Electronic Health Systems Research Articles

Computer-Aided Identification and Validation of Privacy Requirements

Privacy is a software quality that is closely related to security. The main difference is that security properties aim at the protection of assets that are crucial for the considered system, and privacy aims at the protection of personal data that are processed by the system. The identification of privacy protection needs in complex systems is a hard and error prone task. Stakeholders whose personal data are processed might be overlooked, or the sensitivity and the need of protection of the personal data might be underestimated. The later personal data and the needs to protect them are identified during the development process, the more expensive it is to fix these issues, because the needed changes of the system-to-be often affect many functionalities. In this paper, we present a systematic method to identify the privacy needs of a software system based on a set of functional requirements by extending the problem-based privacy analysis (ProPAn) method. Our method is tool-supported and automated where possible to reduce the effort that has to be spent for the privacy analysis, which is especially important when considering complex systems. The contribution of this paper is a semi-automatic method to identify the relevant privacy requirements for a software-to-be based on its functional requirements. The considered privacy requirements address all dimensions of privacy that are relevant for software development. As our method is solely based on the functional requirements of the system to be, we enable users of our method to identify the privacy protection needs that have to be addressed by the software-to-be at an early stage of the development. As initial evaluation of our method, we show its applicability on a small electronic health system scenario.

Privacy in a digital, networked world: technologies, implications and solutions

This comprehensive textbook/reference presents a focused review of the state of the art in privacy research, encompassing a range of diverse topics. The first book of its kind designed specifically to cater to courses on privacy, this authoritative volume provides technical, legal, and ethical perspectives on privacy issues from a global selection of renowned experts. Features: examines privacy issues relating to databases, P2P networks, big data technologies, social networks, and digital information networks; describes the challenges of addressing privacy concerns in various areas; reviews topics of privacy in electronic health systems, smart grid technology, vehicular ad-hoc networks, mobile devices, location-based systems, and crowdsourcing platforms; investigates approaches for protecting privacy in cloud applications; discusses the regulation of personal information disclosure and the privacy of individuals; presents the tools and the evidence to better understand consumers privacy behaviors.

Abstract TMP65: What Changes Improve Door-to-Needle Times? Results From a Single Center Door-to-Needle Improvement Initiative

Background: The benefit of thrombolysis is highly time dependent. Strategies and system changes to reduce door-to-needle time (DNT) have been proposed but the effectiveness of such strategies has not been fully evaluated. Hypothesis: Specific change strategies to the system of delivering thrombolysis significantly improve DNT. Stroke severity also affects DNT significantly. Methods: The Hurry Acute Stroke Treatment and Evaluation (HASTE) project was implemented in 3 phases at a single academic medical center to reduce DNT using four strategies. In HASTE-I (Jun 6 2012 - Jun 5 2013), baseline performance was analyzed with no changes made to stroke treatment. In HASTE-II (Jun 6 2013 - Jan 24 2015), three changes were implemented: 1) a STAT! stroke protocol to pre-notify the stroke team of the severity of incoming stroke patients; 2) administering tPA in the CT scanner; and 3) registering the patient as unknown prior to exact identification, to allow immediate order entry in our electronic health system. In HASTE-III (Jan 25 2015 - Jun 29 2015), we implemented a process to bring the patient directly to CT on the EMS stretcher. Decrease in DNT was analyzed using Wilcoxon rank sum and Kruskal Wallis tests, and multivariable linear regression. Log transformed DNT was modeled using a backward selection approach. Results: There were 350 patients treated with tPA during the project. The results of the univariable and multivariable analyses are shown in the table. In univariable analyses, the following strategies improved DNT: STAT! stroke, patient registered as unknown , and stretcher to CT. Additionally, DNT was lower if tPA was administered in the CT. The stroke severity also affected DNT. Multivariable regression showed the following factors to be significant: giving tPA in the CT, stretcher to CT, patient registered as unknown , and stroke severity. Conclusions: Stretcher to CT, patient registered as unknown , and administering tPA in CT were most efficacious in reducing DNT.

Aligning Healthcare Safety and Quality Competencies: Quality and Safety Education for Nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® Standards Crosswalk

There is little to no improvement in the quality of patient care since the publication of To Err Is Human report in 1999 by the Institute of Medicine. Health care provider education must address quality and patient safety language in order to meet the demands of the 21st century. Academic institutions focus on the quality and safety language as outlined by the Quality and Safety Education for Nurses (QSEN). Conversely, hospitals emphasize competencies and standards as outlined in The Joint Commission accreditation standards and the American Nurses Credentialing Center Magnet® competencies. Nurse leaders need a crosswalk among all 3 standards that can help guide their practice. The crosswalk can help nurse leaders have an increased understanding of the role that QSEN plays in educating a competent and safe nursing workforce.

Awareness Training Transfer and Information Security Content Development for Healthcare Industry

Electronic Health Record (EHR) becomes increasingly pervasive and the need to safeguard EHR becomes more vital for healthcare organizations. Human error is known as the biggest threat to information security in Electronic Health Systems that can be minimized through awareness training programs. There are various techniques available for awareness of information security. However, research is scant regarding effective information security awareness delivery methods. It is essential that effective awareness training delivery method is selected, designed, and executed to ensure the appropriate protection of organizational assets. This study adapts Holton’s transfer of training model to develop a framework for effective information security awareness training program. The framework provides guidelines for organizations to select an effective delivery method based on the organizations’ needs and success factor, and to create information security content from a selected healthcare’s internal information security policy and related international standards. Organizations should make continual efforts to ensure that content of policy is effectively communicated to the employees.

APA Joins Call for Reform of ‘Meaningful Use’ Program

APA and other medical organizations are urging CMS to focus on promoting interoperability and innovation as vendors respond to the demands of physicians and hospitals to progress past the current program where vendors must meet check-the-box requirements.

Optimizing the Use of State Prescription Drug Monitoring Programs for Public Safety

State prescription drug monitoring programs (PMPs), which collect and distribute data on prescription controlled substances dispensed in a state, are tools to curb prescription drug abuse. The programs help identify prescription misuse and abuse, detect diversion of controlled substances, and facilitate access to medication for treatment. Health care professionals, such as the advanced practice registered nurse, may incorporate PMP data into the clinical setting as a tool for educated decision making and monitoring. State officials seek to transform PMPs into more effective health care information delivery tools by implementing five key operational practices: real-time dispenser reporting to PMPs, interstate sharing of PMP data, expanded access to PMP data by health care professionals, integration of PMP data into electronic health systems, and distribution of proactive alerts to health care professionals. As policy makers strive to optimize PMP use, they must also ensure stable, long-term funding for the programs, support the use of evidence-based treatment alternatives, and provide adequate addiction treatment resources. This article describes the history of PMPs, efforts to improve PMP use for clinical decision making, and necessary future steps to optimize the role of PMPs in state prescription drug abuse prevention strategies.

P02.02 Another digi-gap! integrating multifaceted triaging approaches to assist and speed technological transition to electronic medical documentation and booking systems

<h3>&nbsp;Introduction</h3> Recognising and harnessing cultural and technological shifts in both client and healthcare provider arenas are crucial to optimising clinic wide responses to STI education and care. As methods of client-to-service engagement evolve, healthcare providers and their documentation systems must change as well. This is crucial to optimising clinical care and interaction for potential sexual health clients, especially when incorporating mandatory area health service and ministry directives into daily practice. Northern Sydney Sexual Health Service (NSSHS) triage has long allowed for telephone and walk-in enquiries. NSSHS has modified the existing service website to allow for online booking enquiries. This allows a potential patient to perform basic self-triage while engaging with sexual health services in a safe, non-confronting manner. At the same time, this reduces telephone wait times for clients and improves engagement. <h3>Results</h3> 75% of all website enquiries are appropriate for Clinic 16 services. A significant increase in appointments made via our website enquiry system for priority populations has occurred since initiation in November 2014, including with men who have sex with men (MSM) and youth. By improving our priority population engagement, there is a marked improvement in Occasions of Services and a projected improvement in Activity Based Funding (ABF) capture via the new electronic medical record system, Community Health and Outpatient Care system (CHOC). <h3>Conclusion</h3> By integrating a multi-platform approach to patient engagement, NSSHS is growing to fit client needs while incorporating Local Health District and Ministry of Health mandated electronic medical record changes. This improves ABF capture, patient documentation and above all, improves engagement of priority populations with sexual health services. <h3>Disclosure statement</h3> Northern Sydney Sexual Health Service is funded by the Northern Sydney Local Health District. No grants were received in the development of this study or project.

A patient centered electronic health: eHealth system development.

Medical practice and patient-doctor relationship will continue improving while technology is integrated in our everyday life. In recent years the term eHealth landmarked a new era with improved health provider's skills and knowledge, and increased patient participation in medical care activities. To show why the design and implementation of a healthcare system needs to follow a specific philosophy dictated by the level of eHealth maturity of a country and its citizens. Based on the maturity level, an adaptable framework for implementing an Electronic Health System at national level is derived, guided by the Patient Centered Philosophy as defined and introduced by the EU directives. Implementation prerequisites are analyzed together with guiding principles for identifying the maturity level of an organization or country. Cyprus being a small EU country, it can be used as pilot site for the whole Europe, was chosen for this study and its maturity level analysis is presented. Recommendations that determine general steps needed to prepare the ground for an adequate patient-centered national healthcare system are accompanied. The implementation of an integrated Electronic Health Record at National level, as a prerequisite for a patient-centered eHealth environment is evidently demonstrated.

Tracking Future Path of Consumers' Empowerment in E-Health

Developments in ICT have created a new generation of networking technology that affects all areas, including healthcare. The use of ICT in healthcare organizations, for example in health information systems (HIS), has developed the same way as the wider landscape, and includes the use of Internet-based technology. The adoption of social network features as the ‘front end' of electronic health (e-health) systems is believed to boost sharing between consumers, leading to greater satisfaction. E-health is likely to become more consumer-centric, accommodating consumers' participation in the healthcare process, including decision-making. The government of Taiwan has successfully implemented a National Health Insurance (NHI) system as the foundation for e-health. Improvements in technology may drive changing consumer behavior concerning healthcare services. This paper addresses some important concepts, milestones, challenges, and future direction of consumer empowerment in Taiwan, and proposes that empowerment will be personal, social, and medical.

Providing security and fault tolerance in P2P connections between clouds for mHealth services

The mobile health (mHealth) and electronic health (eHealth) systems are useful to maintain a correct administration of health information and services. However, it is mandatory to ensure a secure data transmission and in case of a node failure, the system should not fall down. This fact is important because several vital systems could depend on this infrastructure. On the other hand, a cloud does not have infinite computational and storage resources in its infrastructure or would not provide all type of services. For this reason, it is important to establish an interrelation between clouds using communication protocols in order to provide scalability, efficiency, higher service availability and flexibility which allow the use of services, computing and storage resources of other clouds. In this paper, we propose the architecture and its secure protocol that allows exchanging information, data, services, computing and storage resources between all interconnected mHealth clouds. The system is based on a hierarchic architecture of two layers composed by nodes with different roles. The routing algorithm used to establish the connectivity between the nodes is the shortest path first (SPF), but it can be easily changed by any other one. Our architecture is highly scalable and allows adding new nodes and mHealth clouds easily, while it tries to maintain the load of the cloud balanced. Our protocol design includes node discovery, authentication and fault tolerance. We show the protocol operation and the secure system design. Finally we provide the performance results in a controlled test bench.

Validation of a nurses' views on electronic medical record systems (EMR) questionnaire in Turkish health system.

Using of EMR in health services and organizations is steadily increasing for quality improvement, cost effectiveness and performance development. However, no validated national and international instruments (scale, questionnaire, index, and inventory) have assessed the effectiveness, satisfaction, health care savings, patient safety and cost minimization of electronic medical and health systems from the viewpoint and perceptions of nurses in Turkish health services. The perceptions of health care professionals especially physicians and nurses can contribute important information that may predict their acceptance of EMR and desired mode of use for EMR, evaluation performance of EMR thus guiding EMR implementation in hospitals. This article is a report of validation of the instrument to measure nurses' views on the use, quality and user satisfaction with EMR in Turkish health system. Items in the questionnaire were designed and obtained following O.G. Otieno, H. Toyama, M. Asonuma, M. Kanai-Pak, K. Naitoh's questionnaire about Use, Quality and User Satisfaction with EMR systems. Reliability and validity were examined and investigated in terms of responses from 487 nurses from one education hospital in Ankara, Turkey. This study was planned and conducted at a university hospital. The validation process was based on construct validity in this study. The response rate was 74.92%. Cronbach's alphas of three factors (use, quality and satisfaction of EMR) ranged from 0.78 to 0.94. Goodness-of-fit indices from the confirmatory factor analysis showed a reasonable model fit. Results of confirmatory factor analysis showed that χ2 statistic indicated significant result (p < 0.001) and model fit was acceptable according to relative χ2 statistic (χ2/df = 2.8 < 5). Further validation of the instrument could yield positive results in health systems in the different countries. Also further validation and reliability studies could be planned on physicians and other health professionals.

Health workers' experiences, barriers, preferences and motivating factors in using mHealth forms in Ethiopia.

BackgroundMobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. However, contextual evidence on health workers’ barriers and motivating factors that may influence large-scale implementation of such interfaces for health care delivery is scarce.MethodsA pretested semistructured questionnaire was used to assess health workers’ experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study.ResultsOver a 6-month period, a total of 2,893 electronic health records of 1,122 women were submitted to a central computer through the Internet. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. With regards to language preference, 18 (78.3%) preferred using the local language (Tigrinya) version of the forms to English. Indentified barriers for not using electronic forms consistently include challenges related to electronic forms (for example, problem with username and password setting as reported by 5 (21.7%), smartphones (for example, smartphone froze or locked up as reported by 9 (39.1%) and health system (for example, frequent movement of health workers as reported by 19 (82.6%)).ConclusionsBoth HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.Electronic supplementary materialThe online version of this article (doi:10.1186/1478-4491-13-2) contains supplementary material, which is available to authorized users.

Cost-utility and cost-effectiveness studies of telemedicine, electronic, and mobile health systems in the literature: a systematic review.

A systematic review of cost-utility and cost-effectiveness research works of telemedicine, electronic health (e-health), and mobile health (m-health) systems in the literature is presented. Academic databases and systems such as PubMed, Scopus, ISI Web of Science, and IEEE Xplore were searched, using different combinations of terms such as "cost-utility" OR "cost utility" AND "telemedicine," "cost-effectiveness" OR "cost effectiveness" AND "mobile health," etc. In the articles searched, there were no limitations in the publication date. The search identified 35 relevant works. Many of the articles were reviews of different studies. Seventy-nine percent concerned the cost-effectiveness of telemedicine systems in different specialties such as teleophthalmology, telecardiology, teledermatology, etc. More articles were found between 2000 and 2013. Cost-utility studies were done only for telemedicine systems. There are few cost-utility and cost-effectiveness studies for e-health and m-health systems in the literature. Some cost-effectiveness studies demonstrate that telemedicine can reduce the costs, but not all. Among the main limitations of the economic evaluations of telemedicine systems are the lack of randomized control trials, small sample sizes, and the absence of quality data and appropriate measures.

Implementing for Sustainability: Promoting Use of a Measurement Feedback System for Innovation and Quality Improvement.

Measurement feedback systems (MFSs) are increasingly recognized as evidence-based treatments for improving mental health outcomes, in addition to being a useful administrative tool for service planning and reporting. Promising research findings have driven practice administrators and policymakers to emphasize the incorporation of outcomes monitoring into electronic health systems. To promote MFS integrity and protect against potentially negative outcomes, it is vital that adoption and implementation be guided by scientifically rigorous yet practical principles. In this point of view, the authors discuss and provide examples of three user-centered and theory-based principles: emphasizing integration with clinical values and workflow, promoting administrative leadership with the 'golden thread' of data-informed decision-making, and facilitating sustainability by encouraging innovation. In our experience, enacting these principles serves to promote sustainable implementation of MFSs in the community while also allowing innovation to occur, which can inform improvements to guide future MFS research.

The roles of health literacy, numeracy, and graph literacy on the usability of the VA's personal health record by veterans

Personal Health Records (PHRs) that are tethered to electronic medical health systems are applications that can significantly enhance patients' health and health care. The primary aim of this research was to examine the roles of health literacy, numeracy ability, and graph literacy in enabling a group of veterans to perform health-management tasks using My HealtheVet (MHV), the Department of Veterans Affairs' PHR portal. Forty participants, all users of MHV, were recruited in two age groups: < 65 and ≥ 65 years of age. They were asked to perform 13 tasks representative of this portal's eight major categories of functions, and were categorized into lower and higher performers based on their performance of those tasks. The results indicated that age, health literacy, numeracy, and graph literacy all significantly differentiated lower from higher task performers. Also, older veterans performed more poorly than their younger counterparts. Graph literacy explained a significant amount of the variability in task performance even after computer and Internet proficiency, health status, health literacy, and numeracy ability were taken into consideration. Exit interviews emphasized problems with the presentation of excessive information and with navigating this portal. Participants also offered a number of recommendations for improving this PHR's design. Overall, the findings provided the basis for recommendations that consider both more conventional interface design issues as well as problems that could stem from individual factors such as health and graph literacy. The findings from this study are expected to inform upcoming redesign efforts of MHV as well as other relatively complex PHRs.

SU‐E‐T‐502: Biometrically Accepted Patient Records

Purpose:To implement a clinically useful palm vein pattern recognition biometric system to treat the correct treatment plan to the correct patient each and every time and to check‐in the patient into the department to access the correct medical record.Methods:A commercially available hand vein scanning system was paired to Aria and utilized an ADT interface from the hospital electronic health system. Integration at two points in Aria, version 11 MR2, first at the appointment tracker screen for the front desk medical record access and second at the queue screen on the 4D treatment console took place for patient daily time‐out. A test patient was utilized to check accuracy of identification as well as to check that no unintended interactions take place between the 4D treatment console and the hand vein scanning system. This system has been in clinical use since December 2013.Results:Since implementation, 445 patients have been enrolled into our biometric system. 95% of patients learn the correct methodology of hand placement on the scanner in the first try. We have had two instances of patient not found because of a bad initial scan. We simply erased the scanned metric and the patient enrolled again in those cases. The accuracy of the match is 100% for each patient, we have not had one patient misidentified. We can state this because we still use patient photo and date of birth as identifiers. A QA test patient is run monthly to check the integrity of the system.Conclusion:By utilizing palm vein scans along with the date of birth and patient photo, another means of patient identification now exits. This work indicates the successful implementation of technology in the area of patient safety by closing the gap of treating the wrong plan to a patient in radiation oncology.FOJP Service Corporation covered some of the costs of the hardware and software of the palm vein pattern recognition biometric system.

A secure query assurance approach for distributed health records

Health information system architectures inherently include distributed systems and data repositories across multiple organizations, health providers and with potentially some data stored with the health consumer. This is part of the shift to more fully integrated electronic health systems. Due to the varied stakeholders of these systems, it will become more important to provide a high level of query quality assurance for the parties utilizing these distributed and shared data repositories. A core consideration of health records is providing data confidentiality, including to protect against insider security threats. As such, it will often be desirable that electronic health information be stored in an encrypted format. In this paper, we present and describe the implementation and evaluation of a query assurance model that implements the three requirements of query assurance across sources of searchable encrypted health data. Furthermore, we consider the issue of freshness and data persistence in a multiple data owner environment, including a discussion of the characteristics of consumer interfacing health information systems.

A Usability Study of a Mobile Health Application for Rural Ghanaian Midwives

Midwives in rural Ghana work at the frontline of the health care system, where they have access to essential data about the patient population. However, current methods of data capture, primarily pen and paper, make the data neither accessible nor usable for monitoring patient care or program evaluation. Electronic health (eHealth) systems present a potential mechanism for enhancing the roles of midwives by providing tools for collecting, exchanging, and viewing patient data as well as offering midwives the possibility for receiving information and decision support. Introducing such technology in low-resource settings has been challenging because of low levels of user acceptance, software design that does not match the end-user environment, and/or unforeseen challenges such as irregular power availability. These challenges are often attributable to a lack of understanding by the software developers of the end users' needs and work environment. A mobile health (mHealth) application known as mClinic was designed to support midwife access to the Millennium Village-Global Network, an eHealth delivery platform that captures data for managing patient care as well as program evaluation and monitoring, decision making, and management. We conducted a descriptive usability study composed of 3 phases to evaluate an mClinic prototype: 1) hybrid lab-live software evaluation of mClinic to identify usability issues; 2) completion of a usability questionnaire; and 3) interviews that included low-fidelity prototyping of new functionality proposed by midwives. The heuristic evaluation identified usability problems related to 4 of 8 usability categories. Analysis of usability questionnaire data indicated that the midwives perceived mClinic as useful but were more neutral about the ease of use. Analysis of midwives' reactions to low-fidelity prototypes during the interview process supported the applicability of mClinic to midwives' work and identified the need for additional functionality. User acceptance is essential for the success of any mHealth implementation. Usability testing identified mClinic development flaws and needed software enhancements.

Improving patient care and safety in the community through technology

Introduction: The Central Community Care Access Centre (CCAC) in Ontario, Canada is leveraging technology to improve patient care and safety in the community by: • Implementing leading practices in e-health and health assessment technology to drive outcomebased care. • Enabling evidence-based decision-making through databases and software that systematically measure patient health status and outcomes. • Ensuring consistent, accurate patient information is available across the continuum of care with multiple health partners. These innovations reinforce system sustainability through efficiencies and value for dollar services. Aims and objectives Key examples: • Chaired provincial committee to implement the Client Health Related Information System (CHRIS) standardized database across Ontario’s CCACs, supported by mobile technology that enables care coordinators to work in patient’s home rather than CCAC office. • Implemented Resource Matching & e-Referral (RM&R) electronic health system with Central region hospitals, including first in Canada to automate referrals from emergency departments (ED) to community care. • Studied use of Resident Assessment Instrument for Home Care (RAI-HC) data to inform quality improvement through evidence-based care coordination. Used RAI-HC data to validate outcomes in leading practice initiatives and population health models. • Developed standardized in-home Medication Management Support Services (MMSS), backed by mobile technology and web-based software. • Partnered with Sunnybrook Health Sciences to pilot MyChartTM – a web-based personal health record that allows patients to access and manage selected health information from their CHRIS record. International Congress on Telehealth and Telecare 2013, London, July 01-03, 2013. 2 International Journal of Integrated Care –Volume 13, XX November –URN:NBN:NL:UI:10-1-115684– http://www.ijic.org/