Proceedings of Toward An Electronic Patient Record Europe'97 (London), 1997.
Dynamic Template Driven Data Entry System for Physicians' Direct Input
Hiroshi Takeda, Yasushi Matsumura, Takeo Okada, Shigeki Kuwata
(Department of Medical Information Science, Osaka University Hospital)
Norhiro Hazumi, Hiroaki Nakazawa
(NEC corporation)
1. Introduction
A successful installation of a totally integrated hospital information system, HUMANE ( human-oriented universal medical assessment system under network environment) in the Osaka University Hospital [1][2] follows up developing a comprehensive electronic patient record system (EPROU, electronic patient record system at Osaka University hospital) [3]. Physicians' direct data entry is so common in Japan that an EPR system is required to enable faster input of necessary clinical data. Furthermore, the entered data should provide the basis for synthetic and analytic purposes in clinical research, education, hospital management as well as clinical care. To merge the operability and the utility of an EPR system, we have developed a system (DTDES, "dynamic template" driven data entry system) which allows users to select the desired data from a list of items by means of a graphical user interface.
2. Hospital Information System
The Osaka University Hospital which was renewed on September 1 in 1993 as an intelligent hospital, is a 1076 beds teaching hospital. In the development of HUMANE, the initial goals to be achieved were 1) POE (Physicians order entry) and good MMI(man-machine interface), 2)quick response time at a micro frame and 3) MMD (multi-media database) and PACS(picture archiving and communication system). Final goals would be 1) electronic patient record system, 2) regional health care delivery system and telemedicine and 3) decision making assistance for clinical and hospital management staffs.
Infrastructure of the HUMANE consists of the two element, backbone LAN and branch LAN. The looped backbone LAN has two FDDI based 100 Mbps LAN, one for HIS and another for PACS. The total length of the LAN is about 1 Km. Seventeen nodes for HIS, six nodes for PACS are installed to communicate with Bus type LAN, which is Ether net type (10 Mbps) and its length is about 1.6 Km.
Hardware of the HIS features MMML(main-medium-micro frame link) that is the original configuration of the hospital information system in Japan. Although the system is so-called legacy one, we have chosen the vertical-horizontal-vertical distribution of the information processing in order to solve the problem for ensuring the quicker response time and good MMI within the nominal cost,. The role of main frame is to manage the database and on-line transactions. Medium frame works as a server of the micro frame and files basic patient clinical data and master tables. Micro frame function is to maintain a good MMI and assist POE. In the HUMANE, main frame is ACOS 3600/10 MP (main memory 64 MB, 16 GB hard disk), and forty workstations (EWS 4800 ,OS; UNIX, main memory 36 MB, 1.2 GB hard disk) as medium frames and about six hundred personal computers (PC9821, OS; MS-DOS5.0, Windows 3.1, main memory 11.6 MB, 120 MB hard disk) as micro frames. This MMML configuration is installed with rental contract with NEC Co (Tokyo, Japan).
Software menu of the HIS is divided into two categories. The one is interdepartmental or common application program (IDAP) and the other is department-specific application program.(DSAP). Among IDAPs of the HUMANE are patient registration, accounting and billing system, order entry system ( prescription, laboratory test, radiological examination admission order, surgical operation and food service ), disease name registration, reporting system (laboratory test and radiological examination), reservation ( re-visit, special examination), admission management and nursing care system. DSAPs in the HUMANE are developed in the pharmacy department, laboratory department, radiological examination department (RIS, radiology information system), surgical operation department, meal service department and blood transfusion department.
3. EPROU(electronic patient record system at Osaka University hospital)
3.1 Concept
As POE is well accepted by clinical staffs and there seems no objection against electronic patient record system, a challenge for paperless clinical has been started. The concept of EPROU is illustrated in Figure 1. Ordering and reporting data in HIS will be utilized as fact data of the EPR system. The output of the system will be converted into MML (Medical Markup Language) or SGML format which the Japanese national EPR project will adopt as data exchange standard.
3.2 DTDES (dynamic template driven data entry system)
The concept of "dynamic template" is introduced in order to reduce the physicians' work load for imputing clinical data, and to improve the quality of the EPR contents in the manner of guiding complete history taking. For example, if the chief complaint of a patient is pain, a template is appeared in the CRT display and the physician will choose second key words among pain-related word sets such as chest, abdomen and so on. After taking the history of the present illness, the physician may proceed to taking physical findings, laboratory test and so on. Some data may be simple or others may be complicated. If each entry item were to be displayed in the same manner, the user would have to follow the same procedure as imputing detailed information even for simplified data. In order to input simplified and detailed data more effectively, we have decided that entry items must be displayed in a template in which the size will be adjusted due to the quantity of the information, and that the system will need to be driven by a kind of navigation system which displays entry items based on the previously entered value or category. The physicians' direct entry method was named as the dynamic template driven data entry system (DTDES).
DTDES is equipped with the following functions:
(1) Useless items for clinical data entry are not displayed.
(2) Detailed and simplified data input mode are simultaneously available.
(3) Reference of previously entered contents and edit of alteration are made possible for new records.
(4) Repeated input can be reduced.
(5) Input of frequent data patterns can be simplified.
(6) Choices can be displayed clearly and selected easily.
(7) Registered template contents are generated and changed by end-user.
(8) Templates with diagrams are arrange to visualize the clinical data (Figure 2).
A personal computer (PC9801 series, NEC ) with windows 95 operating system (Microsoft) and Visual Basic 4.0 (Microsoft) and Excel (Microsoft) were used for the development of the system.
3.3 Display of Registered Data
There are two modes for the displaying registered data. One is a Progress Note where data entered from the template are translated into a form of natural language and described on the note of EPROU as shown in Figure 3. The other is a Flow Sheet which summarizes the contents of the clinical record time- serially in a matrix form. By clicking a cell, the detailed data are displayed, and progress note will be shown by clicking date (Figure 4).
3.4 Template Master and its Maintenance Program
The contents and navigation method of templates and their translation method into natural language need to be created through repeated trial and error. The template master must have two parts in which controlling data for the template navigation and contents of items are registered. The master file may be generated and edited by end-users. Rules for translation into natural language are registered in the another master file. This file must be maintained by the system manager. The example display of template master maintenance is shown in Figure 5.
4. Results & Discussion
The test templates for cardiovascular diseases were made with windows 95 operating system , Visual Basic 4.0 and Excel were used for the development of the system to evaluate the acceptance by doctors. Physicians noted that DTDES has enabled swift data entry, and that the entered clinical data are organized and translated into natural language. The design of the template is a crucial element which determines the operability of the system. Therefore, allowing end-users to freely design the structure of the template was deemed essential. This system is considered as a reliable entry method of electronic patient records. The template master maintenance is also appreciated by the end-users.
5. Conclusion
The HUMANE of the Osaka University Hospital is well organized and operated 24 hours a day. POE is well accepted with doctors and the feedback of the laboratory and radiological examination data is functioning. The EPR system of our university hospital (EPROU) is now under development and will operate in a few years. Dynamic template driven entry system (DTDES) is one of the optimal solution in Japan where physicians' direct data entry is very common. However, templates is a kind of tools to assist the data input and there need more efforts to obtain template master files which closely reflect a thesaurus medical knowledge. In another words, generation of template master is to reconstruct knowledge-base in medicine in terms of medical informatics. Since the template master maintenance program has developed, the generation of templates will be facilitated in our university hospital.
References
[1] H.Takeda, Y.Matsumura, H.Kondo, H.Imai and M. Inoue. Development of a totally integrated hospital information system:An intelligent hospital in Osaka University. Proc. MEDINFO92 (eds,K.Lun et al.), 241-246,1992.
[2] Y.Matsumura, H.Takeda and M.Inoue. Implementation of the totally integrated hospital information system (HUMANE) in Osaka University Hospital. Proc. MEDINFO95 (eds,R.Greenes et al. ), 590-593, 1995.
[3] H.Takeda, Y.Matsumura, T.Okada, S.Kuwata, M.Inoue, N.Hazumi and J.Aoki. Development of a cardiovascular disease-oriented electronic patient record model in a Japanese university hospital. Proc.Toward an Electronic Patient Record96, 520-523, 1996.
Figure 1 Concept of the EPR System of the Osaka University Hospital (EPROU)
Figure 2 An Example of the Template with a Diagram (Location of Chest Pain)
Figure 3 An Example Display of the Progress Note
Figure 4 An Example Display of the Flow Sheet
Figure 5 An Example Display of the Template Maintenance Program