Factors Influencing the Effectiveness of Adopting Electronic Medical Record-Based Reporting Systems for Notifiable Disease Surveillance: A Quantitative Analysis.

The coronavirus disease 2019 (COVID-19) pandemic has led to greater attention being given to infectious disease surveillance systems and their notification functionalities. Although numerous studies have explored the benefits of integrating functionalities with electronic medical record (EMR) systems, empirical studies on the topic are rare. The current study assessed which factors influence the effectiveness of EMR-based reporting systems (EMR-RSs) for notifiable disease surveillance. This study interviewed staff from hospitals with a coverage that represented 51.39% of the notifiable disease reporting volume in Taiwan. Exact logistic regression was employed to determine which factors influenced the effectiveness of Taiwan's EMR-RS. The results revealed that the influential factors included hospitals' early participation in the EMR-RS project, frequent consultation with the information technology (IT) provider of the Taiwan Centers for Disease Control (TWCDC), and retrieval of data from at least one internal database. They also revealed that using an EMR-RS resulted in more timely, accurate, and convenient reporting in hospitals. In addition, developing by an internal IT unit instead of outsourcing EMR-RS development led to more accurate and convenient reporting. Automatically loading the required data enhanced the convenience, and designing input fields that may be unavailable in current databases to enable physicians to add data to legacy databases also boosted effectiveness of the reporting system.

[The Application of Information and Communication Technology (ICT) in Nursing Education].

With the rapid development of information and communication technologies (ICT) in the 21st century, all walks of life have experienced disruptive changes, including the healthcare profession. Although nurses represent the largest number of professionals in medical institutions, it is doubtful whether nurses possess sufficient capabilities to face challenges in this era of rapid medical informatization. Currently, the courses necessary to cultivate information literacy in nursing students are insufficient in Taiwan, and traditional instruction methods are largely adopted as nursing teaching strategies. Additionally, most teachers hold a passive attitude towards the application of ICT in teaching. On the contrary, ICT have been integrated into nursing education in many countries around the world for nearly 20 years, achieving good levels of teaching efficacy. Reflecting the Taiwan government's promotion of digital learning projects, academic circles in various fields have also started to gradually integrate ICT into teaching. Nursing educators in Taiwan have much to reference and to learn from these disparate integration experiences. Therefore, this article introduces the concepts of integration of ICT into teaching, the current status of the application of ICT in international nursing education, and the issues faced during this application as a reference for nursing education in Taiwan in order to promote the integration of ICT into nursing education.

[The Development of an Intelligent Long-Term Care Services System That Integrates Innovative Information and Communication Technologies].

Rapid progress in information and communication technologies and the increasing popularity of healthcare-related applications has increased interest in the topic of intelligent medical care. This topic emphasizes the use of information and communication technologies to collect and analyze a variety of data in order to provide physicians and other healthcare professionals with clinical decision support. At present, so-called smart hospitals are the focal point of most intelligent-systems development activity, with little attention currently being focused on long-term care needs. The present article discusses the application of intelligent systems in the field of long-term care, especially in community and home-based models of care. System-implementation components such as the data entry interface components of mobile devices, the data transmission and synchronization components between the mobile device and file server, the data presentation, and the statistics analysis components are also introduced. These components have been used to develop long-term care service-related applications, including home health nursing, home-care services, meals on wheels, and assistive devices rental. We believe that the findings will be useful for the promotion of innovative long-term care services as well as the improvement of healthcare quality and efficiency.

The Effects of Quality of Life and Ability to Perform Activities of Daily Living on Mild Cognitive Impairment in Older People Living in Publicly Managed Congregate Housing.

BACKGROUND: Mild cognitive impairment (MCI) is characterized by a decrease in cognitive abilities that does not affect the ability to perform activities of daily living (ADLs). Therefore, this condition is easily overlooked. The prevalence and factors of influence for MCI in older people living in publicly managed congregate housing are currently unknown. PURPOSE: This study investigated the prevalence and distribution of MCI in older people living in publicly managed congregate housing and assessed the correlations among quality of life (QoL), ADL, and MCI. METHODS: This study applied a correlational study design. The participants were older people who met the study criteria and who lived in public housing in Wanhua District, Taipei City, Taiwan. One-on-one interviews were conducted to measure the cognitive abilities of the participants, and 299 valid samples were collected. RESULTS: The prevalence of MCI in older people living in publicly managed congregate housing was 16.1%. The χ test was employed to evaluate the distribution of MCI prevalence and indicated that the group with higher MCI prevalence exhibited the following characteristics: older than 81 years; married; lived in public housing for more than 20 years; cohabiting; had a history of drinking; and exhibited severe memory regression, physical disabilities, psychological distress, and low QoL. The difference between the groups achieved statistical significance (p < .05). After performing logistical regression analysis to control demographic variables, we found that QoL and ADL were critical for predicting MCI. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: This study confirmed that QoL and ADL correlate significantly with MCI in older people. Maintaining an open and supportive community enables older people to maintain sufficient mental activity, which has been shown to reduce MCI. These findings may provide an important reference for policy makers, educators, researchers, and community practitioners in their development of service strategies for older people.

Design of a Personal Health Record and Health Knowledge Sharing System using IHE-XDS and OWL.

Personal Health Record systems (PHRs) provide opportunities for patients to access their own PHR. However, PHRs are teeming with medical terminologies, such as disease and symptom names, etc. Patients need readily understandable and useful health knowledge in addition to their records in order to enhance their self-care ability. This study describes a Personal Health Record and Health Knowledge Sharing System (PHR&HKS) whereby users not only can maintain and import their PHR, but also can collate useful health Web resources that are related to their personal diseases. Furthermore, they can share the collated Web resources with any user with the same diseases and vice versa. To fulfill these objectives, IHE Cross-Enterprise Document Sharing (XDS) architecture was adopted to share and integrate the PHR. A registry ontology, consisting of part of the XDS document metadata attributes, the ICD-9-CM code, and part of the Dublin Core Metadata Element Set (DCMES), was created to enhance the health knowledge collating and sharing functions. The system was then tested and evaluated by 30 users. Among these individuals, 24 (81 %) held positive views on the ease of use and usefulness of the system while the remainder, who held either neutral (14 %) or negative (5 %) attitudes, were identified as individuals who were somewhat unwilling to maintain any PHR or share any information with others.

Impact of age on end-of-life care for adult Taiwanese cancer decedents, 2001-2006.

BACKGROUND: With increasing patient age in Western countries, evidence indicates a pervasive pattern of decreasing healthcare expenditures and less aggressive medical care, including end-of-life (EOL) care. However, the impact of age on EOL care for Asian cancer patients has not been investigated. PURPOSE: To explore how healthcare use at EOL varies by age among adult Taiwanese cancer patients. METHODS: Retrospective cohort study using administrative data among 203,743 Taiwanese cancer decedents, 2001-2006. Age was categorized as 18-64, 65-74, 75-84, and ≥85 years. RESULTS: Elderly (≥65 years) Taiwanese cancer patients were significantly less likely than those 18-64 years to receive aggressive treatment in their last month of life, including chemotherapy, >1 emergency room visits, >1 hospital admissions, >14 days of hospitalization, hospital death, intensive care unit admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation. However, they were significantly more likely to receive hospice care in their last year of life. CONCLUSION: Elderly Taiwanese cancer patients at EOL received less chemotherapy, less aggressive management of health crises associated with the dying process, and fewer life-extending treatments, but they were more likely to receive hospice care in their last year and to achieve the culturally highly valued goal of dying at home.

Design and development of a tele-healthcare information system based on web services and HL7 standards.

Information and communication technologies progress rapidly and many novel applications have been developed in many domains of human life. In recent years, the demand for healthcare services has been growing because of the increase in the elderly population. Consequently, a number of healthcare institutions have focused on creating technologies to reduce extraneous work and improve the quality of service. In this study, an information platform for tele- healthcare services was implemented. The architecture of the platform included a web-based application server and client system. The client system was able to retrieve the blood pressure and glucose levels of a patient stored in measurement instruments through Bluetooth wireless transmission. The web application server assisted the staffs and clients in analyzing the health conditions of patients. In addition, the server provided face-to-face communications and instructions through remote video devices. The platform deployed a service-oriented architecture, which consisted of HL7 standard messages and web service components. The platform could transfer health records into HL7 standard clinical document architecture for data exchange with other organizations. The prototyping system was pretested and evaluated in a homecare department of hospital and a community management center for chronic disease monitoring. Based on the results of this study, this system is expected to improve the quality of healthcare services.

Aggressive end-of-life care significantly influenced propensity for hospice enrollment within the last three days of life for Taiwanese cancer decedents.

CONTEXT: Late hospice enrollment exacts a substantial toll from patients, families, hospices, and society. The relationship between the propensity for late hospice enrollment and aggressive health services received at the end of life (EOL) has been underinvestigated. OBJECTIVES: To identify determinants of hospice enrollment within the last three days of life. METHODS: Retrospective population-based cohort study using administrative data for 31,529 Taiwanese cancer decedents who used hospice care in their last year of life. RESULTS: Rates of hospice enrollment within the last three days of life (16.80%-18.73%) remained constant over 2001-2006. After adjustment for patient demographics and disease characteristics, physician specialty, availability of health care resources at the hospital and regional levels, and historical trends, late hospice enrollment was more likely if Taiwanese cancer patients received chemotherapy, had multiple emergency room visits or hospital admissions, and used the intensive care unit in their last month of life (adjusted odds ratio [95% confidence interval] (AOR [95% CI]): 1.61 [1.44-1.80], 1.40 [1.29-1.52], 1.78 [1.51-2.09], and 1.45 [1.19-1.76], respectively). Late hospice enrollment was less likely for patients with hospital stays>14 days or who received cardiopulmonary resuscitation in their last month of life (AOR [95% CI]: 0.51 [0.45-0.58] and 0.41 [0.25-0.65], respectively). CONCLUSION: Aggressive EOL care played a more significant role than patient, physician, or hospital characteristics in determining the propensity of Taiwanese cancer patients to be enrolled in hospice care within their last three days of life. Clinical and health policies should aim to avoid aggressive care when it will not benefit patients but may preclude timely hospice enrollment.

Propensity for home death among Taiwanese cancer decedents in 2001-2006, determined by services received at end of life.

CONTEXT: The discrepancy between patients' preferred and actual place of death highlights the dilemma inherent in achieving their preferences for home death. Research on determinants of home death has been limited largely by focusing on individual-level factors and somewhat on health care resources at the primary hospital and regional levels. OBJECTIVES: To investigate factors associated with home death, specifically, services received by cancer patients at the end of life (EOL). METHODS: This was a retrospective cohort study using administrative data from 201,201 Taiwanese cancer decedents in the period 2001-2006. RESULTS: Rates of home death decreased significantly over time (from 35.67% to 32.39%). Dying at home was associated with patient demographics (gender, age, and marital status) and disease characteristics (cancer type, metastatic status, postdiagnosis survival time, and comorbidity level). Taiwanese cancer patients were less likely to die at home if they received care from a medical oncologist and in hospitals or regions with abundant health care resources. Furthermore, Taiwanese cancer patients were less likely to die at home if they used life-sustaining treatments (intensive care unit care, cardiopulmonary resuscitation, intubation, and mechanical ventilation) in the last month of life. However, multiple emergency room visits in the last month of life and receiving hospice care increased Taiwanese cancer patients' propensity to die at home. CONCLUSION: Despite the causal ambiguity in interpreting our research findings, they indicate that using life-sustaining treatments at EOL not only exacts a substantial toll from patients, family members, and society, but also decreases the likelihood of dying at home.

A population-based study on the determinants of hospice utilization in the last year of life for Taiwanese cancer decedents, 2001-2006.

BACKGROUND: No population-based studies conducted outside Western countries have identified determinants of hospice utilization for all ages and cancer groups. OBJECTIVE: To evaluate associations between hospice utilization in the last year of life and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of healthcare resources at the hospital and regional levels in Taiwan. METHODS: Retrospective cohort study using administrative data among 204, 850 Taiwanese cancer decedents, 2001-2006. RESULTS: Rates of hospice utilization increased significantly (12.99-17.24%) over the study period. Hospice utilization was more likely for cancer patients who were female; over 65 years old; currently or formerly married; with ≤1 concurrent disease; diagnosed with breast cancer or cancer having a poorer prognosis; with distant metastasis, and longer illness duration (>2 months since diagnosis); receiving care in a teaching hospital or hospital with an inpatient-hospice unit; and receiving care in a region with greater density of inpatient-hospice beds. However, patients with hematological malignancies and esophageal cancer were less likely to use hospice care. CONCLUSIONS: Despite the 1.33 times increase in hospice utilization among cancer patients who died from 2001 to 2006, only one in six Taiwanese cancer decedents used hospice care in their last year of life. Our findings regarding determinants of hospice utilization should be used by healthcare professionals and policy makers to guide the development of policies and interventions that facilitate prognosis disclosure and EOL care discussions between physicians and patients, especially younger patients, to help the transition from curative to palliative care.

Determinants of aggressive end-of-life care for Taiwanese cancer decedents, 2001 to 2006.

PURPOSE: To assess the association between aggressiveness of end-of-life (EOL) care and patient demographics, disease characteristics, primary physician's specialty, hospital characteristics, and availability of health care resources at the hospital and regional levels in Taiwan for a cohort of 210,976 cancer decedents in 2001 to 2006. METHODS: This retrospective cohort study examined administrative data. Aggressiveness of EOL care was examined by a composite measure adapted from Earle et al. Scores range from 0 to 6, with higher scores indicating more aggressive EOL care. RESULTS: The mean composite score for aggressiveness of EOL care was 2.04 (mean) +/- 1.26 (standard deviation), increasing from 1.96 +/- 1.26 in 2001 to 2.10 +/- 1.26 in 2006. Each successive year of death significantly increased the composite score. Cancer decedents received more aggressive EOL care if they were male, younger, single, had a higher level of comorbidity, had more malignant and extensive diseases or hematologic malignancies, were cared for by oncologists, and received care in a hospital with a greater density of beds. CONCLUSION: Controlling for patient demographics and cormorbidity burden, EOL care in Taiwan was more aggressive for patients with cancer with highly malignant and extensive diseases, for patients with oncologists as primary care providers, or in hospitals with abundant health care resources. Health policies should aim to ensure that all patients receive treatments that best meet their individual needs and interests and that resources are devoted to care that produces the greatest health benefits.

The development of an incident event reporting system for nursing students.

Incident events may occur when nursing students are present in the clinical setting. Their inexperience and unfamiliarity with clinical practice put them at risk for making mistakes that could potentially harm patients and themselves. However, there are deficiencies with incident event reporting systems, including incomplete data and delayed reports. The purpose of this study was to develop an incident event reporting system for nursing students in clinical settings and evaluate its effectiveness. This study was undertaken in three phases. In the first phase, a literature review and focus groups were used to develop the architecture of the reporting system. In the second phase, the reporting system was implemented. Data from incident events that involved nursing students were collected for a 12-month period. In the third phase, a pre-post trial was undertaken to evaluate the performance of the reporting system. The ASP.NET software and Microsoft Access 2003 were used to create an interactive web-based interface and design a database for the reporting system. Email notifications alerted the nursing student's teacher when an incident event was reported. One year after installing the reporting system, the number of reported incident events increased tenfold. However, the time to report the incident event and the time required to complete the reporting procedures were shorter than before implementation of the reporting system. The incident event reporting system appeared to be effective in more comprehensively reporting the number of incident events and shorten the time required for reporting them compared to traditional written reports.

Performance analysis of distributed and centralized models for electronic medical record exchanges.

Electronic medical record exchanges can save time and reduce cost by eliminating redundant data and typing errors. The major steps of record exchange consist of querying information from database, encoding data into messages, and sending and decoding messages. Three medical-record-exchange models were proposed in the past, including the distributed, centralized, and indexed models. In this paper, the queuing theory is applied to evaluate the performance of the three models. We estimate the service time for each queue of the CPU, database and network, and predict the response time, probable bottlenecks and system capacities of each model.

Hospice utilization in Taiwan by cancer patients who died between 2000 and 2004.

To facilitate utilization of hospice services, Taiwan uses the National Health Insurance (NHI) as a major policy instrument. To evaluate the effect of this policy on hospice utilization by cancer patients during their final year of life, a retrospective cohort study was conducted by linking individual patient-level data from the National Register of Deaths Database and the NHI claims database to examine changes in the rates of hospice utilization, durations of patient survival (DOS) after enrollment, and the rates of late referrals to hospice care from 2000 to 2004. Among the 103,097 cancer patients who died between 2000 and 2004, the rate of hospice utilization during their final year of life grew substantially from 5.5% to 15.4%. However, Taiwanese cancer patients were enrolled in hospice care close to death (median DOS ranged from 14 to 47 days). Except for the small proportion of patients who received both inpatient hospice care and hospice home care, one-third to one-fourth of cancer decedents died within 7 days after being enrolled in hospice care. Although the rate of late referrals to hospice care did not vary much over time, the mean DOS for hospice care changed significantly. Many Taiwanese cancer patients who could potentially benefit from hospice care do not receive it in time. Further research is warranted to investigate factors influencing hospice use and the timing of hospice referrals to facilitate appropriate use of hospice care for cancer patients in Taiwan.

Performance analysis of a medical record exchanges model.

Electronic medical record exchange among hospitals can provide more information for physician diagnosis and reduce costs from duplicate examinations. In this paper, we proposed and implemented a medical record exchange model. According to our study, exchange interface servers (EISs) are designed for hospitals to manage the information communication through the intra and interhospital networks linked with a medical records database. An index service center can be given responsibility for managing the EIS and publishing the addresses and public keys. The prototype system has been implemented to generate, parse, and transfer the health level seven query messages. Moreover, the system can encrypt and decrypt a message using the public-key encryption algorithm. The queuing theory is applied to evaluate the performance of our proposed model. We estimated the service time for each queue of the CPU, database, and network, and measured the response time and possible bottlenecks of the model. The capacity of the model is estimated to process the medical records of about 4000 patients/h in the 1-MB network backbone environments, which comprises about the 4% of the total outpatients in Taiwan.

Development of a deterministic XML schema by resolving structure ambiguity of HL7 messages.

Health level 7 (HL7) is a standard for medical information exchange. It defines data transfers for the application systems in the healthcare environment. Alternatively, the extensible markup language (XML) is a standard for data exchange using the Internet. If exchange messages follow the content and the sequence defined by HL7 and are expressed in the XML format, the system may benefit from the advantages of both standards. In creating the XML schema, we found ambiguities in HL7 message structures that cause the XML schema to be non-deterministic. These ambiguous expressions are summarized within 12 structures and can be replaced with equivalent or similar unambiguous structures. The finite state automata are used to verify expression equivalence. Applying this schema, an XML document may eliminate redundant segment group definitions and make the structure simple and easy to reproduce. In this paper, we discuss the methods and our experience in resolving ambiguous problems in HL7 messages to generate a deterministic XML schema.

Design and implementation of a web-based HL7 message generation and validation system.

Health level 7 (HL7) is the standard of electronic data interchange in the health domain. We have developed a web-based message generation and validation system for testing the message format of the data exchange among hospitals and health organizations. Compared with other existing ones, this system has incorporated several novel functions that optimize medical data exchange and helps medical students in learning HL7 messages. When receiving HL7 message from another system with the hypertext transmission protocol or accepting an uploaded HL7 message file, the system shows the validation result through a web browser. In this platform, users may input and edit medical data on-line to test and generate standard HL7 messages. The system supports various data formats and is capable of transforming HL7 messages between the standard delimiter format and the extensible markup language format. This system has been successfully passed our system evaluation among 139 student users for HL7 training. Most of the users agreed that the system is helpful for medical data exchange.