Proceedings of Toward an Electronic Patient Record'96 (San Diego), pp520-523, 1996

Development of a Cardiovascular Disease-Oriented Electronic Patient Record model in a Japanese University Hospital

Hiroshi Takeda, Yasushi Matsumura, Takeo Okada, Shigenori Kuwata and Michitoshi Inoue (Department of Medical Informaton Science, Osaka University Hospital)
Norihiro Hazumi, Jun Aoki (NEC Co.Ltd)


BIOGRAPHY: Hiroshi Takeda, M.D,.D.Sc. has had over 20 years of clinical experience and over 15 years of medical informatics experience. He has been engaged in a specialist of internal medicine, subsupeciality of cardiovascular disease. He was a post-doctoral fellow of clinical pharmacolgy at the Univerity of Chicago and was a senior specialist for scientific affairs in the Ministry of Education, Science and Culture in Japan. He is now the vice-director and associate professor of department of medical information science, Osaka University Hospital.

Hospital Information System

The Osaka University Hospital which was renewed as an intelligent hospital last year, is a 1076 beds teaching hospital and developed a totally integrated hospital information system that is called as "HUMANE" (human oriented universal medical assessment system under network environment) .

In the development of HUMANE, the pimary goals to be achieved were 1) POE (Physicians order entry) and good MMI(man-machine interface), 2) good response at a micro frame and 3) MMD (multi-media database).

Software menu of the HIS is divided into two categories. The one is interdepartmental or common application program and the other is department-specific application program. Common application programs are patient registration, accounting and billing, order entry ( prescription, laboratory test order, radiological examination order, admission order, operation order, food service order ), disease name registration, reporting system ( laboratory test and radiological examination), scheduling ( re-visit, special examination), admission management, nursing care system.

Infrastructure of the HIS consists of the two elements, 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 communicated 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. In order to solve the problem for ensuring the shorter response time, better human ware and stronger security within the nominal cost, we choose the vertical-horizontal-vertical distribution of the information processing. 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.

Japanese state of the art of EPR (National Project)

Ministry of Health and Welfare (MHW) has a pilot study group to facilitate EPR. Major areas are categorized as follows; 1) development of clinical care model, 2) development of viewer of EPR, 3) standardization of medical information , and 4) legal and ethical isssues. Committes on clincal care model and tecknological support are organized. Field study groups are cooperative with the committees and they are requested to collect clinical data to analyze disease group-specific care model and examine the proposed EPR method. Core working group of technological support committee tries to introduce MML (Medical Markup Language) which is medical modification of SGML (Standard Generalized Markup Lnaguage) as a tool for interinstitutional EPR system and the prototype will be open to public soon. Standadization core group will work to standardize grammar and dictionaries for the MML in Japan. Security core ? Field study group consists of eight general hospitals (three uniersity hospitals ) and clinics. Our insitution strongly ties up core working groups and active member of the field study group.

EPR project at the Osaka University Hospital

Owing to success of primary goal of HUMANE, total EPR system (EPROU, Electronic Patient Record system at the Osaka University) would be laumched as the next goal of HIS and would replace conventional medical paper chart. For the initial level, our hospital will make the prototype as a cardiovascular disease-oriented EPR. One of the reasons for choosing cardiovascular disease, diagnostic/therapeutic and care process are well established and cninicians' oeder entry are well accepted by cardiologists in our hospital.

Requirements specification of of the EPROU

1) Data structure model; Chronological data of "fact", "assessment "and "action" are major category of data structue (Fig.1). Clinical process are classified into three group and stored in the EPROU.

2) Dynamic template; In order to register key words, defined as "atom", dynamic template are developed in this project. To solve the proble that text data are necessary but hard to store and retrive, the templare are ready in accordace with a major headline key words. For exapmple, if the key worl is "pain", a template is shown in display amd a clinician will choose second key words among pain-related word sets such as chest, abdomen, back and so on. If "chest" is selected, the template will then display next word set such as onset, duration, freqauency, relieved by rest and so on. This process are regulated with rule-based (knowledge-based in the future) dynamic teplate master file.

3) Order/Reporting system Link in HIS As moost clinical actions such as prescription, clinical test order and so on, will be made by means of ordering, the EPROU should have close link with ordering and reporting system in HIS. Accounting and billing system is also linked through ordering system.

4) problem oriented and retrograde tracking: Cure and care are always in a problem-solving process. Everyone whom is concerned with a patient should recognized and update the problems of the pateint. The EPROU is very conscious for the problem-oriewnted EPR. Besides for the three major category of the data structure, problem list file is also arranged. The relationship between problem and fact-assessment-action data are always linked, and the link provides the basis for retrograde tracking of problem-solving process.

5) Direct data entry by clinicians; The single greatest problem may be direct data entry by clinicians. Since oen hundred percent order entries are made by clinicians in our univeristy hospitals, it will be well accepted to mandate direct data entry of the EPROU in the boundary condition of quick resonce time, good man-machine interfance and high quality of utility and performance.

5) SGML editor interface Intrahospital EPR must convert to generalized standard EPR format as indicated in the national EPR project. Tentative guideline adopted SGML-EPR in Japan ans the EPROU must hve an interface to describe by means of SGML. DTD and other nevessary dictionaries will be given by the national project.

6)Secondary use applicable The EPROU which facilitates the acquisition, communication, storage and access of patient data will be a strong weapon to assist clinical research, and undergraduate education and postgraduate traning. Relational databse and its management system will be ready for the secondary use of the EPR system.

Basic structure of the EPROU

Basic structure of the EPROU is illustrated in Figure 2. The system will consist of viewer/editor module,data base module, template navigation module,HIS interface module, PACS interface and SGML interface. The EPROU project is just started and now prototype development phase. In the viewer module, essential view of the system is shown in Figure 3.

Master maintenance tool for the dynamic templates has already developed by co-workers and cardiovascular disease-oriented templates are generated by clinicians.

Conclusion

Japanese state-of-arts of HIS has reached to the level of post-ordering system. HUMANE's major targets are electronic patient record system and PC-based PACS (Picture Archiving and Communication System). We have already developed a prptotype of PC-PACS and will soon operate in 10 to 20 consultation rooms in the out-patient clinic. The EPR system of our university hospital (EPROU) is now under development and is restricted to the cardiovasular disease oriented-EPR. As we are participated with the national project of EPR system, the developmental process will be facilitated than expected.