Lifestyle physical activity in manual wheelchair users - an overlooked public health opportunity.

Public health guidelines and health promotion efforts have traditionally focused on weekly accumulation of moderate to vigorous physical activity (MVPA) via structured exercise. There has been a recent paradigm shift towards the organic incorporation of MVPA in daily leisure and non-leisure time, termed "Lifestyle Physical Activity" (LPA). However, this paradigm shift and the underlying research has neglected manual wheelchair users (MWCUs) with spinal cord injury (SCI), who could benefit from LPA. This article argues for expanding the LPA paradigm shift into research and health promotion efforts involving MWCUs with SCI. We suggest a working definition of LPA for MWCUs and candidate metrics for quantifying LPA. This is followed by brief overviews of LPA correlates, outcomes/consequences, and interventions and the need for theory based approaches to study these domains. We lastly suggest an approach for mitigating potential negative outcomes of increased LPA in MWCUs and suggest a research agenda.

Quantitative analysis of manual annotation of clinical text samples.

BACKGROUND: Semantic interoperability of eHealth services within and across countries has been the main topic in several research projects. It is a key consideration for the European Commission to overcome the complexity of making different health information systems work together. This paper describes a study within the EU-funded project ASSESS CT, which focuses on assessing the potential of SNOMED CT as core reference terminology for semantic interoperability at European level. OBJECTIVE: This paper presents a quantitative analysis of the results obtained in ASSESS CT to determine the fitness of SNOMED CT for semantic interoperability. METHODS: The quantitative analysis consists of concept coverage, term coverage and inter-annotator agreement analysis of the annotation experiments related to six European languages (English, Swedish, French, Dutch, German and Finnish) and three scenarios: (i) ADOPT, where only SNOMED CT was used by the annotators; (ii) ALTERNATIVE, where a fixed set of terminologies from UMLS, excluding SNOMED CT, was used; and (iii) ABSTAIN, where any terminologies available in the current national infrastructure of the annotators' country were used. For each language and each scenario, we configured the different terminology settings of the annotation experiments. RESULTS: There was a positive correlation between the number of concepts in each terminology setting and their concept and term coverage values. Inter-annotator agreement is low, irrespective of the terminology setting. CONCLUSIONS: No significant differences were found between the analyses for the three scenarios, but availability of SNOMED CT for the assessed language is associated with increased concept coverage. Terminology setting size and concept and term coverage correlate positively up to a limit where more concepts do not significantly impact the coverage values. The results did not confirm the hypothesis of an inverse correlation between concept coverage and IAA due to a lower amount of choices available. The overall low IAA results pose a challenge for interoperability and indicate the need for further research to assess whether consistent terminology implementation is possible across Europe, e.g., improving term coverage by adding localized versions of the selected terminologies, analysing causes of low inter-annotator agreement, and improving tooling and guidance for annotators. The much lower term coverage for the Swedish version of SNOMED CT compared to English together with the similarly high concept coverage obtained with English and Swedish SNOMED CT reflects its relevance as a hub to connect user interface terminologies and serving a variety of user needs.

Qualitative analysis of manual annotations of clinical text with SNOMED CT.

SNOMED CT provides about 300,000 codes with fine-grained concept definitions to support interoperability of health data. Coding clinical texts with medical terminologies it is not a trivial task and is prone to disagreements between coders. We conducted a qualitative analysis to identify sources of disagreements on an annotation experiment which used a subset of SNOMED CT with some restrictions. A corpus of 20 English clinical text fragments from diverse origins and languages was annotated independently by two domain medically trained annotators following a specific annotation guideline. By following this guideline, the annotators had to assign sets of SNOMED CT codes to noun phrases, together with concept and term coverage ratings. Then, the annotations were manually examined against a reference standard to determine sources of disagreements. Five categories were identified. In our results, the most frequent cause of inter-annotator disagreement was related to human issues. In several cases disagreements revealed gaps in the annotation guidelines and lack of training of annotators. The reminder issues can be influenced by some SNOMED CT features.

A future-proof architecture for telemedicine using loose-coupled modules and HL7 FHIR.

BACKGROUND AND OBJECTIVES: Most telemedicine solutions are proprietary and disease specific which cause a heterogeneous and silo-oriented system landscape with limited interoperability. Solving the interoperability problem would require a strong focus on data integration and standardization in telemedicine infrastructures. Our objective was to suggest a future-proof architecture, that consisted of small loose-coupled modules to allow flexible integration with new and existing services, and the use of international standards to allow high re-usability of modules, and interoperability in the health IT landscape. METHODS: We identified core features of our future-proof architecture as the following (1) To provide extended functionality the system should be designed as a core with modules. Database handling and implementation of security protocols are modules, to improve flexibility compared to other frameworks. (2) To ensure loosely coupled modules the system should implement an inversion of control mechanism. (3) A focus on ease of implementation requires the system should use HL7 FHIR (Fast Interoperable Health Resources) as the primary standard because it is based on web-technologies. RESULTS: We evaluated the feasibility of our architecture by developing an open source implementation of the system called ORDS. ORDS is written in TypeScript, and makes use of the Express Framework and HL7 FHIR DSTU2. The code is distributed on GitHub. All modules have been tested unit wise, but end-to-end testing awaits our first clinical example implementations. CONCLUSIONS: Our study showed that highly adaptable and yet interoperable core frameworks for telemedicine can be designed and implemented. Future work includes implementation of a clinical use case and evaluation.

An Empirical Approach to Enhancing Terminology Binding - An HL7 FHIR SNOMED CT Example.

Information exchange at the level of semantic interoperability requires that information models and clinical terminologies work well together. In HL7 FHIR resources, terminology binding to standard terminologies such as SNOMED CT are suggested, and even though most are suggestions rather than rules, they still must reflect the clinical domain accurately. In this study, we suggest a method for empirically evaluating whether a terminology binding represents the value sets used in practice. We evaluated the terminology binding associated with the MedicationRequest.reasonCode using the Danish national indication value set which we mapped to SNOMED CT. We found two problems with the terminology binding, namely, that the reason for prophylactic treatment and that medication given as part of a procedure, but not related to the patients' problems per se could not be expressed within the boundary of HL7 FHIR's example terminology binding. Future work will include showing how more complex terminology binding issues could be informed by looking at value sets in use.

A Method for Developing Standard Patient Education Program.

In Denmark, patients being treated on Haematology Outpatients Departments get instructed to self-manage their blood sample collection from Central Venous Catheter (CVC). However, this is a complex and risky procedure, which can jeopardize patient safety. The aim of the study was to suggest a method for developing standard digital patient education programs for patients in self-administration of blood samples drawn from CVC. The Design Science Research Paradigm was used to develop a digital patient education program, called PAVIOSY, to increase patient safety during execution of the blood sample collection procedure by using videos for teaching as well as procedural support. A step-by-step guide was developed and used as basis for making the videos. Quality assurance through evaluation with a nurse was conducted on both the step-by-step guide and the videos. The quality assurance evaluation of the videos showed; 1) Errors due to the order of the procedure can be determined by reviewing the videos despite that the guide was followed. 2) Videos can be used to identify errors - important for patient safety - in the procedure, which are not identifiable in a written script. To ensure correct clinical content of the educational patient system, health professionals must be engaged early in the development of content and design phase.

Feasibility of Representing a Danish Microbiology Model Using FHIR.

Achieving interoperability in health is a challenge and requires standardization. The newly developed HL7 standard: Fast Healthcare Interoperability Resources (FHIR) promises both flexibility and interoperability. This study investigates the feasibility of expressing a Danish microbiology message model content in FHIR to explore whether complex in-use legacy models can be migrated and what challenges this may pose. The Danish microbiology message model (the DMM) is used as a case to illustrate challenges and opportunities accosted with applying the FHIR standard. Mapping of content from DMM to FHIR was done as close as possible to the DMM to minimize migration costs except when the structure of the content did not fit into FHIR. From the DMM a total of 183 elements were mapped to FHIR. 75 (40.9%) elements were modeled as existing FHIR elements and 96 (52.5%) elements were modeled as extensions and 12 (6.6%) elements were deemed unnecessary because of build-in FHIR characteristics. In this study, it was possible to represent the content of a Danish message model using HL7 FHIR.

SNOMED CT as Reference Terminology in the Danish National Home Care Documentation Standard.

In Danish home care, multiple professions deliver services to citizens. FSIII is a national home care documentation standard, where one of the goals is to share documentation to improve coordination between these professional groups and avoid double documentation. The aim of this study was to develop a SNOMED-CT based navigation hierarchy to ensure that professions could preserve their documentation practice, to help avoid double documentation, and to ensure that the technical implementation did not require sophisticated semantic tools. The method involved mapping of non-SNOMED-CT content to SNOMED CT, visualization of merged graphs, identification of reference concepts, relating reference concepts to the documentation models of each profession, and representation of the navigation hierarchy in a reference set. The navigation hierarchy ensures that citizen conditions appear in a relevant context, regardless of which profession entered the data. Our approach paves the way for incremental standardization projects, where an implementation artefact, such as the navigation hierarchy, highlights the semantic features of SNOMED CT that can be used to reach specific business goals; in this case, sharing data across professional groups.

Terminology-Based Recording of Clinical Data for Multiple Purposes Within Oncology.

INTRODUCTION: Collecting clinical data once for the use in both electronic health record (EHR) and registries requires semantic interoperability. This paper presents the results of a systematic semantic analysis of similarities and differences in clinical documentation across regional EHR and a national oncology registry to assess options for an integration of recording templates. METHODS: A comparison of current clinical information in EHR and the national registry was carried out, using SNOMED CT as frame of reference to find exact-, similar- and non-match. RESULTS: Exact match was found for 9 out of 19 items from the registry and EHR, relating to clinical history, observations and findings at the examination and tumor control. Similar match concerned clinical findings of more common side effects to therapy whether present or absent. Both EHR and the registry had information with no compared match. CONCLUSION: Clinical documentation during a follow-up in head and neck cancer contains a core set of items recorded in both EHR and registry, representing clinical history, observations and more common side effects and tumor evaluation. These core items could be the point of departure for integration or re-design of EHR-systems.

Applying the SNOMED CT Concept Model to Represent Value Sets for Head and Neck Cancer Documentation.

This paper presents an analysis of the extent to which SNOMED CT is suitable for representing data within the domain of head and neck cancer. In this analysis we assess whether the concept model of SNOMED CT comply with the documentation needed within this clinical domain. Attributes from the follow-up template of the clinical quality registry for Danish Head and Neck Cancer, and their respective value sets were mapped to SNOMED CT using existing mapping guidelines. Results show that post-coordination is important to represent specific types of value sets, such as absence of findings and severities. The concept model of SNOMED CT was found suitable for representing the value sets of this material. We argue for the development of further mapping guidelines for consistent post-coordination and for initiatives that demonstrate use of this important terminological feature in actual SNOMED CT implementations.

The Costs and Benefits of SNOMED CT Implementation: An Economic Assessment Model.

As part of its investigations, the EU-funded ASSESS CT project developed an Economic Assessment Model for assessing SNOMED CT's and other terminologies' socio-economic impact in a systematic approach. Methodology and key elements of the model are presented: cost and benefit indicators for assessing deployment, and a cost-benefit analysis tool to collect, estimate, and evaluate data.

Re-use of SNOMED CT subset in development of the Danish national standard for home care nursing problems.

SNOMED CT was chosen as reference terminology for standardisation of homecare nursing documentation to make reporting comparable across the 98 Danish municipalities. The method outlined in this paper for developing a Danish national homecare nursing SNOMED CT subsets is a pragmatic approach to build new SNOMED CT subsets drawing on existing and available SNOMED CT subsets. Combining this approach with awareness of hierarchical coherency in SNOMED CT subsets makes effective retrieval of data possible.

E-health stakeholders experiences with clinical modelling and standardizations.

Stakeholders in e-health such as governance officials, health IT-implementers and vendors have to co-operate to achieve the goal of a future-proof interoperable e-health infrastructure. Co-operation requires knowledge on the responsibility and competences of stakeholder groups. To increase awareness on clinical modeling and standardization we conducted a workshop for Danish and a few Norwegian e-health stakeholders' and made them discuss their views on different aspects of clinical modeling using a theoretical model as a point of departure. Based on the model, we traced stakeholders' experiences. Our results showed there was a tendency that stakeholders were more familiar with e-health requirements than with design methods, clinical information models and clinical terminology as they are described in the scientific literature. The workshop made it possible for stakeholders to discuss their roles and expectations to each other.

Clustering clinical models from local electronic health records based on semantic similarity.

BACKGROUND: Clinical models in electronic health records are typically expressed as templates which support the multiple clinical workflows in which the system is used. The templates are often designed using local rather than standard information models and terminology, which hinders semantic interoperability. Semantic challenges can be solved by harmonizing and standardizing clinical models. However, methods supporting harmonization based on existing clinical models are lacking. One approach is to explore semantic similarity estimation as a basis of an analytical framework. Therefore, the aim of this study is to develop and apply methods for intrinsic similarity-estimation based analysis that can compare and give an overview of multiple clinical models. METHOD: For a similarity estimate to be intrinsic it should be based on an established ontology, for which SNOMED CT was chosen. In this study, Lin similarity estimates and Sokal and Sneath similarity estimates were used together with two aggregation techniques (average and best-match-average respectively) resulting in a total of four methods. The similarity estimations are used to hierarchically cluster templates. The test material consists of templates from Danish and Swedish EHR systems. The test material was used to evaluate how the four different methods perform. RESULT AND DISCUSSION: The best-match-average aggregation technique performed better in terms of clustering similar templates than the average aggregation technique. No difference could be seen in terms of the choice of similarity estimate in this study, but the finding may be different for other datasets. The dendrograms resulting from the hierarchical clustering gave an overview of the templates and a basis of further analysis. CONCLUSION: Hierarchical clustering of templates based on SNOMED CT and semantic similarity estimation with best-match-average aggregation technique can be used for comparison and summarization of multiple templates. Consequently, it can provide a valuable tool for harmonization and standardization of clinical models.

Semantic Krippendorff's α for measuring inter-rater agreement in SNOMED CT coding studies.

Semantic interoperability requires consistency in use of terminologies such as SNOMED CT. Inter-rater agreement measurement can be used to quantify this consistency among terminology users. Increasingly, studies of SNOMED CT include inter-rater agreement measures. However, published studies do not consider distance between concepts when calculating the inter-rater agreement measures. In this paper we propose a semantic inter-rater agreement measure for use with SNOMED CT encoded data. A semantic Krippendorff's α measure is implemented using a path-length based difference function. The measure is tested using three different datasets. Results show that the proposed semantic measure is sensitive to seriousness of coding differences whereas a nominal measure is not. The proposed measure reflects the intuition that distance matters when comparing uses of SNOMED CT.

Content analysis of physical examination templates in electronic health records using SNOMED CT.

OBJECTIVES: Most electronic health record (EHR) systems are built on proprietary information models and terminology, which makes achieving semantic interoperability a challenge. Solving interoperability problems requires well-defined standards. In contrast, the need to support clinical work practice requires a local customization of EHR systems. Consequently, contrasting goals may be evident in EHR template design because customization means that local EHR organizations can define their own templates, whereas standardization implies consensus at some level. To explore the complexity of balancing these two goals, this study analyzes the differences and similarities between templates in use today. METHODS: A similarity analysis was developed on the basis of SNOMED CT. The analysis was performed on four physical examination templates from Denmark and Sweden. The semantic relationships in SNOMED CT were used to quantify similarities and differences. Moreover, the analysis used these identified similarities to investigate the common content of a physical examination template. RESULTS: The analysis showed that there were both similarities and differences in physical examination templates, and the size of the templates varied from 18 to 49 fields. In the SNOMED CT analysis, exact matches and terminology similarities were represented in all template pairs. The number of exact matches ranged from 7 to 24. Moreover, the number of unrelated fields differed a lot from 1/18 to 22/35. Cross-country comparisons tended to have more unrelated content than within-country comparisons. On the basis of identified similarities, it was possible to define the common content of a physical examination. Nevertheless, a complete view on the physical examination required the inclusion of both exact matches and terminology similarities. CONCLUSIONS: This study revealed that a core set of items representing the physical examination templates can be generated when the analysis takes into account not only exact matches but also terminology similarities. This core set of items could be a starting point for standardization and semantic interoperability. However, both unmatched terms and terminology matched terms pose a challenge for standardization. Future work will include using local templates as a point of departure in standardization to see if local requirements can be maintained in a standardized framework.

Developing an acute-physical-examination template for a Tegional EHR system aimed at improving inexperienced physician's documentation.

It is well-established that to increase acceptance of electronic clinical documentation tools, such as electronic health record (EHR) systems, it is important to have a strong relationship between those who document the clinical encounters and those who reaps the benefit of digitalized and more structured documentation. [1] Therefore, templates for EHR systems benefit from being closely related to clinical practice with a strong focus on primarily solving clinical problems. Clinical use as a driver for structured documentation has been the focus of the acute-physical-examination template (APET) development in the North Denmark Region. The template was developed through a participatory design where precision and clarity of documentation was prioritized as well as fast registration. The resulting template has approximately 700 easy accessible input possibilities and will be evaluated in clinical practice in the first quarter of 2013.