Integrated decision support in a hospital cancer registry.

In this paper we present (a) a shell for integrated knowledge-based functions that is destined to support decision processes of the users of the Giessener Tumordokumentationssystem (GTDS) and (b) some results we obtained during a 6-month observation period at one of the customers of the GTDS. A special characteristic of the provided decision support is the high degree of integration in the underlying information system GTDS, i.e. the functions are triggered by events in the patient database, existing patient data is reused as input for the reasoning process and generated alerts are presented instantly to the end-user. The first routine field of application was supporting registrars to adhere to integrity constraints as defined by the International Agency of Research on Cancer (IARC) during the documentation process. This information is important for the registrars since the checks of the IARC are an accepted standard for data quality in cancer registries. The expected benefit of this application area is less effort in achieving adherence to the specification of the IARC by preventing the costly rectification at a later time. During the last 5 months of the observation period 164 alerts were displayed. About 65% of the assessed alerts were considered to be correct. Especially, the analysis of the incorrect alerts revealed some shortcomings in the knowledge behind some of the integrity constraints of the IARC. The general feedback from the end-users indicate positive user satisfaction. Currently, the shell is in use in six hospital cancer registries.

XML-based application interface services--a method to enhance integrability of disease specific systems.

Disease specific systems usually offer excellent functionality for the management of the covered diseases. But the restriction to a certain disease also often hampers their wide spread use since they aren't optimised for clinical workflow. The Giessener Tumordokumentationssystem (GTDS) is such a disease specific system. It is not only designed for the use in tumour registries but also to support clinical care. In order to integrate it into hospital information systems, we implemented standard communication interfaces, but this measure is not sufficient since it doesn't consider aspects of the normal workflow of a clinical user. Therefore, we developed a strategy that should ease the access to the system in the environment of existing systems. From the technical point of view, XML with its capabilities to represent even complex data in a rather simple way helped to implement this strategy. We use it to communicate with API-like services and also created a WWW environment to demonstrate the access to these services. Since this environment itself is a means to integrate systems, we intend to expand this environment to an appropriate region based means to improve the communication with registries. multidisciplinary environments [3]. The large amount of useful functions and its adaptability has made GTDS (http://www.gtds.de) a successful system in more than 30 various registries.

Value of XML in the implementation of clinical practice guidelines--the issue of content retrieval and presentation.

The purpose of guidelines in clinical practice is to improve the effectiveness and efficiency of clinical care. It is known that nationally or internationally produced guidelines which, in particular, do not involve medical processes at the time of consultation, do not take local factors into account, and have no consistent implementation strategy, have limited impact in changing either the behaviour of physicians, or patterns of care. The literature provides evidence for the effectiveness of computerization of CPGs for increasing compliance and improving patient outcomes. Probably the most effective concepts are knowledge-based functions for decision support or monitoring that are integrated in clinical information systems. This approach is mostly restricted by the effort required for development and maintenance of the information systems and the limited number of implemented medical rules. Most of the guidelines are text-based, and are primarily published in medical journals and posted on the internet. However, internet-published guidelines have little impact on the behaviour of physicians. It can be difficult and time-consuming to browse the internet to find (a) the correct guidelines to an existing diagnosis and (b) and adequate recommendation for a specific clinical problem. Our objective is to provide a web-based guideline service that takes as input clinical data on a particular patient and returns as output a customizable set of recommendations regarding diagnosis and treatment. Information in healthcare is to a very large extent transmitted and stored as unstructured or slightly structured text such as discharge letters, reports, forms, etc. The same applies for facilities containing medical information resources for clinical purposes and research such as text books, articles, guidelines, etc. Physicians are used to obtaining information from text-based sources. Since most guidelines are text-based, it would be practical to use a document-based solution that preserves the original cohesiveness. The lack of structure limits the automatic identification and extraction of the information contained in these resources. For this reason, we have chosen a document-based approach using eXtensible Markup Language (XML) with its schema definition and related technologies. XML empowers the applications for in-context searching. In addition it allows the same content to be represented in different ways. Our XML reference clinical data model for guidelines has been realized with the XML schema definition. The schema is used for structuring new text-based guidelines and updating existing documents. It is also used to establish search strategies on the document base. We hypothesize that enabling the physicians to query the available CPGs easily, and to get access to selected and specific information at the point of care will foster increased use. Based on current evidence we are confident that it will have substantial impact on the care provided, and will improve health outcomes.

Development of an oncology data network in Germany.

In the 1990ies, an oncology data network has been set up mainly in the New States of Germany. Although not formally planned and established as a whole, it consists of a number of initiatives, that co-operate well and gain added value from this co-operation. From the technological view, the centre of the network is the Giessener Tumordokumentationssystem (GTDS), that was developed at Giessen University. We present important basic conditions in which this development took place, show some results and describe future directions of the development.

Combining dictionary techniques with extensible markup language (XML)--requirements to a new approach towards flexible and standardized documentation.

In oncology various international and national standards exist for the documentation of different aspects of a disease. Since elements of these standards are repeated in different contexts, a common data dictionary could support consistent representation in any context. For the construction of such a dictionary existing documents have to be worked up in a complex procedure, that considers aspects of hierarchical decomposition of documents and of domain control as well as aspects of user presentation and models of the underlying model of patient data. In contrast to other thesauri, text chunks like definitions or explanations are very important and have to be preserved, since oncologic documentation often means coding and classification on an aggregate level and the safe use of coding systems is an important precondition for comparability of data. This paper discusses the potentials of the use of XML in combination with a dictionary for the promotion and development of standard conformable applications for tumor documentation.

Integrated knowledge-based functions in a hospital cancer registry--specific requirements for routine applicability.

The background of the presented work is the design, realization, and routine use of integrated knowledge-based functions in the context of a hospital cancer registry. The first field of application was supporting registrars to detect data inconsistencies and incompleteness timely during the documentation process. Especially, we focused on the acceptance of the administrator of the underlying information system and on the phenomenon of duplicate and outdated messages. These aspects are specific for integrated knowledge based functions and a precondition for obtaining a routine applicability and acceptance.

Data warehousing as a tool for quality management in oncology.

At present, physicians are constrained by their limited skills to integrate and understand the growing amount of electronic medical information. To handle, extract, integrate, analyse and take advantage of the gathered information regarding the quality of patient care, the concept of a data warehouse seems to be especially interesting in medicine. Medical data warehousing allows the physicians to take advantage of all the operational data they have been collecting over the years. Our purpose is to build a data warehouse in order to use all available information about cancer patients. We think that with the sensible use of this tool, there are economic benefits for the Society and an improvement of quality of medical care for patients.

A model for integration and continuous development of standards for tumour documentation using relational database techniques and extensible markup language.

In oncology various international and national standards exist for different aspects of a disease. These standards, maintained by different organisations, have multiple relationships with each other. A common data dictionary like UMLS would facilitate the reorganisation of such relationships when a new version of a standard is published. While the modelling of relationships usually is restricted to types having a relevant frequency, there are often relationships which are expressed in texts like definitions or explanations. Such texts are a very important supplement for the acceptance and the safe use of coding systems, but often are neglected when implementing coding systems in computerised systems, because they are costly to implement. This paper discusses potentials when integrating various sources in a common, database based dictionary enhanced by XML (Extensible Markup Language) techniques.

Plug and play--fiction or reality?

This paper discusses some experiences with the integration of a tumor documentation system into a distributed healthcare environment using a new European middleware technology. Although the middleware already offers a considerable support to the software engineer, further facilities have been suggested and partially implemented in order to accelerate integration scenarios.

Survey among physicians by means of dynamic access to an Internet information server database.

Current database management systems, client-server architecture and the internet infrastructure are simplifying the exchange of information. Large and widespread electronic medical record systems are accessible via platform-independent browsing applications. The following brief summary shows one of the manifold conceivable applications of these technologies in medicine. It describes a survey among physicians with the scope of quality assurance in medicine. The dynamic, platform-independent, world-wide access to databases offers interesting aspects in medical informatics.

GTDS--a tool for tumor registries to support shared patient care.

German hospital tumor registries play an active role in the treatment of cancer patients. Besides the documentation of the course of a disease, they directly support medical treatment and follow-up care over a long period. As the treatment of oncologic patients is a shared multidisciplinary task, the availability of information is one of the most valuable outputs. Therefore, the documentation has to be integrated into the medical treatment, which only can be achieved when useful services are based on it. Since 1983 the basis of the documentation has been a uniform basic data set which was revised in 1990 and, according to be requirements mentioned above, allows detailed documentation, especially of therapy. During the last four years a new documentation system for tumor diseases has been developed and was implemented in 30 hospital tumor registries by the "Arbeitsgruppe zur Koordination Klinischer Krebsregister". The so-called "Giessener Tumordokumentationssystem" (GTDS) is the basis of the work in those registries. In this paper the functions and services which were implemented in order to support the individual treatment of oncologic patients and the methods of collecting and delivering that information to the physician are presented.