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.     

Security of health care records in Belgium. Application in a University Hospital

Access rules to electronic patient records (EPR) have been issued by the Belgian Council of Physicians. Access to identifiable data of the EPR is restricted to anyone responsible for diagnosis, treatment and continuity of care of the patient. By delegation, associated personnel, like secretaries, can also be authorised to have access. A new perspective is given by the availability in 2003 of a national identification card allowing electronic signature of patients. It could not only authorise but also forbid some accesses. A law in 2002 gives right to patients to access to their own record. Health personnel can also be identified by cards but the system is not yet implemented. In the meantime, local measures have been made. We describe practical solutions that have been taken as priorities in a University Hospital. It was felt more important to allow access to lifesaving EPR data than to restrict its access by too strictly theoretical rules. A pilot study (S3 project) is also in progress for interinstitutional communication in Belgium, using the unique identification number of the patient and a "third server".     

Implementation of a query interface for a generic record server

INTRODUCTION: This paper presents work to define a representation for clinical research queries that can be used for the design of generic interfaces to electronic healthcare record (EHR) systems. Given the increasing prevalence of EHR systems, with the potential to accumulate life-long health records, opportunities exist to analyse and mine these for new knowledge. This potential is presently limited by many factors, one of which is the challenge of extracting information from them in order to execute a research query. METHOD: There is limited pre-existing work on the generic specification of clinical queries. Sets of example queries were obtained from published studies and clinician reference groups. These were re-represented as structured logical expressions, from which a generalisable pattern (information model) was inferred. An iterative design and implementation approach was then pursued to refine the model and evaluate it. RESULTS: This paper presents a set of requirements for the generic representation of clinical research queries, and an information model to represent any arbitrary such query. A middleware component was implemented as an interface to an existing system that holds 20,000 anonymised cancer EHRs in order to validate the model. This component was interfaced in turn to a query design and results presentation tool developed by the Open University, to permit end user demonstrations and feedback as part of the evaluation. CONCLUSION: Although it is difficult to separate cleanly the evaluation of a theoretical model from its implementation, the empirical evaluation of the query-execution interface revealed that clinical queries of the kinds studied could all be represented and executed successfully. However, performance was a problem and this paper outlines some of the challenges faced in building generic components to handle specialised data structures on a large scale. The limitations of this work are also discussed. The work complements many years of European research and standardisation on the interoperable communication of electronic health records, by proposing a way in which one or more EHR systems might be queried in a standardised way.     

Data security and protection in cross-institutional electronic patient records

This paper aims at identifying the specific legal requirements concerning data security and data protection of patient health data that apply to a cross-institutional electronic patient record (EPR) and describes possible solutions for meeting these requirements. In Germany, the legal framework for such records provide that disclosure of patient health information to physicians of third-party institutions is only allowed in case that it is necessary for the joint treatment of the patient, i.e. in case of a “treatment connection”. As a first step, the functionality of a remote-access architecture was proven allowing a one-way connection between the EPR systems of two health institutions in Germany, which jointly treat tumor patients. Besides, a signature system model for ensuring the integrity and authenticity of medical documents was developed and implemented in the existing information system architecture of the University Medical Center of Heidelberg. Especially in Germany, the legal framework for cross-institutional EPRs is very complex and has a considerable influence on the development and implementation of cross-institutional EPRs. However, its introduction is thought to be valuable, since a cross-institutional EPR will improve communication within shared care processes, and thus improve the quality of patient care.     

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, 24 h 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.     

What factors affect the use of electronic patient records by Irish GPs?

Background

The use of electronic patient records (EPR) by Irish GPs has grown substantially over the past decade but a significant number of GPs continue to use manual record systems.

Objectives

This study attempts to determine the factors which affect the uptake of an EPR by Irish GPs.

Methods and materials

Two national postal surveys of Irish General Practitioners (GPs) were carried out in 2000 and again in 2003. Response rates were 69% (n = 1543) and 60% (n = 1408), respectively.

Results

The data collected reveal that electronic patient records are in widespread use among Irish general practitioners. Furthermore the study shows that the use of electronic patient records for common clinical and administrative tasks is increasing.Comparative analysis of the data revealed statistically significant differences between subgroups of responders. GPs were more likely to use an EPR for clinical tasks if they were young and male. GPs in group practice and GPs with mostly state-funded patient lists were more likely to use an EPR as were GPs in rural locations. Much higher use of an EPR for clinical tasks was found among GPs who were involved in the training of newly qualified GPs.The most significant perceived barrier preventing GPs migrating from manual to electronic records was “lack of time”. While lack of financial resources and absence of computer skills were also perceived as barriers, these were found to be less significant.

Discussion

While the increasing use of an EPR among younger GPs was expected, the lower usage among female GPs and those in urban locations was not and has not been previously reported. The data has important implications for the planned roll out of electronic patient records as outlined in Ireland's National Health Information Strategy.     

Beyond the EPR: Complementary roles of the hospital-wide electronic health record and clinical departmental systems

Background  

Many hospital departments have implemented small clinical departmental systems (CDSs) to collect and use patient data for documentation as well as for other department-specific purposes. As hospitals are implementing institution-wide electronic patient records (EPRs), the EPR is thought to be integrated with, and gradually substitute the smaller systems. Many EPR systems however fail to support important clinical workflows. Also, successful integration of systems has proven hard to achieve. As a result, CDSs are still in widespread use. This study was conducted to see which tasks are supported by CDSs and to compare this to the support offered by the EPR.     

Advanced tool kits for EPR security

Responding to the challenge for efficient and high quality health care, the shared care paradigm must be established in health. In that context, information systems such as electronic patient records (EPR) have to meet this paradigm supporting communication and interoperation between the health care establishments (HCE) and health professionals (HP) involved. Due to the sensitivity of personal medical information, this co-operation must be provided in a trustworthy way. To enable different views of HCE and HP ranging from management, doctors, nurses up to systems administrators and IT professionals, a set of models for analysis, design and implementation of secure distributed EPR has been developed and introduced. The approach is based on the popular UML methodology and the component paradigm for open, interoperable systems. Easy to use tool kits deal with both application security services and communication security services but also with the security infrastructure needed. Regarding the requirements for distributed multi-user EPRs, modelling and implementation of policy agreements, authorisation and access control are especially considered. Current developments for a security infrastructure in health care based on cryptographic algorithms as health professional cards (HPC), security services employing digital signatures, and health-related TTP services are discussed. CEN and ISO initiatives for health informatics standards in the context of secure and communicable EPR are especially mentioned.     

Electronic patient records and the impact of the Internet

The term electronic patient record (EPR) means the electronic collection of clinical narrative and diagnostic reports specific to an individual patient. A true EPR should allow physicians and nurses to practice in a paperless fashion. The wide adoption of Internet technologies should allow truly distributed sharing of patient data across traditional organizational barriers. Hence, the meaning of an EPR, as a representation of documents, should be transformed into a collaborative environment that supports workflow, enables new care models and allows secure access to distributed health data. This paper reviews the current realization of EPRs in the context of paper-based medical records. The Internet architecture that Boston-based medical informatics researchers refer to as W3-EMRS is described in the context of a successful implementation of CareWeb at the Beth Israel Deaconess Medical center. Finally, we describe how this Internet-based approach can be extended beyond the boundaries of traditional care settings to help evolve new collaborative models of eHealth.     

Optimizing the user interface of a data entry module for an electronic patient record for cardiac rehabilitation: A mixed method usability approach

IntroductionCumbersome electronic patient record (EPR) interfaces may complicate data-entry in clinical practice. Completeness of data entered in the EPR determines, among other things, the value of computerized clinical decision support (CCDS). Quantitative usability evaluations can provide insight into mismatches between the system design model of data entry and users’ data entry behavior, but not into the underlying causes for these mismatches. Mixed method usability evaluation studies may provide these insights, and thus support generating redesign recommendations for improving an EPR system’s data entry interface.AimTo improve the usability of the data entry interface of an EPR system with CCDS in the field of cardiac rehabilitation (CR), and additionally, to assess the value of a mixed method usability approach in this context.MethodsSeven CR professionals performed a think-aloud usability evaluation both before (beta-version) and after the redesign of the system. Observed usability problems from both evaluations were analyzed and categorized using Zhang et al.’s heuristic principles of good interface design. We combined the think-aloud usability evaluation of the system’s beta-version with the measurement of a new usability construct: users’ deviations in action sequence from the system’s predefined data entry order sequence. Recommendations for redesign were implemented. We assessed whether the redesign improved CR professionals’ (1) task efficacy (with respect to the completeness of data they collected), and (2) task efficiency (with respect to the average number of mouse clicks they needed to complete data entry subtasks).ResultsWith the system’s beta version, 40% of health care professionals’ navigation actions through the system deviated from the predefined next system action. The causes for these deviations as revealed by the think-aloud method mostly concerned mismatches between the system design model for data entry action sequences and users expectations of these action sequences, based on their paper-based daily routines. This caused non completion of data entry tasks (31% of main tasks completed), and more navigation actions than minimally required (146% of the minimum required). In the redesigned system the data entry navigational structure was organized in a flexible way around an overview screen to better mimic users’ paper-based daily routines of collecting patient data. This redesign resulted in an increased number of completed main tasks (70%) and a decrease in navigation actions (133% of the minimum required). The think-aloud usability evaluation of the redesigned system showed that remaining problems concerned flexibility (e.g., lack of customization options) and consistency (mainly with layout and position of items on the screen).ConclusionThe mixed method usability evaluation was supportive in revealing the magnitude and causes of mismatches between the system design model of data-entry with users’ data entry behavior. However, as both task efficacy and efficiency were still not optimal with the redesigned EPR, we advise to perform a cognitive analysis on end users’ mental processes and behavior patterns in daily work processes specifically during the requirements analysis phase of development of interactive healthcare information systems.     

Cross-institutional data exchange using the clinical document architecture (CDA)

PROBLEM: Although electronic communication of clinical data between various actors in the healthcare domain seems crucial for a cost-effective patient treatment, it is mostly restricted to paper based documents. In order to meet the growing need for improved data communication, it is necessary to overcome the barriers of software heterogeneity and lack of standards, especially in cross-institutional shared care communication. HL7's clinical document architecture (CDA) is a new and promising tool to exchange any clinical document. In this paper we show how CDA can be used to (1) share electronic discharge letters and other clinical data generated and stored in the hospitals electronic patient record (EPR) with general practitioners and (2) to transfer these clinical data to a personal electronic health record (EHR). The latter scenario is in routine use. Ease-of-use and data security and integrity were the main design principles in both scenarios. METHODS: Within the electronic patient record a data extraction and exporting mechanism has been built. For both scenarios appropriate data processing and transmission methods have been developed, and the receiving information systems have been prepared for the CDA based data input. RESULTS: Although there still remain technical and organizational issues to be solved, this is a promising method in order to enhance data exchange between hospital and primary care and to move towards an electronic patient record (EPR) and an electronic health record (EHR) crossing institutional borders. This paper describes the design and current implementation and discusses our experiences.     

Developing a virtual patient record using XML and web-based workflow technologies

Virtual patient records (VPR) provide a means for integrated access to patient information that may be scattered around different healthcare settings. Within the boundaries of a health district providing all levels of care, this concept can be implemented in a corporate Intranet environment to support longitudinal patient care activities across the participating healthcare providers. In this context, a VPR implementation enables autonomous healthcare providers to operate in a cooperative working environment and apply continuity of care. Workflow systems bring this collaboration and cooperation into effect by automatically routing the medical information needed by authorised actors in a healthcare process. This paper presents a VPR framework that allows integrating geographically dispersed medical information within a health district and enhancing collaboration and coordination of authorised workgroups by means of a web-based workflow system. An implementation of the proposed framework is also presented.     

Instant availability of patient records,but diminished availability of patient information: A multi-method study of GP's use of electronic patient records

Background  

In spite of succesful adoption of electronic patient records (EPR) by Norwegian GPs, what constitutes the actual benefits and effects of the use of EPRs in the perspective of the GPs and patients has not been fully characterized. We wanted to study primary care physicians' use of electronic patient record (EPR) systems in terms of use of different EPR functions and the time spent on using the records, as well as the potential effects of EPR systems on the clinician-patient relationship.     

Norwegians GPs’ use of electronic patient record systems

Objective

To evaluate GPs use of three major electronic patient record systems with emphasis on the ability of the systems to support important clinical tasks and to compare the findings with results from a study of the three major hospital-wide systems.

Methods

A national, cross-sectional questionnaire survey was conducted in Norwegian primary care. 247 (73%) of 338 GPs responded. Proportions of the respondents who reported to use the EPR system to conduct 23 central clinical tasks, differences in the proportions of users of different EPR systems and user satisfaction and perceived usefulness of the EPR system were measured.

Results

The GPs reported extensive use of their EPR systems to support clinical tasks. There were no significant differences in functionality between the systems, but there were differences in reported software and hardware dysfunction and user satisfaction. The respondents reported high scores in computer literacy and there was no correlation between computer usage and respondent age or gender. A comparison with hospital physicians’ use of three hospital-wide EPR systems revealed that GPs had higher usage than the hospital-based MDs. Primary care EPR systems support clinical tasks far better than hospital systems with better overall user satisfaction and reported impact on the overall quality of the work.

Conclusion

EPR systems in Norwegian primary care that have been developed in accordance with the principles of user-centered design have achieved widespread adoption and highly integrated use. The quality and efficiency of the clinical work has increased in contrast to the situation of their hospital colleagues, who report more modest use and benefits of EPR systems.     

Architectural design and tools to support the transparent access to hospital information systems,radiology information systems,and picture archiving and communication systems

The fragmentation of the electronic patient record among hospital information systems (HIS), radiology information systems (RIS), and picture archiving and communication systems (PACS) makes the viewing of the complete medical patient record inconvenient. The purpose of this report is to describe the system architecture, development tools, and implementation issues related to providing transparent access to HIS, RIS, and PACS information. A client-mediator-server architecture was implemented to facilitate the gathering and visualization of electronic medical records from these independent heterogeneous information systems. The architecture features intelligent data access agents, run-time determination of data access strategies, and an active patient cache. The development and management of the agents were facilitated by data integration CASE (computer-assisted software engineering) tools. HIS, RIS, and PACS data access and translation agents were successfully developed. All pathology, radiology, medical, laboratory, admissions, and radiology reports for a patient are available for review from a single integrated workstation interface. A data caching system provides fast access to active patient data. New network architectures are evolving that support the integration of heterogeneous software subsystems. Commercial tools are available to assist in the integration procedure.     

Operational rules for the implementation of INN prescribing

PurposeThe aim is to describe the process, principles and results of the International Nonproprietary Name (INN) prescribing project in Belgium. The purpose of this project was to operationalize electronic INN prescribing for outpatient care in daily medical practice and to develop a factual database which can be used in electronic INN prescribing applications.MethodsThe operationalization process consisted of three phases: (1) expert consultation, (2) review by regulatory authorities and (3) test phase with stakeholders and end-users.ResultsThe INN prescribing project resulted into (1) operational rules for electronic INN prescribing and (2) a reference database to be implemented in commercial medical software. The operational rules for electronic INN prescribing define valid INN groups as sets of equivalent medicinal products, described by three elements: the therapeutic moiety (the active part of the therapeutic ingredient) or combination of therapeutic moieties, the strength (with standardized denominators), and the method of administration (with simplified but standardized options). The operational rules also define two categories of exemptions for INN prescribing: INN groups where the first choice of treatment should be continued throughout the therapy period (NO SWITCH) and medicinal product groups not suitable for INN prescribing (NO INN). The reference database is the result of the virtual classification of the Belgian therapeutic arsenal into INN groups, according to the operational rules.ConclusionsDefining the operational rules for INN prescribing for and with different stakeholders was a difficult yet feasible assignment. The INN prescribing project resulted into explicit operational rules and a reference database. The Belgian experience may provide important information for other countries planning to operationalize or refine electronic INN prescribing. It can also be used for a thorough evaluation of the impact of the new concept of INN prescribing on daily practice and on medical education.     

What are the standard functions of electronic clinical pathways?

Purpose

The present study was performed to determine the standard functions of electronic clinical pathways (eCP) embedded in electronic medical records with regard to demand definition.

Methods

The standard functions of eCP were decided by the required functions determined from interviews with hospital staff, those derived from the implementation of paper-based clinical pathways (CPs), and additional functions generated through the shift from a paper-based to an electronic system. Moreover, the proposed standard functions and those of eCP embedded in electronic medical records for large hospitals were compared by interviews with five vendors.

Results

Seventeen functions were deemed necessary for eCP, and these were classified into six categories: displaying, recording, ordering, editing, variance, and statistics. Although most of these functions are already included in eCP products, their implementations differ between products.

Conclusions

We propose 17 standard functions required for eCP embedded in electronic medical records. The functions for editing patient checklists, checking the occurrence of variance, and statistics are especially important and should be implemented as standard functions. This study will aid in the future development of eCP embedded in electronic medical records.