Improving clinical decisions and outcomes with information: a review

The clinical information available to clinicians is expanding rapidly. It can enhance clinical decision-making, but it can also confuse the process. To be most useful, information should be available at the time and place it is needed and be specific to the task at hand. In the new paradigm of medicine, one based on continuous quality improvement, useful information must be relevant to both the processes and outcomes of care. Clinical practice guidelines have become increasingly popular for improving the quality of health care. The field of medical informatics can bring cogent information to the point where decisions are being made to augment quality improvement activities in general, and practice guidelines in particular. However, such innovations are dependent on the type, quantity, and quality of information available. This article discusses when guidelines can enhance the quality and outcomes of care and how medical informatics can help achieve these goals. In particular, the barriers to the broad implementation of electronic medical records in a variety of health care settings are explored.     

Improving informed consent to chemotherapy: a randomized controlled trial of written information versus an interactive multimedia CD-ROM

Objective

This randomized controlled trial aimed to determine whether an interactive CD-ROM improved cancer patients’ recall of chemotherapy treatment information over standard written information, and whether demographic, cognitive, and psychological factors better predicted recall than this format of delivery.

Methods

One-hundred-and-one new patients about to commence chemotherapy were randomized to receive written information or a CD-ROM containing treatment information before giving informed consent. Patients’ recall, concentration, short-term memory, reading comprehension, anxiety, depression, and coping styles were assessed with standardized measures pre-treatment. Seventy-seven patients completed tests for recall of treatment information before their second chemotherapy session.

Results

Intention-to-treat analyses indicated no significant differences between the written information and CD-ROM groups across recall questions about number of drugs received (p = .43), treatment length (p = .23), and treatment goal (p = .69). Binary logistic regressions indicated that for groups combined different variables predicted each of the recall questions.

Conclusion

An interactive CD-ROM did not improve cancer patients’ recall of treatment information enough to warrant changes in consent procedures.

Practice implications

Different variables predicted recall of different treatment aspects highlighting the complex nature of attempting to improve patient recall. Attending to the effect of depression on patient knowledge and understanding appears paramount.     

Users' satisfaction with the primary health care information system in Croatia: a cross-sectional study

Aim

To evaluate the primary health care information system from the general practitioner''s (GP) point of view.

Methods

Sixty-seven Croatian GPs were distributed a questionnaire about characteristics of the GP’s office, overall impression of the application, handling of daily routine information, more sophisticated information needs, and data security, and rated their satisfaction with each component from 1 to 5. We also compared two most frequently used applications – application with distantly installed software (DIS) and that with locally installed software (LIS, personal computer-based application).

Results

GPs were most satisfied with the daily procedures and the reminder component of the health information system (rating 4.1). The overall impression ranked second (3.5) and flexibility of applications followed closely (3.4). The most questionable aspect of applications was data security (3.0). LIS system received better overall rate than DIS (4.2 vs 3.2).

Conclusion

Applications received better ratings for daily routine use than for overall impression and ability to get specific information according the GPs’ needs. Poor ratings on the capability of the application, complaints about unreliable links, and doubts about data security point to a need for more user-friendly interfaces, more information on the capability of the application, and a valid certificate of assessment for every application.The application of information and communication technology (ICT) to health care has changed the current medical practice. The most prominent aspect of ICT is the electronic health record (EHR). Some authors confirmed that the EHR indeed led to higher performance ratings on certain quality measures (1,2), whereas others were suspicious about it (3,4). The EHR systems offer better management of clinical data and improvement of management and prevention of chronic diseases (5). Both physicians and patients generally have a positive attitude toward the EHR (6). However, both are concerned about issues like privacy, physician-patient relationship, cost, time, and training needs. Only 10.2% of physicians in ambulatory care declared interest in using information technology in their daily practice (7).Further potential applications of an ICT-based information system in general practice are electronic reminders and decision support. Several studies show positive effects of electronic reminders: a recall system can result in higher immunization rates against seasonal influenza of high-risk groups (8), computerized body mass index charts increase the likelihood that physicians would diagnose obesity and refer patients to treatment (9), and decision support in electronic prescribing leads to more responsible prescribing (10-13). However, the use of electronic reminders does not seem to improve the quality of care in diabetes and coronary artery disease (14).Implementation of ICT leads to decreased financial expenses (15,10). Negative implications of modern technology include increased duration of consultation, more stress for the physicians (16), and increased data entry at least at the beginning of ICT use (17). Computers in the examination room could affect the patient-centered practice, shorten the patient-physician interaction and interfere with it, particularly in the psychosocial and emotional aspects. Looking at the screen is particularly disruptive and often leads to poor eye contact with the patient (18). Still, the most recent studies have not found any negative influence of ICT on the physician-patient relationship, even with psychiatric patients (19,20). Finally, in spite of different attitudes toward an ICT-based health information system in clinical practice, EHR serves as a cohesive clinical basis and allows physicians to carry out research or analyze their professional activities more easily (1).The general challenge for developers of ICT applications in health care is to make them suitable for health professionals’ information needs. Users’ satisfaction or dissatisfaction with ICT applications is one of the most important issues to be considered. There is a number of ICT applications in health care worldwide, and Croatia is not an exception. Primary Health Care Information System (PHCIS) was one of the first e-Government activities in Croatia. It started in 2002 and was fully implemented in 2008. Designed to cover the primary health-care information needs, the PHCIS consists of the central EHR repository (the so-called first level), accessible by locally installed applications in GP’s offices, and the second level for authorized users only (21-23). Development of the PHCIS was initiated by the Ministry of Health and Social Welfare and the Croatian Health Insurance Institute. The tender was announced early in 2003 and its winner, an ICT enterprise, included public health experts and several GPs to serve as health professional consultants in the development. This group primarily worked on the core system or the first level. The second level involved a number of smaller ICT companies working on the local information needs, ie, information needs of GPs in their daily work with the patients. The users of second level ICT applications were obliged to communicate with the first-level users – to send and receive data. There were eight available ICT applications (status on October 12, 2011) enabling the end-users (GPs and nurses) to enter patients’ data and use it in their daily work, as well as to create reports for administrative, professional, and other purposes. Any GP’s office could choose one of the certified ICT applications from the list on the PHCIS web site (http://www.cezih.hr). Two basic approaches in the development of the second level ICT applications were distantly installed software (DIS) and locally installed software (LIS). DIS was web-based approach installed on distant servers connected to the first level of PHCIS, outside of the GP’s office, but the GP could access it by standard browser through the virtual private network. LIS was installed on computers in the GP’s office connected directly to the first level of PHCIS. Both applications were able to send some selected patients’ data to the first level of PHCIS.The aim of this study was to analyze the second (local) level of PHCIS from the users (GPs’) point of view and the specific aims included the following: 1) to find out specific functions of ICT applications that were thought to be appropriate or problematic and 2) to compare two conceptually different approaches to the development of the local applications.     

Retrieval processes in adults with ADHD: a RAVLT study

Attention-deficit hyperactivity disorder (ADHD) is associated with memory deficiencies. In the current study we compared different aspects of verbal memory using standard and constructed measures of the Rey auditory verbal learning test (RAVLT). Performance on learning and recognition measures of RAVLT was similar in both ADHD and control groups. In contrast, adults with ADHD committed more double recalls and intrusion errors, indicating inaccurate recall processes. These findings suggest that memory problems in adults with ADHD may be caused by deficient executive processes that support retrieval from memory.     

Laboratory information and consultation service with a ordering system

We built a laboratory information system that does not require resident medical technologists or medical doctors. The laboratory information system used the following two methods. In the first method, the receiver of questions/complaints/consultations about laboratory tests used e-mail carried by an ordering system. In the second method, the Web utilized a laboratory test information retrieval system by intranet. As for e-mail inquirers, doctors made up 76.7%(46/60), and other types of job were office workers 11.7% (7/60), nurses 8.3%(5/60), and pharmacists 3.3%(2/60). The question(consultation) contents were test methods 30.0%, demands/complaints 28.3% for ordering, specimen saving requests 13.3%, consultations 11.7%, and other 16.7%. Since introducing this system, compared to previously telephone inquiries have by about 60% decreased, and basic questions such as reference intervals or containers have decreased even more. The system operates 24 hours a day and dose not increase the current workload, thus allowing the accumulation of a laboratory information system.     

A new terminal for a hospital information system

Summary We have developed a new hospital terminal that is easy and accurate to handle. We believe that a good terminal is the key to a successful hospital information system. Presented at the 9th ICMBE, Melbourne, Australia, in August 1971     

Modelling health care processes for eliciting user requirements: a way to link a quality paradigm and clinical information system design.

Healthcare institutions are looking at ways to increase their efficiency by reducing costs while providing care services with a high level of safety. Thus, hospital information systems have to support quality improvement objectives. The elicitation of the requirements has to meet users' needs in relation to both the quality (efficacy, safety) and the monitoring of all health care activities (traceability). Information analysts need methods to conceptualise clinical information systems that provide actors with individual benefits and guide behavioural changes. A methodology is proposed to elicit and structure users' requirements using a process-oriented analysis, and it is applied to the blood transfusion process. An object-oriented data model of a process has been defined in order to organise the data dictionary. Although some aspects of activity, such as 'where', 'what else', and 'why' are poorly represented by the data model alone, this method of requirement elicitation fits the dynamic of data input for the process to be traced. A hierarchical representation of hospital activities has to be found for the processes to be interrelated, and for their characteristics to be shared, in order to avoid data redundancy and to fit the gathering of data with the provision of care.     

Parallel and serial attentional processes: A developmental ERP study

We studied the development of attentional processes in parallel and serial visual search tasks. Event‐related potentials (ERPs) were recorded for children (n = 40, age = 7–12 years) from 25 electrodes. Pop‐out paradigms were used in the 2 parallel processing tasks; the standard stimuli were small blue rectangles. In the color parallel task the pop‐out stimuli were small red rectangles. In the size task the targets were large blue squares. In the serial task the targets were a conjunction of features from the parallel tasks (i.e., large red squares). RTs varied with age and task. There were decreases in P3 latency with age, task, and an Age × Task interaction due to slower age‐related changes in the size compared to the color task. The data suggest that developmental changes in visual selective attention are tied more closely to the features of the target stimuli than to the parallel‐serial distinction, results consistent with the guided search model of attention.     

Basic study of a transcutaneous information transmission system using intra-body communication

The transcutaneous communication system (TCS) is one of the key technologies for monitoring and controling artificial hearts and other artificial organs in the body. In this study, we have developed a new TCS that uses the human body as a conductive medium. Having no energy conversion from electric currents into electromagnetic waves and light provides energy-saving data transmission with a simple electrical circuit. Each unit of the TCS mainly consists of two electrodes, an amplitude shift keying (ASK) modulator and an ASK demodulator (carrier frequency: 4 and 10 MHz). A resonant frequency of an L-C tank circuit including the capacitance component of the body is tuned into each carrier frequency in order to apply the data current effectively into the body. Performance of the TCS was evaluated by a communication test on the surface of a human body. The TCS was able to transmit 3,315 bytes of data bi-directionally at a transmission rate of 115 kbps from a left wrist to a right forearm, to an abdomen and to a left calf without communication error. The power consumption of each TCS unit was 125 mW with an ASK modulated current of 7 mA (RMS). While further study is required to secure its safety, the TCS promises to be a next-generation transcutaneous communication device.     

Anthropic agency: a multiagent system for physiological processes

Multiagent systems are powerful and flexible tools for modelling and regulating complex phenomena. In fact, a way to manage the complexity of a phenomenon is to decompose it in such a way that each agent embeds the control model for a portion of the phenomenon. In this perspective, the cooperative interaction among the agents results in the controller for the whole phenomenon. Since the portions in which the phenomenon is decomposed may overlap, the actions the single agents undertake to regulate these portions may conflict; hence a balanced negotiation is required. A class of complex phenomena that present several difficulties in their satisfactory modelling and controlling is the class of physiological processes. The purpose of this paper is to introduce a general multiagent architecture, called anthropic agency, for the modelling and the regulation of complex physiological phenomena.     

Network system: The integrated picture archiving and communication system with the hospital information system

We describe the outline of Hokkaido University picture archiving and communication system (HU-PACS) and its network functions. HU-PACS processes 0.5 Gbytes of images daily through 10 acquisition devices. Functional integration of hospital information system (HIS) and PACS has been implemented. The HU-PACS can access common data base with HIS. Multi-image data-base systems provide fast throughput of image retrieval.

The system is composed of 4 modules: (1) 2 image data-base systems (IDS), (2) 1 image management system (IMS), (3) image display terminals (IDT), and (4) 8 image acquisition nodes interfaced to 10 modalities and 1 film scanner. These 4 modules are connected by branch and loop type local area networks (LAN). HU-PACS has functions other than basic PACS functions. Images in optical disk library (ODL) are loaded onto magnetic disks (MD) in advance according to patient booking information, the images expected to be viewed are transferred to the local storage automatically, and the desired images can be pre-downloaded into local storage by instruction through HIS terminals.

     

Clinical engineering's involvement with a computerized hospital information system

This paper describes a computerized Hospital Information System (HIS) installed in Mount Zion Hospital and Medical Center along with the Clinical Engineering Department's involvement in the minor and major maintenance of the 48 data stations consisting of terminals and printers. This paper also includes a summary of maintenance man-hour distribution, data station repair problems and the type of repair equipment and personnel needed to maintain hospital computer systems.     

Measuring mobile patient safety information system success: an empirical study

OBJECTIVE: The Health Risk Reminders and Surveillance (HRRS) system was designed to deliver critical abnormal test results of severely ill patients from Laboratory, Radiology, and Pathology departments to physicians within 5 min using cell phone text messages. This paper explores the success of the HRRS system. METHOD: This study employed an augmented version of the DeLone and McLean IS success model. Seven variables (system quality, information quality, system use, user satisfaction, mobile healthcare anxiety, impact on the individual and impact on the organization) were used to evaluate the success of the HRRS system. The interrelationships between the seven variables were hypothesized and the hypotheses were empirically tested. RESULTS: The results indicate that the information quality of the HRRS system is positively associated with both system use and user satisfaction. In addition, system use is positively associated with user satisfaction, which is also positively associated with mobile healthcare anxiety. Moreover, results indicate that impact on the individual is positively associated with both user satisfaction and mobile healthcare anxiety. Finally, the impact of the organization is positively associated with impact on the individual. CONCLUSION: The results of the study provide an expanded understanding of the factors that contribute to mobile patient safety information system (IS) success. Implications of the relationship between system use and physician mobile healthcare anxiety are discussed.     

Hospital information system institutionalization processes in indonesian public,government-owned and privately owned hospitals

The Hospital Information System (HIS) could help hospitals as a public entity to provide optimal health services. One of the main challenges of HIS implementation is an institutional change. Using institutional theory as the analytical lens, this study aims to explain the institutionalization of HIS as an instance of e-health initiatives in Indonesia. Furthermore, this paper aims for hospital management and researchers to improve the understanding of the social forces that influence hospital personnel's HIS acceptance within an organizational context. We use case studies from four public, government-owned hospitals and four privately owned (public and specialty) hospitals to explain the HIS institutionalization process by exploring the three concepts of institutional theory: institutional isomorphism, institutional logic, and institutional entrepreneurship. This study reveals that differences exist between public, government-owned and private hospitals with regard to the institutionalization process: public, government-owned hospitals’ management is more motivated to implement HIS to comply with the regulations, while private hospitals’ management views HIS as an urgent requirement that must be achieved. The study findings also reveal that various institutional isomorphism mechanisms and forms of institutional logic emerge during the process. Finally, three factors—self-efficacy, social influence, and management support—have a significant influence on the individual acceptance of HIS.     

Fluorescence diffuse optical tomography with functional and anatomical a priori information: feasibility study

Fluorescence diffuse optical tomography (FT) is an emerging molecular imaging technique that can spatially resolve both fluorophore concentration and lifetime parameters. In this study, we investigate the performance of a frequency-domain FT system for small inclusions that are embedded in a heterogeneous background. The results demonstrate that functional and structural a priori information is crucial to be able to recover both parameters with high accuracy. The functional a priori information is defined by the absorption and scattering maps at both excitation and emission wavelengths. Similarly, the boundaries of the small inclusion and different regions in the background are utilized as the structural a priori information. Without a priori information, the fluorophore concentration of a 5 mm inclusion in a 40 mm medium is recovered with 50% error, while the lifetime cannot be recovered at all. On the other hand, when both functional and structural information are available, the true lifetime can be recovered and the fluorophore concentration can be estimated only with 5% error. This study shows that a hybrid system that can acquire diffuse optical absorption tomography (DOT), FT and anatomical images in the same setting is essential to be able to recover the fluorophore concentration and lifetime accurately in vivo.     

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

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

Improving greater trochanteric reattachment with a novel cable plate system

Cable-grip systems are commonly used for greater trochanteric reattachment because they have provided the best fixation performance to date, even though they have a rather high complication rate. A novel reattachment system is proposed with the aim of improving fixation stability. It consists of a Y-shaped fixation plate combined with locking screws and superelastic cables to reduce cable loosening and limit greater trochanter movement.The novel system is compared with a commercially available reattachment system in terms of greater trochanter movement and cable tensions under different greater trochanteric abductor application angles.A factorial design of experiments was used including four independent variables: plate system, cable type, abductor application angle, and femur model. The test procedure included 50 cycles of simultaneous application of an abductor force on the greater trochanter and a hip force on the femoral head.The novel plate reduces the movements of a greater trochanter fragment within a single loading cycle up to 26%. Permanent degradation of the fixation (accumulated movement based on 50-cycle testing) is reduced up to 46%. The use of superelastic cables reduces tension loosening up to 24%. However this last improvement did not result in a significant reduction of the grater trochanter movement.The novel plate and cables present advantages over the commercially available greater trochanter reattachment system. The plate reduces movements generated by the hip abductor. The superelastic cables reduce cable loosening during cycling. Both of these positive effects could decrease the risks related to grater trochanter non-union.