eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations.

BACKGROUND: Two years ago, the Diabetic Retinopathy (DRP) and Traumatology clinic of the Department of Ophthalmology and Optometrics at the Medical University of Vienna, Austria switched from paper-based to electronic health records. A customized electronic health record system (EHR-S) was implemented. OBJECTIVES: To assess the completeness of information documented electronically compared with manually during patient visits. METHODS: The Preferred Practice Pattern for Diabetic Retinopathy published by the American Academy of Ophthalmology was distilled into a list of medical features grouped into categories to be assessed and documented during the management of patients with DRP. The last seventy paper-based records and all electronic records generated since the switch were analyzed and graded for the presence of features on the list and the resulting scores compared. RESULTS: In all categories, clinical documentation was more complete in the EHR group. CONCLUSIONS: In our setting, the implementation of an EHR-S showed a statistically significant positive impact on documentation completeness.

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.

Semantic validation of standard-based electronic health record documents with W3C XML schema.

OBJECTIVES: The goal of this article is to examine whether W3C XML Schema provides a practicable solution for the semantic validation of standard-based electronic health record (EHR) documents. With semantic validation we mean that the EHR documents are checked for conformance with the underlying archetypes and reference model. METHODS: We describe an approach that allows XML Schemas to be derived from archetypes based on a specific naming convention. The archetype constraints are augmented with additional components of the reference model within the XML Schema representation. A copy of the EHR document that is transformed according to the before-mentioned naming convention is used for the actual validation against the XML Schema. RESULTS: We tested our approach by semantically validating EHR documents conformant to three different ISO/EN 13606 archetypes respective to three sections of the CDA implementation guide "Continuity of Care Document (CCD)" and an implementation guide for diabetes therapy data. We further developed a tool to automate the different steps of our semantic validation approach. CONCLUSIONS: For two particular kinds of archetype prescriptions, individual transformations are required for the corresponding EHR documents. Otherwise, a fully generic validation is possible. In general, we consider W3C XML Schema as a practicable solution for the semantic validation of standard-based EHR documents.

Austria's path toward nationwide electronic health records.

OBJECTIVES: This article discusses current planning activities in Austria after legislation has been passed to introduce the electronic health record (EHR). METHODS: After describing similar activities in several other countries, the authors explore the current situation of healthcare telematics and imminent steps toward the implementation of a lifelong EHR. RESULTS: Substantial efforts have been made to coordinate healthcare telematics in Austria since the mid-1990s. One result of these efforts was the definition of a framework for electronic data exchange. A number of standardization projects were also implemented. Major steps have been taken as part of an ongoing healthcare reform to promote the use of healthcare telematics. One important example is a national initiative whose objective is to implement the EHR. This initiative is extensively discussed along with other national activities related to healthcare telematics. CONCLUSION: This EHR initiative has prepared the ground for extensive planning that is currently under way to implement a lifelong EHR in Austria on a national level. Introducing the EHR will have a strong impact on Austrian healthcare and should be performed in concert with international activities. The authors offer a number of practical recommendations for the implementation of an EHR on a national level.

The strategic approach of managing healthcare data exchange in Austria.

OBJECTIVES: The exchange of electronic medical data between healthcare providers constitutes an integral part of modern medicine, and its importance is growing. Efficient application on a national level requires a uniform approach to the management of healthcare data exchange, avoiding isolated solutions that are expensive and also incompatible. METHODS: In this communication we explain the basic concepts of establishing a nationwide framework to guide healthcare data exchange in Austria. To achieve this goal, a three-step approach was adopted: (i) creating general guidelines to direct electronic medical data exchange; (ii) defining detailed standards for electronic messages; (iii) organizing pilot projects to implement these standards, and further improving the general guidelines based on the results of the pilot projects. RESULTS: We present the MAGDA-LENA framework which guides healthcare data exchange in Austria, and compare it with the US framework HIPAA. We describe several communication scenarios for which concrete message standards were developed in recent years, based on the MAGDA-LENA framework. We further discuss the implementation of these standards in four pilot projects. CONCLUSIONS: The strategic approach of managing healthcare data exchange presented in this paper is expected to have a substantial impact on medical informatics in Austria over the next few years.

Clinical data retrieval: 25 years of temporal query management at the University of Vienna Medical School.

OBJECTIVES: Today, many clinical information systems include analysis components which allow clinicians to apply a selection of predefined statistical functions that satisfy typical cases. They are mostly to inflexible to handle complex, non-standard problems, however. The focus of this paper, therefore, is to present an approach that enables clinicians to autonomously create ad hoc queries including temporal relations in an interactive environment. METHODS: We developed the query language AMAS, which was specifically customized for users from the medical domain to flexibly retrieve and interpret temporal, clinical data. AMAS provides for a significant temporal expressiveness in data retrieval using time-stamped clinical databases and relies on an operator-operand concept for the specification of a query. RESULTS: Within the last 25 years, four different clinical retrieval systems have been implemented at the Department of Medical Computer Sciences, based on the AMAS query language. Currently, these systems allow access to the medical records of more than 2 million patients. Physicians of 46 different departments at the University of Vienna and Graz Medical Schools have made extensive use of these systems in the course of clinical research and patient care, executing more than 10,000 queries per year. CONCLUSIONS: We discuss a list of 20 issues that represent the most essential lessons we have learned in the development of the four systems mentioned above. Amongst others, our experiences indicate that the operator-operand concept allows on intuitive specification of complex, temporal queries. Further, customization to different user classes, based on their statistical background, is essential.

Incorporating family and social structures into clinical documentation and retrieval.

Referencing familial and social relationships between patients supplies valuable information for the retrieval and interpretation of clinical data. We present a technique for the incorporation of patient relations into data retrieval that takes into account the specific properties of routinely collected clinical data. In most clinical databases, family relations are documented in a fragmentary manner at best. Furthermore, clinical retrieval systems do not support inter-patient queries in most cases. Our model is designed to formulate direct relations between patients and to identify patients as members of either temporary or persistent communities. In this way, the model supplies information on both genetic and social relations.

Moving time window aggregates over patient histories.

Moving window concepts are used in temporal query languages for aggregate functions over the dimension 'time'. In the medical domain, aggregation of patient data over time windows builds a powerful mechanism within clinical database queries to satisfy a class of typical medical question formulations. Contrary to other fields, like the business domain for example, there is the additional need to synchronize time windows with the individual course of diseases rather than with the calendar system only. In this paper, we present several variants of shifting time windows over patient histories and suggest a set of essential options for a moving window clause. The proposed parameters for window creation as well as suitable default settings are discussed in the context of retrieving data from medical records.

Knowledge-based verification of clinical guidelines by detection of anomalies.

As shown in numerous studies, a significant part of published clinical guidelines is tainted with different types of semantical errors that interfere with their practical application. The adaptation of generic guidelines, necessitated by circumstances such as resource limitations within the applying organization or unexpected events arising in the course of patient care, further promotes the introduction of defects. Still, most current approaches for the automation of clinical guidelines are lacking mechanisms, which check the overall correctness of their output. In the domain of software engineering in general and in the domain of knowledge-based systems (KBS) in particular, a common strategy to examine a system for potential defects consists in its verification. The focus of this work is to present an approach, which helps to ensure the semantical correctness of clinical guidelines in a three-step process. We use a particular guideline specification language called Asbru to demonstrate our verification mechanism. A scenario-based evaluation of our method is provided based on a guideline for the artificial ventilation of newborn infants. The described approach is kept sufficiently general in order to allow its application to several other guideline representation formats.

ArchiMed: a medical information and retrieval system.

ArchiMed is a highly flexible medical data storage and retrieval system which adds sophisticated clinical research support to a standard hospital information system (HIS). Currently, the HIS of Vienna General Hospital-University Hospital (2000 beds) stores the clinical data of over 2 million patients. While this system supports patient care (e.g., ADT, clinical chemistry, diagnosis, procedures), it has no features to facilitate research, such as the management of clinical studies. ArchiMed is designed to support clinical research. It includes an independent database, which mirrors virtually all the information held in the HIS while also allowing new data to be collected independently and to be added to the database. Flexible retrieval and analysis of data contained in the database are then possible. Thus, existing patient data can be smoothly incorporated into a study together with data collected specifically for research purposes. The system has already been successfully installed in the departments of surgery and soon in other departments as well.

A retrieval system for the selection and statistical analysis of clinical data.

Within the last years computer-aided clinical documentation has provided researchers and administrators with very large volumes of data for research. User-friendly retrieval tools are needed when processing these clinical databases. Clinical researchers require applications by means of which steps in selection and analysis can be performed in an iterative process. During the deduction of statistical parameters from routinely collected data a number of problems occur that do not appear in the analysis of data gathered within clinical studies. Unlike clinical studies, routine data have complex structures and must first be formatted and above all temporally synchronized. In this paper we will describe the medical retrieval system ArchiMed developed at the Vienna General Hospital. A main objective in the design of this system was to support a joint evaluation of data from clinical studies and routinely collected data. The retrieval system comprises the main functions: Selection of Patients; Selection and Joining of Variables; and Statistical Analysis.