Concept and implementation of a single source information system in nuclear medicine for myocardial scintigraphy (SPECT-CT data)
02 December 2009
accepted: 14 March 2010
16 December 2017 (online)
Objective: Data for clinical documentation and medical research are usually managed in separate systems. We developed, implemented and assessed a documentation system for myocardial scintigraphy (SPECT/CT-data) in order to integrate clinical and research documentation. This paper presents concept, implementation and evaluation of this single source system including methods to improve data quality by plausibility checks.
Methods: We analyzed the documentation process for myocardial scintigraphy, especially for collecting medical history, symptoms and medication as well as stress and rest injection protocols. Corresponding electronic forms were implemented in our hospital information system (HIS) including plausibility checks to support correctness and completeness of data entry. Research data can be extracted from routine data by dedicated HIS reports.
Results: A single source system based on HIS-electronic documentation merges clinical and scientific documentation and thus avoids multiple documentation. Within nine months 495 patients were documented with our system by 8 physicians and 6 radiographers (466 medical history protocols, 466 stress and 414 rest injection protocols). Documentation consists of 295 attributes, three quarters are conditional items. Data quality improved substantially compared to previous paper-based documentation.
Conclusion: A single source system to collect routine and research data for myocardial scintigraphy is feasible in a real-world setting and can generate high-quality data through online plausibility checks.
- 1 El Emam K, Jonker E, Sampson M, Krleža-Jeri K, Neisa A. The Use of Electronic Data Capture Tools in Clinical Trials: Web-Survey of 259 Canadian Trials.. J Med Internet Res 2009; 11: e8.
- 2 Dugas M, Breil B, Thiemann V, Lechtenbörger J, Vossen G. Single Source Information System to connect patient care and clinical research.. Stud Health Technol Inform 2009; 150: 61-65.
- 3 Kush R, Alschuler L, Ruggeri R, Cassells S, Gupta N, Bain L, Claise K, Shah M, Nahm M. Implementing Single Source: the STARBRITE proof-of-concept study.. J Am Med Inform Assoc 2007; 14: 662-673.
- 4 Williams JG, Cheung WY, Cohen DR, Hutchings HA, Longo MF, Russell IT. Can randomised trials rely on existing electronic data? A feasibility study to explore the value of routine data in health technology assessment.. Health Technology Assessessment 2003; 7: 1-117.
- 5 Dugas M, Lange M, Berdel BE, Müller-Tidow C. Workflow to improve patient recruitment for clinical trials within hospital informations systems –a case-study.. Trials 2008; 9: 2.
- 6 Dawber TR, Meadors GF, Moore Jr. FE. Epidemiological Approaches to Heart Disease: The Framingham Study.. Am J Publich Health 1951; 41: 279-281.
- 7 Assmann G, Schulte H, Cullen P, Seedorf U. Assessing risk of myocardial infarction and stroke: new data from the Prospective Cardiovascular Münster (PROCAM) Study.. European Journal of Clinical Investigation 2007; 37: 925-932.
- 8 Siemens Healthcare. http://www.medical.siemens.com
- 9 INVIA Medical Solutions. http://www.inviasolutions.com
- 10 Agfa Healtcare. http://healthcare.agfa.com
- 11 Schicha H, Schober O. Nuklearmedizin –Basiswissen und klinische Anwendung.. Schattauer 2000; 9-18.
- 12 OSM. http://www.osm-gmbh.de
- 13 SUN. http://www.sun.com
- 14 SPSS. http://www.spss.com
- 15 Eden KB, Messina R, Li H, Osterweil P, Henderson CR, Guise JM. Examining the value of electronic health records on labor and delivery.. Am J Obstet Gynecol 2008; 199: 307e1-e9.
- 16 Breil B, Semjonow A, Dugas M. HIS-based electronic documentation can significant reduce the time from biopsy to final report for prostate tumours and supports quality management as well as clinical research.. BMC Medical Informatics and Decision Making 2009; 9: 5.
- 17 Hogan WR, Wagner MM. Accuracy of Data in Computer-based Patient Records.. J Am Med Inform Assoc. 1997; 5: 342-355.
- 18 Bürkle T, Beisig A, Ganslmayer M, Prokosch HU. A randomized controlled trial to evaluate an electronic scoring tool in the ICU.. Stud Health Technol Inform. 2008; 136: 279-284.
- 19 de Lusignan S, van Weel C. The use of routinely collected computer data for research in primary care: opportunities and challenges.. Family Practice 2006; 23: 253-263.
- 20 McKee M, Dixon J, Chenet L. Making routine data adequate to support clinical audit.. BMJ 1994; 309: 1246-1247.
- 21 Prokosch HU, Ganslandt T.. Perspectives for Medical Informatics: Reusing the Electronic Medical Record for Clinical Research.. Methods Inf Med 2009; 48: 38-44.
- 22 Ammenwerth E, Spötl HP. The Time Needed for Clinical Documentation versus Direct Patient Care.. Methods Inf Med 2009; 48: 84-91.
- 23 Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The Impact of Electronic Health Record on Time Efficiency of Physicians and Nurses: A systematic Review.. J Am Med Inform Assoc 2005; 12: 505-516.
- 24 Richesson RL, Krischer J. Data Standards in Clinical Research: Gaps, Overlaps, Challenges and Future Directions.. J Am Med Inform Assoc. 2007; 14: 687-696.
- 25 Ohmann C, Kuchinke W. Future Development of Medical Informatics from the Viewpoint of Networked Clinical Research: Interoperability and Integration.. Methods Inf Med 2009; 48: 45-54.
- 26 Campbell MK, Snowdon C, Francis D, Elbourne D, McDonald AM, Knight R, Entwistle V, Garcia J, Roberts I, Grant A. Recruitment to randomised trials: strategies for trial enrolment and participation study. The STEPS study.. Health Technol Assess 2007; 11: 48.
- 27 Powell J, Buchan I. Electronic Health Record Should Support Clinical Reseach.. J Med Internet Res 2005; 7: 1.
- 28 Clinical Data Interchange Standards Consortium (CDISC). http://www.cdisc.org
- 29 Ammenwerth E, Mansmann U, Iller C, Eichstädter R. Factors Affecting and Affected by User Acceptance of Computer-based Nursing Documentation: Results of a Two-year Study.. J Am Med Inform Assoc. 2003; 10: 69-84.