Therapists' experiences with implementing new documentation practices for low back pain in electronic health care records: an interview study.

OBJECTIVE: Clinical practice is constantly changing with new guidelines being published, changes in patients' preferences but also by new qualitative requirements for therapists and institutional surveys on delivered care. Electronic health records (EHR) are used for all these purposes. We involved physiotherapists and occupational therapists in an intervention to change documentation practice in their electronic health record for low back pain (LBP) and later evaluated the feasibility of the new health records. The aim of the present study was to explore therapists' experiences working with the new EHR. RESULTS: Three themes were identified thru interviews: (I) Facilitators and motivators towards implementation, (II) Changing routines as a group and (III) Obstacles against successful implementation. This study identifies a need for involving therapists and management for successful change of electronic health care records usage in municipalities. However, difficulties were encountered in meeting documentation of practice requirements and obtaining sufficient data quality in the EHR for data to be used for daily use, quality assessment and research. In this small descriptive study, developing an EHR that simultaneously serves treatment plans, quality assessment, and research purposes was not expressed being feasible. Further research in this area is needed.

Models Used in Clinical Decision Support Systems Supporting Healthcare Professionals Treating Chronic Wounds: Systematic Literature Review.

BACKGROUND: Chronic wounds such as diabetic foot ulcers, venous leg ulcers, and pressure ulcers are a massive burden to health care facilities. Many randomized controlled trials on different wound care elements have been conducted and published in the Cochrane Library, all of which have only a low evidential basis. Thus, health care professionals are forced to rely on their own experience when making decisions regarding wound care. To progress from experience-based practice to evidence-based wound care practice, clinical decision support systems (CDSS) that help health care providers with decision-making in a clinical workflow have been developed. These systems have proven useful in many areas of the health care sector, partly because they have increased the quality of care, and partially because they have generated a solid basis for evidence-based practice. However, no systematic reviews focus on CDSS within the field of wound care to chronic wounds. OBJECTIVE: The aims of this systematic literature review are (1) to identify models used in CDSS that support health care professionals treating chronic wounds, and (2) to classify each clinical decision support model according to selected variables and to create an overview. METHODS: A systematic review was conducted using 6 databases. This systematic literature review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic reviews. The search strategy consisted of three facets, respectively: Facet 1 (Algorithm), Facet 2 (Wound care) and Facet 3 (Clinical decision support system). Studies based on acute wounds or trauma were excluded. Similarly, studies that presented guidelines, protocols and instructions were excluded, since they do not require progression along an active chain of reasoning from the clinicians, just their focus. Finally, studies were excluded if they had not undergone a peer review process. The following aspects were extracted from each article: authors, year, country, the sample size of data and variables describing the type of clinical decision support models. The decision support models were classified in 2 ways: quantitative decision support models, and qualitative decision support models. RESULTS: The final number of studies included in the systematic literature review was 10. These clinical decision support models included 4/10 (40%) quantitative decision support models and 6/10 (60%) qualitative decision support models. The earliest article was published in 2007, and the most recent was from 2015. CONCLUSIONS: The clinical decision support models were targeted at a variety of different types of chronic wounds. The degree of accessibility of the inference engines varied. Quantitative models served as the engine and were invisible to the health care professionals, while qualitative models required interaction with the user.

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.

Collect Once - Use Many Times: The Research Potential of Low Back Pain Patients' Municipal Electronic Healthcare Records.

Collect Once - Use Many Times can possibly increase the research potential of clinical data from electronic healthcare records (EHR). The objective of this study was to achieve an increased understanding of the research potential of low back pain patients' municipal EHR by assessing the data quality. This explanatory sequentially mixed-methods case study consists of descriptive- and content analysis. The descriptive analysis was based on data extracted from the municipal EHR. The indicators chosen were pain and physical function. Included subjects were low back pain patients in the Northern Denmark. For the content analysis, clinical notes from the municipal EHR was used. The descriptive analysis (n=172) showed that the outcome measure for pain was documented in 50% of the municipal EHR and the outcome measure for physical function was documented in 48% of the municipal EHR. The content analysis (n=5) revealed imprecise, inconsistent, and nonsystematic use of outcome measures. In conclusion, the poor data quality observed is a potential barrier for introducing the Collect Once - Use Many Times paradigm, which is a prerequisite for reusing clinical data for quality assessment and research purposes.

Comparison between Mother, ActiGraph wGT3X-BT, and a hand tally for measuring steps at various walking speeds under controlled conditions.

INTRODUCTION: Walking is endorsed as health enhancing and is the most common type of physical activity among older adults. Accelerometers are superior to self-reports when measuring steps, however, if they are to be used by clinicians the validity is of great importance. The aim of this study was to investigate the criterion validity of Mother and ActiGraph wGT3X-BT in measuring steps by comparing the devices to a hand tally under controlled conditions in healthy participants. METHODS: Thirty healthy participants were fitted with a belt containing the sensor of Mother (Motion Cookie) and ActiGraph. Participants walked on a treadmill for two minutes at each of the following speeds; 3.2, 4.8, and 6.4 km/h. The treadmill walking was video recorded and actual steps were subsequently determined by using a hand tally. Wilcoxon's signed ranks test was used to determine whether Mother and ActiGraph measured an identical number of steps compared to the hand tally. Intraclass correlation coefficients were calculated to determine the relationship and Root Mean Square error was calculated to investigate the average error between the devices and the hand tally. Percent differences (PD) were calculated for between-instrument agreement (Mother vs. the hand tally and ActiGraph vs. the hand tally) and PDs below 3% were interpreted as acceptable and clinically irrelevant. RESULTS: Mother and ActiGraph under-counted steps significantly compared to the hand tally at all walking speeds (p < 0.001). Mother had a median of total differences of 9.5 steps (IQR = 10) and ActiGraph 59 steps (IQR = 77). Mother had smaller PDs at all speeds especially at 3.2 km/h (2.5% compared to 26.7%). Mother showed excellent ICC values ≥0.88 (0.51-0.96) at all speeds whilst ActiGraph had poor and fair to good ICC values ranging from 0.03 (-0.09-0.21) at a speed of 3.2 km/h to 0.64 (0.16-0.84) at a speed of 6.4 km/h. CONCLUSION: Mother provides valid measures of steps at walking speeds of 3.2, 4.8, and 6.4 km/h with clinically irrelevant deviations compared to a hand tally while ActiGraph only provides valid measurements at 6.4 km/h based on the 3% criterion. These results have significant potential for valid objective measurements of low walking speeds. However, further research should investigate the validity of Mother in patients at even slower walking speeds and in free-living conditions.

Participatory heuristic evaluation of a tablet computer system for clinical microbiology.

MultiplexBCT is a molecular-based diagnostic test for rapid identification of microorganisms in positive blood cultures. A MultiplexBCT Android tablet computer application is being developed as an accessory to the diagnostic test. The aim of the application is to facility the end user's workflow by supporting data entry and communication of the MultiplexBCT test results in a hospital environment. This paper reports the results and benefit of a participatory heuristic evaluation conducted on the MultiplexBCT application. The design is an extension of heuristic evaluation that includes end users as work-domain experts to complement usability experts for inspection of a user interface. The user interface assessment identified 86 heuristic violations, which consisted of both product- and domain-related issues. These results will be used to guide further development of the MultiplexBCT application to ensure that the system will fully support the workflow of the end users when using the MultiplexBCT diagnostic test.

Exploring end users' system requirements for a handheld computer supporting both sepsis test workflow and current IT solutions.

Sepsis is a systemic response associated with very high mortality. Early initiation of the correct antimicrobial therapy remains a cornerstone in the treatment of sepsis. Currently, a new microbiological test is under development, which aims to detect major, prevalent pathogens in positive blood cultures within an hour. Concurrently, a tablet-based data entry and reporting system will be developed to facilitate the workflow of the test. This study investigated the system requirements for the tablet-based data entry and reporting system in order to support the clinical workflow. By observing the workflow of the blood culture analysis and through interviews with medical laboratory technicians, four main system requirements were identified. The system requirements are; the ability to receive and send data to the laboratory information system, support for the use of barcodes, the ability to access a browser based instruction system, and communication of results between medical laboratory technicians and physicians. These system requirements will be used as a basis in the future development of the tablet-based data entry and reporting system.