Computerization of the Patient History -Patient Answers Compared with Medical Records

Computerized medical history taking, in which patients answer questions by using a terminal, is compared with the written medical record for a group of 99 patients in internal medicine. Patient complaints were analysed with respect to their frequency of occurrence for all important tracts, such as the respiratory, the gastro-intestinal and the uro-genital tracts. About 36% of over 3,200 patient answers were identical in the patient record and the written record, but a considerable percentage of complaints (56%), that were present in the patient record, were missing in the written record; the reverse was true for 4.5%. A computerized patient record appears to contain more extensive information about patient complaints, still to be interpreted by the experienced physician.

Automatic Coding of Diagnostic Reports

A method is presented for assigning classification codes to pathology reports by searching similar reports from an archive collection. The key for searching is textual similarity, which estimates the true, semantic similarity. This method does not require explicit modeling, and can be applied to any language or any application domain that uses natural language reporting. A number of simulation experiments was run to assess the accuracy of the method and to indicate the role of size of the archive and the transfer of document collections across laboratories. In at least 63% of the simulation trials, the most similar archive text offered a suitable classification on organ, origin and diagnosis. In 85 to 90% ofthe trials, the archive's best solution was found within the first five similar reports. The results indicate that the method is suitable for its purpose: suggesting potentially correct classifications to the reporting diagnostician.

Recommendations for Medical Informatics Training in The Netherlands

In this contribution recommendations for education and training in Medical Informatics as they have been formulated end 1987 by the Subcommittee Medical Informatics of the Royal Netherlands Academy of Arts and Sciences are described. The current situation of education and training is presented and compared with the recommendations. It is concluded that not all recommendations have yet been followed up.

Quality of Health Care: Informatics Foundations

Objective: To discuss in what ways computer systems can contribute to the quality of healthcare and on which principles of informatics successful systems are based.

Methods: Part of the information was obtained via a literature search and part is based on the knowledge of the authors.

Results: The results of the literature search are reported. The answers to the questions whether decision support is useful and which factors determine its success, the foundations of computerized guidelines systems and applications of physician order entry and medical risk management are presented. Conclusions: Despite many publications concerning diagnostic support systems their use in clinical practice is limited. Reminder systems do appear to have an impact on health outcomes. Standards for guideline models are being developed for effective sharing of guidelines across systems. Electronic patient records and physician order entry systems are useful aids in medical risk management.

Evaluation of a Method that Supports Pathology Report Coding

Objectives: The paper focuses on the problem of adequately coding pathology reports using SNOMED. Both the agreement between pathologists in coding and the quality of a system that supports pathologists in coding pathology reports were evaluated.

Methods: Six sets of three pathologists each received a different set of 40 pathology reports. Five different SNOMED code lines accompanied each pathology report. Three pathologists evaluated the correctness of each of these code lines. Kappa values and values for the reliability coefficients were determined to gain insight in the variance observed when coding pathology reports. The system that is evaluated compares a newly entered report, represented as a multi-dimensional word vector, with reports in a library, represented in the same way. The reports in the library are already coded. The system presents the code lines belonging to the five library reports most similar to the newly entered one to the pathologist in this way supporting the pathologist in determining the correct codes. A high similarity between two reports is indicated by a large value of the inproduct of the vector of the newly entered report and the vector of a report in the library.

Results: Agreement between pathologists in coding was fair (average kappa of 0.44). The reliability coefficient varied from 0.81 to 0.89 for the six sets of pathology reports. The system gave correct suggestions in 50% of the reports. In another 30% it was helpful for the pathologists.

Conclusions: On the basis of the level of the reliability coefficients it could be concluded that three pathologists are indeed sufficient for obtaining a gold standard for evaluating the system. The method used for comparing reports is not strong enough to allow fully automatic coding. It could be shown that the system induces a more uniform coding by pathologists. An evaluation of the incorrect suggestions of the system indicates that the performance of the system can still be improved.

Two Patient Care Information Systems in the Same Hospital: Beyond Technical Aspects

Objectives: To compare two clinical workstations in one hospital with respect to technical, organizational, cultural and human factors. One clinical workstation was a GUI to the HIS. The other was an electronic patient record for stroke.

Methods: Data were collected by means of in-depth interviews with end-users of both clinical workstations. The interviews were audio taped and transcribed for analysis.

Results: End users assessed both clinical workstations as user friendly. Coordination between health care workers was perceived to be enhanced. However, in both situations poor communication between management, implementers and users resulted in uncertainty and skepticism about future perspectives. Furthermore, it appeared that inpatient and outpatient settings needed clinical workstations with different requirements for an optimal fit between work practices and information system.

Conclusions: Regardless of the domain and content of a workstation, it can support coordination between disciplines. The communication concerning the information technology strategy deserves much attention. Finally, the requirements for inpatient and outpatient workstations differ.

A Rational Request Behavior: The Development of Prediction Instruments regarding Thyroid Function Tests in Primary Care

A prospective study was performed to encourage a rational thyroid-stimulating hormone (TSH) test request behavior of physicians, using prediction instruments. The latter give direct feedback about request adequacy on the basis of pretest probabilities of hyperthyroidism using patients’ signs and symptoms. For instrument design, stepwise logistic regression was used on diagnostic data acquired through questionnaires, answered by 80 physicians and 668 patients for whom physicians requested a TSH test. Instruments were designed for clinical and subclinical hyperthyroidism and for clinical hyperthyroidism alone. Use of the instrument for clinical or subclinical hyperthyroidism on the selected group, at a 5% probability threshold, can result in a 37% reduction of unnecessary TSH test requests. With the instrument for clinical hyperthyroidism at a 5% probability threshold, the number of unnecessary test requests can be reduced by 57%. Therefore, it can be concluded that the instruments can determine TSH test request adequacy and encourage a rational TSH test request behavior of physicians at low pretest probability thresholds.

Modeling in Biomedical Informatics – An Exploratory Analysis (Part 1)

Objectives: Modeling is a significant part of research, education and practice in biomedical and health informatics. Our objective was to explore, which types of models of processes are used in current biomedical/ health informatics research, as reflected in publications of scientific journals in this field. Also the implications for medical informatics curricula were investigated.

Methods: Retrospective, prolective observational study on recent publications of the two official journals of the International Medical Informatics Association (IMIA), the International Journal of Medical Informatics (IJMI) and Methods of Information in Medicine (MIM).

Results: 384 publications have been analyzed, 190 of IJMI and 194 of MIM. In regular papers (69 in IJMI, 62 in MIM), analyzed here in part 1, all of these model types could be found. In many publications we observed a mixture of models, being used to solve the ‘core’ research questions and also to systematically evaluate the research done. Knowledge of (and models for) software engineering and project management are also often needed. IJMI seems to have a closer focus on research concerning health information systems and electronic patient records, with a strong emphasis on evaluation. MIM seems to have a broader range of research approaches, including also statistical modeling and computational intensive approaches. The aim to provide solutions for problems related to data, information and knowledge processing and to study the general principles of processing data, information and knowledge in medicine and health care in order to contribute to improve the quality of health care, and of research and education in medicine and the health sciences was given in all publications.

Conclusions: Modeling continues to be a major task in research, education and practice in biomedical and health informatics. Knowledge and skills concerning a broad range of model types is needed.

Medical Informatics as a Discipline at the Beginning of the 21st Century

Objectives: To analyse the present situation of the discipline medical informatics and to propose actions for change.

Methods: Evaluation of the current situation mainly based on anecdotal evidence.

Results: The difference between the scientific and the engineering aspects of medical informatics get blurred. Because of the requirements of European funding medical informatics focuses more on engineering than on science. Too many manuscripts are submitted that describe engineered artefacts without a scientific purpose. Some of the subjects (like security issues) that are studied in medical informatics are not considered important by medical faculties thus impeding support.

Conclusions: The methodological underpinnings of our research should be strengthened, impact studies should be more frequently performed; the quality of results reporting should be increased.

Medical Informatics and Problem-based Learning

Problem-based learning (PBL) is an educational method that can be considered as an alternative to the traditional, discipline-based, approach to teaching. In this paper the characteristics of both approaches are discussed and compared. Some background knowledge concerning the principles that determine the success of instructional methods is presented. Finally, it is discussed how medical informatics can be taught in a PBL environment.

A Generic Model of Clinical Practice

Objectives: Many shared-care projects feel the need for electronic patient-record (EPR) systems. In absence of practical experiences from paper record keeping, a theoretical model is the only reference for the design of these systems. In this article, we review existing models of individual clinical practice and integrate their useful elements. We then present a generic model of clinical practice that is applicable to both individual and collaborative clinical practice.

Methods: We followed the principles of the conversation-for-action theory and the DEMO method. According to these principles, information can only be generated by a conversation between two actors. An actor is a role that can be played by one or more human subjects, so the model does not distinguish between inter-individual and intra-individual conversations.

Results: Clinical practice has been divided into four actors: service provider, problem solver, coordinator, and worker. Each actor represents a level of clinical responsibility. Any information in the patient record is the result of a conversation between two of these actors. Connecting different conversations to one another can create a process view with meta-information about the rationale of clinical practice. Such process view can be implemented as an extension to the EPR.

Conclusions: The model has the potential to cover all professional activities, but needs to be further validated. The model can serve as a theoretical basis for the design of EPR-systems for shared care, but a successful EPR-system needs more than just a theoretical model.

On Exemplary Scientific Conduct Regarding Submission of Manuscripts to Biomedical Informatics Journals

As the Editors of leading international biomedical informatics journals, the authors report on a recent pattern of improper manuscript submissions to journals in our field. As a guide for future authors, we describe ethical and pragmatic issues related to submitting work for peer-reviewed journal publication. We propose a coordinated approach to the problem that our respective journals will follow. This Editorial is being jointly published in the following journals represented by the authors: Computer Methods and Programs in Biomedicine, International Journal of Medical Informatics, Journal of Biomedical Informatics, Journal of the American Medical Informatics Association, and Methods of Information in Medicine.

An Approach to Knowledge Base Construction Based on Expert Opinions

Objectives: To describe, validate and demonstrate an approach for knowledge base construction based on expert opinions.

Methods: A knowledge base containing the frequency of occurrence of manifestations in epileptic seizures is constructed based on information provided by neurologists/epileptologists. The reliability of the responses is determined with the inter-rater intraclass correlation coefficient (ICC). If the ICC is not large enough the Spearman-Brown prophecy formula can be used to predict the number of additional experts. We propose a method to assess whether an additional expert provides information consistent with the already acquired data as well as a method to detect experts with deviating opinions. The power of the first method was determined.

Results: Data were collected for five seizure types. The ICCs determined from the responses for the various seizure types after inclusion of the additional experts was in all cases almost equal to 0.9, the target value. Yet one expert with diverging opinions concerning the frequency of occurrence of manifestations for different seizure types could be identified. Excluding this participant improved the reliability of the data. The power of the methods was good (≥ 0.75).

Conclusions: It is shown that human experts can provide reliable information about the frequency of occurrence of manifestations in epileptic seizures. In addition, the described approach correctly identified neurologists/epileptologists with both consistent and diverging opinions about the frequency of occurrence of manifestations in a number of seizure types.

Appropriateness of ICD-coded Diagnostic Inpatient Hospital Discharge Data for Medical Practice Assessment

Objectives: We performed a systematic review to investigate the quality of diagnostic hospital discharge data (DHDD) in order to gain insight in the usefulness of these data for medical practice assessment. We investigated the methods used to evaluate data quality, factors that determine data quality and its consequences for medical practice assessment.

Methods: We selected studies in which both completeness (or sensitivity: SENS) and correctness (or positive predictive value: PPV) were measured. We used the random-effects model to calculate mean SENS and PPV and to explore the effect of a number of covariates.

Results: The 101 included studies were very heterogeneous. We distinguished six typical study designs. We found a mean SENS of 0.67 (95%CI: 0.62– 0.73) and PPV of 0.76 (95%CI: 0.73– 0.79); SENS was significantly lower for comorbidity and complication studies than for some single disease studies. PPV was significantly higher for Scandinavian countries than for other countries. Recoding compared to re-abstracting of the medical record as a gold standard gave a significantly lower PPV. Diagnostic data were considered appropriate by the authors of the studies for quality of care purposes when both SENS and PPV were at least 0.85. Only 13% of the studies fulfilled this criterion.

Conclusions: Variability in quality of care between settings can easily be overshadowed by variability in data quality. However, the use of DHDD by physicians to evaluate their own medical practice may be useful. But only if physicians are willing to critically interpret the meaning of the information for their medical practice assessment.

Discussion of “Biomedical Infor -matics: We Are What We Publish”

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Biomedical Informatics: We Are What We Publish", written by Peter L. Elkin, Steven H. Brown, and Graham Wright. It is introduced by an editorial. This article contains the combined commenta -ries invited to independently comment on the Elkin et al. paper. In subsequent issues the discussion can continue through letters to the editor.

Long-term Impact of Physician Encoding on Detail and Number of Recorded Diagnoses

Objectives: To improve the recording of diagnostic discharge data, pediatricians encoded diagnostic information as part of discharge letter writing supported by a pediatric list of ICD-9-CM-based codes. We evaluated the effect of this new policy on level of detail and number of recorded diagnoses.

Methods: We compared proportions of specific principal diagnoses and numbers of secondary diagnoses of the four years before with the eight years after introduction.

Results: Immediately after introduction, half of the diagnoses for which both generic and specific codes existed was coded specific. In later years this proportion remained stable at 0.35 (p < 0.05). Diagnoses that fall under the pediatrician’s own subspecialty had more often a specific code than diagnoses that do not. The mean number of secondary diagnoses per admission increased from 0.7 before introduction to 1.4 in the third year after introduction (p < 0.05) but gradually fell back to 0.7. This increase and decrease was mainly due to diagnoses that did not fall under the pediatrician’s own subspecialty. The extra codes in individual discharge summaries had added informational value.

Conclusions: Discharge letter-linked encoding by pediatricians supported by a pediatric list of diseases leads initially to increased detail and number of diagnoses with added informational value. When attention diminishes, especially the level of detail and number of secondary diagnoses that do not fall under one’s own subspecialty decrease. The level of detail of principal diagnoses remains stable because of the advantage for pediatricians of having specific diagnostic codes falling under their own subspecialty.

Intention-based Expressions in GASTINE

Objectives: 1) To evaluate the design of the framework for computerized intention-based clinical practice guidelines; 2) to implement runtime features such as plan recognition and backtracking.

Method: To evaluate the design, we implemented the heart failure guideline into GASTINE, a tool for representing and executing intention-based clinical guidelines.

Result: Description of the current implementation of intention-based expressions in GASTINE and analysis of some generic shortcomings. Explanation of how these shortcomings are addressed. Presentation of how plan recognition and backtracking work and how they improve the system.

Conclusion: The improved guideline system is rather flexible, i.e., it allows deviations from the guideline as long as they are in the spirit of the guideline. The recognition of actions as intended by the users facilitates a flexible decision support system. The intentions are used to explain why certain actions were suggested. Therefore it is assumed that showing the intention behind suggested actions provides a better insight into why these actions are advised.

IMIA Accreditation of Biomedical and Health Informatics Education: Current State and Future Directions

Objectives: The educational activities initiated by the International Medical Informatics Association (IMIA) have had global impacts and influenced national societies and local academic programs in the field of Biomedical and Health Informatics (BMHI). After the successful publication and dissemination of its educational recommendations, IMIA launched an accreditation procedure for educational programs in BMHI. The accreditation procedure was pilot tested by several BMHI academic programs in different countries and continents to obtain a global perspective. Methods: This paper presents an overview of IMIA quality assurance and accreditation procedures along with feedback on issues and problems which emerged during the pilot. Results: It appears that IMIA quality assurance and procedures worked quite well in different countries of Europe, the Middle East, South America, and Asia. These first experiences provided adequate information for adapting, modifying, and optimizing the procedures and finally for the planning of future activities. Conclusions: IMIA accreditation framework comprises a single set of standards that apply at various levels to both academic and professional BMHI programs. The pilot phase confirmed the robustness and generalizability of quality assurance standards and associated procedures on which IMIA accreditation is based at an international level.

Commentaries on the IMIA Award of Excellence Lecture by Reinhold Haux

The IMIA Yearbook editorial team asked five internationally renowned biomedical informaticians to respond to Prof. Haux's editorial. This paper summarizes their thoughts and responses. Contributions are ordered alphabetically by the contributor's last name. All authors provided an equal contribution to this manuscript.

Discussion of "Biomedical informatics: we are what we publish"

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Biomedical Informatics: We Are What We Publish", written by Peter L. Elkin, Steven H. Brown, and Graham Wright. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the Elkin et al. paper. In subsequent issues the discussion can continue through letters to the editor.

IMIA Accreditation of Health Informatics Programs

To develop a procedure for accrediting health informatics programs.

Development of a procedure for accreditation. Test of the accreditation procedure via a trial including four or five health informatics programs. A site visit committee consisting of three members evaluates the program based on a self-assessment report written by the program and the experiences and observations of the site visit committee during the site visit.

A procedure for accreditation has been developed. The instructions for health informatics programs have been written and a checklist for the site visit committee members is available. In total six subjects are considered, each one consisting of one or more facets. Each facet is judged using its corresponding criterion. Five health informatics programs volunteered. One health informatics program in Finland has already been visited and a report has been produced by the site visit committee. The next site visits are in June and July 2012. The site visit in Finland showed that English summaries of master theses are not enough to get a first impression of the methods used in the thesis. A table of contents is also needed. This information then can be used to select theses written in a language other than English for discussion.

The accreditation procedure document with instructions about writing the self-assessment report was very well structured and the instructions were clear according to the Finnish program. The site visit team could work well with the checklist. Self-assessment report model was very well structured and the instructions were clear.

Biomedical informatics--a confluence of disciplines?

BACKGROUND

Biomedical informatics is a broad discipline that borrows many methods and techniques from other disciplines.

OBJECTIVE

To reflect a) on the character of biomedical informatics and to determine whether it is multi-disciplinary or inter-disciplinary; b) on the question whether biomedical informatics is more than the sum of its supporting disciplines and c) on the position of biomedical informatics with respect to related disciplines.

METHOD

Inviting an international group of experts in biomedical informatics and related disciplines on the occasion of the 50th anniversary of Methods of Information in Medicine to present their viewpoints.

RESULTS AND CONCLUSIONS

This paper contains the reflections of a number of the invited experts on the character of biomedical informatics. Most of the authors agree that biomedical informatics is an interdisciplinary field of study where researchers with different scientific backgrounds alone or in combination carry out research. Biomedical informatics is a very broad scientific field and still expanding, yet comprised of a constructive aspect (designing and building systems). One author expressed that the essence of biomedical informatics, as opposed to related disciplines, lies in the modelling of the biomedical content. Interdisciplinarity also has consequences for education. Maintaining rigid disciplinary structures does not allow for sufficient adaptability to capitalize on important trends nor to leverage the influences these trends may have on biomedical informatics. It is therefore important for students to become aware of research findings in related disciplines. In this respect, it was also noted that the fact that many scientific fields use different languages and that the research findings are stored in separate bibliographic databases makes it possible that potentially connected findings will never be linked, despite the fact that these findings were published. Bridges between the sciences are needed for the success of biomedical informatics.

IMIA Accreditation of Health Informatics Programs

OBJECTIVE

To develop a procedure for accrediting health informatics programs.

METHODS

Development of a procedure for accreditation. Test of the accreditation procedure via a trial including four or five health informatics programs. A site visit committee consisting of three members evaluates the program based on a self-assessment report written by the program and the experiences and observations of the site visit committee during the site visit.

RESULTS

A procedure for accreditation has been developed. The instructions for health informatics programs have been written and a checklist for the site visit committee members is available. In total six subjects are considered, each one consisting of one or more facets. Each facet is judged using its corresponding criterion. Five health informatics programs volunteered. One health informatics program in Finland has already been visited and a report has been produced by the site visit committee. The next site visits are in June and July 2012. The site visit in Finland showed that English summaries of master theses are not enough to get a first impression of the methods used in the thesis. A table of contents is also needed. This information then can be used to select theses written in a language other than English for discussion.

CONCLUSIONS

The accreditation procedure document with instructions about writing the self-assessment report was very well structured and the instructions were clear according to the Finnish program. The site visit team could work well with the checklist. Self-assessment report model was very well structured and the instructions were clear.

Clinicians satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medication safety

OBJECTIVES

To study the satisfaction of end-users of a computerized physician order entry (CPOE) system concerning ease of use and the effect on users' workflow, efficiency, and medication safety and to seek users' opinions regarding required improvements of the system. Usability evaluation had shown that this system, which was in use for almost a decade, contained a number of severe usability problems. So another objective of the study was to determine whether there was a direct relation between user satisfaction and the results of a usability evaluation of the system.

METHODS

Two survey questionnaires were distributed to CPOE system users (physicians and nurses) working in inpatient departments of a university hospital. Questionnaires included items that were rated using a five point Likert scale. Multiple choice questions with space for free text additions also were used to collect qualitative data concerning the use of the CPOE system and the users' opinion concerning system requirements for improvement. Data were analyzed using descriptive statistics and by the use of Mann-Whitney U and Kruskal Wallis tests.

RESULTS

Two hundred seventeen physicians and 587 nurses were eligible to participate in this study (response rate 49% and 56% respectively). Physicians were satisfied with the CPOE ease of use (median 3.8, interquartile range [IQR] 3.3-4), and the effect on workflow (median 3.7, IQR 3.3-4), medication safety (median 3.75, IQR 3-4), and efficiency (median 4, IQR 3-4). Nurses also had a positive attitude towards CPOE ease of use (median 3.6, IQR 3-4), and its effect on workflow (median 3, IQR 3-3.6), medication safety (median 3, IQR 2.5-3.5), and efficiency (median 3.5, IQR 3-4). Users mainly indicated that the system needs: supplementary functionalities (e.g. alerts for allergies), improvement of current functionalities, integration with other hospital information systems and improvement of information presentation (e.g. a clear medication overview). Users did not use some current functionalities because of lack of awareness of the functionalities or having difficulty in using them.

CONCLUSIONS

Users of this CPOE system, which was used for almost a decade, were satisfied with the system's ease of use and its effect on efficiency, workflow and medication safety although the system showed many usability problems and lacked some functionalities. In this case study, therefore, there seems no direct relation between the results of the earlier performed usability evaluation and user satisfaction as determined in the current study.

From clinical practice guidelines to computer-interpretable guidelines. A literature overview

BACKGROUND

Guidelines are among us for over 30 years. Initially they were used as algorithmic protocols by nurses and other ancillary personnel. Many physicians regarded the use of guidelines as cookbook medicine. However, quality and patient safety issues have changed the attitude towards guidelines. Implementing formalized guidelines in a decision support system with an interface to an electronic patient record (EPR) makes the application of guidelines more personal and therefore acceptable at the moment of care.

OBJECTIVE

To obtain, via a literature review, an insight into factors that influence the design and implementation of guidelines.

METHODS

An extensive search of the scientific literature in PubMed was carried out with a focus on guideline characteristics, guideline development and implementation, and guideline dissemination.

RESULTS

We present studies that enable us to explain the characteristics of high-quality guidelines, and new advanced methods for guideline formalization, computerization, and implementation. We show how the guidelines affect processes of care and the patient outcome. We discuss the reasons of low guideline adherence as presented in the literature and comment upon them.

CONCLUSIONS

Developing high-quality guidelines requires a skilled team of people and sufficient budget. The guidelines should give personalized advice. Computer-interpretable guidelines (CIGs) that have access to the patient's EPR are able to give personal advice. Because of the costs, sharing of CIGs is a critical requirement for guideline development, dissemination, and implementation. Until now this is hardly possible, because of the many models in use. However, some solutions have been proposed. For instance, a standardized terminology should be imposed so that the terms in guidelines can be matched with terms in an EPR. Also, a dissemination model for easy updating of guidelines should be established. The recommendations should be based on evidence instead of on consensus. To test the quality of the guideline, appraisal instruments should be used to assess the guideline as a whole, as well as checking the quality of the recommendations individually. Only in this way optimal guideline advice can be given on an individual basis at a reasonable cost.

What reasons do those with practical experience use in deciding on priorities for healthcare resources? A qualitative study

BACKGROUND

Priority setting is necessary in current healthcare services. Discussion of fair process has highlighted the value of developing reasons for allocation decisions on the basis of experience gained from real cases.

AIM

To identify the reasons that those with experience of real decision-making concerning resource allocation think relevant in deciding on the priority of a new but expensive drug treatment.

METHODS

Semistructured interviews with members of committees with responsibility for making resource allocation decisions at a local level in the British National Health Service, analysed using modified grounded theory.

RESULTS

22 interviews were carried out. 14 reasons were identified. Four reasons were almost universally considered most important: cost effectiveness; clinical effectiveness; equality and gross cost. No one reason was considered dominant. Some considerations, such as political directives and fear of litigation, were thought by many participants to distort decision-making. There was a substantial lack of agreement over the relevance of some reasons, such as the absence of alternative treatment for the condition.

CONCLUSIONS

There is a clear consensus on the importance and role of a limited number of reasons in allocation decisions among participants. A focus on the process of decision-making, however, does not obviate the need for those involved in the process to engage with problematical ethical issues, nor for the importance of further ethical analysis.

Maturity of teledermatology evaluation research: a systematic literature review

BACKGROUND

There is a growing interest in teledermatology in today's clinical practice, but the maturity of the evaluation research of this technology is still unclear.

OBJECTIVES

This systematic review describes the maturity of teledermatology evaluation research over time and explores what kind of teledermatology outcome measures have been evaluated.

METHODS

Systematic review of literature found in Medline database (1966 up to April 2006). A telemedicine evaluation strategy consisting of four consecutive research phases (parallel to drug and diagnostics evaluation research) extended with a fifth postimplementation phase was used to classify all included studies by two independent reviewers. In addition, main characteristics (store-and-forward or real-time, study design, outcome measures) were registered.

RESULTS

Three hundred and forty-five papers were systematically selected from Medline, and 244 papers were excluded. For two randomized controlled trials (RCTs), multiple papers in phase III were found. After correcting for this, 99 studies remained included (11 phase I, 72 phase II, two phase III, six phase IV, eight postimplementation phase). The number of phase II studies is the largest and still growing, while other phases are much less represented. Diagnostic accuracy was the most often used outcome measure and was found in phase I, II and IV. Store-and-forward teledermatology has been evaluated more since 2001, but most phase IV studies (RCTs, including cost aspects) are on real-time teledermatology.

CONCLUSIONS

Most teledermatology evaluation studies are classified as feasibility studies (phase II). The number of phase III and IV studies remains low through the years. Compared with other specialties in telemedicine (i.e. telesurgery, telepaediatrics), teledermatology seems to be a mature application. However, more evaluation studies with a focus on clinical outcomes such as preventable referrals or time to recovery are needed to prove that teledermatology indeed is a promising and cost-saving technology.

Modeling in biomedical informatics—An exploratory analysis

OBJECTIVE

Modeling is a significant part of research, education and practice in biomedical and health informatics. Our objective was to explore which types of models of processes are used in current biomedical/health informatics research, as reflected in publications of scientific journals in this field. Also, the implications for medical informatics curricula were investigated.

METHODS

Retrospective, prolective observational study on recent publications of the two official journals of the International Medical Informatics Association (IMIA), the International Journal of Medical Informatics (IJMI) and Methods of Information in Medicine (MIM). All publications of the years 2004 and 2005 from these journals were indexed according to a given list of model types. Random samples out of these publications were analysed in more depth.

RESULTS

Three hundred and eighty-four publications have been analysed, 190 of IJMI and 194 of MIM. For publications in special issues (121 in IJMI) and special topics (132 in MIM) we found differences between theme-centered and conference-centered special issues/special topics (SIT) publications. In particular, we could observe a high variation between modeling in publications of theme-centered SITs. It became obvious that often sound formal knowledge as well as a strong engineering background is needed for carrying out this type of research. Usually, this knowledge and the related skills can be best provided in consecutive B.Sc. and M.Sc. programs in medical informatics (respectively, health informatics, biomedical informatics). If the focus should be primarily on health information systems and evaluation this can be offered in a M.Sc. program in medical informatics.

CONCLUSIONS

In analysing the 384 publications it became obvious that modeling continues to be a major task in research, education and practice in biomedical and health informatics. Knowledge and skills on a broad range of model types are needed in biomedical/health informatics.

Evaluation of a Course on Patient Records

Objectives: To determine whether self-directed learning about (electronic) patient records during a PBL (problem-based learning) block, dealing with the content of disciplines concerned with the diagnosis and therapy of diseases of the abdomen, increased the knowledge of the students with respect to the patient records.

Methods: At the beginning and at the end of the tenweek block the same questionnaire was offered to the students (180). Cohen’s d for effect size was used to determine the increase in knowledge.

Results: For those students that answered the questionnaire twice (53), a Cohen’s d of 0.94 was obtained.

Conclusions: The knowledge of the students concerning the advantages and limitations of (electronic) patient records increased significantly. The corresponding effect size was large.

Evaluation of a course on patient records

OBJECTIVES

To determine whether self-directed learning about (electronic) patient records during a PBL (problem-based learning) block, dealing with the content of disciplines concerned with the diagnosis and therapy of diseases of the abdomen, increased the knowledge of the students with respect to the patient records.

METHODS

At the beginning and at the end of the ten-week block the same questionnaire was offered to the students (180). Cohen's d for effect size was used to determine the increase in knowledge.

RESULTS

For those students that answered the questionnaire twice (53), a Cohen's d of 0.94 was obtained.

CONCLUSIONS

The knowledge of the students concerning the advantages and limitations of (electronic) patient records increased significantly. The corresponding effect size was large.

[Good medical education is impossible without computers]

Computers are medical instruments, for which reason they must be included in the medical curriculum. As educational tools, electronic teaching environments, multimedia applications and computers stimulate self-study. Moreover, computers make the medical literature readily accessible and facilitate the administration of the training programme. They are thus an indispensable part of medical education, and of academic and student administration.

On exemplary scientific conduct regarding submission of manuscripts to biomedical informatics journals

As the Editors of leading international biomedical informatics journals, the authors report on a recent pattern of improper manuscript submissions to journals in our field. As a guide for future authors, we describe ethical and pragmatic issues related to submitting work for peer-reviewed journal publication. We propose a coordinated approach to the problem that our respective journals will follow. This Editorial is being jointly published in the following journals represented by the authors: Computer Methods and Programs in Biomedicine, International Journal of Medical Informatics, Journal of Biomedical Informatics, Journal of the American Medical Informatics Association, and Methods of Information in Medicine.

EGOOZ: Specifying the Components of Electronic Patient Record-related Education

Objective: To determine whether educators consider electronic patient record (EPR)-related education necessary and if so, what subjects have to be taught more extensively in the future.

Methods: A list of possibly relevant subjects was determined from the literature. A questionnaire was designed which contained those subjects and the respondents were asked to indicate, for each subject, its competency level and required competency level in current teaching. Since the response rate was low a second questionnaire was developed to have the results of the analysis of the first questionnaire validated by a larger group of educators.

Results: In total 45 learning goals were identified from the literature. The questionnaire was sent to representatives of several disciplines: basic medical education, medical specializations, pharmacy, dentistry and nursing. The analysis of the first questionnaire resulted in nine subjects that needed more attention in the future. Because of the low response the needs could not be specified for the individual disciplines. This insight was obtained from a second questionnaire. The response to this questionnaire was high. From the analysis of the second questionnaire differences between views of educators involved in the training of GPs and educators involved in the training of other specializations were observed.

Conclusion: Educators find EPR-related education important. There are different opinions about the phase in which EPR-related education should be given.

Is Medical Informatics an Art or a Science?

Objective: To give an introduction to the special topic on ‘Medical Informatics: Art or Sciene?‘ in honor of Prof. Dr. Jan Hendrik van Bemmel.

Method: Retrospective, personal review on his work.

Results and Conclusions: Jan H. van Bemmel contributed exceptionally to research and education as well as to systematizing and promoting medical informatics. Details are provided in this and the other papers of this special topic of Methods of Information in Medicine.

Modeling in biomedical informatics--an exploratory analysis (part 1)

OBJECTIVES

Modeling is a significant part of research, education and practice in biomedical and health informatics. Our objective was to explore, which types of models of processes are used in current biomedical/health informatics research, as reflected in publications of scientific journals in this field. Also the implications for medical informatics curricula were investigated.

METHODS

Retrospective, prolective observational study on recent publications of the two official journals of the International Medical Informatics Association (IMIA), the International Journal of Medical Informatics (IJMI) and Methods of Information in Medicine (MIM).

RESULTS

384 publications have been analyzed, 190 of IJMI and 194 of MIM. In regular papers (69 in IJMI, 62 in MIM), analyzed here in part 1, all of these model types could be found. In many publications we observed a mixture of models, being used to solve the 'core' research questions and also to systematically evaluate the research done. Knowledge of (and models for) software engineering and project management are also often needed. IJMI seems to have a closer focus on research concerning health information systems and electronic patient records, with a strong emphasis on evaluation. MIM seems to have a broader range of research approaches, including also statistical modeling and computational intensive approaches. The aim to provide solutions for problems related to data, information and knowledge processing and to study the general principles of processing data, information and knowledge in medicine and health care in order to contribute to improve the quality of health care, and of research and education in medicine and the health sciences was given in all publications.

CONCLUSIONS

Modeling continues to be a major task in research, education and practice in biomedical and health informatics. Knowledge and skills concerning a broad range of model types is needed.

EGOOZ: specifying the components of electronic patient record-related education

OBJECTIVE

To determine whether educators consider electronic patient record (EPR)-related education necessary and if so, what subjects have to be taught more extensively in the future.

METHODS

A list of possibly relevant subjects was determined from the literature. A questionnaire was designed which contained those subjects and the respondents were asked to indicate, for each subject, its competency level and required competency level in current teaching. Since the response rate was low a second questionnaire was developed to have the results of the analysis of the first questionnaire validated by a larger group of educators.

RESULTS

In total 45 learning goals were identified from the literature. The questionnaire was sent to representatives of several disciplines: basic medical education, medical specializations, pharmacy, dentistry and nursing. The analysis of the first questionnaire resulted in nine subjects that needed more attention in the future. Because of the low response the needs could not be specified for the individual disciplines. This insight was obtained from a second questionnaire. The response to this questionnaire was high. From the analysis of the second questionnaire differences between views of educators involved in the training of GPs and educators involved in the training of other specializations were observed.

CONCLUSION

Educators find EPR-related education important. There are different opinions about the phase in which EPR-related education should be given.

Triangulation applied to Jan H. van Bemmel

OBJECTIVE

To describe the person of Jan H. van Bemmel from different points of view.

METHOD

Triangulation.

RESULTS AND CONCLUSIONS

Jan H. van Bemmel successfully contributed to research and education in medical informatics. He inspired a lot of people in The Netherlands and internationally.

Diagnostic reference frames for seizures: A validation study

INTRODUCTION

We developed structured descriptions of signs and symptoms for specific seizure types (called Diagnostic Reference Frames-DRFs-by us) that can serve as a frame of reference in the process of classifying patients with epileptic seizures. In this study the validity of the DRFs for clinical use is evaluated and described.

MATERIAL AND METHODS

In this study we use a decision support system based on the DRFs and using Bayes's rule for the validation of the DRFs. Patient's manifestations are entered in the decision support system and by successively applying Bayes's rule posterior probabilities are calculated. The DRFs with the highest posterior probability gives an indication of the classification of the seizure. The validation of the DRFs was performed by comparing the seizure type with the highest posterior probability with the classification of experienced epileptologists on a series of test cases with known epileptic seizures. In this way we assessed the accuracy of the DRFs in classifying patients with epileptic seizures.

RESULTS

We included sixty-six patients in this efficacy study. The patients and/or their relatives described the manifestations occurring during a seizure. Sixty cases (91%) were correctly classified using the decision support system.

DISCUSSION

The accuracy of 91 % indicates that the knowledge encoded in the DRFs for the included seizure types is valid. The next step is to test the DRFs in a clinical setting to evaluate the applicability in daily practice.

Three-Layer Model for the design of a Protocol Support System

OBJECTIVE

The aim of the PropeR project is to investigate the impact of Active Computerized Protocol Support (ACPS) on daily care processes in different settings (home care and hospital care). ACPS consists of an active Protocol Support System (PSS) that is linked to an Electronic Patient Record system. The aim of this paper is to describe how we have taken the organizational and social aspects into account in the hospital setting and the consequences of this approach for the design of the PSS.

METHODS

Socio-technical approaches have been applied. Observations and interviews with various health care providers were performed at the hematology and oncology department of the University Hospital Maastricht. Ten extensive sessions with a specialist physician and research nurse took place to further elaborate a study protocol and to discuss how it is integrated in daily practice. The knowledge editor component of Gaston was used to build a computer interpretable version of the selected protocol.

RESULTS AND CONCLUSIONS

To support the representation of a study protocol integrated in routine clinical care, a Three-Layer Model was developed. This model distinguishes the protocol description, local adaptations to the protocol and communication as three separate layers. These layers have been incorporated into the knowledge acquisition tool Gaston. The Three-Layer Model makes easy updating possible, and also supports transferability of computerized (study) protocols to other organizations.

Nicotine conjugate vaccine: is there a right to a smoking future?

Tobacco consumption is believed to be one of the world's greatest preventable health problems. According to the World Health Organisation, 1.1 billion people worldwide are addicted to nicotine with tobacco causing an estimated four million premature deaths every year. The development of a nicotine conjugate vaccine suggests that immunisation may hold promise as a future therapeutic and preventive strategy for tobacco smoking and nicotine addiction. Allowing parents to immunise their children against smoking could be an infringement of children's right to an open future, however, and is not ethically unproblematic