Toward a Patient-Centered Care Supporting System: Integration of Multidisciplinary Health Records in Breast Cancer Care.

An important paradigm shift within healthcare is the shift toward patient-centered care (PCC). Multidisciplinary team meetings (MDTM) are considered essential for PCC, despite being considered time-consuming and expensive. Patient-centered information (PCI) is known to improve the quality of care. This study investigated where and how the PCI of multidisciplinary professionals' health records exists, and to explore the possibility of a sustainable PCC-supporting healthcare system. We performed an exploratory pilot study of the patient records of three patients with breast cancer. We observed that PCI was documented throughout the care pathway in the cases examined. However, we also found that these data were fragmented and scattered across various medical records, and they were also from different point of views and patient care perspectives. PCI was founded to be less accessible than traditional medical records and was even hard to find using a manual search. We therefore propose that preparing PCI for MDTM may be one of the obvious burdens for healthcare professionals (HPs). We do however believe that integrating PCI from multiple professionals' records likely plays an important function in a shift towards PCC and serves to improve not only the quality of care but also the HPs' experiences without additional burden and could contribute to a more sustainable health care system.

Integrated Electronic Health Record of Multidisciplinary Professionals Throughout the Cancer Care Pathway: A Pilot Study Exploring Patient-Centered Information in Breast Cancer Patients.

Purpose: The aim of this pilot study was to first aggregate and then integrate the medical records of various healthcare professionals involved with breast cancer patients to reveal if and how patient-centered information is documented in multidisciplinary cancer care. Patients and Methods: We aggregated 20 types of medical records from various healthcare professionals such as physicians, nurses and allied healthcare professionals (AHPs) throughout three breast cancer patients' care pathways in a department of breast surgery at a university hospital. Purposeful sampling was used, and three cases were examined. The number of integrated type of records was 14, 14, 17 in case 1, 2 and 3, respectively. We manually annotated and analyzed them exploratively using a thematic analysis. The tags were produced using both a deductive template approach and a data-driven inductive approach. All records were then given tags. We defined patient-centered information related tags and biomedical information related tags and then analyzed for if and how patient-centered information was documented. Results: The number of patient-centered information related tags accounted for 30%, 30% and 20% of the total in case 1, 2 and 3, respectively. In all cases, patient-centered information was distributed across various medical records. The Progress Note written by doctors provided much of the patient-centered information, while other records contained information not described elsewhere in the Progress Notes. The records of nurses and AHPs included more patient-centered information than the doctors' notes. Each piece of patient-centered information was documented in fragments providing from each of the healthcare professionals' viewpoints. Conclusion: The documented information throughout the breast cancer care pathway in the cases examined was dominated by biomedical information. However, our findings suggest that integrating fragmented patient-centered information from various healthcare professionals' medical records produces holistic patient-centered information from multiple perspectives and thus may facilitate an enhanced multidisciplinary patient-centered care.

An important paradigm shift within healthcare is the shift toward patient-centered care and away from disease-centered treatment. Patient-centered care is based on shared decision-making, respecting an individual patient's preferences, needs and values, and considering social context and best available research evidence to improve the quality of care. A multidisciplinary team (MDT) approach plays an important role in patient-centered care and MDTs are already adopted into daily oncology practices in many countries, especially in breast cancer care. Previous studies have shown that an effective MDT needs more patient-centered information but often that patient-centered information is notably absent from medical records. We investigated if and how patient-centered information such as psychosocial entries exists in patient records. For this purpose, we performed an exploratory pilot study in which the patient records of three patients with breast cancer, including two patients with advanced stage disease, were studied throughout their care pathway. We observed that the documentation of patient-centered information was fragmented and scattered across various medical records written by multidisciplinary professionals. Moreover, these pieces of scattered information were recorded from different perspectives and viewpoints. Our findings point to a significant role that healthcare informatics could play, as integrating the various healthcare professionals' electronic health record could likely produce multifaceted and more holistic patient-centered information which could be shared and used in shared decision-making and MDTs with a view to considering both patient and clinical perspectives, potentially improving the quality of care.

Effect of aromatase inhibitors on bone mineral density in a Japanese breast cancer population.

We retrospectively analyzed the bone mineral density (BMD) of postmenopausal Japanese women taking an aromatase inhibitor (AI), exemestane, anastrozole or letrozole, and calculated the decrease rate constant of BMD in each individual to compare the influence of the three AIs on BMD. We also aimed to evaluate the preventive effect of bisphosphonates (BPs) on the AI-induced decrease in BMD. The decrease rate constant of BMD (k(e)) in each individual was determined as a slope of linear regression of the relationship between time and logarithm of BMD value in each patient during the AI therapy. To compensate for the age-related change in BMD level, we estimated the age-related decrease rate constant of BMD (ke,0) in healthy Japanese postmenopausal women from the literature. AIs decreased BMD with a ke value of -0.0329 yr(-1), which was 4.7-fold larger than the k(e,0) value of -0.00699 yr(-1). No significant difference was detected in the influence on BMD among AIs. Co-administration of BP ameliorated the ke value to -0.0117 yr(-1), a value similar to k(e,0). The influence of AIs on BMD was quantitatively evaluated by using the decrease rate constant of BMD (k(e)). The present study also suggests that BPs may be useful to prevent the decrease in BMD induced by AIs.

Identification of UBIAD1 as a novel human menaquinone-4 biosynthetic enzyme.

Vitamin K occurs in the natural world in several forms, including a plant form, phylloquinone (PK), and a bacterial form, menaquinones (MKs). In many species, including humans, PK is a minor constituent of hepatic vitamin K content, with most hepatic vitamin K content comprising long-chain MKs. Menaquinone-4 (MK-4) is ubiquitously present in extrahepatic tissues, with particularly high concentrations in the brain, kidney and pancreas of humans and rats. It has consistently been shown that PK is endogenously converted to MK-4 (refs 4-8). This occurs either directly within certain tissues or by interconversion to menadione (K(3)), followed by prenylation to MK-4 (refs 9-12). No previous study has sought to identify the human enzyme responsible for MK-4 biosynthesis. Previously we provided evidence for the conversion of PK and K(3) into MK-4 in mouse cerebra. However, the molecular mechanisms for these conversion reactions are unclear. Here we identify a human MK-4 biosynthetic enzyme. We screened the human genome database for prenylation enzymes and found UbiA prenyltransferase containing 1 (UBIAD1), a human homologue of Escherichia coli prenyltransferase menA. We found that short interfering RNA against the UBIAD1 gene inhibited the conversion of deuterium-labelled vitamin K derivatives into deuterium-labelled-MK-4 (MK-4-d(7)) in human cells. We confirmed that the UBIAD1 gene encodes an MK-4 biosynthetic enzyme through its expression and conversion of deuterium-labelled vitamin K derivatives into MK-4-d(7) in insect cells infected with UBIAD1 baculovirus. Converted MK-4-d(7) was chemically identified by (2)H-NMR analysis. MK-4 biosynthesis by UBIAD1 was not affected by the vitamin K antagonist warfarin. UBIAD1 was localized in endoplasmic reticulum and ubiquitously expressed in several tissues of mice. Our results show that UBIAD1 is a human MK-4 biosynthetic enzyme; this identification will permit more effective decisions to be made about vitamin K intake and bone health.

Conversion of phylloquinone (Vitamin K1) into menaquinone-4 (Vitamin K2) in mice: two possible routes for menaquinone-4 accumulation in cerebra of mice.

There are two forms of naturally occurring vitamin K, phylloquinone and the menaquinones. Phylloquinone (vitamin K(1)) is a major type (>90%) of dietary vitamin K, but its concentrations in animal tissues are remarkably low compared with those of the menaquinones, especially menaquinone-4 (vitamin K(2)), the major form (>90%) of vitamin K in tissues. Despite this great difference, the origin of tissue menaquinone-4 has yet to be exclusively defined. It is postulated that phylloquinone is converted into menaquinone-4 and accumulates in extrahepatic tissues. To clarify this, phylloquinone with a deuterium-labeled 2-methyl-1,4-naphthoquinone ring was given orally to mice, and cerebra were collected for D NMR and liquid chromatography-tandem mass spectrometry analyses. We identified the labeled menaquinone-4 that was converted from the given phylloquinone, and this conversion occurred following an oral or enteral administration, but not parenteral or intracerebroventricular administration. By the oral route, the phylloquinone with the deuterium-labeled side chain in addition to the labeled 2-methyl-1,4-naphthoquinone was clearly converted into a labeled menaquinone-4 with a non-deuterium-labeled side chain, implying that phylloquinone was converted into menaquinone-4 via integral side-chain removal. The conversion also occurred in cerebral slice cultures and primary cultures. Deuterium-labeled menadione was consistently converted into the labeled menaquinone-4 with all of the administration routes and the culture conditions tested. Our results suggest that cerebral menaquinone-4 originates from phylloquinone intake and that there are two routes of accumulation, one is the release of menadione from phylloquinone in the intestine followed by the prenylation of menadione into menaquinone-4 in tissues, and another is cleavage and prenylation within the cerebrum.