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Use of XML Schema Definition for the Development of Semantically Interoperable Healthcare Applications
Abstract
Multilevel modeling has been proven in software as a viable solution for semantic interoperability, without imposing any specific programming languages or persistence models. The Multilevel Healthcare Information Modeling (MLHIM) specifications have adopted the XML Schema Definition 1.1 as the basis for its reference implementation, since XML technologies are consistent across all platforms and operating systems, with tools available for all mainstream programming languages. In MLHIM, the healthcare knowledge representation is defined by the Domain Model, expressed as Concept Constraint Definitions (CCDs), which provide the semantic interpretation of the objects persisted according to the generic Reference Model classes. This paper reports the implementation of the MLHIM Reference Model in XML Schema Definition language version 1.1 as well as a set of examples of CCDs generated from the National Cancer Institute – Common Data Elements (NCI CDE) repository. The set of CCDs was the base for the simulation of semantically coherent data instances, according to independent XML validators, persisted on an eXistDB database. This paper shows the feasibility of adopting XML technologies for the achievement of semantic interoperability in real healthcare scenarios, by providing application developers with a significant amount of industry experience and a wide array of tools through XML technologies.
... This insures that all DM concept expressions can be interpreted in the context of the RM. Thus, a combination of XML and MMD technologies could provide full semantic interoperability for an HIS and its compliance to the emerging Semantic Web and the Internet of Things [12]. Given the current scenario of the HIS industry worldwide, it is desirable to combine the ubiquitous HL7v2 infrastructure with the emerging Semantic Web technologies, specifically XML syntactic processing with concept semantics expressed in Resource Description Framework (RDF) structures. ...
... The PHTLS initial examination is known as the ABCDE protocol, covering the parameters of airway, breathing, circulation, disability, and exposure [16]. This protocol was modeled as a CCD, an XML schema file with the semantics embeded as RDF statements, which defines constraints on the reference model in accordance with the MMD principles established by the Multilevel Healthcare Information Modeling (MLHIM) specifications, which are described in detail elsewhere [12,15]. The Concept Constraint Definition Generator (CCD-Gen; www.ccdgen.com) was used to create the CCD. ...
... The knowledge modeling process uses the MLHIM reference model to model the concepts of the ABCDE protocol of the PHTLS model. As a result, a CCD was modeled, composed of the following pluggable complex types [12]: ' A' airway obstruction; 'B' breathing; 'C' circulation; 'D' disability, measured by the Glasgow Coma Scale; and 'E' exposure, and one specific PcT to provide the mapping between the OBX segment of the HL7v2 message and the Type 4 universal unique identifier (UUID) of the corresponding PcTs in the CCD. The resulting CCD modeling of the PHTLS concepts is presented in Table 1. ...
Objectives:
To present the technical background and the development of a procedure that enriches the semantics of Health Level Seven version 2 (HL7v2) messages for software-intensive systems in telemedicine trauma care.
Methods:
This study followed a multilevel model-driven approach for the development of semantically interoperable health information systems. The Pre-Hospital Trauma Life Support (PHTLS) ABCDE protocol was adopted as the use case. A prototype application embedded the semantics into an HL7v2 message as an eXtensible Markup Language (XML) file, which was validated against an XML schema that defines constraints on a common reference model. This message was exchanged with a second prototype application, developed on the Mirth middleware, which was also used to parse and validate both the original and the hybrid messages.
Results:
Both versions of the data instance (one pure XML, one embedded in the HL7v2 message) were equally validated and the RDF-based semantics recovered by the receiving side of the prototype from the shared XML schema.
Conclusions:
This study demonstrated the semantic enrichment of HL7v2 messages for intensive-software telemedicine systems for trauma care, by validating components of extracts generated in various computing environments. The adoption of the method proposed in this study ensures the compliance of the HL7v2 standard in Semantic Web technologies.
... The minimalist approach of multilevel modelling in MLHIM removes much of the complexity of the openEHR approach by eliminating the semantic of EHRs while at the same time providing a more generally useful model. The MLHIM approach specifies domain models that can be bound to subsets of controlled vocabularies, achieving semantic validity across healthcare applications of any size that persist or exchange data according to the MLHIM Reference Model via the correspondent domain model [17]. ...
... Since CCDs are constraints of the generic RM, they are fully transportable across all MLHIM based applications. So any instance data created according to a CCD will always be interpreted correctly [17]. ...
... Para sistemas de saúde existem diversas arquiteturas de referência que podem oferecer uma estrutura arquitetural inicial em vários tipos de aplicação, como por exemplo, casas inteligentes para o cuidado de saúde [Garcés 2018], prontuários eletrônicos [The ope-nEHR Foundation 2018, Cavalini and Cook 2014, Losavio et al. 2015, saúde conectada [Bandara 2015], ecossistema de e-saúde [Wartena et al. 2010], além de outros. Em [Garcés et al. 2015, Garcés et al. 2020] são apresentadas diversas arquiteturas de referência para projetar sistemas de software de saúde. ...
Ambient Assisted Living (AAL) intends to support the everyday lives of elderly people, promoting mainly their independence and dignity. Due to the growing interest on AAL from both academia and society, AAL software systems have widely contributed to set up an AAL research area. Similarly to most software areas that are in their infancy, AAL is in need of fundamental research, dealing with the basic aspects required by a new domain, e.g. software architectures. In this perspective, the investigation of Reference Architectures (RA) and Reference Models (RM) specialized for the domain of AAL is expected to be interesting to both researchers and practitioners of this community. However, to the best of our knowledge, there is a lack of a complete, detailed state of the art on RA\&RM for the AAL domain. This lack makes the selection of RA\&RM, when intending to use them to develop, standardize, and evolve AAL systems, a rather difficult task. In this paper we present the state of the art on such RA\&RM, through a systematic literature review. As main results, we identified and analyzed important RA\&RM for AAL, and spotted interesting research directions that should be explored in order to improve existing and future RA&RM for that domain.
The Fast Healthcare Interoperability Resources (FHIR) is an open suite of specifications and software implementations of the Health Level 7 version 3 (HL7v3) standard. It has been proposed to provide a consistent API for the HL7v3 CDA. However, the core issues of HL7v3 are not solved at the API level. The community around the project are proposing the adoption of RDF technologies to overcome the current challenges in interoperating with linked data. However, RDF triples nor ontologies provide semantic interoperability by themselves, a more robust information infrastructure, such as the Multilevel Model-Driven (MMD) approach, is required. An XML implementation of the MMD was used to model the FHIR Schemas as Domain Models (DMs) against a generic Reference Model (RM) to provide syntactic validation. RDF triples were included in the domain models to provide missing semantics. The XML data instances were validated against their Domain Models. The DMs do not create any new types, they only express constraints of the RM types, this provides consistent query and data analysis capability across all DMs. RDF triples were extracted from the DMs and added to a triple store graph with the RM ontology. The XML data is also expressed as Literals in the graph. This study shows the feasibility of using MMD solutions to provide full operational semantic interoperability for the FHIR ecosystem.
Controlled vocabularies such as terminologies and ontologies are regarded as a solution to the achievement of semantic interoperability across healthcare applications. This is yet to be attained. The semantics of current healthcare applications are directly in the source code and database structure and therefore cannot be readily shared. The multilevel model-driven approach is a method to produce semantically interoperable healthcare applications by providing sharable concept models. At this point, the methodology is proven, but implementations are still required. This study presents the fundamentals of knowledge modeling of controlled vocabularies for a XML-based multilevel model specification. The term subset 'Tuberculosis' of the 10th Revision of the International Classification of Diseases (ICD-10) is modeled as constraints to the XML Schema that defines the Reference Model. The Brazilian Mortality and Hospital Information Systems provided sample data for demonstration. The demonstration of the semantic validation of the XML data instances that include the ICD-10 'Tuberculosis' term set, converted to the multilevel model generated, is presented.
The management of Big Data in healthcare is challenging due to of the evolutionary nature of healthcare information systems. Information quality issues are caused by top-down enforced data models not fitted to each point-of-care clinical requirements as well as an overall focus on reimbursement. Therefore, healthcare Big Data is a disjointed collection of semantically confused and incomplete data. This paper presents MedWeb, a multilevel model-driven, social network architecture implementation of the Multilevel Healthcare Information Modeling (MLHIM) specifications. MedWeb profiles are patient and provider-specific, semantically rich computational artifacts called Concept Constraint Definitions (CCDs). The set of XML instances produced and validated according to the MedWeb profiles produce Hyperdata, overcoming of the concept of Big Data. Hyperdata is defined as syntactically coherent and semantically interoperable data that can be exchanged between MedWeb applications and legacy systems without ambiguity. The process of creating, validating and querying MedWeb Hyperdata is presented.
We study the problem of querying virtual security views of XML data that has received a great attention during the past years. A major concern here is that user XPath queries posed on recursive views cannot be rewritten to be evaluated on the underlying XML data. Existing rewriting solutions are based on the non-standard language, “Regular XPath”, which makes rewriting possible under recursion. However, query rewriting under Regular XPath can be of exponential size. We show that query rewriting is always possible for arbitrary security views (recursive or not) by using only the expressive power of the standard XPath. We propose a more expressive language to specify XML access control policies as well as an efficient algorithm to enforce such policies. Finally, we present our system, called SVMAX, that implements our solutions and we show that it scales well through an extensive experimental study based on real-life DTD.
One-stop public services and single window systems are primary goals of many e-government initiatives. How to facilitate the technical and data interoperability among the systems in different government agencies is a key of meeting these goals. While many software standards, such as Web Services and ebXML, have been formulated to address the interoperability between different technical platforms, the data interoperability problem remains to be a big challenge. The data interoperability concerns how different parties agree on what information to exchange, and the definition and representation of such information. To address this problem, the Hong Kong government has released the XML Schema Design and Management Guide as well as the Registry of Data Standards under its e-Government Interoperability Framework initiative. This paper introduces how the data modelling methodology provided by the Guide can be used to develop data interfaces and standards for e-government systems. We also discuss how the Macao government has formulated their data interoperability policy and has applied the Guide in their situation.
In this paper we propose a metamodelling approach to behavioural modelling. The approach combines diagrammatic modelling with formal foundations based on category theory and graph transformations. The static semantics of behavioural models is represented by instances of (meta)models, while their dynamic semantics is represented by transition systems. Transitions are described by coupled model transformations. To illustrate the approach, we present a running example of a workflow model for health services delivery.
Medical information systems today store clinical information about patients in all kinds of proprietary formats. To address the resulting interoperability problems, several Electronic Healthcare Record standards that structure the clinical content for the purpose of exchange are currently under development. In this article, we present a survey of the most relevant Electronic Healthcare Record standards, examine the level of interoperability they provide, and assess their functionality in terms of content structure, access services, multimedia support, and security. We further investigate the complementarity of the standards and assess their market relevance.
Pervasive healthcare focuses on the use of new technologies, tools, and services, in order to help patients to play a more active role in the treatment of their diseases. Since pervasive healthcare environments demand a huge amount of information exchange, the use of technologies like Health Level Seven (HL7) and archetypes has been proposed to provide interoperability between applications for these environments. However, the complexity of such technologies difficults their full adoption as well as the migration from centralized healthcare environments into pervasive ones. Aiming at collaborating to bridge this gap, this paper proposes an approach to integrate archetypes into HL7 v3 messages for the development of pervasive healthcare applications. The approach suggests the use of Domain Specific Languages (DSLs), which simplify the HL7 messages modeling and allow to automate most of the messages schema codification.
The TISS standard is a set of mandatory forms and electronic messages for healthcare authorization and claim submissions among healthcare plans and providers in Brazil. It is not based on formal models as the new generation of health informatics standards suggests. The objective of this paper is to model the TISS in terms of the openEHR archetype-based approach and integrate it into a patient-centered EHR architecture.
Three approaches were adopted to model TISS. In the first approach, a set of archetypes was designed using ENTRY subclasses. In the second one, a set of archetypes was designed using exclusively ADMIN_ENTRY and CLUSTERs as their root classes. In the third approach, the openEHR ADMIN_ENTRY is extended with classes designed for authorization and claim submissions, and an ISM_TRANSITION attribute is added to the COMPOSITION class. Another set of archetypes was designed based on this model. For all three approaches, templates were designed to represent the TISS forms.
The archetypes based on the openEHR RM (Reference Model) can represent all TISS data structures. The extended model adds subclasses and an attribute to the COMPOSITION class to represent information on authorization and claim submissions. The archetypes based on all three approaches have similar structures, although rooted in different classes. The extended openEHR RM model is more semantically aligned with the concepts involved in a claim submission, but may disrupt interoperability with other systems and the current tools must be adapted to deal with it.
Modeling the TISS standard by means of the openEHR approach makes it aligned with ISO recommendations and provides a solid foundation on which the TISS can evolve. Although there are few administrative archetypes available, the openEHR RM is expressive enough to represent the TISS standard. This paper focuses on the TISS but its results may be extended to other billing processes. A complete communication architecture to simulate the exchange of TISS data between systems according to the openEHR approach still needs to be designed and implemented.
Conceptual models have been developed to address challenges inherent in studying health information technology (HIT).
This manuscript introduces an eight-dimensional model specifically designed to address the sociotechnical challenges involved in design, development, implementation, use and evaluation of HIT within complex adaptive healthcare systems.
The eight dimensions are not independent, sequential or hierarchical, but rather are interdependent and inter-related concepts similar to compositions of other complex adaptive systems. Hardware and software computing infrastructure refers to equipment and software used to power, support and operate clinical applications and devices. Clinical content refers to textual or numeric data and images that constitute the 'language' of clinical applications. The human--computer interface includes all aspects of the computer that users can see, touch or hear as they interact with it. People refers to everyone who interacts in some way with the system, from developer to end user, including potential patient-users. Workflow and communication are the processes or steps involved in ensuring that patient care tasks are carried out effectively. Two additional dimensions of the model are internal organisational features (eg, policies, procedures and culture) and external rules and regulations, both of which may facilitate or constrain many aspects of the preceding dimensions. The final dimension is measurement and monitoring, which refers to the process of measuring and evaluating both intended and unintended consequences of HIT implementation and use. We illustrate how our model has been successfully applied in real-world complex adaptive settings to understand and improve HIT applications at various stages of development and implementation.
Semantic interoperability of clinical standards is a major challenge in eHealth across Europe. It would allow healthcare professionals to manage the complete electronic healthcare record of the patient regardless of which institution generated each clinical session. Clinical archetypes are fundamental for the consecution of semantic interoperability, but they are built for particular electronic healthcare record standards. Therefore, methods for transforming archetypes between standards are needed. In this work, a method for transforming archetypes between ISO 13606 and openEHR, based on Model-Driven Engineering and Semantic Web technologies, is presented.
Semantic interoperability (SIOp) is a major issue for health care systems having to share information across professionals, teams, legacies, countries, languages and citizens. The World Health Organisation (WHO) develops and updates a family of health care terminologies (ICD, ICF, ICHI and ICPS) and has embarked on an open web-based cooperation to revise ICD 11 using ontology driven tools. The International Health Terminology Standard Development Organisation (IHTSDO) updates, translates and maps SNOMED CT to ICD 10. We present the application of the CEN/ISO standard on categorial structure to bind terminologies and ontologies to harmonise and to map between these international terminologies.
MedView is a suit of clinical applications for recording, retrieving and visualizing patient records, which has been developed and in use for more than ten years. By the introduction of the openEHR architecture, the MedView project started an investigation to migrate from its locally developed framework to openEHR. Issues related to this process, have been discussed in this paper.
The United States is poised to move the debate over electronic information systems for health care beyond the question of whether to computerize to how to computerize. Developers should heed the experiences of those who have already attempted similar efforts in vertically integrated environments. A key lesson is that the expertise and design perspectives of IT professionals should be supplemented with practical input from the caregivers and administrators who will actually use these systems. The paper by Douglas Bell and colleagues offers a ray of hope, as these authors have begun their process by asking the user community exactly what it needs.
This article reports a study of patients and carers discharged from the Townsville General Hospital into rural and remote communities in north Queensland, Australia. The findings indicate the importance of focusing on the experiences of patients and carers in attempting to understand the impact of discharge procedures. The four stories and their implications exist within a particular healthcare context that impacts disproportionately on rural patients and their carers. Economic rationalism has shaped contemporary healthcare policy in Australia, creating a system that is encouraged to conform to market principles. The costs borne by individuals, groups and communities have been increasingly privatised. Later admission and earlier discharge from hospital is now the norm. Concern about the impact of this policy context on the lives of rural and remote patients and carers prompted the study, which aimed to: (1) examine, from the patient and carer perspective, the social, economic, cultural and emotional cost of hospitalisation away from home communities; (2) identify the needs of rural and remote patients and their carers before, during and after hospitalisation a long way from home; and (3) make recommendations for improved policies and practices concerning the continuum of care: from admission planning, through hospitalisation, discharge-planning, and post-discharge support, in the context of rural and remote location.
The experiences presented highlight the depth of the challenges faced by patients and their carers who live in rural and remote communities. Both quantitative and qualitative methodologies were used to obtain insight into the complexity of patients and carers' lives. The four vignettes presented in this paper are taken from in-depth, qualitative interviews with 12 patients and 12 carers.
The four stories described reveal the high financial and emotional costs, for patients and carers, of negotiating a healthcare system a long way from home. Challenges faced included inadequate admission planning, excessive accommodation and transport costs, and lack of post-discharge support services in home communities, as well as business failure, marital and family strain. There was an over-reliance on carers who lacked medical caring expertise, had other major commitments (family and work) and who may have had a tenuous and uncertain relationship with the patient.
Recognition of these complex circumstances, exacerbated by rural location, during the discharge planning process should mean that attention to ensuring patients and their carers are linked to adequate support services in their communities is of the highest priority. The communication and dissemination of information to patients and carers is also vital. Information on hospital admission, travel benefits, accommodation options, care requirements post-discharge are particular recommendations. To summarise, the experiences highlighted in this study suggest that patients and carers in rural and remote communities have not benefited from adequate discharge planning, and are struggling to cope in a policy context that encourages later admission, earlier discharge and over reliance on family and friends as carers.
The openEHR Foundation is an independent, not-for-profit organisation and community, facilitating the creation and sharing of health records by consumers and clinicians via open-source, standards-based implementations. It was formed as a union of ten-year international R&D efforts in specifying the requirements, information models and implementation of comprehensive and ethico-legally sound electronic health record systems. Between 2000 and 2004 it has grown to having an on-line membership of over 300, published a wide range of EHR information viewpoint specifications. Several groups have now begun collaborative software development, within an open source framework. This chapter summarises the formation of openEHR, its research underpinning, practical demonstrators, the principle design concepts, and the roles openEHR members are playing in international standards.
To contribute a new perspective on recent investigations into the scientific foundations of medical informatics (MI) and bioinformatics (BI). To support efforts that could generate synergies and new research directions.
MI and BI are compared and contrasted from a philosophy of science perspective. Historical examples from MI and BI are analyzed based on contrasting viewpoints about the evolution of scientific disciplines.
Our analysis suggests that the scientific approaches of MI and BI involve different assumptions and foundations, which, together with largely non-overlapping communities of researchers for the two disciplines, have led to different courses of development. We indicate how their respective application domains, medicine, and biology may have contributed to these differences in development.
An analysis from the point of view of the philosophy of science is characteristic of established scientific disciplines. From a Kuhnian perspective, both disciplines may be entering a period of scientific crisis, where their foundations are questioned and where new ideas (or paradigm shifts) and a progressive research programme are needed to advance them scientifically. We discuss research directions and trends both supporting and challenging integration of the subdisciplines of MI and BI into a unified field of biomedical informatics (BMI), centered around the evolution of information cybernetics.
Heavy investment over the past 30 years has made the hospital sector the largest expenditure category of the health system in most developed and developing countries. Despite shifts in attention and emphasis toward primary care as a first point of contact for patients, in most countries, hospitals remain a critical link to health care, providing both advanced and basic care for the population. Often, they are the provider "of last resort" for the poor and critically ill. Although, it is clear that hospitals play a critical role in ensuring delivery of health services there is much less agreement about how to improve the efficiency and quality of care provided. This article reviews recent hospital reforms undertaken throughout the world, with an emphasis on organizational changes such as increased management autonomy (often referred to as autonomization) and corporatization. It provides some insights about these popular reform modalities from a review of the literature, reform experiences in other sectors and empirical evidence from hospital sector itself. The material presented tries to answer three questions: (a) what problems did this type of reform try to address; (b) what are the core elements of their design, implementation and evaluation; and, (c) is there any evidence that this type of reform is successful in addressing problems for which they were intended? While this paper focuses on issues related to the design of the reforms, the paper also reports the findings from a larger study that examined the implementation and evaluation of such reforms so that they will be available to countries that are considering venturing down this reform path.
In the above titled paper (ibid., vol. 33, no. 8, pp. 526-543, Aug 07), there were several mistakes. The corrections are presented here.
The Extensible Markup Language, HTML's likely successor for
capturing much Web content, is receiving a great deal of attention from
the computing and Internet communities. Although the hype raises
unrealistic expectations, XML does reduce the obstacles to sharing data
among diverse applications and databases by providing a common format
for expressing data structure and content. Although some benefits are
already within reach, others will require new database technologies and
vocabularies for affected application communities
Background: Primary care physicians are expected to coordinate care for their patients. Objective: To assess the number of physician peers providing care to the Medicare patients of a primary care physician. Design: Cross-sectional analysis of claims data. Setting: Fee-for-service Medicare in 2005. Participants: 2284 primary care physicians who responded to the 2004 to 2005 Community Tracking Study Physician Survey. Measurements: Primary patients for each physician were defined as beneficiaries for whom the physician billed for more evaluation and management visits than any other physician in 2005. The number of physician peers for each physician was the sum of other unique physicians that the index physician's primary patients visited plus other unique physicians who served as the primary physician for each of the index physician's nonprimary patients during 2005. Results: The typical primary care physician has 229 (interquartile range, 125 to 340) other physicians working in 117 (interquartile range, 66 to 175) practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician. When only the 31 % of a primary care physician's primary patients who had 4 or more chronic conditions was considered, the median number of peers involved was still substantial (86 physicians in 36 practices). The number of peers varied with geographic region, practice type, and reliance on Medicaid revenues. Limitations: Estimates are based only on fee-for-service Medicare patients and physician peers, and the number of peers is therefore probably an underestimate. The modest response rate of the Community Tracking Study Physician Survey may bias results in unpredictable directions. Conclusion: In caring for his or her own primary and nonprimary patients during a single year, each primary care physician potentially must coordinate with a large number of individual physician colleagues who also provide care to these patients. Funding: National Institute on Aging, American Medical Group Association, and the Robert Wood Johnson Foundation.
The long-term maintenance of electronic health records within their original context of information is an ethical requirement that conflicts with the constant need to migrate the information into new systems as they are developed and improved. The specifics of every particular healthcare setting preclude the feasibility of a monolithic health record, and the achievement of interoperability between systems is the primary challenge faced by health informatics researchers. Different multilevel modeling approaches have been studied to deal with this complexity. Nevertheless, the original multilevel modeling specifications are targeted to the development of hospital-based electronic medical records, which adds complexity to the development of simpler purpose-specific applications for extra-hospital healthcare situations. This paper presents the knowledge engineering of a minimalist multilevel model that can be implemented by developers across the broader spectrum of healthcare applications. By using industry standard technologies, this approach enables the wider adoption of interoperable technology for healthcare.
Missing information are key issues for interoperability and semantic coherence in healthcare information systems. This paper presents the implementation of the Exceptional Package in the Multilevel Healthcare Information Modeling (MLHIM) specifications, and it describes two use cases where missing information is critical for decision-making and healthcare technology assessment.
Health information features significant spatial-temporal and domain complexities, which brings challenges to the implementation of patient-centered, interoperable and semantically coherent healthcare information systems. This position paper supports the idea that the multilevel modeling approach is essential to ensure interoperability at the semantic level, but true interoperability is only achieved by the adoption of open standards, and open source implementations are needed for promote competition based on software quality. The Multilevel Healthcare Information Modelling (MLHIM) specifications are presented as the fully open source multilevel modeling reference implementation, and best practices for the development of multilevel-based open source healthcare applications are suggested.
Clinical archetypes provide a means for health professionals to design what should be communicated as part of an Electronic Health Record (EHR). An ever-growing number of archetype definitions follow this health information modelling approach, and this international archetype resource will eventually cover a large number of clinical concepts. On the other hand, clinical terminology systems that can be referenced by archetypes also have a wide coverage over many types of health-care information. No existing work measures the clinical content coverage of archetypes using terminology systems as a metric. Archetype authors require guidance to identify under-covered clinical areas that may need to be the focus of further modelling effort according to this paradigm. This paper develops a first map of SNOMED-CT concepts covered by archetypes in a repository by creating a so-called terminological Shadow. This is achieved by mapping appropriate SNOMED-CT concepts from all nodes that contain archetype terms, finding the top two category levels of the mapped concepts in the SNOMED-CT hierarchy, and calculating the coverage of each category. A quantitative study of the results compares the coverage of different categories to identify relatively under-covered as well as well-covered areas. The results show that the coverage of the well-known National Health Service (NHS) Connecting for Health (CfH) archetype repository on all categories of SNOMED-CT is not equally balanced. Categories worth investigating emerged at different points on the coverage spectrum, including well-covered categories such as Attributes, Qualifier value, under-covered categories such as Microorganism, Kingdom animalia, and categories that are not covered at all such as Cardiovascular drug (product).
There is a little evidence of the impact of clinical information system implementation on nurses' workflow and patient care to guide institutions across the nation as they implement electronic health records. This study compared changes in nurse's perceptions about patient care processes and workflow before and after a comprehensive clinical information system implementation at a rural referral hospital. The study used the Information Systems Expectations and Experiences survey, which consists of seven scales-provider-patient communication, interprovider communication, interorganizational communication, work-life changes, improved care, support and resources, and patient care processes. Survey responses were examined across three administrations-before and after training and after implementation. The survey responses decreased significantly for eight of the 47 survey items from the first administration to the second and for 37 items from the second administration to the third. Perceptions were more positive in nurses who had previous experience with electronic health records and less positive in nurses with more years of work experience. These findings point to the importance of setting realistic expectations, assessing user perceptions throughout the implementation process, designing training to meet the needs of the end user, and adapting training and implementation processes to support nurses who have concerns.
Nowadays, eHealth and pHealth solutions have to meet advanced interoperability challenges. Enabling pervasive computing and even autonomic computing, pHealth system architectures cover many domains, scientifically managed by specialized disciplines using their specific ontologies. Therefore, semantic interoperability has to advance from a communication protocol to an ontology coordination challenge including semantic integration, bringing knowledge representation and artificial intelligence on the table. The resulting solutions comprehensively support multi-lingual and multi-jurisdictional environments.
In the health sector, record linkage is of paramount importance as clinical data can be distributed across different data repositories leading to duplication. Record Linkage is the process of tracking duplicate records that actually refers to the same entity. This paper proposes a fast and efficient method for duplicates detection within the healthcare domain. The first step is to standardize the data in the database using SQL. The second is to match similar pair records, and third step is to organize records into match and non-match status. The system was developed in Unified Modeling Language and Java. In the batch analysis of 31, 177 "supposedly" distinct identities, our method isolates 25, 117 true unique records and 6, 060 suspected duplicates using a healthcare system called MINPHIS (Made in Nigeria Primary Healthcare Information System) as the test bed.
Electronic health records (EHRs) are expected to transform and improve the way medicine is practiced. However, providers perceive many barriers toward implementing new health information technology. Specifically, they are most concerned about the potentially negative impact on their practice finances and productivity. This study compares the productivity of 75 providers at a large urban primary care practice from January 2005 to February 2009, before and after implementing an EHR system, using longitudinal mixed model analyses. While decreases in productivity were observed at the time the EHR system was implemented, most providers quickly recovered, showing increases in productivity per month shortly after EHR implementation. Overall, providers had significant productivity increases of 1.7% per month per provider from pre- to post-EHR adoption. The majority of the productivity gains occurred after the practice instituted a pay-for-performance program, enabled by the data capture of the EHRs. Coupled with pay-for-performance, EHRs can spur rapid gains in provider productivity.
Hospitals engage in medical referral system relations voluntarily, by virtue of their own service capacities. These capacities include medical technology, equipment supply, and patient management, which are assessed individually by medical institutions in efforts to control costs and maintain efficiency in tertiary hospitals. This study assessed referral networks according to the institutional isomorphism theory of new economic sociology. As a result, the referral networks were shown to exhibit emergent structural hierarchy via cumulative clustering by established year and were not affected by attributive variables such as region, bed number, and year of establishment. In particular, the networks evidenced institutional isomorphism with certain central hospitals. As a consequence, personal indices were shown to decrease in accordance with its period, and only the structural index increased. Normative pressures cause organizations to become hierarchically homogenized, in accordance with the principle of organizational learning in specialized fields. Therefore, normative isomorphism on the basis of public domains should be considered an inherent factor in the development of referral networks.
Health information technology (HIT) is perceived as an essential component for addressing inefficiencies in healthcare. Without understanding the challenges that limit meaningful use of HIT, there is a high chance that institutions will convert complex paper-based systems to expensive digital chaos.
Clinical information systems do not communicate with each other automatically because integration of existing data standards is lacking. Data standards for medical specialties need further development. Database architectures are often designed to support single clinical applications and are not easily modified to meet the enterprise-wide needs desired by all end-users. Despite the improvements in charge capture and better access to health information the realized savings and impact on patient throughput is not enough to cover the cost of the technology, maintenance, and support. HIT is necessary for improved quality of care but it increases the cost of doing business. Poor user interface and system design hinders clinical workflow and can result in wasted time, poor data collection, misleading data analysis, and potentially negative clinical outcomes. Healthcare organizations have little recourse if a vendor fails to deliver as intended once the vendor's system becomes embedded into the organization. Decisions on technology acquisitions and implementations are often made by individuals or groups that lack clinical informatics expertise.
Government incentives to increase HIT will likely result in a more computerized clinical environment. Understanding the challenges can help avoid costly mistakes. The future looks promising but caution is warranted, as achievement of full benefits of HIT requires addressing significant challenges.
Interoperability issues are critical for home telehealth applications, electronic health records, electronic medical records, and personal health records. Issues of interoperability affect clinical decision-making and clinician information synthesis. The ability to exchange data collected in the home with an electronic medical record has been positively related to improvements in process outcomes for chronic illness. However, to realize this benefit, risk must be minimized. Evaluation of interoperability challenges and their potential solutions supports data-driven risk management decisions.
The main themes of this panel were patient safety and interoperability, the evolution of the traditional longitudinal health record into a patient managed personal health record (PHR) and the personalization of healthcare itself. The interoperability track D of the National Forum posed the following questions: (1) "How do we achieve syntactic interoperability?"; (2) "How do we achieve semantic interoperability?"; (3) "How do we evolve with emerging standards?"; (4) "How do we integrate new medical devices?"; and (5) "How do we achieve National Health Information Network interoperability?"
EHR systems are core applications in any eHealth/pHealth environment and represent basic services for health telematics platforms. Standards Developing Organizations as well as national programs define EHR architectures as well as related design, implementation, and deployment processes. Claiming to meet the challenge for semantic interoperability and to offer a sustainable pathway, the resulting documents and specifications are sometimes controversial and even inconsistent.
Based on long-term experiences from national and international EHR projects, inputs from related academic groups, and active involvement at CEN, ISO, HL7, an analysis and evaluation study has been performed. Using the Generic Component Model (GCM) reference architecture, the characteristics for advanced and sustainable EHR architectures have been investigated. The dimensions of such an architectural reference model have been described, including basic principles of the underlying formal logical framework.
Strengths and weaknesses of the different standards, specifications, and approaches have been studied and summarized. Migration pathways for re-using and harmonizing the available materials as well as for formally defining standards development roadmaps can be derived.
For providing interoperable and sustainable EHR systems, an EHR architecture reflecting all paradigms of the GCM is absolutely necessary. The resulting EHR solution represents a services architecture of distributed components. The development process shall be completely model-driven and tool-based with formalized specifications of all domains' aspects.
The Agency for Healthcare Research and Quality and its predecessor organizations—collectively referred to here as AHRQ—have a productive history of funding research and development in the field of medical informatics, with grant investments since 1968 totaling $107 million. Many computerized interventions that are commonplace today, such as drug interaction alerts, had their genesis in early AHRQ initiatives.
This review provides a historical perspective on AHRQ investment in medical informatics research. It shows that grants provided by AHRQ resulted in achievements that include advancing automation in the clinical laboratory and radiology, assisting in technology development (computer languages, software, and hardware), evaluating the effectiveness of computer-based medical information systems, facilitating the evolution of computer-aided decision making, promoting computer-initiated quality assurance programs, backing the formation and application of comprehensive data banks, enhancing the management of specific conditions such as HIV infection, and supporting health data coding and standards initiatives.
Other federal agencies and private organizations have also supported research in medical informatics, some earlier and to a greater degree than AHRQ. The results and relative roles of these related efforts are beyond the scope of this review.
Advances in telecommunications, automated processes, web technologies and wireless computing are already forcing dramatic changes in a variety of sectors, ranging from business and industry to education and health. Yet, the electronic business space, in a broader sense, is still in a relatively early state of evolution, and it is only recently that policy makers have started looking at the potential of applying the tools and techniques of e-commerce to the tasks of other sectors. The use of the internet as a source of health information and connectivity between healthcare providers and consumers has increased interest in e-health. E-health offers the rich potential of supplementing traditional delivery of services and channels of communication in ways that extend the healthcare organisation's ability to meet the needs of its patients. To date, some e-health applications have improved the quality of healthcare, and later they will lead to substantial cost savings. However, e-health is not simply a technology but a complex technological and relational process. In this sense, practitioners and researchers who want to successfully exploit e-health need to pay attention to various pending issues that have to be addressed. The aim of this paper is to propose a novel taxonomy for e-health research in the new millennium by instantaneously presenting the current status with some major themes of e-health research.
EHR systems are core applications in any eHealth/pHealth environment and represent basic services for health telematics platforms. Many projects are performed at the level of Standards Developing Organizations or national programs, respectively, for defining EHR architectures as well as related design, implementation, and deployment processes. Claiming to meet the challenge for semantic interoperability and offering the right pathway, the resulting documents and specifications are sometimes controversial and even inconsistent. Based on a long tradition in the EHR domain, on the collective experience of academic groups such as the EFMI EHR Working Group, and on an active involvement at CEN, ISO, HL7 and several national projects around the globe, an analysis and evaluation study has been performed using the Generic Component Model reference architecture. Strengths and weaknesses of the different approaches as well as migration pathways for re-using and harmonizing the available materials are offered.
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