Mapping the delineation of practice to the AMIA foundational domains for applied health informatics.

OBJECTIVE: This article reports on the alignment between the foundational domains and the delineation of practice (DoP) for health informatics, both developed by the American Medical Informatics Association (AMIA). Whereas the foundational domains guide graduate-level curriculum development and accreditation assessment, providing an educational pathway to the minimum competencies needed as a health informatician, the DoP defines the domains, tasks, knowledge, and skills that a professional needs to competently perform in the discipline of health informatics. The purpose of this article is to determine whether the foundational domains need modification to better reflect applied practice. MATERIALS AND METHODS: Using an iterative process and through individual and collective approaches, the foundational domains and the DoP statements were analyzed for alignment and eventual harmonization. Tables and Sankey plot diagrams were used to detail and illustrate the resulting alignment. RESULTS: We were able to map all the individual DoP knowledge statements and tasks to the AMIA foundational domains, but the statements within a single DoP domain did not all map to the same foundational domain. Even though the AMIA foundational domains and DoP domains are not in perfect alignment, the DoP provides good examples of specific health informatics competencies for most of the foundational domains. There are, however, limited DoP knowledge statements and tasks mapping to foundational domain 6-Social and Behavioral Aspects of Health. DISCUSSION: Both the foundational domains and the DoP were developed independently, several years apart, and for different purposes. The mapping analyses reveal similarities and differences between the practice experience and the curricular needs of health informaticians. CONCLUSIONS: The overall alignment of both domains may be explained by the fact that both describe the current and/or future health informatics professional. One can think of the foundational domains as representing the broad foci for educational programs for health informaticians and, hence, they are appropriately the focus of organizations that accredit these programs.

Systematic User-centered Design of a Prototype Clinical Decision Support System for Glaucoma.

Purpose: To rigorously develop a prototype clinical decision support (CDS) system to help clinicians determine the appropriate timing for follow-up visual field testing for patients with glaucoma and to identify themes regarding the context of use for glaucoma CDS systems, design requirements, and design solutions to meet these requirements. Design: Semistructured qualitative interviews and iterative design cycles. Participants: Clinicians who care for patients with glaucoma, purposefully sampled to ensure a representation of a range of clinical specialties (glaucoma specialist, general ophthalmologist, optometrist) and years in clinical practice. Methods: Using the established User-Centered Design Process framework, we conducted semistructured interviews with 5 clinicians that addressed the context of use and design requirements for a glaucoma CDS system. We analyzed the interviews using inductive thematic analysis and grounded theory to generate themes regarding the context of use and design requirements. We created design solutions to address these requirements and used iterative design cycles with the clinicians to refine the CDS prototype. Main Outcome Measures: Themes regarding decision support for determining the timing of visual field testing for patients with glaucoma, CDS design requirements, and CDS design features. Results: We identified 9 themes that addressed the context of use for the CDS system, 9 design requirements for the prototype CDS system, and 9 design features intended to address these design requirements. Key design requirements included the preservation of clinician autonomy, incorporation of currently used heuristics, compilation of data, and increasing and communicating the level of certainty regarding the decision. After completing 3 iterative design cycles using this preliminary CDS system design solution, the design was satisfactory to the clinicians and was accepted as our prototype glaucoma CDS system. Conclusions: We used a systematic design process based on the established User-Centered Design Process to rigorously develop a prototype glaucoma CDS system, which will be used as a starting point for a future, large-scale iterative refinement and implementation process. Clinicians who care for patients with glaucoma need CDS systems that preserve clinician autonomy, compile and present data, incorporate currently used heuristics, and increase and communicate the level of certainty regarding the decision. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

Clinical Decision Support Systems: Contributions from 2021.

OBJECTIVES: To summarize significant research contributions published in 2021 in the field of clinical decision support (CDS) systems and select the best papers for the Decision Support section of the International Medical Informatics Association (IMIA) Yearbook. METHODS: The authors searched the MEDLINE® database for papers focused on clinical decision support (CDS) systems. From search results, section editors established a list of candidate best papers, which were then peer-reviewed by at least three external reviewers. The IMIA Yearbook editorial committee selected the best papers on the basis of all reviews including the section editors' evaluation. RESULTS: A total of 337 articles were retrieved from which 13 candidate papers were identified. Finally, from the candidate papers, the top three papers were selected. The first paper introduces an innovative evaluation approach to CDS systems, the second compares six health institutions on how they are measuring CDS alert fatigue and the last one adds new evidence on how CDS can help to reduce unnecessary interventions.

Evaluation in Life Cycle of Information Technology (ELICIT) framework: Supporting the innovation life cycle from business case assessment to summative evaluation.

OBJECTIVE: Our objective was to develop an evaluation framework for electronic health record (EHR)-integrated innovations to support evaluation activities at each of four information technology (IT) life cycle phases: planning, development, implementation, and operation. METHODS: The evaluation framework was developed based on a review of existing evaluation frameworks from health informatics and other domains (human factors engineering, software engineering, and social sciences); expert consensus; and real-world testing in multiple EHR-integrated innovation studies. RESULTS: The resulting Evaluation in Life Cycle of IT (ELICIT) framework covers four IT life cycle phases and three measure levels (society, user, and IT). The ELICIT framework recommends 12 evaluation steps: (1) business case assessment; (2) stakeholder requirements gathering; (3) technical requirements gathering; (4) technical acceptability assessment; (5) user acceptability assessment; (6) social acceptability assessment; (7) social implementation assessment; (8) initial user satisfaction assessment; (9) technical implementation assessment; (10) technical portability assessment; (11) long-term user satisfaction assessment; and (12) social outcomes assessment. DISCUSSION: Effective evaluation requires a shared understanding and collaboration across disciplines throughout the entire IT life cycle. In contrast with previous evaluation frameworks, the ELICIT framework focuses on all phases of the IT life cycle across the society, user, and IT levels. Institutions seeking to establish evaluation programs for EHR-integrated innovations could use our framework to create such shared understanding and justify the need to invest in evaluation. CONCLUSION: As health care undergoes a digital transformation, it will be critical for EHR-integrated innovations to be systematically evaluated. The ELICIT framework can facilitate these evaluations.

Data and Digital Solutions to Support Surveillance Strategies in the Context of the COVID-19 Pandemic.

Background: In order to prevent spread and improve control of infectious diseases, public health experts need to closely monitor human and animal populations. Infectious disease surveillance is an established, routine data collection process essential for early warning, rapid response, and disease control. The quantity of data potentially useful for early warning and surveillance has increased exponentially due to social media and other big data streams. Digital epidemiology is a novel discipline that includes harvesting, analysing, and interpreting data that were not initially collected for healthcare needs to enhance traditional surveillance. During the current COVID-19 pandemic, the importance of digital epidemiology complementing traditional public health approaches has been highlighted. Objective: The aim of this paper is to provide a comprehensive overview for the application of data and digital solutions to support surveillance strategies and draw implications for surveillance in the context of the COVID-19 pandemic and beyond. Methods: A search was conducted in PubMed databases. Articles published between January 2005 and May 2020 on the use of digital solutions to support surveillance strategies in pandemic settings and health emergencies were evaluated. Results: In this paper, we provide a comprehensive overview of digital epidemiology, available data sources, and components of 21st-century digital surveillance, early warning and response, outbreak management and control, and digital interventions. Conclusions: Our main purpose was to highlight the plausible use of new surveillance strategies, with implications for the COVID-19 pandemic strategies and then to identify opportunities and challenges for the successful development and implementation of digital solutions during non-emergency times of routine surveillance, with readiness for early-warning and response for future pandemics. The enhancement of traditional surveillance systems with novel digital surveillance methods opens a direction for the most effective framework for preparedness and response to future pandemics.

Clinical Decision Support Systems and Computerized Provider Order Entry: Contributions from 2020.

OBJECTIVES: To summarize research contributions published in 2020 in the field of clinical decision support systems (CDSS) and computerized provider order entry (CPOE), and select the best papers for the Decision Support section of the International Medical Informatics Association (IMIA) Yearbook 2021. METHODS: Two bibliographic databases were searched for papers referring to clinical decision support systems. From search results, section editors established a list of candidate best papers, which were then peer-reviewed by seven external reviewers. The IMIA Yearbook editorial committee finally selected the best papers on the basis of all reviews including the section editors' evaluation. RESULTS: A total of 1,919 articles were retrieved. 15 best paper candidates were selected, the reviews of which resulted in the selection of two best papers. One paper reports on the use of electronic health records to support a public health response to the COVID-19 pandemic in the United States. The second paper proposes a combination of CDSS and telemedicine as a technology-based intervention to improve the outcomes of depression as part of a cluster trial. CONCLUSIONS: As shown by the number and the variety of works related to clinical decision support, research in the field is very active. This year's selection highlighted the application of CDSS to fight COVID-19 and a combined technology-based strategy to improve the treatment of depression.

Workflow analysis for design of an electronic health record-based tobacco cessation intervention in community health centers.

OBJECTIVE: Tobacco use is the leading cause of preventable morbidity and mortality in the United States. Quitlines are effective telephone-based tobacco cessation services but are underutilized. The goal of this project was to describe current clinical workflows for Quitline referral and design an optimal electronic health record (EHR)-based workflow for Ask-Advice-Connect (AAC), an evidence-based intervention to increase Quitline referrals. MATERIALS AND METHODS: Ten Community Health Center systems (CHC), which use three different EHRs, participated in this study. Methods included: 9 group discussions with CHC leaders; 33 observations/interviews of clinical teams' workflow; surveys with 57 clinical staff; and assessment of the EHR ecosystem in each CHC. Data across these methods were integrated and coded according to the Fit between Individual, Task, Technology and Environment (FITTE) framework. The current and optimal workflow were notated using Business Process Modelling Notation. We compared the requirements of the optimal workflow with EHR capabilities. RESULTS: Current workflows are inefficient in data collection, variable in who, how, and when tobacco cessation advice and referral are enacted, and lack communication between referring clinics and the Quitline. In the optimal workflow, medical assistants deliver a standardized AAC intervention during the visit intake. Referrals are submitted electronically, and there is bidirectional communication between the clinic and Quitline. We implemented AAC within all three EHRs; however, deviations from the optimal workflow were necessary. CONCLUSION: Current workflows for Quitline referral are inefficient and ineffective. We propose an optimal workflow and discuss improvements in EHR capabilities that would improve the implementation of AAC.

Establishing a multidisciplinary initiative for interoperable electronic health record innovations at an academic medical center.

OBJECTIVE: To establish an enterprise initiative for improving health and health care through interoperable electronic health record (EHR) innovations. MATERIALS AND METHODS: We developed a unifying mission and vision, established multidisciplinary governance, and formulated a strategic plan. Key elements of our strategy include establishing a world-class team; creating shared infrastructure to support individual innovations; developing and implementing innovations with high anticipated impact and a clear path to adoption; incorporating best practices such as the use of Fast Healthcare Interoperability Resources (FHIR) and related interoperability standards; and maximizing synergies across research and operations and with partner organizations. RESULTS: University of Utah Health launched the ReImagine EHR initiative in 2016. Supportive infrastructure developed by the initiative include various FHIR-related tooling and a systematic evaluation framework. More than 10 EHR-integrated digital innovations have been implemented to support preventive care, shared decision-making, chronic disease management, and acute clinical care. Initial evaluations of these innovations have demonstrated positive impact on user satisfaction, provider efficiency, and compliance with evidence-based guidelines. Return on investment has included improvements in care; over $35 million in external grant funding; commercial opportunities; and increased ability to adapt to a changing healthcare landscape. DISCUSSION: Key lessons learned include the value of investing in digital innovation initiatives leveraging FHIR; the importance of supportive infrastructure for accelerating innovation; and the critical role of user-centered design, implementation science, and evaluation. CONCLUSION: EHR-integrated digital innovation initiatives can be key assets for enhancing the EHR user experience, improving patient care, and reducing provider burnout.

Translating Social Determinants of Health into Standardized Clinical Entities.

Social determinants of health (SDH) are a valuable source of health information which still are not fully utilized in the clinical space. Knowing that a certain patient has trouble finding transportation, has a potentially hazardous relationship with a family member or close relative, is currently unemployed, or various other social factors would allow providers to tailor treatment plans in a way to best help that patient. However, these SDH must be gathered, represented, and stored in a standardized way before they can be leveraged by informatics tools designed for health providers. This process of translating SDH to standardized clinical entities includes two main steps. The first is a collaborative effort to establish an ontology of medical terminology codes (i.e., ICD, SNOMED, LOINC, etc.) which can be used to uniformly represent SDH as coded concepts. The second is a collaborative effort to use the FHIR standard to create profiles and extensions which will allow FHIR resources to be used to store the coded SDH as clinical entities. Each of these steps has their own complexities that must be considered and accounted for in future efforts to create interoperable clinical informatics solutions which utilize SDH.

QuitSMART Utah: an implementation study protocol for a cluster-randomized, multi-level Sequential Multiple Assignment Randomized Trial to increase Reach and Impact of tobacco cessation treatment in Community Health Centers.

BACKGROUND: Tobacco use remains the leading cause of death and disability in the USA and is disproportionately concentrated among low socioeconomic status (SES) populations. Community Health Centers (CHCs) are a key venue for reaching low SES populations with evidence-based tobacco cessation treatment such as Quitlines. Electronic health record (EHR)-based interventions at the point-of-care, text messaging (TM), and phone counseling have the potential to increase Quitline reach and are feasible to implement within CHCs. However, there is a lack of data to inform how, when, and in what combination these strategies should be implemented. The aims of this cluster-randomized trial are to evaluate multi-level implementation strategies to increase the Reach (i.e., proportion of tobacco-using patients who enroll in the Quitline) and Impact (i.e., Reach × Efficacy [efficacy is defined as the proportion of tobacco-using patients who enroll in Quitline treatment that successfully quit]) and to evaluate characteristics of healthcare system, providers, and patients that may influence tobacco-use outcomes. METHODS: This study is a multilevel, three-phase, Sequential Multiple Assignment Randomized Trial (SMART), conducted in CHCs (N = 33 clinics; N = 6000 patients). In the first phase, clinics will be randomized to two different EHR conditions. The second and third phases are patient-level randomizations based on prior treatment response. Patients who enroll in the Quitline receive no further interventions. In phase two, patients who are non-responders (i.e., patients who do not enroll in Quitline) will be randomized to receive either TM or continued-EHR. In phase three, patients in the TM condition who are non-responders will be randomized to receive either continued-TM or TM + phone coaching. DISCUSSION: This project will evaluate scalable, multi-level interventions to directly address strategic national priorities for reducing tobacco use and related disparities by increasing the Reach and Impact of evidence-based tobacco cessation interventions in low SES populations. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov (NCT03900767) on April 4th, 2019.

Physicians' strategies for using family history data: having the data is not the same as using the data.

OBJECTIVE: To identify needs in a clinical decision support tool development by exploring how primary care providers currently collect and use family health history (FHH). DESIGN: Survey questionnaires and semi-structured interviews were administered to a mix of primary and specialty care clinicians within the University of Utah Health system (40 surveys, 12 interviews). RESULTS: Three key themes emerged regarding providers' collection and use of FHH: (1) Strategies for collecting FHH vary by level of effort; (2) Documentation practices extend beyond the electronic health record's dedicated FHH module; and (3) Providers desire feedback from genetic services consultation and are uncertain how to refer patients to genetic services. CONCLUSION: Study findings highlight the varying degrees of engagement that providers have with collecting FHH. Improving the integration of FHH into workflow, and providing decision support, as well as links and tools to help providers better utilize genetic counseling may improve patient care.

Critical care information display approaches and design frameworks: A systematic review and meta-analysis.

OBJECTIVE: To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians. METHODS: We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author. RESULTS: Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible. CONCLUSION: Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.

Determining Onset for Familial Breast and Colorectal Cancer from Family History Comments in the Electronic Health Record.

Background. Family health history (FHH) can be used to identify individuals at elevated risk for familial cancers. Risk criteria for common cancers rely on age of onset, which is documented inconsistently as structured and unstructured data in electronic health records (EHRs). Objective. To investigate a natural language processing (NLP) approach to extract age of onset and age of death from free-text EHR fields. Methods. Using 474,651 FHH entries from 89,814 patients, we investigated two methods - frequent patterns (baseline) and NLP classifier. Results. For age of onset, the NLP classifier outperformed the baseline in precision (96% vs. 83%; 95% CI [94, 97] and [80, 86]) with equivalent recall (both 93%; 95% CI [91, 95]). When applied to the full dataset, the NLP approach increased the percentage of FHH entries for which cancer risk criteria could be applied from 10% to 15%. Conclusion. NLP combined with structured data may improve the computation of familial cancer risk criteria for various use cases.

[Legal framework for electronic medical records in the Region of the Americas: definition of domains to legislate and situation analysisEnquadramento legal para os registros eletrônicos em saúde na Região das Américas: definição de domínios para regulamentação e análise da situação]. / Marco legal para registros médicos electrónicos en la Región de las Américas: definición de dominios a legislar y análisis de situación.

OBJECTIVES: Define a legal framework for electronic medical records (EMRs) and determine the degree to which the countries of the Region of the Americas are prepared in this regard. METHODS: The methodology consisted of two phases. In the first, a Delphi methodology was used to develop a questionnaire and define the framework and legal domains applicable to EMRs. In the second, the questionnaire was completed in each country. This included identifying national experts and the data collection process. RESULTS: Information was collected from a total of 21 countries regarding their situation with respect to legislation on EMRs in the following domains: 1) specific legislation on EMRs; 2) protection of patients' data and secondary use of the data; 3) legislation related to the actions of health professionals; 4) regulation on EMRs and the role of patients; and 5) health standards and EMR promotion programs. CONCLUSIONS: There has been progress in the Region with respect to new legislation covering the main areas related to EMRs (for example, protection of sensitive data and use of digital signatures). However, it is necessary to continue to address issues such as access to and updating of information in EMRs. This study contributes information on the essential components of legislation on EMRs, and reports on the situation in the Region of the Americas.

OBJETIVOS: Definir um enquadramento legal para os registros eletrônicos em saúde (RES) e identificar o grau de preparação dos países da Região das Américas neste sentido. MÉTODOS: A metodologia do estudo foi dividida em duas fases. Na primeira fase, foi usado o método Delphi para elaborar o questionário e definir o enquadramento e os domínios legais para RES. Na segunda fase, foi realizada a pesquisa por país, com a identificação de dados referentes nacionais e processo de coleta de dados. RESULTADOS: Ao todo, foram obtidos dados de 21 países sobre os aspectos legais e RES distribuídos nos seguintes domínios: 1) legislação específica para RES, 2) proteção dos dados dos pacientes e uso secundário da informação, 3) legislação relacionada à atuação dos profissionais da saúde, 4) regulamentação dos RES e papel dos pacientes e 5) padrões em saúde e programas de promoção dos RES. CONCLUSÕES: Houve progresso na Região quanto à promulgação de leis que abrangem os principais domínios dos RES (p. ex., proteção de dados sensíveis ou o uso de assinatura digital). Porém, alguns aspectos precisam ser reforçados, como o acesso e a atualização das informações nos registros. Este estudo contribui ao descrever os aspectos básicos da regulamentação e informar a situação dos RES na Região das Américas.

Looking Behind the Curtain: Identifying Factors Contributing to Changes on Care Outcomes During a Large Commercial EHR Implementation.

OBJECTIVE: To identify factors contributing to changes on quality, productivity, and safety outcomes during a large commercial electronic health record (EHR) implementation and to guide future research. METHODS: We conducted a mixed-methods study assessing the impact of a commercial EHR implementation. The method consisted of a quantitative longitudinal evaluation followed by qualitative semi-structured, in-depth interviews with clinical employees from the same implementation. Fourteen interviews were recorded and transcribed. Three authors independently coded interview narratives and via consensus identified factors contributing to changes on 15 outcomes of quality, productivity, and safety. RESULTS: We identified 14 factors that potentially affected the outcomes previously monitored. Our findings demonstrate that several factors related to the implementation (e.g., incomplete data migration), partially related (e.g., intentional decrease in volume of work), and not related (e.g., health insurance changes) may affect outcomes in different ways. DISCUSSION: This is the first study to investigate factors contributing to changes on a broad set of quality, productivity, and safety outcomes during an EHR implementation guided by the results of a large longitudinal evaluation. The diversity of factors identified indicates that the need for organizational adaptation to take full advantage of new technologies is as important for health care as it is for other services sectors. CONCLUSIONS: We recommend continuous identification and monitoring of these factors in future evaluations to hopefully increase our understanding of the full impact of health information technology interventions.

Novel displays of patient information in critical care settings: a systematic review.

OBJECTIVE: Clinician information overload is prevalent in critical care settings. Improved visualization of patient information may help clinicians cope with information overload, increase efficiency, and improve quality. We compared the effect of information display interventions with usual care on patient care outcomes. MATERIALS AND METHODS: We conducted a systematic review including experimental and quasi-experimental studies of information display interventions conducted in critical care and anesthesiology settings. Citations from January 1990 to June 2018 were searched in PubMed and IEEE Xplore. Reviewers worked independently to screen articles, evaluate quality, and abstract primary outcomes and display features. RESULTS: Of 6742 studies identified, 22 studies evaluating 17 information displays met the study inclusion criteria. Information display categories included comprehensive integrated displays (3 displays), multipatient dashboards (7 displays), physiologic and laboratory monitoring (5 displays), and expert systems (2 displays). Significant improvement on primary outcomes over usual care was reported in 12 studies for 9 unique displays. Improvement was found mostly with comprehensive integrated displays (4 of 6 studies) and multipatient dashboards (5 of 7 studies). Only 1 of 5 randomized controlled trials had a positive effect in the primary outcome. CONCLUSION: We found weak evidence suggesting comprehensive integrated displays improve provider efficiency and process outcomes, and multipatient dashboards improve compliance with care protocols and patient outcomes. Randomized controlled trials of physiologic and laboratory monitoring displays did not show improvement in primary outcomes, despite positive results in simulated settings. Important research translation gaps from laboratory to actual critical care settings exist.

Marco legal para registros médicos electrónicos en la Región de las Américas: definición de dominios a legislar y análisis de situación

[RESUMEN]. Objetivos. Definir un marco legal relacionado con los Registros Médicos Electrónicos (RME) y conocer el grado de preparación que tienen los países de la Región de las Américas al respecto. Métodos. La metodología contó con dos fases. En la primera, se utilizó una metodología Delphi para el desarrollo del cuestionario y la definición del marco y dominios legales sobre RME. En la segunda, se realizó el relevamiento por país, que incluyó la identificación de referentes nacionales y el proceso de recolección de datos. Resultados. Se relevó información de un total de 21 países sobre su situación con respecto a los aspectos legales y RME incluidos los siguientes dominios: 1) legislación específica sobre RME, 2) protección de datos de pacientes y uso secundario de la información, 3) legislación relacionada al accionar de los profesionales de la salud, 4) regulación sobre RME y el rol de los pacientes y 5) estándares en salud y programas de promoción de los RME. Conclusiones. Existen avances en la Región con respecto a la publicación de leyes que cubren los principales dominios de los RME (por ejemplo, la protección de datos sensibles o el uso de la firma digital). Sin embargo, temas como el acceso y la actualización de la información en los registros deben seguir siendo fortalecidos. Este estudio contribuye a informar sobre cuáles son los componentes mínimos que deben ser legislados en materia de RME, así como a ofrecer un estado de situación sobre el tema en la Región de las Américas.

[ABSTRACT]. Objectives. Define a legal framework for electronic medical records (EMRs) and determine the degree to which the countries of the Region of the Americas are prepared in this regard. Methods. The methodology consisted of two phases. In the first, a Delphi methodology was used to develop a questionnaire and define the framework and legal domains applicable to EMRs. In the second, the questionnaire was completed in each country. This included identifying national experts and the data collection process. Results. Information was collected from a total of 21 countries regarding their situation with respect to legislation on EMRs in the following domains: 1) specific legislation on EMRs; 2) protection of patients’ data and secondary use of the data; 3) legislation related to the actions of health professionals; 4) regulation on EMRs and the role of patients; and 5) health standards and EMR promotion programs. Conclusions. There has been progress in the Region with respect to new legislation covering the main areas related to EMRs (for example, protection of sensitive data and use of digital signatures). However, it is necessary to continue to address issues such as access to and updating of information in EMRs. This study contributes information on the essential components of legislation on EMRs, and reports on the situation in the Region of the Americas.

[RESUMO]. Objetivos. Definir um enquadramento legal para os registros eletrônicos em saúde (RES) e identificar o grau de preparação dos países da Região das Américas neste sentido. Métodos. A metodologia do estudo foi dividida em duas fases. Na primeira fase, foi usado o método Delphi para elaborar o questionário e definir o enquadramento e os domínios legais para RES. Na segunda fase, foi realizada a pesquisa por país, com a identificação de dados referentes nacionais e processo de coleta de dados. Resultados. Ao todo, foram obtidos dados de 21 países sobre os aspectos legais e RES distribuídos nos seguintes domínios: 1) legislação específica para RES, 2) proteção dos dados dos pacientes e uso secundário da informação, 3) legislação relacionada à atuação dos profissionais da saúde, 4) regulamentação dos RES e papel dos pacientes e 5) padrões em saúde e programas de promoção dos RES. Conclusões. Houve progresso na Região quanto à promulgação de leis que abrangem os principais domínios dos RES (p. ex., proteção de dados sensíveis ou o uso de assinatura digital). Porém, alguns aspectos precisam ser reforçados, como o acesso e a atualização das informações nos registros. Este estudo contribui ao descrever os aspectos básicos da regulamentação e informar a situação dos RES na Região das Américas.

Critical care information display approaches and design frameworks: A systematic review and meta-analysis.

OBJECTIVE: To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians. METHODS: We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author. RESULTS: Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible. CONCLUSION: Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.