Integrating clinical theory and practice in an epilepsy-specific electronic patient record.

This study's objective was to assess the usability of the epilepsy history module of the electronic patient record, developed at Beaumont Hospital, and to identify opportunities for improvement. Observation, interview and document analysis methods were used. Results indicated that the module was useable but the design did not work as well in practice as anticipated by theory. The next iteration of the module included identified enhancements; this iteration is currently in use.

PropeR revisited.

INTRODUCTION: The PropeR EHR system (PropeRWeb) is a multidisciplinary electronic health record (EHR) system for multidisciplinary use in extramural patient care for stroke patients. DESIGN: The system is built using existing open source components and is based on open standards. It is implemented as a web application using servlets and Java Server Pages (JSP's) with a CORBA connection to the database servers, which are based on the OMG HDTF specifications. PropeRWeb is a generic system which can be readily customized for use in a variety of clinical domains. EVALUATION: The system proved to be stable and flexible, although some aspects (a.o. user friendliness) could be improved. These improvements are currently under development in a second version.

Health care in the information society: evolution or revolution?

This brief article is a commentary on the Haux et al. paper on Health Care in the Information Society: a prognosis for the year 2013. The commentary concentrates in particular on the underlying assumptions, which are at the core of the Haux et al. vision for healthcare in 2013. They assume that while there will be a shift towards increased patient-centred, community-based shared care, the underlying healthcare system will remain essentially the same. This commentary suggests that this is a conservative view and indeed questions its validity. Radical financial pressures to control costs as well as demands for equity fueled by more knowledgeable and better informed patients have the potential to bring about fundamental changes, with consequences for the way in which healthcare is delivered and in turn in how information and communications technologies are utilised.

e-clinic: an electronic triage system for the management of type 2 Diabetes Mellitus.

Diabetes Mellitus represents a heterogeneous group of metabolic disorders and its complications are associated with increased morbidity and early mortality. The explosive increase of the number of patients with diabetes, and several recommendations from milestone studies such as the United Kingdom Prospective Study (UKPDS), the Diabetes Prevention Program (DPP) and the Finnish Prevention Study place further constraint on an already overstretched service. This paper examines the care flow process in the current diabetes management and explores the potential role of new technologies and methodologies currently available to support the highly complex clinical requirements. The paper proposes a concept of e-clinic as an electronic triage system with integrated healthcare record, embedded with a decision support system to analyse patients' data and provide a continuous monitoring system according to agreed clinical guidelines.

Archetypes: the PropeR way.

The PropeR project studies the effect of Decision Support in an Electronic Health Record system (EHR) on the quality of care. One of the applications supports a multidisciplinary primary care team rehabilitating stroke patients in their home environment. This project required an EHR system that could handle information of multiple disciplines and multiple, distributed data sources. It should also be flexible enough to handle an entirely different domain with only minor modifications. The resulting EHR system is a distributed system based on international standards and reusable components. It is generic in nature since all references to the domain are stored in separate XML documents: the clinical data are defined through a modified version of the OpenEHR archetypes, described in XML and views on the data, either for review or for data entry are also described in XML documents. Currently, the system is being evaluated by a care team using laptops with a wireless internet connection. The use of standards greatly improves the quality and reusability of the resulting software system, but they do not solve the issues that surface during implementation, such as context and screen representation.

Assessing the quality of epilepsy care with an electronic patient record.

PURPOSE: The American Academy of Neurology (AAN) quality indicators for epilepsy are designed to monitor quality, identify gaps, and ultimately drive improvements in clinical care. Appreciation of electronic patient records (EPR) to support such performance management is growing. This study aimed to demonstrate the use of an epilepsy-specific EPR in applying the AAN measures to objectively monitor clinical performance. METHOD: A sample of out-patient clinics at Beaumont Hospital, Dublin was benchmarked against 4 of the AAN quality indicators. RESULTS: 88% (142/160) of clinical encounters met the requirement to explicitly document seizure type and seizure frequency at each visit; aetiology or epilepsy syndrome was documented/updated for 58% (93/160); evidence of counselling about antiepileptic drug side effects was present in 34% (54/160) of records; counselling for women of childbearing potential was documented in 33% (18/57) of relevant records. CONCLUSION: The EPR makes performance monitoring efficient and objective. Results suggest either failure to carryout recommended clinical tasks or poor documentation. Whichever is the case, a baseline is provided against which improvement goals can be set.

Applying the archetype approach to the database of a biobank information management system.

PURPOSE: The purpose of this study is to investigate the feasibility of applying the openEHR archetype approach to modelling the data in the database of an existing proprietary biobank information management system. A biobank information management system stores the clinical/phenotypic data of the sample donor and sample related information. The clinical/phenotypic data is potentially sourced from the donor's electronic health record (EHR). The study evaluates the reuse of openEHR archetypes that have been developed for the creation of an interoperable EHR in the context of biobanking, and proposes a new set of archetypes specifically for biobanks. The ultimate goal of the research is the development of an interoperable electronic biomedical research record (eBMRR) to support biomedical knowledge discovery. METHODS: The database of the prostate cancer biobank of the Irish Prostate Cancer Research Consortium (PCRC), which supports the identification of novel biomarkers for prostate cancer, was taken as the basis for the modelling effort. First the database schema of the biobank was analyzed and reorganized into archetype-friendly concepts. Then, archetype repositories were searched for matching archetypes. Some existing archetypes were reused without change, some were modified or specialized, and new archetypes were developed where needed. The fields of the biobank database schema were then mapped to the elements in the archetypes. Finally, the archetypes were arranged into templates specifically to meet the requirements of the PCRC biobank. RESULTS: A set of 47 archetypes was found to cover all the concepts used in the biobank. Of these, 29 (62%) were reused without change, 6 were modified and/or extended, 1 was specialized, and 11 were newly defined. These archetypes were arranged into 8 templates specifically required for this biobank. A number of issues were encountered in this research. Some arose from the immaturity of the archetype approach, such as immature modelling support tools, difficulties in defining high-quality archetypes and the problem of overlapping archetypes. In addition, the identification of suitable existing archetypes was time-consuming and many semantic conflicts were encountered during the process of mapping the PCRC BIMS database to existing archetypes. These include differences in the granularity of documentation, in metadata-level versus data-level modelling, in terminologies and vocabularies used, and in the amount of structure imposed on the information to be recorded. Furthermore, the current way of modelling the sample entity was found to be cumbersome in the sample-centric activity of biobanking. CONCLUSIONS: The archetype approach is a promising approach to create a shareable eBMRR based on the study participant/donor for biobanks. Many archetypes originally developed for the EHR domain can be reused to model the clinical/phenotypic and sample information in the biobank context, which validates the genericity of these archetypes and their potential for reuse in the context of biomedical research. However, finding suitable archetypes in the repositories and establishing an exact mapping between the fields in the PCRC BIMS database and the elements of existing archetypes that have been designed for clinical practice can be challenging and time-consuming and involves resolving many common system integration conflicts. These may be attributable to differences in the requirements for information documentation between clinical practice and biobanking. This research also recognized the need for better support tools, modelling guidelines and best practice rules and reconfirmed the need for better domain knowledge governance. Furthermore, the authors propose that the establishment of an independent sample record with the sample as record subject should be investigated. The research presented in this paper is limited by the fact that the new archetypes developed during this research are based on a single biobank instance. These new archetypes may not be complete, representing only those subsets of items required by this particular database. Nevertheless, this exercise exposes some of the gaps that exist in the archetype modelling landscape and highlights the concepts that need to be modelled with archetypes to enable the development of an eBMRR.

Epilepsy in Ireland: towards the primary-tertiary care continuum.

BACKGROUND: Epilepsy is a chronic neurological disease affecting people of every age, gender, race and socio-economic background. The diagnosis and optimal management relies on contribution from a number of healthcare disciplines in a variety of healthcare settings. OBJECTIVE: To explore the interface between primary care and specialist epilepsy services in Ireland. METHODS: Using appreciative inquiry, focus groups were held with healthcare professionals (n=33) from both primary and tertiary epilepsy specialist services in Ireland. RESULTS: There are significant challenges to delivering a consistent high standard of epilepsy care in Ireland. The barriers that were identified are: the stigma of epilepsy, unequal access to care services, insufficient human resources, unclear communication between primary-tertiary services and lack of knowledge. Improving the management of people with epilepsy requires reconfiguration of the primary-tertiary interface and establishing clearly defined roles and formalised clinical pathways. Such initiatives require resources in the form of further education and training and increased usage of information communication technology (ICT). CONCLUSION: Epilepsy services across the primary-tertiary interface can be significantly enhanced through the implementation of a shared model of care underpinned by an electronic patient record (EPR) system and information communication technology (ICT). Better chronic disease management has the potential to halt the progression of epilepsy with ensuing benefits for patients and the healthcare system.

Socio-technical considerations in epilepsy electronic patient record implementation.

PURPOSE: Examination of electronic patient record (EPR) implementation at the socio-technical interface. This study was based on the introduction of an anti-epileptic drug (AED) management module of an EPR in an epilepsy out-patient clinic. The objective was to introduce the module to a live clinical setting within strictly controlled conditions to evaluate its usability and usefulness. METHODS: Qualitative and quantitative methods were employed in an observational field study. A purposeful sample of specialists in epilepsy care (2 doctors and 2 nurses) was recruited. Perception of usefulness and ease of use of the AED module, impact on work processes, and accuracy of use were evaluated using feedback meetings, evaluation forms, ethnographic analysis and data validation techniques. Emerging issues were grouped into three key themes: human, organisational and technological. RESULTS: The electronic patient record use was studied for 49 patients over the course of 18 out-patient clinics. While participants varied in their approach to interacting with the AED module, they expressed satisfaction with its usability and performance. The necessary co-existence of the paper and electronic record, and changes to customary work practice were considered the biggest challenges. 82% accuracy in the use of the electronic record was determined. CONCLUSIONS: Achieving successful electronic patient record implementation is complex. While technical challenges exist, it is possibly more important to acknowledge the social considerations. Initially, an increase in medical record fragmentation and disruption to workflow can arise with the introduction of the technology. Realising the benefits of electronic patient records will require the management of a lengthy transition phase.