Quantification of the resilience of primary care networks by stress testing the health care system

There are practically no quantitative tools for understanding how much stress a health care system can absorb before it loses its ability to provide care. We propose to measure the resilience of health care systems with respect to changes in the density of primary care providers. We develop a computational model on a 1-to-1 scale for a countrywide primary care sector based on patient-sharing networks. Nodes represent all primary care providers in a country; links indicate patient flows between them. The removal of providers could cause a cascade of patient displacements, as patients have to find alternative providers. The model is calibrated with nationwide data from Austria that includes almost all primary care contacts over 2 y. We assign 2 properties to every provider: the “CareRank” measures the average number of displacements caused by a provider’s removal (systemic risk) as well as the fraction of patients a provider can absorb when others default (systemic benefit). Below a critical number of providers, large-scale cascades of patient displacements occur, and no more providers can be found in a given region. We quantify regional resilience as the maximum fraction of providers that can be removed before cascading events prevent coverage for all patients within a district. We find considerable regional heterogeneity in the critical transition point from resilient to nonresilient behavior. We demonstrate that health care resilience cannot be quantified by physician density alone but must take into account how networked systems respond and restructure in response to shocks. The approach can identify systemically relevant providers

Improving the informational continuity of care in diabetes mellitus treatment with a nationwide Shared EHR system: Estimates from Austrian claims data

Purpose Shared Electronic Health Record (EHR) systems, which provide a health information exchange (HIE) within a community of care, were found to be a key enabler of informational continuity of diabetes mellitus (DM) care. Quantitative analyses of the actual contribution of Shared EHR systems to informational continuity of care are rare. The goal of this study was to quantitatively analyze (i) the degree of fragmentation of DM care in Austria as an indicator for the need for HIE, and (ii) the quantity of information (i.e. number of documents) from Austrian DM patients that would be made available by a nationwide Shared EHR system for HIE. Methods Our analyses are based on social security claims data of 7.9 million Austrians from 2006 and 2007. DM patients were identified through medication data and inpatient diagnoses. The degree of fragmentation was determined by the number of different healthcare providers per patient. The amount of information that would be made available by a nationwide Shared EHR system was estimated by the number of documents that would have been available to a healthcare provider if he had access to information on the patient’s visits to any of the other healthcare providers. As a reference value we determined the number of locally available documents that would have originated from the patient’s visits to the healthcare provider himself. We performed our analysis for two types of systems: (i) a “comprehensive” Shared EHR system (SEHRS), where each visit of a patient results in a single document (progress note), and (ii) the Austrian ELGA system, which allows four specific document types to be shared. Results 391,630 DM patients were identified, corresponding to 4.7% of the Austrian population. More than 90% of the patients received health services from more than one healthcare provider in one year. Both, the SEHRS as well as ELGA would have multiplied the available information during a patient visit in comparison to an isolated local EHR system; the median ratio of external to local medical documents was between 1:1 for a typical visit at a primary care provider (SEHRS as well as ELGA) and 39:1 (SEHRS) respectively 28:1 (ELGA) for a typical visit at a hospital. Conclusions Due to the high degree of care fragmentation, there is an obvious need for HIE for Austrian DM patients. Both, the SEHRS as well as ELGA could provide a substantial contribution to informational continuity of care in Austrian DM treatment. Hospitals and specialists would have gained the most amount of external information, primary care providers and pharmacies would have at least doubled their available information. Despite being the most important potential feeders of a national Shared EHR system according to our analysis, primary care providers will not tap their full corresponding potential under the current implementation scenario of ELGA

Semantic validation of standard based electronic health record documents with W3C XML Schema

++43 1 40400 6693 (Phone) [email protected] 2 Summary Objectives. The goal of this article is to examine whether W3C XML Schema provides a practicable solution for the semantic validation of standard based electronic health record (EHR) documents. With semantic validation we mean that the EHR documents are checked for conformance with the underlying archetypes and reference model. Methods. We describe an approach that allows XML Schemas to be derived from archetypes based on a specific naming convention. The archetype constraints are augmented with additional components of the reference model within the XML Schema representation. A copy of the EHR document that is transformed according to the before-mentioned naming convention is used for the actual validation against the XML Schema. Results. We tested our approach by semantically validating EHR documents conformant to three different ISO/EN 13606 archetypes respective to three sections of the CDA implementation guide "Continuity of Care Document (CCD)" and an implementation guide for diabetes therapy data. We further developed a tool to automate the different steps of our semantic validation approach. Conclusions. For two particular kinds of archetype prescriptions, individual transformations are required for the corresponding EHR documents. Otherwise, a fully generic validation is possible. In general, we consider W3C XML Schema as a practicable solution for the semantic validation of standard based EHR documents

Reply to Klitz and Niklasson: Can viral infections explain the cross-sectional Austrian diabetes data?

The vast majority of diabetes patients suffer from type II diabetes. There are several theories for potential causes of its development, the most favored being the "exhaustion" of beta-cells by chronic excess caloric intake combined with inactivity leading to obesity, diabetes, and cardiovascular disease. Viral infection could be a potential cause, however mainly for type I diabetes. Furthermore, autoimmunity might play a role in type I patients..

Knowledge-based verification of clinical guidelines by detection of anomalies

As shown in numerous studies, a significant part of published clinical guidelines is tainted with different types of semantical errors that interfere with their practical application. The adaptation of generic guidelines, necessitated by circumstances such as resource limitations within the applying organization or unexpected events arising in the course of patient care, further promotes the introduction of defects. Still, most current approaches for the automation of clinical guidelines are lacking mechanisms, which check the overall correctness of their output. In the domain of software engineering in general and in the domain of knowledge-based systems (KBS) in particular, a common strategy to examine a system for potential defects consists in its verification. The focus of this work is to present an approach, which helps to ensure the semantical correctness of clinical guidelines in a three-step process. We use a particular guideline specification language called Asbru to demonstrate our verification mechanism. A scenario-based evaluation of our method is provided based on a guideline for the artificial ventilation of newborn infants. The described approach is kept sufficiently general in order to allow its application to several other guideline representatio