 13 were common (e.g. procedures and diagnosis dates) and were used for the generic data model. The electronic follow-up form was integrated in the clinical workflow. Survival data was also retrospectively entered in order to perform survival and quality analyses on a comprehensive data set. Physicians are now able to generate timely Kaplan-Meier plots on current data. We analysed 1029 follow-up forms of 965 patients with survival information between 1992 and 2010. Completeness of forms was 60.2%, completeness of items ranges between 94.3% and 98.5%. Median overall survival time was 16.4 years; median event-free survival time was 7.7 years.

CONCLUSION

It is feasible to integrate survival information into routine HIS documentation such that Kaplan-Meier plots can be generated directly and in a timely manner.

HIS-Based Support of Follow-Up Documentation - Concept and Implementation for Clinical Studies

OBJECTIVE

Follow-up data must be collected according to the protocol of each clinical study, i.e. at certain time points. Missing follow-up information is a critical problem and may impede or bias the analysis of study data and result in delays. Moreover, additional patient recruitment may be necessary due to incomplete follow-up data. Current electronic data capture (EDC) systems in clinical studies are usually separated from hospital information systems (HIS) and therefore can provide limited functionality to support clinical workflow. In two case studies, we assessed the feasibility of HIS-based support of follow-up documentation.

METHODS

We have developed a data model and a HIS-based workflow to provide follow-up forms according to clinical study protocols. If a follow-up form was due, a database procedure created a follow-up event which was translated by a communication server into an HL7 message and transferred to the import interface of the clinical information system (CIS). This procedure generated the required follow-up form and enqueued a link to it in a work list of the relating study nurses and study physicians, respectively.

RESULTS

A HIS-based follow-up system automatically generated follow-up forms as defined by a clinical study protocol. These forms were scheduled into work lists of study nurses and study physicians. This system was integrated into the clinical workflow of two clinical studies. In a study from nuclear medicine, each scenario from the test concept according to the protocol of the single photon emission computer tomography/computer tomography (SPECT/CT) study was simulated and each scenario passed the test. For a study in psychiatry, 128 follow-up forms were automatically generated within 27 weeks, on average five forms per week (maximum 12, minimum 1 form per week).

CONCLUSION

HIS-based support of follow-up documentation in clinical studies is technically feasible and can support compliance with study protocols.