Dual Implementation Guides in FHIR and CDA.

BACKGROUND: The Fast Healthcare Interoperability Resources (FHIR) and Clinical Document Architecture (CDA) are standards for the healthcare industry, designed to improve the exchange of health data by interoperability. Both standards are constrained through what are known as Implementation Guides (IG) for specific use. OBJECTIVES: Both of these two standards are widely in use and play an important role in the Austrian healthcare system. Concepts existing in CDA and FHIR must be aligned between both standards. METHODS: Many existing approaches are presented and discussed, none are fully suited to the needs in Austria. RESULTS: The IG Publisher has already been used for CDA IGs, beside of its intended FHIR support, but never for both in one IG. Even the International Patient Summary (IPS), existing as CDA and FHIR specification, does not solve the needed comparability between these two. CONCLUSION: As the IG Publisher is widely used and supports CDA, it should be used for Dual Implementation Guides. Further work and extension of IG Publisher is necessary to enhance the readability of the resulting IGs.

Generating Actionable Insights from Patient Medical Records and Structured Clinical Knowledge.

While adherence to clinical guidelines improves the quality and consistency of care, personalized healthcare also requires a deep understanding of individual disease models and treatment plans. The structured preparation of medical routine data in a certain clinical context, e.g. a treatment pathway outlined in a medical guideline, is currently a challenging task. Medical data is often stored in diverse formats and systems, and the relevant clinical knowledge defining the context is not available in machine-readable formats. We present an approach to extract information from medical free text documentation by using structured clinical knowledge to guide information extraction into a structured and encoded format, overcoming the known challenges for natural language processing algorithms. Preliminary results have been encouraging, as one of our methods managed to extract 100% of all data-points with 85% accuracy in details. These advancements show the potential of our approach to effectively use unstructured clinical data to elevate the quality of patient care and reduce the workload of medical personnel.

Multi-Perspective Process Mining Interfaces for HL7 AuditEvent Repositories: XES and OCEL.

BACKGROUND: Medical information systems frequently use event logging, but these logs are not suitable for process mining as they are not logged in a standardized format. OBJECTIVES: Our goal is to enrich medical event logs for use in process mining. METHOD: We present an approach to convert events from standards- based repositories into the XES and OCEL formats commonly used in process mining. RESULTS: We tested this approach using simulated data from the Austrian breast cancer screening program. CONCLUSION: We aim to apply it to analyze care guidelines and improve hospital processes in the future.

How do Android developers improve non-functional properties of software?

Nowadays there is an increased pressure on mobile app developers to take non-functional properties into account. An app that is too slow or uses much bandwidth will decrease user satisfaction, and thus can lead to users simply abandoning the app. Although automated software improvement techniques exist for traditional software, these are not as prevalent in the mobile domain. Moreover, it is yet unknown if the same software changes would be as effective. With that in mind, we mined overall 100 Android repositories to find out how developers improve execution time, memory consumption, bandwidth usage and frame rate of mobile apps. We categorised non-functional property (NFP) improving commits related to performance to see how existing automated software improvement techniques can be improved. Our results show that although NFP improving commits related to performance are rare, such improvements appear throughout the development lifecycle. We found altogether 560 NFP commits out of a total of 74,408 commits analysed. Memory consumption is sacrificed most often when improving execution time or bandwidth usage, although similar types of changes can improve multiple non-functional properties at once. Code deletion is the most frequently utilised strategy except for frame rate, where increase in concurrency is the dominant strategy. We find that automated software improvement techniques for mobile domain can benefit from addition of SQL query improvement, caching and asset manipulation. Moreover, we provide a classifier which can drastically reduce manual effort to analyse NFP improving commits.

Open Infrastructure for Standardization of HL7® FHIR® Implementation Guides in Austria.

BACKGROUND: HL7 Austria is a non-profit association dedicated to improving electronic data communication and interoperability in healthcare using the HL7 international standards. OBJECTIVES: We aim to provide an open infrastructure to develop, manage, and maintain HL7 FHIR implementation guides. METHODS: We utilize state-of-the-art open-source tooling developed by the FHIR community to support continuous integration. RESULTS: The implementation guides can be published as static HTML websites and maintained using GitHub. CONCLUSION: The solution supports all steps of a standard's lifecycle, from drafting and reviewing to balloting, publishing, and maintenance.

FHIR2BPMN: Delivering Actionable Knowledge by Transforming Between Clinical Pathways and Executable Models.

Healthcare processes have many particularities captured and described within standards for medical information exchange such as HL7 FHIR. BPMN is a widely used standard to create readily understandable processes models. We show an approach to integrate both these standards via an automated transformation mechanism. This will allow us to use the various tools available for BPMN to visualize and automate processes in the healthcare domain. In the future we plan to extend this approach to enable mining and analyzing executed processes.

[Beyond Content Alone: What Cancer Patients Consider as Important in Professional Psychosocial Support]. / Mehr als Inhalte: Was KrebspatientInnen bei professioneller psychosozialer Unterstützung wichtig ist.

OBJECTIVE: In this study we wanted to find out what cancer patients expect from professional psychosocial support. METHODS: Within a multicenter prospective study, patients were asked about their expectations from professional psychosocial support two years after diagnosis. Using qualitative methods, categories were built from the answers. The answers were assigned to the categories. RESULTS: 447 patients were contacted and 285 answers were obtained. Getting information as well as interaction with enough time for listening was considered as important. Support should result in enhancement of psychological strength. DISCUSSION: Apart from contents, aspects of how support is given such as attention and competence are important. There should be enough time for the consideration of individual needs. CONCLUSION: Both getting information and competence as well as listening and personal conversation are important.

Automated Verification of Structured Questionnaires Using HL7.

Informed consent of patients to research studies is a cornerstone to modern healthcare, which has lead to considerable administrative effort. The purpose of this paper is to show how forms and questionnaires and their respective answers can be captured in a standardized, structured way, in order to enable automated verification. The use of the HL7 FHIR resources Questionnaire and QuestionnaireResponse is discussed with respect to the different implementation options of Extensions, POST Interceptors, FHIR Operations, and CDS Hooks. These four approaches are described and it is determined whether they produce standard-compliant results and how they can be integrated with other solutions. Since all approaches yield advantages and disadvantages, the choice amongst any option must be based on the actual use case.

Challenges and Approaches to Make Multidisciplinary Team Meetings Interoperable - The KIMBo Project.

BACKGROUND: Multidisciplinary team meetings (MDTMs) are already in use for certain areas in healthcare (e.g. treatment of cancer). Due to the lack of common standards and accessibility for the applied IT systems, their potential is not yet completely exploited. OBJECTIVES: Common requirements for MDTMs shall be identified and aggregated into a process definition to be automated by an application architecture utilizing modern standards in electronic healthcare, e.g. HL7 FHIR. METHODS: To identify requirements, an extensive literature review as well as semi-structured expert interviews were conducted. RESULTS: Results showed, that interoperability and flexibility in terms of the process are key requirements to be addressed. An architecture blueprint as well as an aggregated process definition were derived from the insights gained. To evaluate the feasibility of identified requirements, methods of explorative prototyping in software engineering were used. CONCLUSION: MDTMs will become an important part of modern and future healthcare but the need for standardization in terms of interoperability is imminent.

Socio-economic disparities in long-term cancer survival-10 year follow-up with individual patient data.

PURPOSE: Reasons for the social gradient in cancer survival are not fully understood yet. Previous studies were often only able to determine the socio-economic status of the patients from the area they live in, not from their individual socio-economic characteristics. METHODS: In a multi-centre cohort study with 1633 cancer patients and 10-year follow-up, individual socio-economic position was measured using the indicators: education, job grade, job type, and equivalence income. The effect on survival was measured for each indicator individually, adjusting for age, gender, and medical characteristics. The mediating effect of health behaviour (alcohol and tobacco consumption) was analysed in separate models. RESULTS: Patients without vocational training were at increased risk of dying (rate ratio (RR) 1.5, 95% confidence interval (CI) 1.1-2.2) compared to patients with the highest vocational training; patients with blue collar jobs were at increased risk (RR 1.2; 95% CI 1.0-1.5) compared to patients with white collar jobs; income had a gradual effect (RR for the lowest income compared to highest was 2.7, 95% CI 1.9-3.8). Adding health behaviour to the models did not change the effect estimates considerably. There was no evidence for an effect of school education and job grade on cancer survival. CONCLUSIONS: Patients with higher income, better vocational training, and white collar jobs survived longer, regardless of disease stage at baseline and of tobacco and alcohol consumption.

Prefetching of medical imaging data across XDS affinity domains.

Prior studies as well as medical imaging data are crucial for a radiologist to diagnose a patient. In this paper the radiological workflow is analyzed from a patient's perspective in order to gain knowledge on how possible existing prefetching strategies still can be applied in connection with a standardized distributed health information system conforming to architectures defined by IHE and ELGA. As a result an adaption to such architectures is proposed and further evaluated in a testing environment. Although the approach presented works in terms of prefetching relevant prior studies together with medical imaging data, additional research has to be carried out on how to apply intelligent search strategies in order to narrow retrieved results concerning their possible utilization for a specific diagnosis.

Intraoperative imaging with a 3D C-arm system after zygomatico-orbital complex fracture reduction.

PURPOSE: During the repair of zygomatico-orbital complex (ZMC) fractures, the lateral orbital wall and/or the orbital floor is often reduced by merely reducing the zygoma. Intraoperative 3D imaging can help surgeons decide whether the orbit must be reconstructed as well. The purpose of this study was therefore to assess the usefulness of intraoperative 3D C-arm imaging in evaluating the adequacy of fracture reduction. METHODS: A total of 21 patients with unilateral ZMC fractures were enrolled in this retrospective study. Four fractures were treated with a closed reduction technique. Seventeen fractures were repaired with open reduction and internal fixation of the zygomaticomaxillary buttress area. Intraoperative 3D C-arm imaging was performed in all cases. All patients underwent postoperative computed tomography and a clinical examination no earlier than 5 months after the procedure. RESULTS: After reduction of the ZMC fractures, intraoperative 3D scans showed inadequate repair of the orbital floor in 2 patients and inadequate repair of the lateral orbit in 1 patient. Zygoma and zygomatic arch fracture reduction had to be corrected in 1 further case. The other 17 patients did not need an additional procedure. Postoperative imaging showed that no patient required a secondary operation. No postoperative diplopia or enophthalmos developed in any patient. CONCLUSIONS: Intraoperative 3D C-arm imaging appears to be an effective tool for evaluating ZMC fracture reduction. It helps avoid additional procedures and thus helps reduce morbidity. In addition, there appears to be no need for postoperative imaging.

1H-pyrrolo[3,2-h]quinoline: a benchmark molecule for reliable calculations of vibrational frequencies, IR intensities, and Raman activities.

Reliable assignment of 55 out of 57 vibrational modes has been achieved for 1H-pyrrolo[3,2-h]quinoline using IR, Raman, and fluorescence spectroscopy combined with quantum chemical calculations. The experiments provided a data set for assessing the performance of different models/basis sets for predicting the vibrational frequencies, as well as IR and Raman intensities for a molecule with 13 heavy atoms. Among six different tested DFT functionals, the hybrid B3LYP used with Pople's split-valence basis sets is suggested as the best choice for accurate and cost-effective IR/Raman spectral simulations. Neither HF nor MP2 methods can satisfactorily describe the vibrational structure. Increasing the basis set size from double to triple-ζ and by adding polarization and diffuse functions does not necessarily improve the results, especially regarding the predictions of vibrational frequencies. With respect to the intensities, extending the basis set helps, with the accuracy increasing systematically for the Raman spectra, and in a less regular fashion for the IR. A large difference in accuracy is observed while comparing the spectral parameters predicted for in-plane and out-of-plane normal modes. The former are reliably computed with modest basis sets, whereas for the out-of-plane vibrations, larger basis sets are necessary, but even in this case, the out-of-plane vibrations are reproduced with much less accuracy than in-plane modes. This effect is general, as it has been observed using different functionals and basis sets.

Predictors of emotional distress in patients with head and neck cancer.

BACKGROUND: Patients with head and neck cancer are known to be more commonly emotionally distressed than patients with other tumors. This study investigates reasons for this difference. METHODS: Patients in this prospective cohort study included those with head and neck cancer (n = 113) and those with other cancers (n = 1690). The Hospital Anxiety and Depression Scale, measuring emotional distress, along with additional questions regarding emotional support wished and provided were administered. RESULTS: Patients with head and neck tumors were 1.5-fold (at the time of admission), 1.2-fold (before discharge), and 2.7-fold (half a year after admission) more frequently distressed than the other patients with cancer. This association was confounded by perceived social support and sociodemographic factors. Patients with head and neck cancer expressed less frequently the wish for and received less support by psycho-oncologists. CONCLUSIONS: Emotional distress is more common in patients with head and neck tumors; this is largely a result of the psychosocial context the patients live in, especially the amount of social support received.

Specific microsolvation triggers dissociation-mediated anomalous red-shifted fluorescence in the gas phase.

Ion-depletion IR spectroscopy has revealed that at least two water molecules are required in complexes with 4-(dimethylamino)benzoic acid methyl ester (DMABME) for anomalous red-shifted fluorescence to occur in the gas phase. Through the use of high-level quantum-chemical calculations, two experimentally observed isoenergetic isomers are assigned to complexes in which a water dimer is hydrogen-bonded either to the carbonyl oxygen of the ester function or to the amino nitrogen. Surprisingly, computed IR spectra reveal that the N-bonded isomer is responsible for the observed red-shifted fluorescence. For an explanation, the mechanism of twisted intramolecular charge-transfer (TICT) formation and energy dissipation is investigated in detail. In general, for red-shifted fluorescence to occur, the N-bonded complexes must be able to dissipate energy, which in the gas phase can only happen nonradiatively via fragmentation. Arguments are given that only the N-bonded isomer photodissociates rapidly enough into free DMABME and a water dimer as a result of the immediate repulsion between the amino nitrogen and the water dimer in the TICT state. The O-bonded isomer, on the other hand, stays intact because the hydrogen bond is strengthened by additional electrostatic attraction in the ICT state. Furthermore, an experiment to further corroborate that mechanism is suggested.

Anxiety and depression in patients with prostate cancer and other urogenital cancer: a longitudinal study.

OBJECTIVE: The aim of this study was to assess the degree and the course of psychological distress (anxiety and depression) in cancer patients and to detect sociodemographic determinants of the scores. METHODS AND MATERIALS: Patients with prostate cancer (n = 287) and other urogenital cancer (n = 126) were tested with the Hospital Anxiety and Depression Scale (HADS) at the following time points: at the beginning (T1) and the end (T2) of the treatment in the hospital, 6 months later (T3), and 1 year later (T4). RESULTS: Anxiety mean scores were highest at the start of the stay in the hospital. About 36% of the patients were at least doubtful cases at T1. However, the anxiety mean scores from T2 to T4 were similar to those of the general population and lower than those of cardiac patients. Depression mean scores were even lower than those of the general population. Young age and receiving radio- and/or chemotherapy were predictive of higher psychological distress. CONCLUSIONS: The low mean scores of anxiety and depression from T2 to T4 indicate that most of the prostate cancer patients do not need help from mental health professionals. Nevertheless, some patients may profit from mental health support, especially at the beginning of the stay in the hospital.

Longitudinal analysis of psychiatric morbidity in cancer patients.

BACKGROUND: About one third of cancer patients suffers from a psychiatric disorder. However, only few studies feature long-term assessment of psychiatric disease in cancer patients, covering a broad range of diagnoses, and employing high-quality instruments. PATIENTS AND METHODS: A total of 62 patients underwent assessments during a 3-year follow-up period after initial cancer diagnosis. The Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was used to measure psychiatric morbidity at baseline (t1) and 2 follow-up assessments (t2 and t3). Follow-up assessments took place between 6 and 18 months (t2) and between 24 and 36 months (t3) after baseline measurement. RESULTS: At t1, at least one DSM-IV diagnosis was found in 29% of the patients. During follow-up, the frequency of psychiatric morbidity increased to 36% at t2 and 44% at t3. New occurrence of psychiatric disease during follow-up was 18% at t2 and 38% at t3. CONCLUSION: Persistence and number of newly diagnosed psychiatric disorders during the first 3 years after cancer treatment should be considered in the treatment of cancer patients, especially in individuals with according predictive factors.

The Course of Anxiety and Depression in Patients with Breast Cancer and Gynaecological Cancer.

BACKGROUND/AIMS: The aim of this study was to assess the course of anxiety and depression in cancer patients over time and to detect determinants of the changes in the scores. PATIENTS AND METHOD: Women with breast cancer and gynaecological cancer (n = 367) were tested at the beginning (T1) and at the end (T2) of treatment in the hospital, 6 months later (T3), and 12 months later (T4), using the Hospital Anxiety and Depression Scale (HADS). RESULTS: Anxiety and depression were highest at the start of the stay in the hospital. More than half of the women are at least doubtful cases in at least one of the two HADS dimensions. The mean scores declined from T1 to T4. After 1 year, depression scores are similar to those of the general population, while anxiety scores remain elevated. The decline of the HADS scores depends on treatment, time since diagnosis, and education. CONCLUSIONS: Women receiving radio- or chemotherapy (compared with surgery only), with a long time since diagnosis, and with a low educational level are at high risk of maintaining high anxiety and depression scores over time.

Screening for mental disorders in laryngeal cancer patients: a comparison of 6 methods.

OBJECTIVES: The aim of this study was to determine how accurate mental distress screening instruments are in identifying psychological sequelae in ambulatory laryngeal cancer patients who have undergone surgery. METHODS: Two-hundred and fifty subjects were tested for mental disorders according to the guidelines defined in the Diagnostic Statistical Manual of Psychological Illnesses, Version 4. Screening instruments tested were: the 'Hospital Anxiety and Depression Scale' (HADS), the subscale 'Emotional Functioning' of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the 'Hornheider Fragebogen' (HFB), and a single-item visual analogues scale (VAS). Accuracy was assessed by calculating the sensitivity rates, specificity rates, and areas under the curve from the receiver operating characteristic curves. RESULTS: The relative frequency of mental disorders was 19.8%. All of the screening instruments tested were found to be highly accurate. The best levels of sensitivity and specificity were associated with the total score of the HADS. CONCLUSIONS: These results confirm that a significant minority of laryngeal cancer patients suffer from severe mental distress, and that accurate screening for clinically significant mental disorders is possible using any of the instruments evaluated here.

Long-term course of psychiatric disorders in cancer patients: a pilot study.

BACKGROUND: About one third of cancer patients suffer from a psychiatric disorder. However, only few studies feature long-term assessment of psychiatric disease in cancer patients, covering a broad range of diagnoses, and employing high-quality instruments. PATIENTS AND METHODS: A total of 62 patients underwent assessments during a 3-year follow-up period after initial cancer diagnosis. The Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders was administered to measure psychiatric morbidity at baseline (t1) and two follow-ups (t2 and t3). Follow-up assessments took place from 6 to 18 months (t2) and from 24 to 36 months (t3) after baseline. Biomedical and psychosocial factors were evaluated to identify predictors of psychiatric disorders using univariate and multivariate analyses. RESULTS: At t1, at least one DSM-IV diagnosis was found in 29% of the cases. At follow-ups, the frequency of psychiatric morbidity increased to 36% at t2 and 44% at t3, respectively. New occurrence of psychiatric disease at follow-ups was 18% at t2, and 38%, at t3. Predictors of psychiatric disorders were low social support, low physical functioning, metastases, complications of disease, and loss of sportive activity. CONCLUSION: Persistence and amount of newly diagnosed psychiatric disorders during three years after cancer treatment should be considered in the treatment of cancer patients, especially in individuals with accordant predictive factors.