Diogene

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The DIOGENE hospital information system is the primary Electronic Medical Record at the University Hospital in Geneva Switzerland. It has been expanded with a centralized and integrated patient clinical database recording structured patient data. The objective was to provide a standardized framework for the building of future clinical databases and for the integration of existing heterogeneous ones. The combined 'across time view' and 'across departments view' generated from the integrated clinical data will enable an evolutionary view of the patient state, both across time and across medical specialties.

For the purpose of permitting communication and exchange of data, a new controlled vocabulary for representing clinical data has been created. The construction of this vocabulary is based on the international ICD classification, already being used in DIOGENE for encoding patient diagnosis and procedures. A new extension of the ICD is proposed for medical information that goes beyond diagnosis and procedures encoding. The building of a common clinical findings dictionary, recording the definition of clinical entities, is based on this newly developed clinical vocabulary. This process is incremental, manual and substantial. DIOGENE integrates four axes of knowledge:

  • medico-economical context for better understanding and influencing resources consumption
  • the whole set of patient reports and documents(reports, encoded summaries, clinical findings, images, lab data, etc.)
  • patient-dependent knowledge, in a vision integrating time and space
  • external knowledge bases such as Medline (patient-independent knowledge)

The integration of these patient-dependent and independent knowledge in a case-based reasoning format, aims to provide on the physician desktop all relevant information for helping him to take the most appropriate adequate decision.(6)

History

Diogene was developed in the 1970's (1) by Professeur Jean-Raoul Scherrer, MD at the University Hospital in Geneva, Switzerland (2). The need for this hospital information system arose as medical expenses had to be directly compared to the quality of healthcare provided (6).

The system had both a centralized patient database, and centralized group of operators who train and support users. The centralized patient database included mechanisms for data protection and recovery of a transaction-oriented system. It also included a separate network of remote printers that provided service throughout the entire institution; and a three-component structure that enhanced communication between administrative and medical applications (1). It retained its architectural unity until Diogene 2 was launched.

In 1993, Unimage, a radiology information system was created and implemented at the Cantonal University Hospital of Geneva as a part of the migration towards the Diogene 2 hospital information system. It was designed to fit the needs of the radiology department, and to operate in different services, (i.e. diagnostic radiology, nuclear medicine and therapy radiology) offering a simple two-way data communication with the PACS world; created for a distributed environment, as well as a graphical (X/Motif) user interface (4).

In June 1995, the need for modification and extension over the years led to the creation of a full-scale distributed/open hospital information system “Diogene 2” (5). "Diogene 2" integrated technology by incorporating knowledge bases such as Medline; providing relevant information for helping the physician to make adequate decision on medico-economical issues to understand resources consumption (6).

In 1999, an effort was made to integrate the many clinical databases that have developed over the years in different hospital departments with "Diogene 2". The challenge was in the different systems developed by different teams with different references and vocabulary (8). Therefore, a newly developed clinical vocabulary was created based on the international ICD classification which facilitated the communication and exchange of data (7).

Doclin is a clinical information system that is integrated with DIOGENE. DOCLIN was created for the communication and the exchange of data between different medical departments at the University of Geneva that had independently created and operated databases. The 4-year project began in 1997. (7)

The purpose of the 4-year project was to expand DIOGENE with clinical data and medical protocals to form the DIOGENE HIS. The new HIS was an open network of information systems managing many types of data. The data types included admission and discharge data, laboratory data, coding and patient medical records. (11)

Diogene now supports many applications including lab, radiology, and pharmacy (2). It went from centralized to an open distributed architecture; therefore, reaching other public hospitals and general practitioners in Geneva.

Clinical Applications

Microbiology/Infection Control

Methicillin-resistant Staphylococcus aureus (MRSA) is a growing international health risk. Admission of an infected or colonized patient into a hospital poses a significant risk and requires appropriate infection control measures (ICM) to prevent or reduce transmission. At the University Hospital of Geneva, investigators applied an expert system within their DIOGENE hospital information system to deliver daily alerts to the Infection Control Program office. Two different alert mechanisms were implemented. The first is a "readmission alert" that is generated for any patient admitted to the hospital with a documented previous infection or colonization from a prior hospital visit. The second is a laboratory alert generated each day at 1:15 pm consisting of two reports:

  1. "the positive lab alert" is a listing of patient information from positive cultures for MRSA within the preceding 24 hours.
  2. a surveillance cultures report for all MRSA cultures with no growth within the preceding 24 hours

During the first 12 months the system was active, the lab alert identified an average of 4.6 isolates each day. This translates into a total of 248 patients representing 314 admissions. In addition, 438 readmission alerts were generated, 33% of which (114) were found to be positive for MRSA. (12)

References

1. Scherrer JR, Baud RH, Hochstrasser D, Ratib O. An integrated hospital information system in Geneva. MD Comput 1990 Mar-Apr;7(2):81-9.

2. Scherrer JR, Baud R, de Roulet D. Moving toward the future design of HIS: A view from the seventies to the end of the nineties, The Diogene paradigm. in Hospital Information Systems by Prokosch and Dudeck

3. Borst F, Griesser P, Bourdilloud R, Scherrer JR. Fifteen years of medical encoding in the Diogene HIS. Medinfo. 1995;8 Pt 1:43-6.

4. Do QH, Conti S, Muñoz J, Pillou E, Tacchino M, Ratib O, Trayser G. Unimage, a new RIS for the DIOGENE 2 environment at Geneva Cantonal University Hospital. Med Inform (Lond). 1993;18(2):143-8

5. 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.

6. Borst F, Lovis C, Thurler G, Maricot P, Rossier P, Revillard C, Scherrer JR.Happy birthday DIOGENE: a hospital information system born 20 years ago. Stud Health Technol Inform. 1998;52 Pt 2:922-6.

7. Bréant C, Borst F, Campi D, Griesser V, Le HS. Expanding DIOGENE with a clinical information system based on a new hospital-wide clinical finding dictionary. Stud Health Technol Inform. 1999;68:7-11.

8. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2232696&blobtype=pdf

9. Shachak A, Hadas-Dayagi M, Ziv A, Reis S. Primary Care Physicians' Use of an Electronic Medical Record System: A Cognitive Task Analysis. J Gen Intern Med 2009 Mar;24(3):341-8. Epub 2009 Jan 7.

10. Li L, Chase HS, Patel CO, Friedman C, Weng C. Comparing ICD9-encoded diagnoses and NLP-processed discharge dummaries for clinical trials pre-screening: a case study. AMIA Annu Symp Proc 2008 Nov 6:404-8.

11. Breant C, Borst F, Campi D, Griesser V, Le HS, Junod JM. Expanding DIOGENE with a clinical information system based on a new hospital-wide clinical findings dictionary. International Journal of Medical Informatics. 2000; 58-59: 167-177.

12. Pittet D, Safran E, Harbarth S, Borst F, Copin P, Rohner P, Scherrer J-R, Auckenthaler R. Automatic Alerts for Methicillin-Resistant Staphylococcus aureus Surveillance and Control: Role of a Hospital Information System . Infection Control and Hospital Epidemiology. 1996 Aug;17(8):496-502.