Patient-centered care via health information technology: a qualitative study with experts from Israel and the U.S.

Although patient-centered care (PCC) is one of the cornerstones of modern healthcare, the role that health information technology (HIT) plays in supporting PCC remains unclear. In this qualitative study, we interviewed academic and clinical experts from the US and Israel to understand to what extent current HIT systems are supportive of PCC and how PCC should be supported by HIT in the future. A maximum variation sampling approach was used to identify nine experts in both HIT and PCC from clinical and academic settings in Israel and the US. A qualitative descriptive method was used to analyze the interviews and identify major themes. Experts suggested that patient ownership of their disease is a core component of PCC. The majority of the experts agreed that in both Israel and the US, the current situation of PCC implementation is relatively poor. However, HIT should play an important role in making patients owners of their health and treatment and helping providers in delivering better PCC. Central domains of PCC via HIT were providing clear information and support for patients and promoting care that is based on patient values and preferences.

Risk factors for urinary tract infection caused by Enterobacteriaceae with extended-spectrum beta-lactamase resistance in patients admitted to internal medicine departments.

BACKGROUND: Extended-spectrum beta-lactamase (ESBL) resistance is a growing concern in and outside hospitals. Physicians often face a true clinical dilemma when initiating empirical antibiotic treatment in patients admitted to internal medicine departments. OBJECTIVES: To determine the prevalence of risk factors for ESBL resistance in patients with urinary tract infection (UTI) admitted to internal medicine departments. METHODS: We conducted a retrospective analysis of the medical records of patients with UTI admitted to an internal medicine division in a community-based academic hospital over a 1 year period. We collected clinical, laboratory and imaging data that were available to the treating physician at admission. Outcome measures included ESBL resistance and death. RESULTS: Of the 6754 admissions 366 patients were included in the study. Hospitalization during the previous 3 months (odds ratio 3.4, P < 0.0001), residency in a long-term-care facility (OR 2.4, P = 0.004), and the presence of a permanent urinary catheter (OR 2.2, P = 0.015) were correlated to ESBL resistance with statistical significance. These risk factors were extremely prevalent in our patient cohort. CONCLUSIONS: ESBL resistance is becoming prevalent outside hospital settings, and patients admitted to an internal medicine department with UTI frequently carry risk factors for harboring resistant bacteria. In such patients a high index of suspicion and early targeted antibiotic treatment for ESBL-producing Enterobacteriaceae may be justified.

TiMeDDx--a multi-phase anchor-based diagnostic decision-support model.

Main Clinical Manifestation (MCM)-oriented diagnosis starts with a chief problem and reasons about possible diagnoses that can be manifested in that way. The reasoning process often starts by considering abstract diagnosis groups (e.g., infectious vs. non-infectious diarrhea) and refines them. Most existing diagnostic decision-support systems (DSSs) are not specially tailored toward assisting non-expert physicians in the proper and efficient investigation workup of MCM-oriented diagnosis. We developed a prototype diagnostic decision-support model called TiMeDDx that is MCM-oriented and follows the hypothetico-deductive clinical reasoning process of differential diagnosis. The model guides users in a phase-by-phase manner regarding abstract diagnosis groups and diagnoses that should be considered and appropriate data that should be collected during the clinical investigation process. TiMeDDx's knowledge base contains, when possible, knowledge derived from MCM-oriented evidence-based sources. We explain the knowledge model and diagnostic algorithms (Bayesian and heuristic) of TiMeDDx, using the clinical problem of diarrhea as a case study, and contrast TiMeDDx with models of existing diagnostic DSSs.

Situation-Based Access Control: privacy management via modeling of patient data access scenarios.

Access control is a central problem in privacy management. A common practice in controlling access to sensitive data, such as electronic health records (EHRs), is Role-Based Access Control (RBAC). RBAC is limited as it does not account for the circumstances under which access to sensitive data is requested. Following a qualitative study that elicited access scenarios, we used Object-Process Methodology to structure the scenarios and conceive a Situation-Based Access Control (SitBAC) model. SitBAC is a conceptual model, which defines scenarios where patient's data access is permitted or denied. The main concept underlying this model is the Situation Schema, which is a pattern consisting of the entities Data-Requestor, Patient, EHR, Access Task, Legal-Authorization, and Response, along with their properties and relations. The various data access scenarios are expressed via Situation Instances. While we focus on the medical domain, the model is generic and can be adapted to other domains.

Mapping computerized clinical guidelines to electronic medical records: knowledge-data ontological mapper (KDOM).

Clinical guidelines recommend quality standards for patient care. Encoding guidelines in a computer-interpretable format and integrating them with an Electronic Medical Record (EMR) can enable delivery of patient-specific recommendations when and where needed. GLIF3 is a language for representing computer-interpretable guidelines (CIGs) and sharing them among healthcare institutions. Sharing a CIG necessitates mapping its data items to the institutional EMRs. We developed a framework called Knowledge-Data Ontological Mapper (KDOM) that enables bridging the gap from abstractions used in CIGs to specific EMRs. Briding the gap involves: (1) using an ontology of mappings, and an optional reference information model, to map an abstraction gradually into EMR codes, and (2) automatically creating SQL queries to retrieve the EMR data. We evaluated the KDOM framework by mapping a GLIF3-encoded guideline into two different EMR schemas and by using the mapping ontology to define mappings from 15 GLIF3 CIGs and one SAGE CIG into our reference information model.

Clinical decision support systems for addressing information needs of physicians.

Clinicians routinely practice in a state of incomplete information--about the patient, and about medical knowledge pertaining to patients' care. Consequently, there is now growing interest in the use of CDSS to bring decision support to the point of care. CDSS can impact physician behavior in routine practice. Nonetheless, CDSSs are meant to support humans who are ultimately responsible for the clinical decisions, rather than replace them. Although the adoption of CDSS has proceeded at a slow pace, there is a widespread recognition that CDSSs are expected to play a crucial role in reducing medical errors and improving the quality and efficacy of health care. This will be facilitated by the gradual maturation of electronic health record systems and the emergence of standard terminologies and messaging standards for the exchange of clinical data.

Characterization of the knowledge contained in diagnostic problem oriented clinical practice guidelines.

Several data types (symptoms, signs, and tests) are gathered and used in the process of investigating a clinical problem. In this study, we aimed to quantitatively evaluate how often the knowledge contained in clinical practice guidelines refer to these data types, and to what extent evidence based medicine principles are applied to them. To this end, we analyzed the knowledge contained in diagnostic problem-oriented guidelines using a set of relevant characteristics that we developed. We believe that the results of this study may be helpful for developers of clinical decision-support systems.

Exploring methods of visualizing laboratorial data in electronic medical record systems.

Physicians in their daily practice are exposed to vast amount of laboratorial data in electronic medical record (EMR) systems, that should be taken into account in the clinical decision making process. The aim of this study is to explore the impact of different methods of visualizing laboratorial data on physicians' ability to perform common tasks related to processing laboratorial data. For this end, we developed an innovative computerized system based on a set of methods that we used.

Changes in the slope of the first major deflection of the ECG complex during acute coronary occlusion.

To evaluate the effect of acute coronary occlusion (ACO) during percutaneous coronary intervention (PCI) on the slope of the first major deflection of the QRS complex (the initial QRS slope). Standard ECG signals of 18 patients (89 leads), undergoing PCI were recorded prior to and during ACO. The initial QRS slope was calculated in the baseline state and during ACO. Changes in the standard ECG were detected in 36 of 89 leads (40%). The initial QRS slope during ACO was significantly different from baseline in 74 of 89 leads (83%). The specificity of the change in the slope during ACO was low (29%).

A clinical problem-oriented decision support model based on extended temporal database functionalities.

Several diagnostic decision support systems have been proposed. Yet, such systems are not commonly used partly due to insufficient temporal reasoning. We have developed a clinical problem-oriented diagnostic decision support model that employs temporal reasoning by using extended temporal database functionalities developed at our lab. In addition, our model supports the workflow of the diagnostic process and employs detailed clinical data. We developed a prototype system that implements the concepts of the model.

Electronic medical record systems in Israel's public hospitals.

BACKGROUND: Various medical centers in Israel have recently incorporated electronic medical record systems. Knowing the EMR systems' features and pattern of use is an essential step for developing locally and nationally integrated systems. OBJECTIVES: To evaluate the status of EMR systems in all major general hospitals in Israel in terms of the applications used and the patterns of use. METHODS: Structured questionnaires were sent to hospital directors and directors of medical informatics units of 26 general and pediatric hospitals serving the vast majority of the population in Israel. The questionnaire included questions pertaining to the EMR systems, their usage, and the attitude of the participants to data security issues. RESULTS: Of the 26 general hospitals 23 (88.4%) returned the questionnaires. Of these, 21 (91.3%) use EMR systems. Twenty-seven different types of systems are in use in Israeli hospitals, and generally more than one type is used in a hospital. Physicians work with EMR systems in over 98% of the departments. Also, the EMR systems are used for clinical admission and discharge in over 90% of the departments and for medical daily follow-up in about 45%. CONCLUSIONS: Most of the hospitals in Israel use EMR systems but there is no standard data model. Physicians are the main users but the amount of data entered is still limited. Adoption of standards is essential for the integration of electronic patient records across Israeli healthcare organizations.

A methodology for modular representation of guidelines.

Computer-based clinical practice guidelines often need to be modified when medical knowledge evolves or when guidelines are implemented in a local setting with specific constraints and preferences. To enable easy modifications to guidelines and maintain their integrity, we have developed a methodology for modular representation of guidelines. Using this approach, we create guidelines in a hierarchical and modular manner. We use the Axiomatic Design methodology to facilitate the development of independent modules. Design matrices capture the interactions among modules. The design matrices can be used during guideline modification to create a change process and to enable identification of other modules that are affected by a change to a module. We implemented this modular knowledge representation approach by incorporating it into the Guideline Interchange Format (GLIF) language. We applied this approach to encode parts of three outdated guidelines released during 2000-2001, and we revised these designs to model updated releases of the guideline. Qualitative and quantitative metrics were developed to assess the types of changes made to the encoded guidelines.

A meta-data model for knowledge in decision support systems.

Clinical decision support such as alerts, reminders and guidance are driven by rules often distributed among a variety of applications in a healthcare information system. Due to the increasing size of rule bases, there is a growing need to manage this dispersed knowledge in an integrated environment. A system for management of executable clinical knowledge such as rules should (1) assist in the development and maintenance of rules throughout the rules' life-cycles, (2) support search and retrieval of rules in the knowledge base (e.g., rules for diabetes, rules created by a particular individual), and (3) facilitate the analyses of rules in the knowledge base (e.g., identify rules not updated in the last year). In order to create such a clinical knowledge management system it is necessary to model the meta-data of rules. There have been efforts to document meta-data about rules within the Arden Syntax Medical Logical Modules' project. However, the maintenance and library categories in that project allow mainly free-text information about a rule. We have created a comprehensive meta-data structure and taxonomy for describing clinical rules that supports the features of a knowledge management system. We also tested this model using a representative set of rules.

Applying axiomatic design methodology for guideline revision.

We are investigating the use of axiomatic design (AD) as a principled approach to the revision of guidelines. AD models guidelines in a modular and hierarchical manner and captures interactions be-tween modules. To test this approach we applied AD to encode segments of three guidelines and their revised versions. Guideline encodings for the original versions were modified to incorporate changes made in the revised documents. The results indicate that AD is a promising approach for guideline modeling.

Evaluation of the phase-plane ECG as a technique for detecting acute coronary occlusion.

OBJECTIVE: To evaluate the phase plane (PP) ECG as a method for detecting acute coronary occlusion (ACO). BACKGROUND: Balloon inflation in a coronary artery during PTCA produces acute myocardial ischemia. The sensitivity of the standard ECG for detecting ACO is approximately 50%, depending on the number of leads recorded. METHODS: The standard ECG signals of 18 patients (91 leads), undergoing PTCA were sampled and converted to digital data, prior to, and during acute coronary occlusion. PPs were constructed by projecting the ECG signals and their first derivatives onto a two-dimensional plane. Standard ECG signals and PPs, prior to ACO, were compared to their respective recordings and PPs during ACO. RESULTS: Using the standard ECG analysis, the acute occlusion was detected in 39 of 91 leads (43%), and in 15 of 18 patients (83%), whereas using the PP analysis it was detected in 82 of 91 leads (90%), and in all 18 patients (100%) (P<0.001, for leads). The median number of leads per patient demonstrating standard ECG changes was 2.0, whereas for the PP analysis it was 5.5 (P<0.001). The specificity of the PP method was 83.5%. CONCLUSIONS: The sensitivity of the PP method for detecting ACO during PTCA was superior to that of the standard ECG analysis. A smaller lead system is required to detect changes of ACO, during PTCA, when the PP method is used. The PP method is simple, low-priced, and may serve to detect acute myocardial ischemia in a number of clinical settings.