T Austin

Dementia Diagnosis and Management in Primary Care Developing and testing educational models

Dementia presents a challenge for primary care and the advent of new therapeutic options has highlighted the need to improve its detection so that early decisions about medication use can be made. Efforts at earlier diagnosis should be targeted at primary care as the gateway to specialist health and social services. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice throughout the world. This article reviews the obstacles to early recognition of dementia and the factors causing sub-optimal management in the community, and discusses educational approaches to enhancing professional skills in the recognition of and response to dementia. Three educational interventions with different characteristics and methods of delivery are described.

A prototype computer decision support system for the management of asthma

Asthma is a chronic disease estimated to affect 6–7% of the total UK population. In addition, a number of studies have shown that asthma has become commoner since the 1970s, especially in children. The diagnosis of asthma can be difficult and its management requires the involvement of patients in a long-term treatment plan, something which general practitioners may be unable to achieve easily in the average 10-min consultation. As a consequence, asthma is underdiagnosed and undertreated. Deaths from the disease are often avoidable with timely and sufficient use of the available medication.(3,4) In order to support this, the British Thoracic Society (BTS) has published guidelines for asthma management based upon a stepwise approach, in which a patient is categorized as being on one of five steps according to the severity of his or her asthma. The guidelines give “rules of thumb” for deciding when the patient should move up or down the steps. The most recent version of the guidelines also included special rules for children.(5,6) Within a recent European Community project on Advanced Informatics in Medicien (AIM), we developed a prototype decision support system for asthma management targeted at the primary care setting and based on the British Thoracic Society guidelines. This paper reports this development, and describes the further work needed on the prototype. Plans for evaluation of the knowledge bases and for future full application production are also described.

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.

An Electronic Healthcare Record Server Implemented in PostgreSQL

This paper describes the implementation of an Electronic Healthcare Record server inside a PostgreSQL relational database without dependency on any further middleware infrastructure. The five-part international standard for communicating healthcare records (ISO EN 13606) is used as the information basis for the design of the server. We describe some of the features that this standard demands that are provided by the server, and other areas where assumptions about the durability of communications or the presence of middleware lead to a poor fit. Finally, we discuss the use of the server in two real-world scenarios including a commercial application.

A Data Types Profile Suitable for Use with ISO EN 13606

ISO EN 13606 is a five part International Standard specifying how Electronic Healthcare Record (EHR) information should be communicated between different EHR systems and repositories. Part 1 of the standard defines an information model for representing the EHR information itself, including the representation of types of data value. A later International Standard, ISO 21090:2010, defines a comprehensive set of models for data types needed by all health IT systems. This latter standard is vast, and duplicates some of the functions already handled by ISO EN 13606 part 1. A profile (sub-set) of ISO 21090 would therefore be expected to provide EHR system vendors with a more specially tailored set of data types to implement and avoid the risk of providing more than one modelling option for representing the information properties. This paper describes the process and design decisions made for developing a data types profile for EHR interoperability.

Design of an Electronic Healthcare Record Server Based on Part 1 of ISO EN 13606

ISO EN 13606 is a newly approved standard at European and ISO levels for the meaningful exchange of clinical information between systems. Although conceived as an inter-operability standard to which existing electronic health record (EHR) systems will transform legacy data, the requirements met and architectural approach reflected in this standard also make it a good candidate for the internal architecture of an EHR server. The authors have built such a server for the storage of healthcare records and demonstrated that it is possible to use ISO EN 13606 part 1 as the basis of an internal system architecture. The development of the system and some of the applications of the server are described in this paper. It is the first known operational implementation of the standard as an EHR system.

Analysis of Clinical Record Data for Anticoagulation Management within an EHR System

Objectives: This paper reports an evaluation of the properties of a generic electronic health record information model that were actually required and used when importing an existing clinical application into a generic EHR repository. Method: A generic EHR repository and system were developed as part of the EU Projects Synapses and SynEx. A Web application to support the management of anticoagulation therapy was developed to interface to the EHR system, and deployed within a north London hospital with five years of cumulative clinical data from the previous existing anticoagulation management application. This offered the opportunity to critique those parts of the generic EHR that were actually needed to represent the legacy data. Results: The anticoagulation records from 3,226 patients were imported and represented using over 900,000 Record Components (i.e. each patient’s record contained on average 289 nodes), of which around two thirds were Element Items (i.e. value-containing leaf nodes), the remainder being container nodes (i.e. headings and sub-headings). Each node is capable of incorporating a rich set of context properties, but in reality it was found that many properties were not used at all, and some infrequently (e.g. only around 0.5% of Record Components had ever been revised). Conclusions: The process of developing generic EHR information models, arising from research and embodied within new-generation interoperability standards and specifications, has been strongly driven by requirements. These requirements have been gathered primarily by collecting use cases and examples from clinical communities, and been added to successive generations of these models. A priority setting approach has not to date been pursued - all requirements have been received and almost invariably met. This work has shown how little of the resulting model is actually needed to represent useful and usable clinical data. A wider range of such evaluations, looking at different kinds of existing clinical system, is needed to balance the theoretical requirements gathering processes, in order to result in EHR information models of an ideal level of complexity.

Evaluation of ISO EN 13606 as a result of its implementation in XML

The five parts of the ISO EN 13606 standard define a means by which health-care records can be exchanged between computer systems. Starting within the European standardisation process, it has now become internationally ratified in ISO. However, ISO standards do not require that a reference implementation be provided, and in order for ISO EN 13606 to deliver the expected benefits, it must be provided not as a document, but as an operational system that is not vendor specific. This article describes the evolution of an Extensible Markup Language (XML) Schema through three iterations, each of which emphasised one particular approach to delivering an executable equivalent to the printed standard. Developing these operational versions and incorporating feedback from users of these demonstrated where implementation compromises were needed and exposed defects in the standard. These are discussed herein. They may require a future technical revision to ISO EN 13606 to resolve the issues identified.

Clinical advantages of decision support tool for anticoagulation control

Computer-based decision support (CDSS) systems can deliver real patient care and increase chances of long-term survival in areas of chronic disease management prone to poor control. Computer-based Decision Support Systems (CDSS) can provide candidate opinions based on available data that clinicians can use (or not) to shape their strategy for managing the condition. One such CDSS, for the management of warfarin for anticoagulation, is described in this paper and the outcomes shown. Data is derived from the system implemented and running and show a performance consistently around 20% better than the applicable guidelines.

Evaluation of clinical information modeling tools

OBJECTIVE Clinical information models are formal specifications for representing the structure and semantics of the clinical content within electronic health record systems. This research aims to define, test, and validate evaluation metrics for software tools designed to support the processes associated with the definition, management, and implementation of these models. METHODOLOGY The proposed framework builds on previous research that focused on obtaining agreement on the essential requirements in this area. A set of 50 conformance criteria were defined based on the 20 functional requirements agreed by that consensus and applied to evaluate the currently available tools. RESULTS Of the 11 initiative developing tools for clinical information modeling identified, 9 were evaluated according to their performance on the evaluation metrics. Results show that functionalities related to management of data types, specifications, metadata, and terminology or ontology bindings have a good level of adoption. Improvements can be made in other areas focused on information modeling and associated processes. Other criteria related to displaying semantic relationships between concepts and communication with terminology servers had low levels of adoption. CONCLUSIONS The proposed evaluation metrics were successfully tested and validated against a representative sample of existing tools. The results identify the need to improve tool support for information modeling and software development processes, especially in those areas related to governance, clinician involvement, and optimizing the technical validation of testing processes. This research confirmed the potential of these evaluation metrics to support decision makers in identifying the most appropriate tool for their organization. OBJECTIVO Los Modelos de Información Clínica son especificaciones para representar la estructura y características semánticas del contenido clínico en los sistemas de Historia Clínica Electrónica. Esta investigación define, prueba y valida un marco para la evaluación de herramientas informáticas diseñadas para dar soporte en la en los procesos de definición, gestión e implementación de estos modelos. METODOLOGIA El marco de evaluación propuesto se basa en una investigación previa para obtener consenso en la definición de requisitos esenciales en esta área. A partir de los 20 requisitos funcionales acordados, un conjunto de 50 criterios de conformidad fueron definidos y aplicados en la evaluación de las herramientas existentes. RESULTADOS Un total de 9 de las 11 iniciativas identificadas desarrollando herramientas para el modelado de información clínica fueron evaluadas. Los resultados muestran que las funcionalidades relacionadas con la gestión de tipos de datos, especificaciones, metadatos y mapeo con terminologías u ontologías tienen un buen nivel de adopción. Se identifican posibles mejoras en áreas relacionadas con los procesos de modelado de información. Otros criterios relacionados con presentar las relaciones semánticas entre conceptos y la comunicación con servidores de terminología tienen un bajo nivel de adopción. CONCLUSIONES El marco de evaluación propuesto fue probado y validado satisfactoriamente contra un conjunto representativo de las herramientas existentes. Los resultados identifican la necesidad de mejorar el soporte de herramientas a los procesos de modelado de información y desarrollo de software, especialmente en las áreas relacionadas con gobernanza, participación de profesionales clínicos y la optimización de la validación técnica en los procesos de pruebas técnicas. Esta investigación ha confirmado el potencial de este marco de evaluación para dar soporte a los usuarios en la toma de decisiones sobre que herramienta es más apropiadas para su organización.