Ricardo Cruz-Correia

Reviewing the integration of patient data: how systems are evolving in practice to meet patient needs

BackgroundThe integration of Information Systems (IS) is essential to support shared care and to provide consistent care to individuals – patient-centred care. This paper identifies, appraises and summarises studies examining different approaches to integrate patient data from heterogeneous IS.MethodsThe literature was systematically reviewed between 1995–2005 to identify articles mentioning patient records, computers and data integration or sharing.ResultsOf 3124 articles, 84 were included describing 56 distinct projects. Most of the projects were on a regional scale. Integration was most commonly accomplished by messaging with pre-defined templates and middleware solutions. HL7 was the most widely used messaging standard. Direct database access and web services were the most common communication methods. The user interface for most systems was a Web browser. Regarding the type of medical data shared, 77% of projects integrated diagnosis and problems, 67% medical images and 65% lab results. More recently significantly more IS are extending to primary care and integrating referral letters.ConclusionIt is clear that Information Systems are evolving to meet peoples needs by implementing regional networks, allowing patient access and integration of ever more items of patient data. Many distinct technological solutions coexist to integrate patient data, using differing standards and data architectures which may difficult further interoperability.

Secure Integration of Distributed Medical Data Using Mobile Agents

Healthcare is information driven and knowledge driven. Good healthcare depends on making decisions at the right time and place, using the right patient data and applicable knowledge. Communication is of utmost relevance in todays healthcare settings, in that delivery of care, research, and management all depend on sharing information. The proposed system can securely gather, integrate, and display distributed medical information using mobile-agent technology and agent-driven security

Control of allergic rhinitis and asthma test – a formal approach to the development of a measuring tool

BackgroundThe concurrent management of allergic rhinitis and asthma (ARA) has been recommended by Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. However, a tool capable of assessing simultaneously the control of upper and lower airways diseases is lacking.AimTo describe the studies conducted to design the control of ARA test (CARAT) questionnaire.MethodsWe performed a literature review to generate a list of potentially important items for the assessment of control of ARA. A formal consensus development process, that used an innovative web-based application, was designed – 111 experts in ARA and 60 patients participated. At the final consensus meeting, 25 primary and secondary care physicians formulated the questions and response options. A qualitative feasibility study (n = 31 patients) was conducted to evaluate the comprehensibility of the questionnaire while testing two different designs.ResultsThirty-four potentially important items were identified. All the steps of the consensus process were completed in 2.5 months. The opinions of experts and patients lead to the formulation of 17 questions. At the feasibility study the instructions and wording problems were corrected and a semi-tabular format was chosen.ConclusionA tool to measure the control of allergic rhinitis and asthma was developed using a comprehensive set of methodological steps ensuring the design quality and the face and content validity. Additional validation studies to assess the psychometric properties of the questionnaire have started.

Challenges of a Mobile Application for Asthma and Allergic Rhinitis Patient Enablement—Interface and Synchronization

BACKGROUND Asthma and allergic rhinitis (ARA) are common inflammatory diseases of the airways. Enhancement of a patients participation on clinical decisions is related to better results in control of diseases. To control ARA, patients should monitor their symptoms, avoid triggers, and follow their treatment plan. This study described the challenges of developing a mobile application, called m.Carat, that records the main events related to ARA. MATERIALS AND METHODS The mobile application m.Carat was developed for Android™ (Google, Mountain View, CA) and iPhone(®) (Apple, San Jose, CA) smartphones. It was developed using PhoneGap, which allows the development of applications for several mobile operating systems. To generate the user interface, jQuery Mobile, HTML, Javascript, and CSS were used. Despite the use of mobile development frameworks, some input and output elements had to be improved. To evaluate the interface, a pilot study was performed with eight users who performed 10 different tasks in the application. To synchronize m.Carat with an online database, an algorithm was developed from scratch. This feature represents a major challenge because all the changes must be reflected in all devices. RESULTS Currently m.Carat is a mobile application where ARA patients fill out a questionnaire to assess the degree of control of ARA and record their exacerbations, triggers, symptoms, medications, lung function tests, and visits to the doctor or the hospital. They also can receive information and news about ARA, define medication and tasks notifications, and synchronize all records at caratnetwork.org with an online database. The evaluation showed some of the adopted solutions to improve interface usability did not work as expected. Of the 80 total tasks tested the users had no difficulty in 37(46%). Most of the problems observed were easily solved. CONCLUSIONS m.Carat is a mobile application for ARA that may contribute to patient enablement. The development of m.Carat suggests that mobile applications may introduce specific challenges that need new solutions.

Promoting Spontaneous Adverse Drug Reaction Reporting in Hospitals Using a Hyperlink to the Online Reporting Form

AbstractBackground: Spontaneous adverse drug reaction (ADR) reporting has been described as an efficient method to detect drug safety signals. However, under-reporting is a major issue undermining the effectiveness of spontaneous reports. Among hospitalized patients, ADRs are a particularly serious problem because these patients are often treated with more than one drug, and these drugs are often new and aggressive. Objective: To promote spontaneous ADR reporting by healthcare professionals working in hospitals in the northern regions of Portugal, we propose the inclusion of a hyperlink to an online ADR reporting form on hospitals’ electronic patient records (EPRs). The main aim of this study was to evaluate the impact of these hyperlinks on the number of spontaneous ADR reports to the Northern Pharmacovigilance Centre (UFN — Unidade de Farm-acovigilância do Norte). We also assess the number of daily UFN website visits before and after the inclusion of the hyperlinks. Methods: An ecological study was performed in northern Portuguese hospitals from 2006 to 2010. The hyperlinks were included in either EPRs or on computer desktops. The median of spontaneous ADR reports (total and online) per month and the respective ranges were presented before and after the intervention in all hospitals in this study. The comparisons were performed using the Mann-Whitney U-test. Results: Sixteen hospital centres were involved in the study (27 hospitals). Eleven centres (18 hospitals) included the hyperlinks. Considering the hospitals with hyperlink access to the EPRs, the median ADR reports per month significantly increased, from two (range 0–12) to five reports (range 1–17). The median of ADR reports per month using the online form also increased significantly, from one (range 0–5) before the intervention to four (range 1–17) after it. Moreover, serious ADRs increased 3-fold, and non-previously described ADRs increased 4.5-fold. None of these significant increases were observed in the hospitals where the hyperlink was not installed. We also found a significant increase in daily UFN website visits, from ten before the intervention to 27 after it (p<0.001). Conclusion: The increase in ADR reporting shows that the inclusion of hyperlinks to online ADR reporting forms is an easy and cost-effective way to change health professional behaviours with regard to spontaneous ADR reports.

Determinants of frequency and longevity of hospital encounters' data use

BackgroundThe identification of clinically relevant information enables improvement in user interfaces and in data management. However, it is difficult to identify what information is important in daily clinical care, and what is used occasionally. This study aims to determine for how long clinical documents are used in a Hospital Information System (HIS).MethodsThe access logs of 3 years of usage of a HIS were analysed concerning report departmental source, type of hospital encounter, and inpatient encounter ICD-9-CM main diagnosis. Reports median life indicates the median time elapsed between information creation and its usage. The models that better explains report views over time were explored.ResultsThe number of report views in the study period was 656 583. Fifty two percent of the reports viewed by medical doctors in emergency encounters were from previous encounters - 21% at outpatient attendance, 19% in inpatient (wards) and 12% during emergency encounters. In an inpatient setting, 20% of the reports viewed were produced in previous encounters. The median life of information in documents is 1.5 days for emergency, 4.8 days for inpatient and 37.8 days for outpatient encounters. Immune-haemotherapy reports reach their median lives faster (7 days) than clinical pathology (15 days), gastroenterology (80 days) and pathology (118 days). The median life of reports produced in inpatient encounters varied from 36 days for neoplasms as the main diagnosis to 0.7 days for injury and poisoning. The model with the best fit (R2 > 0.9) was the exponential.ConclusionsThe usage of past patient information varied significantly according to patient age, type of information, type of hospital encounter and medical cause (main diagnosis) for the encounter. The exponential model is a good fit to model how the reports are seen over time, so the design of user interfaces and repository management algorithms should take it in consideration.

Analysis of the quality of hospital information systems Audit Trails.

BackgroundAudit Trails (AT) are fundamental to information security in order to guarantee access traceability but can also be used to improve Health information System’s (HIS) quality namely to assess how they are used or misused. This paper aims at analysing the existence and quality of AT, describing scenarios in hospitals and making some recommendations to improve the quality of information.MethodsThe responsibles of HIS for eight Portuguese hospitals were contacted in order to arrange an interview about the importance of AT and to collect audit trail data from their HIS. Five institutions agreed to participate in this study; four of them accepted to be interviewed, and four sent AT data. The interviews were performed in 2011 and audit trail data sent in 2011 and 2012. Each AT was evaluated and compared in relation to data quality standards, namely for completeness, comprehensibility, traceability among others. Only one of the AT had enough information for us to apply a consistency evaluation by modelling user behaviour.ResultsThe interviewees in these hospitals only knew a few AT (average of 1 AT per hospital in an estimate of 21 existing HIS), although they all recognize some advantages of analysing AT. Four hospitals sent a total of 7 AT – 2 from Radiology Information System (RIS), 2 from Picture Archiving and Communication System (PACS), 3 from Patient Records. Three of the AT were understandable and three of the AT were complete. The AT from the patient records are better structured and more complete than the RIS/PACS.ConclusionsExisting AT do not have enough quality to guarantee traceability or be used in HIS improvement. Its quality reflects the importance given to them by the CIO of healthcare institutions. Existing standards (e.g. ASTM:E2147, ISO/TS 18308:2004, ISO/IEC 27001:2006) are still not broadly used in Portugal.

A Mobile Based Authorization Mechanism for Patient Managed Role Based Access Control

The Internet has proved the enormous benefits that can be accrued to all players involved in online services. However, it has also clearly demonstrated the risks involved in exposing personal data to the outside world and constitutes at the same time a teeming breeding ground of innovation for highly flexible security solutions that can minimize these risks. It is now widely believed that the benefits of online services to healthcare in general supplant the risks involved, provided adequate security measures are taken and the role played by all the parties involved, be they physicians, nurses or patients are clearly outlined. Due to the highly sensitive nature of the data held on the Electronic Health Record (EHR), it is commonly agreed that providing online access to patients EHR to the outside world carries an unacceptable level of risk not only to the patients but also to the healthcare institution that plays a custodian to that sensitive data. However, by sharing these risks with the patients, healthcare institutions can start to equate the possibility of providing controlled exterior online access to patients EHR. The mobile phone is nowadays the preferred mean by which people can interact with each other at a distance. Not only that, the smartphone constitutes the full embodiment of the truly personal device users carry constantly with them, everywhere. They are therefore the ideal means by which the user can casually and conveniently interact with information systems. In this paper we propose a discretionary online access rights management mechanism based on the Role Based Access Control (RBAC) model that takes advantage on the personal/technical characteristics and data communications capabilities of the smartphone in order to provide patients with the means by which they can conveniently exercise safe discretionary online access permissions to their own EHR.

Survey of openEHR storage implementations

Efficiently storing and retrieving archetype-based patient information can be a challenging task. This paper surveys current archetype-based system implementations in the world and in particular the different approaches that have been used to create 13606- or openEHR-based storage repositories. Data is reported from systems with a few records to millions of records, including both deployed systems in production and experimental systems. Worldwide 21 projects were found, 4 did not reply and 1 did not provide data. Many systems (n=11) base their storage on RDBMS, then often (n=6) with some XML data fields. Dedicated XML (n=3) and object-oriented (n=2) databases were other examples of storage used. Query formalisms used include SQL, AQL, XQuery and XPath. Service interfaces via SOAP (n=12) or REST (n=6) are common. Most systems support dynamic configuration using new/changed archetypes and templates dynamically without system restart. Some (n=7) systems use demographic archetypes. In addition to the built in DBMS indexing mechanisms, one project reports use of an additional inverted index to achieve improved performance.

Extracting BI-RADS features from Portuguese clinical texts

In this work we build the first BI-RADS parser for Portuguese free texts, modeled after existing approaches to extract BI-RADS features from English medical records. Our concept finder uses a semantic grammar based on the BI-RADS lexicon and on iterative transferred expert knowledge. We compare the performance of our algorithm to manual annotation by a specialist in mammography. Our results show that our parsers performance is comparable to the manual method.