Medical informatics

Clinical data systems, part 2: components and techniques

With electronic health records (EHRs) becoming ubiquitous, computer use in exam rooms during patient-provider interactions is commonplace. Although computer use brings many benefits to providers, and patients generally rate computer-use as having a positive impact, the use of mobile devices could eliminate existing issues, for example allowing providers to enter or review records while face-to-face with patients. Using mobile devices increases flexibility of providers, but also creates challenges associated with the mobile device itself. For example, the form factor (i.e., display size) of the mobile device may affect provider performance, satisfaction and usability of the EHR. This study assessed the impact of the device form factor on usability of the EHR by measuring the most commonly used devices. This question relates to the applicability of Fitts’ law, which does not predict differences in usability of devices varying in their form factor, assuming a linear scaling of the user interface.

Health care providers participated in this study by performing common EHR related tasks using devices differing in their form factor. Each participant performed these tasks on each of the devices. Interaction with a desktop computer served as baseline.

Usability and task load ratings for all mobile devices were significantly lower than for the desktop. Among the mobile devices, the iPad with its largest form factors performed best, where the iPhone performed the worst. The time to complete the tasks revealed that the mobile devices took more time to complete the tasks with the iPad requiring the least time among the mobile devices. Finally, in terms of error rates, all mobile devices had a significantly higher error rate than the desktop control. Again, the lowest error rate was observed with the devices that had the largest form factor.

The results of this study suggest that the form factor of mobile devices is of critical importance for usability and task performance with none of the mobile devices performing as well as the desktop. In addition, it appears that Fitt’s law requires some additional examination in the context of touch screen devices. Given these results, challenges associated with mobile access to the EHR exist that need to be addressed in the future.

La informatización consiste básicamente en una alternativa a la gestión clásica de la información, pasando del soporte en papel al electrónico. Este modelo aporta ventajas en la legibilidad, uniformidad, accesibilidad y explotación de los datos. Sin embargo, no es sencillo aplicar este proceso a la práctica clínica, pues requiere un adecuado soporte de equipos en red, el desarrollo continuo de las aplicaciones, una estrategia de implantación y la colaboración de todo el personal implicado. Revisamos nuestra experiencia en el desarrollo e implantación de una historia clínica (HC) en formato electrónico y su adaptación a un Servicio de Dermatología pionero en España. El modelo elegido en nuestro hospital desde su apertura en 1998 fue el de historia única centralizada electrónica de uso común (HCE) que se complementa con aplicaciones departamentales. La HCE se concibe como una base de datos relacional, centrada en el paciente y estructurada por procesos, que cumple los requisitos legales y permite prescindir del soporte físico (papel o placa) en la práctica totalidad de las situaciones.

El sistema funciona en los servidores centrales bajo el mantenimiento del departamento de sistemas de información. Las potencialidades son ilimitadas, destacando: asistencia por guías de actuación clínica, conexión remota con Atención Primaria, gestión on-line de actividad, consumos y estándares de calidad. Buscando alcanzar estas potencialidades en 2003 se inició un cambio tecnológico hacia lo que después sería el sistema elegido en la Comunidad de Madrid para soportar el trabajo de los nuevos hospitales.

Computerization, with a change from paper to electronic format, represents an alternative to traditional information management. This model offers advantages in legibility, uniformity, accessibility, and use of the data. However, it is not easy to apply this process to clinical practice as it requires a suitable network, continuous application development, an implementation strategy, and the cooperation of all staff involved. We have reviewed our experience in the development and introduction of electronic health records and their adaptation to a pioneer dermatology department in Spain. Since our hospital was opened 1998, the model used is that of a single, centralized electronic health record, with supplementary departmental attributes. The electronic health record is conceived as an interactive database designed around the patient, with a procedure-based structure, and that obviates the need for hardcopies (paper or films) in practically all situations; it must comply with legal requirements.

The system is installed on central servers maintained by the information technology department. The potential is unlimited; particularly important possibilities include clinical guideline-directed care, remote connection for general practitioners, and online activity, stock, and quality management. With the aim of realizing this potential, a technological change was started in 2003, moving towards what was to become the chosen system in the Community of Madrid to cope with the workload arising from new hospitals.

Re-use of patient data from an electronic patient record heavily relies on structured, coded data. Terminological systems (TSs) are meant to support this. TSs are more commonly implemented nowadays, especially those that support post-coordination. The effect of using a compositional TS on correctness and specificity of captured patient data is unknown.

To evaluate the agreement between free-text reasons for admission to intensive care captured in a patient data management system (PDMS) and reasons for admission that were recorded using a compositional TS embedded in the PDMS.

Observational study comparing pairs of free-text reasons for admission to intensive care with reasons for admission that were recorded using a compositional TS. Both reasons for admission were captured in the PDMS by clinicians during regular care practice. Each pair was judged as exact match, partial match or mismatch by two independent raters. Partial matches were further analyzed to investigate whether free-text or TS-based reasons for admissions included more detail and whether these differences could be explained by the content, the interface of the TS or by user or usability characteristics.

Eleven percent of the pairs matched exactly, 79% of the pairs matched partially and 10% of the pairs did not match. Compared to free-text registration TS-based registration resulted in more detail for 21% of the partial matches, in less detail for 43% of the partial matches and in 36% of the partial matches some detail was added while at the same time other detail was lacking. In 65% of the cases in which the TS-based registration lacked some detail, this detail was available in the content of the TS. Physicians who used the TS occasionally had a significantly higher percentage of mismatches.

In practice, post-coordination leads to information with different detail but a level of detail comparable to free-text registration of reasons for admission. Details missing in the TS-based reasons for admission were most often available in the TS, indicating that user interaction with the system is more of an impediment than the contents of the TS.

Clinical use of computer systems has been hampered by their poorly designed user interfaces. The objective of this study was to design a user interface for a pediatric oncologists’ computerized patient record with great consideration of their working behavior and of human computer interfacing principles so as to contribute to oncologists’ efficiency and satisfaction in interaction with the system.

The think aloud method was used in combination with video recording to get a deep understanding of the way in which four pediatric oncologists searched through the paper-based patient record in preparing a patient visit. Protocol and video analyses was used to develop a cognitive task model reflecting pediatric oncologists’ task behavior. This model was input for a prototype user interface, which was subsequently evaluated by eight other pediatric oncologists.

The resulting computerized medical record system proved to meet pediatric oncologists’ information needs and task behavior patterns. The design of the user interface minimized pediatric oncologists’ work load and was highly efficient in supporting the pediatric oncologists in preparing their patient visits. The pediatric oncologists were very much satisfied with the computer system.

It is argued that early involvement of cognitive engineering methods in the system design process may be of great help in designing systems that fully support health care professionals’ work practices. The think aloud method, if applied under prescribed conditions, is a valuable information source of human task-behavior and as such a useful technique for requirements analysis in designing clinical computer systems.

This paper aims at identifying the specific legal requirements concerning data security and data protection of patient health data that apply to a cross-institutional electronic patient record (EPR) and describes possible solutions for meeting these requirements. In Germany, the legal framework for such records provide that disclosure of patient health information to physicians of third-party institutions is only allowed in case that it is necessary for the joint treatment of the patient, i.e. in case of a “treatment connection”. As a first step, the functionality of a remote-access architecture was proven allowing a one-way connection between the EPR systems of two health institutions in Germany, which jointly treat tumor patients. Besides, a signature system model for ensuring the integrity and authenticity of medical documents was developed and implemented in the existing information system architecture of the University Medical Center of Heidelberg. Especially in Germany, the legal framework for cross-institutional EPRs is very complex and has a considerable influence on the development and implementation of cross-institutional EPRs. However, its introduction is thought to be valuable, since a cross-institutional EPR will improve communication within shared care processes, and thus improve the quality of patient care.

Those who face the difficulties of developing useful patient care information systems (PCISs) often stress the importance of ‘organizational issues’. Building upon recent sociological insights in the construction and use of information technologies for (health care) work, this paper underscores the importance of these insights for the development and evaluation of these systems. A sociotechnical approach to PCISs in health care is outlined, and two implications of this empirically grounded approach for the practices of developing and evaluating IT applications in health care practices are discussed. First, getting such technologies to work in concrete health care practices appears to be a politically textured process of organizational change, in which users have to be put at center-stage. This requires an iterative approach, in which the distinctions between ‘analysis’, ‘design’, ‘implementation’ and ‘evaluation’ blur. Second, a sociotechnical approach sheds new light on the potential roles of IT applications in health care practices. It is critical of approaches that denounce the ‘messy’ and ‘ad hoc’ nature of health care work, and that attempt to structure this work through the formal, standardized and ‘rational’ nature of IT systems. Optimal utilization of IT applications, it is argued, is dependent on the meticulous interrelation of the system’s functioning with the skilled and pragmatically oriented work of health care professionals.