[Optimizing radiological diagnostic management via mobile devices in trauma surgery]. / Anforderung von radiologischer Diagnostik in der Unfallchirurgie mittels mobiler Endgeräte.

BACKGROUND: Time is a scarce resource for physicians. One medical task is the request for radiological diagnostics. This process is characterized by high administrative complexity and sometimes considerable time consumption. Measures that lead to an administrative relief in favor of patient care have so far been lacking. AIM OF THE STUDY: Process optimization of the request for radiological diagnostics. As a proof of concept the request for radiological diagnostics was conducted using a mobile, smartphone and tablet-based application with dedicated voice recognition software in the Department of Trauma Surgery at the University Hospital of Würzburg (UKW). MATERIAL AND METHODS: In a prospective study, time differences and efficiency of the mobile app-based method (ukw.mobile based Application = UMBA) compared to the PC-based method (PC-based application = PCBA) for requesting radiological services were analyzed. The time from the indications to the completed request and the time required to create the request on the device were documented and assessed. Due to the non-normal distribution of the data, a Mann-Whitney U test was performed. RESULTS: The time from the indications to the completed request was significantly (p < 0.05) reduced using UMBA compared to PCBA (PCBA: mean ± standard difference [SD] 19.57 ± 33.24 min, median 3.00 min, interquartile range [IQR] 1.00-30.00 min vs. UMBA: 9.33 ± 13.94 min, median 1.00 min, IQR 0.00-20.00 min). The time to complete the request on the device was also significantly reduced using UMBA (PCBA: mean ± SD 63.77 ± 37.98 s, median 51.96 s, IQR 41.68-68.93 s vs. UMBA: 25.21 ± 11.18 s, median 20.00 s, IQR 17.27-29.00 s). CONCLUSION: The mobile, voice-assisted request process leads to a considerable time reduction in daily clinical routine and illustrates the potential of user-oriented, targeted digitalization in healthcare. In future, the process will be supported by artificial intelligence.

Usability of a mHealth Solution using Speech Recognition for Point-of-care Diagnostic Management.

The administrative burden for physicians in the hospital can affect the quality of patient care. The Service Center Medical Informatics (SMI) of the University Hospital Würzburg developed and implemented the smartphone-based mobile application (MA) ukw.mobile1 that uses speech recognition for the point-of-care ordering of radiological examinations. The aim of this study was to examine the usability of the MA workflow for the point-of-care ordering of radiological examinations. All physicians at the Department of Trauma and Plastic Surgery at the University Hospital Würzburg, Germany, were asked to participate in a survey including the short version of the User Experience Questionnaire (UEQ-S) and the Unified Theory of Acceptance and Use of Technology (UTAUT). For the analysis of the different domains of user experience (overall attractiveness, pragmatic quality and hedonic quality), we used a two-sided dependent sample t-test. For the determinants of the acceptance model, we employed regression analysis. Twenty-one of 30 physicians (mean age 34 ± 8 years, 62% male) completed the questionnaire. Compared to the conventional desktop application (DA) workflow, the new MA workflow showed superior overall attractiveness (mean difference 2.15 ± 1.33), pragmatic quality (mean difference 1.90 ± 1.16), and hedonic quality (mean difference 2.41 ± 1.62; all p < .001). The user acceptance measured by the UTAUT (mean 4.49 ± 0.41; min. 1, max. 5) was also high. Performance expectancy (beta = 0.57, p = .02) and effort expectancy (beta = 0.36, p = .04) were identified as predictors of acceptance, the full predictive model explained 65.4% of its variance. Point-of-care mHealth solutions using innovative technology such as speech-recognition seem to address the users' needs and to offer higher usability in comparison to conventional technology. Implementation of user-centered mHealth innovations might therefore help to facilitate physicians' daily work.

Point-of-Care Speech-Recognition Based mHealth Solution to Facilitate Physicians' Daily Work.

We developed and implemented a smartphone-based mobile application that uses speech recognition for the point-of-care ordering of radiological examinations. 21 out of 30 physicians completed a usability questionnaire including the Short version of the User Experience Questionnaire (UEQ-S) and the Unified Theory of Acceptance and Use of Technology (UTAUT). The mobile application showed high user acceptance and superior user experience when compared to the conventional workflow. Due to the high usability of our mHealth solution, it might help to facilitate the physician's daily work.

Structured, Harmonized, and Interoperable Integration of Clinical Routine Data to Compute Heart Failure Risk Scores.

Risk prediction in patients with heart failure (HF) is essential to improve the tailoring of preventive, diagnostic, and therapeutic strategies for the individual patient, and effectively use health care resources. Risk scores derived from controlled clinical studies can be used to calculate the risk of mortality and HF hospitalizations. However, these scores are poorly implemented into routine care, predominantly because their calculation requires considerable efforts in practice and necessary data often are not available in an interoperable format. In this work, we demonstrate the feasibility of a multi-site solution to derive and calculate two exemplary HF scores from clinical routine data (MAGGIC score with six continuous and eight categorical variables; Barcelona Bio-HF score with five continuous and six categorical variables). Within HiGHmed, a German Medical Informatics Initiative consortium, we implemented an interoperable solution, collecting a harmonized HF-phenotypic core data set (CDS) within the openEHR framework. Our approach minimizes the need for manual data entry by automatically retrieving data from primary systems. We show, across five participating medical centers, that the implemented structures to execute dedicated data queries, followed by harmonized data processing and score calculation, work well in practice. In summary, we demonstrated the feasibility of clinical routine data usage across multiple partner sites to compute HF risk scores. This solution can be extended to a large spectrum of applications in clinical care.

Automated provision of clinical routine data for a complex clinical follow-up study: A data warehouse solution.

A deep integration of routine care and research remains challenging in many respects. We aimed to show the feasibility of an automated transformation and transfer process feeding deeply structured data with a high level of granularity collected for a clinical prospective cohort study from our hospital information system to the study's electronic data capture system, while accounting for study-specific data and visits. We developed a system integrating all necessary software and organizational processes then used in the study. The process and key system components are described together with descriptive statistics to show its feasibility in general and to identify individual challenges in particular. Data of 2051 patients enrolled between 2014 and 2020 was transferred. We were able to automate the transfer of approximately 11 million individual data values, representing 95% of all entered study data. These were recorded in n = 314 variables (28% of all variables), with some variables being used multiple times for follow-up visits. Our validation approach allowed for constant good data quality over the course of the study. In conclusion, the automated transfer of multi-dimensional routine medical data from HIS to study databases using specific study data and visit structures is complex, yet viable.

[Smartphone-based photographic wound documentation improves the quality of medical accounting in orthopedic and plastic surgery]. / Qualitätssteigerung der Abrechnungsprüfung durch Smartphone-basierte Fotodokumentation in der Unfall­, Hand- und plastischen Chirurgie.

BACKGROUND: Photographic documentation of wounds, decubitus ulcers, tumors, open fractures and infections is an important part of digital patient files. It is unclear whether the photographic documentation has an effect on medical accounting with health insurance companies. OBJECTIVE: It was hypothesized that Smartphone-based systematic photographic documentation can improve the confirmation of proceeds-relevant diagnoses and procedures as well as the duration. MATERIAL AND METHODS: Staff in the emergency room, operating theater, outpatient clinic and on the wards were equipped with digital devices (Smartphone, tablet) including a photo-app. Medical accounting with the health insurance companies and identification of all case conferences in which the photographic documentation had effected a change in proceeds were analyzed for 2019 in a retrospective manner. RESULTS: Overall, 372 cases were discussed of which 27 cases were affected by the digital photographic documentation. Photographic documentation was used for clarification of the operative procedure (n = 5), primary diagnosis (n = 10), secondary diagnosis (n = 3), and length of hospitalization (n = 9). An average of 2119 € was negotiated and added per case affected by photographic documentation. Hereby, a level 1 trauma center gained an estimated 65,328 € in revenue. DISCUSSION: The use of Smartphone based photographic documentation can improve the overall quality of patient files and thus avoid loss of revenue. The implementation of digital devices with corresponding software is an important component of the digital structural change in hospitals.

Unlocking the PACS DICOM Domain for its Use in Clinical Research Data Warehouses.

Clinical Data Warehouses (DWHs) are used to provide researchers with simplified access to pseudonymized and homogenized clinical routine data from multiple primary systems. Experience with the integration of imaging and metadata from picture archiving and communication systems (PACS), however, is rare. Our goal was therefore to analyze the viability of integrating a production PACS with a research DWH to enable DWH queries combining clinical and medical imaging metadata and to enable the DWH to display and download images ad hoc. We developed an application interface that enables to query the production PACS of a large hospital from a clinical research DWH containing pseudonymized data. We evaluated the performance of bulk extracting metadata from the PACS to the DWH and the performance of retrieving images ad hoc from the PACS for display and download within the DWH. We integrated the system into the query interface of our DWH and used it successfully in four use cases. The bulk extraction of imaging metadata required a median (quartiles) time of 0.09 (0.03-2.25) to 12.52 (4.11-37.30) seconds for a median (quartiles) number of 10 (3-29) to 103 (8-693) images per patient, depending on the extraction approach. The ad hoc image retrieval from the PACS required a median (quartiles) of 2.57 (2.57-2.79) seconds per image for the download, but 5.55 (4.91-6.06) seconds to display the first and 40.77 (38.60-41.63) seconds to display all images using the pure web-based viewer. A full integration of a production PACS with a research DWH is viable and enables various use cases in research. While the extraction of basic metadata from all images can be done with reasonable effort, the extraction of all metadata seems to be more appropriate for subgroups.

Implementation of a HL7-CQL Engine Using the Graph Database Neo4J.

The Clinical Quality Language (CQL) is a useful tool for defining search requests for data stores containing FHIR data. Unfortunately, there are only few execution engines that are able to evaluate CQL queries. As FHIR data represents a graph structure, the authors pursue the approach of storing all data contained in a FHIR server in the graph database Neo4J and to translate CQL queries into Neo4J's query language Cypher. The query results returned by the graph database are retranslated into their FHIR representation and returned to the querying user. The approach has been positively tested on publicly available FHIR servers with a handcrafted set of example CQL queries.

Query Translation Between AQL and CQL.

Secondary use of electronic health records using data aggregation systems (DAS) with standardized access interfaces (e.g. openEHR, i2b2, FHIR) have become an attractive approach to support clinical research. In order to increase the volume of underlying patient data, multiple DASs at different institutions can be connected to research networks. Two obstacles to connect a DAS to such a network are the syntactical differences between the involved DAS query interfaces and differences in the data models the DASs operate on. The current work presents an approach to tackle both problems by translating queries from a DAS using openEHR's query language AQL (Archetype Query Language) into queries using the query language CQL (Clinical Quality Language) and vice versa. For the subset of queries which are expressible in both query languages the presented approach is well feasible.

Query Translation Between openEHR and i2b2.

Secondary use of electronic health records using data warehouses (DW) has become an attractive approach to support clinical research. In order to increase the volume of underlying patient data DWs at different institutions can be connected to research networks. Two obstacles to connect a DW to such a network are the syntactical differences between the involved DW technologies and differences in the data models of the connected DWs. The current work presents an approach to tackle both problems by translating queries from the DW system openEHR into queries from the DW system i2b2 and vice versa. For the subset of queries expressible in the query languages of both systems, the presented approach is well feasible.

Replicating medication trend studies using ad hoc information extraction in a clinical data warehouse.

BACKGROUND: Medication trend studies show the changes of medication over the years and may be replicated using a clinical Data Warehouse (CDW). Even nowadays, a lot of the patient information, like medication data, in the EHR is stored in the format of free text. As the conventional approach of information extraction (IE) demands a high developmental effort, we used ad hoc IE instead. This technique queries information and extracts it on the fly from texts contained in the CDW. METHODS: We present a generalizable approach of ad hoc IE for pharmacotherapy (medications and their daily dosage) presented in hospital discharge letters. We added import and query features to the CDW system, like error tolerant queries to deal with misspellings and proximity search for the extraction of the daily dosage. During the data integration process in the CDW, negated, historical and non-patient context data are filtered. For the replication studies, we used a drug list grouped by ATC (Anatomical Therapeutic Chemical Classification System) codes as input for queries to the CDW. RESULTS: We achieve an F1 score of 0.983 (precision 0.997, recall 0.970) for extracting medication from discharge letters and an F1 score of 0.974 (precision 0.977, recall 0.972) for extracting the dosage. We replicated three published medical trend studies for hypertension, atrial fibrillation and chronic kidney disease. Overall, 93% of the main findings could be replicated, 68% of sub-findings, and 75% of all findings. One study could be completely replicated with all main and sub-findings. CONCLUSION: A novel approach for ad hoc IE is presented. It is very suitable for basic medical texts like discharge letters and finding reports. Ad hoc IE is by definition more limited than conventional IE and does not claim to replace it, but it substantially exceeds the search capabilities of many CDWs and it is convenient to conduct replication studies fast and with high quality.

Information Extraction from Echocardiography Reports for a Clinical Follow-up Study-Comparison of Extracted Variables Intended for General Use in a Data Warehouse with Those Intended Specifically for the Study.

BACKGROUND: The interest in information extraction from clinical reports for secondary data use is increasing. But experience with the productive use of information extraction processes over time is scarce. A clinical data warehouse has been in use at our university hospital for several years, which also provides an information extraction of echocardiography reports developed for general use. OBJECTIVES: This study aims to illustrate the difficulties encountered, while using data from a preexisting information extraction process for a large clinical study. To compare the data from the preexisting process with the data obtained from a specially developed process designed to improve the quality and completeness of the study data. METHODS: We extracted the echocardiography variables for 440 patients from the general-use information extraction of the data warehouse (678 reports). Then we developed an information extraction process for the same variables but specifically for this study, with the aim to extract as much information as possible from the text. The extracted data of both processes were compared with a newly created gold standard defined by a cardiologist with long-standing experience in heart failure. RESULTS: Among 57 echocardiography variables considered relevant for the study, 50 were documented in the routine text reports and could be extracted. Twenty of the required variables were not provided by the general-use extraction process, some others were not provided correctly. The median macro F1-score (precision, recall) across the 30 variables for which values were extracted was 0.81 (0.94, 0.77). Across all 50 variables, as relevant for the study, median macro F1-score was only 0.49 (0.56, 0.46). Employing the study-specific approach considerably improved the quality and completeness of the variables, resulting in F1-scores of 0.97 (0.98, 0.96) across all variables. CONCLUSION: Data from information extractions can be used for large clinical studies. However, preexisting information extraction processes should be treated with caution, as the time and effort spent defining each variable in the information extraction process may not be clear.

Finding Needles in the Haystack: Identifying Patients with Rare Subtype of Multiple Myeloma Supported by a Data Warehouse and Information Extraction.

Finding patient cases with extremely rare pathologies is a laborious task. To decrease time spent on manually searching through thousands of discharge letters and reports, a data warehouse with a fast fulltext search index was queried. Our use case is to find "macrofocal myeloma", i.e. Multiple Myeloma patients with few large lesions. We guessed the number of those patients in the University Hospital Würzburg at about 20. Most criteria were available in the data warehouse in an unstructured form requiring information extraction. 8 patient cases were found by searching for different spellings of "macrofocal myeloma" in discharge letters directly. With an indirect search combining several criteria, we found additional 23 candidate patient cases, from which 10 were classified by a domain expert as correct. The most difficult criteria were determining the degree of bone marrow infiltration. We achieved an F1 score of 93.2 % for this task. The number of patient cases to be screened manually for this disease decreased from about 25000 to 23.

Ad Hoc Information Extraction for Clinical Data Warehouses.

BACKGROUND: Clinical Data Warehouses (CDW) reuse Electronic health records (EHR) to make their data retrievable for research purposes or patient recruitment for clinical trials. However, much information are hidden in unstructured data like discharge letters. They can be preprocessed and converted to structured data via information extraction (IE), which is unfortunately a laborious task and therefore usually not available for most of the text data in CDW. OBJECTIVES: The goal of our work is to provide an ad hoc IE service that allows users to query text data ad hoc in a manner similar to querying structured data in a CDW. While search engines just return text snippets, our systems also returns frequencies (e.g. how many patients exist with "heart failure" including textual synonyms or how many patients have an LVEF < 45) based on the content of discharge letters or textual reports for special investigations like heart echo. Three subtasks are addressed: (1) To recognize and to exclude negations and their scopes, (2) to extract concepts, i.e. Boolean values and (3) to extract numerical values. METHODS: We implemented an extended version of the NegEx-algorithm for German texts that detects negations and determines their scope. Furthermore, our document oriented CDW PaDaWaN was extended with query functions, e.g. context sensitive queries and regex queries, and an extraction mode for computing the frequencies for Boolean and numerical values. RESULTS: Evaluations in chest X-ray reports and in discharge letters showed high F1-scores for the three subtasks: Detection of negated concepts in chest X-ray reports with an F1-score of 0.99 and in discharge letters with 0.97; of Boolean values in chest X-ray reports about 0.99, and of numerical values in chest X-ray reports and discharge letters also around 0.99 with the exception of the concept age. DISCUSSION: The advantages of an ad hoc IE over a standard IE are the low development effort (just entering the concept with its variants), the promptness of the results and the adaptability by the user to his or her particular question. Disadvantage are usually lower accuracy and confidence.This ad hoc information extraction approach is novel and exceeds existing systems: Roogle [1] extracts predefined concepts from texts at preprocessing and makes them retrievable at runtime. Dr. Warehouse [2] applies negation detection and indexes the produced subtexts which include affirmed findings. Our approach combines negation detection and the extraction of concepts. But the extraction does not take place during preprocessing, but at runtime. That provides an ad hoc, dynamic, interactive and adjustable information extraction of random concepts and even their values on the fly at runtime. CONCLUSIONS: We developed an ad hoc information extraction query feature for Boolean and numerical values within a CDW with high recall and precision based on a pipeline that detects and removes negations and their scope in clinical texts.

Exporting Data from a Clinical Data Warehouse.

Data Warehouses (DW) are useful tools to support clinical studies as they can provide exports of routine care data for scientific reuse. Exported DW data is usually post-processed and integrated into study databases by study staff that is reasonably trained in specific tools like SPSS and Excel but which are no programmers or computer scientists. DW systems should therefore be configurable to satisfy export format desiderata as much as possible so that exports contain no unnecessary post-processing obstacles. In the presented work the authors analyze various existing DW systems in respect to a list of potential export formats.

Underestimated prevalence of heart failure in hospital inpatients: a comparison of ICD codes and discharge letter information.

BACKGROUND: Heart failure is the predominant cause of hospitalization and amongst the leading causes of death in Germany. However, accurate estimates of prevalence and incidence are lacking. Reported figures originating from different information sources are compromised by factors like economic reasons or documentation quality. METHODS: We implemented a clinical data warehouse that integrates various information sources (structured parameters, plain text, data extracted by natural language processing) and enables reliable approximations to the real number of heart failure patients. Performance of ICD-based diagnosis in detecting heart failure was compared across the years 2000-2015 with (a) advanced definitions based on algorithms that integrate various sources of the hospital information system, and (b) a physician-based reference standard. RESULTS: Applying these methods for detecting heart failure in inpatients revealed that relying on ICD codes resulted in a marked underestimation of the true prevalence of heart failure, ranging from 44% in the validation dataset to 55% (single year) and 31% (all years) in the overall analysis. Percentages changed over the years, indicating secular changes in coding practice and efficiency. Performance was markedly improved using search and permutation algorithms from the initial expert-specified query (F1 score of 81%) to the computer-optimized query (F1 score of 86%) or, alternatively, optimizing precision or sensitivity depending on the search objective. CONCLUSIONS: Estimating prevalence of heart failure using ICD codes as the sole data source yielded unreliable results. Diagnostic accuracy was markedly improved using dedicated search algorithms. Our approach may be transferred to other hospital information systems.

Estimating a Bias in ICD Encodings for Billing Purposes.

ICD encoded diagnoses are a popular criterion for eligibility algorithms for study cohort recruitment. However, "official" ICD encoded diagnoses used for billing purposes are afflicted with a bias originating from legal issues. This work presents an approach to estimate the degree of the encoding bias for the complete ICD catalogue at a German university hospital. The free text diagnoses sections of discharge letters are automatically classified using a supervised machine learning algorithm. The automatic classifications are compared with the official, manually classified codes. For selected ICD codes the approach works sufficiently well.

A Customizable Importer for the Clinical Data Warehouses PaDaWaN and I2B2.

In recent years, clinical data warehouses (CDW) storing routine patient data have become more and more popular to support scientific work in the medical domain. Although CDW systems provide interfaces to import new data, these interfaces have to be used by processing tools that are often not included in the systems themselves. In order to establish an extraction-transformation-load (ETL) workflow, already existing components have to be taken or new components have to be developed to perform the load part of the ETL. We present a customizable importer for the two CDW systems PaDaWaN and I2B2, which is able to import the most common import formats (plain text, CSV and XML files). In order to be run, the importer only needs a configuration file with the user credentials for the target CDW and a list of XML import configuration files, which determine how already exported data is indented to be imported. The importer is provided as a Java program, which has no further software requirements.

Extending the Query Language of a Data Warehouse for Patient Recruitment.

Patient recruitment for clinical trials is a laborious task, as many texts have to be screened. Usually, this work is done manually and takes a lot of time. We have developed a system that automates the screening process. Besides standard keyword queries, the query language supports extraction of numbers, time-spans and negations. In a feasibility study for patient recruitment from a stroke unit with 40 patients, we achieved encouraging extraction rates above 95% for numbers and negations and ca. 86% for time spans.