Utilization of electronic medical records to build a detection model for surveillance of healthcare-associated urinary tract infections.

In this study, we propose an approach to build a detection model for surveillance of healthcare-associated urinary tract infection (HA-UTI) based on the variables extracted from the electronic medical records (EMRs) in a 730-bed, tertiary-care teaching hospital in Taiwan. Firstly we mapped the CDC's HA-UTI case definitions to a set of variables, and identified the variables whose values could be derived from the EMRs of the hospital automatically. Then with these variables we performed discriminant analysis (DA) on a training set of the EMRs to construct a discriminant function (DF) for the classification of a patient with or without HA-UTI. Finally, we evaluated the sensitivity, specificity, and overall accuracy of the function using a testing set of EMRs. In this study, six surveillance variables (fever, urine culture, blood culture, routine urinalysis, antibiotic use, and invasive devices) were identified whose values could be derived from the EMRs of the hospital. The sensitivity, specificity and overall accuracy of the built DF were 100 %, 94.61 %, and 94.65 %, respectively. Since most hospitals may adopt their EMRs piece-by-piece to meet their functional requirements, the variables that are available in the EMRs may differ. Our approach can build a detection model with these variables to achieve a high sensitivity, specificity and accuracy for automatically detecting suspected HA-UTI cases. Therefore, our approach on one hand can reduce the efforts in building the model; on the other hand, can facilitate adoption of EMRs for HAI surveillance and control.

Authorship Correction: A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation.

[This corrects the article DOI: 10.2196/medinform.9064.].

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation.

BACKGROUND: A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients' integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients' medication records prescribed by different health care facilities across Taiwan. OBJECTIVE: This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters. METHODS: A CDS engine was developed that can download patients' up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians' responses to handling the alerts for each encounter. RESULTS: The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When prescribing using the CDS engine, the median encounter time was 4.3 (IQR 2.3-7.3) min, longer than that without using the CDS engine (median 3.6, IQR 2.0-6.3 min). From the physicians' responses, we found that 42.06% (1908/4536) of the potential duplicate medications were recognized by the physicians and the medication orders were canceled. CONCLUSIONS: The CDS engine could easily extend functions for detection of adverse drug reactions when more and more electronic health record systems are adopted. Moreover, the CDS engine can retrieve more updated and completed medication histories in the PharmaCloud, so it can have better performance for detection of duplicate medications. Although our CDS engine approach could enhance medication safety, it would make for a longer encounter time. This problem can be mitigated by careful evaluation of adopted solutions for implementation of the CDS engine. The successful key component of a CDS engine is the completeness of the patient's medication history, thus further research to assess the factors in increasing the PharmaCloud consent rate is required.

Development and evaluation of a patient-oriented education system for diabetes management.

PURPOSE: To develop and evaluate a Web-based, patient-orientated diabetic education management (POEM) system. METHODS: The POEM system has been developed to extend hospital patient education by integrating patients' medical care data into their education program components and presenting them on the Web. Since most patients are concerned about their medical care data, the POEM system can provide the incentives for patients to continuously and persistently log in and learn the required knowledge and skills, improving their clinical outcomes. A quasi-experimental method that uses control groups and pretests was used to evaluate the outcomes of the system intervention. We recruited patients with type-2 diabetes and alternatively assigned them to intervention and control groups. We compared laboratory test results including fasting blood glucose, HbA1c, total cholesterol, triglyceride (TG), and HDL between the two groups from the first visit through each follow-up visit. The study period progressed from September 2003 to May 2004 at the Metabolism Center of a medical teaching hospital in Taipei. RESULTS: In this study, we recruited 274 participants: 134 (57% males and 43% females) in the intervention group and 140 (46% males and 54% females) in the control group. The patients' laboratory test results from the first visit for fasting blood glucose, HbA1c, total cholesterol level, TG, and HDL in the intervention and control groups were respectively 187.54+/-77.10 and 189.99+/-73.49 mg/dl, 9.03 +/- 2.79% and 8.95 +/- 2.23%, 193.29 +/- 47.93 and 202.52 +/- 58.45 mg/dl, 152.48 +/- 70.85 and 157.37 +/- 74.88 mg/dl, and 44.97 +/- 12.09 and 45.32 +/- 12.08 mg/dl. There were three follow-up visits during the study period. We collected laboratory test results of the two groups through each of the following visits and analyzed them using ANCOVA. We discovered a significant difference in fasting blood glucose levels between intervention and control group as early as the first follow-up. At the second follow-up, both fasting blood glucose and HBA1c levels were significantly different between intervention and control group. At the third follow-up, there was a significant difference in fasting blood glucose, HBA1c, and total cholesterol between intervention and control group. We also monitored the number of logins for the patients in the intervention group during the follow-up period. The result showed the patients had consistently logged into the POEM system (about 8.5 +/- 3.7 logins per person per month after 3 months enrollment). Thus, the patients in the intervention group had better control of their fasting blood glucose, HbA1c and total cholesterol levels than those in the control group due to the assistance of the system. CONCLUSIONS: The POEM system can help patients control their glucose, HbA1c and total cholesterol levels to manage their diabetes, providing an easy and inexpensive way to extend hospital-based patient education services for community-based continuous patient education.

Development of Day Care Management Systems for Elderly.

The purpose of this study is to build a practical, highly efficient management information system (MIS) for elderly day care (EDC) centers to improve elders' lives. Based on system requirements and the management operation guidelines for EDC, we have developed an MIS. The introduction of the system will help EDC management to be more accurate, comprehensive, and efficient.

The impacts of smart cards on hospital information systems--an investigation of the first phase of the national health insurance smart card project in Taiwan.

PURPOSE: To investigate the impacts of the first phase of Taiwan's Bureau of National Health Insurance (TBNHI) smart card project on existing hospital information systems. SETTING: TBNHI has launched a nationwide project for replacement of its paper-based health insurance cards by smart cards (or NHI-IC cards) since November 1999. The NHI-IC cards have been used since 1 July 2003, and they have fully replaced the paper-based cards since 1 January 2004. Hospitals must support the cards in order to provide medical services for insured patients. METHODS: We made a comprehensive study of the current phase of the NHI-IC card system, and conducted a questionnaire survey (from 1 October to 30 November, 2003) to investigate the impacts of NHI-IC cards on the existing hospital information systems. A questionnaire was distributed by mail to 479 hospitals, including 23 medical centers, 71 regional hospitals, and 355 district hospitals. The returned questionnaires were also collected by prepaid mail. RESULTS: The questionnaire return rates of the medical centers, regional hospitals and district hospitals were 39.1, 29.6 and 20.9%, respectively. In phase 1 of the project, the average number of card readers purchased per medical center, regional hospital, and district hospital were 202, 45 and 10, respectively. The average person-days for the enhancement of existing information systems of a medical center, regional hospital and district hospital were 175, 74 and 58, respectively. Three months after using the NHI-IC cards most hospitals (60.6%) experienced prolonged service time for their patients due to more interruptions caused mainly by: (1) impairment of the NHI-IC cards (31.2%), (2) failure in authentication of the SAMs (17.0%), (3) malfunction in card readers (15.3%) and (4) problems with interfaces between the card readers and hospital information systems (15.8%). The overall hospital satisfaction on the 5-point Likert scale was 2.86. Although most hospitals were OK with the project, there was about 22% dissatisfied and strongly dissatisfied, that is twice as many hospitals with satisfied (about 10%). CONCLUSIONS: Our recommendations for those who are planning to implement similar projects are: (1) provide public-awareness programs or campaigns across the country for elucidating the smart card policy and educate the public on the proper usage and storage of the cards, (2) improve the quality of the NHI-IC cards, (3) conduct comprehensive tests in software and hardware components associated with NHI-IC cards before operating the systems and (4) perform further investigations in authentication approaches and develop tools that can quickly identify where and what the problems are.

Development and evaluation of an integrated patient-oriented education management system for diabetes.

This paper describes and evaluates a Patient-Oriented education management system for diabetes using the Internet (POEM). With this system at each patient visit, the system can automatically download a patient's medical services records, prescriptions, laboratory test results and his/her patient education materials, and organize them into a series of case folders based on his/her medical service history in a hospital. The system can also provide patients with reminders to call for return to their hospitals for further treatment under certain conditions, such as one week before their appointments, the period of their HbA1C test if it is more than three months away, and emergency calls for any anomaly in a laboratory test result. We present them on the Web to support continued patient education at a low cost. The evaluation results showed that the system was able to help patients maintain better control of their glucose levels and better management of their diabetes condition as well. More importantly, the system supports routine hospital patient education services and assists patients to acquire the diabetes knowledge and skills for self care.

Integrating hospital medical care data with pharmaceutical education materials for diabetes self management.

Diabetic patients need long-term treatment and follow-up exams as well as appropriate self-care pharmaceutical education to get the disease under control and to prevent possible complications. Pharmaceutical treatment plays an essential role in diabetes. If patients don't understand the medicines and dosages they take, their blood glucose control may be affected. In addition, the possibility of developing hypoglycemia may be increased. In this paper, we enhance the POEM system, previously developed for diabetic patient education, by providing diabetic patients' pharmaceutical education. The new system integrates both diabetic patients' pharmaceutical education information and medical care information to provide them with more comprehensive personalized medication information so that they can access the on-line system afterwards. It also strengthens patients' understanding of pharmaceutical functions, side-effects and relevant knowledge thus increasing patients' adherence of medication orders and having better control in their blood glucose levels.

Pyogenic liver abscess in end-stage renal disease patients: a nationwide longitudinal study.

End-stage renal disease (ESRD) patients are more prone to infectious disease because of their immunocompromised status. However, the association between pyogenic liver abscess (PLA) and ESRD remains not clear. The aim of our study is to evaluate the incidence, risk factors, and outcomes of PLA in ESRD patients. We recruited all incident ESRD patients from the Taiwan National Health Insurance database from 1998 to 2006. The incidence rate of PLA in ESRD patients was compared with that of a randomly selected non-ESRD control group matched for age, sex gender, Charlson comorbidity score, diabetes mellitus, and cirrhosis. Among the 57,761 incident dialysis patients, there were 538 cases of PLA. The incidence rate of PLA was 18.20 per 10,000 person-years in the ESRD cohort and 6.34 per 10,000 person-years in matched control cohort. The rate of PLA was significantly higher in the ESRD cohort (hazard ratio 3.63, 95% confidence interval 2.83-4.65, P < 0.001). The mortality rates of PLA were higher in the ESRD cohort than those in matched control cohort. Diabetes mellitus was an independent risk factor for mortality of PLA. Compared with non-ESRD patients, ESRD patients have a higher risk of PLA and poorer outcomes.

Development and evaluation of an integrated pharmaceutical education system.

There is increasing evidence that patient safety can be improved by the introduction of an integrated computer-based medical care system in hospital settings. In this paper, we describe an integrated pharmaceutical information system (IPIS) in which a patient's profile including his/her medication records and prescriptions are collected from physician order entry systems and pharmaceutical systems along with the history of patient care in the hospital. Based on an individual patient's profile the IPIS can provide pharmaceutical education information specifically to meet the patient's needs. The IPIS has been developed and installed at Taipei Medical University Wanfang Hospital (TMUWFH) since July 2002. Evaluation of the system showed that it can help patients to effectively acquire drug information. This enables them to have a much better understanding of the pharmacological properties of the medicines they are taking, including adverse drug reactions and side-effects. In our opinion the system has the potential to improve both patient safety and treatment outcomes.

Improving the work efficiency of healthcare-associated infection surveillance using electronic medical records.

In this study, we developed an integrated hospital-associated urinary tract infection (HAUTI) surveillance information system (called iHAUTISIS) based on existing electronic medical records (EMR) systems for improving the work efficiency of infection control professionals (ICPs) in a 730-bed, tertiary-care teaching hospital in Taiwan. The iHAUTISIS can automatically collect data relevant to HAUTI surveillance from the different EMR systems, and provides a visualization dashboard that helps ICPs make better surveillance plans and facilitates their surveillance work. In order to measure the system performance, we also created a generic model for comparing the ICPs' work efficiency when using existing electronic culture-based surveillance information system (eCBSIS) and iHAUTISIS, respectively. This model can demonstrate a patient's state (unsuspected, suspected, and confirmed) and corresponding time spent on surveillance tasks performed by ICPs for the patient in that state. The study results showed that the iHAUTISIS performed better than the eCBSIS in terms of ICPs' time cost. It reduced the time by 73.27 s, when using iHAUTISIS (114.26 s) and eCBSIS (187.53 s), for each patient on average. With increased adoption of EMR systems, the development of the integrated HAI surveillance information systems would be more and more cost-effective. Moreover, the iHAUTISIS adopted web-based technology that enables ICPs to online access patient's surveillance information using laptops or mobile devices. Therefore, our system can further facilitate the HAI surveillance and reduce ICPs' surveillance workloads.

Detection of potential drug-drug interactions for outpatients across hospitals.

The National Health Insurance Administration (NHIA) has adopted smart cards (or NHI-IC cards) as health cards to carry patients' medication histories across hospitals in Taiwan. The aims of this study are to enhance a computerized physician order entry system to support drug-drug interaction (DDI) checking based on a patient's medication history stored in his/her NHI-IC card. For performance evaluation, we developed a transaction tracking log to keep track of every operation on NHI-IC cards. Based on analysis of the transaction tracking log from 1 August to 31 October 2007, physicians read patients' NHI-IC cards in 71.01% (8,246) of patient visits; 33.02% (2,723) of the card reads showed at least one medicine currently being taken by the patient, 82.94% of which were prescribed during the last visit. Among 10,036 issued prescriptions, seven prescriptions (0.09%) contained at least one drug item that might interact with the currently-taken medicines stored in NHI-IC cards and triggered pop-up alerts. This study showed that the capacity of an NHI-IC card is adequate to support DDI checking across hospitals. Thus, the enhanced computerized physician order entry (CPOE) system can support better DDI checking when physicians are making prescriptions and provide safer medication care, particularly for patients who receive medication care from different hospitals.

Evaluating an online pharmaceutical education system for pharmacy interns in critical care settings.

Incorporating electronic learning (eLearning) system into professional experimental programs such as pharmacy internships is a challenge. However, none of the current systems can fully support the unique needs of clinical pharmacy internship. In this study we enhanced a commercial eLearning system for clinical pharmacy internship (The Clinical Pharmacy Internship eLearning System, CPIES). The KAP questionnaire was used to evaluate the performance of group A with the traditional teaching model and group B with the CPIES teaching model. The CPIES teaching model showed significant improvement in interns' knowledge and practice (p = 0.002 and 0.031, respectively). The traditional teaching model only demonstrated significant improvement in practice (p = 0.011). Moreover, professionalism, such as attitudes on cooperating with other health professionals, is developed by learning from a good mentor. The on-line teaching and traditional teaching methods should undoubtedly be blended in a complete teaching model in order to improve learners' professional knowledge, facilitate correct attitude, and influence good practice.

Application of multiscale amplitude modulation features and fuzzy C-means to brain-computer interface.

This study proposed a recognized system for electroencephalogram (EEG) data classification. In addition to the wavelet-based amplitude modulation (AM) features, the fuzzy c-means (FCM) clustering is used for the discriminant of left finger lifting and resting. The features are extracted from discrete wavelet transform (DWT) data with the AM method. The FCM is then applied to recognize extracted features. Compared with band power features, k-means clustering, and linear discriminant analysis (LDA) classifier, the results indicate that the proposed method is satisfactory in applications of brain-computer interface (BCI).

Using health smart cards to check drug allergy history: the perspective from Taiwan's experiences.

In Taiwan, national health insurance coverage began in 1994, and the Bureau of National Health Insurance has issued health smart cards since 2004. In addition to tracking medical reimbursements, these smart cards store healthcare information, including electronic prescriptions, medical procedure and vaccination records, drug allergy histories, and information about a patient's willingness to be an organ donor. We conducted this study 4 years after the smart cards had been introduced in order to review how drug allergy history is recorded using this system. Our results reveal that the drug allergy histories are incomplete in many cases, and the format used to record a patient's drug allergy history is not consistent. We offer suggestions to promote the standardization of drug allergy history records.

Online detection of potential duplicate medications and changes of physician behavior for outpatients visiting multiple hospitals using national health insurance smart cards in Taiwan.

OBJECTIVES: Doctor shopping (or hospital shopping), which means changing doctors (or hospitals) without professional referral for the same or similar illness conditions, is common in Hong Kong, Taiwan and Japan. Due to the lack of infrastructure for sharing health information and medication history among hospitals, doctor-shopping patients are more likely to receive duplicate medications and suffer adverse drug reactions. The Bureau of National Health Insurance (BNHI) adopted smart cards (or NHI-IC cards) as health cards in Taiwan. With their NHI-IC cards, patients can freely access different medical institutions. Because an NHI-IC card carries information about a patient's prescribed medications received from different hospitals nationwide, we used this system to address the problem of duplicate medications for outpatients visiting multiple hospitals. METHODS: A computerized physician order entry (CPOE) system was enhanced with the capability of accessing NHI-IC cards and providing alerts to physicians when the system detects potential duplicate medications at the time of prescribing. Physician responses to the alerts were also collected to analyze changes in physicians' behavior. Chi-square tests and two-sided z-tests with Bonferroni adjustments for multiple comparisons were used to assess statistical significance of differences in actions taken by physicians over the three months. RESULTS: The enhanced CPOE system for outpatient services was implemented and installed at the Pediatric and Urology Departments of Taipei Medical University Wan-Fang Hospital in March 2007. The "Change Log" that recorded physician behavior was activated during a 3-month study period from April to June 2007. In 67.93% of patient visits, the physicians read patient NHI-IC cards, and in 16.76% of the reads, the NHI-IC card contained at least one prescribed medication that was taken by the patient. Among the prescriptions issued by physicians, on average, there were 2.36% prescriptions containing at least one medication that might be duplicative to the prior prescriptions stored in NHI-IC cards. The rate of potential duplicate medication alerts for the Pediatric Department was higher than that for the Urology Department (2.78% versus 1.67%). However, the rate of revisions to prescriptions was higher in the Urology Department than the Pediatric Department. Overall, the rate of physicians reviewing and revising their prescriptions was 29.25%; the rate of physicians reviewing without revising their prescriptions was 43.62%; the rate of physicians turning off the alert screens right after the screens popped up (overridden) was 27.13%. Thus, physicians accepted alerts to review their prescriptions with patients in most situations (72.87%). Moreover, over the study period, the rate of total revisions made to prescriptions increased and the "overridden" rate decreased. CONCLUSIONS: Our approach enhances the capability of CPOE systems using NHI-IC cards as a nationwide infrastructure to provide more complete patient health information and medication history sharing among hospitals in Taiwan. Thus, our system can provide a better prescribing tool to help physicians detect potential duplicate medications for frequent doctor-shopping patients and hence enhance patient safety across hospital boundaries. However, the effectiveness of detecting duplicate medications with our approach is very much dependent on the completeness of NHI-IC cards, which in turn primarily depends on physician use of the cards when prescribing.

A HL7 transformer application for vaccination data report.

In this paper, we design a data transformer to transform Comma Separated Value (CSV) format into Health Level Seven (HL7) messages without losing syntax and semantics. The algorithm of the data transformer is similar to a generic parser for solving scheme-level mapping problems. It can be extended to transform non-uniform formats for exchanges among different hospital information systems. To show the flexibility and scalability of the algorithm, we use it for the transformation of reported data in the Vaccination Reporting System (VRS). Through the data transformer, different formats of vaccination data can be reported directly to the Taiwan's Center for Disease Control.

Pervasive Observation Medicine: The Application of RFID to Improve Patient Safety in Observation Unit of Hospital Emergency Department.

Over the past decade, observation medicine has become an important component of emergency medicine. There are several settings in which observation medicine has been useful and valuable.(1) RFID as the patient identification, not only generates the on-line laboratory data and radiology report via hand-held wireless PDA, this RFID system help physician stream-line patient admission to acute bed or ICU in the emergency department more effectively.