Clinical Information Systems Research in the Pandemic Year 2020

Objective: In this synopsis, we give an overview of recent research and propose a selection of best papers published in 2020 in the field of Clinical Information Systems (CIS).

Method: As CIS section editors, we annually apply a systematic process to retrieve articles for the International Medical Informatics Association Yearbook of Medical Informatics. For seven years now, we use the same query to find relevant publications in the CIS field. Each year we retrieve more than 2,400 papers which we categorize in a multi-pass review to distill a preselection of 15 candidate papers. External reviewers and yearbook editors then assess the selected candidate papers. Based on the review results, the IMIA Yearbook editorial board chooses up to four best publications for the section at a selection meeting. To get an overview of the content of the retrieved articles, we use text mining and term co-occurrence mapping techniques.

Results: We carried out the query in mid-January 2021 and retrieved a deduplicated result set of 2,787 articles from 1,135 different journals. We nominated 15 papers as candidates and finally selected four of them as the best papers in the CIS section. As in the previous years, the content analysis of the articles revealed the broad spectrum of topics covered by CIS research. Thus, this year we could observe a significant impact of COVID-19 on CIS research.

Conclusions: The trends in CIS research, as seen in recent years, continue to be observable. What was very visible was the impact of the Corona Virus Disease 2019 (COVID-19) pandemic, which has affected not only our lives but also CIS.

Trends in Clinical Information Systems Research in 2019

Objective : To give an overview of recent research and to propose a selection of best papers published in 2019 in the field of Clinical Information Systems (CIS).

Method : Each year, we apply a systematic process to retrieve articles for the CIS section of the IMIA Yearbook of Medical Informatics. For six years now, we use the same query to find relevant publications in the CIS field. Each year we retrieve more than 2,000 papers. As CIS section editors, we categorize the retrieved articles in a multi-pass review to distill a pre-selection of 15 candidate best papers. Then, Yearbook editors and external reviewers assess the selected candidate best papers. Based on the review results, the IMIA Yearbook Editorial Committee chooses the best papers during the selection meeting. We used text mining, and term co-occurrence mapping techniques to get an overview of the content of the retrieved articles.

Results : We carried out the query in mid-January 2020 and retrieved a de-duplicated result set of 2,407 articles from 1,023 different journals. This year, we nominated 14 papers as candidate best papers, and three of them were finally selected as best papers in the CIS section. As in previous years, the content analysis of the articles revealed the broad spectrum of topics covered by CIS research.

Conclusions : We could observe ongoing trends, as seen in the last years. Patient benefit research is in the focus of many research activities, and trans-institutional aggregation of data remains a relevant field of work. Powerful machine-learning-based approaches, that use readily available data now often outperform human-based procedures. However, the ethical perspective of this development often comes too short in the considerations. We thus assume that ethical aspects will and should deliver much food for thought for future CIS research.

Clinical Information Systems as the Backbone of a Complex Information Logistics Process: Findings from the Clinical Information Systems Perspective for 2016

Objective: To summarize recent research and to propose a selection of best papers published in 2016 in the field of Clinical Information Systems (CIS). Method: The query used to retrieve the articles for the CIS section of the 2016 edition of the IMIA Yearbook of Medical Informatics was reused. It again aimed at identifying relevant publications in the field of CIS from PubMed and Web of Science and comprised search terms from the Medical Subject Headings (MeSH) catalog as well as additional free text search terms. The retrieved articles were categorized in a multi-pass review carried out by the two section editors. The final selection of candidate papers was then peer-reviewed by Yearbook editors and external reviewers. Based on the review results, the best papers were then chosen at the selection meeting with the IMIA Yearbook editorial board. Text mining, term co-occurrence mapping, and topic modelling techniques were used to get an overview on the content of the retrieved articles. Results: The query was carried out in mid-January 2017, yielding a consolidated result set of 2,190 articles published in 921 different journals. Out of them, 14 papers were nominated as candidate best papers and three of them were finally selected as the best papers of the CIS field. The content analysis of the articles revealed the broad spectrum of topics covered by CIS research. Conclusions: The CIS field is multi-dimensional and complex. It is hard to draw a well-defined outline between CIS and other domains or other sections of the IMIA Yearbook. The trends observed in the previous years are progressing. Clinical information systems are more than just sociotechnical systems for data collection, processing, exchange, presentation, and archiving. They are the backbone of a complex, trans-institutional information logistics process.

EsPRit: ethics committee proposals for Long Term Medical Data Registries in rapidly evolving research fields - a future-proof best practice approach

Background

Long-term data collection is a challenging task in the domain of medical research. Many effects in medicine require long periods of time to become traceable e.g. the development of secondary malignancies based on a given radiotherapeutic treatment of the primary disease. Nevertheless, long-term studies often suffer from an initial lack of available information, thus disallowing a standardized approach for their approval by the ethics committee. This is due to several factors, such as the lack of existing case report forms or an explorative research approach in which data elements may change over time.

In connection with current medical research and the ongoing digitalization in medicine, Long Term Medical Data Registries (MDR-LT) have become an important means of collecting and analyzing study data. As with any clinical study, ethical aspects must be taken into account when setting up such registries.

This work addresses the problem of creating a valid, high-quality ethics committee proposal for medical registries by suggesting groups of tasks (building blocks), information sources and appropriate methods for collecting and analyzing the information, as well as a process model to compile an ethics committee proposal (EsPRit).

Methods

To derive the building blocks and associated methods software and requirements engineering approaches were utilized. Furthermore, a process-oriented approach was chosen, as information required in the creating process of ethics committee proposals remain unknown in the beginning of planning an MDR-LT. Here, we derived the needed steps from medical product certification. This was done as the medical product certification itself also communicates a process-oriented approach rather than merely focusing on content. A proposal was created for validation and inspection of applicability by using the proposed building blocks. The proposed best practice was tested and refined within SEMPER (Secondary Malignoma - Prospective Evaluation of the Radiotherapeutics dose distribution as the cause for induction) as a case study.

Results

The proposed building blocks cover the topics of “Context Analysis”, “Requirements Analysis”, “Requirements Validation”, “Electronic Case Report (eCRF) Design” and “Overall Concept Creation”. Additional methods are attached with regards to each topic. The goals of each block can be met by applying those methods. The proposed methods are proven methods as applied in e.g. existing Medical Data Registry projects, as well as in software or requirements engineering.

Conclusion

Several building blocks and attached methods could be identified in the creation of a generic ethics committee proposal. Hence, an Ethics Committee can make informed decisions on the suggested study via said blocks, using the suggested methods such as “Defining Clinical Questions” within the Context Analysis. The study creators have to confirm that they adhere to the proposed procedure within the ethic proposal statement. Additional existing Medical Data Registry projects can be compared to EsPRit for conformity to the proposed procedure. This allows for the identification of gaps, which can lead to amendments requested by the ethics committee.

New Problems - New Solutions: A Never Ending Story. Findings from the Clinical Information Systems Perspective for 2015

OBJECTIVE

To summarize recent research and to propose a selection of best papers published in 2015 in the field of Clinical Information Systems (CIS).

METHOD

The query which had been used last year to retrieve articles for the CIS section of the IMIA Yearbook of Medical Informatics 2015 was refined. It again aimed at identifying relevant publications in the field of CIS and comprised search terms from the Medical Subject Headings (MeSH) catalog as well as additional free text search terms from PubMed and Web of Science. The retrieved articles were categorized in a multi-pass review carried out separately by the two section editors. The final selection of 15 candidate papers was then peer-reviewed by Yearbook editors and external reviewers. Based on the review results the four best papers were then selected at the best papers selection meeting with the IMIA Yearbook editorial board. To get an overview on the content of the retrieved articles we applied text mining and term co-occurrence mapping techniques.

RESULTS

The query was carried out in mid-January 2016, yielding a combined result set of 1851 articles which were published in 790 different journals. The most relevant terms from abstracts and titles of these articles were assigned to six different clusters. A majority of articles dealt with two thematic blocks, problems and solutions in the CIS field. The majority of the 2016 CIS candidate papers and all four best papers could be assigned to these two thematic blocks.

CONCLUSIONS

We identified two main tracks among the CIS candidate and best papers as well as in CIS research activities in general: problems and solutions. A never ending cycle of continuous improvement.

SPIRIT: Systematic Planning of Intelligent Reuse of Integrated Clinical Routine Data. A Conceptual Best-practice Framework and Procedure Model

BACKGROUND

Secondary use of clinical routine data is receiving an increasing amount of attention in biomedicine and healthcare. However, building and analysing integrated clinical routine data repositories are nontrivial, challenging tasks. As in most evolving fields, recognized standards, well-proven methodological frameworks, or accurately described best-practice approaches for the systematic planning of solutions for secondary use of routine medical record data are missing.

OBJECTIVE

We propose a conceptual best-practice framework and procedure model for the systematic planning of intelligent reuse of integrated clinical routine data (SPIRIT).

METHODS

SPIRIT was developed based on a broad literature overview and further refined in two case studies with different kinds of clinical routine data, including process-oriented nursing data from a large hospital group and high-volume multimodal clinical data from a neurologic intensive care unit.

RESULTS

SPIRIT aims at tailoring secondary use solutions to specific needs of single departments without losing sight of the institution as a whole. It provides a general conceptual best-practice framework consisting of three parts: First, a secondary use strategy for the whole organization is determined. Second, comprehensive analyses are conducted from two different viewpoints to define the requirements regarding a clinical routine data reuse solution at the system level from the data perspective (BOTTOM UP) and at the strategic level from the future users perspective (TOP DOWN). An obligatory clinical context analysis (IN BETWEEN) facilitates refinement, combination, and integration of the different requirements. The third part of SPIRIT is dedicated to implementation, which comprises design and realization of clinical data integration and management as well as data analysis solutions.

CONCLUSIONS

The SPIRIT framework is intended to be used to systematically plan the intelligent reuse of clinical routine data for multiple purposes, which often was not intended when the primary clinical documentation systems were implemented. SPIRIT helps to overcome this gap. It can be applied in healthcare institutions of any size or specialization and allows a stepwise setup and evolution of holistic clinical routine data reuse solutions.

Findings from the Clinical Information Systems Perspective

OBJECTIVE

To summarize recent research and to propose a selection of best papers published in 2014 in the field of Clinical Information Systems (CIS).

METHOD

A query with search terms from the Medical Subject Headings (MeSH) catalog as well as additional free text search terms was designed to identify relevant publications in the field of clinical information systems from PubMed and Web of Science®. The retrieved articles were then categorized in a multi-pass review carried out separately by the section editors. The final selection of 15 candidate papers was then peerreviewed by Yearbook editors and external reviewers. Based on the review results the four best papers were then selected at the best papers selection meeting with the IMIA Yearbook editorial board.

RESULTS

The query was carried out in mid-January 2015, yielding a combined result set of 1525 articles which were published in 722 different journals. Among these articles two main thematic sections were identified: i) Interoperability from a syntactical and semantic point of view as well as from a longterm preservation and organizational/legal point of view and ii) secondary use of existing health data in all its shades. Here, patient safety was a major scope of application.

CONCLUSIONS

CIS have become mature over the last years. The focus has now moved beyond data acquisition for just supporting the local care workflows. Actual research efforts in the CIS domain comprise the breakdown of information silos, the reduction of barriers between different systems of different care providers and secondary use of accumulated health data for multiple purposes.

A Nursing Intelligence System to Support Secondary Use of Nursing Routine Data

BACKGROUND

Nursing care is facing exponential growth of information from nursing documentation. This amount of electronically available data collected routinely opens up new opportunities for secondary use.

OBJECTIVES

To present a case study of a nursing intelligence system for reusing routinely collected nursing documentation data for multiple purposes, including quality management of nursing care.

METHODS

The SPIRIT framework for systematically planning the reuse of clinical routine data was leveraged to design a nursing intelligence system which then was implemented using open source tools in a large university hospital group following the spiral model of software engineering.

RESULTS

The nursing intelligence system is in routine use now and updated regularly, and includes over 40 million data sets. It allows the outcome and quality analysis of data related to the nursing process.

CONCLUSIONS

Following a systematic approach for planning and designing a solution for reusing routine care data appeared to be successful. The resulting nursing intelligence system is useful in practice now, but remains malleable for future changes.

Job Profiles of Biomedical Informatics Graduates. Results of a Graduate Survey

BACKGROUND

Biomedical informatics programs exist in many countries. Some analyses of the skills needed and of recommendations for curricular content for such programs have been published. However, not much is known of the job profiles and job careers of their graduates.

OBJECTIVES

To analyse the job profiles and job careers of 175 graduates of the biomedical informatics bachelor and master program of the Tyrolean university UMIT.

METHODS

Survey of all biomedical informatics students who graduated from UMIT between 2001 and 2013.

RESULTS

Information is available for 170 graduates. Eight percent of graduates are male. Of all bachelor graduates, 86% started a master program. Of all master graduates, 36% started a PhD. The job profiles are quite diverse: at the time of the survey, 35% of all master graduates worked in the health IT industry, 24% at research institutions, 9% in hospitals, 9% as medical doctors, 17% as informaticians outside the health care sector, and 6% in other areas. Overall, 68% of the graduates are working as biomedical informaticians. The results of the survey indicate a good job situation for the graduates.

CONCLUSIONS

The job opportunities for biomedical informaticians who graduated with a bachelor or master degree from UMIT seem to be quite good. The majority of graduates are working as biomedical informaticians. A larger number of comparable surveys of graduates from other biomedical informatics programs would help to enhance our knowledge about careers in biomedical informatics.

Early brain injury after aneurysmal subarachnoid hemorrhage: a multimodal neuromonitoring study

Introduction

There is a substantial amount of evidence from animal models that early brain injury (EBI) may play an important role for secondary brain injury after aneurysmal subarachnoid hemorrhage (aSAH). Cerebral microdialysis (CMD) allows online measurement of brain metabolites, including the pro-inflammatory cytokine interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9), which is indicative for disruption of the blood-brain barrier.

Methods

Twenty-six consecutive poor-grade aSAH patients with multimodal neuromonitoring were analyzed for brain hemodynamic and metabolic changes, including CMD-IL-6 and CMD-MMP-9 levels. Statistical analysis was performed by using a generalized estimating equation with an autoregressive function.

Results

The baseline cerebral metabolic profile revealed brain metabolic distress and an excitatory response which improved over the following 5 days (P <0.001). Brain tissue hypoxia (brain tissue oxygen tension of less than 20 mm Hg) was common (more than 60% of patients) in the first 24 hours of neuromonitoring and improved thereafter (P <0.05). Baseline CMD-IL-6 and CMD-MMP-9 levels were elevated in all patients (median = 4,059 pg/mL, interquartile range (IQR) = 1,316 to 12,456 pg/mL and median = 851 pg/mL, IQR = 98 to 25,860 pg/mL) and significantly decreased over days (P <0.05). A higher pro-inflammatory response was associated with the development of delayed cerebral ischemia (P = 0.04), whereas admission disease severity and early brain tissue hypoxia were associated with higher CMD-MMP-9 levels (P <0.03). Brain metabolic distress and increased IL-6 levels were associated with poor functional outcome (modified Rankin Scale of more than 3, P ≤0.01). All models were adjusted for probe location, aneurysm securing procedure, and disease severity as appropriate.

Conclusions

Multimodal neuromonitoring techniques allow insight into pathophysiologic changes in the early phase after aSAH. The results may be used as endpoints for future interventions targeting EBI in poor-grade aSAH patients.

Higher brain extracellular potassium is associated with brain metabolic distress and poor outcome after aneurysmal subarachnoid hemorrhage

Introduction

Elevated brain potassium levels ([K⁺]) are associated with neuronal damage in experimental models. The role of brain extracellular [K⁺] in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) and its association with hemorrhage load, metabolic dysfunction and outcome has not been studied so far.

Methods

Cerebral microdialysis (CMD) samples from 28 poor grade aSAH patients were analyzed for CMD [K⁺] for 12 consecutive days after ictus, and time-matched to brain metabolic and hemodynamic parameters as well as corresponding plasma [K⁺]. Statistical analysis was performed using a generalized estimating equation with an autoregressive function to handle repeated observations of an individual patient.

Results

CMD [K⁺] did not correlate with plasma [K⁺] (Spearman’s ρ = 0.114, P = 0.109). Higher CMD [K⁺] was associated with the presence of intracerebral hematoma on admission head computed tomography, CMD lactate/pyruvate ratio >40 and CMD lactate >4 mmol/L (P < 0.05). In vitro retrodialysis data suggest that high CMD [K⁺] was of brain cellular origin. Higher CMD [K⁺] was significantly associated with poor 3-month outcome, even after adjusting for age and disease severity (P < 0.01).

Conclusions

The results of this pilot study suggest that brain extracellular [K⁺] may serve as a biomarker for brain tissue injury in poor-grade aSAH patients. Further studies are needed to elucidate the relevance of brain interstitial K⁺ levels in the pathophysiology of secondary brain injury after aSAH.

Crucial factors for the acceptance of a computerized national medication list: insights into findings from the evaluation of the Austrian e-Medikation pilot

OBJECTIVE

The objective of this paper is to present crucial factors among registered doctors and pharmacists for acceptance of the Austrian 'e-Medikation' system which is aimed at providing, on a national level, complete and recent information on all the medication that were prescribed or dispensed to a patient.

METHODS

As the accompanying formative evaluation study of the pilot project showed different overall acceptance rates among participating physicians and pharmacists, a decision tree analysis of 30 standardized survey items was performed to identify crucial acceptance factors.

RESULTS

For the physicians' group, only two items (fear of improper data use and satisfaction with software support) were crucial for overall e-Medikation acceptance. The analysis of the pharmacists' data resulted in five crucial factors primarily focusing on functional aspects and the perceived benefits of e-Medikation.

CONCLUSION

The results indicate that the acceptance among physicians and pharmacists depends on quite different factors. This must be taken into account during the planned rollout of e-Medikation or of comparable products.

eHealth in Europe - Status and Challenges

OBJECTIVES

To present European reflections on the concept of eHealth and emerging challenges related to further development of eHealth in Europe.

METHODS

A survey with 10 questions was distributed to representatives of the national member associations of the European Federation of Medical Informatics (EFMI).

RESULTS

The results document a shift from a constricting ICT-orientation to development of the entire health system where eHealth strategies, organizational change, and appropriate technological infrastructure are singled out as important aspects.

CONCLUSION

There are urgent needs to ensure that eHealth strategies and policies for further design and deployment of eHealth applications support sociable services and innovations in health care.

"Why the hell do we need electronic health records?". EHR acceptance among physicians in private practice in Austria: a qualitative study

BACKGROUND

Progress in the medical sciences, together with related technologies, in the past has led to higher specialization and has created a strong need to exchange health information across institutional borders. The concept of electronic health records (EHR) was introduced to fulfill these needs. Remarkably, many EHR introduction projects ran into trouble, not least because they lacked the acceptance of EHR among physicians. Negative emotions, such as anxiety and fear due to a lack of information, may cause change barriers and hamper physicians' acceptance of such projects.

OBJECTIVES

The goal of this study was to gain deeper insight into the negative emotions related to the intended implementation of a mandatory national electronic health record system (called ELGA) in Austria among physicians in private practice.

METHODS

Qualitative, problem-centered interviews were conducted with eight physicians in private practice in the capital region of Tyrol. The methods of qualitative content analysis were used to analyze the data.

RESULTS

Three hundred and twenty-eight passages in the interviews were selected, annotated, and paraphrased. These passages were assigned to 139 different primary categories. Finally, 18 main categories in the form of statements were derived. They were correlated and a theoretical model was formed to explain the genesis of the detected fears and anxiety related to the ELGA project. The results show that the physicians feel uninformed and snubbed. They fear unknown changes, increased costs, as well as workload and surveillance without obtaining any advantages from using electronic health records in their daily practice.

CONCLUSION

Impartial information campaigns that are tailored to the physicians' needs and questions as along with a comprehensive cost-benefit analysis could benefit the physicians' opinion of EHRs.