International electronic health record-derived COVID-19 clinical course profiles: the 4CE consortium

We leveraged the largely untapped resource of electronic health record data to address critical clinical and epidemiological questions about Coronavirus Disease 2019 (COVID-19). To do this, we formed an international consortium (4CE) of 96 hospitals across five countries (www.covidclinical.net). Contributors utilized the Informatics for Integrating Biology and the Bedside (i2b2) or Observational Medical Outcomes Partnership (OMOP) platforms to map to a common data model. The group focused on temporal changes in key laboratory test values. Harmonized data were analyzed locally and converted to a shared aggregate form for rapid analysis and visualization of regional differences and global commonalities. Data covered 27,584 COVID-19 cases with 187,802 laboratory tests. Case counts and laboratory trajectories were concordant with existing literature. Laboratory tests at the time of diagnosis showed hospital-level differences equivalent to country-level variation across the consortium partners. Despite the limitations of decentralized data generation, we established a framework to capture the trajectory of COVID-19 disease in patients and their response to interventions.

International electronic health record-derived COVID-19 clinical course profiles: the 4CE consortium

We leveraged the largely untapped resource of electronic health record data to address critical clinical and epidemiological questions about Coronavirus Disease 2019 (COVID-19). To do this, we formed an international consortium (4CE) of 96 hospitals across five countries (www.covidclinical.net). Contributors utilized the Informatics for Integrating Biology and the Bedside (i2b2) or Observational Medical Outcomes Partnership (OMOP) platforms to map to a common data model. The group focused on temporal changes in key laboratory test values. Harmonized data were analyzed locally and converted to a shared aggregate form for rapid analysis and visualization of regional differences and global commonalities. Data covered 27,584 COVID-19 cases with 187,802 laboratory tests. Case counts and laboratory trajectories were concordant with existing literature. Laboratory tests at the time of diagnosis showed hospital-level differences equivalent to country-level variation across the consortium partners. Despite the limitations of decentralized data generation, we established a framework to capture the trajectory of COVID-19 disease in patients and their response to interventions.

The nephrology eHealth-system of the metropolitan region of Hannover for digitalization of care, establishment of decision support systems and analysis of health care quality

Background

Even though a high demand for sector spanning communication exists, so far no eHealth platform for nephrology is established within Germany. This leads to insufficient communication between medical providers and therefore suboptimal nephrologic care. In addition, Clinical Decision Support Systems have not been used in Nephrology until now.

Methods

The aim of NEPHRO-DIGITAL is to create a eHealth platform in the Hannover region that facilitates integrated, cross-sectoral data exchange and includes teleconsultation between outpatient nephrology, primary care, pediatricians and nephrology clinics to reduce communication deficits and prevent data loss, and to enable the creation and implementation of an interoperable clinical decision support system. This system will be based on input data from multiple sources for early identification of patients with cardiovascular comorbidity and progression of renal insufficiency. Especially patients will be able to enter and access their own data. A transfer to a second nephrology center (metropolitan region of Erlangen-Nuremburg) is included in the study to prove feasibility and scalability of the approach.

Discussion

A decision support system should lead to earlier therapeutic interventions and thereby improve the prognosis of patients as well as their treatment satisfaction and quality of life. The system will be integrated in the data integration centres of two large German university medicine consortia (HiGHmed (highmed.org) and MIRACUM (miracum.org)).

Trial registration

ISRCTN16755335 (09.07.2019).

Towards Implementation of OMOP in a German University Hospital Consortium

Background  In 2015, the German Federal Ministry of Education and Research initiated a large data integration and data sharing research initiative to improve the reuse of data from patient care and translational research. The Observational Medical Outcomes Partnership (OMOP) common data model and the Observational Health Data Sciences and Informatics (OHDSI) tools could be used as a core element in this initiative for harmonizing the terminologies used as well as facilitating the federation of research analyses across institutions.

Objective  To realize an OMOP/OHDSI-based pilot implementation within a consortium of eight German university hospitals, evaluate the applicability to support data harmonization and sharing among them, and identify potential enhancement requirements.

Methods  The vocabularies and terminological mapping required for importing the fact data were prepared, and the process for importing the data from the source files was designed. For eight German university hospitals, a virtual machine preconfigured with the OMOP database and the OHDSI tools as well as the jobs to import the data and conduct the analysis was provided. Last, a federated/distributed query to test the approach was executed.

Results  While the mapping of ICD-10 German Modification succeeded with a rate of 98.8% of all terms for diagnoses, the procedures could not be mapped and hence an extension to the OMOP standard terminologies had to be made.

Overall, the data of 3 million inpatients with approximately 26 million conditions, 21 million procedures, and 23 million observations have been imported.

A federated query to identify a cohort of colorectal cancer patients was successfully executed and yielded 16,701 patient cases visualized in a Sunburst plot.

Conclusion  OMOP/OHDSI is a viable open source solution for data integration in a German research consortium. Once the terminology problems can be solved, researchers can build on an active community for further development.

Design and multicentric implementation of a generic software architecture for patient recruitment systems re-using existing HIS tools and routine patient data

OBJECTIVE

(1) To define features and data items of a Patient Recruitment System (PRS); (2) to design a generic software architecture of such a system covering the requirements; (3) to identify implementation options available within different Hospital Information System (HIS) environments; (4) to implement five PRS following the architecture and utilizing the implementation options as proof of concept.

METHODS

Existing PRS were reviewed and interviews with users and developers conducted. All reported PRS features were collected and prioritized according to their published success and user's request. Common feature sets were combined into software modules of a generic software architecture. Data items to process and transfer were identified for each of the modules. Each site collected implementation options available within their respective HIS environment for each module, provided a prototypical implementation based on available implementation possibilities and supported the patient recruitment of a clinical trial as a proof of concept.

RESULTS

24 commonly reported and requested features of a PRS were identified, 13 of them prioritized as being mandatory. A UML version 2 based software architecture containing 5 software modules covering these features was developed. 13 data item groups processed by the modules, thus required to be available electronically, have been identified. Several implementation options could be identified for each module, most of them being available at multiple sites. Utilizing available tools, a PRS could be implemented in each of the five participating German university hospitals.

CONCLUSION

A set of required features and data items of a PRS has been described for the first time. The software architecture covers all features in a clear, well-defined way. The variety of implementation options and the prototypes show that it is possible to implement the given architecture in different HIS environments, thus enabling more sites to successfully support patient recruitment in clinical trials.

[Implementation of a patient data management system. Effects on intensive care documentation]

BACKGROUND

Patient data management systems (PDMS) enable digital documentation on intensive care units (ICU). A commercial PDMS was implemented in a 25-bed ICU replacing paper-based patient charting. The ICU electronic patient record is completely managed inside the PDMS. It compiles data from vital signs monitors, ventilators and further medical devices and facilitates some drug dose and fluid balance calculations as well as data reuse for administrative purposes. Ventilation time and patient severity scoring as well as coding of diagnoses and procedures is supported. Billing data transferred via interface to the central billing system of the hospital. Such benefits should show in measurable parameters, such as documented ventilator time, number of coded diagnoses and procedures and others. These parameters influence reimbursement in the German DRG system. Therefore, measurable changes in cost and reimbursement data of the ICU were expected.

MATERIAL AND METHODS

A retrospective analysis of documentation quality parameters, cost data and mortality rate of a 25-bed surgical ICU within a German university hospital 3 years before (2004-2006) and 5 years after (2007-2011) PDMS implementation. Selected parameters were documented electronically, consistently and reproducibly for the complete time span of 8 years including those years where no electronic patient recording was available. The following parameters were included: number of cleared DRG, cleared ventilator time, case mix (CM), case mix index (CMI), length of stay, number of coded diagnoses and procedures, detailed overview of a specific procedure code based on daily Apache II and TISS Core 10 scores, mortality, total ICU costs and revenues and partial profits for specific ICU procedures, such as renal replacement therapy and blood products.

RESULTS

Systematic shifts were detected over the study period, such as increasing case numbers and decreasing length of stay as well as annual fluctuations in severity of disease seen in the CM and CMI. After PDMS introduction, the total number of coded diagnoses increased but the proportion of DRG relevant diagnoses dropped significantly. The number of procedures increased (not significantly) and the number of procedures per case did not rise significantly. The procedure 8-980 showed a significant increase after PDMS introduction whereas the DRG-relevant proportion of those procedures dropped insignificantly. The number of ventilator-associated DRG cases as well as the total ventilator time increased but not significantly. Costs and revenues increased slightly but profit varied considerably from year to year in the 5 years after system implementation. A small increase was observed per case, per nursing day and per case mix point. Additional revenues for specific ICU procedures increased in the years before and dropped after PDMS implementation. There was an insignificant increase in ICU mortality rate from 7.4 % in the year 2006 (before) to 8.5 % in 2007 (after PDMS implementation). In the following years mortality dropped below the base level.

CONCLUSION

The implementation of the PDMS showed only small effects on documentation of reimbursement-relevant parameters which were too small to set off against the total investment. The method itself, a long-term follow-up of different parameters proved successful and can be adapted by other organizations. The quality of results depends on the availability of long-term parameters in good quality. No significant influence of PDMS on mortality was found.

Unlocking Data for Clinical Research - The German i2b2 Experience

OBJECTIVE

Data from clinical care is increasingly being used for research purposes. The i2b2 platform has been introduced in some US research communities as a tool for data integration and querying by clinical users. The purpose of this project was to assess the applicability of i2b2 in Germany regarding use cases, functionality and integration with privacy enhancing tools.

METHODS

A set of four research usage scenarios was chosen, including the transformation and import of ontology and fact data from existing clinical data collections into i2b2 v1.4 instances. Query performance was measured in comparison to native SQL queries. A setup and administration tool for i2b2 was developed. An extraction tool for CDISC ODM data was programmed. Interfaces for the TMF privacy enhancing tools (PID Generator, Pseudonymization Service) were implemented.

RESULTS

Data could be imported in all tested scenarios from various source systems, including the generation of i2b2 ontology definitions. The integration of TMF privacy enhancing tools was possible without modification of the platform. Limitations were found regarding query performance in comparison to native SQL and certain temporal queries.

CONCLUSIONS

i2b2 is a viable platform for data query tasks in use cases typical for networked medical research in Germany. The integration of privacy enhancing tools facilitates the use of i2b2 within established data protection concepts. Entry barriers should be lowered by providing tools for simplified setup and import of medical standard formats like CDISC ODM.

IT Infrastructure Components for Biobanking

OBJECTIVE

Within translational research projects in the recent years large biobanks have been established, mostly supported by homegrown, proprietary software solutions. No general requirements for biobanking IT infrastructures have been published yet. This paper presents an exemplary biobanking IT architecture, a requirements specification for a biorepository management tool and exemplary illustrations of three major types of requirements.

METHODS

We have pursued a comprehensive literature review for biobanking IT solutions and established an interdisciplinary expert panel for creating the requirements specification. The exemplary illustrations were derived from a requirements analysis within two university hospitals.

RESULTS

The requirements specification comprises a catalog with more than 130 detailed requirements grouped into 3 major categories and 20 subcategories. Special attention is given to multitenancy capabilities in order to support the project-specific definition of varying research and bio-banking contexts, the definition of workflows to track sample processing, sample transportation and sample storage and the automated integration of preanalytic handling and storage robots.

CONCLUSION

IT support for biobanking projects can be based on a federated architectural framework comprising primary data sources for clinical annotations, a pseudonymization service, a clinical data warehouse with a flexible and user-friendly query interface and a biorepository management system. Flexibility and scalability of all such components are vital since large medical facilities such as university hospitals will have to support biobanking for varying monocentric and multicentric research scenarios and multiple medical clients.

Perspectives for medical informatics. Reusing the electronic medical record for clinical research

OBJECTIVES

Even though today most university hospitals have already implemented commercial hospital information systems and started to build up comprehensive electronic medical records, reuse of such data for data warehousing and research purposes is still very rare. Given this situation, the focus of this paper is to present an overview on exemplary projects, which have already tackled this challenge, reflect on current initiatives within the United States of America and the European Union to establish IT infrastructures for clinical and translational research, and draw attention to new challenges in this area.

METHODS

This paper does not intend to provide a fully comprehensive review on all the issues of clinical routine data reuse. It is based, however, on a presentation of a large variety of historical, but also most recent activities in data warehousing, data retrieval and linking medical informatics with translational research.

RESULTS

The article presents an overview of the various international approaches to this issue and illustrates concepts and solutions which have been published, thus giving an impression of activities pursued in this field of medical informatics. Further, problems and open questions, which have also been named in the literature, are presented and three challenges (to establish comprehensive clinical data warehouses, to establish professional IT infrastructure applications supporting clinical trial data capture and to integrate medical record systems and clinical trial databases) related to this area of medical informatics are identified and presented.

CONCLUSIONS

Translational biomedical research with the aim "to integrate bedside and biology" and to bridge the gap between clinical care and medical research today and in the years to come, provides a large and interesting field for medical informatics researchers. Especially the need for integrating clinical research projects with data repositories built up during documentation of routine clinical care, today still leaves many open questions and research challenges. Consideration of regulatory requirements, data privacy issues, data standards as well as people/organizational issues are prerequisites in order to vanquish existing obstacles.

Experiences with an interoperable data acquisition platform for multi-centric research networks based on HL7 CDA

A remote data entry (RDE) module was successfully integrated within a Web-based telemedicine system in a German multi-centric research network for a rare disease called Epidermolysis Bullosa. The use of standards like XML and HL7 CDA (Clinical Document Architecture) for structured data storage, guarantees long-term accessibility and high level interoperability.

[A multidisciplinary mModule for oncological documentation within a hospital information system]

The follow-up documentation of oncological patients in Germany is inadequate in many cases: it is usually limited to a minimal dataset mandated by the epidemiological tumor registers; it is carried out in a paper-based fashion and rarely in a multi-disciplinary context. Parallel documentation efforts can result in redundant or erroneous data and excess work. The introduction of hospital information systems (HIS) allows the implementation of digital oncological documentation systems integrated in surrounding clinical workflows that can provide access to existing data sources as well as data entry and presentation across departmental boundaries. This concept enables the integration of tumor documentation, quality assurance and process optimization within HIS. Feasibility requirements include a high flexibility and adaptability of the underlying HIS to reach a seamless integration of oncological documentation forms within routine clinical workflows. This paper presents the conceptual design and implementation of a modular oncological documentation system at the Muenster University Hospital that is capable of integrating the documentation requirements of multiple departments within the hospital.

The new navigation in EHRs: enabling teamwork of professionals and patients

After development of a state of the art electronic health record, which is accessible via the internet and belongs to a patient, who can manage access to it, the methods of introducing it into routine use in the environment of children's oncology is the theme of this paper. The new navigation in an EHR intends a shared use for the patient, relatives, and different HCPs. The laboratory devices were equipped with an HL7-interface to send messages to the HIS. These messages are combined in documents according to the CDA and sent to the EHR. In a similar way referral letters are uploaded directly from the HIS. Several information resources are used to enlighten the patient and help to enable him to become a member of a team for collaborative care. The varying roles of patient and HCPs lead to some very interesting questions, which have to be answered by a following study.

Functions of an electronic health record

The functionality of a personal electronic health record (EHR) may vary from a simple web-based interface for interactive data entry and data review up to a much more powerful system, additionally supporting electronic data/document communication between clinical information systems of primary care practitioners or hospitals, and even reminder-based support for the empowered citizen to actively take care of his/her health, based on relevant disease management programs. It is a means of supporting patient empowerment. Since storage and communication of data in an EHR involves sensitive personal health data, it is necessary to implement specific security and access management requirements for each of these functions.

An XML-based system for the flexible classification and retrieval of clinical practice guidelines

Beneficial effects of clinical practice guidelines (CPGs) have not yet reached expectations due to limited routine adoption. Electronic distribution and reminder systems have the potential to overcome implementation barriers. Existing electronic CPG repositories like the National Guideline Clearinghouse (NGC) provide individual access but lack standardized computer-readable interfaces necessary for automated guideline retrieval. The aim of this paper was to facilitate automated context-based selection and presentation of CPGs. Using attributes from the NGC classification scheme, an XML-based metadata repository was successfully implemented, providing document storage, classification and retrieval functionality. Semi-automated extraction of attributes was implemented for the import of XML guideline documents using XPath. A hospital information system interface was exemplarily implemented for diagnosis-based guideline invocation. Limitations of the implemented system are discussed and possible future work is outlined. Integration of standardized computer-readable search interfaces into existing CPG repositories is proposed.

Optimizing coding quality: the role of the electronic medical record in the context of diagnosis related groups

In 2003, a new prospective payment system will be introduced in Germany, which is based on the Australian Refined Diagnosis related Groups (AR-DRGs). Physicians must code diagnoses and procedures themselves. Inaccurately or incompletely coded patient records can result in considerable underpayment, so enhancing physicians' coding compliance and competence seems crucial. Coding shall be well integrated in the electronic patient record, providing a simple interface with background information, which is invoked out of the clinical documentation. This paper describes an existing implementation and possible further development.

Strategic information management plans: the basis for systematic information management in hospitals

Information management in hospitals is a complex task. In order to reduce complexity, we distinguish strategic, tactical, and operational information management. This is essential, because each of these information management levels views hospital information systems from different perspectives, and therefore uses other methods and tools. Since all these management activities deal only in part with computers, but mainly with human beings and their social behavior, we define a hospital information system as a sociotechnical subsystem of a hospital. Without proper strategic planning it would be a matter of chance, if a hospital information system would fulfil the information strategies goals. In order to support strategic planning and to reduce efforts for creating strategic plans, we propose a practicable structure.

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

PROBLEM

Clinicians' acceptance of clinical decision support depends on its workflow-oriented, context-sensitive accessibility and availability at the point of care, integrated into the Electronic Patient Record (EPR). Commercially available Hospital Information Systems (HIS) often focus on administrative tasks and mostly do not provide additional knowledge based functionality. Their traditionally monolithic and closed software architecture encumbers integration of and interaction with external software modules. Our aim was to develop methods and interfaces to integrate knowledge sources into two different commercial hospital information systems to provide the best decision support possible within the context of available patient data.

METHODS

An existing, proven standalone scoring system for acute abdominal pain was supplemented by a communication interface. In both HIS we defined data entry forms and developed individual and reusable mechanisms for data exchange with external software modules. We designed an additional knowledge support frontend which controls data exchange between HIS and the knowledge modules. Finally, we added guidelines and algorithms to the knowledge library.

RESULTS

Despite some major drawbacks which resulted mainly from the HIS' closed software architectures we showed exemplary, how external knowledge support can be integrated almost seamlessly into different commercial HIS. This paper describes the prototypical design and current implementation and discusses our experiences.

Evaluation of clinical information systems. What can be evaluated and what cannot?

The evaluation of clinical information systems is essential as they are increasingly used in clinical routine and may even influence patient outcome on the basis of reminder functions and decision support. Therefore we try to answer three questions in this paper: what to evaluate; how to evaluate; how to interpret the results. Those key questions lead to the discussion of goals, methods and results of evaluation studies in a common context. We will compare the objectivist and the subjectivist evaluation approach and illustrate the evaluation process itself in some detail, discussing different phases of software development and potential evaluation techniques in each phase. We use four different practical examples of evaluation studies that were conducted in various settings to demonstrate how defined evaluation goals may be achieved with a limited amount of resources. This also illustrates advantages, limitations and costs of the different evaluation methods and techniques that may be used when evaluating clinical information systems.

Telepathology network: conceptual groundwork and evaluation

Telepathology uses telecommunication technology to transmit microscopic images for diagnostic or teaching purposes. Basic requirements for a telepathology system are described. Usage scenarios for a telepathology network are presented including applications in intraoperative frozen section diagnosis, scientific collaboration and computer based training. Results of an evaluation of 4 currently available telepathology systems are presented.

Teaching computer classes at the University Hospital of Münster--evaluation of long-term results

With the increasing use of computers in the hospital, staff have to face working with a new medium and technology. Computer training is required to increase user acceptance. After a brief presentation of the current teaching concept, the effectiveness and long-term results of computer classes that have been offered at the University Hospital of Münster since August 1998 are evaluated. A questionnaire was sent to 300 course participants covering aspects of motivation, confidence, satisfaction, reluctance and some general data. Overall results were very positive. Some comments have led to considerations regarding some alterations to the program as for instance adjusting the program more to the differing needs of various professional groups or reconsidering the ways of its distribution.

Graphical tool for navigation within the semantic network of the UMLS metathesaurus on a locally installed database

Knowledge in the environment of information technologies is bound to structured vocabularies. Medical data dictionaries are necessary for uniquely describing findings like diagnoses, procedures or functions. Therefore we decided to locally install a version of the Unified Medical Language System (UMLS) of the U.S. National Library of Medicine as a repository for defining entries of a medical multimedia database. Because of the requirement to extend the vocabulary in concepts and relations between existing concepts a graphical tool for appending new items to the database has been developed: Although the database is an instance of a semantic network the focus on single entries offers the opportunity of reducing the net to a tree within this detail. Based on the graph theorem, there are definitions of nodes of concepts and nodes of knowledge. The UMLS additionally offers the specification of sub-relations, which can be represented, too. Using this view it is possible to manage these 1:n-Relations in a simple tree view. On this background an explorer like graphical user interface has been realised to add new concepts and define new relationships between those and existing entries for adapting the UMLS for specific purposes such as describing medical multimedia objects.

Integrating knowledge based functionality in commercial hospital information systems

Successful integration of knowledge-based functions in the electronic patient record depends on direct and context-sensitive accessibility and availability to clinicians and must suit their workflow. In this paper we describe an exemplary integration of an existing standalone scoring system for acute abdominal pain into two different commercial hospital information systems using Java/Corba technolgy.

[Electronic documentation in medicine; flexible concepts versus isolated solutions]

Computer-based medical documentation so far proved advantageous especially through standardization of data entry and increased access speed. Additional benefits can be achieved through the implementation of integrated, cross-project documentation tools and their integration into the clinical work-flow, which allow data to be used for a wide variety of applications (e.g. quality management, clinical research, clinic management). The presence of incompatible documentation software often complicates the realization of these goals. Implementation of new documentation tools therefore should consider flexibility and multiple-use of data as primary design goals. In the presented paper requirements for flexible documentation tools are introduced. The Entity-Attribute-Value-Model is described as a possible means of implementation. Practical experiences made with a prototype application are reported.

[Steps towards a hospital information system: illustrated by the example of the medical setting of the Westphalian Wilhelms University of Münster]

Implementing hospital information systems for an efficient application of electronic data processing requires the integration of previously introduced departmental systems, which traditionally have been designed only from the viewpoint of an isolated hospital department. Those efforts have to be accompanied by a parallel implementation of a hospital-wide network and the introduction of PC workstations on clinical wards and in outpatient clinics. In this paper currently ongoing efforts at the University Hospital of Münster are presented in order to illustrate how such integration efforts can improve communication and information retrieval in all clinical areas of a hospital.

Stepwise evaluation of information systems in an university hospital

A prospective intervention study with historical control has been performed at Giessen University Hospital, Germany, to investigate the influence of electronic data processing systems on nurses' working environment. Two wards of the medical department were selected for this study, using the combined approach of work-sampling methods and questionnaires. In the first intervention a central information system with restricted functions was introduced. For the second intervention an additional nursing information system was installed. The distribution of nurses' worktime into the fields of general nursing care, specific nursing care and administrative activities was not influenced by electronic data processing. No time saving could be measured. Results of the questionnaires did, however, indicate a positive influence of the hospital information system on nurses' working environment.

Data dictionaries at Giessen University Hospital: past--present--future

The concept of maintaining a medical data dictionary as a HIS core component was fundamental for all HIS development phases since the mid eighties at Giessen University Hospital. Being influenced by an early experimental installation of the HELP hospital information system and its PTXT data dictionary, we kept this approach through a number of development cycles of our own hospital information system. While our first data dictionary implementation (GMDD) was still very close to the PTXT structure (polyhierarchical design with an eight level hierarchy), the second generation dictionary (MDD-GIPHARM) has already been designed using a more flexible semantic network model. GMDD was a mainframe development (realized on Tandem Computers) based on the Tandem Nonstop SQL RDBMS. The major clinical applications established on top of the GMDD were laboratory results review, diagnosis documentation and physician discharge summaries. The MDD-GIPHARM development was initiated on PC-basis as the core of a rheumatology departmental system using MS-Access and then further enhanced within a research project to build knowledge-based functions for drug therapy. A first set of such functions based on MDD-GIPHARM is in routine use since 1996. Our current focus is to enhance MDD-GIPHARM towards an application independent vocabulary server (GDDS), which may be used for a variety of applications with the intranet of Giessen University Hospital. In this paper the evolutionary development of those data dictionary concepts at Giessen University Hospital is illustrated and compared with international activities in the last decade.

Workflow analysis and evidence-based medicine: towards integration of knowledge-based functions in hospital information systems

The large extent and complexity of scientific evidence described in the concept of evidence-based medicine often overwhelms clinicians who want to apply best external evidence. Hospital Information Systems usually do not provide knowledge-based functions to support context-sensitive linking to external information sources. Knowledge-based components need specific data, which must be entered manually and should be well adapted to clinical environment to be accepted by clinicians. This paper describes a workflow-based approach to understand and visualize clinical reality as a preliminary to designing software applications, and possible starting points for further software development.

Knowledge based functions for routine use at a German university hospital setting: the issue of fine tuning

In this paper we present the introduction of knowledge based functions into clinical routine at Giessen University Hospital. For this purpose a therapy planning module at the medical intensive care unit has been extensively redesigned in order to support the structured documentation of drug prescriptions. After introduction of this new HIS component in January 1996 research has been initiated to establish a basic drug therapy knowledge base. The main components of a knowledge based system have been fully incorporated into the hospital information system WING and are in routine use since December 1996. During a pre-production phase warnings of reminder functions were logged and reviewed by an interdisciplinary team in order to adapt the system to the actual clinical environment. The paper describes experiences during this fine tuning and adaptation process which was necessary to bring a small set of knowledge modules into clinical routine.

From HIS to IAIMS: expanding the scope of information processing applications in a German university hospital

Since the mid eighties the department of medical informatics at the University Hospital of Giessen (Germany) has been engaged in the development of a comprehensive hospital information system. The installation of a campus wide network has set the basis to provide not only clinical patient-oriented information, but also general information resources for research, medical education and administrative purposes, thus creating an environment which in the U.S. became known as an integrated academic information management system (IAIMS). The underlying concept of the whole approach is to provide one-stop information shopping capabilities at the clinicians and administrators desktop in order to meet the increasing information needs of health professionals with the emerging reality of the potential benefits of computer and communication technologies. This paper describes the various steps performed to realize this concept at Giessen University Hospital and the evaluation results derived from analysis of the acceptance of these new technologies among our hospital staff.

WING--entering a new phase of electronic data processing at the Giessen University Hospital

At the Giessen University Hospital electronic data processing systems have been in routine use since 1975. In the early years developments were focused on ADT functions (admission/discharge/transfer) and laboratory systems. In the next decade additional systems were introduced supporting various functional departments. In the mid-eighties the need to stop the ongoing trend towards more and more separated stand-alone systems was realized and it was decided to launch a strategic evaluation and planning process which sets the foundation for an integrated hospital information system (HIS). The evaluation of the HELP system for its portability into the German hospital environment was the first step in this process. Despite its recognized capabilities in integrating decision support and communication technologies, and its powerful HIS development tools, the large differences between American and German hospital organization, influencing all existing HELP applications, and the incompatibility of the HELP tools with modern software standards were two important factors forcing the investigation of alternative solutions. With the HELP experience in mind, a HIS concept for the Giessen University Hospital was developed. This new concept centers on the idea of a centralized relational patient database on a highly reliable database server, and clinical front-end applications which might be running on various other computer systems (mainframes, departmental UNIX satellites or PCs in a LAN) integrated into a comprehensive open HIS network. The first step towards this integrated approach was performed with the implementation of ADT and results reporting functions on care units.

Knowledge representation in pharmacology. A possible application area for the Arden Syntax?

In 1990 the Arden Syntax was proposed as a first version of a standardized syntax for the representation of medical knowledge. For the evaluation of the practicability of this first release we have analyzed the medical and pharmacological knowledge applied in the process of drug prescription. The separation of declarative (e.g. in a semantic network) and procedural knowledge is a basic issue of our research. We therefore propose to further extend the Arden syntax with declarative knowledge representation facilities. One way to do this may be the incorporation of a standardized medical data dictionary (e.g. the UMLS Metathesaurus) which promotes the representation of medical terms in a semantic network. Furthermore the problem of 'institution-specific knowledge', which is especially important for the issue of knowledge sharing between different institutions, is analyzed based on examples of knowledge modules for monitoring drug allergies and drug-drug-interactions.

Applying expert system techniques to human genetics

Although expert systems have been developed in a variety of medical areas, there has been very little application of expert system techniques to the field of human genetics. The purpose of the research project described in this paper was (1) to experiment with different types of knowledge representation for data and knowledge structures in human genetics and (2) to explore the applicability of different inference mechanisms for various genetic problems. We present an object-oriented and a fact-based model for the representation of genealogical information and describe two prototype systems.