Analysis and classification of oncology activities on the way to workflow based single source documentation in clinical information systems

BMC Medical Informatics and Decision Making

Research Article

Stefan Wagner¹  Hans-Ulrich Prokosch²  Matthias W. Beckmann³  Markus Ries⁴  Bernd Wullich⁵  Thomas Bürkle⁶  Christof Seggewies⁷ 

[1] Chair of Medical Informatics at the Friedrich-Alexander-University Erlangen-Nuremberg, Am Wetterkreuz 13, D-91058, Erlangen-Tennenlohe, Germany;Department of Anaesthesiology, University Hospital Erlangen, Krankenhausstraße 12, D-91054 Erlangen, Germany;Chair of Medical Informatics at the Friedrich-Alexander-University Erlangen-Nuremberg, Am Wetterkreuz 13, D-91058, Erlangen-Tennenlohe, Germany;Medical Informatics and Communication Center, University Hospital Erlangen, Glückstraße 11, D-91054, Erlangen, Germany;Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Östliche Stadtmauerstraße 30, D-91054 Erlangen, Germany;Department of Obstetrics and Gynecology, University Hospital Erlangen, Universitätsstraße 21-23, D-91054, Erlangen, Germany;Department for Organizational Development, Klinikum Nuremberg, Prof.-Ernst-Nathan-Str. 1, D-90419, Nuremberg, Germany;Department of Urology, University Hospital Erlangen, Maximiliansplatz 2, D-91054, Erlangen, Germany;Institute for Medical Informatics I4MI, Bern University of Applied Sciences BFH, Höheweg 80, CH-2502, Biel/Bienne/Bern, Switzerland;Medical Informatics and Communication Center, University Hospital Erlangen, Glückstraße 11, D-91054, Erlangen, Germany;

关键词: Acute Myeloid Leukemia;    Clinical Pathway;    Computerize Physician Order Entry;    Clinical Information System;    Clinical Documentation;   

DOI  :  10.1186/s12911-015-0231-x

 received in 2015-03-05, accepted in 2015-12-15,  发布年份 2015

来源: Springer

【 摘 要 】

BackgroundToday, cancer documentation is still a tedious task involving many different information systems even within a single institution and it is rarely supported by appropriate documentation workflows.MethodsIn a comprehensive 14 step analysis we compiled diagnostic and therapeutic pathways for 13 cancer entities using a mixed approach of document analysis, workflow analysis, expert interviews, workflow modelling and feedback loops. These pathways were stepwise classified and categorized to create a final set of grouped pathways and workflows including electronic documentation forms.ResultsA total of 73 workflows for the 13 entities based on 82 paper documentation forms additionally to computer based documentation systems were compiled in a 724 page document comprising 130 figures, 94 tables and 23 tumour classifications as well as 12 follow-up tables. Stepwise classification made it possible to derive grouped diagnostic and therapeutic pathways for the three major classes- solid entities with surgical therapy- solid entities with surgical and additional therapeutic activities and- non-solid entities.For these classes it was possible to deduct common documentation workflows to support workflow-guided single-source documentation.ConclusionsClinical documentation activities within a Comprehensive Cancer Center can likely be realized in a set of three documentation workflows with conditional branching in a modern workflow supporting clinical information system.

【 授权许可】

CC BY   
© Wagner et al. 2015