International Journal of Medical Informatics - Articles in Press

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit - Corrected Proof

2012-05-18

Abstract: Purpose: To develop, conduct, and evaluate a proactive risk assessment (PRA) of the design and implementation of CPOE in an ICU.Methods: We developed a PRA method based on issues identified from documented experience with conventional PRA methods and the constraints of an organization about to implement CPOE in an intensive care unit. The PRA method consists of three phases: planning (three months), team (one five-hour meeting), and evaluation (short- and long-term).Results: Sixteen unique relevant vulnerabilities were identified as a result of the PRA team's efforts. Negative consequences resulting from the vulnerabilities included potential patient safety and quality of care issues, non-compliance with regulatory requirements, increases in cognitive burden on CPOE users, and/or worker inconvenience or distress. Actions taken to address the vulnerabilities included redesign of the technology, process (workflow) redesign, user training, and/or ongoing monitoring. Verbal and written evaluation by the team members indicated that the PRA method was useful and that participants were willing to participate in future PRAs. Long-term evaluation was accomplished by monitoring an ongoing “issues list” of CPOE problems identified by or reported to IT staff. Vulnerabilities identified by the team were either resolved prior to CPOE implementation (n=7) or shortly thereafter (n=9). No other issues were identified beside those identified by the team.Conclusions: Generally positive results from the various evaluations including a long-term evaluation demonstrate the value of developing an efficient PRA method that meets organizational and contextual requirements and constraints.

Detecting temporal expressions in medical narratives - Corrected Proof

2012-05-18

Highlights: ► TimeML's temporal model can represent temporal expressions in medical records. ► Automated temporal reference extraction and classification is achievable. ► Med-TTK's temporal reference classification in EHRs: 0.86 recall and 0.85 precision.Abstract: Background: Clinical practice and epidemiological information aggregation require knowing when, how long, and in what sequence medically relevant events occur. The Temporal Awareness and Reasoning Systems for Question Interpretation (TARSQI) Toolkit (TTK) is a complete, open source software package for the temporal ordering of events within narrative text documents. TTK was developed on newspaper articles. We extended TTK to support medical notes using veterans’ affairs (VA) clinical notes and compared it to TTK.Methods: We used a development set consisting of 200 VA clinical notes to modify and append rules to TTK's time tagger, creating Med-TTK. We then evaluated the performances of TTK and Med-TTK on an independent random selection of 100 clinical notes. Evaluation tasks were to identify and classify time-referring expressions as one of four temporal classes (DATE, TIME, DURATION, and SET). The reference standard for this test set was generated by dual human manual review with disagreements resolved by a third reviewer. Outcome measures included recall and precision for each class, and inter-rater agreement scores.Results: There were 3146 temporal expressions in the reference standard. TTK identified 1595 temporal expressions. Recall was 0.15 (95% confidence interval [CI] 0.12–0.15) and precision was 0.27 (95% CI 0.25–0.29) for TTK. Med-TTK identified 3174 expressions. Recall was 0.86 (95% CI 0.84–0.87) and precision was 0.85 (95% CI 0.84–0.86) for Med-TTK.Conclusion: The algorithms for identifying and classifying temporal expressions in medical narratives developed within Med-TTK significantly improved performance compared to TTK. Natural language processing applications such as Med-TTK provide a foundation for meaningful longitudinal mapping of patient history events among electronic health records. The tool can be accessed at the following site: http://code.google.com/p/med-ttk/.

The Epilepsy Phenome/Genome Project (EPGP) informatics platform - Corrected Proof

2012-05-14

Highlights: ► A web-based system to manage and coordinate multi-site studies is essential. ► EPGP has benefited from its custom developed informatics platform. ► The quality of the data collected has been improved. ► EPGP's informatics platform will help with the design of new informatics tools.Abstract: Background: The Epilepsy Phenome/Genome Project (EPGP) is a large-scale, multi-institutional, collaborative network of 27 epilepsy centers throughout the U.S., Australia, and Argentina, with the objective of collecting detailed phenotypic and genetic data on a large number of epilepsy participants. The goals of EPGP are (1) to perform detailed phenotyping on 3750 participants with specific forms of non-acquired epilepsy and 1500 parents without epilepsy, (2) to obtain DNA samples on these individuals, and (3) to ultimately genotype the samples in order to discover novel genes that cause epilepsy. To carry out the project, a reliable and robust informatics platform was needed for standardized electronic data collection and storage, data quality review, and phenotypic analysis involving cases from multiple sites.Methods: EPGP developed its own suite of web-based informatics applications for participant tracking, electronic data collection (using electronic case report forms/surveys), data management, phenotypic data review and validation, specimen tracking, electroencephalograph and neuroimaging storage, and issue tracking. We implemented procedures to train and support end-users at each clinical site.Results: Thus far, 3780 study participants have been enrolled and 20,957 web-based study activities have been completed using this informatics platform. Over 95% of respondents to an end-user satisfaction survey felt that the informatics platform was successful almost always or most of the time.Conclusions: The EPGP informatics platform has successfully and effectively allowed study management and efficient and reliable collection of phenotypic data. Our novel informatics platform met the requirements of a large, multicenter research project. The platform has had a high level of end-user acceptance by principal investigators and study coordinators, and can serve as a model for new tools to support future large scale, collaborative research projects collecting extensive phenotypic data.

Telemedicine: Technology mediated service relationship, encounter, or something else? - Corrected Proof

Cynthia LeRouge, Monica J. Garfield, Rosann Webb Collins — 2012-05-14

Highlights: ► Understanding the relationships between primary telemedicine actors. ► Understanding organizational actions needed in telemedicine service processes. ► Identification of the telemedicine service as an Advanced Encounter. ► Identification of seven organization controls to support telemedicine services.Abstract: Purpose: Service interactions between service providers and health care consumers happen daily in health care organizations, and can occur face-to-face or through mediating technology. We use the demanding and rich environment of telemedicine to better understand the nature of the real time service-encounter interactions among the human and technology actors engaged in the process and to inform telemedicine providers about key factors to consider in telemedicine design.Methods: We conducted a case study of medical video conferencing (MVC) for the delivery of patient healthcare (a form of telemedicine) using multiple data collection and analysis techniques involving a range of telemedicine stakeholders.Results: The research reveals that telemedicine requires a new kind of service relationship, an Advanced Encounter, with unique relationships between the telemedicine service providers, presenters, patients, and technology. Seven facilitating factors for the Advanced Encounter of telemedicine are identified and discussed, including the telemedicine servicescape: a set of supporting structures that are critical to telemedicine success.Conclusions: Key contributions are a deep understanding of the relationships between telemedicine actors, and the organizational actions needed to deploy a technology-mediated telemedicine service.

How physicians document outpatient visit notes in an electronic health record - Corrected Proof

2012-04-30

Highlights: ► Physicians predominantly used one method to document visit notes and were satisfied. ► Variation existed in method used across physician and practice characteristics. ► Further research to understand why variation exists and quality of the documentation.Abstract: Background: Clinical documentation, an essential process within electronic health records (EHRs), takes a significant amount of clinician time. How best to optimize documentation methods to deliver effective care remains unclear.Objective: We evaluated whether EHR visit note documentation method was influenced by physician or practice characteristics, and the association of physician satisfaction with an EHR notes module.Measurements: We surveyed primary care physicians (PCPs) and specialists, and used EHR and provider data to perform a multinomial logistic regression of visit notes from 2008. We measured physician documentation method use and satisfaction with an EHR notes module and determined the relationship between method and physician and practice characteristics.Results: Of 1088 physicians, 85% used a single method to document the majority of their visits. PCPs predominantly documented using templates (60%) compared to 34% of specialists, while 38% of specialists predominantly dictated. Physicians affiliated with academic medical centers (OR 1.96, CI (1.23, 3.12)), based at a hospital (OR 1.57, 95% CI (1.04, 2.36)) and using the EHR for longer (OR 1.13, 95% CI (1.03, 1.25)) were more likely to dictate than use templates. Most physicians of 383 survey responders were satisfied with the EHR notes module, regardless of their preferred documentation method.Conclusions: Physicians predominantly utilized a single method of visit note documentation and were satisfied with their approach, but the approaches they chose varied. Demographic characteristics were associated with preferred documentation method. Further research should focus on why variation exists, and the quality of the documentation resulting from different methods used.

Evaluation of an integrated graphical display to promote acute change detection in ICU patients - Corrected Proof

2012-04-25

Highlights: ► Nurses found the integrated graphical display more usable than their current hospital system. ► Performance improved using the graphical display only at the primary design institution. ► Medical information displays optimized for use at one clinical site may not be as favorable for other clinical sites. ► Health information technology needs to be flexible and configurable to meet local design constraints.Abstract: Objective: The purpose of this study was to evaluate ICU nurses’ ability to detect patient change using an integrated graphical information display (IGID) versus a conventional tabular ICU patient information display (i.e. electronic chart).Design: Using participants from two different sites, we conducted a repeated measures simulator-based experiment to assess ICU nurses’ ability to detect abnormal patient variables using a novel IGID versus a conventional tabular information display. Patient scenarios and display presentations were fully counterbalanced.Measurements: We measured percent correct detection of abnormal patient variables, nurses’ perceived workload (NASA-TLX), and display usability ratings.Results: 32 ICU nurses (87% female, median age of 29 years, and median ICU experience of 2.5 years) using the IGID detected more abnormal variables compared to the tabular display [F(1, 119)=13.0, p<0.05]. There was a significant main effect of site [F(1, 119)=14.2], with development site participants doing better. There were no significant differences in nurses’ perceived workload. The IGID display was rated as more usable than the conventional display [F(1, 60)=31.7].Conclusion: Overall, nurses reported more important physiological information with the novel IGID than tabular display. Moreover, the finding of site differences may reflect local influences in work practice and involvement in iterative display design methodology. Information displays developed using user-centered design should accommodate the full diversity of the intended user population across use sites.

Guided ordering: Clinician interactions with complex order-sets - Corrected Proof

Daniel Shine, Himali Weerahandi, Katherine Hochman, Lily Wang, Martha Radford — 2012-04-11

Highlights: ► Clinicians often report and practice non-cooperation. ► With logic-driven electronic orders, possibly impairing effectiveness. ► Poor placement of required queries and screens in the admission work flow emerged as the likeliest cause of non-cooperation. ► Innate reluctance of clinicians to be electronically guided remains a possibly important cause of non-cooperation.Abstract: Background: Electronic order-sets increasingly ask clinicians to answer questions or follow algorithms. Cooperation with such requests has not been studied.Setting: Internal Medicine service of an academic medical center.Objective: We studied the accuracy of clinician responses to questions embedded in electronic admission and discharge order-sets. Embedded questions asked whether any of three “core” diagnoses was present; a response was required to submit orders. Endorsement of any diagnosis made available best-practice ordering screens for that diagnosis.Design: Three reviewers examined 180 electronic records (8% of discharges), drawn equally (for each core diagnosis) from possible combinations of Yes/No responses on admission and discharge. In addition to noting responses, we identified whether the core diagnosis was coded, determined from notes whether the admitting clinician believed that diagnosis present, and sought clinical evidence of disease on admission. We also surveyed participating clinicians anonymously about practices in answering embedded questions.Measurements: We measured occurrence of six admission and five discharge scenarios relating medical record evidence of disease to clinician responses about its presence.Results: The commonest discordant pattern between response and evidence was a negative response to disease presence on admission despite both early clinical evidence and documentation.Survey of study clinicians found that 75% endorsed some intentional inaccuracy; the commonest reason given was that questions were sometimes irrelevant to the clinical situation at the point asked.Conclusion: Through faults in order-set design, limitations of software, and/or because of an inherent tendency to resist directed behavior, clinicians may often ignore questions embedded in order-sets.

Adoption of a clinical decision support system to promote judicious use of antibiotics for acute respiratory infections in primary care - Corrected Proof

2012-04-06

Highlights: ► Successful implementation of a CDSS within a primary care practice requires: The perception by providers that the CDSS assists with decision making. ► Engagement of non-physician staff. ► An iterative CDSS development process.Abstract: Purpose: Overuse of antibiotics for acute respiratory infections (ARIs) in primary care is an established risk factor for worsening antimicrobial resistance. The “Reducing Inappropriate Prescribing of Antibiotics by Primary Care Clinicians” study is assessing the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs using a multimethod intervention to facilitate CDSS adoption. The purpose of this report is to describe use of the CDSS, as well as facilitators and barriers to its adoption, during the first year of the 15-month intervention.Methods: Between January 1, 2010 and December 31, 2010, 39 providers in 9 practices in US states participated in this study. Quarterly EHR based audit and feedback, practice site visits for academic detailing, performance review and CDSS training, and “best-practice” dissemination during two meetings of study participants were used to facilitate CDSS adoption. Mixed methods were used to evaluate adoption of the CDSS. Using data extracted from the EHR, CDSS use for ARI was calculated. To determine facilitators and barriers of CDSS adoption, semi-structured group interviews were conducted with providers and staff at each practice.Results: During the first year of implementation, the ABX-TRIP CDSS was used 14,086 times for ARI encounters. Overall, practice use of the CDSS during ARI encounters ranged from 39.4% to 77.2%. Median use of the CDSS for adult patients was 58.2% and 68.6% for pediatric patients. Key factors associated with CDSS adoption include the perception by providers that it assists with decision making and stimulates patient discussions, engagement of non-physician staff and an iterative CDSS development process.Conclusions: Adoption of a custom designed CDSS in the first year of implementation is promising. Successful implementation of such technology requires a focus not only on the technological solution itself, but on its integration with the entire clinical workplace.

Physician experiences transitioning between an older versus newer electronic health record for electronic prescribing - Corrected Proof

2012-04-05

Highlights: ► Use of electronic health records for e-prescribing is expected to increase. ► There is limited research on the provider experience transitioning between systems. ► We found even experienced providers found the transition very difficult. ► Providers preferred simple and efficient systems for prescribing. ► Understanding physician preferences can improve system implementations and designs.Abstract: Purpose: Federal incentives to adopt interoperable, certified electronic health records (EHRs) with electronic prescribing (e-prescribing) are motivating providers using older EHRs to transition to newer EHRs. The objective of this study was to describe, from the perspective of experienced EHR users, the transition from an older, locally developed EHR with minimal clinical decision support (CDS) for e-prescribing to a newer, commercial EHR with more robust CDS for e-prescribing.Methods: This qualitative, case study consisted of observations and semi-structured interviews of adult internal medicine faculty members (n=19) at an academic-affiliated ambulatory care clinic from January through November 2009. All providers transitioned from the older, locally developed EHR to the newer, commercial EHR in April 2008. We analyzed field notes of observations and transcripts of semi-structured interviews using qualitative methods guided by a grounded theory approach.Results: We identified key themes describing physician experiences. Despite intensive effort by the information systems team to ease the transition, even these experienced e-prescribers found transitioning extremely difficult. The commercial EHR was not perceived as improving medication safety, despite having more robust CDS. Additionally, physicians felt the commercial EHR was too complex, reducing their efficiency.Conclusions: This is among the first studies examining physician experiences transitioning between an older, locally developed EHR to a newer, commercial EHR with more robust CDS for e-prescribing. Understanding physician experiences with this type of transition and their general preferences for prescribing applications may lead to less disruptive system implementations and better designed EHRs that are more readily accepted by providers. In this way, productivity and safety benefits may be maximized while mitigating potential threats associated with transitions.Trial registration: ClinicalTrials.gov, Identifier: NCT00603070.

Developing healthcare rule-based expert systems: Case study of a heart failure telemonitoring system - Corrected Proof

2012-04-05

Highlights: ► A practical process for development of rule sets for healthcare expert systems. ► A feasible and effective rule set for heart failure telemonitoring systems. ► Identification of clinician and patient concerns on telemonitoring expert systems.Abstract: Background: The use of expert systems to generate automated alerts and patient instructions based on telemonitoring data could enable increased self-care and improve clinical management. However, of great importance is the development of the rule set to ensure safe and clinically relevant alerts and instructions are sent. The purpose of this work was to develop a rule-based expert system for a heart failure mobile phone-based telemonitoring system, to evaluate the expert system, and to generalize the lessons learned from the development process for use in other healthcare applications.Methods: Semi-structured interviews were conducted with 10 heart failure clinicians to inform the development of a draft heart failure rule set for alerts and patient instructions. The draft rule set was validated and refined with 9 additional interviews with heart failure clinicians. Finally, the clinical champion of the project vetted the rule set. The concerns voiced by the clinicians during the interviews were noted, and methods to mitigate these concerns were employed. The rule set was then evaluated as part of a 6-month randomized controlled trial of a mobile phone-based heart failure telemonitoring system (n=50 for each of the telemonitoring and control groups).Results: The developed expert system generated alerts and instructions based on the patient's weight, blood pressure, heart rate, and symptoms. During the trial, 1620 alerts were generated, which led to various clinical actions including 105 medication changes/instructions. The findings from the trial indicated the rule set was associated with improved quality of life and self-care.Conclusions: A rule set was developed with extensive input by heart failure clinicians. The results from the trial indicated the rule set was associated with significantly increased self-care and improved the clinical management of heart failure. The developed rule set can be used as a basis for other heart failure telemonitoring systems, but should be validated and modified as necessary. In addition, the process used to develop the rule set can be generalized and applied to create robust and complete rule sets for other healthcare expert systems.

Integrating usability testing and think-aloud protocol analysis with “near-live” clinical simulations in evaluating clinical decision support - Corrected Proof

2012-03-29

Highlights: ► This study successfully combined “think-aloud” protocol analysis with “near-live” clinical simulations in a usability evaluation of a new primary care CDS tool. ► These two forms of usability evaluation provided complementary observations on problems with the new tool and were used to refine both its usability and workflow integration. ► Their synergistic use provided a robust assessment of how CDS tools would interact in live clinical environments and allowed for enhanced early redesign to augment clinician utilization. ► These findings suggest the importance of using complementary testing methods before releasing CDS for live use.Abstract: Purpose: Usability evaluations can improve the usability and workflow integration of clinical decision support (CDS). Traditional usability testing using scripted scenarios with think-aloud protocol analysis provide a useful but incomplete assessment of how new CDS tools interact with users and clinical workflow. “Near-live” clinical simulations are a newer usability evaluation tool that more closely mimics clinical workflow and that allows for a complementary evaluation of CDS usability as well as impact on workflow.Methods: This study employed two phases of testing a new CDS tool that embedded clinical prediction rules (an evidence-based medicine tool) into primary care workflow within a commercial electronic health record. Phase I applied usability testing involving “think-aloud” protocol analysis of 8 primary care providers encountering several scripted clinical scenarios. Phase II used “near-live” clinical simulations of 8 providers interacting with video clips of standardized trained patient actors enacting the clinical scenario. In both phases, all sessions were audiotaped and had screen-capture software activated for onscreen recordings. Transcripts were coded using qualitative analysis methods.Results: In Phase I, the impact of the CDS on navigation and workflow were associated with the largest volume of negative comments (accounting for over 90% of user raised issues) while the overall usability and the content of the CDS were associated with the most positive comments. However, usability had a positive-to-negative comment ratio of only 0.93 reflecting mixed perceptions about the usability of the CDS. In Phase II, the duration of encounters with simulated patients was approximately 12min with 71% of the clinical prediction rules being activated after half of the visit had already elapsed. Upon activation, providers accepted the CDS tool pathway 82% of times offered and completed all of its elements in 53% of all simulation cases. Only 12.2% of encounter time was spent using the CDS tool. Two predominant clinical workflows, accounting for 75% of all cases simulations, were identified that characterized the sequence of provider interactions with the CDS. These workflows demonstrated a significant variation in temporal sequence of potential activation of the CDS.Conclusions: This study successfully combined “think-aloud” protocol analysis with “near-live” clinical simulations in a usability evaluation of a new primary care CDS tool. Each phase of the study provided complementary observations on problems with the new onscreen tool and was used to refine both its usability and workflow integration. Synergistic use of “think-aloud” protocol analysis and “near-live” clinical simulations provide a robust assessment of how CDS tools would interact in live clinical environments and allows for enhanced early redesign to augment clinician utilization. The findings suggest the importance of using complementary testing methods before releasing CDS for live use.

The use of information technologies for knowledge sharing by secondary healthcare organisations in New Zealand - Corrected Proof

Nor’ashikin Ali, Dick Whiddett, Alexei Tretiakov, Inga Hunter — 2012-03-29

Highlights: ► We surveyed use of IT for sharing knowledge in secondary care organisations in NZ. ► We found IT is used extensively to share explicit knowledge. ► Explicit knowledge is shared significantly more than tacit knowledge. ► Established technologies are used significantly more than social media technologies.Abstract: Purpose: To explore the extent of use of information technologies (ITs) for knowledge sharing by secondary healthcare organisations in New Zealand.Methods: We used a self-administered questionnaire to survey Chief Information Officers at all 21 of New Zealand's District Health Boards regarding the extent to which their organisations use knowledge sharing activities involving ITs. The list of activities to include in the questionnaire was compiled by reviewing the literature. We analysed the extent of use of the knowledge sharing activities using descriptive statistics, repeated measures ANOVA, and correlation analysis.Results: The response rate was 76%. Although all the responding organisations reported using ITs to share knowledge, they used ITs to share documents significantly more than to support discussions or to connect employees to experts. Discussions via teleconferencing, videoconferencing, and email lists were significantly more common than discussions via social media technologies: electronic discussion forums, blogs, and on-line chatrooms. There were significant positive correlations between publishing and accessing documents, between using teleconferencing and using videoconferencing, and between publishing and finding contact details of experts.Conclusion: New Zealand's District Health Boards are using a range of ITs to share knowledge. Knowledge sharing activities emphasising the sharing of explicit knowledge (via exchanging documents in electronic form) are significantly more common than knowledge sharing activities emphasising the sharing of tacit knowledge (via technology-mediated discussions and via using technology to connect employees to experts). In view of the evidence in the literature that information technology may be highly effective in supporting tacit knowledge exchanges, our results suggest that health organisations should consider greater adoption of ITs for sharing tacit knowledge. The finding that several organisations are currently making extensive use of teleconferencing and videoconferencing facilities and expertise databases suggests that these technologies are useful and could be of benefit to other healthcare providers and that barriers to their adoption can be overcome. In order to facilitate the wider adoption of technologies, early adopters of both relatively established technologies and of the emerging technologies such as social media should be encouraged to publish accounts of their experiences of success and lessons learnt from any failures so that the knowledge gained is disseminated to the wider medical informatics community.

Empowering citizens with access control mechanisms to their personal health resources - Corrected Proof

J. Calvillo, I. Román, L.M. Roa — 2012-03-22

Highlights: ► Promotion of a citizen-centred paradigm based on standards and a reference architecture. ► Person-Oriented Virtual Organization scenario joining resources related to a citizen. ► Usability as asset to promote the active role of subject of care. ► Subject of care empowered to friendly administration of his/her health resources.Abstract: Background: Advancements in information and communication technologies have allowed the development of new approaches to the management and use of healthcare resources. Nowadays it is possible to address complex issues such as meaningful access to distributed data or communication and understanding among heterogeneous systems. As a consequence, the discussion focuses on the administration of the whole set of resources providing knowledge about a single subject of care (SoC). New trends make the SoC administrator and responsible for all these elements (related to his/her demographic data, health, well-being, social conditions, etc.) and s/he is granted the ability of controlling access to them by third parties. The subject of care exchanges his/her passive role without any decision capacity for an active one allowing to control who accesses what.Purpose: We study the necessary access control infrastructure to support this approach and develop mechanisms based on semantic tools to assist the subject of care with the specification of access control policies. This infrastructure is a building block of a wider scenario, the Person-Oriented Virtual Organization (POVO), aiming at integrating all the resources related to each citizen's health-related data. The POVO covers the wide range and heterogeneity of available healthcare resources (e.g., information sources, monitoring devices, or software simulation tools) and grants each SoC the access control to them.Methods: Several methodological issues are crucial for the design of the targeted infrastructure. The distributed system concept and focus are reviewed from the service oriented architecture (SOA) perspective. The main frameworks for the formalization of distributed system architectures (Reference Model-Open Distributed Processing, RM-ODP; and Model Driven Architecture, MDA) are introduced, as well as how the use of the Unified Modelling Language (UML) is standardized. The specification of access control policies and decision making mechanisms are essential keys for this approach and they are accomplished by using semantic technologies (i.e., ontologies, rule languages, and inference engines).Results: The results are mainly focused on the security and access control of the proposed scenario. An ontology has been designed and developed for the POVO covering the terminology of the scenario and easing the automation of administration tasks. Over that ontology, an access control mechanism based on rule languages allows specifying access control policies, and an inference engine performs the decision making process automatically. The usability of solutions to ease administration tasks to the SoC is improved by the Me-As-An-Admin (M3A) application. This guides the SoC through the specification of personal access control policies to his/her distributed resources by using semantic technologies (e.g., metamodeling, model-to-text transformations, etc.). All results are developed as services and included in an architecture in accordance with standards and principles of openness and interoperability.Conclusions: Current technology can bring health, social and well-being care actually centered on citizens, and granting each person the management of his/her health information. However, the application of technology without adopting methodologies or normalized guidelines will reduce the interoperability of solutions developed, failing in the development of advanced services and improved scenarios for health delivery. Standards and reference architectures can be cornerstones for future-proof and powerful developments. Finally, not only technology must follow citizen-centric approaches, but also the gaps needing legislative efforts that support these new paradigms of healthcare delivery must be identified and addressed.

Internet use for information seeking in clinical practice: A cross-sectional survey among French general practitioners - Corrected Proof

Erik Bernard, Michel Arnould, Olivier Saint-Lary, Didier Duhot, Gilles Hebbrecht — 2012-03-19

Highlights: ► Internet use has not replaced the “traditional” sources of medical information. ► French GP users were significantly younger and worked in group practice. ► Language barrier and financial non-recognition were obstacles.Abstract: Background: Medical information needs regarding patient care are particularly large for general practitioners (GPs). The Internet seems to be a relevant but underused tool to seek medical information.Objective: We aimed to describe the characteristics of the French GPs using the Internet for information seeking, to identify the barriers to its use and the factors that could facilitate it.Method: We conducted a cross-sectional survey among GPs currently practicing in France, using an online questionnaire, in July 2009. We analysed the answers of 721 respondents.Results: Most of the respondents used the Internet to seek information. They were significantly younger, worked in group practice, had Internet training and had Internet access at the practice. The main barriers were related to the physician (lack of knowledge or specific skills), to the practice conditions (lack of time, concerns about relationship with patient, financial non-recognition) and to the information (information overload, quality concerns, low relevance, language barrier). Practitioners wanted more reliable and more relevant documents for daily practice. Websites with already selected resources could increase the GPs use of the Internet for medical information seeking.Conclusion: The reported obstacles were largely common with those previously described in other countries, except the language barrier and the financial non-recognition. Even if the generalization of our results to all French GPs should be cautious, the study provided better insights into the obstacles to the Internet use to seek clinical information in family practice and the factors that could facilitate it.

Semantic similarity-based alignment between clinical archetypes and SNOMED CT: An application to observations - Corrected Proof

2012-03-16

Highlights: ► About one third of the archetype clinical information is grouped logically. ► Context-based methods can validate bindings resulting from lexical techniques. ► Context-based methods can resolve ambiguous binding conflicts.Abstract: Purpose: One of the main challenges of eHealth is semantic interoperability of health systems. But, this will only be possible if the capture, representation and access of patient data is standardized. Clinical data models, such as OpenEHR Archetypes, define data structures that are agreed by experts to ensure the accuracy of health information. In addition, they provide an option to normalize clinical data by means of binding terms used in the model definition to standard medical vocabularies. Nevertheless, the effort needed to establish the association between archetype terms and standard terminology concepts is considerable. Therefore, the purpose of this study is to provide an automated approach to bind OpenEHR archetypes terms to the external terminology SNOMED CT, with the capability to do it at a semantic level.Methods: This research uses lexical techniques and external terminological tools in combination with context-based techniques, which use information about structural and semantic proximity to identify similarities between terms and so, to find alignments between them. The proposed approach exploits both the structural context of archetypes and the terminology context, in which concepts are logically defined through the relationships (hierarchical and definitional) to other concepts.Results: A set of 25 OBSERVATION archetypes with 477 bound terms was used to test the method. Of these, 342 terms (74.6%) were linked with 96.1% precision, 71.7% recall and 1.23 SNOMED CT concepts on average for each mapping. It has been detected that about one third of the archetype clinical information is grouped logically. Context-based techniques take advantage of this to increase the recall and to validate a 30.4% of the bindings produced by lexical techniques.Conclusions: This research shows that it is possible to automatically map archetype terms to a standard terminology with a high precision and recall, with the help of appropriate contextual and semantic information of both models. Moreover, the semantic-based methods provide a means of validating and disambiguating the resulting bindings. Therefore, this work is a step forward to reduce the human participation in the mapping process.

Determinants of physicians’ technology acceptance for e-health in ambulatory care - Corrected Proof

Sebastian Dünnebeil, Ali Sunyaev, Ivo Blohm, Jan Marco Leimeister, Helmut Krcmar — 2012-03-07

Highlights: ► Validity of the TAM constructs in the environment of German ambulatory healthcare. ► The factors influencing important constructs of e-health in ambulatory environment. ► Significant burdens and drivers for adoption of e-health in ambulatory care.Abstract: Background: Germany is introducing a nation-wide telemedicine infrastructure that enables electronic health services. The project is facing massive resistance from German physicians, which has led to a delay of more than five years. Little is known about the actual burdens and drivers for adoption of e-health innovations by physicians.Objective: Based on a quantitative study of German physicians who participated in the national testbed for telemedicine, this article extends existing technology acceptance models (TAM) for electronic health (e-health) in ambulatory care settings and elaborates on determinants of importance to physicians in their decision to use e-health applications.Methods: This study explores the opinions, attitudes, and knowledge of physicians in ambulatory care to find drivers for technology acceptance in terms of information technology (IT) utilization, process and security orientation, standardization, communication, documentation and general working patterns. We identified variables within the TAM constructs used in e-health research that have the strongest evidence to determine the intention to use e-health applications.Results: The partial least squares (PLS) regression model from data of 117 physicians showed that the perceived importance of standardization and the perceived importance of the current IT utilization (p<0.01) were the most significant drivers for accepting electronic health services (EHS) in their practice. Significant influence (p<0.05) was shown for the perceived importance of information security and process orientation as well as the documentation intensity and the e-health-related knowledge.Conclusions: This study extends work gleaned from technology acceptance studies in healthcare by investigating factors which influence perceived usefulness and perceived ease of use of e-health services. Based on these empirical findings, we derive implications for the design and introduction of e-health services including suggestions for introducing the topic to physicians in ambulatory care and incentive structures for using e-health.

Evaluation of the national nursing model and four nursing documentation systems in Finland – Lessons learned and directions for the future - Corrected Proof

Pirkko Nykänen, Johanna Kaipio, Anne Kuusisto — 2012-03-02

Highlights: ► A triangulation approach in the users’ clinical context was applied in this study. ► The results indicate direct clinical response and they have high descriptive value. ► Documentation model can be made more specific with templates and standard plans. ► One generally acceptable model contributes to standardized nursing practices. ► The design criteria should cover information utilization and exchange aspects.Abstract: Objectives: To evaluate the feasibility of the national nursing model and usability of four widely used nursing documentation systems and to study their usefulness in multi-professional collaboration and information exchange.Methods: Qualitative usability study methods were used, including the use of scenario walkthroughs, contextual inquiries, thematic interviews and inspection-based expert reviews in the users’ clinical contexts.Results: The nursing process model was shown to be feasible in nursing practice but the national nursing classification was considered too detailed, multi-layered and difficult to use and understand. The four evaluated nursing documentation systems had many usability problems which resulted in them being difficult to use and produced extra documentation workload. Generally, electronic nursing documentation improves patients’ and health professionals’ legal protection and makes nursing care more transparent; however, the documentation systems did not provide good support for multi-professional care and information exchange.Conclusions: Nursing models should comply better with nursing practices and support nurses in patient care and interventions. An essential improvement in practice would be the use of specific templates that are easy to apply in specific situations with homogeneous patient groups. Collaborative care aspects and better utilization of information require that the nursing model is designed to support not just documentation but also information utilization.

Organizational framework for health information technology - Corrected Proof

Helga E. Rippen, Eric C. Pan, Cynthia Russell, Colene M. Byrne, Elaine K. Swift — 2012-02-29

Abstract: Purpose: We do not yet know how best to design, implement, and use health information technology (IT). A comprehensive framework that captures knowledge on the implementation, use, and optimization of health IT will help guide more effective approaches in the future.Methods: The authors conducted a targeted review of existing literature on health IT implementation and use, including health IT-related theories and models. By crosswalking elements of current theories and models, the authors identified five major facets of an organizational framework that provides a structure to organize and capture information on the implementation and use of health IT.Results: The authors propose a novel organizational framework for health IT implementation and use with five major facets: technology, use, environment, outcomes, and temporality. Each major facet is described in detail along with associated categories and measures.Conclusion: The proposed framework is an essential first step toward ensuring a more consistent and comprehensive understanding of health IT implementation and use and a more rigorous approach to data collection, measurement development, and theory building.

Towards an understanding of the information dynamics of the handover process in aged care settings—A prerequisite for the safe and effective use of ICT - Corrected Proof

Svend Lyhne, Andrew Georgiou, Anne Marks, Amina Tariq, Johanna I. Westbrook — 2012-02-29

Highlights: ► The provision of care in aged care facilities relies on the exchange of information to ensure continuity, safety and coordination of residential care. ► Process models of handover procedures can help to identify inefficiencies with the transfer of information and help to optimise its accessibility. ► Process models can be used to identify areas where information and communication technologies can be of significant benefit.Abstract: Background: Poor clinical handover has been associated with inaccurate clinical assessment and diagnosis, delays in diagnosis and test ordering, medication errors and decreased patient satisfaction in the acute care setting. Research on the handover process in the residential aged care sector is very limited.Purpose: The aims of this study were to: (i) Develop an in-depth understanding of the handover process in aged care by mapping all the key activities and their information dynamics, (ii) Identify gaps in information exchange in the handover process and analyze implications for resident safety, (iii) Develop practical recommendations on how information communication technology (ICT) can improve the process and resident safety.Methods: The study was undertaken at a large metropolitan facility in NSW with more than 300 residents and a staff including 55 registered nurses (RNs) and 146 assistants in nursing (AINs). A total of 3 focus groups, 12 interviews and 3 observation sessions were conducted over a period from July to October 2010. Process mapping was undertaken by translating the qualitative data via a five-category code book that was developed prior to the analysis.Results: Three major sub-processes were identified and mapped. The three major stages are Handover process (HOP) I “Information gathering by RN”, HOP II “Preparation of preliminary handover sheet” and HOP III “Execution of handover meeting”. Inefficient processes were identified in relation to the handover including duplication of information, utilization of multiple communication modes and information sources, and lack of standardization.Conclusion: By providing a robust process model of handover this study has made two critical contributions to research in aged care: (i) a means to identify important, possibly suboptimal practices; and (ii) valuable evidence to plan and improve ICT implementation in residential aged care. The mapping of this process enabled analysis of gaps in information flow and potential impacts on resident safety. In addition it offers the basis for further studies into a process that, despite its importance for securing resident safety and continuity of care, lacks research.

A Rasch model analysis of technology usage in Minnesota hospitals - Corrected Proof

John R. Olson, James A. Belohlav, Lori S. Cook — 2012-02-24

Highlights: ► Implementation of healthcare information technologies varied by the particular technology. ► A roadmap for implementing technology exists that can aid hospital decision makers ► The degree of healthcare information technology implementation within a hospital was significantly related to patient safety. ► Technological capability of a hospital is a key consideration in determining the level of resources that are necessary to implement specific healthcare technologies within a hospital.Abstract: Purpose: To identify whether the level of difficulty varied among various healthcare technologies. In addition, to examine the whether the degree of healthcare technology adoption was related to patient safety.Methods: The data on healthcare technology usage came from a survey of hospitals in Minnesota. There were responses from individuals within 104 hospitals for an effective response rate of 72.7%. The data on patient safety was taken from the Hospital Compare database. Rasch model analysis and regression analysis were used to analyze the data.Results: Rasch model analysis revealed that the difficulty of implementation of healthcare information technologies varied by the particular technology. That is, some technologies were more difficult than other technologies. Further, it was found that the degree of healthcare information technology implementation within a hospital was significantly related to patient safety.Conclusion: This study identified design and policy implications for hospital decision makers. In particular, it was shown that the technological capability of a hospital is a key consideration in determining the level of resources that are necessary to implement specific healthcare technologies within a hospital.

The many faces of the computer: An analysis of clinical software in the primary care consultation - Corrected Proof

2012-02-10

Highlights: ► Computers are becoming ever present in health in developed nations and are creating a three-way relationship in the consultation. ► Findings describe the way in which screen presentation and specific requirements for recording affect the consultation. ► Summary screens and prompts are active agents in shaping the consultation. ► Patients and doctors will have to adapt their communicative styles in response to these changes.Abstract: Background: Almost all general practitioners in Australia now use a computer for some part of the consultation, and mostly use one of eight clinical software applications. There has been little research into the impact of clinical software on the clinical consultation. Clinical software broadly functions in two ways: it replaces the paper record of the patient's history of health and clinical contacts within the general practice, and it communicates directly to the doctor in various ways about outstanding clinical actions.Aim: This paper draws on Goffman's notion of “face” to explore the way in which the actions, visual presentation, and interactions between general practitioners, patients and the computer can imbue the software with its own “face” in the consultation.Methods: Analysis of 141 consultations by 20 doctors (13 men, 7 women), who used one of four medical software applications commonly used in Australian general practice. Consultations were videotaped, tagged, analysed using a hermeneutic framework.Results: All four software packages replicated constitutive elements of the paper health record, such as medical history, current medications, and the patient's social history, but also introduced other content not present in a paper system. They differed in their use of communicative strategies. This necessitated differing interactions between the software and the doctor. The differences in communicative work of each software package led to their different “faces”, along a gradient from a relatively passive mode that provided context dependent information in an unobtrusive way, to a relatively active mode that interrupted to provide information and to demand responses. We conclude that the more active the mode of presence of the computer in the consultation, the more patients and doctors may have to adapt their communicative styles in response.

Bedside information technology to support patient-centered care - Corrected Proof

2012-01-30

Highlights: ► Requirements for a bedside communication tool were identified. ► Patients’ and nurses’ information requirements are prioritized differently. ► Nurses’ information requirements are focused on patient safety. ► Patients’ information requirements are focused on understanding their care plan.Abstract: Purpose: Patients and health care providers often lack real time access to information at the bedside required to provide safe patient-centered care. Both groups identified pertinent information needed at the patient's bedside. The purpose of our research was to identify the essential data elements that will be used to define requirements for a useful bedside communication tool in the acute care hospital setting.Methods: Descriptive research methods were used to identify bedside information requirements through group and individual interviews. Data from patients and health care providers were analyzed to identify common themes, compiled into a survey, and validated by both groups.Results: Thirty-seven information requirements were identified and classified under five themes: (1) plan of care, (2) patient education, (3) communication of safety alerts, (4) diet, and (5) medications. A survey completed by 30 patients and 30 health care providers confirmed 36 specific bedside information requirements (mean≥5 on an 11-point scale). Patients and health providers each identified 24 specific information requirements that were similar in importance. When compared with nurses, significant differences were noted in the degree to which patients identified knowing the “daily routine schedule,” e.g. when their doctor typically sees patients as a key requirement for the electronic bedside communication tool, t=3.52, p=.001.Conclusion: Patients and health care providers identified information requirements at the bedside to promote self-care management of healthcare needs and an understanding of the hospital environment. Accurate, easily accessed information at the bedside is needed for providing safe patient-centered care.

Caring for individual patients and beyond: Enhancing care through secondary use of data in a general practice setting - Corrected Proof

Marianne Tolar, Ellen Balka — 2012-01-30

Highlights: ► The case reports on the successful implementation of secondary usage of EMR data. ► A continuous process of cultivating EMR data has to be in place. ► To ensure accessibility for secondary purposes a shared coding system is needed. ► Initiatives have to be integrated into daily work practices to enhance sustainability.Abstract: It is argued that with the introduction of electronic medical record (EMR) systems into the primary care sector, data collected can be used for secondary purposes which extend beyond individual patient care (e.g., for chronic disease management, prevention and clinical performance evaluation). However, EMR systems are primarily designed to support clinical tasks, and data entry practices of clinicians focus on the treatment of individual patients. Hence data collected through EMRs is not always useful in meeting these ends.Purpose: In this paper we follow a community health centre (CHC), and document the changes in work practices of the personnel that were necessary in order to make EMR data useful for secondary purposes.Methods: This project followed an action research approach, in which ethnographic data were collected mainly by participant observations, by a researcher who also acted as an IT support person for the clinic's secondary usage of EMR data. Additionally, interviews were carried out with the clinical and administrative personnel of the CHC.Results: The case study demonstrates that meaningful use of secondary data occurs only after a long process, aimed at creating the pre-conditions for meaningful use of secondary data, has taken place.Preconditions: Specific areas of focus have to be chosen for secondary data use, and initiatives have to be continuously evaluated and adapted to the workflow through a team approach. Collaboration between IT support and physicians is necessary to tailor the software to allow for the collection of clinically relevant data. Data entry procedures may have to be changed to encourage the usage of an agreed-upon coding scheme, required for meaningful use of secondary data. And finally resources in terms of additional personnel or dedicated time are necessary to keep up with data collection and other tasks required as a pre-condition to secondary use of data, communication of the results to the clinic, and eventual re-evaluation.Consequences: Changes in the work practices observed in this case which were required to support secondary data use from the EMR included completion of additional tasks by clinical and administrative personnel related to the organization of follow-up tasks. Among physicians increased awareness of specific initiatives and guideline compliance in terms of chronic disease management and prevention was noticed. Finally, the clinic was able to evaluate their own practice and present the results to varied stakeholders.Conclusions: The case describes the secondary usage of data by a clinic aimed at improving management of the clinic's patients. It illustrates that creating the pre-conditions for secondary use of data from EMRs is a complex process which can be seen as a shift in paradigms from a focus on individual patient care to chronic disease management and performance measurement. More research is needed about how to best support clinics in the process of change management necessitated by emerging clinical management goals.

Characterizing “information transfer” by using a Joint Cognitive Systems model to improve continuity of care in the aged - Corrected Proof

Iona Thraen, Byron Bair, Shantel Mullin, Charlene R. Weir — 2012-01-09

Abstract: Purpose: This study explores multidisciplinary and cross-sector health professional experiences with the information needs for safe patient transfers across the care continuum using a Joint Cognitive Systems (JCS) model. Qualitative experiences of three JCS components and their attributes and are presented.Methods: A qualitative content analysis using Joint Cognitive Systems constructs were extracted from sixteen multidisciplinary and cross-sector health professional interviews. Participants were asked to describe their information needs and experiences with the patient transfer process.Results: Information transfer associated with three JCS constructs (alignment of goals, enhanced control, and co-agency dynamics) was examined. The breakdown in the information transfer process might be due to the relative strengths of each sector's core expertise. Alignment must cross settings and disciplines and consist of the: (1) transfer of goal relevant and integrated information; (2) accommodation to the control attributes of increased clinical complexity, lack of systematic work processes and feedback or feed forward information; and (3) improvement in the co-agency dynamics of interdependency, trust, inter-related actions and expertise.Conclusions: Economic pressures and care complexities of the aged require improved effectiveness and efficiencies in the information transfer process. This study aims to understand the information transfer needs from hospitals to skilled nursing care laying a foundation towards a medical informatics solution. An informatics solution must accommodate the differing contextual environments and subsequent information needs and paradigms of the Joint Cognitive System of care across the continuum.

Development and evaluation of data entry templates based on the entity-attribute-value model for clinical decision support of pressure ulcer wound management - Corrected Proof

Hyun-Young Kim, Hyeoun-Ae Park — 2011-11-14

Highlights: ► We identified 13 data entities for pressure ulcer wound management. ► Thirteen entity-attribute-value models were created to represent these entities. ► Six structured data entry templates and the relational database based on these models were developed and integrated with the CDSS to provide patient-specific recommendations. ► Five nurses successfully entered all data and retrieved expected recommendations in six scenarios except one. ► We conclude that the data models and structured data entry templates were useful in supporting decision making.Abstract: Purposes: The purpose of this study was to develop and evaluate the functionality of structured data entry templates using the entity-attribute-value (EAV) model for clinical decision support of pressure ulcer wound management.Methods: A data set for wound assessment of pressure ulcers that has commonly been recommended by clinical practice guidelines was identified, and then the EAV models on each data were developed. Structured data entry templates and a database were developed based on these EAV models. These were integrated with a knowledge engine into the clinical decision support system (CDSS) to provide patient-specific recommendations on pressure ulcer wound management. The functionality of the EAV model and structured data entry templates for the CDSS was evaluated heuristically by five nurse experts using clinical scenarios.Results: The data set containing 13 entities was identified and EAV models of these entities were created. Cardinalities and data types of attributes were defined to represent the models in more detail. Terms used in the EAV models were mapped to SNOMED CT concepts. Six data entry templates and the relational database with ten tables were developed. Five nurses successfully entered all data in the scenarios except one data element and retrieved expected recommendations successfully from the clinical decision support system when all data were entered correctly.Conclusions: The clinical data models and structured data entry templates developed in this study were useful in supporting clinical decision making on pressure ulcer wound management.

Supporting medical communication for older patients with a shared touch-screen computer - Corrected Proof

Anne Marie Piper, James D. Hollan — 2011-04-15

Highlights: ► We examine the usability and appeal of a multiuser touch-screen for presenting electronic medical information to older patients. ► We found that older adults quickly adapted to the system and found it easy to use. ► Older adults suggested that having a shared view of their medical information on a shared touch-screen computer system would enhance communication.Abstract: Objective: Increasingly health care facilities are adopting electronic medical record systems and installing computer workstations in patient exam rooms. The introduction of computer workstations into the medical interview process makes it important to consider the impact of such technology on older patients as well as new types of interfaces that may better suit the needs of older adults. While many older adults are comfortable with a traditional computer workstation with a keyboard and mouse, this article explores how a large horizontal touch-screen (i.e., a surface computer) may suit the needs of older patients and facilitates the doctor–patient interview process.Method: Twenty older adults (age 60 to 88) used a prototype multiuser, multitouch system in our research laboratory to examine seven health care scenarios. Behavioral observations as well as results from questionnaires and a structured interview were analyzed.Results: The older adults quickly adapted to the prototype system and reported that it was easy to use. Participants also suggested that having a shared view of one's medical records, especially charts and images, would enhance communication with their doctor and aid understanding.Conclusion: While this study is exploratory and some areas of interaction with a surface computer need to be refined, the technology is promising for sharing electronic patient information during medical interviews involving older adults. Future work must examine doctors’ and nurses’ interaction with the technology as well as logistical issues of installing such a system in a real world medical setting.

Older adults: Are they ready to adopt health-related ICT? - Corrected Proof

Tsipi Heart, Efrat Kalderon — 2011-04-13

Abstract: Background: : The proportion of older adults in the population is steadily increasing, causing healthcare costs to rise dramatically. This situation calls for the implementation of health-related information and communication technologies (ICT) to assist in providing more cost-effective healthcare to the elderly. In order for such a measure to succeed, older adults must be prepared to adopt these technologies. Prior research shows, however, that this population lags behind in ICT adoption, although some believe that this is a temporary phenomenon that will soon change.Objectives: : To assess use by older adults of technology in general and ICT in particular, in order to evaluate their readiness to adopt health-related ICT.Method: : We employed the questionnaire used by Selwyn et al. in 2000 in the UK, as well as a survey instrument used by Morris and Venkatesh, to examine the validity of the theory of planned behavior (TPB) in the context of computer use by older employees. 123 respondents answered the questions via face-to-face interviews, 63 from the US and 60 from Israel. SPSS 17.0 was used for the data analysis.Results: : The results show that although there has been some increase in adoption of modern technologies, including ICT, most of the barriers found by Selwyn et al. are still valid. ICT use was determined by accessibility of computers and support and by age, marital status, education, and health. Health, however, was found to moderate the effect of age, healthier older people being far more likely to use computers than their unhealthy coevals. The TPB was only partially supported, since only perceived behavioral control (PBC) emerged as significantly affecting intention to use a computer, while age, contrary to the findings of Morris and Venkatesh, interacted differently for Americans and Israelis. The main reason for non-use was ‘no interest’ or ‘no need’, similar to findings from data collected in 2000.Conclusions: : Adoption of technology by older adults is still limited, though it has increased as compared with results of the previous study. Modern technologies have been adopted (albeit selectively) by older users, who were presumably strongly motivated by perceived usefulness. Particularly worrying are the effects of health, PBC, and the fact that many older adults do not share the perception that ICT can significantly improve their quality of life. We therefore maintain that older adults are not yet ready to adopt health-related ICT. Health-related ICT for the elderly should be kept simple and demonstrate substantial benefits, and special attention should be paid to training and support and to specific personal and cultural characteristics. These are mandatory conditions for adoption by potential unhealthy and older consumers.

Innovations in health care services: The CAALYX system - Corrected Proof

2011-04-11

Abstract: Purpose: This paper describes proposed health care services innovations, provided by a system called CAALYX (Complete Ambient Assisted Living eXperiment). CAALYX aimed to provide healthcare innovation by extending the state-of-the-art in tele-healthcare, by focusing on increasing the confidence of elderly people living autonomously, by building on the knowledge base of the most common disorders and respective characteristic vital sign changes for this age group.Methods: A review of the state-of-the-art on health care services was carried out. Then, extensive research was conducted on the particular needs of the elderly in relation to home health services that, if offered to them, could improve their day life by giving them greater confidence and autonomy. To achieve this, we addressed issues associated with the gathering of clinical data and interpretation of these data, as well as possibilities of automatically triggering appropriate clinical measures. Considering this initial work we started the identification of initiatives, ongoing works and technologies that could be used for the development of the system. After that, the implementation of CAALYX was done.Findings: The innovation in CAALYX system considers three main areas of contribution: (i) The Roaming Monitoring System that is used to collect information on the well-being of the elderly users; (ii) The Home Monitoring System that is aimed at helping the elders independently living at home being implemented by a device (a personal computer or a set top box) that supports the connection of sensors and video cameras that may be used for monitoring and for interaction with the elder; (iii) The Central Care Service and Monitoring System that is implemented by a Caretaker System where attention and care services are provided to elders, where actors as Caretakers, Doctors and Relatives are logically linked to elders. Innovations in each of these areas are presented here.Conclusions: The ageing European society is placing an added burden on future generations, as the ‘elderly-to-working-age-people’ ratio is set to steadily increase in the future. Nowadays, quality of life and fitness allows for most older persons to have an active life well into their eighties. Furthermore, many older persons prefer to live in their own house and choose their own lifestyle. The CAALYX system can have a clear impact in increasing older persons’ autonomy, by ensuring that they do not need to leave their preferred environment in order to be properly monitored and taken care of.

Using informatics to capture older adults’ wellness - Corrected Proof

2011-04-11

Abstract: Purpose: The aim of this paper is to demonstrate how informatics applications can support the assessment and visualization of older adults’ wellness. A theoretical framework is presented that informs the design of a technology enhanced screening platform for wellness. We highlight an ongoing pilot demonstration in an assisted living facility where a community room has been converted into a living laboratory for the use of diverse technologies (including a telehealth component to capture vital signs and customized questionnaires, a gait analysis component and cognitive assessment software) to assess the multiple aspects of wellness of older adults.Methods: A demonstration project was introduced in an independent retirement community to validate our theoretical framework of informatics and wellness assessment for older adults. Subjects are being recruited to attend a community room and engage in the use of diverse technologies to assess cognitive performance, physiological and gait variables as well as psychometrics pertaining to social and spiritual components of wellness for a period of eight weeks. Data are integrated from various sources into one study database and different visualization approaches are pursued to efficiently display potential correlations between different parameters and capture overall trends of wellness.Results: Preliminary findings indicate that older adults are willing to participate in technology-enhanced interventions and embrace different information technology applications given appropriate and customized training and hardware and software features that address potential functional limitations and inexperience with computers.Conclusion: Informatics can advance health care for older adults and support a holistic assessment of older adults’ wellness. The described framework can support decision making, link formal and informal caregiving networks and identify early trends and patterns that if addressed could reduce adverse health events.

User profiles and personas in the design and development of consumer health technologies - Corrected Proof

Cynthia LeRouge, Jiao Ma, Sweta Sneha, Kristin Tolle — 2011-04-11

Abstract: Background: “The graying of the globe” has resulted in exponential rise in health care expenses, over-worked health care professionals and a growing patient base suffering from multiple chronic diseases, one of which is diabetes. Consumer health technologies (CHT) are considered important catalysts for empowering health care consumers to take a proactive role in managing their health and related costs. Adoption rate and usability of such devices among the aging is far from being satisfactory. Past studies noted the motivation for adoption by the aging is dependent on the suitability/relevance, perceived usability and anticipated benefits associated with usage of technological innovation. Traditional information technology (IT) development adopts a systematic approach without necessarily using a specific user model that personalizes the system to the aging user groups. The aging patient population has unique needs arising from progressive deterioration in both physiological and psychological abilities. These needs are often ignored in the design, development, trial and adoption of consumer health products resulting in low adoption and usage.Objectives: The main objective of this research is to investigate the user-centered design (UCD), specifically user profiles and personas, as methodological tools to inform the design and development of CHT devices for an aging population. The adoption of user profile and persona has not received much attention in health care informatics research and, in particular, research involving CHT. Our work begins to fill this void in three ways. We (1) illuminate the process of developing CHT user profiles and personas for a Chinese elder population with a demanding health care needs, i.e., self-management of chronic diabetes, with the hope that the resulting profiles and personas may be used as foundational material for informing the design, development and evaluation of CHT in other similar contexts; (2) call attention to how to further enhance and complement traditional user profile and persona techniques for CHT design by integrating cognitive structures and present behavior that drive health care thinking, future behavior and demand; (3) show how the profiles and personas can be used to inform requirements, design and implementation decisions for a technology aimed at facilitating CHT adoption and diffusion for the elderly.Methodology: To exemplify process and application, we use an action-research methodology, where user profiles and personas of an aging patient population were developed. The resultant profiles and personas were leveraged to improve the design, development and implementation plans of a smart phone application to assist chronically ill aging Chinese diabetic population capable of disease self-management.Results: The results from the study show that user profile and persona can be a valuable methodological approach in capturing the conceptual model of the aging and informing the design and development decisions of CHT. The demonstration of techniques used in this study can serve as a guideline to CHT developers in bringing conceptual user modeling into the design of software interfaces targeted for users with specific health care needs. Specifically, the study provides guidance on the creation and use of profiles and personas to tap into the conceptual models of the targeted elderly population reflecting their preferences, capabilities and attitudes towards using technology in self-management care in general and the smart phone diabetes management application in particular. Insight into the mental model of the aging group has been shown to inform later stages of UCD development (e.g., the creation of prototypes and usability testing) as well as implementation and adoption strategies. The World Health Organization (WHO) predicts that by 2025, 80% of all new cases of diabetes are expected to appear in the developing countries. In fact, the number of diabetic patients in China is estimated to rise to 42.3 million in 2030 from 20.8 million in 2000. Thus, we investigate the Chinese aging population in order to demonstrate the process of developing and using user profile and persona. We hope that the resultant conceptual model of the Chinese aging diabetic population can be used in future research to guide CHT designers interested in designing health care devices for this vulnerable user group.

Development and evaluation of SOA-based AAL services in real-life environments: A case study and lessons learned - Corrected Proof

Erlend Stav, Ståle Walderhaug, Marius Mikalsen, Sten Hanke, Ivan Benc — 2011-04-11

Abstract: Intro: The proper use of ICT services can support seniors in living independently longer. While such services are starting to emerge, current proprietary solutions are often expensive, covering only isolated parts of seniors’ needs, and lack support for sharing information between services and between users. For developers, the challenge is that it is complex and time consuming to develop high quality, interoperable services, and new techniques are needed to simplify the development and reduce the development costs.This paper provides the complete view of the experiences gained in the MPOWER project with respect to using model-driven development (MDD) techniques for Service Oriented Architecture (SOA) system development in the Ambient Assisted Living (AAL) domain.Method: To address this challenge, the approach of the European research project MPOWER (2006–2009) was to investigate and record the user needs, define a set of reusable software services based on these needs, and then implement pilot systems using these services. Further, a model-driven toolchain covering key development phases was developed to support software developers through this process. Evaluations were conducted both on the technical artefacts (methodology and tools), and on end user experience from using the pilot systems in trial sites.Results: The outcome of the work on the user needs is a knowledge base recorded as a Unified Modeling Language (UML) model. This comprehensive model describes actors, use cases, and features derived from these. The model further includes the design of a set of software services, including full trace information back to the features and use cases motivating their design. Based on the model, the services were implemented for use in Service Oriented Architecture (SOA) systems, and are publicly available as open source software. The services were successfully used in the realization of two pilot applications. There is therefore a direct and traceable link from the user needs of the elderly, through the service design knowledge base, to the service and pilot implementations.The evaluation of the SOA approach on the developers in the project revealed that SOA is useful with respect to job performance and quality. Furthermore, they think SOA is easy to use and support development of AAL applications. An important finding is that the developers clearly report that they intend to use SOA in the future, but not for all type of projects. With respect to using model-driven development in web services design and implementation, the developers reported that it was useful. However, it is important that the code generated from the models is correct if the full potential of MDD should be achieved.The pilots and their evaluation in the trial sites showed that the services of the platform are sufficient to create suitable systems for end users in the domain.Conclusions: A SOA platform with a set of reusable domain services is a suitable foundation for more rapid development and tailoring of assisted living systems covering reoccurring needs among elderly users. It is feasible to realize a tool-chain for model-driven development of SOA applications in the AAL domain, and such a tool-chain can be accepted and found useful by software developers.

Designing and evaluating an electronic patient falls reporting system: Perspectives for the implementation of health information technology in long-term residential care facilities - Corrected Proof

Yi You Mei, Jenna Marquard, Cynthia Jacelon, Audrey L. DeFeo — 2011-04-11

Abstract: Background and purpose: Patient falls are the leading cause of unintentional injury and death among older adults. In 2000, falls resulted in over 10,300 elderly deaths, costing the United States approximately $179 million in incidence and medical costs. Furthermore, non-fatal injuries caused by falls cost the United States $19 billion annually. Health information technology (IT) applications, specifically electronic falls reporting systems, can aid quality improvement efforts to prevent patient falls. Yet, long-term residential care facilities (LTRCFs) often do not have the financial resources to implement health IT, and workers in these settings are often not ready to adopt such systems. Additionally, most health IT evaluations are conducted in large acute-care settings, so LTRCF administrators currently lack evidence to support the value of health IT.Methods: In this paper, we detail the development of a novel, easy-to-use system to facilitate electronic patient falls reporting within a LTRCF using off-the-shelf technology that can be inexpensively implemented in a wide variety of settings. We report the results of four complimentary system evaluation measures that take into consideration varied organizational stakeholders’ perspectives: (1) System-level benefits and costs, (2) system usability, via scenario-based use cases, (3) a holistic assessment of users’ physical, cognitive, and marcoergonomic (work system) challenges in using the system, and (4) user technology acceptance. We report the viability of collecting and analyzing data specific to each evaluation measure and detail the relative merits of each measure in judging whether the system is acceptable to each stakeholder.Results and conclusions: The electronic falls reporting system was successfully implemented, with 100% reporting at 3-months post-implementation. The system-level benefits and costs approach showed that the electronic system required no initial investment costs aside from personnel costs and significant benefits accrued from user time savings. The usability analysis revealed several fixable design flaws and demonstrated the importance of scenario-based user training. The technology acceptance model showed that users perceived the reporting system to be useful and easy to use, even more so after implementation. Finally, the holistic human factors evaluation identified challenges encountered when nurses used the system as a part of their daily work, guiding further system redesign. The four-pronged evaluation framework accounted for varied stakeholder perspectives and goals and is a highly scalable framework that can be easily applied to health IT implementations in other LTRCFs.