The computerized patient record: balancing effort and benefit

Understanding Healthcare Providers’ Electronic Health Record (EHR) Interface Preferences via Conjoint Analysis

OBJECTIVE

The emergence of Electronic Health Records (EHRs) has been beneficial in processing administrative and clinical data for quality healthcare information. Despite being patient-centered, a number of these technologies have a fractional consideration of the human-computer interaction, which affects the healthcare professionals as end-users. This attempted to surface the healthcare providers' preferences of an ideal EHR system interface in the community setting.

MATERIALS AND METHOD

Using an orthogonal main effect design of conjoint analysis, a select group of healthcare providers (n = 300) were asked to sort choice cards, which contains five (5) attributes of EHR interface with specific level. Data were analyzed using Sawtooth v.18 and SPSS v.21.

RESULTS

High importance was given to color scheme and device platform. Further, the part-worth analysis revealed the preference for an EHR with the following attributes: (a) smartphone device, (b) triadic color, (c) minimalist design, (d) chunked layout and (e) icon-centered menu.

DISCUSSION

Visual interest and technology needs of the community healthcare providers shaped their preferences. These provide substantial perspectives on how to improve usability of EHR interface systems.

CONCLUSION

Findings underscored the expanded roles of the healthcare professionals in the successful development of EHR systems.

MULTIPROFESSIONAL ELECTRONIC PROTOCOL FOR DIGESTIVE SURGERY VALIDATION

Background:

The creation of a computerized clinical database with the ability to collect prospective information from patients and with the possibility of rescue and crossing data enables scientific studies of higher quality and credibility in less time.

Aim:

To validate, in a single master protocol, the clinical data referring to Surgery of Digestive System in a multidisciplinary way, incorporating in the SINPE^© platform, and to verify the incidence of digestive diseases based on the prospectively performed collections.

Method:

Organize in one software, in a standardized structure, all the pre-existing items in the SINPE^© database; the theoretical basis was computerized through the MIGRASINPE^© module creating a single multiprofessional master protocol for use as a whole.

Results:

The existing specific protocols were created and/or adapted - they correspond to the most prevalent digestive diseases - unifying them. The possibility of multiprofessional use was created by integrating all data collected from medicine, nursing, physiotherapy, nutrition and health management in a prospective way. The total was 4,281 collections, distributed as follows: extrahepatic biliary tract, n=1,786; esophagus, n=1015; anorectal, n=736; colon, n=550; small intestine, n=86; pancreas, n=71; stomach, n=23; liver, n=14.

Conclusions:

The validation of the unification and structuring in a single master protocol of the clinical data referring to the Surgery of the Digestive System in a multiprofessional and prospective way was possible and the epidemiological study carried out allowed to identify the most prevalent digestive diseases.

The Moroccan medical file between practice and politics: a cross-sectional study

Introduction

the medical file is a key element of quality reflecting good hospital management. Many steps have been taken through its history leading up to computerization. This Process allows the sharing of files with both the health staff and patients, while respecting the professional confidentiality between parties. However, in Morocco, as is the case in other countries that are unable to computerize all their hospitals, it is necessary to study first the medical file in paper before proceeding with its computerization. The purpose of our study is to describe the state of the hard copy medical record in our Host University and international hospital, Cheikh Zaid in Morocco.

Methods

that is a cross-sectional study that lasted for three months in Cheikh Zaid hospital. The collection of data from this institution was based on the evaluation of 100 medical records of inpatients, seeing as they respond to our study criteria and requirements better than outpatients. Said evaluation was inspired by a clinical audit grid recommended by the High Authority for Health (HAS). Extraction of the results is done using the SPSS 13.0, Microsoft Excel, and Microsoft Visio software. In addition, we used the observation method to correct the errors found.

Results

the results showed that 75% of the files are in good condition and well organized. However, administrative documents were missing in 70% of the cases (national identity card, health insurance card and copy of the patient's consent form). Moreover, in 83% of cases, the identity of the person to be notified in case of complications and the consent form were missing. It is also the case for the discharge report. The latter is incomplete in 97% of the cases. Also, the file transfer data from one service to another were missing in 82% of the medical files.

Conclusion

according to the results, improving the medical file is necessary both administratively and medically. Thus, all parties, including doctors and nurses must be aware of their tasks and roles in this process. Despite the advances in the computerization of the medical file in several hospitals in Morocco, the maintenance of the hard copy version remains unavoidable and still necessary, to protect the rights of both the patient and his medical staff.

Elicitation and prioritization of requirements for electronic health records for oncology in low resource settings: A concept mapping study

BACKGROUND

Understanding functional and non-functional requirements is essential to successfully implement electronic medical record (EMR) systems. Actual requirements will be different for different contexts.

OBJECTIVE

To elicit and prioritize requirements for implementing EMRs in oncology in low and middle income countries (LMICs), and to relate these to requirements from high-income countries.

PARTICIPANTS AND SETTING

Cancer care stakeholders including oncologists, general doctors, nurses, biostatisticians, information technologists, from different LMICs, were involved.

METHODS

Concept mapping was used. Statements of requirements were obtained during focus group discussions (FGDs) and interviews. Using surveys, the requirements were clustered and ranked on importance and feasibility. Data were analyzed in SPSS using agglomerative hierarchical clustering and multidimensional scaling, to create cluster maps and go-zone maps reflecting the relationships between the requirements and their prioritization.

RESULTS

Four FGD sessions, with twenty participants, were conducted. In addition, six participants were interviewed. Twenty-two participants clustered the requirements and sixty-three participants ranked them on importance and feasibility. One hundred and sixty requirement statements were generated which were reduced to sixty-four after de-duplication and merging. Nine clusters were obtained encompassing the following domains, in order of importance: Security, Conducive organization, Management/Governance, General EMR functionalities, Computer infrastructure, Data management, Usability, Oncology decision support, and Ancillary requirements. On ranking, the requirements scored between 3.74 and 4.80 on importance, and between 3.55 and 4.46 on feasibility, on a 5-point Likert scale. We generated concept maps for use when communicating with stakeholders.

CONCLUSION

For oncology EMRs in LMICs, requirements overlap those from high-income countries, but generic EMR functionalities, Infrastructural and organizational requirements are still considered priority in LMICs compared to oncology-specific requirements or advanced EMR features e.g. computerized decision support or interoperability. Concept mapping is a fast and cost-effective method for eliciting and prioritizing EMR requirements in a user-centered manner.

Hospitals' adoption of medical device registers: Evidence from the German Arthroplasty Register

BACKGROUND

Hospitals in many countries do not record and analyze artificial hip and knee joint surgeries systematically, leading to a lack of reliable quality assurance data. Arthroplasty registers have the potential to alleviate this and improve quality of care and health care expenditures. In Germany, the current introduction of the Arthroplasty Register acts as a prototype for various medical device registers. However, participation is voluntary for hospitals in most countries, leading to problems with nonadoption.

PURPOSE

Implementing successful registers requires adoption by most relevant hospitals. Therefore, we assess variables influencing medical device register adoption.

METHODOLOGY

We collect longitudinal data from 343 hospitals that are potential adopters of the German Arthroplasty Register in two surveys. The first survey on the implementation process is conducted in 2014; the second survey is conducted in 2016 to collect data on actual adoption of the surveyed hospitals in 2014. The survey data are matched with published hospital characteristics and administrative data. The hypotheses are tested with a mediated regression model, using partial least squares structural equation modeling.

FINDINGS

Hospital specialization positively affects adoption, directly and indirectly, depending on top management support and user involvement. Quality benefits and hospital size impact adoption positively; economic benefits impact adoption negatively.

CONCLUSION

Important factors influencing adoption of medical device registers for the first time were revealed in this study, providing a starting point to influence adoption proactively and avoid nonadoption.

PRACTICE IMPLICATIONS

The results provide important guidelines for decision-makers at hospitals, registers, and health insurance companies and policy makers about how to foster register adoption and encourage hospitals toward adopting medical device registers.

Does adoption of electronic health records improve organizational performances of hospital surgical units? Results from the French e-SI (PREPS-SIPS) study

BACKGROUND

Electronic health records (EHR) are increasingly being adopted by healthcare systems worldwide. In France, the "Hôpital numérique 2012-2017" program was implemented as part of a strategic plan to modernize health information technology (HIT), including promotion of widespread EHR use. With significant upfront investment costs as well as ongoing operational expenses, it is important to assess this system in terms of its ability to result in improvements in hospital performances. The aim of this study was to evaluate the impact of EHR use on the organizational performances of acute care hospital surgical units throughout France.

METHODS

This retrospective study was based on data derived from three national databases for year the 2012: IPAQSS (Indicators of improvement in the quality and the management of healthcare, "IPAQSS"), Hospi-Diag (French hospital performance indicators), and the national accreditation database. National data and methodological support were provided by the French Ministry of Health (DGOS) and the French National Authority for Health (HAS). Multivariate linear models were used to assess four organizational performance indicators: the occupancy rate of surgical inpatient beds, operating room utilization, the activity per surgeon, and the activity per both nurse anesthetist and anesthesiologist which were dependent variables. Several independent variables were taken into account, including the degree of EHR use.

RESULTS

The models revealed a significant positive impact of EHR use on operating room utilization and bed occupancy rates for surgical inpatient units. No significant association was found between the activity per surgeon or the activity per nurse anesthetist and anesthesiologist with EHR use. All four organizational performance indicators were impacted by the type of hospital, the geographical region, and the severity of the pathologies.

CONCLUSION

We were able to verify the purported potential benefits of EHR use on the organizational performances of surgical units in French hospitals.

Effect of implementation of a coded problem list entry subsystem

OBJECTIVES

Complete patient problem lists may improve the quality of care. To improve the completeness of the lists at our institution, we implemented the coded problem list entry subsystem (CPLES) in our electronic medical record system. Subsequently, physicians used the CPLES instead of handwritten notes to document coded problem lists and progress notes. We evaluated the effect of implementing the CPLES on the completeness of problem lists.

METHODS

We compared the completeness of coded problem lists input after CPLES implementation with that of problem lists handwritten before CPLES implementation and determined the differences. Moreover, the efficiency and usability of the CPLES were evaluated.

RESULTS

The efficiency and usability of CPLES were acceptable. However, the completeness of problem lists was reduced after CPLES implementation. The possible reasons for this reduction, namely system usability, efficacy, incentives, leadership, and education, were crucial for successful CPLES implementation and are discussed in the text.

CONCLUSION

CPLES implementation reduced the completeness of problem lists. Institutions may learn from our experience and carefully implement their own coded problem list systems to avoid this consequence.

e-Business connections in the health sector: IT challenges and the effects of practice size

The use of information technology (IT) in the health sector is critically important for enhanced patient care and ultimately cost savings. However, the uptake of IT in health has been slow when compared with other industry sectors, due to the range of issues and IT inconsistencies associated with the needs of its stakeholders. This study explored the challenges experienced by 108 New Zealand medical practitioners in their IT interface with other key primary and secondary health providers. We found IT interface challenges were negatively related to e-business activity (receiving) but held no effect on e-business activity (sending). Further, we tested for and found significant moderating effects of practice size, based on patient numbers. Large practices were able to buffer the negative influence of IT interface challenges on e-business activity (receiving), while small practices were severely hampered by IT interface challenges. The implications of operating in a modular industry structure are discussed.

Organizational learning in the implementation and adoption of national electronic health records: Case studies of two hospitals participating in the National Programme for Information Technology in England

Objective:

To explore the role of organizational learning in enabling implementation and supporting adoption of electronic health record systems into two English hospitals.

Methods and setting:

In the course of conducting our prospective and sociotechnical evaluation of the implementation and adoption of electronic health record into 12 “early adopter” hospitals across England, we identified two hospitals implementing virtually identical versions of the same “off-the-shelf” software (Millennium) within a comparable timeframe. We undertook a longitudinal qualitative case study–based analysis of these two hospitals (referred to hereafter as Alpha and Omega) and their implementation experiences. Data included the following: 63 in-depth interviews with various groups of internal and external stakeholders; 41-h on-site observation; and content analysis of 218 documents of various types. Analysis was both inductive and deductive, the latter being informed by the “sociotechnical changing” theoretical perspective.

Results:

Although Alpha and Omega shared a number of contextual similarities, our evaluation revealed fundamental differences in visions of electronic health record and the implementation strategy between the hospitals, which resulted in distinct local consequences of electronic health record implementation and impacted adoption. Both hospitals did not, during our evaluation, see the hoped-for benefits to the organization as a result of the introduction of electronic health record, such as speeding-up tasks. Nonetheless, the Millennium software worked out to be easier to use at Omega. Interorganizational learning was at the heart of this difference.

Conclusion:

Despite the turbulent overall national “roll out” of electronic health record systems into the English hospitals, considerable opportunities for organizational learning were offered by sequential delivery of the electronic health record software into “early adopter” hospitals. We argue that understanding the process of organizational learning and its enabling factors has the potential to support efforts at implementing national electronic health record implementation endeavors.

Impacts of structuring the electronic health record: a systematic review protocol and results of previous reviews

PURPOSE

This paper (1) presents the protocol of an on-going systematic literature review on the methods of structuring electronic health record (EHR) data and studying the impacts of implemented structures, thus laying basis for the analysis of the empirical articles (2) describes previous reviews published on the subject and retrieved during the search of bibliographic databases, and (3) presents a summary of the results of previous reviews.

METHODS

Cochrane instructions were exploited to outline the review protocol - phases and search elements. Test searches were conducted to refine the search. The abstracts and/or full texts of review papers captured by the search were read by two of the team members independently, with disagreements first negotiated between them and if necessary eventually resolved in the team meetings. Additional review articles were picked from the reference lists of the reviews included in our search results. The elements defined in the search strategy and analytic framework were converted to a data extraction tool, which was tested by extracting data from the reviews captured by the search. Descriptive analysis of the extracted data was conducted.

RESULTS

The 12-stage review protocol that we developed includes definition of the problem, the search strategy and search terms, testing the strategy, conducting the search, updating search from references found, removing duplicates, defining the inclusion and exclusion criteria, exclusion and inclusion of papers, definition of the analytic framework to extract data, extracting data and reporting results. Our searches in fifteen electronic bibliographic databases retrieved 27 reviews, of which 14 were included for full text analysis. Of these, 11 focused on medical and three on nursing record structures. The data structures included forms, ontologies, classifications and terminologies. Some evidence was found on data structure impact on information quality, process quality and efficiency, but not on patients or professionals.

CONCLUSIONS

The 12 step review protocol resulted in a variety of reviews of different ways to structure EHR data. None of them compared outcomes of different structuring methods; all had a narrower definition of the Intervention (a specific EHR structure) and Outcome (a specific impact category). Several reviews missed a clear connection between the data structures (interventions) and outcomes, indicating that the methods and applications for structuring patient data have rarely been viewed as independent variables. The review protocol should be defined in a manner that allows replication of the review. There are different ways of structuring patient data with varying impacts, which should be distinguished in further empirical studies, as well as reviews.

A Novel Graphical-Oriented Framework for Capturing Data within Clinical Information Systems

One of the main challenges in the development and implementation of computerized health care systems is the physicians and nurses’ resistance, stemming in particular from the use of text based environments for the capture of their medical examination data. The purpose of the present study was to propose the basis for a graphical oriented framework which can be used to capture data for a medical examination therefore easing the data-entry using the keyboard. Following analysis of a classical general medical examination, an XML schema was designed to describe physical examinations. Based on the physical examination XML schema, XML data structures are transformed to HTML using XML transformation style sheets to create dynamic graphical user interface (GUI) widgets; user interactions with the widgets leads to the generation of sentences. The key advantages of the proposed system are: a) a reduction in the keyboard usage, b) the ability to codify the generation sentence accurately and c) an operating system platform independence. A prototype of usage of the above framework is also presented.

Implementation of Telecytology in Georgia for Quality Assurance Programs

The field of eHealth is rapidly evolving. The new models and protocols of application of info-communication technologies for healthcare purposes are developed. Despite of obvious advantages and benefits practical application of eHealth and its possibilities in everyday practice is slow. Much progress has been made around the world in the field of digital imaging and virtual slides. But in Georgia telecytology is still in evolving stages. It revolves around static telecytology. It has been revealed, that the application of easy available and adaptable technology together with the improvement of the infrastructure conditions is the essential basis for telecytology. This is a very useful and applicable tool for consulting on difficult cases and implementation of quality assurance programs in the field of cytology. Telecytology has significantly increased knowledge exchange and thereby ensured a better medical service. The chapter aimed description of practical application of telecytology under conditions of Georgia as well as presentation of telecytology usage for implementation of quality assurance programs in the field of cytology.

[Evaluation of a new computerized recording system for preoperative assessment data]

BACKGROUND AND OBJECTIVES

Little information is available on the use of computerized systems in preanesthetic assessment. Our aim was to evaluate staff acceptance of a computerized system for the structured recording of preoperative assessment data in our hospital. The time taken to complete the assessment was compared to the time usually taken to record the information on paper.

MATERIAL AND METHODS

Observational, descriptive cross-sectional survey of user satisfaction 3 months after the system had been launched. We later carried out a prospective observational study of 796 preanesthetic assessment visits, comparing the mean time the users took to record information on paper to the time required to enter the data into the computer, analyzing differences between anesthesiologists and according to American Society of Anesthesiologists (ASA) classification and patient age.

RESULTS

A total of 401 paper records and 395 electronic files were included. The users believed that the computerized system improved quality and accessibility of recorded data and clinical decision-making. The time required to enter data into the computer was believed to be the main drawback; the users took a mean (SD) 15.21 (5.41) minutes to enter the electronic data and 13.37 (5.08) minutes to record the information on paper (P < .001). There were also significant differences in the time taken to record data according to ASA classification and between anesthesiologists (P < .001).

CONCLUSIONS

In spite of drawbacks such as extra time taken to record electronic data, the users perceived benefits, such as improved quality and accessibility of records. For this reason, the computerized system was well accepted.

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP

Objectives

The purpose of this study is to explore possibility of information sharing between the medical and nursing domains.

Methods

Narrative medical records of 281 hospitalization days of 36 gastrectomy patients were decomposed into single-meaning statements. These single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problem and medical procedures were mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and International Classification for Nursing Practice (ICNP) concepts.

Results

A total 4,717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and medical procedures, about 85.5% statements were fully mapped to SNOMED CT. The remaining statements were partially mapped. In the mapping to the ICNP concepts, 17.4% of unique statements were fully mapped, 62.8% were partially mapped, and 19.8% were not mapped. About 32.3% of 705 concepts extracted from the statements were mapped to both SNOMED CT and ICNP concepts.

Conclusions

These mapping results suggest that physicians' narrative medical records can be structured and can be used for electronic medical record system, and also it is possible for medicine and nursing to share patient care information.

Application of medical information system for telepathology--Georgian experience

INTRODUCTION

The field of healthcare informatics is rapidly evolving. The new models and protocols of medical information system (MIS) are developed. Despite obvious advantages and benefits, practical application of MIS in everyday practice is slow. Much progress has been made around the world in the field of digital imaging and virtual slides, but in Georgia telepathology is still in evolving stages. It revolves around static telepathology.

OBJECTIVE

Practical application of MIS has been started in Georgia. The architecture of the mentioned system and its usage for telepathology will be presented.

MATERIALS AND METHODS

The MIS has been created with .Net technology and structure query language (SQL) database architecture. It involves a multiuser Web-based approach. By this, local (intranet) and remote (Internet) access of the system and management of databases can be achieved. Two hundred electronic medical records illustrated by images were selected for telepathology consultations. These electronic medical records were written in Georgian. This predetermines organization of regional second opinion consultations. For security reasons all experts have been registered as users at MIS.

RESULTS

MIS has been launched in Georgia. Its primary goal is patient management. However, the system can be successfully applied for static telepathology purposes.

DISCUSSION

The ideal of healthcare in the information age must be to create a situation where healthcare professionals spend more time creating knowledge from medical information and less time managing medical information. The application of easily available and adaptable technology and improvement of the infrastructure conditions is the basis for telemedical applications. The usage of MIS holds the potential to realize telepathology in the effective and comprehensive mode.

Use of Headings and Classifications by Physicians in Medical Narratives of EHRs: An evaluation study in a Finnish hospital

OBJECTIVE

The purpose of this study was to describe and evaluate patient care documentation by hospital physicians in EHRs and especially the use of national headings and classifications in these documentations.

MATERIAL AND METHODS

The initial material consisted of a random sample of 3,481 medical narratives documented in EHRs during the period 2004-2005 in one department of a Finnish central hospital. The final material comprised a subset of 1,974 medical records with a focus on consultation requests and consultation responses by two specialist groups from 871 patients. This electronic documentation was analyzed using deductive content analyses and descriptive statistics.

RESULTS

The physicians documented patient care in EHRs principally as narrative text. The medical narratives recorded by specialists were structured with headings in less than half of the patient cases. Consultation responses in general were more often structured with headings than consultation requests. The use of classifications was otherwise insignificant, but diagnoses were documented as ICD 10 codes in over 50% of consultation responses by both medical specialties.

CONCLUSION

There is an obvious need to improve the structuring of narrative text with national headings and classifications. According to the findings of this study, reason for care, patient history, health status, follow-up care plan and diagnosis are meaningful headings in physicians' documentation. The existing list of headings needs to be analyzed within a consistent unified terminology system as a basis for further development. Adhering to headings and classifications in EHR documentation enables patient data to be shared and aggregated. The secondary use of data is expected to improve care management and quality of care.

A study on agent-based secure scheme for electronic medical record system

Patient records, including doctors' diagnoses of diseases, trace of treatments and patients' conditions, nursing actions, and examination results from allied health profession departments, are the most important medical records of patients in medical systems. With patient records, medical staff can instantly understand the entire medical information of a patient so that, according to the patient's conditions, more accurate diagnoses and more appropriate in-depth treatments can be provided. Nevertheless, in such a modern society with booming information technologies, traditional paper-based patient records have faced a lot of problems, such as lack of uniform formats, low data mobility, slow data transfer, illegible handwritings, enormous and insufficient storage space, difficulty of conservation, being easily damaged, and low transferability. To improve such drawbacks, reduce medical costs, and advance medical quality, paper-based patient records are modified into electronic medical records and reformed into electronic patient records. However, since electronic patient records used in various hospitals are diverse and different, in consideration of cost, it is rather difficult to establish a compatible and complete integrated electronic patient records system to unify patient records from heterogeneous systems in hospitals. Moreover, as the booming of the Internet, it is no longer necessary to build an integrated system. Instead, doctors can instantly look up patients' complete information through the Internet access to electronic patient records as well as avoid the above difficulties. Nonetheless, the major problem of accessing to electronic patient records cross-hospital systems exists in the security of transmitting and accessing to the records in case of unauthorized medical personnels intercepting or stealing the information. This study applies the Mobile Agent scheme to cope with the problem. Since a Mobile Agent is a program, which can move among hosts and automatically disperse arithmetic processes, and moves from one host to another in heterogeneous network systems with the characteristics of autonomy and mobility, decreasing network traffic, reducing transfer lag, encapsulating protocol, availability on heterogeneous platforms, fault-tolerance, high flexibility, and personalization. However, since a Mobile Agent contacts and exchanges information with other hosts or agents on the Internet for rapid exchange and access to medical information, the security is threatened. In order to solve the problem, this study proposes a key management scheme based on Lagrange interpolation formulas and hierarchical management structure to make Mobile Agents a more secure and efficient access control scheme for electronic patient record systems when applied to the access of patients' personal electronic patient records cross hospitals. Meanwhile, with the comparison of security and efficacy analyses being the feasibility of validation scheme and the basis of better efficiency, the security of Mobile Agents in the process of operation can be guaranteed, key management efficacy can be advanced, and the security of the Mobile Agent system can be protected.

Nurses' perception of the use of computerised information systems in practice: questionnaire development

AIM

To develop and validate a questionnaire to explore the perceptions of nurses about the implementation of a computerised information system in clinical practice.

BACKGROUND

A growing interest in understanding nurses' experience of developing and implementing clinically relevant Information Technology systems and the lack of measurement tools in this area, justifies further research into the development of instruments to provide an insight into nurses' experience.

DESIGN

Survey and questionnaire development.

METHOD

An initial draft of the questionnaire was developed based on the literature and expert opinion. The questionnaire was piloted by ten nurses to check face validity, reliability and test-retest reliability. A revised version of the questionnaire was distributed to nurses working in the in-patient area of a university hospital in Spain (n = 227). Principal components analysis with oblique rotation was carried out to test theoretically developed underlying dimensions and to test construct validity. Cronbach's alpha coefficient was used to determine internal consistency.

RESULTS

Cronbach's alpha for all the items included in the different scales was 0.88 in the pilot questionnaire and test-retest reliability was adequate. Principal components analysis of items related to mechanisms produced a three-component structure ('IT support', 'usability' and 'information characteristics'). The three factors explained 48.6% of the total variance and Cronbach's alpha ranged from 0.66-0.79. Principal components analysis of items related to outcomes produced a three factor solution ('impact on patient care', 'impact on communication' and 'image profile'). The factors explained 65.9% of the total variance and Cronbach's alpha ranged from 0.64-0.85.

CONCLUSION

The study provides a detailed description and justification of an instrument development process. The instrument is valid and reliable for the setting where it has been used.

RELEVANCE TO CLINICAL PRACTICE

The instrument could provide insight into nurses' experience of IT implementation that will guide further development of systems to enhance clinical practice.

e-Business connections in the health sector: IT challenges and the effects of practice size

The use of information technology (IT) in the health sector is critically important for enhanced patient care and ultimately cost savings. However, the uptake of IT in health has been slow when compared with other industry sectors, due to the range of issues and IT inconsistencies associated with the needs of its stakeholders. This study explored the challenges experienced by 108 New Zealand medical practitioners in their IT interface with other key primary and secondary health providers. We found IT interface challenges were negatively related to e-business activity (receiving) but held no effect on e-business activity (sending). Further, we tested for and found significant moderating effects of practice size, based on patient numbers. Large practices were able to buffer the negative influence of IT interface challenges on e-business activity (receiving), while small practices were severely hampered by IT interface challenges. The implications of operating in a modular industry structure are discussed.

Development of electronic software for the management of trauma patients on the orthopaedic unit

INTRODUCTION

Continuity of patient care is an essential prerequisite for the successful running of a trauma surgery service. This is becoming increasingly difficult because of the new working arrangements of junior doctors. Handover is now central to ensure continuity of care following shift change over. The purpose of this study was to compare the quality of information handed over using the traditional ad hoc method of a handover sheet versus a web-based electronic software programme. It was hoped that through improved quality of handover the new system would have a positive impact on clinical care, risk and time management.

METHODS

Data was prospectively collected and analyzed using the SPSS 14 statistical package. The handover data of 350 patients using a paper-based system was compared to the data of 357 cases using the web-based system. Key data included basic demographic data, responsible surgeon, location of patient, injury site including site, whether fractures were open or closed, concomitant injuries and the treatment plan. A survey was conducted amongst health care providers to assess the impact of the new software.

RESULTS

With the introduction of the electronic handover system, patients with missing demographic data reduced from 35.1% to 0.8% (p<0.0001) and missing patient location from 18.6% to 3.6% (p<0.0001). Missing consultant information and missing diagnosis dropped from 12.9% to 2.0% (p<0.0001) and from 11.7% to 0.8% (p<0.0001), respectively. The missing information regarding side and anatomical site of the injury was reduced from 31.4% to 0.8% (p<0.0001) and from 13.7% to 1.1% (p<0.0001), respectively. In 96.6% of paper ad hoc handovers it was not stated whether the injury was 'closed' or 'open', whereas in the electronic group this information was evident in all 357 patients (p<0.0001). A treatment plan was included only in 52.3% of paper handovers compared to 94.7% (p<0.0001) of electronic handovers. A survey revealed 96% of members of the trauma team felt an improvement of handover since the introduction of the software, and 94% of members were satisfied with the software.

CONCLUSIONS

The findings of our study show that the use of web-based electronic software is effective in facilitating and improving the quality of information passed during handover. Structured software also aids in improving work flow amongst the trauma team. We argue that an improvement in the quality of handover is an improvement in clinical practice.

Factors affecting cross-hospital exchange of Electronic Medical Records

Adopting Electronic Medical Record (EMR) exchange may save patients’ lives and also improve their health. Most Electronic Data Interchange studies have considered commercial enterprises and necessary funding to support business activities, EMR exchange focuses on saving patients’ lives. Our study combined transaction cost and sociological perspectives to identify factors that affect a hospitals’ willingness to implement EMR exchange. A survey was conducted with regional hospitals and medical centers in Taiwan to justify the validity of a resulting model. Our findings indicated that the model was valuable and determined which factors influenced the decision to implement EMR exchange at these hospitals (perceived benefits, uncertainty, influence, and reciprocal investments). Based on these findings, healthcare policy makers can promote EMR exchange and hospitals can identify desirable partners that will form a strategic alliance to meet the dynamic challenges in the healthcare industry.

The organizing vision of integrated health information systems

The notion of `integration' in the context of health information systems is ill-defined yet in widespread use. We identify a variety of meanings ranging from the purely technical integration of information systems to the integration of services. This ambiguity (or interpretive flexibility), we argue, is inherent rather than accidental: it is a necessary prerequisite for mobilizing political and ideological support among stakeholders for integrated health information systems. Building on this, our aim is to trace out the career dynamics of the vision of `integration/ integrated'. The career dynamics is the transformation of both the imaginary and the material (technological) realizations of the unfolding implementation of the vision of integrated care. Empirically we draw on a large, ongoing project at the University Hospital of North Norway (UNN) to establish an integrated health information system.

X-PAT: a multiplatform patient referral data management system for small healthcare institution requirements

We present X-PAT, a platform-independent software prototype that is able to manage patient referral multimedia data in an intranet network scenario according to the specific control procedures of a healthcare institution. It is a self-developed storage framework based on a file system, implemented in eXtensible Markup Language (XML) and PHP Hypertext Preprocessor Language, and addressed to the requirements of limited-dimension healthcare entities (small hospitals, private medical centers, outpatient clinics, and laboratories). In X-PAT, healthcare data descriptions, stored in a novel Referral Base Management System (RBMS) according to Health Level 7 Clinical Document Architecture Release 2 (CDA R2) standard, can be easily applied to the specific data and organizational procedures of a particular healthcare working environment thanks also to the use of standard clinical terminology. Managed data, centralized on a server, are structured in the RBMS schema using a flexible patient record and CDA healthcare referral document structures based on XML technology. A novel search engine allows defining and performing queries on stored data, whose rapid execution is ensured by expandable RBMS indexing structures. Healthcare personnel can interface the X-PAT system, according to applied state-of-the-art privacy and security measures, through friendly and intuitive Web pages that facilitate user acceptance.

Positive effects of electronic patient records on three clinical activities

PURPOSE

To investigate the effects of a fully functional electronic patient record (EPR) system on clinicians' work during team conferences, ward rounds, and nursing handovers.

METHOD

In collaboration with clinicians an EPR system was configured for a stroke unit and in trial use for 5 days, 24h a day. During the trial period the EPR system was used by all clinicians at the stroke unit and it replaced all paper records. The EPR system simulated a fully integrated clinical-process EPR where the clinicians experienced the system as if all transactions were IT supported. Such systems are not to be expected to be in operational use in Denmark until at least 2 years from now. The EPR system was evaluated with respect to its effects on clinicians' mental workload, overview, and need for exchanging information. Effects were measured by comparing the use of electronic records with the use of paper records prior to the trial period. The data comprise measurements from 11 team conferences, 7 ward rounds, and 10 nursing handovers.

RESULTS

During team conferences the clinicians experienced a reduction on five of six subscales of mental workload, and the physicians experienced an overall reduction in mental workload. The physician in charge also experienced increased clarity about the importance of and responsibilities for work tasks, and reduced mental workload during ward rounds. During nursing handovers the nurses experienced fewer missing pieces of information and fewer messages to pass on after the handover. Further, the status of the nursing plans for each patient was clearer for all nurses at the nursing handovers except the nurse team leader, who experienced less clarity about the status of the plans.

CONCLUSION

The clinicians experienced positive effects of electronic records over paper records for the three clinical activities involved in the evaluation. This is important in its own right and likely to affect clinicians' acceptance of EPR systems, their command of their work, and consequently the attainment of 'downstream' effects on patient outcomes.

Formative evaluation: a critical component in EHR implementation

This Viewpoint paper has grown out of a presentation at the American College of Medical Informatics 2007 Winter Symposium, the resulting discussion, and several activities that have coalesced around an issue that most informaticians accept as true but is not commonly considered during the implementation of Electronic Health Records (EHR) outside of academia or research institutions. Successful EHR implementation is facilitated and sometimes determined by formative evaluation, usually focusing on process rather than outcomes. With greater federal funding for the implementation of electronic health record systems in health care organizations unfamiliar with research protocols, the need for formative evaluation assistance is growing. Such assistance, in the form of tools and protocols necessary to do formative evaluation and resulting in successful EHR implementations, should be provided by practicing medical informaticians.

Randomized controlled trial of an automated problem list with improved sensitivity

PURPOSE

To improve the completeness and timeliness of an electronic problem list, we have developed a system using Natural Language Processing (NLP) to automatically extract potential medical problems from clinical, free-text documents; these problems are then proposed for inclusion in an electronic problem list management application.

METHODS

A prospective randomized controlled evaluation of the Automatic Problem List (APL) system in an intensive care unit and in a cardiovascular surgery unit is reported here. A total of 247 patients were enrolled: 76 in an initial control phase and 171 in the randomized controlled trial that followed. During this latter phase, patients were randomly assigned to a control or an intervention group. All patients had their documents analyzed by the system, but the medical problems discovered were only proposed in the problem list for intervention patients. We measured the sensitivity, specificity, positive and negative predictive values, likelihood ratios and the timeliness of the problem lists.

RESULTS

Our system significantly increased the sensitivity of the problem lists in the intensive care unit, from about 9% to 41%, and even 77% if problems automatically proposed but not acknowledged by users were also considered. Timeliness of addition of problems to the list was greatly improved, with a time between a problem's first mention in a clinical document and its addition to the problem list reduced from about 6 days to less than 2 days. No significant effect was observed in the cardiovascular surgery unit.

Problem-oriented patient record model as a conceptual foundation for a multi-professional electronic patient record

OBJECTIVE

It is widely accepted that the development of electronic patient records, or even of a common electronic patient record, is one possible way to improve cooperation and data communication between nurses and physicians. Yet, little has been done so far to develop a common conceptual model for both medical and nursing patient records, which is a first challenge that should be met to set up a common electronic patient record. In this paper, we describe a problem-oriented conceptual model and we show how it may suit both nursing and medical perspectives in a hospital setting.

METHODS

We started from existing nursing theory and from an initial model previously set up for primary care. In a hospital pilot site, a multi-disciplinary team refined this model using one large and complex clinical case (retrospective study) and nine ongoing cases (prospective study). An internal validation was performed through hospital-wide multi-professional interviews and through discussions around a graphical user interface prototype. To assess the consistency of the model, a computer engineer specified it. Finally, a Belgian expert working group performed an external assessment of the model.

RESULTS

As a basis for a common patient record we propose a simple problem-oriented conceptual model with two levels of meta-information. The model is mapped with current nursing theories and it includes the following concepts: "health care element", "health approach", "health agent", "contact", "subcontact" and "service". These concepts, their interrelationships and some practical rules for using the model are illustrated in this paper. Our results are compatible with ongoing standardization work at the Belgian and European levels.

CONCLUSIONS

Our conceptual model is potentially a foundation for a multi-professional electronic patient record that is problem-oriented and therefore patient-centred.

An electronic health record based on structured narrative

OBJECTIVE

To develop an electronic health record that facilitates rapid capture of detailed narrative observations from clinicians, with partial structuring of narrative information for integration and reuse.

DESIGN

We propose a design in which unstructured text and coded data are fused into a single model called structured narrative. Each major clinical event (e.g., encounter or procedure) is represented as a document that is marked up to identify gross structure (sections, fields, paragraphs, lists) as well as fine structure within sentences (concepts, modifiers, relationships). Marked up items are associated with standardized codes that enable linkage to other events, as well as efficient reuse of information, which can speed up data entry by clinicians. Natural language processing is used to identify fine structure, which can reduce the need for form-based entry.

VALIDATION

The model is validated through an example of use by a clinician, with discussion of relevant aspects of the user interface, data structures and processing rules.

DISCUSSION

The proposed model represents all patient information as documents with standardized gross structure (templates). Clinicians enter their data as free text, which is coded by natural language processing in real time making it immediately usable for other computation, such as alerts or critiques. In addition, the narrative data annotates and augments structured data with temporal relations, severity and degree modifiers, causal connections, clinical explanations and rationale.

CONCLUSION

Structured narrative has potential to facilitate capture of data directly from clinicians by allowing freedom of expression, giving immediate feedback, supporting reuse of clinical information and structuring data for subsequent processing, such as quality assurance and clinical research.

Review: evaluating information systems in nursing

AIMS

To review existing nursing research on inpatient hospitals' information technology (IT) systems in order to explore new approaches for evaluation research on nursing informatics to guide further design and implementation of effective IT systems.

BACKGROUND

There has been an increase in the use of IT and information systems in nursing in recent years. However, there has been little evaluation of these systems and little guidance on how they might be evaluated.

METHODS

A literature review was conducted between 1995 and 2005 inclusive using CINAHL and Medline and the search terms 'nursing information systems', 'clinical information systems', 'hospital information systems', 'documentation', 'nursing records', 'charting'.

RESULTS

Research in nursing information systems was analysed and some deficiencies and contradictory results were identified which impede a comprehensive understanding of effective implementation. There is a need for IT systems to be understood from a wider perspective that includes aspects related to the context where they are implemented.

CONCLUSIONS

Social and organizational aspects need to be considered in evaluation studies and realistic evaluation can provide a framework for the evaluation of information systems in nursing.

RELEVANCE TO CLINICAL PRACTICE

The rapid introduction of IT systems for clinical practice urges evaluation of already implemented systems examining how and in what circumstances they work to guide effective further development and implementation of IT systems to enhance clinical practice. Evaluation involves more factors than just involving technologies such as changing attitudes, cultures and healthcare practices. Realistic evaluation could provide configurations of context-mechanism-outcomes that explain the underlying relationships to understand why and how a programme or intervention works.

Factors affecting the adoption of electronic signature: Executives' perspective of hospital information department

The healthcare industry is experiencing a major transformation towards e-healthcare, which delivers and enhances related information through the Internet among healthcare stakeholders and makes the electronic signature (e-signature) more and more important. This paper uses a mature framework, Technology-Organization-Environment (TEO), in information system discipline to identify factors that affect hospitals in adopting e-signature. A survey was conducted on regional hospitals and medical centers in Taiwan to verify the validity of the research framework. The results show that TEO framework is useful in distinguishing hospitals as adopters and non-adopters of e-signature. Based on the research findings, implications and limitations are discussed.

Variety in mental health research data: when does more become too much?

BACKGROUND

Institutes for mental health care consider scientific research an important activity. A good way to stimulate research is by simplifying data collection. Creating a minimal data set for research purposes would be one way to achieve this, however, this would only be possible if the researchers use a limited variety of data types. This article will address the question whether or not this is the case.

METHODS

Researchers working in Dutch mental health institutes were approached and asked to complete an internet questionnaire on the individual variables they collected for, and measurement instruments used in, their studies.

RESULTS

In the 92 studies described by the researchers, 124 different variables were collected, and 223 different instruments were used. A total of 66% of the variables and 73% of the instruments were only used in one study.

CONCLUSION

There is little commonality among research data, hence flexibility will be a crucial factor in facilitating data collection for research in mental health institutes. Nevertheless, reducing the variety of variables and instruments used is important to increase the comparability of results.

An integrated approach to breast diseases and breast cancer registry and research: BDRS as a web-based multi-institutional model

Accurate, complete, and timely health data sources are essential for progress in health care. Registry and research systems are foundations for conducting clinical and epidemiological research. Developing countries lack these systems due to the scarcity of the resources allocated for health information systems. In this study, we provide an integrated model for Turkey in order to optimize the utilization of resources. The Breast Diseases Registry system (BDRS) is implemented as an integrated disease-specific system for breast diseases in order to obtain a comprehensive use of patient health data for research and Breast Cancer Registry as well as an ancillary clinical tool.

Computerized extraction of information on the quality of diabetes care from free text in electronic patient records of general practitioners

OBJECTIVE

This study evaluated a computerized method for extracting numeric clinical measurements related to diabetes care from free text in electronic patient records (EPR) of general practitioners.

DESIGN AND MEASUREMENTS

Accuracy of this number-oriented approach was compared to manual chart abstraction. Audits measured performance in clinical practice for two commonly used electronic record systems.

RESULTS

Numeric measurements embedded within free text of the EPRs constituted 80% of relevant measurements. For 11 of 13 clinical measurements, the study extraction method was 94%-100% sensitive with a positive predictive value (PPV) of 85%-100%. Post-processing increased sensitivity several points and improved PPV to 100%. Application in clinical practice involved processing times averaging 7.8 minutes per 100 patients to extract all relevant data.

CONCLUSION

The study method converted numeric clinical information to structured data with high accuracy, and enabled research and quality of care assessments for practices lacking structured data entry.

Integrating incident reporting into an electronic patient record system

Developments in information technology offer new opportunities to design electronic patient record systems (EPR) which integrate a broad range of functions such as clinical decision support, order entry, or electronic alerts. It has been recently suggested that EPR could support new applications for disease surveillance and patient safety. We describe the integration of a voluntary incident reporting system into an EPR used in operating theatres, to allow the reporting of accidents and preventable complications. We assessed system's reliability and users' acceptance. During the 4-years observation period (2002-2006), 48,983 interventional procedures were performed. Clinicians documented 85.1% of procedures on the incident reporting form. Agreement between chart review and electronically reported incidents was 80.6%. The integration of an incident reporting system into an EPR is reliable and well supported by health care professionals.

Structured data entry for narrative data in a broad specialty: patient history and physical examination in pediatrics

Background

Whereas an electronic medical record (EMR) system can partly address the limitations, of paper-based documentation, such as fragmentation of patient data, physical paper records missing and poor legibility, structured data entry (SDE, i.e. data entry based on selection of predefined medical concepts) is essential for uniformity of data, easier reporting, decision support, quality assessment, and patient-oriented clinical research. The aim of this project was to explore whether a previously developed generic (i.e. content independent) SDE application to support the structured documentation of narrative data (called OpenSDE) can be used to model data obtained at history taking and physical examination of a broad specialty.

Methods

OpenSDE was customized for the broad domain of general pediatrics: medical concepts and its descriptors from history taking and physical examination were modeled into a tree structure.

Results

An EMR system allowing structured recording (OpenSDE) of pediatric narrative data was developed. Patient history is described by 20 main concepts and physical examination by 11. In total, the thesaurus consists of about 1800 items, used in 8648 nodes in the tree with a maximum depth of 9 levels. Patient history contained 6312 nodes, and physical examination 2336. User-defined entry forms can be composed according to individual needs, without affecting the underlying data representation. The content of the tree can be adjusted easily and sharing records among different disciplines is possible. Data that are relevant in more than one context can be accessed from multiple branches of the tree without duplication or ambiguity of data entry via "shortcuts".

Conclusion

An expandable EMR system with structured data entry (OpenSDE) for pediatrics was developed, allowing structured documentation of patient history and physical examination. For further evaluation in other environments, the tree structure for general pediatrics is available at the Erasmus MC Web site (in Dutch, translation into English in progress) [1]. The generic OpenSDE application is available at the OpenSDE Web site [2].

Why are structured data different? Relating differences in data representation to the rationale of OpenSDE

OpenSDE is an application that supports clinicians with structured recording of narrative patient data to enable use of data in both clinical practice and research. OpenSDE is based on a rationale and requirements for structured data entry. In this study, we analyse the impact of the rationale and the requirements on data representation using OpenSDE. Three paediatricians transcribed 20 paper patient records using OpenSDE. The transcribed records were compared; the findings that were the same in content but differed in representation (e.g. recorded as free text instead of in a structured manner) were categorized in one of three categories of difference in representation. The transcribed records contained 1764 findings in total. The medical content of 302 of these findings was represented differently by at least one clinician and was thus included in this study. In OpenSDE, clinicians are free to determine the degree of detail at which patient data are described. This flexibility accounts for 87% of the differences in data representation. Thirteen per cent of the differences are due to clinicians interpreting and translating phrases from the source text and transcribing these to (different) concepts in OpenSDE. The differences in data representation largely result from initial design decisions for OpenSDE.

User interpretations of future information system use: a snapshot with technological frames

Integrated information systems for managing patient data transform the nature of hospital work to the extent that the work practices, the responsibilities, even the professional identities are likely to undergo major changes. Therefore, during the organizational implementation of the IS, attention should be paid to the future users and how they understand and see what is going on. Here the focus is on these interpretation processes, analyzed as technological frames. That is, people develop different assumptions, expectations and knowledge concerning new technology. During this sense-making process they build their idea of that technology, its technological frame. We analyzed the pre-implementation frames that could be discerned in 24 interviews of hospital personnel. Main influences on the frames in this case were the work role in the organization, knowledge about the new system, and attitudes toward the old systems. The social context appeared to have a significant influence in the users' interpretation processes and the frames seemed to be congruent within one group. So far, the incongruence between groups appeared to have caused no major problems for the implementation.

A secure web-based approach for accessing transitional health information for people with traumatic brain injury

A web-based transitional health record was created to provide regional healthcare professionals with ubiquitous access to information on people with brain injuries as they move through the healthcare system. Participants included public, private, and community healthcare organizations/providers in Eastern Ontario (Canada). One hundred and nineteen service providers and 39 brain injury survivors registered over 6 months. Fifty-eight percent received English and 42% received bilingual services (English-French). Public health providers contacted the regional service coordinator more than private providers (52% urban centres, 26% rural service providers, and 22% both areas). Thirty-five percent of contacts were for technical difficulties, 32% registration inquiries, 21% forms and processes, 6% resources, and 6% education. Seventeen technical enquiries required action by technical support personnel: 41% digital certificates, 29% web forms, and 12% log-in. This web-based approach to clinical information sharing provided access to relevant data as clients moved through or re-entered the health system. Improvements include automated digital certificate management, institutional health records system integration, and more referral tracking tools. More sensitive test data could be accessed on-line with increasing consumer/clinician confidence. In addition to a strong technical infrastructure, human resource issues are a major information security component and require continuing attention to ensure a viable on-line information environment.

Flexible information storage in MUDRII EHR

An important research task of the EuroMISE Centre is the applied research in the field of electronic health record (EHR) design including electronic medical guidelines and intelligent systems for data mining and decision support. The research in this field was inspired by several European projects. We have proposed a mathematical meta-description of a flexible information storage model based on the experience gathered in cooperation in those projects. In this model, we use two basic structures called a knowledge base and data files. We describe those two structures using the graph theory concepts. Furthermore, we use logical formulas to express conditions that should be valid. Additionally, we present a description of a global system architecture of a 3-tier EHR application with interfaces based on the latest technologies; predominately on Web Services, SOAP, XML, HTTP, CORBA, etc. According to our experience and test results gained from the MUDR EHR usage, we describe an open universal solution, which can be applied as the EHR kernel of hospital information systems. To realize this approach in a daily practice for health professionals we have started a co-operative project with clinical information systems developers. Within that project we are developing a new system for continual shared health care.

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.