Availability Of Electronic Health Records Research Articles

Healthcare information exchange using blockchain technology

Current trend in health-care industry is to shift its data on the cloud, to increase availability of Electronic Health Records (EHR) e.g. Patient’s medical history in real time, which will allow sharing of EHR with ease. However, this conventional cloud-based data sharing environment has data security and privacy issues. This paper proposes a distributed solution based on blockchain technology for trusted Health Information Exchange (HIE). In addition to exchange of EHR between patient and doctor, the proposed system is also used in other aspects of healthcare such as improving the insurance claim and making data available for research organizations. Medical data is very sensitive, in both social as well as legal aspects, so permissioned block-chain such as Hyperledger Fabric is used to retain the necessary privacy required in the proposed system. As, this is highly permissioned network where the owner of the network i.e. patient holds all the access rights, so in case of emergency situations the proposed system has a Backup Access System which will allow healthcare professionals to access partial EHR and this backup access is provided by using wearable IOT device.

Comorbidity4j: a tool for interactive analysis of disease comorbidities over large patient datasets.

Pushed by the growing availability of Electronic Health Records for data mining, the identification of relevant patterns of co-occurring diseases over a population of individuals-referred to as comorbidity analysis-has become a common practice due to its great impact on life expectancy, quality of life and healthcare costs. In this scenario, the availability of scalable, easy-to-use software frameworks tailored to support the study of comorbidities over large datasets of patients is essential. We introduce Comorbidity4j, an open-source Java tool to perform systematic analyses of comorbidities by generating interactive Web visualizations to explore and refine results. Comorbidity4j processes user-provided clinical data by identifying significant disease co-occurrences and computing a comprehensive set of comorbidity indices. Patients can be stratified by sex, age and user-defined criteria. Comorbidity4j supports the analysis of the temporal directionality and the sex ratio of diseases. The incremental upload and validation of clinical input data and the customization of comorbidity analyses are performed by an interactive Web interface. With a Web browser, the results of such analyses can be filtered with respect to comorbidity indexes and disease names and explored by means of heat maps and network charts of disease associations. Comorbidity4j is optimized to efficiently process large datasets of clinical data. Besides a software tool for local execution, we provide Comorbidity4j as a Web service to enable users to perform online comorbidity analyses. Doc: http://comorbidity4j.readthedocs.io/; Source code: https://github.com/fra82/comorbidity4j, Web tool: http://comorbidity.eu/comorbidity4web/.

Blockchain for Secure EHRs Sharing of Mobile Cloud Based E-Health Systems

Recent years have witnessed a paradigm shift in the storage of Electronic Health Records (EHRs) on mobile cloud environments, where mobile devices are integrated with cloud computing to facilitate medical data exchanges among patients and healthcare providers. This advanced model enables healthcare services with low operational cost, high flexibility, and EHRs availability. However, this new paradigm also raises concerns about data privacy and network security for e-health systems. How to reliably share EHRs among mobile users while guaranteeing high-security levels in the mobile cloud is a challenging issue. In this paper, we propose a novel EHRs sharing framework that combines blockchain and the decentralized interplanetary file system (IPFS) on a mobile cloud platform. Particularly, we design a trustworthy access control mechanism using smart contracts to achieve secure EHRs sharing among different patients and medical providers. We present a prototype implementation using Ethereum blockchain in a real data sharing scenario on a mobile app with Amazon cloud computing. The empirical results show that our proposal provides an effective solution for reliable data exchanges on mobile clouds while preserving sensitive health information against potential threats. The system evaluation and security analysis also demonstrate the performance improvements in lightweight access control design, minimum network latency with high security and data privacy levels, compared to the existing data sharing models.

Commentary: Paradigms, Axiology, and Praxeology in Medical Education Research.

This supplement includes 11 research papers accepted by the 2018 Research in Medical Education Committee. In this Commentary, the authors draw the attention of medical educators and researchers to questions about the researcher's philosophical paradigm. Such questions fundamentally guide research-the choice of conceptual frameworks, methods, and methodology. The authors provide a brief overview of research paradigms and the related concept of axiology and praxeology in medical education research. The authors map the 11 accepted research articles, describing the researchers' stated or implied worldviews and the impact on chosen methods. The authors close by encouraging researchers to state the research paradigm behind their research, comment on how they ensured that the methods used displayed consistency with that paradigm, and highlight the value the research adds to everyday education.

Comparing Population-based Risk-stratification Model Performance Using Demographic, Diagnosis and Medication Data Extracted From Outpatient Electronic Health Records Versus Administrative Claims.

There is an increasing demand for electronic health record (EHR)-based risk stratification and predictive modeling tools at the population level. This trend is partly due to increased value-based payment policies and the increasing availability of EHRs at the provider level. Risk stratification models, however, have been traditionally derived from claims or encounter systems. This study evaluates the challenges and opportunities of using EHR data instead of or in addition to administrative claims for risk stratification. This study used the structured EHR records and administrative claims of 85,581 patients receiving outpatient care at a large integrated provider system. Common data elements for risk stratification (ie, age, sex, diagnosis, and medication) were extracted from outpatient EHR records and administrative claims. The performance of a validated risk-stratification model was assessed using data extracted from claims alone, EHR alone, and claims and EHR combined. EHR-derived metrics overlapped considerably with administrative claims (eg, number of chronic conditions). The accuracy of the model, when using EHR data alone, was acceptable with an area under the curve of ∼0.81 for hospitalization and ∼0.85 for identifying top 1% utilizers using the concurrent model. However, when using EHR data alone, the predictive model explained a lower amount of variation in utilization-based outcomes compared with administrative claims. The results show a promising performance of models predicting cost and hospitalization using outpatient EHR's diagnosis and medication data. More research is needed to evaluate the benefits of other EHR data types (eg, lab values and vital signs) for risk stratification.

A Fast and Accurate Algorithm to Test for Binary Phenotypes and Its Application to PheWAS

The availability of electronic health record (EHR)-based phenotypes allows for genome-wide association analyses in thousands of traits and has great potential to enable identification of genetic variants associated with clinical phenotypes. We can interpret the phenome-wide association study (PheWAS) result for a single genetic variant by observing its association across a landscape of phenotypes. Because a PheWAS can test thousands of binary phenotypes, and most of them have unbalanced or often extremely unbalanced case-control ratios (1:10 or 1:600, respectively), existing methods cannot provide an accurate and scalable way to test for associations. Here, we propose a computationally fast score-test-based method that estimates the distribution of the test statistic by using the saddlepoint approximation. Our method is much (∼100 times) faster than the state-of-the-art Firth's test. It can also adjust for covariates and control type I error rates even when the case-control ratio is extremely unbalanced. Through application to PheWAS data from the Michigan Genomics Initiative, we show that the proposed method can control type I error rates while replicating previously known association signals even for traits with a very small number of cases and a large number of controls.

The Effect of Access to Electronic Health Records on Throughput Efficiency and Imaging Utilization in the Emergency Department.

To evaluate whether the availability of Electronic Health Records (EHRs) reduces throughput time and utilization of advanced imaging for patients in an academic ED. All patients arriving at an academic Emergency Department (ED) via ambulance between June 1, 2011, and June 4, 2012, were included in the study. This accounted for 9,970 unique ambulance patient visits. Retrospective noninterventional analysis of patients in an academic ED. The primary independent variable was whether the patient had a prior EHR at the study hospital. Main outcomes were throughput time, number of advanced diagnostic imaging studies (CT, MRI, ultrasound), and the associated cost of these imaging studies. A set of controls, including age, gender, ICD9 codes, acuity measures, and NYU ED algorithm case severity classifications, was used in an ordinary least-squares (OLS) regression framework to estimate the association between EHR availability and the outcome measures. A patient with a prior EHR experienced a mean reduction in CT scans of 13.9 percent ([4.9, 23.0]). There was no material change in throughput time for patients with a prior EHR and no difference in utilization of other imaging studies across patients with a prior EHR and those without. Cost savings associated with prior EHRs are $22.52 per patient visit. EHR availability for ED patients is associated with a reduction in CT scans and cost savings but had no impact on throughput time or order frequency of other imaging studies.

Enhancing Risk Assessment in Patients Receiving Chronic Opioid Analgesic Therapy Using Natural Language Processing

Clinical guidelines for the use of opioids in chronic noncancer pain recommend assessing risk for aberrant drug-related behaviors prior to initiating opioid therapy. Despite recent dramatic increases in prescription opioid misuse and abuse, use of screening tools by clinicians continues to be underutilized. This research evaluated natural language processing (NLP) together with other data extraction techniques for risk assessment of patients considered for opioid therapy as a means of predicting opioid abuse. Using a retrospective cohort of 3,668 chronic noncancer pain patients with at least one opioid agreement between January 1, 2007, and December 31, 2012, we examined the availability of electronic health record structured and unstructured data to populate the Opioid Risk Tool (ORT) and other selected outcomes. Clinician-documented opioid agreement violations in the clinical notes were determined using NLP techniques followed by manual review of the notes. Confirmed through manual review, the NLP algorithm had 96.1% sensitivity, 92.8% specificity, and 92.6% positive predictive value in identifying opioid agreement violation. At the time of most recent opioid agreement, automated ORT identified 42.8% of patients as at low risk, 28.2% as at moderate risk, and 29.0% as at high risk for opioid abuse. During a year following the agreement, 22.5% of patients had opioid agreement violations. Patients classified as high risk were three times more likely to violate opioid agreements compared with those with low/moderate risk. Our findings suggest that NLP techniques have potential utility to support clinicians in screening chronic noncancer pain patients considered for long-term opioid therapy.

PhenoTree: Interactive Visual Analytics for Hierarchical Phenotyping From Large-Scale Electronic Health Records

Electronic health records (EHRs) capture comprehensive patient information in digital form from a variety of sources. Increasing availability of EHRs has facilitated development of data and visual analytic tools for healthcare analytics, such as clinical decision support and patient care management systems. Many healthcare analytic tools are used to investigate fundamental problems, such as study of patient population, exploring complicated interactions among patients and their medical histories, and extracting structured phenotypes characterizing the patient population. In this paper, we propose PhenoTree , a novel data-driven, hierarchical, and interactive phenotyping tool, that enables physicians and medical researchers to participate in the phenotyping process of large-scale EHR cohorts. The proposed visual analytic tool allows users to interactively explore EHR cohorts, and generate, interpret, evaluate, and refine phenotypes by building and navigating a phenotype hierarchy. Specifically, given a cohort or subcohort, PhenoTree employs sparse principal component analysis (SPCA) to identify key clinical features that characterize the population. The clinical features provide a natural way to generate deeper phenotypes at finer granularities by expanding the phenotype hierarchy. To facilitate the intensive computation required for interactive analytics, we design an efficient SPCA solver based on a variance reduced stochastic gradient technique. The benefits of our method are demonstrated by analyzing two different EHR patient cohorts, a public and a private dataset containing EHRs of $101\,767$ and $223\,076$ patients, respectively. Our evaluations show that PhenoTree can detect clinically meaningful hierarchical phenotypes.

Using electronic health record collected clinical variables to predict medical intensive care unit mortality.

BackgroundClinical decision support systems are used to help predict patient stability and mortality in the Intensive Care Unit (ICU). Accurate patient information can assist clinicians with patient management and in allocating finite resources. However, systems currently in common use have limited predictive value in the clinical setting. The increasing availability of Electronic Health Records (EHR) provides an opportunity to use medical information for more accurate patient stability and mortality prediction in the ICU.ObjectiveDevelop and evaluate an algorithm which more accurately predicts patient mortality in the ICU, using the correlations between widely available clinical variables from the EHR.MethodsWe have developed an algorithm, AutoTriage, which uses eight common clinical variables from the EHR to assign patient mortality risk scores. Each clinical variable produces a subscore, and combinations of two or three discretized clinical variables also produce subscores. A combination of weighted subscores produces the overall score. We validated the performance of this algorithm in a retrospective study on the MIMIC III medical ICU dataset.ResultsAutoTriage 12 h mortality prediction yields an Area Under Receiver Operating Characteristic value of 0.88 (95% confidence interval 0.86 to 0.88). At a sensitivity of 80%, AutoTriage maintains a specificity of 81% with a diagnostic odds ratio of 16.26.ConclusionsThrough the multidimensional analysis of the correlations between eight common clinical variables, AutoTriage provides an improvement in the specificity and sensitivity of patient mortality prediction over existing prediction methods.

Modeling Healthcare Quality via Compact Representations of Electronic Health Records.

Increased availability of Electronic Health Record (EHR) data provides unique opportunities for improving the quality of health services. In this study, we couple EHRs with the advanced machine learning tools to predict three important parameters of healthcare quality. More specifically, we describe how to learn low-dimensional vector representations of patient conditions and clinical procedures in an unsupervised manner, and generate feature vectors of hospitalized patients useful for predicting their length of stay, total incurred charges, and mortality rates. In order to learn vector representations, we propose to employ state-of-the-art language models specifically designed for modeling co-occurrence of diseases and applied clinical procedures. The proposed model is trained on a large-scale EHR database comprising more than 35 million hospitalizations in California over a period of nine years. We compared the proposed approach to several alternatives and evaluated their effectiveness by measuring accuracy of regression and classification models used for three predictive tasks considered in this study. Our model outperformed the baseline models on all tasks, indicating a strong potential of the proposed approach for advancing quality of the healthcare system.

The Effect of Perceived Expected Satisfaction with Electronic Health Records Availability on Expected Satisfaction with Electronic Health Records Portability in a Multi-Stakeholder Environment

A central premise for the creation of Electronic Health Records (EHR) is ensuring the portability of patient health records across various clinical, insurance, and regulatory entities. From portability standards such as International Classification of Diseases (ICD) to data sharing across institutions, a lack of portability of health data can jeopardize optimal care and reduce meaningful use. This research empirically investigates the relationship between health records availability and portability. Using data collected from 168 medical providers and patients, we confirm the positive relationship between user perceptions of expected satisfaction with EHR availability and the expected satisfaction with portability. Our findings contribute to more informed practice by understanding how ensuring the availability of patient data by virtue of enhanced data sharing standards, device independence, and better EHR data integration can subsequently drive perceptions of portability across a multitude of stakeholders.

An access control framework for secured sharing of electronic health records using hierarchy similarity analyser

Sharing relevant and authorised health data referred as electronic health records (EHRs) among interoperable e-health environments requires identification and mitigation of security gaps accruing out of these collaborations. Ensuring confidentiality and availability of EHR during transit requires a standard access control framework that can efficiently and securely realise collaborations. Disparity in access policies often result in policy conflicts and rule redundancy. The framework must encompass heterogeneity of workflow and frequently changing demands of health professionals and resolves policy conflicts and reduces rule-redundancy. This paper proposes a framework and its verification for integrating access control policies based on similarities between user and resource hierarchies of healthcare units. The framework comprises of a hierarchical similarity analyser (HSA) that assign a security level to each attribute generated on the similarities obtained. The verification of the framework is performed through access control policy testing (ACPT) developed by National Institute of Standards and Technology (NIST).

Clinical research informatics and electronic health record data.

The goal of this survey is to discuss the impact of the growing availability of electronic health record (EHR) data on the evolving field of Clinical Research Informatics (CRI), which is the union of biomedical research and informatics. Major challenges for the use of EHR-derived data for research include the lack of standard methods for ensuring that data quality, completeness, and provenance are sufficient to assess the appropriateness of its use for research. Areas that need continued emphasis include methods for integrating data from heterogeneous sources, guidelines (including explicit phenotype definitions) for using these data in both pragmatic clinical trials and observational investigations, strong data governance to better understand and control quality of enterprise data, and promotion of national standards for representing and using clinical data. The use of EHR data has become a priority in CRI. Awareness of underlying clinical data collection processes will be essential in order to leverage these data for clinical research and patient care, and will require multi-disciplinary teams representing clinical research, informatics, and healthcare operations. Considerations for the use of EHR data provide a starting point for practical applications and a CRI research agenda, which will be facilitated by CRI's key role in the infrastructure of a learning healthcare system.

Mining the electronic health record for disease knowledge.

The growing amount and availability of electronic health record (EHR) data present enhanced opportunities for discovering new knowledge about diseases. In the past decade, there has been an increasing number of data and text mining studies focused on the identification of disease associations (e.g., disease-disease, disease-drug, and disease-gene) in structured and unstructured EHR data. This chapter presents a knowledge discovery framework for mining the EHR for disease knowledge and describes each step for data selection, preprocessing, transformation, data mining, and interpretation/validation. Topics including natural language processing, standards, and data privacy and security are also discussed in the context of this framework.

Redundancy in electronic health record corpora: analysis, impact on text mining performance and mitigation strategies

BackgroundThe increasing availability of Electronic Health Record (EHR) data and specifically free-text patient notes presents opportunities for phenotype extraction. Text-mining methods in particular can help disease modeling by mapping named-entities mentions to terminologies and clustering semantically related terms. EHR corpora, however, exhibit specific statistical and linguistic characteristics when compared with corpora in the biomedical literature domain. We focus on copy-and-paste redundancy: clinicians typically copy and paste information from previous notes when documenting a current patient encounter. Thus, within a longitudinal patient record, one expects to observe heavy redundancy. In this paper, we ask three research questions: (i) How can redundancy be quantified in large-scale text corpora? (ii) Conventional wisdom is that larger corpora yield better results in text mining. But how does the observed EHR redundancy affect text mining? Does such redundancy introduce a bias that distorts learned models? Or does the redundancy introduce benefits by highlighting stable and important subsets of the corpus? (iii) How can one mitigate the impact of redundancy on text mining?ResultsWe analyze a large-scale EHR corpus and quantify redundancy both in terms of word and semantic concept repetition. We observe redundancy levels of about 30% and non-standard distribution of both words and concepts. We measure the impact of redundancy on two standard text-mining applications: collocation identification and topic modeling. We compare the results of these methods on synthetic data with controlled levels of redundancy and observe significant performance variation. Finally, we compare two mitigation strategies to avoid redundancy-induced bias: (i) a baseline strategy, keeping only the last note for each patient in the corpus; (ii) removing redundant notes with an efficient fingerprinting-based algorithm. aFor text mining, preprocessing the EHR corpus with fingerprinting yields significantly better results.ConclusionsBefore applying text-mining techniques, one must pay careful attention to the structure of the analyzed corpora. While the importance of data cleaning has been known for low-level text characteristics (e.g., encoding and spelling), high-level and difficult-to-quantify corpus characteristics, such as naturally occurring redundancy, can also hurt text mining. Fingerprinting enables text-mining techniques to leverage available data in the EHR corpus, while avoiding the bias introduced by redundancy.

Use of Electronic Health Records in sub-Saharan Africa: Progress and challenges.

The Electronic Health Record (EHR) is a key component of medical informatics that is increasingly being utilized in industrialized nations to improve healthcare. There is limited information on the use of EHR in sub-Saharan Africa. This paper reviews availability of EHRs in sub-Saharan Africa. Searches were performed on PubMed and Google Scholar databases using the terms 'Electronic Health Records OR Electronic Medical Records OR e-Health and Africa'. References from identified publications were reviewed. Inclusion criterion was documented use of EHR in Africa. The search yielded 147 publications of which 21papers from 15 sub-Saharan African countries documented the use of EHR in Africa and were reviewed. About 91% reported use of Open Source healthcare software, with OpenMRS being the most widely used. Most reports were from HIV related health centers. Barriers to adoption of EHRs include high cost of procurement and maintenance, poor network infrastructure and lack of comfort among health workers with electronic medical records. There has been an increase in the use of EHRs in sub-Saharan Africa, largely driven by utilization by HIV treatment programs. Penetration is still however very low.

The impact of electronic health records on care of heart failure patients in the emergency room

To evaluate if electronic health records (EHR) have observable effects on care outcomes, we examined quality and efficiency measures for patients presenting to emergency departments (ED). We conducted a retrospective study of 5166 adults with heart failure in three metropolitan EDs. Patients were termed internal if prior information was in the EHR upon ED presentation, otherwise external. Associations of internality with hospitalization, mortality, length of stay (LOS), and numbers of tests, procedures, and medications ordered in the ED were examined after adjusting for age, gender, race, marital status, comorbidities and hospitalization as a proxy for acuity level where appropriate. At two EDs internals had lower odds of mortality if hospitalized (OR 0.55; 95% CI 0.38 to 0.81 and 0.45; 0.21 to 0.96), fewer laboratory tests during the ED visit (-4.6%; -8.9% to -0.1% and -14.0%; -19.5% to -8.1%) as well as fewer medications (-33.6%; -38.4% to -28.4% and -21.3%; -33.2% to -7.3%). At one of these two EDs, internals had lower odds of hospitalization (0.37; 0.22 to 0.60). At the third ED, internal patients only experienced a prolonged ED LOS (32.3%; 6.3% to 64.8%) but no other differences. There was no association with hospital LOS or number of procedures ordered. EHR availability was associated with salutary outcomes in two of three ED settings and prolongation of ED LOS at a third, but evidence was mixed and causality remains to be determined. An EHR may have the potential to be a valuable adjunct in the care of heart failure patients.

The “Meaningful Use” Regulation for Electronic Health Records

The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers' decisions and patients' outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice. But inevitability does not mean easy transition. We have years of professional agreement and bipartisan consensus regarding the potential value of EHRs. Yet we have not moved significantly to extend the availability of EHRs from a few large institutions to the smaller clinics and practices where most Americans . . .