Swiss Medical Informatics

Edition 2012/00

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SMI

Lessons learnt – Bericht eines Universitätsspitals

Extended abstract
Balthasar Hug, et. al.
Published on 20.08.2012
CS2\Cs2Journal\Domain\Model\Author:105851
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Introduction: Generally, scientific publications emphasize positive research results. However, negative results may encompass valuable information. In a tertiary referral hospital in a university setting in central Europe within a period of about 10 years, three futile attempts were made to introduce a comprehensive clinical information system (CIS). Goal: To clarify lessons learnt from earlier experiences regarding introduction of a CIS. Methods: Semi-structured interviews of internal stakeholders in those projects. Results: There were seven main points to be learnt from these interviews regarding leadership, communication, organisation, integration of users into the project, resources, technological standards as well as prioritisation of work packages. Discussion: A review of literature showed that most of the lessons learnt at this hospital have been described by other institutions. Conclusion: The seven lessons learnt described here may be generalised since most of them have been described elsewhere. When introducing CIS systems it is important to consider lessons learnt in house as well as by other groups and institutions.
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Benoît Gaillard, et. al.
Published on 20.08.2012
Benoît Gaillard
+1

Many believe that e-health will make use of complex data and technology to drive efficiency like IT did in other industries. Our findings about what patients actually need go against this belief: e-health raises interest of users if it helps to create a better doctor/patient relationship.Our innovative research methodology eConceptlab.com makes use of experimental Google search ads to test the value of new ideas. Click-Through-Rate is an indication of the interest for a given idea expressed as an advertisement.

David-Zacharie Issom
Published on 20.08.2012
David-Zacharie Issom

Information and communication technologies have a role to play in improving a citizen’s quality of life. The ageing world population  demonstrates the major challenge of assisting citizens in their various activities. ICTs could help them to have a healthier lifestyle, reduce physical efforts, reduce the risk of disease and prevent accidents or illnesses. PEACE aims to provide a system allowing the association of any type of sensors or data sources  with any action  within the user’s environment. The generic approach of this system allows it to be deployed  in several backgrounds. Indeed, multiple purposes can concern home automation, clinical environment automation and progress in the Ambient Assisted Living field. Creating this system required focusing on multiple areas like user interaction paradigms, I/O management, security management systems and automatic services discovery. Developing this project has demonstrated  significant future  job possibilities. Indeed, the implemented use-case is applicable to clinical environments and to domestic environments. Furthermore, this opens the door to  enable the realisation of  automation in the citizen’s environment. 

Marc Oertle, MD MSc
Published on 20.08.2012
Marc Oertle, MD MSc
Marc Oertle
Published on 20.08.2012
Marc Oertle

Information and communication technologies have been widely distributed throughout the healthcare system during the past ten years. Process optimisations, increased efficiency and efficacy as well as improved patient safety have been the positive outcomes of this evolution. Negative outcomes exist as well: scaring reports on increased mortality due to badly implemented IT systems might be the top of the pyramid. However, publications addressing computer-related adverse events in healthcare are only scarce. As the risk of e-iatrogenesis rises, this publication presents outcomes of the CIRS database in our hospital, including 312 reports during 2011 with the clinical information system being mentioned most frequently. Additionally, a framework consisting of ten technical and ten sociotechnical archetypes (TST-20) associated with adverse events is proposed. By requesting, recording, classifying and publishing computer-related adverse events, we move ahead towards the era of evidence-based medical informatics.

Gilles Mérier, et. al.
Published on 20.08.2012
Gilles Mérier
+1

eHealth constitutes a very complex field which will probably induce structural, organic and cultural major modifications in many activities related to the human health. It is even probable that one can speak here about singularity, that means the moment when technological change becomes so rapid and profound, it represents a rupture in the fabric of human history. E-toile is a community medical electronic network centered on the patient with universal vocation developed in Geneva, which passed from the state of project to that of pilot in 2011. The objective of this presentation is to confront the data of the international literature with the first experiments carried out in the framework of the doctor's offices, solo or group, with an aim of drawing the preliminary conclusions, identifying and priorising the necessary innovations and initializing the essential cultural changes.

Stéphane Grosjean
Published on 20.08.2012
Stéphane Grosjean

MERCURE is the first ehealth project to be introduced in the Canton of Vaud by the care networks in partnership with the Public Health Service. The care network system is a regional structure coordinating hospitals, health centres, general practitioners and nursing homes. Vaud is divided into 4 zones with a care network system in each zone. Each care network system works through a BRIO (a regional information and orientation office) which is responsible for the occupation of beds in the different nursing homes, ensuring equal treatment of requests. To treat each request, we need a DMST (Document medico-social de transmission) which is a document with the person’s administrative and care details. This DMST is the principal document for the electronic exchanges between the different institutions. The pilot project focused on transmission of information between the BRIO and the nursing homes. The initial test phase was carried out with 10 nursing homes. Following the success of this initial phase, the project was extended to the whole canton. This presented a major challenge. The financial aspect was the first element to be dealt with; the second stage was the practical organisation of implementation of the project on a large scale with a small staff. The centralised coordination of computerised information was a major undertaking involving different IT partners and project managers located in each local care network system. Centralisation of the technical expertise allowed a rapid choice of technical elements and utilisation of competences in different sectors allowed a major undertaking in a short time.

Frederic Ehrler
Published on 20.08.2012
Frederic Ehrler

Introduction: The introduction of Clinical Information Systems (CIS) to manage and store patient information has deeply modified the workflow of caregivers. As the information is no longer stored on a physical medium, caregivers depend on the presence of a computer to access patient data. This constraint has built up an invisible barrier between the source of information and the place of its use. The popularisation of mobile devices offers an oportunity to break this barrier by providing a ubiquitous access to information. The use of a mobile platform merges the advantages of a modern CIS and the mobility offered by paper. We have developed an application on a mobile device that nurses can carry along on all their visits. It allows the information gathered during their visits to be entered directly into the system.Method: The tool we present aims to manage the daily interventions of nurses. The interventions concern all kinds of treatments provided by nurses to patients. In the current organisation, nurses start their day by printing out all the daily interventions and use it as a procedure to follow. Every time a nurse performs an intervention, she takes a note indicating that the task has been done properly. When they have some spare time, nurses enter all the gathered information in the CIS. Once nurses are equipped with mobile devices, paper becomes useless. Consequently, the process is simplified. Replacing the paper by a mobile device application is not straightforward. In order to access patient information, the tool must be linked to the existing CIS of the hospital without creating too strong dependencies. Moreover, the mobile interface must be adapted to the specificities of the mobile device such as a smaller display size, a reduced computational power, a tactile-based interaction and a real-time usage. Results: In order to link the mobile application to the existing CIS, we relied on a Service Oriented Architecture (SOA). It was mandatory to think of a software architecture that would not create a dependency with any legacy system. Thus, we defined a gateway server providing centralised access for the mobile application to any required information to or from the CIS. Integrating any mobile application would only require integrating this bridge. The gateway server also clearly separates the services that are available remotely from the ones proposed as usual Web services.The developed application not only allows the validation of the interventions and the input of measures, but it also offers a simple way to define the context in which nurses are working. This context is necessary to identify the specific list of interventions for the patients under the caregiver’s responsibility. The current CIS of the HUG includes a module that provides information concerning the interventions. Its interface is adjusted for a personal computer screen. Since caregivers are accustomed to this organisation of the information, we aimed to develop an interface on a mobile device that guarantees a certain level of homogeneity with the existing PC application. However, a mobile device’s screen is of limited size, therefore the interface has been completely rebuilt to be adapted to the new display. To deal with the limited display size, we rely on hierarchy and indexicality principles. For instance, based on the hypothesis that all tasks belonging to one category and planned at the same time can be regrouped under a single item; we regroup the interventions of similar top level in a common item. Moreover, to minimise user manipulations, relevant items are automatically moved to the top.Conclusion: The current daily workflow of nurses cannot be managed consistently using a unique tool. The need to switch from paper to computer induces work overload and is a source of errors. Therefore, we have developed a program running on a mobile device that nurses can carry during their visits. This program allows to manage nurses' daily interventions in real-time. The development of such a tool has required a complete reconstruction of the classical personal computer interface. This new interface takes into account a smaller display size, an innovative interaction paradigm, and real-time constraints.

Michelle Bruylands
Published on 20.08.2012
Michelle Bruylands

Research questions The main purpose of this study was to evaluate the impact of the educational program \"Guided Clinical Reasoning\"(GCR) on the quality of nursing documentation in an acute hospital in Switzerland. Additionally the effect of the introduction of an intelligent electronic nursing documentation expert system (e-doc) and simultaneous cessation of GCR were examined in 2011. Methods To evaluate the impact of GCR a cross-sectional evaluation study was conducted at three measurement points in the years 2005, 2006 and 2011. Each sample of 36 documentations was rated by the instrument “Quality of Nursing Diagnoses, Interventions and Outcomes” (Q-DIO) and the results compared with a quantitative design. To study the effects of the e-doc a descriptive design was used. The amount of chosen nursing diagnoses and their degree of content accuracy was analyzed for both nurses and the electronic documentation system. Furthermore the level of correct “decision support” in hypothetical nursing diagnosis by the e-doc and the use of this offer by nurses were contrasted. Findings The GCR program showed the best effects regarding the quality of the nursing process in 2006. Despite implementing an intelligent e-doc system as decision support tool, measurement point three (2011) proved the lowest scores, except for phrasing accurate nursing diagnoses. The quality of documentation regressed to the level of 2005, one year after implementing nursing diagnostics. The skills for using the NNN (NANDA, NIC, NOC) nursing process accurately, acquired in 2006, did not sustain. While nurses wrote detailed reports, they used a limited amount of recurring diagnoses. In comparison e-doc consistently and abundantly provided correct hypothetical nursing diagnoses. Despite this support they were scantly used by nurses. Conclusions Being at close temporal proximity the first two measurement points provided constant training for nurses in GRC and a high documentation quality was achieved. To accurately depict the nursing process, an electronic support system alone did not suffice, particularly as the GCR program was terminated. Electronic support systems can assist in conducting a theory-based nursing process, but clinical reasoning is essential for a meaningful use of e-docs. Constant support of nurses and awareness of barriers in conducting the nursing process and using intelligent decision supporting tools are crucial for a high level of quality in nursing documentation.

Emilie Pasche, et. al.
Published on 20.08.2012
Emilie Pasche
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Objective: While the broad use of antibiotics has reached its limits with the apparition of bacterial resistance, it became of major importance to regulate antibiotic prescriptions. In this paper, we present KART, a system to facilitate the creation of clinical guidelines in the context of infectious diseases. Methods: This system is composed of three main modules. The first module aims at facilitating the step of systematic reviews with the use of question-answering techniques, in order to create recommendations by querying a question-answering engine. Then, the second module proposes an approach to semi-automatically normalize the different parameters forming clinical recommendations. Finally, the third module aims to automatically formalize and store the generated recommendations into a knowledge repository. Results: The question-answering module is able to answer about two thirds of the queries correctly. The normalization, however, has had very mixed success upon evaluation of the system by infectious diseases specialists. Conclusion: In conclusion, KART is an innovative and promising system to create clinical guidelines; however, preliminary qualitative and quantitative evaluations show the need for further improvements.

Alex Gnaegi
Published on 20.08.2012
Alex Gnaegi

During hospitalisation, the patient's drug therapy is frequently modified or adapted for medical reasons or simply for logistical reasons (\"internal\"drugs list). On leaving the hospital, pharmacists and general practitioner are not always informed about changes in medications. A module allowing to edit a drug history and to automate a reconciliation of the patient’s home drugs with the equivalents available at the hospital was developed. It can also generate a comparison list between the drugs found at the admission and at the discharge of the hospital which is given to the patient, the general practitioner and the pharmacist.

Dieter Baumberger
Published on 20.08.2012
Dieter Baumberger

Integrated healthcare requires a consistent data exchange system. The ISO reference terminology model for nursing action (ISO-RTM) facilitates a standardised structure for the terminology used for care intervention and its interoperability. Accordingly, in this study, three nursing experts examined the congruence between the nursing action of LEP Nursing 3 and that of ISO-RTM. The results show a substantial level of congruence. The deviations can be used directly to improve LEP Nursing 3 nursing action in terms of interoperability, mapping in the ICNP and for the purposes of statistical analysis.

Edith Safran, et. al.
Published on 20.08.2012
Edith Safran
+7

INTRODUCTION: The overall demand in neonatal care is increasing in a number of countries, and the adequacy of nursing human resources to the needs is to be addressed.OBJECTIVES: To estimate demand for neonatal intensive and intermediate care in Geneva University Hospitals (HUG), with corresponding bed capacity.METHODS: The demand was estimated according to several methods. The first method was based on HUG statistics for both newborns cared in neonatology and those newborns which could not be cared for in HUG. The second method considered national Swiss births and early neonatal mortality rate per degree of prematurity, with estimated length of stay. The third method was based on available international benchmarks on ratio of neonatal beds per 1’000 births.RESULTS: Considering HUG statistics, the estimation of the demand in neonatal care amounted to 500 newborns, while taking into account both newborns cared in HUG and those for which care could not be given by HUG. The corresponding need for staffed beds was estimated to 34.6 beds. This result was obtained by applying average length of stay for newborns cared in HUG and estimated stay for newborns transferred to other institutions or refused by HUG.With an another method, applying Swiss distribution of prematurity to Geneva births and an estimated length of stay per degree of prematurity, the need for neonatal beds was estimated to 723 cases, corresponding to 33.6 beds..In order to validate these estimations, an available benchmark of 5 beds per 1’000 births was applied to all births in Geneva, including newborns born but not residents in Geneva. This method led to an estimation of 31.6 beds needed for neonatology.DISCUSSION: Considering the 20 neonatal staffed beds in HUG, with additional unknown but small number of beds in private clinics, all three estimations indicate an important need of additional neonatal beds. These estimations should be further completed with a study of DRG lengths of stay, staff needs corresponding to nurse workload, and demographic trends in Geneva.