An Interoperable Electronic Health Record System for Clinical Cardiology

Round 1

Reviewer 1 Report

The subject of the article is interesting and worth describing. However, the method of implementation requires correction. In the Introduction, the authors presented an introduction to the subject. The Introduction section is deficient. It does not contain all the necessary elements. The main goal of the research and specific goals were not clearly defined. The main goal is in section 2 but should be in section 1. The Introduction section should include research hypotheses or research questions. At the end there should be information about the content of each section.
The layout of the work is not entirely correct. I have already listed what should be in section 1 Introduction. The Materials and Methods section needs to be supplemented. There should be information about the research period and more detailed about the scope of the research. This information was found in the Discussion section, which is a misunderstanding. There is space in section 2 for listing the test steps.
The Results section actually contains a description of the system, procedures. Of course, this can be seen as a presentation of a new system. This part is more informative than scientific.
There should be a separate Discussion section. It was created as Discussion and Conclusions. The content of this section is a misunderstanding. I understand a discussion as referring to other studies after presenting my research results. In my opinion, doing research without a clear comparison and reference to other research results in the fact that the obtained results cannot be properly assessed. There is some literature review in this Chapter 1, but it is more concerned with the Introduction section. There is no broad scientific discussion.
Conclusion section is incomplete and should be a separate section. The conclusions can be bulleted. You must certainly refer to the hypotheses set at work. Have they been verified positively or negatively? Future research directions should also be provided.
Reading the article, I have the impression that this is a description of the organization of the system, not a scientific work.
Other remarks:
There are too many shortcuts. It often feels as if the abbreviation has not been explained beforehand. You can explain the abbreviations in one article place.

Author Response

We have added the suggested parts in the introduction and in the materials and methods section.

We have added UML diagrams and practical implications of the system in the results section

We have inserted a discussion section with the suggested content and a description of security issues.

We have inserted the suggested parts in the conclusion section

Reviewer 2 Report

The paper presents an interesting subject, certainly appropriate and worth publishing. Unfortunately, the presentation style is difficult to follow. I have a few language issues listed below, but that list is far to be comprehensive. The authors must consider to carefully proofread the whole article and considerably improve the presentation style.

A few language issues (the list is not comprehensive):

• line 14: EHR acronym is first used, but not explained
• line 16: "ex-change" should be "exchange", I don't see why using the hyphen
• line 34: "of a e-Health services" should be either "of a e-Health service" or "of e-Health services"
• line 42: "digitised" should be "digitise"
• line 49: "record" should be "records"
• lines 54-55: the phrase ending with citation [5] needs to be rephrased, it is difficult to understand
• line 57: "system" should be "systems"
• line 63: "which are increasingly" should be "which is increasingly"
• line 64: "represent" should be "represents" (alternatively: change everything to plural: "EHR systems", etc)
• line 83: "and is regarded" should be "and it is regarded"
• line 92: "exchange data to with", remove "to"
• line 98: should be "is to design, produce, deploy and test"
• line 106: it looks like RHII first appears here, what is it?
• line 114: "in Italy is" should be "in Italy, is"
• line 122: "is needed, with" should be "is needed, from"
• line 129: RHII again?
• line 130: "all documents to the" should be "all documents of the"; what are these standards, anyway? Note that the reader is likely not that familiar with these terminology/standards. They need to be explained and cited, as appropriate
• line 141: VS and PAM? What are they and where in Figure 2? Below, in line 150, Figure 2 is described as representing CEHRS. What's the relation with the VS and PAM? The claim is that there are three main sections, but there are four squares at that level (what's the "closed admission"?)
• line 154 (and subsequent): is it "amnesis" or "amnesia"?
• line 219: should be "Figure 3", for consistency (please check other places, like in lines 243, 251)
• line 322: "..." should better be "etc"
• line 323: It doesn't look like you should use a new paragraph, let alone start the sentence with lower case.
• A suggestion for discussion/conclusion: using some graphs (or even tables) would improve the presentation and better show the significance of contributions

Author Response

We have revised the manuscript. If further improvements are required we would use the journal's language support service.

We have added a therapy administration class graph, however we have included it in the results section rather than in discussion/conclusion because it relates to the therapy management subsection. 

It's anamnesis, that is an account of the medical history of the patient.

Reviewer 3 Report

This article presents an Electronic Health Record (EHR) System dedicated to a cardiology ward as a web-based platform, being integrated to a Hospital Information Systems, being used by two Italian hospitals in Genova. The article describes in its results section the architectural schemes about HER System’s modules and interfaces with other components of the major systems to which the EHR System was deployed. It is an interesting technical report, but it still can be improved. 

Following I make some indications to support authors:

1.    In the abstract you defined: “An EHR system has been 14 specifically developed…”. However I understood HER means Electronic Health Record, it is necessary to present the complete name of the system before to introduce the acronym. The same for HL7. The concept of Health Level 7 is formally presented just on Introduction’s line 73, page 2.

2.    About the engineering process of the system, does the authors have any UML essential diagram to include or in the text or in an appendix. Examples: diagrams of use cases, activities, classes, states, sequence. I believe the provision of diagrams like these make the most interesting project report for software engineers, for example.

3.    About the interfaces implemented, could not you provide some examples? This would also considerably enrich the presentation of the results part.

4.    On the issue of information security, considering that sensible information circulates in the EHR System developed: how the authors dealt with it? It is important to have a section at work to address this issue at technical and managerial level. Some suggestions of materials to help authors:

Sittig, D.F.; Belmont, E.; Singh, H. Improving the safety of health information technology requires shared responsibility: It is time we all step up. Healthcare 2018, 6, 7–12. https://doi.org/10.1016/j.hjdsi.2017.06.004

Alami, H.; Gagnon, M.; Ali, M.; Ahmed, A.; Fortin, J. Digital health: Cybersecurity is a value creation lever, not only a source of expenditure. Health Policy Technol. 2019, 8, 319–321. https://doi.org/10.1016/j.hlpt.2019.09.002

Poleto, T.; Carvalho, V.D.H.d.; Silva, A.L.B.d.; Clemente, T.R.N.; Silva, M.M.; Gusmão, A.P.H.d.; Costa, A.P.C.S.; Nepomuceno, T.C.C. Fuzzy Cognitive Scenario Mapping for Causes of Cybersecurity in Telehealth Services. Healthcare 2021, 9, 1504. https://doi.org/10.3390/healthcare9111504

Butt GQ, Sayed TA, Riaz R, Rizvi SS, Paul A. Secure Healthcare Record Sharing Mechanism with Blockchain. Applied Sciences 2022; 12(5):2307. https://doi.org/10.3390/app12052307

Lima, Vinicius Costa and Felipe Carvalho Pellison, Filipe Andrade Bernardi, Domingos Alves, and Rui Pedro Charters Lopes Rijo. Security Framework for Tuberculosis Health Data Interoperability Through the Semantic Web. International Journal of Web Portals (IJWP) 2021, 13, no.2: 36-57. http://doi.org/10.4018/IJWP.2021070103

5.    I suggest that authors create a new section, on the practical implications of the developed system, trying to respond in an objective way questions such as: How did it improve the availability and circulation of patient data, for example, given their use in two hospitals? What has this system brought from innovative to clinical information management? Did it improve the efficiency of the activities exercised by the professionals who use it?

Author Response

We have introduced the EHR acronym both in the abstract and in the introduction, because a EHR is one of the keywords because of its very frequent use, and the same for HL7 standard, which is also very frequently used. Therefore we have introduced both EHR and HL7 in the abstract even though introduction of acronyms in abstracts is not very frequent. We have added references on the used HL7 standards in the methods section.

We have added UML diagrams in the results section.

Examples of the messages produced by the interfaces that have been implemented are in figure 6 and 8

We have added aspects on security in the discussion section. We also added an appendix describing details on the security aspects of the system with specific features relating to the requirements of Liguria region.

Practical implication of the developed system are described in the conclusion section.

Round 2

Reviewer 1 Report

The article was well corrected and can be published.

Reviewer 2 Report

I find the revised version satisfactory for publication.