RESUMEN

The number of health-related websites has proliferated over the past few years. Health information consumers confront a myriad of health related resources on the internet that have varying levels of quality and are not always easy to comprehend. There is thus a need to help health information consumers to bridge the gap between access to information and information understanding-i.e. to help consumers understand health related web-based resources so that they can act upon it. At the same time health information consumers are becoming not only more involved in their own health care but also more information technology minded. One way to address this issue is to provide consumers with tailored information that is contextualized and personalized e.g. directly relevant and easily comprehensible to the person's own health situation. This paper presents a current trend in Consumer Health Informatics which focuses on theory-based design and development of contextualized and personalized tools to allow the evolving consumer with varying backgrounds and interests to use online health information efficiently. The proposed approach uses a theoretical framework of communication in order to support the consumer's capacity to understand health-related web-based resources.

RESUMEN

OBJECTIVE: To investigate the internal consistency, validity and responsiveness of the Rehabilitation Activities Profile (RAP; a rehabilitation tool structuring the multidisciplinary team care process) in patients with rheumatoid arthritis. METHODS: In 85 rheumatoid arthritis patients admitted to a rheumatology clinic the RAP was applied at admission, at discharge, and six weeks thereafter. Additional assessments included measures of physical and psychological functioning, disease activity and quality of life. The internal consistency of the RAP was determined with Cronbach's alpha. Associations between the RAP and other outcome measures were determined by Spearman rank correlation coefficients. Responsiveness measures included the standardized response mean (SRM), effect size (ES) and responsiveness ratio (RR). RESULTS: Cronbach's alpha of the RAP total score was 0.78. The RAP total score correlated significantly with all other outcome measures. The mean RAP total score improved from 15.2 to 13.2 at discharge (change -2.0; 95% confidence interval (CI) -3.4 to -0.7) and to 11.5 (change -3.7; 95% CI -3.9 to -1.5) six weeks thereafter. The responsiveness of the RAP total score was low (standardized response mean -0.34, effect size -0.30) to high (responsiveness ratio -0.87) at discharge and moderate (standardized response mean -0.54, effect size -0.55) to high (responsiveness ratio -1.56) six weeks thereafter. CONCLUSIONS: The RAP appeared to be an internally consistent, valid and responsive measure to reflect limitations on the level of activities and participation in patients with rheumatoid arthritis admitted for multidisciplinary team care.

Asunto(s)

RESUMEN

OBJECTIVE: To investigate the impact of introducing a rehabilitation tool on multidisciplinary team members' satisfaction with team functioning, team conferences and written information exchange. DESIGN: Pretest posttest design. SETTING: Day patient and inpatient wards of a rheumatology rehabilitation clinic. SUBJECTS: Members of two multidisciplinary teams. INTERVENTIONS: The introduction of an electronic version of the Rehabilitation Activities Profile. MAIN MEASURES: The Group Environment Scale and questionnaires on satisfaction with team conferences and administrative procedures administered before (T1) and 12 months after (T2) the introduction of the Rehabilitation Activities Profile. RESULTS: The Group Environment Scale cohesion subscale was significantly higher at T2 than at T1 in the day patient setting (mean difference 1.9; 95% confidence interval (CI) 0.3; 3.4), whereas in the inpatient setting the Group Environment Scale cohesion and the order and organization subscales were significantly lower (mean differences -3.0; 95% CI -4.7; -1.3 and -2.7; 95% CI -4.3; -1.1, respectively). Satisfaction with team conferences was significantly higher at T2 compared with T1 in the day patient setting (mean difference total score 0.6; 95% CI 0.3; 1.0), but not in the inpatient setting (mean difference -0.3; 95% CI -0.7; 0.2). In both settings, the proportions of health professionals spending >10 minutes on administrative tasks per patient contact were significantly higher at T2 than at T1. CONCLUSIONS: In the day patient setting, the introduction of a rehabilitation tool had a positive effect on team members' satisfaction with team functioning and team conferences, whereas in the inpatient setting the effect was absent or the opposite. In both settings, the time spent on administrative tasks increased.

Asunto(s)

RESUMEN

The Internet offers unlimited possibilities for finding health information. However, the user is often faced with the problem of understanding it. Contextualization has a role to play in enhancing the user's comprehension. We report on a study which addresses this issue, using a theoretical model of communication whose central theme is that of context. A randomized controlled experimental design was chosen, using as a test-bed the website SeniorGezond we had previously developed. The study was composed of a pre-test, the intervention with the website and a post-test. Participants (n=40) were randomly assigned to exposure or no exposure to contextualization with the website. Results show that contextualization increases understanding for non-knowledgeable users. Furthermore, the participant's cognitive style was found to be a significant factor on understanding. We also found that participants bring their own contexts such as social context and psychological context to support their understanding.

RESUMEN

The study aims to elicit user requirements for internet-based applications disclosing fellow patients' illness stories for the benefit of breast cancer patients. Twenty-six breast cancer patients, recruited via the Dutch Patient Organization for Breast Cancer, were interviewed about their preferences with regards to content, appearance, and search options concerning fellow patients' illness stories online. The interviews were analysed quantitatively (SPSS) and qualitatively (NVivo). Participants were mainly interested in fellow patients' experiences about how to cope with emotions, the impact of cancer in daily life, and physical discomforts. Most participants preferred a section of an illness story in text format about a specific topic; some of them wanted to be able to click on to the corresponding complete story, comprising of text alone or supported by voice or video clip. A majority of participants wanted to be able to select illness stories on the basis of several authors' features, i.e. treatment underwent, age, presence of metastases, time since diagnosis, and whether or not caring for children. Participants gave arguments for their preferences. The findings of this study will be used for designing an online trial with breast cancer patients aiming at refining the user requirements.

Asunto(s)

RESUMEN

OBJECTIVE: Problems with multidisciplinary team conferences in health care include the exchange of too much (discipline-specific) information. The aim of this study was to investigate the effect of the implementation of a rehabilitation tool on the contents of communication during multidisciplinary team conferences in a rheumatology setting. METHODS: All initial and follow-up team conferences of 25 consecutive patients with rheumatoid arthritis admitted to a day patient care ward were videotaped during a period before (period I) and after (period II) the introduction of a rehabilitation tool. The aims of the rehabilitation tool were to enhance discussions on the co-ordination of care rather than merely exchange of information. This was achieved by providing a framework for the setting and evaluation of common treatment goals and management strategies as well as accompanying electronic and printed records. For every team conference, the duration of time spent on three types of communication was recorded: (1) grounding regarding the patient's health status, (2) the making of practical arrangements by no more than two health professionals, and (3) the co-ordination of common treatment goals or management strategies. Comparisons of the proportions of time spent on the different types of communication between the two periods were done by means of the Mann-Whitney U-test. RESULTS: Apart from the 25 initial team conferences in both periods, 86 and 71 follow-up team conferences were available in periods I and II, respectively. Regarding the initial team conferences, the proportion of time spent on grounding and practical arrangements was significantly smaller in period II than in period I. In addition, the proportion of time spent on common goals or management strategies was significantly greater in period II than in period I. For the follow-up team conferences, the proportion of time spent on practical arrangements was significantly smaller in period II, than in period I. Moreover, the proportions of time spent on the other types of communication did not differ significantly between the two periods. CONCLUSION: The implementation of a rehabilitation tool including a computer application increased the proportion of time spent on the discussion of common treatment goals or management strategies during initial but not during follow-up team conferences in a day patient rheumatology clinic.

Asunto(s)

RESUMEN

BACKGROUND: Coordinated teams with multidisciplinary team conferences are generally seen as a solution to the management of complex health conditions. However, problems regarding the process of communication during team conferences are reported, such as the absence of a common language or viewpoint and the exchange of irrelevant or repeated information. To determine the outcome of interventions aimed at improving communication during team conferences, a reliable and valid assessment method is needed. AIM: To investigate the feasibility of a theory-based measurement instrument for assessing the process of the communication during multidisciplinary team conferences in rheumatology. METHOD: An observation instrument was developed based on communication theory. The instrument distinguishes three types of communication: (I) grounding activities, (II) coordination of non-team activities, and (III) coordination of team activities. To assess the process of communication during team conferences in a rheumatology clinic with inpatient and day patient facilities, team conferences were videotaped. To determine the inter-rater reliability, in 20 conferences concerning 10 patients with rheumatoid arthritis admitted to the inpatient unit, the instrument was applied by two investigators independently. Content validity was determined by analysing and comparing the results of initial and follow-up team conferences of 25 consecutive patients with rheumatoid arthritis admitted to the day patient unit (Wilcoxon signed rank test). RESULTS: The inter-rater reliability was excellent with the intra-class correlation coefficients being >0.98 for both types I and III communications in 10 initial and 10 follow-up conferences (type II was not observed). An analysis of an additional 25 initial and 86 follow-up team conferences showed that time spent on grounding (type I) made up the greater part of the contents of communication (87% S.D. 14 and 60% S.D. 29 in initial and follow-up conferences, respectively), which is significantly more compared to time spent on co-ordination (p<0.001 and 0.02 for categories II and III, respectively). Moreover, significantly less time spent was spent on grounding in follow-up as compared to initial team conferences, whereas the time spent on coordination (type III) increased (both p-values<0.001). CONCLUSION: This theory-based measurement instrument for describing and evaluating the communication process during team conferences proved to be reliable and valid in this pilot study. Its usefulness to detect changes in the communication process, e.g. after implementing systems for re-structuring team conferences mediated by ICT applications, should be further examined.

Asunto(s)

RESUMEN

Communication processes are pervasive in the daily practice of health professionals. Reorganizing these daily practices by introducing ICT, inevitably effects one or more communication processes. Understanding exactly what these effects are, is a major problem in designing and implementing ICT-applications. In this paper we present an analysis of these effects, based on a theory of communication processes. The concept of 'decoupling' is pivotal in our analysis. Based on the identified effects, and some preconditions that have to be met in order for these effects to take place, we derive a number of guidelines for reorganizing communication processes by means of applying ICT. The application of these guidelines will be demonstrated and discussed in the context of the reorganization of a team conference at the Rehabilitation Clinic of the Rheumatology Department of the Leiden University Medical Center (RCRD/LUMC).

Asunto(s)

RESUMEN

Communication processes are pervasive in the daily practice of health professionals. Reorganizing these daily practices by introducing ICT, inevitably effects one or more communication processes. Understanding exactly what these effects are, is a major problem in designing and implementing ICT-applications. In this paper we present an analysis of these effects, based on a theory of communication processes. The concept of 'decoupling' is pivotal in our analysis. Based on the identified effects, and some preconditions that have to be met in order for these effects to take place, we derive a number of guidelines for reorganizing communication processes by means of applying ICT. The application of these quidelines will be demonstrated and discussed in the context of the reorganization of a team conference at the Rehabilitation Clinic of the Rheumatology Department of the Leiden University Medical Center (RCRD/LUMC), a multidisciplinary team care setting.

Asunto(s)

RESUMEN

In this paper we present an assessment instrument for evaluating the quality of communication processes in health care. This instrument is based on communication theory, and does not only indicate the level of quality, but also explains it. This makes it also useful as a design tool in reorganising communication processes, in order to make them more effective. Such a tool is highly needed when Information and Communication Technology is applied in health care to support communication between professionals. The instrument is demonstrated for a case in multidisciplinary team care.

Asunto(s)

RESUMEN

OBJECTIVES: The proper alignment of functional features of the ICT-infrastructure to business processes is a major challenge in health care organisations. This alignment takes into account that the organisational structure not only shapes the ICT-infrastructure, but that the inverse also holds. To solve the alignment problem, relevant features of the ICT-infrastructure should be derived from the organisational structure and the influence of this envisaged ICT to the work practices should be pointed out. The objective of our study was to develop a method to solve this alignment problem. METHODS: In a previous study we demonstrated the appropriateness of the business process modelling methodology Dynamic Essential Modelling of Organizations (DEMO). A proven and widely used modelling language for expressing functional features is Unified Modelling Language (UML). In the context of a specific case study at the University Medical Centre Utrecht in the Netherlands we investigated if the combined use of DEMO and UML could solve the alignment problem. RESULTS AND CONCLUSION: The study demonstrated that the DEMO models were suited as a starting point in deriving system functionality by using the use case concept of UML. Further, the case study demonstrated that in using this approach for the alignment problem, insight is gained into the mutual influence of ICT-infrastructure and organisation structure: (a) specification of independent, re-usable components-as a set of related functionalities-is realised, and (b) a helpful representation of the current and future work practice is provided for in relation to the envisaged ICT support.

Asunto(s)

RESUMEN

OBJECTIVE: We analyzed availability and usability of the electronic patient data required for assessment of medical practice for a specific patient group. DESIGN: Case study in which physicians defined performance indicators and additional exploratory information. Data availability in the hospital information system was determined. Data usability was evaluated based on reason for recording, administrative procedures, and comparison with paper data. SETTING: A 155 bed pediatric department in a public academic medical center. STUDY PARTICIPANTS: Pediatricians and children with suspected meningitis. MAIN OUTCOME MEASURES: Availability and usability of electronic patient data. Usability criteria were standardization, completeness, and accuracy. RESULTS: A total of 14 performance indicators were defined. Of 39 data items required for indicator quantification, 29 were available, and 19 were usable without manual handling. Completeness and accuracy of the registration of reason for admission and discharge diagnoses were insufficient, leading to problematic patient selection and complication detection. Time-points of patient events were inaccurate or not available. Data regarding outpatient diagnosis, signs and symptoms, indications for test ordering, and medication administration were missing. Test result reports were not adequately standardized. Based on electronic patient data, five out of 14 performance indicators could be quantified reliably, but only after patient selection problems were overcome. For exploratory information, 16 out of 25 required data items were available and 13 were usable. CONCLUSIONS: Availability and usability of electronic patient data are insufficient for physician-led and detailed assessment of medical practice for specific patient groups. Extended registration of the reason for admission will improve patient selection and assessment of diagnostic process.

Asunto(s)

RESUMEN

Communication makes up a very important part of the daily practice of health professionals. Current trends in health care indicate that this will even increase. However, the explicit application of Information and Communication Technologies (ICT) in order to support communication is relatively rare. This leaves a great potential of ICT in health care unused. The clinical informatics group at the Leiden University Medical Centre has established a research program which aims at eliciting, analysing, and specifying requirements for communication supporting ICT-applications in health care. Several research projects are part of this program already. Two of these, that focus on supporting a specific kind of health professional/client communication, are discussed in this paper against the background of the research program.

Asunto(s)

RESUMEN

Terminological systems are an important research issue within the field of medical informatics. For precise understanding of existing terminological systems a referential framework is needed that provides a uniform terminology and typology of terminological systems themselves. In this article a uniform terminology is described by putting relevant fundamental notions and definitions used by standard organizations such as CEN and ISO into perspective, and interrelating them to arrive at a useful typology of terminological systems. This typology is illustrated by applying it to five well-known existing terminological systems.

Asunto(s)

RESUMEN

The need of an electronic patient record with a process view on medical care is widely acknowledged. Characteristics of DEMO (Dynamic Essential Modeling of Organizations) suggest that with this methodology an adequate process view of medical practice can be obtained. In applying DEMO to the care process of the emergency department at the University Medical Centre Utrecht, it was investigated if DEMO fulfilled our expectations. This practical application showed that DEMO yields an adequate process view by a clear and comprehensible view of the core processes, responsibilities, co-ordination of activities, and a clear description of causal and conditional relations between activities.

Asunto(s)

RESUMEN

OBJECTIVE: Diagnostic data are essential for the assessment of medical practice: they are needed for retrieval of clinical cases and describing co-morbidity and complications. In most Western countries, diagnosis registration in hospital information systems is based mainly on completing forms after patient discharge. As this registration plays no role in patient care, data quality is usually unsatisfactory. To improve data quality, we redesigned the process of diagnosis registration at a paediatric department, and now paediatricians provide diagnoses with codes in a separate registration heading of the discharge letter. We compared the quality of this discharge letter-linked diagnosis registration with the quality of the previous form based registration. DESIGN: Retrospective study with blinded before and after measurement. Re-abstracted diagnosis descriptions of the text of discharge letters were taken as gold standard. SETTING: A paediatric department in an academic medical centre. STUDY PARTICIPANTS: From each registration period, 60 admissions were selected randomly. Mean age of the patients was 4.5 (SD +/- 5.5) and 5.2 (SD +/- 5.2) years for the old and new situation respectively. Mean length of stay was 8.8 (SD +/- 11.0) and 7.2 (SD +/- 12.4) days. INTERVENTION: Discharge letter-linked diagnosis registration. MAIN OUTCOME MEASURES: Completeness and accuracy, both at three-digit level of ICD-9-CM. RESULTS: Completeness of form-based diagnosis registration was 51% (95% CI, 44-58%) and of discharge letter-linked diagnosis registration 54% (95% CI, 47-60%). Accuracy was 65% (95% CI, 58-72%) and 67% (95% CI, 60-74%) respectively. CONCLUSIONS: The discharge letter-linked diagnosis registration does not provide a better basis for assessment of medical practice than the form based diagnosis registration.

Asunto(s)

RESUMEN

UNLABELLED: We analyzed availability and accuracy of electronic patient data needed to assess medical practice. A case study was performed in which pediatricians formulated 14 performance indicators that cover aspects of care for children with suspected meningitis. Data items needed to quantify these indicators were listed. Required patient data were gathered from hospital information system and paper medical records. Accuracy of electronically available data was based on comparison with paper data and, when paper data were not available, on how data were recorded at the source, administrative procedures and original goal for which data were recorded. CONCLUSION: Registration of reason for admission and diagnoses gives no reliable basis to select patients with 'suspicion on a disease' as selection criterion. Besides, many performance indicators cannot be reliably quantified because data are not recorded electronically (indication, medication, outpatient diagnosis), are not recorded specific enough (intervention time), are not standardized (radiology report), or cannot be obtained from other hospitals.

Asunto(s)

RESUMEN

Information about the patient's health status and about medical problems in general, play an important role in stratifying a patient population for quality assurance of intensive care. A terminological system which supports both the description of health problems for daily care practice and the aggregation of diagnostic information for evaluative research, is desirable for description of the patient population. This study describes the engineering of an ontology that facilitates a terminological system for intensive care diagnoses. We analyzed the criteria for such an ontology and evaluated existing terminological systems according to these criteria. The analysis shows that none of the existing terminological systems completely satisfies all our criteria. We describe choices regarding design, content and representation of a new ontology on which an adequate terminological system is based. The proposed ontology is characterized by the explicit and formal representation of the domain model, the metaspecification of its concepts, the vocabulary to define concepts and the nomenclature to support the composition of new concepts.

Asunto(s)

RESUMEN

Since its inception in 1987, the 4-year Medical Information Sciences (MIS) curriculum at the Academic Medical Centre (AMC), Amsterdam has gone through several major changes. The present curriculum started in 1994. The course takes 4 years, the first 3 years are programmed in integrated modules of 7 weeks in duration each. In these modules much attention is given to interactive teaching, problem based learning and private study. Typical for the Amsterdam curriculum is a strong emphasis on the role and significance of data and information in health care and its management. The authors see information technology per se as auxiliary to this orientation. Presently, about 150 students follow the courses.

Asunto(s)

RESUMEN

The medical staff at the Department of Pediatrics in the Academic Medical Center, Amsterdam, are strongly involved in the analysis of the effectiveness and efficiency of the clinical care provided. One method to increase effectiveness and efficiency is to provide clinicians with a comprehensive summary of their medical activities.

Asunto(s)