Chapter

Global Health Informatics—An Overview

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Available at https://www.elsevier.com/books/global-health-informatics/marin/978-0-12-804591-6 Global Health Informatics is a growing multidisciplinary field that combines research methods and applications of technology to improve healthcare systems and outcomes. Healthcare systems are facing many challenges including a growing population, the increasing complexity of care services, and limited resources to deliver services. These challenges will require more innovative approaches to scale healthcare services to larger numbers of people. This chapter outlines health informatics systems that have been developed to address these problems.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Digital health records play a crucial role in replacing paperwork in hospitals and clinics, and it has many advantages, for example, patients' information will be easily available, identifying patients' diagnoses and providing treatments quickly, as well as it will be an important tool for researches (Dieterich et al., 2016;Barsley, Sharp and Smith, 2017;Cresswell and Sheikh, 2017;Quintana and Safran, 2017;Gordon et al., 2018). Improving the relationship between patients and medical staff also ensuring medical services are provided properly and accurately a hospital customer relationship management system has been proposed by (Li, 2020). ...
Article
Full-text available
It is difficult for hospitals and clinics to manage their documents related to their patients and routine works without having management software. The purpose of this paper is to design and develop a web-based dental clinic application for educating and managing patients. Recent web technologies such as ASP.NET, JavaScript, Bootstrap, and Web Service have been used for developing the application; it is hosted in the Cloud and it is powered by Microsoft Azure Cloud computing Service. A clinic has been selected to use and evaluate the application. The evaluation results of the application show that the application meets its objectives of educating and managing patients. It can be updated and extended to use in various private and public hospitals and clinics for educating and managing patients.
... © YuriQuintana 2016Quintana -2018 Alicanto™ -Applications http://www.alicantocloud.com ...
... 'Big data' and health informatics are not just a priority for high-income settings but have great potential in low-income countries as well. 8 If postgraduate training in GH does not incorporate knowledge of data management and analysis, then the 'digital divide' between high-income and low-income countries 28 may be exacerbated by a 'digital health education' gap. Competencies in evidence-based medicine, 29 medical ethics 30 and informatics 31 have been successfully integrated into the training of all clinicians. ...
Article
Full-text available
Objective To assess global health (GH) training in all postgraduate medical education in the UK. Design Mixed methodology: scoping review and curricular content analysis using two GH competency frameworks. Setting and participants A scoping review (until December 2017) was used to develop a framework of GH competencies for doctors. National postgraduate medical training curricula were analysed against this and a prior framework for GH competencies. The number of core competencies addressed and/or appearing in each programme was recorded. Outcomes The scoping review identified eight relevant publications. A 16-competency framework was developed and, with a prior 5-competency framework, used to analyse each of 71 postgraduate medical curricula. Curricula were examined by a team of researchers and relevant learning outcomes were coded as one of the 5 or 16 core competencies. The number of core competencies in each programme was recorded. Results Using the 5-competency and 16-competency frameworks, 23 and 20, respectively, out of 71 programmes contained no global health competencies, most notably the Foundation Programme (equivalent to internship), a compulsory programme for UK medical graduates. Of a possible 16 competencies, the mean number across all 71 programmes was 1.73 (95% CI 1.42 to 2.04) and the highest number were in paediatrics and infectious diseases, each with five competencies. Of the 16 core competencies, global burden of disease and socioeconomic determinants of health were the two most cited with 47 and 35 citations, respectively. 8/16 competencies were not cited in any curriculum. Conclusions Equity of care and the challenges of practising in an increasingly globalised world necessitate GH competencies for all doctors. Across the whole of postgraduate training, the majority of UK doctors are receiving minimal or no training in GH. Our GH competency framework can be used to map and plan integration across postgraduate programmes.
... [1][2][3][4][5][6] To facilitate further research and to streamline hospital work, electronic health records (EHRs) were introduced in clinical informatics to digitally store, update, and maintain real-time clinical information. 7 Much of the medical information in EHRs comes from clinical notes (eg, clinician's case summaries), which are documented as free text, and thus require intensive use of natural language processing (NLP) techniques to extract structured information. 8 Screening clinical narratives for the mention of diseases can help identify subjects of specific therapeutic areas (eg, neurology, cardiology), which, in turn, can contribute greatly to the analysis of a clinician's diagnosis. ...
Article
Full-text available
Objective: In this era of digitized health records, there has been a marked interest in using de-identified patient records for conducting various health related surveys. To assist in this research effort, we developed a novel clinical data representation model entitled medical knowledge-infused convolutional neural network (MKCNN), which is used for learning the clinical trial criteria eligibility status of patients to participate in cohort studies. Materials and methods: In this study, we propose a clinical text representation infused with medical knowledge (MK). First, we isolate the noise from the relevant data using a medically relevant description extractor; then we utilize log-likelihood ratio based weights from selected sentences to highlight "met" and "not-met" knowledge-infused representations in bichannel setting for each instance. The combined medical knowledge-infused representation (MK) from these modules helps identify significant clinical criteria semantics, which in turn renders effective learning when used with a convolutional neural network architecture. Results: MKCNN outperforms other Medical Knowledge (MK) relevant learning architectures by approximately 3%; notably SVM and XGBoost implementations developed in this study. MKCNN scored 86.1% on F1metric, a gain of 6% above the average performance assessed from the submissions for n2c2 task. Although pattern/rule-based methods show a higher average performance for the n2c2 clinical data set, MKCNN significantly improves performance of machine learning implementations for clinical datasets. Conclusion: MKCNN scored 86.1% on the F1 score metric. In contrast to many of the rule-based systems introduced during the n2c2 challenge workshop, our system presents a model that heavily draws on machine-based learning. In addition, the MK representations add more value to clinical comprehension and interpretation of natural texts.
... For instance, the exciting field of chemogenomics for malaria is hampered in its efforts to construct a grid-enabled chemogenomic knowledge space by a lack of both genomic data and functional gene annotation of Plasmodium populations (resulting from lagging sequencing output, as well as technical obstacles only recently overcome as in AT-bias and frequent protein insertions) [77]. A similar innovation has been recently accomplished (the Cancer Biomedical Informatics Grid) x extracting research value, and lowering the cost of comparative effectiveness studies [78]. The recently launched European Helix Nebula xi similarly demonstrates that common cloud platforms can accommodate data-harmonization challenges. ...
Article
Molecular surveillance of antimalarial drug resistance markers has become an important part of resistance detection and containment. In the current climate of multidrug resistance, including resistance to the global front-line drug artemisinin, there is a consensus to upscale molecular surveillance. The most salient limitation to current surveillance efforts is that skill and infrastructure requirements preclude many regions. This includes sub-Saharan Africa, where Plasmodium falciparum is responsible for most of the global malaria disease burden. New molecular and data technologies have emerged with an emphasis on accessibility. These may allow surveillance to be conducted in broad settings where it is most needed, including at the primary healthcare level in endemic countries, and extending to the village health worker.
Thesis
Full-text available
Health is the most important aspect of human life. For sustainable social or economic development good health is essential for all. Hence the health care facilities are the most important sectors for all nations which is directly playing role for health improvement of the society. Healthcare industry is one of the largest industries in the world. Health sector is consisting of a complex system where numbers of entities are connected together to deliver the service. Health industry is saturated with large volume of personal data. For the efficient delivery of health service proper information management system is required. In the world history prior to 1960s, all of the reports of health sector were used to stored using filing system. With the implementation of advance technology, the medical records have changed its face from traditional paper based to completely digitized and secure records. For a developing nation poor infrastructure and the reach of the technologies in limited society are the major challenges and obstacles for providing efficient and cost-effective health service. Current health record system being implemented are mostly centralized, lacking interoperability and data ownership to patients. Blockchain being the decentralized technology with tamper proof data seems to be appropriate technology to fulfill the requirement of the health sector. Though implementation of the blockchain technology initiated in cryptocurrency, currently many possibilities of implementing this technology in non-financial sectors are being researched. Hyperledger is the third generation of blockchain which is permissioned blockchain and has extended the possibility of implementation of blockchain in non-financial sector. On the basis of the existing gapping in health industry and the upgradation of the blockchain technology, this research is aimed to develop the architecture of blockchain based health record system architecture. Architecture developed on the basis of Hyperledger Fabric is evaluated through architecture trade-off analysis method of architecture evaluation. Architecture designed is evaluated taking its quality attributes such as latency, transaction throughput, data security, expandability, portability, and authorization.
Chapter
Full-text available
In this day and age with technology advancing rapidly, it has become possible to store and access tremendous amount of data at the touch of one’s fingertips. Diligent utilization of patient medical records is essential for making judicious clinical decisions and for providing health care of the highest order. Public health concerns are steadily increasing as a result of the expanding population. Hence, there is an exponential surge in the amount of data that requires processing. Big data tools that can efficiently minimize the processing time and eliminate errors are the need of the hour. The clinical decision support system (CDSS) is one such advancement that has been gaining traction in recent years. CDSS can be defined as “any electronic or non-electronic active knowledge system specifically designed to aid in clinical decision-making, in which parameters of individual patient health can be used to intelligently filter and generate patient-specific evaluations and assessments which serve as recommendations to clinicians during treatment, thereby enhancing patient care.” CDSS is an information technology tool that, depending on the patient’s input data, can give the assessments, prognosis and medical recommendations based on the nature of the medical condition. CDSS is a major player in the field of artificial intelligence in medicine. It is a revolutionary method that has the potential to galvanize the field of health care, as evidenced by statistical analysis and the multiple successful case studies that have been documented in this chapter.
Chapter
Online travel agency (OTA) plays a crucial role in travel and tourism business for the dissemination of information from business to customer (B2C) to plan, contrast, decide, and book their travel-related product and service online. However, it could be only possible when their websites are easily accessible, understandable, and readable for all the users especially persons with disabilities (PwDs). This study addresses the importance and issues of web accessibility and readability of OTA websites, their relevance, and rankings with corporations to find their overall performance regarding accessible tourism perspective. Using multiple online automatic evaluation tools based on WCAG 2.0 guidelines to analyze 35 OTA websites belongs to three US international corporations. Based on the result obtained, the ranking comparison of websites conducted and suggestions are provided to enhance their rankings in terms of attributes used. Finally, some implications regarding the identified issues are discussed and further enhancement of the work is proposed.
Conference Paper
Full-text available
The purpose of this article is to present an ongoing research that aims to demonstrate the use of indirect alignment techniques, based on ontological scrutiny guided by principles of governance, to add quality to the integration of clinical terminologies. The methodology provides for the adoption of quality principles from ISO / ABNT: 12300, the OBO Foundry Initiative and the Basic Formal Ontology (BFO) for governance of the processes of indirect alignment and integration of clinical terminologies. The expected result includes a public, open and documented set of four ontologies of integration between the SNOMED CT and the ICD within the field of obstetrics.
Article
Full-text available
Purpose of the study: to examine the costs and cost-effectiveness of ‘second-generation’ telecare, in addition to standard support and care that could include ‘first-generation’ forms of telecare, compared with standard support and care that could include ‘first-generation’ forms of telecare. Design and methods: a pragmatic cluster-randomised controlled trial with nested economic evaluation. A total of 2,600 people with social care needs participated in a trial of community-based telecare in three English local authority areas. In the Whole Systems Demonstrator Telecare Questionnaire Study, 550 participants were randomised to intervention and 639 to control. Participants who were offered the telecare intervention received a package of equipment and monitoring services for 12 months, additional to their standard health and social care services. The control group received usual health and social care. Primary outcome measure: incremental cost per quality-adjusted life year (QALY) gained. The analyses took a health and social care perspective. Results: cost per additional QALY was £297,000. Cost-effectiveness acceptability curves indicated that the probability of cost-effectiveness at a willingness-to-pay of £30,000 per QALY gained was only 16%. Sensitivity analyses combining variations in equipment price and support cost parameters yielded a cost-effectiveness ratio of £161,000 per QALY. Implications: while QALY gain in the intervention group was similar to that for controls, social and health services costs were higher. Second-generation telecare did not appear to be a cost-effective addition to usual care, assuming a commonly accepted willingness to pay for QALYs. Trial registration number: ISRCTN 43002091.
Article
Full-text available
Only a few years ago, the mention of informatics in clinical circles generated questions regarding the rigor or relevance of the field. With the expanding interest and investment in health information technology by hospitals, health systems, and practitioners, however, interest in and acceptance of clinical informatics has increased substantially. Since 1972, the National Institutes of Health, principally through the National Library of Medicine (NLM), has supported a number of centers of excellence that focus on workforce education in computer applications and the underlying science. Additional efforts to help ensure a supply of competently trained individuals capable of maintaining progress with respect to applied clinical informatics are a recent development.
Article
Full-text available
eHealth potentially enhances quality of care and may reduce health care costs. However, a review of systematic reviews published in 2010 concluded that high-quality evidence on the benefits of eHealth interventions was still lacking. We conducted a systematic review of systematic reviews and meta-analyses on the effectiveness/cost-effectiveness of eHealth interventions in patients with somatic diseases to analyze whether, and to what possible extent, the outcome of recent research supports or differs from previous conclusions. Literature searches were performed in PubMed, EMBASE, The Cochrane Library, and Scopus for systematic reviews and meta-analyses on eHealth interventions published between August 2009 and December 2012. Articles were screened for relevance based on preset inclusion and exclusion criteria. Citations of residual articles were screened for additional literature. Included papers were critically appraised using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement before data were extracted. Based on conclusions drawn by the authors of the included articles, reviews and meta-analyses were divided into 1 of 3 groups: suitable, promising, or limited evidence on effectiveness/cost-effectiveness. Cases of uncertainty were resolved by consensus discussion. Effect sizes were extracted from papers that included a meta-analysis. To compare our results with previous findings, a trend analysis was performed. Our literature searches yielded 31 eligible reviews, of which 20 (65%) reported on costs. Seven papers (23%) concluded that eHealth is effective/cost-effective, 13 (42%) underlined that evidence is promising, and others found limited or inconsistent proof. Methodological quality of the included reviews and meta-analyses was generally considered high. Trend analysis showed a considerable accumulation of literature on eHealth. However, a similar percentage of papers concluded that eHealth is effective/cost-effective or evidence is at least promising (65% vs 62%). Reviews focusing primarily on children or family caregivers still remained scarce. Although a pooled (subgroup) analysis of aggregate data from randomized studies was performed in a higher percentage of more recently published reviews (45% vs 27%), data on economic outcome measures were less frequently reported (65% vs 85%). The number of reviews and meta-analyses on eHealth interventions in patients with somatic diseases has increased considerably in recent years. Most articles show eHealth is effective/cost-effective or at least suggest evidence is promising, which is consistent with previous findings. Although many researchers advocate larger, well-designed, controlled studies, we believe attention should be given to the development and evaluation of strategies to implement effective/cost-effective eHealth initiatives in daily practice, rather than to further strengthen current evidence.
Article
Full-text available
The panel intended to collect data, opinions and views for a systematic and multiaxial approach for a comprehensive presentation of "History of Medical Informatics", treating both general (global) characteristics, but emphasizing the particular features for Europe. The topic was not only a subject of large interest but also of great importance in preparing a detailed material for celebration of forty years of medical informatics in Europe. The panel comprised a list of topics, trying to cover all major aspects to be discussed. Proposals of staging the major periods of medical informatics history were also discussed.
Article
Full-text available
Information technology is an essential tool to improve patient safety and the quality of care, and to reduce healthcare costs. There is a scarcity of large sustainable implementations in developing countries. The objective of this paper is to review the challenges faced by developing countries to achieve sustainable implementations in health informatics and possible ways to address them. In this non-systematic review of the literature, articles were searched using the keywords medical informatics, developing countries, implementation, and challenges in PubMed, LILACS, CINAHL, Scopus, and EMBASE. The authors, after reading the literature, reached a consensus to classify the challenges into six broad categories. The authors describe the problems faced by developing countries arising from the lack of adequate infrastructure and the ways these can be bypassed; the fundamental need to develop nationwide e-Health agendas to achieve sustainable implementations; ways to overcome public uncertainty with respect to privacy and security; the difficulties shared with developed countries in achieving interoperability; the need for a trained workforce in health informatics and existing initiatives for its development; and strategies to achieve regional integration. Central to the success of any implementation in health informatics is knowledge of the challenges to be faced. This is even more important in developing countries, where uncertainty and instability are common. The authors hope this article will assist policy makers, healthcare managers, and project leaders to successfully plan their implementations and make them sustainable, avoiding unexpected barriers and making better use of their resources.
Article
Full-text available
The rise of personalized medicine and the availability of high-throughput molecular analyses in the context of clinical care have increased the need for adequate tools for translational researchers to manage and explore these data. We reviewed the biomedical literature for translational platforms allowing the management and exploration of clinical and omics data, and identified seven platforms: BRISK, caTRIP, cBio Cancer Portal, G-DOC, iCOD, iDASH and tranSMART. We analyzed these platforms along seven major axes. (1) The community axis regrouped information regarding initiators and funders of the project, as well as availability status and references. (2) We regrouped under the information content axis the nature of the clinical and omics data handled by each system. (3) The privacy management environment axis encompassed functionalities allowing control over data privacy. (4) In the analysis support axis, we detailed the analytical and statistical tools provided by the platforms. We also explored (5) interoperability support and (6) system requirements. The final axis (7) platform support listed the availability of documentation and installation procedures. A large heterogeneity was observed in regard to the capability to manage phenotype information in addition to omics data, their security and interoperability features. The analytical and visualization features strongly depend on the considered platform. Similarly, the availability of the systems is variable. This review aims at providing the reader with the background to choose the platform best suited to their needs. To conclude, we discuss the desiderata for optimal translational research platforms, in terms of privacy, interoperability and technical features.
Article
Full-text available
Background Mobile phone technologies for health promotion and disease prevention have evolved rapidly, but few studies have tested the efficacy of mobile health in full-fledged programs. Text4baby is an example of mobile health based on behavioral theory, and it delivers text messages to traditionally underserved pregnant women and new mothers to change their health, health care beliefs, practices, and behaviors in order to improve clinical outcomes. The purpose of this pilot evaluation study is to assess the efficacy of this text messaging campaign. Methods We conducted a randomized pilot evaluation study. All participants were pregnant women first presenting for care at the Fairfax County, Virginia Health Department. We randomized participants to enroll in text4baby and receive usual health care (intervention), or continue simply to receive usual care (control). We then conducted a 24-item survey by telephone of attitudes and behaviors related to text4baby. We surveyed participants at baseline, before text4baby was delivered to the intervention group, and at follow-up at approximately 28 weeks of baby’s gestational age. Results We completed 123 baseline interviews in English and in Spanish. Overall, the sample was predominantly of Hispanic origin (79.7%) with an average age of 27.6 years. We completed 90 follow-up interviews, and achieved a 73% retention rate. We used a logistic generalized estimating equation model to evaluate intervention effects on measured outcomes. We found a significant effect of text4baby intervention exposure on increased agreement with the attitude statement “I am prepared to be a new mother” (OR = 2.73, CI = 1.04, 7.18, p = 0.042) between baseline and follow-up. For those who had attained a high school education or greater, we observed a significantly higher overall agreement to attitudes against alcohol consumption during pregnancy (OR = 2.80, CI = 1.13, 6.90, p = 0.026). We also observed a significant improvement of attitudes toward alcohol consumption from baseline to follow-up (OR = 3.57, CI = 1.13 – 11.24, p = 0.029). Conclusions This pilot study is the first randomized evaluation of text4baby. It is a promising program in that exposure to the text messages was associated with changes in specific beliefs targeted by the messages.
Article
Full-text available
We are entering an era in which the cost of clinical whole-genome and targeted sequencing tests is no longer prohibitive to their application. However, currently the infrastructure is not in place to support both the patient and the physicians that encounter the resultant data. Here, we ask five experts to give their opinions on whether clinical data should be treated differently from other medical data, given the potential use of these tests, and on the areas that must be developed to improve patient outcome.
Article
Full-text available
Objective: To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality. Design: Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat. Setting: 179 general practices in three areas in England. Participants: 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009. Interventions: Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients' diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth. Main outcome measure: Proportion of patients admitted to hospital during 12 month trial period. Results: Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P = 0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P < 0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P = 0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference -0.64 days, -1.14 to -0.10, P = 0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group. Conclusions: Telehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect. Trial registration number: International Standard Randomised Controlled Trial Number Register ISRCTN43002091.
Article
Full-text available
The AMIA biomedical informatics (BMI) core competencies have been designed to support and guide graduate education in BMI, the core scientific discipline underlying the breadth of the field's research, practice, and education. The core definition of BMI adopted by AMIA specifies that BMI is 'the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health.' Application areas range from bioinformatics to clinical and public health informatics and span the spectrum from the molecular to population levels of health and biomedicine. The shared core informatics competencies of BMI draw on the practical experience of many specific informatics sub-disciplines. The AMIA BMI analysis highlights the central shared set of competencies that should guide curriculum design and that graduate students should be expected to master.
Article
Full-text available
Lack of infrastructure, including information and communication systems, is considered a barrier to successful HIV treatment programmes in resource poor areas. The authors describe how they set up a web based medical record system linking remote areas in rural Haiti and how it is used to track clinical outcomes, laboratory tests, and drug supplies and to create reports for funding agencies Introduction HIV/AIDS has become the world's leading infectious cause of adult deaths1 and takes its greatest toll in remote, resource poor areas. Dramatic improvements in survival have been seen with use of antiretroviral drugs in developed countries2 and in Brazil.3 Since 2001, substantial resources have been pledged to treat HIV infected patients in developing countries,4 but concerns have been expressed that many such countries lack the infrastructure to support the complex treatment regimen for this chronic disease.5 6 This article describes approaches to improving important infrastructure components for HIV treatment in very impoverished areas—clinical communications, data analysis, and drug supply management. Background Haiti is the poorest country in the western hemisphere and, with about 6% of adults infected with HIV, is the most severely affected by HIV/AIDS.7 Six years ago the non-governmental organisations Partners In Health and Zanmi Lasante launched an innovative, community based HIV treatment programme in Haiti's impoverished central plateau.8 Zanmi Lasante currently monitors more than 7000 patients with HIV, of whom more than 1300 are currently receiving highly active antiretroviral therapy (HAART). In 2002, Zanmi Lasante was awarded part of Haiti's grant from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)4 to expand this successful programme to five more sites in the central plateau—Thomonde, Lascahobas, Boucan Carre, Belladere, and Hinche. Zanmi Lasante runs a central hospital housing the laboratory and main drug warehouse, with a second laboratory recently set up in Lascahobas and smaller pharmacies and laboratories in the other sites. Highly active antiretroviral therapy requires daily administration of three antiretroviral drugs to maintain control of the disease and to minimise emergence of resistance.9 Scaling up care to thousands of patients requires good information management to ensure that each patient can be identified and traced, that his or her health status is monitored effectively, that results from critical laboratory tests are monitored and communicated to doctors, and that drug supplies are always available at each site. Implementing this rapid treatment expansion in a region with few doctors and virtually no roads, electricity, or communications is a major challenge. Zanmi Lasante's initial experience, in Cange, of access to the internet via a satellite link suggested that establishing communication with the new sites was feasible with new technologies to leapfrog the lack of infrastructure and that electronic record keeping was feasible and helpful in programme and patient management (fig 1). View larger version:In a new windowDownload as PowerPoint SlideFig 1 Clinical staff in Belladere, rural Haiti, find their web based medical record system helpful for managing patients with AIDS Information and communication Medical information can be a critical lifesaving resource,10 but staff in remote hospitals often have to function almost entirely on their own, without access to up to date medical information or the support of more experienced colleagues. This situation is changing with increasing access to the internet, particularly with the expanded use of email.11 Consultation can include sending digital camera images, termed “store-and-forward” telemedicine.12 13 Our treatment sites in Haiti, Peru, and Russia have used email extensively over the past decade for clinical communication and logistics. Our experience in the original Haitian site, Cange, indicated that the cheapest and most flexible communication strategy was to establish a small satellite connection to the internet in each of the five new sites (box 1). Box 1: Technical details of satellite systems The main site (Cange) has a 256 kbs bidirectional link, using the USA Teleport Satellite signal, connected to a local area network (LAN) which provides broadband connection to the internet (256 kbs fractional-T1 line). The expansion sites have lower cost systems from Skycasters. Equipment includes a satellite dish and satellite modem that plugs into a standard PC server or a router. The asymmetric connection provides 400 kbs or better download speed but 30 kbs upload speed on the basic configuration, upgradeable to 64 kbs. The cost of basic hardware including the server PC is currently $6000 (£3260; €4695), and monthly charges range from $130 to $260 depending on bandwidth. These specifications are similar to those for “Mini VSAT” satellite networks in west Africa and South Africa. For connecting different buildings in a site, we use a standard Ethernet LAN or wireless LAN (802.11). Wireless technology allows low cost connection by avoiding additional wiring costs, and “in line of site” connections can be made up to 12 km at low cost ($1000). Medical data management Despite the value of email for supporting patient care, lack of structure and organisation limits its potential as the sole information management tool. Email also lacks good tools to ensure security and confidentiality of data. Creating a database of core information allows staff to track individual patients as well as to monitor the care of an entire group. For patients with HIV, this includes tracking critical laboratory results such as CD4 counts. The traditional approach to electronic data management in a remote location is to place servers in the clinic sites,14 and in some systems data are periodically transmitted to a central server.15 In rural Haiti this is problematic because of unstable electrical power, humidity, dust, security concerns, and difficulty in providing technical support. Implementing a secure, web based electronic medical record allows data collection and review to occur from many remote sites. Using a shared server in a secure environment with stable power and good data backup (including a duplicate machine off site) has the additional advantage that the most recent data are available to all users. Scaling up treatment also calls for training new health workers; using decision support tools may assist them to become familiar with the management of HIV. The HIV electronic medical record The HIV electronic medical record (HIV-EMR) is based on the technology we developed for a web based tuberculosis electronic medical record in Peru16 (box 2) and is hosted on a server in Boston, USA. Clinical data forms include demographic data, clinical assessment, laboratory investigations, and social circumstances (box 3) and are based on the paper forms that Zanmi Lasante has used for several years. The electronic medical record was developed in French and English, with close consultation with local Haitian users to ensure it supported their needs. The system includes a library of web page analyses, developed for a related project,16 that simplify searches for patient groups based on characteristics such as age, drug regimen, and laboratory results. Other pages generate graphs and tables and allow data to be downloaded to statistical analysis packages. Box 2: Technical details of the HIV-EMR The HIV-EMR is based on the web based electronic medical record we developed to support a treatment programme for drug resistant tuberculosis in Peru.16 It is built with standard, open source software—Linux operating system, Apache web server, the Tomcat Java Servlet engine. We are using an Oracle database, but an open source database is being considered to allow free distribution of the whole system. Drug supplies and use A crucial part of treating HIV infection or other complex chronic diseases in developing countries is ensuring an uninterrupted supply of drugs. This includes procurement, shipping, storage, and issuing to patients. Accurate information on current stocks and estimates of future requirements are crucial to ensure optimum prices and avoid stocks running out or passing their expiry date. In the HIV-EMR drug regimens are recorded for all patients receiving treatment. We can calculate the total requirements for a patient group for a specified period based on their prescribed regimens.16 17 This is useful when treating a large cohort with one disease type, especially when the number of treated patients is expanding rapidly. An alternative approach is to calculate the amount of drugs that enter and leave the warehouse each month, typically with WHO stock cards, to assess use. Several database systems have been developed to automate this process, but they generally need servers at each site.17 18 The HIV-EMR supports both of these methods. Web pages representing stock cards provide a familiar interface for staff to keep track of drugs in the warehouse. Recording drug regimens and use in one networked system allows automatic cross checks of estimates from both methods, and enables the geographically dispersed drug procurement team to share the same data and analyses. Box 3: Categories of data collected in HIV-EMR Patient demographicsHistory of presenting complaintPrevious treatment and any adverse eventsSymptomsPhysical examinationLaboratory investigationsSocial circumstances, housing, occupationDrugsNarrative text is also allowed in some categories such as clinical history and assessment Data security and confidentiality To develop a web based electronic medical record for this project, we built on extensive previous work on encryption and web security for financial transactions and medical records.19 20 Users are required to have complex passwords and can access only the parts of the site they needAll logins and viewed pages are recorded and reviewed to ensure that no unauthorised access occursA centralised database allows the computer and data to be physically secure and backed up regularlyThe capability to view patient details securely in the electronic medical record removes the need to send patient information by non-secure emailEncryption of data transfers is done with the Secure Sockets Layer (SSL) protocol. Current experience with the HIV-EMR in Haiti Communications Zanmi Lasante staff have fully adopted email to coordinate care between sites. This includes scheduling and obtaining the results of specialist investigations in the capital, Port au Prince, or the United States, organising patient transfers for surgery, and ensuring staff are ready for emergencies. Email consultation with doctors is done daily, especially by junior staff in remote clinics, who often require advice on treatment options. Patient names and addresses are excluded from non-secure email. Email also assists in ordering and monitoring shipments of drugs and equipment. Medical information websites are also used extensively. Use of the HIV-EMR The HIV-EMR has been operational for over nine months and is accessible at the six sites in the central plateau. Doctors and nurses enter all clinical and drug data using a standard patient registration form. To speed data entry, the form has a checklist to order patient management items, including investigations and standard sets of drugs (fig 2). Once this form has been submitted, the subsequent page displays any drugs that were selected. Doctors can check the drugs, their doses, and the times of day to be administered. Finally, when submitting this form, the user can print out an order for the pharmacy. As drugs are entered, they are cross checked for allergies, inappropriate doses, and incompatible drug combinations. The system displays warnings about any problems detected, such as prescribing zidovudine and stavudine together. View larger version:In a new windowDownload as PowerPoint SlideFig 2 Part of the checklist of items in the patient registration form of the HIV-EMR electronic medical record (PPD=tuberculosis skin test, INH=isoniazid, HREZ=four standard antituberculous drugs, VCF=voluntary counselling and testing, PF=family planning, NRTI and NNRTI/PI=antiretroviral drug lists) Decision support is also used for laboratory results. Technicians in two clinical sites, Cange and Lascahobas, enter CD4 cell counts. Each night, a program checks for patients with low CD4 counts who are not receiving the appropriate drug regimen. A warning email is sent to all 20 Zanmi Lasante clinicians and contains a link to the electronic medical records of patients who require additional treatment. Reminders can also be generated for patients who require extra drugs or investigations. Currently more than 150 new cases are entered each month, mostly via the “Offline EMR” (see below). Of the 2500 cases that have been entered, more than 1300 have full registration data and vital signs, and 800 have full antiretroviral drug regimens recorded. Drug stocks in the warehouse are recorded regularly by the pharmacists using web based stock cards. Regular analyses monitor the expected drug use from the drug regimens entered. Problems and challenges Offline data entry Loss of network connection regularly interrupts the use of our web based system, especially in the rainy season. We therefore developed the “Offline EMR” for offline data entry. This includes the core functions of the web based system but stores data on the local computer. When the network becomes available again, it transmits data to the server using a secure web connection.20 Entered cases can be stored for an unlimited time, but delays in uploading the data increase the risk of their loss because of computer problems. Case summaries are stored in password protected, secure form in the application and are updated when an internet connection is available, allowing updates and changes to be made to existing cases. Periodically, the application needs to be updated or fixed: to reduce the need for IT staff to visit remote sites, the application can be tested and upgraded over the internet. Patient identification Low literacy in Haiti contributes to inconsistent spelling of patients' names and addresses. We have developed search tools to match duplicate records based on name, address, age, and sex, and then either merge the two records or email the details to the users for advice. Use of patient identity cards may be helpful once the system is not limited to HIV patients.21 Data quality Initial training sessions are held on site with clinicians by IT staff, and follow up visits are made regularly. Data forms contain checks for out of range values. Data checking and cleaning are done by means of web based forms as well as email support for clinicians. Usability Training and time requirements to keep the data in the electronic medical record up to date are vital for sustaining the system. Although our doctors have been able to complete the patient intake forms effectively, we recognise the need to provide more support for follow up data and data quality checking as the electronic medical record system expands to thousands of patients. Discussion Global experience in treating HIV in resource poor areas, including information management, is limited. Electronic medical record systems to support HIV treatment date back 10 years to Safran et al, who developed an ambulatory medical record component of the information system at Beth Israel hospital in Boston.22 Their system included email alerts for doctors about patients with low CD4 counts, and they showed it improved quality of care.22 Our HIV-EMR system shows that effective information management is also possible in a poor community with no modern infrastructure. The electronic medical record and communications systems continued to function even during the armed uprising in Haiti this year. Box 4 describes existing systems for HIV information management in developing countries. The strategies for information management vary depending on the nature of a particular treatment programme, the number of sites where patients are treated, and the available infrastructure and human resources. Stand alone databases have the advantage of being easier to develop and maintain, but they typically lack valuable tools to coordinate data between sites. The use of guidelines and alerts to guide prescribing has been shown to improve the quality of treatment and reduce medical errors in developed countries.23 Given the limited experience in treating HIV in developing countries, decision support may have an important role, but this requires further evaluation. Cost is a major concern with any technology intended to be used in very poor areas. Can the expenditure be justified with so many other pressing needs? The annual cost of internet access per site in Haiti is $1600, equivalent to about two years' highly active antiretroviral therapy and clinical care for one patient. Capital costs of $6000, along with staff training and assistance with data entry, increase the overall expense. This must be balanced against potential benefits including support for clinical care and research; our drug costs alone are currently more than $500 000 a year and rising. Strict reporting requirements by funders such as the Global Fund provide further incentives for effective monitoring. Conclusions HIV-EMR has proved itself in some of the most challenging field conditions in the world, similar to those found in much of sub-Saharan Africa. Future work will focus on refining the system and developing a core data set and functions to support other HIV treatment projects, including incorporation of data representation and exchange standards such as Health Level Seven document architecture.28 Common standards for creating computerised guidelines are also important to allow sharing of knowledge between projects and information systems.29 Sharing of ideas, models, and software (such as the Offline EMR) between projects is essential if we are to quickly expand HIV treatment in resource poor areas. Unfortunately projects tend to “go it alone” rather than collaborating. We are working with the WHO and the US Government Health Resources and Services Agency and others to develop common data models, components, and designs for HIV information systems. Local staff with training in information systems are also required, and we have set up a masters degree programme in medical informatics with colleagues at the University of Kwa-Zulu Natal, South Africa, and Tufts University, USA. Box 4: Examples of information systems to support HIV treatment in developing countries Stand alone databases The Brazilian public health system currently delivers antiretroviral treatment to more than 100 000 patients15—by far the largest group in the developing world. The “Computerized System for the Control of Drug Logistics (SICLOM)”1524 is an internet based drug management program developed to support treatment and is considered a “key factor helping to overcome logistical challenges to delivery of antiretroviral treatment in Brazil.” It connects to a central server to update its records, an approach similar to the Offline EMR in Haiti.The Mosoriot medical record in Kenya has been heavily used for general medical care in one hospital for more than two years and was recently extended to support HIV treatment at Moi University. It was developed using Microsoft Access; data are entered from a paper record.14 A web based version is under development.The Children's Hospital in Lilongwe, Malawi, has made heavy use of a touch-screen medical record system for more than two years. Developed by Gerry Douglas, this system runs on a local network and is built using Microsoft SQL server and Visual Basic. Doctors, nurses, and other staff enter all data, including drug orders.21 It is being extended to collect data on HIV patients.The Cuban health ministry has a Microsoft Access database system called SIDATRAT that registers general patient data, clinical data, opportunistic infections, staging, viral load and CD4 cell count, treatment, side effects, drug resistance, and drug adherence. It includes the more than 5000 people diagnosed with HIV in Cuba since 1986.A team at the US Department of Health and Human Services led by John Milberg have developed the Careware system (using Microsoft Access). It provides comprehensive tools for tracking HIV patients and their treatment. Currently used in more than 300 US health centres and hospitals, it was deployed in Uganda in October 2003. An internet accessible version is under development. Software is available free at http://hab.hrsa.gov/careware.FUCHIA was developed by Epicentre, the epidemiology group of Médecins Sans Frontières, to support their HIV treatment projects.25 It supports clinical care and long term follow up of patients, including scheduling of visits, and includes data on drugs and certain investigations and generates some reports. It was developed using Microsoft Access and the Delphi programming language, and the software is available free at http://www.epicentre.msf.org/. Internet based medical record systems • The PIH-EMR system was created to support the management of drug resistant tuberculosis in Peru.16 This system was built using the Linux operating system, Apache web server, Tomcat Java Servlet engine, and Oracle database. It supports clinical care, logistics such as assessment of drug requirements, and research studies. Heavily used for more than two years, most data are entered from paper forms, with nurse entry of drug orders now implemented in some sites. Web based collaboration and telemedicine systems (not specifically for HIV) The RAFT project permits remote collaboration, case discussion, and data sharing over low bandwidth networks between Geneva University Hospitals and Bamako, Mali.26 The collaboration is being extended to other French west African countries. It is built using Linux and other open source software.The IPATH server allows image sharing in pathology and radiology and is being used in South Africa and the Pacific as well as Switzerland.27 It is built with open source software and is available free at http://www.sourceforge.net/Telemedmail is a secure email and web based telemedicine system under evaluation in South Africa and Peru; it was built using Java and open source software12 and is available free at http://www.sourceforge.net/Satellife are using the cell phone network in Uganda to transfer data to a central site. Local healthcare workers collect data on Palm Pilots and then connect to a local, battery powered server called a Wide Ray Jack. This server allows data to be sent to and from a central database via a cell phone modem. More information is at http://pda.healthnet.org/ Summary points Recent studies have shown the feasibility of treating HIV/AIDS in developing countries Lack of infrastructure, including information and communication systems, is considered a barrier to successful HIV treatment programmes Internet based information systems offer a way to provide communication infrastructure in remote, resource-poor areas such as rural Haiti A web based medical record system can be effectively used to track clinical outcomes, laboratory tests and drug supplies, and create reports for funding agencies Development and evaluation of practical, low cost clinical information systems should be a priority in rolling out HIV treatment in developing countries HIV treatment does not occur in isolation, and the infrastructure we have developed in central Haiti is augmenting the care of other acute and chronic diseases, including tuberculosis and heart disease. The similar web based tuberculosis electronic medical record in Peru provides important support for treatment, drug supply, and research with more than 2500 complete patient records entered to date.16 We plan to make our HIV-EMR available to other organisations once it is complete, using an open source model for software distribution.30 Footnotes We thank all the physicians, nurses, and laboratory technicians caring for HIV patients at Zanmi Lasante for their hard work and enthusiasm. We thank Libby Levison for advice on drug supply management and critically reviewing this article. Contributors and sources The information in this article comes from our own work in developing the information systems and in treating HIV in Haiti for many years. HSFF led the project, co-designed the electronic medical record, and is the guarantor and lead author of the article. DJ co-designed and built the electronic medical record. YK designed and built the satellite systems and networks with help from PN, who maintains all the IT systems in Haiti and helped train the users. FL, PEF, EL, and JSM are physicians who set up the HIV treatment programme, designed the forms, and oversaw the implementation and use of the electronic medical record. SSC and MKCSF did background research and helped write and revise the article. Funding We thank Thomas J White for long term support of Partners in Health and Zanmi Lasante. The Izumi foundation provided support for the development of the drug management systems, and the Bill and Melinda Gates Foundation supported earlier development work on the technologies used for this system. The Global Fund for AIDS Tuberculosis and Malaria pays the costs of the treatment of the HIV patients through a grant to the Haitian government and Zanmi Lasante. Much of the financial support for the clinical care in Haiti comes from individual contributions to Partners In Health, a non-profit corporation that provides health care for the poor. HSFF receives funding from the US National Institutes of Health (NIH) Fogarty International Center as part of the informatics training for global health program awarded to Tufts University in Boston, USA, and the University of Kwa-Zulu Natal, South Africa. He also receives NIH funding for work on patient controlled medical records in collaboration with the Informatics Program at the Children's Hospital Boston. Competing interests None declared. Ethical approval Not required. References1.↵Report on the global HIV/AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS, 2000.2.↵Palella FJ Jr., Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998;338: 853–60.OpenUrlCrossRefMedlineWeb of Science3.↵Marins JR, Jamal LF, Chen SY, Barros MB, Hudes ES, Barbosa AA, et al. Dramatic improvement in survival among adult Brazilian AIDS patients. AIDS 2003;17: 1675–82.OpenUrlCrossRefMedlineWeb of Science4.↵Richards T. New global health fund. BMJ 2001;322: 1321–2.OpenUrlFREE Full Text5.↵Betraying the sick in Africa. New York Times 2003 September 4: 22.6.↵Loewenson R, McCoy D. Access to antiretroviral treatment in Africa. BMJ 2004;328: 241–2.OpenUrlFREE Full Text7.↵Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections. Geneva: WHO, UNAIDS, Unicef, PAHO, 2003: 2.8.↵Farmer P, Leandre F, Mukherjee JS, Claude M, Nevil P, Smith-Fawzi MC, et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet 2001;358: 404–9.OpenUrlCrossRefMedlineWeb of Science9.↵Harries A, Nyangulu D, Hargreaves N, Kaluwa O, Salaniponi F. Preventing antiretroviral anarchy in sub-Saharan Africa. Lancet 2001;358: 410–4.OpenUrlCrossRefMedlineWeb of Science10.↵Pakenham-Walsh N, Priestly C, Smith R. Meeting the information needs of health workers in developing countries. BMJ 1997;314: 90.OpenUrlFREE Full Text11.↵Fraser HS, McGrath SJ. Information technology and telemedicine in sub-Saharan Africa. BMJ 2000;321: 465–6.OpenUrlFREE Full Text12.↵Fraser HS, Jazayeri D, Bannach L, Szolovits P, McGrath D. TeleMedMail: free software to facilitate telemedicine in developing countries. Medinfo 2001;10(Pt 1): 815–9.OpenUrlMedline13.↵Della Mea V. Internet electronic mail: a tool for low-cost telemedicine. J Telemed Telecare 1999;5(2): 84–9.OpenUrlCrossRefMedlineWeb of Science14.↵Rotich JK, Hannan TJ, Smith FE, Bii J, Odero WW, Vu N, et al. Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot medical record system. J Am Med Inform Assoc 2003;10: 295–303.OpenUrlFREE Full Text15.↵Galvao J. Access to antiretroviral drugs in Brazil. Lancet 2002;360: 1862–5.OpenUrlCrossRefMedlineWeb of Science16.↵Fraser H, Jazayeri D, Mitnick C, Mukherjee J, Bayona J. Informatics tools to monitor progress and outcomes of patients with drug resistant tuberculosis in Peru. Proc AMIA Symp 2002: 270–4.17.↵Quick J, Rankin J, Laing R, O'Connor R, Hogerzeil H, Dukes M, et al.Olson C, Rankin J. Quantifying drug requirements. In: Quick J, Rankin J, Laing R, O'Connor R, Hogerzeil H, Dukes M, et al., eds. Managing drug supply Hartford, CT: Kumarian Press, 1997: 184–20618.↵Milberg J. Adapting an HIV/AIDS clinical information system for use in Kampala, Uganda. Proceedings of Helina 2003, Johannesburg: International Medical Informatics Association, 2003: 44–519.↵Rind DM, Kohane IS, Szolovits P, Safran C, Chueh HC, Barnett GO. Maintaining the confidentiality of medical records shared over the internet and the world wide web. Ann Intern Med 1997;127: 138–41.OpenUrlFREE Full Text20.↵Halamka JD, Szolovits P, Rind D, Safran C. A WWW implementation of national recommendations for protecting electronic health information. J Am Med Inform Assoc 1997;4: 458–64.OpenUrlFREE Full Text21.↵Douglas G. The Lilongwe Central Hospital patient management information system: a success in computer-based order entry where one might least expect. Proc AMIA Symp 2003: 833.22.↵Safran C, Rind DM, Davis RB, Ives D, Sands DZ, Currier J, et al. Guidelines for management of HIV infection with computer-based patient's record. Lancet 1995;346: 341–6.OpenUrlCrossRefMedlineWeb of Science23.↵Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 2001;8: 299–308.OpenUrlFREE Full Text24.↵Ministry of Health Brazil. National AIDS drug policy: June 2001. AIDS drugs logistic system. www.aids.gov.br/final/biblioteca/drug/drug4.htm (accessed 18 Oct 2004).25.↵Tassie J, Balandine S, Szumilin E, Andrieux-Meyer I, Biot M, Cavailler P, et al. FUCHIA: a free computer program for the monitoring of HIV/AIDS medical care at the population level. Int Conf AIDS 2002;14: C11029.OpenUrl26.↵Geissbuhler A, Ly O, Lovis C, L'Haire J. Telemedicine in western Africa: lessons learned from a pilot project in Mali, perspectives and recommendations. Proc AMIA Symp 2003: 249–53.27.↵Oberholzer M, Christen H, Haroske G, Helfrich M, Oberli H, Jundt G, et al. Modern telepathology: a distributed system with open standards. Curr Probl Dermatol 2003;32: 102–14.OpenUrlMedline28.↵Dolin RH, Alschuler L, Beebe C, Biron PV, Boyer SL, Essin D, et al. The HL7 clinical document architecture. J Am Med Inform Assoc 2001;8: 552–69.OpenUrlFREE Full Text29.↵Peleg M, Boxwala AA, Tu S, Zeng Q, Ogunyemi O, Wang D, et al. The InterMed approach to sharable computer-interpretable guidelines: a review. J Am Med Inform Assoc 2004;11: 1–10.OpenUrlFREE Full Text30.↵Carnall D. Medical software's free future. Open collaboration over the internet is changing development methods. BMJ 2000;321: 976.OpenUrlFREE Full Text
Article
Full-text available
Computerised clinical decision support systems (CDSSs) are being used increasingly to support evidence-based decision-making by health care professionals. This systematic review evaluated the impact of CDSSs targeting pharmacists on physician prescribing, clinical and patient outcomes. We compared the impact of CDSSs addressing safety concerns (drug interactions, contraindications, dose monitoring and adjustment) and those focusing on medicines use in line with guideline recommendations (hereafter referred to as Quality Use of Medicines, or QUM). We also examined the influence of clinical setting (institutional versus ambulatory care), system- or user-initiation of CDSS, prescribing versus clinical outcomes reported and use of multi-faceted versus single interventions on system effectiveness. We searched Medline, Embase, CINAHL and PsycINFO (1990-2009) for methodologically adequate studies (experiments and strong quasi-experiments) comparing a CDSS with usual pharmacy care. Individual study results are reported as positive trends or statistically significant results in the direction of the intentions of the CDSS being tested. Studies are aggregated and compared as the proportions of studies showing the effectiveness of the CDSS on the majority (> or = 50%) of outcomes reported in the individual study. Of 21 eligible studies, 11 addressed safety and 10 QUM issues. CDSSs addressing safety issues were more effective than CDSSs focusing on QUM (10/11 versus 4/10 studies reporting statistically significant improvements in favour of CDSSs on > or = 50% of all outcomes reported; P = 0.01). A number of QUM studies noted the limited contact between pharmacists and physicians relating to QUM treatment recommendations. More studies demonstrated CDSS benefits on prescribing outcomes than clinical outcomes (10/10 versus 0/3 studies; P = 0.002). There were too few studies to assess the impact of system- versus user-initiated CDSS, the influence of setting or multi-faceted interventions on CDSS effectiveness. Our study demonstrated greater effectiveness of safety-focused compared with QUM-focused CDSSs. Medicine safety issues are traditional areas of pharmacy activity. Without good communication between pharmacists and physicians, the full benefits of QUM-focused CDSSs may not be realised. Developments in pharmacy-based CDSSs need to consider these inter-professional relationships as well as computer-system enhancements.
Article
Full-text available
Is there any evidence that e-health-using information technology to manage patient care-can have a positive impact in developing countries? Our systematic review of evaluations of e-health implementations in developing countries found that systems that improve communication between institutions, assist in ordering and managing medications, and help monitor and detect patients who might abandon care show promise. Evaluations of personal digital assistants and mobile devices convincingly demonstrate that such devices can be very effective in improving data collection time and quality. Donors and funders should require and sponsor outside evaluations to ensure that future e-health investments are well-targeted.
Article
Full-text available
Despite the pressing need for the creation of applications that facilitate the aggregation of clinical and molecular data, most current applications are proprietary and lack the necessary compliance with standards that would allow for cross-institutional data exchange. In line with its mission of accelerating research discoveries and improving patient outcomes by linking networks of researchers, physicians, and patients focused on cancer research, caBIG (cancer Biomedical Informatics Grid) has sponsored the creation of the caTRIP (Cancer Translational Research Informatics Platform) tool, with the purpose of aggregating clinical and molecular data in a repository that is user-friendly, easily accessible, as well as compliant with regulatory requirements of privacy and security. caTRIP has been developed as an N-tier architecture, with three primary tiers: domain services, the distributed query engine, and the graphical user interface, primarily making use of the caGrid infrastructure to ensure compatibility with other tools currently developed by caBIG. The application interface was designed so that users can construct queries using either the Simple Interface via drop-down menus or the Advanced Interface for more sophisticated searching strategies to using drag-and-drop. Furthermore, the application addresses the security concerns of authentication, authorization, and delegation, as well as an automated honest broker service for deidentifying data. Currently being deployed at Duke University and a few other centers, we expect that caTRIP will make a significant contribution to further the development of translational research through the facilitation of its data exchange and storage processes.
Article
Full-text available
The Informatics for Integrating Biology and the Bedside (i2b2) is one of the sponsored initiatives of the NIH Roadmap National Centers for Biomedical Computing (http://www.bisti.nih.gov/ncbc/). One of the goals of i2b2 is to provide clinical investigators broadly with the software tools necessary to collect and manage project-related clinical research data in the genomics age as a cohesive entity, a software suite to construct and manage the modern clinical research chart. The i2b2 "hive" is a set of software modules called "cells" that have a common messaging protocol that allow them to interact using web services and XML messages. Each cell can be developed by independent investigators to achieve specific analytic goals, and then be integrated into the hive to enhance the functionality available in the i2b2 Hive. We have applied this architecture through several ongoing clinical studies and found it to be of high value. The current version of this software has been released into the public domain and is available at the URL-http://www.i2b2.org.
Article
Full-text available
We have built a clinical workstation to help doctors and nurses care for patients with HIV infection. This knowledge-based medical record system provides medication alerts, reminders about primary care, and on-line information to support the care of patients with HIV infection. We are conducting a controlled clinical trial of this computer system in a single practice setting, which consists of 18 staff physicians, 13 nurses, and 113 residents, who cooperatively practice in four teams. Two teams of physicians are assigned to an intervention group and two teams to a control group. This paper reports preliminary results from the first year of study, January 15, 1992, through January 14, 1993. During this period 274 patients with HIV infection were followed by the general medical practice--130 in a control group and 144 in an intervention group. Physicians in the intervention group more rapidly and more completely followed primary care guidelines than did physicians in the control group. Patients in the intervention group had 2476 ambulatory or emergency visits (17.2 visits per patient) compared with 1882 visits (14.5 visits per patient) for the control patients (p < 0.01). There were 101 hospitalizations for 51 patients in the intervention group (an admission rate of 0.7) compared with 104 admissions for 54 patients in the control group (an admission rate of 0.8) (p = NS). There were 8 deaths in the intervention group (5.6%) compared with 13 (10%) in the control group (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Full-text available
Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient. Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physician computer order entry (POE) and the combination of POE plus a team intervention. Large tertiary care hospital. For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period. A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units. Nonintercepted serious medication errors. Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additional benefit over POE. Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.
Article
Full-text available
The complexity of cancer is prompting researchers to find new ways to synthesize information from diverse data sources and to carry out coordinated research efforts that span multiple institutions. There is a need for standard applications, common data models, and software infrastructure to enable more efficient access to and sharing of distributed computational resources in cancer research. To address this need the National Cancer Institute (NCI) has initiated a national-scale effort, called the cancer Biomedical Informatics Grid (caBIGtrade mark), to develop a federation of interoperable research information systems. At the heart of the caBIG approach to federated interoperability effort is a Grid middleware infrastructure, called caGrid. In this paper we describe the caGrid framework and its current implementation, caGrid version 0.5. caGrid is a model-driven and service-oriented architecture that synthesizes and extends a number of technologies to provide a standardized framework for the advertising, discovery, and invocation of data and analytical resources. We expect caGrid to greatly facilitate the launch and ongoing management of coordinated cancer research studies involving multiple institutions, to provide the ability to manage and securely share information and analytic resources, and to spur a new generation of research applications that empower researchers to take a more integrative, trans-domain approach to data mining and analysis. The caGrid version 0.5 release can be downloaded from https://cabig.nci.nih.gov/workspaces/Architecture/caGrid/. The operational test bed Grid can be accessed through the client included in the release, or through the caGrid-browser web application http://cagrid-browser.nci.nih.gov.
Article
Full-text available
The PIH-EMR is a Web based electronic medical record that has been in operation for over four years in Peru supporting the treatment of drug resistant TB. We describe here the types of evaluations that have been performed on the EMR to assess its impact on patient care, reporting, logistics and observational research. Formal studies have been performed on components for drug order entry, drug requirements prediction tools and the use of PDAs to collect bacteriology data. In addition less formal data on the use of the EMR for reporting and research are reviewed. Experience and insights from porting the PIH-EMR to the Philippines, and modifying it to support HIV treatment in Haiti and Rwanda are discussed. We propose that additional data of this sort is valuable in assessing medical information systems especially in resource poor areas.
Article
Full-text available
Multi-drug resistant tuberculosis patients in resource-poor settings experience large delays in starting appropriate treatment and may not be monitored appropriately due to an overburdened laboratory system, delays in communication of results, and missing or error-prone laboratory data. The objective of this paper is to describe an electronic laboratory information system implemented to alleviate these problems and its expanding use by the Peruvian public sector, as well as examine the broader issues of implementing such systems in resource-poor settings. A web-based laboratory information system "e-Chasqui" has been designed and implemented in Peru to improve the timeliness and quality of laboratory data. It was deployed in the national TB laboratory, two regional laboratories and twelve pilot health centres. Using needs assessment and workflow analysis tools, e-Chasqui was designed to provide for improved patient care, increased quality control, and more efficient laboratory monitoring and reporting. Since its full implementation in March 2006, 29,944 smear microscopy, 31,797 culture and 7,675 drug susceptibility test results have been entered. Over 99% of these results have been viewed online by the health centres. High user satisfaction and heavy use have led to the expansion of e-Chasqui to additional institutions. In total, e-Chasqui will serve a network of institutions providing medical care for over 3.1 million people. The cost to maintain this system is approximately US$0.53 per sample or 1% of the National Peruvian TB program's 2006 budget. Electronic laboratory information systems have a large potential to improve patient care and public health monitoring in resource-poor settings. Some of the challenges faced in these settings, such as lack of trained personnel, limited transportation, and large coverage areas, are obstacles that a well-designed system can overcome. e-Chasqui has the potential to provide a national TB laboratory network in Peru. Furthermore, the core functionality of e-Chasqui as been implemented in the open source medical record system OpenMRS http://www.openmrs.org for other countries to use.
With the evolution of nursing informatics (NI), the list of skills has advanced from the original definition that included 21 competencies to 168 basic competencies identified in the TIGER-based Assessment of Nursing Informatics Competencies (TANIC) and 178 advanced skills in the Nursing Informatics Competency Assessment (NICA) L3/L4 developed by Chamberlain College of Nursing, Nursing Informatics Research Team (NIRT). Of these competencies, project management is one of the most important essentials identified since it impacts all areas of NI skills and provides an organizing framework for processes and projects including skills such as design, planning, implementation, follow-up and evaluation. Examples of job roles that specifically require project management skills as an essential part of the NI functions include management, administration, leadership, faculty, graduate level master's and doctorate practicum courses. But first, better understanding of the NI essential skills is vital before adequate education and training programs can be developed.
Article
Elderly patients often share control of their personal health information and decision making with family and friends when needed. Patient portals can help with information sharing, but concerns about privacy and autonomy of elderly patients remain. Health systems that implement patient portals would benefit from guidance about how best to implement access to portals for caregivers of elderly patients. To identify how patients older than 75 years (hereinafter, elders) and family caregivers of such patients approach sharing of health information, with the hope of applying the results to collaborative patient portals. A qualitative study was conducted from October 20, 2013, to February 16, 2014, inviting participants older than 75 years (n = 30) and participants who assist a family member older than 75 years (n = 23) to 1 of 10 discussion groups. Participants were drawn from the Information Sharing Across Generations (InfoSAGE) Living Laboratory, an ongoing study of information needs of elders and families based within an academically affiliated network of senior housing in metropolitan Boston, Massachusetts. Groups were separated into elders and caregivers to allow for more detailed discussion. A professional moderator led groups using a discussion guide. Group discussions were audiotaped, transcribed, and analyzed inductively using immersion/crystallization methods for central themes. Central themes regarding sharing of health information between elderly patients and family caregivers. Seven lessons emerged from 2 main themes. First, sharing information has consequences: (1) elders and caregivers have different perspectives on what is seen as the "burden" of information, (2) access to medical information by families can have unintended consequences, and (3) elders do not want to feel "spied on" by family. Second, control of information sharing is dynamic: (4) elders wish to retain control of decision making as long as possible, (5) transfer of control occurs gradually depending on elders' health and functional status, (6) control of information sharing and decision making should be fluid to maximize elders' autonomy, and (7) no "one-size-fits-all" approach can satisfy individuals' different preferences. Information sharing and control are complex issues even under the most well-meaning circumstances. While elders may delegate control and share information with family, they want to retain granular control of their information. When using patient portals, simple proxy access may not adequately address the needs and concerns of aging patients.
Article
In 2011, 84% of hospital emergency departments (EDs) used an electronic health record (EHR) system. Adoption of a basic EHR system with a specific set of functionalities by EDs increased from 19% in 2007 to 54% in 2011. In 2011, 73% of hospital outpatient departments (OPDs) used an EHR system, up from 29% in 2006. Adoption of a basic EHR system with a specific set of functionalities by OPDs increased from 9% in 2007 to 57% in 2011. From 2007 through 2011, adoption of Stage 1 Meaningful Use objectives by EDs and OPDs increased. In 2011, 14% of EDs and 16% of OPDs had EHR technology able to support nine Stage 1 Meaningful Use objectives. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.
Article
Objectives: Evolving technology and infrastructure can benefit patients even in the poorest countries through mobile health (mHealth). Yet, what makes mobile-phone-based services succeed in low and middle-income countries (LMIC) and what opportunities does the future hold that still need to be studied. We showcase demonstrator services that leverage mobile phones in the hands of patients to promote health and facilitate health care. Methods: We surveyed the recent biomedical literature for demonstrator services that illustrate well-considered examples of mobile phone interventions for consumer health. We draw upon those examples to discuss enabling factors, scalability, reach, and potential of mHealth as well as obstacles in LMIC. Results: Among the 227 articles returned by a PubMed search, we identified 55 articles that describe services targeting health consumers equipped with mobile phones. From those articles, we showcase 19 as demonstrator services across clinical care, prevention, infectious diseases, and population health. Services range from education, reminders, reporting, and peer support, to epidemiologic reporting, and care management with phone communication and messages. Key achievements include timely adherence to treatment and appointments, clinical effectiveness of treatment reminders, increased vaccination coverage and uptake of screening, and capacity for efficient disease surveillance. We discuss methodologies of delivery and evaluation of mobile-phone-based mHealth in LMIC, including service design, social context, and environmental factors to success. Conclusion: Demonstrated promises using mobile phones in the poorest countries encourage a future in which IMIA takes a lead role in leveraging mHealth for citizen empowerment through Consumer Health Informatics.
Article
The US health care system has been slow to adopt Internet, mobile, and video technologies, which have the capability to engage patients in their own care, increase patients' access to providers, and possibly improve the quality of care while reducing costs. Nevertheless, there are some pockets of progress, including Kaiser Permanente Northern California (KPNC). In 2008 KPNC implemented an inpatient and ambulatory care electronic health record system for its 3.4 million members and developed a suite of patient-friendly Internet, mobile, and video tools. KPNC has achieved many successes. For example, the number of virtual "visits" grew from 4.1 million in 2008 to an estimated 10.5 million in 2013. This article describes KPNC's experience with Internet, mobile, and video technologies and the obstacles faced by other health care providers interested in embracing them. The obstacles include the predominant fee-for-service payment model, which does not reimburse for virtual visits; the considerable investment needed to deploy these technologies; and physician buy-in.
Internationally, the adoption of health information technology is increasing. However, a number of issues have complicated the adoption of electronic health records (EHRs). In addition to adoption issues, it is becoming increasingly recognized that healthcare providers face a variety of usability issues. In this paper, we consider approaches that have been taken to assess both adoption and usability of EHRs in Canada, Denmark and Finland. Although all three countries deploy surveys to assess adoption, the approach and focus of the surveys differs across the countries. In Denmark and Finland, these surveys are dedicated to assessing information technology (IT) usage; while in Canada, questions about IT usage are part of a larger physician survey. Regarding usability, approaches vary considerably. In Finland, the approach includes a national survey about EHR usability. In Canada, ratings of system usability are reported regionally on web sites; while in Denmark, regional study results are reported based on evaluation of commercial products. This paper highlights the need to consider different evaluation approaches internationally.
The International Medical Informatics Association (IMIA) biomedical informatics educational recommendations of 2010 provided an excellent guide for institutions across the world in updating their curricula or establishing new programs. IMIA subsequently decided to offer an accreditation process, guided by the earlier recommendations, to assess existing educational programs in the field of biomedical informatics. This paper presents an overview and SWOT analysis of the accreditation process based on a two-year trial period at three sites across continents. Because other sites are now requesting similar accreditation visits by IMIA, the lessons learned by the committee that performed the assessments during trial period will provide useful guidance for both IMIA and those educational institutions.
Article
Creative use of new mobile and wearable health information and sensing technologies (mHealth) has the potential to reduce the cost of health care and improve well-being in numerous ways. These applications are being developed in a variety of domains, but rigorous research is needed to examine the potential, as well as the challenges, of utilizing mobile technologies to improve health outcomes. Currently, evidence is sparse for the efficacy of mHealth. Although these technologies may be appealing and seemingly innocuous, research is needed to assess when, where, and for whom mHealth devices, apps, and systems are efficacious. In order to outline an approach to evidence generation in the field of mHealth that would ensure research is conducted on a rigorous empirical and theoretic foundation, on August 16, 2011, researchers gathered for the mHealth Evidence Workshop at NIH. The current paper presents the results of the workshop. Although the discussions at the meeting were cross-cutting, the areas covered can be categorized broadly into three areas: (1) evaluating assessments; (2) evaluating interventions; and (3) reshaping evidence generation using mHealth. This paper brings these concepts together to describe current evaluation standards, discuss future possibilities, and set a grand goal for the emerging field of mHealth research.
The Pediatric Oncology Network Database, (www.pond4kids.org, POND), is a secure, web-based, multilingual pediatric hematology/oncology database created for use in countries with limited resources to meet various clinical data management needs including cancer registration, delivery of protocol-based care, outcome evaluation, and assessment of psychosocial support programs. Established as a part of the International Outreach Program at St. Jude Children's Research Hospital in Memphis, Tennessee, POND serves as a tool for oncology units to store patient data for easy retrieval and analysis and to achieve uniform data collection to facilitate meaningful comparison of information among centers. Launched in 2003, POND now has 233 sites registered with over 1,000 users in 66 countries. However, adoption and usage of POND varies widely among sites. This paper reviews some of the challenges to developing a global collaborative clinical platform based on the experiences of developing POND. The paper also presents a case study of POND use in Guatemala, where the Guatemalan National Oncology Unit (UNOP) has developed extensive internal and external global collaborations using POND.
Article
In 2009, the US Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, which offers nearly $30 billion in financial incentives to physicians and hospitals that adopt and choose to meaningfully use electronic health records (EHRs).1 The act is meant to help a health care system that consumes $2.5 trillion each year and produces health care that is below the standards of safety, quality, and efficiency that should be expected in the United States. There is broad consensus among US policy makers that EHRs will play a key role in transforming health care into a safer, more effective, and more efficient system.
Article
When the Global Fund to Fight AIDS, Tuberculosis and Malaria was created in 2001, the world responded enthusiastically. In the ensuing decade, wealthy countries and donors have poured more than $11 billion into fighting these three diseases. But an increasing chorus of global health experts believes the world has been ignoring another health crisis of equal or even greater magnitude: the spiraling epidemic of noncommunicable diseases. Long the scourge of Western nations, cardiovascular disease, cancer, diabetes, and respiratory diseases like asthma now kill more people worldwide than all other causes combined. And the trend will only accelerate as the global population ages and sedentary lifestyles and unhealthy food become more common around the world.
Article
Since 1995, the Veterans Health Administration (VHA) has had an ongoing process of systems improvement that has led to dramatic improvement in the quality of care delivered. A major component of the redesign of the VHA has been the creation of a fully developed enterprise-wide Electronic Health Record (EHR). VHA's Health Information Technology was developed in a collaborative fashion between local clinical champions and central software engineers. Successful national EHR implementation was achieved by 1999, since when the VHA has been able to increase its productivity by nearly 6 per cent per year.
Article
To the Editor: In their Commentary on the need for a comprehensive monitoring and evaluation framework for electronic health record (EHR) use, Drs Sittig and Classen1 called for a national EHR adverse event investigation board, similar to the National Transportation Safety Board. I believe that this approach confuses systemic errors within EHRs with errors caused by inadequate EHRs and would miss almost all of the latter.
Article
The importance of training physicians and nurses in the art, skill and science of clinical informatics has never been greater. What level of training is necessary and sufficient to equip the 21st century healthcare workforce for the transformative opportunity enabled by widespread deployment of EHRs? Building on the success of its 10x10 program, AMIA with support from the Robert Wood Johnson foundation took its next step to create the necessary documents to have clinical informatics recognized as a sub-specialty by the American Board of Medical Specialties (ABMS). We defined the core content that had to be mastered and describing how physicians interested in the sub-specialty clinical informatics would be trained. The results of this work have been approved by the board of AMIA and have been published in its journal JAMIA. The health challenges of the 21 century require that we rapidly train the clinical workforce in clinical informatics. In addition to buying hardware and software, our health systems need to sponsor this training. Two percent of every Health IT budget should be targeted for clinician education.
Article
Objective: OpenMRS (www.openmrs.org) is a configurable open source electronic medical record application developed and maintained by a large network of open source developers coordinated by the Regenstrief Institute and Partners in Health and mainly used for HIV patient and treatment information management in Africa. Our objective is to develop an open Implementers Network for OpenMRS to provide regional support for the growing number of OpenMRS implementations in Africa and to include African developers and implementers in the future growth of OpenMRS. Methods: We have developed the OpenMRS Implementers Network using a dedicated Wiki site and e-mail server. We have also organized annual meetings in South Africa and regional training courses at African locations where OpenMRS is being implemented. An OpenMRS Internship program has been initiated and we have started collaborating with similar networks and projects working in Africa. To evaluate its potential, OpenMRS was implemented initially at one site in South Africa by a single implementer using a downloadable OpenMRS application and only the OpenMRS Implementers Network for support. Results: The OpenMRS Implementers Network Wiki and list server have grown into effective means of providing implementation support and forums for exchange of implementation experiences. The annual OpenMRS Implementers meeting has been held in South Africa for the past three years and is attracting successively larger numbers of participants with almost 200 implementers and developers attending the 2008 meeting in Durban, South Africa. Six African developers are presently registered on the first intake of the OpenMRS Internship program. Successful collaborations have been started with several African developer groups and projects initiated to develop interoperability between OpenMRS and various applications. The South African OpenMRS Implementer group successfully configured, installed and maintained an integrated HIV/TB OpenMRS application without significant programming support. Since then, this model has been replicated in several other African sites. The OpenMRS Implementers Network has contributed substantially to the growth and sustainability of OpenMRS in Africa and has become a useful way of including Africans in the development and implementation of OpenMRS in developing countries. The Network provides valuable support and enables a basic OpenMRS application to be implemented in the absence of onsite programmers.
Article
Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHA's anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.
Article
The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data are recorded on a paper encounter form, eliminating duplicate documentation in multiple clinic logbooks. Data are entered into an MS-Access database supported by redundant power systems. The system was initiated in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After system implementation, patient visits were 22% shorter. They spent 58% less time with providers (p < 0.001) and 38% less time waiting (p = 0.06). Clinic personnel spent 50% less time interacting with patients, two thirds less time interacting with each other, and more time in personal activities. This simple electronic medical record system has bridged the "digital divide." Financial and technical sustainability by Kenyans will be key to its future use and development.
Article
Iatrogenic injuries related to medications are common, costly, and clinically significant. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates. We identified trials that evaluated the effects of CPOE and CDSSs on medication safety by electronically searching MEDLINE and the Cochrane Library and by manually searching the bibliographies of retrieved articles. Studies were included for systematic review if the design was a randomized controlled trial, a nonrandomized controlled trial, or an observational study with controls and if the measured outcomes were clinical (eg, adverse drug events) or surrogate (eg, medication errors) markers. Two reviewers extracted all the data. Discussion resolved any disagreements. Five trials assessing CPOE and 7 assessing isolated CDSSs met the criteria. Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement in corollary orders, 1 an improvement in 5 prescribing behaviors, and 1 an improvement in nephrotoxic drug dose and frequency. Of the 7 studies evaluating isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. The remaining 3 studies had nonsignificant results. Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems. Research is needed to evaluate commercial systems, to compare the various applications, to identify key components of applications, and to identify factors related to successful implementation of these systems.
Article
As new directions and priorities emerge in health care, nursing informatics leaders must prepare to guide the profession appropriately. To use an analogy, where a road bends or changes directions, guideposts indicate how drivers can stay on course. The AMIA Nursing Informatics Working Group (NIWG) produced this white paper as the product of a meeting convened: 1) to describe anticipated nationwide changes in demographics, health care quality, and health care informatics; 2) to assess the potential impact of genomic medicine and of new threats to society; 3) to align AMIA NIWG resources with emerging priorities; and 4) to identify guideposts in the form of an agenda to keep the NIWG on course in light of new opportunities. The anticipated societal changes provide opportunities for nursing informatics. Resources described below within the Department of Health and Human Services (HHS) and the National Committee for Health and Vital Statistics (NCVHS) can help to align AMIA NIWG with emerging priorities. The guideposts consist of priority areas for action in informatics, nursing education, and research. Nursing informatics professionals will collaborate as full participants in local, national, and international efforts related to the guideposts in order to make significant contributions that empower patients and providers for safer health care.
Article
There are limited data regarding implementing electronic health records (EHR) in underserved settings. We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans. We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005. The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings. We fit a multivariable logistic regression model to identify correlates of increased utilization of the EHR. The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient-doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05-8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records. Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.
  • Alvarez Flores
  • M G Guarner
  • J Terres Speziale
Alvarez Flores, M.G., Guarner, J., Terres Speziale, A.M., 1995. [Productivity before and after installing a computerized system in a clinical laboratory]. Rev. Invest. Clin. 47 (1), 29À34.
AWeb-based laboratory information system to improve quality of care of
  • J A Blaya
  • S S Shin
  • M J Yagui
  • G Yale
  • C Z Suarez
  • L L Asencios
Blaya, J.A., Shin, S.S., Yagui, M.J., Yale, G., Suarez, C.Z., Asencios, L.L., et al., 2007. AWeb-based laboratory information system to improve quality of care of tuberculosis patients in Peru: References 9
Electronic Health Records
Centers for Medicare & Medicaid Services (2016). Electronic Health Records [Definition]. ,https://www.cms.gov/ehealthrecords/..
Global health care outlook, Shared Challenges, Shared Opportunities. ,https:// www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/dttllshc-2014-global-health-care-sector-report
  • Deloitte
Deloitte, 2014. Global health care outlook, Shared Challenges, Shared Opportunities.,https:// www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/dttllshc-2014-global-health-care-sector-report.pdf. (accessed 16.07.16).
The 'Big Data Revolution in Healthcare. Accelerating Value and Innovation
  • P Groves
  • K Basel
  • D Knott
  • S V Van Kuiken
Groves, P., Basel, K., Knott, D., Van Kuiken, S.V., 2013. The 'Big Data Revolution in Healthcare. Accelerating Value and Innovation. McKinsey & Company, New York: NY, January 2013.,http://www.mckinsey.com/insights/health_systems_and_services/the_big-data_ revolution_in_us_health_care. (accessed 11.07.16).
IMIA accreditation of health informatics programs
  • A Hasman
  • J Mantas
Hasman, A., Mantas, J., 2013. IMIA accreditation of health informatics programs. Healthc. Inform. Res. 19 (3), 154À161, http://dx.doi.org/10.4258/hir.2013.19.3.154. Epub 2013 Sep 30. Review. PubMed PMID: 24175114; PubMed Central PMCID: PMC3810522.,http:// www.ncbi.nlm.nih.gov/pubmed/24175114. (accessed 11.07.16).
National Cancer Institute. Archived from the original on
  • G A Komatsoulis
Komatsoulis, G.A. "Program Announcement". National Cancer Institute. Archived from the original on July 30, 2012.,http://web.archive.org/web/20120730234757/https://cabig.nci. nih.gov/program_announcement. (accessed 05.07.16).
Global Partnerships: Strengthening Human Resources for Health Approach Together
  • J Mccaffery
McCaffery, J., 2009. Global Partnerships: Strengthening Human Resources for Health Approach Together, September 2009.,http://www.capacityplus.org/global-partnerships-strengtheninghuman-resources-health-approaches-together. (accessed 16.07.16).
United Kingdom). Definition of health informatics
National Library of Medicine, 2016. Health Informatics. Original from Procter, R. Dr. (Editor, Health Informatics Journal, Edinburgh, United Kingdom). Definition of health informatics [Internet]. Message to: Virginia Van Horne (Content Manager, HSR Information Central, Bethesda, MD). August 16, 2009 (cited September 21, 2009),https://www.nlm.nih.gov/ hsrinfo/informatics.html. (accessed July 16, 2016).