WAX ActiveLibrary: a tool to manage information overload.

WAX Active-Library (Cambridge Centre for Clinical Informatics) is a knowledge management system that seeks to support doctors' decision making through the provision of electronic books containing a wide range of clinical knowledge and locally based information. WAX has been piloted in several regions in the United Kingdom and formally evaluated in 17 GP surgeries based in Cambridgeshire. The evaluation has provided evidence that WAX Active-Library significantly improves GPs' access to relevant information sources and by increasing appropriate patient management and referrals this might also lead to an improvement in clinical outcomes.

Evaluation as a tool to increase knowledge in healthcare informatics.

The evaluation of information systems is an important topic in Clinical Informatics. It is argued that past evaluations have not been particularly informative in progressing the effective use of IT in healthcare due to their narrow focus. The different roles of evaluation in Clinical Informatics are examined, and the breadth and diversity of the available methodological tool kit highlighted. The aim is to stimulate a greater awareness of the roles and methods of evaluation. Challenges in evaluation which face the Clinical Informatics community are discussed and finally some comments made concerning the way in which evaluation might be made more effective in order to improve our knowledge of how to deliver useful systems into healthcare.

Evaluating large scale health information systems: from practice towards theory.

With the introduction of large scale health information systems which are incrementally developed from legacy systems, evaluators are faced with difficult methodological and practical problems. Some of the problems involved in multidisciplinary multi-method evaluations care discussed. It is argued that the development of a framework for evaluation is necessary in order to successfully plan an evaluation, understand the implications of the results and make future predictions based upon them. Some suggestions for arriving at such a framework are put forward.

Data entry in computer-based care planning.

If computer-based care planning is to be acceptable to nurses, they must be able to enter care plans in a flexible and intuitive manner that does not distort their observations about the patient. The limitations of existing computer-based data entry techniques are discussed. A novel method of data entry called Predictive Data Entry is presented, and the underlying model of nursing terminology which supports it is described. The results of user evaluations are discussed.

Computer-based medical clerking.

All admissions to hospital begin with medical clerking. Thus, it is an essential element of any electronic patient record system. This paper describes some initial experiments to develop a computer-based clerking tool with which doctors can record their clinical observations. The clerking tool uses a structured data entry technique which is based upon an underlying semantic network of clinical terminology. This enables data to be captured and stored in a semantically structured manner, facilitating its use in computer-based record systems and also for audit, management, and decision support purposes. The prototype tool is described, and the evaluation and preliminary results obtained are reported. Initial results indicate that structured data entry is feasible for hospital-based clerking.

A clerking tool for the patient record system.

1. BACKGROUND. The goal of the PEN&PAD (Elderly Care) project is to develop a patient record system to assist the many different professionals that care for patients in a hospital setting. At the core of the project is the use of structured data which can be reused in a variety of ways--both within the system for further manipulation and display, and externally for auditing and statistical purposes. To accommodate these needs, a compositional method of data entry called Structured Data Entry (SDE) was used in this application. SDE was developed in an earlier project PEN&PAD (GP)(1). Our application utilizes a network representation of the medical semantics that can be queried to obtain what is sensible to "say" about a particular concept. This functionality is contained within a separate application known as the Terminology Server (TeS), which has been developed within the GALEN project (2). The client application (the patient record system) requests information from the TeS which can then be used to produce compositional data entry forms that require the user to choose values for given attributes (e.g., if information pertaining to chest pain were being recorded, the attribute 'location' and a choice of possible values i.e., 'left' 'right' and 'bilateral' might appear on the form). Given the importance of capturing clinical information in a highly structured format, SDE is a valuable tool. However, its long term success depends on a very comprehensive model of the medical terminology corpus. This component is currently being studied by the GALEN team. 2. CURRENT WORK. We are developing a clerking tool to be used to create records for the newly admitted patient. The clinician seeks to identify a patient's problems based on physical examination and information obtained through conversation with the patient. Patients are usually admitted with a presenting complaint and obtaining more information about this complaint is an important part of the clerking process. While the physician may be able to use the clerking data to consider possible diagnoses right away, he/she often needs to review relevant body systems before a diagnosis is made. In traditional paper based clerking systems, notes are highly formalized but still subject to variation between clinicians. A typical clerking records information such as: 1) history of the presenting complaint; 2) previous medical history; 3) review of body systems; 4) medication; 5) social history; and 6) investigations. We have attempted to retain this clerking outline as much as possible, focusing primarily on the presenting complaint and review of body systems sections. To begin the clerking process, the user chooses a presenting complaint (from the list provided) to launch the 'clerking' window. Access buttons for the different clerking sections are positioned above a data entry window. This window contains a form for collecting information on the presenting complaint. The form is divided into sections to allow the user to record the absence or presence of an associated symptoms and other details. Free text comments can be added to the window, and a data display area shows information entered so far. The user can query the body system database by choosing a system from a menu. At this point the presenting complaint window is replaced by one on the body system in question. The user is free to switch back and forth between the presenting complaint and body system screens. On returning to a previously visited window, the user may pick up where he/she left off when exiting the window. Once the clerking is completed, the information is entered as a unit into the patient record with the date and clinicians name attached. Thereafter, the file becomes read-only. We are currently putting a prototype clerking system through field trials with clinicians from of a local hospital. In our demonstration, we hope to elaborate on these trials and their outcomes.

The PEN & PAD medical record model: development of a nursing record for hospital-based care of the elderly.

The PEN & PAD Medical Record model describes a framework for an information model, designed to meet the requirements of an electronic medical record. This model has been successfully tested in a computer-based record system for General Practitioners as part of the PEN & PAD (GP) Project. Experiences of using the model for developing computer-based nursing records are reported. Results show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient's care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work had highlighted the need for nurses to clarify and make explicit their uses of information, and also provided them with some tools to assist in this task.

Development of Design-a-Trial, a knowledge-based critiquing system for authors of clinical trial protocols.

Many published clinical trials are poorly designed, suggesting that the protocol was incomplete, disorganised or contained errors. This fact, doctors' limited statistical skills and the shortage of medical statisticians, prompted us to develop a knowledge-based aid, Design-a-Trial, for authors of clinical trial protocols. This interviews a physician, prompts them with suitable design options, comments on the statistical rigour and feasibility of their proposed design and generates a 6-page draft protocol document. This paper outlines the process used to develop Design-a-Trial, presents preliminary evaluation results, and discusses lessons we learned which may apply to the developed of other medical decision-aids.

Using the PEN&PAD information model to support hospital-based clinical care.

The PEN&PAD model for clinical record systems has been successfully used for medical records in both General Practice and hospital-based care. This paper describes experiences of using the model for developing computer-based nursing records. Results from this work show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient's care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work has highlighted the need for nurses to clarify and make explicit, their uses of information, and also provided them with some tools to assist in this task.

Philosophies for the design and development of clinical decision-support systems.

Little significance is attached by medical informatics workers to the many practical issues which affect the development of clinical decision-support systems. We examine the current state of research in clinical decision-support, the characteristics and motivations of developers, and the perceptions of intended end-users. Factors which adversely affect the success of systems are highlighted and pointers to good practice discussed. We then propose a coherent approach to system development, consisting of requirements analysis, software design, implementation, testing, evaluation and maintenance.

PEN&PAD (Elderly Care): designing a patient record system for elderly care.

Practical experiences in the work analysis and design of a computer-based patient record system for use by doctors on an elderly care ward are discussed. A diagrammatic technique named "Task Oriented Flow Diagrams" is briefly described. This technique enables designers to formalise their understanding of users work tasks in manner that is comprehensible to users, and thus can form the basis of a dialogue between designer and users. A prototype patient record system is described and the results of its evaluation with users presented.

A computer-based decision support system for diagnostic histopathology of the breast.

Accurate histological diagnosis of breast lesions is essential for the appropriate management of the patient. However, the technique of histological typing is problematic due to the large number of histological patterns, often of a complex and variable nature, which occur in breast disease. The introduction of the Breast Screening Programme has increased the burden on pathologists, and emphasised the need for training. Problems arise because mammographic screening detects a greater proportion of special histological types, with their attendant difficulties of identification, when compared to clinically palpable lesions. A computer-based decision support tool has been developed to assist pathologists in the histological diagnosis of breast disease. Unlike conventional expert systems, which seek to recreate the problem-solving processes of an expert, this system has been designed to act as an intelligent assistant to the pathologist. The system represents knowledge in the form of 'disease profiles', and utilises a novel inference model based upon the mathematical technique of hypergraphs. Initial trials with this system have demonstrated that a high level of diagnostic accuracy can be achieved.

PEN&PAD (Geriatrics): a Collaborative Patient Record System for the shared care of the elderly.

The PEN&PAD (Geriatrics) project seeks to develop a Collaborative Patient Record System for the hospital based shared care of the elderly. The goal of the project is to produce a single, integrated information system which is both useful and usable by the different practitioner groups involved in geriatric care. A User Centred Design methodology is proposed which makes users and human issues central to the design and development process. Preliminary results indicate that the specification of a Minimum Basic Data Set as the basis of a shared record system is infeasible and undesirable. An architecture is presented which illustrates how the diversity between the different disciplines may be preserved in a Collaborative Patient Record System.

A cooperative approach to decision support in the differential diagnosis of breast disease.

The problem of differential diagnosis in breast histopathology is described and areas in need of decision support identified. It is argued that the conventional role played by decision support systems, i.e. that of the 'autonomous problem-solver', is unacceptable in this domain and that support must be given to the actual cognitive functions of potential system users. Decision-making processes of pathologists are examined with particular reference to Rector's category of 'broad experts'. Pathologists possess a rich set of general diagnostic concepts for their domain, but their knowledge of detailed aspects of differential diagnosis may contain gaps and errors. A cooperative model of decision support, which utilizes the strengths and complements the weaknesses of pathologists' problem-solving skills, is described and the operation of this model within a functioning system illustrated.