Bell Eapen

eHealth and Health Information System Consultant

Interoperability for Doctors and Healthcare professionals Part I

It is important for health information systems to talk to each other. Unfortunately they speak different languages. This article is not for eHealth experts to understand the nuances of interoperability (HIE), but for health care professionals to have an idea about what is out there and what can be expected in the future.

When we consider HIE we have to think about what is being exchanged (package), how the information is organized (format) and how it is being transported (protocol). Though it is not essential to know, few terms that you might recognize are: HL7, XML for format and HTTP, TCP/IP for protocol. (Have you heard of MLLP? Google it!) The donor has the information in a certain format and protocol while the recipient expects it in a particular format and protocol.

At the core of all HIE platforms such as MirthConnect or OrionHealth’s Rhapsody, is an engine that does this conversion. Format and protocol of donor to format and protocol of recipient. Simple eh?

Is pragmatic interoperability the best solution?- M. Martineau @eHealthMusings explores a pragmatic Rhapsody approach http://t.co/XMkMXAEdt7

— Orion Health Canada (@OrionHealthCA) December 11, 2014

Now most of these platforms have a user interface or IDE for making this connection. You can also introduce certain filters at this stage. Enterprise systems like Rhapsody presents an attractive visual interface, whereas open source solutions may not be very user friendly.

What else can the engine do? It usually keeps a log of all package deliveries and whether the delivery was successful. If the delivery failed, it can attempt again and alert the maintenance team through a console. The console can even be mobile as in rhapsody. Though the engine can store the package itself for a limited time, storing the package is not really its job.

The donors could be:

  • A single department in a hospital sending lab reports.
  • All departments in a hospital sending all sorts of information.
  • Several hospitals in a region.

The recipient could be:

  • Another department in the same hospital expecting a lab test report.
  • A family physician who wants real time access to the lab reports for his patients admitted in the hospital.
  • A researcher who wants to know blood sugar status of all the diabetes patients. (population health)

We need a separate layer between the engine and the recipient to support all these use cases. Let us call this layer mediator.

The mediator can pull data in real time from donors or store it in a local database. The first one is the federated model while the other one is the centralized model. Federated is slow but up-to-date while centralized is fast but not concurrent. Mixed model has both and is preferred. The so called clinical viewers are federated mediators with a web interface.

Emerging paradigms like NoSQL and RDF may be ideal for data representation in mixed model. I have discussed RDF before. Will discuss NoSQL soon!

Psoriasis support : eHealth gaming tools for patient engagement

Psoriasis manum
Psoriasis manum (Photo credit: Wikipedia)

Here is the IFPA  survey to compare 17 different strategies and activities that can be used to advance psoriasis education, advocacy and awareness. Preliminary results of the survey will be presented on World Psoriasis Day and the final results will be announced at the 4th World Psoriasis & Psoriatic Arthritis Conference in Stockholm July 8-11, 2015.

I have listed below some of my random ideas on eHealth tools for patient engagement in psoriasis:

An Agent based model (ABM) offers visual simulations of complex systems that can be displayed on a web browser. Psoriasis disease process can be modelled using psoriasis patients as ‘turtles’ with the known probabilities of auto-remission, exacerbation, response to conventional treatments and response to newer drugs added to the model. The patients and caregivers could interact with the model to understand how the treatment decisions affect the quality of life. ABM could be an innovative and useful web based patient education tool that portrays the reality of psoriasis without giving any false promises. Those in the  patient’s circle of care and the patient would understand the odds of improving quality of life.

Psoriasis: The naked truth
Psoriasis: The naked truth (Photo credit: SomosMedicina)

An android or iPhone app to calculate and log the PASI score of the patient would be a less obtrusive disease monitoring tool. The app may be designed to send the log to patient’s caregiver. I have not checked the apple app store or google play, probably such apps already exist.

A ‘push’ strategy such as email alerts is unlikely to work for psoriatics. An innovative strategy game where the body is modelled as a kingdom and the immunological perturbations as a t-cell mutiny could be a useful engagement tool. Vascular and systemic changes could also be part of the game. The game would be web based and would continue for a long time with the patient required to login periodically to make strategic alterations (treatment choices). Everytime the patient login to the game, medication reminders would be displayed. The game would mimic reality with changes reflecting new clinical studies. New clinical studies that has an impact on the ‘game plan’ would be available under the ‘game resources’ for everyone to read. Reading and understanding these resources would improve the performance in the game.

SUSie: SUS based questionnaire for assessing usability and physician attitude toward health information exchange

evaluation of eyetracking after an usability test
evaluation of eyetracking after an usability test (Photo credit: Wikipedia)

Health information exchange (HIE) allows healthcare providers and patients to access and securely share medical information electronically. Several organizations are now emerging to provide both form and function for HIE efforts, both on independent and governmental/regional levels. However the biggest challenge is Change Management, as healthcare providers are exposed to one more ICT tool that they need to master for providing quality care.

There are no formal tools to study individual and organizational attitude towards HIE or to measure their usability. Physician attitude towards the impact of HIE on reducing healthcare costs, improving quality of patient care, saving time and their concern about data privacy and security are important in HIE adoption. Usability is also of vital importance in the meaningful use of HIE tools.

SUSie (SUS for HIE) is an attempt at creating a useful tool for measuring the above factors. It is modelled based on System Usability Scale (SUS), one of the most used questionnaire for measuring perceptions of usability. Five additional questions were added to assess factors that are specific for HIE. The scoring is based on a scale of 5 ranging from Strongly disagree(1) to Strongly agree (5). The ratio of positively and negatively worded questions are maintained and the final multiplication factor was changed to 1.67 to represent the final score on a scale of 100. I hope that this would make the interpretation similar to SUS and benefit from the prior experience available for SUS. The questions and details of scoring are explained below.

If you use SUSie, please cite this webpage and the articles below:

  • Brooke, J. (1996). “SUS: a “quick and dirty” usability scale”. In P. W. Jordan, B. Thomas, B. A. Weerdmeester, & A. L. McClelland. Usability Evaluation in Industry. London: Taylor and Francis.
  • Wright, Adam et al. “Physician attitudes toward health information exchange: results of a statewide survey.” Journal of the American Medical Informatics Association 17.1 (2010): 66-70.
  • Eapen BR (2014). “SUSie: SUS based questionnaire for assessing usability and provider attitude toward health information exchange.” Applied Bimatics – An Informatics & eHealth Blog.[Internet] Accessible from: http://bioblog.gulfdoctor.net/2014/06/susie-hie-usability-physician-attitude.html

Questions:

  1. I think that I would like to use this Health Information Exchange System frequently. 
  2. I found this Health Information Exchange System unnecessarily complex. 
  3. I think this Health Information Exchange System will reduce healthcare costs. 
  4. I think that I would need the support of a technical person to be able to use this Health Information Exchange System. 
  5. I thought this Health Information Exchange System was easy to use. 
  6. I thought there was too much inconsistency in this Health Information Exchange System. 
  7. I think this Health Information Exchange System will improve Quality of Patient Care. 
  8. I found this Health Information Exchange System very cumbersome to use. 
  9. I found the various functions in this Health Information Exchange System were well integrated. 
  10. I am concerned about the privacy and security of healthcare information on this Health Information Exchange System. 
  11. I found this Health Information Exchange System can save me time. 
  12. I needed to learn a lot of things before I could get going with this Health Information Exchange System. 
  13. I would imagine that most people would learn to use this Health Information Exchange System very quickly. 
  14. I found that I had to significantly change my workflow to use this Health Information Exchange System.
  15. I felt very confident using this Health Information Exchange System.

SUSie uses the following response format:

Scoring SUSie

  • For odd items: subtract one from the user response.
  • For even-numbered items: subtract the user responses from 5
  • This scales all values from 0 to 4 (with four being the most positive response).
  • Add up the converted responses for each user and multiply that total by 1.67
  • This converts the range of possible values from 0 to 100 instead of from 0 to 60.

Interpreting SUSie (Based on SUS)

  • The value is not a percentage.
  • Average value is approximately 68.
  • This is not a validated questionnaire.
  • A percentile graph for SUS and other relevant information is available here: http://www.measuringusability.com/sus.php (courtesy: Jeff Sauro )
  • SUSie may be used to compare groups or for comparing pre and post intervention.

I have created a wiki page for updates. Please add any use-cases you can think of to the Wiki page.