The computerized patient record: balancing effort and benefit

Paper versus computer: feasibility of an electronic medical record in general pediatrics

BACKGROUND

Implementation of electronic medical record systems promises significant advances in patient care, because such systems enhance readability, availability, and data quality. Structured data entry (SDE) applications can prompt for completeness, provide greater accuracy and better ordering for searching and retrieval, and permit validity checks for data quality monitoring, research, and especially decision support. A generic SDE application (OpenSDE) to support documentation of patient history and physical examination findings was developed and tailored for the domain of general pediatrics.

OBJECTIVE

To evaluate OpenSDE for its completeness, uniformity of reporting, and usability in general pediatrics.

METHODS

Four (trainee) pediatricians documented data for 8 first-visit patients in the traditional, paper-based, medical record and immediately thereafter in OpenSDE (electronic record). The 32 paper records obtained served as the common data source for data entry in OpenSDE by the other 3 physicians (transcribed record). Data entered by 2 experienced users, with all patient information present in the paper record, served as the control record. Data entry times were recorded, and a questionnaire was used to assess users' experiences with OpenSDE.

RESULTS

Clinicians documented 44% of all available patient information identically in the paper and electronic records. Twenty-five percent of all patient information was documented only in the paper record, and 31% was present only in the electronic record. Differences were found in patient history and physical examination documentation in the electronic record; more information was missing for patient history (38%) than for physical examination (15%). Furthermore, physical examination contained more additional information (39%) than did patient history (21%). The interobserver agreement of documentation of patient information from the same data source was fair to moderate, with kappa values of 0.39 for patient history and 0.40 for physical examination. Data entry times in OpenSDE decreased from 25 minutes to <15 minutes, indicating a learning effect. The questionnaire revealed a positive attitude toward the use of OpenSDE in daily practice.

CONCLUSION

OpenSDE seems to be a promising application for the support of physician data entry in general pediatrics.

Natural language processing to extract medical problems from electronic clinical documents: performance evaluation

In this study, we evaluate the performance of a Natural Language Processing (NLP) application designed to extract medical problems from narrative text clinical documents. The documents come from a patient's electronic medical record and medical problems are proposed for inclusion in the patient's electronic problem list. This application has been developed to help maintain the problem list and make it more accurate, complete, and up-to-date. The NLP part of this system-analyzed in this study-uses the UMLS MetaMap Transfer (MMTx) application and a negation detection algorithm called NegEx to extract 80 different medical problems selected for their frequency of use in our institution. When using MMTx with its default data set, we measured a recall of 0.74 and a precision of 0.756. A custom data subset for MMTx was created, making it faster and significantly improving the recall to 0.896 with a non-significant reduction in precision.

OpenSDE: a strategy for expressive and flexible structured data entry

PURPOSE

This description focuses on the expressiveness and flexibility of OpenSDE: an application that supports recording of structured narrative data.

METHODS

OpenSDE enables data entry with (customizable) forms based on trees of medical concepts. The relevant scope for data entry can be tailored per medical domain by construction of a domain-specific tree. OpenSDE is intended for structuring narrative data to make these available for both care and research.

RESULTS

The OpenSDE application is currently in use at several departments in our academic hospital, including radiology, neurology, pediatrics, and child psychiatry. OpenSDE is available for all in open source.

User interface of MUDR electronic health record

Development of the electronic health record architecture at the EuroMISE Center was inspired by existing European standards and several European projects. The developed EHR named MUDR implements a 3-layer architecture, using XML for communication between application layer and clients. A decision support module implementing the "1999 WHO/ISH Guidelines for the Management of Hypertension" is part of an application layer. Universal graph structure is used both to represent the set of medical concepts in the EHR and to represent the collected data. Advanced methods of interaction between EHR and its user are studied, software prototypes of client applications are developed and their effectiveness evaluated.

Breaking the Translational Barriers: The Value of Integrating Biomedical Informatics and Translational Research

The conduct of translational health research has become a vital national enterprise. However, multiple barriers prevent the effective translation of basic science discoveries into clinical and community practice. New information technology (IT) applications could help address these barriers. Unfortunately, owing to a combination of organizational, technical, and social factors, neither physician-investigators and research staff nor their clinical and community counterparts have harnessed such applications. Recently, at the request of the Institute of Medicine's Clinical Research Roundtable, a qualitative study of these factors was conducted at several leading academic medical centers. We explore the current status of IT in the translational research domain, describe the qualitative results, and conclude with a proposed set of initiatives to further increase the integration of IT into translational research.

He@lthCo-op: a web-based system to support distributed healthcare co-operative work

Healthcare is characterized by close collaboration and information sharing among many distinct actors, who co-operate for the patient care in different temporal moments, also at a distance. In this context, availability to care givers of all relevant patient health data and of specific healthcare co-operative work supporting tools is fundamental for best patient treatment. We designed and implemented He@lthCo-op, a web-based modular system supporting co-operative work and patient information secure sharing among healthcare personnel also from remotely located sites. He@lthCo-op enables easily gathering, storing, and accessing patient clinical and personal data anytime and from anywhere an Internet connection is available.

Information access at the point of care: what can we learn for designing a mobile CPR system?

OBJECTIVES

Hospitals have started to migrate their paper-based records to computerized patient records (CPR). The majority of today's CPR systems are stationary, which means that physicians use a clinical workstation to access CPR information. But health care professionals need to request and enter information at different locations, for example, on their daily ward round. This suggests the use of mobile computers, enabling an ubiquitous access to needed data. Different studies show that health care professionals are reluctant to use poorly designed mobile CPR systems, as the work at the point of care is very time-pressured and hectic. To design a system with high acceptance, it is essential to obtain empirical insight into the work practices and context in which the mobile CPR system will be used.

METHOD

We investigated the physicians' work with the patient record during their daily round. With the help of a compact notation method, the physicians' interaction with the information system was recorded in real time. Fourteen physicians from three different departments (internal medicine, surgery, and geriatrics) of a middle-sized Swiss hospital participated in our study.

RESULTS

Physicians have clear access preferences when they interact with the patient record during their daily round. There exists a clear profile of access frequencies and patterns, respectively. As an example, approximately 50% of all patient record accesses concern information about medications, vital signs and lab test results.

DISCUSSION/CONCLUSION

A CPR system which is designed to reflect the access frequencies and patterns should improve the efficiency of data entry and retrieval and thus result in a system with high acceptance among physicians in the demanding environment during hospital rounds.

Overcoming structural constraints to patient utilization of electronic medical records: a critical review and proposal for an evaluation framework

There are constraints embedded in medical record structure that limit use by patients in self-directed disease management. Through systematic review of the literature from a critical perspective, four characteristics that either enhance or mitigate the influence of medical record structure on patient utilization of an electronic patient record (EPR) system have been identified: environmental pressures, physician centeredness, collaborative organizational culture, and patient centeredness. An evaluation framework is proposed for use when considering adaptation of existing EPR systems for online patient access. Exemplars of patient-accessible EPR systems from the literature are evaluated utilizing the framework. From this study, it appears that traditional information system research and development methods may not wholly capture many pertinent social issues that arise when expanding access of EPR systems to patients. Critically rooted methods such as action research can directly inform development strategies so that these systems may positively influence health outcomes.