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Information technology and patient safety in nursing practice: an international perspective.

When people become patients, they place their trust in their health care providers. As providers assume responsibility for their diagnosis and treatment, patients have a right to expect that this will include responsibility for their safety during all aspects of care. However, increasing epidemiological data make it clear that patient safety is a global problem. Improved nursing care may prevent many adverse events, and nursing must take a stronger leadership role in this area. Although errors are almost inevitable, safety can be improved, and health care institutions are increasingly making safety a top priority. Information technology provides safety benefits by enhancing communication and delivering decision-support; its use will likely be a cornerstone for improving safety. This paper will discuss the status of patient safety from an international viewpoint, provide case studies from different countries, and discuss information technology solutions from a nursing perspective.

Humans↗

The comparative study on concept representation between the UMLS and the clinical terms in Korean medical records.

OBJECTIVE: The National Library of Medicine's Unified Medical Language System (UMLS) is a rich source of knowledge in the biomedical domain. The UMLS is used for research and development across wide range of different applications. In this paper, we evaluated the coverage of UMLS as compared with medical terms extracted from Korean medical records and identified differences in concept representation between two terminology sets. DESIGN AND MEASUREMENT: We measured the concept coverage of the UMLS. For this study, we mapped the clinical terms extracted from the discharge records of Seoul National University Hospital (SNUH) to the UMLS. RESULTS: Thirty-five percent of the entry terms used in chief complaint of SNUH were conceptually matched with the UMLS 'Sign or Symptom' concepts. Fifty-eight percent of the terms were found to be matched with the UMLS 'Disease or Syndrome' concept rather than the 'Sign or Symptom' concept. The remaining 7% were not found in the UMLS concepts. We then analyzed some of different expression patterns used by the two term sets and addressed issues to be taken into consideration. CONCLUSION: We found out that the UMLS was comparable with Korean medical records, since most of concepts of Korean medical records were covered with the UMLS concepts.

Humans↗

Impact of clinical information-retrieval technology on physicians: a literature review of quantitative, qualitative and mixed methods studies.

PURPOSE: This paper appraises empirical studies examining the impact of clinical information-retrieval technology on physicians and medical students. METHODS: The world literature was reviewed up to February 2004. Two reviewers independently identified studies by scrutinising 3368 and 3249 references from bibliographic databases. Additional studies were retrieved by hand searches, and by searching ISI Web of Science for citations of articles. Six hundred and five paper-based articles were assessed for relevance. Of those, 40 (6.6%) were independently appraised by two reviewers for relevance and methodological quality. These articles were quantitative, qualitative or of mixed methods, and 26 (4.3%) were retained for further analysis. For each retained article, two teams used content analysis to review extracted textual material (quantitative results and qualitative findings). RESULTS: Observational studies suggest that nearly one-third of searches using information-retrieval technology may have a positive impact on physicians. Two experimental and three laboratory studies do not reach consensus in support of a greater impact of this technology compared with other sources of information, notably printed educational material. Clinical information-retrieval technology may affect physicians, and further research is needed to examine its impact in everyday practice.

Attitude of Health Personnel↗

The significance of cognitive modeling in building healthcare interfaces.

BACKGROUND: Although there are many reasons that widespread adoption of healthcare information systems has not transpired, one reason is a failure to take into account the cognitive needs of the users. AIM: To understand the cognitive needs of nurses and physicians and determine how these needs should influence the design of healthcare interfaces. DESIGN OF STUDY: A qualitative and quantitative study that compares how nurses and physicians comprehend patient information. SETTING: Twenty-four registered nurses and twenty-four physicians working in the specialties of gastrointestinal or internal medicine. METHODS: Each clinician reviewed two mock electronic medical records and summarized the cases using a think-aloud protocol. All verbalizations were coded for medical and conceptual information. RESULTS: The nurses included a larger mean proportion (p<0.001) of recalls than did the physicians. As compared to the nurses, the physicians included a statistically significant (p<0.001) larger mean proportion of inferences, conditional statements, and interventions. The nurses concentrated on functional problems, whereas the physicians focused on diagnosis, treatment, and management. CONCLUSION: The main cognitive differences between the physicians and the nurses are explained through the differences in their practice models. Therefore, healthcare IT must develop separate interfaces for each discipline to address their unique needs.

Adult↗

Evaluation of teleconsultation systems.

The aim of this study was to identify criteria used for evaluation of teleconsulatation systems in evaluation studies, and to estimate trend of their changes. Evaluation of teleconsultation (TC) systems was made on the basis of 82 evaluation studies from the inventory of evaluation studies in medical informatics consisting of all the information and communication technology (ICT) evaluation studies published in 1982-2002. In order to estimate trend of changes in using evaluation criteria, the whole period with at least one evaluation study, it means the period of 1995-2002 was divided to 2 of 4 years, 1995-1998 and 1999-2002. Proportions of evaluation studies according to any single criterion were calculated. Index of changes I(ci) for ith criterion was defined as difference of proportion of studies evaluating teleconsultation by using a certain criterion in the second period and the same proportion in the first period divided by the number of all studies evaluating teleconsultation systems. This research showed that hardware and technical aspects were the leading evaluation criterion, but it has been decreasing (from 74.2% in the first period to 43.1% in the second one). Satisfactions of both health care provider and patient achieved the highest increase in the second period (from 3.2 to 19.6% and from 0 to 15.7%, respectively). Appropriateness and cost of patient care were on the second place (from 22.6 to 33.3% and from 16.1 to 23.5%, respectively). Considering defined index of changes it can be concluded that there are four criteria for evaluation of teleconsultation systems, having a positive trend (in frequency of evaluation studies): user satisfaction (Ic=0.20), satisfaction of patient with patient care (Ic=0.19), appropriateness of patient care (Ic=0.13) and cost of patient care (Ic=0.09). Hardware and technical aspects shows negative trend in the number of evaluation studies (Ic=-0.38), as well as cost of IT (Ic=-0.10).

Biotechnology↗

Test the artefact--develop the organization. The implementation of an electronic medication plan.

OBJECTIVE AND METHODS: The paper aims to develop further insights into the process of implementation of IT in health care by describing findings from a study of a trial implementation of a newly developed electronic medication plan (EMP) in three hospitals in a county in Denmark. A sociotechnical perspective is applied to data acquired by the qualitative methods of participant observation and semi-structured open-ended interviews. CONCLUSIONS: The achievement of fit between IT technology and work processes in health care involves the establishment of new organizational structures that cut across the existing divisionalized hospital organization and a detailed alignment of artefact, functionality and work process. This process can be furthered by supporting 'communities of practice', i.e. informal groups of engaged clinicians. A sociotechnical perspective is beneficial to the analysis of such processes.

Artifacts↗

Context awareness in health care: a review.

BACKGROUND: Health care systems will integrate new computing paradigms in the coming years. Context-awareness computing is a research field which often refers to health care as an interesting and rich area of application. AIM: Through a survey of the research literature, we intended to derive an objective view of the actual dynamism of context awareness in health care, and to identify strengths and weaknesses in this field. METHODS: After discussing definitions of context, we proposed a simple framework to analyse and characterize the use of context through three main axes. We then focused on context-awareness computing and reported on the main teams working in this area. We described some of the context-awareness projects in health care. A deeper analysis of the hospital-based projects demonstrated the gap between recommendations expressed for modelling context awareness and the actual use in a prototype. Finally, we identified pitfalls encountered in this area of research. RESULTS: A number of opportunities remain for this evolving field of research. We found relatively few groups with such a specific focus. As yet there is no consensus as to the most appropriate models or attributes to include in context awareness. We conclude that a greater understanding of which aspects of context are important in a health care setting is required; the inherent sociotechnical nature of context-aware applications in health care; and the need to draw on a number of disciplines to conduct this research.

Biomedical Technology↗

Building a reference functional model for EHR systems.

INTRODUCTION: Our aim was to develop a reference functional model for electric health record systems (RFM). Such a RFM is built from functions using functional descriptive elements (FDEs) and represents the static relationships between them. This paper presents a new format for describing electric health record (EHR) system functions. METHODS: Questionnaire and field interview survey was conducted in five hospitals in Japan and one in the USA, to collect data on EHR system functions. Based on survey results, a reference functional list (RFL) was created, in which each EHR system function was listed and divided into 13 FDE types. By analyzing the RFL, we built the meta-functional model and the functional model using UML class diagrams. The former defines language for expressing the functional model, while the latter represents functions, FDEs and their static relationships. RESULTS: A total of 385 functions were represented in the RFL. Six patterns were found for the relationships between functions. The meta-functional model was created as a new format for describing functions. Examples of the functional model, which included the six patterns in the relationships between functions and 11 verbs, were created. DISCUSSIONS: We present the meta-functional model, which is a new description format for the functional structure and relationships. Although a more detailed description is required to apply the RFM to the semiautomatic generation of functional specification documents, our RFM can visualize functional structures and functional relationships, classify functions using multiple axes and identify the similarities and differences between functions. The RFM will promote not only the standardization of EHR systems, but also communications between system developers and healthcare providers in the EHR system-design processes.

Japan↗

Acceptance and cognitive load in a clinical setting of a novel device allowing natural real-time data acquisition.

INTRODUCTION: This paper reports the findings of an evaluation study in the field of human-computer interaction about the use of a new data acquisition device, the digital pen. It focuses on specific aspects of the interaction between the users and the technology: the cognitive burden induced by the design of the tool in real conditions of use and its impact on user acceptance. METHODOLOGY: Human cognition is embedded in a complex sociocultural world. Therefore, we opted for ethnographically informed investigations reinforced by a satisfaction survey. The work context chosen for these investigations was the emergency room triage process. RESULTS: The technology meets a high acceptance (median 3 on a [-5,5] scale) shaded by unexpected additional cognitive burdens. These burdens originate in several technological and ergonomic flaws that have been discovered during the observations. These results have been used to improve the technology. CONCLUSION: We demonstrate the importance of this kind of field study to uncover unexpected possible sources of failure of acceptance of a new technology. Such kind of study should be held prior to the introduction of a new technology to lower the common failure rate encountered in the field of medical informatics.

Attitude to Computers↗

The aging of a clinical information system.

The senescence of a clinical information system is more likely to have administrative than technical bases. Supporting this claim is a case study of one aging oncology information system. The case study is qualitative, as behooves the subject matter. Content analysis of several documents suggests that the change in job description of the data coordinator led to a workflow breakdown. Next, twenty-two individuals were interviewed. Notes from the interviews were coded, and the resulting patterns led to partial support for the workflow breakdown conjecture, refutation of the hypothesis that users disliked the character-based, human-computer interface, support of the conjecture that political rather than technical factors drive the usage patterns of the system, and evidence that 'political' activity will determine the future of the information system. A stakeholder matrix is proposed that addresses administrative concerns. Also, the issue of the uniqueness of any oncology clinical information system is linked to the plans for this legacy system.

Databases, Factual↗

Measures of semantic similarity and relatedness in the biomedical domain.

Measures of semantic similarity between concepts are widely used in Natural Language Processing. In this article, we show how six existing domain-independent measures can be adapted to the biomedical domain. These measures were originally based on WordNet, an English lexical database of concepts and relations. In this research, we adapt these measures to the SNOMED-CT ontology of medical concepts. The measures include two path-based measures, and three measures that augment path-based measures with information content statistics from corpora. We also derive a context vector measure based on medical corpora that can be used as a measure of semantic relatedness. These six measures are evaluated against a newly created test bed of 30 medical concept pairs scored by three physicians and nine medical coders. We find that the medical coders and physicians differ in their ratings, and that the context vector measure correlates most closely with the physicians, while the path-based measures and one of the information content measures correlates most closely with the medical coders. We conclude that there is a role both for more flexible measures of relatedness based on information derived from corpora, as well as for measures that rely on existing ontological structures.

Database Management Systems↗

Anatomy of data integration.

Producing reliable information is the ultimate goal of data processing. The ocean of data created with the advances of science and technologies calls for integration of data coming from heterogeneous sources that are diverse in their purposes, business rules, underlying models and enabling technologies. Reference models, Semantic Web, standards, ontology, and other technologies enable fast and efficient merging of heterogeneous data, while the reliability of produced information is largely defined by how well the data represent the reality. In this paper, we initiate a framework for assessing the informational value of data that includes data dimensions; aligning data quality with business practices; identifying authoritative sources and integration keys; merging models; uniting updates of varying frequency and overlapping or gapped data sets.

Algorithms↗

Information infrastructure for inter-organizational mental health services: an actor network theory analysis of psychiatric rehabilitation.

In the supply of mental health services to communities, data and information are managed not only by clinical organizations, but also by welfare state agencies and charities. The aim of this study is to use methods of analysis from actor network theory to identify organizational interventions necessary for the development of an information infrastructure for inter-organizational mental health services. Data was collected in a project aimed at developing an information system that supports inter-organizational psychiatric rehabilitation in a Swedish municipality. Three organizational interventions were identified: an integrated service policy defined by the national government, a common legal framework allowing sharing of high-level client data, and commissioned support for local inter-agency workspaces. It is concluded that organizational interventions must be regarded when configuring an information infrastructure for mental health services. Organizational interventions should also routinely be addressed in systems design methods to be used in inter-organizational settings.

Interinstitutional Relations↗

EMBASE search strategies achieved high sensitivity and specificity for retrieving methodologically sound systematic reviews.

OBJECTIVES: Systematic reviews of the literature are instrumental for bridging research to health care practice and are widely available through databases such as MEDLINE and EMBASE. Search strategies have been developed to aid users in MEDLINE, but no empirical work has been done for EMBASE. The objective of this study was to develop search strategies that optimize the retrieval of methodologically sound systematic reviews from EMBASE. STUDY DESIGN AND SETTING: An analytic survey was conducted, comparing hand searches of 55 journals with retrievals from EMBASE for 4,843 candidate search terms and 17,004 combinations. Candidate search strategies were run in EMBASE, the retrievals being compared with the hand search data. The sensitivity, specificity, precision, and accuracy of the search strategies were calculated. RESULTS: Two hundred twenty (16.2%) of the 1,354 articles classified as a review met basic criteria for scientific merit. Combinations of search terms reached peak sensitivities of 94.6% with specificity at 63.7%, whereas combinations of search terms to optimize specificity reached peak specificities of 99.3% with sensitivity at 61.4%. CONCLUSION: Empirically derived search strategies can achieve high sensitivity and specificity for retrieving methodologically sound systematic reviews from EMBASE.

Databases, Bibliographic↗

Quality and variability of osteoporosis data in general practice computer records: implications for disease registers.

OBJECTIVE: To determine the extent to which routinely collected general practitioner computer data could be used to create disease registers of patients with osteoporosis, and to report any improvement in data quality since previous studies. STUDY DESIGN: Audit using anonymized data extracted from general practice computer records from across England. METHODS: Morbidity Query Information and Export Syntax (MIQUEST) software was used to extract structured data from the 78 volunteer practices that participated in the study. The data were aggregated and analysed. RESULTS: There were 100-fold differences in the rates of recording of relevant data. Many patients receiving treatment had no diagnostic codes. Data about secondary causes of osteoporosis and fractures were more consistently recorded than data relating to falls. There were no data to indicate whether fractures were low impact. T-scores, the gold-standard measure of bone density, were very infrequently recorded. CONCLUSIONS: Sufficient data about secondary causes of osteoporosis exist, and these could be searched to identify patients at risk. Meanwhile, fracture recoding could be improved, including likely fragility fractures, and T-scores could be added to computer records. A systematic approach is needed to raise the computer records to a standard where they can be used as valid and reliable disease registers.

Accidental Falls↗

Shedding our illusions: a better way of medicine.

Caregivers are constantly trying to organize their collective efforts in a way that serves the needs of individual patients. And patients themselves seek active involvement and control in their own care. Disorder in medical practice frustrates achievement of all of these goals. Escaping that disorder requires using information tools designed for two purposes: (A) combining patient data with medical knowledge more effectively than the unaided human mind permits, and (B) organizing the multiple processes involved in patient care.

Humans↗