Section 2: Patient Records: Electronic Patient Records and their Benefit for Patient Care

To summarize current excellent research in the field of patient records.

Synopsis of the articles selected for the IMIA Yearbook 2006.

Current research in the field of patient records analyses users’ needs and attitudes as well as the potential and limitations of electronic patient record systems. Particular topics are the questions physicians have when assessing patients during ward rounds, the timeliness of results when ordered electronically, the quality of documenting haemophilia home therapy, attitudes towards patient access to health records and adequate strategies for record linkage in dependence on the intended purpose.

The best paper selection of articles on patient records shows examples of excellent research on methods used for the management of patient records and for processing their content as well as assessing the potential, limitations of and user attitudes towards electronic patient record systems. Computerized patient records are mature, so that they can contribute to high quality patient care and efficient patient management.

Electronic patient records and their benefit for patient care. Findings from the Section on Patient Records

OBJECTIVES

To summarize current excellent research in the field of patient records.

METHOD

Synopsis of the articles selected for the IMIA Yearbook 2006.

RESULTS

Current research in the field of patient records analyses users' needs and attitudes as well as the potential and limitations of electronic patient record systems. Particular topics are the questions physicians have when assessing patients during ward rounds, the timeliness of results when ordered electronically, the quality of documenting haemophilia home therapy, attitudes towards patient access to health records and adequate strategies for record linkage in dependence on the intended purpose.

CONCLUSIONS

The best paper selection of articles on patient records shows examples of excellent research on methods used for the management of patient records and for processing their content as well as assessing the potential, limitations of and user attitudes towards electronic patient record systems. Computerized patient records are mature, so that they can contribute to high quality patient care and efficient patient management.

The computerized patient record: where do we stand ?

OBJECTIVES

To provide an overview of trends in research, developments and implementations of the computerized patient record (CPR) of the last two years.

METHODS

We surveyed the medical informatics literature, spanning the years 2004-2005, focusing on publications on CPRs.

RESULTS

The main trends revealed were: 1) the development of technologies to realize privacy and security goals or remote data entry and access to CPRs; 2) investigations into how to enhance the quality and reuse of CPR data; 3) the development and evaluation of decision support functions to be integrated with CPRs; 4) evaluations of the impact of CPRs on clinicians, patients, clinical work settings and patient outcomes; and 5) the further development and use of standards to move towards shared electronic health records (EHRs).

CONCLUSION

The CPR is playing a growing part in medical informatics research and evaluation studies, but the goal of establishing a comprehensive lifelong EHR is still a long way off. In moving forward to EHRs, convergence of EHR standards seems required to realize true interoperability of health care applications. User acceptance of present-day CPRs (for all categories of users) and compatibility with work patterns has not been achieved yet, and can only be realized by giving these goals high priority. This will require substantial resources for in-depth work flow analysis, development and evaluation of CPRs. Besides this, the implementation of effective CPRs asks for health care organizations that are willing to invest in new developments and to contribute to evaluation studies, to further improve CPRs' functionalities and enhance their use in practice.

CSI-ISC--Concepts for smooth integration of health care information system components into established processes of patient care

OBJECTIVES

The introduction of information system components (ISCs) usually leads to a change in existing processes, e.g. processes of patient care. These processes might become even more complex and variable than before. An early participation of end users and a better understanding of human factors during design and introduction of ISCs are key factors for a successful introduction of ISCs in health care. Nonetheless no specialized methods have been developed until now to systematically support the integration of ISCs in existing processes of patient care while taking into account these requirements. In this paper, therefore, we introduce a procedure model to implement Concepts for Smooth Integration of ISCs (CSI-ISC).

METHODS

Established theories from economics and social sciences have been applied in our model, among them the stress-strain-concept, the contrastive task analysis (KABA), and the phase model for the management of information systems.

RESULTS

CSI-ISC is based on the fact that while introducing new information system components, users experience additional workload. One essential aim during the introduction process therefore should be to systematically identify, prioritize and ameliorate workloads that are being imposed on human beings by information technology in health care. To support this, CSI-ISC consists of a static part (workload framework) and a dynamic part (guideline for the introduction of information system components into existing processes of patient care).

CONCLUSIONS

The application of CSI-ISC offers the potential to minimize additional workload caused by information system components systematically. CSI-ISC rationalizes decisions and supports the integration of the information system component into existing processes of patient care.

Standardized documentation of drug recommendations in discharge letters--a contribution to quality management in cooperative care

OBJECTIVES

To analyze the necessity and potential usefulness of a computerized physician order entry (CPOE) system in supporting the writing of pharmacotherapeutic recommendations in discharge letters.

METHODS

Systematic analysis of drug recommendations in discharge letters of a hospital providing tertiary care, structured interviews with in-hospital prescribers, and focus groups with general practitioners who admit patients to this hospital.

RESULTS

We analyzed 1800 randomly selected discharge letters, 1205 of which contained pharmacotherapeutic recommendations. The frequencies, structure, and quality of these recommendations varied considerably between departments. Nearly 16% of the recommendations contained both proprietary (brand) and non-proprietary names (active ingredient). Interviewed clinicians expressed interest in CPOE systems that check for contraindications and interactions between drugs, suggest cheaper products, and automatically insert active ingredients when omitted. The focus group sessions confirmed that the pharmacotherapeutic recommendations in current discharge letters do not effectively support daily clinical practice.

CONCLUSIONS

Documenting active ingredients as well as brand names in drug therapy recommendations is currently not part of clinical practice. Computerized decision support can help to optimise the structure and communication of therapeutic information across interfaces and can be a quality factor with considerable influence on process quality, outcome quality, and costs of cooperative patient care.

The challenge of ubiquitous computing in health care: technology, concepts and solutions. Findings from the IMIA Yearbook of Medical Informatics 2005

OBJECTIVES

To review recent research efforts in the field of ubiquitous computing in health care. To identify current research trends and further challenges for medical informatics.

METHODS

Analysis of the contents of the Yearbook on Medical Informatics 2005 of the International Medical Informatics Association (IMIA).

RESULTS

The Yearbook of Medical Informatics 2005 includes 34 original papers selected from 22 peer-reviewed scientific journals related to several distinct research areas: health and clinical management, patient records, health information systems, medical signal processing and biomedical imaging, decision support, knowledge representation and management, education and consumer informatics as well as bioinformatics. A special section on ubiquitous health care systems is devoted to recent developments in the application of ubiquitous computing in health care. Besides additional synoptical reviews of each of the sections the Yearbook includes invited reviews concerning E-Health strategies, primary care informatics and wearable healthcare.

CONCLUSIONS

Several publications demonstrate the potential of ubiquitous computing to enhance effectiveness of health services delivery and organization. But ubiquitous computing is also a societal challenge, caused by the surrounding but unobtrusive character of this technology. Contributions from nearly all of the established sub-disciplines of medical informatics are demanded to turn the visions of this promising new research field into reality.

Medical informatics at Heidelberg/Heilbronn: status–evaluation–new challenges in a specialised curriculum for medical informatics after thirty years of evolution

After reporting on characteristics, structure and contents of the specialised informatics-based curriculum for medical informatics (MI) at the University of Heidelberg/University of Applied Sciences Heilbronn, the paper describes the development during the last 5 years, and in particular a complementary health care oriented postgraduate program in 'Health Information Management' (IM). Furthermore, it outlines results of a study among the MI graduates, which aims to assess their job situation and to evaluate the curriculum from their viewpoint and so establishes a summary of 30 years of experience with the program. Finally, the paper discusses new challenges of the program, considering the results of the study, perspectives of health care provision in the next decade, content changes to be focused on and the growing competition in the field of programs for medical informatics.

A meta-model of chemotherapy planning in the multi-hospital/multi-trial-center-environment of pediatric oncology

OBJECTIVE

Chemotherapy planning in pediatric oncology is complex and time-consuming. The correctness of the calculation according to state-of-the-art research is crucial for curing the child. Computer-assistance can be of great value. The objective of our research was to work out a meta-model of chemotherapy planning based on the Unified Modeling Language (UML). The meta-model is used for the development of an application system which serves as a knowledge-acquisition tool for chemotherapy protocols in pediatric oncology as well as for providing protocol-based care.

METHODS

We applied evolutionary prototyping, software reengineering techniques and grounded theory, a qualitative method in social research. We repeated the following steps several times over the years: Based on a requirements analysis (i) a meta-model was developed or adapted, respectively (ii). The meta-model served as a basis for implementing evolutionary prototypes (iii). Further requirements were identified (i) from clinical use of the systems.

RESULTS

We developed a comprehensive UML-based meta-model for chemotherapy planning in pediatric oncology (chemoMM). We implemented it and introduced evolutionary prototypes (CATIPO and DOSPO) in several medical centers. Systematic validation of the prototypes enabled us to derive a final meta-model which covers the requirements that have turned out to be necessary in clinical routine.

CONCLUSIONS

We have developed an application system that fits well into clinical routine of pediatric oncology in Germany. Validation results have shown that the implementation of the meta-model chemoMM can adequately support the knowledge acquisition process for protocol-based care.

Towards clinical bioinformatics: advancing genomic medicine with informatics methods and tools

OBJECTIVES

To summarize the challenges facing clinical applications in the light of growing research results in genomic medicine and bioinformatics.

METHODS

Analysis of the contents of the Yearbook of Medical Informatics 2004 of the International Medical Informatics Association (IMIA).

RESULTS

The Yearbook of Medical Informatics 2004 includes 32 articles selected from 22 peer-reviewed scientific journals. A special section on clinical bioinformatics highlights recent developments in this field. Several guest editors review the promises and limitations of available methods and resources from biomedical informatics that are relevant to clinical medicine. Integrated data and knowledge resources are generally regarded to be central and key issues for clinical bioinformatics. Further review papers deal with public health implications of bioinformatics, knowledge management and trends in health care education. The Yearbook includes for the first time a section on the history of medical informatics, where the significant impact of the Reisensburg protocol 1973 on international health and medical informatics education is examined.

CONCLUSIONS

Close collaboration between bioinformatics and medical informatics researchers can contribute to new insights in genomic medicine and contribute towards the more efficient and effective use of genomic data to advance clinical care.

Medical informatics and the quality of health: new approaches to support patient care - findings from the IMIA Yearbook of Medical Informatics 2003

OBJECTIVES

The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of excellent papers on medical informatics research which have been recently published (http://www. yearbook.uni-hd.de). The 2003 Yearbook of Medical Informatics took as its theme the role of medical informatics for the quality of health care. In this paper, we will discuss challenges for health care, and the lessons learned from editing IMIA Yearbook 2003.

RESULTS AND CONCLUSIONS

Modern information processing methodology and information and communication technology have strongly influenced our societies and health care. As a consequence of this, medical informatics as a discipline has taken a leading role in the further development of health care. This involves developing information systems that enhance opportunities for global access to health services and medical knowledge. Informatics methodology and technology will facilitate high quality of care in aging societies, and will decrease the possibilities of health care errors. It will also enable the dissemination of the latest medical and health information on the web to consumers and health care providers alike. The selected papers of the IMIA Yearbook 2003 present clear examples and future challenges, and they highlight how various sub-disciplines of medical informatics can contribute to this.

Medical informatics specialists: what are their job profiles? Results of a study on the first 1024 medical informatics graduates of the Universities of Heidelberg and Heilbronn

OBJECTIVES

Since 1972, the University of Heidelberg and the University of Applied Sciences Heilbronn have jointly been running a medical informatics program. To continuously provide high quality education, the curriculum is regularly evaluated among its graduates. The objectives of this study were to assess the job situation of the graduates and to evaluate the curriculum from their viewpoint.

METHOD

Anonymous inquiry of all medical informatics graduates, having finished their studies before March 31, 2001 (n=1024) using a structured questionnaire.

RESULTS

The questionnaire was answered by 446 (compliance: 45.5%) graduates. About one third (146 of 444 valid cases) are working in software/hardware companies. 179 (43.0% of 416 valid cases) graduates are working within medical informatics, 214 (51.4%) are working outside of medical informatics, but within other informatics. 23 (5.5%) graduates are working neither in medical nor in other informatics. 15 percent of the responding graduates have received a doctor's degree. Software engineering, database and information systems are regarded as most important parts of the education. The majority of the graduates are satisfied with their education as well as with their personal career.

CONCLUSIONS

The variety of jobs, the job profiles, and the high level of our graduates' satisfaction with their education indicate the relevance of specialized medical informatics programs with a curricular profile like the one in Heidelberg/Heilbronn. Investigations like this can help to adjust the contents of the curriculum to professional needs.

Medical Imaging Informatics and Medical Informatics: opportunities and constraints. Findings from the IMIA yearbook of Medical Informatics 2002

OBJECTIVES

The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of recent excellent papers on medical informatics research (http://www.yearbook.uni-hd.de). The 2002 Yearbook of Medical Informatics took as its theme the topic of Medical Imaging Informatics. In this paper, we will summarize the contributions of medical informatics researchers to the development of medical imaging informatics, discuss challenges and opportunities of imaging informatics, and present the lessons learned from the IMIA Yearbook 2002.

RESULTS AND CONCLUSIONS

Medical informatics researchers have contributed to the development of medical imaging methods and systems since the inception of this field approximately 40 years ago. The Yearbook presents selected papers and reviews on this important topic. In addition, as usual, the Yearbook 2002 also contains a variety of papers and reviews on other subjects relevant to medical informatics, such as Bioinformatics, Computer-supported education, Health and clinical management, Health information systems, Knowledge processing and decision support, Patient records, and Signal processing.

[Standardizing terminology in pediatric oncology--the basic data set]

BACKGROUND

In the context of more than 20 therapy optimizing clinical trials in pediatric oncology an extensive documentation with a big number of case report forms was developed in the last 20 to 25 years. Across these trials same information is partially captured in different terminological ways, by which documentation about patients in the clinics is made more difficult.

METHOD

Terminology of therapy optimizing clinical trials of German Society for Pediatric Oncology and Hematology (GPOH) is standardized by a central "standards committee".

RESULT

As a first result the basic data set of GPOH could be revised and made available in internet via http://www.dospo.uni-hd.de.

CONCLUSION

A basis of a unique documentation language in pediatric oncology is available for German speaking regions.

Object-oriented business process analysis of the cooperative soft tissue sarcoma trial of the german society for paediatric oncology and haematology (GPOH)

The German Society for Paediatric Oncology and Haematology (GPOH) runs nation-wide multicentre clinical trials to improve the treatment of children suffering from malignant diseases. We want to provide methods and tools to support the centres of these trials in developing trial specific modules for the computer-based DOcumentation System for Paediatric Oncology (DOSPO). For this we carried out an object-oriented business process analysis for the Cooperative Soft Tissue Sarcoma Trial at the Olgahospital Stuttgart for Child and Adolescent Medicine. The result is a comprehensive business process model consisting of UML-diagrams and use case specifications. We recommend the object-oriented business process analysis as a method for the definition of requirements in information processing projects in the field of clinical trials in general. For this our model can serve as basis because it slightly can be adjusted to each type of clinical trial.

Digital Libraries and Recent Medical Informatics Research. Findings from the IMIA Yearbook of Medical Informatics 2001

The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of recent excellent papers on medical informatics research (http://www.med.uni-heidelberg.de/mi/yearbook/index.htm). The special topic of the just published Yearbook 2001 is "Digital Libraries and Medicine". Digital libraries have changed dramatically and will continue to change the way we work with medical knowledge. The selected papers present recent research and new results on digital libraries. As usual, the Yearbook 2001 also contains a variety of papers on other subjects relevant to medical informatics, such as Electronic Patient Records, Health Information Systems, Health and Clinical Management, Decision Support Systems, Education, as well as Image and Signal Processing. This paper will briefly introduce the contributions covering digital libraries and will show how medical informatics research contributes to this important topic.

Information processing in healthcare at the start of the third Millennium: potential and limitations

The 21st century is said to be a century of the information society. We should be aware that continuing progress in information processing methodology (IPM) and information and communication technology (ICT) is changing our societies, including medicine and health care. At the start of the third Millennium we should ask ourselves, what progress can we expect from modern IPM/ICT for healthcare in the coming decade, what concerns does the information society have to face, and what steps have to be taken. These questions were addressed by clinicians, researchers and industrial representatives in a panel discussion at the joint conference ISCB-GMDS-99 of the International Society of Clinical Biostatistics and the German Society for Medical Informatics, Biometry and Epidemiology. Important aspects raised by the panelists and in the subsequent discussion were: (1) the main goal of expanding IPM/ICT should be to further improve quality of care, while maintaining reasonable costs; (2) with the support of modern IPM and ICT the boundaries between inpatient and outpatient care will fade away enabling a more efficient, patient-centered health care; (3) cooperation between health-care professionals will increase; there will be different ways of communication between them and with the patient, including modern ICT and the Internet; (4) society must be concerned with achieving equal opportunities in being informed about and in using new ICT; (5) misuse of data will remain a serious problem and can become an obstacle to progress.

On the necessity of systematically planning clinical tumor documentation

Tumor documentation is an important task for both clinical research and patient care. Documentation systems for these purposes have to be planned systematically and should be goal oriented. We applied the method of a so-called 'standardized documentation protocol' for systematically planning two documentation systems in oncology: one for the tumor center Heidelberg/Mannheim and the other for a nationwide project in the field of documentation and therapy planning in pediatric oncology. The method proved to be helpful in both cases even though the resulting documentation protocols are completely different and although they served different objectives. Therefore, the aim of the paper is to motivate and help medical informatics professionals to systematically plan other documentation systems using this method.

Requirements and design aspects of a data model for a data dictionary in paediatric oncology

German children suffering from cancer are mostly treated within the framework of multicentre clinical trials. An important task of conducting these trials is an extensive information and knowledge exchange, which has to be based on a standardised documentation. To support this effort, it is the aim of a nationwide project to define a standardised terminology that should be used by clinical trials for therapy documentation. In order to support terminology maintenance we are currently developing a data dictionary. In this paper we describe requirements and design aspects of the data model used for the data dictionary as first results of our research. We compare it with other terminology systems.

Integrating specialized application systems into hospital information systems--obstacles and factors for success

Hospital information systems are often huge and heterogeneous systems. To support physicians with their daily clinical work, application systems are developed which are dedicated to particular medical fields or tasks and which have to be integrated into the hospital information system. The integration process is quite complicated, because it makes the information system's infrastructure even more heterogeneous. We developed an application system for documentation and therapy planning in pediatric oncology (DOSPO) and we started to introduce it into the Department of Pediatric Oncology of Heidelberg University Hospital. The fact that DOSPO is developed as a universal system for nationwide use made the integration process more difficult. In any case, the introduction of specialized application systems has to be planned systematically in advance, regarding the prevailing information system's infrastructure, available resources and established processes. To simplify the integration process comprehensive electronic patient records for the future should be designed in a way that they can be enhanced easily by new clinical functions.

Recording clinical data--from a general set of record items to case report forms (CRF) for clinics

Standardising a documentary language makes only sense if we use it for documentation consequently. Using an example of Paediatric Oncology in Germany we have developed a procedure that generates CRFs from a documentary language. The introduced procedure has proved to be feasible in practice. With it we can support developers of documentation systems in creating their CRFs; through the guaranteed use of the documentation terminology we further achieve that information recorded with the created CRFs may be statistically analysed across different institutions.

[Computer-assisted documentation and therapy planning in pediatric oncology--introduction of a nationwide solution]

In Pediatric Oncology in Germany, 90% of the patients are treated according to multicenter clinical trials, which means an enormous effort for documentation in the participating clinics. In order to enable multiple use of data for patient records as well as for clinical trials a computer-based documentation system for pediatric oncology (DOSPO) is being developed, which can be used nationwide. DOSPO currently comprises a minimum basic data set, which represents the common core of all multicenter trials and which has been approved by the German Society for Pediatric Oncology and Hematology (GPOH). It is intended to enhance the documentation by specific items of each clinical trial. Functions for computer-aided chemotherapy planning and medical report writing have already been implemented in the documentation system. Various centers in Germany are currently validating the system in routine use.

Computer-aided documentation and therapy planning in pediatric oncology

In the past 20 years considerable progress was made in pediatric oncology concerning the results of therapy in Germany. Nationwide multicentre trials provide protocols for the therapy of the children. The calculation of the chemotherapy according to the protocols is rather complex and the documentation efforts for the pediatricians are enormous. Thus, we developed as a first step an application system for Computer Aided Therapy Planning In Pediatric Oncology (CATIPO), that is in routine use in about 20 pediatric clinics in Germany. In order to support the physician comprehensively with the documentation that is necessary for the trials we currently develop a Documentation System for Pediatric Oncology (DOSPO) that comprises the functionality of chemotherapy planning according to the protocols released by the trial centres. Besides supporting the physician in clinical routine the major objective is to improve the quality of the documented data. To reach this aims DOSPO combines research aspects of decision support and clinical documentation: formal representation of general protocols, calculating of a particular therapy for a patient, data acquisition, communication interfaces for transferring the data to the trial centres. In order to support trial centres an authoring system and a central data dictionary will be developed. This will enable the trial centres to develop new modules for trial-specific data acquisition in the clinics.