BMC Medical Informatics and Decision Making - Latest Articles

Latent class cluster analysis to understand heterogeneity in prostate cancer treatment utilities

Salimah Meghani — 2009-11-27T00:00:00Z

Background: Men with prostate cancer are often challenged to choose between conservative management and a range of available treatment options each carrying varying risks and benefits. The trade-offs are between an improved life-expectancy with treatment accompanied by important risks such as urinary incontinence and erectile dysfunction. Previous studies of preference elicitation for prostate cancer treatment have found considerable heterogeneity in individuals' preferences for health states given similar treatments and clinical risks. Methods: Using latent class mixture model (LCA), we first sought to understand if there are unique patterns of heterogeneity or subgroups of individuals based on their prostate cancer treatment utilities (calculated time trade-off utilities for various health states) and if such unique subgroups exist, what demographic and urological variables may predict membership in these subgroups. Results: The sample (N=244) included men with prostate cancer (n=188) and men at-risk for disease (n=56). The sample was predominantly white (77%), with mean age of 60 years (SD+/- 9.5). Most (85.9%) were married or living with a significant other. Using LCA, a three class solution yielded the best model evidenced by the smallest Bayesian Information Criterion (BIC), substantial reduction in BIC from a 2-class solution, and Lo-Mendell-Rubin significance of <.001. The three identified clusters were named high-traders (n=31), low-traders (n=116), and no-traders (n=97). High-traders were more likely to trade survival time associated with treatment to avoid potential risks of treatment. Low-traders were less likely to trade survival time and accepted risks of treatment. No-traders were likely to make no trade-offs in any direction favouring the status quo. There was significant difference among the clusters in the importance of sexual activity (Pearson's chi2=16.55, P=0.002; Goodman and Kruskal tau = 0.039, P<0.001). In multinomial logistic regression, the level of importance assigned to sexual activity remained an independent predictor of class membership. Age and prostate cancer at-risk status were not significant factors in the multinomial model. Conclusions: Most existing utility work is undertaken focusing on how people choose on average. Distinct clusters of prostate cancer treatment utilities in our sample point to the need for further understanding of subgroups and need for tailored assessment and interventions.

The feasibility of a web-based counselling program for occupational physicians and employees on sick leave due to back or neck pain

Tanja de Jong — 2009-11-06T00:00:00Z

Background: The objective of this feasibility study was to gain insight into occupational physicians' (OPs) and employees' use of, and attitudes towards, 'Snelbeter' (Get Well Fast), a new web-based counselling program for employees on sick leave due to non-specific back or neck pain and their OPs. Methods: Registered user information was collected from the website to get insight in the use of the program by employees (n = 24). Qualitative information was obtained through semi-structured in-depth interviews with 19 OPs and nine employees in order to get insight in the actual use of the provided information, the attitudes towards the program and possible improvements of the program. Results: Actual use of the program among OPs was low. The majority of OPs, eight out of 11 (73%), never or only occasionally signed in. The greatest obstacle for OPs to use the program was the low number of eligible employees involved. Employees appreciated the program but their use was moderate. A small majority of the employees who used the program, 14 out of 24 (58%), opened 50% to 100% of the provided documents, a majority of the interviewed employees, seven out of nine (78%), used the provided information sometimes or regularly. The absence of personal contact was found to be a major barrier towards use of the program by employees. Conclusion: Although both OPs and employees appreciated the idea of the program and employees appreciated using it, program utilization was moderate to low. The discussion section reveals that before implementation can be started to any extent, the program will need adaptations that make it more attractive to use. The program should be considered for both return to work (RTW) and the prevention of sick leave. Adding personal contact (e.g. involving physiotherapists) to the program may also be promising.

Retraction: Estimation of progression of multi-state chronic disease using the Markov model and prevalence pool concept

Hui-Chuan Shih — 2009-10-20T00:00:00Z

This article 1 has been retracted because the Editors are unable to ensure the scientific veracity of the findings or the ethical conduct of the authors despite an extensive investigation.

Information management to enable personalized medicine: stakeholder roles in building clinical decision support

Gregory Downing — 2009-10-08T00:00:00Z

Background: Advances in technology and the scientific understanding of disease processes are presenting new opportunities to improve health through individualized approaches to patient management referred to as personalized medicine. Future health care strategies that deploy genomic technologies and molecular therapies will bring opportunities to prevent, predict, and pre-empt disease processes but will be dependent on knowledge management capabilities for health care providers that are not currently available. A key cornerstone to the potential application of this knowledge will be effective use of electronic health records. In particular, appropriate clinical use of genomic test results and molecularly-targeted therapies present important challenges in patient management that can be effectively addressed using electronic clinical decision support technologies.DiscussionApproaches to shaping future health information needs for personalized medicine were undertaken by a work group of the American Health Information Community. A needs assessment for clinical decision support in electronic health record systems to support personalized medical practices was conducted to guide health future development activities. Further, a suggested action plan was developed for government, researchers and research institutions, developers of electronic information tools (including clinical guidelines, and quality measures), and standards development organizations to meet the needs for personalized approaches to medical practice. In this article, we focus these activities on stakeholder organizations as an operational framework to help identify and coordinate needs and opportunities for clinical decision support tools to enable personalized medicine.SummaryThis perspective addresses conceptual approaches that can be undertaken to develop and apply clinical decision support in electronic health record systems to achieve personalized medical care. In addition, to represent meaningful benefits to personalized decision-making, a comparison of current and future applications of clinical decision support to enable individualized medical treatment plans is presented. If clinical decision support tools are to impact outcomes in a clear and positive manner, their development and deployment must therefore consider the needs of the providers, including specific practice needs, information workflow, and practice environment.

An interdisciplinary team communication framework and its application to healthcare 'e-teams' systems design

Craig Kuziemsky — 2009-09-15T00:00:00Z

Background: There are few studies that examine the processes that interdisciplinary teams engage in and how we can design health information systems (HIS) to support those team processes. This was an exploratory study with two purposes: (1) To develop a framework for interdisciplinary team communication based on structures, processes and outcomes that were identified as having occurred during weekly team meetings. (2) To use the framework to guide 'e-teams' HIS design to support interdisciplinary team meeting communication. Methods: An ethnographic approach was used to collect data on two interdisciplinary teams. Qualitative content analysis was used to analyze the data according to structures, processes and outcomes. Results: We present details for team meta-concepts of structures, processes and outcomes and the concepts and sub concepts within each meta-concept. We also provide an exploratory framework for interdisciplinary team communication and describe how the framework can guide HIS design to support 'e-teams'. Conclusion: The structures, processes and outcomes that describe interdisciplinary teams are complex and often occur in a non-linear fashion. Electronic data support, process facilitation and team video conferencing are three HIS tools that can enhance team function.

A global approach to the management of EMR (Electronic Medical Records) of patients with HIV/AIDS in Sub-Saharan Africa: the experience of DREAM Software

Andrea Nucita — 2009-09-11T00:00:00Z

Background: The DREAM Project operates within the framework of the national health systems of several sub-Saharan African countries and aims to introduce the essential components of an integrated strategy for the prevention and treatment of HIV/AIDS. The project is intended to serve as a model for a wide-ranging scale-up in the response to the epidemic. This paper aims to show DREAM's challenges and the solutions adopted. One of the solutions is the efficient management of the clinical data regarding the treatment of the patients and epidemiological analyses. Methods: Specific software for the management of the patients' EMR has been created within the DREAM programme in order to deal with the challenges deriving from the context in which DREAM operates. Setting up a computer infrastructure in health centres, providing a power supply, as well as managing the data and the project resources efficiently and reliably, are some of the questions that have been analysed in this study. Results: Over the years this software has proved that it is able to respond to the need for efficient management of the clinical data and organization of the health centres. Today it is used in 10 countries in sub-Saharan Africa by thousands of professionals and by now it has reached its fourth version. The medical files of over 73,000 assisted patients are managed by this software and the data collected with it have become essential for the epidemiological research that is carried out to improve the effectiveness of the therapy. Conclusion: Sub-Saharan Africa is the region hardest hit by HIV and AIDS in the world. However, the resources and responses adopted so far, to confront the epidemic, have at times been rather minimalist. The DREAM project has faced the battle against the epidemic by equipping itself with qualitative standards comparable to Western ones. The experience of DREAM has revealed that it is indeed possible to guarantee levels of excellence in developing countries, also in the sphere of ICT (Information and Communication Technology), thus making the intervention even more effective and contributing to bridging the digital divide.

Privacy-preserving record linkage using Bloom filters

Rainer Schnell — 2009-08-25T00:00:00Z

Background: Combining multiple databases with disjunctive or additional information on the same person is occurring increasingly throughout research. If unique identification numbers for these individuals are not available, probabilistic record linkage is used for the identification of matching record pairs. In many applications, identifiers have to be encrypted due to privacy concerns. Methods: A new protocol for privacy-preserving record linkage with encrypted identifiers allowing for errors in identifiers has been developed. The protocol is based on Bloom filters on q-grams of identifiers. Results: Tests on simulated and actual databases yield linkage results comparable to non-encrypted identifiers and superior to results from phonetic encodings. Conclusion: We proposed a protocol for privacy-preserving record linkage with encrypted identifiers allowing for errors in identifiers. Since the protocol can be easily enhanced and has a low computational burden, the protocol might be useful for many applications requiring privacy-preserving record linkage.

Improving healthcare consumer effectiveness: An Animated, Self-serve, Web-based Research Tool (ANSWER) for people with early rheumatoid arthritis

Linda Li — 2009-08-20T00:00:00Z

Background: People with rheumatoid arthritis (RA) should use DMARDs (disease-modifying anti-rheumatic drugs) within the first three months of symptoms in order to prevent irreversible joint damage. However, recent studies report the delay in DMARD use ranges from 6.5 months to 11.5 months in Canada. While most health service delivery interventions are designed to improve the family physician's ability to refer to a rheumatologist and prescribe treatments, relatively little has been done to improve the delivery of credible, relevant, and user-friendly information for individuals to make treatment decisions. To address this care gap, the Animated, Self-serve, Web-based Research Tool (ANSWER) will be developed and evaluated to assist people in making decisions about the use of methotrexate, a type of DMARD. The objectives of this project are: 1) to develop ANSWER for people with early RA; and 2) to assess the extent to which ANSWER reduces people's decisional conflict about the use of methotrexate, improves their knowledge about RA, and improves their skills of being 'effective healthcare consumers'.Methods/designConsistent with the International Patient Decision Aid Standards, the development process of ANSWER will involve: 1.) creating a storyline and scripts based on the best evidence on the use of methotrexate and other management options in RA, and the contextual factors that affect a patient's decision to use a treatment as found in ERAHSE; 2.) using an interactive design methodology to create, test, analyze and refine the ANSWER prototype; 3.) testing the content and user interface with health professionals and patients; and 4.) conducting a pilot study with 51 patients, who are diagnosed with RA in the past 12 months, to assess the extent to which ANSWER improves the quality of their decisions, knowledge and skills in being effective consumers.DiscussionWe envision that the ANSWER will help accelerate the dissemination of knowledge and skills necessary for people with early RA to make informed choices about treatment and to manage their health. The latest in animation and online technology will ensure ANSWER fills a knowledge translation gap, focusing on the next generation of people living with RA.

Disease surveillance using a hidden Markov model

Rochelle Watkins — 2009-08-10T00:00:00Z

Background: Routine surveillance of disease notification data can enable the early detection of localised disease outbreaks. Although hidden Markov models (HMMs) have been recognised as an appropriate method to model disease surveillance data, they have been rarely applied in public health practice. We aimed to develop and evaluate a simple flexible HMM for disease surveillance which is suitable for use with sparse small area count data and requires little baseline data. Methods: A Bayesian HMM was designed to monitor routinely collected notifiable disease data that are aggregated by residential postcode. Semi-synthetic data were used to evaluate the algorithm and compare outbreak detection performance with the established Early Aberration Reporting System (EARS) algorithms and a negative binomial cusum. Results: Algorithm performance varied according to the desired false alarm rate for surveillance. At false alarm rates around 0.05, the cusum-based algorithms provided the best overall outbreak detection performance, having similar sensitivity to the HMMs and a shorter average time to detection. At false alarm rates around 0.01, the HMM algorithms provided the best overall outbreak detection performance, having higher sensitivity than the cusum-based Methods and a generally shorter time to detection for larger outbreaks. Overall, the 14-day HMM had a significantly greater area under the receiver operator characteristic curve than the EARS C3 and 7-day negative binomial cusum algorithms. Conclusion: Our findings suggest that the HMM provides an effective method for the surveillance of sparse small area notifiable disease data at low false alarm rates. Further investigations are required to evaluation algorithm performance across other diseases and surveillance contexts.

Access to electronic health records by care setting and provider type: perceptions of cancer care providers in Ontario, Canada

Margo Orchard — 2009-08-10T00:00:00Z

Background: The use of electronic health records (EHRs) to support the organization and delivery of healthcare is evolving rapidly. However, little is known regarding potential variation in access to EHRs by provider type or care setting. This paper reports on observed variation in the perceptions of access to EHRs by a wide range of cancer care providers covering diverse cancer care settings in Ontario, Canada. Methods: Perspectives were sought regarding EHR access and health record completeness for cancer patients as part of an internet survey of 5663 cancer care providers and administrators in Ontario. Data were analyzed using a multilevel logistic regression model. Provider type, location of work, and access to computer or internet were included as covariates in the model. Results: A total of 1997 of 5663 (35%) valid responses were collected. Focusing on data from cancer care providers (N = 1247), significant variation in EHR access and health record completeness was observed between provider types, location of work, and level of computer access. Providers who worked in community hospitals were half as likely as those who worked in teaching hospitals to have access to their patients' EHRs (OR 0.45 95% CI: 0.24–0.85, p < 0.05) and were six times less likely to have access to other organizations' EHRs (OR 0.15 95% CI: 0.02–1.00, p < 0.05). Compared to surgeons, nurses (OR 3.47 95% CI: 1.80–6.68, p < 0.05), radiation therapists/physicists (OR 7.86 95% CI: 2.54–25.34, p < 0.05), and other clinicians (OR 4.92 95% CI: 2.15–11.27, p < 0.05) were more likely to report good access to their organization's EHRs. Conclusion: Variability in access across different provider groups, organization types, and geographic locations illustrates the fragmented nature of EHR adoption in the cancer system. Along with focusing on technological aspects of EHR adoption within organizations, it is essential that there is cross-organizational and cross-provider access to EHRs to ensure patient continuity of care, system efficiency, and high quality care.