Methodological framework for evaluating clinical processes: A cognitive informatics perspective

We propose a methodological framework for evaluating clinical cognitive activities in complex real-world environments that provides a guiding framework for characterizing the patterns of activities. This approach, which we refer to as a process-based approach, is particularly relevant to cognitive informatics (CI) research—an interdisciplinary domain utilizing cognitive approaches in the study of computing systems and applications—as it provides new ways for understanding human information processing, interactions, and behaviors. Using this approach involves the identification of a process of interest (e.g., a clinical workflow), and the contributing sequences of activities in that process (e.g., medication ordering). A variety of analytical approaches can then be used to characterize the inherent dependencies and relations within the contributing activities within the considered process. Using examples drawn from our own research and the extant research literature, we describe the theoretical foundations of the process-based approach, relevant practical and pragmatic considerations for using such an approach, and a generic framework for applying this approach for evaluation studies in clinical settings. We also discuss the potential for this approach in future evaluations of interactive clinical systems, given the need for new approaches for evaluation, and significant opportunities for automated, unobtrusive data collection.     

New frontiers for nursing and health care informatics

Health care and health information have been around since the time of Hippocrates or even before. Through the historical evolution, it is observed that the knowledge and information that were simple and easy to learn and retain by that time, became much more complex. This paper presents a brief reviewing on the evolution of MEDINFO conferences, and how nursing informatics grew up and made itself visible during all these years of IMIA conferences.     

A survey of informatics approaches to whole-exome and whole-genome clinical reporting in the electronic health record

PurposeGenome-scale clinical sequencing is being adopted more broadly in medical practice. The National Institutes of Health developed the Clinical Sequencing Exploratory Research (CSER) program to guide implementation and dissemination of best practices for the integration of sequencing into clinical care. This study describes and compares the state of the art of incorporating whole-exome and whole-genome sequencing results into the electronic health record, including approaches to decision support across the six current CSER sites.MethodsThe CSER Medical Record Working Group collaboratively developed and completed an in-depth survey to assess the communication of genome-scale data into the electronic health record. We summarized commonalities and divergent approaches.ResultsDespite common sequencing platform (Illumina) adoptions, there is a great diversity of approaches to annotation tools and workflow, as well as to report generation. At all sites, reports are human-readable structured documents available as passive decision support in the electronic health record. Active decision support is in early implementation at two sites.ConclusionThe parallel efforts across CSER sites in the creation of systems for report generation and integration of reports into the electronic health record, as well as the lack of standardized approaches to interfacing with variant databases to create active clinical decision support, create opportunities for cross-site and vendor collaborations.Genet Med15 10, 824–832.     

Anniversary paper: roles of medical physicists and health care applications of informatics

Over the past 100 years, both diagnostic radiology and radiation therapy have grown from infancy to maturity. Accompanying this growth, the discipline of medical physics has evolved and advanced accordingly. New diagnostic and therapeutic procedures continue to be developed, for example, multidetector computed tomography, multileaf collimation, magnetic resonance imaging, dual-source computed tomography, and intensity-modulated radiation therapy. These are now incorporated in health care facilities throughout the world. Modern technologies such as these provide information on underlying pathology at increasingly higher resolutions, generating more information; thus requiring complex methods of image recording and storage. The management of the storage and retrieval of accumulated information is a domain of informatics. In this short review, we describe the different roles of medical physicists and the effective contribution of the American Association of Physicists in Medicine in the evolution of informatics. Medical physicists have contributed to the development of informatics in numerous ways, such as designing hospital information systems and infrastructures that better serve radiologists and other physicians. In addition, the positive exploitation of knowledge gathered in medical settings and effective interdisciplinary collaborations between scientists of different backgrounds have increased. These developments provide future medical physicists the opportunity to develop strategic roles in information technology and thus better contribute to health care.     

Medical informatics training programme to support the Romanian health care management information system

The Health Management Information System (HMIS) project initiated by the Romanian Ministry of Health as a component of the healthcare reform is aiming to ensure the technical, functional and operative support for: (i) a better overview of the population health status, of the medical care needs and of the Health System performances; (ii) the improvement of the resource allocation and consumption; and (iii) reform support. This system is supposed to assure a better information flow from the lower to the upper levels of the healthcare network by help of a modern IT support. In the first development stage the system is planned to link the Ministry of Health with the 41 District Health Authorities (DHAs) and with more than 200 pilot health units. The implementation of such a large system raises serious problems of acceptability and a thorough training programme for both technical staff and end users must be considered in order to face this challenge.     

Master of science program in health information management at Heidelberg/Heilbronn: a health care oriented approach to medical informatics

In the year 2000 the University of Heidelberg and the University of Applied Sciences Heilbronn established a second educational program in medical informatics, leading to a Master of Science (MSc) degree. In addition to their 4.5 year medical informatics program as an informatics-based approach to medical informatics, a postgraduate program in 'health information management' (Informationsmanagement in der Medizin) was set up as a complementary health care oriented approach to this field. The aim of the MSc program is to qualify physicians and other health care professionals to work as medical informaticians, particularly in the area of health information management. We admit 15 new students into the program each year. The intended program length is 15 months, comprising two study semesters (14 weeks per semester) and three months for the Master's thesis. The graduates are awarded the title 'Master of Science' by the Medical Faculty of the University of Heidelberg. The program is part of the International Partnership in Health Informatics Education of the Universities of Amsterdam, Heidelberg/Heilbronn, Minnesota and Utah. We report on this new program and on our experience with our very first students. The curriculum is compared with the related MSc programs.     

Playing in the mud: health psychology, the arts and creative approaches to health care

Health psychologists' use of the arts is an emerging area for research and practice. This article examines recent research findings and suggests strategies for incorporating the arts in health care across a wide range of clinical and community settings. Ethological theories support the evolutionary significance of the arts in human development and help form a foundation to understand the biopsychosocial processes involved in arts participation. This article builds upon this foundation and presents a wide range of arts and health interventions in the areas of health promotion and prevention, illness management, clinical assessment and improvement of the health care system.     

Evaluation in health informatics: computer simulation

The evaluation of complex medical informatics applications involves not only the information system, but also its impact on the organizational environment in which it is implemented. In instances where these applications cannot be evaluated with traditional experimental methods, computer simulation provides a flexible approach to evaluation. The construction of a computer simulation model involves the development of a model that represents important aspects of the system under evaluation. Once validated, the model can be used to study the effects of variation in system inputs, differences in initial conditions and changes in the structure of the system. Three examples are discussed, namely, a wide-area health care network, physician order entry into a hospital information system, and the use of an information system designed to prevent medical errors that lead to adverse drug events in hospitals.     

Evaluation in health informatics: social network analysis

Social network analysis comprises a set of research methods that can be used to analyze the relationships among entities such as people, departments, and organizations. The purpose of the analysis is to discover patterns of relationships that affect both individual and organizational attitudes and behavior such as the adoption, diffusion, and use of new medical informatics applications. This paper presents an introduction to the concepts and methods of social network analysis. Several applications to health informatics are described.     

Synergy between medical informatics and bioinformatics: facilitating genomic medicine for future health care

In this paper, we review the results of BIOINFOMED, a study funded by the European Commission (EC) with the purpose to analyse the different issues and challenges in the area where Medical Informatics and Bioinformatics meet. Traditionally, Medical Informatics has been focused on the intersection between computer science and clinical medicine, whereas Bioinformatics have been predominantly centered on the intersection between computer science and biological research. Although researchers from both areas have occasionally collaborated, their training, objectives and interests have been quite different. The results of the Human Genome and related projects have attracted the interest of many professionals, and introduced new challenges that will transform biomedical research and health care. A characteristic of the 'post genomic' era will be to correlate essential genotypic information with expressed phenotypic information. In this context, Biomedical Informatics (BMI) has emerged to describe the technology that brings both disciplines (BI and MI) together to support genomic medicine. In recognition of the dynamic nature of BMI, institutions such as the EC have launched several initiatives in support of a research agenda, including the BIOINFOMED study.     

Women's decision-making about their health care: views over the life cycle

This paper describes a compilation and further analysis of three qualitative studies, conducted independently, on women's health care decisions. Key areas regarding women's health, which span the life cycle, were examined including prenatal genetic screening, hormone replacement therapy and the use of complementary/alternative medicine in the treatment of breast cancer. Common themes were evident across all the focus groups in each of the three studies including: women's information seeking behavior; reliance on trusted information sources; the desire for information sharing; active involvement in the decision-making process; and accepting the consequences of the final decision. The findings have important implications for health care professionals as they engage women in the decision-making process about health concerns.     

The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care

Several studies have shown that there is information loss during interruptions, and that multitasking creates higher memory load, both of which contribute to medical error. Nowhere is this more critical than in the emergency department (ED), where the emphasis of clinical decision is on the timely evaluation and stabilization of patients. This paper reports on the nature of multitasking and shift change and its implications for patient safety in an adult ED, using the methods of ethnographic observation and interviews. Data were analyzed using grounded theory to study cognition in the context of the work environment. Analysis revealed that interruptions within the ED were prevalent and diverse in nature. On average, there was an interruption every 9 and 14 min for the attending physicians and the residents, respectively. In addition, the workflow analysis showed gaps in information flow due to multitasking and shift changes. Transfer of information began at the point of hand-offs/shift changes and continued through various other activities, such as documentation, consultation, teaching activities and utilization of computer resources. The results show that the nature of the communication process in the ED is complex and cognitively taxing for the clinicians, which can compromise patient safety. The need to tailor existing generic electronic tools to support adaptive processes like multitasking and handoffs in a time-constrained environment is discussed.     

Experimental approaches to age-related cognitive impairments

Rats exhibit morphological, biochemical, and metabolic changes in their brains, as well as cognitive deficits, with aging. Aged rats were found to be significantly impaired compared to young rats in a water maze task and test of motor coordination, and show reduced locomotor activity and exploration. Although aged rats did exhibit deficits as a group, not all aged rats were impaired. Additionally, the subgroup that was impaired on one task was not necessarily the subgroup that was impaired on another task. The cholinergic projection neurons in the basal forebrain region were significantly atrophied in the aged rodent. The degree of atrophy was highly correlated with the cognitive impairment exhibited on the Morris water maze task. Swollen choline acetyltransferase (ChAT)-positive "plaque-like" structures were observed in the neocortex of the aged but not the young rats. Declines in cholinergic activity in the brain has also been observed during aging. Biochemical measurements of ChAT in the basal forebrain region of aged rats revealed small but consistent decreases in ChAT activity compared to young rats. General metabolic activity, measured by the 2-deoxyglucose method, was also decreased in the hippocampal CA1 and CA3 fields, the dentate gyrus, the medial septal-diagonal band area, and the prefrontal cortex of aged rats. There was a significant correlation between the decrease in glucose utilization and deficits on the Morris water maze. Most aged rats exhibit pathological EEG patterns as reflected by frequent long-duration high voltage neocortical spindles (HVS) during immobility. Bilateral lesions of the nucleus basalis and scopolamine treatment increased the incidence of HVS, thereby mimicking changes in the aged brain. We attempted to ameliorate the cognitive deficits observed in subgroups or impaired rats by either: (1) implanting fetal cells of basal forebrain origin into the hippocampus, or (2) infusing nerve growth factor (NGF) chronically into the lateral ventricle. The grafts appeared to facilitate an improvement in the ability of the impaired aged rats to perform in the Morris water maze. This improved performance was reversed by injections of atropine at doses that did not affect the behavior of young animals that performed well in the same task. These results suggest that enhancement of the cholinergic system could have an effect on the performance of the impaired aged animals. The study of the effects of infusions of NGF clearly demonstrate that the ability of impaired aged rats to remember what they had previously learned was increased after NGF treatment.(ABSTRACT TRUNCATED AT 400 WORDS)     

International Master Classes in health informatics

Master Classes arose within the performing arts and are now being offered in system sciences. The IPhiE group of faculty from six universities in Europe and the United States has offered Master Classes in health informatics to provide an integrative forum for honors students. Featured are international views of health systems, varied opportunities for student interaction and promotion of informatics professionalism. Five years of experience indicate the success of this concept and suggest changes that will be considered for the future.     

Skill needs for nurses in their role as health informatics professionals: a survey in the context of global health informatics education

In the process of developing global health informatics education, a common understanding of educational outcomes is required. Therefore, an educational framework for health informatics professionals is desirable to support student mobility, trans-national and borderless education. Nurses form a significant part of the health workforce and need to be properly educated for their roles in health informatics. To ascertain their perceptions of needs and priorities, we developed a web-based questionnaire and surveyed Australian nurses on the preferred knowledge/skills set for health informatics professionals. Among others, the questionnaire is based on the International Medical Informatics Association's (IMIA) set of recommendations on education and IMIA's scientific map. Benner's five levels of competencies were applied to measure the degree of competency required for each skill/knowledge. Altogether, 82 Australian nurses completed the questionnaire. The nurses' perceived degree of competency required for a total of 74 specific skills and knowledge in five skill categories is presented in this paper as well as the overall results for each of the five categories. Further, significant differences between the nurses' primary roles and primary interest in health informatics are discussed. The development of a comprehensive health informatics education framework needs to take into account nurses as well as other health professionals. Repeating the survey in other countries and for various professions is essential to develop an international educational framework.