Behavioral signs of an unintended error in nursing information sharing with electronic clinical pathways: a mixed research approach.

Electronic clinical pathways (ECPs) strongly encourage the standardization of medical treatment and the sharing of information among medical staff. The goal of this study was to determine the influence of ECPs on information sharing among nurses in a university hospital. Four experienced nurses, selected based on ECP composing and operation experience, were recruited from the department with the most frequent users in the first-round interview, 132 nurses' questionnaire answers were analyzed, and eight nurses participated in the second-round interview. This study conducted a mixed-method (interview-questionnaire-interview) investigation to extract the behavioral signs of unintended errors in information sharing after the ethical approval was obtained. On the basis of ANOVA and t-test for the questionnaire and constant comparison for interview, this study found that the greater extent of user dependency on convenient ECPs in the frequent-use group led to mistakes under hectic conditions. This study also found evidence of poor management of ECPs when problems occurred. The immature design of ECPs provoked inappropriate behaviors among nurses even though they brought about some benefits such as mitigation of the burden of daily recording tasks. The findings empirically showed the ECP user's behavioral changes regarding the technology-induced error.

A random forest algorithm-based approach to capture latent decision variables and their cutoff values.

Although reference intervals (RIs) and clinical decision limits (CDLs) are vital laboratory information for supporting the interpretation of numerical clinical pathology results, there is evidence that RIs and CDLs vary in certain contexts as well as other evidence that RIs and CDLs are flawed. We propose a random forest algorithm-based exploration methodology by using phenotype transformation of independent variables in relation to dependent variables to capture latent decision variables and their cutoff values. We denote certain CDLs within the RIs estimated by an indirect method that affect some diagnostics or outcomes in the context of specific patients' conditions as latent CDLs. We then apply the proposed methodology to clinical laboratory data regarding bodily fluids, such as blood, urine at the admission of patients for the exploration of latent CDLs of hospital length of stay (HLOS) for each patients' condition identified by diseases of patients who undergoing surgeries. From the exploration results, we found that free Thyroxine (T4) above five unique cutoff values: 1.16 ng/dL, 1.19 ng/dL, 1.2 ng/dL, 1.23 ng/dL and 1.25 ng/dL for tachyarrhythmia predicted longer HLOS, though these cutoff values fall within the estimated RIs as well as the hospital-determined RIs. In addition to the evidence that higher free Thyroxine (T4) levels within the RIs have an association with the corresponding disease, on the whole, the cutoff values except 1.16 ng/dL tended to affect long HLOS with the significant differences. The cutoff values could be taken up for discussion among clinical experts whether it is meaningful to alert the risk of patients' conditions and the long HLOS at the admission of patients. If clinical experts appreciate its meaningfulness in clinical practice, the alerts could be embedded in electronic medical records for handling those risks at the admission of patients.

Creating personalised clinical pathways by semantic interoperability with electronic health records.

OBJECTIVE: There is a growing realisation that clinical pathways (CPs) are vital for improving the treatment quality of healthcare organisations. However, treatment personalisation is one of the main challenges when implementing CPs, and the inadequate dynamic adaptability restricts the practicality of CPs. The purpose of this study is to improve the practicality of CPs using semantic interoperability between knowledge-based CPs and semantic electronic health records (EHRs). METHODS: Simple protocol and resource description framework query language is used to gather patient information from semantic EHRs. The gathered patient information is entered into the CP ontology represented by web ontology language. Then, after reasoning over rules described by semantic web rule language in the Jena semantic framework, we adjust the standardised CPs to meet different patients' practical needs. RESULTS: A CP for acute appendicitis is used as an example to illustrate how to achieve CP customisation based on the semantic interoperability between knowledge-based CPs and semantic EHRs. A personalised care plan is generated by comprehensively analysing the patient's personal allergy history and past medical history, which are stored in semantic EHRs. Additionally, by monitoring the patient's clinical information, an exception is recorded and handled during CP execution. According to execution results of the actual example, the solutions we present are shown to be technically feasible. CONCLUSION: This study contributes towards improving the clinical personalised practicality of standardised CPs. In addition, this study establishes the foundation for future work on the research and development of an independent CP system.

Design and development of EMR supporting medical process management.

Current EMR system benefits physicians by facilitating order entry and reducing errors. It can improve the safety and effectiveness of medical services, but cannot manage the whole medical process and the quality of medical services. In addition to physicians, EMR should be designed for all medical professionals because medical services cannot be accomplished by physicians alone, but also requires the involvement of other medical professionals. Therefore, we applied PDCA, the famous quality management cycle to design a comprehensive and coherent EMR system which can be used throughout the entire treatment process. EMR with the PDCA Cycle can record every order state and every treatment procedure in order to monitor the whole medical process. This extends the safety from planning the treatment to fulfilling it. By analyzing the records, doctors and hospital managers can perfect the medical process and improve healthcare quality. The EMR we designed with the PDCA Cycle provides a record entry interface for physicians and a worksheet interface for nurses and other professionals. Every treatment procedure and every change of orders or tasks will be fed back to medical professionals. So information generated from the beginning to the end of treatment will link with each other to avoid any information islands. Furthermore, the EMR can display the additional information intuitively and real-timely without increasing the burden of medical professionals' work.

Performance assessment of EMR systems based on post-relational database.

Post-relational databases provide high performance and are currently widely used in American hospitals. As few hospital information systems (HIS) in either China or Japan are based on post-relational databases, here we introduce a new-generation electronic medical records (EMR) system called Hygeia, which was developed with the post-relational database Caché and the latest platform Ensemble. Utilizing the benefits of a post-relational database, Hygeia is equipped with an "integration" feature that allows all the system users to access data-with a fast response time-anywhere and at anytime. Performance tests of databases in EMR systems were implemented in both China and Japan. First, a comparison test was conducted between a post-relational database, Caché, and a relational database, Oracle, embedded in the EMR systems of a medium-sized first-class hospital in China. Second, a user terminal test was done on the EMR system Izanami, which is based on the identical database Caché and operates efficiently at the Miyazaki University Hospital in Japan. The results proved that the post-relational database Caché works faster than the relational database Oracle and showed perfect performance in the real-time EMR system.

Ontology-based clinical pathways with semantic rules.

Clinical Pathways (CP) enhance the quality of patient care, and are thus important in health management. However, there is a need to address the challenge of adaptation of treatment procedures in CP-that is, the treatment schemes must be re-modified once the clinical status and other care conditions of patients in the healthcare setting change, which happen frequently. In addition, the widespread and frequent use of Electronic Medical Records (EMR) implies an increasing need to combine CP with other healthcare information systems, especially EMR, in order to greatly improve healthcare quality and efficiency. This study proposed an ontology-based method to model CP: ontology was used to model CP domain terms; Semantic Web Rule language was used to model domain rules. In this way, the CP could reason over the rules, knowledge, and information collected, and provides automated error checking for the next steps of the treatment in runtime, which is adaptive to treatment procedures. To evaluate our method, we built a Lobectomia Pulmonalis CP and realized it based on an EMR system.

Operational problems of Haniwa net as a form of social capital: interdependence between human networks of physicians and information networks.

In August 2009, Miyazaki Health and Welfare Network (Haniwa Net, hereafter referred to as "the Net"), centrally led by University of Miyazaki Hospital (UMH), adopted a center hospital-based system offering a unilateral linkage that enables the viewing of UMH's medical records through a web-based browser (electronic medical records (EMR)). By the end of December 2010, the network had developed into a system of 79 collaborating physicians from within the prefecture. Beginning in August 2010, physicians in 12 medical institutions were visited and asked to speak freely on the operational issues concerning the Net. Recordings and written accounts were coded using the text analysis software MAXQDA 10 to understand the actual state of operations. Analysis of calculations of Kendall's rank correlation confirmed that the interdependency between human networks and information networks is significant. At the same time, while the negative opinions concerning the functions of the Net were somewhat conspicuous, the results showed a correlation between requests and proposals for operational improvements of the Net, clearly indicating the need for a more user-friendly system and a better viewer.

Phase II clinical study of cladribine in the treatment of hairy cell leukemia.

We conducted a phase II clinical study to evaluate the therapeutic efficacy of cladribine (2-chlorodeoxyadenosine [2-CdA]) in the treatment of Japanese patients with hairy cell leukemia (HCL). Seven patients with classic HCL and 3 with a prolymphocytic HCL variant were administered 2-CdA (0.09 mg/kg per day) by continuous intravenous infusion for 7 days. Seven patients responded to this therapy, with 5 patients achieving a complete response (CR). After a median follow-up of 792 days (range, 599-1253 days), there were no cases of clinical relapse, and the median duration of the response in the responders was 670+ days (range, 470+ to 1121+ days). The median duration of the CR in the CR patients was 953+ days (range, 480+ to 1121+ days). At treatment initiation, most patients had hematologic impairment as a manifestation of HCL. During the early stage after administration, further hematologic impairment occurred, but subsequent peripheral blood counts gradually recovered as 2-CdA treatment showed antitumor activity. Infections occurred at a high incidence at this time, but all cases could be controlled with appropriate treatment. 2-CdA was surmised to represent a useful therapeutic approach for Japanese patients with HCL.

Enhancement of CLAIM (clinical accounting information) for a localized Chinese version.

CLinical Accounting InforMation (CLAIM) is a standard for the exchange of data between patient accounting systems and electronic medical record (EMR) systems. It uses eXtensible Markup Language (XML) as a meta-language and was developed in Japan. CLAIM is subordinate to the Medical Markup Language (MML) standard, which allows the exchange of medical data between different medical institutions. It has inherited the basic structure of MML 2.x and the current version, version 2.1, contains two modules and nine data definition tables. In China, no data exchange standard yet exists that links EMR systems to accounting systems. Taking advantage of CLAIM's flexibility, we created a localized Chinese version based on CLAIM 2.1. Since Chinese receipt systems differ from those of Japan, some information such as prescription formats, etc. are also different from those in Japan. Two CLAIM modules were re-engineered and six data definition tables were either added or redefined. The Chinese version of CLAIM takes local needs into account, and consequently it is now possible to transfer data between the patient accounting systems and EMR systems of Chinese medical institutions effectively.

Enhancement of MML medical data exchange standard for a localized Chinese version.

Medical Markup Language (MML) is a standard for the exchange of medical data among different medical institutions. It was developed in Japan in 1995. Since version 2.21, MML has used eXtensible Markup Language (XML) as a meta-language. The latest version, 3.0, conforms to HL7 Clinical Document Architecture (CDA) and contains 14 modules and 36 data definition tables. In China, a standard which structures entire medical records in XML does not yet exist. Taking advantage of MML's flexibility, we created a localized Chinese version based on MML 3.0. Parts of the original specifications have been enhanced; these include a newly developed health insurance information module and 12 additional or redefined data definition tables. The Chinese version takes local needs into account and now makes it possible to exchange medical data among Chinese medical institutions.

Dolphin project--cooperative regional clinical system centered on clinical information center.

In 2001, a system was created to improve patient service, improve the quality of medical care, and achieve efficient medical care. A Data Center was established to accumulate and manage clinical information in the regions and share clinical information safely and appropriately. The system has already been in operation for 3 years. Even though a patient may have been examined at multiple hospitals, his medical record information will be integrated at the Center. This ensures medical care continuity and enables the patient to view his own medical records at home. Its usefulness in obtaining informed consent has been demonstrated as well. XML instances established in the MML standards (MML (Medical Markup Language): http.//www.medxml.net/E_mml30/mmlv3_E_index.htm Accessed July 2004; Jpn. J. Med. Informatics (JJMI) 17(3):203-207, 1997; J. Med. Syst. 24(3):195-211, 2000; J. Med. Syst. 27(4):357-366, 2003; J. Med. Syst. 28(6):523-533, 2004) are used for Electronic Medical Record System data exchange between the Data Center and each medical institution. The openness provided by XML makes it possible to connect diverse electronic medical records to the Center. As of the year 2004, over 10 types of electronic medical records have an MML interface, enabling connection to the Center.

CLAIM (CLinical Accounting InforMation)--an XML-based data exchange standard for connecting electronic medical record systems to patient accounting systems.

With the evolving and diverse electronic medical record (EMR) systems, there appears to be an ever greater need to link EMR systems and patient accounting systems with a standardized data exchange format. To this end, the CLinical Accounting InforMation (CLAIM) data exchange standard was developed. CLAIM is subordinate to the Medical Markup Language (MML) standard, which allows the exchange of medical data among different medical institutions. CLAIM uses eXtensible Markup Language (XML) as a meta-language. The current version, 2.1, inherited the basic structure of MML 2.x and contains two modules including information related to registration, appointment, procedure and charging. CLAIM 2.1 was implemented successfully in Japan in 2001. Consequently, it was confirmed that CLAIM could be used as an effective data exchange format between EMR systems and patient accounting systems.

Possible involvement of neutrophils in a serum level increase of hepatocyte growth factor in non-Hodgkin's lymphoma.

Serum levels of hepatocyte growth factor (HGF), a potent angiogenic factor, increase during various haematological malignancies. In this study, we examined serum HGF in 59 patients with non-Hodgkin's lymphoma (NHL). Serum HGF levels in NHL patients were increased, as were levels in patients with multiple myeloma, chronic myeloproliferative disorders, and myelodysplastic syndrome. Some 29 patients with T-cell lymphoma, including 20 with adult T-cell leukemia/lymphoma, exhibited a significant increase in serum HGF, as did 23 with B-cell lymphoma. The levels of serum HGF correlated with increased neutrophil counts (r=0.487, p<0.0001), and also paralleled a neutrophil increase in NHL patients who received granulocyte-colony stimulating factor (G-CSF) at the nadir of neutrophil count following chemotherapy. Additionally, in in vitro experiments, HGF secretion from polymorphonuclear neutrophils and its expression in bone marrow myeloid cells were stimulated by G-CSF. Although HGF has been thought to be involved in the pathogenesis of NHL through its angiogenic activities, these results suggest that HGF production by neutrophils and myeloid lineage cells may also contribute to an increase in serum HGF in NHL patients.

Telomerase activity and telomere length as prognostic factors of adult T-cell leukemia.

For the oncogenesis of many malignancies, it is crucial to prevent the shortening of the telomeres by the action of telomerase. In this study, clinical data and disease outcomes were analyzed in conjunction with the telomerase activity (TA) and telomere length (TL) of peripheral blood mononuclear cells. The study was carried out in 22 patients with adult T-cell leukemia (ATL) (7 chronic and 15 acute types) and in 13 asymptomatic human T-lymphotropic virus type 1 (HTLV-1) carriers. The mean values of TA in acute and chronic type patients were 13.8 and 1.6 total product generated (TPG) units, respectively, as determined by telomeric repeat amplification assays. The mean TA values in HTLV-1 carriers and healthy volunteers were 1.8 and 0.7 TPG, respectively. The mean TA value in acute type patients was significantly higher than in the three other subject groups. The mean TL values in patients with acute and chronic types were 5.39 and 4.38 Kb, respectively, while the mean TL values in HTLV-1 carriers and healthy volunteers were 7.69 and 7.06 Kb, respectively. The mean TL values in all ATL patients and in non-ATL subjects were 5.2 and 7.3 Kb, respectively. The former value is significantly shorter than the latter (p < 0.01). Neither TA nor TL of ATL cells showed any significant association with the number of ATL cells, serum soluble interleukin-2 receptor, or serum lactate dehydrogenase in the peripheral blood of acute type patients. This suggests that the levels of TA and TL did not reflect the ATL tumor load. The median survival period of acute ATL patients with high TA and shortened TL was 0.47 years, however, which was significantly shorter than that of acute ATL patients with low TA and normal TL (4.21 years) (p < 0.002). These data suggest that high TA and shortened TL were associated with poorer prognosis, and that TA and TL may be novel markers for the prognosis of ATL patients.

The development of MML (Medical Markup Language) version 3.0 as a medical document exchange format for HL7 messages.

Medical Markup Language (MML), as a set of standards, has been developed over the last 8 years to allow the exchange of medical data between different medical information providers. MML Version 2.21 used XML as a metalanguage and was announced in 1999. In 2001, MML was updated to Version 2.3, which contained 12 modules. The latest version--Version 3.0--is based on the HL7 Clinical Document Architecture (CDA). During the development of this new version, the structure of MML Version 2.3 was analyzed, subdivided into several categories, and redefined so the information defined in MML could be described in HL7 CDA Level One. As a result of this development, it has become possible to exchange MML Version 3.0 medical documents via HL7 messages.

The latest MML (Medical Markup Language) version 2.3--XML-based standard for medical data exchange/storage.

As a set of standards, Medical Markup Language (MML) has been developed over the last 8 years to allow the exchange of medical data between different medical information providers MML version 2.21 was characterized by XML as metalanguage and was announced in 1999, at which time full-scale implementation tests were carried out; subsequently, various information and functional inadequacies were discovered in this version. MML was therefore updated to version 2.3 in 2001. At present, MML contains 12 MML modules including the new referral, test result, and report modules. In version 2.3, the group ID element was added; the access right definition and health insurance module were amended.