Towards integration of clinical decision support in commercial hospital information systems using distributed, reusable software and knowledge components

Healthcare Information Technology: A Systematic Mapping Study

OBJECTIVES

This paper presents a systematic mapping of studies related to information systems and technology in the field of healthcare, enabling a visual mapping of the different lines of knowledge that can provide an overview of the scientific literature in this field. This map can help to clarify critical aspects of healthcare informatics, such as the main types of information systems, the ways in which they integrate with each other, and the technological trends in this field.

METHODS

Systematic mapping refers to a process of classifying information in a given area of knowledge. It provides an overview of the state of the art in a particular discipline or area of knowledge, establishing a map that describes how knowledge is structured in that particular area. In this study, we proposed and carried out a specific implementation of the methodology for mapping. In total, 1,619 studies that combine knowledge related to information systems, computer science, and healthcare were selected and compiled from prestigious publications.

RESULTS

The results established a distribution of the available literature and identified papers related to certain research questions, thereby providing a map of knowledge that structures the different trends and main areas of research, making it possible to address the research questions and serving as a guide to deepen specific aspects of the field of study.

CONCLUSIONS

We project and propose future research for the trends that stand out because of their interest and the possibility of exploring these topics in greater depth.

Clinical decision support systems at the Vienna General Hospital using Arden Syntax: Design, implementation, and integration

INTRODUCTION

The Allgemeines Krankenhaus Informations Management (AKIM) project was started at the Vienna General Hospital (VGH) several years ago. This led to the introduction of a new hospital information system (HIS), and the installation of the expert system platform (EXP) for the integration of Arden-Syntax-based clinical decision support systems (CDSSs). In this report we take a look at the milestones achieved and the challenges faced in the creation and modification of CDSSs, and their integration into the HIS over the last three years.

MATERIALS AND METHODS

We introduce a three-stage development method, which is followed in nearly all CDSS projects at the Medical University of Vienna and the VGH. Stage one comprises requirements engineering and system conception. Stage two focuses on the implementation and testing of the system. Finally, stage three describes the deployment and integration of the system in the VGH HIS. The HIS provides a clinical work environment for healthcare specialists using customizable graphical interfaces known as parametric medical documents. Multiple Arden Syntax servers are employed to host and execute the CDSS knowledge bases: two embedded in the EXP for production and development, and a further three in clinical routine for production, development, and quality assurance.

RESULTS

Three systems are discussed; the systems serve different purposes in different clinical areas, but are all implemented with Arden Syntax. MONI-ICU is an automated surveillance system for monitoring healthcare-associated infections in the intensive care setting. TSM-CDS is a CDSS used for risk prediction in the formation of cutaneous melanoma metastases. Finally, TacroDS is a CDSS for the manipulation of dosages for tacrolimus, an immunosuppressive agent used after kidney transplantation. Problems in development and integration were related to data quality or availability, although organizational difficulties also caused delays in development and integration.

DISCUSSION AND CONCLUSION

Since the inception of the AKIM project at the VGH and its ability to support standards such as Arden Syntax and integrate CDSSs into clinical routine, the clinicians' interest in, and demand for, decision support has increased substantially. The use of Arden Syntax as a standard for CDSSs played a substantial role in the ability to rapidly create high-quality CDSS systems, whereas the ability to integrate these systems into the HIS made CDSSs more popular among physicians. Despite these successes, challenges such as lack of (consistent and high-quality) electronic data, social acceptance among healthcare personnel, and legislative issues remain. These have to be addressed effectively before CDSSs can be more widely accepted and adopted.

On creating a patient-centric database from multiple Hospital Information Systems

BACKGROUND

The information present in Hospital Information Systems (HIS) is heterogeneous and is used primarily by health practitioners to support and improve patient care. Conducting clinical research, data analyses or knowledge discovery projects using electronic patient data in secondary care centres relies on accurate data collection, which is often an ad-hoc process poorly described in the literature.

OBJECTIVES

This paper aims at facilitating and expanding on the process of retrieving and collating patient-centric data from multiple HIS for the purpose of creating a research database. The development of a process roadmap for this purpose illustrates and exposes the constraints and drawbacks of undertaking such work in secondary care centres.

METHODS

A data collection exercise was carried using a combined approach based on segments of well established data mining and knowledge discovery methodologies, previous work on clinical data integration and local expert consultation. A case study on prostate cancer was carried out at an English regional National Health Service (NHS) hospital.

RESULTS

The process for data retrieval described in this paper allowed patient-centric data, pertaining to the case study on prostate cancer, to be successfully collected from multiple heterogeneous hospital sources, and collated in a format suitable for further clinical research.

CONCLUSIONS

The data collection exercise described in this paper exposes the lengthy and difficult journey of retrieving and collating patient-centric, multi-source data from a hospital, which is indeed a non-trivial task, and one which will greatly benefit from further attention from researchers and hospital IT management.

Computer-based execution of clinical guidelines: a review

PURPOSE

Clinical guidelines are useful tools to standardize and improve health care. The automation of the guideline execution process is a basic step towards its widespread use in medical centres. This paper presents an analysis and a comparison of eight systems that allow the enactment of clinical guidelines in a (semi) automatic fashion.

METHODS

This paper presents a review of the literature (2000-2007) collected from medical databases as well as international conferences in the medical informatics area.

RESULTS

Eight systems containing a guideline execution engine were selected. The language used to represent the guidelines as well as the architecture of these systems were compared. Different aspects have been assessed for each system, such as the integration with external elements or the coordination mechanisms used in the execution of clinical guidelines. Security and terminology issues complement the above study.

CONCLUSIONS

Although these systems could be beneficial for clinicians and patients, it is an ongoing research area, and they are not yet fully implemented and integrated into existing careflow management systems and hence used in daily practice in health care institutions.

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

Background

The 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.

Methods

The literature was systematically reviewed between 1995–2005 to identify articles mentioning patient records, computers and data integration or sharing.

Results

Of 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.

Conclusion

It is clear that Information Systems are evolving to meet people's 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.

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.

Towards shared patient records: An architecture for using routine data for nationwide research

Ubiquitous information is currently one of the most challenging slogans in medical informatics research. An adequate architecture for shared electronic patient records is needed which can use data for multiple purposes and which is extensible for new research questions. We introduce eardap as architecture for using routine data for nationwide clinical research in a multihospital environment. eardap can be characterized as terminology-based. Main advantage of our approach is the extensibility by new items and new research questions. Once the definition of items for a research question is finished, a consistent, corresponding database can be created without any informatics skills. Our experiences in pediatric oncology in Germany have shown the applicability of eardap. The functions of our core system were in routine clinical use in several hospitals. We validated the terminology management system (TMS) and the module generation tool with the basic data set of pediatric oncology. The multiple usability depends mainly on the quality of item planning in the TMS. High quality harmonization will lead to a higher amount of multiply used data. When using eardap, special emphasis is to be placed on interfaces to local hospital information systems and data security issues.

The diagnosis related groups enhanced electronic medical record

PROBLEM

The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians' coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources.

METHODS

Within the Electronic Medical Record (EMR) a user interface ('DRG Control Center') for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well.

RESULTS

With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.