Øystein Nytrø

Characterising cooperation in the ward: framework for producing requirements to mobile electronic healthcare records

We present a framework for characterising hospital scenarios involving the patient chart. The paper-based chart is regarded as simple, efficient, and handy for mobile use by patient-care teams. However, the chart is available in only one physical place at a time, and it needs to be manually synchronised with the electronic healthcare record (EHR). The framework presented in this paper has been developed for use in non-participatory, observational studies performed at the University Hospital of Trondheim, conducted as a part of the MOBEL (MOBile ELectronic patient chart) project at NTNU. We have developed the framework iteratively; repeatedly observing groups in the ward, characterising observations in the framework, and changing attributes and outcome values. This paper presents our latest framework, a representative choice of scenarios, and their characterisation. We conclude with a discussion of results so far, the method, and the utility in the development of the MEPC.

Characteristics of Finnish and Swedish intensive care nursing narratives: a comparative analysis to support the development of clinical language technologies

BackgroundFree text is helpful for entering information into electronic health records, but reusing it is a challenge. The need for language technology for processing Finnish and Swedish healthcare text is therefore evident; however, Finnish and Swedish are linguistically very dissimilar. In this paper we present a comparison of characteristics in Finnish and Swedish free-text nursing narratives from intensive care. This creates a framework for characterising and comparing clinical text and lays the groundwork for developing clinical language technologies.MethodsOur material included daily nursing narratives from one intensive care unit in Finland and one in Sweden. Inclusion criteria for patients were an inpatient period of least five days and an age of at least 16 years. We performed a comparative analysis as part of a collaborative effort between Finnish- and Swedish-speaking healthcare and language technology professionals that included both qualitative and quantitative aspects. The qualitative analysis addressed the content and structure of three average-sized health records from each country. In the quantitative analysis 514 Finnish and 379 Swedish health records were studied using various language technology tools.ResultsAlthough the two languages are not closely related, nursing narratives in Finland and Sweden had many properties in common. Both made use of specialised jargon and their content was very similar. However, many of these characteristics were challenging regarding development of language technology to support producing and using clinical documentation.ConclusionsThe way Finnish and Swedish intensive care nursing was documented, was not country or language dependent, but shared a common context, principles and structural features and even similar vocabulary elements. Technology solutions are therefore likely to be applicable to a wider range of natural languages, but they need linguistic tailoring.AvailabilityThe Finnish and Swedish data can be found at: http://www.dsv.su.se/hexanord/data/.

Personalized access control for a personally controlled health record

Access control is a key feature of healthcare systems. Up until recently most healthcare information systems have been local to a healthcare facility and accessible only to clinicians. Currently there is a move towards making health information more accessible to patients. One example is the Personally Controlled Health Record (PCHR) where the patient is in charge of deciding who gets access to the information. In the PCHR the patient is the administrator of access control. While it certainly is possible to create roles representing people most patients would want to share with, like primary physician, it is also likely, and desirable, to afford the patients a high level of control and freedom to be able to create specialized access policies tailored to their personal wishes. We entitle this personalized access control. In this paper we present a semi-formal model for how we believe personalized access control may be realized. The model draws on and combines properties and concepts of both Role-Based Access Control (RBAC) and Discretionary Access Control (DAC) to achieve the desired properties. Throughout the paper we use the PCHR as a motivating example and to explain our reasoning and practical use of the model.

Designing Pervasive Computing for Hospitals: Learning from the Media Affordances of Paper-Based Medication Charts

The current article investigates the affordances associated with paper out of the motivation that this can help inform design of pervasive and ubiquitous computing solutions for clinical use. In particular, we focus on paper-based medication charts, and discuss how these artifacts differ from various digital and context-aware solutions both in terms of media properties and functionalities. Based on a comparison of media, we argue that the affordances offered by the paper-based medication charts are not fully transferable to one digital medium, but that a combination of complementary digital media is required

Access Control and Integration of Health Care Systems: An Experience Report and Future Challenges

Health information about a patient is usually scattered among several clinical systems, which limits the availability of the information. Integration of the most central systems is a possible solution to this problem. In this paper we present one such integration effort, with a focus on how access control is handled in the integrated system. Although this effort has not yet solved all the issues of access control integration, it demonstrates a practical approach for creating something that works today and serves as input to the discussion on future challenges for access control when integrating multiple systems

Ontologies for knowledge representation in a computer-based patient record

In contrast to existing patient-record systems, which merely offer static applications for storage and presentation, a helpful patient-record system is a problem-oriented, knowledge-based system, which provides clinicians with situation-dependent information. We propose a practical approach to extend the current data model with (1) means to recognize and interpret situations, (2) knowledge of how clinicians work and what information they need, and (3) means to rank information according to its relevance in a given care situation. Following the methodology of second-generation knowledge-based systems, that use ontologies to define fundamental concepts, their properties, and interrelationships within a particular domain, we present an ontology that supports three prerequisite features for a future helpful patient-record system: a family-care workflow process, a problem-oriented patient record, and means to identify relevant information to the care process and medical problems.

Towards a tomographic framework for structured observation of communicative behaviour in hospital wards

The research presented in this paper investigates how observation of information- and communication-intensive work in hospital wards can be used to produce requirements for mobile clinical information systems. Over a number of years, we have explored how important properties of clinical situations can be captured through structured observations of actors, processes, and systems. In the paper, we present experience from four observational studies of a total of more than 400 hours in hospital wards. Based on the observational studies, we propose a framework for structured, tomographic, observation of clinical work practice. We also briefly discuss and illustrate how the field data can be analyzed and used as input to the requirements engineering process.

Does the Electronic Patient Record Support the Discharge Process? A Study on Physicians' Use of Clinical Information Systems during Discharge of Patients with Coronary Heart Disease

This study has been performed in order to categorise and measure usage of different information sources and types in a well defined stage of clinical work. The underlying motivation is to improve computer-supported presentation and retrieval of relevant information and to be able to evaluate the functionality of a future improved interface to the electronic patient record (EPR). By observing 52 discharge processes and categorising information types and sources, we have observed that the paper chart is used as a primary source of information about recent events and procedures, while the EPR is mostly used for retrieving background information and verification. Direct communication with other clinicians and the patient is also important during the discharge process. Results from an additional survey show that the physicians report greater use of the EPR than the result from the observational study. The study clearly indicates that there is a large potential for improved EPR systems that support the physicians in their work regarding discharge of patients, especially in the future planning part of the discharge.

Clinical guidelines as decision support for referrals from primary care

This work describes the use of clinical guidelines in public health care for decision support in a primary care record system. The clinical guidelines were used for decision support in primary care in order to improve the quality of electronic referrals to a hospital. Guidelines were developed by the specialists at the hospital, but the design and the development of the system was done in collaboration with general practitioners working in primary care. This paper sums up the findings from a study six months after the introduction of the decision support system, and is based on interviews with users in primary care. The work processes differed between the practices; General practitioners who wrote the referrals after the patient had left the office did not find the system as useful as the ones who wrote them when the patient was present. The general practitioners were reluctant to use guidelines that resulted in an additional workload in terms of providing the hospital with more information than before, but found the system useful as a support for assuring that they made the right clinical decisions. The guidelines were also seen as useful as a support for refusing to refer the patient to specialized care.

Usability Evaluation of Published Clinical Guidelines on the Web: A Case Study

Publishing clinical guidelines (GLs) on the web improves their accessibility. Although such publication is common, usability evaluation of GLs and their web presentation has been neglected. In this study we have carried out such an evaluation. Four of the most commonly used GL websites in Norway were selected for evaluation. In addition, we included UpToDate, which is widely used under a national licence in Norway. A total of 14 volunteer GL users participated in our case study. A pretest survey, scenario-based task completion, system usability scale (SUS) questionnaire, observation, and semi-structured interview were methods we employed. A step-by-step thematic synthesis method was used on the interview transcripts to identify themes. Analysis of the SUS results show that except for UpToDate, there was no correlation between user familiarity with the studied website and higher SUS score. Users were mostly concerned about the amount of text and scrolling, font size, no more than one navigation bar and no redirection to other websites. Keeping the same format and structure for presentation in all web pages and presenting numerical information in tabular format were the other suggestions for improvement. The results of this paper can be used by GL publishers to improve their websites usability.