Balancing documentation and direct patient care activities: A study of a mature electronic health record system

US hospitals now fully embrace electronic documentation systems as a way to reduce medical errors and improve patient safety outcomes. Whether spending time on electronic documentation detracts from the time available for direct patient care, however, is still unresolved. There is no knowledge on the permanent effects of documenting electronically and whether it takes away significant time from patient care when the healthcare information system is mature. To understand the time spent on documentation, direct patient care tasks, and other clinical tasks in a mature information system, we conducted an observational and interview study in a midwestern academic hospital. The hospital implemented an electronic medical record system 11 years ago. We observed 22 health care workers across intensive care units, inpatient floors, and an outpatient clinic in the hospital. Results show that healthcare workers spend more time on documentation activities compared to patient care activities. Clinical roles have no influence on the time spent on documentation. This paper describes results on the time spent between documentation and patient care tasks, and discusses implications for future practice.Relevance to industryThe study applies to healthcare industry that faces immense challenges in balancing documentation activities and patient care activities.     

网格环境下的电子病历整合设计

不同电子病历在数据上的异构性阻碍了信息的共享,本文采用基于OSGA-DAI的中间件法解决异构医疗数据的集成问题。OGSA-DAI通过Web Service的方式对数据源进行服务化的封装,屏蔽了数据资源在存储管理上的异构。对于数据资源在信息表示上的异构性,则采用信息映射的方法,将原数据库中的数据映射到一张虚拟的表中,使用户不必了解原数据资源的表示信息即可查询获取数据。     

Complexity of biomedical data models in cardiology: the Intranet-based AF registry

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with major complications. Ongoing research is focused on new pacing devices for alternative treatment of this disease. The objective of an AF registry is to store prospectively all relevant data covering clinical information, quality of life and device parameters and by this means provide a platform for long-term follow-up. For statistical analysis, categorical and numerical items are required, thus a high-granular data structure must be defined and implemented in the clinical setting. Facing the limits of formalization, we developed an XML-based documentation scheme consisting of 619 items in eight tables and implemented it with state-of-the-art Intranet technology. At present detailed information on 88 patients is recorded. The pacing device generates per patient and follow-up visit a file consisting of approximately 400-500 parameters provided on a floppy disk, which are transferred by means of a specific interface into the database. Success factors for integration of a complex research database into the routine workflow of a busy university hospital are interfaces between data sources to enable non-redundant data entry, intensive fine tuning by iterative software engineering and benefit for the clinical users in form of clinical reports and patient-specific summaries. Data quality must be assured by plausibility checks. To get an overview of this complex dataset we developed a dedicated visualization tool. Due to the high number of items a large patient collective must be recruited for statistical evaluation. Interinstitutional cooperation is required for a consensus on common minimal documentation schemes to enable pooling of data.     

文档管理系统的研究与设计

文件档案管理系统是办公自动化系统的一个重要的组成部分。本系统的重点在于将文档按照部门机关和文档类别进行分类列表,从而方便用户查询文档信息。文件列表减少了用户在查找时所耗费的时间。强大的管理功能保证了文档资料能够最大化实现其价值,作为公司各个部门有力的参考资料,优化企业资源。     

Infrastructuring in Healthcare through the OpenEHR Architecture

In Norway, a national initiative is currently aiming at standardising the electronic patient record (EPR) content based on an openEHR framework. The openEHR architecture, offers users the capability to conduct standardisation and structuration of the EPR content in a distributed manner, through an internet-based tool. Systems based on this architecture, is expected to ensure universal (also internationally) interoperability among all forms of electronic data. A crude estimate is that it is necessary to define somewhere between 1000 and 2000 standardised elements or clinical concepts (so-called archetypes), to constitute a functioning EPR system. Altogether, the collection of defined archetypes constitutes a backbone of an interoperable EPR system lending on the openEHR architecture. We conceptualize the agreed-upon archetypes as a large-scale information infrastructure, and the process of developing the archetypes as a infrastructuring effort. With this as a backdrop, we focus on the following research question: What are the challenges of infrastructuring in a large-scale user-driven standardisation process in healthcare? This question is operationalized into three sub-questions: First, how are the openEHR-based archetypes standardised in practice? Second, what is the role of daily clinical practice, and existing systems in the process of developing archetypes? Third, how may related, but supposedly independent infrastructuring projects shape each other’s progress? We contribute with insight into how power relations and politics shape the infrastructuring process. Empirically, we have studied the formative process of establishing a national information infrastructure based on the openEHR approach in the period 2012–2016 in Norway.     

A Survey on Multimodal Medical Data Visualization

Multi‐modal data of the complex human anatomy contain a wealth of information. To visualize and explore such data, techniques for emphasizing important structures and controlling visibility are essential. Such fused overview visualizations guide physicians to suspicious regions to be analysed in detail, e.g. with slice‐based viewing. We give an overview of state of the art in multi‐modal medical data visualization techniques. Multi‐modal medical data consist of multiple scans of the same subject using various acquisition methods, often combining multiple complimentary types of information. Three‐dimensional visualization techniques for multi‐modal medical data can be used in diagnosis, treatment planning, doctor–patient communication as well as interdisciplinary communication. Over the years, multiple techniques have been developed in order to cope with the various associated challenges and present the relevant information from multiple sources in an insightful way. We present an overview of these techniques and analyse the specific challenges that arise in multi‐modal data visualization and how recent works aimed to solve these, often using smart visibility techniques. We provide a taxonomy of these multi‐modal visualization applications based on the modalities used and the visualization techniques employed. Additionally, we identify unsolved problems as potential future research directions.     

Wireless sensor networks for rehabilitation applications: Challenges and opportunities

Rehabilitation supervision has emerged as a new application of wireless sensor networks (WSN), with unique communication, signal processing and hardware design requirements. It is a broad and complex interdisciplinary research area on which more than one hundred papers have been published by several research communities (electronics, bio-mechanical, control and computer science). In this paper, we present WSN for rehabilitation supervision with a focus on key scientific and technical challenges that have been solved as well as interdisciplinary challenges that are still open. We thoroughly review existing projects conducted by several research communities involved in this exciting field. Furthermore, we discuss the open research issues and give directions for future research works. Our aim is to gather information that encourage engineers, clinicians and computer scientists to work together in this field to tackle the arising challenges. We believe that bridging researchers with different scientific backgrounds could have a significant impact on the development of WSN for rehabilitation and could improve the way rehabilitation is provided today.     

社交网络研究综述

社交网络已成为Web2.0时代最流行的应用,其服务范围已逐步从社交关系管理扩展到媒体信息、应用集成、电子商务等领域。社交网络中大量的活跃用户为研究网络行为、数据安全、信息传播以及其他跨学科问题提供了宝贵的数据和场景。自Facebook出现以来,研究者先后从不同的角度对社交网络进行了大量的研究,这些研究对人们认识社交网络内部规律、促进ICP服务改进具有重大意义。首先对社交网络的发展进行了简单的回顾;然后从社交网络的数据采集技术、社交网络用户行为分析、社交网络中的信息传播及社交网络中的用户隐私4个方面对已有的研究工作进行总结评价;最后,总结了当前研究中出现的问题并对未来研究发展趋势进行了展望。希望能为该领域的研究者提供一些有益的启示。     

Methods and implementation of a central biosample and data management in a three-centre clinical study

In our report we describe concept, strategies and implementation of a central biosample and data management (CSDM) system in the three-centre clinical study of the Transregional Collaborative Research Centre "Inflammatory Cardiomyopathy - Molecular Pathogenesis and Therapy" SFB/TR 19, Germany. Following the requirements of high system resource availability, data security, privacy protection and quality assurance, a web-based CSDM was developed based on Java 2 Enterprise Edition using an Oracle database. An efficient and reliable sample documentation system using bar code labelling, a partitioning storage algorithm and an online documentation software was implemented. An online electronic case report form is used to acquire patient-related data. Strict rules for access to the online applications and secure connections are used to account for privacy protection and data security. Challenges for the implementation of the CSDM resided at project, technical and organisational level as well as at staff level.     

Interactive analysis of discrete-event logistics systems with support of a data warehouse

We propose an interactive approach for the flexible analysis of detailed state-transition data collected from discrete-event simulation models of logistics systems. To this end, we focus on multidimensional modeling in order to reveal the drivers of time-variant system performance. Online Analytical Processing functionality provides fast and flexible organization, aggregation and visualization of information. We illustrate the advantages of such an approach with data from simulation studies of the Upper Mississippi River waterway system.     

Analysis of Big Data technologies for use in agro-environmental science

Recent developments like the movements of open access and open data and the unprecedented growth of data, which has come forward as Big Data, have shifted focus to methods to effectively handle such data for use in agro-environmental research. Big Data technologies, together with the increased use of cloud based and high performance computing, create new opportunities for data intensive science in the multi-disciplinary agro-environmental domain. A theoretical framework is presented to structure and analyse data-intensive cases and is applied to three case studies, together covering a broad range of technologies and aspects related to Big Data usage. The case studies indicate that most persistent issues in the area of data-intensive research evolve around capturing the huge heterogeneity of interdisciplinary data and around creating trust between data providers and data users. It is therefore recommended that efforts from the agro-environmental domain concentrate on the issues of variety and veracity.     

妇幼专科医院病理信息系统的设计和实施

随着医疗信息化的发展,病理信息化的重要性被人们所认识,对病理科的工作流程、质控环节、病历信息及图像资料进行全面管理,不仅能提高科室管理水平,提升科研能力,减少人为误差,降低误诊风险,而且能与医院电子病历系统共享信息,使病理科能快速调阅病人的临床资料,临床科室也可以及时浏览病理报告,从而为病人的诊断治疗提供更快速、更准确的指导。该文就妇幼专科医院病理信息系统应用于病理科实验室的系统设计和实施情况进行介绍,并对问题进行了探讨。     

基于Web方式的小型专科病电子病历系统的设计

在专科病治疗中,随访及科研对于临床医生具有重要的意义。但是,由于门诊病历由病人自行保管,使得门诊病历资料在临床科研以及教学中无法加以利用。而且,传统的随访方式也难于及时、准确地收集病人的随访信息,科研信息的收集积累和处理则更加困难。针对重症肌无力专科病,提出了基于Web方式的小型电子病历系统的设计。     

Ubiquitous monitoring and assessment of childhood obesity

Childhood obesity is a significant health problem in current societies that is increasing at an alarming way among population of all ages. To date, studies on the effectiveness of treatments for childhood obesity in the medium and long term suggest a moderate effect on weight loss and maintenance, which has led to suggestions that early interventions have a preventive nature on adult obesity. The long-term recovery of the weight lost is often associated with a lack of adherence to recommendations for changing life habits. Then, obesity becomes a chronic problem, difficult to approach, and the main difficulty lies in promoting and ensuring adherence to a change in lifestyle. A system known as ETIOBE has been developed to improve the treatment adherence, to promote the mechanisms of self-control in patients and to prevent relapses. An important part of the ETIOBE system is the ubiquitous monitoring platform since it enables the clinician to obtain relevant information from patients (contextual, physiological and psychological), which enables treatment customization and adaptation, depending on the patient’s evolution. The aim of this paper is to describe the monitoring platform which is intended to establish a sensor network whose focus is the obese children under clinical treatment, and the various elements that compose it: electronic PDA records to establish diet habits, HAS: home ambulatory system (data integration of biomedical devices; blood pressure to study hypertension; pulse oximeter to detect Sleep Disorders; and electronic t-shirt to detect physical activity). This paper presents the first validations of the electronic PDA records and the electronic t-shirt. These validations suggest that the monitoring platform can help to achieve the goals previously mentioned, by offering constant support and increasing motivation to change.     

Eine modulare gesundheitsakte als antwort auf kommunikationsprobleme im gesundheitswesen

Since 2000 the University of Muenster has developed an electronic health record (EHR) called ?akteonline.de“. Several clinics and departments use the EHR in routine. ?akteonline.de“ in its current structure supports patients as well as health care professionals and aims at providing a collaborative health information system which perfectly supports the clinical workflow even across institutional boundaries. In order to fulfill high data security and data protection requirements strictly, complex encryption, authorization and access control components have been developed. The IT-structure of the German health care system is very heterogeneous and peripheral. The thereby generated additional costs in the economic and social area are comprehensible and the patient is unable to claim the central position intended by politics and society. The development effort of ?akteonline.de“ currently focuses on the introduction of an electronic foundation for an ?integrated care“. For that communication possibilities for different clinical systems, like systems for physician or clinical information systems as well as communication possibilities between different departments in a hospital or networking between Institutions and the patient himself, have to be provided. The various needs of the institutions and people involved, have to be considered individually within one concept. Based on gathered experiences and with regard to increasing requirements in the areas of interoperability, integration and international cooperation the system architecture and the basic data model underwent several evolutionary enhancements. The focus of this paper lies on describing the use of new technologies and open standards in order to create and enhance a loosely coupled, modular and flexible EHR, that represents a common information and communication tool for patients and health care professionals.     

Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety

According to the human factors paradigm for patient safety, health care work systems and innovations such as electronic medical records do not have direct effects on patient safety. Instead, their effects are contingent on how the clinical work system, whether computerized or not, shapes health care providers’ performance of cognitive work processes. An application of the human factors paradigm to interview data from two hospitals in the Midwest United States yielded numerous examples of the performance-altering effects of electronic medical records, electronic clinical documentation, and computerized provider order entry. Findings describe both improvements and decrements in the ease and quality of cognitive performance, both for interviewed clinicians and for their colleagues and patients. Changes in cognitive performance appear to have desirable and undesirable implications for patient safety as well as for quality of care and other important outcomes. Cognitive performance can also be traced to interactions between work system elements, including new technology, allowing for the discovery of problems with “fit” to be addressed through design interventions.     

Development of a clinical data warehouse from an intensive care clinical information system

There are relatively few institutions that have developed clinical data warehouses, containing patient data from the point of care. Because of the various care practices, data types and definitions, and the perceived incompleteness of clinical information systems, the development of a clinical data warehouse is a challenge.In order to deal with managerial and clinical information needs, as well as educational and research aims that are important in the setting of a university hospital, Erasmus Medical Center Rotterdam, The Netherlands, developed a data warehouse incrementally. In this paper we report on the in-house development of an integral part of the data warehouse specifically for the intensive care units (ICU-DWH). It was modeled using Atos Origin Metadata Frame method. The paper describes the methodology, the development process and the content of the ICU-DWH, and discusses the need for (clinical) data warehouses in intensive care.     

Implementation and evaluation of an Asbru-based decision support system for adjuvant treatment in breast cancer

The domain of cancer treatment is a promising field for the implementation and evaluation of a protocol-based clinical decision support system, because of the algorithmic nature of treatment recommendations. However, many factors can limit such systems’ potential to support the decision of clinicians: technical challenges related to the interoperability with existing electronic patient records and clinical challenges related to the inherent complexity of the decisions, often collectively taken by panels of different specialists. In this paper, we evaluate the performances of an Asbru-based decision support system implementing treatment protocols for breast cancer, which accesses data from an oncological electronic patient record. Focusing on the decision on the adjuvant pharmaceutical treatment for patients affected by early invasive breast cancer, we evaluate the matching of the system's recommendations with those issued by the multidisciplinary panel held weekly in a hospital.     

TERMTrial--terminology-based documentation systems for cooperative clinical trials

Within cooperative groups of multi-center clinical trials a standardized documentation is a prerequisite for communication and sharing of data. Standardizing documentation systems means standardizing the underlying terminology. The management and consistent application of terminology systems is a difficult and fault-prone task, which should be supported by appropriate software tools. Today, documentation systems for clinical trials are often implemented as so-called Remote-Data-Entry-Systems (RDE-systems). Although there are many commercial systems, which support the development of RDE-systems there is none offering a comprehensive terminological support. Therefore, we developed the software system TERMTrial which consists of a component for the definition and management of terminology systems for cooperative groups of clinical trials and two components for the terminology-based automatic generation of trial databases and terminology-based interactive design of electronic case report forms (eCRFs). TERMTrial combines the advantages of remote data entry with a comprehensive terminological control.     

The transformation of surgery patient care with a clinical research information system

Implementing a computerized clinical research information system (CRIS) can make clinical research easier and more efficient while improving patient care by providing surgeons with performance feedback. To transform the original manual patient information management system so it delivers patient care, this study developed a CRIS for cardiovascular disease to facilitate surgery treatment tracking. The CRIS tracks hundreds of pieces of data through surgical stages and converts these data into computerized registries, provides surveillance mechanisms, and generates clinical interpretive reports in a timely manner. Surgeons can use the CRIS to identify surgical-related data and interventional cardiovascular procedure risks based on specific patient characteristics, and it has increased the quality and efficiency of patient care. An intelligent data analysis (IDA) tool based on the Weka library that seamlessly integrates with the CRIS has helped provide models for clinical research.