Modeling problem-oriented clinical notes.

OBJECTIVES: To develop a model as a starting-point for developing a problem-oriented clinical notes application as a generic component of an Electronic Health Record (EHR). METHODS: We used the generic conceptualization of Weed's problem-oriented medical record (POMR) to link progress notes to problems, and the Subjective, Objective, Assessment, Plan (SOAP) headings to classify elements of these notes. Health Level 7 (HL7) Version 3 and Unified Modeling Language (UML) were used for modeling. We looked especially at the role of Conditions and Concerns, and how to model these to document clinical reasoning. RESULTS: We developed a generic HL7-based model for progress notes. In this model the specific clinical note has a condition as its reason. An assertion can be made about a condition. Any condition, observation or procedure can be a concern that has to be tracked. Utmost important is the relationship between constituting parts of a progress note and specially between progress notes by linking a progress note to conditions that are part of an earlier progress note. From this model a comprehensive hierarchical condition tree can be built. Several views, such as chronological, SOAP and condition-oriented, are possible. The clinical notes application is used in daily clinical practice. The model meets explicit design criteria and clinical needs. CONCLUSIONS: With the comprehensive HL7 standard it is possible to model and map progress notes using SOAP headings and POMR methodology. We have developed a generic, flexible and applicable paradigm by using acts for each assessment that refer to a condition (1), by separating conditions from concerns (2), and by an extensive use of the working list act (3).

IVF patients show three types of online behaviour.

BACKGROUND: The internet introduces new ways to deal with stress. However, it is unclear how its resources are used in everyday life. Using a web-based personal health record (PHR), we observed the patient's online behaviour and linked this to distress, theories on dealing with stress and demographics. METHODS: Between 2004 and 2007, all viewed web-pages were logged and categorized into 14 content types. Behavioural styles were elicited using factor analysis. These behavioural styles were subsequently correlated to data on demographics, coping mechanisms and distress from the female partner of the first 53 patient couples that used the PHR. RESULTS: One thousand and fifty patient couples viewed 588 887 web pages during their first treatment cycle. Factor analysis elicited three online behavioural styles explaining 66.9% of all variance in usage of the website: an 'individual information style', a 'generic information style' and a 'communication style'. The 'individual information style' correlated negatively to having paid employment (Spearman = -0.364, P = 0.007) and emotional coping mechanisms (Spearman = -0.305, P = 0.028). The 'communication style' correlated positively to having paid employment (Spearman = 0.318, P = 0.021) and anxiety (Spearman = 0.381, P = 0.005). CONCLUSIONS: IVF patients show three types of online behaviour. Only limited correlations exist between these styles and demographics, coping mechanisms or distress. When planning a website or portal for IVF patients, content should be adopted accordingly.

Estimating morbidity rates from electronic medical records in general practice. Evaluation of a grouping system.

OBJECTIVES: In this study, we evaluated the internal validity of EPICON, an application for grouping ICPC-coded diagnoses from electronic medical records into episodes of care. These episodes are used to estimate morbidity rates in general practice. METHODS: Morbidity rates based on EPICON were compared to a gold standard; i.e. the rates from the second Dutch National Survey of General Practice. We calculated the deviation from the gold standard for 677 prevalence and 681 incidence rates, based on the full dataset. Additionally, we examined the effect of case-based reasoning within EPICON using a comparison to a simple, not case-based method (EPI-0). Finally, we used a split sample procedure to evaluate the performance of EPICON. RESULTS: Morbidity rates that are based on EPICON deviate only slightly from the gold standard and show no systematic bias. The effect of case-based reasoning within EPICON is evident. The addition of case-based reasoning to the grouping system reduced both systematic and random error. Although the morbidity rates that are based on the split sample procedure show no systematic bias, they do deviate more from the gold standard than morbidity rates for the full dataset. CONCLUSIONS: Results from this study indicate that the internal validity of EPICON is adequate. Assuming that the standard is gold, EPICON provides valid outcomes for this study population. EPICON seems useful for registries in general practice for the purpose of estimating morbidity rates.

Impact of a spirometry expert system on general practitioners' decision making.

The present study assessed the impact of computerised spirometry interpretation expert support on the diagnostic achievements of general practitioners (GPs), and on GPs' decision making in diagnosing chronic respiratory disease. A cluster-randomised controlled trial was performed in 78 GPs who each completed 10 standardised paper case descriptions. Intervention consisted of support for GPs' spirometry interpretation either by an expert system (expert support group) or by sham information (control group). Agreement of GPs' diagnoses was compared with an expert panel judgement, which served as the primary outcome. Secondary outcomes were: additional diagnostic test rates; width of differential diagnosis; certainty of diagnosis; estimated severity of disease; referral rate; and medication or nonmedication changes. Effects were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). There were no differences between the expert support and control groups in the agreement between GPs and expert panel diagnosis of chronic obstructive pulmonary disease (OR (95% CI) 1.08 (0.70-1.66)), asthma (1.13 (0.70-1.80)), and absence of respiratory disease (1.32 (0.61-2.86)). A higher rate of additional diagnostic tests was observed in the expert support group (2.5 (1.17-5.35)). Computerised spirometry expert support had no detectable benefit on general practitioners' diagnostic achievements and the decision-making process when diagnosing chronic respiratory disease.

[Clinical knowledge cannot only be acquired in practice]. / Klinische kennis kan niet alleen in de praktijk verkregen worden.

Methodological training is necessary in order to cope with the ever-growing volume of knowledge by clinical experience. This training involves ways of reasoning and collecting relevant evidence. This type of instruction should be given in concurrence with the first exercises in clinical reasoning. Such instruction should focus on acquisition of the ability to clearly substantiate decisions made during medical practice.

Patient-centred care: using online personal medical records in IVF practice.

BACKGROUND: Generic patient-accessible medical records have shown promise in enhancing patient-centred care for patients with chronic diseases. We sought to design, implement and evaluate a patient-accessible medical record specifically for patients undergoing a course of assisted reproduction (IVF or ICSI). METHODS: The personal medical record (PMR) database was developed using three formative evaluation steps, and its user-experience was evaluated through a cross-sectional study. Fifty-four patient-couples receiving an IVF or ICSI treatment in our hospital were granted access to the PMR. Main outcomes concern the usage of the PMR, the perceived usefulness of its functions and user attitudes towards privacy and financial issues. RESULTS: The PMR consists of 15 major functions that can be classified into personal information, general information and communication functions. Fifty-three patient-couples accessed the website and 51 couples filled out the evaluation questionnaire. They rated most functions as useful and preferred personalized to general functions. The results also show that some functions require further development. Patients using the PMR have little concerns regarding privacy, and 76% are willing to pay for such a service in the future. CONCLUSIONS: The patients in this study frequently and intensively used the Internet-accessible PMR. This suggests that the PMR offers very useful functions from an IVF/ICSI patient's perspective.

EGOOZ: specifying the components of electronic patient record-related education.

OBJECTIVE: To determine whether educators consider electronic patient record (EPR)-related education necessary and if so, what subjects have to be taught more extensively in the future. METHODS: A list of possibly relevant subjects was determined from the literature. A questionnaire was designed which contained those subjects and the respondents were asked to indicate, for each subject, its competency level and required competency level in current teaching. Since the response rate was low a second questionnaire was developed to have the results of the analysis of the first questionnaire validated by a larger group of educators. RESULTS: In total 45 learning goals were identified from the literature. The questionnaire was sent to representatives of several disciplines: basic medical education, medical specializations, pharmacy, dentistry and nursing. The analysis of the first questionnaire resulted in nine subjects that needed more attention in the future. Because of the low response the needs could not be specified for the individual disciplines. This insight was obtained from a second questionnaire. The response to this questionnaire was high. From the analysis of the second questionnaire differences between views of educators involved in the training of GPs and educators involved in the training of other specializations were observed. CONCLUSION: Educators find EPR-related education important. There are different opinions about the phase in which EPR-related education should be given.

A generic model of clinical practice.

OBJECTIVES: Many shared-care projects feel the need for electronic patient-record (EPR) systems. In absence of practical experiences from paper record keeping, a theoretical model is the only reference for the design of these systems. In this article, we review existing models of individual clinical practice and integrate their useful elements. We then present a generic model of clinical practice that is applicable to both individual and collaborative clinical practice. METHODS: We followed the principles of the conversation-for-action theory and the DEMO method. According to these principles, information can only be generated by a conversation between two actors. An actor is a role that can be played by one or more human subjects, so the model does not distinguish between inter-individual and intra-individual conversations. RESULTS: Clinical practice has been divided into four actors: service provider, problem solver, coordinator, and worker. Each actor represents a level of clinical responsibility. Any information in the patient record is the result of a conversation between two of these actors. Connecting different conversations to one another can create a process view with meta-information about the rationale of clinical practice. Such process view can be implemented as an extension to the EPR. CONCLUSIONS: The model has the potential to cover all professional activities, but needs to be further validated. The model can serve as a theoretical basis for the design of EPR-systems for shared care, but a successful EPR-system needs more than just a theoretical model.

Why don't medical textbooks teach? The lack of logic in the differential diagnosis.

Medical textbooks are an important aid in the process of diagnosing and treating patients. Medical students use these books to acquire the skills necessary for this process, while medical teachers and experienced doctors use them for teaching these competences. We posed the question whether medical textbooks are structured in such a way that medical students are taught to structure knowledge and to make a differential diagnosis in a logical way. Five major textbooks were compared with regard to four clinical problems (gastrointestinal bleeding, anaemia, oedema and heart failure). The presentation appeared to be very variable in respect of logic and systematic arrangement. In fact, it was disappointing that even in well-reputed textbooks, a systematic approach is lacking. We feel there is a need for improvement, in order to facilitate the learning of medical students and to enhance their abilities in clinical problem solving.

Efficient diagnostic test sequence: applications of the probability-modifying plot.

Excessive diagnostic testing rarely leads to complete certainty of the disease status of a patient. Because of constraints of health care budgets, physicians should be aware of the diminishing marginal gain of each subsequent test in a testing strategy related to costs. We developed the probability-modifying plot to determine economically efficient sequence of testing without losing clinical effectiveness. Two applications of the model are presented: diagnosis of Helicobacter pylori and diagnosis of benign prostatic hyperplasia. The probability-modifying plots are drawn to visualize and calculate the economic efficiency of all possible test sequences, meaning that although the different test sequences are equally accurate, some have even lower costs than others.

A formal framework of knowledge to support rational psychoactive drug selection.

Rational psychoactive drug selection is a data and knowledge intensive task which requires true expertise from clinical, pathophysiological and pharmacotherapeutic knowledge. This paper presents a framework of knowledge, which relates concepts from several disciplines required for psychoactive drug selection in a formal way. A framework, when based on formal semantics, avoids ambiguity and gives conceptual clarity and supports precise use of terminology which is required when many domain experts (clinicians, pharmacologists and basic science researchers) are involved. A formal framework permits linking of existing classification systems. It furthermore can serve as a knowledge base for drug selection decision support systems.

Towards a more rational use of psychoactive substances in clinical practice.

Complex knowledge and data intensive nature of the psychoactive drug selection and prescription process often makes for irrational and inconsistent use of psychoactive drugs in clinical practice. After describing the state of the art with respect to psychoactive drug prescription practices and selection processes, our aim is to analyze the advantages of computer support systems in assisting the clinician in his clinical decisions. Finally, we will review the neuropsychiatric expert systems developed for the neuropsychiatric domain. Suboptimal psychoactive drug therapy is common practice, which leads to hospital admissions, extended length of hospital stay, ineffective therapy and increased costs. Furthermore, the psychoactive drug selection process is a complex decision process, using up-to-date integrative knowledge of drugs from basic sciences to the clinical level. Due to the information load, the lack of appropriate up-to-date information at the point of clinical care and the problem of integrating and weighing all information relatively equally, it is questionable whether any clinician can manage such a complex situation with optimal effectiveness. As has been shown in a number of experiments, clinicians can benefit from computer-based systems that provide access to accurate, up-to-date information. We maintain that more rational use of psychoactive drugs in clinical practice is needed, and conclude that rational psychoactive drug prescription is a knowledge and data-intensive task requiring true expertise derived from clinical, pathophysiological and pharmacotherapeutic knowledge. We will be developing a Multidisciplinary Psychoactive Drug Selection advisor system, M-PADS, to support the integration of various types of biomedical information and deliver that integrated information supportive to evidence-based rational drug prescription in the practice of medicine for the drug treatment of individual patients.

Clinical problem analysis (CPA): a systematic approach to teaching complex medical problem solving.

The authors describe and discuss clinical problem analysis (CPA), an approach to solving complex clinical problems. They outline the five steps of the CPA model and the essential elements of each step. Next, they discuss the value of CPA's content-independent (methodical) approach and argue that teaching students to use CPA will enable them to avoid some common diagnostic reasoning errors and pitfalls. Finally, they compare CPA with two existing approaches to clinical problem solving.

Formal description of temporal knowledge in case reports.

Patient case analysis is an elementary and crucial process which clinicians are daily confronted with. The importance and complexity is reflected in the need to discuss cases in clinicopathological conferences and the documentation of more than 70,000 patient cases in MEDLINE. This paper introduces a generic patient case report language (PCRL) based on general medical temporal concepts to formalise temporal knowledge as present in case descriptions. The lack of such a generic technique is reflected by the fact that computers are very restrictive in accepting patient specific temporal information. Acceptance is almost always controlled and guided by specific predefined disease or treatment models. We strive for a case library consisting of unambiguous patient case descriptions formulated independent from future use.

Optimizing diagnostic test sequences: the probability modifying plot.

The problem of deciding the optimal sequence of diagnostic tests can be structured in decision trees, but unmanageable bushy decision trees result when the sequence of two or more tests is investigated. Most modelling techniques include tests on the basis of gain in certainty. The aim of this study was to explore a model for optimizing the sequence of diagnostic tests based on efficiency criteria. The probability modifying plot shows, when in a specific test sequence further testing is redundant and which costs are involved. In this way different sequences can be compared. The model is illustrated with data on urinary tract infection. The sequence of diagnostic tests was optimized on the basis of efficiency, which was either defined as the test sequence with the least number of tests or the least total cost for testing. Further research on the model is needed to handle current limitations.

Guidelines for using diagnostic imaging devices: an inference system.

This paper deals with optimising the use of magnetic resonance imaging (MRI) scanners through the development of a new kind of clinical guidelines called 'substrate-specific protocols'. These protocols would link the descriptive elements of lesions to the most appropriate imaging techniques on the basis of the biophysics of MRI. As many lesions have elements in common, substrate-specific protocols could have a more general character and be more firmly based on evidence than conventional guidelines. We developed an inference model to enter, structure and retrieve knowledge acquired through a literature search. This proved a practicable and attractive approach. Its exactness, however, reveals the imperfections of medical knowledge and clinical practice. We conclude that it could be hard to establish an 'evidence basis' for clinical guidelines, if 'evidence based' means rooted in natural science.

Reducing normative bias in health technology assessment: interactive evaluation and casuistry.

Health technology assessment (HTA) is often biased in the sense that it neglects relevant perspectives on the technology in question. To incorporate different perspectives in HTA, we should pursue agreement about what are relevant, plausible, and feasible research questions; interactive technology assessment (iTA) might be suitable for this goal. In this way a kind of procedural ethics is established. Currently, ethics too often is focussed on the application of general principles, which leaves a lot of confusion as to what really is the matter in specific cases; in an iTA clashes of values should not be approached by use of such ethics. Instead, casuistry, as a tool used within the framework of iTA, should help to articulate and clarify what is the matter, as to make room for explication and consensus building.

Nosology and causal necessity; the relation between defining a disease and discovering its necessary cause.

The problem of disease definition is related to the problem of proving that a certain agent is the necessary cause of a certain disease. Natural kind terms like 'rheumatoid arthritis' and 'AIDS' refer to essences which are discoverable rather than predeterminate. No statement about such diseases is a priori necessarily true. Because theories on necessary causes involve natural kind semantics, Koch's postulates cannot be used to falsify or verify such theories. Instead of proving that agent A is the necessary cause of disease D, we include A in a theoretical definition of D, take this to represent the real meaning of 'D', and discard the pretheoretical definition. This is illustrated by Koch's own attempt to prove he had discovered the necessary cause of tuberculosis. Methodological arguments about disease causation require a clear view of our use of diagnostic terms. Medical lexicographers should do more to provide such a view.

Three types of IS-A statement in diagnostic classifications: three types of knowledge needed for development and maintenance.

Update mechanisms for diagnostic classifications should capture changes in medical knowledge but also allow for comparability across versions. This paper provides a basis for such a mechanism by describing types of IS-A statement and types of knowledge used in the construction of diagnostic classifications. Three types of IS-A statement are used: 'A is by definition a B', 'A is probably a B' and 'A is in theory necessarily a B'. Each relates to a different type of knowledge: knowledge of linguistic conventions, of probabilities, and of empirical theories and their status, respectively. Consequently, the development and maintenance of diagnostic classifications requires a collaboration of medical terminologists and medical scientists. The role of the latter is especially important during updating. Updating is necessitated by changing probabilities and by the introduction or changing status of empirical theories. The linguistic notion of hyponymy oversimplifies the issue.