The research was undertaken using anonymised samples of patient records from homoeopathy practices, to investigate if the patient data could be modelled using the forthcoming joint European and International Standard for EHR Communications (ISO/EN 13606). The research deliberately did not consider the effectiveness of complementary and alternative medicine or the clinical evidence for any particular CAM practice or treatment. The focus was purely on the patient data captured routinely by CAM therapists, to determine whether current approaches to the representation and communication of EHRs could incorporate such records.
Results
Five homoeopathic patient records, authored by different practitioners in different practice settings, were re-represented in a structured form in conformance with the ISO/EN 13606 reference Model. A sixth practitioner confirmed that the transposition had been as faithful to the original records as was possible given some limitations in the clarity of the originals.
Conclusion
The authors conclude that the ISO/EN 13606 model can be used to represent patient records from homoeopathy, including the evidence and reasoning used to arrive at a formulation and to determine the appropriate remedy. It is therefore feasible that future EHR systems adopting this standard could enable patient records to be shared between complementary and conventional medical practice, in support of integrated healthcare.
Introduction
“Integrated medicine or healthcare … focuses on health and healing, rather than just disease and treatment and seeks to bring together body, mind and spirit so that healthcare encompasses the whole person.” [1]
The term “integrated healthcare” has often been used to mean the availability of complementary and alternative medicine (CAM) therapies within conventional medical practice or referrals to CAM therapies from conventional medicine, particularly general practice. It has also been used to describe a richer view of healthcare that looks at a patient's health as resulting from a wide variety of factors and consequently the need to rely on both conventional and complementary medicine to fully address the patient's health. Thus, “integrative medicine has a larger meaning and mission, its focus being on health and healing, rather than disease and treatment” [2].
“The concept of integrated health “involves patients and doctors working to maintain health” … In such a partnership, conventional and complementary practitioners would work together. For example, a physician might prescribe medication for migraine, but look for underlying factors such as stress or diet that could cause or perpetuate the condition. An integrated therapeutic package agreed with the patient and with complementary practitioners could include acupuncture to reduce the frequency of attacks and induce relaxation, nutritional advice, a herbal remedy as a preventive measure and yoga, relaxation and other stress management techniques to encourage natural healing processes.” [1]
The idea of partnership is key to integrated healthcare, specifically that conventional and CAM therapists will cooperate as members of an interdisciplinary team. Scepticism regarding the effectiveness of CAM therapies has been a barrier to the willingness to refer to such therapies, and to inclusion as a full partner in a system of integrated healthcare. Consequently, the vast majority of research concerning CAM therapies has focused on demonstrating the clinical effectiveness of CAM therapies.
However, another key issue has so far been overlooked: the sharing of patient information between conventional and CAM practices. If integrated medicine is to be truly interdisciplinary, i.e., a partnership, then the exchange or sharing of data between different practitioners would seem vital to the process. All members would need to know what the other members are thinking, what they have found, what conclusions they have reached, and what they are recommending towards the maintenance of a patient's health—not just at the time of a referral but on a continuing care basis as a patient's health and illnesses evolve.
The need to share data goes beyond the immediate interdisciplinary team. In the future, other general or specialist conventional practitioners are likely to become involved in the patient's care. A patient may move, and change his/her general practitioner and CAM therapists. Or, other practitioners may become involved in the patient's care as his/her condition evolves and changes. The concept of an interdisciplinary team must allow for practitioners that are not yet members, and the concept of integrated healthcare must allow for therapies that have not yet been applied and clinical contexts that do not yet exist. Likewise, the sharing of data has to be future-focused as well as focused on the immediate interactions between current practitioners. The direct exchange of data between clinical and electronic health record (EHR) systems is problematic, since different EHRs used by different practitioners are frequently structured differently, and reformatting the data from one system to match the format of another system is complex and expensive.
The mechanism for exchanging data therefore ought to be independent of any individual computer system, and it should be based on a structure or model of patient and/or clinical data that exists as an entity in its own right. In this manner, it would be available to any system of recording patient data, including systems used by conventional and CAM practitioners. EHR communications (interoperability) standards, discussed below, are intended to achieve this purpose.
Section snippets
Requirements
There is now a wealth of published clinical and ethico-legal requirements for the information architecture of an EHR if it is to effectively and safely enable health records to be shared between teams and sites, through the interconnection of diverse clinical systems. These requirements have been published and accepted internationally through the International Organisation for Standardisation (ISO) as a Technical Specification, ISO TS 18308 [3] and a formal definition of the scope and purpose
Research into representing and sharing electronic health records
The increasing limitations of paper-based records, the potential benefits of electronic health records and the acknowledged challenges of delivering these in practice have stimulated a considerable investment in research and development over the past 15 years.
Realising the electronic health record has been at the heart of the European Union's Health Telematics Framework Programmes, beginning with its third Framework Programme in 1992 and continuing through to its seventh in 2007. The vision
Methodology
Records from several homoeopathic practitioners were chosen to be the patient data sources, for pragmatic reasons. Ideally, had time and resources permitted, a larger study covering a wider range of CAM therapies would have been studied.
The draft European and International Standard for EHR Communication (13606) was chosen as the target model representation because its scope is consistent with the inclusion of CAM data, it is close to final publication and is anticipated to shape the way in
Representing homoeopathic observations
The notes gathered for the research represent the work of 6 different homoeopathys, who each took notes differently, organised the notes differently, used different terms and abbreviations, and had radically different handwriting. In modelling the actual record samples, the main focus was on accurately modelling each set of notes, i.e., to be faithful to each set of notes as they existed, rather than to model all 6 sets of data with some idea or goal as to consistency or uniform presentation.
Discussion
In evaluating the patient data and modelling it against the 13606-1 standard, a number of issues made themselves apparent. Some of these relate specifically to the data and the modelling of the data, others are more general. Some have been discussed briefly or at least mentioned in passing in the previous section. We will look at some issues in more detail here.
Conclusions
This study set out to ask and answer three questions:
1.
Does the 13606-1 model accommodate (represent) patient data from CAM therapies?
2.
Does the 13606-1 model accommodate (represent) the clinical reasoning of CAM therapists, as documented in their clinical notes?
3.
Does the 13606-1 model represent the broader analytical framework of CAM therapies?
The answer to the first 2 questions was yes. As to the third question, the answer was no. This is not surprising since the Reference Model is designed to
Conflict of interest
None
This work was originally undertaken by the first author and supervised by the second author, as the dissertation of a Masters in Health Informatics undertaken at UCL, London.
Summary points
What was already known on this topic
•
There is no regular practice of sharing patient records between complementary and conventional health care.
•
Little is known about the culture, attitudes or clinical benefit of sharing records between these paradigms of health care.
This reporting will provide the opportunity to screen for adverse effects and drug interactions so that patients can be appropriately counseled on the risks and benefits. Suggestions for improving the usability of electronic health records with the integration of CIM use have been described in other studies22; adopting this approach may facilitate optimal coordination in complementary and conventional care.23 The human and financial burdens of CVD continue to increase despite major advances in pharmacologic and device-based interventions.
This study aimed to evaluate the use and frequency of complementary and integrative medicine (CIM) therapies in an outpatient cohort with cardiovascular disease (CVD) and compare trends over time. This cross-sectional point-of-care prospective study assessed patients attending a cardiology outpatient clinic. As in our 2009 cohort, data were collected with a 17-question survey on demographic characteristics, CVD history, current use and future interest in CIM. In total, 964 patients completed the survey. CIM use continues to be high (2009 vs 2018, 83.4% vs 81.8%) (p = 0.34), with dietary supplements the most common therapy (75% in both studies). We observed increased use of mind-body therapies (28.5% vs 23.9%, p = 0.02), especially meditation, yoga, and tai chi. Of the patients receiving CIM therapies, 41.9% reported using CIM for heart-related symptoms. Relaxation, stress management, and meditation were the top three mind-body therapies for CVD-related symptoms in both cohorts. Reporting of CIM use to clinicians is low (15%) and interest on future use is high (47%). In conclusion, CIM is highly used in cardiology patients—4 of 10 patients use CIM for CVD-related symptoms. Most take dietary supplements, with an increased use of mind-body therapies. Our data highlight the importance of documenting CIM use in practice and the need for research to document efficacy.
2018, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
A review of the literature did not locate any IH history intake forms outside of one small trial that assessed the feasibility of collecting self-reported cardiology-specific dietary supplements using a simple computer interview application with a database backend for storage.25 In addition, the review identified an electronic health record (EHR) that was successfully adopted for use in homeopathic practices.26 However, it has been argued that conventional hospital or health care system EHRs are not suitable for alternative or IH documentation because practitioners do not have a shared understanding of practice-specific care.27
Complementary medicine incorporates the use of non–evidence-based complementary modalities into conventional (Western) medicine. Alternative medicines are approaches that are used in place of conventional medicine. Integrative medicine is the synthesis of conventional medical treatments with “evidence-based” complementary medical practices. When complementary approaches are incorporated into mainstream health care, it is called integrative health (IH). Among children and adults, IH is common despite not all therapies being safe and/or effective. Clinicians have suboptimal knowledge of their patients' IH use because, in part, they do not know what questions to ask and/or do not have a standard intake form to collect an IH history, as recently demonstrated by an American Academy of Allergy, Asthma, and Immunology membership survey. To address this unmet need, a group of Complementary and Alternative Practice in Allergy Committee members and interprofessional collaborators reviewed the existing literature to locate IH history forms that could assist in identifying patients' IH use. When none was located, the group created 3 templates for the systematic collection and documentation of IH practices: 2 general screening surveys that could be given to patients to complete before an appointment and a third template that provides the clinician with open-ended questions to help uncover IH practices in culturally diverse patient populations. Specialists, already acknowledged as skillful interviewers, can expand their patient-centered expertise by developing their own IH competencies.
To provide person-centered care, healthcare needs to be team-based (i.e., providers from both CAM and conventional medicine working together to provide optimal patient care) as well as integrative (i.e., the integration of CAM with conventional medical practices).89–93 Previous studies54–55 have suggested that CAM data be shared with conventional doctors via EHR initiatives that incorporate CAM providers into the system to create integrative health care delivery for patients.52 However, self-care CAM practices and CAM products use might not be shared in EHRs, even when EHRs systems incorporate CAM providers’ practices, because CAM users would need to intentionally disclose this information and may not do so consistently.
To test a hypothesis that patients' use of Internet-based personal health records (PHRs) will be positively related to their disclosure of their CAM use to medical doctors, controlling for covariates' effects (e.g., health, human capital, and demographics), and to examine the factors influencing patients' CAM use disclosures.
Cross-sectional survey.
We analyzed data in a subsample of CAM users who used both the internet and healthcare services (n = 1457) from the Health Information National Trends Survey, a nationally representative study of U.S. adults (≥18), by using a multivariate logistic analysis.
Among the subsample, 52.7% disclosed their use of CAM to their doctors and 19.3% used PHRs. Both the bivariate (64.1% vs. 35.9%, p < 0.01) and multivariate (β = 0.558, SE = 0.220, OR = 1.75, p < 0.05) analyses revealed a positive relationship between PHR use and CAM use disclosure. Other significant factors for CAM use disclosure included being older, being a female, having insurance, and having regular source of care. Particularly, foreign-born adults had significantly lower odds of disclosing their CAM use than U.S.-born adults.
We found that patients' PHR use facilitated their disclosure of CAM use to medical doctors. To ensure integrative healthcare and integrative medicine in the healthcare sector and optimum care for patients, education for CAM users regarding PHR adoption is encouraged. Next-generation PHR designs should consider incorporating domains for CAM data that allow patients to store CAM data and also incorporating ‘intelligent' PHRs, whose contents can be converted into the patient's first language.
However, even experienced clinicians sometimes find it difficult to keep up to date with the large amount of medical knowledge available to help them complete a particular goal. It has been identified in previous research that many detection failures in clinical work are due to the fact that the necessary knowledge is either not received by clinicians or lost or distorted in clinical information systems, especially when clinical contexts are uncertain and flexible [4,5]. Thus, in the constantly changing clinical environment, clinical organizations must exploit effective methods of sharing and recommending appropriate knowledge in order to assist clinicians’ work [6,7].
Clinicians rely on a large amount of medical knowledge when performing clinical work. In clinical environment, clinical organizations must exploit effective methods of seeking and recommending appropriate medical knowledge in order to help clinicians perform their work.
Aiming at supporting medical knowledge search more accurately and realistically, this paper proposes a collaboration-based medical knowledge recommendation approach. In particular, the proposed approach generates clinician trust profile based on the measure of trust factors implicitly from clinicians’ past rating behaviors on knowledge items. And then the generated clinician trust profile is incorporated into collaborative filtering techniques to improve the quality of medical knowledge recommendation, to solve the information-overload problem by suggesting knowledge items of interest to clinicians.
Two case studies are conducted at Zhejiang Huzhou Central Hospital of China. One case study is about the drug recommendation hold in the endocrinology department of the hospital. The experimental dataset records 16 clinicians’ drug prescribing tracks in six months. This case study shows a proof-of-concept of the proposed approach. The other case study addresses the problem of radiological computed tomography (CT)-scan report recommendation. In particular, 30 pieces of CT-scan examinational reports about cerebral hemorrhage patients are collected from electronic medical record systems of the hospital, and are evaluated and rated by 19 radiologists of the radiology department and 7 clinicians of the neurology department, respectively. This case study provides some confidence the proposed approach will scale up.
The experimental results show that the proposed approach performs well in recommending medical knowledge items of interest to clinicians, which indicates that the proposed approach is feasible in clinical practice.
2011, International Journal of Medical Informatics
Citation Excerpt :
The openEHR specification defines several ENTRY subtypes, such as ACTION, OBSERVATION, and EVALUATION. Finally, ENTRYs contain ELEMENTs, which can optionally be organized within a CLUSTER hierarchy as a means to organize multi-part data and to represent columns of a table [31,33]. Elements are thus the leaf nodes of the EHR EXTRACT hierarchy and contain the actual Data Values, while the other levels in the EHR EXTRACT hierarchy provide the context of the individual clinical data points, i.e. they position the data into its clinical context.
The purpose of this study is to investigate the feasibility of applying the openEHR archetype approach to modelling the data in the database of an existing proprietary biobank information management system. A biobank information management system stores the clinical/phenotypic data of the sample donor and sample related information. The clinical/phenotypic data is potentially sourced from the donor's electronic health record (EHR). The study evaluates the reuse of openEHR archetypes that have been developed for the creation of an interoperable EHR in the context of biobanking, and proposes a new set of archetypes specifically for biobanks. The ultimate goal of the research is the development of an interoperable electronic biomedical research record (eBMRR) to support biomedical knowledge discovery.
The database of the prostate cancer biobank of the Irish Prostate Cancer Research Consortium (PCRC), which supports the identification of novel biomarkers for prostate cancer, was taken as the basis for the modelling effort. First the database schema of the biobank was analyzed and reorganized into archetype-friendly concepts. Then, archetype repositories were searched for matching archetypes. Some existing archetypes were reused without change, some were modified or specialized, and new archetypes were developed where needed. The fields of the biobank database schema were then mapped to the elements in the archetypes. Finally, the archetypes were arranged into templates specifically to meet the requirements of the PCRC biobank.
A set of 47 archetypes was found to cover all the concepts used in the biobank. Of these, 29 (62%) were reused without change, 6 were modified and/or extended, 1 was specialized, and 11 were newly defined. These archetypes were arranged into 8 templates specifically required for this biobank. A number of issues were encountered in this research. Some arose from the immaturity of the archetype approach, such as immature modelling support tools, difficulties in defining high-quality archetypes and the problem of overlapping archetypes. In addition, the identification of suitable existing archetypes was time-consuming and many semantic conflicts were encountered during the process of mapping the PCRC BIMS database to existing archetypes. These include differences in the granularity of documentation, in metadata-level versus data-level modelling, in terminologies and vocabularies used, and in the amount of structure imposed on the information to be recorded. Furthermore, the current way of modelling the sample entity was found to be cumbersome in the sample-centric activity of biobanking.
The archetype approach is a promising approach to create a shareable eBMRR based on the study participant/donor for biobanks. Many archetypes originally developed for the EHR domain can be reused to model the clinical/phenotypic and sample information in the biobank context, which validates the genericity of these archetypes and their potential for reuse in the context of biomedical research. However, finding suitable archetypes in the repositories and establishing an exact mapping between the fields in the PCRC BIMS database and the elements of existing archetypes that have been designed for clinical practice can be challenging and time-consuming and involves resolving many common system integration conflicts. These may be attributable to differences in the requirements for information documentation between clinical practice and biobanking. This research also recognized the need for better support tools, modelling guidelines and best practice rules and reconfirmed the need for better domain knowledge governance. Furthermore, the authors propose that the establishment of an independent sample record with the sample as record subject should be investigated. The research presented in this paper is limited by the fact that the new archetypes developed during this research are based on a single biobank instance. These new archetypes may not be complete, representing only those subsets of items required by this particular database. Nevertheless, this exercise exposes some of the gaps that exist in the archetype modelling landscape and highlights the concepts that need to be modelled with archetypes to enable the development of an eBMRR.