Adding Instructiveness to IHE-XDS Based Electronic Health Records.

eHealth system users need adequate, timely access to health-related information; including the functionality of alerting and notifications on events. This was addressed through requirements engineering techniques. The analysis resulted in a requirements' list and architecture based on IHE standards. Patients, professionals and administrators were identified as main actors, core notification attributes were type and transport channel, and notifications always event-triggered. One challenge is system-based data access events, potentially leading to an invalid triggering of events.

End-to-End Notifications and Interactivity in Standard Based EHR Networks.

One of the main challenges of EHR system is providing information in an adequate and timely manner to its user which can be as well professionals as patients. In both usage scenarios the acceptance and usage of such system benefits from alerting and notification functionality on events. Since this aspect is hardly covered in interoperability and EHR standards the goal of this paper is to identify workflows and extensions to standard based EHR system to provide this functionality. Using requirements engineering technics and a three-tire analysis phase a list of requirements and an architecture based on IHE standards could be identified. In this concept patients, professional and administrators have been identified as main user groups of such systems. Notification events for the user groups could be categorized to the core attribute families Type and Transport Channel. The notifications itself are triggered by events that could be defined. Outlining the workflows that trigger events in the IHE based infrastructure we identified the challenge of differentiating system generated or based events which are also caused by the notification system's operation. This might lead to invalid event triggers and therefore must be discussed in future work.

Blockchains in IHE-Based Networks.

INTRODUCTION: Interoperability of health information systems is one of the key challenges of modern healthcare systems. A weak spot in this technology stack of interoperability protocols as defined by HL7 and IHE is cross affinity domain exchange of access control information and policies. In several industries the Blockchain technology had a major breakthrough. The goal of this paper is to elaborate how to exchange cross affinity domain access information enhancing well established IHE networks with block chain technology. METHODS: Using literature analysis and research on current interoperability standards the state of the art of securely exchanging medical information was elaborated. We enhanced this system with the capabilities of the peer2peer based Blockchain network elaborating the workflows of exchanging the access control specific information. RESULTS: We extended an IHE based affinity domain by adding a block chain ledger to the deployment. This ledger is fed with XACML based policies which are propagated through the peer2peer based system. Using the Blockchain protocol other affinity domains are informed of the change and can retrieve the information. Acting as an additional source of policies and consents the policy decision point is capable of querying this network and building a decision based on the retrieved information.

Patient Summaries in Context of Large Scale EHR Networks with Fine Granular Access Control Restrictions.

BACKGROUND: Large Scale Electronic Health Record (EHR) systems tend to contain a significant higher amount of patient data compared to traditional local Electronic Medical Record (EMR) silos. This demands the requirement of providing a user context and role specific summary of the patient record. Security and Access Control systems are a crucial part of modern EHR systems controlling legal policies and patient consents. Goal of this paper is to elaborate a concept enhancing an already existing, commonly based on IHE XDS and XACML based, EHR systems with summarization functionalities. METHODS: Using literature review and analysis of technical background of standards and currently running eHealth projects the state of the art is compiled. Based on this knowledge a workflow concept is derived and verified using a prototype based on an EHR product. RESULTS: Using the IHE Profiles XDR and On-Demand a standard based connection to the EHR product is established. The data is extracted and stored with a link to the document reference it was contained in. With a standard based IHE ITI-18 transaction the query is filtered by the ACS of the domain. Using the resulting information a patient summary document can be compiled including only data which was gathered from documents the user has access to.

Dynamic Creation of Patient Summaries: A CDA and IHE XDS Based Approach for Regional EHRs.

Cooperative healthcare is regarded as one of the major goals for providing adequate health related information to physicians. To achieve this goal, national authorities and large hospital organizations are introducing large scale, standard based transactional EHR systems. Those systems record and distribute a significant amount of medical related data. This raises the concern of information overload for the intended users. The objective is to elaborate on an architecture and consequently a workflow that allows the generation of an automatic patient summary in a standard based IHE XDS environment. A literature review evaluating the current state of research is conducted. Current eHealth projects, laws and technical background are analyzed. An architecture is suggested, prototyped and compared using SAAM (Software Architecture Analysis Method) against alternative approaches. A technical workflow built on IHE XDR and HL7 FHIR observations is suggested introducing two new services within an IHE XDS product for extracting observations from CDA documents and storing the data on domain level scope. The information is published as an OnDemand Document in the IHE XDS infrastructure.

Developing an Approach for Aggregating Information From a EHR into a Fully Structured Patient Summary.

BACKGROUND: Providing healthcare professionals with adequate access to well-filled electronic patient records and health-related information contributes to an improvement of the treatment process. Compared to conventional Electronic Medical Records these EHR systems commonly contain more medical artifacts due to their cross institutional, multipurpose use cases. Physicians and health professionals are therefore concerned about information overflow. OBJECTIVES: Goal of this paper is to elaborate new concepts for the automated aggregation of a fully-structured patient summary document based on information extracted from documents which are published in large-scale EHRs. METHODS: The first step was the conduction of semi-structured group interviews with experts and customers. This was followed by a qualitative literature analysis. Consequently technical and medical standards in the field of interoperability were screened. RESULTS: The result of this paper is the elaboration of an architectural approach to integrate an automatic patient summary creation into well established workflows of large ehealth projects based on standard IHE XDS infrastructures, taking the Austrian ELGA as an example.

The EHR-ARCHE project: satisfying clinical information needs in a Shared Electronic Health Record system based on IHE XDS and Archetypes.

PURPOSE: While contributing to an improved continuity of care, Shared Electronic Health Record (EHR) systems may also lead to information overload of healthcare providers. Document-oriented architectures, such as the commonly employed IHE XDS profile, which only support information retrieval at the level of documents, are particularly susceptible for this problem. The objective of the EHR-ARCHE project was to develop a methodology and a prototype to efficiently satisfy healthcare providers' information needs when accessing a patient's Shared EHR during a treatment situation. We especially aimed to investigate whether this objective can be reached by integrating EHR Archetypes into an IHE XDS environment. METHODS: Using methodical triangulation, we first analysed the information needs of healthcare providers, focusing on the treatment of diabetes patients as an exemplary application domain. We then designed ISO/EN 13606 Archetypes covering the identified information needs. To support a content-based search for fine-grained information items within EHR documents, we extended the IHE XDS environment with two additional actors. Finally, we conducted a formative and summative evaluation of our approach within a controlled study. RESULTS: We identified 446 frequently needed diabetes-specific information items, representing typical information needs of healthcare providers. We then created 128 Archetypes and 120 EHR documents for two fictive patients. All seven diabetes experts, who evaluated our approach, preferred the content-based search to a conventional XDS search. Success rates of finding relevant information was higher for the content-based search (100% versus 80%) and the latter was also more time-efficient (8-14min versus 20min or more). CONCLUSIONS: Our results show that for an efficient satisfaction of health care providers' information needs, a content-based search that rests upon the integration of Archetypes into an IHE XDS-based Shared EHR system is superior to a conventional metadata-based XDS search.

Searching for document contents in an IHE-XDS EHR architecture via archetype-based indexing of document types.

The shared EHR (electronic health record) system architecture IHE XDS is widely adopted internationally. It ensures a high level of data privacy via distributed storage of EHR documents. Its standard search capabilities, however, are limited; it only allows a retrieval of complete documents by querying a restricted set of document metadata. Existing approaches that aim to extend XDS queries to document contents typically employ a central index of document contents. Hereby they undermine XDS' basic characteristic of distributed data storage. To avoid data privacy concerns, we propose querying EHR contents in XDS by indexing document types based on Archetypes instead. We successfully tested our approach within the ISO/EN 13606 standard.

Archetype based search in an IHE XDS environment.

To prevent information overload of physicians when accessing EHRs we introduce a method to extend the IHE XDS profile metadata-based search towards a content-based search. Detailed queries are created based on predefined information needs mapped to ISO/EN 13606 Archetypes. They are aggregated to a metadata-based query to retrieve all relevant documents, which are then analyzed for the desired contents. The results are presented in a tabular form. The content-based search in IHE-XDS could be implemented efficiently and was found helpful by the evaluating physicians.

An EHR prototype using structured ISO/EN 13606 documents to respond to identified clinical information needs of diabetes specialists: a controlled study on feasibility and impact.

Cross-institutional longitudinal Electronic Health Records (EHR), as introduced in Austria at the moment, increase the challenge of information overload of healthcare professionals. We developed an innovative cross-institutional EHR query prototype that offers extended query options, including searching for specific information items or sets of information items. The available query options were derived from a systematic analysis of information needs of diabetes specialists during patient encounters. The prototype operates in an IHE-XDS-based environment where ISO/EN 13606-structured documents are available. We conducted a controlled study with seven diabetes specialists to assess the feasibility and impact of this EHR query prototype on efficient retrieving of patient information to answer typical clinical questions. The controlled study showed that the specialists were quicker and more successful (measured in percentage of expected information items found) in finding patient information compared to the standard full-document search options. The participants also appreciated the extended query options.

Clinical situations and information needs of physicians during treatment of diabetes mellitus patients: a triangulation study.

Physicians should have access to the information they need to provide the most effective health care. Medical knowledge and patient-oriented information is dynamic and expanding rapidly so there is a rising risk of information overload. We investigated the information needs of physicians during treatment of Diabetes mellitus patients, using a combination of interviews, observations, literature research and analysis of recorded medical information in hospitals as part of a methodical triangulation. 446 information items were identified, structured in a set of 9 main categories each, as well as 6 time windows, 10 clinical situations and 68 brief queries. The physician's information needs as identified in this study will now be used to develop sophisticated query tools to efficiently support finding of information in an electronic health record.

Developing a model for the adequate description of electronic communication in hospitals.

Adequate information and communication systems (ICT) can help to improve the communication in hospitals. Changes to the ICT-infrastructure of hospitals must be planed carefully. In order to support a comprehensive planning, we presented a classification of 81 common errors of the electronic communication on the MIE 2008 congress. Our objective now was to develop a data model that defines specific requirements for an adequate description of electronic communication processes We first applied the method of explicating qualitative content analysis on the error categorization in order to determine the essential process details. After this, we applied the method of subsuming qualitative content analysis on the results of the first step. A data model for the adequate description of electronic communication. This model comprises 61 entities and 91 relationships. The data model comprises and organizes all details that are necessary for the detection of the respective errors. It can be for either used to extend the capabilities of existing modeling methods or as a basis for the development of a new approach.

The Archetype-enabled EHR system ZK-ARCHE - integrating the ISO/EN 13606 standard and IHE XDS profile.

The EHR system ZK-ARCHE automatically generates forms from ISO/EN 13606 archetypes. For this purpose the archetypes are augmented with components of the reference model to achieve so-called "comprehensive archetypes". Data collected via the forms are stored in a list which associates each value with the path of the corresponding comprehensive archetype node coded as W3C XPath. From this list archetype-conformant EHR extracts can be created. The system is embedded with the IHE XDS profile to allow direct data exchange in an environment of distributed data storage.

Creating ISO/EN 13606 archetypes based on clinical information needs.

Archetypes model individual EHR contents and build the basis of the dual-model approach used in the ISO/EN 13606 EHR architecture. We present an approach to create archetypes using an iterative development process. It includes automated generation of electronic case report forms from archetypes. We evaluated our approach by developing 128 archetypes which represent 446 clinical information items from the diabetes domain.

Measurement and quantification of generalized tonic-clonic seizures in epilepsy patients by means of accelerometry--an explorative study.

Epilepsy is one of the most common neurological diseases, which has a cumulative lifetime incidence of 3%. Two to threefold increased morbidity and mortality rates are reported, especially if generalized tonic-clonic seizures (GTCS) occur. A wireless small and user-friendly detection system would be helpful in early identification of seizures. This could minimize the risk of seizure-related injuries and further allow complete seizure frequency documentation, especially in a non-clinical private setting. The aim of our study was to develop a design and to conduct an exploratory validation of an accelerometry (ACM)-based detection system for GTCS detection in real-time. Patients were recruited via the Epilepsy Monitoring Unit at the Department of Neurology, Medical University Innsbruck. In three out of 20 patients, four GTCS could be recorded. The ACM sensors recorded increased activities at the stated seizure time, which clearly differed from everyday movements. The temporary sensitivity (100%), specificity (≥88%) and the positive predictive value (≥75%) of the detection suggests a promising alarm/false alarm ratio. The validity of the detection device has to be evaluated with more data in order to be able to significantly confirm the positive results and to further develop a cut-off algorithm for automatic seizure detection.

Categorizing communication errors in integrated hospital information systems.

OBJECTIVES: Hospital information systems (HIS) are the hospital's nervous system. The HIS are mostly grown over several years, dedicated to specific needs and comprise individual workarounds. Changes to such complex systems may cause a variety of differ-ent negative side-effects. In order to understand the nature of incorrect communication in integrated HIS, a concise structured categorization of common communication problems and their reasons is essential. The objective of this paper is to present such a categorization, its development and verification. METHODS: We used a combined approach for the development of the error categorization: We started with a qualitative content analysis on available literature in PubMed. In order to ensure the validity and completeness of the results, we chose the method of problem-centered expert interviews. RESULTS: The resulting categorization of communication problems is represented as a five-level hierarchy. It comprises 81 problems that are related to the electronic communication. Further, it contains in total 229 entries that are either the reasons of these problems or recommendation for avoiding the problems. CONCLUSION: To our knowledge there is no similar summary that concisely summarizes common communication problems and also refers to their underlying reasons. Equivalent content is mostly published in experience reports that just concentrate on single aspects. We used the details of such references in order to compile our categorization - it thus can be regarded as an intersection of relevant experiences. The categorization can raise a basic awareness on potential problems and supports the understanding of the underlying reasons. An evaluation in a real environment must prove whether the content of the categorization is correct.

Developing a taxonomy of communication errors in heterogeneous information systems.

BACKGROUND: Although established communication standards do exist in the health care domain (i.e., DICOM and HL7) the communication within heterogeneous information systems still shows a variety of errors. The complexity of these systems aggravates the identification of error reasons. A structured summary of communication errors and their reasons is essential for developing methods that support the error detection. METHODS: In order to summarize communication errors, a systematic literature review in PubMed was conducted. Selected references were filtered iteratively and analyzed by applying subsuming qualitative content analysis. RESULTS: The taxonomy currently contains 12 different problem classes that group 42 problems, with in total 130 reasons. DISCUSSION: Although, not all selected literature references are yet analyzed, we observe a saturation concerning new errors/error classes. In order to increase validity and completeness expert interviews are in planning stage. However, the first results are promising.

MedFlow - Improving Modelling and Assessment of Clinical Processes.

INTRODUCTION: Clinical processes are meant to restore the patient's health but often show weaknesses regarding their efficiency (e.g. ineffective task distribution for clinicians, long waiting times for patients). In order to improve these processes an assessment of their quality is needed. This assessment is based on adequate process models and proper systematic assessment procedures. Both seem not sufficiently present in the Activity Diagrams of the Unified Modeling Language (UML) or ARIS Event-driven Process Chains (EPC). OBJECTIVES: The aim of this paper is to develop and test a process modelling method which explicitly includes all details of clinical processes necessary for a systematic and even semiautomatic quality assessment. METHODS: We propose a model which is separated into process model, tool model, organisation model and information model. Its visualisation is based on the extended UML Activity Diagrams. RESULTS: After being defined formally the graphical elements of the proposed model were implemented into a commonly used modelling software. As a first validation step, various versions of the process of ordering a radiological examination were modelled. DISCUSSION: The advantage of our modelling approach is the combination of different aspects (i.e. description of processes, used tools, information objects and actor roles) into an integrated model so that details important for a systematic process assessment are now more explicitly included than in Activity Diagrams or EPC. Further evaluations will help to improve the model and to develop strategies for the semi-automatic analysis.