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Biomedical subjects

P F de Vries Robbé

Publications and source records attributed to P F de Vries Robbé.

At least 19 recordsLinked to original sources
PubMed2006

Patient-centred care: using online personal medical records in IVF practice.

BACKGROUND: Generic patient-accessible medical records have shown promise in enhancing patient-centred care for patients with chronic diseases. We sought to design, implement and evaluate a patient-accessible medical record specifically for patients undergoing a course of assisted reproduction (IVF or ICSI). METHODS: The personal medical record (PMR) database was developed using three formative evaluation steps, and its user-experience was evaluated through a cross-sectional study. Fifty-four patient-couples receiving an IVF or ICSI treatment in our hospital were granted access to the PMR. Main outcomes concern the usage of the PMR, the perceived usefulness of its functions and user attitudes towards privacy and financial issues. RESULTS: The PMR consists of 15 major functions that can be classified into personal information, general information and communication functions. Fifty-three patient-couples accessed the website and 51 couples filled out the evaluation questionnaire. They rated most functions as useful and preferred personalized to general functions. The results also show that some functions require further development. Patients using the PMR have little concerns regarding privacy, and 76% are willing to pay for such a service in the future. CONCLUSIONS: The patients in this study frequently and intensively used the Internet-accessible PMR. This suggests that the PMR offers very useful functions from an IVF/ICSI patient's perspective.

Databases, Factual↗
PubMed2003

A generic model of clinical practice.

OBJECTIVES: Many shared-care projects feel the need for electronic patient-record (EPR) systems. In absence of practical experiences from paper record keeping, a theoretical model is the only reference for the design of these systems. In this article, we review existing models of individual clinical practice and integrate their useful elements. We then present a generic model of clinical practice that is applicable to both individual and collaborative clinical practice. METHODS: We followed the principles of the conversation-for-action theory and the DEMO method. According to these principles, information can only be generated by a conversation between two actors. An actor is a role that can be played by one or more human subjects, so the model does not distinguish between inter-individual and intra-individual conversations. RESULTS: Clinical practice has been divided into four actors: service provider, problem solver, coordinator, and worker. Each actor represents a level of clinical responsibility. Any information in the patient record is the result of a conversation between two of these actors. Connecting different conversations to one another can create a process view with meta-information about the rationale of clinical practice. Such process view can be implemented as an extension to the EPR. CONCLUSIONS: The model has the potential to cover all professional activities, but needs to be further validated. The model can serve as a theoretical basis for the design of EPR-systems for shared care, but a successful EPR-system needs more than just a theoretical model.

Communication↗
PubMed2003

Why don't medical textbooks teach? The lack of logic in the differential diagnosis.

Medical textbooks are an important aid in the process of diagnosing and treating patients. Medical students use these books to acquire the skills necessary for this process, while medical teachers and experienced doctors use them for teaching these competences. We posed the question whether medical textbooks are structured in such a way that medical students are taught to structure knowledge and to make a differential diagnosis in a logical way. Five major textbooks were compared with regard to four clinical problems (gastrointestinal bleeding, anaemia, oedema and heart failure). The presentation appeared to be very variable in respect of logic and systematic arrangement. In fact, it was disappointing that even in well-reputed textbooks, a systematic approach is lacking. We feel there is a need for improvement, in order to facilitate the learning of medical students and to enhance their abilities in clinical problem solving.

Diagnosis, Differential↗
PubMed2001

Towards a more rational use of psychoactive substances in clinical practice.

Complex knowledge and data intensive nature of the psychoactive drug selection and prescription process often makes for irrational and inconsistent use of psychoactive drugs in clinical practice. After describing the state of the art with respect to psychoactive drug prescription practices and selection processes, our aim is to analyze the advantages of computer support systems in assisting the clinician in his clinical decisions. Finally, we will review the neuropsychiatric expert systems developed for the neuropsychiatric domain. Suboptimal psychoactive drug therapy is common practice, which leads to hospital admissions, extended length of hospital stay, ineffective therapy and increased costs. Furthermore, the psychoactive drug selection process is a complex decision process, using up-to-date integrative knowledge of drugs from basic sciences to the clinical level. Due to the information load, the lack of appropriate up-to-date information at the point of clinical care and the problem of integrating and weighing all information relatively equally, it is questionable whether any clinician can manage such a complex situation with optimal effectiveness. As has been shown in a number of experiments, clinicians can benefit from computer-based systems that provide access to accurate, up-to-date information. We maintain that more rational use of psychoactive drugs in clinical practice is needed, and conclude that rational psychoactive drug prescription is a knowledge and data-intensive task requiring true expertise derived from clinical, pathophysiological and pharmacotherapeutic knowledge. We will be developing a Multidisciplinary Psychoactive Drug Selection advisor system, M-PADS, to support the integration of various types of biomedical information and deliver that integrated information supportive to evidence-based rational drug prescription in the practice of medicine for the drug treatment of individual patients.

Decision Making, Computer-Assisted↗
PubMed2001

Interactive technology assessment and wide reflective equilibrium.

Interactive technology assessment (iTA) provides an answer to the ethical problem of normative bias in evaluation research. This normative bias develops when relevant perspectives on the evaluand (the thing being evaluated) are neglected. In iTA this bias is overcome by incorporating different perspectives into the assessment. As a consequence, justification of decisions based on the assessment is provided by stakeholders having achieved agreement. In this article, agreement is identified with wide reflective equilibrium to show that it indeed has the potential of justifying decisions. We work out several conditions for this agreement to be achievable and just.

Consensus↗
PubMed1999

Formal description of temporal knowledge in case reports.

Patient case analysis is an elementary and crucial process which clinicians are daily confronted with. The importance and complexity is reflected in the need to discuss cases in clinicopathological conferences and the documentation of more than 70,000 patient cases in MEDLINE. This paper introduces a generic patient case report language (PCRL) based on general medical temporal concepts to formalise temporal knowledge as present in case descriptions. The lack of such a generic technique is reflected by the fact that computers are very restrictive in accepting patient specific temporal information. Acceptance is almost always controlled and guided by specific predefined disease or treatment models. We strive for a case library consisting of unambiguous patient case descriptions formulated independent from future use.

Decision Making, Computer-Assisted↗
PubMed1999

Guidelines for using diagnostic imaging devices: an inference system.

This paper deals with optimising the use of magnetic resonance imaging (MRI) scanners through the development of a new kind of clinical guidelines called 'substrate-specific protocols'. These protocols would link the descriptive elements of lesions to the most appropriate imaging techniques on the basis of the biophysics of MRI. As many lesions have elements in common, substrate-specific protocols could have a more general character and be more firmly based on evidence than conventional guidelines. We developed an inference model to enter, structure and retrieve knowledge acquired through a literature search. This proved a practicable and attractive approach. Its exactness, however, reveals the imperfections of medical knowledge and clinical practice. We conclude that it could be hard to establish an 'evidence basis' for clinical guidelines, if 'evidence based' means rooted in natural science.

Biophysical Phenomena↗
PubMed1999

Reducing normative bias in health technology assessment: interactive evaluation and casuistry.

Health technology assessment (HTA) is often biased in the sense that it neglects relevant perspectives on the technology in question. To incorporate different perspectives in HTA, we should pursue agreement about what are relevant, plausible, and feasible research questions; interactive technology assessment (iTA) might be suitable for this goal. In this way a kind of procedural ethics is established. Currently, ethics too often is focussed on the application of general principles, which leaves a lot of confusion as to what really is the matter in specific cases; in an iTA clashes of values should not be approached by use of such ethics. Instead, casuistry, as a tool used within the framework of iTA, should help to articulate and clarify what is the matter, as to make room for explication and consensus building.

Casuistry↗
PubMed1999

Nosology and causal necessity; the relation between defining a disease and discovering its necessary cause.

The problem of disease definition is related to the problem of proving that a certain agent is the necessary cause of a certain disease. Natural kind terms like 'rheumatoid arthritis' and 'AIDS' refer to essences which are discoverable rather than predeterminate. No statement about such diseases is a priori necessarily true. Because theories on necessary causes involve natural kind semantics, Koch's postulates cannot be used to falsify or verify such theories. Instead of proving that agent A is the necessary cause of disease D, we include A in a theoretical definition of D, take this to represent the real meaning of 'D', and discard the pretheoretical definition. This is illustrated by Koch's own attempt to prove he had discovered the necessary cause of tuberculosis. Methodological arguments about disease causation require a clear view of our use of diagnostic terms. Medical lexicographers should do more to provide such a view.

Diagnosis, Differential↗
PubMed1999

Optimizing diagnostic test sequences: the probability modifying plot.

The problem of deciding the optimal sequence of diagnostic tests can be structured in decision trees, but unmanageable bushy decision trees result when the sequence of two or more tests is investigated. Most modelling techniques include tests on the basis of gain in certainty. The aim of this study was to explore a model for optimizing the sequence of diagnostic tests based on efficiency criteria. The probability modifying plot shows, when in a specific test sequence further testing is redundant and which costs are involved. In this way different sequences can be compared. The model is illustrated with data on urinary tract infection. The sequence of diagnostic tests was optimized on the basis of efficiency, which was either defined as the test sequence with the least number of tests or the least total cost for testing. Further research on the model is needed to handle current limitations.

Decision Support Techniques↗
PubMed1998

[Re-restoration decisions].

OBJECTIVE: In this study an attempt was made to explain some of the interobserver variation in re-restoration decision making using. METHOD: A simplified re-restoration case was shown to 22 dentists who were asked what treatment decision they would make, and what factors would play a role in their decision. The treatment decisions were compared to the outcomes of a knowledge-system on re-restoration decision making. RESULTS: The dentists unanimously selected re-restoration as the treatment alternative. Half of the dentists preferred amalgam, and the other half chose composite as restorative material. This variation could be explained almost fully by the dentists' weighs on the factors 'tissue loss during preparation', 'restoration and preservation of the chewing function' and 'prognosis and durability of the restoration'. The knowledge system indicated that more than 80% of the dentists actually should have selected composite resin for a restorative material. CONCLUSIONS: It was concluded that the availability of knowledge and its application can explain variation in re-restoration decisions. Knowledge systems can be used in designing practice guidelines.

Decision Making↗
PubMed1998

Three types of IS-A statement in diagnostic classifications: three types of knowledge needed for development and maintenance.

Update mechanisms for diagnostic classifications should capture changes in medical knowledge but also allow for comparability across versions. This paper provides a basis for such a mechanism by describing types of IS-A statement and types of knowledge used in the construction of diagnostic classifications. Three types of IS-A statement are used: 'A is by definition a B', 'A is probably a B' and 'A is in theory necessarily a B'. Each relates to a different type of knowledge: knowledge of linguistic conventions, of probabilities, and of empirical theories and their status, respectively. Consequently, the development and maintenance of diagnostic classifications requires a collaboration of medical terminologists and medical scientists. The role of the latter is especially important during updating. Updating is necessitated by changing probabilities and by the introduction or changing status of empirical theories. The linguistic notion of hyponymy oversimplifies the issue.

Artificial Intelligence↗
PubMed1997

Medical narratives in electronic medical records.

In this article, we describe the state of the art and directions of current development and research with respect to the inclusion of medical narratives in electronic medical-record systems. We used information about 20 electronic medical-record systems as presented in the literature. We divided these systems into 'classical' systems that matured before 1990 and are now used in a broad range of medical domains, and 'experimental' systems, more recently developed and, in general, more innovative. In the literature, three major challenges were addressed: facilitation of direct data entry, achieving unambiguous understandability of data, and improvement of data presentation. Promising approaches to tackle the first and second challenge are the use of dynamic data-entry forms that anticipate sensible input, and free-text data entry followed by natural-language interpretation. Both these approaches require a highly expressive medical terminology. How to facilitate the access to medical narratives has not been studied much. We found facilitating examples of presenting this information as fluent prose, of optimising the screen design with fixed position cues, and of imposing medical narratives with a structure of indexable paragraphs that can be used in flowsheets. We conclude that further study is needed to develop an optimal searching structure for medical narratives.

Database Management Systems↗
PubMed1995

Primary care guidelines from an organizational point of view.

Guidelines in primary health care have been developed to reduce assumed and undesired variation in certain aspects of care delivery by professionals. If systematically applied guidelines no doubt effect the quality of care. It is argued however that taking an organizational point of view on quality management yields new requirements with respect to development and application of guidelines. It is considered to be essential for managerial control purposes that guidelines have simple and valid indicators to monitor the actual application and to measure the preferred outcome. It is essential that the choice of guidelines to be implemented in an organization is determined in the context of an explicit plan for quality management.

Humans↗