- Research article
- Open Access
Reviewing the integration of patient data: how systems are evolving in practice to meet patient needs
BMC Medical Informatics and Decision Making volume 7, Article number: 14 (2007)
The integration of Information Systems (IS) is essential to support shared care and to provide consistent care to individuals – patient-centred care. This paper identifies, appraises and summarises studies examining different approaches to integrate patient data from heterogeneous IS.
The literature was systematically reviewed between 1995–2005 to identify articles mentioning patient records, computers and data integration or sharing.
Of 3124 articles, 84 were included describing 56 distinct projects. Most of the projects were on a regional scale. Integration was most commonly accomplished by messaging with pre-defined templates and middleware solutions. HL7 was the most widely used messaging standard. Direct database access and web services were the most common communication methods. The user interface for most systems was a Web browser. Regarding the type of medical data shared, 77% of projects integrated diagnosis and problems, 67% medical images and 65% lab results. More recently significantly more IS are extending to primary care and integrating referral letters.
It is clear that Information Systems are evolving to meet people's needs by implementing regional networks, allowing patient access and integration of ever more items of patient data. Many distinct technological solutions coexist to integrate patient data, using differing standards and data architectures which may difficult further interoperability.
This review appraises studies examining the different approaches to integrating patient data from heterogeneous IS. Special attention is given to the type of integration engine and the type of integrated data. Articles published in the English literature between 1995 and 2005 with abstracts available were reviewed. We aimed to specifically review the integration of patient data, and how systems are evolving in practice to meet patient, professional and organisational needs.
A patient record is a set of documents containing clinical and administrative information regarding one particular patient, supporting communication and decision making in daily practice, and having different users and purposes . Clinical care increasingly requires healthcare professionals to access patient record information that may be distributed across multiple sites, held in a variety of paper and electronic formats, and represented as mixtures of narrative, structured, coded and multimedia entries . In hospitals, information technologies tend to combine different modules or subsystems, resulting in a best-of-breed approach . Integration of healthcare Information Systems (IS) is essential to support shared care in hospitals, to provide proper care to mobile individuals and to make regional healthcare systems more efficient. However, to integrate clinical IS in a way that will improve communication and data use for healthcare delivery, research and management, many different issues must be addressed [4–6]. Consistently combining data from heterogeneous sources takes a great deal of effort because the individual feeder systems usually differ in several aspects, such as functionality, presentation, terminology, data representation and semantics . It is still a challenge to make electronic health records interoperable because good solutions to the preservation of clinical meaning across heterogeneous systems remain to be explored . Over the years different solutions to these problems have been proposed and some applied. Many of these solutions coexist in today's healthcare settings and are influenced by technology innovation and changes in healthcare delivery. Some of these solutions use differing standards and data architectures that may prove to be the greatest obstacle to semantic operability .
Only studies describing or evaluating IS implementation for integrating patient data from heterogeneous IS were selected.
The review team was composed of three Computer Scientists, namely Ana Margarida Ferreira, Pedro Vieira Marques, and Ricardo Cruz Correia, one medical doctor Filipa Canário Almeida advised by health informaticians experienced in systematic reviewing, Jeremy Crispin Wyatt and Altamiro Costa Pereira.
Studies were searched between September and October 2005 in the bibliographic databases. Since there is no specific standardised MeSH term, we developed a search string that includes the concepts of patient record, computers and data integration or sharing. Only articles with an abstract in English were considered. Given the significant evolution in ICT in the last decade, only studies published after 1994 (the last ten years) were included.
Three distinct bibliographic databases were searched: Medline (via Pubmed), ISI (ISI Web of Knowledge) and IEEE (IEEE Xplore). The query search string used in each database was ((medical or clinical or patient) and record*) and (comput* or digital or electronic*) and (integrat* or link* or sharing or share or shared).
This search method found 2443 articles in Pubmed, 961 in ISI and 414 in IEEE Xplore, a total of 3818 articles. After eliminating duplicate articles 3124 were selected.
Selection of studies for the review
All four reviewers from the review team were involved in study selection. Six combinations of reviewer pairs were defined, due to the large number of articles found. The first selection was based on the study title. Each pair of reviewers read 512 titles. The study was considered eligible when at least one of the reviewers considered that the title mentioned one of three key concepts:
– Patient Records (e.g.: patient record, EPR, EHR, EMR, clinical documents – CDA, administrative database)
– Integration (e.g.: IS integration, record linkage, information sharing)
– Distributed environment (e.g.: e-Health, distributed healthcare, shared healthcare)
A total of 923 of 3124 articles were selected in this first selection on title alone.
The second phase of the study selection was based on abstracts. Again, six combinations of reviewer pairs were defined. Each pair of reviewers read 154 abstracts. The inclusion criterion in this phase was that articles should fulfil all three of the following conditions:
– Describe or assess IS implementations
– Integrate patient data from various IS
– Describe the technology used to integrate
To maximize specificity, only selection by both reviewers was considered adequate. In cases of disagreement a third reviewer was called to decide. A total of 84 out of 923 articles were selected to be read entirely. These 84 articles were grouped into 69 distinct integration projects to avoid the distortion created by multiple papers describing the same project. All statistical analysis is based on projects and not on articles. Some of articles (n = 13) were descriptions of project plans or architecture models that were not already implemented on a real scenario nor even as a prototype. These projects were also excluded, leaving only 56 projects. Figure 1 is a flowchart illustrating the different stages of paper selection.
Underlying model and definition of variables
Figure 2 illustrates the stages of a generic integration of heterogeneous IS. The variables examined in this review are related to these stages and intend to describe the context where the integration takes place (country, date, area covered, institutions involved, type of final users), the type of data integrated and the technology used (standards, communication methods, integration model, repositories of data, client applications).
The variables are:
– Country where the system is implemented;
– Date of article publication;
– Area covered by each project (country, region, hospital, department);
– Institutions involved as sources for patient data integration, i.e., institutions that own feeder systems to integration (departments, hospitals, primary care, private clinics, private labs, patient health portals) – multiple values are accepted;
– What type of medical data is integrated (lab orders, lab results, prescription orders, diagnosis or problems, procedures, admission letters, discharge letter, transfers letters, referral letters, medical images, biosignals) – multiple values are accepted;
– Medical informatics standards used (e.g.: HL7 – Health Level 7, CDA – Clinical Document Architecture, GEHR – Good European Health Record, SCIPHOX – Standardized Communication of Information Systems in Physician Offices and Hospitals using XML, DICOM -Digital Imaging and Communications in Medicine, MML – Medical Markup Language) – multiple values are accepted;
– Communication method (DICOM, DDE – Dynamic Data Exchange, e-mail, computer agents, Web services, Direct database access, CGI – Common Gateway Interface, CORBA – Common Object Request Broker Architecture, DHE – Distributed Healthcare Environment) – multiple values are accepted;
– Type of integration model for semantic interoperability (direct communication ie. when the systems create different interfaces to connect to each other; middleware ie. when an application programming interface is made available to talk with the central repository; semantic ie. when all possible data has a predefined message template, both semantic and syntax is known; generic ie. when the document structure accepts a certain degree of evolution without re-defining the whole template) – adapted from Bernstein et al.  – only one type of model is accepted;
– Type of data repository (File System, Database, PACS – Picture Archiving and Communication System, LDAP – Lightweight Directory Access Protocol, Virtual repository system) – multiple values are accepted;
– How data are made available to users (client application or web browser) – multiple values are accepted;
– How data are made available to other IS (Web services, CORBA or others) – multiple values are accepted;
– User groups (health professionals – medical users, nurses and other clinicians, clerical staff and patients) – multiple values are accepted;
Time intervals considered
To analyse time trends, we divided the total period up into three shorter periods because of the small overall number of projects identified. The first period includes projects with their last publication in 1994–1999, the second period with their last publication in 2000–2002 and the third period with their last publication in 2003–2005.
The statistical analysis was performed with SPSS® version 14. P values in Table 1 were calculated using Pearson and linear-by-linear association chi-square tests with significance level of 0.05.
The agreement rate for the first phase was 83%, and for the second phase was 77%. The number of different IS implemented was 56. Table 2 lists all integrated IS considered in this review, their country, number of publications and period of publication. Countries with the most published projects were the USA (15), Germany (8), Greece (6), Denmark (4) and China (4). Most IS (73%) have just one publication. 52% of the IS had their last publication in the period 2003–5, and 36% during 2000–2.
Area covered by integration
59% of the IS covered only a region, while 29% covered a hospital, 9% a department and 4% a whole country. There was a downward trend in publications related to projects that cover a hospital from 57% until 1999, 35% in 2000–02 and 17% in 2003–05. The number of projects covering a region or country has increased over the years, and currently represents 76% (p = 0.037).
Institutions involved in the integration
Most of the integrated information comes from hospital IS (69%), with departmental (40%) and primary care (33%) IS representing the next two most frequent institution types. Four projects (8%) integrated information from health portals; all were published in the most recent period considered (2003–05).
As expected, all information systems provided access to health professionals. Two recent projects claim giving data access to patients [9, 10]. Medical doctors are more often referenced as users (48%) than nurses (10%).
77% of the projects integrated diagnosis and problems, 67% medical images, 65% lab results, 63% discharge notes and 60% procedures. There has been an increase in projects integrating referral letters (from 0% until 1999, to 18% in 2000–02 and to 25% in 2003–05).
Type of models
Regarding the type of integration model, although the number of projects found using a predefined message templates (semantic – all data structured) and middleware are very similar (44% and 40% respectively), it seems that there is a trend to use more predefined message templates (46% in 2003–05) and fewer middleware solutions (31% in 2003–05). This tendency is clearer, if the values of the projects using messaging (both "Semantic – all data structured" and "Generic – structure and data dynamic") are added, representing 54% in 2003–05. Direct communication to databases is very low (10%) and more flexible messaging is now appearing (12% in 2003–05).
HL7 is the most frequently used messaging standard (68%). It seems that CDA is becoming the reference to use inside HL7 (25% in 2003–05). DICOM is becoming less used when compared to other standards, which is understandable as it is mainly for images. Nevertheless, DICOM is no more the only success example of standards use in medical communication protocols. Other standards have very low usage nowadays (19% in 2003–05).
Regarding the type of data storage, 77% of the projects stored data in databases, 25% used virtual repositories and 16% stored in files. There is no real change over the periods considered.
Recently (since 2000) more different technologies have been used to establish communication (3 until 1999, 8 in 2000–02 and again 8 in 2003–05). Web services have increasing importance (p = 0.042), whilst Database direct access and Common Gateway Interface have decreasing importance.
How data are made available for users
92% of the Information Systems use a Web browser to deploy their applications, whilst only 19% give user access through client-server applications.
How data are made available for other IS
88% of the IS use Web services to communicate with other systems, whilst only 13% use CORBA. The absolute number of systems using Web Services has grown from zero until 1999, two in 2000–2 and 5 in 2003–05.
Current status (results regarding 2003–05)
Currently there are more projects carrying out regional integration, especially between hospitals and primary care. Referral letters are mentioned in 7 of the 29 projects described in articles published in 2003–05. It is also clear that patients are also becoming active participants because they appear for the first time as a user group in more recent projects.
Regarding integration models, messaging between systems, both Semantic and Generic, is lately used more frequently (58%) than middleware (31%). Databases are still the most common method for data storage (86%). Communication between integrated systems uses many different technologies with Web services being used in 41% of the projects. The most common user interface by far is the Web browser (90%).
Our results show an increasing number of publications describing projects which integrate data from multiple Information Systems. This is in agreement with our initial assumption about the interest in improving the communication of health related data to support person-centred healthcare. As the number of heterogeneous health IS grows, their integration becomes a priority. Moreover, we may be witnessing an increasing interest in regional integration between heterogeneous healthcare information systems across different institutions, to help communication between the different stake holders (primary and secondary care doctors, nurses and patients). This is also supported by the increasing communication of referral letters.
It should be noticed the efforts being put into integration in countries like Germany, Greece and Denmark which are trying to implement nationwide healthcare integrated networks feed by heterogeneous information systems.
Messaging technologies (in particular HL7) are more used than middleware solutions (like DCOM or CORBA). Web based technologies (web-services and web-browsers) support most of the projects, indicating that these new technologies are quickly adopted in healthcare institutions. Nevertheless, it is obvious that many distinct technological solutions coexist to integrate patient data.
The concept of message passing appears to be radically different from the conventional concept of procedure calls or operation invocation, but the difference is more one of pedagogical emphasis than of semantics. Message passing emphasizes the remoteness of the object and the caller's lack of knowledge of the code body which will be executed. However, any procedure call can be viewed as an exchange of messages . The main difference is both approaches is the reliance on open Internet standards like HTTP, XML, SOAP, WSDL, UDDI and WSFL by the Web services (messaging), in opposition to DCOM and CORBA solutions (middleware) that resulted many times in single-vendor implementation requirements.
One key omission from the literature reviewed is that most of the project publications failed to mention any type of error detection. We feel that is mandatory to verify the quality of integrated data, so that instead of propagating data errors, alerts regarding data quality can be triggered and correction processes can take place .
One of the main limitations of this review is lack of detail reported in most of the articles, and especially the non existence of any impact evaluation of the technologies they describe, despite the enormous cost of such systems and the evident change in working practices that they entail. The percentage of missing values for each time interval varied between 0 and nearly 50% depending on the type of variable analysed and interval of time considered.
Another limitation is only considering papers published in the last ten years may exclude early work on integration at the hospitals, although we feel it is justifiable given the significant evolution in ICT in the last decade.
Although we feel that grouping the papers into projects is essential to decrease the bias of multiple publications of the same project, on some of the papers it was difficult to determine if they were describing the same project or not.
Currently people have more mobility, longer lives and health care is more shared than ever before. It is clear that Information Systems are evolving to meet people's needs by implementing regional networks, allowing patient access and integration of ever more items of patient data. We conclude that patient information is becoming more accessible as there are more integrated IS which are more likely to involve primary care and a wider range of patient data.
Web based technologies and messaging technologies are supporting most of the current integration projects, indicating that these new technologies are quickly adopted in healthcare institutions. Many distinct technological solutions coexist to integrate patient data, using differing standards and data architectures which may difficult further interoperability.
Wyatt JC: Clinical data systems, Part 1: Data and medical records. Lancet. 1994, 344: 1543-1547.
Kalra D: Electronic health record standards. Methods Inf Med. 2006, 45 (1): 136-144.
Lenz R, Kuhn KA: Integration of Heterogeneous and Autonomous Systems in Hospitals. Business Briefing: Data management & Storage Technology. 2002
Heathfield H, Pitty D, Hanka R: Evaluating information technology in health care: barriers and challenges. BMJ. 1998, 316: 1959-1961.
Berg M: Implementing information systems in health care organizations: myths and challenges. Int J Med Inf. 2001, 64 (2-3): 143-156.
Littlejohns P, Wyatt JC, Garvican L: Evaluating computerised health information systems: hard lessons still to be learnt. BMJ. 2003, 326: 860-863.
Ferranti J, Musser C, Kawamoto K, Hammon E: The Clinical Document Architecture and the Continuity of Care Record: A Critical Analysis. J Am Med Inform Assoc. 2006, 13 (3): 245-252.
Bernstein K, Bruun-Rasmussen M, Vingtoft S, Andersen SK, Nohr C: Modelling and implementing electronic health records in Denmark. International Journal of Medical Informatics - MIE 2003. 2005, 74 (2-4): 213-220.
Takada A, Guo J, Tanaka K, Sato J, Suzuki M, Suenaga T, Kikuchi K, Araki K, Yoshihara H: Dolphin Project—Cooperative Regional Clinical System Centered on Clinical Information Center. Journal of Medical Systems. 2005, 29 (4): 391-400.
Koch S, Hägglund M, Scandurra I, Moström D: Towards a virtual health record for mobile home care of elderly citizens. Proceedings of Medinfo. 2004, 11 (Pt 2): 960-963.
Strom R: A comparison of the object-oriented and process paradigms. 1986, ACM Press New York, NY, USA, 88-97.
Cruz-Correia R, Vieira-Marques P, Ferreira A, Oliveira-Palhares E, Costa P, Costa-Pereira A: Monitoring the integration of hospital information systems: how it may ensure and improve the quality of data. Stud Health Technol Inform. 2006, The Hague, The Netherlands , 121: 176-182.
Wagner M, Collins B: Using electronic medical record data for clinical workflow and analysis: a single center experience. J Crit Care. 2004, 19 (4): 234-242.
Quade G, Novotny J, Burde B, May F, Beck LE, Goldschmidt A: Worldwide telemedicine services based on distributed multimedia electronic patient records by using the second generation Web server hyperwave. Proc AMIA Symp. 1999, : 916-920.
Li H, Tang S, Yang D, Yu Y: An XML Based Electronic Medical Record Integration System. The Second International Conference on Web-Age Information Management Berlin: Springer-Verlag Berlin Heidelberg. 2001, 160167:
Halamka JD, Osterland C, Safran C: CareWeb, a web-based medical record for an integrated health care delivery system. Int J Med Inform. 1999, 54 (1): 1-8.
Safran C, Goldberg H: Electronic patient records and the impact of the Internet. Int J Med Inf. 2000, 60 (2): 77-83.
Munch H, Engelmann U, Schroter A, Meinzer HP: The integration of medical images with the electronic patient record and their web-based distribution. Acad Radiol. 2004, 11 (6): 661-668.
Lin SC, Mba KR, Fadlalla A, Henricks WH: Integrating Data from Legacy Systems Using Object Linking and Embedding Technology. Journal of the American Medical Informatics Association. 2000, 7: 357-360.
Zuker A: From Computerized Patient Records to National Resource. Stud Health Technol Inform. 2003, 95: 892-897.
Jost RG, Blaine GJ, Fritz K, Blume H, Sadhra S: Enhanced Interfaces for Web-Based Enterprise-Wide Image Distribution. Journal of Digital Imaging. 2002, 15: 189-193.
Cheunga NT, Lamb A, Chanb W, Kong JHB: Integrating images into the electronic patient record of the hospital authority of Hong Kong. Computerized Medical Imaging and Graphics. 2005, 29 (2-3): 137-142.
Kim IK, Yun JH: Agent-Based Intelligent Clinical Information System for Persistent Lifelong Electronic Medical Record. Intelligent Agents and Multi-Agent Systems. 2003, Springer Berlin / Heidelberg, 2891/2003: 194-204.
Bandon D, Lovis C, GeissbüHler A, Vallée JP: Enterprise-wide PACS: beyond radiology, an architecture to manage all medical images. Academic Radiology. 2005, 12 (8): 1000-1009.
Borst F, Appel R, Baud R, Ligier Y, Scherrer JR: Happy birthday DIOGENE: a hospital information system born 20 years ago. Int J Med Inf. 1999, 54 (3): 157-167.
Breant C, Borst F, Campi D, Griesser V, Son Le H JJM: Expanding DIOGENE with a clinical information system based on a new hospital-wide clinical findings dictionary. Int J Med Inf. 2000, 58 (59): 167-177.
Scherrer JR, Lovis C, Baud R, Borst F, Spahni S: Integrated computerized patient records: the DIOGENE 2 distributed architecture paradigm with special emphasis on its middleware design. Stud Health Technol Inform. 1998, 56: 15-31.
Thurler G, Borst F, Bréant C, Campi D, Jenc J, Lehner-Godinho B, Maricot P, Scherrer JR: ARCHIMED: A network of integrated information systems. Methods of Information in Medicine (2000). 39 (1): 36-43.
Goulas NA, Nanou DG, Fotiadis DI: Epirus-net: a wireless health telematics network in Greece. Engineering in Medicine and Biology Society, 2001 Proceedings of the 23rd Annual International Conference of the IEEE. 2001, 4: 3488-3491.
Kaae T: A regional health network supported by organisational change. Cross sectorial electronic referral and confirmation of booking. Stud Health Technol Inform. 2000, 77: 988-991.
Poulymenopoulou M, Vassilacopoulos G: An electronic patient record implementation using clinical document architecture. Stud Health Technol Inform. 2004, 103: 50-57.
Malamateniou F, Vassilacopoulos G: An implementation of a virtual patient record using Web services. Stud Health Technol Inform. 2003, 95: 158-163.
Malamateniou F, Vassilacopoulos G: Developing a virtual patient record using XML and web-based workflow technologies. International Journal of Medical Informatics - MIE 2002 Special Issue. 2003, 70 (2-3): 131-139.
Malamateniou F, Vassilacopoulos G: Developing a virtual patient record as a web-based workflow system. Stud Health Technol Inform. 2002, 90: 298-304.
Bird L, Goodchild A, Tun Z: Experiences with a Two-Level Modelling Approach to Electronic Health Records. Journal of Research and Practice in Information Technology. 2003, 35 (2): 121-
Altmann U, Tafazzoli AG, Katz FR, Dudeck J: XML-Based Application Interface Services–A Method to Enhance Integrability of Disease Specific Systems: Medinfo. London, UK.2001, , 10 (Pt 1): 589-593.
Schabetsberger T, Gross E, Haux R, Lechleitner G, Pellizzari T, Schindelwig K, Stark C, Vogl R, Wilhelmy I: Approaches Towards a Regional, Shared Electronic Patient Record for Health Care Facilities of Different Health Care Organizations—–IT-Strategy and First Results. MEDINFO. 2004, 11 (Pt 2): 979-982.
Schabetsberger T, Ammenwerth E, Andreatta S, Gratl G, Haux R, Lechleitner G, Schindelwig K, Stark C, Vogl R, Wilhelmy I: From a paper-based transmission of discharge summaries to electronic communication in health care regions. Int J Med Inform. 2005, 75 (3-4): 209-215.
Wolff AC, Mludek V, van der Haak M, Bork W, Bülzebruck H, Drings P, Schmücker P, Wannenmacher M, Haux R: Using the eXtensible Markup Language (XML) in a Regional Electronic Patient Record for Patients with Malignant Diseases. Stud Health Technol Inform. 2001, IOS Press, 10 (Pt 1): 698-702.
Clayton PD, Narus SP, Huff SM, Pryor TA, Haug PJ, Larkin T, Matney S, Evans RS, Rocha BH, Bowes WA: Building a comprehensive clinical information system from components. The approach at Intermountain Health Care. Methods Inf Med. 2003, 42 (1): 1-7.
Bouam S, Girou E, Brun-Buisson C, Lepage E: Development of a Web-based clinical information system for surveillance of multiresistant organisms and nosocomial infections. Proc AMIA Symp. 1999, 696: 700-
Zviran M, Armoni A, Glezer C: HIS/BUI: A Conceptual Model for Bottom-Up Integration of Hospital Information Systems. Journal of Medical Systems. 1998, 22 (3): 147-159.
Law MYY: A model of DICOM-based electronic patient record in radiation therapy. Computerized Medical Imaging and Graphics. 2005, 29 (2-3): 125-136.
Lowe HJ, Walker WK, Polonkey SE, Jiang F, Vries JK, McCray A: The Image Engine HPCC Project: A Medical Digital Library System using Agent-Based Technology to Create an Integrated View of the Electronic Medical Record. Proceedings of the 3rd International Forum on Research and Technology Advances in Digital Libraries. 1996
Tsiknakis M, Katehakis DG, Orphanoudakis SC: An open, component-based information infrastructure for integrated health information networks. Int J Med Inform. 2002, 68 (1-3): 3-26.
Katehakis DG, Sfakianakis S, Tsiknakis M, Orphanoudakis SC: An infrastructure for Integrated Electronic Health Record services: the role of XML (Extensible Markup Language). J Med Internet Res. 2001 , 3 (1): E7-
Potamias G, Tsiknakis M, Katehakis D, Karabela E, Moustakis V, Orphanoudakis S: Role-based access to patients clinical data: the InterCare approach in the region of Crete. Stud Health Technol Inform. 2000, 77: 1074-1079.
Orphanoudakis S: HYGEIAnet: the Integrated Regional Health Information Network of Crete. E-Health: Current Situation and Examples of Implemented and Beneficial E-Health Applications. 2004, 100: 66-78.
Chiarugi F, Lombardi D, Lees PJ, Chronaki CE, Tsiknakis M, Orphanoudakis SC: Support of daily ECG procedures in a cardiology department via the integration of an existing clinical database and a commercial ECG management system. Ann Noninvasive Electrocardiol. 2002, 7 (3): 263-270.
Katehakis D, Tsiknakis M, Armaganidis A, Orphanoudakis SC: Functional and Control Integration of an ICU, LIS and PACS Information System. Proceedings of MIE. 97: 25-29.
McDonald CJ: Hickam 2000: the maturation of, and linkages between, medical informatics and bioinformatics. J Lab Clin Med. 2001, 138 (6): 359-366.
Biondich PG, Grannis SJ: The Indiana Network for Patient Care: An Integrated Clinical Information System Informed by Over Thirty Years of Experience. Journal of Public Health Management and Practice. 2004, 10: 81-86.
Kalinski T, Hofmann H, Franke DS, Roessner A: Digital imaging and electronic patient records in pathology using an integrated department information system with PACS. Pathol Res Pract. 2002, 198 (10): 679-684.
Bernarding J, Thiel A, Grzesik A: A JAVA-based DICOM server with integration of clinical findings and DICOM-conform data encryption. J Med Inform. 2001, 64 (2-3): 429-38.
Stewart BK, Langer SG: Integration of DICOM Images into an Electronic Medical Record Using Thin Viewing Clients. Proc AMIA Symp. 1998, 902-906.
Hanzlicek P, Spidlen J, Nagy M: Universal electronic health record MUDR. Stud Health Technol Inform. 2004, 105: 190-201.
Müller ML, Ückert F, Bürkle T, Prokosch HU: Cross-institutional data exchange using the clinical document architecture (CDA). International Journal of Medical Informatics. 2005, 74: 245-256.
Muller ML, Burkle T, Irps S, Roeder N, Prokosch HU: The diagnosis related groups enhanced electronic medical record. Int J Med Inform. 2003 , 70 (2-3): 221-228.
Uckert F, Gorz M, Ataian M, Tessmann S, Prokosch HU: The new navigation in EHRs: enabling teamwork of professionals and patients. Stud Health Technol Inform. 2003, 95: 334-339.
Muller ML, Butta R, Prokosch HU: Electronic discharge letters using the Clinical Document Architecture (CDA). Stud Health Technol Inform. 2003, 95: 824-828.
Muller ML, Ganslandt T, Eich HP, Lang K, Ohmann C, Prokosch HU: Towards integration of clinical decision support in commercial hospital information systems using distributed, reusable software and knowledge components. Int J Med Inform. 2001 , 64 (2-3): 369-377.
Berler A, Pavlopoulos S, Karkalis G, Sakka E, Konnis G, Koutsouris D: Implementation of a novel virtual patient record architecture. Engineering in Medicine and Biology, 2002 24th Annual Conference and the Annual Fall Meeting of the Biomedical Engineering Society] EMBS/BMES Conference, 2002 Proceedings of the Second Joint. 2002, 3:
Bui AAT, McNitt-Gray MF, Goldin JG, Cardenas AF, Aberle DR: Problem-oriented Prefetching for an Integrated Clinical Imaging Workstation. Journal of the American Medical Informatics Association. 2001, 8: 242-253.
Hägglund M, Scandurra I, Moström D, Koch S: Integration Architecture of a Mobile Virtual Health Record for Shared Home Care. Connecting Medical Informatics and Bioinformatics, Studies in Health Technology and Informatics. 2005, 116: 340–345-
Kay JD, Nurse D, Bountis C, Paddon K: The Oxford clinical intranet: providing clinicians with access to patient records and multiple knowledge bases with internet technology. Stud Health Technol Inform. 2004, 100: 130-138.
Kay JD, Nurse D: Construction of a virtual EPR and automated contextual linkage to multiple sources of support information on the Oxford Clinical Intranet. Proc AMIA Symp. 1999, 829-33.
Mycek S: The IT connection. An integrated health care system gets wired. Trustee. 2004, 57 (2): 18-21.
Lober WB, Baer A, Karras BT, Duchin JS: Collection and integration of clinical data for surveillance. Medinfo. 2004, 2004: 1211-1215.
Overhage J, McDonald CJ, Suico JG: The regenstrief medical record system 2000: Expanding the breadth and depth of a community wide EMR. Proc AMIA Symp. 2000, 1173-
McDonald CJ, Overhage JM, Tierney WM, Dexter PR, Martin DK, Suico JG, Zafar A, Schadow G, Blevins L, Glazener T: The Regenstrief Medical Record System: a quarter century experience. Int J Med Inf. 1999, 54 (3): 225-253.
Overhage JM, Aisen A, Barnes M, Tucker M, McDonald CJ: Integration of radiographic images with an electronic medical record. Proc AMIA Symp. 2001, 513: 7-
Zhang J, Sun J, Yang Y, Chen X, Meng L, Lian P: Web-based electronic patient records for collaborative medical applications. Computerized Medical Imaging and Graphics. 2005, 29: 115-124.
Taddei A, Macerata A, Dalmiani S, Cecchetti G, Carpeggiani C, Chelozzi L, Emdin M, Raciti M, Micalizzi M, Kraft G: Medical record system for cardiology and cardiac surgery. Computers in Cardiology 1999. 1999, 85-88.
Morales MA, Dalmiani S, Carpeggiani C, Macerata A, Ghione S: Electronic medical records in a cardiological outpatient clinic. Computers in Cardiology, 2002. 2002, 381-384.
Carpeggiani C, Dalmiani S, Taddei A, Franchi D, Michelassi C, Chelozzi L, Emdin M, Macerata A, Benassi A, L'Abbate A: Use of an electronic medical record in a department of cardiology. Computers in Cardiology 2000. 2000, 291-294.
Taddei A, Carpeggiani C, Emdin M, Balocchi R, Dalmiani S, Cecchetti G, Macerata A, Pierotti D, Marchesi C: Development of an electronic medical record for patient care in cardiology. Computers in Cardiology 1997. 1997, 641-644.
Taddei A, Fiaschi A, Kraft G, Fania A, Furfori P, Del Sarto M, Santoli F: Integrated system for anesthesia records in cardiac surgery. Computers in Cardiology 2000. 2000, 789-792.
Gong P, Feng D, Lim YS: An Intelligent Middleware for Dynamic Integration of Heterogeneous Health Care Applications. Multimedia Modelling Conference, 2005 MMM 2005 Proceedings of the 11th International. 2005, 198-205.
Grimson J, Stephens G, Jung B, Grimson W, Berry D, Pardon S: Sharing health-care records over the Internet. Internet Computing, IEEE. 2001, 5 (3): 49-58.
Grimson J, Felton E, Stephens G, Grimson W, Berry D: Interoperability issues in sharing electronic healthcare records-the Synapses approach. Engineering of Complex Computer Systems, 1997 Proceedings, Third IEEE International Conference on. 1997, 180-185.
Grimson W, Sottile PA: Synapses in the context of healthcare information systems. Stud Health Technol Inform. 1997, 45: 30-39.
Grimson J, Grimson W, Berry D, Stephens G, Felton E, Kalra D, Toussaint P, Weier OW: A CORBA-based integration of distributed electronic healthcarerecords using the Synapses approach. Information Technology in Biomedicine, IEEE Transactions on. 1998, 2 (3): 124-138.
Grimson W, Jung B, van Mulligen EM, van Ginneken A, Pardon S, Sottile PA: Extensions to the HISA standard–the SynEx computing environment. Methods of Information in Medicine. 2002, 41 (5): 401-410.
Xu Y, Sauquet D, Zapletal E, Lemaitre D, Degoulet P: The" mediator service", a component to ease the integration of medical applications in the SynEx framework. Stud Health Technol Inform. 1999, 68: 768-773.
Aloisio G, Blasi E, Cafaro M, Fiore S, Lezzi D, Mirto M: Web services for a biomedical imaging portal. Information Technology: Coding and Computing [Computers and Communications], 2003 Proceedings ITCC 2003 International Conference on. 2003, 432-436.
Spyrou SS, Berler AA, Bamidis PD: Information system interoperability in a regional health care system infrastructure: a pilot study using health care information standards. Stud Health Technol Inform. 2003, 95: 364-369.
Dayhoff RE, Kuzmak PM, Kirin G, Frank S: Providing a complete online multimedia patient record. Proc AMIA Symp. 1999, 241: 5-
Kuzmak PM, Dayhoff RE: The use of digital imaging and communications in medicine (DICOM) in the integration of imaging into the electronic patient record at the Department of Veterans Affairs. J Digit Imaging. 2000, 13 (2 Suppl 1): 133-137.
Bergmann J, Bott OJ, Hoffmann I, Pretschner DP: An eConsent-based System Architecture Supporting Cooperation in Integrated Healthcare Networks. Stud Health Technol Inform. 2005, 116: 961-966.
Reina-Tosina J, Roa LM, Caceres J, Gomez-Cia T: New approaches toward the fully digital integrated management of a burn unit. IEEE Transaction on Biomedical Engineering. 2002, 49 (12): 1470-1476.
Duncan RG, Saperia D, Dulbandzhyan R, Shabot MM, Polaschek JX, Jones DT: Integrated web-based viewing and secure remote access to a clinical data repository and diverse clinical systems. Proc AMIA Symp. 2001, 149-153.
Hripcsak G, Cimino JJ, Sengupta S: WebCIS: Large scale deployment of a web-based clinical information system. Proc of the AMIA Symposium. 1999
Tachinardi U, de Sa Rebelo M, de Magalhaes Oliveira Jr PP, Pilon PE: Real time information from bedside monitors as part of a web-based patient record. Proc AMIA Symp. 2001, 691: 5-
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/7/14/prepub
The authors thank Cristina Maria Nogueira Costa Santos of the Department of Biostatistics and Medical Informatics for her help in the statistical analysis.
The author(s) declare that they have no competing interests.
RCC was responsible for the study design, organization, analyses and manuscript preparation. RCC, AMF, PVM and FCA were part of the articles review team. JCW and ACP advised the study design and supervised statistical analysis and the manuscript preparation. All authors read and approved the final manuscript.
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Cruz-Correia, R.J., Vieira-Marques, P.M., Ferreira, A.M. et al. Reviewing the integration of patient data: how systems are evolving in practice to meet patient needs. BMC Med Inform Decis Mak 7, 14 (2007). https://doi.org/10.1186/1472-6947-7-14
- Information System
- Referral Letter
- Common Object Request Broker Architecture
- Clinical Document Architecture
- Common Gateway Interface