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OJHAS Vol. 9, Issue 3:
(Jul - Sep, 2010) |
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| Development
of a Cost-Effective Database Software for Psychiatric Research: A Study From Tertiary Care Teaching Hospital |
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Sabu Karakkamandapam, Professor & Head, Department of Health Information Management, Manipal college of Allied Health
Sciences, Manipal University, Karnataka, India,
Narayanan SreeKumaran
Nair, Professor & HOD, Department
of Statistics, Manipal University, Karnataka, India,
PSVN Sharma, Professor & HOD, Department
of Psychiatry, Kasturba Medical College, Manipal University, Karnataka,
India. |
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Address For Correspondence |
Associate Professor & HOD,
Department of Health Information
Management,
Manipal college of Allied Health Sciences,
Manipal University,
Manipal - 576104,
Karnataka, India.
E-mail:
sabu.km@manipal.edu |
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Sabu KM, Nair NS, Sharma PSVN. Development
of a Cost-Effective Database Software for Psychiatric Research: A Study From Tertiary Care Teaching Hospital. Online J Health Allied Scs.
2010;9(3):8 |
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Submitted: Feb 22, 2010;
Suggested revision: Jul 26, 2010;p Revised: Jul 28, 2010; Accepted:
Sep 30, 2010; Published: Oct 15, 2010 |
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| Abstract: |
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Background: Technological progression
made drastic changes in health care. Still there is a growing concern
about proper utilization of health information within hospitals for
various research activities. Huge volumes of such health information
in majority of hospitals are redundant due to lack of appropriate and
cost-effective technological tools for retrieving relevant health information
for research purpose. Objective: To develop a cost-effective
and user-friendly computerized medical record database for psychiatry
using available technology with the department.
Methodology: Study performed at a tertiary care teaching hospital
in Udupi district of South India. Various datasets from psychiatry medical
records were utilized for the design and creation of database. A computerized
database called PsyCase was developed with the help of technology available
within the department. A 4612 patient’s data were entered into the
PsyCase and subjected to various analyses. Results: Applications
of PsyCase in various epidemiological studies were explored through
performing numerous analyses with actual data. PsyCase was found effective
in supporting psychiatric research as well as routine clinical and administrative
activities. Conclusion: This study emphasizes need of appropriate
use of technology available within a healthcare system to facilitate
medical research in psychiatry and role of health information professional
in such initiatives. Healthcare organization must focus on collective
utilization of resources within the system to improve the utilization
of health information for medical research.
Key Words: Cost-effective; Database; Epidemiology;
Medical records; Psychiatry
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Proper maintenance of medical record
information and its successful utilization is crucial at all levels
of health care management. Even though health care settings maintains
Health Information Systems (HIS), there are not many provisions available
with majority of the hospital health information system to comprise
appropriate indicators to monitor continuity of care of individual patients’
as well as to enable medical research.(1) Health Information Management
(HIM) professionals need to address various issues in managing health
care data in a scientific way.
Information Technology for effective
data management functions in a variety of applications including outcomes
management, research databases, decision-making and strategy development
by using variety of analytic tools and databases.(2) Epidemiology and
health information management are two fields that complement each other,
validity and reliability of the data managed by health information professionals
are essential to the soundness and integrity of epidemiological research.(3)
HIM professionals play a significant role in managing health information
in any health care setup. In view of the complexity of psychiatric clinical
data and the lack of appropriate database management system for psychiatry,
innovative research on how effectively technology can exploit psychiatric
health care data to enable medical research is highly relevant. Many
a time’s individual medical departments find it difficult to use HIS
available in hospital or market either due to lack of appropriate specialty
specific modules in HIS or due to high cost factor. However, in India
no scientific attempt has been made so far by HIM professionals and
psychiatrists together to develop a customized and computerized database
on medical records with available technology to meet requirements of
psychiatric research.
Objective
To develop a cost-effective and user-friendly
computerized medical records database for psychiatry for easy retrieval of health information, to enhance research and to explore the feasibility of usage of the developed
database for understanding the clinical epidemiology of psychiatric
disorders.
Study Setting
Study was conducted at the department
of psychiatry in a tertiary care teaching hospital located in Udupi
district of Karnataka state. The department of Psychiatry has an average
patient strength of 1000 new patients per year. About 75% of patients’
are from Karnataka state and 15% of patients’ are from Kerala state.
Data Source
Department maintains a well-structured
medical record for each patient and that formed the data source for
the study. A total of 4612 patients’ records for five years were utilized
for the study. Each psychiatry record includes a psychiatry outpatient
detailed evaluation record with other relevant reports according to
type of care received by the patient. Entries into psychiatry outpatient
detailed evaluation record are made by attending psychiatrist through
systematic deliberation and discussion with patient and patient relatives
based on standard diagnostic criteria. Patient treatment was planned
based on this information along with other investigation reports.
Compare to other medical specialties
the psychiatry outpatient detailed evaluation record is exhaustive,
it contains patient identification data, provisional, differential and
final diagnosis and treatment details, socio-demographic data, patient
& informants report, past illness details, family history, personal
history, pre-morbid personality details, mental status examination and
diagnostic formulation details. Diagnosis is based on International
classification for disease coding (ICD) 10th revision classification
of mental and behavioral disorders diagnostic criteria for research
guidelines. In Psychiatry, diagnosis is arrived based on multi-axial
system of classification. Axis – I refers to mental state diagnosis,
axis 2 to abnormalities of personality, axis 3 describes physical illnesses
contributing to the emotional problems, axis 4 refers to the optimum
level of social functioning and axis 5 to stressors.(4) Socio-demographic details includes – Marital status, religion, education,
occupation, residence, distance, income source, total family income
from all source, family type, family size, head of family & occupation.
Past illness contains details about past psychiatric illness, total
duration, course of illness and past physical illness. Family history
part includes details of consanguinity between patient parents, family
tree, family history of mental illness and intrafamilial relationships.
Personal history contains details about patient birth and early development,
presence of childhood disorders, home atmosphere in childhood and adolescence,
scholastic and extra curricular activities, adolescent sexual activity,
occupational history, marital history and family of procreation, interpersonal
relations and social activity and menstrual history.
Pilot Study
A pilot study was carried out to identify
the relevant datasets to include for the design of database module as
well as data collection instruments according to the study objectives.
A 100 psychiatry patients’ medical record with detailed patient evaluation
report was used for this purpose. Each patient medical record and detail
evaluation report was thoroughly analyzed for consistency, accuracy
and relevance of information documented. Based on the pilot study and
further discussion with psychiatrist, pertinent areas in patient detail
evaluation report which is relevant for research and clinical evaluation
purpose were included for creation of database module.
Development of Database
Customized, cost effective and user-friendly
database software for psychiatry was developed with the help of Ms.
Access and Visual Basic (Windows programming language). Visual
basic is a powerful programming language used to develop sophisticated
windows program very quickly and it is one of the Rapid Application
Development (RAD) tools which enable development of application very
easily and quickly.(5) During development of this software factors like
user-friendliness, different type of epidemiological analysis and flexibility
for future modification were considered. This particular software was named as PsyCase.
Various phases in development
of PsyCase
PsyCase was developed through various
phases. All phases underwent regular systematic validation and efficiency
check for prompt generation of desired outcome. Adequate trial run and
modifications was carried out before finalization of each component
of database based on expert opinion. In first phase different database
tables were designed. In second phase various user-Interface
structures for the database were developed with Visual Basic 6.0 version
as this application was readily available within the facility during
development of this software. In third phase, a query module was developed
exclusively to facilitate epidemiological research. A follow-up module
was designed in fourth phase to update patient’s information during
follow-up visits without altering any of the previous follow-up visits
details. The last phase of PsyCase development was creation of different
utilities to generate various formatted reports. The software was specifically
designed for use in individual computer systems even without Visual
Basic. 6 tools.
PsyCase
Validation & Analysis
All 4612 patients’ data were entered
into the database for validation of PsyCase and analysis of data. Validation
of PsyCase software was carried out through two steps. In first step
ten different queries were framed and were analyzed manually and as
a second step all the same 10 analyses were carried out with PsyCase
software. Results of all 10 analysis carried out by both methods were
compared for accuracy and consistency. After validation of software,
different application of PsyCase in epidemiological research was explored
through performing various analyses.
The objective of the study was to develop
a computerized psychiatry patient database to enable various psychiatric
research activities, and it was achieved by successful development of
PsyCase. It contains 23 User interface modules, one master table and
18 sub tables. PsyCase can be installed in a system with Windows 98
or higher versions as operating system, 500MHz system or higher, 256MB
RAM memory, 700MB of free hard drive space and minimum supportive application
software
PsyCase Modules
PsyCase contains five main modules. Details and its application are
discussed below
Data Entry Module
This module contains five frames. The
first frame is ‘patient abstract’ which contains patient identification,
diagnosis, treatment particulars and ICD coding options. The second
frame contains 15 fields, which represents socio-demographic aspects
of patient. Third frame ‘patient report’ contains 17 fields which
include information such as reliability and adequacy of patient and
informants report, stressors, past psychiatric and physical illness,
course and duration of illness. The fourth frame ‘family history’
contains 13 fields which include consanguinity of parents, information
about first degree relatives, family history of mental illness and Intrafamilial
relationship. The fifth frame ‘Patient personal History’ contains
18 fields to accommodate information on patient personal history. User
can login to the PsyCase with the password according to type of user.
Three types of user options are available; they are ‘Authorized user’,
‘Visitor’ and ‘Data entry’. Authorized user can access all the
facility, while some of the facilities are restricted to other users.
Through data entry module first visit particulars of patient
can be entered in the database. It has been observed that on an average
it takes 4-5 minutes to complete the entire data entry of a single medical
record into PsyCase.
View record and Edit record are two
sub modules available with data entry module. View Record module
meets the requirements of viewing the particulars of entire patients’
or selected patient data. Through ‘Edit Record’
facility only authorized user can edit the first visit details of patients
based on changes made in actual medical records. All the facilities
in this software can be protected with password according to type of
user.
Follow-up Module
Psychiatric patient’s management
and treatment is a long term approach and patients visits clinic for
many years for follow-up. So, follow-up details are also very important
for research and evaluation of patient and this module of PsyCase meet
these requirements. Add follow-up module permits the user to update
some of the specified information of patient on each follow-up visit
with out altering previous visits or first visit details. View Follow-up
option generates outputs in a tabular format, which provides user a
quick access to first visit and any number of follow-up details of a
particular patient simultaneously.
ICD Module
Maintaining uniformity in entry of
diagnosis and its code by various clinicians and data entry persons
is very important for the reliability of the database, this module assures
that reliability. The main utility of this module is to provide information
on various ICD codes based on ICD-10th revision classification
of mental and behavioral disorders diagnostic criteria for research
guidelines. ICD Code module provides maximum utility through its two
sub modules add ICD codes and view ICD codes. Authorized user can update
or modify the details in ICD table.
Query Module
From analysis and epidemiological perspective
this is one of the important modules in PsyCase. This module was designed
in way to give maximum usage of patient information available in the
database for epidemiological and other research activities. This facility
permits the user to do independent query as well as group query. All
fields present in the database are available in a separate selection
window for the user’s convenience to frame a condition. A condition
or query for analysis can be designed by selecting desired fields and
its value with appropriate tools available in query window. On execution
of query user get a desired output and these results are also automatically
stored in an Excel file which can be later used for detailed statistical
analysis.
Follow-up analysis module allows the
user to analyze the patient first visit and all follow-up details simultaneously.
For example if a psychiatrist want to do an analysis, on how many patients’
diagnosed with – ‘Schizophrenia’ in the first visit changed to
a new diagnosis ‘Paranoid schizophrenia’ over a period of five years
follow up and contributing factors such as age, occupation etc. To perform
the above mentioned analysis by manual methods is difficult and time
consuming. With this module such analysis are done quickly. Once an
analysis or query is administered, on an average PsyCase take two minutes
to generate the result.
Utility Module
This module contains various utilities
which can be used for routine administrative and research activities.
The search module helps users to locate the patient psychiatry number
and brief identification details. It helps to view basic details of
the patient during the instance when medical record was not able to
retrieve. ‘Reports’ module generates various types of formatted
reports based on information available in the main database table. Nine
built-in options are available for generation of formatted reports for
any specified period. Through ‘Patient specific report’ option complete
report of a specific patient can be generated. ‘Statistics’ module enables the user to generate descriptive statistics based on
some of the common entities such as state, district, age, religion,
marital status etc. There are 12 such options available to derive gender
specific descriptive statistics on distribution of mental disorders.
This module helps administrators, psychiatrists and policy makers to
generate routine statistics quickly and comfortably through formatted
reports.
Validation of Software
The important step towards implementation
of software package is assessment of its validity. Validity of instrument
is, verifying whether it is doing what it is expect to do. The PsyCase
package also underwent this testing. Results generated by manual method
with the help of Microsoft Access and results generated by PsyCase for
all 10 analyses were cross-examined for the accuracy and consistency.
Results of all 10 analysis performed by both methods are matching and
found to be correct.
The
structure and facilities provided in the PsyCase database ensure easy
maintenance and retrieval of patient information for various epidemiological
studies. PsyCase have many unique facilities compared to many conventional
database packages available in market. On evaluating various facilities
of PsyCase with the existing database packages available in market such
as PsyReport,(6) VitalNet,(7) GPRD etc,(8) PsyCase modules are distinct as it is specifically designed
to facilitate epidemiological research exclusively for psychiatry. Many
database packages available are vendor made and designed for administrative purposes such as billing or processing of insurance claims.
GC’s Technologies HIMS software(9) and Medic Aid – windows based
patient database developed by AMLA MEDIQUIP,(10) are some of the software
available in India. In a study on ‘an international review on database
use in psychiatry research’ conducted by Nicola Higgins and Louise
Howard reveals that most studies used essentially administrative
databases, containing basic diagnostic, demographic and service use
data.(8) The General Practice Research Database (GPRD) in the UK, the
world's largest clinical database is sourced from over 400 practices
which include mainly patient diagnoses, prescriptions, hospital referrals
and treatment outcomes.(8) However, there is no such database available
in India exclusively for Psychiatric research. With growing utility
of IT in health care, databases become an integral part of medical research,
patient’s diagnosis, treatment, monitoring and management in medical
practice. FilaDB (Filariasis patient information based database),
TbDB (Tuberculosis patient information based database), GynSoft
(Complete Gynecology patient information based database) ObSoft (Complete
Obstetrics patient information based database) PsySoft (Psychiatry patient
information based database) are some of the databases developed by Bioinformatics
centre of Mahatma Gandhi Institute of Medical Sciences, Sevagram on
these context.
Customized and cost effective database
which can supports clinicians, administrators, policy makers, epidemiologist
and researchers are vital in healthcare. Disease specific database for
epidemiological research are rarely found. Psychiatry is an area where
we cannot find such comprehensive computerized databases exclusively
designed to facilitate epidemiological research based on medical records.
Application of PsyCase
Descriptive studies are usually the
first phase of an epidemiological investigation. Through PsyCase various
kinds of simple and complex descriptive analyses were performed quickly
and easily. Healthcare administrators and policy makers require various
statistics on distribution of illness within the community for planning,
monitoring and implementation of health care process. Trends in occurrence
of disease and changing patterns of disease over a period of time, geographical
distribution of illness based on different parameters helps in health
care planning and initiation of various health care policies. Distribution
of patients’ on different geographic parameters such as district,
taluk, place etc is also useful information on this account. PsyCase
is successful in generating such type information for general or specific
purpose.
Presence of various co-morbid conditions
along with the main disorder can affect the prognosis. For example systematic
assessment and efficient medication are essential for management of
co-morbidity of schizophrenia.(11) With the help of PsyCase software
one can generate various baseline information to help such analysis.
Many psychiatric disorders are associated with several chronic physical
illnesses. Improving the monitoring of physical illness at psychiatry
setting is important for prognosis.(12) Through PsyCase software, various
co-morbidities (both psychiatric as well as physical) for a main diagnosis
or a group of diagnosis can be analyzed. Association of various risk
factors or attributes with different co-morbidities can be easily studied
with the help of PsyCase.
PsyCase was found effective in generating
cases for case control studies. In an example case control study to
examine the association of adult personality and behavioral disorders
and co-morbidity with gender, age, occupation and residence, a database
for cases was generated through PsyCase. For this particular study cases
are people with adult personality and behavioral disorders. The results
shows Adult personality and behavior disorders were rare disorder among
the study population. Among 4612 patients’, only 95 patients’ (2.06%)
diagnosed under this diagnostic category and it was predominant in men
(73.6%). A 62.11% of patients’ with this disorder were between the
age 15 and 29 and students (27.3%) contribute the single largest occupation
group. Both rural as well as urban populations had equal representation.
Like this one can get a clear picture about the characteristics of cases
and it will help in selection of cases. Thus PsyCase helps in quick
creation of database for cases.
Another application of PsyCase is in
advanced statistics like Discriminant analysis. Discriminant analysis
is a statistical technique that examines the set of variables
or predictors associated with a given subject and uses similarities
and differences to assign the subject to a group or class.(13) Discriminant
Analysis identifies those variables that contribute most to the differences
between groups. Once data has been periodically entered into PsyCase
database it can be used to generate various cross tables. In an example
analysis to identify factors or characteristics which discriminate patients’
with persistent mood [affective] disorders from patients’ with obsessive
compulsive disorders carried out with PsyCase shows that gender, age
group, martial status , education are statistically significant factors.
Further analysis can be carried out to identify various characteristics
or risk factors which discriminate one morbid entity from other as well
as identifying significant factors contributing to disease process.
Maintaining confidentiality of patient information when using medical
records for research is always a concern and it is more when medical
records are accessed manually. Such confidentiality issues can overcome
to a great extend by using computerized medical record database with
adequate security features.(14) PsyCase also assure the protection of
confidentiality of patient information when medical records are utilized
for research.
This study proved the attempt of developing
comprehensive computerized database for psychiatry research with out
a cost involvement. Such models of research are very essential to improve
the effective management and utilization of abundant health information
generated in thousands of hospital and clinics across our country. PsyCase
was found very helpful in carrying out various basic epidemiological
analysis, clinical studies and routine day-to day activities of psychiatry
department. Similar thoughts among various health information professionals
and clinicians in various healthcare organizations can drastically reduce
burden of hospital or departments on cost of acquiring costly HIS. Appropriate
use of technology available within health organizations can enhance
research based on medical records and improve the clinical outcomes.
This software was developed on windows
based application Visual Basic.6 for individual computer systems according
to requirements of psychiatric department. So this software is not compatible
with advanced web based application versions like VB.NET. However, based
on requirements, with necessary modifications this software can be upgraded
to higher versions.
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