[Establishment of an electronic medical record in a psychiatric hospital: evolution of professionals' perceptions]. / Mise en place d'un dossier patient informatisé dans un établissement public de psychiatrie : évolution des perceptions des professionnels de santé

OBJECTIVE: The potential benefits of the application of an electronic medical record (EMR) in medical care are well recognized. However, if these benefits are to be accomplished, professionals must adopt and utilize EMR as a part of their practice. The aim of this study was to assess the evolution of the health care professionals' opinions of EMR and their use on a period of 1 year in a French Public Psychiatric Hospital. SETTING: Our institution is a 204-bed psychiatric hospital, employing 328 professionals and comprising three sectors: six units of complete hospitalisation (102 beds), one unit of week hospitalisation (15 beds), one unit of emergency (seven beds) and one unit of night hospitalisation (15 beds). Three extrahospital structures include the day hospitalisation (65 places), the medicopsychological centres (CMP) and the part-time therapeutic reception centres (CATTP) of the three sectors. METHODS: We conducted face-to-face, semi-structured interviews with health care professionals of a public psychiatric hospital on two occasions: 1 month after the establishment of the EMR (t0) and one year later (t1). All the solicited people agreed to participate in the investigation. The interviews were conducted until no new ideas emerged in the content analysis performed in real time, comprising 60 care professionals at t0 (10 psychiatrists, 42 nurses and eight paramedical professionals) and 55 at t1 (six psychiatrists, 42 nurses and seven paramedical professionals). Content analysis was performed by two members of the steering committee who were skilled in textual analysis. A descriptive analysis was also performed. The variables were described by proportions and means. The proportions were compared using the Chi-squared test or Fisher exact test where appropriate. A two-tailed p-value of greater than 0.05 was considered to indicate statistical significance. Statistical analyses were carried out using SPSS version. RESULTS: The proportion of EMR use remained stable and high (respectively 97% in 2007 and 93% in 2008). However, there was an increase in the proportion of pages used in 2008 (77% of the pages) compared to 2007 (58%) (p=0.02). The analysis of interviews highlighted some elements which explained the "under-utilization" of the EMR: "the record contains too many pages", "complete all the pages is sometimes hard", "It's difficult to have a global vision of the EMR". These difficulties are reported in an equivalent way between 2007 and 2008. For the "good users", the EMR had real strengths: "the EMR contains information recorded in a synthetic and precise way"; "the EMR provides complete and rapid information on the patient". There is an improvement of positive perceptions between 2007 and 2008; for example 38% of respondents in 2008 (against 18% in 2007) appreciated the multidisciplinary nature of the EMR and 51% in 2008 (against 40%) in 2007 appreciated the "centralisation of data". The general opinion on EMR had not changed between 2007 and 2008: 70% of professionals had a favourable opinion. Similarly, we did not find statistical difference between 2007 and 2008 on the perception of the impact of EMR on the quality of relationships between professionals and between professionals and patients. The impact on the quality of care remained high. In 2007, 72% of professionals reported that EMR could have a positive impact on the care of patients against 85% in 2008 (non significant). The main impact was the improvement of the continuity and coordination of care. The proportion of professionals who did not consider that EMR could deteriorate impact on professionals-patients relationships was not statistically different between in 2007 (44%) and 2008 (56%). Sixty-six percent of professionals in 2008 against 50% in 2007 did not consider that EMR deteriorates relationships between professionals (p=0.06). However, the rates of adverse opinions remained high in 2008 on the impact of EMR on relationships in general. This was directly related to the "loss of time in completing the EMR". However, in analysing the verbatim, there was a change of potential consequences of this loss of time. "The lack of availability for patients" was less expressed than "the loss of oral communication between professionals" which was reported more frequently. CONCLUSION: This study allowed us to identify the residual problems which each hospital could face, 1 year after setting up an EMR. This preliminary work constitutes the first step in the development of a measurement tool of the use and perception of the EMR by health care professionals.

[Perception and use of an electronic medical record system by professionals of a public psychiatric hospital]. / Perception et utilisation d'un dossier patient informatisé par les professionnels d'un établissement public de psychiatrie.

OBJECTIVES: The aim of this study was to evaluate the interest taken by the health care providers in the electronic medical file and its use within the quality improvement process. SETTING: Our institution is a 204-bed psychiatric hospital, employing 328 professionals and comprising three sectors: six units of complete hospitalisation (102 beds), one unit of week hospitalisation (15 beds), one unit of emergency (7 beds) and one unit of night hospitalisation (15 beds). Three extrahospital structures include the day hospitalisation (65 places), the medicopsychological centers (CMP) and the part-time therapeutic reception centers (CATTP) of the three sectors. METHODS: We conducted face-to-face, semi-structured interviews with health care providers of a public psychiatric hospital. All the solicited people agreed to answer the investigation. The interviews were conducted until no new ideas emerged in the content analysis performed in real time, comprising 60 care providers: 10 psychiatrists, 42 nurses and eight paramedical professionals. Content analysis was performed by two members of the steering committee who were skilled in textual analysis. A descriptive analysis was also performed. The variables were described by proportions and means. The proportions were compared using the Chi-squared test or Fisher exact test where appropriate. A two-tailed P-value of greater than 0.05 was considered to indicate statistical significance. Statistical analyses were carried out using SPSS version 13.0. RESULTS: Ninety-six percent of the interviewed subjects used the electronic medical file. The average number of daily use was seven (S.D.=5). Sixty-seven percent had a favorable opinion of the electronic medical file. Physicians had more frequent favorable opinions than nurses who considered that electronic medical files cannot capture real nursing activity. Health care providers considered that electronic medical file could be associated with improved quality of care, but two points should be taken into account: the increased documentation time (slow system response, multiple screens, the lack of computer knowledge, the absence of bedside documentation technology...) and dysfunctions in the information processing system. This could have an impact on documentation completeness, and quality and could also lead to a reduction of time devoted to care. CONCLUSION: This study proposes tracks of improvement in the use of the DPIP. In spite of this, a true debate must be initiated on these new information systems in psychiatry since their real objectives can be perceived as ambiguous, so that programs of clarification, education and reinsurance can be set-up.

[Searching for evidence-based data]. / Recherche de données factuelles.

The foundation of evidence-based medicine is critical analysis and synthesis of the best data available concerning a given health problem. These factual data are accessible because of the availability on the Internet of web tools specialized in research for scientific publications. A bibliographic database is a collection of bibliographic references describing the documents indexed. Such a reference includes at least the title, summary (or abstract), a set of keywords, and the type of publication. To conduct a strategically effective search, it is necessary to formulate the question - clinical, diagnostic, prognostic, or related to treatment or prevention - in a form understandable by the research engine. Moreover, it is necessary to choose the specific database or databases, which may have particular specificity, and to analyze the results rapidly to refine the strategy. The search for information is facilitated by the knowledge of the standardized terms commonly used to describe the desired information. These come from a specific thesaurus devoted to document indexing. The most frequently used is MeSH (Medical Subject Heading). The principal bibliographic database whose references include a set of describers from the MeSH thesaurus is Medical Literature Analysis and Retrieval System Online (Medline), which has in turn become a subpart of a still more vast bibliography called PubMed, which indexes an additional 1.4 million references. Numerous other databases are maintained by national or international entities. These include the Cochrane Library, Embase, and the PASCAL and FRANCIS databases.

Virtual biomedical universities and e-learning.

In this special issue on virtual biomedical universities and e-learning we will make a survey on the principal existing teaching applications of ICT used in medical Schools around the world. In the following we identify five types of research and experiments in this field of medical e-learning and virtual medical universities. The topics of this special issue goes from educational computer program to create and simulate virtual patients with a wide variety of medical conditions in different clinical settings and over different time frames to using distance learning in developed and developing countries program training medical informatics of clinicians. We also present the necessity of good indexing and research tools for training resources together with workflows to manage the multiple source content of virtual campus or universities and the virtual digital video resources. A special attention is given to training new generations of clinicians in ICT tools and methods to be used in clinical settings as well as in medical schools.

[Regression models for crude and relative survival: a comparative review]. / Revue comparative des modèles régressifs de survie brute et de survie relative.

BACKGROUND: Statistical analysis of lifetime data is frequently used in the biomedical area. Our objective was to present a comparative review of the different regression models according to the survival concept (crude survival or relative survival) in order to express guidelines. METHODS: From a methodological point of view, we compared a regressive crude survival model (Cox model) and regressive relative survival models for grouped data (Hakulinen and Tenkanen) and for individuals data (Esteve et al.). We illustrated our work with an analysis of survival data of 3,355 incident cases of breast cancer identified by a hospital registry. Comportment of the models was studied in situation where censors rates ranged from 31.7 to 96.5%. RESULTS: Because relative survival analysis takes into account natural mortality, the risk of death was smaller for women older than 50 years than for women aged from 35 to 49; this was not demonstrated in the crude survival analysis (Cox). Estimations obtained from Cox model were more accurate than those obtained from both studied regressive relative survival models. Estimations obtained from Esteve et al. model were not very different from those obtained from Hakulinen and Tenkanen model and they were more accurate. CONCLUSION: By definition, analysis of relative survival is more appropriate to estimate survival to a specific cause of death. It is preferable to use models based on individual estimation when data set is small or when the number of individual per strata is small.

UMLS-based conceptual queries to biomedical information databases: an overview of the project ARIANE. Unified Medical Language System.

OBJECTIVE: The aim of the project ARIANE is to model and implement seamless, natural, and easy-to-use interfaces with various kinds of heterogeneous biomedical information databases. DESIGN: A conceptual model of some of the Unified Medical Language System (UMLS) knowledge sources has been developed to help end users to query information databases. A query is represented by a conceptual graph that translates the deep structure of an end-user's interest in a topic. A computational model exploits this conceptual model to build a query interactively represented as query graph. A query graph is then matched to the data graph built with data issued from each record of a database by means of a pattern-matching (projection) rule that applies to conceptual graphs. RESULTS: Prototypes have been implemented to test the feasibility of the model with different kinds of information databases. Three cases are studied: 1) information in records is structured according to the UMLS knowledge sources; 2) information is able to be structured without error in the frame of the UMLS knowledge; 3) information cannot be structured. In each case the pattern-matching is processed by the projection rule according to the structure of information that has been implemented in the databases. CONCLUSION: The conceptual graphs theory provides with a homogeneous and powerful formalism able to represent both concepts, instances of concepts in medical contexts, and associations by means of relationships, and to represent data at different levels of details. The conceptual-graphs formalism allows powerful capabilities to operate a semantic integration of information databases using the UMLS knowledge sources.

Evaluation of the Unified Medical Language System as a medical knowledge source.

OBJECTIVE: The authors evaluated the use of the Unified Medical Language System (UMLS) as a medical knowledge source for the representation of medical procedures in the MAOUSSC system. DESIGN: MAOUSSC, a multiaxial coding system, was used for the representation of 1500 procedures from 15 clinical specialties, using UMLS concepts (augmented by full sources for three new vocabularies being added to the UMLS) and relationships whenever possible. Evaluation criteria for the UMLS included (1) completeness of representation of concepts and of inter-concept relationships, (2) consistency in the categorization of both concepts and inter-concept relationships, and (3) usability, including adaptability of the UMLS to a foreign language (French), its suitability to a geographic region with different medical practices than the USA, and issues relative to the annual update changes in the test vocabularies. RESULTS: During the MAOUSSC trial, the number of missing concepts or relationships identified in the augmented UMLS sources was deemed to be inconsequential relative to overall project goals. "Missing" UMLS inter-concept relationships were identified, although they were small in number. Some inconsistencies in the UMLS were noted, especially in the area of hierarchic relationships. CONCLUSION: After UMLS was used for five years as a knowledge source for representing 1500 complex medical procedures in MAOUSSC, its value is considered significant. Future editions of the UMLS are expected to improve representation of inter-concept relationships and global consistency.

A Web terminology server using UMLS for the description of medical procedures.

The Model for Assistance in the Orientation of a User within Coding Systems (MAOUSSC) project has been designed to provide a representation for medical and surgical procedures that allows several applications to be developed from several viewpoints. It is based on a conceptual model, a controlled set of terms, and Web server development. The design includes the UMLS knowledge sources associated with additional knowledge about medico-surgical procedures. The model was implemented using a relational database. The authors developed a complete interface for the Web presentation, with the intermediary layer being written in PERL. The server has been used for the representation of medico-surgical procedures that occur in the discharge summaries of the national survey of hospital activities that is performed by the French Health Statistics Agency in order to produce inpatient profiles. The authors describe the current status of the MAOUSSC server and discuss their interest in using such a server to assist in the coordination of terminology tasks and in the sharing of controlled terminologies.

Expert systems for medical consultation.

After reviewing some of the elements that permit a clearer understanding of what characterizes the "expert systems" approach, representation of medical concepts, symbolic manipulation rather than numeric calculation, causal reasoning, etc., this paper will try to deal with some of the most noteworthy developments in medical decision aid, teaching, research, before discussing some problems raised by the evaluation of expert systems in medicine.

Decision support systems from the standpoint of knowledge representation.

Relationships between decision-support systems and knowledge representation are examined from three different points of view: the characteristics of medical decisions that might influence the selection of appropriate knowledge representations,--the extent to which different knowledge representations can support efficient medical decisions and,--the validation of knowledge hypotheses through the practice of decision support systems. A three-level model of knowledge representation is proposed that includes a contextual, a conceptual and a computational level. Taking into consideration the context that leads to the selection of a given representation raises the issue of multiexpertise and multirepresentation modeling. Implementation of decision support systems as sets of cooperative agents and integration in the health information systems are considered.

Review of biomedical knowledge and data representation with conceptual graphs.

The basis of conceptual graphs theory is an ontology of types of concepts. Concepts issued from the ontology are interlinked by semantic relationships and constitute canonical conceptual graphs. Canonical graphs may be combined to derive new conceptual graphs by means of formation rules. This formalism allows to separate knowledge representation into a conceptual level and a domain-dependent level, and enables to share and reuse a representation. This paper presents conceptual graph applications to biomedical data and concept representation, classification systems, information retrieval, and natural language understanding and processing. A discussion on the unifying role conceptual graphs theory plays in the implementation of knowledge-based systems is also presented.

Confidentiality issues within a clinical information system: moving from data-driven to event-driven design.

Within a hospital, the moving of medical information systems from retrospective data-gathering methods to prospective clinical information systems raises the question of the confidentiality of patient data. A method of improving the traditional matrix model usually used to achieve access controls is described. The event-driven model refers to the way a security system ensures that a given user has a valid "need-to" relationship to a given patient. Events are defined as the occurrence of specific data that trigger the creation or the updating of the relationship between the identity of a user and the identity of a patient (e.g., admission, discharge, transfer, prescription, and report). The creation and the deletion of the relationships between users and patients are based on numerous repositories and working lists of patients. This implementation requires an organization of the hospital activities which is able to manage, in a real-time manner, those repositories as closely as possible to the steps occurring during the patient's care process. Although this approach seems to reasonably fit the dynamic of the care process, it adds significant organizational constraints.

Medical decision support systems: old dilemmas and new paradigms?

OBJECTIVES: The purpose of this paper is to examine past and present medical decision support systems and the environment in which they operate and to propose specific research tracks that improve integration and adoption of these systems in today's health care systems. METHODS: In preamble, we examine the objectives, decision models, and performances of past decision support systems. RESULTS: Medical decision support tools were essentially formulated from a technical capability perspective and this view has met limited adoption and slowed down new development as well as integration of these important systems into patient management work flows and clinical information systems. The science base of these systems needs to include evidence-based medicine and clinical practice guidelines and the paradigms need to be extended to include a collaborative provider model, the users and the organization perspectives. The availability of patient record and medical terminology standards is essential to the dissemination of decision support systems and so is their integration into the care process. CONCLUSION: To build new decision support systems based on practice guidelines and taking into account users preferences, we do not so much advocate new technological solutions but rather suggest that technology is not enough to ensure successful adoption by the users, the integration into practice workflow, and consequently, the realisation of improved health care outcomes.

Elaboration and formalization of current scientific knowledge of risks and preventive measures illustrated by colorectal cancer.

OBJECTIVES: Present the method used to elaborate and formalize current scientific knowledge to provide physicians with tools available on the Internet, that enable them to evaluate individual patient risk, give personalized preventive recommendations or early screening measures. METHODS: The approach suggested in this article is in line with medical procedures based on levels of evidence (Evidence-based Medicine). A cyclical process for developing recommendations allows us to quickly incorporate current scientific information. At each phase, the analysis is reevaluated by experts in the field collaborating on the project. The information is formalized through the use of levels of evidence and grades of recommendations. GLIF model is used to implement recommendations for clinical practice guidelines. RESULTS: The most current scientific evidence incorporated in a cyclical process includes several steps: critical analysis according to the Evidence-based Medicine method; identification of predictive factors; setting-up risk levels; identification of prevention measures; elaboration of personalized recommendation. The information technology implementation of the clinical practice guideline enables physicians to quickly obtain personalized information for their patients. Cases of colorectal prevention illustrate our approach. CONCLUSIONS: Integration of current scientific knowledge is an important process. The delay between the moment new information arrives and the moment the practitioner applies it, is thus reduced.

[Top-Forum: an interactive multimedia knowledge database to improve quality of care in pediatric oncology]. / Top-Forum: une base de connaissances multimédia interactive pour améliorer la qualité des soins en oncologie pédiatrique.

The treatment of pediatric cancer patients is characterised by complex and aggressive chemotherapy, difficult decision making, the numerous protocols available and the necessity of highly skilled caregivers. Quality of care is a major issue in all pediatric oncology units. We created an interactive multi-media database available to each caregiver to permit him/her to have easy access to information and thus increase his/her knowledge and participate in increasing their group's know-how. The computer database is available to all on a free-access basis in each ward. This is a novel approach to quality care, as it accords great importance to personal formation, allowing each caregiver to broaden his/her knowledge via easily obtained data which he/she can help enrich by permanent feedback. This database may become the backbone of department know-how.

Critical dimensions in medical informatics.

A typology of medical informatics applications is proposed around three dimensions: the dimension of care, the dimension of information and knowledge, and the aspects of the computerized society. These dimension can help both to evaluate application or research papers in the field or to derive long term goals for the discipline. In the first dimension medical informatics appears more as a technology driven by external forces such as the general progress of medicine or the integration of economical constraints in the choice of optimal procedures. It is argued that barriers to overcome as well as challenges for future research mainly remain in the two last dimensions.

Modelling health care processes for eliciting user requirements: a way to link a quality paradigm and clinical information system design.

Healthcare institutions are looking at ways to increase their efficiency by reducing costs while providing care services with a high level of safety. Thus, hospital information systems have to support quality improvement objectives. The elicitation of the requirements has to meet users' needs in relation to both the quality (efficacy, safety) and the monitoring of all health care activities (traceability). Information analysts need methods to conceptualise clinical information systems that provide actors with individual benefits and guide behavioural changes. A methodology is proposed to elicit and structure users' requirements using a process-oriented analysis, and it is applied to the blood transfusion process. An object-oriented data model of a process has been defined in order to organise the data dictionary. Although some aspects of activity, such as 'where', 'what else', and 'why' are poorly represented by the data model alone, this method of requirement elicitation fits the dynamic of data input for the process to be traced. A hierarchical representation of hospital activities has to be found for the processes to be interrelated, and for their characteristics to be shared, in order to avoid data redundancy and to fit the gathering of data with the provision of care.

ARIANE: integration of information databases within a hospital intranet.

Large information systems handle massive volume of data stored in heterogeneous sources. Each server has its own model of representation of concepts with regard to its aims. One of the main problems end-users encounter when accessing different servers is to match their own viewpoint on biomedical concepts with the various representations that are made in the databases servers. The aim of the project ARIANE is to provide end-users with easy-to-use and natural means to access and query heterogeneous information databases. The objectives of this research work consist in building a conceptual interface by means of the Internet technology inside an enterprise Intranet and to propose a method to realize it. This method is based on the knowledge sources provided by the Unified Medical Language System (UMLS) project of the US National Library of Medicine. Experiments concern queries to three different information servers: PubMed, a Medline server of the NLM; Thériaque, a French database on drugs implemented in the Hospital Intranet; and a Web site dedicated to Internet resources in gastroenterology and nutrition, located at the Faculty of Medicine of Nice (France). Accessing to each of these servers is different according to the kind of information delivered and according to the technology used to query it. Dealing with health care professional workstation, the authors introduced in the ARIANE project quality criteria in order to attempt a homogeneous and efficient way to build a query system able to be integrated in existing information systems and to integrate existing and new information sources.

[Computer-based hospital transfusion process: why and how does one establish a link between continuous quality improvement and clinical information system?]. / Informatisation du processus transfusionnel à l'hôpital: pourquoi et comment établir le lien entre amélioration continue de la qualité et système d'information clinique?

Within a hospital, the need for a computer-based transfusion system has became mandatory. It facilitates the tracing of healthcare activities, which is the basis of the security of the care and a functional element of continuous quality improvement procedures. In order to implement this traceability, reactive and real-time information systems are needed close to healthcare participants, which is not the case of current information systems which rely on a recorded collection of data, far from the needs of the caregiver, and mainly answering to an objective evaluation of results. In the context of continuous quality improvement programmes started in our hospital, hemovigilance was the first to use a process analysis approach, from the prescription of blood units to their administration and follow-up. Several questions arise from this: 1) how to use the process analysis work to specify the users' needs of a generalized and real-time transfusion information system? 2) how to spread this model to other healthcare activities? 3) how to integrate or interface the whole of these quality programmes with a clinical information system? A user-centered methodology was used, based on 'usage cases'. For each step of the transfusion process, this method allowed us to specify participants, data necessary for an activity (observed, deduced or decision-support data), data issuing from the activity, roles (the interaction between user and activity) and functions (the result of the interaction between user and activity).

Modeling and implementing a database on drugs into a hospital intranet.

Our objective was to develop a drug information service, implementing a database on drugs in our university hospitals information system. Thériaque is a database, maintained by a group of pharmacists and physicians, on all the drugs available in France. Before its implementation we modeled its content (chemical classes, active components, excipients, indications, contra-indications, side effects, and so on) according to an object-oriented method. Then we designed HTML pages whose appearance translates the structure of classes of objects of the model. Fields in pages are dynamically fulfilled by the results of queries to a relational database in which information on drugs is stored. This allowed a fast implementation and did not imply to port a client application on the thousands of workstations over the network. The interface provides end-users with an easy-to-use and natural way to access information related to drugs in an internet environment.