This paper focuses on the prevention of technology induced errors in Health Information Technology (HIT) applications through usability tests in which patient safety-oriented usability goals have been included. A case study presents the evaluation of a web-based medication-related Clinical Decision Support System (CDSS). Systematically defining beforehand usability goals according to the potential use errors is an objective and replicable approach to identify the strengths and weaknesses of an application in terms of patient safety.

This paper describes the role of simulation involving end-users in Health Informatics. Simulation has long been established as a widely accepted method in clinical skills training. During the last decade simulation has also gained a place in the development and evaluation of clinical information systems. Simulation is especially well suited for the evaluation of human factors and organizational aspects in relation to application of information systems. In full-scale simulation tests it is possible to evaluate socio-technical interaction. A near to real life experience can be achieved by creating high fidelity environments. The paper discusses how simulation may be used during the lifecycle of clinical information systems, and the requirements on simulation fidelity in various situations. We recommend that simulation should get a more prominent role in the design and evaluation of clinical information systems.

Experience shows that the precondition for development of successful health-information-technologies (HIT) is a thorough insight into clinical work practices. In contemporary clinical work practices, clinical work and health information technology are closely integrated. Research within Virtual Centre for Health Informatics at Aalborg University, Denmark have during recent years focused on video observation to supplementing traditional ethnographical research methods in providing insight into complex clinical work practices. The objective of this paper is to argue for the potentials of the video observation method to inform and to improve HIT development compared to traditional ethnographic methods. Based on several studies conducted within the healthcare sector, we find, that the video observation method is superior to other ethnographical research methods when it comes to rapidly disclosing the complexity in clinical sociomaterial work practices. We also find that the video techniques used in the healthcare context allows us to revisit the field of observation through the data, to broaden our initial focus and to share data with both the clinical staff involved and other researchers. Hence, it provides us a more in depth insight in the complex clinical sociomaterial work practices than when observing by the use of pen and paper.

Consolidated information from multiple sources (patient monitors, electronic medical records, infusion pumps, ventilators, medication references) may improve nurses' work and patient safety. Objective. Two hypotheses were tested, that integrated information displays (a) improve nurses' satisfaction and (b) lower perceived mental workload. Methods. In a counter-balanced, repeated measures design (integrated vs. traditional display) 12 ICU nurses performed realistic tasks using both display types. Results. Nurses' user interaction satisfaction was higher with the integrated display and it received more positive comments. Nurses' mean perceived mental workload scores were also lower, having significant differences in effort and frustration dimensions. A lower mental workload may reduce errors and improve treatment times. Integrated information displays have great promise, but technological factors such as bidirectional device communication must be addressed if these displays are to achieve their potential for improving patient safety.

Notifications and alerts play an important role in clinical daily routine. Rising prevalence of clinical decision support systems and electronic health records also result in increasing demands on notification systems. Failure adequately to communicate a critical value is a potential cause of adverse events. Critical laboratory values and changing vital data depend on timely notifications of medical staff. Vital monitors and medical devices rely on acoustic signals for alerting which are prone to “alert fatigue” and require medical staff to be present within audible range. Personal computers are unsuitable to display time critical notification messages, since the targeted medical staff are not always operating or watching the computer. On the other hand, mobile phones and smart devices enjoy increasing popularity. Previous notification systems sending text messages to mobile phones depend on asynchronous confirmations. By utilizing an automated telephony server, we provide a method to deliver notifications quickly and independently of the recipients' whereabouts while allowing immediate feedback and confirmations. Evaluation results suggest the feasibility of the proposed notification system for real-time notifications.

In Germany the core data set for anesthesia version 3.0 was recently introduced for external quality assurance, which includes five surgical tracer procedures. We found a low rate of correctly documented tracers when compared to procedure data (OPS-Codes) documented separately. Examination revealed that the graphical user interface (GUI) contravened the dialogue principles as defined in EN ISO 9241-110. We worked with the manufacturer to implement small improvements and roll out the software. A crossover study was conducted at a university hospital and a municipal hospital chain with five hospitals. All study sites and surgical tracer procedures combined, we found an improvement from 42% to 65% (<0.001; N=34,610) correctly documented anesthesias. We also saw improvements for most of the observed surgical tracer procedures at all hospitals. Our results show the big effect small changes to the GUI can have on data quality. They also raise the question, if highly flexible and parameterized clinical documentation systems are suited to achieve high usability. Finding the right balance between GUIs designed by usability experts and the flexibility of parameterization by administrators will be a difficult task for the future and subject to further research.

This paper reports preliminary findings of a study relating to the development and use of electronic patient record (EPR) systems in cancer services. The research literature demonstrates an increasing emphasis on reporting clinical outcomes and the need for effective EPR systems and high quality information, which should ultimately influence the quality of life of patients. The study is interpretative and forms part a wider research programme to define and validate CICERO, a reference model for ‘Onco-EPR’ systems. Preliminary conclusions from the primary study site, a leading UK cancer treatment centre, confirm the requirement for more effective Onco-EPR system design and implementation planning with emphasis on the socio-technical aspects of health informatics.

Guidelines on cardiac rehabilitation (CR) state that a patient-tailored, comprehensive CR programme should be constructed for each patient based on a structured needs assessment procedure. We performed a usability evaluation with seven end-users of the MediScore CARDSS 2.0 system which implements such a procedure based on the Dutch guidelines. The analysis showed that users deviated strongly from the predefined data entry order; could not complete all subtasks for a complete needs assessment procedure, and needed more navigation actions than minimally required. We conclude that the design model of systems which implement guidelines requiring data entry should adapt to users' mental model concerning data entry to guarantee complete data collection.

The Internet has totally changed the way information is published and shared in medicine. With web 2.0 and semantic web technologies, web applications allow now collaborative information editing in a way that can be reused by machines. These new tools could be used to in local health networks to promote the editing and sharing of medical knowledge between practitioners. Oncolor, a French oncology network, has edited 144 decision guidelines. These local guidelines rely upon national French guidelines and are built and updated collaboratively by medical experts. To improve working conditions, the need of an online collaborative tool has been expressed. This paper presents ONCOLOGIK, a semantic wiki approach for local oncology guideline editing. Semantic wikis allow online collaborative work and manage semantic annotations which can be reused automatically to bring new services. Applied to oncology guidelines, semantic technologies improve the guideline management and provide additional services such as targeted queries to external bibliographical resources.

Although, clinical guidelines are regarded as best practices for clinicians, clinician activities are not always compliant with guideline recommendations. This paper aims to improve clinician compliance with guidelines. We have developed an engine to automatically report three non-compliance situations: 1) guideline recommendations exist, and the clinician performed some activities, but not according to the guidelines; 2) guideline recommendations exist, but the clinician did nothing; 3) guideline recommendations do not exist, but the clinician performed some activities. In particular, we highlight effective time for compliance checking, as well as membership, numeric relationships, concept subsumption and contextualization. We deployed our engine to a clinical setting involving the daily care routine of diabetes patients, and generated non-compliance reports for pilot users.

The Logical Elements Rule Method (LERM) is a step-wise method for formalizing if-then clinical rules. We applied LERM to a set of 40 clinical rules used in pharmacological quality assessment initiatives to assess (1) the amenability of the rules to formalization for decision support application (2) comparing adherence to rules that can and cannot be formalized, and (3) the usefulness of LERM as a tool for this task. Five rules could not be formalized, all due to unclear decision criteria. The adherence to ambiguous, non-formalizable rules was significantly lower than for formalizable ones (<0.001). We modified LERM with three additions for this task: (a) adding the sub-step of restating the rules in a consistent natural-language grammar before decomposing them into normal form, (b) creating rules to use in lieu of a controlled vocabulary, and (c) adding the requirement that a time frame must be defined for all medications (before hospitalization, current medication, new medication, or discharge medication). Although the clinical rules in this sample are all stated as semi-structured if-then recommendations and are used in quality assessment initiatives, many ambiguities and inconsistencies in the clinical rules were identified by using LERM.

The Dutch Childhood Oncology Group (DCOG) has developed evidence-based guidelines for screening childhood cancer survivors for possible late complications of treatment. These paper-based guidelines appeared to not suit clinicians' information retrieval strategies; it was thus decided to communicate the guidelines through a Computerized Decision Support (CDS) tool. To ensure high usability of this tool, an analysis of clinicians' cognitive strategies in retrieving information from the paper-based guidelines was used as requirements elicitation method. An information processing model was developed through an analysis of think aloud protocols and used as input for the design of the CDS user interface. Usability analysis of the user interface showed that the navigational structure of the CDS tool fitted well with the clinicians' mental strategies employed in deciding on survivors screening protocols. Clinicians were more efficient and more complete in deciding on patient-tailored screening procedures when supported by the CDS tool than by the paper-based guideline booklet. The think-aloud method provided detailed insight into users' clinical work patterns that supported the design of a highly usable CDS system.

Although it is widely accepted that the adoption of computerized clinical guidelines would improve the quality of the provided health care, their influence in the daily practice is limited. In this paper we provide insights on the core topics related to computer interpretable clinical guidelines and we present shortly the main approaches in the area. Then we discuss the current limitations, and we present three simple principles that according to our view should be adopted to enhance the penetration of computerized clinical guidelines in the health care organizations. The overall goal of this paper is not only to give readers a quick overview of the works in the area, but also to provide necessary insights for the practical understanding of the issues involved and draw directions for future research and development activities.

Managing cardiac diseases in an emergency department is a challenge, as it demands rapid decision-making in a life-threating situation. This paper presents a knowledge model for clinical guideline mediated Clinical Decision Support System for Acute Coronary Syndrome (ACS), targeting the ED care setting. We take a healthcare knowledge management approach to model clinical guideline using a clinical guideline ontology that is used to computerize the clinical guideline on the management of ACS, published by the American Heart Association, as a first step toward developing a clinical decision support system suitable for emergency departments at tertiary hospitals in Saudi Arabia.

Data quality of paper health records remain problematic and little is known about mobile health data quality. A semiotic data quality framework is used as an analytical lens to identify the quality of data in care health service provision in resource-restricted communities. A mobile application was developed using a co-design approach. The results of the empirical study indicate data quality problems on the syntactic, semantic, pragmatic and social semiotic levels. The social aspect of data quality is an important contributor of quality associated problems. It is important to consider this human involvement in the capturing and using of data for the value of care data to be fully utilized. With better quality data a better care service can be provided and ultimately resulting in better quality life.

Reaching a good indoor geolocation without deploying extensive and expensive infrastructure is a challenge, because satellite positioning system is not available indoors. Geolocation could be of major use in healthcare facilities; to help care providers, visitors and patients to navigate, to improve movements and flows efficiency or to implement location-awareness systems. A system able to provide the location of a person in a hospital requires precision, multi-floors and obstacles management and should also perform in basements and outdoors. Such system needs also to be insensitive to environmental variations occurring in a hospital. These changes may be various kinds of obstacles. These can be the displacement of metallic objects, metallic machines, strong magnetic fields or simply human displacement. A system conforming to the above requirements can also answer various security questions, operational workflow management but also assist movement of people.

Based on a clinical intervention study this paper adds to the significance of users involvement in design processes and substantiate the potential of online, flexible health informatics tools as useful components to accommodate organizational changes that short stay treatment demands. A dialogue-based web application was designed and implemented to accommodate patients' information and communication needs in short stay hospital settings. To ensure the system meet the patients' needs, both patients and healthcare professionals were involved in the design process by applying various participatory methods. Contextualization of the new application was also central in all phases to ensure a focus not only on the technology itself, but also the way it is used and in which relations and contexts. In evaluation of the tool, the patients' descriptions as user substantiate that the use of Internet applications can expand the time for dialogue between the individual patient and healthcare professionals. The patients experience being partners in an on going dialogue, and thereby are empowered, e.g. in managing their care even at home, as these dialogues generate individualized information.

Personalized wellness decision support has gained significant attention, owing to the shift to a patient-centric paradigm in healthcare domains, and the consequent availability of a wealth of patient-related data. Despite the success of data-driven analytics in improving practice outcome, there is a gap towards their deployment in guideline-based practice. In this paper we report on findings related to computer-supported guideline refinement, which maps a patient's guideline requirements to personalized recommendations that suit the patient's current context. In particular, we present a novel data-driven personalization framework, casting the mapping task as a statistical decision problem in search of a solution to maximize expected utility. The proposed framework is well suited to produce personalized recommendations based on not only clinical factors but contextual factors that reflect individual differences in non-clinical settings. We then describe its implementation within the guideline-based clinical decision support system and discuss opportunities and challenges looking forward.

Availability of personal health information for individual use from professional patient records is an important success factor for personal health information management (PHIM) solutions such as personal health records. In this paper we focus on this crucial part of personal wellbeing information management splutions and report the interoperability design of personal information import service. Key requirements as well as design factors for interfaces between PHRs and EPRs are discussed. Open standards, low implementation threshold and the acknowledgement of local market and conventions are emphasized in the design.

The drive in using health and social care resources more effectively has resulted in undertaking various efforts towards better coordination in order to improve patient-centered and personalized care for the individuals. This requires horizontal integration in terms of processes among health and social care organizations existing information systems (ISs) and personal health records (PHRs) in order to enable integrated patient information sharing among all the health and social care staff and individuals involved. Service-oriented and business process management (BPM) technologies are considered most appropriate for achieving such integration especially when is required to change existing processes and to integrate diverse information systems. On these grounds, a patient-centered approach is proposed for redesigning health and social care processes and for integrating diverse ISs and PHRs with the objective to meet holistic care goals.

Some studies suggest that the implementation of health information technology (HIT) introduces unpredicted and unintended consequences including e-iatrogenesis. OncoDoc2 is a guideline-based clinical decision support system (CDSS) applied to the management of breast cancer. The system is used by answering closed-ended questions in order to document patient data while navigating through the knowledge base until the best patient-specific recommended treatments are obtained. OncoDoc2 has been used by three hospitals in real clinical settings and for genuine patients. We analysed 394 navigations, recorded on a 10-month period, which correspond to 6,025 data entries. The data entry error rate is 4.2%, spread over 52% of incorrect navigations (N-). However, the overall compliance rate of clinical decisions with guidelines significantly increased from 72.8% (without CDSS) to 87.3% (with CDSS). Although this increase is lowered because of N- navigations (compliance rates are respectively 95% and 80% for N+ and N- navigations), the benefits of HIT outweighted its disadvantages in our study.

Because they provide patient-specific guideline-based recommendations, clinical decision support systems (CDSSs) are expected to promote the implementation of clinical practice guidelines (CPGs). OncoDoc2 is a CDSS applied to the management of breast cancer. However, despite it was routinely used during weekly multidisciplinary staff meetings (MSMs) at the Tenon Hospital (Paris, France), the compliance rate of MSMs' decisions with CPGs did not reach 100%. Formal Concept Analysis (FCA) has been applied to elicit formal concepts related to non-compliance. A statistical pre-treatment of attributes has been proposed to leverage FCA and discriminate between compliant and non-compliant decisions. Among the 1,889 decisions made over a 3 year-period, 199 decisions of recommended re-excisions have been considered for analysis. In this sample, non-compliance was explained by uncommon clinical profiles and specific patient-centred clinical criteria.

Electronic patient records are important for quality health services. Aim of this study is to support the trauma patient care with the development of an electronic system. A survey was conducted in the Emergency Department (ED) of a University hospital to study the effectiveness of an electronic monitoring system in a group of trauma patients, as well as the acceptance of this electronic system by the health professionals of the ED. A questionnaire collected information about the perceptions of 50 health professionals working in the ED on various aspects of patient care. The 86% (Nu=43) replied that there is lack of staff working in their department, 44% (N=22) is satisfied with the co-operation with other departments and 48% (N=24) believe that they spend precious time in administrative work during the care. For the purpose of a more efficient patient monitoring there was developed an electronic trauma patient monitoring system which was evaluated by the above mentioned professionals. The severity, length of care and the health outcomes of 200 trauma patients, were investigated. Half of the patients (N=100) have been monitored by the electronic system and the other 100 were monitored without the use of the system. The time between the admission and completion of the planned care was significantly lower in the electronic monitoring patient group (100±92 minutes) compared to the control group (149±29 minutes).

In light of the lack of integration between electronic health records and decision support, this research explores how semantic electronic health record technology, particularly openEHR, can be used to represent clinical practice guidelines (CPGs). We used the tool Visual Understanding Environment (VUE) to build a graphical representation of the European ischaemic stroke clinical management guidelines. We used openEHR archetypes to conceptually support this process and also to represent clinical concepts in stroke treatment compliance criteria. Our results show that, as an intermediate step in authoring computer-interpretable guidelines, an openEHR-based representation of CPGs and their compliance criteria supports the process of identifying the relevant knowledge and data elements in the care process to be modelled. It further eases the separation of the CPGs into data and logic components and is useful as a communication means for guideline verification by clinicians. Additionally, we retrieved existing and authored new openEHR archetypes for the acute stroke clinical management process. We conclude that openEHR-based guideline and compliance data representations may be a promising first step in building future decision support applications that are well connected to the electronic health record, can be useful in locating discrepancies between different sets of guidelines within the same care context and provide a helpful tool for driving the archetype authoring and review process.