BoB, a best-of-breed automated text de-identification system for VHA clinical documents.

PubMed

Ferrández, Oscar; South, Brett R; Shen, Shuying; Friedlin, F Jeffrey; Samore, Matthew H; Meystre, Stéphane M

2013-01-01

De-identification allows faster and more collaborative clinical research while protecting patient confidentiality. Clinical narrative de-identification is a tedious process that can be alleviated by automated natural language processing methods. The goal of this research is the development of an automated text de-identification system for Veterans Health Administration (VHA) clinical documents. We devised a novel stepwise hybrid approach designed to improve the current strategies used for text de-identification. The proposed system is based on a previous study on the best de-identification methods for VHA documents. This best-of-breed automated clinical text de-identification system (aka BoB) tackles the problem as two separate tasks: (1) maximize patient confidentiality by redacting as much protected health information (PHI) as possible; and (2) leave de-identified documents in a usable state preserving as much clinical information as possible. We evaluated BoB with a manually annotated corpus of a variety of VHA clinical notes, as well as with the 2006 i2b2 de-identification challenge corpus. We present evaluations at the instance- and token-level, with detailed results for BoB's main components. Moreover, an existing text de-identification system was also included in our evaluation. BoB's design efficiently takes advantage of the methods implemented in its pipeline, resulting in high sensitivity values (especially for sensitive PHI categories) and a limited number of false positives. Our system successfully addressed VHA clinical document de-identification, and its hybrid stepwise design demonstrates robustness and efficiency, prioritizing patient confidentiality while leaving most clinical information intact.

A study on design and development of enterprise-wide concepts for clinical documentation templates.

PubMed

Zhou, Li; Gurjar, Rupali; Regier, Rachel; Morgan, Stephen; Meyer, Theresa; Aroy, Teal; Goldman, Debora Scavone; Hongsermeier, Tonya; Middleton, Blackford

2008-11-06

Structured clinical documents are associated with many potential benefits. Underlying terminologies and structure of information are keys to their successful implementation and use. This paper presents a methodology for design and development of enterprise-wide concepts for clinical documentation templates for an ambulatory Electronic Medical Record (EMR) system.

Review and comparison of quality standards, guidelines and regulations for laboratories.

PubMed

Datema, Tjeerd A M; Oskam, Linda; Klatser, Paul R

2012-01-01

The variety and number of laboratory quality standards, guidelines and regulations (hereafter: quality documents) makes it difficult to choose the most suitable one for establishing and maintaining a laboratory quality management system. There is a need to compare the characteristics, suitability and applicability of quality documents in view of the increasing efforts to introduce quality management in laboratories, especially in clinical diagnostic laboratories in low income and middle income countries. This may provide valuable insights for policy makers developing national laboratory policies, and for laboratory managers and quality officers in choosing the most appropriate quality document for upgrading their laboratories. We reviewed the history of quality document development and then selected a subset based on their current use. We analysed these documents following a framework for comparison of quality documents that was adapted from the Clinical Laboratory Standards Institute guideline GP26 Quality management system model for clinical laboratory services . Differences were identified between national and international, and non-clinical and clinical quality documents. The most salient findings were the absence of provisions on occurrence management and customer service in almost all non-clinical quality documents, a low number of safety requirements aimed at protecting laboratory personnel in international quality documents and no requirements regarding ethical behaviour in almost all quality documents. Each laboratory needs to investigate whether national regulatory standards are present. These are preferred as they most closely suit the needs of laboratories in the country. A laboratory should always use both a standard and a guideline: a standard sums up the requirements to a quality management system, a guideline describes how quality management can be integrated in the laboratory processes.

Electronic Nursing Documentation: Patient Care Continuity Using the Clinical Care Classification System (CCC).

PubMed

Whittenburg, Luann; Meetim, Aunchisa

2016-01-01

An innovative nursing documentation project conducted at Bumrungrad International Hospital in Bangkok, Thailand demonstrated patient care continuity between nursing patient assessments and nursing Plans of Care using the Clinical Care Classification System (CCC). The project developed a new generation of interactive nursing Plans of Care using the six steps of the American Nurses Association (ANA) Nursing process and the MEDCIN^® clinical knowledgebase to present CCC coded concepts as a natural by-product of a nurse's documentation process. The MEDCIN^® clinical knowledgebase is a standardized point-of-care terminology intended for use in electronic health record systems. The CCC is an ANA recognized nursing terminology.

A Preliminary Study of Clinical Abbreviation Disambiguation in Real Time.

PubMed

Wu, Y; Denny, J C; Rosenbloom, S T; Miller, R A; Giuse, D A; Song, M; Xu, H

2015-01-01

To save time, healthcare providers frequently use abbreviations while authoring clinical documents. Nevertheless, abbreviations that authors deem unambiguous often confuse other readers, including clinicians, patients, and natural language processing (NLP) systems. Most current clinical NLP systems "post-process" notes long after clinicians enter them into electronic health record systems (EHRs). Such post-processing cannot guarantee 100% accuracy in abbreviation identification and disambiguation, since multiple alternative interpretations exist. Authors describe a prototype system for real-time Clinical Abbreviation Recognition and Disambiguation (rCARD) - i.e., a system that interacts with authors during note generation to verify correct abbreviation senses. The rCARD system design anticipates future integration with web-based clinical documentation systems to improve quality of healthcare records. When clinicians enter documents, rCARD will automatically recognize each abbreviation. For abbreviations with multiple possible senses, rCARD will show a ranked list of possible meanings with the best predicted sense at the top. The prototype application embodies three word sense disambiguation (WSD) methods to predict the correct senses of abbreviations. We then conducted three experments to evaluate rCARD, including 1) a performance evaluation of different WSD methods; 2) a time evaluation of real-time WSD methods; and 3) a user study of typing clinical sentences with abbreviations using rCARD. Using 4,721 sentences containing 25 commonly observed, highly ambiguous clinical abbreviations, our evaluation showed that the best profile-based method implemented in rCARD achieved a reasonable WSD accuracy of 88.8% (comparable to SVM - 89.5%) and the cost of time for the different WSD methods are also acceptable (ranging from 0.630 to 1.649 milliseconds within the same network). The preliminary user study also showed that the extra time costs by rCARD were about 5% of total document entry time and users did not feel a significant delay when using rCARD for clinical document entry. The study indicates that it is feasible to integrate a real-time, NLP-enabled abbreviation recognition and disambiguation module with clinical documentation systems.

Usage experience with the document archiving and communication system for the storage and retrieval of medical records.

PubMed

Takeda, Toshihiro; Ueda, Kanayo; Manabe, Shiro; Teramoto, Kei; Mihara, Naoki; Matsumura, Yasushi

2013-01-01

Standard Japanese electronic medical record (EMR) systems are associated with major shortcomings. For example, they do not assure lifelong readability of records because each document requires its own viewing software program, a system that is difficult to maintain over long periods of time. It can also be difficult for users to comprehend a patient's clinical history because different classes of documents can only be accessed from their own window. To address these problems, we developed a document-based electronic medical record that aggregates all documents for a patient in a PDF or DocuWorks format. We call this system the Document Archiving and Communication System (DACS). There are two types of viewers in the DACS: the Matrix View, which provides a time line of a patient's history, and the Tree View, which stores the documents in hierarchical document classes. We placed 2,734 document classes into 11 categories. A total of 22,3972 documents were entered per month. The frequency of use of the DACS viewer was 268,644 instances per month. The DACS viewer was used to assess a patient's clinical history.

[Development of an ophthalmological clinical information system for inpatient eye clinics].

PubMed

Kortüm, K U; Müller, M; Babenko, A; Kampik, A; Kreutzer, T C

2015-12-01

In times of increased digitalization in healthcare, departments of ophthalmology are faced with the challenge of introducing electronic clinical health records (EHR); however, specialized software for ophthalmology is not available with most major EHR sytems. The aim of this project was to create specific ophthalmological user interfaces for large inpatient eye care providers within a hospitalwide EHR. Additionally the integration of ophthalmic imaging systems, scheduling and surgical documentation should be achieved. The existing EHR i.s.h.med (Siemens, Germany) was modified using advanced business application programming (ABAP) language to create specific ophthalmological user interfaces for reproduction and moreover optimization of the clinical workflow. A user interface for documentation of ambulatory patients with eight tabs was designed. From June 2013 to October 2014 a total of 61,551 patient contact details were documented. For surgical documentation a separate user interface was set up. Digital clinical orders for documentation of registration and scheduling of operations user interfaces were also set up. A direct integration of ophthalmic imaging modalities could be established. An ophthalmologist-orientated EHR for outpatient and surgical documentation for inpatient clinics was created and successfully implemented. By incorporation of imaging procedures the foundation of future smart/big data analyses was created.

Semantic Clinical Guideline Documents

PubMed Central

Eriksson, Henrik; Tu, Samson W.; Musen, Mark

2005-01-01

Decision-support systems based on clinical practice guidelines can support physicians and other health-care personnel in the process of following best practice consistently. A knowledge-based approach to represent guidelines makes it possible to encode computer-interpretable guidelines in a formal manner, perform consistency checks, and use the guidelines directly in decision-support systems. Decision-support authors and guideline users require guidelines in human-readable formats in addition to computer-interpretable ones (e.g., for guideline review and quality assurance). We propose a new document-oriented information architecture that combines knowledge-representation models with electronic and paper documents. The approach integrates decision-support modes with standard document formats to create a combined clinical-guideline model that supports on-line viewing, printing, and decision support. PMID:16779037

Evaluation of Electronic Health Record Implementation in Ophthalmology at an Academic Medical Center (An American Ophthalmological Society Thesis)

PubMed Central

Chiang, Michael F.; Read-Brown, Sarah; Tu, Daniel C.; Choi, Dongseok; Sanders, David S.; Hwang, Thomas S.; Bailey, Steven; Karr, Daniel J.; Cottle, Elizabeth; Morrison, John C.; Wilson, David J.; Yackel, Thomas R.

2013-01-01

Purpose: To evaluate three measures related to electronic health record (EHR) implementation: clinical volume, time requirements, and nature of clinical documentation. Comparison is made to baseline paper documentation. Methods: An academic ophthalmology department implemented an EHR in 2006. A study population was defined of faculty providers who worked the 5 months before and after implementation. Clinical volumes, as well as time length for each patient encounter, were collected from the EHR reporting system. To directly compare time requirements, two faculty providers who utilized both paper and EHR systems completed time-motion logs to record the number of patients, clinic time, and nonclinic time to complete documentation. Faculty providers and databases were queried to identify patient records containing both paper and EHR notes, from which three cases were identified to illustrate representative documentation differences. Results: Twenty-three faculty providers completed 120,490 clinical encounters during a 3-year study period. Compared to baseline clinical volume from 3 months pre-implementation, the post-implementation volume was 88% in quarter 1, 93% in year 1, 97% in year 2, and 97% in year 3. Among all encounters, 75% were completed within 1.7 days after beginning documentation. The mean total time per patient was 6.8 minutes longer with EHR than paper (P<.01). EHR documentation involved greater reliance on textual interpretation of clinical findings, whereas paper notes used more graphical representations, and EHR notes were longer and included automatically generated text. Conclusion: This EHR implementation was associated with increased documentation time, little or no increase in clinical volume, and changes in the nature of ophthalmic documentation. PMID:24167326

[Development and integration of the Oncological Documentation System ODS].

PubMed

Raab, G; van Den Bergh, M

2001-08-01

To simplify clinical routine and to improve medical quality without exceeding the existing resources. Intensifying communication and cooperation between all institutions of patients' health care. The huge amount of documentation work of physicians can no longer be done without modern tools of paperless data processing. The development of ODS was a tight cooperation between physician and technician which resulted in a mutual understanding and led to a high level of user convenience. - At present all cases of gynecology, especially gynecologic oncology can be documented and processed by ODS. Users easily will adopt the system as data entry within different program areas follows the same rules. In addition users can choose between an individual input of data and assistants guiding them through highly specific areas of documentation. ODS is a modern, modular structured and very fast multiuser database environment for in- and outpatient documentation. It automatically generates a lot of reports for clinical day to day business. Statistical routines will help the user reflecting his work and its quality. Documentation of clinical trials according to the GCP guidelines can be done by ODS using the internet or offline datasharing. As ODS is the synthesis of a computer based patient administration system and an oncological documentation database, it represents the basis for the construction of the electronical patient chart as well as the digital documentation of clinical trials. The introduction of this new technology to physicians and nurses has to be done slowly and carefully, in order to increase motivation and to improve the results.

Relevance of health level 7 clinical document architecture and integrating the healthcare enterprise cross-enterprise document sharing profile for managing chronic wounds in a telemedicine context.

PubMed

Finet, Philippe; Gibaud, Bernard; Dameron, Olivier; Le Bouquin Jeannès, Régine

2016-03-01

The number of patients with complications associated with chronic diseases increases with the ageing population. In particular, complex chronic wounds raise the re-admission rate in hospitals. In this context, the implementation of a telemedicine application in Basse-Normandie, France, contributes to reduce hospital stays and transport. This application requires a new collaboration among general practitioners, private duty nurses and the hospital staff. However, the main constraint mentioned by the users of this system is the lack of interoperability between the information system of this application and various partners' information systems. To improve medical data exchanges, the authors propose a new implementation based on the introduction of interoperable clinical documents and a digital document repository for managing the sharing of the documents between the telemedicine application users. They then show that this technical solution is suitable for any telemedicine application and any document sharing system in a healthcare facility or network.

Electronic health record systems in ophthalmology: impact on clinical documentation.

PubMed

Sanders, David S; Lattin, Daniel J; Read-Brown, Sarah; Tu, Daniel C; Wilson, David J; Hwang, Thomas S; Morrison, John C; Yackel, Thomas R; Chiang, Michael F

2013-09-01

To evaluate quantitative and qualitative differences in documentation of the ophthalmic examination between paper and electronic health record (EHR) systems. Comparative case series. One hundred fifty consecutive pairs of matched paper and EHR notes, documented by 3 attending ophthalmologist providers. An academic ophthalmology department implemented an EHR system in 2006. Database queries were performed to identify cases in which the same problems were documented by the same provider on different dates, using paper versus EHR methods. This was done for 50 consecutive pairs of examinations in 3 different diseases: age-related macular degeneration (AMD), glaucoma, and pigmented choroidal lesions (PCLs). Quantitative measures were used to compare completeness of documenting the complete ophthalmologic examination, as well as disease-specific critical findings using paper versus an EHR system. Qualitative differences in paper versus EHR documentation were illustrated by selecting representative paired examples. (1) Documentation score, defined as the number of examination elements recorded for the slit-lamp examination, fundus examination, and complete ophthalmologic examination and for critical clinical findings for each disease. (2) Paired comparison of qualitative differences in paper versus EHR documentation. For all 3 diseases (AMD, glaucoma, PCL), the number of complete examination findings recorded was significantly lower with paper than the EHR system (P ≤ 0.004). Among the 3 individual examination sections (general, slit lamp, fundus) for the 3 diseases, 5 of the 9 possible combinations had significantly lower mean documentation scores with paper than EHR notes. For 2 of the 3 diseases, the number of critical clinical findings recorded was significantly lower using paper versus EHR notes (P ≤ 0.022). All (150/150) paper notes relied on graphical representations using annotated hand-drawn sketches, whereas no (0/150) EHR notes contained drawings. Instead, the EHR systems documented clinical findings using textual descriptions and interpretations. There were quantitative and qualitative differences in the nature of paper versus EHR documentation of ophthalmic findings in this study. The EHR notes included more complete documentation of examination elements using structured textual descriptions and interpretations, whereas paper notes used graphical representations of findings. The author(s) have no proprietary or commercial interest in any materials discussed in this article. Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

A Document-Based EHR System That Controls the Disclosure of Clinical Documents Using an Access Control List File Based on the HL7 CDA Header.

PubMed

Takeda, Toshihiro; Ueda, Kanayo; Nakagawa, Akito; Manabe, Shirou; Okada, Katsuki; Mihara, Naoki; Matsumura, Yasushi

2017-01-01

Electronic health record (EHR) systems are necessary for the sharing of medical information between care delivery organizations (CDOs). We developed a document-based EHR system in which all of the PDF documents that are stored in our electronic medical record system can be disclosed to selected target CDOs. An access control list (ACL) file was designed based on the HL7 CDA header to manage the information that is disclosed.

Embedding the shapes of regions of interest into a Clinical Document Architecture document.

PubMed

Minh, Nguyen Hai; Yi, Byoung-Kee; Kim, Il Kon; Song, Joon Hyun; Binh, Pham Viet

2015-03-01

Sharing a medical image visually annotated by a region of interest with a remotely located specialist for consultation is a good practice. It may, however, require a special-purpose (and most likely expensive) system to send and view them, which is an unfeasible solution in developing countries such as Vietnam. In this study, we design and implement interoperable methods based on the HL7 Clinical Document Architecture and the eXtensible Markup Language Stylesheet Language for Transformation standards to seamlessly exchange and visually present the shapes of regions of interest using web browsers. We also propose a new integration architecture for a Clinical Document Architecture generator that enables embedding of regions of interest and simultaneous auto-generation of corresponding style sheets. Using the Clinical Document Architecture document and style sheet, a sender can transmit clinical documents and medical images together with coordinate values of regions of interest to recipients. Recipients can easily view the documents and display embedded regions of interest by rendering them in their web browser of choice. © The Author(s) 2014.

Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research.

PubMed

Hanson, Janice L; Stephens, Mark B; Pangaro, Louis N; Gimbel, Ronald W

2012-11-19

There are no empirically-grounded criteria or tools to define or benchmark the quality of outpatient clinical documentation. Outpatient clinical notes document care, communicate treatment plans and support patient safety, medical education, medico-legal investigations and reimbursement. Accurately describing and assessing quality of clinical documentation is a necessary improvement in an increasingly team-based healthcare delivery system. In this paper we describe the quality of outpatient clinical notes from the perspective of multiple stakeholders. Using purposeful sampling for maximum diversity, we conducted focus groups and individual interviews with clinicians, nursing and ancillary staff, patients, and healthcare administrators at six federal health care facilities between 2009 and 2011. All sessions were audio-recorded, transcribed and qualitatively analyzed using open, axial and selective coding. The 163 participants included 61 clinicians, 52 nurse/ancillary staff, 31 patients and 19 administrative staff. Three organizing themes emerged: 1) characteristics of quality in clinical notes, 2) desired elements within the clinical notes and 3) system supports to improve the quality of clinical notes. We identified 11 codes to describe characteristics of clinical notes, 20 codes to describe desired elements in quality clinical notes and 11 codes to describe clinical system elements that support quality when writing clinical notes. While there was substantial overlap between the aspects of quality described by the four stakeholder groups, only clinicians and administrators identified ease of translation into billing codes as an important characteristic of a quality note. Only patients rated prioritization of their medical problems as an aspect of quality. Nurses included care and education delivered to the patient, information added by the patient, interdisciplinary information, and infection alerts as important content. Perspectives of these four stakeholder groups provide a comprehensive description of quality in outpatient clinical documentation. The resulting description of characteristics and content necessary for quality notes provides a research-based foundation for assessing the quality of clinical documentation in outpatient health care settings.

Analysis of Documentation Speed Using Web-Based Medical Speech Recognition Technology: Randomized Controlled Trial.

PubMed

Vogel, Markus; Kaisers, Wolfgang; Wassmuth, Ralf; Mayatepek, Ertan

2015-11-03

Clinical documentation has undergone a change due to the usage of electronic health records. The core element is to capture clinical findings and document therapy electronically. Health care personnel spend a significant portion of their time on the computer. Alternatives to self-typing, such as speech recognition, are currently believed to increase documentation efficiency and quality, as well as satisfaction of health professionals while accomplishing clinical documentation, but few studies in this area have been published to date. This study describes the effects of using a Web-based medical speech recognition system for clinical documentation in a university hospital on (1) documentation speed, (2) document length, and (3) physician satisfaction. Reports of 28 physicians were randomized to be created with (intervention) or without (control) the assistance of a Web-based system of medical automatic speech recognition (ASR) in the German language. The documentation was entered into a browser's text area and the time to complete the documentation including all necessary corrections, correction effort, number of characters, and mood of participant were stored in a database. The underlying time comprised text entering, text correction, and finalization of the documentation event. Participants self-assessed their moods on a scale of 1-3 (1=good, 2=moderate, 3=bad). Statistical analysis was done using permutation tests. The number of clinical reports eligible for further analysis stood at 1455. Out of 1455 reports, 718 (49.35%) were assisted by ASR and 737 (50.65%) were not assisted by ASR. Average documentation speed without ASR was 173 (SD 101) characters per minute, while it was 217 (SD 120) characters per minute using ASR. The overall increase in documentation speed through Web-based ASR assistance was 26% (P=.04). Participants documented an average of 356 (SD 388) characters per report when not assisted by ASR and 649 (SD 561) characters per report when assisted by ASR. Participants' average mood rating was 1.3 (SD 0.6) using ASR assistance compared to 1.6 (SD 0.7) without ASR assistance (P<.001). We conclude that medical documentation with the assistance of Web-based speech recognition leads to an increase in documentation speed, document length, and participant mood when compared to self-typing. Speech recognition is a meaningful and effective tool for the clinical documentation process.

Evaluating current automatic de-identification methods with Veteran's health administration clinical documents.

PubMed

Ferrández, Oscar; South, Brett R; Shen, Shuying; Friedlin, F Jeffrey; Samore, Matthew H; Meystre, Stéphane M

2012-07-27

The increased use and adoption of Electronic Health Records (EHR) causes a tremendous growth in digital information useful for clinicians, researchers and many other operational purposes. However, this information is rich in Protected Health Information (PHI), which severely restricts its access and possible uses. A number of investigators have developed methods for automatically de-identifying EHR documents by removing PHI, as specified in the Health Insurance Portability and Accountability Act "Safe Harbor" method.This study focuses on the evaluation of existing automated text de-identification methods and tools, as applied to Veterans Health Administration (VHA) clinical documents, to assess which methods perform better with each category of PHI found in our clinical notes; and when new methods are needed to improve performance. We installed and evaluated five text de-identification systems "out-of-the-box" using a corpus of VHA clinical documents. The systems based on machine learning methods were trained with the 2006 i2b2 de-identification corpora and evaluated with our VHA corpus, and also evaluated with a ten-fold cross-validation experiment using our VHA corpus. We counted exact, partial, and fully contained matches with reference annotations, considering each PHI type separately, or only one unique 'PHI' category. Performance of the systems was assessed using recall (equivalent to sensitivity) and precision (equivalent to positive predictive value) metrics, as well as the F(2)-measure. Overall, systems based on rules and pattern matching achieved better recall, and precision was always better with systems based on machine learning approaches. The highest "out-of-the-box" F(2)-measure was 67% for partial matches; the best precision and recall were 95% and 78%, respectively. Finally, the ten-fold cross validation experiment allowed for an increase of the F(2)-measure to 79% with partial matches. The "out-of-the-box" evaluation of text de-identification systems provided us with compelling insight about the best methods for de-identification of VHA clinical documents. The errors analysis demonstrated an important need for customization to PHI formats specific to VHA documents. This study informed the planning and development of a "best-of-breed" automatic de-identification application for VHA clinical text.

Transforming to a computerized system for nursing care: organizational success within Magnet idealism.

PubMed

Lindgren, Carolyn L; Elie, Leslie G; Vidal, Elizabeth C; Vasserman, Alex

2010-01-01

In reaching the goal for standardized, quality care, a not-for-profit healthcare system consisting of seven institutional entities is transforming nursing practice guidelines, patient care workflow, and patient documents into electronic, online, real-time modalities for use across departments and all healthcare delivery entities of the system. Organizational structure and a strategic plan were developed for the 2-year Clinical Transformation Project. The Siemens Patient Care Document System was adopted and adapted to the hospitals' documentation and information needs. Two fast-track sessions of more than 100 nurses and representatives from other health disciplines were held to standardize assessments, histories, care protocols, and interdisciplinary plans of care for the top 10 diagnostic regulatory groups. Education needs of the users were addressed. After the first year, a productive, functional system is evidenced. For example, the bar-coded Medication Administration Check System is in full use on the clinical units of one of the hospitals, and the other institutional entities are at substantial stages of implementation of Patient Care Documentation System. The project requires significant allocation of personnel and financial resources for a highly functional informatics system that will transform clinical care. The project exemplifies four of the Magnet ideals and serves as a model for others who may be deciding about launching a similar endeavor.

A Pilot Study of Contextual UMLS Indexing to Improve the Precision of Concept-based Representation in XML-structured Clinical Radiology Reports

PubMed Central

Huang, Yang; Lowe, Henry J.; Hersh, William R.

2003-01-01

Objective: Despite the advantages of structured data entry, much of the patient record is still stored as unstructured or semistructured narrative text. The issue of representing clinical document content remains problematic. The authors' prior work using an automated UMLS document indexing system has been encouraging but has been affected by the generally low indexing precision of such systems. In an effort to improve precision, the authors have developed a context-sensitive document indexing model to calculate the optimal subset of UMLS source vocabularies used to index each document section. This pilot study was performed to evaluate the utility of this indexing approach on a set of clinical radiology reports. Design: A set of clinical radiology reports that had been indexed manually using UMLS concept descriptors was indexed automatically by the SAPHIRE indexing engine. Using the data generated by this process the authors developed a system that simulated indexing, at the document section level, of the same document set using many permutations of a subset of the UMLS constituent vocabularies. Measurements: The precision and recall scores generated by simulated indexing for each permutation of two or three UMLS constituent vocabularies were determined. Results: While there was considerable variation in precision and recall values across the different subtypes of radiology reports, the overall effect of this indexing strategy using the best combination of two or three UMLS constituent vocabularies was an improvement in precision without significant impact of recall. Conclusion: In this pilot study a contextual indexing strategy improved overall precision in a set of clinical radiology reports. PMID:12925544

A pilot study of contextual UMLS indexing to improve the precision of concept-based representation in XML-structured clinical radiology reports.

PubMed

Huang, Yang; Lowe, Henry J; Hersh, William R

2003-01-01

Despite the advantages of structured data entry, much of the patient record is still stored as unstructured or semistructured narrative text. The issue of representing clinical document content remains problematic. The authors' prior work using an automated UMLS document indexing system has been encouraging but has been affected by the generally low indexing precision of such systems. In an effort to improve precision, the authors have developed a context-sensitive document indexing model to calculate the optimal subset of UMLS source vocabularies used to index each document section. This pilot study was performed to evaluate the utility of this indexing approach on a set of clinical radiology reports. A set of clinical radiology reports that had been indexed manually using UMLS concept descriptors was indexed automatically by the SAPHIRE indexing engine. Using the data generated by this process the authors developed a system that simulated indexing, at the document section level, of the same document set using many permutations of a subset of the UMLS constituent vocabularies. The precision and recall scores generated by simulated indexing for each permutation of two or three UMLS constituent vocabularies were determined. While there was considerable variation in precision and recall values across the different subtypes of radiology reports, the overall effect of this indexing strategy using the best combination of two or three UMLS constituent vocabularies was an improvement in precision without significant impact of recall. In this pilot study a contextual indexing strategy improved overall precision in a set of clinical radiology reports.

Web-based documentation system with exchange of DICOM RT for multicenter clinical studies in particle therapy

NASA Astrophysics Data System (ADS)

Kessel, Kerstin A.; Bougatf, Nina; Bohn, Christian; Engelmann, Uwe; Oetzel, Dieter; Bendl, Rolf; Debus, Jürgen; Combs, Stephanie E.

2012-02-01

Conducting clinical studies is rather difficult because of the large variety of voluminous datasets, different documentation styles, and various information systems, especially in radiation oncology. In this paper, we describe our development of a web-based documentation system with first approaches of automatic statistical analyses for transnational and multicenter clinical studies in particle therapy. It is possible to have immediate access to all patient information and exchange, store, process, and visualize text data, all types of DICOM images, especially DICOM RT, and any other multimedia data. Accessing the documentation system and submitting clinical data is possible for internal and external users (e.g. referring physicians from abroad, who are seeking the new technique of particle therapy for their patients). Thereby, security and privacy protection is ensured with the encrypted https protocol, client certificates, and an application gateway. Furthermore, all data can be pseudonymized. Integrated into the existing hospital environment, patient data is imported via various interfaces over HL7-messages and DICOM. Several further features replace manual input wherever possible and ensure data quality and entirety. With a form generator, studies can be individually designed to fit specific needs. By including all treated patients (also non-study patients), we gain the possibility for overall large-scale, retrospective analyses. Having recently begun documentation of our first six clinical studies, it has become apparent that the benefits lie in the simplification of research work, better study analyses quality and ultimately, the improvement of treatment concepts by evaluating the effectiveness of particle therapy.

Application of portable CDA for secure clinical-document exchange.

PubMed

Huang, Kuo-Hsuan; Hsieh, Sung-Huai; Chang, Yuan-Jen; Lai, Feipei; Hsieh, Sheau-Ling; Lee, Hsiu-Hui

2010-08-01

Health Level Seven (HL7) organization published the Clinical Document Architecture (CDA) for exchanging documents among heterogeneous systems and improving medical quality based on the design method in CDA. In practice, although the HL7 organization tried to make medical messages exchangeable, it is still hard to exchange medical messages. There are many issues when two hospitals want to exchange clinical documents, such as patient privacy, network security, budget, and the strategies of the hospital. In this article, we propose a method for the exchange and sharing of clinical documents in an offline model based on the CDA-the Portable CDA. This allows the physician to retrieve the patient's medical record stored in a portal device, but not through the Internet in real time. The security and privacy of CDA data will also be considered.

Closing the Loop in ICU Decision Support: Physiologic Event Detection, Alerts, and Documentation

PubMed Central

Norris, Patrick R.; Dawant, Benoit M.

2002-01-01

Automated physiologic event detection and alerting is a challenging task in the ICU. Ideally care providers should be alerted only when events are clinically significant and there is opportunity for corrective action. However, the concepts of clinical significance and opportunity are difficult to define in automated systems, and effectiveness of alerting algorithms is difficult to measure. This paper describes recent efforts on the Simon project to capture information from ICU care providers about patient state and therapy in response to alerts, in order to assess the value of event definitions and progressively refine alerting algorithms. Event definitions for intracranial pressure and cerebral perfusion pressure were studied by implementing a reliable system to automatically deliver alerts to clinical users’ alphanumeric pagers, and to capture associated documentation about patient state and therapy when the alerts occurred. During a 6-month test period in the trauma ICU at Vanderbilt University Medical Center, 530 alerts were detected in 2280 hours of data spanning 14 patients. Clinical users electronically documented 81% of these alerts as they occurred. Retrospectively classifying documentation based on therapeutic actions taken, or reasons why actions were not taken, provided useful information about ways to potentially improve event definitions and enhance system utility.

Implementing personal digital assistant documentation of pharmacist interventions in a military treatment facility.

PubMed

Ford, Stephen; Illich, Stan; Smith, Lisa; Franklin, Arthur

2006-01-01

To describe the use of personal digital assistants (PDAs) in documenting pharmacists' clinical interventions. Evans Army Community Hospital (EACH), a 78-bed military treatment facility, in Colorado Springs. Pharmacists on staff at EACH. All pharmacists at EACH used PDAs with the pilot software to record interventions for 1 month. The program underwent final design changes and then became the sole source for recording pharmacist interventions. The results of this project are being evaluated every 3 months for the first year and yearly thereafter. Visual CE (Syware Inc. Cambridge, Mass.) software was selected to develop fields for the documentation tool. This software is simple and easy to use, and users can retrieve reports of interventions from both inpatient and outpatient sections. The software needed to be designed so that data entry would only take a few minutes and ad hoc reports could be produced easily. Number of pharmacist interventions reported, time spent in clinical interventions, and outcome of clinical intervention. Implementing a PDA-based system for documenting pharmacist interventions across ambulatory, inpatient, and clinical services dramatically increased reporting during the first 6 months after implementation (August 2004-February 2005). After initial fielding, clinical pharmacists in advanced practice settings (such as disease management clinic, anticoagulation clinic) recognized a need to tailor the program to their specific activities, which resulted in a spin-off program unique to their practice roles. A PDA-based system for documenting clinical interventions at a military treatment facility increased reporting of interventions across all pharmacy points of service. Pharmacy leadership used these data to document the impact of pharmacist interventions on safety and quality of pharmaceutical care provided.

WITH: a system to write clinical trials using XML and RDBMS.

PubMed Central

Fazi, Paola; Luzi, Daniela; Manco, Mariarosaria; Ricci, Fabrizio L.; Toffoli, Giovanni; Vignetti, Marco

2002-01-01

The paper illustrates the system WITH (Write on Internet clinical Trials in Haematology) which supports the writing of a clinical trial (CT) document. The requirements of this system have been defined analysing the writing process of a CT and then modelling the content of its sections together with their logical and temporal relationships. The system WITH allows: a) editing the document text; b) re-using the text; and c) facilitating the cooperation and the collaborative writing. It is based on XML mark-up language, and on a RDBMS. This choice guarantees: a) process standardisation; b) process management; c) efficient delivery of information-based tasks; and d) explicit focus on process design. PMID:12463823

A Decade of Experience in Creating and Maintaining Data Elements for Structured Clinical Documentation in EHRs

PubMed Central

Zhou, Li; Collins, Sarah; Morgan, Stephen J.; Zafar, Neelam; Gesner, Emily J.; Fehrenbach, Martin; Rocha, Roberto A.

2016-01-01

Structured clinical documentation is an important component of electronic health records (EHRs) and plays an important role in clinical care, administrative functions, and research activities. Clinical data elements serve as basic building blocks for composing the templates used for generating clinical documents (such as notes and forms). We present our experience in creating and maintaining data elements for three different EHRs (one home-grown and two commercial systems) across different clinical settings, using flowsheet data elements as examples in our case studies. We identified basic but important challenges (including naming convention, links to standard terminologies, and versioning and change management) and possible solutions to address them. We also discussed more complicated challenges regarding governance, documentation vs. structured data capture, pre-coordination vs. post-coordination, reference information models, as well as monitoring, communication and training. PMID:28269927

Information systems for administration, clinical documentation and quality assurance in an Austrian disease management programme.

PubMed

Beck, Peter; Truskaller, Thomas; Rakovac, Ivo; Bruner, Fritz; Zanettin, Dominik; Pieber, Thomas R

2009-01-01

5.9% of the Austrian population is affected by diabetes mellitus. Disease Management is a structured treatment approach that is suitable for application to the diabetes mellitus area and often is supported by information technology. This article describes the information systems developed and implemented in the Austrian disease management programme for type 2 diabetes. Several workflows for administration as well as for clinical documentation have been implemented utilizing the Austrian e-Health infrastructure. De-identified clinical data is available for creating feedback reports for providers and programme evaluation.

A KPI framework for process-based benchmarking of hospital information systems.

PubMed

Jahn, Franziska; Winter, Alfred

2011-01-01

Benchmarking is a major topic for monitoring, directing and elucidating the performance of hospital information systems (HIS). Current approaches neglect the outcome of the processes that are supported by the HIS and their contribution to the hospital's strategic goals. We suggest to benchmark HIS based on clinical documentation processes and their outcome. A framework consisting of a general process model and outcome criteria for clinical documentation processes is introduced.

[Establishing a clinical information system for surgical ophthalmology and orthopedics specialties with reference to GSG '93].

PubMed

Dick, B; Basad, E

1996-04-01

As a result of new health care guidelines (Gesundheitsstrukturgesetz) and the federal hospital and nursing ordinance, there has been a large increase in the documentation required for diagnoses (ICD-9) and service ("Operationenschlüssel nach section 301 SGB V" = ICPM), all of which is done in the form of a numeric code. The method of coding diagnoses is supposed to make possible data entry and statistical evaluation of plausibility controls, as well as conspicuous and random testing of economic feasibility. Our data processing system is designed to assist in the planning and organization of clinical activities, while at the same time making documentation in accordance with health care guidelines easier and providing scientific documentation and evaluation. The application MedAccess was developed by clinicians on the basis of a relational client-server database. The application has been in use since June 1992 and has been further developed during operation according to the requirements and wishes of clinic and administrative staff. In cooperation with the Institute for Medical Information Technology, a computer interface with the patient check-in system was created, making possible the importing of patient data. The application is continuously updated according to the current needs of the clinic and administration. The primary functions of MedAccess include managing patient data, planning of in-patient admissions, surgical planning, organization, documentation (surgery book, reports with follow-up treatment records), administration of the tissue bank, clinic communications, clinic work processing, and management of the staff duty roster. Clinical data are entered into a computer and processed on site, and the user is assisted by practical applications which do not require special knowledge of data processing or encoding systems. The data is entered only once, but can be further used for other purposes, such as evaluations or selective transfer, for example, to clinical documents. Through an integrated flow of data, information entered one time remains readily available, while, at the same time, preventing duplicate entries. The integration of hardware and software via a mainframe computer (clinic system WING) has proven to be well-suited for the exchange of data. The use of this thesaurus-supported and graphics-oriented system required no special knowledge of the ICD code and makes documentation much easier to produce. The advantages of computer-supported encoding not only include a savings in time, but also an improvement in the quality of the encoding from which clinical and scientific reports can be derived. The relational client-server, operating in a graphics-supported programming environment, makes it possible for the clinic's doctors to further develop and improve the system. Through the installation and support of a Macintosh network, and training of doctors, medical personnel and clerical staff, cost as well as investment of time have been kept to a minimum in comparison to other LAN servers.

Documentation and User's Guide to the Computer Management System for the Clinical Teacher Curriculum.

ERIC Educational Resources Information Center

Dia, Ahmed

The guide to the computer management system for individualized instructional strategy associated with the clinical teacher curriculum at Florida State University is presented. The system is described in terms of 27 Cobol programs and the Multiple Access and Retrieval System (MARS VI), which were adapted to requirements of the clinical teacher…

[Evaluation of a context sensitive system for intra-operative usage of the electronic patient record].

PubMed

Dressler, C R; Fischer, M; Burgert, O; Strauß, G

2012-06-01

This article analyzes the usage of an electronic patient record (EPR), which may be accessed intra-operatively by the surgeon. The focus lies on the automatic prioritization of documents to dramatically reduce the surgeon's interaction with the EPR system. An EPR system has been developed, which displays documents in accordance to the current procedure. The system is controlled by a foot switch and the documents are displayed on a large-scale screen in the operating room. The usage of the system by 2 surgeons has been recorded in clinical routine. 55 surgical procedures have been recorded. The EPR system has been used 2 times per procedure in average for surgeries at the middle ear, for surgeries of the paranasal sinuses, it has been used 1.3 times per procedure. The EPR-system has been used pre-operatively in 58% of cases. The surgeons did not have to interact with the EPR system for more than the half of the procedures to view the desired document. The existence of digitized documents in a clinic does not automatically lead to improved workflows. The evaluated EPR system presented the patient data in a simple and comfortable way. The extensive pre-operative usage had not been expected. Because of the low barrier to view patient data, higher patient safety may be assumed. On the other hand, the surgeon could be encouraged to skip the important preparation before the procedure. Due to the low pervasiveness of medical communication standards at this time, the integrated connection between clinic IT and an EPR system would nowadays only be possible by great efforts. © Georg Thieme Verlag KG Stuttgart · New York.

Challenges in reusing transactional data for daily documentation in neonatal intensive care.

PubMed

Kim, G R; Lawson, E E; Lehmann, C U

2008-11-06

The reuse of transactional data for clinical documentation requires navigation of computational, institutional and adaptive barriers. We describe organizational and technical issues in developing and deploying a daily progress note tool in a tertiary neonatal intensive care unit that reuses and aggregates data from a commercial integrated clinical information system.

A Qualitative Analysis Evaluating The Purposes And Practices Of Clinical Documentation

PubMed Central

Ho, Y.-X.; Gadd, C. S.; Kohorst, K.L.; Rosenbloom, S.T.

2014-01-01

Summary Objectives An important challenge for biomedical informatics researchers is determining the best approach for healthcare providers to use when generating clinical notes in settings where electronic health record (EHR) systems are used. The goal of this qualitative study was to explore healthcare providers’ and administrators’ perceptions about the purpose of clinical documentation and their own documentation practices. Methods We conducted seven focus groups with a total of 46 subjects composed of healthcare providers and administrators to collect knowledge, perceptions and beliefs about documentation from those who generate and review notes, respectively. Data were analyzed using inductive analysis to probe and classify impressions collected from focus group subjects. Results We observed that both healthcare providers and administrators believe that documentation serves five primary domains: clinical, administrative, legal, research, education. These purposes are tied closely to the nature of the clinical note as a document shared by multiple stakeholders, which can be a source of tension for all parties who must use the note. Most providers reported using a combination of methods to complete their notes in a timely fashion without compromising patient care. While all administrators reported relying on computer-based documentation tools to review notes, they expressed a desire for a more efficient method of extracting relevant data. Conclusions Although clinical documentation has utility, and is valued highly by its users, the development and successful adoption of a clinical documentation tool largely depends on its ability to be smoothly integrated into the provider’s busy workflow, while allowing the provider to generate a note that communicates effectively and efficiently with multiple stakeholders. PMID:24734130

Evidence-based use of electronic clinical tracking systems in advanced practice registered nurse education: an integrative review.

PubMed

Branstetter, M Laurie; Smith, Lynette S; Brooks, Andrea F

2014-07-01

Over the past decade, the federal government has mandated healthcare providers to incorporate electronic health records into practice by 2015. This technological update in healthcare documentation has generated a need for advanced practice RN programs to incorporate information technology into education. The National Organization of Nurse Practitioner Faculties created core competencies to guide program standards for advanced practice RN education. One core competency is Technology and Information Literacy. Educational programs are moving toward the utilization of electronic clinical tracking systems to capture students' clinical encounter data. The purpose of this integrative review was to evaluate current research on advanced practice RN students' documentation of clinical encounters utilizing electronic clinical tracking systems to meet advanced practice RN curriculum outcome goals in information technology as defined by the National Organization of Nurse Practitioner Faculties. The state of the science depicts student' and faculty attitudes, preferences, opinions, and data collections of students' clinical encounters. Although electronic clinical tracking systems were utilized to track students' clinical encounters, these systems have not been evaluated for meeting information technology core competency standards. Educational programs are utilizing electronic clinical tracking systems with limited evidence-based literature evaluating the ability of these systems to meet the core competencies in advanced practice RN programs.

Toward Medical Documentation That Enhances Situational Awareness Learning

PubMed Central

Lenert, Leslie A.

2016-01-01

The purpose of writing medical notes in a computer system goes beyond documentation for medical-legal purposes or billing. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record. For the past 50 years, one of the primary organizing structures for physicians’ clinical documentation have been the SOAP note (Subjective, Objective, Assessment, Plan). The cognitive check list is well-suited to differential diagnosis but may not support detection of changes in systems and/or learning from cases. We describe an alternative cognitive checklist called the OODA Loop (Observe, Orient, Decide, Act. Through incorporation of projections of anticipated course events with and without treatment and by making “Decisions” an explicit category of documentation in the medical record in the context of a variable temporal cycle for observations, OODA may enhance opportunities to learn from clinical care. PMID:28269872

Lessons learned from the implementation of clinical messaging systems.

PubMed

Barnes, Mike

2007-10-11

The Regenstrief Institute has designed and implemented two clinical messaging systems over the past six years, both called DOCS4DOCS. These systems receive HL7 messages from data sources and deliver results to clinicians via the web, fax, or as HL7 directed to an EMR. This paper focuses on some of the lessons we have learned, both good and bad. We discuss important issues in clinical messaging including provider mapping, document delivery and duplicate prevention, creating uniform HL7 outbound feeds, user authentication, the problems of allowing Active-X controls, why automatic printing of documents is not important although a frequently requested feature, and assorted other pearls of wisdom we have acquired.

Lessons Learned from the Implementation of Clinical Messaging Systems

PubMed Central

Barnes, Mike

2007-01-01

The Regenstrief Institute has designed and implemented two clinical messaging systems over the past six years, both called DOCS4DOCS®. These systems receive HL7 messages from data sources and deliver results to clinicians via the web, fax, or as HL7 directed to an EMR. This paper focuses on some of the lessons we have learned, both good and bad. We discuss important issues in clinical messaging including provider mapping, document delivery and duplicate prevention, creating uniform HL7 outbound feeds, user authentication, the problems of allowing Active-X controls, why automatic printing of documents is not important although a frequently requested feature, and assorted other pearls of wisdom we have acquired. PMID:18693793

Closing the loop in ICU decision support: physiologic event detection, alerts, and documentation.

PubMed Central

Norris, P. R.; Dawant, B. M.

2001-01-01

Automated physiologic event detection and alerting is a challenging task in the ICU. Ideally care providers should be alerted only when events are clinically significant and there is opportunity for corrective action. However, the concepts of clinical significance and opportunity are difficult to define in automated systems, and effectiveness of alerting algorithms is difficult to measure. This paper describes recent efforts on the Simon project to capture information from ICU care providers about patient state and therapy in response to alerts, in order to assess the value of event definitions and progressively refine alerting algorithms. Event definitions for intracranial pressure and cerebral perfusion pressure were studied by implementing a reliable system to automatically deliver alerts to clinical users alphanumeric pagers, and to capture associated documentation about patient state and therapy when the alerts occurred. During a 6-month test period in the trauma ICU at Vanderbilt University Medical Center, 530 alerts were detected in 2280 hours of data spanning 14 patients. Clinical users electronically documented 81% of these alerts as they occurred. Retrospectively classifying documentation based on therapeutic actions taken, or reasons why actions were not taken, provided useful information about ways to potentially improve event definitions and enhance system utility. PMID:11825238

Development and Validation of a Natural Language Processing Tool to Identify Patients Treated for Pneumonia across VA Emergency Departments.

PubMed

Jones, B E; South, B R; Shao, Y; Lu, C C; Leng, J; Sauer, B C; Gundlapalli, A V; Samore, M H; Zeng, Q

2018-01-01

Identifying pneumonia using diagnosis codes alone may be insufficient for research on clinical decision making. Natural language processing (NLP) may enable the inclusion of cases missed by diagnosis codes. This article (1) develops a NLP tool that identifies the clinical assertion of pneumonia from physician emergency department (ED) notes, and (2) compares classification methods using diagnosis codes versus NLP against a gold standard of manual chart review to identify patients initially treated for pneumonia. Among a national population of ED visits occurring between 2006 and 2012 across the Veterans Affairs health system, we extracted 811 physician documents containing search terms for pneumonia for training, and 100 random documents for validation. Two reviewers annotated span- and document-level classifications of the clinical assertion of pneumonia. An NLP tool using a support vector machine was trained on the enriched documents. We extracted diagnosis codes assigned in the ED and upon hospital discharge and calculated performance characteristics for diagnosis codes, NLP, and NLP plus diagnosis codes against manual review in training and validation sets. Among the training documents, 51% contained clinical assertions of pneumonia; in the validation set, 9% were classified with pneumonia, of which 100% contained pneumonia search terms. After enriching with search terms, the NLP system alone demonstrated a recall/sensitivity of 0.72 (training) and 0.55 (validation), and a precision/positive predictive value (PPV) of 0.89 (training) and 0.71 (validation). ED-assigned diagnostic codes demonstrated lower recall/sensitivity (0.48 and 0.44) but higher precision/PPV (0.95 in training, 1.0 in validation); the NLP system identified more "possible-treated" cases than diagnostic coding. An approach combining NLP and ED-assigned diagnostic coding classification achieved the best performance (sensitivity 0.89 and PPV 0.80). System-wide application of NLP to clinical text can increase capture of initial diagnostic hypotheses, an important inclusion when studying diagnosis and clinical decision-making under uncertainty. Schattauer GmbH Stuttgart.

Integrated information systems for electronic chemotherapy medication administration.

PubMed

Levy, Mia A; Giuse, Dario A; Eck, Carol; Holder, Gwen; Lippard, Giles; Cartwright, Julia; Rudge, Nancy K

2011-07-01

Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations.

Clinical documentation variations and NLP system portability: a case study in asthma birth cohorts across institutions.

PubMed

Sohn, Sunghwan; Wang, Yanshan; Wi, Chung-Il; Krusemark, Elizabeth A; Ryu, Euijung; Ali, Mir H; Juhn, Young J; Liu, Hongfang

2017-11-30

To assess clinical documentation variations across health care institutions using different electronic medical record systems and investigate how they affect natural language processing (NLP) system portability. Birth cohorts from Mayo Clinic and Sanford Children's Hospital (SCH) were used in this study (n = 298 for each). Documentation variations regarding asthma between the 2 cohorts were examined in various aspects: (1) overall corpus at the word level (ie, lexical variation), (2) topics and asthma-related concepts (ie, semantic variation), and (3) clinical note types (ie, process variation). We compared those statistics and explored NLP system portability for asthma ascertainment in 2 stages: prototype and refinement. There exist notable lexical variations (word-level similarity = 0.669) and process variations (differences in major note types containing asthma-related concepts). However, semantic-level corpora were relatively homogeneous (topic similarity = 0.944, asthma-related concept similarity = 0.971). The NLP system for asthma ascertainment had an F-score of 0.937 at Mayo, and produced 0.813 (prototype) and 0.908 (refinement) when applied at SCH. The criteria for asthma ascertainment are largely dependent on asthma-related concepts. Therefore, we believe that semantic similarity is important to estimate NLP system portability. As the Mayo Clinic and SCH corpora were relatively homogeneous at a semantic level, the NLP system, developed at Mayo Clinic, was imported to SCH successfully with proper adjustments to deal with the intrinsic corpus heterogeneity. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Improving Warfarin Management Within the Medical Home: A Health-System Approach.

PubMed

Rose, Anne E; Robinson, Erin N; Premo, Joan A; Hauschild, Lori J; Trapskin, Philip J; McBride, Ann M

2017-03-01

Anticoagulation clinics have been considered the optimal strategy for warfarin management with demonstrated improved patient outcomes through increased time in therapeutic international normalized ratio (INR) range, decreased critical INR values, and decreased anticoagulation-related adverse events. However, not all health systems are able to support a specialized anticoagulation clinic or may see patient volume exceed available anticoagulation clinic resources. The purpose of this study was to utilize an anticoagulation clinic model to standardize warfarin management in a primary care clinic setting. A warfarin management program was developed that included standardized patient assessment, protocolized warfarin-dosing algorithm, and electronic documentation and reporting tools. Primary care clinics were targeted for training and implementation of this program. The warfarin management program was applied to over 2000 patients and implemented at 39 clinic sites. A total of 160 nurses and 15 pharmacists were trained on the program. Documentation of warfarin dose and date of the next INR increased from 70% to 90% (P <.0001), documentation occurring within 24 hours of the INR result increased from 75% to 87% (P <.0001), and monitoring the INR at least every 4 weeks increased from 71% to 83% (P <.0001) per patient encounter. Time in therapeutic INR range improved from 65% to 75%. Incorporating a standardized approach to warfarin management in the primary care setting significantly improves warfarin-related documentation and time in therapeutic INR range. Copyright © 2016 Elsevier Inc. All rights reserved.

Tools in a clinical information system supporting clinical trials at a Swiss University Hospital.

PubMed

Weisskopf, Michael; Bucklar, Guido; Blaser, Jürg

2014-12-01

Issues concerning inadequate source data of clinical trials rank second in the most common findings by regulatory authorities. The increasing use of electronic clinical information systems by healthcare providers offers an opportunity to facilitate and improve the conduct of clinical trials and the source documentation. We report on a number of tools implemented into the clinical information system of a university hospital to support clinical research. In 2011/2012, a set of tools was developed in the clinical information system of the University Hospital Zurich to support clinical research, including (1) a trial registry for documenting metadata on the clinical trials conducted at the hospital, (2) a patient-trial-assignment-tool to tag patients in the electronic medical charts as participants of specific trials, (3) medical record templates for the documentation of study visits and trial-related procedures, (4) online queries on trials and trial participants, (5) access to the electronic medical records for clinical monitors, (6) an alerting tool to notify of hospital admissions of trial participants, (7) queries to identify potentially eligible patients in the planning phase as trial feasibility checks and during the trial as recruitment support, and (8) order sets to facilitate the complete and accurate performance of study visit procedures. The number of approximately 100 new registrations per year in the voluntary trial registry in the clinical information system now matches the numbers of the existing mandatory trial registry of the hospital. Likewise, the yearly numbers of patients tagged as trial participants as well as the use of the standardized trial record templates increased to 2408 documented trial enrolments and 190 reports generated/month in the year 2013. Accounts for 32 clinical monitors have been established in the first 2 years monitoring a total of 49 trials in 16 clinical departments. A total of 15 months after adding the optional feature of hospital admission alerts of trial participants, 107 running trials have activated this option, including 48 out of 97 studies (49.5%) registered in the year 2013, generating approximately 85 alerts per month. The popularity of the presented tools in the clinical information system illustrates their potential to facilitate the conduct of clinical trials. The tools also allow for enhanced transparency on trials conducted at the hospital. Future studies on monitoring and inspection findings will have to evaluate their impact on quality and safety. © The Author(s) 2014.

ANMCO/SIC Consensus Document: cardiology networks for outpatient heart failure care

PubMed Central

Gulizia, Michele Massimo; Di Lenarda, Andrea; Mortara, Andrea; Battistoni, Ilaria; De Maria, Renata; Gabriele, Michele; Iacoviello, Massimo; Navazio, Alessandro; Pini, Daniela; Di Tano, Giuseppe; Marini, Marco; Ricci, Renato Pietro; Alunni, Gianfranco; Radini, Donatella; Metra, Marco; Romeo, Francesco

2017-01-01

Abstract Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics. The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals. The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment. In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services. PMID:28751837

The Effects of a Web-Based Nursing Process Documentation Program on Stress and Anxiety of Nursing Students in South Korea.

PubMed

Lee, Eunjoo; Noh, Hyun Kyung

2016-01-01

To examine the effects of a web-based nursing process documentation system on the stress and anxiety of nursing students during their clinical practice. A quasi-experimental design was employed. The experimental group (n = 110) used a web-based nursing process documentation program for their case reports as part of assignments for a clinical practicum, whereas the control group (n = 106) used traditional paper-based case reports. Stress and anxiety levels were measured with a numeric rating scale before, 2 weeks after, and 4 weeks after using the web-based nursing process documentation program during a clinical practicum. The data were analyzed using descriptive statistics, t tests, chi-square tests, and repeated-measures analyses of variance. Nursing students who used the web-based nursing process documentation program showed significant lower levels of stress and anxiety than the control group. A web-based nursing process documentation program could be used to reduce the stress and anxiety of nursing students during clinical practicum, which ultimately would benefit nursing students by increasing satisfaction with and effectiveness of clinical practicum. © 2015 NANDA International, Inc.

TU-B-19A-01: Image Registration II: TG132-Quality Assurance for Image Registration

DOE Office of Scientific and Technical Information (OSTI.GOV)

Brock, K; Mutic, S

2014-06-15

AAPM Task Group 132 was charged with a review of the current approaches and solutions for image registration in radiotherapy and to provide recommendations for quality assurance and quality control of these clinical processes. As the results of image registration are always used as the input of another process for planning or delivery, it is important for the user to understand and document the uncertainty associate with the algorithm in general and the Result of a specific registration. The recommendations of this task group, which at the time of abstract submission are currently being reviewed by the AAPM, include themore » following components. The user should understand the basic image registration techniques and methods of visualizing image fusion. The disclosure of basic components of the image registration by commercial vendors is critical in this respect. The physicists should perform end-to-end tests of imaging, registration, and planning/treatment systems if image registration is performed on a stand-alone system. A comprehensive commissioning process should be performed and documented by the physicist prior to clinical use of the system. As documentation is important to the safe implementation of this process, a request and report system should be integrated into the clinical workflow. Finally, a patient specific QA practice should be established for efficient evaluation of image registration results. The implementation of these recommendations will be described and illustrated during this educational session. Learning Objectives: Highlight the importance of understanding the image registration techniques used in their clinic. Describe the end-to-end tests needed for stand-alone registration systems. Illustrate a comprehensive commissioning program using both phantom data and clinical images. Describe a request and report system to ensure communication and documentation. Demonstrate an clinically-efficient patient QA practice for efficient evaluation of image registration.« less

Automated Methods to Extract Patient New Information from Clinical Notes in Electronic Health Record Systems

ERIC Educational Resources Information Center

Zhang, Rui

2013-01-01

The widespread adoption of Electronic Health Record (EHR) has resulted in rapid text proliferation within clinical care. Clinicians' use of copying and pasting functions in EHR systems further compounds this by creating a large amount of redundant clinical information in clinical documents. A mixture of redundant information (especially outdated…

Trustworthiness and relevance in web-based clinical question answering.

PubMed

Cruchet, Sarah; Boyer, Célia; van der Plas, Lonneke

2012-01-01

Question answering systems try to give precise answers to a user's question posed in natural language. It is of utmost importance that the answers returned are relevant to the user's question. For clinical QA, the trustworthiness of answers is another important issue. Limiting the document collection to certified websites helps to improve the trustworthiness of answers. On the other hand, limited document collections are known to harm the relevancy of answers. We show, however, in a comparative evaluation, that promoting trustworthiness has no negative effect on the relevance of the retrieved answers in our clinical QA system. On the contrary, the answers found are in general more relevant.

Data Linkage from Clinical to Study Databases via an R Data Warehouse User Interface. Experiences from a Large Clinical Follow-up Study.

PubMed

Kaspar, Mathias; Ertl, Maximilian; Fette, Georg; Dietrich, Georg; Toepfer, Martin; Angermann, Christiane; Störk, Stefan; Puppe, Frank

2016-08-05

Data that needs to be documented for clinical studies has often been acquired and documented in clinical routine. Usually this data is manually transferred to Case Report Forms (CRF) and/or directly into an electronic data capture (EDC) system. To enhance the documentation process of a large clinical follow-up study targeting patients admitted for acutely decompensated heart failure by accessing the data created during routine and study visits from a hospital information system (HIS) and by transferring it via a data warehouse (DWH) into the study's EDC system. This project is based on the clinical DWH developed at the University of Würzburg. The DWH was extended by several new data domains including data created by the study team itself. An R user interface was developed for the DWH that allows to access its source data in all its detail, to transform data as comprehensively as possible by R into study-specific variables and to support the creation of data and catalog tables. A data flow was established that starts with labeling patients as study patients within the HIS and proceeds with updating the DWH with this label and further data domains at a daily rate. Several study-specific variables were defined using the implemented R user interface of the DWH. This system was then used to export these variables as data tables ready for import into our EDC system. The data tables were then used to initialize the first 296 patients within the EDC system by pseudonym, visit and data values. Afterwards, these records were filled with clinical data on heart failure, vital parameters and time spent on selected wards. This solution focuses on the comprehensive access and transformation of data for a DWH-EDC system linkage. Using this system in a large clinical study has demonstrated the feasibility of this approach for a study with a complex visit schedule.

Documenting clinical pharmacist intervention before and after the introduction of a web-based tool.

PubMed

Nurgat, Zubeir A; Al-Jazairi, Abdulrazaq S; Abu-Shraie, Nada; Al-Jedai, Ahmed

2011-04-01

To develop a database for documenting pharmacist intervention through a web-based application. The secondary endpoint was to determine if the new, web-based application provides any benefits with regards to documentation compliance by clinical pharmacists and ease of calculating cost savings compared with our previous method of documenting pharmacist interventions. A tertiary care hospital in Saudi Arabia. The documentation of interventions using a web-based documentation application was retrospectively compared with previous methods of documentation of clinical pharmacists' interventions (multi-user PC software). The number and types of interventions recorded by pharmacists, data mining of archived data, efficiency, cost savings, and the accuracy of the data generated. The number of documented clinical interventions increased from 4,926, using the multi-user PC software, to 6,840 for the web-based application. On average, we observed 653 interventions per clinical pharmacist using the web-based application, which showed an increase compared to an average of 493 interventions using the old multi-user PC software. However, using a paired Student's t-test there was no statistical significance difference between the two means (P = 0.201). Using a χ² test, which captured management level and the type of system used, we found a strong effect of management level (P < 2.2 × 10⁻¹⁶) on the number of documented interventions. We also found a moderately significant relationship between educational level and the number of interventions documented (P = 0.045). The mean ± SD time required to document an intervention using the web-based application was 66.55 ± 8.98 s. Using the web-based application, 29.06% of documented interventions resulted in cost-savings, while using the multi-user PC software only 4.75% of interventions did so. The majority of cost savings across both platforms resulted from the discontinuation of unnecessary drugs and a change in dosage regimen. Data collection using the web-based application was consistently more complete when compared to the multi-user PC software. The web-based application is an efficient system for documenting pharmacist interventions. Its flexibility and accessibility, as well as its detailed report functionality is a useful tool that will hopefully encourage other primary and secondary care facilities to adopt similar applications.

Connection of European particle therapy centers and generation of a common particle database system within the European ULICE-framework

PubMed Central

2012-01-01

Background To establish a common database on particle therapy for the evaluation of clinical studies integrating a large variety of voluminous datasets, different documentation styles, and various information systems, especially in the field of radiation oncology. Methods We developed a web-based documentation system for transnational and multicenter clinical studies in particle therapy. 560 patients have been treated from November 2009 to September 2011. Protons, carbon ions or a combination of both, as well as a combination with photons were applied. To date, 12 studies have been initiated and more are in preparation. Results It is possible to immediately access all patient information and exchange, store, process, and visualize text data, any DICOM images and multimedia data. Accessing the system and submitting clinical data is possible for internal and external users. Integrated into the hospital environment, data is imported both manually and automatically. Security and privacy protection as well as data validation and verification are ensured. Studies can be designed to fit individual needs. Conclusions The described database provides a basis for documentation of large patient groups with specific and specialized questions to be answered. Having recently begun electronic documentation, it has become apparent that the benefits lie in the user-friendly and timely workflow for documentation. The ultimate goal is a simplification of research work, better study analyses quality and eventually, the improvement of treatment concepts by evaluating the effectiveness of particle therapy. PMID:22828013

Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System

PubMed Central

Park, Hyeoun-Ae; Jeon, Eunjoo; Chung, Eunja

2012-01-01

Objectives The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. Methods This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. Results We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. Conclusions The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system. PMID:22844649

Electronic implementation of national nursing standards--NANDA, NOC and NIC as an effective teaching tool.

PubMed

Allred, Sharon K; Smith, Kevin F; Flowers, Laura

2004-01-01

With the increased interest in evidence-based medicine, Internet access and the growing emphasis on national standards, there is an increased challenge for teaching institutions and nursing services to teach and implement standards. At the same time, electronic clinical documentation tools have started to become a common format for recording nursing notes. The major aim of this paper is to ascertain and assess the availability of clinical nursing tools based on the NANDA, NOC and NIC standards. Faculty at 20 large nursing schools and directors of nursing at 20 hospitals were interviewed regarding the use of nursing standards in clinical documentation packages, not only for teaching purposes but also for use in hospital-based systems to ensure patient safety. A survey tool was utilized that covered questions regarding what nursing standards are being taught in the nursing schools, what standards are encouraged by the hospitals, and teaching initiatives that include clinical documentation tools. Information was collected on how utilizing these standards in a clinical or hospital setting can improve the overall quality of care. Analysis included univariate and bivariate analysis. The consensus between both groups was that the NANDA, NOC and NIC national standards are the most widely taught and utilized. In addition, a training initiative was identified within a large university where a clinical documentation system based on these standards was developed utilizing handheld devices.

Computerized clinical documentation system in the pediatric intensive care unit

PubMed Central

2001-01-01

Background To determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity. Methods Before and after implementation of CDS, a time study involving nursing care, medication delivery, and normalization of serum calcium and potassium values was performed. In addition, an evaluation of completeness of documentation and a clinician survey of shift to shift reporting were also completed. This was a modified one group, pretest-posttest design. Results With the CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable. Conclusions When compared to a paper chart, the CDS provided a more legible, compete, and accessible patient record without affecting time spent in direct patient care. The availability of the CDS improved shift to shift reporting. Other observations showed that the CDS improved management capabilities; helped physicians deliver care; improved reimbursement; limited data entry errors; and reduced costs. PMID:11604105

Designing an Electronic Patient Management System for Multiple Sclerosis: Building a Next Generation Multiple Sclerosis Documentation System.

PubMed

Kern, Raimar; Haase, Rocco; Eisele, Judith Christina; Thomas, Katja; Ziemssen, Tjalf

2016-01-08

Technologies like electronic health records or telemedicine devices support the rapid mediation of health information and clinical data independent of time and location between patients and their physicians as well as among health care professionals. Today, every part of the treatment process from diagnosis, treatment selection, and application to patient education and long-term care may be enhanced by a quality-assured implementation of health information technology (HIT) that also takes data security standards and concerns into account. In order to increase the level of effectively realized benefits of eHealth services, a user-driven needs assessment should ensure the inclusion of health care professional perspectives into the process of technology development as we did in the development process of the Multiple Sclerosis Documentation System 3D. After analyzing the use of information technology by patients suffering from multiple sclerosis, we focused on the needs of neurological health care professionals and their handling of health information technology. Therefore, we researched the status quo of eHealth adoption in neurological practices and clinics as well as health care professional opinions about potential benefits and requirements of eHealth services in the field of multiple sclerosis. We conducted a paper-and-pencil-based mail survey in 2013 by sending our questionnaire to 600 randomly chosen neurological practices in Germany. The questionnaire consisted of 24 items covering characteristics of participating neurological practices (4 items), the current use of network technology and the Internet in such neurological practices (5 items), physicians' attitudes toward the general and MS-related usefulness of eHealth systems (8 items) and toward the clinical documentation via electronic health records (4 items), and physicians' knowledge about the Multiple Sclerosis Documentation System (3 items). From 600 mailed surveys, 74 completed surveys were returned. As much as 9 of the 10 practices were already connected to the Internet (67/74), but only 49% preferred a permanent access. The most common type of HIT infrastructure was a complete practice network with several access points. Considering data sharing with research registers, 43% opted for an online interface, whereas 58% decided on an offline method of data transmission. eHealth services were perceived as generally useful for physicians and nurses in neurological practices with highest capabilities for improvements in clinical documentation, data acquisition, diagnosis of specific MS symptoms, physician-patient communication, and patient education. Practices specialized in MS in comparison with other neurological practices presented an increased interest in online documentation. Among the participating centers, 91% welcomed the opportunity of a specific clinical documentation for MS and 87% showed great interest in an extended and more interconnected electronic documentation of MS patients. Clinical parameters (59/74) were most important in documentation, followed by symptomatic parameters like measures of fatigue or depression (53/74) and quality of life (47/74). Physicians and nurses may significantly benefit from an electronically assisted documentation and patient management. Many aspects of patient documentation and education will be enhanced by eHealth services if the most informative measures are integrated in an easy-to-use and easily connectable approach. MS-specific eHealth services were highly appreciated, but the current level of adoption is still behind the level of interest in an extended and more interconnected electronic documentation of MS patients.

Representing Information in Patient Reports Using Natural Language Processing and the Extensible Markup Language

PubMed Central

Friedman, Carol; Hripcsak, George; Shagina, Lyuda; Liu, Hongfang

1999-01-01

Objective: To design a document model that provides reliable and efficient access to clinical information in patient reports for a broad range of clinical applications, and to implement an automated method using natural language processing that maps textual reports to a form consistent with the model. Methods: A document model that encodes structured clinical information in patient reports while retaining the original contents was designed using the extensible markup language (XML), and a document type definition (DTD) was created. An existing natural language processor (NLP) was modified to generate output consistent with the model. Two hundred reports were processed using the modified NLP system, and the XML output that was generated was validated using an XML validating parser. Results: The modified NLP system successfully processed all 200 reports. The output of one report was invalid, and 199 reports were valid XML forms consistent with the DTD. Conclusions: Natural language processing can be used to automatically create an enriched document that contains a structured component whose elements are linked to portions of the original textual report. This integrated document model provides a representation where documents containing specific information can be accurately and efficiently retrieved by querying the structured components. If manual review of the documents is desired, the salient information in the original reports can also be identified and highlighted. Using an XML model of tagging provides an additional benefit in that software tools that manipulate XML documents are readily available. PMID:9925230

Using Natural Language Processing to Improve Efficiency of Manual Chart Abstraction in Research: The Case of Breast Cancer Recurrence

PubMed Central

Carrell, David S.; Halgrim, Scott; Tran, Diem-Thy; Buist, Diana S. M.; Chubak, Jessica; Chapman, Wendy W.; Savova, Guergana

2014-01-01

The increasing availability of electronic health records (EHRs) creates opportunities for automated extraction of information from clinical text. We hypothesized that natural language processing (NLP) could substantially reduce the burden of manual abstraction in studies examining outcomes, like cancer recurrence, that are documented in unstructured clinical text, such as progress notes, radiology reports, and pathology reports. We developed an NLP-based system using open-source software to process electronic clinical notes from 1995 to 2012 for women with early-stage incident breast cancers to identify whether and when recurrences were diagnosed. We developed and evaluated the system using clinical notes from 1,472 patients receiving EHR-documented care in an integrated health care system in the Pacific Northwest. A separate study provided the patient-level reference standard for recurrence status and date. The NLP-based system correctly identified 92% of recurrences and estimated diagnosis dates within 30 days for 88% of these. Specificity was 96%. The NLP-based system overlooked 5 of 65 recurrences, 4 because electronic documents were unavailable. The NLP-based system identified 5 other recurrences incorrectly classified as nonrecurrent in the reference standard. If used in similar cohorts, NLP could reduce by 90% the number of EHR charts abstracted to identify confirmed breast cancer recurrence cases at a rate comparable to traditional abstraction. PMID:24488511

Integrated Information Systems for Electronic Chemotherapy Medication Administration

PubMed Central

Levy, Mia A.; Giuse, Dario A.; Eck, Carol; Holder, Gwen; Lippard, Giles; Cartwright, Julia; Rudge, Nancy K.

2011-01-01

Introduction: Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. Methods: We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. Results: We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. Conclusion: Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations. PMID:22043185

Fine-grained information extraction from German transthoracic echocardiography reports.

PubMed

Toepfer, Martin; Corovic, Hamo; Fette, Georg; Klügl, Peter; Störk, Stefan; Puppe, Frank

2015-11-12

Information extraction techniques that get structured representations out of unstructured data make a large amount of clinically relevant information about patients accessible for semantic applications. These methods typically rely on standardized terminologies that guide this process. Many languages and clinical domains, however, lack appropriate resources and tools, as well as evaluations of their applications, especially if detailed conceptualizations of the domain are required. For instance, German transthoracic echocardiography reports have not been targeted sufficiently before, despite of their importance for clinical trials. This work therefore aimed at development and evaluation of an information extraction component with a fine-grained terminology that enables to recognize almost all relevant information stated in German transthoracic echocardiography reports at the University Hospital of Würzburg. A domain expert validated and iteratively refined an automatically inferred base terminology. The terminology was used by an ontology-driven information extraction system that outputs attribute value pairs. The final component has been mapped to the central elements of a standardized terminology, and it has been evaluated according to documents with different layouts. The final system achieved state-of-the-art precision (micro average.996) and recall (micro average.961) on 100 test documents that represent more than 90 % of all reports. In particular, principal aspects as defined in a standardized external terminology were recognized with f 1=.989 (micro average) and f 1=.963 (macro average). As a result of keyword matching and restraint concept extraction, the system obtained high precision also on unstructured or exceptionally short documents, and documents with uncommon layout. The developed terminology and the proposed information extraction system allow to extract fine-grained information from German semi-structured transthoracic echocardiography reports with very high precision and high recall on the majority of documents at the University Hospital of Würzburg. Extracted results populate a clinical data warehouse which supports clinical research.

Standardized exchange of clinical documents--towards a shared care paradigm in glaucoma treatment.

PubMed

Gerdsen, F; Müller, S; Jablonski, S; Prokosch, H-U

2006-01-01

The exchange of medical data from research and clinical routine across institutional borders is essential to establish an integrated healthcare platform. In this project we want to realize the standardized exchange of medical data between different healthcare institutions to implement an integrated and interoperable information system supporting clinical treatment and research of glaucoma. The central point of our concept is a standardized communication model based on the Clinical Document Architecture (CDA). Further, a communication concept between different health care institutions applying the developed document model has been defined. With our project we have been able to prove that standardized communication between an Electronic Medical Record (EMR), an Electronic Health Record (EHR) and the Erlanger Glaucoma Register (EGR) based on the established conceptual models, which rely on CDA rel.1 level 1 and SCIPHOX, could be implemented. The HL7-tool-based deduction of a suitable CDA rel.2 compliant schema showed significant differences when compared with the manually created schema. Finally fundamental requirements, which have to be implemented for an integrated health care platform, have been identified. An interoperable information system can enhance both clinical treatment and research projects. By automatically transferring screening findings from a glaucoma research project to the electronic medical record of our ophthalmology clinic, clinicians could benefit from the availability of a longitudinal patient record. The CDA as a standard for exchanging clinical documents has demonstrated its potential to enhance interoperability within a future shared care paradigm.

Definition of an XML markup language for clinical laboratory procedures and comparison with generic XML markup.

PubMed

Saadawi, Gilan M; Harrison, James H

2006-10-01

Clinical laboratory procedure manuals are typically maintained as word processor files and are inefficient to store and search, require substantial effort for review and updating, and integrate poorly with other laboratory information. Electronic document management systems could improve procedure management and utility. As a first step toward building such systems, we have developed a prototype electronic format for laboratory procedures using Extensible Markup Language (XML). Representative laboratory procedures were analyzed to identify document structure and data elements. This information was used to create a markup vocabulary, CLP-ML, expressed as an XML Document Type Definition (DTD). To determine whether this markup provided advantages over generic markup, we compared procedures structured with CLP-ML or with the vocabulary of the Health Level Seven, Inc. (HL7) Clinical Document Architecture (CDA) narrative block. CLP-ML includes 124 XML tags and supports a variety of procedure types across different laboratory sections. When compared with a general-purpose markup vocabulary (CDA narrative block), CLP-ML documents were easier to edit and read, less complex structurally, and simpler to traverse for searching and retrieval. In combination with appropriate software, CLP-ML is designed to support electronic authoring, reviewing, distributing, and searching of clinical laboratory procedures from a central repository, decreasing procedure maintenance effort and increasing the utility of procedure information. A standard electronic procedure format could also allow laboratories and vendors to share procedures and procedure layouts, minimizing duplicative word processor editing. Our results suggest that laboratory-specific markup such as CLP-ML will provide greater benefit for such systems than generic markup.

Cost consideration in the clinical guidance documents of physician specialty societies in the United States.

PubMed

Schwartz, Jennifer A T; Pearson, Steven D

2013-06-24

Despite increasing concerns regarding the cost of health care, the consideration of costs in the development of clinical guidance documents by physician specialty societies has received little analysis. To evaluate the approach to consideration of cost in publicly available clinical guidance documents and methodological statements produced between 2008 and 2012 by the 30 largest US physician specialty societies. Qualitative document review. Whether costs are considered in clinical guidance development, mechanism of cost consideration, and the way that cost issues were used in support of specific clinical practice recommendations. Methodological statements for clinical guidance documents indicated that 17 of 30 physician societies (57%) explicitly integrated costs, 4 (13%) implicitly considered costs, 3 (10%) intentionally excluded costs, and 6 (20%) made no mention. Of the 17 societies that explicitly integrated costs, 9 (53%) consistently used a formal system in which the strength of recommendation was influenced in part by costs, whereas 8 (47%) were inconsistent in their approach or failed to mention the exact mechanism for considering costs. Among the 138 specific recommendations in these guidance documents that included cost as part of the rationale, the most common form of recommendation (50 [36%]) encouraged the use of a specific medical service because of equal effectiveness and lower cost. Slightly more than half of the largest US physician societies explicitly consider costs in developing their clinical guidance documents; among these, approximately half use an explicit mechanism for integrating costs into the strength of recommendations. Many societies remain vague in their approach. Physician specialty societies should demonstrate greater transparency and rigor in their approach to cost consideration in documents meant to influence care decisions.

A portable digital microphotography unit for rapid documentation of periungual nailfold capillary changes in autoimmune connective tissue diseases.

PubMed

Sontheimer, Richard D

2004-03-01

While employing a DermLite dermoscopy unit to assess pigment pattern networks in melanocytic skin lesions, it was observed that this compact, portable dermoscopy unit can also be used to quickly detect nailfold capillary changes when entertaining a diagnosis of autoimmune connective tissue diseases (CTD) such as dermatomyositis (DM), scleroderma/systemic sclerosis (SSc), or systemic lupus erythematosus. Aware that the suppliers of the DermLite dermoscopy unit also market a portable digital microphotography unit based on the DermLite optical principles for efficiently documenting cutaneous pigment network patterns, we investigated whether this unit (DermLite Foto flash unit attached to a Nikon Coolpix digital camera) might be used to photographically document nailfold capillary changes in patients with autoimmune CTD. A DermLite Foto flash unit attached to a Nikon Coolpix digital camera was used in a controlled observational study to obtain digital photographs of nailfold capillaries in a small sequential sample of patients with autoimmune CTD attending a rheumatic skin disease subspecialty clinic in an academic department of dermatology. The digital microphotography system proved to be highly useful in documenting the nailfold vascular changes observed in a small sample of patients with DM. We observed that the nailfold capillary changes seen in patients with clinically amyopathic DM were qualitatively and quantitatively similar to those seen in patients with classical DM. Digital microphotography systems designed for examining pigmented skin lesions can be used easily to document nailfold capillary changes often observed in DM and SSc. Nailfold capillary changes documented in this manner appear to be indistinguishable in clinically amyopathic DM and classical DM.

The Development of Clinical Document Standards for Semantic Interoperability in China

PubMed Central

Yang, Peng; Pan, Feng; Wan, Yi; Tu, Haibo; Tang, Xuejun; Hu, Jianping

2011-01-01

Objectives This study is aimed at developing a set of data groups (DGs) to be employed as reusable building blocks for the construction of the eight most common clinical documents used in China's general hospitals in order to achieve their structural and semantic standardization. Methods The Diagnostics knowledge framework, the related approaches taken from the Health Level Seven (HL7), the Integrating the Healthcare Enterprise (IHE), and the Healthcare Information Technology Standards Panel (HITSP) and 1,487 original clinical records were considered together to form the DG architecture and data sets. The internal structure, content, and semantics of each DG were then defined by mapping each DG data set to a corresponding Clinical Document Architecture data element and matching each DG data set to the metadata in the Chinese National Health Data Dictionary. By using the DGs as reusable building blocks, standardized structures and semantics regarding the clinical documents for semantic interoperability were able to be constructed. Results Altogether, 5 header DGs, 48 section DGs, and 17 entry DGs were developed. Several issues regarding the DGs, including their internal structure, identifiers, data set names, definitions, length and format, data types, and value sets, were further defined. Standardized structures and semantics regarding the eight clinical documents were structured by the DGs. Conclusions This approach of constructing clinical document standards using DGs is a feasible standard-driven solution useful in preparing documents possessing semantic interoperability among the disparate information systems in China. These standards need to be validated and refined through further study. PMID:22259722

Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System.

PubMed

Patel, Malhar P; Schettini, Priscille; O'Leary, Colin P; Bosworth, Hayden B; Anderson, John B; Shah, Kevin P

2018-05-01

Ideally, a referral from a primary care physician (PCP) to a specialist results in a completed specialty appointment with results available to the PCP. This is defined as "closing the referral loop." As health systems grow more complex, regulatory bodies increase vigilance, and reimbursement shifts towards value, closing the referral loop becomes a patient safety, regulatory, and financial imperative. To assess the ability of a large health system to close the referral loop, we used electronic medical record (EMR)-generated data to analyze referrals from a large primary care network to 20 high-volume specialties between July 1, 2015 and June 30, 2016. The primary metric was documented specialist appointment completion rate. Explanatory analyses included documented appointment scheduling rate, individual clinic differences, appointment wait times, and geographic distance to appointments. Of the 103,737 analyzed referral scheduling attempts, only 36,072 (34.8%) resulted in documented complete appointments. Low documented appointment scheduling rates (38.9% of scheduling attempts lacked appointment dates), individual clinic differences in closing the referral loop, and significant differences in wait times and distances to specialists between complete and incomplete appointments drove this gap. Other notable findings include high variation in wait times among specialties and correlation between high wait times and low documented appointment completion rates. The rate of closing the referral loop in this health system is low. Low appointment scheduling rates, individual clinic differences, and patient access issues of wait times and geographic proximity explain much of the gap. This problem is likely common among large health systems with complex provider networks and referral scheduling. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve rates of closing the referral loop. More research is necessary to determine the impact of these changes and other potential driving factors.

HIS-Based Support of Follow-Up Documentation – Concept and Implementation for Clinical Studies

PubMed Central

Herzberg, S.; Fritz, F.; Rahbar, K.; Stegger, L.; Schäfers, M.; Dugas, M.

2011-01-01

Objective Follow-up data must be collected according to the protocol of each clinical study, i.e. at certain time points. Missing follow-up information is a critical problem and may impede or bias the analysis of study data and result in delays. Moreover, additional patient recruitment may be necessary due to incomplete follow-up data. Current electronic data capture (EDC) systems in clinical studies are usually separated from hospital information systems (HIS) and therefore can provide limited functionality to support clinical workflow. In two case studies, we assessed the feasibility of HIS-based support of follow-up documentation. Methods We have developed a data model and a HIS-based workflow to provide follow-up forms according to clinical study protocols. If a follow-up form was due, a database procedure created a follow-up event which was translated by a communication server into an HL7 message and transferred to the import interface of the clinical information system (CIS). This procedure generated the required follow-up form and enqueued a link to it in a work list of the relating study nurses and study physicians, respectively. Results A HIS-based follow-up system automatically generated follow-up forms as defined by a clinical study protocol. These forms were scheduled into work lists of study nurses and study physicians. This system was integrated into the clinical workflow of two clinical studies. In a study from nuclear medicine, each scenario from the test concept according to the protocol of the single photon emission computer tomography/computer tomography (SPECT/CT) study was simulated and each scenario passed the test. For a study in psychiatry, 128 follow-up forms were automatically generated within 27 weeks, on average five forms per week (maximum 12, minimum 1 form per week). Conclusion HIS-based support of follow-up documentation in clinical studies is technically feasible and can support compliance with study protocols. PMID:23616857

Integrating radiology information systems with healthcare delivery environments using DICOM and HL7 standards.

PubMed

Blazona, Bojan; Koncar, Miroslav

2006-01-01

Integration based on open standards, in order to achieve communication and information interoperability, is one of the key aspects of modern health care information systems. Interoperability presents data and communication layer interchange. In this context we identified the HL7 standard as the world's leading medical Information and communication technology (ICT) standard for the business layer in healthcare information systems and we tried to explore the ability to exchange clinical documents with minimal integrated healthcare information systems (IHCIS) change. We explored HL7 Clinical Document Architecture (CDA) abilities to achieve radiology information system integration (DICOM) to IHCIS (HL7). We introduced the use of WADO service interconnection to IHCIS and finally CDA rendering in widely used Internet explorers.

Review of medical discharge summaries and medical documentation in a metropolitan hospital: impact on diagnostic-related groups and Weighted Inlier Equivalent Separation.

PubMed

Chin, N; Perera, P; Roberts, A; Nagappan, R

2013-07-01

Accurate and comprehensive clinical documentation is crucial for effective ongoing patient care, follow up and to optimise case mix-based funding. Each Diagnostic Related Group (DRG) is assigned a 'weight', leading to Weighted Inlier Equivalent Separation (WIES), a system many public and private hospitals in Australia subscribe to. To identify the top DRG in a general medical inpatient service, the completeness of medical discharge documentation, commonly missed comorbidities and system-related issues and subsequent impact on DRG and WIES allocation. One hundred and fifty completed discharge summaries were randomly selected from the top 10 medical DRG in our health service. From a detailed review of the clinical documentation, principal diagnoses, associated comorbidities and complications, where appropriate, the DRG and WIES were modified. Seventy-two (48%) of the 150 reviewed admissions resulted in a revision of DRG and WIES equivalent to an increase of AUD 142,000. Respiratory-based DRG generated the largest revision of DRG and WIES, while 'Cellulitis' DRG had the largest relative change. Twenty-seven per cent of summaries reviewed necessitated a change in coding with no subsequent change in DRG allocation or WIES. Acute renal failure, anaemia and electrolyte disturbances were the most commonly underrepresented entities in clinical discharge documentation. Seven patients had their WIES downgraded. Comprehensive documentation of principal diagnosis/diagnoses, comorbidities and their complications is imperative to optimal DRG and WIES allocation. Regular meetings between clinical and coding staff improve the quality and timeliness of medical documentation, ensure adequate communication with general practitioners and lead to appropriate funding. © 2013 The Authors; Internal Medicine Journal © 2013 Royal Australasian College of Physicians.

Accuracy and Efficiency of Recording Pediatric Early Warning Scores Using an Electronic Physiological Surveillance System Compared With Traditional Paper-Based Documentation.

PubMed

Sefton, Gerri; Lane, Steven; Killen, Roger; Black, Stuart; Lyon, Max; Ampah, Pearl; Sproule, Cathryn; Loren-Gosling, Dominic; Richards, Caitlin; Spinty, Jean; Holloway, Colette; Davies, Coral; Wilson, April; Chean, Chung Shen; Carter, Bernie; Carrol, E D

2017-05-01

Pediatric Early Warning Scores are advocated to assist health professionals to identify early signs of serious illness or deterioration in hospitalized children. Scores are derived from the weighting applied to recorded vital signs and clinical observations reflecting deviation from a predetermined "norm." Higher aggregate scores trigger an escalation in care aimed at preventing critical deterioration. Process errors made while recording these data, including plotting or calculation errors, have the potential to impede the reliability of the score. To test this hypothesis, we conducted a controlled study of documentation using five clinical vignettes. We measured the accuracy of vital sign recording, score calculation, and time taken to complete documentation using a handheld electronic physiological surveillance system, VitalPAC Pediatric, compared with traditional paper-based charts. We explored the user acceptability of both methods using a Web-based survey. Twenty-three staff participated in the controlled study. The electronic physiological surveillance system improved the accuracy of vital sign recording, 98.5% versus 85.6%, P < .02, Pediatric Early Warning Score calculation, 94.6% versus 55.7%, P < .02, and saved time, 68 versus 98 seconds, compared with paper-based documentation, P < .002. Twenty-nine staff completed the Web-based survey. They perceived that the electronic physiological surveillance system offered safety benefits by reducing human error while providing instant visibility of recorded data to the entire clinical team.

Evaluating the usability of speech recognition to create clinical documentation using a commercial electronic health record.

PubMed

Hodgson, Tobias; Magrabi, Farah; Coiera, Enrico

2018-05-01

To conduct a usability study exploring the value of using speech recognition (SR) for clinical documentation tasks within an electronic health record (EHR) system. Thirty-five emergency department clinicians completed a system usability scale (SUS) questionnaire. The study was undertaken after participants undertook randomly allocated clinical documentation tasks using keyboard and mouse (KBM) or SR. SUS scores were analyzed and the results with KBM were compared to SR results. Significant difference in SUS scores between EHR system use with and without SR were observed (KBM 67, SR 61; P = 0.045; CI, 0.1 to 12.0). Nineteen of 35 participants scored higher for EHR with KBM, 11 higher for EHR with SR and 5 gave the same score for both. Factor analysis showed no significant difference in scores for the sub-element of usability (EHR with KBM 65, EHR with SR 62; P = 0.255; CI, -2.6 to 9.5). Scores for the sub-element of learnability were significantly different (KBM 72, SR 55; P < 0.001; CI, 9.8 to 23.5). A significant correlation was found between the perceived usability of the two system configurations (EHR with KBM or SR) and the efficiency of documentation (time to document) (P = 0.002; CI, 10.5 to -0.1) but not with safety (number of errors) (P = 0.90; CI, -2.3 to 2.6). SR was associated with significantly reduced overall usability scores, even though it is often positioned as ease of use technology. SR was perceived to impose larger costs in terms of learnability via training and support requirements for EHR based documentation when compared to using KBM. Lower usability scores were significantly associated with longer documentation times. The usability of EHR systems with any input modality is an area that requires continued development. The addition of an SR component to an EHR system may cause a significant reduction in terms of perceived usability by clinicians. Copyright © 2018 Elsevier B.V. All rights reserved.

Clinical benchmarking enabled by the digital health record.

PubMed

Ricciardi, T N; Masarie, F E; Middleton, B

2001-01-01

Office-based physicians are often ill equipped to report aggregate information about their patients and practice of medicine, since their practices have relied upon paper records for the management of clinical information. Physicians who do not have access to large-scale information technology support can now benefit from low-cost clinical documentation and reporting tools. We developed a hosted clinical data mart for users of a web-enabled charting tool, targeting the solo or small group practice. The system uses secure Java Server Pages with a dashboard-like menu to provide point-and-click access to simple reports such as case mix, medications, utilization, productivity, and patient demographics in its first release. The system automatically normalizes user-entered clinical terms to enhance the quality of structured data. Individual providers benefit from rapid patient identification for disease management, quality of care self-assessments, drug recalls, and compliance with clinical guidelines. The system provides knowledge integration by linking to trusted sources of online medical information in context. Information derived from the clinical record is clinically more accurate than billing data. Provider self-assessment and benchmarking empowers physicians, who may resent "being profiled" by external entities. In contrast to large-scale data warehouse projects, the current system delivers immediate value to individual physicians who choose an electronic clinical documentation tool.

Capturing Essential Information to Achieve Safe Interoperability.

PubMed

Weininger, Sandy; Jaffe, Michael B; Rausch, Tracy; Goldman, Julian M

2017-01-01

In this article, we describe the role of "clinical scenario" information to assure the safety of interoperable systems, as well as the system's ability to deliver the requisite clinical functionality to improve clinical care. Described are methods and rationale for capturing the clinical needs, workflow, hazards, and device interactions in the clinical environment. Key user (clinician and clinical engineer) needs and system requirements can be derived from this information, therefore, improving the communication from clinicians to medical device and information technology system developers. This methodology is intended to assist the health care community, including researchers, standards developers, regulators, and manufacturers, by providing clinical definition to support requirements in the systems engineering process, particularly those focusing on development of Integrated Clinical Environments described in standard ASTM F2761. Our focus is on identifying and documenting relevant interactions and medical device capabilities within the system using a documentation tool called medical device interface data sheets and mitigating hazardous situations related to workflow, product usability, data integration, and the lack of effective medical device-health information technology system integration to achieve safe interoperability. Portions of the analysis of a clinical scenario for a "patient-controlled analgesia safety interlock" are provided to illustrate the method. Collecting better clinical adverse event information and proposed solutions can help identify opportunities to improve current device capabilities and interoperability and support a learning health system to improve health care delivery. Developing and analyzing clinical scenarios are the first steps in creating solutions to address vexing patient safety problems and enable clinical innovation. A Web-based research tool for implementing a means of acquiring and managing this information, the Clinical Scenario Repository™ (MD PnP Program), is described.

A systematic review of near real-time and point-of-care clinical decision support in anesthesia information management systems.

PubMed

Simpao, Allan F; Tan, Jonathan M; Lingappan, Arul M; Gálvez, Jorge A; Morgan, Sherry E; Krall, Michael A

2017-10-01

Anesthesia information management systems (AIMS) are sophisticated hardware and software technology solutions that can provide electronic feedback to anesthesia providers. This feedback can be tailored to provide clinical decision support (CDS) to aid clinicians with patient care processes, documentation compliance, and resource utilization. We conducted a systematic review of peer-reviewed articles on near real-time and point-of-care CDS within AIMS using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Studies were identified by searches of the electronic databases Medline and EMBASE. Two reviewers screened studies based on title, abstract, and full text. Studies that were similar in intervention and desired outcome were grouped into CDS categories. Three reviewers graded the evidence within each category. The final analysis included 25 articles on CDS as implemented within AIMS. CDS categories included perioperative antibiotic prophylaxis, post-operative nausea and vomiting prophylaxis, vital sign monitors and alarms, glucose management, blood pressure management, ventilator management, clinical documentation, and resource utilization. Of these categories, the reviewers graded perioperative antibiotic prophylaxis and clinical documentation as having strong evidence per the peer reviewed literature. There is strong evidence for the inclusion of near real-time and point-of-care CDS in AIMS to enhance compliance with perioperative antibiotic prophylaxis and clinical documentation. Additional research is needed in many other areas of AIMS-based CDS.

Predictors of successful use of a web-based healthcare document storage and sharing system for pediatric cancer survivors: Cancer SurvivorLink™.

PubMed

Williamson, Rebecca; Meacham, Lillian; Cherven, Brooke; Hassen-Schilling, Leann; Edwards, Paula; Palgon, Michael; Espinoza, Sofia; Mertens, Ann

2014-09-01

Cancer SurvivorLink™, www.cancersurvivorlink.org , is a patient-controlled communication tool where survivors can electronically store and share documents with healthcare providers. Functionally, SurvivorLink serves as an electronic personal health record-a record of health-related information managed and controlled by the survivor. Recruitment methods to increase registration and the characteristics of registrants who completed each step of using SurvivorLink are described. Pediatric cancer survivors were recruited via mailings, survivor clinic, and community events. Recruitment method and Aflac Survivor Clinic attendance was determined for each registrant. Registration date, registrant type (parent vs. survivor), zip code, creation of a personal health record in SurvivorLink, storage of documents, and document sharing were measured. Logistic regression was used to determine the characteristics that predicted creation of a health record and storage of documents. To date, 275 survivors/parents have completed registration: 63 were recruited via mailing, 99 from clinic, 56 from community events, and 57 via other methods. Overall, 66.9 % registrants created a personal health record and 45.7 % of those stored a health document. There were no significant predictors for creating a personal health record. Attending a survivor clinic was the strongest predictor of document storage (p < 0.01). Of those with a document stored, 21.4 % shared with a provider. Having attended survivor clinic is the biggest predictor of registering and using SurvivorLink. Many survivors must advocate for their survivorship care. Survivor Link provides educational material and supports the dissemination of survivor-specific follow-up recommendations to facilitate shared clinical care decision making.

Capturing Essential Information to Achieve Safe Interoperability

PubMed Central

Weininger, Sandy; Jaffe, Michael B.; Rausch, Tracy; Goldman, Julian M.

2016-01-01

In this article we describe the role of “clinical scenario” information to assure the safety of interoperable systems, as well as the system’s ability to deliver the requisite clinical functionality to improve clinical care. Described are methods and rationale for capturing the clinical needs, workflow, hazards, and device interactions in the clinical environment. Key user (clinician and clinical engineer) needs and system requirements can be derived from this information, therefore improving the communication from clinicians to medical device and information technology system developers. This methodology is intended to assist the health care community, including researchers, standards developers, regulators, and manufacturers, by providing clinical definition to support requirements in the systems engineering process, particularly those focusing on development of Integrated Clinical Environments described in standard ASTM F2761. Our focus is on identifying and documenting relevant interactions and medical device capabilities within the system using a documentation tool called medical device interface data sheets (MDIDSa) and mitigating hazardous situations related to workflow, product usability, data integration, and the lack of effective medical device-health information technology system integration to achieve safe interoperability. Portions of the analysis of a clinical scenario for a “Patient-controlled analgesia safety interlock” are provided to illustrate the method. Collecting better clinical adverse event information and proposed solutions can help identify opportunities to improve current device capabilities and interoperability and support a Learning Health System to improve health care delivery. Developing and analyzing clinical scenarios are the first steps in creating solutions to address vexing patient safety problems and enable clinical innovation. A web-based research tool for implementing a means of acquiring and managing this information, the Clinical Scenario Repository™, is described. PMID:27387840

Development of a digital clinical pathway for emergency medicine: Lessons from usability testing and implementation failure.

PubMed

Gutenstein, Marc; Pickering, John W; Than, Martin

2018-06-01

Clinical pathways are used to support the management of patients in emergency departments. An existing document-based clinical pathway was used as the foundation on which to design and build a digital clinical pathway for acute chest pain, with the aim of improving clinical calculations, clinician decision-making, documentation, and data collection. Established principles of decision support system design were used to build an application within the existing electronic health record, before testing with a multidisciplinary team of doctors using a think-aloud protocol. Technical authoring was successful, however, usability testing revealed that the user experience and the flexibility of workflow within the application were critical barriers to implementation. Emergency medicine and acute care decision support systems face particular challenges to existing models of linear workflow that should be deliberately addressed in digital pathway design. We make key recommendations regarding digital pathway design in emergency medicine.

Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-year study.

PubMed

Ammenwerth, Elske; Mansmann, Ulrich; Iller, Carola; Eichstädter, Ronald

2003-01-01

The documentation of the nursing process is an important but often neglected part of clinical documentation. Paper-based systems have been introduced to support nursing process documentation. Frequently, however, problems such as low quality of documentation are reported. It is unclear whether computer-based documentation systems can reduce these problems and which factors influence their acceptance by users. We introduced a computer-based nursing documentation system on four wards of the University Hospitals of Heidelberg and systematically evaluated its preconditions and its effects in a pretest-posttest intervention study. For the analysis of user acceptance, we concentrated on subjective data drawn from questionnaires and interviews. A questionnaire was developed using items from published questionnaires and items that had to be developed for the special purpose of this study. The quantitative results point to two factors influencing the acceptance of a new computer-based documentation system: the previous acceptance of the nursing process and the previous amount of self-confidence when using computers. On one ward, the diverse acceptance scores heavily declined after the introduction of the nursing documentation system. Explorative qualitative analysis on this ward points to further success factors of computer-based nursing documentation systems. Our results can be used to assist the planning and introduction of computer-based nursing documentation systems. They demonstrate the importance of computer experience and acceptance of the nursing process on a ward but also point to other factors such as the fit between nursing workflow and the functionality of a nursing documentation system.

[Multimodal document management in radiotherapy].

PubMed

Fahrner, H; Kirrmann, S; Röhner, F; Schmucker, M; Hall, M; Heinemann, F

2013-12-01

After incorporating treatment planning and the organisational model of treatment planning in the operating schedule system (BAS, "Betriebsablaufsystem"), complete document qualities were embedded in the digital environment. The aim of this project was to integrate all documents independent of their source (paper-bound or digital) and to make content from the BAS available in a structured manner. As many workflow steps as possible should be automated, e.g. assigning a document to a patient in the BAS. Additionally it must be guaranteed that at all times it could be traced who, when, how and from which source documents were imported into the departmental system. Furthermore work procedures should be changed that the documentation conducted either directly in the departmental system or from external systems can be incorporated digitally and paper document can be completely avoided (e.g. documents such as treatment certificate, treatment plans or documentation). It was a further aim, if possible, to automate the removal of paper documents from the departmental work flow, or even to make such paper documents superfluous. In this way patient letters for follow-up appointments should automatically generated from the BAS. Similarly patient record extracts in the form of PDF files should be enabled, e.g. for controlling purposes. The available document qualities were analysed in detail by a multidisciplinary working group (BAS-AG) and after this examination and assessment of the possibility of modelling in our departmental workflow (BAS) they were transcribed into a flow diagram. The gathered specifications were implemented in a test environment by the clinical and administrative IT group of the department of radiation oncology and subsequent to a detailed analysis introduced into clinical routine. The department has succeeded under the conditions of the aforementioned criteria to embed all relevant documents in the departmental workflow via continuous processes. Since the completion of the concepts and the implementation in our test environment 15,000 documents were introduced into the departmental workflow following routine approval. Furthermore approximately 5000 appointment letters for patient aftercare per year were automatically generated by the BAS. In addition patient record extracts in the form of PDF files for the medical services of the healthcare insurer can be generated.

A generic, web-based clinical information system architecture using HL7 CDA: successful implementation in dermatological routine care.

PubMed

Schuler, Thilo; Boeker, Martin; Klar, Rüdiger; Müller, Marcel

2007-01-01

The requirements of highly specialized clinical domains are often underrepresented in hospital information systems (HIS). Common consequences are that documentation remains to be paper-based or external systems with insufficient HIS integration are used. This paper presents a solution to overcome this deficiency in the form of a generic framework based on the HL7 Clinical Document Architecture. The central architectural idea is the definition of customized forms using a schema-controlled XML language. These flexible form definitions drive the user interface, the data storage, and standardized data exchange. A successful proof-of-concept application in a dermatologic outpatient wound care department has been implemented, and is well accepted by the clinicians. Our work with HL7 CDA revealed the need for further practical research in the health information standards realm.

Enhancing healthcare process design with human factors engineering and reliability science, part 2: applying the knowledge to clinical documentation systems.

PubMed

Boston-Fleischhauer, Carol

2008-02-01

The demand to redesign healthcare processes that achieve efficient, effective, and safe results is never-ending. Part 1 of this 2-part series introduced human factors engineering and reliability science as important knowledge to enhance existing operational and clinical process design methods in healthcare organizations. In part 2, the author applies this knowledge to one of the most common operational processes in healthcare: clinical documentation. Specific implementation strategies and anticipated results are discussed, along with organizational challenges and recommended executive responses.

Implementation of a School-wide Clinical Intervention Documentation System

PubMed Central

Stevenson, T. Lynn; Fox, Brent I.; Andrus, Miranda; Carroll, Dana

2011-01-01

Objective. To evaluate the effectiveness and impact of a customized Web-based software program implemented in 2006 for school-wide documentation of clinical interventions by pharmacy practice faculty members, pharmacy residents, and student pharmacists. Methods. The implementation process, directed by a committee of faculty members and school administrators, included preparation and refinement of the software, user training, development of forms and reports, and integration of the documentation process within the curriculum. Results. Use of the documentation tool consistently increased from May 2007 to December 2010. Over 187,000 interventions were documented with over $6.2 million in associated cost avoidance. Conclusions. Successful implementation of a school-wide documentation tool required considerable time from the oversight committee and a comprehensive training program for all users, with ongoing monitoring of data collection practices. Data collected proved to be useful to show the impact of faculty members, residents, and student pharmacists at affiliated training sites. PMID:21829264

Comprehensive Reproductive System Care Program - Clinical Breast Care Project (CRSCP-CBCP)

DTIC Science & Technology

2006-09-01

policy or decision unless so designated by other documentation. REPORT DOCUMENTATION PAGE Form Approved OMB No. 0704-0188 Public reporting burden...on those results. 5 W81 XWH-05-2-0053 Principal Investigator: Craig D. Shriver, COL MC Summary of the methodology of the project. The five pillars...exploration of warehoused data from an individual patient. An application prototype has been developed to enable users to access clinical or experimental

Poster — Thur Eve — 52: A Web-based Platform for Collaborative Document Management in Radiotherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kildea, J.; Joseph, A.

We describe DepDocs, a web-based platform that we have developed to manage the committee meetings, policies, procedures and other documents within our otherwise paperless radiotherapy clinic. DepDocs is essentially a document management system based on the popular Drupal content management software. For security and confidentiality, it is hosted on a linux server internal to our hospital network such that documents are never sent to the cloud or outside of the hospital firewall. We used Drupal's in-built role-based user rights management system to assign a role, and associated document editing rights, to each user. Documents are accessed for viewing using eithermore » a simple Google-like search or by generating a list of related documents from a taxonomy of categorization terms. Our system provides document revision tracking and an document review and approval mechanism for all official policies and procedures. Committee meeting schedules, agendas and minutes are maintained by committee chairs and are restricted to committee members. DepDocs has been operational within our department for over six months and has already 45 unique users and an archive of over 1000 documents, mostly policies and procedures. Documents are easily retrievable from the system using any web browser within our hospital's network.« less

Perceptions of the effect of information and communication technology on the quality of care delivered in emergency departments: a cross-site qualitative study.

PubMed

Callen, Joanne; Paoloni, Richard; Li, Julie; Stewart, Michael; Gibson, Kathryn; Georgiou, Andrew; Braithwaite, Jeffrey; Westbrook, Johanna

2013-02-01

We identify and describe emergency physicians' and nurses' perceptions of the effect of an integrated emergency department (ED) information system on the quality of care delivered in the ED. A qualitative study was conducted in 4 urban EDs, with each site using the same ED information system. Participants (n=97) were physicians and nurses with data collected by 69 detailed interviews, 5 focus groups (28 participants), and 26 hours of structured observations. Results revealed new perspectives on how an integrated ED information system was perceived to affect incentives for use, awareness of colleagues' activities, and workflow. A key incentive was related to the positive effect of the ED information system on clinical decisionmaking because of improved and quicker access to patient-specific and knowledge-base information compared with the previous stand-alone ED information system. Synchronous access to patient data was perceived to lead to enhanced awareness by individual physicians and nurses of what others were doing within and outside the ED, which participants claimed contributed to improved care coordination, communication, clinical documentation, and the consultation process. There was difficulty incorporating the use of the ED information system with clinicians' work, particularly in relation to increased task complexity; duplicate documentation, and computer issues related to system usability, hardware, and individuals' computer skills and knowledge. Physicians and nurses perceived that the integrated ED information system contributed to improvements in the delivery of patient care, enabling faster and better-informed decisionmaking and specialty consultations. The challenge of electronic clinical documentation and balancing data entry demands with system benefits necessitates that new methods of data capture, suited to busy clinical environments, be developed. Copyright © 2012. Published by Mosby, Inc.

Accuracy and Efficiency of Recording Pediatric Early Warning Scores Using an Electronic Physiological Surveillance System Compared With Traditional Paper-Based Documentation

PubMed Central

Sefton, Gerri; Lane, Steven; Killen, Roger; Black, Stuart; Lyon, Max; Ampah, Pearl; Sproule, Cathryn; Loren-Gosling, Dominic; Richards, Caitlin; Spinty, Jean; Holloway, Colette; Davies, Coral; Wilson, April; Chean, Chung Shen; Carter, Bernie; Carrol, E.D.

2017-01-01

Pediatric Early Warning Scores are advocated to assist health professionals to identify early signs of serious illness or deterioration in hospitalized children. Scores are derived from the weighting applied to recorded vital signs and clinical observations reflecting deviation from a predetermined “norm.” Higher aggregate scores trigger an escalation in care aimed at preventing critical deterioration. Process errors made while recording these data, including plotting or calculation errors, have the potential to impede the reliability of the score. To test this hypothesis, we conducted a controlled study of documentation using five clinical vignettes. We measured the accuracy of vital sign recording, score calculation, and time taken to complete documentation using a handheld electronic physiological surveillance system, VitalPAC Pediatric, compared with traditional paper-based charts. We explored the user acceptability of both methods using a Web-based survey. Twenty-three staff participated in the controlled study. The electronic physiological surveillance system improved the accuracy of vital sign recording, 98.5% versus 85.6%, P < .02, Pediatric Early Warning Score calculation, 94.6% versus 55.7%, P < .02, and saved time, 68 versus 98 seconds, compared with paper-based documentation, P < .002. Twenty-nine staff completed the Web-based survey. They perceived that the electronic physiological surveillance system offered safety benefits by reducing human error while providing instant visibility of recorded data to the entire clinical team. PMID:27832032

Time-motion analysis of clinical nursing documentation during implementation of an electronic operating room management system for ophthalmic surgery.

PubMed

Read-Brown, Sarah; Sanders, David S; Brown, Anna S; Yackel, Thomas R; Choi, Dongseok; Tu, Daniel C; Chiang, Michael F

2013-01-01

Efficiency and quality of documentation are critical in surgical settings because operating rooms are a major source of revenue, and because adverse events may have enormous consequences. Electronic health records (EHRs) have potential to impact surgical volume, quality, and documentation time. Ophthalmology is an ideal domain to examine these issues because procedures are high-throughput and demand efficient documentation. This time-motion study examines nursing documentation during implementation of an EHR operating room management system in an ophthalmology department. Key findings are: (1) EHR nursing documentation time was significantly worse during early implementation, but improved to a level near but slightly worse than paper baseline, (2) Mean documentation time varied significantly among nurses during early implementation, and (3) There was no decrease in operating room turnover time or surgical volume after implementation. These findings have important implications for ambulatory surgery departments planning EHR implementation, and for research in system design.

Time-Motion Analysis of Clinical Nursing Documentation During Implementation of an Electronic Operating Room Management System for Ophthalmic Surgery

PubMed Central

Read-Brown, Sarah; Sanders, David S.; Brown, Anna S.; Yackel, Thomas R.; Choi, Dongseok; Tu, Daniel C.; Chiang, Michael F.

2013-01-01

Efficiency and quality of documentation are critical in surgical settings because operating rooms are a major source of revenue, and because adverse events may have enormous consequences. Electronic health records (EHRs) have potential to impact surgical volume, quality, and documentation time. Ophthalmology is an ideal domain to examine these issues because procedures are high-throughput and demand efficient documentation. This time-motion study examines nursing documentation during implementation of an EHR operating room management system in an ophthalmology department. Key findings are: (1) EHR nursing documentation time was significantly worse during early implementation, but improved to a level near but slightly worse than paper baseline, (2) Mean documentation time varied significantly among nurses during early implementation, and (3) There was no decrease in operating room turnover time or surgical volume after implementation. These findings have important implications for ambulatory surgery departments planning EHR implementation, and for research in system design. PMID:24551402

Critical issues in an electronic documentation system.

PubMed

Weir, Charlene R; Nebeker, Jonathan R

2007-10-11

The Veterans Health Administration (VHA), of the U.S. Department of Veteran Affairs has instituted a medical record (EMR) that includes electronic documentation of all narrative components of the medical record. To support clinicians using the system, multiple efforts have been instituted to ease the creation of narrative reports. Although electronic documentation is easier to read and improves access to information, it also may create new and additional hazards for users. This study is the first step in a series of studies to evaluate the issues surrounding the creation and use of electronic documentation. Eighty-eight providers across multiple clinical roles were interviewed in 10 primary care sites in the VA system. Interviews were tape-recorded, transcribed and qualitatively analyzed for themes. In addition, specific questions were asked about perceived harm due to electronic documentation practices. Five themes relating to difficulties with electronic documentation were identified: 1) information overload; 2) hidden information; 3) lack of trust; 4) communication; 5) decision-making. Three providers reported that they knew of an incident where current documentation practices had caused patient harm and over 75% of respondents reported significant mis-trust of the system.

Implementation of a scalable, web-based, automated clinical decision support risk-prediction tool for chronic kidney disease using C-CDA and application programming interfaces.

PubMed

Samal, Lipika; D'Amore, John D; Bates, David W; Wright, Adam

2017-11-01

Clinical decision support tools for risk prediction are readily available, but typically require workflow interruptions and manual data entry so are rarely used. Due to new data interoperability standards for electronic health records (EHRs), other options are available. As a clinical case study, we sought to build a scalable, web-based system that would automate calculation of kidney failure risk and display clinical decision support to users in primary care practices. We developed a single-page application, web server, database, and application programming interface to calculate and display kidney failure risk. Data were extracted from the EHR using the Consolidated Clinical Document Architecture interoperability standard for Continuity of Care Documents (CCDs). EHR users were presented with a noninterruptive alert on the patient's summary screen and a hyperlink to details and recommendations provided through a web application. Clinic schedules and CCDs were retrieved using existing application programming interfaces to the EHR, and we provided a clinical decision support hyperlink to the EHR as a service. We debugged a series of terminology and technical issues. The application was validated with data from 255 patients and subsequently deployed to 10 primary care clinics where, over the course of 1 year, 569 533 CCD documents were processed. We validated the use of interoperable documents and open-source components to develop a low-cost tool for automated clinical decision support. Since Consolidated Clinical Document Architecture-based data extraction extends to any certified EHR, this demonstrates a successful modular approach to clinical decision support. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association.

Advance Care Planning Documentation in Electronic Health Records: Current Challenges and Recommendations for Change.

PubMed

Lamas, Daniela; Panariello, Natalie; Henrich, Natalie; Hammes, Bernard; Hanson, Laura C; Meier, Diane E; Guinn, Nancy; Corrigan, Janet; Hubber, Sean; Luetke-Stahlman, Hannah; Block, Susan

2018-04-01

To develop a set of clinically relevant recommendations to improve the state of advance care planning (ACP) documentation in the electronic health record (EHR). Advance care planning (ACP) is a key process that supports goal-concordant care. For preferences to be honored, clinicians must be able to reliably record, find, and use ACP documentation. However, there are no standards to guide ACP documentation in the electronic health record (EHR). We interviewed 21 key informants to understand the strengths and weaknesses of EHR documentation systems for ACP and identify best practices. We analyzed these interviews using a qualitative content analysis approach and subsequently developed a preliminary set of recommendations. These recommendations were vetted and refined in a second round of input from a national panel of content experts. Informants identified six themes regarding current inadequacies in documentation and accessibility of ACP information and opportunities for improvement. We offer a set of concise, clinically relevant recommendations, informed by expert opinion, to improve the state of ACP documentation in the EHR.

An HL7-CDA wrapper for facilitating semantic interoperability to rule-based Clinical Decision Support Systems.

PubMed

Sáez, Carlos; Bresó, Adrián; Vicente, Javier; Robles, Montserrat; García-Gómez, Juan Miguel

2013-03-01

The success of Clinical Decision Support Systems (CDSS) greatly depends on its capability of being integrated in Health Information Systems (HIS). Several proposals have been published up to date to permit CDSS gathering patient data from HIS. Some base the CDSS data input on the HL7 reference model, however, they are tailored to specific CDSS or clinical guidelines technologies, or do not focus on standardizing the CDSS resultant knowledge. We propose a solution for facilitating semantic interoperability to rule-based CDSS focusing on standardized input and output documents conforming an HL7-CDA wrapper. We define the HL7-CDA restrictions in a HL7-CDA implementation guide. Patient data and rule inference results are mapped respectively to and from the CDSS by means of a binding method based on an XML binding file. As an independent clinical document, the results of a CDSS can present clinical and legal validity. The proposed solution is being applied in a CDSS for providing patient-specific recommendations for the care management of outpatients with diabetes mellitus. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Development and Evaluation of a Clinical Note Section Header Terminology

PubMed Central

Denny, Joshua C.; Miller, Randolph A.; Johnson, Kevin B.; Spickard, Anderson

2008-01-01

Clinical documentation is often expressed in natural language text, yet providers often use common organizations that segment these notes in sections, such as “history of present illness” or “physical examination.” We developed a hierarchical section header terminology, supporting mappings to LOINC and other vocabularies; it contained 1109 concepts and 4332 synonyms. Physicians evaluated it compared to LOINC and the Evaluation and Management billing schema using a randomly selected corpus of history and physical notes. Evaluated documents contained a median of 54 sections and 27 “major sections.” There were 16,196 total sections in the evaluation note corpus. The terminology contained 99.9% of the clinical sections; LOINC matched 77% of section header concepts and 20% of section header strings in those documents. The section terminology may enable better clinical note understanding and interoperability. Future development and integration into natural language processing systems is needed. PMID:18999303

KAT: A Flexible XML-based Knowledge Authoring Environment

PubMed Central

Hulse, Nathan C.; Rocha, Roberto A.; Del Fiol, Guilherme; Bradshaw, Richard L.; Hanna, Timothy P.; Roemer, Lorrie K.

2005-01-01

As part of an enterprise effort to develop new clinical information systems at Intermountain Health Care, the authors have built a knowledge authoring tool that facilitates the development and refinement of medical knowledge content. At present, users of the application can compose order sets and an assortment of other structured clinical knowledge documents based on XML schemas. The flexible nature of the application allows the immediate authoring of new types of documents once an appropriate XML schema and accompanying Web form have been developed and stored in a shared repository. The need for a knowledge acquisition tool stems largely from the desire for medical practitioners to be able to write their own content for use within clinical applications. We hypothesize that medical knowledge content for clinical use can be successfully created and maintained through XML-based document frameworks containing structured and coded knowledge. PMID:15802477

Effect of an obesity best practice alert on physician documentation and referral practices.

PubMed

Fitzpatrick, Stephanie L; Dickins, Kirsten; Avery, Elizabeth; Ventrelle, Jennifer; Shultz, Aaron; Kishen, Ekta; Rothschild, Steven

2017-12-01

The Centers for Medicare & Medicaid Services Electronic Health Record Meaningful Use Incentive Program requires physicians to document body mass index (BMI) and a follow-up treatment plan for adult patients with BMI ≥ 25. To examine the effect of a best practice alert on physician documentation of obesity-related care and referrals to weight management treatment, in a cluster-randomized design, 14 primary care clinics at an academic medical center were randomized to best practice alert intervention (n = 7) or comparator (n = 7). The alert was triggered when both height and weight were entered and BMI was ≥30. Both intervention and comparator clinics could document meaningful use by selecting a nutrition education handout within the alert. Intervention clinics could also select a referral option from the list of clinic and community-based weight management programs embedded in the alert. Main outcomes were proportion of eligible patients with (1) obesity-related documentation and (2) referral. There were 26,471 total primary care encounters with 12,981 unique adult patients with BMI ≥ 30 during the 6-month study period. Documentation doubled (17 to 33%) with implementation of the alert. However, intervention clinics were not significantly more likely to refer patients to weight management than comparator clinics (2.8 vs. 1.3%, p = 0.07). Although the alert was associated with increased physician meaningful use compliance, it was not an effective strategy for improving patient access to weight management services. Further research is needed to understand system-level characteristics that influence obesity management in primary care.

Comparison of provider-documented and patient-reported brief intervention for unhealthy alcohol use in VA outpatients.

PubMed

Lapham, Gwen T; Rubinsky, Anna D; Shortreed, Susan M; Hawkins, Eric J; Richards, Julie; Williams, Emily C; Berger, Douglas; Chavez, Laura J; Kivlahan, Daniel R; Bradley, Katharine A

2015-08-01

Performance measures for brief alcohol interventions (BIs) are currently based on provider documentation of BI. However, provider documentation may not be a reliable measure of whether or not patients are offered clinically meaningful BIs. In particular, BI documented with clinical decision support in an electronic medical record (EMR) could appear identical irrespective of the quality of BI provided. We hypothesized that differences in how BI was implemented across health systems could lead to differences in the proportion of documented BI recalled and reported by patients across health systems. Male outpatients with unhealthy alcohol use identified by confidential satisfaction surveys (2009-2012) were assessed for whether they reported receiving BI in the past year (patient-reported BI) and whether they had BI documented in the EMR during the same period (documented BI). We evaluated and compared the prevalence of documented BI to patient-reported BI across 21 VA networks to determine whether documented BI had a variable association with patient-reported BI across the networks. Of 9896 eligible male outpatients with unhealthy alcohol use, 59.0% (95% CI 57.4-60.5%) reported BI (50.4-64.9% across networks) and 37.4% (95% CI 36.0-38.9%) had BI documented in the EMR (28.0-44.2% across networks). Overall, 72.9% (95% CI 70.8-75.5%) of patients with documented BI also reported BI. The association between documented BI and patient-reported BI did not vary across VA networks in adjusted logistic regression models. Performance measures of BI that rely on provider documentation in EMRs appear comparable to patient report for comparing care across VA networks. Published by Elsevier Ireland Ltd.

Acute asthma severity identification of expert system flow in emergency department

NASA Astrophysics Data System (ADS)

Sharif, Nurul Atikah Mohd; Ahmad, Norazura; Ahmad, Nazihah; Desa, Wan Laailatul Hanim Mat

2017-11-01

Integration of computerized system in healthcare management help in smoothening the documentation of patient records, highly accesses of knowledge and clinical practices guideline, and advice on decision making. Exploit the advancement of artificial intelligent such as fuzzy logic and rule-based reasoning may improve the management of emergency department in terms of uncertainty condition and medical practices adherence towards clinical guideline. This paper presenting details of the emergency department flow for acute asthma severity identification with the embedding of acute asthma severity identification expert system (AASIES). Currently, AASIES is still in preliminary stage of system validation. However, the implementation of AASIES in asthma bay management is hope can reduce the usage of paper for manual documentation and be a pioneer for the development of a more complex decision support system to smoothen the ED management and more systematic.

Review of Developments in Electronic, Clinical Data Collection, and Documentation Systems over the Last Decade - Are We Ready for Big Data in Routine Health Care?

PubMed

Kessel, Kerstin A; Combs, Stephanie E

2016-01-01

Recently, information availability has become more elaborate and widespread, and treatment decisions are based on a multitude of factors, including imaging, molecular or pathological markers, surgical results, and patient's preference. In this context, the term "Big Data" evolved also in health care. The "hype" is heavily discussed in literature. In interdisciplinary medical specialties, such as radiation oncology, not only heterogeneous and voluminous amount of data must be evaluated but also spread in different styles across various information systems. Exactly this problem is also referred to in many ongoing discussions about Big Data - the "three V's": volume, velocity, and variety. We reviewed 895 articles extracted from the NCBI databases about current developments in electronic clinical data management systems and their further analysis or postprocessing procedures. Few articles show first ideas and ways to immediately make use of collected data, particularly imaging data. Many developments can be noticed in the field of clinical trial or analysis documentation, mobile devices for documentation, and genomics research. Using Big Data to advance medical research is definitely on the rise. Health care is perhaps the most comprehensive, important, and economically viable field of application.

Wearable technology as a booster of clinical care

NASA Astrophysics Data System (ADS)

Jonas, Stephan; Hannig, Andreas; Spreckelsen, Cord; Deserno, Thomas M.

2014-03-01

Wearable technology defines a new class of smart devices that are accessories or clothing equipped with computational power and sensors, like Google Glass. In this work, we propose a novel concept for supporting everyday clinical pathways with wearable technology. In contrast to most prior work, we are not focusing on the omnipresent screen to display patient information or images, but are trying to maintain existing workflows. To achieve this, our system supports clinical staff as a documenting observer, only intervening adequately if problems are detected. Using the example of medication preparation and administration, a task known to be prone to errors, we demonstrate the full potential of the new devices. Patient and medication identifier are captured with the built-in camera, and the information is send to a transaction server. The server communicates with the hospital information system to obtain patient records and medication information. The system then analyses the new medication for possible side-effects and interactions with already administered drugs. The result is sent to the device while encapsulating all sensitive information respecting data security and privacy. The user only sees a traffic light style encoded feedback to avoid distraction. The server can reduce documentation efforts and reports in real-time on possible problems during medication preparation or administration. In conclusion, we designed a secure system around three basic principles with many applications in everyday clinical work: (i) interaction and distraction is kept as low as possible; (ii) no patient data is displayed; and (iii) device is pure observer, not part of the workflow. By reducing errors and documentation burden, our approach has the capability to boost clinical care.

Measuring performance to drive improvement: development of a clinical indicator set for general medicine.

PubMed

Brand, C; Lam, S K L; Roberts, C; Gorelik, A; Amatya, B; Smallwood, D; Russell, D

2009-06-01

There are delays in implementing evidence about effective therapy into clinical practice. Clinical indicators may support implementation of guideline recommendations. To develop and evaluate the short-term impact of a clinical indicator set for general medicine. A set of clinical process indicators was developed using a structured process. The indicator set was implemented between January 2006 and December 2006, using strategies based on evidence about effectiveness and local contextual factors. Evaluation included a structured survey of general medical staff to assess awareness and attitudes towards the programme and qualitative assessment of barriers to implementation. Impact on documentation of adherence to clinical indicators was assessed by auditing a random sample of medical records before (2003-2005) and after (2006) implementation. Clinical indicators were developed for the following areas: venous thromboembolism, cognition, chronic heart failure, chronic obstructive pulmonary disease, diabetes, low trauma fracture, patient written care plans. The programme was well supported and incurred little burden to staff. Implementation occurred largely as planned; however, documentation of adherence to clinical indicators was variable. There was a generally positive trend over time, but for most indicators this was independent of the implementation process and may have been influenced by other system improvement activities. Failure to demonstrate a significant impact during the pilot phase is likely to have been influenced by administrative factors, especially lack of an integrative data documentation and collection process. Successful implementation in phase two is likely to depend upon an effective data collection system integrated into usual care.

Clinical benchmarking for the office practitioner enabled by the online health record

PubMed Central

Ricciardi, TN; Masarie, FE; Landholt, T; Middleton, B

2000-01-01

Payer organizations, regulatory entities, and delivery networks are placing increasing pressure on physicians to report aggregate information about their patients and practice of medicine. Historically, clinicians have been ill-equipped to respond to these pressures when their practices have relied upon payer records for clinical information management. Key Industry Drivers: Physicians need specific information from their practices for the purposes of contract management, preventive care, office productivity, and utilization reviews. Value Statement: Clinical data captured at the point of care can support reporting requirements, and supplement or replace laboriously-collected data derived from billing and other administrative systems. Information from the Online Health Record can empower the individual physician to assess what is going on in their practice of medicine, as opposed to being "profiled" by an external entity. We created a secure web-based system that provides access to a clinical data mart, to allow online benchmarking for the individual or office practitioner. Providers used a web-enabled documentation system to document the clinical facts of the encounter. A nightly set of routines extracts data from the online chart into the clinical data mart built in a relational database. The system uses a clinical vocabulary server to map provider-entered strings to normalized clinical concepts. The system loads chart data into a dimensional data model, to simplify data representation and ensure fast query performance. Providers can access their own profiles from a secure web browser. PMID:11080030

Instant replay.

PubMed

Rosenthal, David I

2013-06-01

With widespread adoption of electronic health records (EHRs) and electronic clinical documentation, health care organizations now have greater faculty to review clinical data and evaluate the efficacy of quality improvement efforts. Unfortunately, I believe there is a fundamental gap between actual health care delivery and what we document in the current EHR systems. This process of capturing the patient encounter, which I'll refer to as transcription, is prone to significant data loss due to inadequate methods of data capture, multiple points of view, and bias and subjectivity in the transcriptional process. Our current EHR, text-based clinical documentation systems are lossy abstractions - one sided accounts of what take place between patients and providers. Our clinical notes contain the breadcrumbs of relationships, conversations, physical exams, and procedures but often lack the ability to capture the form, the emotions, the images, the nonverbal communication, and the actual narrative of interactions between human beings. I believe that a video record, in conjunction with objective transcriptional services and other forms of data capture, may provide a closer approximation to the truth of health care delivery and may be a valuable tool for healthcare improvement. Copyright © 2013 Elsevier Inc. All rights reserved.

Home-centered health-enabling technologies and regional health information systems. An integration approach based on international standards.

PubMed

Gietzelt, M; von Bargen, T; Kohlmann, M; Marschollek, M; Schwartze, J; Song, B; Wagner, M; Wolf, K-H; Haux, R

2014-01-01

This article is part of the Focus Theme of Methods of Information in Medicine on "Using Data from Ambient Assisted Living and Smart Homes in Electronic Health Records". In this paper, we present a prototype of a Home-Centered Health-Enabling Technology (HET-HC), which is able to capture, store, merge and process data from various sensor systems at people's home. In addition, we present an architecture designed to integrate HET-HC into an exemplary regional Health Information System (rHIS). rHIS are traditionally document-based to fit to the needs in a clinical context. However, HET-HC are producing continuous data streams for which documents might be an inappropriate representation. Therefore, the HET-HC could register placeholder-documents at rHIS. These placeholder-documents are assembled upon user-authenticated request by the HET-HC and are always up-to-date. Moreover, it is not trivial to find a clinical coding system for continuous sensor data and to make the data machine-readable in order to enhance the interoperability of such systems. Therefore, we propose the use of SNOCAP-HET, which is a nomenclature to describe the context of sensor-based measurements in health-enabling technologies. We present an architectural approach to integrate HET-HC into rHIS. Our solution is the centralized registration of placeholder-documents with rHIS and the decentralized data storage at people's home. We concluded that the presented architecture of integrating HET-HC into rHIS might fit well to the traditional approach of document-based data storage. Data security and privacy issues are also duly considered.

Effective Information Extraction Framework for Heterogeneous Clinical Reports Using Online Machine Learning and Controlled Vocabularies

PubMed Central

Zheng, Shuai; Ghasemzadeh, Nima; Hayek, Salim S; Quyyumi, Arshed A

2017-01-01

Background Extracting structured data from narrated medical reports is challenged by the complexity of heterogeneous structures and vocabularies and often requires significant manual effort. Traditional machine-based approaches lack the capability to take user feedbacks for improving the extraction algorithm in real time. Objective Our goal was to provide a generic information extraction framework that can support diverse clinical reports and enables a dynamic interaction between a human and a machine that produces highly accurate results. Methods A clinical information extraction system IDEAL-X has been built on top of online machine learning. It processes one document at a time, and user interactions are recorded as feedbacks to update the learning model in real time. The updated model is used to predict values for extraction in subsequent documents. Once prediction accuracy reaches a user-acceptable threshold, the remaining documents may be batch processed. A customizable controlled vocabulary may be used to support extraction. Results Three datasets were used for experiments based on report styles: 100 cardiac catheterization procedure reports, 100 coronary angiographic reports, and 100 integrated reports—each combines history and physical report, discharge summary, outpatient clinic notes, outpatient clinic letter, and inpatient discharge medication report. Data extraction was performed by 3 methods: online machine learning, controlled vocabularies, and a combination of these. The system delivers results with F1 scores greater than 95%. Conclusions IDEAL-X adopts a unique online machine learning–based approach combined with controlled vocabularies to support data extraction for clinical reports. The system can quickly learn and improve, thus it is highly adaptable. PMID:28487265

Development of an electronic claim system based on an integrated electronic health record platform to guarantee interoperability.

PubMed

Kim, Hwa Sun; Cho, Hune; Lee, In Keun

2011-06-01

We design and develop an electronic claim system based on an integrated electronic health record (EHR) platform. This system is designed to be used for ambulatory care by office-based physicians in the United States. This is achieved by integrating various medical standard technologies for interoperability between heterogeneous information systems. The developed system serves as a simple clinical data repository, it automatically fills out the Centers for Medicare and Medicaid Services (CMS)-1500 form based on information regarding the patients and physicians' clinical activities. It supports electronic insurance claims by creating reimbursement charges. It also contains an HL7 interface engine to exchange clinical messages between heterogeneous devices. The system partially prevents physician malpractice by suggesting proper treatments according to patient diagnoses and supports physicians by easily preparing documents for reimbursement and submitting claim documents to insurance organizations electronically, without additional effort by the user. To show the usability of the developed system, we performed an experiment that compares the time spent filling out the CMS-1500 form directly and time required create electronic claim data using the developed system. From the experimental results, we conclude that the system could save considerable time for physicians in making claim documents. The developed system might be particularly useful for those who need a reimbursement-specialized EHR system, even though the proposed system does not completely satisfy all criteria requested by the CMS and Office of the National Coordinator for Health Information Technology (ONC). This is because the criteria are not sufficient but necessary condition for the implementation of EHR systems. The system will be upgraded continuously to implement the criteria and to offer more stable and transparent transmission of electronic claim data.

Health level 7 development framework for medication administration.

PubMed

Kim, Hwa Sun; Cho, Hune

2009-01-01

We propose the creation of a standard data model for medication administration activities through the development of a clinical document architecture using the Health Level 7 Development Framework process based on an object-oriented analysis and the development method of Health Level 7 Version 3. Medication administration is the most common activity performed by clinical professionals in healthcare settings. A standardized information model and structured hospital information system are necessary to achieve evidence-based clinical activities. A virtual scenario is used to demonstrate the proposed method of administering medication. We used the Health Level 7 Development Framework and other tools to create the clinical document architecture, which allowed us to illustrate each step of the Health Level 7 Development Framework in the administration of medication. We generated an information model of the medication administration process as one clinical activity. It should become a fundamental conceptual model for understanding international-standard methodology by healthcare professionals and nursing practitioners with the objective of modeling healthcare information systems.

Evaluation of Nursing Documentation Completion of Stroke Patients in the Emergency Department: A Pre-Post Analysis Using Flowsheet Templates and Clinical Decision Support.

PubMed

Richardson, Karen J; Sengstack, Patricia; Doucette, Jeffrey N; Hammond, William E; Schertz, Matthew; Thompson, Julie; Johnson, Constance

2016-02-01

The primary aim of this performance improvement project was to determine whether the electronic health record implementation of stroke-specific nursing documentation flowsheet templates and clinical decision support alerts improved the nursing documentation of eligible stroke patients in seven stroke-certified emergency departments. Two system enhancements were introduced into the electronic record in an effort to improve nursing documentation: disease-specific documentation flowsheets and clinical decision support alerts. Using a pre-post design, project measures included six stroke management goals as defined by the National Institute of Neurological Disorders and Stroke and three clinical decision support measures based on entry of orders used to trigger documentation reminders for nursing: (1) the National Institutes of Health's Stroke Scale, (2) neurological checks, and (3) dysphagia screening. Data were reviewed 6 months prior (n = 2293) and 6 months following the intervention (n = 2588). Fisher exact test was used for statistical analysis. Statistical significance was found for documentation of five of the six stroke management goals, although effect sizes were small. Customizing flowsheets to meet the needs of nursing workflow showed improvement in the completion of documentation. The effects of the decision support alerts on the completeness of nursing documentation were not statistically significant (likely due to lack of order entry). For example, an order for the National Institutes of Health Stroke Scale was entered only 10.7% of the time, which meant no alert would fire for nursing in the postintervention group. Future work should focus on decision support alerts that trigger reminders for clinicians to place relevant orders for this population.

Comprehensible knowledge model creation for cancer treatment decision making.

PubMed

Afzal, Muhammad; Hussain, Maqbool; Ali Khan, Wajahat; Ali, Taqdir; Lee, Sungyoung; Huh, Eui-Nam; Farooq Ahmad, Hafiz; Jamshed, Arif; Iqbal, Hassan; Irfan, Muhammad; Abbas Hydari, Manzar

2017-03-01

A wealth of clinical data exists in clinical documents in the form of electronic health records (EHRs). This data can be used for developing knowledge-based recommendation systems that can assist clinicians in clinical decision making and education. One of the big hurdles in developing such systems is the lack of automated mechanisms for knowledge acquisition to enable and educate clinicians in informed decision making. An automated knowledge acquisition methodology with a comprehensible knowledge model for cancer treatment (CKM-CT) is proposed. With the CKM-CT, clinical data are acquired automatically from documents. Quality of data is ensured by correcting errors and transforming various formats into a standard data format. Data preprocessing involves dimensionality reduction and missing value imputation. Predictive algorithm selection is performed on the basis of the ranking score of the weighted sum model. The knowledge builder prepares knowledge for knowledge-based services: clinical decisions and education support. Data is acquired from 13,788 head and neck cancer (HNC) documents for 3447 patients, including 1526 patients of the oral cavity site. In the data quality task, 160 staging values are corrected. In the preprocessing task, 20 attributes and 106 records are eliminated from the dataset. The Classification and Regression Trees (CRT) algorithm is selected and provides 69.0% classification accuracy in predicting HNC treatment plans, consisting of 11 decision paths that yield 11 decision rules. Our proposed methodology, CKM-CT, is helpful to find hidden knowledge in clinical documents. In CKM-CT, the prediction models are developed to assist and educate clinicians for informed decision making. The proposed methodology is generalizable to apply to data of other domains such as breast cancer with a similar objective to assist clinicians in decision making and education. Copyright © 2017 Elsevier Ltd. All rights reserved.

Comparing two anesthesia information management system user interfaces: a usability evaluation.

PubMed

Wanderer, Jonathan P; Rao, Anoop V; Rothwell, Sarah H; Ehrenfeld, Jesse M

2012-11-01

Anesthesia information management systems (AIMS) have been developed by multiple vendors and are deployed in thousands of operating rooms around the world, yet not much is known about measuring and improving AIMS usability. We developed a methodology for evaluating AIMS usability in a low-fidelity simulated clinical environment and used it to compare an existing user interface with a revised version. We hypothesized that the revised user interface would be more useable. In a low-fidelity simulated clinical environment, twenty anesthesia providers documented essential anesthetic information for the start of the case using both an existing and a revised user interface. Participants had not used the revised user interface previously and completed a brief training exercise prior to the study task. All participants completed a workload assessment and a satisfaction survey. All sessions were recorded. Multiple usability metrics were measured. The primary outcome was documentation accuracy. Secondary outcomes were perceived workload, number of documentation steps, number of user interactions, and documentation time. The interfaces were compared and design problems were identified by analyzing recorded sessions and survey results. Use of the revised user interface was shown to improve documentation accuracy from 85.1% to 92.4%, a difference of 7.3% (95% confidence interval [CI] for the difference 1.8 to 12.7). The revised user interface decreased the number of user interactions by 6.5 for intravenous documentation (95% CI 2.9 to 10.1) and by 16.1 for airway documentation (95% CI 11.1 to 21.1). The revised user interface required 3.8 fewer documentation steps (95% CI 2.3 to 5.4). Airway documentation time was reduced by 30.5 seconds with the revised workflow (95% CI 8.5 to 52.4). There were no significant time differences noted in intravenous documentation or in total task time. No difference in perceived workload was found between the user interfaces. Two user interface design problems were identified in the revised user interface. The usability of anesthesia information management systems can be evaluated using a low-fidelity simulated clinical environment. User testing of the revised user interface showed improvement in some usability metrics and highlighted areas for further revision. Vendors of AIMS and those who use them should consider adopting methods to evaluate and improve AIMS usability.

How to improve vital sign data quality for use in clinical decision support systems? A qualitative study in nine Swedish emergency departments.

PubMed

Skyttberg, Niclas; Vicente, Joana; Chen, Rong; Blomqvist, Hans; Koch, Sabine

2016-06-04

Vital sign data are important for clinical decision making in emergency care. Clinical Decision Support Systems (CDSS) have been advocated to increase patient safety and quality of care. However, the efficiency of CDSS depends on the quality of the underlying vital sign data. Therefore, possible factors affecting vital sign data quality need to be understood. This study aims to explore the factors affecting vital sign data quality in Swedish emergency departments and to determine in how far clinicians perceive vital sign data to be fit for use in clinical decision support systems. A further aim of the study is to provide recommendations on how to improve vital sign data quality in emergency departments. Semi-structured interviews were conducted with sixteen physicians and nurses from nine hospitals and vital sign documentation templates were collected and analysed. Follow-up interviews and process observations were done at three of the hospitals to verify the results. Content analysis with constant comparison of the data was used to analyse and categorize the collected data. Factors related to care process and information technology were perceived to affect vital sign data quality. Despite electronic health records (EHRs) being available in all hospitals, these were not always used for vital sign documentation. Only four out of nine sites had a completely digitalized vital sign documentation flow and paper-based triage records were perceived to provide a better mobile workflow support than EHRs. Observed documentation practices resulted in low currency, completeness, and interoperability of the vital signs. To improve vital sign data quality, we propose to standardize the care process, improve the digital documentation support, provide workflow support, ensure interoperability and perform quality control. Vital sign data quality in Swedish emergency departments is currently not fit for use by CDSS. To address both technical and organisational challenges, we propose five steps for vital sign data quality improvement to be implemented in emergency care settings.

A multi-agent system for monitoring patient flow.

PubMed

Rosati, Samanta; Tralli, Augusta; Balestra, Gabriella

2013-01-01

Patient flow within a healthcare facility may follow different and, sometimes, complicated paths. Each path phase is associated with the documentation of the activities carried out during it and may require the consultation of clinical guidelines, medical literature and the use of specific software and decision aid systems. In this study we present the design of a Patient Flow Management System (PFMS) based on Multi Agent Systems (MAS) methodology. System requirements were identified by means of process modeling tools and a MAS consisting of six agents was designed and is under construction. Its main goal is to support both the medical staff during the health care process and the hospital managers in assuring that all the required documentation is completed and available. Moreover, such a tool can be used for the assessment and comparison of different clinical pathways, in order to identify possible improvementsand the optimum patient flow.

Capability of Using Clinical Care Classification System to Represent Nursing Practice in Acute Setting in Taiwan

PubMed Central

Feng, Rung-Chuang; Tseng, Kuan-Jui; Yan, Hsiu-Fang; Huang, Hsiu-Ya; Chang, Polun

2012-01-01

This study examines the capability of the Clinical Care Classification (CCC) system to represent nursing record data in a medical center in Taiwan. Nursing care records were analyzed using the process of knowledge discovery in data sets. The study data set included all the nursing care plan records from December 1998 to October 2008, totaling 2,060,214 care plan documentation entries. Results show that 75.42% of the documented diagnosis terms could be mapped using the CCC system. A total of 21 established nursing diagnoses were recommended to be added into the CCC system. Results show that one-third of the assessment and care tasks were provided by nursing professionals. This study shows that the CCC system is useful for identifying patterns in nursing practices and can be used to construct a nursing database in the acute setting. PMID:24199066

Implementation of a standards-based anaesthesia record compliant with the health level 7 (HL7) clinical document architecture (CDA).

PubMed

Hurrell, M J; Monk, T G; Nicol, A; Norton, A N; Reich, D L; Walsh, J L

2012-08-01

With the increasing use of anaesthesia information management systems (AIMS) there is the opportunity for different institutions to aggregate and share information both nationally and internationally. Potential uses of such aggregated data include outcomes research, benchmarking and improvement in clinical practice and patient safety. However, these goals can only be achieved if data contained in records from different sources are truly comparable and there is semantic inter-operability. This paper describes the development of a standard terminology for anaesthesia and also a Domain Analysis Model and implementation guide to facilitate a standard representation of AIMS records as extensible markup language documents that are compliant with the Health Level 7 Version 3 clinical document architecture. A representation of vital signs that is compliant with the International Standards Organization 11073 standard is also discussed.

Laying the Groundwork for Enterprise-Wide Medical Language Processing Services: Architecture and Process

PubMed Central

Chen, Elizabeth S.; Maloney, Francine L.; Shilmayster, Eugene; Goldberg, Howard S.

2009-01-01

A systematic and standard process for capturing information within free-text clinical documents could facilitate opportunities for improving quality and safety of patient care, enhancing decision support, and advancing data warehousing across an enterprise setting. At Partners HealthCare System, the Medical Language Processing (MLP) services project was initiated to establish a component-based architectural model and processes to facilitate putting MLP functionality into production for enterprise consumption, promote sharing of components, and encourage reuse. Key objectives included exploring the use of an open-source framework called the Unstructured Information Management Architecture (UIMA) and leveraging existing MLP-related efforts, terminology, and document standards. This paper describes early experiences in defining the infrastructure and standards for extracting, encoding, and structuring clinical observations from a variety of clinical documents to serve enterprise-wide needs. PMID:20351830

Laying the groundwork for enterprise-wide medical language processing services: architecture and process.

PubMed

Chen, Elizabeth S; Maloney, Francine L; Shilmayster, Eugene; Goldberg, Howard S

2009-11-14

A systematic and standard process for capturing information within free-text clinical documents could facilitate opportunities for improving quality and safety of patient care, enhancing decision support, and advancing data warehousing across an enterprise setting. At Partners HealthCare System, the Medical Language Processing (MLP) services project was initiated to establish a component-based architectural model and processes to facilitate putting MLP functionality into production for enterprise consumption, promote sharing of components, and encourage reuse. Key objectives included exploring the use of an open-source framework called the Unstructured Information Management Architecture (UIMA) and leveraging existing MLP-related efforts, terminology, and document standards. This paper describes early experiences in defining the infrastructure and standards for extracting, encoding, and structuring clinical observations from a variety of clinical documents to serve enterprise-wide needs.

Improved clinical documentation leads to superior reportable outcomes: An accurate representation of patient's clinical status.

PubMed

Elkbuli, Adel; Godelman, Steven; Miller, Ashley; Boneva, Dessy; Bernal, Eileen; Hai, Shaikh; McKenney, Mark

2018-05-01

Clinical documentation can be an underappreciated. Trauma Centers (TCs) are now routinely evaluated for quality performance. TCs with poor documentation may not accurately reflect actual injury burden or comorbidities and can impact accuracy of mortality measures. Markers exist to adjust crude death rates for injury severity: observed over expected deaths (O/E) adjust for injury; Case Mix Index (CMI) reflects disease burden, and Severity of Illness (SOI) measures organ dysfunction. We aim to evaluate the impact of implementing a Clinical Documentation Improvement Program (CDIP) on reported outcomes. Review of 2-years of prospectively collected data for trauma patients, during the implementation of CDIP. A two-group prospective observational study design was used to evaluate the pre-implementation and the post-implementation phase of improved clinical documentation. T-test and Chi-Squared were used with significance defined as p < 0.05. In the pre-implementation period, there were 49 deaths out of 1419 (3.45%), while post-implementation period, had 38 deaths out of 1454 (2.61%), (non-significant). There was however, a significant difference between O/E ratios. In the pre-phase, the O/E was 1.36 and 0.70 in the post-phase (p < 0.001). The two groups also differed on CMI with a pre-group mean of 2.48 and a post-group of 2.87 (p < 0.001), indicating higher injury burden in the post-group. SOI started at 2.12 and significantly increased to 2.91, signifying more organ system dysfunction (p < 0.018). Improved clinical documentation results in improved accuracy of measures of mortality, injury severity, and comorbidities and a more accurate reflection in O/E mortality ratios, CMI, and SOI. Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Comparison of fingerprint and facial biometric verification technologies for user access and patient identification in a clinical environment

NASA Astrophysics Data System (ADS)

Guo, Bing; Zhang, Yu; Documet, Jorge; Liu, Brent; Lee, Jasper; Shrestha, Rasu; Wang, Kevin; Huang, H. K.

2007-03-01

As clinical imaging and informatics systems continue to integrate the healthcare enterprise, the need to prevent patient mis-identification and unauthorized access to clinical data becomes more apparent especially under the Health Insurance Portability and Accountability Act (HIPAA) mandate. Last year, we presented a system to track and verify patients and staff within a clinical environment. This year, we further address the biometric verification component in order to determine which Biometric system is the optimal solution for given applications in the complex clinical environment. We install two biometric identification systems including fingerprint and facial recognition systems at an outpatient imaging facility, Healthcare Consultation Center II (HCCII). We evaluated each solution and documented the advantages and pitfalls of each biometric technology in this clinical environment.

Methods and Techniques for Clinical Text Modeling and Analytics

ERIC Educational Resources Information Center

Ling, Yuan

2017-01-01

This study focuses on developing and applying methods/techniques in different aspects of the system for clinical text understanding, at both corpus and document level. We deal with two major research questions: First, we explore the question of "How to model the underlying relationships from clinical notes at corpus level?" Documents…

The development and evaluation of a nursing information system for caring clinical in-patient.

PubMed

Fang, Yu-Wen; Li, Chih-Ping; Wang, Mei-Hua

2015-01-01

The research aimed to develop a nursing information system in order to simplify the admission procedure for caring clinical in-patient, enhance the efficiency of medical information documentation. Therefore, by correctly delivering patients’ health records, and providing continues care, patient safety and care quality would be effectively improved. The study method was to apply Spiral Model development system to compose a nursing information team. By using strategies of data collection, working environment observation, applying use-case modeling, and conferences of Joint Application Design (JAD) to complete the system requirement analysis and design. The Admission Care Management Information System (ACMIS) mainly included: (1) Admission nursing management information system. (2) Inter-shift meeting information management system. (3) The linkage of drug management system and physical examination record system. The framework contained qualitative and quantitative components that provided both formative and summative elements of the evaluation. System evaluation was to apply information success model, and developed questionnaire of consisting nurses’ acceptance and satisfaction. The results of questionnaires were users’ satisfaction, the perceived self-involvement, age and information quality were positively to personal and organizational effectiveness. According to the results of this study, the Admission Care Management Information System was practical to simplifying clinic working procedure and effective in communicating and documenting admission medical information.

[Development and clinical evaluation of an anesthesia information management system].

PubMed

Feng, Jing-yi; Chen, Hua; Zhu, Sheng-mei

2010-09-21

To study the design, implementation and clinical evaluation of an anesthesia information management system. To record, process and store peri-operative patient data automatically, all kinds of bedside monitoring equipments are connected into the system based on information integrating technology; after a statistical analysis of those patient data by data mining technology, patient status can be evaluated automatically based on risk prediction standard and decision support system, and then anesthetist could perform reasonable and safe clinical processes; with clinical processes electronically recorded, standard record tables could be generated, and clinical workflow is optimized, as well. With the system, kinds of patient data could be collected, stored, analyzed and archived, kinds of anesthesia documents could be generated, and patient status could be evaluated to support clinic decision. The anesthesia information management system is useful for improving anesthesia quality, decreasing risk of patient and clinician, and aiding to provide clinical proof.

Combining a clinical ladder and performance appraisal system as a reward strategy: the EXCEL clinical ladder program.

PubMed

Moe, J K; Lonowski, L R; Yancer, D A

1994-09-01

In response to the dramatic changes occurring in health care today and a desire to reward professional nurses for clinical behaviors that would be valued in the future, Bergan Mercy Medical Center (BMMC) has developed an innovative clinical ladder/performance appraisal system. The BMMC EXCEL Clinical Ladder program, which is based on the developmental model of Patricia Benner, is a competency-based system that uniquely combines a clinical ladder and performance appraisal system. The program is clinically focused and contains optional components in which registered nurses (RNs) can receive additional credit for participation in professional growth and leadership activities. Nurses document examples of their practice through nursing narratives that describe actual clinical situations. The development and implementation processes, challenges encountered, and recommendations for alternative approaches to the implementation of such a unique system are discussed.

Clinical map document based on XML (cMDX): document architecture with mapping feature for reporting and analysing prostate cancer in radical prostatectomy specimens.

PubMed

Eminaga, Okyaz; Hinkelammert, Reemt; Semjonow, Axel; Neumann, Joerg; Abbas, Mahmoud; Koepke, Thomas; Bettendorf, Olaf; Eltze, Elke; Dugas, Martin

2010-11-15

The pathology report of radical prostatectomy specimens plays an important role in clinical decisions and the prognostic evaluation in Prostate Cancer (PCa). The anatomical schema is a helpful tool to document PCa extension for clinical and research purposes. To achieve electronic documentation and analysis, an appropriate documentation model for anatomical schemas is needed. For this purpose we developed cMDX. The document architecture of cMDX was designed according to Open Packaging Conventions by separating the whole data into template data and patient data. Analogue custom XML elements were considered to harmonize the graphical representation (e.g. tumour extension) with the textual data (e.g. histological patterns). The graphical documentation was based on the four-layer visualization model that forms the interaction between different custom XML elements. Sensible personal data were encrypted with a 256-bit cryptographic algorithm to avoid misuse. In order to assess the clinical value, we retrospectively analysed the tumour extension in 255 patients after radical prostatectomy. The pathology report with cMDX can represent pathological findings of the prostate in schematic styles. Such reports can be integrated into the hospital information system. "cMDX" documents can be converted into different data formats like text, graphics and PDF. Supplementary tools like cMDX Editor and an analyser tool were implemented. The graphical analysis of 255 prostatectomy specimens showed that PCa were mostly localized in the peripheral zone (Mean: 73% ± 25). 54% of PCa showed a multifocal growth pattern. cMDX can be used for routine histopathological reporting of radical prostatectomy specimens and provide data for scientific analysis.

Clinical map document based on XML (cMDX): document architecture with mapping feature for reporting and analysing prostate cancer in radical prostatectomy specimens

PubMed Central

2010-01-01

Background The pathology report of radical prostatectomy specimens plays an important role in clinical decisions and the prognostic evaluation in Prostate Cancer (PCa). The anatomical schema is a helpful tool to document PCa extension for clinical and research purposes. To achieve electronic documentation and analysis, an appropriate documentation model for anatomical schemas is needed. For this purpose we developed cMDX. Methods The document architecture of cMDX was designed according to Open Packaging Conventions by separating the whole data into template data and patient data. Analogue custom XML elements were considered to harmonize the graphical representation (e.g. tumour extension) with the textual data (e.g. histological patterns). The graphical documentation was based on the four-layer visualization model that forms the interaction between different custom XML elements. Sensible personal data were encrypted with a 256-bit cryptographic algorithm to avoid misuse. In order to assess the clinical value, we retrospectively analysed the tumour extension in 255 patients after radical prostatectomy. Results The pathology report with cMDX can represent pathological findings of the prostate in schematic styles. Such reports can be integrated into the hospital information system. "cMDX" documents can be converted into different data formats like text, graphics and PDF. Supplementary tools like cMDX Editor and an analyser tool were implemented. The graphical analysis of 255 prostatectomy specimens showed that PCa were mostly localized in the peripheral zone (Mean: 73% ± 25). 54% of PCa showed a multifocal growth pattern. Conclusions cMDX can be used for routine histopathological reporting of radical prostatectomy specimens and provide data for scientific analysis. PMID:21078179

Implementation of a Clinical Documentation Improvement Curriculum Improves Quality Metrics and Hospital Charges in an Academic Surgery Department.

PubMed

Reyes, Cynthia; Greenbaum, Alissa; Porto, Catherine; Russell, John C

2017-03-01

Accurate clinical documentation (CD) is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. New requirements have mandated adoption of ICD-10-CM coding systems, adding another layer of complexity to CD. A clinical documentation improvement (CDI) and ICD-10 training program was created for health care providers in our academic surgery department. We aimed to assess the impact of our CDI curriculum by comparing quality metrics, coding, and reimbursement before and after implementation of our CDI program. A CDI/ICD-10 training curriculum was instituted in September 2014 for all members of our university surgery department. The curriculum consisted of didactic lectures, 1-on-1 provider training, case reviews, e-learning modules, and CD queries from nurse CDI staff and hospital coders. Outcomes parameters included monthly documentation completion rates, severity of illness (SOI), risk of mortality (ROM), case-mix index (CMI), all-payer refined diagnosis-related groups (APR-DRG), and Surgical Care Improvement Program (SCIP) metrics. Financial gain from responses to CDI queries was determined retrospectively. Surgery department delinquent documentation decreased by 85% after CDI implementation. Compliance with SCIP measures improved from 85% to 97%. Significant increases in surgical SOI, ROM, CMI, and APR-DRG (all p < 0.01) were found after CDI/ICD-10 training implementation. Provider responses to CDI queries resulted in an estimated $4,672,786 increase in charges. Clinical documentation improvement/ICD-10 training in an academic surgery department is an effective method to improve documentation rates, increase the hospital estimated reimbursement based on more accurate CD, and provide better compliance with surgical quality measures. Copyright © 2016 American College of Surgeons. All rights reserved.

Implementation of standardized nomenclature in the electronic medical record.

PubMed

Klehr, Joan; Hafner, Jennifer; Spelz, Leah Mylrea; Steen, Sara; Weaver, Kathy

2009-01-01

To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation. Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity. Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation.

Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital

PubMed Central

Hahn, J.S.; Bernstein, J.A.; McKenzie, R.B.; King, B.J.; Longhurst, C.A.

2012-01-01

Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children’s Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution. PMID:23620718

Expert System Shells for Rapid Clinical Decision Support Module Development: An ESTA Demonstration of a Simple Rule-Based System for the Diagnosis of Vaginal Discharge

PubMed Central

2012-01-01

Objectives This study demonstrates the feasibility of using expert system shells for rapid clinical decision support module development. Methods A readily available expert system shell was used to build a simple rule-based system for the crude diagnosis of vaginal discharge. Pictures and 'canned text explanations' are extensively used throughout the program to enhance its intuitiveness and educational dimension. All the steps involved in developing the system are documented. Results The system runs under Microsoft Windows and is available as a free download at http://healthcybermap.org/vagdisch.zip (the distribution archive includes both the program's executable and the commented knowledge base source as a text document). The limitations of the demonstration system, such as the lack of provisions for assessing uncertainty or various degrees of severity of a sign or symptom, are discussed in detail. Ways of improving the system, such as porting it to the Web and packaging it as an app for smartphones and tablets, are also presented. Conclusions An easy-to-use expert system shell enables clinicians to rapidly become their own 'knowledge engineers' and develop concise evidence-based decision support modules of simple to moderate complexity, targeting clinical practitioners, medical and nursing students, as well as patients, their lay carers and the general public (where appropriate). In the spirit of the social Web, it is hoped that an online repository can be created to peer review, share and re-use knowledge base modules covering various clinical problems and algorithms, as a service to the clinical community. PMID:23346475

Coding and Billing in Surgical Education: A Systems-Based Practice Education Program.

PubMed

Ghaderi, Kimeya F; Schmidt, Scott T; Drolet, Brian C

Despite increased emphasis on systems-based practice through the Accreditation Council for Graduate Medical Education core competencies, few studies have examined what surgical residents know about coding and billing. We sought to create and measure the effectiveness of a multifaceted approach to improving resident knowledge and performance of documenting and coding outpatient encounters. We identified knowledge gaps and barriers to documentation and coding in the outpatient setting. We implemented a series of educational and workflow interventions with a group of 12 residents in a surgical clinic at a tertiary care center. To measure the effect of this program, we compared billing codes for 1 year before intervention (FY2012) to prospectively collected data from the postintervention period (FY2013). All related documentation and coding were verified by study-blinded auditors. Interventions took place at the outpatient surgical clinic at Rhode Island Hospital, a tertiary-care center. A cohort of 12 plastic surgery residents ranging from postgraduate year 2 through postgraduate year 6 participated in the interventional sequence. A total of 1285 patient encounters in the preintervention group were compared with 1170 encounters in the postintervention group. Using evaluation and management codes (E&M) as a measure of documentation and coding, we demonstrated a significant and durable increase in billing with supporting clinical documentation after the intervention. For established patient visits, the monthly average E&M code level increased from 2.14 to 3.05 (p < 0.01); for new patients the monthly average E&M level increased from 2.61 to 3.19 (p < 0.01). This study describes a series of educational and workflow interventions, which improved resident coding and billing of outpatient clinic encounters. Using externally audited coding data, we demonstrate significantly increased rates of higher complexity E&M coding in a stable patient population based on improved documentation and billing awareness by the residents. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Effective Information Extraction Framework for Heterogeneous Clinical Reports Using Online Machine Learning and Controlled Vocabularies.

PubMed

Zheng, Shuai; Lu, James J; Ghasemzadeh, Nima; Hayek, Salim S; Quyyumi, Arshed A; Wang, Fusheng

2017-05-09

Extracting structured data from narrated medical reports is challenged by the complexity of heterogeneous structures and vocabularies and often requires significant manual effort. Traditional machine-based approaches lack the capability to take user feedbacks for improving the extraction algorithm in real time. Our goal was to provide a generic information extraction framework that can support diverse clinical reports and enables a dynamic interaction between a human and a machine that produces highly accurate results. A clinical information extraction system IDEAL-X has been built on top of online machine learning. It processes one document at a time, and user interactions are recorded as feedbacks to update the learning model in real time. The updated model is used to predict values for extraction in subsequent documents. Once prediction accuracy reaches a user-acceptable threshold, the remaining documents may be batch processed. A customizable controlled vocabulary may be used to support extraction. Three datasets were used for experiments based on report styles: 100 cardiac catheterization procedure reports, 100 coronary angiographic reports, and 100 integrated reports-each combines history and physical report, discharge summary, outpatient clinic notes, outpatient clinic letter, and inpatient discharge medication report. Data extraction was performed by 3 methods: online machine learning, controlled vocabularies, and a combination of these. The system delivers results with F1 scores greater than 95%. IDEAL-X adopts a unique online machine learning-based approach combined with controlled vocabularies to support data extraction for clinical reports. The system can quickly learn and improve, thus it is highly adaptable. ©Shuai Zheng, James J Lu, Nima Ghasemzadeh, Salim S Hayek, Arshed A Quyyumi, Fusheng Wang. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 09.05.2017.

From a Content Delivery Portal to a Knowledge Management System for Standardized Cancer Documentation.

PubMed

Schlue, Danijela; Mate, Sebastian; Haier, Jörg; Kadioglu, Dennis; Prokosch, Hans-Ulrich; Breil, Bernhard

2017-01-01

Heterogeneous tumor documentation and its challenges of interpretation of medical terms lead to problems in analyses of data from clinical and epidemiological cancer registries. The objective of this project was to design, implement and improve a national content delivery portal for oncological terms. Data elements of existing handbooks and documentation sources were analyzed, combined and summarized by medical experts of different comprehensive cancer centers. Informatics experts created a generic data model based on an existing metadata repository. In order to establish a national knowledge management system for standardized cancer documentation, a prototypical tumor wiki was designed and implemented. Requirements engineering techniques were applied to optimize this platform. It is targeted to user groups such as documentation officers, physicians and patients. The linkage to other information sources like PubMed and MeSH was realized.

Clinician preferences for verbal communication compared to EHR documentation in the ICU

PubMed Central

Collins, S.A.; Bakken, S.; Vawdrey, D.K.; Coiera, E.; Currie, L

2011-01-01

Background Effective communication is essential to safe and efficient patient care. Additionally, many health information technology (HIT) developments, innovations, and standards aim to implement processes to improve data quality and integrity of electronic health records (EHR) for the purpose of clinical information exchange and communication. Objective We aimed to understand the current patterns and perceptions of communication of common goals in the ICU using the distributed cognition and clinical communication space theoretical frameworks. Methods We conducted a focus group and 5 interviews with ICU clinicians and observed 59.5 hours of interdisciplinary ICU morning rounds. Results Clinicians used an EHR system, which included electronic documentation and computerized provider order entry (CPOE), and paper artifacts for documentation; yet, preferred the verbal communication space as a method of information exchange because they perceived that the documentation was often not updated or efficient for information retrieval. These perceptions that the EHR is a “shift behind” may lead to a further reliance on verbal information exchange, which is a valuable clinical communication activity, yet, is subject to information loss. Conclusions Electronic documentation tools that, in real time, capture information that is currently verbally communicated may increase the effectiveness of communication. PMID:23616870

Improving and Measuring Inpatient Documentation of Medical Care within the MS-DRG System: Education, Monitoring, and Normalized Case Mix Index

PubMed Central

Rosenbaum, Benjamin P.; Lorenz, Robert R.; Luther, Ralph B.; Knowles-Ward, Lisa; Kelly, Dianne L.; Weil, Robert J.

2014-01-01

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the “normalized case mix index,” that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved. PMID:25214820

Improving and measuring inpatient documentation of medical care within the MS-DRG system: education, monitoring, and normalized case mix index.

PubMed

Rosenbaum, Benjamin P; Lorenz, Robert R; Luther, Ralph B; Knowles-Ward, Lisa; Kelly, Dianne L; Weil, Robert J

2014-01-01

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the "normalized case mix index," that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved.

[Law courts and clinical documentation].

PubMed

Jiménez Carnicero, M P; Magallón, A I; Gordillo, A

2006-01-01

Background. Until 2004, requests for clinical documentation proceeding from the Judicial Administration on Specialist Care of Pamplona were received in six different centres and were processed independently, with different procedures, and documents were even sent in duplicate, with the resulting work load. This article describes the procedure for processing requests for documentation proceeding from the Law Courts and analyses the requests received. Methods. A circuit was set up to channel the judicial requests that arrived at the Specialist Health Care Centres of Pamplona and at the Juridical Regime Service of the Health System of Navarra-Osasunbidea, and a Higher Technician in Health Documentation was contracted to centralise these requests. A proceedings protocol was established to unify criteria and speed up the process, and a database was designed to register the proceedings. Results. In the course of 2004, 210 requests for documentation by legal requirement were received. Of these, 24 were claims of patrimonial responsibility and 13 were requested by lawyers with the patient's authorisation. The most frequent jurisdictional order was penal (43.33%). Ninety-three point one five percent (93.15%) of the requests proceeded from law courts in the autonomous community of Navarra. The centre that received the greatest number of requests was the "Príncipe de Viana" Consultation Centre (33.73%).The most frequently requested documentation was a copy of reports (109) and a copy of the complete clinical record (39). On two occasions the original clinical record was required. The average time of response was 6.6 days. Conclusions. The centralisation of administration has brought greater agility to the process and homogeneity in the criteria of processing. Less time is involved in preparing and dispatching the documentation, the dispatch of duplicate documents is avoided, the work load has been reduced and the dispersal of documentation is avoided, a situation that guarantees greater privacy for the patient.

An XML-based system for the flexible classification and retrieval of clinical practice guidelines.

PubMed Central

Ganslandt, T.; Mueller, M. L.; Krieglstein, C. F.; Senninger, N.; Prokosch, H. U.

2002-01-01

Beneficial effects of clinical practice guidelines (CPGs) have not yet reached expectations due to limited routine adoption. Electronic distribution and reminder systems have the potential to overcome implementation barriers. Existing electronic CPG repositories like the National Guideline Clearinghouse (NGC) provide individual access but lack standardized computer-readable interfaces necessary for automated guideline retrieval. The aim of this paper was to facilitate automated context-based selection and presentation of CPGs. Using attributes from the NGC classification scheme, an XML-based metadata repository was successfully implemented, providing document storage, classification and retrieval functionality. Semi-automated extraction of attributes was implemented for the import of XML guideline documents using XPath. A hospital information system interface was exemplarily implemented for diagnosis-based guideline invocation. Limitations of the implemented system are discussed and possible future work is outlined. Integration of standardized computer-readable search interfaces into existing CPG repositories is proposed. PMID:12463831

Effect of the PREPARE Website vs an Easy-to-Read Advance Directive on Advance Care Planning Documentation and Engagement Among Veterans: A Randomized Clinical Trial.

PubMed

Sudore, Rebecca L; Boscardin, John; Feuz, Mariko A; McMahan, Ryan D; Katen, Mary T; Barnes, Deborah E

2017-08-01

Documentation rates of patients' medical wishes are often low. It is unknown whether easy-to-use, patient-facing advance care planning (ACP) interventions can overcome barriers to planning in busy primary care settings. To compare the efficacy of an interactive, patient-centered ACP website (PREPARE) with an easy-to-read advance directive (AD) to increase planning documentation. This was a comparative effectiveness randomized clinical trial from April 2013 to July 2016 conducted at multiple primary care clinics at the San Francisco VA Medical Center. Inclusion criteria were age of a least 60 years; at least 2 chronic and/or serious conditions; and 2 or more primary care visits; and 2 or more additional clinic, hospital, or emergency room visits in the last year. Participants were randomized to review PREPARE plus an easy-to-read AD or the AD alone. There were no clinician and/or system-level interventions or education. Research staff were blinded for all follow-up measurements. The primary outcome was new ACP documentation (ie, legal forms and/or discussions) at 9 months. Secondary outcomes included patient-reported ACP engagement at 1 week, 3 months, and 6 months using validated surveys of behavior change process measures (ie, 5-point knowledge, self-efficacy, readiness scales) and action measures (eg, surrogate designation, using a 0-25 scale). We used intention-to-treat, mixed-effects logistic and linear regression, controlling for time, health literacy, race/ethnicity, baseline ACP, and clustering by physician. The mean (SD) age of 414 participants was 71 (8) years, 38 (9%) were women, 83 (20%) had limited literacy, and 179 (43%) were nonwhite. No participant characteristic differed significantly among study arms at baseline. Retention at 6 months was 90%. Advance care planning documentation 6 months after enrollment was higher in the PREPARE arm vs the AD-alone arm (adjusted 35% vs 25%; odds ratio, 1.61 [95% CI, 1.03-2.51]; P = .04). PREPARE also resulted in higher self-reported ACP engagement at each follow-up, including higher process and action scores; P <.001 at each follow-up). Easy-to-use, patient-facing ACP tools, without clinician- and/or system-level interventions, can increase planning documentation 25% to 35%. Combining the PREPARE website with an easy-to-read AD resulted in higher planning documentation than the AD alone, suggesting that PREPARE may increase planning documentation with minimal health care system resources. clinicaltrials.gov Identifier: NCT01550731.

Impact of an electronic health record operating room management system in ophthalmology on documentation time, surgical volume, and staffing.

PubMed

Sanders, David S; Read-Brown, Sarah; Tu, Daniel C; Lambert, William E; Choi, Dongseok; Almario, Bella M; Yackel, Thomas R; Brown, Anna S; Chiang, Michael F

2014-05-01

Although electronic health record (EHR) systems have potential benefits, such as improved safety and quality of care, most ophthalmology practices in the United States have not adopted these systems. Concerns persist regarding potential negative impacts on clinical workflow. In particular, the impact of EHR operating room (OR) management systems on clinical efficiency in the ophthalmic surgery setting is unknown. To determine the impact of an EHR OR management system on intraoperative nursing documentation time, surgical volume, and staffing requirements. For documentation time and circulating nurses per procedure, a prospective cohort design was used between January 10, 2012, and January 10, 2013. For surgical volume and overall staffing requirements, a case series design was used between January 29, 2011, and January 28, 2013. This study involved ophthalmic OR nurses (n = 13) and surgeons (n = 25) at an academic medical center. Electronic health record OR management system implementation. (1) Documentation time (percentage of operating time documenting [POTD], absolute documentation time in minutes), (2) surgical volume (procedures/time), and (3) staffing requirements (full-time equivalents, circulating nurses/procedure). Outcomes were measured during a baseline period when paper documentation was used and during the early (first 3 months) and late (4-12 months) periods after EHR implementation. There was a worsening in total POTD in the early EHR period (83%) vs paper baseline (41%) (P < .001). This improved to baseline levels by the late EHR period (46%, P = .28), although POTD in the cataract group remained worse than at baseline (64%, P < .001). There was a worsening in absolute mean documentation time in the early EHR period (16.7 minutes) vs paper baseline (7.5 minutes) (P < .001). This improved in the late EHR period (9.2 minutes) but remained worse than in the paper baseline (P < .001). While cataract procedures required more circulating nurses in the early EHR (mean, 1.9 nurses/procedure) and late EHR (mean, 1.5 nurses/procedure) periods than in the paper baseline (mean, 1.0 nurses/procedure) (P < .001), overall staffing requirements and surgical volume were not significantly different between the periods. Electronic health record OR management system implementation was associated with worsening of intraoperative nursing documentation time especially in shorter procedures. However, it is possible to implement an EHR OR management system without serious negative impacts on surgical volume and staffing requirements.

An Evaluation of the UMLS in Representing Corpus Derived Clinical Concepts

PubMed Central

Friedlin, Jeff; Overhage, Marc

2011-01-01

We performed an evaluation of the Unified Medical Language System (UMLS) in representing concepts derived from medical narrative documents from three domains: chest x-ray reports, discharge summaries and admission notes. We detected concepts in these documents by identifying noun phrases (NPs) and N-grams, including unigrams (single words), bigrams (word pairs) and trigrams (word triples). After removing NPs and N-grams that did not represent discrete clinical concepts, we processed the remaining with the UMLS MetaMap program. We manually reviewed the results of MetaMap processing to determine whether MetaMap found full, partial or no representation of the concept. For full representations, we determined whether post-coordination was required. Our results showed that a large portion of concepts found in clinical narrative documents are either unrepresented or poorly represented in the current version of the UMLS Metathesaurus and that post-coordination was often required in order to fully represent a concept. PMID:22195097

Evaluation of clinical pharmacy services in a hematology/oncology outpatient setting.

PubMed

Shah, Sachin; Dowell, Jonathan; Greene, Shane

2006-09-01

The Veterans Affairs North Texas Health Care System in Dallas, TX, provides a unique opportunity for clinical pharmacists to work as providers. Even though clinical pharmacists are actively involved in patient care, many of their efforts remain undocumented, resulting in an underestimation of the importance of their services and missed opportunities for improvements and new directions. To document and evaluate the services of a hematology/oncology clinical pharmacy in the outpatient setting. Pendragon Forms 3.2 software was used to design the documentation template. The template was designed to collect diagnoses, supportive care issues, drug-specific interventions, and prescriptions written. This template was uploaded to the personal digital assistant (PDA) for documentation. Patient-specific information was documented in a password-protected PDA. Data collected from November 1, 2002, to October 31, 2003, were retrospectively analyzed. Clinical pharmacists were involved in 423 patient visits for chemotherapy follow-up or disease management. Cancer diagnoses included colorectal (n = 99), multiple myeloma (59), non-small cell lung (56), chronic lymphocytic leukemia (44), myelodysplastic syndromes (22), and chronic myelogenous leukemia (19). During the 423 patient visits, 342 supportive care issues were addressed including anemia (34%), pain management (22%), constipation/diarrhea (15%), and nausea/vomiting (8%). Major drug-specific interventions included drug addition (41%), discontinuation (23%), and adjustment (21%). Four hundred forty-five prescriptions were filled, of which 181 were new and 150 were refilled. This is the first study, as of July 25, 2006, to document considerable contribution of an outpatient clinical pharmacist in direct cancer patient care. Although the disease management and supportive care issues addressed here may differ based on institution and patient population, the results of our study show that clinical pharmacists have ever-growing roles in the management of these patients.

[Quality management and strategic consequences of assessing documentation and coding under the German Diagnostic Related Groups system].

PubMed

Schnabel, M; Mann, D; Efe, T; Schrappe, M; V Garrel, T; Gotzen, L; Schaeg, M

2004-10-01

The introduction of the German Diagnostic Related Groups (D-DRG) system requires redesigning administrative patient management strategies. Wrong coding leads to inaccurate grouping and endangers the reimbursement of treatment costs. This situation emphasizes the roles of documentation and coding as factors of economical success. The aims of this study were to assess the quantity and quality of initial documentation and coding (ICD-10 and OPS-301) and find operative strategies to improve efficiency and strategic means to ensure optimal documentation and coding quality. In a prospective study, documentation and coding quality were evaluated in a standardized way by weekly assessment. Clinical data from 1385 inpatients were processed for initial correctness and quality of documentation and coding. Principal diagnoses were found to be accurate in 82.7% of cases, inexact in 7.1%, and wrong in 10.1%. Effects on financial returns occurred in 16%. Based on these findings, an optimized, interdisciplinary, and multiprofessional workflow on medical documentation, coding, and data control was developed. Workflow incorporating regular assessment of documentation and coding quality is required by the DRG system to ensure efficient accounting of hospital services. Interdisciplinary and multiprofessional cooperation is recognized to be an important factor in establishing an efficient workflow in medical documentation and coding.

[Document management systems to support quality management systems at university hospitals - an interview-based study].

PubMed

Holderried, Martin; Bökel, Ann-Catrin; Ochsmann, Elke

2018-05-01

In order to save and control the processes and quality of medical services, a suitable steering system of all relevant documents is essential from the point of view of clinical quality management. Systems supporting an automated steering system of documents are called document management systems (DMS), and they also enter the healthcare sector. The use of DMS in the German healthcare sector has hardly been investigated so far. To close this knowledge gap, interviews were carried out with German university hospitals over a six-month period and subjected to a qualitative content analysis according to Mayring. In total, 25 university hospitals agreed to participate in this study, 19 of which have been working with a digital DMS for about six years on average. There was a great variety among the IT systems used. Document management and usability of the DMS as well as its integration into existing IT structures were key decision-making criteria for the selection of a digital DMS. In general, the long-term usability of the DMS is supported by regular evaluation of one's own requirements for the system, administration and training programs. In addition, DMS have a positive effect on patient safety and the quality of medical care. Copyright © 2018. Published by Elsevier GmbH.

Incorporating PROMIS Symptom Measures into Primary Care Practice-a Randomized Clinical Trial.

PubMed

Kroenke, Kurt; Talib, Tasneem L; Stump, Timothy E; Kean, Jacob; Haggstrom, David A; DeChant, Paige; Lake, Kittie R; Stout, Madison; Monahan, Patrick O

2018-04-05

Symptoms account for more than 400 million clinic visits annually in the USA. The SPADE symptoms (sleep, pain, anxiety, depression, and low energy/fatigue) are particularly prevalent and undertreated. To assess the effectiveness of providing PROMIS (Patient-Reported Outcome Measure Information System) symptom scores to clinicians on symptom outcomes. Randomized clinical trial conducted from March 2015 through May 2016 in general internal medicine and family practice clinics in an academic healthcare system. Primary care patients who screened positive for at least one SPADE symptom. After completing the PROMIS symptom measures electronically immediately prior to their visit, the 300 study participants were randomized to a feedback group in which their clinician received a visual display of symptom scores or a control group in which scores were not provided to clinicians. The primary outcome was the 3-month change in composite SPADE score. Secondary outcomes were individual symptom scores, symptom documentation in the clinic note, symptom-specific clinician actions, and patient satisfaction. Most patients (84%) had multiple clinically significant (T-score ≥ 55) SPADE symptoms. Both groups demonstrated moderate symptom improvement with a non-significant trend favoring the feedback compared to control group (between-group difference in composite T-score improvement, 1.1; P = 0.17). Symptoms present at baseline resolved at 3-month follow-up only one third of the time, and patients frequently still desired treatment. Except for pain, clinically significant symptoms were documented less than half the time. Neither symptom documentation, symptom-specific clinician actions, nor patient satisfaction differed between treatment arms. Predictors of greater symptom improvement included female sex, black race, fewer medical conditions, and receiving care in a family medicine clinic. Simple feedback of symptom scores to primary care clinicians in the absence of additional systems support or incentives is not superior to usual care in improving symptom outcomes. clinicaltrials.gov identifier: NCT02383862.

Implementation of Medical Information Exchange System Based on EHR Standard

PubMed Central

Han, Soon Hwa; Kim, Sang Guk; Jeong, Jun Yong; Lee, Bi Na; Choi, Myeong Seon; Kim, Il Kon; Park, Woo Sung; Ha, Kyooseob; Cho, Eunyoung; Kim, Yoon; Bae, Jae Bong

2010-01-01

Objectives To develop effective ways of sharing patients' medical information, we developed a new medical information exchange system (MIES) based on a registry server, which enabled us to exchange different types of data generated by various systems. Methods To assure that patient's medical information can be effectively exchanged under different system environments, we adopted the standardized data transfer methods and terminologies suggested by the Center for Interoperable Electronic Healthcare Record (CIEHR) of Korea in order to guarantee interoperability. Regarding information security, MIES followed the security guidelines suggested by the CIEHR of Korea. This study aimed to develop essential security systems for the implementation of online services, such as encryption of communication, server security, database security, protection against hacking, contents, and network security. Results The registry server managed information exchange as well as the registration information of the clinical document architecture (CDA) documents, and the CDA Transfer Server was used to locate and transmit the proper CDA document from the relevant repository. The CDA viewer showed the CDA documents via connection with the information systems of related hospitals. Conclusions This research chooses transfer items and defines document standards that follow CDA standards, such that exchange of CDA documents between different systems became possible through ebXML. The proposed MIES was designed as an independent central registry server model in order to guarantee the essential security of patients' medical information. PMID:21818447

Implementation of Medical Information Exchange System Based on EHR Standard.

PubMed

Han, Soon Hwa; Lee, Min Ho; Kim, Sang Guk; Jeong, Jun Yong; Lee, Bi Na; Choi, Myeong Seon; Kim, Il Kon; Park, Woo Sung; Ha, Kyooseob; Cho, Eunyoung; Kim, Yoon; Bae, Jae Bong

2010-12-01

To develop effective ways of sharing patients' medical information, we developed a new medical information exchange system (MIES) based on a registry server, which enabled us to exchange different types of data generated by various systems. To assure that patient's medical information can be effectively exchanged under different system environments, we adopted the standardized data transfer methods and terminologies suggested by the Center for Interoperable Electronic Healthcare Record (CIEHR) of Korea in order to guarantee interoperability. Regarding information security, MIES followed the security guidelines suggested by the CIEHR of Korea. This study aimed to develop essential security systems for the implementation of online services, such as encryption of communication, server security, database security, protection against hacking, contents, and network security. The registry server managed information exchange as well as the registration information of the clinical document architecture (CDA) documents, and the CDA Transfer Server was used to locate and transmit the proper CDA document from the relevant repository. The CDA viewer showed the CDA documents via connection with the information systems of related hospitals. This research chooses transfer items and defines document standards that follow CDA standards, such that exchange of CDA documents between different systems became possible through ebXML. The proposed MIES was designed as an independent central registry server model in order to guarantee the essential security of patients' medical information.

Smart Extraction and Analysis System for Clinical Research.

PubMed

Afzal, Muhammad; Hussain, Maqbool; Khan, Wajahat Ali; Ali, Taqdir; Jamshed, Arif; Lee, Sungyoung

2017-05-01

With the increasing use of electronic health records (EHRs), there is a growing need to expand the utilization of EHR data to support clinical research. The key challenge in achieving this goal is the unavailability of smart systems and methods to overcome the issue of data preparation, structuring, and sharing for smooth clinical research. We developed a robust analysis system called the smart extraction and analysis system (SEAS) that consists of two subsystems: (1) the information extraction system (IES), for extracting information from clinical documents, and (2) the survival analysis system (SAS), for a descriptive and predictive analysis to compile the survival statistics and predict the future chance of survivability. The IES subsystem is based on a novel permutation-based pattern recognition method that extracts information from unstructured clinical documents. Similarly, the SAS subsystem is based on a classification and regression tree (CART)-based prediction model for survival analysis. SEAS is evaluated and validated on a real-world case study of head and neck cancer. The overall information extraction accuracy of the system for semistructured text is recorded at 99%, while that for unstructured text is 97%. Furthermore, the automated, unstructured information extraction has reduced the average time spent on manual data entry by 75%, without compromising the accuracy of the system. Moreover, around 88% of patients are found in a terminal or dead state for the highest clinical stage of disease (level IV). Similarly, there is an ∼36% probability of a patient being alive if at least one of the lifestyle risk factors was positive. We presented our work on the development of SEAS to replace costly and time-consuming manual methods with smart automatic extraction of information and survival prediction methods. SEAS has reduced the time and energy of human resources spent unnecessarily on manual tasks.

76 FR 1173 - Draft Guidance for Industry on Electronic Source Documentation in Clinical Investigations...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-07

...] Draft Guidance for Industry on Electronic Source Documentation in Clinical Investigations; Availability... Documentation in Clinical Investigations.'' This document provides guidance to sponsors, contract research organizations (CROs), data management centers, and clinical investigators on capturing, using, and archiving...

Development of a prediction model on the acceptance of electronic laboratory notebooks in academic environments.

PubMed

Kloeckner, Frederik; Farkas, Robert; Franken, Tobias; Schmitz-Rode, Thomas

2014-04-01

Documentation of research data plays a key role in the biomedical engineering innovation processes. It makes an important contribution to the protection of intellectual property, the traceability of results and fulfilling the regulatory requirement. Because of the increasing digitalization in laboratories, an electronic alternative to the commonly-used paper-bound notebooks could contribute to the production of sophisticated documentation. However, compared to in an industrial environment, the use of electronic laboratory notebooks is not widespread in academic laboratories. Little is known about the acceptance of an electronic documentation system and the underlying reasons for this. Thus, this paper aims to establish a prediction model on the potential preference and acceptance of scientists either for paper-based or electronic documentation. The underlying data for the analysis originate from an online survey of 101 scientists in industrial, academic and clinical environments. Various parameters were analyzed to identify crucial factors for the system preference using binary logistic regression. The analysis showed significant dependency between the documentation system preference and the supposed workload associated with the documentation system (p<0.006; odds ratio=58.543) and an additional personal component. Because of the dependency of system choice on specific parameters it is possible to predict the acceptance of an electronic laboratory notebook before implementation.

A usability evaluation of four commercial dental computer-based patient record systems

PubMed Central

Thyvalikakath, Thankam P.; Monaco, Valerie; Thambuganipalle, Hima Bindu; Schleyer, Titus

2008-01-01

Background The usability of dental computer-based patient record (CPR) systems has not been studied, despite early evidence that poor usability is a problem for dental CPR system users at multiple levels. Methods The authors conducted formal usability tests of four dental CPR systems by using a purposive sample of four groups of five novice users. The authors measured task outcomes (correctly completed, incorrectly completed and incomplete) in each CPR system while the participants performed nine clinical documentation tasks, as well as the number of usability problems identified in each CPR system and their potential relationship to task outcomes. The authors reviewed the software application design aspects responsible for these usability problems. Results The range for correctly completed tasks was 16 to 64 percent, for incorrectly completed tasks 18 to 38 percent and for incomplete tasks 9 to 47 percent. The authors identified 286 usability problems. The main types were three unsuccessful attempts, negative affect and task incorrectly completed. They also identified six problematic interface and interaction designs that led to usability problems. Conclusion The four dental CPR systems studied have significant usability problems for novice users, resulting in a steep learning curve and potentially reduced system adoption. Clinical Implications The significant number of data entry errors raises concerns about the quality of documentation in clinical practice. PMID:19047669

Perspective: Whither the problem list? Organ-based documentation and deficient synthesis by medical trainees.

PubMed

Kaplan, Daniel M

2010-10-01

The author argues that the well-formulated problem list is essential for both organizing and evaluating diagnostic thinking. He considers evidence of deficiencies in problem lists in the medical record. He observes a trend among medical trainees toward organizing notes in the medical record according to lists of organ systems or medical subspecialties and hypothesizes that system-based documentation may undermine the art of problem formulation and diagnostic synthesis. Citing research linking more sophisticated problem representation with diagnostic success, he suggests that documentation style and clinical reasoning are closely connected and that organ-based documentation may predispose trainees to several varieties of cognitive diagnostic error and deficient synthesis. These include framing error, premature or absent closure, failure to integrate related findings, and failure to recognize the level of diagnostic resolution attained for a given problem. He acknowledges the pitfalls of higher-order diagnostic resolution, including the application of labels unsupported by firm evidence, while maintaining that diagnostic resolution as far as evidence permits is essential to both rational care of patients and rigorous education of learners. He proposes further research, including comparison of diagnostic efficiency between organ- and problem-oriented thinkers. He hypothesizes that the subspecialty-based structure of academic medical services helps perpetuate organ-system-based thinking, and calls on clinical educators to renew their emphasis on the formulation and documentation of complete and precise problem lists and progressively refined diagnoses by trainees.

Visual design for the user interface, Part 1: Design fundamentals.

PubMed

Lynch, P J

1994-01-01

Digital audiovisual media and computer-based documents will be the dominant forms of professional communication in both clinical medicine and the biomedical sciences. The design of highly interactive multimedia systems will shortly become a major activity for biocommunications professionals. The problems of human-computer interface design are intimately linked with graphic design for multimedia presentations and on-line document systems. This article outlines the history of graphic interface design and the theories that have influenced the development of today's major graphic user interfaces.

An evaluation system for electronic retrospective analyses in radiation oncology: implemented exemplarily for pancreatic cancer

NASA Astrophysics Data System (ADS)

Kessel, Kerstin A.; Jäger, Andreas; Bohn, Christian; Habermehl, Daniel; Zhang, Lanlan; Engelmann, Uwe; Bougatf, Nina; Bendl, Rolf; Debus, Jürgen; Combs, Stephanie E.

2013-03-01

To date, conducting retrospective clinical analyses is rather difficult and time consuming. Especially in radiation oncology, handling voluminous datasets from various information systems and different documentation styles efficiently is crucial for patient care and research. With the example of patients with pancreatic cancer treated with radio-chemotherapy, we performed a therapy evaluation by using analysis tools connected with a documentation system. A total number of 783 patients have been documented into a professional, web-based documentation system. Information about radiation therapy, diagnostic images and dose distributions have been imported. For patients with disease progression after neoadjuvant chemoradiation, we designed and established an analysis workflow. After automatic registration of the radiation plans with the follow-up images, the recurrence volumes are segmented manually. Based on these volumes the DVH (dose-volume histogram) statistic is calculated, followed by the determination of the dose applied to the region of recurrence. All results are stored in the database and included in statistical calculations. The main goal of using an automatic evaluation system is to reduce time and effort conducting clinical analyses, especially with large patient groups. We showed a first approach and use of some existing tools, however manual interaction is still necessary. Further steps need to be taken to enhance automation. Already, it has become apparent that the benefits of digital data management and analysis lie in the central storage of data and reusability of the results. Therefore, we intend to adapt the evaluation system to other types of tumors in radiation oncology.

European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection.

PubMed

Debast, S B; Bauer, M P; Kuijper, E J

2014-03-01

In 2009 the first European Society of Clinical Microbiology and Infection (ESCMID) treatment guidance document for Clostridium difficile infection (CDI) was published. The guideline has been applied widely in clinical practice. In this document an update and review on the comparative effectiveness of the currently available treatment modalities of CDI is given, thereby providing evidence-based recommendations on this issue. A computerized literature search was carried out to investigate randomized and non-randomized trials investigating the effect of an intervention on the clinical outcome of CDI. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The ESCMID and an international team of experts from 11 European countries supported the process. To improve clinical guidance in the treatment of CDI, recommendations are specified for various patient groups, e.g. initial non-severe disease, severe CDI, first recurrence or risk for recurrent disease, multiple recurrences and treatment of CDI when oral administration is not possible. Treatment options that are reviewed include: antibiotics, toxin-binding resins and polymers, immunotherapy, probiotics, and faecal or bacterial intestinal transplantation. Except for very mild CDI that is clearly induced by antibiotic usage antibiotic treatment is advised. The main antibiotics that are recommended are metronidazole, vancomycin and fidaxomicin. Faecal transplantation is strongly recommended for multiple recurrent CDI. In case of perforation of the colon and/or systemic inflammation and deteriorating clinical condition despite antibiotic therapy, total abdominal colectomy or diverting loop ileostomy combined with colonic lavage is recommended. © 2013 The Authors Clinical Microbiology and Infection © 2013 European Society of Clinical Microbiology and Infectious Diseases.

Evaluation of Measles-Mumps-Rubella Vaccination Among Newly Arrived Refugees.

PubMed

Lee, Deborah; Weinberg, Michelle; Benoit, Stephen

2017-05-01

To assess US availability and use of measles-mumps-rubella (MMR) vaccination documentation for refugees vaccinated overseas. We selected 1500 refugee records from 14 states from March 2013 through July 2015 to determine whether overseas vaccination records were available at the US postarrival health assessment and integrated into the Advisory Committee on Immunization Practices schedule. We assessed number of doses, dosing interval, and contraindications. Twelve of 14 (85.7%) states provided data on 1118 (74.5%) refugees. Overseas records for 972 (86.9%) refugees were available, most from the Centers for Disease Control and Prevention's Electronic Disease Notification system (66.9%). Most refugees (829; 85.3%) were assessed appropriately for MMR vaccination; 37 (3.8%) should have received MMR vaccine but did not; 106 (10.9%) did not need the MMR vaccine but were vaccinated. Overseas documentation was available at most clinics, and MMR vaccinations typically were given when needed. Further collaboration between refugee health clinics and state immunization information systems would improve accessibility of vaccination documentation.

Beyond Information Retrieval—Medical Question Answering

PubMed Central

Lee, Minsuk; Cimino, James; Zhu, Hai Ran; Sable, Carl; Shanker, Vijay; Ely, John; Yu, Hong

2006-01-01

Physicians have many questions when caring for patients, and frequently need to seek answers for their questions. Information retrieval systems (e.g., PubMed) typically return a list of documents in response to a user’s query. Frequently the number of returned documents is large and makes physicians’ information seeking “practical only ‘after hours’ and not in the clinical settings”. Question answering techniques are based on automatically analyzing thousands of electronic documents to generate short-text answers in response to clinical questions that are posed by physicians. The authors address physicians’ information needs and described the design, implementation, and evaluation of the medical question answering system (MedQA). Although our long term goal is to enable MedQA to answer all types of medical questions, currently, we currently implement MedQA to integrate information retrieval, extraction, and summarization techniques to automatically generate paragraph-level text for definitional questions (i.e., “What is X?”). MedQA can be accessed at http://www.dbmi.columbia.edu/~yuh9001/research/MedQA.html. PMID:17238385

A nursing-specific model of EPR documentation: organizational and professional requirements.

PubMed

von Krogh, Gunn; Nåden, Dagfinn

2008-01-01

To present the Norwegian documentation KPO model (quality assurance, problem solving, and caring). To present the requirements and multiple electronic patient record (EPR) functions the model is designed to address. The model's professional substance, a conceptual framework for nursing practice is developed by examining, reorganizing, and completing existing frameworks. The model's methodology, an information management system, is developed using an expert group. Both model elements were clinically tested over a period of 1 year. The model is designed for nursing documentation in step with statutory, organizational, and professional requirements. Complete documentation is arranged for by incorporating the Nursing Minimum Data Set. A systematic and comprehensive documentation is arranged for by establishing categories as provided in the model's framework domains. Consistent documentation is arranged for by incorporating NANDA-I Nursing Diagnoses, Nursing Intervention Classification, and Nursing Outcome Classification. The model can be used as a tool in cooperation with vendors to ensure the interests of the nursing profession is met when developing EPR solutions in healthcare. The model can provide clinicians with a framework for documentation in step with legal and organizational requirements and at the same time retain the ability to record all aspects of clinical nursing.

Design of a Clinical Information Management System to Support DNA Analysis Laboratory Operation

PubMed Central

Dubay, Christopher J.; Zimmerman, David; Popovich, Bradley

1995-01-01

The LabDirector system has been developed at the Oregon Health Sciences University to support the operation of our clinical DNA analysis laboratory. Through an iterative design process which has spanned two years, we have produced a system that is both highly tailored to a clinical genetics production laboratory and flexible in its implementation, to support the rapid growth and change of protocols and methodologies in use in the field. The administrative aspects of the system are integrated with an enterprise schedule management system. The laboratory side of the system is driven by a protocol modeling and execution system. The close integration between these two aspects of the clinical laboratory facilitates smooth operations, and allows management to accurately measure costs and performance. The entire application has been designed and documented to provide utility to a wide range of clinical laboratory environments.

Apache Clinical Text and Knowledge Extraction System (cTAKES) | Informatics Technology for Cancer Research (ITCR)

Cancer.gov

The tool extracts deep phenotypic information from the clinical narrative at the document-, episode-, and patient-level. The final output is FHIR compliant patient-level phenotypic summary which can be consumed by research warehouses or the DeepPhe native visualization tool.

The Efficacy of Optometric Vision Therapy.

ERIC Educational Resources Information Center

Journal of the American Optometric Association, 1988

1988-01-01

This review aims to document the efficacy and validity of vision therapy for modifying and improving vision functioning. The paper describes the essential components of the visual system and disorders which can be physiologically and clinically identified. Vision therapy is defined as a clinical approach for correcting and ameliorating the effects…

Feasibility of encoding the Institute for Clinical Systems Improvement Depression Guideline using the Omaha System.

PubMed

Monsen, Karen A; Neely, Claire; Oftedahl, Gary; Kerr, Madeleine J; Pietruszewski, Pam; Farri, Oladimeji

2012-08-01

Evidence-based clinical guidelines are being developed to bridge the gap between research and practice with the goals of improving health care quality and population health. However, disseminating, implementing, and ensuring ongoing use of clinical guidelines in practice settings is challenging. The purpose of this study was to demonstrate the feasibility of encoding evidence-based clinical guidelines using the Omaha System. Clinical documentation with Omaha System-encoded guidelines generates individualized, meaningful data suitable for program evaluation and health care quality research. The use of encoded guidelines within the electronic health record has potential to reinforce use of guidelines, and thus improve health care quality and population health. Research using Omaha System data generated by clinicians has potential to discover new knowledge related to guideline use and effectiveness. Copyright © 2012 Elsevier Inc. All rights reserved.

Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education.

PubMed

Rowlands, Stella; Coverdale, Steven; Callen, Joanne

2016-12-01

Clinical documentation is essential for communication between health professionals and the provision of quality care to patients. To examine medical students' perspectives of their education in documentation of clinical care in hospital patients' medical records. A qualitative design using semi-structured interviews with fourth-year medical students was undertaken at a hospital-based clinical school in an Australian university. Several themes reflecting medical students' clinical documentation education emerged from the data: formal clinical documentation education using lectures and tutorials was minimal; most education occurred on the job by junior doctors and student's expressed concerns regarding variation in education between teams and receiving limited feedback on performance. Respondents reported on the importance of feedback for their learning of disease processes and treatments. They suggested that improvements could be made in the timing of clinical documentation education and they stressed the importance of training on the job. On-the-job education with feedback in clinical documentation provides a learning opportunity for medical students and is essential in order to ensure accurate, safe, succinct and timely clinical notes. © The Author(s) 2016.

Using Technology, Clinical Workflow Redesign, and Team Solutions to Achieve the Patient Centered Medical Home

DTIC Science & Technology

2011-01-01

The Quadruple Aim: Working Together, Achieving Success 2011 Military Health System Conference TMA and Services Using Technology, Clinical Workflow...Redesign, and Team Solutions to Achieve the Patient Centered Medical Home LTC Nicole Kerkenbush, MHA, MN Army Medical Department, Office of the...Surgeon General Chief Medical Information Officer 1 Military Health System Conference Report Documentation Page Form ApprovedOMB No. 0704-0188 Public

An automated system for chromosome analysis. Volume 1: Goals, system design, and performance

NASA Technical Reports Server (NTRS)

Castleman, K. R.; Melnyk, J. H.

1975-01-01

The design, construction, and testing of a complete system to produce karyotypes and chromosome measurement data from human blood samples, and a basis for statistical analysis of quantitative chromosome measurement data is described. The prototype was assembled, tested, and evaluated on clinical material and thoroughly documented.

Automated Reporting of Trainee Metrics Using Electronic Clinical Systems.

PubMed

Levin, Jonathan C; Hron, Jonathan

2017-06-01

The Accreditation Council for Graduate Medical Education has called for increased emphasis on reporting objective performance measures to trainees and programs. However, reporting of objective measures, including clinical volume, is largely omitted from training programs. To use automated electronic medical systems at a tertiary pediatric care hospital to create a dashboard that reports objective trainee and program metrics, including clinical volume and diagnoses in a pediatrics residency. We queried an enterprise data warehouse that aggregates data daily from multiple hospital systems to identify patient encounters during which senior pediatrics residents at Boston Children's Hospital had entered documentation over a 9-month period. From this query, we created a filterable dashboard to display clinical volume and diagnosis data by individual resident and in aggregate. A total of 44 of 45 senior residents (98%) in the program were included in analysis. We identified 12 198 patient encounters during which a senior pediatrics resident had entered documentation; these included a median of 332 inpatient encounters per resident, 122 emergency department encounters, and 84 outpatient encounters. The most common diagnoses stratified by clinical site were: inpatient - dehydration (median = 61); emergency department - long-term/current drug therapy (median = 16); and outpatient - encounter for immunization (median = 48). We used electronic health record systems to generate performance dashboards for trainees in a pediatrics residency across different sites of care with reported volume by diagnosis. Our dashboards provide feedback to program leadership regarding individual and aggregate trainee experience and allow individual trainees to compare their clinical exposure to peers.

Automatic de-identification of textual documents in the electronic health record: a review of recent research

PubMed Central

2010-01-01

Background In the United States, the Health Insurance Portability and Accountability Act (HIPAA) protects the confidentiality of patient data and requires the informed consent of the patient and approval of the Internal Review Board to use data for research purposes, but these requirements can be waived if data is de-identified. For clinical data to be considered de-identified, the HIPAA "Safe Harbor" technique requires 18 data elements (called PHI: Protected Health Information) to be removed. The de-identification of narrative text documents is often realized manually, and requires significant resources. Well aware of these issues, several authors have investigated automated de-identification of narrative text documents from the electronic health record, and a review of recent research in this domain is presented here. Methods This review focuses on recently published research (after 1995), and includes relevant publications from bibliographic queries in PubMed, conference proceedings, the ACM Digital Library, and interesting publications referenced in already included papers. Results The literature search returned more than 200 publications. The majority focused only on structured data de-identification instead of narrative text, on image de-identification, or described manual de-identification, and were therefore excluded. Finally, 18 publications describing automated text de-identification were selected for detailed analysis of the architecture and methods used, the types of PHI detected and removed, the external resources used, and the types of clinical documents targeted. All text de-identification systems aimed to identify and remove person names, and many included other types of PHI. Most systems used only one or two specific clinical document types, and were mostly based on two different groups of methodologies: pattern matching and machine learning. Many systems combined both approaches for different types of PHI, but the majority relied only on pattern matching, rules, and dictionaries. Conclusions In general, methods based on dictionaries performed better with PHI that is rarely mentioned in clinical text, but are more difficult to generalize. Methods based on machine learning tend to perform better, especially with PHI that is not mentioned in the dictionaries used. Finally, the issues of anonymization, sufficient performance, and "over-scrubbing" are discussed in this publication. PMID:20678228

Automatic de-identification of textual documents in the electronic health record: a review of recent research.

PubMed

Meystre, Stephane M; Friedlin, F Jeffrey; South, Brett R; Shen, Shuying; Samore, Matthew H

2010-08-02

In the United States, the Health Insurance Portability and Accountability Act (HIPAA) protects the confidentiality of patient data and requires the informed consent of the patient and approval of the Internal Review Board to use data for research purposes, but these requirements can be waived if data is de-identified. For clinical data to be considered de-identified, the HIPAA "Safe Harbor" technique requires 18 data elements (called PHI: Protected Health Information) to be removed. The de-identification of narrative text documents is often realized manually, and requires significant resources. Well aware of these issues, several authors have investigated automated de-identification of narrative text documents from the electronic health record, and a review of recent research in this domain is presented here. This review focuses on recently published research (after 1995), and includes relevant publications from bibliographic queries in PubMed, conference proceedings, the ACM Digital Library, and interesting publications referenced in already included papers. The literature search returned more than 200 publications. The majority focused only on structured data de-identification instead of narrative text, on image de-identification, or described manual de-identification, and were therefore excluded. Finally, 18 publications describing automated text de-identification were selected for detailed analysis of the architecture and methods used, the types of PHI detected and removed, the external resources used, and the types of clinical documents targeted. All text de-identification systems aimed to identify and remove person names, and many included other types of PHI. Most systems used only one or two specific clinical document types, and were mostly based on two different groups of methodologies: pattern matching and machine learning. Many systems combined both approaches for different types of PHI, but the majority relied only on pattern matching, rules, and dictionaries. In general, methods based on dictionaries performed better with PHI that is rarely mentioned in clinical text, but are more difficult to generalize. Methods based on machine learning tend to perform better, especially with PHI that is not mentioned in the dictionaries used. Finally, the issues of anonymization, sufficient performance, and "over-scrubbing" are discussed in this publication.

Authentication systems for securing clinical documentation workflows. A systematic literature review.

PubMed

Schwartze, J; Haarbrandt, B; Fortmeier, D; Haux, R; Seidel, C

2014-01-01

Integration of electronic signatures embedded in health care processes in Germany challenges health care service and supply facilities. The suitability of the signature level of an eligible authentication procedure is confirmed for a large part of documents in clinical practice. However, the concrete design of such a procedure remains unclear. To create a summary of usable user authentication systems suitable for clinical workflows. A Systematic literature review based on nine online bibliographic databases. Search keywords included authentication, access control, information systems, information security and biometrics with terms user authentication, user identification and login in title or abstract. Searches were run between 7 and 12 September 2011. Relevant conference proceedings were searched manually in February 2013. Backward reference search of selected results was done. Only publications fully describing authentication systems used or usable were included. Algorithms or purely theoretical concepts were excluded. Three authors did selection independently. DATA EXTRACTION AND ASSESSMENT: Semi-structured extraction of system characteristics was done by the main author. Identified procedures were assessed for security and fulfillment of relevant laws and guidelines as well as for applicability. Suitability for clinical workflows was derived from the assessments using a weighted sum proposed by Bonneau. Of 7575 citations retrieved, 55 publications meet our inclusion criteria. They describe 48 different authentication systems; 39 were biometric and nine graphical password systems. Assessment of authentication systems showed high error rates above European CENELEC standards and a lack of applicability of biometric systems. Graphical passwords did not add overall value compared to conventional passwords. Continuous authentication can add an additional layer of safety. Only few systems are suitable partially or entirely for use in clinical processes. Suitability strongly depends on national or institutional requirements. Four authentication systems seem to fulfill requirements of authentication procedures for clinical workflows. Research is needed in the area of continuous authentication with biometric methods. A proper authentication system should combine all factors of authentication implementing and connecting secure individual measures.

Documentation of Nursing Practice Using a Computerized Medical Information System

PubMed Central

Romano, Carol

1981-01-01

This paper discusses a definition of the content of the computerized nursing data base developed by the Nursing Department for the Clinical Center Medical Information System at the National Institutes of Health in Bethesda, Maryland. The author describes the theoretical framework for the content and presents a model to describe the organization of the nursing data components in relation to the process of nursing care delivery. Nursing documentation requirements of Nurse Practice Acts, American Nurses Association Standards of Practice and the Joint Commission on Accreditation of Hospitals are also addressed as they relate to this data base. The advantages and disadvantages of such an approach to computerized documentation are discussed.

A case study evaluation of a Critical Care Information System adoption using the socio-technical and fit approach.

PubMed

Yusof, Maryati Mohd

2015-07-01

Clinical information systems have long been used in intensive care units but reports on their adoption and benefits are limited. This study evaluated a Critical Care Information System implementation. A case study summative evaluation was conducted, employing observation, interview, and document analysis in operating theatres and 16-bed adult intensive care units in a 400-bed Malaysian tertiary referral centre from the perspectives of users (nurses and physicians), management, and information technology staff. System implementation, factors influencing adoption, fit between these factors, and the impact of the Critical Care Information System were evaluated after eight months of operation. Positive influences on system adoption were associated with technical factors, including system ease of use, usefulness, and information relevancy; human factors, particularly user attitude; and organisational factors, namely clinical process-technology alignment and champions. Organisational factors such as planning, project management, training, technology support, turnover rate, clinical workload, and communication were barriers to system implementation and use. Recommendations to improve the current system problems were discussed. Most nursing staff positively perceived the system's reduction of documentation and data access time, giving them more time with patients. System acceptance varied among doctors. System use also had positive impacts on timesaving, data quality, and clinical workflow. Critical Care Information Systems is crucial and has great potentials in enhancing and delivering critical care. However, the case study findings showed that the system faced complex challenges and was underutilised despite its potential. The role of socio-technical factors and their fit in realizing the potential of Critical Care Information Systems requires continuous, in-depth evaluation and stakeholder understanding and acknowledgement. The comprehensive and specific evaluation measures of the Human-Organisation-Technology Fit framework can flexibly evaluate Critical Care Information Systems. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Clinical Information Systems Integration in New York City's First Mobile Stroke Unit.

PubMed

Kummer, Benjamin R; Lerario, Michael P; Navi, Babak B; Ganzman, Adam C; Ribaudo, Daniel; Mir, Saad A; Pishanidar, Sammy; Lekic, Tim; Williams, Olajide; Kamel, Hooman; Marshall, Randolph S; Hripcsak, George; Elkind, Mitchell S V; Fink, Matthew E

2018-01-01

Mobile stroke units (MSUs) reduce time to thrombolytic therapy in acute ischemic stroke. These units are widely used, but the clinical information systems underlying MSU operations are understudied. The first MSU on the East Coast of the United States was established at New York Presbyterian Hospital (NYP) in October 2016. We describe our program's 7-month pilot, focusing on the integration of our hospital's clinical information systems into our MSU to support patient care and research efforts. NYP's MSU was staffed by two paramedics, one radiology technologist, and a vascular neurologist. The unit was equipped with four laptop computers and networking infrastructure enabling all staff to access the hospital intranet and clinical applications during operating hours. A telephone-based registration procedure registered patients from the field into our admit/discharge/transfer system, which interfaced with the institutional electronic health record (EHR). We developed and implemented a computerized physician order entry set in our EHR with prefilled values to permit quick ordering of medications, imaging, and laboratory testing. We also developed and implemented a structured clinician note to facilitate care documentation and clinical data extraction. Our MSU began operating on October 3, 2016. As of April 27, 2017, the MSU transported 49 patients, of whom 16 received tissue plasminogen activator (t-PA). Zero technical problems impacting patient care were reported around registration, order entry, or intranet access. Two onboard network failures occurred, resulting in computed tomography scanner malfunctions, although no patients became ineligible for time-sensitive treatment as a result. Thirteen (26.5%) clinical notes contained at least one incomplete time field. The main technical challenges encountered during the integration of our hospital's clinical information systems into our MSU were onboard network failures and incomplete clinical documentation. Future studies are necessary to determine whether such integrative efforts improve MSU care quality, and which enhancements to information systems will optimize clinical care and research efforts. Schattauer GmbH Stuttgart.

Using Adaptive Turnaround Documents to Electronically Acquire Structured Data in Clinical Settings

PubMed Central

Biondich, Paul G.; Anand, Vibha; Downs, Stephen M.; McDonald, Clement J.

2003-01-01

We developed adaptive turnaround documents (ATDs) to address longstanding challenges inherent in acquiring structured data at the point of care. These computer-generated paper forms both request and receive patient tailored information specifically for electronic storage. In our pilot, we evaluated the usability, accuracy, and user acceptance of an ATD designed to enrich a pediatric preventative care decision support system. The system had an overall digit recognition rate of 98.6% (95% CI: 98.3 to 98.9) and a marksense accuracy of 99.2% (95% CI: 99.1 to 99.3). More importantly, the system reliably extracted all data from 56.6% (95% CI: 53.3 to 59.9) of our pilot forms without the need for a verification step. These results translate to a minimal workflow burden to end users. This suggests that ATDs can serve as an inexpensive, workflow-sensitive means of structured data acquisition in the clinical setting. PMID:14728139

Methods and implementation of a central biosample and data management in a three-centre clinical study.

PubMed

Angelow, Aniela; Schmidt, Matthias; Weitmann, Kerstin; Schwedler, Susanne; Vogt, Hannes; Havemann, Christoph; Hoffmann, Wolfgang

2008-07-01

In our report we describe concept, strategies and implementation of a central biosample and data management (CSDM) system in the three-centre clinical study of the Transregional Collaborative Research Centre "Inflammatory Cardiomyopathy - Molecular Pathogenesis and Therapy" SFB/TR 19, Germany. Following the requirements of high system resource availability, data security, privacy protection and quality assurance, a web-based CSDM was developed based on Java 2 Enterprise Edition using an Oracle database. An efficient and reliable sample documentation system using bar code labelling, a partitioning storage algorithm and an online documentation software was implemented. An online electronic case report form is used to acquire patient-related data. Strict rules for access to the online applications and secure connections are used to account for privacy protection and data security. Challenges for the implementation of the CSDM resided at project, technical and organisational level as well as at staff level.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper.

PubMed

López-Sendón, José; González-Juanatey, José Ramón; Pinto, Fausto; Cuenca Castillo, José; Badimón, Lina; Dalmau, Regina; González Torrecilla, Esteban; López-Mínguez, José Ramón; Maceira, Alicia M; Pascual-Figal, Domingo; Pomar Moya-Prats, José Luis; Sionis, Alessandro; Zamorano, José Luis

2015-11-01

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries. Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Connected commercial vehicles-integrated truck project : driver clinics, performance tests, and lessons learned.

DOT National Transportation Integrated Search

2002-04-01

The National ITS Architecture Mission Definition includes the system level concepts and requirements that document the fundamental needs which will be fulfilled by a successful ITS architecture. It provides a representation of the system that is usef...

A ward-based time study of paper and electronic documentation for recording vital sign observations.

PubMed

Wong, David; Bonnici, Timothy; Knight, Julia; Gerry, Stephen; Turton, James; Watkinson, Peter

2017-07-01

To investigate time differences in recording observations and an early warning score using traditional paper charts and a novel e-Obs system in clinical practice. Researchers observed the process of recording observations and early warning scores across 3 wards in 2 university teaching hospitals immediately before and after introduction of the e-Obs system. The process of recording observations included both measurement and documentation of vital signs. Interruptions were timed and subtracted from the measured process duration. Multilevel modeling was used to compensate for potential confounding factors. In all, 577 nurse events were observed (281 paper, 296 e-Obs). The geometric mean time to take a complete set of vital signs was 215 s (95% confidence interval [CI], 177 s-262 s) on paper, and 150 s (95% CI, 130 s-172 s) electronically. The treatment effect ratio was 0.70 (95% CI, 0.57-0.85, P  < .001). The treatment effect ratio in ward 1 was 0.37 (95% CI, 0.26-0.53), in ward 2 was 0.98 (95% CI, 0.70-1.38), and in ward 3 was 0.93 (95% CI, 0.66-1.33). Introduction of an e-Obs system was associated with a statistically significant reduction in overall time to measure and document vital signs electronically compared to paper documentation. The reductions in time varied among wards and were of clinical significance on only 1 of 3 wards studied. Our results suggest that introduction of an e-Obs system could lower nursing workload as well as increase documentation quality. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Multimedia platform for authoring and presentation of clinical rounds in cardiology

NASA Astrophysics Data System (ADS)

Ratib, Osman M.; Allada, Vivekanand; Dahlbom, Magdalena; Lapstra, Lorelle

2003-05-01

We developed a multimedia presentation platform that allows retrieving data from any digital and analog modalities and to prepare a script of a clinical presentation in an XML format. This system was designed for cardiac multi-disciplinary conferences involving different cardiology specialists as well as cardiovascular surgeons. A typical presentation requires preparation of summary reports of data obtained from the different investigations and imaging techniques. An XML-based scripting methodology was developed to allow for preparation of clinical presentations. The image display program uses the generated script for the sequential presentation of different images that are displayed on pre-determined presentation settings. The ability to prepare and present clinical conferences electronically is more efficient and less time consuming than conventional settings using analog and digital documents, films and videotapes. The script of a given presentation can further be saved as part of the patient record for subsequent review of the documents and images that supported a given medical or therapeutic decision. This also constitutes a perfect documentation method for surgeons and physicians responsible of therapeutic procedures that were decided upon during the clinical conference. It allows them to review the relevant data that supported a given therapeutic decision.

Is real world evidence influencing practice? A systematic review of CPRD research in NICE guidances.

PubMed

Oyinlola, Jessie O; Campbell, Jennifer; Kousoulis, Antonis A

2016-07-26

There is currently limited evidence regarding the extent Real World Evidence (RWE) has directly impacted the health and social care systems. The aim of this review is to identify national guidelines or guidances published in England from 2000 onwards which have referenced studies using the governmental primary care data provider the Clinical Practice Research Datalink (CPRD). The methodology recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Four databases were searched and documents of interest were identified through a search algorithm containing keywords relevant to CPRD. A search diary was maintained with the inclusion/exclusion decisions which were performed by two independent reviewers. Twenty-five guidance documents were included in the final review (following screening and assessment for eligibility), referencing 43 different CPRD/GPRD studies, all published since 2007. The documents covered 12 disease areas, with the majority (N =7) relevant to diseases of the Central Nervous system (CNS). The 43 studies provided evidence of disease epidemiology, incidence/prevalence, pharmacoepidemiology, pharmacovigilance and health utilisation. A slow uptake of RWE in clinical and therapeutic guidelines (as provided by UK governmental structures) was noticed. However, there seems to be an increasing trend in the use of healthcare system data to inform clinical practice, especially as the real world validity of clinical trials is being questioned. In order to accommodate this increasing demand and meet the paradigm shift expected, organisations need to work together to enable or improve data access, undertake translational and relevant research and establish sources of reliable evidence.

Evidence of effectiveness of health care professionals using handheld computers: a scoping review of systematic reviews.

PubMed

Mickan, Sharon; Tilson, Julie K; Atherton, Helen; Roberts, Nia Wyn; Heneghan, Carl

2013-10-28

Handheld computers and mobile devices provide instant access to vast amounts and types of useful information for health care professionals. Their reduced size and increased processing speed has led to rapid adoption in health care. Thus, it is important to identify whether handheld computers are actually effective in clinical practice. A scoping review of systematic reviews was designed to provide a quick overview of the documented evidence of effectiveness for health care professionals using handheld computers in their clinical work. A detailed search, sensitive for systematic reviews was applied for Cochrane, Medline, EMBASE, PsycINFO, Allied and Complementary Medicine Database (AMED), Global Health, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. All outcomes that demonstrated effectiveness in clinical practice were included. Classroom learning and patient use of handheld computers were excluded. Quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A previously published conceptual framework was used as the basis for dual data extraction. Reported outcomes were summarized according to the primary function of the handheld computer. Five systematic reviews met the inclusion and quality criteria. Together, they reviewed 138 unique primary studies. Most reviewed descriptive intervention studies, where physicians, pharmacists, or medical students used personal digital assistants. Effectiveness was demonstrated across four distinct functions of handheld computers: patient documentation, patient care, information seeking, and professional work patterns. Within each of these functions, a range of positive outcomes were reported using both objective and self-report measures. The use of handheld computers improved patient documentation through more complete recording, fewer documentation errors, and increased efficiency. Handheld computers provided easy access to clinical decision support systems and patient management systems, which improved decision making for patient care. Handheld computers saved time and gave earlier access to new information. There were also reports that handheld computers enhanced work patterns and efficiency. This scoping review summarizes the secondary evidence for effectiveness of handheld computers and mhealth. It provides a snapshot of effective use by health care professionals across four key functions. We identified evidence to suggest that handheld computers provide easy and timely access to information and enable accurate and complete documentation. Further, they can give health care professionals instant access to evidence-based decision support and patient management systems to improve clinical decision making. Finally, there is evidence that handheld computers allow health professionals to be more efficient in their work practices. It is anticipated that this evidence will guide clinicians and managers in implementing handheld computers in clinical practice and in designing future research.

ContextD: an algorithm to identify contextual properties of medical terms in a Dutch clinical corpus.

PubMed

Afzal, Zubair; Pons, Ewoud; Kang, Ning; Sturkenboom, Miriam C J M; Schuemie, Martijn J; Kors, Jan A

2014-11-29

In order to extract meaningful information from electronic medical records, such as signs and symptoms, diagnoses, and treatments, it is important to take into account the contextual properties of the identified information: negation, temporality, and experiencer. Most work on automatic identification of these contextual properties has been done on English clinical text. This study presents ContextD, an adaptation of the English ConText algorithm to the Dutch language, and a Dutch clinical corpus. We created a Dutch clinical corpus containing four types of anonymized clinical documents: entries from general practitioners, specialists' letters, radiology reports, and discharge letters. Using a Dutch list of medical terms extracted from the Unified Medical Language System, we identified medical terms in the corpus with exact matching. The identified terms were annotated for negation, temporality, and experiencer properties. To adapt the ConText algorithm, we translated English trigger terms to Dutch and added several general and document specific enhancements, such as negation rules for general practitioners' entries and a regular expression based temporality module. The ContextD algorithm utilized 41 unique triggers to identify the contextual properties in the clinical corpus. For the negation property, the algorithm obtained an F-score from 87% to 93% for the different document types. For the experiencer property, the F-score was 99% to 100%. For the historical and hypothetical values of the temporality property, F-scores ranged from 26% to 54% and from 13% to 44%, respectively. The ContextD showed good performance in identifying negation and experiencer property values across all Dutch clinical document types. Accurate identification of the temporality property proved to be difficult and requires further work. The anonymized and annotated Dutch clinical corpus can serve as a useful resource for further algorithm development.

Medical Device Plug-and-Play Interoperability Standards & Technology Leadership

DTIC Science & Technology

2011-10-01

official Department of the Army position, policy or decision unless so designated by other documentation. REPORT DOCUMENTATION PAGE Form Approved...biomedical engineering students completed their senior design project on the X-Ray / Ventilator Use Case. We worked closely with the students to...Supporting Medical Device Adverse Event Analysis in an Interoperable Clinical Environment: Design of a Data Logging and Playback System,” Publication in

The Clinical Teacher for Special Education. Final Report: Volume II; Evaluating the Model.

ERIC Educational Resources Information Center

Schwartz, Louis; Oseroff, Andrew

Effectiveness of the clinical teaching model (CTM) developed at Florida State University is documented in Volume II of the project's final report. Reviewed is literature related to teacher effectiveness and conceptual changes, conceptual models and instructional systems, and evaluation research in education. Research design and procedures are…

Automatic Word Sense Disambiguation of Acronyms and Abbreviations in Clinical Texts

ERIC Educational Resources Information Center

Moon, Sungrim

2012-01-01

The use of acronyms and abbreviations is increasing profoundly in the clinical domain in large part due to the greater adoption of electronic health record (EHR) systems and increased electronic documentation within healthcare. A single acronym or abbreviation may have multiple different meanings or senses. Comprehending the proper meaning of an…

Documenting progress: hand therapy treatment shift from biomechanical to occupational adaptation.

PubMed

Jack, Jada; Estes, Rebecca I

2010-01-01

The investment of time and self to develop therapeutic relationships with clients appears incongruent with today's time-constrained health care system, yet bridging the gap of these incongruencies is the challenge therapists face to provide high-quality, client-centered, occupation-based treatment. This case report illustrates a shift in approach from biomechanical to occupational adaptation (OA) in an orthopedic outpatient clinic. The progress of a client with lupus-related arthritis who was 6 days postsurgery is documented. The intervention initially used a biomechanical frame of reference, but when little progress had been made at 10 weeks after surgery, a shift was made to the more client-centered OA approach. The Canadian Occupational Performance Measure was administered, and an OA approach was initiated. On reassessment, clinically important improvements were documented in all functional tasks addressed. An OA approach provides the bridge between the application of clinical expertise, client-centered, occupation-based therapy and the time constraints placed by payer sources.

[Database supported electronic retrospective analyses in radiation oncology: establishing a workflow using the example of pancreatic cancer].

PubMed

Kessel, K A; Habermehl, D; Bohn, C; Jäger, A; Floca, R O; Zhang, L; Bougatf, N; Bendl, R; Debus, J; Combs, S E

2012-12-01

Especially in the field of radiation oncology, handling a large variety of voluminous datasets from various information systems in different documentation styles efficiently is crucial for patient care and research. To date, conducting retrospective clinical analyses is rather difficult and time consuming. With the example of patients with pancreatic cancer treated with radio-chemotherapy, we performed a therapy evaluation by using an analysis system connected with a documentation system. A total number of 783 patients have been documented into a professional, database-based documentation system. Information about radiation therapy, diagnostic images and dose distributions have been imported into the web-based system. For 36 patients with disease progression after neoadjuvant chemoradiation, we designed and established an analysis workflow. After an automatic registration of the radiation plans with the follow-up images, the recurrence volumes are segmented manually. Based on these volumes the DVH (dose volume histogram) statistic is calculated, followed by the determination of the dose applied to the region of recurrence. All results are saved in the database and included in statistical calculations. The main goal of using an automatic analysis tool is to reduce time and effort conducting clinical analyses, especially with large patient groups. We showed a first approach and use of some existing tools, however manual interaction is still necessary. Further steps need to be taken to enhance automation. Already, it has become apparent that the benefits of digital data management and analysis lie in the central storage of data and reusability of the results. Therefore, we intend to adapt the analysis system to other types of tumors in radiation oncology.

A systematic literature review of automated clinical coding and classification systems

PubMed Central

Williams, Margaret; Fenton, Susan H; Jenders, Robert A; Hersh, William R

2010-01-01

Clinical coding and classification processes transform natural language descriptions in clinical text into data that can subsequently be used for clinical care, research, and other purposes. This systematic literature review examined studies that evaluated all types of automated coding and classification systems to determine the performance of such systems. Studies indexed in Medline or other relevant databases prior to March 2009 were considered. The 113 studies included in this review show that automated tools exist for a variety of coding and classification purposes, focus on various healthcare specialties, and handle a wide variety of clinical document types. Automated coding and classification systems themselves are not generalizable, nor are the results of the studies evaluating them. Published research shows these systems hold promise, but these data must be considered in context, with performance relative to the complexity of the task and the desired outcome. PMID:20962126

A systematic literature review of automated clinical coding and classification systems.

PubMed

Stanfill, Mary H; Williams, Margaret; Fenton, Susan H; Jenders, Robert A; Hersh, William R

2010-01-01

Clinical coding and classification processes transform natural language descriptions in clinical text into data that can subsequently be used for clinical care, research, and other purposes. This systematic literature review examined studies that evaluated all types of automated coding and classification systems to determine the performance of such systems. Studies indexed in Medline or other relevant databases prior to March 2009 were considered. The 113 studies included in this review show that automated tools exist for a variety of coding and classification purposes, focus on various healthcare specialties, and handle a wide variety of clinical document types. Automated coding and classification systems themselves are not generalizable, nor are the results of the studies evaluating them. Published research shows these systems hold promise, but these data must be considered in context, with performance relative to the complexity of the task and the desired outcome.

The Clinical Practice Library of Medicine (CPLM): An on-line biomedical computer library. System documentation

NASA Technical Reports Server (NTRS)

Grams, R. R.

1982-01-01

A system designed to access a large range of available medical textbook information in an online interactive fashion is described. A high level query type database manager, INQUIRE, is used. Operating instructions, system flow diagrams, database descriptions, text generation, and error messages are discussed. User information is provided.

Clinical simulation as a boundary object in design of health IT-systems.

PubMed

Rasmussen, Stine Loft; Jensen, Sanne; Lyng, Karen Marie

2013-01-01

Healthcare organizations are very complex, holding numerous stakeholders with various approaches and goals towards the design of health IT-systems. Some of these differences may be approached by applying the concept of boundary objects in a participatory IT-design process. Traditionally clinical simulation provides the opportunity to evaluate the design and the usage of clinical IT-systems without endangering the patients and interrupting clinical work. In this paper we present how clinical simulation additionally holds the potential to function as a boundary object in the design process. The case points out that clinical simulation provides an opportunity for discussions and mutual learning among the various stakeholders involved in design of standardized electronic clinical documentation templates. The paper presents and discusses the use of clinical simulation in the translation, transfer and transformation of knowledge between various stakeholders in a large healthcare organization.

[Infrastructure and contents of clinical data management plan].

PubMed

Shen, Tong; Xu, Lie-dong; Fu, Hai-jun; Liu, Yan; He, Jia; Chen, Ping-yan; Song, Yu-fei

2015-11-01

Establishment of quality management system (QMS) plays a critical role in the clinical data management (CDM). The objectives of CDM are to ensure the quality and integrity of the trial data. Thus, every stage or element that may impact the quality outcomes of clinical studies should be in the controlled manner, which is referred to the full life cycle of CDM associated with the data collection, handling and statistical analysis of trial data. Based on the QMS, this paper provides consensus on how to develop a compliant clinical data management plan (CDMP). According to the essential requirements of the CDM, the CDMP should encompass each process of data collection, data capture and cleaning, medical coding, data verification and reconciliation, database monitoring and management, external data transmission and integration, data documentation and data quality assurance and so on. Creating and following up data management plan in each designed data management steps, dynamically record systems used, actions taken, parties involved will build and confirm regulated data management processes, standard operational procedures and effective quality metrics in all data management activities. CDMP is one of most important data management documents that is the solid foundation for clinical data quality.

Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians

PubMed Central

Embi, Peter J.; Yackel, Thomas R.; Logan, Judith R.; Bowen, Judith L.; Cooney, Thomas G.; Gorman, Paul N.

2004-01-01

Objective: Computerized physician documentation (CPD) has been implemented throughout the nation's Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace handwritten documentation in other institutions. The use of this technology may affect educational and clinical activities, yet little has been reported in this regard. The authors conducted a qualitative study to determine the perceived impacts of CPD among faculty and housestaff in a VAMC. Design: A cross-sectional study was conducted using semistructured interviews with faculty (n = 10) and a group interview with residents (n = 10) at a VAMC teaching hospital. Measurements: Content analysis of field notes and taped transcripts were done by two independent reviewers using a grounded theory approach. Findings were validated using member checking and peer debriefing. Results: Four major themes were identified: (1) improved availability of documentation; (2) changes in work processes and communication; (3) alterations in document structure and content; and (4) mistakes, concerns, and decreased confidence in the data. With a few exceptions, subjects felt documentation was more available, with benefits for education and patient care. Other impacts of CPD were largely seen as detrimental to aspects of clinical practice and education, including documentation quality, workflow, professional communication, and patient care. Conclusion: CPD is perceived to have substantial positive and negative impacts on clinical and educational activities and environments. Care should be taken when designing, implementing, and using such systems to avoid or minimize any harmful impacts. More research is needed to assess the extent of the impacts identified and to determine the best strategies to effectively deal with them. PMID:15064287

Integrated clinical workstations for image and text data capture, display, and teleconsultation.

PubMed

Dayhoff, R; Kuzmak, P M; Kirin, G

1994-01-01

The Department of Veterans Affairs (VA) DHCP Imaging System digitally records clinically significant diagnostic images selected by medical specialists in a variety of hospital departments, including radiology, cardiology, gastroenterology, pathology, dermatology, hematology, surgery, podiatry, dental clinic, and emergency room. These images, which include true color and gray scale images, scanned documents, and electrocardiogram waveforms, are stored on network file servers and displayed on workstations located throughout a medical center. All images are managed by the VA's hospital information system (HIS), allowing integrated displays of text and image data from all medical specialties. Two VA medical centers currently have DHCP Imaging Systems installed, and other installations are underway.

Regenstrief Institute's Medical Gopher: a next-generation homegrown electronic medical record system.

PubMed

Duke, Jon D; Morea, Justin; Mamlin, Burke; Martin, Douglas K; Simonaitis, Linas; Takesue, Blaine Y; Dixon, Brian E; Dexter, Paul R

2014-03-01

Regenstrief Institute developed one of the seminal computerized order entry systems, the Medical Gopher, for implementation at Wishard Hospital nearly three decades ago. Wishard Hospital and Regenstrief remain committed to homegrown software development, and over the past 4 years we have fully rebuilt Gopher with an emphasis on usability, safety, leveraging open source technologies, and the advancement of biomedical informatics research. Our objective in this paper is to summarize the functionality of this new system and highlight its novel features. Applying a user-centered design process, the new Gopher was built upon a rich-internet application framework using an agile development process. The system incorporates order entry, clinical documentation, result viewing, decision support, and clinical workflow. We have customized its use for the outpatient, inpatient, and emergency department settings. The new Gopher is now in use by over 1100 users a day, including an average of 433 physicians caring for over 3600 patients daily. The system includes a wizard-like clinical workflow, dynamic multimedia alerts, and a familiar 'e-commerce'-based interface for order entry. Clinical documentation is enhanced by real-time natural language processing and data review is supported by a rapid chart search feature. As one of the few remaining academically developed order entry systems, the Gopher has been designed both to improve patient care and to support next-generation informatics research. It has achieved rapid adoption within our health system and suggests continued viability for homegrown systems in settings of close collaboration between developers and providers. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Increased systemic vascular resistance in neonates with pulmonary hypertension.

PubMed

Milstein, J M; Goetzman, B W; Riemenschneider, T A; Wennberg, R P

1979-11-01

The time necessary for aortic diastolic pressure to decrease to 50 percent of an initially selected value after dissipation of the dicrotic notch (T 1/2) was determined in newborn infants with and without pulmonary hypertension. The mean T 1/2 was 671 +/- 167 msec in seven infants with clinical evidence of pulmonary hypertension and documented right to left ductus arteriosus shunting; 849 +/- 243 msec in nine infants with clinical evidence of pulmonary hypertension but no documented right to left ductus arteriosus shunting; and 457 +/- 66 msec in eight infants with hyaline membrane disease and no clinical evidence of pulmonary hypertension or a patent ductus arteriosus. The mean T 1/2 values in the former two groups were significantly different from that in the group with no pulmonary hypertension (P less than 0.01). An evaluation of factors affecting T 1/2 leads to the conclusion that the patients with pulmonary hypertension had increased systemic vascular resistance as well. This finding has important diagnostic, etiologic and therapeutic implications.

Concordance Between Veterans' Self-Report and Documentation of Surrogate Decision Makers: Implications for Quality Measurement.

PubMed

Garner, Kimberly K; Dubbert, Patricia; Lensing, Shelly; Sullivan, Dennis H

2017-01-01

The Measuring What Matters initiative of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association identified documentation of a surrogate decision maker as one of the top 10 quality indicators in the acute hospital and hospice settings. To better understand the potential implementation of this Measuring What Matters quality measure #8, Documentation of Surrogate in outpatient primary care settings by describing primary care patients' self-reported identification and documentation of a surrogate decision maker. Examination of patient responses to self-assessment questions from advance health care planning educational groups conducted in one medical center primary care clinic and seven community-based outpatient primary care clinics. We assessed the concordance between patient reports of identifying and naming a surrogate decision maker and having completed an advance directive (AD) with presence of an AD in the electronic medical record. Of veterans without a documented AD on file, more than half (66%) reported that they had talked with someone they trusted and nearly half (52%) reported that they had named someone to communicate their preferences. Our clinical project data suggest that many more veterans may have initiated communications with surrogate decision makers than is evident in the electronic medical record. System changes are needed to close the gap between veterans' plans for a surrogate decision maker and the documentation available to acute care health care providers. Published by Elsevier Inc.

Rubber stamp templates for improving clinical documentation: A paper-based, m-Health approach for quality improvement in low-resource settings.

PubMed

Kleczka, Bernadette; Musiega, Anita; Rabut, Grace; Wekesa, Phoebe; Mwaniki, Paul; Marx, Michael; Kumar, Pratap

2018-06-01

The United Nations' Sustainable Development Goal #3.8 targets 'access to quality essential healthcare services'. Clinical practice guidelines are an important tool for ensuring quality of clinical care, but many challenges prevent their use in low-resource settings. Monitoring the use of guidelines relies on cumbersome clinical audits of paper records, and electronic systems face financial and other limitations. Here we describe a unique approach to generating digital data from paper using guideline-based templates, rubber stamps and mobile phones. The Guidelines Adherence in Slums Project targeted ten private sector primary healthcare clinics serving informal settlements in Nairobi, Kenya. Each clinic was provided with rubber stamp templates to support documentation and management of commonly encountered outpatient conditions. Participatory design methods were used to customize templates to the workflows and infrastructure of each clinic. Rubber stamps were used to print templates into paper charts, providing clinicians with checklists for use during consultations. Templates used bubble format data entry, which could be digitized from images taken on mobile phones. Besides rubber stamp templates, the intervention included booklets of guideline compilations, one Android phone for digitizing images of templates, and one data feedback/continuing medical education session per clinic each month. In this paper we focus on the effect of the intervention on documentation of three non-communicable diseases in one clinic. Seventy charts of patients enrolled in the chronic disease program (hypertension/diabetes, n=867; chronic respiratory diseases, n=223) at one of the ten intervention clinics were sampled. Documentation of each individual patient encounter in the pre-intervention (January-March 2016) and post-intervention period (May-July) was scored for information in four dimensions - general data, patient assessment, testing, and management. Control criteria included information with no counterparts in templates (e.g. notes on presenting complaints, vital signs). Documentation scores for each patient were compared between both pre- and post-intervention periods and between encounters documented with and without templates (post-intervention only). The total number of patient encounters in the pre-intervention (282) and post-intervention periods (264) did not differ. Mean documentation scores increased significantly in the post-intervention period on average by 21%, 24% and 17% for hypertension, diabetes and chronic respiratory diseases, respectively. Differences were greater (47%, 43% and 27%, respectively) when documentation with and without templates was compared. Changes between pre- vs.post-intervention, and with vs.without template, varied between individual dimensions of documentation. Overall, documentation improved more for general data and patient assessment than in testing or management. The use of templates improves paper-based documentation of patient care, a first step towards improving the quality of care. Rubber stamps provide a simple and low-cost method to print templates on demand. In combination with ubiquitously available mobile phones, information entered on paper can be easily and rapidly digitized. This 'frugal innovation' in m-Health can empower small, private sector facilities, where large numbers of urban patients seek healthcare, to generate digital data on routine outpatient care. These data can form the basis for evidence-based quality improvement efforts at large scale, and help deliver on the SDG promise of quality essential healthcare services for all. Copyright © 2017 Elsevier B.V. All rights reserved.

Cross-mapping clinical notes between hospitals: an application of the LOINC Document Ontology.

PubMed

Li, Li; Morrey, C Paul; Baorto, David

2011-01-01

Standardization of document titles is essential for management as the volume of electronic clinical notes increases. The two campuses of the New York Presbyterian Hospital have over 2,700 distinct document titles. The LOINC Document Ontology (DO) provides a standard for the naming of clinical documents in a multi-axis structure. We have represented the latest LOINC DO structure in the MED, and developed an automated process mapping the clinical documents from both the West (Columbia) and East (Cornell) campuses to the LOINC DO. We find that the LOINC DO can represent the majority of our documents, and about half of the documents map between campuses using the LOINC DO as a reference. We evaluated the possibility of using current LOINC codes in document exchange between different institutions. While there is clear success in the ability of the LOINC DO to represent documents and facilitate exchange we find there are granularity issues.

Injuries after Hurricane Katrina among Gulf Coast Evacuees sheltered in Houston, Texas.

PubMed

Faul, Mark; Weller, Nancy F; Jones, Julie A

2011-09-01

After Hurricane Katrina and a decline in the living conditions at a major temporary shelter in New Orleans, Louisiana, residents were offered transport to a Mega-Shelter in Houston, Texas. Approximately 200,000 Gulf Coast residents were transported to Houston's Astrodome/Reliant Center Complex for appropriate triage and transfer to other shelter facilities. The Katrina Clinic was quickly organized to treat evacuees with acute injuries and illnesses as well as chronic medical conditions. Clinic physicians documented 1130 hurricane-related injuries during Katrina Clinic's operational interval, September 1-22, 2005. This article documents the nature, extent, and location of injuries treated at that clinic. We compare the frequency of injury among Katrina evacuees who visited the clinic to that of injuries among clinic outpatient records recorded in a nationally representative database. Using the Barell Matrix system and codes from the International Classification of Diseases, Ninth Revision, we classify Katrina injuries by body region and nature of injury; we also document the large number of hurricane-related immunizations distributed at the temporary outpatient clinic. The results show a 42% higher injury proportion among Katrina evacuees and that approximately half of all of the evacuees required immunizations. Lower leg extremity injuries were among the most frequent injuries. Future planning for hurricanes should take into account nonfatal injuries requiring medical treatment and other supportive care. Copyright © 2011 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.

Memorandum "Open Metadata". Open Access to Documentation Forms and Item Catalogs in Healthcare.

PubMed

Dugas, M; Jöckel, K-H; Friede, T; Gefeller, O; Kieser, M; Marschollek, M; Ammenwerth, E; Röhrig, R; Knaup-Gregori, P; Prokosch, H-U

2015-01-01

At present, most documentation forms and item catalogs in healthcare are not accessible to the public. This applies to assessment forms of routine patient care as well as case report forms (CRFs) of clinical and epidemiological studies. On behalf of the German chairs for Medical Informatics, Biometry and Epidemiology six recommendations to developers and users of documentation forms in healthcare were developed. Open access to medical documentation forms could substantially improve information systems in healthcare and medical research networks. Therefore these forms should be made available to the scientific community, their use should not be unduly restricted, they should be published in a sustainable way using international standards and sources of documentation forms should be referenced in scientific publications.

An Electronic Nursing Patient Care Plan Helps in Clinical Decision Support.

PubMed

Wong, C M; Wu, S Y; Ting, W H; Ho, K H; Tong, L H; Cheung, N T

2015-01-01

Information technology can help to improve health care delivery. The utilisation of informatics principle enhances the quality of nursing practices through improved communication, documentation and efficiency. The Nursing Profession constitutes 34% of the total workforce in the Hong Kong Hospital Authority (HA) and includes 21,000 nurses in 2012. To enhance the quality of care and patient safety in both hospitals and community care setting, it is essential that an integrated electronic decision support system for nurses is designed to track documentation and support care or service including observations, decisions, actions and outcomes throughout the care process at each point-of-care. The Patient Care Plan project was set up to achieve these objectives. The Project adheres to strict documentation information architecture to ensure data sharing is freely available. Preliminary results showed very promising improvement in clinical care.

Outpatients flow management and ophthalmic electronic medical records system in university hospital using Yahgee Document View.

PubMed

Matsuo, Toshihiko; Gochi, Akira; Hirakawa, Tsuyoshi; Ito, Tadashi; Kohno, Yoshihisa

2010-10-01

General electronic medical records systems remain insufficient for ophthalmology outpatient clinics from the viewpoint of dealing with many ophthalmic examinations and images in a large number of patients. Filing systems for documents and images by Yahgee Document View (Yahgee, Inc.) were introduced on the platform of general electronic medical records system (Fujitsu, Inc.). Outpatients flow management system and electronic medical records system for ophthalmology were constructed. All images from ophthalmic appliances were transported to Yahgee Image by the MaxFile gateway system (P4 Medic, Inc.). The flow of outpatients going through examinations such as visual acuity testing were monitored by the list "Ophthalmology Outpatients List" by Yahgee Workflow in addition to the list "Patients Reception List" by Fujitsu. Patients' identification number was scanned with bar code readers attached to ophthalmic appliances. Dual monitors were placed in doctors' rooms to show Fujitsu Medical Records on the left-hand monitor and ophthalmic charts of Yahgee Document on the right-hand monitor. The data of manually-inputted visual acuity, automatically-exported autorefractometry and non-contact tonometry on a new template, MaxFile ED, were again automatically transported to designated boxes on ophthalmic charts of Yahgee Document. Images such as fundus photographs, fluorescein angiograms, optical coherence tomographic and ultrasound scans were viewed by Yahgee Image, and were copy-and-pasted to assigned boxes on the ophthalmic charts. Ordering such as appointments, drug prescription, fees and diagnoses input, central laboratory tests, surgical theater and ward room reservations were placed by functions of the Fujitsu electronic medical records system. The combination of the Fujitsu electronic medical records and Yahgee Document View systems enabled the University Hospital to examine the same number of outpatients as prior to the implementation of the computerized filing system.

Teaching home care electronic documentation skills to undergraduate nursing students.

PubMed

Nokes, Kathleen M; Aponte, Judith; Nickitas, Donna M; Mahon, Pamela Y; Rodgers, Betsy; Reyes, Nancy; Chaya, Joan; Dornbaum, Martin

2012-01-01

Although there is general consensus that nursing students need knowledge and significant skill to document clinical findings electronically, nursing faculty face many barriers in ensuring that undergraduate students can practice on electronic health record systems (EHRS). External funding supported the development of an educational innovation through a partnership between a home care agency staff and nursing faculty. Modules were developed to teach EHRS skills using a case study of a homebound person requiring wound care and the Medicare-required OASIS documentation system. This article describes the development and implementation of the module for an upper-level baccalaureate nursing program located in New York City. Nursing faculty are being challenged to develop creative and economical solutions to expose nursing students to EHRSs in nonclinical settings.

Clinical diagnosis of syphilis: a ten-year retrospective analysis in a South Australian urban sexual health clinic.

PubMed

Forrest, C E; Ward, A

2016-12-01

National notifications for infectious syphilis in Australia have increased in recent years. Outside of sexual health clinics, junior clinicians seldom encounter this disease in its infectious stage (primary, secondary and early latent). With such a variable clinical presentation, textbook teaching is no substitute for real-life experience. The importance of accurate classification and staging of disease is relevant to the risk of transmission and determines treatment duration. In this article, the authors review the clinical presentation of syphilis over ten years in an urban sexual health clinic with a focus on the clinical presentation and diagnosis of infectious syphilis, in particular secondary syphilis, compared with that outlined in the Australian National Notifiable Diseases Surveillance System guidelines. This retrospective review of all patients diagnosed with syphilis at an urban sexual health clinic showed that between 2005 and 2015, 226 cases of syphilis were diagnosed. Documentation of impression of clinical staging of disease was present in 46% of the cases. Seventeen of these cases were recorded as secondary syphilis. The criteria used by clinicians to diagnose the secondary syphilis cases were consistent with criteria defined by the Australian National Notifiable Diseases Surveillance System. All cases of secondary syphilis had at least one cutaneous manifestation of disease. The demographic of the cohort of syphilis cases was consistent with that recorded in the literature. This review showed that the clinician's diagnosis of secondary syphilis in this service is consistent with the National Notifiable Diseases Surveillance System guidelines. Continuing education of junior medical staff is important to facilitate diagnosis and improve documentation of clinical staging, minimise disease transmission and ensure appropriate treatment. © The Author(s) 2016.

Bridging the Gap between HL7 CDA and HL7 FHIR: A JSON Based Mapping.

PubMed

Rinner, Christoph; Duftschmid, Georg

2016-01-01

The Austrian electronic health record (EHR) system ELGA went live in December 2016. It is a document oriented EHR system and is based on the HL7 Clinical Document Architecture (CDA). The HL7 Fast Healthcare Interoperability Resources (FHIR) is a relatively new standard that combines the advantages of HL7 messages and CDA Documents. In order to offer easier access to information stored in ELGA we present a method based on adapted FHIR resources to map CDA documents to FHIR resources. A proof-of-concept tool using Java, the open-source FHIR framework HAPI-FHIR and publicly available FHIR servers was created to evaluate the presented mapping. In contrast to other approaches the close resemblance of the mapping file to the FHIR specification allows existing FHIR infrastructure to be reused. In order to reduce information overload and facilitate the access to CDA documents, FHIR could offer a standardized way to query CDA data on a fine granular base in Austria.

HIS-based Kaplan-Meier plots--a single source approach for documenting and reusing routine survival information.

PubMed

Breil, Bernhard; Semjonow, Axel; Müller-Tidow, Carsten; Fritz, Fleur; Dugas, Martin

2011-02-16

Survival or outcome information is important for clinical routine as well as for clinical research and should be collected completely, timely and precisely. This information is relevant for multiple usages including quality control, clinical trials, observational studies and epidemiological registries. However, the local hospital information system (HIS) does not support this documentation and therefore this data has to generated by paper based or spreadsheet methods which can result in redundantly documented data. Therefore we investigated, whether integrating the follow-up documentation of different departments in the HIS and reusing it for survival analysis can enable the physician to obtain survival curves in a timely manner and to avoid redundant documentation. We analysed the current follow-up process of oncological patients in two departments (urology, haematology) with respect to different documentation forms. We developed a concept for comprehensive survival documentation based on a generic data model and implemented a follow-up form within the HIS of the University Hospital Muenster which is suitable for a secondary use of these data. We designed a query to extract the relevant data from the HIS and implemented Kaplan-Meier plots based on these data. To re-use this data sufficient data quality is needed. We measured completeness of forms with respect to all tumour cases in the clinic and completeness of documented items per form as incomplete information can bias results of the survival analysis. Based on the form analysis we discovered differences and concordances between both departments. We identified 52 attributes from which 13 were common (e.g. procedures and diagnosis dates) and were used for the generic data model. The electronic follow-up form was integrated in the clinical workflow. Survival data was also retrospectively entered in order to perform survival and quality analyses on a comprehensive data set. Physicians are now able to generate timely Kaplan-Meier plots on current data. We analysed 1029 follow-up forms of 965 patients with survival information between 1992 and 2010. Completeness of forms was 60.2%, completeness of items ranges between 94.3% and 98.5%. Median overall survival time was 16.4 years; median event-free survival time was 7.7 years. It is feasible to integrate survival information into routine HIS documentation such that Kaplan-Meier plots can be generated directly and in a timely manner.

Building a common pipeline for rule-based document classification.

PubMed

Patterson, Olga V; Ginter, Thomas; DuVall, Scott L

2013-01-01

Instance-based classification of clinical text is a widely used natural language processing task employed as a step for patient classification, document retrieval, or information extraction. Rule-based approaches rely on concept identification and context analysis in order to determine the appropriate class. We propose a five-step process that enables even small research teams to develop simple but powerful rule-based NLP systems by taking advantage of a common UIMA AS based pipeline for classification. Our proposed methodology coupled with the general-purpose solution provides researchers with access to the data locked in clinical text in cases of limited human resources and compact timelines.

Creation of structured documentation templates using Natural Language Processing techniques.

PubMed

Kashyap, Vipul; Turchin, Alexander; Morin, Laura; Chang, Frank; Li, Qi; Hongsermeier, Tonya

2006-01-01

Structured Clinical Documentation is a fundamental component of the healthcare enterprise, linking both clinical (e.g., electronic health record, clinical decision support) and administrative functions (e.g., evaluation and management coding, billing). One of the challenges in creating good quality documentation templates has been the inability to address specialized clinical disciplines and adapt to local clinical practices. A one-size-fits-all approach leads to poor adoption and inefficiencies in the documentation process. On the other hand, the cost associated with manual generation of documentation templates is significant. Consequently there is a need for at least partial automation of the template generation process. We propose an approach and methodology for the creation of structured documentation templates for diabetes using Natural Language Processing (NLP).

Development of the Integrated Info Tech System

DTIC Science & Technology

2006-01-01

automated data gathering John Schaefer, MD Q&A LUNCH- Military Medicine Simulation Working Group (Open session, bring buffet lunch into designated ...Department of the Army position, policy or decision unless so designated by other documentation. REPORT DOCUMENTATION PAGE Form Approved OMB No... designed to not only demonstrate the utility ofWSI as a technology, but also to show that WSI can be used reliably in the real-world, clinical environment

Clinical care costing method for the Clinical Care Classification System.

PubMed

Saba, Virginia K; Arnold, Jean M

2004-01-01

To provide a means for calculating the cost of nursing care using the Clinical Care Classification System (CCCS). Three CCCS indicators of care components, actions, and outcomes in conjunction with Clinical Care Pathways (CCPs). The cost of patient care is based on the type of action time multiplied by care components and nursing costs. The CCCM for the CCCS makes it possible to measure and cost out clinical practice. The CCCM may be used with CCPs in the electronic patient medical record. The CCPs make it easy to track the clinical nursing care across time, settings, population groups, and geographical locations. Collected data may be used many times, allowing for improved documentation, analysis, and costing out of care.

Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation.

PubMed

Shiffman, Richard N; Michel, George; Essaihi, Abdelwaheb; Thornquist, Elizabeth

2004-01-01

A gap exists between the information contained in published clinical practice guidelines and the knowledge and information that are necessary to implement them. This work describes a process to systematize and make explicit the translation of document-based knowledge into workflow-integrated clinical decision support systems. This approach uses the Guideline Elements Model (GEM) to represent the guideline knowledge. Implementation requires a number of steps to translate the knowledge contained in guideline text into a computable format and to integrate the information into clinical workflow. The steps include: (1) selection of a guideline and specific recommendations for implementation, (2) markup of the guideline text, (3) atomization, (4) deabstraction and (5) disambiguation of recommendation concepts, (6) verification of rule set completeness, (7) addition of explanations, (8) building executable statements, (9) specification of origins of decision variables and insertions of recommended actions, (10) definition of action types and selection of associated beneficial services, (11) choice of interface components, and (12) creation of requirement specification. The authors illustrate these component processes using examples drawn from recent experience translating recommendations from the National Heart, Lung, and Blood Institute's guideline on management of chronic asthma into a workflow-integrated decision support system that operates within the Logician electronic health record system. Using the guideline document as a knowledge source promotes authentic translation of domain knowledge and reduces the overall complexity of the implementation task. From this framework, we believe that a better understanding of activities involved in guideline implementation will emerge.

Integration of clinical research documentation in electronic health records.

PubMed

Broach, Debra

2015-04-01

Clinical trials of investigational drugs and devices are often conducted within healthcare facilities concurrently with clinical care. With implementation of electronic health records, new communication methods are required to notify nonresearch clinicians of research participation. This article reviews clinical research source documentation, the electronic health record and the medical record, areas in which the research record and electronic health record overlap, and implications for the research nurse coordinator in documentation of the care of the patient/subject. Incorporation of clinical research documentation in the electronic health record will lead to a more complete patient/subject medical record in compliance with both research and medical records regulations. A literature search provided little information about the inclusion of clinical research documentation within the electronic health record. Although regulations and guidelines define both source documentation and the medical record, integration of research documentation in the electronic health record is not clearly defined. At minimum, the signed informed consent(s), investigational drug or device usage, and research team contact information should be documented within the electronic health record. Institutional policies should define a standardized process for this integration in the absence federal guidance. Nurses coordinating clinical trials are in an ideal position to define this integration.

The Therapy Process Observational Coding System for Child Psychotherapy Strategies Scale

ERIC Educational Resources Information Center

McLeod, Bryce D.; Weisz, John R.

2010-01-01

Most everyday child and adolescent psychotherapy does not follow manuals that document the procedures. Consequently, usual clinical care has remained poorly understood and rarely studied. The Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) is an observational measure of youth psychotherapy procedures…

Advanced Medical Technology and Network Systems Research.

DTIC Science & Technology

1999-09-01

for image-guided therapies . Advanced technologies included in this report are impedance imaging and a palpation training system. 14. SUBJECT...Summary 1 Virtual Clinic for Patients with Chronic Illness Project Planning Document • 2 Telemedicine for Hemodialysis 21 A...imaging systems and’ surgical procedures effort is accomplished in part by establishing the technology requirements for image-guided therapies . Advanced

Evidence and diagnostic reporting in the IHE context.

PubMed

Loef, Cor; Truyen, Roel

2005-05-01

Capturing clinical observations and findings during the diagnostic imaging process is increasingly becoming a critical step in diagnostic reporting. Standards developers-notably HL7 and DICOM-are making significant progress toward standards that enable exchanging clinical observations and findings among the various information systems of the healthcare enterprise. DICOM-like the HL7 Clinical Document Architecture (CDA) -uses templates and constrained, coded vocabulary (SNOMED, LOINC, etc.). Such a representation facilitates automated software recognition of findings and observations, intrapatient comparison, correlation to norms, and outcomes research. The scope of DICOM Structured Reporting (SR) includes many findings that products routinely create in digital form (measurements, computed estimates, etc.). In the Integrating the Healthcare Enterprise (IHE) framework, two Integration Profiles are defined for clinical data capture and diagnostic reporting: Evidence Document, and Simple Image and Numeric Report. This report describes these two DICOM SR-based integration profiles in the diagnostic reporting process.

Homogenization of the lipid profile values.

PubMed

Pedro-Botet, Juan; Rodríguez-Padial, Luis; Brotons, Carlos; Esteban-Salán, Margarita; García-Lerín, Aurora; Pintó, Xavier; Lekuona, Iñaki; Ordóñez-Llanos, Jordi

Analytical reports from the clinical laboratory are essential to guide clinicians about what lipid profile values should be considered altered and, therefore, require intervention. Unfortunately, there is a great heterogeneity in the lipid values reported as "normal, desirable, recommended or referenced" by clinical laboratories. This can difficult clinical decisions and be a barrier to achieve the therapeutic goals for cardiovascular prevention. A recent international recommendation has added a new heterogeneity factor for the interpretation of lipid profile, such as the possibility of measuring it without previous fasting. All this justifies the need to develop a document that adapts the existing knowledge to the clinical practice of our health system. In this regard, professionals from different scientific societies involved in the measurement and use of lipid profile data have developed this document to establish recommendations that facilitate their homogenization. Copyright © 2017. Publicado por Elsevier España, S.L.U.

Orienting and Onboarding Clinical Nurse Specialists: A Process Improvement Project.

PubMed

Garcia, Mayra G; Watt, Jennifer L; Falder-Saeed, Karie; Lewis, Brennan; Patton, Lindsey

Clinical nurse specialists (CNSs) have a unique advanced practice role. This article describes a process useful in establishing a comprehensive orientation and onboarding program for a newly hired CNS. The project team used the National Association of Clinical Nurse Specialists core competencies as a guide to construct a process for effectively onboarding and orienting newly hired CNSs. Standardized documents were created for the orientation process including a competency checklist, needs assessment template, and professional evaluation goals. In addition, other documents were revised to streamline the orientation process. Standardizing the onboarding and orientation process has demonstrated favorable results. As of 2016, 3 CNSs have successfully been oriented and onboarded using the new process. Unique healthcare roles require special focus when onboarding and orienting into a healthcare system. The use of the National Association of Clinical Nurse Specialists core competencies guided the project in establishing a successful orientation and onboarding process for newly hired CNSs.

E-nursing documentation as a tool for quality assurance.

PubMed

Rajkovic, Vladislav; Sustersic, Olga; Rajkovic, Uros

2006-01-01

The article presents the results of a project with which we describe the reengineering of nursing documentation. Documentation in nursing is an efficient tool for ensuring quality health care and consequently quality patient treatment along the whole clinical path. We have taken into account the nursing process and patient treatment based on Henderson theoretical model of nursing that consists of 14 basic living activities. The model of new documentation enables tracing, transparency, selectivity, monitoring and analyses. All these factors lead to improvements of a health system as well as to improved safety of patients and members of nursing teams. Thus the documentation was developed for three health care segments: secondary and tertiary level, dispensaries and community health care. The new quality introduced to the documentation process by information and communication technology is presented by a database model and a software prototype for managing documentation.

Death certificate data and causes of death in patients with parkinsonism.

PubMed

Moscovich, Mariana; Boschetti, Gabriela; Moro, Adriana; Teive, Helio A G; Hassan, Anhar; Munhoz, Renato P

2017-08-01

Assessment of variables related to mortality in Parkinson disease (PD) and other parkinsonian syndromes relies, among other sources, on accurate death certificate (DC) documentation. We assessed the documentation of the degenerative disorder on DCs and evaluated comorbidities and causes of death among parkinsonian patients. Demographic and clinical data were systematically and prospectively collected on deceased patients followed at a tertiary movement disorder clinic. DCs data included the documentation of parkinsonism, causes, and place of death. Among 138 cases, 84 (60.9%) male, mean age 77.9 years, mean age of onset 66.7, and mean disease duration 10.9 years. Clinical diagnoses included PD (73.9%), progressive supranuclear palsy (10.9%), multiple system atrophy (7.2%), Lewy body dementia (7.2%) and corticobasal degeneration (0.7%). Psychosis occurred in 60.1% cases, dementia in 48.5%. Most PD patients died due to heterogeneous causes before reaching advanced stages. Non-PD parkinsonian patients died earlier due to causes linked to the advanced neurodegenerative process. PD was documented in 38.4% of DCs with different forms of inconsistencies. That improved, but remained significant when it was signed by a specialist. More than half of PD cases died while still ambulatory and independent, after a longer disease course and due to causes commonly seen in that age group. Deaths among advanced PD patients occurred due to causes similar to what we found in non-PD cases. These findings can be useful for clinical, prognostic and counseling purposes. Underlying parkinsonian disorders are poorly documented in DCs, undermining its' use as sources of data collection. Copyright © 2017 Elsevier Ltd. All rights reserved.

Drug-related problems: evaluation of a classification system in the daily practice of a Swiss University Hospital.

PubMed

Lampert, Markus L; Kraehenbuehl, Stephan; Hug, Balthasar L

2008-12-01

To evaluate the Pharmaceutical Care Network Europe (PCNE) classification system as a tool for documenting the impact of a hospital clinical pharmacology service. Two medical wards comprising totally 85 beds in a university hospital. Number of events classified with the PCNE-system, their acceptance by the medical staff and cost implications. Clinical pharmacy review of pharmacotherapy on ward rounds and from case notes were documented, and identified drug-related problems (DRPs) were classified using the PCNE system version 5.00. During 70 observation days 216 interventions were registered of which 213 (98.6%) could be classified: 128 (60.1%) were detected by reviewing the case notes, 33 (15.5%) on ward rounds, 32 (15.0%) by direct reporting to the clinical pharmacist (CP), and 20 (9.4%) on non-formulary prescriptions. Of 148 suggested interventions by the CP 123 (83.0%) were approved by the responsible physician, 12 ADR reports (8.1%) were submitted to the local pharmacovigilance centre and 31 (20.9%) specific information given without further need for action. An evaluation of the DRPs showed that direct drug costs of 2,058 within the study period or 10,731 per year could be avoided. We consider the PCNE system to be a practical tool in the hospital setting, which demonstrates the values of a clinical pharmacy service in terms of identifying and reducing DRPs and also has the potential to reduce prescribing costs.

Abnormal appearances: inspection, display and the clinic.

PubMed

Featherstone, Katie; Atkinson, Paul

2014-01-01

We provide an examination of the field of dysmorphology, a clinical speciality that in its current form combines a long history of inspection and display with the identification and representation of associated underlying molecular changes. The recognition and description of abnormal appearances is thus increasingly accompanied by genetic and other molecular investigations. Our analysis draws on our long-term ethnographic engagement with a UK clinical genetics service and the work of two clinical genetics teams within a regional teaching hospital. We document the intersection of genetic science with clinical work to suggest that while molecular testing often identifies the genetic basis for unusual appearances and abnormal development, it does not fully supplant clinical apperception and interpretation. The two modes of knowledge--the clinical and the biomedical--co-exist in the work and the discourse of dysmorphology practice. The contemporary dysmorphology clinic thus encapsulates the epistemological systems of modern medicine, grounded in the clinical gaze and on the classificatory systems of classic nosology. Within such a system of clinical knowledge, the 'monstrous' does not escape the boundaries of knowledge. Monstrous appearances are accommodated and domesticated within the classificatory systems of normal medicine.

Information Model for Reusability in Clinical Trial Documentation

ERIC Educational Resources Information Center

Bahl, Bhanu

2013-01-01

In clinical research, New Drug Application (NDA) to health agencies requires generation of a large number of documents throughout the clinical development life cycle, many of which are also submitted to public databases and external partners. Current processes to assemble the information, author, review and approve the clinical research documents,…

[3-dimensional imaging systems: first experience in planning and documentation of plastic surgery procedures].

PubMed

Spanholtz, T A; Leitsch, S; Holzbach, T; Volkmer, E; Engelhardt, T; Giunta, R E

2012-08-01

A reproducible 3-dimensional photographic system enables plastic surgeons to perform preoperative planning and helps them to understand the patient's expectations. There are a few systems available that allow a reproducible 3-dimensional scans of the patient with direct simulation of the planned procedure. The Vectra Volumetric 3D Surface Imaging® by Canfield® provides such an option and helps the surgeons to document and compare postoperative changes at different time points. Since January 2011 we are digitally documenting all patients receiving form-modulating procedures in our plastic surgery unit. We present the spectrum of clinical implications and discuss advantages and disadvantages of the system. Furthermore, we have studied the accuracy of the system in comparison to direct measurement in 15 volunteers. The system is especially suited for planning and evaluation of breast augmentation, facial aesthetic and reconstructive surgery as well as volumetric measurements before and after liposuction and lipofilling. Computer-assisted measurements correlate with a median deviation of 2.3% with manually measured distances in the face. We found the user-friendly Vectra® system to be a reliable and reproducible device for planning plastic surgery therapies and for documenting postoperative results. © Georg Thieme Verlag KG Stuttgart · New York.

Louhi 2010: Special issue on Text and Data Mining of Health Documents

PubMed Central

2011-01-01

The papers presented in this supplement focus and reflect on computer use in every-day clinical work in hospitals and clinics such as electronic health record systems, pre-processing for computer aided summaries, clinical coding, computer decision systems, as well as related ethical concerns and security. Much of this work concerns itself by necessity with incorporation and development of language processing tools and methods, and as such this supplement aims at providing an arena for reporting on development in a diversity of languages. In the supplement we can read about some of the challenges identified above. PMID:21992545

[Computerized system validation of clinical researches].

PubMed

Yan, Charles; Chen, Feng; Xia, Jia-lai; Zheng, Qing-shan; Liu, Daniel

2015-11-01

Validation is a documented process that provides a high degree of assurance. The computer system does exactly and consistently what it is designed to do in a controlled manner throughout the life. The validation process begins with the system proposal/requirements definition, and continues application and maintenance until system retirement and retention of the e-records based on regulatory rules. The objective to do so is to clearly specify that each application of information technology fulfills its purpose. The computer system validation (CSV) is essential in clinical studies according to the GCP standard, meeting product's pre-determined attributes of the specifications, quality, safety and traceability. This paper describes how to perform the validation process and determine relevant stakeholders within an organization in the light of validation SOPs. Although a specific accountability in the implementation of the validation process might be outsourced, the ultimate responsibility of the CSV remains on the shoulder of the business process owner-sponsor. In order to show that the compliance of the system validation has been properly attained, it is essential to set up comprehensive validation procedures and maintain adequate documentations as well as training records. Quality of the system validation should be controlled using both QC and QA means.

Modern Corneal Eye-Banking Using a Software-Based IT Management Solution.

PubMed

Kern, C; Kortuem, K; Wertheimer, C; Nilmayer, O; Dirisamer, M; Priglinger, S; Mayer, W J

2018-01-01

Increasing government legislation and regulations in manufacturing have led to additional documentation regarding the pharmaceutical product requirements of corneal grafts in the European Union. The aim of this project was to develop a software within a hospital information system (HIS) to support the documentation process, to improve the management of the patient waiting list and to increase informational flow between the clinic and eye bank. After an analysis of the current documentation process, a new workflow and software were implemented in our electronic health record (EHR) system. The software takes over most of the documentation and reduces the time required for record keeping. It guarantees real-time tracing of all steps during human corneal tissue processing from the start of production until allocation during surgery and includes follow-up within the HIS. Moreover, listing of the patient for surgery as well as waiting list management takes place in the same system. The new software for corneal eye banking supports the whole process chain by taking over both most of the required documentation and the management of the transplant waiting list. It may provide a standardized IT-based solution for German eye banks working within the same HIS.

An Integrated Computerized Triage System in the Emergency Department

PubMed Central

Aronsky, Dominik; Jones, Ian; Raines, Bill; Hemphill, Robin; Mayberry, Scott R; Luther, Melissa A; Slusser, Ted

2008-01-01

Emergency department (ED) triage is a fast-paced process that prioritizes the allocation of limited health care resources to patients in greatest need. This paper describes the experiences with an integrated, computerized triage application. The system exchanges information with other information systems, including the ED patient tracking board, the longitudinal electronic medical record, the computerized provider order entry, and the medication reconciliation application. The application includes decision support capabilities such as assessing the patient’s acuity level, age-dependent alerts for vital signs, and clinical reminders. The browser-based system utilizes the institution’s controlled vocabulary, improves data completeness and quality, such as compliance with capturing required data elements and screening questions, initiates clinical processes, such as pneumococcal vaccination ordering, and reminders to start clinical pathways, issues alerts for clinical trial eligibility, and facilitates various reporting needs. The system has supported the triage documentation of >290,000 pediatric and adult patients. PMID:18999190

HTML5 microdata as a semantic container for medical information exchange.

PubMed

Kimura, Eizen; Kobayashi, Shinji; Ishihara, Ken

2014-01-01

Achieving interoperability between clinical electronic medical records (EMR) systems and cloud computing systems is challenging because of the lack of a universal reference method as a standard for information exchange with a secure connection. Here we describe an information exchange scheme using HTML5 microdata, where the standard semantic container is an HTML document. We embed HL7 messages describing laboratory test results in the microdata. We also annotate items in the clinical research report with the microdata. We mapped the laboratory test result data into the clinical research report using an HL7 selector specified in the microdata. This scheme can provide secure cooperation between the cloud-based service and the EMR system.

Integrated clinical workstations for image and text data capture, display, and teleconsultation.

PubMed Central

Dayhoff, R.; Kuzmak, P. M.; Kirin, G.

1994-01-01

The Department of Veterans Affairs (VA) DHCP Imaging System digitally records clinically significant diagnostic images selected by medical specialists in a variety of hospital departments, including radiology, cardiology, gastroenterology, pathology, dermatology, hematology, surgery, podiatry, dental clinic, and emergency room. These images, which include true color and gray scale images, scanned documents, and electrocardiogram waveforms, are stored on network file servers and displayed on workstations located throughout a medical center. All images are managed by the VA's hospital information system (HIS), allowing integrated displays of text and image data from all medical specialties. Two VA medical centers currently have DHCP Imaging Systems installed, and other installations are underway. PMID:7949899

Centrality based Document Ranking

DTIC Science & Technology

2014-11-01

clinical domain and very uncommon elsewhere. A regular IR system may fail to rank documents from such a domain, dealing with symptoms, diagnosis and...description). We prepared a hand-crafted list of synonyms for each of the query types, viz. diagnosis , test and treatment. This list was used to expand the...Miller. Semantic search. In INTERNATIONAL WORLD WIDE WEB CONFERENCE, pages 700–709. ACM, 2003. 8. A. Hanbury and M. Lupu . Toward a Model of Domain

X-PAT: a multiplatform patient referral data management system for small healthcare institution requirements.

PubMed

Masseroli, Marco; Marchente, Mario

2008-07-01

We present X-PAT, a platform-independent software prototype that is able to manage patient referral multimedia data in an intranet network scenario according to the specific control procedures of a healthcare institution. It is a self-developed storage framework based on a file system, implemented in eXtensible Markup Language (XML) and PHP Hypertext Preprocessor Language, and addressed to the requirements of limited-dimension healthcare entities (small hospitals, private medical centers, outpatient clinics, and laboratories). In X-PAT, healthcare data descriptions, stored in a novel Referral Base Management System (RBMS) according to Health Level 7 Clinical Document Architecture Release 2 (CDA R2) standard, can be easily applied to the specific data and organizational procedures of a particular healthcare working environment thanks also to the use of standard clinical terminology. Managed data, centralized on a server, are structured in the RBMS schema using a flexible patient record and CDA healthcare referral document structures based on XML technology. A novel search engine allows defining and performing queries on stored data, whose rapid execution is ensured by expandable RBMS indexing structures. Healthcare personnel can interface the X-PAT system, according to applied state-of-the-art privacy and security measures, through friendly and intuitive Web pages that facilitate user acceptance.

Evidence of Effectiveness of Health Care Professionals Using Handheld Computers: A Scoping Review of Systematic Reviews

PubMed Central

2013-01-01

Background Handheld computers and mobile devices provide instant access to vast amounts and types of useful information for health care professionals. Their reduced size and increased processing speed has led to rapid adoption in health care. Thus, it is important to identify whether handheld computers are actually effective in clinical practice. Objective A scoping review of systematic reviews was designed to provide a quick overview of the documented evidence of effectiveness for health care professionals using handheld computers in their clinical work. Methods A detailed search, sensitive for systematic reviews was applied for Cochrane, Medline, EMBASE, PsycINFO, Allied and Complementary Medicine Database (AMED), Global Health, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. All outcomes that demonstrated effectiveness in clinical practice were included. Classroom learning and patient use of handheld computers were excluded. Quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A previously published conceptual framework was used as the basis for dual data extraction. Reported outcomes were summarized according to the primary function of the handheld computer. Results Five systematic reviews met the inclusion and quality criteria. Together, they reviewed 138 unique primary studies. Most reviewed descriptive intervention studies, where physicians, pharmacists, or medical students used personal digital assistants. Effectiveness was demonstrated across four distinct functions of handheld computers: patient documentation, patient care, information seeking, and professional work patterns. Within each of these functions, a range of positive outcomes were reported using both objective and self-report measures. The use of handheld computers improved patient documentation through more complete recording, fewer documentation errors, and increased efficiency. Handheld computers provided easy access to clinical decision support systems and patient management systems, which improved decision making for patient care. Handheld computers saved time and gave earlier access to new information. There were also reports that handheld computers enhanced work patterns and efficiency. Conclusions This scoping review summarizes the secondary evidence for effectiveness of handheld computers and mhealth. It provides a snapshot of effective use by health care professionals across four key functions. We identified evidence to suggest that handheld computers provide easy and timely access to information and enable accurate and complete documentation. Further, they can give health care professionals instant access to evidence-based decision support and patient management systems to improve clinical decision making. Finally, there is evidence that handheld computers allow health professionals to be more efficient in their work practices. It is anticipated that this evidence will guide clinicians and managers in implementing handheld computers in clinical practice and in designing future research. PMID:24165786

Translation of clinical practice guidelines for childhood obesity prevention in primary care mobilizes a rural Midwest community.

PubMed

Gibson, S Jo

2016-03-01

The purpose of this project was to implement clinic system changes that support evidence-based guidelines for childhood obesity prevention. Adherence rates for prevention and screening of children in a rural Midwest primary care setting were used to measure the success of the program. Retrospective chart reviews reflected gaps in current practice and documentation. An evidence-based toolkit for childhood obesity prevention was used to implement clinic system changes for the identified gaps. The quality improvement approach proved to be effective in translating knowledge of obesity prevention guidelines into rural clinic practices with significant improvements in documentation of prevention measures that may positively impact the childhood obesity epidemic. Primary care providers, including nurse practitioners (NPs), are at the forefront of diagnosing, educating, and counseling children and families on obesity prevention and need appropriate resources and tools to deliver premier care. The program successfully demonstrated how barriers to practice, even with the unique challenges in a rural setting, can be overcome. NPs fulfill a pivotal primary care role and can provide leadership that may positively impact obesity prevention in their communities. ©2015 American Association of Nurse Practitioners.

Understanding Providers' Interaction with Graphical User Interface Pertaining to Clinical Document Usage in an Electronic Health Record System

ERIC Educational Resources Information Center

Rizvi, Rubina Fatima

2017-01-01

Despite high Electronic Health Record (EHR) system adoption rates by hospital and office-based practices, many users remain highly dissatisfied with the current state of EHRs. Sub-optimal EHR usability as a result of insufficient incorporation of User-Centered Design (UCD) approach during System Development Life Cycle process (SDLC) is considered…

The registry case finding engine: an automated tool to identify cancer cases from unstructured, free-text pathology reports and clinical notes.

PubMed

Hanauer, David A; Miela, Gretchen; Chinnaiyan, Arul M; Chang, Alfred E; Blayney, Douglas W

2007-11-01

The American College of Surgeons mandates the maintenance of a cancer registry for hospitals seeking accreditation. At the University of Michigan Health System, more than 90% of all registry patients are identified by manual review, a method common to many institutions. We hypothesized that an automated computer system could accurately perform this time- and labor-intensive task. We created a tool to automatically scan free-text medical documents for terms relevant to cancer. We developed custom-made lists containing approximately 2,500 terms and phrases and 800 SNOMED codes. Text is processed by the Case Finding Engine (CaFE), and relevant terms are highlighted for review by a registrar and used to populate the registry database. We tested our system by comparing results from the CaFE to those by trained registrars who read through 2,200 pathology reports and marked relevant cases for the registry. The clinical documentation (eg, electronic chart notes) of an additional 476 patients was also reviewed by registrars and compared with the automated process by the CaFE. For pathology reports, the sensitivity for automated case identification was 100%, but specificity was 85.0%. For clinical documentation, sensitivity was 100% and specificity was 73.7%. Types of errors made by the CaFE were categorized to direct additional improvements. Use of the CaFE has resulted in a considerable increase in the number of cases added to the registry each month. The system has been well accepted by our registrars. CaFE can improve the accuracy and efficiency of tumor registry personnel and helps ensure that cancer cases are not overlooked.

Integrating query of relational and textual data in clinical databases: a case study.

PubMed

Fisk, John M; Mutalik, Pradeep; Levin, Forrest W; Erdos, Joseph; Taylor, Caroline; Nadkarni, Prakash

2003-01-01

The authors designed and implemented a clinical data mart composed of an integrated information retrieval (IR) and relational database management system (RDBMS). Using commodity software, which supports interactive, attribute-centric text and relational searches, the mart houses 2.8 million documents that span a five-year period and supports basic IR features such as Boolean searches, stemming, and proximity and fuzzy searching. Results are relevance-ranked using either "total documents per patient" or "report type weighting." Non-curated medical text has a significant degree of malformation with respect to spelling and punctuation, which creates difficulties for text indexing and searching. Presently, the IR facilities of RDBMS packages lack the features necessary to handle such malformed text adequately. A robust IR+RDBMS system can be developed, but it requires integrating RDBMSs with third-party IR software. RDBMS vendors need to make their IR offerings more accessible to non-programmers.

Bedside patient data viewer using RFID and e-Ink technology.

PubMed

Nikodijevic, Aleksandar; Pichler, Patrick; Forjan, Mathias; Sauermann, Stefan

2014-01-01

In the daily routine of hospitals, which work with paper based medical records, the staff has to find the appropriate patient file if it needs information about the patient. With the introduction of ELGA the Austrian hospitals have to use specific standards for their clinical documentation. These structured documents can be used to feed an e-Ink reader with information about every patient in a hospital. Combined with RFID and security measures, the clinical staff is supported during the patient file searching process. The developed experimental setup of the Bedside Patient Data Viewer demonstrates a prototype of such a system. An Amazon Kindle Paperwhite is used to display processed data, supplied by a Raspberry Pi with an attached RFID module for identification purposes. Results show that such a system can be implemented, however a lot of organizational and technical issues remain to be solved.

An analysis of electronic document management in oncology care.

PubMed

Poulter, Thomas; Gannon, Brian; Bath, Peter A

2012-06-01

In this research in progress, a reference model for the use of electronic patient record (EPR) systems in oncology is described. The model, termed CICERO, comprises technical and functional components, and emphasises usability, clinical safety and user acceptance. One of the functional components of the model-an electronic document and records management (EDRM) system-is monitored in the course of its deployment at a leading oncology centre in the UK. Specifically, the user requirements and design of the EDRM solution are described.The study is interpretative and forms part a wider research programme to define and validate the CICERO model. Preliminary conclusions confirm the importance of a socio-technical perspective in Onco-EPR system design.

Medical Language Processing for Knowledge Representation and Retrievals

PubMed Central

Lyman, Margaret; Sager, Naomi; Chi, Emile C.; Tick, Leo J.; Nhan, Ngo Thanh; Su, Yun; Borst, Francois; Scherrer, Jean-Raoul

1989-01-01

The Linguistic String Project-Medical Language Processor, a system for computer analysis of narrative patient documents in English, is being adapted for French Lettres de Sortie. The system converts the free-text input to a semantic representation which is then mapped into a relational database. Retrievals of clinical data from the database are described.

Requirements and design aspects of a data model for a data dictionary in paediatric oncology.

PubMed

Merzweiler, A; Knaup, P; Creutzig, U; Ehlerding, H; Haux, R; Mludek, V; Schilling, F H; Weber, R; Wiedemann, T

2000-01-01

German children suffering from cancer are mostly treated within the framework of multicentre clinical trials. An important task of conducting these trials is an extensive information and knowledge exchange, which has to be based on a standardised documentation. To support this effort, it is the aim of a nationwide project to define a standardised terminology that should be used by clinical trials for therapy documentation. In order to support terminology maintenance we are currently developing a data dictionary. In this paper we describe requirements and design aspects of the data model used for the data dictionary as first results of our research. We compare it with other terminology systems.

Patient reminder systems and asthma medication adherence: a systematic review.

PubMed

Tran, Nancy; Coffman, Janet M; Sumino, Kaharu; Cabana, Michael D

2014-06-01

One of the most common reasons for medication non-adherence for asthma patients is forgetfulness. Daily medication reminder system interventions in the form of text messages, automated phone calls and audiovisual reminder devices can potentially address this problem. The aim of this review was to assess the effectiveness of reminder systems on patient daily asthma medication adherence. We conducted a systematic review of the literature to identify randomized controlled trials (RCTs) which assessed the effect of reminder systems on daily asthma medication adherence. We searched all English-language articles in Pub Med (MEDLINE), CINAHL, EMBASE, PsychINFO and the Cochrane Library through May 2013. We abstracted data on the year of study publication, location, inclusion and exclusion criteria, patient characteristics, reminder system characteristics, effect on patient adherence rate and other outcomes measured. Descriptive statistics were used to summarize the characteristics and results of the studies. Five RCTs and one pragmatic RCT were included in the analysis. Median follow-up time was 16 weeks. All of the six studies suggested that the reminder system intervention was associated with greater levels of participant asthma medication adherence compared to those participants in the control group. None of the studies documented a change in asthma-related quality of life or clinical asthma outcomes. All studies in our analysis suggest that reminder systems increase patient medication adherence, but none documented improved clinical outcomes. Further studies with longer intervention durations are needed to assess effects on clinical outcomes, as well as the sustainability of effects on patient adherence.

Bridging the Guideline Implementation Gap: A Systematic, Document-Centered Approach to Guideline Implementation

PubMed Central

Shiffman, Richard N.; Michel, George; Essaihi, Abdelwaheb; Thornquist, Elizabeth

2004-01-01

Objective: A gap exists between the information contained in published clinical practice guidelines and the knowledge and information that are necessary to implement them. This work describes a process to systematize and make explicit the translation of document-based knowledge into workflow-integrated clinical decision support systems. Design: This approach uses the Guideline Elements Model (GEM) to represent the guideline knowledge. Implementation requires a number of steps to translate the knowledge contained in guideline text into a computable format and to integrate the information into clinical workflow. The steps include: (1) selection of a guideline and specific recommendations for implementation, (2) markup of the guideline text, (3) atomization, (4) deabstraction and (5) disambiguation of recommendation concepts, (6) verification of rule set completeness, (7) addition of explanations, (8) building executable statements, (9) specification of origins of decision variables and insertions of recommended actions, (10) definition of action types and selection of associated beneficial services, (11) choice of interface components, and (12) creation of requirement specification. Results: The authors illustrate these component processes using examples drawn from recent experience translating recommendations from the National Heart, Lung, and Blood Institute's guideline on management of chronic asthma into a workflow-integrated decision support system that operates within the Logician electronic health record system. Conclusion: Using the guideline document as a knowledge source promotes authentic translation of domain knowledge and reduces the overall complexity of the implementation task. From this framework, we believe that a better understanding of activities involved in guideline implementation will emerge. PMID:15187061

ClinGen Pathogenicity Calculator: a configurable system for assessing pathogenicity of genetic variants.

PubMed

Patel, Ronak Y; Shah, Neethu; Jackson, Andrew R; Ghosh, Rajarshi; Pawliczek, Piotr; Paithankar, Sameer; Baker, Aaron; Riehle, Kevin; Chen, Hailin; Milosavljevic, Sofia; Bizon, Chris; Rynearson, Shawn; Nelson, Tristan; Jarvik, Gail P; Rehm, Heidi L; Harrison, Steven M; Azzariti, Danielle; Powell, Bradford; Babb, Larry; Plon, Sharon E; Milosavljevic, Aleksandar

2017-01-12

The success of the clinical use of sequencing based tests (from single gene to genomes) depends on the accuracy and consistency of variant interpretation. Aiming to improve the interpretation process through practice guidelines, the American College of Medical Genetics and Genomics (ACMG) and the Association for Molecular Pathology (AMP) have published standards and guidelines for the interpretation of sequence variants. However, manual application of the guidelines is tedious and prone to human error. Web-based tools and software systems may not only address this problem but also document reasoning and supporting evidence, thus enabling transparency of evidence-based reasoning and resolution of discordant interpretations. In this report, we describe the design, implementation, and initial testing of the Clinical Genome Resource (ClinGen) Pathogenicity Calculator, a configurable system and web service for the assessment of pathogenicity of Mendelian germline sequence variants. The system allows users to enter the applicable ACMG/AMP-style evidence tags for a specific allele with links to supporting data for each tag and generate guideline-based pathogenicity assessment for the allele. Through automation and comprehensive documentation of evidence codes, the system facilitates more accurate application of the ACMG/AMP guidelines, improves standardization in variant classification, and facilitates collaborative resolution of discordances. The rules of reasoning are configurable with gene-specific or disease-specific guideline variations (e.g. cardiomyopathy-specific frequency thresholds and functional assays). The software is modular, equipped with robust application program interfaces (APIs), and available under a free open source license and as a cloud-hosted web service, thus facilitating both stand-alone use and integration with existing variant curation and interpretation systems. The Pathogenicity Calculator is accessible at http://calculator.clinicalgenome.org . By enabling evidence-based reasoning about the pathogenicity of genetic variants and by documenting supporting evidence, the Calculator contributes toward the creation of a knowledge commons and more accurate interpretation of sequence variants in research and clinical care.

Systematic data ingratiation of clinical trial recruitment locations for geographic-based query and visualization

PubMed Central

Luo, Jake; Chen, Weiheng; Wu, Min; Weng, Chunhua

2018-01-01

Background Prior studies of clinical trial planning indicate that it is crucial to search and screen recruitment sites before starting to enroll participants. However, currently there is no systematic method developed to support clinical investigators to search candidate recruitment sites according to their interested clinical trial factors. Objective In this study, we aim at developing a new approach to integrating the location data of over one million heterogeneous recruitment sites that are stored in clinical trial documents. The integrated recruitment location data can be searched and visualized using a map-based information retrieval method. The method enables systematic search and analysis of recruitment sites across a large amount of clinical trials. Methods The location data of more than 1.4 million recruitment sites of over 183,000 clinical trials was normalized and integrated using a geocoding method. The integrated data can be used to support geographic information retrieval of recruitment sites. Additionally, the information of over 6000 clinical trial target disease conditions and close to 4000 interventions was also integrated into the system and linked to the recruitment locations. Such data integration enabled the construction of a novel map-based query system. The system will allow clinical investigators to search and visualize candidate recruitment sites for clinical trials based on target conditions and interventions. Results The evaluation results showed that the coverage of the geographic location mapping for the 1.4 million recruitment sites was 99.8%. The evaluation of 200 randomly retrieved recruitment sites showed that the correctness of geographic information mapping was 96.5%. The recruitment intensities of the top 30 countries were also retrieved and analyzed. The data analysis results indicated that the recruitment intensity varied significantly across different countries and geographic areas. Conclusion This study contributed a new data processing framework to extract and integrate the location data of heterogeneous recruitment sites from clinical trial documents. The developed system can support effective retrieval and analysis of potential recruitment sites using target clinical trial factors. PMID:29132636

Systematic data ingratiation of clinical trial recruitment locations for geographic-based query and visualization.

PubMed

Luo, Jake; Chen, Weiheng; Wu, Min; Weng, Chunhua

2017-12-01

Prior studies of clinical trial planning indicate that it is crucial to search and screen recruitment sites before starting to enroll participants. However, currently there is no systematic method developed to support clinical investigators to search candidate recruitment sites according to their interested clinical trial factors. In this study, we aim at developing a new approach to integrating the location data of over one million heterogeneous recruitment sites that are stored in clinical trial documents. The integrated recruitment location data can be searched and visualized using a map-based information retrieval method. The method enables systematic search and analysis of recruitment sites across a large amount of clinical trials. The location data of more than 1.4 million recruitment sites of over 183,000 clinical trials was normalized and integrated using a geocoding method. The integrated data can be used to support geographic information retrieval of recruitment sites. Additionally, the information of over 6000 clinical trial target disease conditions and close to 4000 interventions was also integrated into the system and linked to the recruitment locations. Such data integration enabled the construction of a novel map-based query system. The system will allow clinical investigators to search and visualize candidate recruitment sites for clinical trials based on target conditions and interventions. The evaluation results showed that the coverage of the geographic location mapping for the 1.4 million recruitment sites was 99.8%. The evaluation of 200 randomly retrieved recruitment sites showed that the correctness of geographic information mapping was 96.5%. The recruitment intensities of the top 30 countries were also retrieved and analyzed. The data analysis results indicated that the recruitment intensity varied significantly across different countries and geographic areas. This study contributed a new data processing framework to extract and integrate the location data of heterogeneous recruitment sites from clinical trial documents. The developed system can support effective retrieval and analysis of potential recruitment sites using target clinical trial factors. Copyright © 2017 Elsevier B.V. All rights reserved.

The role, responsibilities and status of the clinical medical physicist in AFOMP.

PubMed

Ng, K H; Cheung, K Y; Hu, Y M; Inamura, K; Kim, H J; Krisanachinda, A; Leung, J; Pradhan, A S; Round, H; van Doomo, T; Wong, T J; Yi, B Y

2009-12-01

This document is the first of a series of policy statements being issued by the Asia-Oceania Federation of Organizations for Medical Physics (AFOMP). The document was developed by the AFOMP Professional Development Committee (PDC) and was endorsed for official release by AFOMP Council in 2006. The main purpose of the document was to give guidance to AFOMP member organizations on the role and responsibilities of clinical medical physicists. A definition of clinical medical physicist has also been provided. This document discusses the following topics: professional aspects of education and training; responsibilities of the clinical medical physicist; status and organization of the clinical medical physics service and the need for clinical medical physics service.

A retrospective review of how nonconformities are expressed and finalized in external inspections of health-care facilities.

PubMed

Hovlid, Einar; Høifødt, Helge; Smedbråten, Bente; Braut, Geir Sverre

2015-09-23

External inspections are widely used in health care as a means of improving the quality of care. However, the way external inspections affect the involved organization is poorly understood. A better understanding of these processes is important to improve our understanding of the varying effects of external inspections in different organizations. In turn, this can contribute to the development of more effective ways of conducting inspections. The way the inspecting organization states their grounds for noncompliant behavior and subsequently follows up to enforce the necessary changes can have implications for the inspected organization's change process. We explore how inspecting organizations express and state their grounds for noncompliant behavior and how they follow up to enforce improvements. We conducted a retrospective review, in which we performed a content analysis of the documents from 36 external inspections in Norway. Our analysis was guided by Donabedian's structure, process, and outcome model. Deficiencies in the management system in combination with clinical work processes was considered as nonconformity by the inspecting organizations. Two characteristic patterns were identified in the way observations led to a statement of nonconformity: one in which it was clearly demonstrated how deficiencies in the management system could affect clinical processes, and one in which this connection was not demonstrated. Two characteristic patterns were also identified in the way the inspecting organization followed up and finalized their inspection: one in which the inspection was finalized solely based on the documented changes in structural deficiencies addressed in the nonconformity statement, and one based on the documented changes in structural and process deficiencies addressed in the nonconformity statement. External inspections are performed to improve the quality of care. To accomplish this aim, we suggest that nonconformities should be grounded by observations that clearly demonstrate how deficiencies in the management system might affect the clinical processes, and that the inspection should be finalized based on documented changes in both structural and process deficiencies addressed in the nonconformity statement.

Terminology Services: Standard Terminologies to Control Health Vocabulary.

PubMed

González Bernaldo de Quirós, Fernán; Otero, Carlos; Luna, Daniel

2018-04-22

Healthcare Information Systems should capture clinical data in a structured and preferably coded format. This is crucial for data exchange between health information systems, epidemiological analysis, quality and research, clinical decision support systems, administrative functions, among others. Structured data entry is an obstacle for the usability of electronic health record (EHR) applications and their acceptance by physicians who prefer to document patient EHRs using "free text". Natural language allows for rich expressiveness but at the same time is ambiguous; it has great dependence on context and uses jargon and acronyms. Although much progress has been made in knowledge and natural language processing techniques, the result is not yet satisfactory enough for the use of free text in all dimensions of clinical documentation. In order to address the trade-off between capturing data with free text and at the same time coding data for computer processing, numerous terminological systems for the systematic recording of clinical data have been developed. The purpose of terminology services consists of representing facts that happen in the real world through database management in order to allow for semantic interoperability and computerized applications. These systems interrelate concepts of a particular domain and provide references to related terms with standards codes. In this way, standard terminologies allow the creation of a controlled medical vocabulary, making terminology services a fundamental component for health data management in the healthcare environment. The Hospital Italiano de Buenos Aires has been working in the development of its own terminology server. This work describes its experience in the field. Georg Thieme Verlag KG Stuttgart.

A decision-support system for the analysis of clinical practice patterns.

PubMed

Balas, E A; Li, Z R; Mitchell, J A; Spencer, D C; Brent, E; Ewigman, B G

1994-01-01

Several studies documented substantial variation in medical practice patterns, but physicians often do not have adequate information on the cumulative clinical and financial effects of their decisions. The purpose of developing an expert system for the analysis of clinical practice patterns was to assist providers in analyzing and improving the process and outcome of patient care. The developed QFES (Quality Feedback Expert System) helps users in the definition and evaluation of measurable quality improvement objectives. Based on objectives and actual clinical data, several measures can be calculated (utilization of procedures, annualized cost effect of using a particular procedure, and expected utilization based on peer-comparison and case-mix adjustment). The quality management rules help to detect important discrepancies among members of the selected provider group and compare performance with objectives. The system incorporates a variety of data and knowledge bases: (i) clinical data on actual practice patterns, (ii) frames of quality parameters derived from clinical practice guidelines, and (iii) rules of quality management for data analysis. An analysis of practice patterns of 12 family physicians in the management of urinary tract infections illustrates the use of the system.

Ubiquitous computing in shared-care environments.

PubMed

Koch, S

2006-07-01

In light of future challenges, such as growing numbers of elderly, increase in chronic diseases, insufficient health care budgets and problems with staff recruitment for the health-care sector, information and communication technology (ICT) becomes a possible means to meet these challenges. Organizational changes such as the decentralization of the health-care system lead to a shift from in-hospital to both advanced and basic home health care. Advanced medical technologies provide solutions for distant home care in form of specialist consultations and home monitoring. Furthermore, the shift towards home health care will increase mobile work and the establishment of shared care teams which require ICT-based solutions that support ubiquitous information access and cooperative work. Clinical documentation and decision support systems are the main ICT-based solutions of interest in the context of ubiquitous computing for shared care environments. This paper therefore describes the prerequisites for clinical documentation and decision support at the point of care, the impact of mobility on the documentation process, and how the introduction of ICT-based solutions will influence organizations and people. Furthermore, the role of dentistry in shared-care environments is discussed and illustrated in the form of a future scenario.

A SOA-Based Solution to Monitor Vaccination Coverage Among HIV-Infected Patients in Liguria.

PubMed

Giannini, Barbara; Gazzarata, Roberta; Sticchi, Laura; Giacomini, Mauro

2016-01-01

Vaccination in HIV-infected patients constitutes an essential tool in the prevention of the most common infectious diseases. The Ligurian Vaccination in HIV Program is a proposed vaccination schedule specifically dedicated to this risk group. Selective strategies are proposed within this program, employing ICT (Information and Communication) tools to identify this susceptible target group, to monitor immunization coverage over time and to manage failures and defaulting. The proposal is to connect an immunization registry system to an existing regional platform that allows clinical data re-use among several medical structures, to completely manage the vaccination process. This architecture will adopt a Service Oriented Architecture (SOA) approach and standard HSSP (Health Services Specification Program) interfaces to support interoperability. According to the presented solution, vaccination administration information retrieved from the immunization registry will be structured according to the specifications within the immunization section of the HL7 (Health Level 7) CCD (Continuity of Care Document) document. Immunization coverage will be evaluated through the continuous monitoring of serology and antibody titers gathered from the hospital LIS (Laboratory Information System) structured into a HL7 Version 3 (v3) Clinical Document Architecture Release 2 (CDA R2).

Save medical personnel's time by improved user interfaces.

PubMed

Kindler, H

1997-01-01

Common objectives in the industrial countries are the improvement of quality of care, clinical effectiveness, and cost control. Cost control, in particular, has been addressed through the introduction of case mix systems for reimbursement by social-security institutions. More data is required to enable quality improvement, increases in clinical effectiveness and for juridical reasons. At first glance, this documentation effort is contradictory to cost reduction. However, integrated services for resource management based on better documentation should help to reduce costs. The clerical effort for documentation should be decreased by providing a co-operative working environment for healthcare professionals applying sophisticated human-computer interface technology. Additional services, e.g., automatic report generation, increase the efficiency of healthcare personnel. Modelling the medical work flow forms an essential prerequisite for integrated resource management services and for co-operative user interfaces. A user interface aware of the work flow provides intelligent assistance by offering the appropriate tools at the right moment. Nowadays there is a trend to client/server systems with relational databases or object-oriented databases as repository. The work flows used for controlling purposes and to steer the user interfaces must be represented in the repository.

Document Exploration and Automatic Knowledge Extraction for Unstructured Biomedical Text

NASA Astrophysics Data System (ADS)

Chu, S.; Totaro, G.; Doshi, N.; Thapar, S.; Mattmann, C. A.; Ramirez, P.

2015-12-01

We describe our work on building a web-browser based document reader with built-in exploration tool and automatic concept extraction of medical entities for biomedical text. Vast amounts of biomedical information are offered in unstructured text form through scientific publications and R&D reports. Utilizing text mining can help us to mine information and extract relevant knowledge from a plethora of biomedical text. The ability to employ such technologies to aid researchers in coping with information overload is greatly desirable. In recent years, there has been an increased interest in automatic biomedical concept extraction [1, 2] and intelligent PDF reader tools with the ability to search on content and find related articles [3]. Such reader tools are typically desktop applications and are limited to specific platforms. Our goal is to provide researchers with a simple tool to aid them in finding, reading, and exploring documents. Thus, we propose a web-based document explorer, which we called Shangri-Docs, which combines a document reader with automatic concept extraction and highlighting of relevant terms. Shangri-Docsalso provides the ability to evaluate a wide variety of document formats (e.g. PDF, Words, PPT, text, etc.) and to exploit the linked nature of the Web and personal content by performing searches on content from public sites (e.g. Wikipedia, PubMed) and private cataloged databases simultaneously. Shangri-Docsutilizes Apache cTAKES (clinical Text Analysis and Knowledge Extraction System) [4] and Unified Medical Language System (UMLS) to automatically identify and highlight terms and concepts, such as specific symptoms, diseases, drugs, and anatomical sites, mentioned in the text. cTAKES was originally designed specially to extract information from clinical medical records. Our investigation leads us to extend the automatic knowledge extraction process of cTAKES for biomedical research domain by improving the ontology guided information extraction process. We will describe our experience and implementation of our system and share lessons learned from our development. We will also discuss ways in which this could be adapted to other science fields. [1] Funk et al., 2014. [2] Kang et al., 2014. [3] Utopia Documents, http://utopiadocs.com [4] Apache cTAKES, http://ctakes.apache.org

XML technologies for the Omaha System: a data model, a Java tool and several case studies supporting home healthcare.

PubMed

Vittorini, Pierpaolo; Tarquinio, Antonietta; di Orio, Ferdinando

2009-03-01

The eXtensible markup language (XML) is a metalanguage which is useful to represent and exchange data between heterogeneous systems. XML may enable healthcare practitioners to document, monitor, evaluate, and archive medical information and services into distributed computer environments. Therefore, the most recent proposals on electronic health records (EHRs) are usually based on XML documents. Since none of the existing nomenclatures were specifically developed for use in automated clinical information systems, but were adapted to such use, numerous current EHRs are organized as a sequence of events, each represented through codes taken from international classification systems. In nursing, a hierarchically organized problem-solving approach is followed, which hardly couples with the sequential organization of such EHRs. Therefore, the paper presents an XML data model for the Omaha System taxonomy, which is one of the most important international nomenclatures used in the home healthcare nursing context. Such a data model represents the formal definition of EHRs specifically developed for nursing practice. Furthermore, the paper delineates a Java application prototype which is able to manage such documents, shows the possibility to transform such documents into readable web pages, and reports several case studies, one currently managed by the home care service of a Health Center in Central Italy.

Building a comprehensive syntactic and semantic corpus of Chinese clinical texts.

PubMed

He, Bin; Dong, Bin; Guan, Yi; Yang, Jinfeng; Jiang, Zhipeng; Yu, Qiubin; Cheng, Jianyi; Qu, Chunyan

2017-05-01

To build a comprehensive corpus covering syntactic and semantic annotations of Chinese clinical texts with corresponding annotation guidelines and methods as well as to develop tools trained on the annotated corpus, which supplies baselines for research on Chinese texts in the clinical domain. An iterative annotation method was proposed to train annotators and to develop annotation guidelines. Then, by using annotation quality assurance measures, a comprehensive corpus was built, containing annotations of part-of-speech (POS) tags, syntactic tags, entities, assertions, and relations. Inter-annotator agreement (IAA) was calculated to evaluate the annotation quality and a Chinese clinical text processing and information extraction system (CCTPIES) was developed based on our annotated corpus. The syntactic corpus consists of 138 Chinese clinical documents with 47,426 tokens and 2612 full parsing trees, while the semantic corpus includes 992 documents that annotated 39,511 entities with their assertions and 7693 relations. IAA evaluation shows that this comprehensive corpus is of good quality, and the system modules are effective. The annotated corpus makes a considerable contribution to natural language processing (NLP) research into Chinese texts in the clinical domain. However, this corpus has a number of limitations. Some additional types of clinical text should be introduced to improve corpus coverage and active learning methods should be utilized to promote annotation efficiency. In this study, several annotation guidelines and an annotation method for Chinese clinical texts were proposed, and a comprehensive corpus with its NLP modules were constructed, providing a foundation for further study of applying NLP techniques to Chinese texts in the clinical domain. Copyright © 2017. Published by Elsevier Inc.

Nursing in the information age: status quo and future of ICT use in German hospitals.

PubMed

Hübner, Ursula; Sellemann, Björn

2004-01-01

Hospital information systems (HIS) should give support to nurses in their clinical and managerial duties. Though there are statistical data on the current use of HIS systems we know only little about the numbers of nursing modules implemented. We therefore conducted a nationwide survey in Germany (n = 2182) on the current state and future plans of HIS modules including nursing applications (response rate of 27.6 %). The findings show that management applications (84 % accounting) are still more frequent than clinical applications, in particular clinical patient record systems (19 %). What applied for HIS modules in general held also true for nursing on a lower level. Whereas 51 % of the hospitals had rostering systems in place only 6 % used care planning software. Priorities and plans for the future reveal no change in the rank order of systems. We argue that in order for clinical documentation and planning systems to catch up they must be immediately rewarding for the clinicians in their daily need for information

Improving clinic- and neighborhood-based smoking cessation services within federally qualified health centers serving low-income, minority neighborhoods.

PubMed

Fisher, Edwin; Musick, Judy; Scott, Catina; Miller, J Philip; Gram, Richard; Richardson, Veronica; Clark, Jane; Pachalla, Vani

2005-04-01

Within federally qualified health centers serving low-income, African American audiences, participatory approaches to system changes were organized through multidisciplinary committees that (a) drew on evidence-based guidelines, (b) guided system changes including the requirement of documenting smoking status and readiness to quit in encounter forms, (c) tested and refined practice improvements prior to their general adoption, and (d) guided development of neighborhood-based resources and supports for smoking cessation that were linked to clinic-based services. Documentation of smoking status or readiness to quit increased from 2% of encounter forms in the first 3 months to 94.3% in the last 3 months of the 24-month program. This rate remained over 90% throughout the following year. Exit interviews also indicated increased key clinic-based services, including "explained importance of quitting" (to 78% and 82% of interview respondents in the two intervention clinics in year 2), "tell you that you should quit" (to 80% in each), "tell you about nicotine gum...or other medications" (to 69% and 58%), "offer to help you quit" (to 61% and 64%), and "tell you about programs or help in your neighborhood" (to 51% and 56%). These rates exceeded those in one comparison clinic and equaled those in a second that also had launched a smoking cessation initiative. From exit interviews, improvements in neighborhood resources and support (e.g., people and activities that encourage nonsmoking) also exceeded those in comparison clinics. Thus, participatory approaches to system changes and quality improvement can enhance clinic- and neighborhood-based smoking cessation services within health centers serving low-income, minority populations.

Classification of forensic autopsy reports through conceptual graph-based document representation model.

PubMed

Mujtaba, Ghulam; Shuib, Liyana; Raj, Ram Gopal; Rajandram, Retnagowri; Shaikh, Khairunisa; Al-Garadi, Mohammed Ali

2018-06-01

Text categorization has been used extensively in recent years to classify plain-text clinical reports. This study employs text categorization techniques for the classification of open narrative forensic autopsy reports. One of the key steps in text classification is document representation. In document representation, a clinical report is transformed into a format that is suitable for classification. The traditional document representation technique for text categorization is the bag-of-words (BoW) technique. In this study, the traditional BoW technique is ineffective in classifying forensic autopsy reports because it merely extracts frequent but discriminative features from clinical reports. Moreover, this technique fails to capture word inversion, as well as word-level synonymy and polysemy, when classifying autopsy reports. Hence, the BoW technique suffers from low accuracy and low robustness unless it is improved with contextual and application-specific information. To overcome the aforementioned limitations of the BoW technique, this research aims to develop an effective conceptual graph-based document representation (CGDR) technique to classify 1500 forensic autopsy reports from four (4) manners of death (MoD) and sixteen (16) causes of death (CoD). Term-based and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) based conceptual features were extracted and represented through graphs. These features were then used to train a two-level text classifier. The first level classifier was responsible for predicting MoD. In addition, the second level classifier was responsible for predicting CoD using the proposed conceptual graph-based document representation technique. To demonstrate the significance of the proposed technique, its results were compared with those of six (6) state-of-the-art document representation techniques. Lastly, this study compared the effects of one-level classification and two-level classification on the experimental results. The experimental results indicated that the CGDR technique achieved 12% to 15% improvement in accuracy compared with fully automated document representation baseline techniques. Moreover, two-level classification obtained better results compared with one-level classification. The promising results of the proposed conceptual graph-based document representation technique suggest that pathologists can adopt the proposed system as their basis for second opinion, thereby supporting them in effectively determining CoD. Copyright © 2018 Elsevier Inc. All rights reserved.

The Role of Documentation Quality in Anesthesia-Related Closed Claims: A Descriptive Qualitative Study.

PubMed

Wilbanks, Bryan A; Geisz-Everson, Marjorie; Boust, Rebecca R

2016-09-01

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

Clinician search behaviors may be influenced by search engine design.

PubMed

Lau, Annie Y S; Coiera, Enrico; Zrimec, Tatjana; Compton, Paul

2010-06-30

Searching the Web for documents using information retrieval systems plays an important part in clinicians' practice of evidence-based medicine. While much research focuses on the design of methods to retrieve documents, there has been little examination of the way different search engine capabilities influence clinician search behaviors. Previous studies have shown that use of task-based search engines allows for faster searches with no loss of decision accuracy compared with resource-based engines. We hypothesized that changes in search behaviors may explain these differences. In all, 75 clinicians (44 doctors and 31 clinical nurse consultants) were randomized to use either a resource-based or a task-based version of a clinical information retrieval system to answer questions about 8 clinical scenarios in a controlled setting in a university computer laboratory. Clinicians using the resource-based system could select 1 of 6 resources, such as PubMed; clinicians using the task-based system could select 1 of 6 clinical tasks, such as diagnosis. Clinicians in both systems could reformulate search queries. System logs unobtrusively capturing clinicians' interactions with the systems were coded and analyzed for clinicians' search actions and query reformulation strategies. The most frequent search action of clinicians using the resource-based system was to explore a new resource with the same query, that is, these clinicians exhibited a "breadth-first" search behaviour. Of 1398 search actions, clinicians using the resource-based system conducted 401 (28.7%, 95% confidence interval [CI] 26.37-31.11) in this way. In contrast, the majority of clinicians using the task-based system exhibited a "depth-first" search behavior in which they reformulated query keywords while keeping to the same task profiles. Of 585 search actions conducted by clinicians using the task-based system, 379 (64.8%, 95% CI 60.83-68.55) were conducted in this way. This study provides evidence that different search engine designs are associated with different user search behaviors.

Pharmaceutical liposomal drug delivery: a review of new delivery systems and a look at the regulatory landscape.

PubMed

Zylberberg, Claudia; Matosevic, Sandro

2016-11-01

Liposomes were the first nanoscale drug to be approved for clinical use in 1995. Since then, the technology has grown considerably, and pioneering recent work in liposome-based delivery systems has brought about remarkable developments with significant clinical implications. This includes long-circulating liposomes, stimuli-responsive liposomes, nebulized liposomes, elastic liposomes for topical, oral and transdermal delivery and covalent lipid-drug complexes for improved drug plasma membrane crossing and targeting to specific organelles. While the regulatory bodies' opinion on liposomes is well-documented, current guidance that address new delivery systems are not. This review describes, in depth, the current state-of-the-art of these new liposomal delivery systems and provides a critical overview of the current regulatory landscape surrounding commercialization efforts of higher-level complexity systems, the expected requirements and the hurdles faced by companies seeking to bring novel liposome-based systems for clinical use to market.

Stakeholder Participation in System Change: A New Conceptual Model.

PubMed

O'Rourke, Tammy; Higuchi, Kathryn S; Hogg, William

2016-08-01

A recent change in Canada's primary care system led to the introduction of Nurse Practitioner-Led clinics. The literature suggests that stakeholders can influence system change initiatives. However, very little is known about healthcare stakeholder motivations, particularly stakeholders who are seen as resistors to change. To examine stakeholder participation in the system change process that led to the introduction of the first Nurse Practitioner-Led clinic in Ontario. This single case study included two site visits, semistructured individual tape-recorded interviews, and the examination of relevant public documents. Qualitative content analysis was used to analyze the data. Sixteen individuals from different healthcare sectors and professions participated in the interviews and 20 documents were reviewed. Six key themes emerged from the data. Linking Evidence to Action The findings from the study present a new perspective on stakeholder participation that includes both those who supported the proposed change and those who advocated for a different change. The findings identify stakeholder activities used to shape, share, and protect their visions for system change. The conceptual model presented in this study adds to the understanding of challenges and complexities involved in healthcare system change. Understanding why and how stakeholders participate in change can help healthcare leaders in planning activities to enhance stakeholder involvement in healthcare system change. © 2016 Sigma Theta Tau International.

[Computer graphic display of retinal examination results. Software improving the quality of documenting fundus changes].

PubMed

Jürgens, Clemens; Grossjohann, Rico; Czepita, Damian; Tost, Frank

2009-01-01

Graphic documentation of retinal examination results in clinical ophthalmological practice is often depicted using pictures or in handwritten form. Popular software products used to describe changes in the fundus do not vary much from simple graphic programs that enable to insert, scale and edit basic graphic elements such as: a circle, rectangle, arrow or text. Displaying the results of retinal examinations in a unified way is difficult to achieve. Therefore, we devised and implemented modern software tools for this purpose. A computer program enabling to quickly and intuitively form graphs of the fundus, that can be digitally archived or printed was created. Especially for the needs of ophthalmological clinics, a set of standard digital symbols used to document the results of retinal examinations was developed and installed in a library of graphic symbols. These symbols are divided into the following categories: preoperative, postoperative, neovascularization, retinopathy of prematurity. The appropriate symbol can be selected with a click of the mouse and dragged-and-dropped on the canvas of the fundus. Current forms of documenting results of retinal examinations are unsatisfactory, due to the fact that they are time consuming and imprecise. Unequivocal interpretation is difficult or in some cases impossible. Using the developed computer program a sketch of the fundus can be created much more quickly than by hand drawing. Additionally the quality of the medica documentation using a system of well described and standardized symbols will be enhanced. (1) Graphic symbols used to document the results of retinal examinations are a part of everyday clinical practice. (2) The designed computer program will allow quick and intuitive graphical creation of fundus sketches that can be either digitally archived or printed.

Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation.

PubMed

Shoolin, J; Ozeran, L; Hamann, C; Bria, W

2013-01-01

In 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of 'note bloat'. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display.

A Three-Phase Decision Model of Computer-Aided Coding for the Iranian Classification of Health Interventions (IRCHI).

PubMed

Azadmanjir, Zahra; Safdari, Reza; Ghazisaeedi, Marjan; Mokhtaran, Mehrshad; Kameli, Mohammad Esmail

2017-06-01

Accurate coded data in the healthcare are critical. Computer-Assisted Coding (CAC) is an effective tool to improve clinical coding in particular when a new classification will be developed and implemented. But determine the appropriate method for development need to consider the specifications of existing CAC systems, requirements for each type, our infrastructure and also, the classification scheme. The aim of the study was the development of a decision model for determining accurate code of each medical intervention in Iranian Classification of Health Interventions (IRCHI) that can be implemented as a suitable CAC system. first, a sample of existing CAC systems was reviewed. Then feasibility of each one of CAC types was examined with regard to their prerequisites for their implementation. The next step, proper model was proposed according to the structure of the classification scheme and was implemented as an interactive system. There is a significant relationship between the level of assistance of a CAC system and integration of it with electronic medical documents. Implementation of fully automated CAC systems is impossible due to immature development of electronic medical record and problems in using language for medical documenting. So, a model was proposed to develop semi-automated CAC system based on hierarchical relationships between entities in the classification scheme and also the logic of decision making to specify the characters of code step by step through a web-based interactive user interface for CAC. It was composed of three phases to select Target, Action and Means respectively for an intervention. The proposed model was suitable the current status of clinical documentation and coding in Iran and also, the structure of new classification scheme. Our results show it was practical. However, the model needs to be evaluated in the next stage of the research.

Usability Evaluation of an Unstructured Clinical Document Query Tool for Researchers.

PubMed

Hultman, Gretchen; McEwan, Reed; Pakhomov, Serguei; Lindemann, Elizabeth; Skube, Steven; Melton, Genevieve B

2018-01-01

Natural Language Processing - Patient Information Extraction for Researchers (NLP-PIER) was developed for clinical researchers for self-service Natural Language Processing (NLP) queries with clinical notes. This study was to conduct a user-centered analysis with clinical researchers to gain insight into NLP-PIER's usability and to gain an understanding of the needs of clinical researchers when using an application for searching clinical notes. Clinical researcher participants (n=11) completed tasks using the system's two existing search interfaces and completed a set of surveys and an exit interview. Quantitative data including time on task, task completion rate, and survey responses were collected. Interviews were analyzed qualitatively. Survey scores, time on task and task completion proportions varied widely. Qualitative analysis indicated that participants found the system to be useful and usable in specific projects. This study identified several usability challenges and our findings will guide the improvement of NLP-PIER 's interfaces.

Natural language processing and the representation of clinical data.

PubMed Central

Sager, N; Lyman, M; Bucknall, C; Nhan, N; Tick, L J

1994-01-01

OBJECTIVE: Develop a representation of clinical observations and actions and a method of processing free-text patient documents to facilitate applications such as quality assurance. DESIGN: The Linguistic String Project (LSP) system of New York University utilizes syntactic analysis, augmented by a sublanguage grammar and an information structure that are specific to the clinical narrative, to map free-text documents into a database for querying. MEASUREMENTS: Information precision (I-P) and information recall (I-R) were measured for queries for the presence of 13 asthma-health-care quality assurance criteria in a database generated from 59 discharge letters. RESULTS: I-P, using counts of major errors only, was 95.7% for the 28-letter training set and 98.6% for the 31-letter test set. I-R, using counts of major omissions only, was 93.9% for the training set and 92.5% for the test set. PMID:7719796

EHR Documentation: The Hype and the Hope for Improving Nursing Satisfaction and Quality Outcomes.

PubMed

OʼBrien, Ann; Weaver, Charlotte; Settergren, Theresa Tess; Hook, Mary L; Ivory, Catherine H

2015-01-01

The phenomenon of "data rich, information poor" in today's electronic health records (EHRs) is too often the reality for nursing. This article proposes the redesign of nursing documentation to leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing care across the continuum. The principles consider the need to optimize nurses' documentation efficiency while contributing to knowledge generation. The nursing process must be supported by EHRs through integration of best care practices: seamless workflows that display the right tools, evidence-based content, and information at the right time for optimal clinical decision making. Design of EHR documentation must attain a balance that ensures the capture of nursing's impact on safety, quality, highly reliable care, patient engagement, and satisfaction, yet minimizes "death by data entry." In 2014, a group of diverse informatics leaders from practice, academia, and the vendor community formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. As our health care system moves toward reimbursement on the basis of quality outcomes and prevention, the value of nursing data in this business proposition will become a key differentiator for health care organizations' economic success.

SFINX-a drug-drug interaction database designed for clinical decision support systems.

PubMed

Böttiger, Ylva; Laine, Kari; Andersson, Marine L; Korhonen, Tuomas; Molin, Björn; Ovesjö, Marie-Louise; Tirkkonen, Tuire; Rane, Anders; Gustafsson, Lars L; Eiermann, Birgit

2009-06-01

The aim was to develop a drug-drug interaction database (SFINX) to be integrated into decision support systems or to be used in website solutions for clinical evaluation of interactions. Key elements such as substance properties and names, drug formulations, text structures and references were defined before development of the database. Standard operating procedures for literature searches, text writing rules and a classification system for clinical relevance and documentation level were determined. ATC codes, CAS numbers and country-specific codes for substances were identified and quality assured to ensure safe integration of SFINX into other data systems. Much effort was put into giving short and practical advice regarding clinically relevant drug-drug interactions. SFINX includes over 8,000 interaction pairs and is integrated into Swedish and Finnish computerised decision support systems. Over 31,000 physicians and pharmacists are receiving interaction alerts through SFINX. User feedback is collected for continuous improvement of the content. SFINX is a potentially valuable tool delivering instant information on drug interactions during prescribing and dispensing.

Future of electronic health records: implications for decision support.

PubMed

Rothman, Brian; Leonard, Joan C; Vigoda, Michael M

2012-01-01

The potential benefits of the electronic health record over traditional paper are many, including cost containment, reductions in errors, and improved compliance by utilizing real-time data. The highest functional level of the electronic health record (EHR) is clinical decision support (CDS) and process automation, which are expected to enhance patient health and healthcare. The authors provide an overview of the progress in using patient data more efficiently and effectively through clinical decision support to improve health care delivery, how decision support impacts anesthesia practice, and how some are leading the way using these systems to solve need-specific issues. Clinical decision support uses passive or active decision support to modify clinician behavior through recommendations of specific actions. Recommendations may reduce medication errors, which would result in considerable savings by avoiding adverse drug events. In selected studies, clinical decision support has been shown to decrease the time to follow-up actions, and prediction has proved useful in forecasting patient outcomes, avoiding costs, and correctly prompting treatment plan modifications by clinicians before engaging in decision-making. Clinical documentation accuracy and completeness is improved by an electronic health record and greater relevance of care data is delivered. Clinical decision support may increase clinician adherence to clinical guidelines, but educational workshops may be equally effective. Unintentional consequences of clinical decision support, such as alert desensitization, can decrease the effectiveness of a system. Current anesthesia clinical decision support use includes antibiotic administration timing, improved documentation, more timely billing, and postoperative nausea and vomiting prophylaxis. Electronic health record implementation offers data-mining opportunities to improve operational, financial, and clinical processes. Using electronic health record data in real-time for decision support and process automation has the potential to both reduce costs and improve the quality of patient care. © 2012 Mount Sinai School of Medicine.

Outcomes of Computerized Physician Order Entry in an Electronic Health Record After Implementation in an Outpatient Oncology Setting

PubMed Central

Harshberger, Cara A.; Harper, Abigail J.; Carro, George W.; Spath, Wayne E.; Hui, Wendy C.; Lawton, Jessica M.; Brockstein, Bruce E.

2011-01-01

Purpose: Computerized physician order entry (CPOE) in electronic health records (EHR) has been recognized as an important tool in optimal health care provision that can reduce errors and improve safety. The objective of this study is to describe documentation completeness and user satisfaction of medical charts before and after implementation of an outpatient oncology EHR/ CPOE system in a hospital-based outpatient cancer center within three treatment sites. Methods: This study is a retrospective chart review of 90 patients who received one of the following regimens between 1999 and 2006: FOLFOX, AC, carboplatin + paclitaxel, ABVD, cisplatin + etoposide, R-CHOP, and clinical trials. Documentation completeness scores were assigned to each chart based on the number of documented data points found out of the total data points assessed. EHR/CPOE documentation completeness was compared with completeness of paper charts orders of the same regimens. A user satisfaction survey of the paper chart and EHR/CPOE system was conducted among the physicians, nurses, and pharmacists who worked with both systems. Results: The mean percentage of identified data points successfully found in the EHR/CPOE charts was 93% versus 67% in the paper charts (P < .001). Regimen complexity did not alter the number of data points found. The survey response rate was 64%, and the results showed that satisfaction was statistically significant in favor of the EHR/CPOE system. Conclusion: Using EHR/CPOE systems improves completeness of medical record and chemotherapy order documentation and improves user satisfaction with the medical record system. EHR/CPOE requires constant vigilance and maintenance to optimize patient safety. PMID:22043187

Clinical dashboards: impact on workflow, care quality, and patient safety.

PubMed

Egan, Marie

2006-01-01

There is a vast array of technical data that is continuously generated within the intensive care unit environment. In addition to physiological monitors, there is information being captured by the ventilator, intravenous infusion pumps, medication dispensing units, and even the patient's bed. The ability to retrieve and synchronize data is essential for both clinical documentation and real-time problem solving for individual patients and the intensive care unit population as a whole. Technical advances that permit the integration of all relevant data into a singular display or "dashboard" may improve staff efficiency, accelerate decisions, streamline workflow processes, and reduce oversights and errors in clinical practice. Critical care nurses must coordinate all aspects of care for one or more patients. Clinical data are constantly being retrieved, documented, analyzed, and communicated to others, all within the daily routine of nursing care. In addition, many bedside monitors and devices have alarms systems that must be evaluated throughout the workday, and actions taken on the basis of the patient's condition and other data. It is obvious that the complexity within such care processes presents many potential opportunities for overlooking important details. The capability to systematically and logically link physiological monitors and other selected data sets into a cohesive dashboard system holds tremendous promise for improving care quality, patient safety, and clinical outcomes in the intensive care unit.

XML syntax for clinical laboratory procedure manuals.

PubMed

Saadawi, Gilan; Harrison, James H

2003-01-01

We have developed a document type description (DTD) in Extensable Markup Language (XML) for clinical laboratory procedures. Our XML syntax can adequately structure a variety of procedure types across different laboratories and is compatible with current procedure standards. The combination of this format with an XML content management system and appropriate style sheets will allow efficient procedure maintenance, distributed access, customized display and effective searching across a large body of test information.

[Problem list in computer-based patient records].

PubMed

Ludwig, C A

1997-01-14

Computer-based clinical information systems are capable of effectively processing even large amounts of patient-related data. However, physicians depend on rapid access to summarized, clearly laid out data on the computer screen to inform themselves about a patient's current clinical situation. In introducing a clinical workplace system, we therefore transformed the problem list-which for decades has been successfully used in clinical information management-into an electronic equivalent and integrated it into the medical record. The table contains a concise overview of diagnoses and problems as well as related findings. Graphical information can also be integrated into the table, and an additional space is provided for a summary of planned examinations or interventions. The digital form of the problem list makes it possible to use the entire list or selected text elements for generating medical documents. Diagnostic terms for medical reports are transferred automatically to corresponding documents. Computer technology has an immense potential for the further development of problem list concepts. With multimedia applications sound and images will be included in the problem list. For hyperlink purpose the problem list could become a central information board and table of contents of the medical record, thus serving as the starting point for database searches and supporting the user in navigating through the medical record.

Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey.

PubMed

Johnson, Kevin B; Ravich, William J; Cowan, John A

2004-09-01

Computer-based software to record histories, physical exams, and progress or procedure notes, known as computer-based documentation (CBD) software, has been touted as an important addition to the electronic health record. The functionality of CBD systems has remained static over the past 30 years, which may have contributed to the limited adoption of these tools. Early users of this technology, who have tried multiple products, may have insight into important features to be considered in next-generation CBD systems. We conducted a cross-sectional, observational study of the clinical working group membership of the American Medical Informatics Association (AMIA) to generate a set of features that might improve adoption of next-generation systems. The study was conducted online over a 4-month period; 57% of the working group members completed the survey. As anticipated, CBD tool use was higher (53%) in this population than in the US physician offices. The most common methods of data entry employed keyboard and mouse, with agreement that these modalities worked well. Many respondents had experience with pre-printed data collection forms before interacting with a CBD system. Respondents noted that CBD improved their ability to document large amounts of information, allowed timely sharing of information, enhanced patient care, and enhanced medical information with other clinicians (all P < 0.001). Respondents also noted some important but absent features in CBD, including the ability to add images, get help, and generate billing information. The latest generation of CBD systems is being used successfully by early adopters, who find that these tools confer many advantages over the approaches to documentation that they replaced. These users provide insights that may improve successive generations of CBD tools. Additional surveys of CBD non-users and failed adopters will be necessary to provide other useful insights that can address barriers to the adoption of CBD by less computer literate physicians.

Variations in the implementation and characteristics of chiropractic services in VA.

PubMed

Lisi, Anthony J; Khorsan, Raheleh; Smith, Monica M; Mittman, Brian S

2014-12-01

In 2004, the US Department of Veterans Affairs expanded its delivery of chiropractic care by establishing onsite chiropractic clinics at select facilities across the country. Systematic information regarding the planning and implementation of these clinics and describing their features and performance is lacking. To document the planning, implementation, key features and performance of VA chiropractic clinics, and to identify variations and their underlying causes and key consequences as well as their implications for policy, practice, and research on the introduction of new clinical services into integrated health care delivery systems. Comparative case study of 7 clinics involving site visit-based and telephone-based interviews with 118 key stakeholders, including VA clinicians, clinical leaders and administrative staff, and selected external stakeholders, as well as reviews of key documents and administrative data on clinic performance and service delivery. Interviews were recorded, transcribed, and analyzed using a mixed inductive (exploratory) and deductive approach. Interview data revealed considerable variations in clinic planning and implementation processes and clinic features, as well as perceptions of clinic performance and quality. Administrative data showed high variation in patterns of clinic patient care volume over time. A facility's initial willingness to establish a chiropractic clinic, along with a higher degree of perceived evidence-based and collegial attributes of the facility chiropractor, emerged as key factors associated with higher and more consistent delivery of chiropractic services and higher perceived quality of those services.

Communication and the laboratory physician

PubMed Central

Penistan, J. L.

1973-01-01

A clinical laboratory documentation system is described, suitable for community hospitals without computer services. The system is cumulative and is designed to provide the laboratory physician with the clinical information necessary for intelligent review and comment on the laboratory's findings. The mode of presentation of requests to the laboratory and lay-out of the reports to the clinicians are designed to make the two-way communication as close and personal as possible; to encourage the selection of those investigations likely to prove rewarding, and to discourage unnecessary investigation. The possibility of important data escaping notice is minimized. The system is economical in capital equipment, labour and supplies. PMID:4758594

Patient-generated Digital Images after Pediatric Ambulatory Surgery.

PubMed

Miller, Matthew W; Ross, Rachael K; Voight, Christina; Brouwer, Heather; Karavite, Dean J; Gerber, Jeffrey S; Grundmeier, Robert W; Coffin, Susan E

2016-07-06

To describe the use of digital images captured by parents or guardians and sent to clinicians for assessment of wounds after pediatric ambulatory surgery. Subjects with digital images of post-operative wounds were identified as part of an on-going cohort study of infections after ambulatory surgery within a large pediatric healthcare system. We performed a structured review of the electronic health record (EHR) to determine how digital images were documented in the EHR and used in clinical care. We identified 166 patients whose parent or guardian reported sending a digital image of the wound to the clinician after surgery. A corresponding digital image was located in the EHR in only 121 of these encounters. A change in clinical management was documented in 20% of these encounters, including referral for in-person evaluation of the wound and antibiotic prescription. Clinical teams have developed ad hoc workflows to use digital images to evaluate post-operative pediatric surgical patients. Because the use of digital images to support follow-up care after ambulatory surgery is likely to increase, it is important that high-quality images are captured and documented appropriately in the EHR to ensure privacy, security, and a high-level of care.

Patient-Generated Digital Images after Pediatric Ambulatory Surgery

PubMed Central

Ross, Rachael K.; Voight, Christina; Brouwer, Heather; Karavite, Dean J.; Gerber, Jeffrey S.; Grundmeier, Robert W.; Coffin, Susan E.

2016-01-01

Summary Objective To describe the use of digital images captured by parents or guardians and sent to clinicians for assessment of wounds after pediatric ambulatory surgery. Methods Subjects with digital images of post-operative wounds were identified as part of an ongoing cohort study of infections after ambulatory surgery within a large pediatric healthcare system. We performed a structured review of the electronic health record (EHR) to determine how digital images were documented in the EHR and used in clinical care. Results We identified 166 patients whose parent or guardian reported sending a digital image of the wound to the clinician after surgery. A corresponding digital image was located in the EHR in only 121 of these encounters. A change in clinical management was documented in 20% of these encounters, including referral for in-person evaluation of the wound and antibiotic prescription. Conclusion Clinical teams have developed ad hoc workflows to use digital images to evaluate post-operative pediatric surgical patients. Because the use of digital images to support follow-up care after ambulatory surgery is likely to increase, it is important that high-quality images are captured and documented appropriately in the EHR to ensure privacy, security, and a high-level of care. PMID:27452477

Completeness of patient records in community pharmacies post-discharge after in-patient medication reconciliation: a before-after study.

PubMed

Karapinar-Çarkıt, Fatma; van Breukelen, Ben R L; Borgsteede, Sander D; Janssen, Marjo J A; Egberts, Antoine C G; van den Bemt, Patricia M L A

2014-08-01

Transfer of discharge medication related information to community pharmacies could improve continuity of care. This requires for community pharmacies to accurately update their patient records when new information is transferred. An instruction manual that specifies how to document information regarding medication changes and clinical information (i.e. allergies/contraindications) could support community pharmacies. To explore the effect of instruction manuals sent to community pharmacies on completeness of their patient records. A before-after study was performed (July 2009-August 2010) in the St Lucas Andreas Hospital, a general teaching hospital in Amsterdam, The Netherlands. Patients discharged from the cardiology and respiratory ward were included consecutively. The intervention consisted of a training session for community pharmacies regarding documentation problems and faxing an instruction manual to community pharmacies specifying how to document discharge information in their information system. Usual care consisted of faxing a discharge medication overview to community pharmacies without additional instructions. Two weeks after discharge the medication records of community pharmacies were collected by fax. These were compared with the initial discharge overviews regarding completeness of medication changes (i.e. explicit explanation that medication had been changed) and clinical information documentation. MAIN OUTCOME MEASURE OUTCOMES: were the number and percentage of completely documented medication changes (either needing to be dispensed or not) and clinical information items. The sample size was calculated at 107 patients per measurement period. Multivariable logistic regression was used for analysis. Two hundred and eighteen patients (112 before-106 after) were included. Completeness of medication changes documentation increased marginally after the intervention (46.6 vs 56.3 %, adjusted Odds Ratio 1.4 [95 % confidence interval 1.07-1.83]). Documentation increased when medication was actually dispensed by the community pharmacy. No significant improvements were seen for allergy and contraindication documentation. The intervention is insufficient to increase the completeness of documentation by community pharmacies as marginal improvements were achieved. Future studies should evaluate whether electronic infrastructures may help in achieving updated medication records to improve continuity of pharmaceutical care.

Variability in the quality of overdose advice in Summary of Product Characteristics (SPC) documents: gut decontamination recommendations for CNS drugs.

PubMed

Wall, Andrew J B; Bateman, D N; Waring, W S

2009-01-01

Deliberate self-poisoning is a major cause of morbidity and mortality. The Summary of Product Characteristics (SPC) document is a legal requirement for all drugs, and Section 4.9 addresses the features of toxicity and clinical advice on management of overdose. The quality and appropriateness of this advice have received comparatively little attention. Section 4.9 of the SPC was examined for all drugs in the central nervous system (CNS) category of the British National Formulary. Advice concerning gut decontamination was examined with respect to specific interventions: induced vomiting, oral activated charcoal, gastric lavage, and other interventions. Data were compared with standard reference sources for clinical management advice in poisoning. These were graded 'A' if no important differences existed, 'B' if differences were noted but not thought clinically important, and 'C' if differences were thought to be clinically significant. SPC documents were examined for 258 medications from 67 manufacturers. The overall agreement was 'A' in 23 (8.9%), 'B' in 28 (10.9%) and 'C' in 207 (80.2%). Discrepancies were due to inappropriate recommendation of induced emesis in 21.7% (95% confidence interval 17.1, 27.1), gastric lavage in 38.4% (32.7, 44.4), other gut decontamination in 5.8% (3.6, 9.4) and failure to recommend oral activated charcoal in 57.4% (51.1, 63.4). Gut decontamination advice in SPC documents with respect to CNS drugs was inadequate. Possible reasons for the observed discrepancies and ways of improving the consistency of advice are proposed.

The cardiovascular and cardiac actions of ecstasy and its metabolites.

PubMed

Shenouda, S K; Carvalho, F; Varner, K J

2010-08-01

The recreational use of 3, 4 methylenedioxymethamphetamine (ecstasy or MDMA) has increased dramatically over the past thirty years due to its ability to increase stamina and produce feelings of emotional closeness and wellbeing. In spite of the popular perception that MDMA is a safe drug, there is a large literature documenting that the drug can produce significant neurotoxicity, especially in serotonergic and catecholaminergic systems. There are also experimental and clinical data which document that MDMA can alter cardiovascular function and produce cardiac toxicity, including rhythm disturbances, infarction and sudden death. This manuscript will review the literature documenting the cardiovascular responses elicited by MDMA in humans and experimental animals and will examine the underlying mechanisms mediating these responses. We will also review the available clinical, autopsy and experimental data linking MDMA with cardiac toxicity. Most available data indicate that oxidative stress plays an important role in the cardiotoxic actions of MDMA. Moreover, new data indicates that redox active metabolites of MDMA may play especially important roles in MDMA induced toxicity.

Automatic de-identification of French clinical records: comparison of rule-based and machine-learning approaches.

PubMed

Grouin, Cyril; Zweigenbaum, Pierre

2013-01-01

In this paper, we present a comparison of two approaches to automatically de-identify medical records written in French: a rule-based system and a machine-learning based system using a conditional random fields (CRF) formalism. Both systems have been designed to process nine identifiers in a corpus of medical records in cardiology. We performed two evaluations: first, on 62 documents in cardiology, and on 10 documents in foetopathology - produced by optical character recognition (OCR) - to evaluate the robustness of our systems. We achieved a 0.843 (rule-based) and 0.883 (machine-learning) exact match overall F-measure in cardiology. While the rule-based system allowed us to achieve good results on nominative (first and last names) and numerical data (dates, phone numbers, and zip codes), the machine-learning approach performed best on more complex categories (postal addresses, hospital names, medical devices, and towns). On the foetopathology corpus, although our systems have not been designed for this corpus and despite OCR character recognition errors, we obtained promising results: a 0.681 (rule-based) and 0.638 (machine-learning) exact-match overall F-measure. This demonstrates that existing tools can be applied to process new documents of lower quality.

An Internationally Consented Standard for Nursing Process-Clinical Decision Support Systems in Electronic Health Records.

PubMed

Müller-Staub, Maria; de Graaf-Waar, Helen; Paans, Wolter

2016-11-01

Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named Advanced Nursing Process. It contains valid assessments, nursing diagnoses, interventions, and nursing-sensitive patient outcomes. Electronic decision support systems can assist nurses to apply the Advanced Nursing Process. However, nursing decision support systems are missing, and no "gold standard" is available. The study aim is to develop a valid Nursing Process-Clinical Decision Support System Standard to guide future developments of clinical decision support systems. In a multistep approach, a Nursing Process-Clinical Decision Support System Standard with 28 criteria was developed. After pilot testing (N = 29 nurses), the criteria were reduced to 25. The Nursing Process-Clinical Decision Support System Standard was then presented to eight internationally known experts, who performed qualitative interviews according to Mayring. Fourteen categories demonstrate expert consensus on the Nursing Process-Clinical Decision Support System Standard and its content validity. All experts agreed the Advanced Nursing Process should be the centerpiece for the Nursing Process-Clinical Decision Support System and should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes.

[Trauma and accident documentation in Germany compared with elsewhere in Europe].

PubMed

Probst, C; Richter, M; Haasper, C; Lefering, R; Otte, D; Oestern, H J; Krettek, C; Hüfner, T

2008-07-01

The role of trauma documentation has grown continuously since the 1970s. Prevention and management of injuries were adapted according to the results of many analyses. Since 1993 there have been two different trauma databases in Germany: the German trauma registry (TR) and the database of the Accident Research Unit (UFO). Modern computer applications improved the data processing. Our study analysed the pros and cons of each system and compared them with those of our European neighbours. We compared the TR and the UFO databases with respect to aims and goals, advantages and disadvantages, and current status. Results were reported as means +/- standard errors of the mean. The level of significance was set at P<0.05. There were differences between the two databases concerning number and types of items, aims and goals, and demographics. The TR documents care for severely injured patients and the clinical course of different types of accidents. The UFO describes traffic accidents, accident conditions, and interrelations. The German and British systems are similar, and the French system shows interesting differences. The German trauma documentation systems focus on different points. Therefore both can be used for substantiated analyses of different hypotheses. Certain intersections of both databases may help to answer very special questions in the future.

Clinical Nursing Records Study

DTIC Science & Technology

1991-08-01

In-depth assessment of current AMEDD nursing documentation system used in fixed facilities; 2 - 4) development, implementation and assessment of...used in fixed facilities to: a) identify system problems; b) identify potential solutions to problems; c) set priorities fc problem resolution; d...enhance compatibility between any " hard copy" forms the group might develop and automation requirements. Discussions were also held with personnel from

Use of a remote clinical decision support service for a multicenter trial to implement prediction rules for children with minor blunt head trauma.

PubMed

Goldberg, Howard S; Paterno, Marilyn D; Grundmeier, Robert W; Rocha, Beatriz H; Hoffman, Jeffrey M; Tham, Eric; Swietlik, Marguerite; Schaeffer, Molly H; Pabbathi, Deepika; Deakyne, Sara J; Kuppermann, Nathan; Dayan, Peter S

2016-03-01

To evaluate the architecture, integration requirements, and execution characteristics of a remote clinical decision support (CDS) service used in a multicenter clinical trial. The trial tested the efficacy of implementing brain injury prediction rules for children with minor blunt head trauma. We integrated the Epic(®) electronic health record (EHR) with the Enterprise Clinical Rules Service (ECRS), a web-based CDS service, at two emergency departments. Patterns of CDS review included either a delayed, near-real-time review, where the physician viewed CDS recommendations generated by the nursing assessment, or a real-time review, where the physician viewed recommendations generated by their own documentation. A backstopping, vendor-based CDS triggered with zero delay when no recommendation was available in the EHR from the web-service. We assessed the execution characteristics of the integrated system and the source of the generated recommendations viewed by physicians. The ECRS mean execution time was 0.74 ±0.72 s. Overall execution time was substantially different at the two sites, with mean total transaction times of 19.67 and 3.99 s. Of 1930 analyzed transactions from the two sites, 60% (310/521) of all physician documentation-initiated recommendations and 99% (1390/1409) of all nurse documentation-initiated recommendations originated from the remote web service. The remote CDS system was the source of recommendations in more than half of the real-time cases and virtually all the near-real-time cases. Comparisons are limited by allowable variation in user workflow and resolution of the EHR clock. With maturation and adoption of standards for CDS services, remote CDS shows promise to decrease time-to-trial for multicenter evaluations of candidate decision support interventions. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Contraceptive Provision in the VA Healthcare System to Women Who Report Military Sexual Trauma

PubMed Central

Mattocks, Kristin; Schwarz, Eleanor Bimla; Borrero, Sonya; Skanderson, Melissa; Zephyrin, Laurie; Brandt, Cynthia; Haskell, Sally

2014-01-01

Abstract Background: Women Veterans who suffered military sexual trauma (MST) may be at high risk for unintended pregnancy and benefit from contraceptive services. The objective of this study is to compare documented provision of contraceptives to women Veterans using the Department of Veterans Affairs (VA) health system who report or deny MST. Methods: This retrospective cohort study included women Veterans aged 18–45 years who served in Operation Enduring or Iraqi Freedom and had at least one visit to a VA medical center between 2002 and 2010. Data were obtained from VA administrative and clinical databases. Chi-squared tests and logistic regression were conducted to evaluate the association between MST, ascertained by routine clinical screening, and first documented receipt of hormonal or long-acting contraception. Results: Of 68,466 women Veterans, 13% reported, 59% denied and 28% had missing data for the MST screen. Among the entire study cohort, 30% of women had documented receipt of a contraceptive method. Women reporting MST were significantly more likely than those denying MST to receive a method of contraception (adjusted odds ratio [aOR] 1.12, 95% confidence interval [CI] 1.07–1.18) including an intrauterine device (odds ratio [OR] 1.29, 95% CI 1.17–1.41) or contraceptive injection (OR 1.17, 95% CI 1.05–1.29). Women who were younger, unmarried, seen at a women's health clinic, or who had more than one visit were more likely to receive contraception. Conclusions: A minority of women Veterans of reproductive age receive contraceptive services from the VA. Women Veterans who report MST, and particularly those who seek care at VA women's health clinics, are more likely to receive contraception. PMID:24787680

An electronic registry for physiotherapists in Belgium.

PubMed

Buyl, Ronald; Nyssen, Marc

2008-01-01

This paper describes the results of the KINELECTRICS project. Since more and more clinical documents are stored and transmitted in an electronic way, the aim of this project was to design an electronic version of the registry that contains all acts of physiotherapists. The solution we present here, not only meets all legal constraints, but also enables to verify the traceability and inalterability of the generated documents, by means of SHA-256 codes. The proposed structure, using XML technology can also form a basis for the development of tools that can be used by the controlling authorities. By means of a certification procedure for software systems, we succeeded in developing a user friendly system that enables end-users that use a quality labeled software package, to automatically produce all the legally necessary documents concerning the registry. Moreover, we hope that this development will be an incentive for non-users to start working in an electronic way.

Interactive Cohort Identification of Sleep Disorder Patients Using Natural Language Processing and i2b2.

PubMed

Chen, W; Kowatch, R; Lin, S; Splaingard, M; Huang, Y

2015-01-01

Nationwide Children's Hospital established an i2b2 (Informatics for Integrating Biology & the Bedside) application for sleep disorder cohort identification. Discrete data were gleaned from semistructured sleep study reports. The system showed to work more efficiently than the traditional manual chart review method, and it also enabled searching capabilities that were previously not possible. We report on the development and implementation of the sleep disorder i2b2 cohort identification system using natural language processing of semi-structured documents. We developed a natural language processing approach to automatically parse concepts and their values from semi-structured sleep study documents. Two parsers were developed: a regular expression parser for extracting numeric concepts and a NLP based tree parser for extracting textual concepts. Concepts were further organized into i2b2 ontologies based on document structures and in-domain knowledge. 26,550 concepts were extracted with 99% being textual concepts. 1.01 million facts were extracted from sleep study documents such as demographic information, sleep study lab results, medications, procedures, diagnoses, among others. The average accuracy of terminology parsing was over 83% when comparing against those by experts. The system is capable of capturing both standard and non-standard terminologies. The time for cohort identification has been reduced significantly from a few weeks to a few seconds. Natural language processing was shown to be powerful for quickly converting large amount of semi-structured or unstructured clinical data into discrete concepts, which in combination of intuitive domain specific ontologies, allows fast and effective interactive cohort identification through the i2b2 platform for research and clinical use.

Interactive Cohort Identification of Sleep Disorder Patients Using Natural Language Processing and i2b2

PubMed Central

Chen, W.; Kowatch, R.; Lin, S.; Splaingard, M.

2015-01-01

Summary Nationwide Children’s Hospital established an i2b2 (Informatics for Integrating Biology & the Bedside) application for sleep disorder cohort identification. Discrete data were gleaned from semistructured sleep study reports. The system showed to work more efficiently than the traditional manual chart review method, and it also enabled searching capabilities that were previously not possible. Objective We report on the development and implementation of the sleep disorder i2b2 cohort identification system using natural language processing of semi-structured documents. Methods We developed a natural language processing approach to automatically parse concepts and their values from semi-structured sleep study documents. Two parsers were developed: a regular expression parser for extracting numeric concepts and a NLP based tree parser for extracting textual concepts. Concepts were further organized into i2b2 ontologies based on document structures and in-domain knowledge. Results 26,550 concepts were extracted with 99% being textual concepts. 1.01 million facts were extracted from sleep study documents such as demographic information, sleep study lab results, medications, procedures, diagnoses, among others. The average accuracy of terminology parsing was over 83% when comparing against those by experts. The system is capable of capturing both standard and non-standard terminologies. The time for cohort identification has been reduced significantly from a few weeks to a few seconds. Conclusion Natural language processing was shown to be powerful for quickly converting large amount of semi-structured or unstructured clinical data into discrete concepts, which in combination of intuitive domain specific ontologies, allows fast and effective interactive cohort identification through the i2b2 platform for research and clinical use. PMID:26171080

Integrating Query of Relational and Textual Data in Clinical Databases: A Case Study

PubMed Central

Fisk, John M.; Mutalik, Pradeep; Levin, Forrest W.; Erdos, Joseph; Taylor, Caroline; Nadkarni, Prakash

2003-01-01

Objectives: The authors designed and implemented a clinical data mart composed of an integrated information retrieval (IR) and relational database management system (RDBMS). Design: Using commodity software, which supports interactive, attribute-centric text and relational searches, the mart houses 2.8 million documents that span a five-year period and supports basic IR features such as Boolean searches, stemming, and proximity and fuzzy searching. Measurements: Results are relevance-ranked using either “total documents per patient” or “report type weighting.” Results: Non-curated medical text has a significant degree of malformation with respect to spelling and punctuation, which creates difficulties for text indexing and searching. Presently, the IR facilities of RDBMS packages lack the features necessary to handle such malformed text adequately. Conclusion: A robust IR+RDBMS system can be developed, but it requires integrating RDBMSs with third-party IR software. RDBMS vendors need to make their IR offerings more accessible to non-programmers. PMID:12509355

Using clinical governance levers to support change in a cancer care reform.

PubMed

Brault, Isabelle; Denis, Jean-Louis; Sullivan, Terrence James

2015-01-01

Introducing change is a difficult issue facing all health care systems. The use of various clinical governance levers can facilitate change in health care systems. The purpose of this paper is to define clinical governance levers, and to illustrate their use in a large-scale transformation. The empirical analysis deals with the in-depth study of a specific case, which is the organizational model for Ontario's cancer sector. The authors used a qualitative research strategy and drew the data from three sources: semi-structured interviews, analysis of documents, and non-participative observations. From the results, the authors identified three phases and several steps in the reform of cancer services in this province. The authors conclude that a combination of clinical governance levers was used to transform the system. These levers operated at different levels of the system to meet the targeted objectives. To exercise clinical governance, managers need to acquire new competencies. Mobilizing clinical governance levers requires in-depth understanding of the role and scope of clinical governance levers. This study provides a better understanding of clinical governance levers. Clinical governance levers are used to implement an organizational environment that is conducive to developing clinical practice, as well as to act directly on practices to improve quality of care.

Sharing and reuse of individual participant data from clinical trials: principles and recommendations

PubMed Central

Ohmann, Christian; Banzi, Rita; Canham, Steve; Battaglia, Serena; Matei, Mihaela; Ariyo, Christopher; Becnel, Lauren; Bierer, Barbara; Bowers, Sarion; Clivio, Luca; Dias, Monica; Druml, Christiane; Faure, Hélène; Fenner, Martin; Galvez, Jose; Ghersi, Davina; Gluud, Christian; Houston, Paul; Karam, Ghassan; Kalra, Dipak; Krleža-Jerić, Karmela; Kubiak, Christine; Kuchinke, Wolfgang; Kush, Rebecca; Lukkarinen, Ari; Marques, Pedro Silverio; Newbigging, Andrew; O’Callaghan, Jennifer; Ravaud, Philippe; Schlünder, Irene; Shanahan, Daniel; Sitter, Helmut; Spalding, Dylan; Tudur-Smith, Catrin; van Reusel, Peter; van Veen, Evert-Ben; Visser, Gerben Rienk; Wilson, Julia; Demotes-Mainard, Jacques

2017-01-01

Objectives We examined major issues associated with sharing of individual clinical trial data and developed a consensus document on providing access to individual participant data from clinical trials, using a broad interdisciplinary approach. Design and methods This was a consensus-building process among the members of a multistakeholder task force, involving a wide range of experts (researchers, patient representatives, methodologists, information technology experts, and representatives from funders, infrastructures and standards development organisations). An independent facilitator supported the process using the nominal group technique. The consensus was reached in a series of three workshops held over 1 year, supported by exchange of documents and teleconferences within focused subgroups when needed. This work was set within the Horizon 2020-funded project CORBEL (Coordinated Research Infrastructures Building Enduring Life-science Services) and coordinated by the European Clinical Research Infrastructure Network. Thus, the focus was on non-commercial trials and the perspective mainly European. Outcome We developed principles and practical recommendations on how to share data from clinical trials. Results The task force reached consensus on 10 principles and 50 recommendations, representing the fundamental requirements of any framework used for the sharing of clinical trials data. The document covers the following main areas: making data sharing a reality (eg, cultural change, academic incentives, funding), consent for data sharing, protection of trial participants (eg, de-identification), data standards, rights, types and management of access (eg, data request and access models), data management and repositories, discoverability, and metadata. Conclusions The adoption of the recommendations in this document would help to promote and support data sharing and reuse among researchers, adequately inform trial participants and protect their rights, and provide effective and efficient systems for preparing, storing and accessing data. The recommendations now need to be implemented and tested in practice. Further work needs to be done to integrate these proposals with those from other geographical areas and other academic domains. PMID:29247106

[Control of intubator associated pneumonia in intensive care unit: results of the GISIO-SItI SPIN-UTI Project].

PubMed

Agodi, Antonella; Auxilia, Francesco; Barchitta, Martina; D'Errico, Marcello Mario; Montagna, Maria Teresa; Pasquarella, Cesira; Tardivo, Stefano; Mura, Ida

2014-01-01

To document reported Intubator Associated Pneumonia (IAP) prevention practices in Intensive Care Units (ICUs) and attitudes towards the implementation of a measurement system. In the framework of the SPIN-UTI project the «Italian Nosocomial Infections Surveillance in ICUs network», two questionnaires were made available online. The first was filled out by physicians working in ICUs in order to collect data on characteristics of physicians and ICUs, on clinical and measurement practices for IAP prevention, and attitudes towards the implementation of a measurement system. The second questionnaire was filled out for each intubated patient in order to collect data on prevention practices during ICU stay. ICUs participating to the fourth edition (2012-2013) of the SPIN-UTI project. Compliance to the component of the European bundle. The components of the bundle for the prevention of IAP are implemented, although to a different level, in the 26 participating ICUs. Overall compliance to all five practices of the European bundle has been reported in 21.1% of the 768 included patients. The present survey has documented a large potential for improvement in clinical and non-clinical practices aimed at preventing IAP in ICUs.

Provision of test results and posttest counseling at STD clinics in 24 health departments: U.S., 2007.

PubMed

Begley, Elin; VanHandel, Michelle

2012-01-01

We determined the demographic and HIV test characteristics of tests conducted in CDC-funded sexually transmitted disease (STD) clinics with provision of test results and posttest counseling. We used CDC's HIV Counseling and Testing System data from 2007 for the 24 U.S. health departments that reported test-level data from STD clinics. We calculated and analyzed newly identified HIV positivity and the percentage of tests with provision of test results and posttest counseling (provision of posttest counseling), by demographic and HIV-related characteristics. Of 372,757 tests conducted among people without a previous HIV diagnosis by self-report, provision of posttest counseling was documented for 191,582 (51.4%) HIV tests overall and 1,922 (71.2%) newly identified HIV-positive test results. At these STD clinics, provision of posttest counseling varied by HIV serostatus, age, race/ethnicity, test type, and risk category; however, documentation of posttest counseling was missing for more than 20% of tests. The newly identified HIV positivity among all testers was 0.7%. One of the main goals of HIV counseling and testing is to inform people of their HIV status, because knowledge of one's HIV-positive serostatus can result in a reduction in risk behaviors and allow the person to access HIV medical care and treatment. STD clinics offering HIV testing may need to further their emphasis on increasing the proportion of clients who are provided posttest counseling and on improving documentation of this information.

How the provenance of electronic health record data matters for research: a case example using system mapping.

PubMed

Johnson, Karin E; Kamineni, Aruna; Fuller, Sharon; Olmstead, Danielle; Wernli, Karen J

2014-01-01

The use of electronic health records (EHRs) for research is proceeding rapidly, driven by computational power, analytical techniques, and policy. However, EHR-based research is limited by the complexity of EHR data and a lack of understanding about data provenance, meaning the context under which the data were collected. This paper presents system flow mapping as a method to help researchers more fully understand the provenance of their EHR data as it relates to local workflow. We provide two specific examples of how this method can improve data identification, documentation, and processing. EHRs store clinical and administrative data, often in unstructured fields. Each clinical system has a unique and dynamic workflow, as well as an EHR customized for local use. The EHR customization may be influenced by a broader context such as documentation required for billing. We present a case study with two examples of using system flow mapping to characterize EHR data for a local colorectal cancer screening process. System flow mapping demonstrated that information entered into the EHR during clinical practice required interpretation and transformation before it could be accurately applied to research. We illustrate how system flow mapping shaped our knowledge of the quality and completeness of data in two examples: (1) determining colonoscopy indication as recorded in the EHR, and (2) discovering a specific EHR form that captured family history. Researchers who do not consider data provenance risk compiling data that are systematically incomplete or incorrect. For example, researchers who are not familiar with the clinical workflow under which data were entered might miss or misunderstand patient information or procedure and diagnostic codes. Data provenance is a fundamental characteristic of research data from EHRs. Given the diversity of EHR platforms and system workflows, researchers need tools for evaluating and reporting data availability, quality, and transformations. Our case study illustrates how system mapping can inform researchers about the provenance of their data as it pertains to local workflows.

Does teaching of documentation of shoulder dystocia delivery through simulation result in improved documentation in real life?

PubMed

Comeau, Robyn; Craig, Catherine

2014-03-01

Documentation of deliveries complicated by shoulder dystocia is a valuable communication skill necessary for residents to attain during residency training. Our objective was to determine whether the teaching of documentation of shoulder dystocia in a simulation environment would translate to improved documentation of the event in an actual clinical situation. We conducted a cohort study involving obstetrics and gynaecology residents in years 2 to 5 between November 2010 and December 2012. Each resident participated in a shoulder dystocia simulation teaching session and was asked to write a delivery note immediately afterwards. They were given feedback regarding their performance of the delivery and their documentation of the events. Following this, dictated records of shoulder dystocia deliveries immediately before and after the simulation session were identified through the Meditech system. An itemized checklist was used to assess the quality of residents' dictated documentation before and after the simulation session. All eligible residents (18) enrolled in the study, and 17 met the inclusion criteria. For 10 residents (59%) documentation of a delivery with shoulder dystocia was present before and after the simulation session, for five residents (29%) it was only present before the session, and for two residents (18%) it was only present after the session. When residents were assessed as a group, there were no differences in the proportion of residents recording items on the checklist before and after the simulation session (P > 0.05 for all). Similarly, analysis of the performance of the10 residents who had dictated documentation both before and after the session showed no differences in the number of elements recorded on dictations done before and after the simulation session (P > 0.05 for all). The teaching of shoulder dystocia documentation through simulation did not result in a measurable improvement in the quality of documentation of shoulder dystocia in actual clinical situations.

Health System Advance Care Planning Culture Change for High-Risk Patients: The Promise and Challenges of Engaging Providers, Patients, and Families in Systematic Advance Care Planning.

PubMed

Reidy, Jennifer; Halvorson, Jennifer; Makowski, Suzana; Katz, Delila; Weinstein, Barbara; McCluskey, Christine; Doering, Alex; DeCarli, Kathryn; Tjia, Jennifer

2017-04-01

The success of a facilitator-based model for advance care planning (ACP) in LaCrosse, Wisconsin, has inspired health systems to aim for widespread documentation of advance directives, but limited resources impair efforts to replicate this model. One promising strategy is the development of interactive, Internet-based tools that might increase access to individualized ACP at minimal cost. However, widespread adoption and implementation of Internet-based ACP efforts has yet to be described. We describe our early experiences in building a systematic, population-based ACP initiative focused on health system-wide deployment of an Internet-based tool as an adjunct to a facilitator-based model. With the sponsorship of our healthcare system's population health leadership, we engaged a diverse group of clinical stakeholders as champions to design an Internet-based ACP tool and facilitate local practice change. We describe how we simultaneously began to train clinicians in ACP conversations, engage patients and health system employees in thinking about ACP, redesign clinic workflows to accommodate ACP discussions, and integrate the Internet-based tool into the electronic medical record (EMR). Over 18 months, our project engaged two subspecialty clinics in a systematic ACP process and began work with a large primary care practice with a large Medicare Accountable Care Organization at-risk population. Overall, 807 people registered at the Internet site and 85% completed ACPs. We learned that changing culture and systems to promote ACP requires a comprehensive vision with simultaneous, interconnected strategies targeting patient education, clinician training, EMR documentation, and community awareness.

[Medical record management and risk management processes. State of the art and new normative guidelines about the organization and the management of the sanitary documentation in the National Health System or Hospital Trusts].

PubMed

Spolaore, P; Murolo, G; Sommavilla, M

2003-01-01

Recent health care reforms, the start of accreditation processes of health institutions, and the introduction also in the health system of risk management concepts and instruments, borrowed from the enterprise culture and the emphasis put on the protection of privacy, render evident the need and the urgency to define and to implement improvement processes of the organization and management of the medical documentation in the hospital with the aim of facilitation in fulfilment of regional and local health authorities policies about protection of the safety and improvement of quality of care. Currently the normative context that disciplines the management of medical records inside the hospital appears somewhat fragmentary, incomplete and however not able to clearly orientate health operators with the aim of a correct application of the enforced norms in the respect of the interests of the user and of local health authority. In this job we individuate the critical steps in the various phases of management process of the clinical folder and propose a new model of regulations, with the purpose to improve and to simplify the management processes and the modalities of compilation, conservation and release to entitled people of all clinical documentation.

Documenting pharmacist interventions on an intranet.

PubMed

Simonian, Armen I

2003-01-15

The process of developing and implementing an intranet Web site for clinical intervention documentation is described. An inpatient pharmacy department initiated an organizationwide effort to improve documentation of interventions by pharmacists at its seven hospitals to achieve real-time capture of meaningful benchmarking data. Standardization of intervention types would allow the health system to contrast and compare medication use, process improvement, and patient care initiatives among its hospitals. After completing a needs assessment and reviewing current methodologies, a computerized tracking tool was developed in-house and integrated with the organization's intranet. Representatives from all hospitals agreed on content and functionality requirements for the Web site. The site was completed and activated in February 2002. Before this Web site was established, the most documented intervention types were Renal Adjustment and Clarify Dose, with a daily average of four and three, respectively. After site activation, daily averages for Renal Adjustment remained unchanged, but Clarify Dose is now documented nine times per day. Drug Information and i.v.-to-p.o. intervention types, which previously averaged less than one intervention per day, are now documented an average of four times daily. Approximately 91% of staff pharmacists are using this site. Future plans for this site include enhanced accessibility to the site with wireless personal digital assistants. The design and implementation of an intranet Web site to document pharmacists' interventions doubled the rate of intervention documentation and standardized the intervention types among hospitals in the health system.

Examination to assess the clinical examination and documentation of spine pathology among orthopedic residents.

PubMed

Haglin, Jack M; Zeller, John L; Egol, Kenneth A; Phillips, Donna P

2017-12-01

The Accreditation Council for Graduate Medical Education (ACGME) guidelines requires residency programs to teach and evaluate residents in six overarching "core competencies" and document progress through educational milestones. To assess the progress of orthopedic interns' skills in performing a history, physical examination, and documentation of the encounter for a standardized patient with spinal stenosis, an objective structured clinical examination (OSCE) was conducted for 13 orthopedic intern residents, following a 1-month boot camp that included communications skills and curriculum in history and physical examination. Interns were objectively scored based on their performance of the physical examination, communication skills, completeness and accuracy of their electronic medical record (EMR), and their diagnostic conclusions gleaned from the patient encounter. The purpose of this study was to meaningfully assess the clinical skills of orthopedic post-graduate year (PGY)-1 interns. The findings can be used to develop a standardized curriculum for documenting patient encounters and highlight common areas of weakness among orthopedic interns with regard to the spine history and physical examination and conducting complete and accurate clinical documentation. A major orthopedic specialty hospital and academic medical center. Thirteen PGY-1 orthopedic residents participated in the OSCE with the same standardized patient presenting with symptoms and radiographs consistent with spinal stenosis. Videos of the encounters were independently viewed and objectively evaluated by one investigator in the study. This evaluation focused on the completeness of the history and the performance and completion of the physical examination. The standardized patient evaluated the communication skills of each intern with a separate objective evaluation. Interns completed these same scoring guides to evaluate their own performance in history, physical examination, and communications skills. The interns' documentation in the EMR was then scored for completeness, internal consistency, and inaccuracies. The independent review revealed objective deficits in both the orthopedic interns' history and the physical examination, as well as highlighted trends of inaccurate and incomplete documentation in the corresponding medical record. Communication skills with the patient did not meet expectations. Further, interns tended to overscore themselves, especially with regard to their performance on the physical examination (p<.0005). Inconsistencies, omissions, and inaccuracies were common in the corresponding medical notes when compared with the events of the patient encounter. Nine of the 13 interns (69.2%) documented at least one finding that was not assessed or tested in the clinical encounter, and four of the 13 interns (30.8%) included inaccuracies in the medical record, which contradicted the information collected at the time of the encounter. The results of this study highlighted significant shortcomings in the completeness of the interns' spine history and physical examination, and the accuracy and completeness oftheir EMR note. The study provides a valuable exercise for evaluating residents in a multifaceted, multi-milestone manner that more accurately documents residents' clinical strengths and weaknesses. The study demonstrates that orthopedic residents require further instruction on the complexities of the spinal examination. It validates a need for increased systemic support for improving resident documentation through comprehensive education and evaluation modules. Copyright © 2017 Elsevier Inc. All rights reserved.

ODMSummary: A Tool for Automatic Structured Comparison of Multiple Medical Forms Based on Semantic Annotation with the Unified Medical Language System.

PubMed

Storck, Michael; Krumm, Rainer; Dugas, Martin

2016-01-01

Medical documentation is applied in various settings including patient care and clinical research. Since procedures of medical documentation are heterogeneous and developed further, secondary use of medical data is complicated. Development of medical forms, merging of data from different sources and meta-analyses of different data sets are currently a predominantly manual process and therefore difficult and cumbersome. Available applications to automate these processes are limited. In particular, tools to compare multiple documentation forms are missing. The objective of this work is to design, implement and evaluate the new system ODMSummary for comparison of multiple forms with a high number of semantically annotated data elements and a high level of usability. System requirements are the capability to summarize and compare a set of forms, enable to estimate the documentation effort, track changes in different versions of forms and find comparable items in different forms. Forms are provided in Operational Data Model format with semantic annotations from the Unified Medical Language System. 12 medical experts were invited to participate in a 3-phase evaluation of the tool regarding usability. ODMSummary (available at https://odmtoolbox.uni-muenster.de/summary/summary.html) provides a structured overview of multiple forms and their documentation fields. This comparison enables medical experts to assess multiple forms or whole datasets for secondary use. System usability was optimized based on expert feedback. The evaluation demonstrates that feedback from domain experts is needed to identify usability issues. In conclusion, this work shows that automatic comparison of multiple forms is feasible and the results are usable for medical experts.

Clinical services provided by staff pharmacists in a community hospital.

PubMed

Garrelts, J C; Smith, D F

1990-09-01

A program for developing staff pharmacists' clinical skills and documenting pharmacists' clinical interventions in a large community teaching hospital is described. A coordinator hired in 1984 to develop clinical pharmacy services began a didactic and experiential program for baccalaureate-level staff pharmacists. Fourteen educational modules are supplemented by journal and textbook articles and small-group discussions of clinical cases, and the clinical coordinator provides individual training on the patient-care units for each pharmacist. Monitoring of clinical pharmacy services began in June 1987; each intervention provided by a pharmacist is recorded on a specially designed form. A target-drug program is used to document cost avoidance achieved through clinical services. Information collected through these monitoring activities is used to educate the pharmacy staff, shared with the pharmacy and therapeutics committee, and used to monitor prescribing patterns of individual physicians. The data are used in the hospital's productivity-monitoring system. All pharmacists who were on staff in 1984 have completed the educational modules, and all new employees are in the process. Since monitoring began, the number of clinical interventions has averaged 2098 per month. Cost avoidance has averaged $9306 per month. Over a five-year period, the development of staff pharmacists' clinical services raised the level of professional practice, produced substantial cost avoidance, and increased the number of pharmacist interventions in medication use.

An OAIS-Based Hospital Information System on the Cloud: Analysis of a NoSQL Column-Oriented Approach.

PubMed

Celesti, Antonio; Fazio, Maria; Romano, Agata; Bramanti, Alessia; Bramanti, Placido; Villari, Massimo

2018-05-01

The Open Archive Information System (OAIS) is a reference model for organizing people and resources in a system, and it is already adopted in care centers and medical systems to efficiently manage clinical data, medical personnel, and patients. Archival storage systems are typically implemented using traditional relational database systems, but the relation-oriented technology strongly limits the efficiency in the management of huge amount of patients' clinical data, especially in emerging cloud-based, that are distributed. In this paper, we present an OAIS healthcare architecture useful to manage a huge amount of HL7 clinical documents in a scalable way. Specifically, it is based on a NoSQL column-oriented Data Base Management System deployed in the cloud, thus to benefit from a big tables and wide rows available over a virtual distributed infrastructure. We developed a prototype of the proposed architecture at the IRCCS, and we evaluated its efficiency in a real case of study.

Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot Medical Record System.

PubMed

Rotich, Joseph K; Hannan, Terry J; Smith, Faye E; Bii, John; Odero, Wilson W; Vu, Nguyen; Mamlin, Burke W; Mamlin, Joseph J; Einterz, Robert M; Tierney, William M

2003-01-01

The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data are recorded on a paper encounter form, eliminating duplicate documentation in multiple clinic logbooks. Data are entered into an MS-Access database supported by redundant power systems. The system was initiated in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After system implementation, patient visits were 22% shorter. They spent 58% less time with providers (p < 0.001) and 38% less time waiting (p = 0.06). Clinic personnel spent 50% less time interacting with patients, two thirds less time interacting with each other, and more time in personal activities. This simple electronic medical record system has bridged the "digital divide." Financial and technical sustainability by Kenyans will be key to its future use and development.

Implementing Single Source: The STARBRITE Proof-of-Concept Study

PubMed Central

Kush, Rebecca; Alschuler, Liora; Ruggeri, Roberto; Cassells, Sally; Gupta, Nitin; Bain, Landen; Claise, Karen; Shah, Monica; Nahm, Meredith

2007-01-01

Objective Inefficiencies in clinical trial data collection cause delays, increase costs, and may reduce clinician participation in medical research. In this proof-of-concept study, we examine the feasibility of using point-of-care data capture for both the medical record and clinical research in the setting of a working clinical trial. We hypothesized that by doing so, we could increase reuse of patient data, eliminate redundant data entry, and minimize disruption to clinic workflow. Design We developed and used a point-of-care electronic data capture system to record data during patient visits. The standards-based system was used for clinical research and to generate the clinic note for the medical record. The system worked in parallel with data collection procedures already in place for an ongoing multicenter clinical trial. Our system was iteratively designed after analyzing case report forms and clinic notes, and observing clinic workflow patterns and business procedures. Existing data standards from CDISC and HL7 were used for database insertion and clinical document exchange. Results Our system was successfully integrated into the clinic environment and used in two live test cases without disrupting existing workflow. Analyses performed during system design yielded detailed information on practical issues affecting implementation of systems that automatically extract, store, and reuse healthcare data. Conclusion Although subject to the limitations of a small feasibility study, our study demonstrates that electronic patient data can be reused for prospective multicenter clinical research and patient care, and demonstrates a need for further development of therapeutic area standards that can facilitate researcher use of healthcare data. PMID:17600107

A computer-based maintenance reminder and record-keeping system for clinical laboratories.

PubMed

Roberts, B I; Mathews, C L; Walton, C J; Frazier, G

1982-09-01

"Maintenance" is all the activity an organization devotes to keeping instruments within performance specifications to assure accurate and precise operation. The increasing use of complex analytical instruments as "workhorses" in clinical laboratories requires more maintenance awareness by laboratory personnel. Record-keeping systems that document maintenance completion and that should prompt the continued performance of maintenance tasks have not kept up with instrumentation development. We report here a computer-based record-keeping and reminder system that lists weekly the maintenance items due for each work station in the laboratory, including the time required to complete each item. Written in BASIC, the system uses a DATABOSS data base management system running on a time-shared Digital Equipment Corporation PDP 11/60 computer with a RSTS V 7.0 operating system.

Drug allergy passport and other documentation for patients with drug hypersensitivity - An ENDA/EAACI Drug Allergy Interest Group Position Paper.

PubMed

Brockow, K; Aberer, W; Atanaskovic-Markovic, M; Bavbek, S; Bircher, A; Bilo, B; Blanca, M; Bonadonna, P; Burbach, G; Calogiuri, G; Caruso, C; Celik, G; Cernadas, J; Chiriac, A; Demoly, P; Oude Elberink, J N G; Fernandez, J; Gomes, E; Garvey, L H; Gooi, J; Gotua, M; Grosber, M; Kauppi, P; Kvedariene, V; Laguna, J J; Makowska, J S; Mosbech, H; Nakonechna, A; Papadopolous, N G; Ring, J; Romano, A; Rockmann, H; Sargur, R; Sedlackova, L; Sigurdardottir, S; Schnyder, B; Storaas, T; Torres, M; Zidarn, M; Terreehorst, I

2016-11-01

The strongest and best-documented risk factor for drug hypersensitivity (DH) is the history of a previous reaction. Accidental exposures to drugs may lead to severe or even fatal reactions in sensitized patients. Preventable prescription errors are common. They are often due to inadequate medical history or poor risk assessment of recurrence of drug reaction. Proper documentation is essential information for the doctor to make sound therapeutic decision. The European Network on Drug Allergy and Drug Allergy Interest Group of the European Academy of Allergy and Clinical Immunology have formed a task force and developed a drug allergy passport as well as general guidelines of drug allergy documentation. A drug allergy passport, a drug allergy alert card, a certificate, and a discharge letter after medical evaluation are adequate means to document DH in a patient. They are to be handed to the patient who is advised to carry the documentation at all times especially when away from home. A drug allergy passport should at least contain information on the culprit drug(s) including international nonproprietary name, clinical manifestations including severity, diagnostic measures, potential cross-reactivity, alternative drugs to prescribe, and where more detailed information can be obtained from the issuer. It should be given to patients only after full allergy workup. In the future, electronic prescription systems with alert functions will become more common and should include the same information as in paper-based documentation. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Patterns of clinical response to PSA elevation in American Indian/Alaska Native men: a multi-center pilot study.

PubMed

Tilburt, Jon C; Koller, Kathryn; Tiesinga, James J; Wilson, Robin T; Trinh, Anne C; Hill, Kristin; Hall, Ingrid J; Smith, Judith Lee; Ekwueme, Donatus U; Petersen, Wesley O

2013-11-01

To assess clinical treatment patterns and response times among American Indian/Alaska Native men with a newly elevated PSA. We retrospectively identified men ages 50-80 receiving care in one of three tribally-operated clinics in Northern Minnesota, one medical center in Alaska, and who had an incident PSA elevation (> 4 ng/ml) in a specified time period. A clinical response was considered timely if it was documented as occurring within 90 days of the incident PSA elevation. Among 82 AI/AN men identified from medical records with an incident PSA elevation, 49 (60%) received a timely clinical response, while 18 (22%) had no documented clinical response. One in five AI/AN men in our study had no documented clinical action following an incident PSA elevation. Although a pilot study, these findings suggest the need to improve the documentation, notification, and care following an elevated PSA at clinics serving AI/AN men.

Automated clinical annotation of tissue bank specimens.

PubMed

Gilbertson, John R; Gupta, Rajnish; Nie, Yimin; Patel, Ashokkumar A; Becich, Michael J

2004-01-01

Modern, molecular bio-medicine is driving a growing demand for extensively annotated tissue bank specimens. With careful clinical, pathologic and outcomes annotation, samples can be better matched to the research question at hand and experimental results better understood and verified. However, the difficulty and expense of detailed specimen annotation is well beyond the capability of most banks and has made access to well documented tissue a major limitation in medical re-search. In this context, we have implemented automated annotation of banked tissue by integrating data from three clinical systems--the cancer registry, the pathology LIS and the tissue bank inventory system--through a classical data warehouse environment. The project required modification of clinical systems, development of methods to identify patients between and map data elements across systems and the creation of de-identified data in data marts for use by researchers. The result has been much more extensive and accurate initial tissue annotation with less effort in the tissue bank, as well as dynamic ongoing annotation as the cancer registry follows patients over time.

Repurposing the clinical record: can an existing natural language processing system de-identify clinical notes?

PubMed

Morrison, Frances P; Li, Li; Lai, Albert M; Hripcsak, George

2009-01-01

Electronic clinical documentation can be useful for activities such as public health surveillance, quality improvement, and research, but existing methods of de-identification may not provide sufficient protection of patient data. The general-purpose natural language processor MedLEE retains medical concepts while excluding the remaining text so, in addition to processing text into structured data, it may be able provide a secondary benefit of de-identification. Without modifying the system, the authors tested the ability of MedLEE to remove protected health information (PHI) by comparing 100 outpatient clinical notes with the corresponding XML-tagged output. Of 809 instances of PHI, 26 (3.2%) were detected in output as a result of processing and identification errors. However, PHI in the output was highly transformed, much appearing as normalized terms for medical concepts, potentially making re-identification more difficult. The MedLEE processor may be a good enhancement to other de-identification systems, both removing PHI and providing coded data from clinical text.

A system for classifying disease comorbidity status from medical discharge summaries using automated hotspot and negated concept detection.

PubMed

Ambert, Kyle H; Cohen, Aaron M

2009-01-01

OBJECTIVE Free-text clinical reports serve as an important part of patient care management and clinical documentation of patient disease and treatment status. Free-text notes are commonplace in medical practice, but remain an under-used source of information for clinical and epidemiological research, as well as personalized medicine. The authors explore the challenges associated with automatically extracting information from clinical reports using their submission to the Integrating Informatics with Biology and the Bedside (i2b2) 2008 Natural Language Processing Obesity Challenge Task. DESIGN A text mining system for classifying patient comorbidity status, based on the information contained in clinical reports. The approach of the authors incorporates a variety of automated techniques, including hot-spot filtering, negated concept identification, zero-vector filtering, weighting by inverse class-frequency, and error-correcting of output codes with linear support vector machines. MEASUREMENTS Performance was evaluated in terms of the macroaveraged F1 measure. RESULTS The automated system performed well against manual expert rule-based systems, finishing fifth in the Challenge's intuitive task, and 13(th) in the textual task. CONCLUSIONS The system demonstrates that effective comorbidity status classification by an automated system is possible.

Systemic mycoplasmosis with dystocia and abortion in North American bison (Bison bison) herd

USDA-ARS?s Scientific Manuscript database

Mycoplasma bovis has recently emerged as a significant health threat in bison and is an increasing concern and source of economic loss for producers. Clinical manifestations of infection documented in bison include pneumonia, respiratory distress and polyarthritis. The current study describes the ...

[From data entry to data presentation at a clinical workstation--experiences with Anesthesia Information Management Systems (AIMS)].

PubMed

Benson, M; Junger, A; Quinzio, L; Michel, A; Sciuk, G; Fuchs, C; Marquardt, K; Hempelmannn, G

2000-09-01

Anesthesia Information Management Systems (AIMS) are required to supply large amounts of data for various purposes such as performance recording, quality assurance, training, operating room management and research. It was our objective to establish an AIMS that enables every member of the department to independently access queries at his/her work station and at the same time allows the presentation of data in a suitable manner in order to increase the transfer of different information to the clinical workstation. Apple Macintosh Clients (Apple Computer, Inc. Cupertino, California) and the file- and database servers were installed into the already partially existing hospital network. The most important components installed on each computer are the anesthesia documenting software NarkoData (ProLogic GmbH, Erkrath), HIS client software and a HTML browser. More than 250 queries for easy evaluation were formulated with the software Voyant (Brossco Systems, Espoo, Finland). Together with the documentation they are the evaluation module of the AIMS. Today, more than 20,000 anesthesia procedures are recorded each year at 112 decentralised workstations with the AIMS. In 1998, 90.8% of the 20,383 performed anesthetic procedures were recorded online and 9.2% entered postopeatively into the system. With a corresponding user access it is possible to receive all available patient data at each single anesthesiological workstation via HIS (diagnoses, laboratory results) anytime. The available information includes previous anesthesia records, statistics and all data available from the hospitals intranet. This additional information is of great advantage in comparison to previous working conditions. The implementation of an AIMS allowed to greatly enhance the quota but also the quality of documentation and an increased flow of information at the anesthesia workstation. The circuit between data entry and the presentation and evaluation of data, statistics and results directly available at the clinical workstation was put into practice.

An ontologically founded architecture for information systems in clinical and epidemiological research.

PubMed

Uciteli, Alexandr; Groß, Silvia; Kireyev, Sergej; Herre, Heinrich

2011-08-09

This paper presents an ontologically founded basic architecture for information systems, which are intended to capture, represent, and maintain metadata for various domains of clinical and epidemiological research. Clinical trials exhibit an important basis for clinical research, and the accurate specification of metadata and their documentation and application in clinical and epidemiological study projects represents a significant expense in the project preparation and has a relevant impact on the value and quality of these studies.An ontological foundation of an information system provides a semantic framework for the precise specification of those entities which are presented in this system. This semantic framework should be grounded, according to our approach, on a suitable top-level ontology. Such an ontological foundation leads to a deeper understanding of the entities of the domain under consideration, and provides a common unifying semantic basis, which supports the integration of data and the interoperability between different information systems.The intended information systems will be applied to the field of clinical and epidemiological research and will provide, depending on the application context, a variety of functionalities. In the present paper, we focus on a basic architecture which might be common to all such information systems. The research, set forth in this paper, is included in a broader framework of clinical research and continues the work of the IMISE on these topics.

An Intelligent Computerized Stretch Reflex Measurement System For Clinical And Investigative Neurology

NASA Astrophysics Data System (ADS)

Flanagan, P. M.; Chutkow, J. G.; Riggs, M. T.; Cristiano, V. D.

1987-05-01

We describe the design of a reliable, user-friendly preprototype system for quantifying the tendon stretch reflexes in humans and large mammals. A hand-held, instrumented reflex gun, the impactor of which contains a single force sensor, interfaces with a computer. The resulting test system can deliver sequences of reproducible stimuli at graded intensities and adjustable durations to a muscle's tendon ("tendon taps"), measure the impacting force of each tap, and record the subsequent reflex muscle contraction from the same tendon -- all automatically. The parameters of the reflex muscle contraction include latency; mechanical threshold; and peak time, peak magnitude, and settling time. The results of clinical tests presented in this paper illustrate the system's potential usefulness in detecting neurologic dysfunction affecting the tendon stretch reflexes, in documenting the course of neurologic illnesses and their response to therapy, and in clinical and laboratory neurologic research.

[Formation of epicrises using the ESER computer R 21 based on the data-marking technic in gynecology].

PubMed

Jäger, G; Hagemeier, J H; Schneider, P; Heber, E

1978-01-01

Report about an electronic data processing system for gynaecology. The developed data document design and data flowchart are shown. The accumulated data allowed a detailed interpretation record. For all clinical treated patients the computer printed out a final gynaecological epicrisis. The system is an improvement of the information and the typewriting work of medial staff has been reduced.

Local and Systemic Effects of Unpolymerised Monomers

PubMed Central

Gosavi, Sulekha Siddharth; Gosavi, Siddharth Yuvraj; Alla, Rama Krishna

2010-01-01

Methyl methacrylate (MMA), a widely used monomer in dentistry and medicine has been reported to cause abnormalities or lesions in several organs. Experimental and clinical studies have documented that monomers may cause a wide range of adverse health effects such as irritation to skin, eyes, and mucous membranes, allergic dermatitis, stomatitis, asthma, neuropathy, disturbances of the central nervous system, liver toxicity, and fertility disturbances. PMID:22013462

Documentation of violence risk information in psychiatric hospital patient charts: an empirical examination.

PubMed

Elbogen, Eric B; Tomkins, Alan J; Pothuloori, Antara P; Scalora, Mario J

2003-01-01

Studies have identified risk factors that show a strong association with violent behavior in psychiatric populations. Yet, little research has been conducted on the documentation of violence risk information in actual clinical practice, despite the relevance of such documentation to risk assessment liability and to conducting effective risk management. In this study, the documentation of cues of risk for violence were examined in psychiatric settings. Patient charts (n = 283) in four psychiatric settings were reviewed for documentation of violence risk information summarized in the MacArthur Violence Risk Assessment Study. The results revealed that particular patient and institutional variables influenced documentation practices. The presence of personality disorder, for example, predicted greater documentation of cues of violence risk, regardless of clinical setting. These findings have medicolegal implications for risk assessment liability and clinical implications for optimizing risk management in psychiatric practice.

Quality assurance in digital dental radiography--justification and dose reduction in dental and maxillofacial radiology.

PubMed

Hellstern, F; Geibel, M-A

2012-01-01

To evaluate the implementation of quality assurance requirements for digital dental radiography in routine clinical practice. The results should be discussed by radiation protection authorities in the context of the relevant legal requirements and current debates on radiation protection. Two hundred digital dental radiographs were randomly selected from the digital database of the Department of Dentistry's Dental and Maxillofacial Surgery Clinic, Ulm University, and evaluated for various aspects of image quality and compliance with radiographic documentation requirements. The dental films were prepared by different radiology assistants (RAs) using one of two digital intraoral radiographic systems: Sirona Heliodent DS, 60 kV, focal spot size: 0.7 mm (group A) or KaVo Gendex 765 DC, 65 kV, focal spot size: 0.4 mm (group B). Radiographic justification was documented in 70.5% of cases, and the radiographic findings in 76.5%. Both variables were documented in the patient records as well as in the software in 14% of cases. Clinical documentation of the required information (name of the responsible dentist and radiology assistant, date, patient name, department, tube voltage, tube current, exposure time, type of radiograph, film size, department and serial number of the dental radiograph) was 100% complete in all cases. Moreover, the department certified according to DIN ISO 9001:2008 specifications demonstrated complete clinical documentation of radiographic justifications and radiographic findings. The entire dentition was visible on 83% of the digital films. The visible area corresponded to the target region on 85.7% of the digital dental radiographs. Seven to 8.5% of the images were classified as "hypometric" or "hypermetric". This study indicates that improvements in radiology training and continuing education fordentists and dental staff performing x-ray examinations are needed to ensure consistent high quality of digital dental radiography. Implementation of internal radiological quality assurance programs, as required by public law in Germany since 2010 (SGB V), would appear prudent.

Documentation of pharmaceutical care: Validation of an intervention oriented classification system.

PubMed

Maes, Karen A; Studer, Helene; Berger, Jérôme; Hersberger, Kurt E; Lampert, Markus L

2017-12-01

During the dispensing process, pharmacists may come across technical and clinical issues requiring a pharmaceutical intervention (PI). An intervention-oriented classification system is a helpful tool to document these PIs in a structured manner. Therefore, we developed the PharmDISC classification system (Pharmacists' Documentation of Interventions in Seamless Care). The aim of this study was to evaluate the PharmDISC system in the daily practice environment (in terms of interrater reliability, appropriateness, interpretability, acceptability, feasibility, and validity); to assess its user satisfaction, the descriptive manual, and the online training; and to explore first implementation aspects. Twenty-one pharmacists from different community pharmacies each classified 30 prescriptions requiring a PI with the PharmDISC system on 5 selected days within 5 weeks. Interrater reliability was determined using model PIs and Fleiss's kappa coefficients (κ) were calculated. User satisfaction was assessed by questionnaire with a 4-point Likert scale. The main outcome measures were interrater reliability (κ); appropriateness, interpretability, validity (ratio of completely classified PIs/all PIs); feasibility, and acceptability (user satisfaction and suggestions). The PharmDISC system reached an average substantial agreement (κ = 0.66). Of documented 519 PIs, 430 (82.9%) were completely classified. Most users found the system comprehensive (median user agreement 3 [2/3.25 quartiles]) and practical (3[2.75/3]). The PharmDISC system raised the awareness regarding drug-related problems for most users (n = 16). To facilitate its implementation, an electronic version that automatically connects to the prescription together with a task manager for PIs needing follow-up was suggested. Barriers could be time expenditure and lack of understanding the benefits. Substantial interrater reliability and acceptable user satisfaction indicate that the PharmDISC system is a valid system to document PIs in daily community pharmacy practice. © 2017 John Wiley & Sons, Ltd.

Online database for documenting clinical pathology resident education.

PubMed

Hoofnagle, Andrew N; Chou, David; Astion, Michael L

2007-01-01

Training of clinical pathologists is evolving and must now address the 6 core competencies described by the Accreditation Council for Graduate Medical Education (ACGME), which include patient care. A substantial portion of the patient care performed by the clinical pathology resident takes place while the resident is on call for the laboratory, a practice that provides the resident with clinical experience and assists the laboratory in providing quality service to clinicians in the hospital and surrounding community. Documenting the educational value of these on-call experiences and providing evidence of competence is difficult for residency directors. An online database of these calls, entered by residents and reviewed by faculty, would provide a mechanism for documenting and improving the education of clinical pathology residents. With Microsoft Access we developed an online database that uses active server pages and secure sockets layer encryption to document calls to the clinical pathology resident. Using the data collected, we evaluated the efficacy of 3 interventions aimed at improving resident education. The database facilitated the documentation of more than 4 700 calls in the first 21 months it was online, provided archived resident-generated data to assist in serving clients, and demonstrated that 2 interventions aimed at improving resident education were successful. We have developed a secure online database, accessible from any computer with Internet access, that can be used to easily document clinical pathology resident education and competency.

A Strategy for Reusing the Data of Electronic Medical Record Systems for Clinical Research.

PubMed

Matsumura, Yasushi; Hattori, Atsushi; Manabe, Shiro; Tsuda, Tsutomu; Takeda, Toshihiro; Okada, Katsuki; Murata, Taizo; Mihara, Naoki

2016-01-01

There is a great need to reuse data stored in electronic medical records (EMR) databases for clinical research. We previously reported the development of a system in which progress notes and case report forms (CRFs) were simultaneously recorded using a template in the EMR in order to exclude redundant data entry. To make the data collection process more efficient, we are developing a system in which the data originally stored in the EMR database can be populated within a frame in a template. We developed interface plugin modules that retrieve data from the databases of other EMR applications. A universal keyword written in a template master is converted to a local code using a data conversion table, then the objective data is retrieved from the corresponding database. The template element data, which are entered by a template, are stored in the template element database. To retrieve the data entered by other templates, the objective data is designated by the template element code with the template code, or by the concept code if it is written for the element. When the application systems in the EMR generate documents, they also generate a PDF file and a corresponding document profile XML, which includes important data, and send them to the document archive server and the data sharing saver, respectively. In the data sharing server, the data are represented by an item with an item code with a document class code and its value. By linking a concept code to an item identifier, an objective data can be retrieved by designating a concept code. We employed a flexible strategy in which a unique identifier for a hospital is initially attached to all of the data that the hospital generates. The identifier is secondarily linked with concept codes. The data that are not linked with a concept code can also be retrieved using the unique identifier of the hospital. This strategy makes it possible to reuse any of a hospital's data.

Speech Recognition as a Transcription Aid: A Randomized Comparison With Standard Transcription

PubMed Central

Mohr, David N.; Turner, David W.; Pond, Gregory R.; Kamath, Joseph S.; De Vos, Cathy B.; Carpenter, Paul C.

2003-01-01

Objective. Speech recognition promises to reduce information entry costs for clinical information systems. It is most likely to be accepted across an organization if physicians can dictate without concerning themselves with real-time recognition and editing; assistants can then edit and process the computer-generated document. Our objective was to evaluate the use of speech-recognition technology in a randomized controlled trial using our institutional infrastructure. Design. Clinical note dictations from physicians in two specialty divisions were randomized to either a standard transcription process or a speech-recognition process. Secretaries and transcriptionists also were assigned randomly to each of these processes. Measurements. The duration of each dictation was measured. The amount of time spent processing a dictation to yield a finished document also was measured. Secretarial and transcriptionist productivity, defined as hours of secretary work per minute of dictation processed, was determined for speech recognition and standard transcription. Results. Secretaries in the endocrinology division were 87.3% (confidence interval, 83.3%, 92.3%) as productive with the speech-recognition technology as implemented in this study as they were using standard transcription. Psychiatry transcriptionists and secretaries were similarly less productive. Author, secretary, and type of clinical note were significant (p < 0.05) predictors of productivity. Conclusion. When implemented in an organization with an existing document-processing infrastructure (which included training and interfaces of the speech-recognition editor with the existing document entry application), speech recognition did not improve the productivity of secretaries or transcriptionists. PMID:12509359

[Homozygous familial hypercholesterolaemia: Spanish adaptation of the position paper from the Consensus Panel on Familial Hypercholesterolaemia of the European Atherosclerosis Society. Consensus document of the Spanish Society of Arteriosclerosis (SEA) and Familial Hypercholesterolaemia Foundation (FHF)].

PubMed

Ascaso, Juan F; Mata, Pedro; Arbona, Cristina; Civeira, Fernando; Valdivielso, Pedro; Masana, Luis

2015-01-01

Homozygous familial hypercholesterolaemia (HoFH) is a rare life-threatening disease characterized by markedly elevated circulating levels of low-density lipoprotein cholesterol (LDL-C) and accelerated, premature atherosclerotic cardiovascular disease (ACVD). The Consensus Panel on Familial Hypercholesterolaemia of the European Atherosclerosis Society (EAS) has recently published a clinical guide to diagnose and manage HoFH (Eur Heart J. 2014;35:2146-57). Both the Spanish Society of Atherosclerosis (SEA) and Familial Hypercholesterolaemia Foundation (FHF) consider this European Consensus document of great value and utility. However, there are particularities in our country which advise to have a Spanish adaptation of the European HoFH document in order to approximate this clinical guide to our environment. In Spain, chronic treatment with statins, ezetimibe and resins (colesevelam) has a reduced contribution in the National Health System (NHS) and is one of the few European countries where LDL apheresis is included in the Basic Service Portfolio coverage. This Spanish document also includes clinical experience in the management of these patients in our country. The Drafting Committee emphasizes the need for early identification of HoFH patients, prompt referral to specialized units, and an early and appropriate treatment. These recommendations will provide a guidance for HoFH patient management in Spain. Copyright © 2015 Sociedad Española de Arteriosclerosis. Published by Elsevier España. All rights reserved.

Development of an open metadata schema for prospective clinical research (openPCR) in China.

PubMed

Xu, W; Guan, Z; Sun, J; Wang, Z; Geng, Y

2014-01-01

In China, deployment of electronic data capture (EDC) and clinical data management system (CDMS) for clinical research (CR) is in its very early stage, and about 90% of clinical studies collected and submitted clinical data manually. This work aims to build an open metadata schema for Prospective Clinical Research (openPCR) in China based on openEHR archetypes, in order to help Chinese researchers easily create specific data entry templates for registration, study design and clinical data collection. Singapore Framework for Dublin Core Application Profiles (DCAP) is used to develop openPCR and four steps such as defining the core functional requirements and deducing the core metadata items, developing archetype models, defining metadata terms and creating archetype records, and finally developing implementation syntax are followed. The core functional requirements are divided into three categories: requirements for research registration, requirements for trial design, and requirements for case report form (CRF). 74 metadata items are identified and their Chinese authority names are created. The minimum metadata set of openPCR includes 3 documents, 6 sections, 26 top level data groups, 32 lower data groups and 74 data elements. The top level container in openPCR is composed of public document, internal document and clinical document archetypes. A hierarchical structure of openPCR is established according to Data Structure of Electronic Health Record Architecture and Data Standard of China (Chinese EHR Standard). Metadata attributes are grouped into six parts: identification, definition, representation, relation, usage guides, and administration. OpenPCR is an open metadata schema based on research registration standards, standards of the Clinical Data Interchange Standards Consortium (CDISC) and Chinese healthcare related standards, and is to be publicly available throughout China. It considers future integration of EHR and CR by adopting data structure and data terms in Chinese EHR Standard. Archetypes in openPCR are modularity models and can be separated, recombined, and reused. The authors recommend that the method to develop openPCR can be referenced by other countries when designing metadata schema of clinical research. In the next steps, openPCR should be used in a number of CR projects to test its applicability and to continuously improve its coverage. Besides, metadata schema for research protocol can be developed to structurize and standardize protocol, and syntactical interoperability of openPCR with other related standards can be considered.

Quality and efficiency successes leveraging IT and new processes.

PubMed

Chaiken, Barry P; Christian, Charles E; Johnson, Liz

2007-01-01

Today, healthcare annually invests billions of dollars in information technology, including clinical systems, electronic medical records and interoperability platforms. While continued investment and parallel development of standards are critical to secure exponential benefits from clinical information technology, intelligent and creative redesign of processes through path innovation is necessary to deliver meaningful value. Reports from two organizations included in this report review the steps taken to reinvent clinical processes that best leverage information technology to deliver safer and more efficient care. Good Samaritan Hospital, Vincennes, Indiana, implemented electronic charting, point-of-care bar coding of medications prior to administration, and integrated clinical documentation for nursing, laboratory, radiology and pharmacy. Tenet Healthcare, during its implementation and deployment of multiple clinical systems across several hospitals, focused on planning that included team-based process redesign. In addition, Tenet constructed valuable and measurable metrics that link outcomes with its strategic goals.

Electronic Medical Record-Based Radiation Oncology Toxicity Recording Instrument Aids Benchmarking and Quality Improvement in the Clinic.

PubMed

Albuquerque, Kevin; Rodgers, Kellie; Spangler, Ann; Rahimi, Asal; Willett, DuWayne

2018-03-01

The on-treatment visit (OTV) for radiation oncology is essential for patient management. Radiation toxicities recorded during the OTV may be inconsistent because of the use of free text and the lack of treatment site-specific templates. We developed a radiation oncology toxicity recording instrument (ROTOX) in a health system electronic medical record (EMR). Our aims were to assess improvement in documentation of toxicities and to develop clinic toxicity benchmarks. A ROTOX that was based on National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.0) with flow-sheet functionality was developed in the EMR. Improvement in documentation was assessed at various time intervals. High-grade toxicities (ie, grade ≥ 3 by CTCAE) by site were audited to develop benchmarks and to track nursing and physician actions taken in response to these. A random sample of OTV notes from each clinic physician before ROTOX implementation was reviewed and assigned a numerical document quality score (DQS) that was based on completeness and comprehensiveness of toxicity grading. The mean DQS improved from an initial level of 41% to 99% (of the maximum possible DQS) when resampled at 6 months post-ROTOX. This high-level DQS was maintained 3 years after ROTOX implementation at 96% of the maximum. For months 7 to 9 after implementation (during a 3-month period), toxicity grading was recorded in 4,443 OTVs for 698 unique patients; 107 episodes of high-grade toxicity were identified during this period, and toxicity-specific intervention was documented in 95%. An EMR-based ROTOX enables consistent recording of treatment toxicity. In a uniform sample of patients, local population toxicity benchmarks can be developed, and clinic response can be tracked.

A Methodology for Validating Safety Heuristics Using Clinical Simulations: Identifying and Preventing Possible Technology-Induced Errors Related to Using Health Information Systems

PubMed Central

Borycki, Elizabeth; Kushniruk, Andre; Carvalho, Christopher

2013-01-01

Internationally, health information systems (HIS) safety has emerged as a significant concern for governments. Recently, research has emerged that has documented the ability of HIS to be implicated in the harm and death of patients. Researchers have attempted to develop methods that can be used to prevent or reduce technology-induced errors. Some researchers are developing methods that can be employed prior to systems release. These methods include the development of safety heuristics and clinical simulations. In this paper, we outline our methodology for developing safety heuristics specific to identifying the features or functions of a HIS user interface design that may lead to technology-induced errors. We follow this with a description of a methodological approach to validate these heuristics using clinical simulations. PMID:23606902

Promoting Nursing Students' Clinical Learning Through a Mobile e-Portfolio.

PubMed

Lai, Chin-Yuan; Wu, Cheng-Chih

2016-11-01

Portfolios have been advocated in nursing education to help student link theory and practice. In this study, we document the development of a mobile e-portfolio-based system, which was used to improve nursing education. The e-portfolio-based system has the advantage of allowing students to record, assess, and reflect upon their learning whether at school, a clinical site, or at home. This e-portfolio system was field tested in a 3-week psychiatric nursing practicum session involving 10 female students who were enrolled in a junior nursing college. A mixed-methods study combining qualitative and quantitative data was conducted to investigate the effects of using the system. The results of the study demonstrated that students made professional progress in both theory and practice after using the e-portfolio system. The system could also promote self-regulated learning in clinical context. Students displayed very positive attitudes overall when using the system, although there were some occasional stresses and technical difficulties. Important factors when implementing such a system included the following: adopting the proper mobile device, providing students with clear guidance on constructing the e-portfolio, and how to use the e-portfolio in a clinical setting.

Identification of design features to enhance utilization and acceptance of systems for Internet-based decision support at the point of care.

PubMed

Gadd, C S; Baskaran, P; Lobach, D F

1998-01-01

Extensive utilization of point-of-care decision support systems will be largely dependent on the development of user interaction capabilities that make them effective clinical tools in patient care settings. This research identified critical design features of point-of-care decision support systems that are preferred by physicians, through a multi-method formative evaluation of an evolving prototype of an Internet-based clinical decision support system. Clinicians used four versions of the system--each highlighting a different functionality. Surveys and qualitative evaluation methodologies assessed clinicians' perceptions regarding system usability and usefulness. Our analyses identified features that improve perceived usability, such as telegraphic representations of guideline-related information, facile navigation, and a forgiving, flexible interface. Users also preferred features that enhance usefulness and motivate use, such as an encounter documentation tool and the availability of physician instruction and patient education materials. In addition to identifying design features that are relevant to efforts to develop clinical systems for point-of-care decision support, this study demonstrates the value of combining quantitative and qualitative methods of formative evaluation with an iterative system development strategy to implement new information technology in complex clinical settings.

Crossing the "digital divide:" implementing an electronic medical record system in a rural Kenyan health center to support clinical care and research.

PubMed

Tierney, William M; Rotich, Joseph K; Smith, Faye E; Bii, John; Einterz, Robert M; Hannan, Terry J

2002-01-01

To improve care, one must measure it. In the US, electronic medical record systems have been installed in many institutions to support health care management, quality improvement, and research. Developing countries lack such systems and thus have difficulties managing scarce resources and investigating means of improving health care delivery and outcomes. We describe the implementation and use of the first documented electronic medical record system in ambulatory care in sub-Saharan Africa. After one year, it has captured data for more than 13,000 patients making more than 26,000 visits. We present lessons learned and modifications made to this system to improve its capture of data and ability to support a comprehensive clinical care and research agenda.

Mapping the Early Intervention System in Ontario, Canada

ERIC Educational Resources Information Center

Underwood, Kathryn

2012-01-01

This study documents the wide range of early intervention services across the province of Ontario. The services are mapped across the province showing geographic information as well as the scope of services (clinical, family-based, resource support, etc.), the range of early intervention professionals, sources of funding and the populations served…

Categorizing Drugs and Drug-Taking: A More Meaningful Approach.

ERIC Educational Resources Information Center

Gold, Robert S.; Duncan, David F.

This document reviews various definitions of the nature and classification of drugs. Difficulties with existing categorizations which use such bases as clinical utility, molecular structure, effects on the central nervous system, legality, and hazard potential are disucssed. A more meaningful categorization based on the availability and sources of…

The effects of the application of SIMPRO on the completeness and time efficiency of nursing documentation in the outpatient instalation at Dompet Dhuafa Hospital Parung

NASA Astrophysics Data System (ADS)

Dwisatyadini, M.; Hariyati, R. T. S.; Afifah, E.

2018-03-01

Nursing documentation is clinical information that has a vital role in nursing services. The nursing process includes assessment, diagnosis, intervention, implementation, and evaluation. The purpose of this study was to determine the effects of the application of SIMPRO on the completeness and the efficiency of nursing documentation in the outpatient installation at Dompet Dhuafa Hospital Parung. This study used quantitative method with pre experimental (pre and posttest without control group) design. The mean of the documentation completeness marks before the application of SIMPRO was 1.87 (SD 0.922), and after SIMPRO was applied increased to 3.61 (0.588). This increase indicated an improvement of the nursing documentation completeness after the implementation of SIMPRO. The mean of time needed by nurses in documenting the nursing care before the application of SIMPRO was 476.13 seconds (SD 78.896). The mean of documenting time decreased more than a half after the application of SIMPRO which was 202.52 seconds (SD 196.723). SIMPRO made a nurse easier to take a decision analysis and decision support system to nursing care plan and documentation.

Automated encoding of clinical documents based on natural language processing.

PubMed

Friedman, Carol; Shagina, Lyudmila; Lussier, Yves; Hripcsak, George

2004-01-01

The aim of this study was to develop a method based on natural language processing (NLP) that automatically maps an entire clinical document to codes with modifiers and to quantitatively evaluate the method. An existing NLP system, MedLEE, was adapted to automatically generate codes. The method involves matching of structured output generated by MedLEE consisting of findings and modifiers to obtain the most specific code. Recall and precision applied to Unified Medical Language System (UMLS) coding were evaluated in two separate studies. Recall was measured using a test set of 150 randomly selected sentences, which were processed using MedLEE. Results were compared with a reference standard determined manually by seven experts. Precision was measured using a second test set of 150 randomly selected sentences from which UMLS codes were automatically generated by the method and then validated by experts. Recall of the system for UMLS coding of all terms was .77 (95% CI.72-.81), and for coding terms that had corresponding UMLS codes recall was .83 (.79-.87). Recall of the system for extracting all terms was .84 (.81-.88). Recall of the experts ranged from .69 to .91 for extracting terms. The precision of the system was .89 (.87-.91), and precision of the experts ranged from .61 to .91. Extraction of relevant clinical information and UMLS coding were accomplished using a method based on NLP. The method appeared to be comparable to or better than six experts. The advantage of the method is that it maps text to codes along with other related information, rendering the coded output suitable for effective retrieval.

Sustainable ubiquitous home health care--architectural considerations and first practical experiences.

PubMed

Marschollek, Michael; Wolf, Klaus-H; Bott, Oliver-J; Geisler, Mirko; Plischke, Maik; Ludwig, Wolfram; Hornberger, Andreas; Haux, Reinhold

2007-01-01

Despite the abundance of past home care projects and the maturity of the technologies used, there is no widespread dissemination as yet. The absence of accepted standards and thus interoperability and the inadequate integration into transinstitutional health information systems (tHIS) are perceived as key factors. Based on the respective literature and previous experiences in home care projects we propose an architectural model for home care as part of a transinstitutional health information system using the HL7 clinical document architecture (CDA) as well as the HL7 Arden Syntax for Medical Logic Systems. In two short case studies we describe the practical realization of the architecture as well as first experiences. Our work can be regarded as a first step towards an interoperable - and in our view sustainable - home care architecture based on a prominent document standard from the health information system domain.

Update of the Mexican College of Rheumatology guidelines for the pharmacologic treatment of rheumatoid arthritis.

PubMed

Cardiel, Mario H; Díaz-Borjón, Alejandro; Vázquez del Mercado Espinosa, Mónica; Gámez-Nava, Jorge Iván; Barile Fabris, Leonor A; Pacheco Tena, César; Silveira Torre, Luis H; Pascual Ramos, Virginia; Goycochea Robles, María Victoria; Aguilar Arreola, Jorge Enrique; González Díaz, Verónica; Alvarez Nemegyei, José; González-López, Laura del Carmen; Salazar Páramo, Mario; Portela Hernández, Margarita; Castro Colín, Zully; Xibillé Friedman, Daniel Xavier; Alvarez Hernández, Everardo; Casasola Vargas, Julio; Cortés Hernández, Miguel; Flores-Alvarado, Diana E; Martínez Martínez, Laura A; Vega-Morales, David; Flores-Suárez, Luis Felipe; Medrano Ramírez, Gabriel; Barrera Cruz, Antonio; García González, Adolfo; López López, Susana Marisela; Rosete Reyes, Alejandra; Espinosa Morales, Rolando

2014-01-01

The pharmacologic management of rheumatoid arthritis has progressed substantially over the past years. It is therefore desirable that existing information be periodically updated. There are several published international guidelines for the treatment of rheumatoid arthritis that hardly adapt to the Mexican health system because of its limited healthcare resources. Hence, it is imperative to unify the existing recommendations and to incorporate them to a set of clinical, updated recommendations; the Mexican College of Rheumatology developed these recommendations in order to offer an integral management approach of rheumatoid arthritis according to the resources of the Mexican health system. To review, update and improve the available evidence within clinical practice guidelines on the pharmacological management of rheumatoid arthritis and produce a set of recommendations adapted to the Mexican health system, according to evidence available through December 2012. The working group was composed of 30 trained and experienced rheumatologists with a high quality of clinical knowledge and judgment. Recommendations were based on the highest quality evidence from the previously established treatment guidelines, meta-analysis and controlled clinical trials for the adult population with rheumatoid arthritis. During the conformation of this document, each working group settled the existing evidence from the different topics according to their experience. Finally, all the evidence and decisions were unified into a single document, treatment algorithm and drug standardization tables. This update of the Mexican Guidelines for the Pharmacologic Treatment of Rheumatoid Arthritis provides the highest quality information available at the time the working group undertook this review and contextualizes its use for the complex Mexican health system. Copyright © 2013 Elsevier España, S.L. All rights reserved.

A Data Accounting System for Clinical Investigators

PubMed Central

Kashner, T. Michael; Hinson, Robert; Holland, Gloria J.; Mickey, Don D.; Hoffman, Keith; Lind, Lisa; Johnson, Linda D.; Chang, Barbara K.; Golden, Richard M.; Henley, Steven S.

2007-01-01

Clinical investigators often preprocess, process, and analyze their data without benefit of formally organized research centers to oversee data management. This article outlines a practical three-file structure to help guide these investigators track and document their data through processing and analyses. The proposed process can be implemented without additional training or specialized software. Thus, it is particularly well suited for research projects with small budgets or limited access to viable research/data coordinating centers. PMID:17460138

Differences in the diagnosis and management of systemic lupus erythematosus by primary care and specialist providers in the American Indian/Alaska Native population.

PubMed

McDougall, J A; Helmick, C G; Lim, S S; Johnston, J M; Gaddy, J R; Gordon, C; Ferucci, E D

2018-06-01

Objectives The objective of this study is to investigate differences in the diagnosis and management of systemic lupus erythematosus (SLE) by primary care and specialist physicians in a population-based registry. Methods This study includes individuals from the 2009 Indian Health Service lupus registry population with a diagnosis of SLE documented by either a primary care provider or specialist. SLE classification criteria, laboratory testing, and medication use at any time during the course of disease were determined by medical record abstraction. Results Of the 320 individuals with a diagnosis of SLE, 249 had the diagnosis documented by a specialist, with 71 documented by primary care. Individuals with a specialist diagnosis of SLE were more likely to have medical record documentation of meeting criteria for SLE by all criteria sets (American College of Rheumatology, 79% vs 22%; Boston Weighted, 82% vs 32%; and Systemic Lupus International Collaborating Clinics, 83% vs 35%; p < 0.001 for all comparisons). In addition, specialist diagnosis was associated with documentation of ever having been tested for anti-double-stranded DNA antibody and complement 3 and complement 4 ( p < 0.001). Documentation of ever receiving hydroxychloroquine was also more common with specialist diagnosis (86% vs 64%, p < 0.001). Conclusions Within the population studied, specialist diagnosis of SLE was associated with a higher likelihood of having SLE classification criteria documented, being tested for biomarkers of disease, and ever receiving treatment with hydroxychloroquine. These data support efforts both to increase specialist access for patients with suspected SLE and to provide lupus education to primary care providers.

Goals of patient care system change with video-based education increases rates of advance cardiopulmonary resuscitation decision-making and discussions in hospitalised rehabilitation patients.

PubMed

Johnson, Claire E; Chong, Jeffrey C; Wilkinson, Anne; Hayes, Barbara; Tait, Sonia; Waldron, Nicholas

2017-07-01

Advance cardiopulmonary resuscitation (CPR) discussions and decision-making are not routine clinical practice in the hospital setting. Frail older patients may be at risk of non-beneficial CPR. To assess the utility and safety of two interventions to increase CPR decision-making, documentation and communication for hospitalised older patients. A pre-post study tested two interventions: (i) standard ward-based education forums with CPR content; and (ii) a combined, two-pronged strategy with 'Goals of Patient Care' (GoPC) system change and a structured video-based workshop; against usual practice (i.e. no formal training). Participants were a random sample of patients in a hospital rehabilitation unit. The outcomes were the proportion of patients documented as: (i) not for resuscitation (NFR); and (ii) eligible for rapid response team (RRT) calls, and rates of documented discussions with the patient, family and carer. When compared with usual practice, patients were more likely to be documented as NFR following the two-pronged intervention (adjusted odds ratio (aOR): 6.4, 95% confidence interval (CI): 3.0; 13.6). Documentation of discussions with patients was also more likely (aOR: 3.3, 95% CI:1.8; 6.2). Characteristics of patients documented NFR were similar between the phases, but were more likely for RRT calls following Phase 3 (P 0.03). An increase in advance CPR decisions occurred following GoPC system change with education. This appears safe as NFR patients had the same level of frailty between phases but were more likely to be eligible for RRT review. Increased documentation of discussions suggests routine use of the GoPC form may improve communication with patients about their care. © 2017 Royal Australasian College of Physicians.

Evaluating faculty clinical excellence in the academic health sciences center.

PubMed

Carey, R M; Wheby, M S; Reynolds, R E

1993-11-01

Although excellence in the clinical care of patients is the cornerstone of medicine, academic health sciences centers have increasingly given more weight to research and correspondingly less emphasis to patient care. To better recognize and reward clinical excellence, it is first necessary to effectively evaluate physicians' performances in patient care. In addition to addressing the value of faculty clinical excellence in the academic setting, the authors discuss different approaches to clinical assessment, theoretical and practical problems in assessing the performances of clinical faculty, and a system of evaluation being initiated at the University of Virginia School of Medicine. This system of evaluation combines--in annual individual reviews--a limited amount of objective assessment data with subjective evaluations from several sources. The objective data include board certification and recertification, analysis of outcomes data, and documentation of scholarly activity. The subjective evaluations include letters of recognition and appreciation from faculty colleagues and written observations from department chairs, housestaff, students, and nurses. The system has been accepted by department chairs, members of the Promotion and Tenure Committee, and the general faculty. In implementing this new system, periodic review of the pace and direction of change will be crucial to track progress and provide feedback for further modification.

[SmartCare: automatizing clinical guidelines].

PubMed

Mersmann, Stefan

2009-10-01

In critical care environments, important medical and economic challenges are presented by the enhancement of therapeutic quality and the reduction of therapeutic costs. For this purpose, several clinical studies have demonstrated a positive impact of the adoption of so-called clinical guidelines. Clinical guidelines represent well documented best practices in healthcare and are fundamental aspects of evidence-based medicine. However, at the bedside, such clinical guidelines remain difficult to use by clinical staff. The knowledge-based technology SmartCare allows incorporation of arbitrary computerized clinical guidelines into various medical target systems. SmartCare constitutes a clinical guideline engine because it executes one or more clinical guidelines on a specific medical device. SmartCare was initially applied for the automated control of a mechanical ventilator to assist the process of weaning from a medical device. The methodology allows further applications to be implemented effectively with other medical devices and/or with other appropriate guidelines. In this paper, we report on the methodology and the resulting versatility of such a system, as well as the clinical evaluation of SmartCare/PS and its perspectives.

Neuroradiological findings of trisomy 13 in a rare long-term survivor.

PubMed

Goff, Ryan D; Soares, Bruno P

2017-01-01

Patau syndrome remains a difficult diagnosis for parents and a challenging conversation for clinicians due to the overall poor prognosis. Previous population-based reports have documented the sobering life expectancies of these patients, with few surviving to 1 year of age. Despite the high mortality rate in infants born with trisomy 13, there are several reports of survival into late childhood and early adulthood. While clinical outcomes have been well documented, there has been a paucity of literature describing postnatal imaging findings in long-term survivors. We present a case report of a 2-year-old girl with trisomy 13 who underwent brain magnetic resonance imaging examination at our institution to evaluate for possible structural abnormalities contributing to central sleep apnea. We describe the clinical and postnatal neuroimaging findings of this rare patient with trisomy 13. Understanding the spectrum of neuroradiological findings in long-term survivors with trisomy 13, in combination with other organ system abnormalities, could add important clinical information and help better predict patient outcomes and expectations among parents.

“Smart Forms” in an Electronic Medical Record: Documentation-based Clinical Decision Support to Improve Disease Management

PubMed Central

Schnipper, Jeffrey L.; Linder, Jeffrey A.; Palchuk, Matvey B.; Einbinder, Jonathan S.; Li, Qi; Postilnik, Anatoly; Middleton, Blackford

2008-01-01

Clinical decision support systems (CDSS) integrated within Electronic Medical Records (EMR) hold the promise of improving healthcare quality. To date the effectiveness of CDSS has been less than expected, especially concerning the ambulatory management of chronic diseases. This is due, in part, to the fact that clinicians do not use CDSS fully. Barriers to clinicians' use of CDSS have included lack of integration into workflow, software usability issues, and relevance of the content to the patient at hand. At Partners HealthCare, we are developing “Smart Forms” to facilitate documentation-based clinical decision support. Rather than being interruptive in nature, the Smart Form enables writing a multi-problem visit note while capturing coded information and providing sophisticated decision support in the form of tailored recommendations for care. The current version of the Smart Form is designed around two chronic diseases: coronary artery disease and diabetes mellitus. The Smart Form has potential to improve the care of patients with both acute and chronic conditions. PMID:18436911

"Smart Forms" in an Electronic Medical Record: documentation-based clinical decision support to improve disease management.

PubMed

Schnipper, Jeffrey L; Linder, Jeffrey A; Palchuk, Matvey B; Einbinder, Jonathan S; Li, Qi; Postilnik, Anatoly; Middleton, Blackford

2008-01-01

Clinical decision support systems (CDSS) integrated within Electronic Medical Records (EMR) hold the promise of improving healthcare quality. To date the effectiveness of CDSS has been less than expected, especially concerning the ambulatory management of chronic diseases. This is due, in part, to the fact that clinicians do not use CDSS fully. Barriers to clinicians' use of CDSS have included lack of integration into workflow, software usability issues, and relevance of the content to the patient at hand. At Partners HealthCare, we are developing "Smart Forms" to facilitate documentation-based clinical decision support. Rather than being interruptive in nature, the Smart Form enables writing a multi-problem visit note while capturing coded information and providing sophisticated decision support in the form of tailored recommendations for care. The current version of the Smart Form is designed around two chronic diseases: coronary artery disease and diabetes mellitus. The Smart Form has potential to improve the care of patients with both acute and chronic conditions.

What big size you have! Using effect sizes to determine the impact of public health nursing interventions.

PubMed

Johnson, K E; McMorris, B J; Raynor, L A; Monsen, K A

2013-01-01

The Omaha System is a standardized interface terminology that is used extensively by public health nurses in community settings to document interventions and client outcomes. Researchers using Omaha System data to analyze the effectiveness of interventions have typically calculated p-values to determine whether significant client changes occurred between admission and discharge. However, p-values are highly dependent on sample size, making it difficult to distinguish statistically significant changes from clinically meaningful changes. Effect sizes can help identify practical differences but have not yet been applied to Omaha System data. We compared p-values and effect sizes (Cohen's d) for mean differences between admission and discharge for 13 client problems documented in the electronic health records of 1,016 young low-income parents. Client problems were documented anywhere from 6 (Health Care Supervision) to 906 (Caretaking/parenting) times. On a scale from 1 to 5, the mean change needed to yield a large effect size (Cohen's d ≥ 0.80) was approximately 0.60 (range = 0.50 - 1.03) regardless of p-value or sample size (i.e., the number of times a client problem was documented in the electronic health record). Researchers using the Omaha System should report effect sizes to help readers determine which differences are practical and meaningful. Such disclosures will allow for increased recognition of effective interventions.

Comprehensive modeling of critical health care activities, costs, and data needs within the context of addiction rehabilitiation

NASA Astrophysics Data System (ADS)

Hoffman, Kenneth J.; Keithley, Hudson

1994-12-01

There are few systems which aggregate standardized pertinent clinical observations of discrete patient problems and resolutions. The systematic information supplied by clinicians is generally provided to justify reimbursement from insurers. Insurers, by their nature, and expert in modeling health care costs by diagnosis, procedures, and population risk groups. Medically, they rely on clinician generated diagnostic and coded procedure information. Clinicians will document a patient's status at a discrete point in time through narrative. Clinical notes do not support aggregate and systematic analysis of outcome. A methodology exists and has been used by the US Army Drug and Alcohol Program to model the clinical activities, associated costs, and data requirements of an outpatient clinic. This has broad applicability for a comprehensive health care system to which patient costs and data requirements can be established.

A dictionary server for supplying context sensitive medical knowledge.

PubMed

Ruan, W; Bürkle, T; Dudeck, J

2000-01-01

The Giessen Data Dictionary Server (GDDS), developed at Giessen University Hospital, integrates clinical systems with on-line, context sensitive medical knowledge to help with making medical decisions. By "context" we mean the clinical information that is being presented at the moment the information need is occurring. The dictionary server makes use of a semantic network supported by a medical data dictionary to link terms from clinical applications to their proper information sources. It has been designed to analyze the network structure itself instead of knowing the layout of the semantic net in advance. This enables us to map appropriate information sources to various clinical applications, such as nursing documentation, drug prescription and cancer follow up systems. This paper describes the function of the dictionary server and shows how the knowledge stored in the semantic network is used in the dictionary service.

Developing a system to track meaningful outcome measures in head and neck cancer treatment.

PubMed

Walters, Ronald S; Albright, Heidi W; Weber, Randal S; Feeley, Thomas W; Hanna, Ehab Y; Cantor, Scott B; Lewis, Carol M; Burke, Thomas W

2014-02-01

The health care industry, including consumers, providers, and payers of health care, recognize the importance of developing meaningful, patient-centered measures. This article describes our experience using an existing electronic medical record largely based on free text formats without structured documentation, in conjunction with tumor registry abstraction techniques, to obtain and analyze data for use in clinical improvement and public reporting. We performed a retrospective analysis of 2467 previously untreated patients treated with curative intent who presented with laryngeal, pharyngeal, or oral cavity cancer in order to develop a system to monitor and report meaningful outcome metrics of head and neck cancer treatment. Patients treated between 1995 and 2006 were analyzed for the primary outcomes of survival at 1 and 2 years, the ability to speak at 1 year posttreatment, and the ability to swallow at 1 year posttreatment. We encountered significant limitations in clinical documentation because of the lack of standardization of meaningful measures, as well limitations with data abstraction using a retrospective approach to reporting measures. Almost 5000 person-hours were required for data abstraction, quality review, and reporting, at a cost of approximately $134,000. Our multidisciplinary teams document extensive patient information; however, data is not stored in easily accessible formats for measurement, comparison, and reporting. We recommend identifying measures meaningful to patients, providers, and payers to be documented throughout the patients' entire treatment cycle, and significant investment in the improvements to electronic medical records and tumor registry reporting in order to provide meaningful quality measures for the future. Copyright © 2013 Wiley Periodicals, Inc.

Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey.

PubMed

Kilic, Bulent; Kalaca, Sibel; Unal, Belgin; Phillimore, Peter; Zaman, Shahaduz

2015-01-01

Current capacity of the Turkish health system is reviewed to evaluate and develop appropriate policies for cardiovascular diseases (CVD), diabetes mellitus (DM) and related risk factors. This paper qualitatively evaluates existing policies; interviews with key informants (KIs); and rapid appraisal fieldwork in clinical settings about CVD-DM through the framework of Walt and Gilson (Health Policy Plan 9:353-370, 1994). Document review shows that prevention and control of CVD-DM were strongly addressed in Turkey, yet no document mentioned country-wide early detection or screening programs. KIs indicated over-fragmented management of CVD-DM by the Ministry of Health (MoH). Coordination among the MoH, organizational structure at provincial level and civil society organizations are poor where mutual trust is a significant problem according to KIs. Clinical setting findings point to a complete lack of a referral structure and a lack of follow-up, compounding the absence of functioning health information systems for patient records. Primary care services for CVD-DM require urgent attention, focusing particularly on the training of staff in public facilities, the integration of patient data, referrals and follow-up across all levels of the health system.

Process-oriented integration and coordination of healthcare services across organizational boundaries.

PubMed

Tello-Leal, Edgar; Chiotti, Omar; Villarreal, Pablo David

2012-12-01

The paper presents a methodology that follows a top-down approach based on a Model-Driven Architecture for integrating and coordinating healthcare services through cross-organizational processes to enable organizations providing high quality healthcare services and continuous process improvements. The methodology provides a modeling language that enables organizations conceptualizing an integration agreement, and identifying and designing cross-organizational process models. These models are used for the automatic generation of: the private view of processes each organization should perform to fulfill its role in cross-organizational processes, and Colored Petri Net specifications to implement these processes. A multi-agent system platform provides agents able to interpret Colored Petri-Nets to enable the communication between the Healthcare Information Systems for executing the cross-organizational processes. Clinical documents are defined using the HL7 Clinical Document Architecture. This methodology guarantees that important requirements for healthcare services integration and coordination are fulfilled: interoperability between heterogeneous Healthcare Information Systems; ability to cope with changes in cross-organizational processes; guarantee of alignment between the integrated healthcare service solution defined at the organizational level and the solution defined at technological level; and the distributed execution of cross-organizational processes keeping the organizations autonomy.

[The Breast Unit in the European and national policy documents: similarities and differences].

PubMed

Marcon, Anna; Albertini, Giovanna; Di Gregori, Valentina; Ghirarduzzi, Angelo; Fantini, Maria Pia

2013-11-01

Aim of this study is to assess differences and similarities in official European and Italian Ministry of Health policy documents referring to the subject "Breast Unit". The T-Lab software package for textual analysis was used to analyze the documents. This instrument permits the identification of the most frequent used words and the semantic network associated with "Breast Unit". Results show that the European document gives more emphasis to the concept of "integrated care", delivered by a multi-professional team that meets the clinical, psychological and informational needs of the patient. The Italian document gives more prominence to themes related to the clinical content of the interventions and managerial aspects through the use of clinical guidelines.

Cutaneous sarcoidosis: clinicopathologic study of 76 patients from Lebanon.

PubMed

Ishak, Rim; Kurban, Mazen; Kibbi, Abdul-Ghani; Abbas, Ossama

2015-01-01

Sarcoidosis is a multi-system granulomatous disease of unknown etiology. The skin is involved in 25% of cases. Studies on cutaneous sarcoidosis from our region are lacking. This study was conducted to describe clinical and histopathologic findings in all patients diagnosed with cutaneous sarcoidosis at the American University of Beirut Medical Center between 1992 and 2010 and to compare findings with those published in the literature. Clinical charts of patients with cutaneous sarcoidosis were retrospectively reviewed. Extracutaneous lesions were classified by organ involvement. Treatment was documented. Pathology specimens were reviewed. Cutaneous sarcoidosis was diagnosed in 76 Lebanese patients, 79% of whom were women. Mean age at diagnosis was 48 years. A total of 29% of patients had systemic disease that was commonly associated with lupus pernio lesions and subcutaneous sarcoidosis. The most common cutaneous lesions were sarcoidal plaques. The histopathologic features in our series did not differ from those described in the literature, except for the documented presence of a grenz zone. Interestingly, 23% of biopsy specimens contained perineural granulomas, raising the possibility of tuberculoid or borderline tuberculoid leprosy. Foreign bodies were detected in 10% of cases (all had systemic involvement), supporting the opinion that sarcoidosis and granulomatous foreign body reaction are not mutually exclusive. The clinical and histopathologic features of cutaneous sarcoidosis patients in the present series are generally comparable with those published in the literature, with minor differences. Clinically, the most commonly seen lesion was plaque. Microscopically, cutaneous sarcoidosis may exhibit a grenz zone and may show perineural inflammation and foreign bodies. © 2014 The International Society of Dermatology.

Implementation of an Anesthesia Information Management System (AIMS)

PubMed Central

Douglas, James R.; Ritter, Melody J.

2011-01-01

During the administration of anesthesia, the anesthesia provider has historically created a paper record, charted manually, that included extensive patient care–related data (vital signs, other parameters, etc) and commentaries. DocuSys, a proprietary anesthesia information management system (AIMS), creates an electronic version of the anesthesia record and provides additional information. It electronically captures data from clinical monitors and other sources, including scheduling applications and laboratory computers. The AIMS facilitates chart entries such as drug doses and case narratives. Benefits of an AIMS include improved legibility of the anesthesia record and greater efficiency in documentation efforts. Use of the AIMS assists the practitioner with decision support logic, such as the timing of antibiotic administration and the inclusion of legally required documentation. Upon case completion, the AIMS data are immediately available to other information systems, such as billing and medical records. Data can be made available from a single case or, more important, from thousands of cases to analyze variables such as efficiency of services, adherence to best practices, patient outcomes, and clinical research. The AIMS was deployed at the main campus of the Ochsner Health System on March 26, 2009. In this article, we discuss the issues involved in the AIMS implementation process: the successes, surprises, and continued challenges. PMID:21734847

Implementation of an Anesthesia Information Management System (AIMS).

PubMed

Douglas, James R; Ritter, Melody J

2011-01-01

During the administration of anesthesia, the anesthesia provider has historically created a paper record, charted manually, that included extensive patient care-related data (vital signs, other parameters, etc) and commentaries. DocuSys, a proprietary anesthesia information management system (AIMS), creates an electronic version of the anesthesia record and provides additional information. It electronically captures data from clinical monitors and other sources, including scheduling applications and laboratory computers. The AIMS facilitates chart entries such as drug doses and case narratives. Benefits of an AIMS include improved legibility of the anesthesia record and greater efficiency in documentation efforts. Use of the AIMS assists the practitioner with decision support logic, such as the timing of antibiotic administration and the inclusion of legally required documentation. Upon case completion, the AIMS data are immediately available to other information systems, such as billing and medical records. Data can be made available from a single case or, more important, from thousands of cases to analyze variables such as efficiency of services, adherence to best practices, patient outcomes, and clinical research. The AIMS was deployed at the main campus of the Ochsner Health System on March 26, 2009. In this article, we discuss the issues involved in the AIMS implementation process: the successes, surprises, and continued challenges.

Advances in heart rate variability signal analysis: joint position statement by the e-Cardiology ESC Working Group and the European Heart Rhythm Association co-endorsed by the Asia Pacific Heart Rhythm Society.

PubMed

Sassi, Roberto; Cerutti, Sergio; Lombardi, Federico; Malik, Marek; Huikuri, Heikki V; Peng, Chung-Kang; Schmidt, Georg; Yamamoto, Yoshiharu

2015-09-01

Following the publication of the Task Force document on heart rate variability (HRV) in 1996, a number of articles have been published to describe new HRV methodologies and their application in different physiological and clinical studies. This document presents a critical review of the new methods. A particular attention has been paid to methodologies that have not been reported in the 1996 standardization document but have been more recently tested in sufficiently sized populations. The following methods were considered: Long-range correlation and fractal analysis; Short-term complexity; Entropy and regularity; and Nonlinear dynamical systems and chaotic behaviour. For each of these methods, technical aspects, clinical achievements, and suggestions for clinical application were reviewed. While the novel approaches have contributed in the technical understanding of the signal character of HRV, their success in developing new clinical tools, such as those for the identification of high-risk patients, has been rather limited. Available results obtained in selected populations of patients by specialized laboratories are nevertheless of interest but new prospective studies are needed. The investigation of new parameters, descriptive of the complex regulation mechanisms of heart rate, has to be encouraged because not all information in the HRV signal is captured by traditional methods. The new technologies thus could provide after proper validation, additional physiological, and clinical meaning. Multidisciplinary dialogue and specialized courses in the combination of clinical cardiology and complex signal processing methods seem warranted for further advances in studies of cardiac oscillations and in the understanding normal and abnormal cardiac control processes. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

PACS and electronic health records

NASA Astrophysics Data System (ADS)

Cohen, Simona; Gilboa, Flora; Shani, Uri

2002-05-01

Electronic Health Record (EHR) is a major component of the health informatics domain. An important part of the EHR is the medical images obtained over a patient's lifetime and stored in diverse PACS. The vision presented in this paper is that future medical information systems will convert data from various medical sources -- including diverse modalities, PACS, HIS, CIS, RIS, and proprietary systems -- to HL7 standard XML documents. Then, the various documents are indexed and compiled to EHRs, upon which complex queries can be posed. We describe the conversion of data retrieved from PACS systems through DICOM to HL7 standard XML documents. This enables the EHR system to answer queries such as 'Get all chest images of patients at the age of 20-30, that have blood type 'A' and are allergic to pine trees', which a single PACS cannot answer. The integration of data from multiple sources makes our approach capable of delivering such answers. It enables the correlation of medical, demographic, clinical, and even genetic information. In addition, by fully indexing all the tagged data in DICOM objects, it becomes possible to offer access to huge amounts of valuable data, which can be better exploited in the specific radiology domain.

The Ohio Gestational Diabetes Postpartum Care Learning Collaborative: Development of a Quality Improvement Initiative to Improve Systems of Care for Women.

PubMed

Shellhaas, Cynthia; Conrey, Elizabeth; Crane, Dushka; Lorenz, Allison; Wapner, Andrew; Oza-Frank, Reena; Bouchard, Jo

2016-11-01

Objectives To improve clinical practice and increase postpartum visit Type 2 diabetes mellitus (T2DM) screening rates in women with a history of gestational diabetes mellitus (GDM). Methods We recruited clinical sites with at least half of pregnant patients enrolled in Medicaid to participate in an 18-month quality improvement (QI) project. To support clinical practice changes, we developed provider and patient toolkits with educational and clinical practice resources. Clinical subject-matter experts facilitated a learning network to train sites and promote discussion and learning among sites. Sites submitted data from patient chart reviews monthly for key measures that we used to provide rapid-cycle feedback. Providers were surveyed at completion regarding toolkit usefulness and satisfaction. Results Of fifteen practices recruited, twelve remained actively engaged. We disseminated more than 70 provider and 2345 patient toolkits. Documented delivery of patient education improved for timely GDM prenatal screening, reduction of future T2DM risk, smoking cessation, and family planning. Sites reported toolkits were useful and easy to use. Of women for whom postpartum data were available, 67 % had a documented postpartum visit and 33 % had a postpartum T2DM screen. Lack of information sharing between prenatal and postpartum care providers was are barriers to provision and documentation of care. Conclusions for Practice QI and toolkit resources may improve the quality of prenatal education. However, postpartum care did not reach optimal levels. Future work should focus on strategies to support coordination of care between obstetrical and primary care providers.

Taking advantage of continuity of care documents to populate a research repository.

PubMed

Klann, Jeffrey G; Mendis, Michael; Phillips, Lori C; Goodson, Alyssa P; Rocha, Beatriz H; Goldberg, Howard S; Wattanasin, Nich; Murphy, Shawn N

2015-03-01

Clinical data warehouses have accelerated clinical research, but even with available open source tools, there is a high barrier to entry due to the complexity of normalizing and importing data. The Office of the National Coordinator for Health Information Technology's Meaningful Use Incentive Program now requires that electronic health record systems produce standardized consolidated clinical document architecture (C-CDA) documents. Here, we leverage this data source to create a low volume standards based import pipeline for the Informatics for Integrating Biology and the Bedside (i2b2) clinical research platform. We validate this approach by creating a small repository at Partners Healthcare automatically from C-CDA documents. We designed an i2b2 extension to import C-CDAs into i2b2. It is extensible to other sites with variances in C-CDA format without requiring custom code. We also designed new ontology structures for querying the imported data. We implemented our methodology at Partners Healthcare, where we developed an adapter to retrieve C-CDAs from Enterprise Services. Our current implementation supports demographics, encounters, problems, and medications. We imported approximately 17 000 clinical observations on 145 patients into i2b2 in about 24 min. We were able to perform i2b2 cohort finding queries and view patient information through SMART apps on the imported data. This low volume import approach can serve small practices with local access to C-CDAs and will allow patient registries to import patient supplied C-CDAs. These components will soon be available open source on the i2b2 wiki. Our approach will lower barriers to entry in implementing i2b2 where informatics expertise or data access are limited. © The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

ODMSummary: A Tool for Automatic Structured Comparison of Multiple Medical Forms Based on Semantic Annotation with the Unified Medical Language System

PubMed Central

Krumm, Rainer; Dugas, Martin

2016-01-01

Introduction Medical documentation is applied in various settings including patient care and clinical research. Since procedures of medical documentation are heterogeneous and developed further, secondary use of medical data is complicated. Development of medical forms, merging of data from different sources and meta-analyses of different data sets are currently a predominantly manual process and therefore difficult and cumbersome. Available applications to automate these processes are limited. In particular, tools to compare multiple documentation forms are missing. The objective of this work is to design, implement and evaluate the new system ODMSummary for comparison of multiple forms with a high number of semantically annotated data elements and a high level of usability. Methods System requirements are the capability to summarize and compare a set of forms, enable to estimate the documentation effort, track changes in different versions of forms and find comparable items in different forms. Forms are provided in Operational Data Model format with semantic annotations from the Unified Medical Language System. 12 medical experts were invited to participate in a 3-phase evaluation of the tool regarding usability. Results ODMSummary (available at https://odmtoolbox.uni-muenster.de/summary/summary.html) provides a structured overview of multiple forms and their documentation fields. This comparison enables medical experts to assess multiple forms or whole datasets for secondary use. System usability was optimized based on expert feedback. Discussion The evaluation demonstrates that feedback from domain experts is needed to identify usability issues. In conclusion, this work shows that automatic comparison of multiple forms is feasible and the results are usable for medical experts. PMID:27736972

An approach for software-driven and standard-based support of cross-enterprise tumor boards.

PubMed

Mangesius, Patrick; Fischer, Bernd; Schabetsberger, Thomas

2015-01-01

For tumor boards, the networking of different medical disciplines' expertise continues to gain importance. However, interdisciplinary tumor boards spread across several institutions are rarely supported by information technology tools today. The aim of this paper is to point out an approach for a tumor board management system prototype. For analyzing the requirements, an incremental process was used. The requirements were surveyed using Informal Conversational Interview and documented with Use Case Diagrams defined by the Unified Modeling Language (UML). Analyses of current EHR standards were conducted to evaluate technical requirements. Functional and technical requirements of clinical conference applications were evaluated and documented. In several steps, workflows were derived and application mockups were created. Although there is a vast amount of common understanding concerning how clinical conferences should be conducted and how their workflows should be structured, these are hardly standardized, neither on a functional nor on a technical level. This results in drawbacks for participants and patients. Using modern EHR technologies based on profiles such as IHE Cross Enterprise document sharing (XDS), these deficits could be overcome.

Nurses using futuristic technology in today's healthcare setting.

PubMed

Wolf, Debra M; Kapadia, Amar; Kintzel, Jessie; Anton, Bonnie B

2009-01-01

Human computer interaction (HCI) equates nurses using voice assisted technology within a clinical setting to document patient care real time, retrieve patient information from care plans, and complete routine tasks. This is a reality currently utilized by clinicians today in acute and long term care settings. Voice assisted documentation provides hands & eyes free accurate documentation while enabling effective communication and task management. The speech technology increases the accuracy of documentation, while interfacing directly into the electronic health record (EHR). Using technology consisting of a light weight headset and small fist size wireless computer, verbal responses to easy to follow cues are converted into a database systems allowing staff to obtain individualized care status reports on demand. To further assist staff in their daily process, this innovative technology allows staff to send and receive pages as needed. This paper will discuss how leading edge and award winning technology is being integrated within the United States. Collaborative efforts between clinicians and analyst will be discussed reflecting the interactive design and build functionality. Features such as the system's voice responses and directed cues will be shared and how easily data can be documented, viewed and retrieved. Outcome data will be presented on how the technology impacted organization's quality outcomes, financial reimbursement, and employee's level of satisfaction.

Impact of registration on clinical trials on infection risk in pediatric acute myeloid leukemia.

PubMed

Dix, David; Aplenc, Richard; Bowes, Lynette; Cellot, Sonia; Ethier, Marie-Chantal; Feusner, Jim; Gillmeister, Biljana; Johnston, Donna L; Lewis, Victor; Michon, Bruno; Mitchell, David; Portwine, Carol; Price, Victoria; Silva, Mariana; Stobart, Kent; Yanofsky, Rochelle; Zelcer, Shayna; Beyene, Joseph; Sung, Lillian

2016-04-01

Little is known about the impact of enrollment on therapeutic clinical trials on adverse event rates. Primary objective was to describe the impact of clinical trial registration on sterile site microbiologically documented infection for children with newly diagnosed acute myeloid leukemia (AML). We conducted a multicenter cohort study that included children aged ≤18 years with de novo AML. Primary outcome was microbiologically documented sterile site infection. Infection rates were compared between those registered and not registered on clinical trials. Five hundred seventy-four children with AML were included of which 198 (34.5%) were registered on a therapeutic clinical trial. Overall, 400 (69.7%) had at least one sterile site microbiologically documented infection. In multiple regression, registration on clinical trials was independently associated with a higher risk of microbiologically documented sterile site infection [adjusted odds ratio (OR) 1.24, 95% confidence interval (CI) 1.01-1.53; p = 0.040] and viridans group streptococcal infection (OR 1.46, 95% CI 1.08-1.98; p = 0.015). Registration on trials was not associated with Gram-negative or invasive fungal infections. Children with newly diagnosed AML enrolled on clinical trials have a higher risk of microbiologically documented sterile site infection. This information may impact on supportive care practices in pediatric AML. © 2015 UICC.

A Three-Phase Decision Model of Computer-Aided Coding for the Iranian Classification of Health Interventions (IRCHI)

PubMed Central

Azadmanjir, Zahra; Safdari, Reza; Ghazisaeedi, Marjan; Mokhtaran, Mehrshad; Kameli, Mohammad Esmail

2017-01-01

Introduction: Accurate coded data in the healthcare are critical. Computer-Assisted Coding (CAC) is an effective tool to improve clinical coding in particular when a new classification will be developed and implemented. But determine the appropriate method for development need to consider the specifications of existing CAC systems, requirements for each type, our infrastructure and also, the classification scheme. Aim: The aim of the study was the development of a decision model for determining accurate code of each medical intervention in Iranian Classification of Health Interventions (IRCHI) that can be implemented as a suitable CAC system. Methods: first, a sample of existing CAC systems was reviewed. Then feasibility of each one of CAC types was examined with regard to their prerequisites for their implementation. The next step, proper model was proposed according to the structure of the classification scheme and was implemented as an interactive system. Results: There is a significant relationship between the level of assistance of a CAC system and integration of it with electronic medical documents. Implementation of fully automated CAC systems is impossible due to immature development of electronic medical record and problems in using language for medical documenting. So, a model was proposed to develop semi-automated CAC system based on hierarchical relationships between entities in the classification scheme and also the logic of decision making to specify the characters of code step by step through a web-based interactive user interface for CAC. It was composed of three phases to select Target, Action and Means respectively for an intervention. Conclusion: The proposed model was suitable the current status of clinical documentation and coding in Iran and also, the structure of new classification scheme. Our results show it was practical. However, the model needs to be evaluated in the next stage of the research. PMID:28883671

Audit of Endotracheal Tube Suction in a Pediatric Intensive Care Unit.

PubMed

Davies, Kylie; Bulsara, Max K; Ramelet, Anne-Sylvie; Monterosso, Leanne

2017-02-01

We report outcomes of a clinical audit examining criteria used in clinical practice to rationalize endotracheal tube (ETT) suction, and the extent these matched criteria in the Endotracheal Suction Assessment Tool(ESAT)©. A retrospective audit of patient notes ( N = 292) and analyses of criteria documented by pediatric intensive care nurses to rationalize ETT suction were undertaken. The median number of documented respiratory and ventilation status criteria per ETT suction event that matched the ESAT© criteria was 2 [Interquartile Range (IQR) 1-6]. All criteria listed within the ESAT© were documented within the reviewed notes. A direct link was established between criteria used for current clinical practice of ETT suction and the ESAT©. The ESAT©, therefore, reflects documented clinical decision making and could be used as both a clinical and educational guide for inexperienced pediatric critical care nurses. Modification to the ESAT © requires "preparation for extubation" to be added.

Electronic processing of informed consents in a global pharmaceutical company environment.

PubMed

Vishnyakova, Dina; Gobeill, Julien; Oezdemir-Zaech, Fatma; Kreim, Olivier; Vachon, Therese; Clade, Thierry; Haenning, Xavier; Mikhailov, Dmitri; Ruch, Patrick

2014-01-01

We present an electronic capture tool to process informed consents, which are mandatory recorded when running a clinical trial. This tool aims at the extraction of information expressing the duration of the consent given by the patient to authorize the exploitation of biomarker-related information collected during clinical trials. The system integrates a language detection module (LDM) to route a document into the appropriate information extraction module (IEM). The IEM is based on language-specific sets of linguistic rules for the identification of relevant textual facts. The achieved accuracy of both the LDM and IEM is 99%. The architecture of the system is described in detail.

Critical care providers refer to information tools less during communication tasks after a critical care clinical information system introduction.

PubMed

Ballermann, Mark; Shaw, Nicola T; Mayes, Damon C; Gibney, R T Noel

2011-01-01

Electronic documentation methods may assist critical care providers with information management tasks in Intensive Care Units (ICUs). We conducted a quasi-experimental observational study to investigate patterns of information tool use by ICU physicians, nurses, and respiratory therapists during verbal communication tasks. Critical care providers used tools less at 3 months after the CCIS introduction. At 12 months, care providers referred to paper and permanent records, especially during shift changes. The results suggest potential areas of improvement for clinical information systems in assisting critical care providers in ensuring informational continuity around their patients.

Beyond the EPR: Complementary roles of the hospital-wide electronic health record and clinical departmental systems

PubMed Central

2009-01-01

Background Many hospital departments have implemented small clinical departmental systems (CDSs) to collect and use patient data for documentation as well as for other department-specific purposes. As hospitals are implementing institution-wide electronic patient records (EPRs), the EPR is thought to be integrated with, and gradually substitute the smaller systems. Many EPR systems however fail to support important clinical workflows. Also, successful integration of systems has proven hard to achieve. As a result, CDSs are still in widespread use. This study was conducted to see which tasks are supported by CDSs and to compare this to the support offered by the EPR. Methods Semi-structured interviews with users of 16 clinicians using 15 different clinical departmental systems (CDS) at a Medium-sized University hospital in Norway. Inductive analysis of transcriptions from the audio taped interviews. Results The roles of CDSs were complementary to those of the hospital-wide EPR system. The use of structured patient data was a characteristic feature. This facilitated quality development and supervision, tasks that were poorly supported by the EPR system. The structuring of the data also improved filtering of information to better support clinical decision-making. Because of the high value of the structured patient data, the users put much effort in maintaining their integrity and representativeness. Employees from the departments were also engaged in the funding, development, implementation and maintenance of the systems. Conclusion Clinical departmental systems are vital to the activities of a clinical hospital department. The development, implementation and clinical use of such systems can be seen as bottom-up, user-driven innovations. PMID:19523198

Distributed user interfaces for clinical ubiquitous computing applications.

PubMed

Bång, Magnus; Larsson, Anders; Berglund, Erik; Eriksson, Henrik

2005-08-01

Ubiquitous computing with multiple interaction devices requires new interface models that support user-specific modifications to applications and facilitate the fast development of active workspaces. We have developed NOSTOS, a computer-augmented work environment for clinical personnel to explore new user interface paradigms for ubiquitous computing. NOSTOS uses several devices such as digital pens, an active desk, and walk-up displays that allow the system to track documents and activities in the workplace. We present the distributed user interface (DUI) model that allows standalone applications to distribute their user interface components to several devices dynamically at run-time. This mechanism permit clinicians to develop their own user interfaces and forms to clinical information systems to match their specific needs. We discuss the underlying technical concepts of DUIs and show how service discovery, component distribution, events and layout management are dealt with in the NOSTOS system. Our results suggest that DUIs--and similar network-based user interfaces--will be a prerequisite of future mobile user interfaces and essential to develop clinical multi-device environments.

Comparative Systems Analyses Reveal Molecular Signatures of Clinically tested Vaccine Adjuvants

NASA Astrophysics Data System (ADS)

Olafsdottir, Thorunn A.; Lindqvist, Madelene; Nookaew, Intawat; Andersen, Peter; Maertzdorf, Jeroen; Persson, Josefine; Christensen, Dennis; Zhang, Yuan; Anderson, Jenna; Khoomrung, Sakda; Sen, Partho; Agger, Else Marie; Coler, Rhea; Carter, Darrick; Meinke, Andreas; Rappuoli, Rino; Kaufmann, Stefan H. E.; Reed, Steven G.; Harandi, Ali M.

2016-12-01

A better understanding of the mechanisms of action of human adjuvants could inform a rational development of next generation vaccines for human use. Here, we exploited a genome wide transcriptomics analysis combined with a systems biology approach to determine the molecular signatures induced by four clinically tested vaccine adjuvants, namely CAF01, IC31, GLA-SE and Alum in mice. We report signature molecules, pathways, gene modules and networks, which are shared by or otherwise exclusive to these clinical-grade adjuvants in whole blood and draining lymph nodes of mice. Intriguingly, co-expression analysis revealed blood gene modules highly enriched for molecules with documented roles in T follicular helper (TFH) and germinal center (GC) responses. We could show that all adjuvants enhanced, although with different magnitude and kinetics, TFH and GC B cell responses in draining lymph nodes. These results represent, to our knowledge, the first comparative systems analysis of clinically tested vaccine adjuvants that may provide new insights into the mechanisms of action of human adjuvants.

Long-term Mechanical Circulatory Support System reliability recommendation by the National Clinical Trial Initiative subcommittee.

PubMed

Lee, James

2009-01-01

The Long-Term Mechanical Circulatory Support (MCS) System Reliability Recommendation was published in the American Society for Artificial Internal Organs (ASAIO) Journal and the Annals of Thoracic Surgery in 1998. At that time, it was stated that the document would be periodically reviewed to assess its timeliness and appropriateness within 5 years. Given the wealth of clinical experience in MCS systems, a new recommendation has been drafted by consensus of a group of representatives from the medical community, academia, industry, and government. The new recommendation describes a reliability test methodology and provides detailed reliability recommendations. In addition, the new recommendation provides additional information and clinical data in appendices that are intended to assist the reliability test engineer in the development of a reliability test that is expected to give improved predictions of clinical reliability compared with past test methods. The appendices are available for download at the ASAIO journal web site at www.asaiojournal.com.

[Clinical practice guidelines for systemic lupus erythematosus: Recommendations for general clinical management].

PubMed

Trujillo-Martín, María M; Rúa-Figueroa Fernández de Larrinoa, Iñigo; Ruíz-Irastorza, Guillermo; Pego-Reigosa, José María; Sabio Sánchez, José Mario; Serrano-Aguilar, Pedro

2016-05-06

Systemic lupus erythematosus (SLE) is a complex rheumatic multisystemic disease of autoimmune origin with significant potential morbidity and mortality. It is one of the most common autoimmune diseases with an estimated prevalence of 20-150 cases per 100,000 inhabitants. The clinical spectrum of SLE is wide and variable both in clinical manifestations and severity. This prompted the Spanish Ministry of Health, Social Services and Equality to promote and fund the development of a clinical practice guideline (CPG) for the clinical care of SLE patients within the Programme of CPG in the National Health System which coordinates GuiaSalud. This CPG is is intended as the reference tool in the Spanish National Health System in order to support the comprehensive clinical management of people with SLE by all health professionals involved, regardless of specialty and level of care, helping to standardize and improve the quality of clinical decisions in our context in order to improve the health outcomes of the people affected. The purpose of this document is to present and discuss the rationale of the recommendations on the general management of SLE, specifically, clinical follow-up, general therapeutic approach, healthy lifestyles, photoprotection, and training programmes for patients. These recommendations are based on the best available scientific evidence, on discussion and the consensus of expert groups. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

Developing drugs for treatment of atopic dermatitis in children (≥3 months to <18 years of age): Draft guidance for industry.

PubMed

Siegfried, Elaine C; Jaworski, Jennifer C; Eichenfield, Lawrence F; Paller, Amy; Hebert, Adelaide A; Simpson, Eric L; Altman, Emily; Arena, Charles; Blauvelt, Andrew; Block, Julie; Boguniewicz, Mark; Chen, Suephy; Cordoro, Kelly; Hanna, Diane; Horii, Kimberly; Hultsch, Thomas; Lee, James; Leung, Donald Y; Lio, Peter; Milner, Joshua; Omachi, Theodore; Schneider, Christine; Schneider, Lynda; Sidbury, Robert; Smith, Timothy; Sugarman, Jeffrey; Taha, Sharif; Tofte, Susan; Tollefson, Megha; Tom, Wynnis L; West, Dennis P; Whitney, Lucinda; Zane, Lee

2018-05-01

Atopic dermatitis is the most common chronic skin disease, and it primarily affects children. Although atopic dermatitis (AD) has the highest effect on burden of skin disease, no high-level studies have defined optimal therapy for severe disease. Corticosteroids have been used to treat AD since the 1950s and remain the only systemic medication with Food and Drug Administration approval for this indication in children, despite published guidelines of care that recommend against this option. Several clinical trials with level 1 evidence have supported the use of topical treatments for mild to moderate atopic dermatitis in adults and children, but these trials have had little consistency in protocol design. Consensus recommendations will help standardize clinical development and trial design for children. The Food and Drug Administration issues guidance documents for industry as a source for "the Agency's current thinking on a particular subject." Although they are nonbinding, industry considers these documents to be the standard for clinical development and trial design. Our consensus group is the first to specifically address clinical trial design in this population. We developed a draft guidance document for industry, Developing Drugs for Treatment of Atopic Dermatitis in Children (≥3 months to <18 years of age). This draft guidance has been submitted to the Food and Drug Administration based on a provision in the Federal Register (Good Guidance Practices). © 2018 Wiley Periodicals, Inc.

Emergency department-based interventions for women suffering domestic abuse: a critical literature review.

PubMed

Ansari, Sereena; Boyle, Adrian

2017-02-01

Domestic abuse represents a serious public health and human rights concern. Interventions to reduce the risk of abuse include staff training and standardized documentation improving detection and adherence to referral pathways. Interventional studies have been conducted in primary care, maternity and outpatient settings. Women disclosing abuse in emergency departments differ from women attending other healthcare settings, and it is unclear whether these interventions can be transferred to the emergency care setting. This review examines interventional studies to evaluate the effectiveness of emergency department-based interventions in reducing domestic abuse-related morbidity. Medline, EMBASE, CINAHL, PsycINFO and Cochrane Library were searched, according to prespecified selection criteria. Study quality was assessed using the Jadad scale. Of 273 search results, nine were eligible for review. Interventions involving staff training demonstrated benefits in subjective measures, such as staff knowledge regarding abuse, but no changes in clinical practice, based on detection and referral rates. When staff training was implemented in conjunction with supporting system changes - for example, standardized documentation for assessment and referral - clinically relevant improvements were noted. Interventions centred around staff training are insufficient to bring about improvements in the management and, thus, outcome of patients suffering abuse. Instead, system changes, such as standardized documentation and referral pathways, supported by training, may bring about beneficial changes. It remains uncertain whether surrogate outcomes employed by most studies translate to changes in abuse-related morbidity: the ultimate goal.

Development of a competency based training programme to support multidisciplinary working in a combined biochemistry/haematology laboratory

PubMed Central

Woods, R; Longmire, W; Galloway, M; Smellie, W

2000-01-01

The aim of this study was to develop a competency based training programme to support multidisciplinary working in a combined biochemistry and haematology laboratory. The training programme was developed to document that staff were trained in the full range of laboratory tests that they were expected to perform. This programme subsequently formed the basis for the annual performance review of all staff. All staff successfully completed the first phase of the programme. This allowed laboratory staff to work unsupervised at night as part of a partial shift system. All staff are now working towards achieving a level of competence equivalent to the training level required for state registration by the Council for Professions Supplementary to Medicine. External evaluation of the training programme has included accreditation by the Council for Professions Supplementary to Medicine and reinspection by Clinical Pathology Accreditation (UK) Ltd. The development of a competency based training system has facilitated the introduction of multidisciplinary working in the laboratory. In addition, it enables the documentation of all staff to ensure that they are fully trained and are keeping up to date, because the continuing professional development programme in use in our laboratory has been linked to this training scheme. This approach to documentation of training facilitated a recent reinspection by Clinical Pathology Accreditation (UK) Ltd. Key Words: Keyword: multidisciplinary working • competency based training PMID:10889827

A classification of errors in lay comprehension of medical documents.

PubMed

Keselman, Alla; Smith, Catherine Arnott

2012-12-01

Emphasis on participatory medicine requires that patients and consumers participate in tasks traditionally reserved for healthcare providers. This includes reading and comprehending medical documents, often but not necessarily in the context of interacting with Personal Health Records (PHRs). Research suggests that while giving patients access to medical documents has many benefits (e.g., improved patient-provider communication), lay people often have difficulty understanding medical information. Informatics can address the problem by developing tools that support comprehension; this requires in-depth understanding of the nature and causes of errors that lay people make when comprehending clinical documents. The objective of this study was to develop a classification scheme of comprehension errors, based on lay individuals' retellings of two documents containing clinical text: a description of a clinical trial and a typical office visit note. While not comprehensive, the scheme can serve as a foundation of further development of a taxonomy of patients' comprehension errors. Eighty participants, all healthy volunteers, read and retold two medical documents. A data-driven content analysis procedure was used to extract and classify retelling errors. The resulting hierarchical classification scheme contains nine categories and 23 subcategories. The most common error made by the participants involved incorrectly recalling brand names of medications. Other common errors included misunderstanding clinical concepts, misreporting the objective of a clinical research study and physician's findings during a patient's visit, and confusing and misspelling clinical terms. A combination of informatics support and health education is likely to improve the accuracy of lay comprehension of medical documents. Published by Elsevier Inc.

IT adoption of clinical information systems in Austrian and German hospitals: results of a comparative survey with a focus on nursing

PubMed Central

2010-01-01

Background IT adoption is a process that is influenced by different external and internal factors. This study aimed 1. to identify similarities and differences in the prevalence of medical and nursing IT systems in Austrian and German hospitals, and 2. to match these findings with characteristics of the two countries, in particular their healthcare system, and with features of the hospitals. Methods In 2007, all acute care hospitals in both countries received questionnaires with identical questions. 12.4% in Germany and 34.6% in Austria responded. Results The surveys revealed a consistent higher usage of nearly all clinical IT systems, especially nursing systems, but also PACS and electronic archiving systems, in Austrian than in German hospitals. These findings correspond with a significantly wider use of standardised nursing terminologies and a higher number of PC workstations on the wards (average 2.1 PCs in Germany, 3.2 PCs in Austria). Despite these differences, Austrian and German hospitals both reported a similar IT budget of 2.6% in Austria and 2.0% in Germany (median). Conclusions Despite the many similarities of the Austrian and German healthcare system there are distinct differences which may have led to a wider use of IT systems in Austrian hospitals. In nursing, the specific legal requirement to document nursing diagnoses in Austria may have stimulated the use of standardised terminologies for nursing diagnoses and the implementation of electronic nursing documentation systems. Other factors which correspond with the wider use of clinical IT systems in Austria are: good infrastructure of medical-technical devices, rigorous organisational changes which had led to leaner processes and to a lower length of stay, and finally a more IT friendly climate. As country size is the most pronounced difference between Germany and Austria it could be that smaller countries, such as Austria, are more ready to translate innovation into practice. PMID:20122275

Health system strategies supporting transition to adult care.

PubMed

Hepburn, Charlotte Moore; Cohen, Eyal; Bhawra, Jasmin; Weiser, Natalie; Hayeems, Robin Z; Guttmann, Astrid

2015-06-01

The transition from paediatric to adult care is associated with poor clinical outcomes, increased costs and low patient and family satisfaction. However, little is known about health system strategies to streamline and safeguard care for youth transitioning to adult services. Moreover, the needs of children and youth are often excluded from broader health system reform discussions, leaving this population especially vulnerable to system 'disintegration'. (1) To explore the international policy profile of paediatric-to-adult care transitions, and (2) to document policy objectives, initiatives and outcomes for jurisdictions publicly committed to addressing transition issues. An international policy scoping review of all publicly available government documents detailing transition-related strategies was completed using a web-based search. Our analysis included a comparable cohort of nine wealthy Organisation for Economic Co-operation and Development (OECD) jurisdictions with Beveridge-style healthcare systems (deemed those most likely to benefit from system-level transition strategies). Few jurisdictions address transition of care issues in either health or broader social policy documents. While many jurisdictions refer to standardised practice guidelines, a few report the intention to use powerful policy levers (including physician remuneration and non-physician investments) to facilitate the uptake of best practice. Most jurisdictions do not address the policy infrastructure required to support successful transitions, and rigorous evaluations of transition strategies are rare. Despite the well-documented risks and costs associated with a poor transition from paediatric to adult care, little policy attention has been paid to this issue. We recommend that healthcare providers engage health system planners in the design and evaluation of system-level, policy-sensitive transition strategies. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Brown-Vialetto-Van Laere syndrome.

PubMed

Francis, D A; Ponsford, J R; Wiles, C M; Thomas, P K; Duchen, L W

1993-02-01

The clinical and pathological findings of a male with the Brown-Vialetto-Van Laere syndrome are described. This rare and fatal affection of the nervous system involves mainly the brain stem with the prominent and early manifestation of sensorineural deafness. Increased awareness and documentation of this disorder has added information on the mode of inheritance.

Eleven Years of Primary Health Care Delivery in an Academic Nursing Center.

ERIC Educational Resources Information Center

Hildebrandt, Eugenie; Baisch, Mary Jo; Lundeen, Sally P.; Bell-Calvin, Jean; Kelber, Sheryl

2003-01-01

Client visits to an academic community nursing center (n=25,495) were coded and analyzed. Results show expansion of nursing practice and services, strong case management, and management of illness care. The usefulness of computerized clinical documentation system and of the Lundeen conceptional model of community nursing care was demonstrated.…

Building a national electronic medical record exchange system - experiences in Taiwan.

PubMed

Li, Yu-Chuan Jack; Yen, Ju-Chuan; Chiu, Wen-Ta; Jian, Wen-Shan; Syed-Abdul, Shabbir; Hsu, Min-Huei

2015-08-01

There are currently 501 hospitals and about 20,000 clinics in Taiwan. The National Health Insurance (NHI) system, which is operated by the NHI Administration, uses a single-payer system and covers 99.9% of the nation's total population of 23,000,000. Taiwan's NHI provides people with a high degree of freedom in choosing their medical care options. However, there is the potential concern that the available medical resources will be overused. The number of doctor consultations per person per year is about 15. Duplication of laboratory tests and prescriptions are not rare either. Building an electronic medical record exchange system is a good method of solving these problems and of improving continuity in health care. In November 2009, Taiwan's Executive Yuan passed the 'Plan for accelerating the implementation of electronic medical record systems in medical institutions' (2010-2012; a 3-year plan). According to this plan, a patient can, at any hospital in Taiwan, by using his/her health insurance IC card and physician's medical professional IC card, upon signing a written agreement, retrieve all important medical records for the past 6 months from other participating hospitals. The focus of this plan is to establish the National Electronic Medical Record Exchange Centre (EEC). A hospital's information system will be connected to the EEC through an electronic medical record (EMR) gateway. The hospital will convert the medical records for the past 6 months in its EMR system into standardized files and save them on the EMR gateway. The most important functions of the EEC are to generate an index of all the XML files on the EMR gateways of all hospitals, and to provide search and retrieval services for hospitals and clinics. The EEC provides four standard inter-institution EMR retrieval services covering medical imaging reports, laboratory test reports, discharge summaries, and outpatient records. In this system, we adopted the Health Level 7 (HL7) Clinical Document Architecture (CDA) standards to generate clinical documents and Integrating the Healthcare Enterprise (IHE) Cross-enterprise Document Sharing (XDS) profile for the communication infrastructure. By December of 2014, the number of hospitals that provide an inter-institution EMR exchange service had reached 321. Hospitals that had not joined the service were all smaller ones with less than 100 beds. Inter-institution EMR exchange can make it much easier for people to access their own medical records, reduce the waste of medical resources, and improve the quality of medical care. The implementation of an inter-institution EMR exchange system faces many challenges. This article provides Taiwan's experiences as a reference. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Audit cycle of documentation in laser hair removal.

PubMed

Cohen, S N; Lanigan, S W

2005-09-01

Lasercare clinics are one of the largest providers of skin laser treatment in the United Kingdom, in both private sector and National Health Service. Laser hair removal is performed by trained nurses following written protocols. Choice of laser and fluence is tailored to Fitzpatrick skin type. We audited and re-audited documentation of six criteria in patients receiving laser hair removal (signed consent, Fitzpatrick skin type, use of appropriate laser, appropriate fluence, patient satisfaction and objective assessment) across 13 clinics at different points in time. Data were obtained on 772 treatments. Overall findings revealed excellent documentation of consent, use of appropriate laser and fluence (median 100%), good documentation of skin type (median 90%) and poor documentation of patient satisfaction and objective assessment (median 67% and 53%, respectively). Comparison between baseline and repeat audit at 6-8 months (nine clinics) showed significant improvement across clinics in these latter two criteria [patient satisfaction: odds ratio (OR) 0.38, 95% confidence interval (CI) 0.15-0.78, P=0.01; objective assessment: OR 0.23, 95% CI 0.07-0.50, P=0.0003 (Mantel-Haenszel weighted odds ratios)]. We conclude that quality of documentation was generally and consistently high in multiple clinics and that re-auditing led to significant improvement in poor scores. This simple measure could easily be implemented more widely across many disciplines.

A Nursing Intelligence System to Support Secondary Use of Nursing Routine Data

PubMed Central

Rauchegger, F.; Ammenwerth, E.

2015-01-01

Summary Background Nursing care is facing exponential growth of information from nursing documentation. This amount of electronically available data collected routinely opens up new opportunities for secondary use. Objectives To present a case study of a nursing intelligence system for reusing routinely collected nursing documentation data for multiple purposes, including quality management of nursing care. Methods The SPIRIT framework for systematically planning the reuse of clinical routine data was leveraged to design a nursing intelligence system which then was implemented using open source tools in a large university hospital group following the spiral model of software engineering. Results The nursing intelligence system is in routine use now and updated regularly, and includes over 40 million data sets. It allows the outcome and quality analysis of data related to the nursing process. Conclusions Following a systematic approach for planning and designing a solution for reusing routine care data appeared to be successful. The resulting nursing intelligence system is useful in practice now, but remains malleable for future changes. PMID:26171085

Nurses' perceptions of e-portfolio use for on-the-job training in Taiwan.

PubMed

Tsai, Pei-Rong; Lee, Ting-Ting; Lin, Hung-Ru; Lee-Hsieh, Jane; Mills, Mary Etta

2015-01-01

Electronic portfolios can be used to record user performance and achievements. Currently, clinical learning systems and in-service education systems lack integration of nurses' clinical performance records with their education or training outcomes. For nurses with less than 2 years' work experience (nursing postgraduate year), use of an electronic portfolio is essential. This study aimed to assess the requirements of using electronic portfolios in continuing nursing education for clinical practices. Fifteen nurses were recruited using a qualitative purposive sampling approach between April 2013 and May 2013. After obtaining participants' consent, data were collected in a conference room of the study hospital by one-on-one semistructured in-depth interviews. Through data analyses, the following five main themes related to electronic learning portfolios were identified: instant access to in-service education information, computerized nursing postgraduate year training manual, diversity of system functions and interface designs, need for sufficient computers, and protection of personal documents. Because electronic portfolios are beginning to be used in clinical settings, a well-designed education information system not only can meet the needs of nurses but also can facilitate their learning progress.

National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: exploratory qualitative investigation.

PubMed

Morrison, Zoe; Fernando, Bernard; Kalra, Dipak; Cresswell, Kathrin; Sheikh, Aziz

2014-01-01

We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs). Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics. Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients. The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive, accurate processing of data. As data structures may impact upon clinician/patient interactions, new models of documentation may be necessary if EHRs are to be read and authored by patients.

National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: exploratory qualitative investigation

PubMed Central

Morrison, Zoe; Fernando, Bernard; Kalra, Dipak; Cresswell, Kathrin; Sheikh, Aziz

2014-01-01

Objective We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs). Materials and methods Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics. Results Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients. Conclusions The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive, accurate processing of data. As data structures may impact upon clinician/patient interactions, new models of documentation may be necessary if EHRs are to be read and authored by patients. PMID:24186957

Perspectives of rural and remote primary healthcare services on the meaning and goals of clinical governance.

PubMed

Kwedza, Ruyamuro K; Larkins, Sarah; Johnson, Julie K; Zwar, Nicholas

2017-10-01

Definitions of clinical governance are varied and there is no one agreed model. This paper explored the perspectives of rural and remote primary healthcare services, located in North Queensland, Australia, on the meaning and goals of clinical governance. The study followed an embedded multiple case study design with semi-structured interviews, document analysis and non-participant observation. Participants included clinicians, non-clinical support staff, managers and executives. Similarities and differences in the understanding of clinical governance between health centre and committee case studies were evident. Almost one-third of participants were unfamiliar with the term or were unsure of its meaning; alongside limited documentation of a definition. Although most cases linked the concept of clinical governance to key terms, many lacked a comprehensive understanding. Similarities between cases included viewing clinical governance as a management and administrative function. Differences included committee members' alignment of clinical governance with corporate governance and frontline staff associating clinical governance with staff safety. Document analysis offered further insight into these perspectives. Clinical governance is well-documented as an expected organisational requirement, including in rural and remote areas where geographic, workforce and demographic factors pose additional challenges to quality and safety. However, in reality, it is not clearly, similarly or comprehensively understood by all participants.

IL-6 blockade in systemic juvenile idiopathic arthritis - achievement of inactive disease and remission (data from the German AID-registry).

PubMed

Bielak, M; Husmann, E; Weyandt, N; Haas, J-P; Hügle, B; Horneff, G; Neudorf, U; Lutz, T; Lilienthal, E; Kallinich, T; Tenbrock, K; Berendes, R; Niehues, T; Wittkowski, H; Weißbarth-Riedel, E; Heubner, G; Oommen, P; Klotsche, J; Foell, Dirk; Lainka, E

2018-04-05

Systemic juvenile idiopathic arthritis (sJIA) is a complex disease with an autoinflammatory component of unknown etiology related to the innate immune system. A major role in the pathogenesis has been ascribed to proinflammatory cytokines like interleukin-6 (IL-6), and effective drugs inhibiting their signaling are being developed. This study evaluates sJIA patients treated with the IL-6 inhibitor tocilizumab (TCZ) concerning clinical response rate, disease course and adverse effects in a real-life clinical setting. In 2009 a clinical and research consortium was established, including an online registry for autoinflammatory diseases (AID) ( https://aid-register.de ). Data for this retrospective TCZ study were documented by 13 centers. From 7/2009 to 4/2014, 200 patients with sJIA were recorded in the AID-registry. Out of these, 46 (19 m, 27 f, age 1-18 years) received therapy with TCZ. Long term treatment (median 23 months) has been documented in 24/46 patients who were evaluated according to Wallace criteria (active disease 6/24, inactive disease 5/24, remission 13/24 cases). Under observation co-medication were used in 40/46 cases. Adverse events were reported in 11/46 patients. The clinical response rate (no clinical manifestation, no increased inflammation parameters) within the first 12 weeks of treatment was calculated to be 35%. Out of 200 sJIA children reported in the German AID-registry, 46 were treated with TCZ, showing a clinical response rate of 35% during the first 12 weeks, and inactive disease and/or remission under medication in 75% after one year. Adverse events were seen in 24% and severe adverse events in 4%. The AID-Registry is funded by the BMBF (01GM08104, 01GM1112D, 01GM1512D).

Design of a clinical notification system.

PubMed

Wagner, M M; Tsui, F C; Pike, J; Pike, L

1999-01-01

We describe the requirements and design of an enterprise-wide notification system. From published descriptions of notification schemes, our own experience, and use cases provided by diverse users in our institution, we developed a set of functional requirements. The resulting design supports multiple communication channels, third party mappings (algorithms) from message to recipient and/or channel of delivery, and escalation algorithms. A requirement for multiple message formats is addressed by a document specification. We implemented this system in Java as a CORBA object. This paper describes the design and current implementation of our notification system.

Care and feeding of the endocannabinoid system: a systematic review of potential clinical interventions that upregulate the endocannabinoid system.

PubMed

McPartland, John M; Guy, Geoffrey W; Di Marzo, Vincenzo

2014-01-01

The "classic" endocannabinoid (eCB) system includes the cannabinoid receptors CB1 and CB2, the eCB ligands anandamide (AEA) and 2-arachidonoylglycerol (2-AG), and their metabolic enzymes. An emerging literature documents the "eCB deficiency syndrome" as an etiology in migraine, fibromyalgia, irritable bowel syndrome, psychological disorders, and other conditions. We performed a systematic review of clinical interventions that enhance the eCB system--ways to upregulate cannabinoid receptors, increase ligand synthesis, or inhibit ligand degradation. We searched PubMed for clinical trials, observational studies, and preclinical research. Data synthesis was qualitative. Exclusion criteria limited the results to 184 in vitro studies, 102 in vivo animal studies, and 36 human studies. Evidence indicates that several classes of pharmaceuticals upregulate the eCB system, including analgesics (acetaminophen, non-steroidal anti-inflammatory drugs, opioids, glucocorticoids), antidepressants, antipsychotics, anxiolytics, and anticonvulsants. Clinical interventions characterized as "complementary and alternative medicine" also upregulate the eCB system: massage and manipulation, acupuncture, dietary supplements, and herbal medicines. Lifestyle modification (diet, weight control, exercise, and the use of psychoactive substances--alcohol, tobacco, coffee, cannabis) also modulate the eCB system. Few clinical trials have assessed interventions that upregulate the eCB system. Many preclinical studies point to other potential approaches; human trials are needed to explore these promising interventions.

Quality assurance and quality control in mammography: a review of available guidance worldwide.

PubMed

Reis, Cláudia; Pascoal, Ana; Sakellaris, Taxiarchis; Koutalonis, Manthos

2013-10-01

Review available guidance for quality assurance (QA) in mammography and discuss its contribution to harmonise practices worldwide. Literature search was performed on different sources to identify guidance documents for QA in mammography available worldwide in international bodies, healthcare providers, professional/scientific associations. The guidance documents identified were reviewed and a selection was compared for type of guidance (clinical/technical), technology and proposed QA methodologies focusing on dose and image quality (IQ) performance assessment. Fourteen protocols (targeted at conventional and digital mammography) were reviewed. All included recommendations for testing acquisition, processing and display systems associated with mammographic equipment. All guidance reviewed highlighted the importance of dose assessment and testing the Automatic Exposure Control (AEC) system. Recommended tests for assessment of IQ showed variations in the proposed methodologies. Recommended testing focused on assessment of low-contrast detection, spatial resolution and noise. QC of image display is recommended following the American Association of Physicists in Medicine guidelines. The existing QA guidance for mammography is derived from key documents (American College of Radiology and European Union guidelines) and proposes similar tests despite the variations in detail and methodologies. Studies reported on QA data should provide detail on experimental technique to allow robust data comparison. Countries aiming to implement a mammography/QA program may select/prioritise the tests depending on available technology and resources. •An effective QA program should be practical to implement in a clinical setting. •QA should address the various stages of the imaging chain: acquisition, processing and display. •AEC system QC testing is simple to implement and provides information on equipment performance.

A dictionary server for supplying context sensitive medical knowledge.

PubMed Central

Ruan, W.; Bürkle, T.; Dudeck, J.

2000-01-01

The Giessen Data Dictionary Server (GDDS), developed at Giessen University Hospital, integrates clinical systems with on-line, context sensitive medical knowledge to help with making medical decisions. By "context" we mean the clinical information that is being presented at the moment the information need is occurring. The dictionary server makes use of a semantic network supported by a medical data dictionary to link terms from clinical applications to their proper information sources. It has been designed to analyze the network structure itself instead of knowing the layout of the semantic net in advance. This enables us to map appropriate information sources to various clinical applications, such as nursing documentation, drug prescription and cancer follow up systems. This paper describes the function of the dictionary server and shows how the knowledge stored in the semantic network is used in the dictionary service. PMID:11079978

Sharing and reuse of individual participant data from clinical trials: principles and recommendations.

PubMed

Ohmann, Christian; Banzi, Rita; Canham, Steve; Battaglia, Serena; Matei, Mihaela; Ariyo, Christopher; Becnel, Lauren; Bierer, Barbara; Bowers, Sarion; Clivio, Luca; Dias, Monica; Druml, Christiane; Faure, Hélène; Fenner, Martin; Galvez, Jose; Ghersi, Davina; Gluud, Christian; Groves, Trish; Houston, Paul; Karam, Ghassan; Kalra, Dipak; Knowles, Rachel L; Krleža-Jerić, Karmela; Kubiak, Christine; Kuchinke, Wolfgang; Kush, Rebecca; Lukkarinen, Ari; Marques, Pedro Silverio; Newbigging, Andrew; O'Callaghan, Jennifer; Ravaud, Philippe; Schlünder, Irene; Shanahan, Daniel; Sitter, Helmut; Spalding, Dylan; Tudur-Smith, Catrin; van Reusel, Peter; van Veen, Evert-Ben; Visser, Gerben Rienk; Wilson, Julia; Demotes-Mainard, Jacques

2017-12-14

We examined major issues associated with sharing of individual clinical trial data and developed a consensus document on providing access to individual participant data from clinical trials, using a broad interdisciplinary approach. This was a consensus-building process among the members of a multistakeholder task force, involving a wide range of experts (researchers, patient representatives, methodologists, information technology experts, and representatives from funders, infrastructures and standards development organisations). An independent facilitator supported the process using the nominal group technique. The consensus was reached in a series of three workshops held over 1 year, supported by exchange of documents and teleconferences within focused subgroups when needed. This work was set within the Horizon 2020-funded project CORBEL (Coordinated Research Infrastructures Building Enduring Life-science Services) and coordinated by the European Clinical Research Infrastructure Network. Thus, the focus was on non-commercial trials and the perspective mainly European. We developed principles and practical recommendations on how to share data from clinical trials. The task force reached consensus on 10 principles and 50 recommendations, representing the fundamental requirements of any framework used for the sharing of clinical trials data. The document covers the following main areas: making data sharing a reality (eg, cultural change, academic incentives, funding), consent for data sharing, protection of trial participants (eg, de-identification), data standards, rights, types and management of access (eg, data request and access models), data management and repositories, discoverability, and metadata. The adoption of the recommendations in this document would help to promote and support data sharing and reuse among researchers, adequately inform trial participants and protect their rights, and provide effective and efficient systems for preparing, storing and accessing data. The recommendations now need to be implemented and tested in practice. Further work needs to be done to integrate these proposals with those from other geographical areas and other academic domains. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Getting a handle on DNFB strategies for boosting performance.

PubMed

2015-03-01

Keeping tabs on DNFB requires a commitment from multiple departments, including clinical documentation, health information management, utilization management, and patient financial services. Monitoring DNFB performance daily, weekly, and monthly can help an organization quickly resolve short-term problems and also identify and respond to more systemic issues. By leveraging historical and comparison data, including performance information from peer organizations, hospitals and health systems can set more realistic targets and further highlight improvement opportunities.

Automated Health Surveillance

PubMed Central

Block, Bruce; Brennan, J.A.

1987-01-01

A successful health maintenance program requires physicians interested in and knowledgeable about the appropriate health surveillance actions to pursue. But even well-informed physicians need help transforming good intentions into effective health surveillance. An automated health surveillance system was designed and implemented to simplify documentation of health maintenance and remind physicians when actions were overdue. The system has increased insight into the complex process of health promotion and promises to be an important clinical, educational, and research tool.

SU-G-201-01: An Automated Treatment Plan Quality Assurance Program for High-Dose Rate (HDR) Brachytherapy with a VaginalCylinder Applicator

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zhou, Y; Tan, J; Jiang, S

Purpose: Plan specific quality assurance (QA) is an important step in high dose rate (HDR) brachytherapy to ensure the integrity of a treatment plan. The conventional approach is to assemble a set of plan screen-captures in a document and have an independent plan-checker to verify it. Not only is this approach cumbersome and time-consuming, using a document also limits the items that can be verified, hindering plan quality and patient safety. We have initiated efforts to develop a web-based HDR brachytherapy QA system called AutoBrachy QA, for comprehensive and efficient QA. This abstract reports a new plugin in this systemmore » for the QA of a cylinder HDR brachytherapy treatment. Methods: A cylinder plan QA module was developed using Python. It was plugged into our AutoBrachy QA system. This module extracted information from CT images and treatment plan. Image processing techniques were employed to obtain geometric parameters, e.g. cylinder diameter. A comprehensive set of eight geometrical and eight dosimetric features of the plan were validated against user specified planning parameter, such as prescription value, treatment depth and length, etc. A PDF document was generated, consisting of a summary QA sheet with all the QA results, as well as images showing plan details. Results: The cylinder QA program has been implemented in our clinic. To date, it has been used in 11 patient cases and was able to successfully perform QA tests in all of them. The QA program reduced the average plan QA time from 7 min using conventional manual approach to 0.5 min. Conclusion: Being a new module in our AutoBrachy QA system, an automated treatment plan QA module for cylinder HDR brachytherapy has been successfully developed and clinically implemented. This module improved clinical workflow and plan integrity compared to the conventional manual approach.« less

Implementing Routine Health Literacy Assessment in Hospital and Primary Care Patients

PubMed Central

Cawthon, Courtney; Mion, Lorraine C.; Willens, David E.; Roumie, Christianne L.; Kripalani, Sunil

2014-01-01

Background Patients with inadequate health literacy often have poorer health outcomes and increased utilization and costs, compared to those with adequate health literacy skills. The Institute of Medicine has recommended that health literacy assessment be incorporated into health care information systems, which would facilitate large-scale studies of the effects of health literacy, as well as evaluation of system interventions to improve care by addressing health literacy. As part of the Health Literacy Screening (HEALS) study, a brief health literacy screen (BHLS) was incorporated into the electronic health record (EHR) at a large academic medical center. Methods Changes were implemented to the nursing intake documentation across all adult hospital units, the emergency department, and three primary care practices. The change involved replacing previous education screening items with the BHLS. Implementation was based on a quality improvement framework, with a focus on acceptability, adoption, appropriateness, feasibility, fidelity and sustainability. Support was gained from nursing leadership, education and training was provided, a documentation change was rolled out, feedback was obtained, and uptake of the new health literacy screening items was monitored. Results Between November 2010 and April 2012, there were 55,611 adult inpatient admissions, and from November 2010 to September 2011, 23,186 adult patients made 39,595 clinic visits to the three primary care practices. The completion (uptake) rate in the hospital for November 2010 through April 2012 was 91.8%. For outpatient clinics, the completion rate between November 2010 and October 2011 was 66.6%. Conclusions Although challenges exist, it is feasible to incorporate health literacy screening into clinical assessment and EHR documentation. Next steps are to evaluate the association of health literacy with processes and outcomes of care across inpatient and outpatient populations. PMID:24716329

Evaluating an integrated approach to clinical quality improvement: clinical guidelines, quality measurement, and supportive system design.

PubMed

Cretin, S; Farley, D O; Dolter, K J; Nicholas, W

2001-08-01

Implementing clinical practice guidelines to change patient outcomes presents a challenge. Studies of single interventions focused on changing provider behavior demonstrate modest effects, suggesting that effective guideline implementation requires a multifaceted approach. Traditional biomedical research designs are not well suited to evaluating systems interventions. RAND and the Army Medical Department collaborated to develop and evaluate a system for implementing guidelines and documenting their effects on patient care. The evaluation design blended quality improvement, case study, and epidemiologic methods. A formative evaluation of implementation process and an outcome evaluation of patient impact were combined. Guidelines were implemented in 3 successive demonstrations targeting low back pain, asthma, and diabetes. This paper reports on the first wave of 4 facilities implementing a low back pain guideline. Organizational climate and culture, motivation, leadership commitment, and resources were assessed. Selected indicators of processes and outcomes of care were compared before, during, and after guideline implementation at the demonstration facilities and at comparison facilities. Logistic regression analysis was used to test for guideline effects on patient care. Process evaluation documented varied approaches to quality improvement across sites. Outcome evaluation revealed a significant downward trend in the percentage of acute low back pain patients referred to physical therapy or chiropractic care (10.7% to 7.2%) at demonstration sites and no such trend at control sites. Preliminary results suggest the power of this design to stimulate improvements in guideline implementation while retaining the power to evaluate rigorously effects on patient care.

Identification of design features to enhance utilization and acceptance of systems for Internet-based decision support at the point of care.

PubMed Central

Gadd, C. S.; Baskaran, P.; Lobach, D. F.

1998-01-01

Extensive utilization of point-of-care decision support systems will be largely dependent on the development of user interaction capabilities that make them effective clinical tools in patient care settings. This research identified critical design features of point-of-care decision support systems that are preferred by physicians, through a multi-method formative evaluation of an evolving prototype of an Internet-based clinical decision support system. Clinicians used four versions of the system--each highlighting a different functionality. Surveys and qualitative evaluation methodologies assessed clinicians' perceptions regarding system usability and usefulness. Our analyses identified features that improve perceived usability, such as telegraphic representations of guideline-related information, facile navigation, and a forgiving, flexible interface. Users also preferred features that enhance usefulness and motivate use, such as an encounter documentation tool and the availability of physician instruction and patient education materials. In addition to identifying design features that are relevant to efforts to develop clinical systems for point-of-care decision support, this study demonstrates the value of combining quantitative and qualitative methods of formative evaluation with an iterative system development strategy to implement new information technology in complex clinical settings. Images Figure 1 PMID:9929188

Feasibility of hospital-initiated non-facilitator assisted advance care planning documentation for patients with palliative care needs.

PubMed

Kok, Maaike; van der Werff, Gertruud F M; Geerling, Jenske I; Ruivenkamp, Jaap; Groothoff, Wies; van der Velden, Annette W G; Thoma, Monique; Talsma, Jaap; Costongs, Louk G P; Gans, Reinold O B; de Graeff, Pauline; Reyners, Anna K L

2018-05-24

Advance Care Planning (ACP) and its documentation, accessible to healthcare professionals regardless of where patients are staying, can improve palliative care. ACP is usually performed by trained facilitators. However, ACP conversations would be more tailored to a patient's specific situation if held by a patient's clinical healthcare team. This study assesses the feasibility of ACP by a patient's clinical healthcare team, and analyses the documented information including current and future problems within the palliative care domains. This multicentre study was conducted at the three Groningen Palliative Care Network hospitals in the Netherlands. Patients discharged from hospital with a terminal care indication received an ACP document from clinical staff (non-palliative care trained staff at hospitals I and II; specialist palliative care nurses at hospital III) after they had held ACP conversations. An anonymised copy of this ACP document was analysed. Documentation rates of patient and contact details were investigated, and documentation of current and future problems were analysed both quantitatively and qualitatively. One hundred sixty ACP documents were received between April 2013 and December 2014, with numbers increasing for each consecutive 3-month time period. Advance directives were frequently documented (82%). Documentation rates of current problems in the social (24%), psychological (27%) and spiritual (16%) domains were low compared to physical problems (85%) at hospital I and II, but consistently high (> 85%) at hospital III. Of 545 documented anticipated problems, 92% were physical or care related in nature, 2% social, 5% psychological, and < 1% spiritual. Half of the anticipated non-physical problems originated from hospital III. Hospital-initiated ACP documentation by a patient's clinical healthcare team is feasible: the number of documents received per time period increased throughout the study period, and overall, documentation rates were high. Nonetheless, symptom documentation predominantly regards physical symptoms. With the involvement of specialist palliative care nurses, psychological and spiritual problems are addressed more frequently. Whether palliative care education for non-palliative care experts will improve identification and documentation of non-physical problems remains to be investigated.

Use of Flowchart for Automation of Clinical Protocols in mHealth.

PubMed

Dias, Karine Nóra; Welfer, Daniel; Cordeiro d'Ornellas, Marcos; Pereira Haygert, Carlos Jesus; Dotto, Gustavo Nogara

2017-01-01

For healthcare professionals to use mobile applications we need someone who knows software development, provide them. In healthcare institutions, health professionals use clinical protocols to govern care, and sometimes these documents are computerized through mobile applications to assist them. This work aims to present a proposal of an application of flow as a way of describing clinical protocols for automatic generation of mobile applications to assist health professionals. The purpose of this research is to enable health professionals to develop applications from the description of their own clinical protocols. As a result, we developed a web system that automates clinical protocols for an Android platform, and we validated with two clinical protocols used in a Brazilian hospital. Preliminary results of the developed architecture demonstrate the feasibility of this study.

Informed Consent: Does Anyone Really Understand What Is Contained In The Medical Record?

PubMed

Fenton, S H; Manion, F; Hsieh, K; Harris, M

2015-01-01

Despite efforts to provide standard definitions of terms such as "medical record", "computer-based patient record", "electronic medical record" and "electronic health record", the terms are still used interchangeably. Initiatives like data and information governance, research biorepositories, and learning health systems require availability and reuse of data, as well as common understandings of the scope for specific purposes. Lacking widely shared definitions, utilization of the afore-mentioned terms in research informed consent documents calls to question whether all participants in the research process - patients, information technology and regulatory staff, and the investigative team - fully understand what data and information they are asking to obtain and agreeing to share. This descriptive study explored the terminology used in research informed consent documents when describing patient data and information, asking the question "Does the use of the term "medical record" in the context of a research informed consent document accurately represent the scope of the data involved?" Informed consent document templates found on 17 Institutional Review Board (IRB) websites with Clinical and Translational Science Awards (CTSA) were searched for terms that appeared to be describing the data resources to be accessed. The National Library of Medicine's (NLM) Terminology Services was searched for definitions provided by key standards groups that deposit terminologies with the NLM. The results suggest research consent documents are using outdated terms to describe patient information, health care terminology systems need to consider the context of research for use cases, and that there is significant work to be done to assure the HIPAA Omnibus Rule is applied to contemporary activities such as biorepositories and learning health systems. "Medical record", a term used extensively in research informed consent documents, is ambiguous and does not serve us well in the context of contemporary information management and governance.

Space Flight-Associated Neuro-ocular Syndrome.

PubMed

Lee, Andrew G; Mader, Thomas H; Gibson, C Robert; Tarver, William

2017-09-01

New and unique physiologic and pathologic systemic and neuro-ocular responses have been documented in astronauts during and after long-duration space flight. Although the precise cause remains unknown, space flight-associated neuro-ocular syndrome (SANS) has been adopted as an appropriate descriptive term. The Space Medicine Operations Division of the US National Aeronautics and Space Administration (NASA) has documented the variable occurrence of SANS in astronauts returning from long-duration space flight on the International Space Station. These clinical findings have included unilateral and bilateral optic disc edema, globe flattening, choroidal and retinal folds, hyperopic refractive error shifts, and nerve fiber layer infarcts. The clinical findings of SANS have been correlated with structural changes on intraorbital and intracranial magnetic resonance imaging and in-flight and terrestrial ultrasonographic studies and ocular optical coherence tomography. Further study of SANS is ongoing for consideration of future manned missions to space, including a return trip to the moon or Mars.

[Chronic diarrhoea: Definition, classification and diagnosis].

PubMed

Fernández-Bañares, Fernando; Accarino, Anna; Balboa, Agustín; Domènech, Eugeni; Esteve, Maria; Garcia-Planella, Esther; Guardiola, Jordi; Molero, Xavier; Rodríguez-Luna, Alba; Ruiz-Cerulla, Alexandra; Santos, Javier; Vaquero, Eva

2016-10-01

Chronic diarrhoea is a common presenting symptom in both primary care medicine and in specialized gastroenterology clinics. It is estimated that >5% of the population has chronic diarrhoea and nearly 40% of these patients are older than 60 years. Clinicians often need to select the best diagnostic approach to these patients and choose between the multiple diagnostic tests available. In 2014 the Catalan Society of Gastroenterology formed a working group with the main objective of creating diagnostic algorithms based on clinical practice and to evaluate diagnostic tests and the scientific evidence available for their use. The GRADE system was used to classify scientific evidence and strength of recommendations. The consensus document contains 28 recommendations and 6 diagnostic algorithms. The document also describes criteria for referral from primary to specialized care. Copyright © 2015 Elsevier España, S.L.U. y AEEH y AEG. All rights reserved.

Machine learning-based coreference resolution of concepts in clinical documents

PubMed Central

Ware, Henry; Mullett, Charles J; El-Rawas, Oussama

2012-01-01

Objective Coreference resolution of concepts, although a very active area in the natural language processing community, has not yet been widely applied to clinical documents. Accordingly, the 2011 i2b2 competition focusing on this area is a timely and useful challenge. The objective of this research was to collate coreferent chains of concepts from a corpus of clinical documents. These concepts are in the categories of person, problems, treatments, and tests. Design A machine learning approach based on graphical models was employed to cluster coreferent concepts. Features selected were divided into domain independent and domain specific sets. Training was done with the i2b2 provided training set of 489 documents with 6949 chains. Testing was done on 322 documents. Results The learning engine, using the un-weighted average of three different measurement schemes, resulted in an F measure of 0.8423 where no domain specific features were included and 0.8483 where the feature set included both domain independent and domain specific features. Conclusion Our machine learning approach is a promising solution for recognizing coreferent concepts, which in turn is useful for practical applications such as the assembly of problem and medication lists from clinical documents. PMID:22582205

A Mobile Computerized Decision Support System to Prevent Hypoglycemia in Hospitalized Patients With Type 2 Diabetes Mellitus

PubMed Central

Spat, Stephan; Donsa, Klaus; Beck, Peter; Höll, Bernhard; Mader, Julia K.; Schaupp, Lukas; Augustin, Thomas; Chiarugi, Franco; Lichtenegger, Katharina M.; Plank, Johannes; Pieber, Thomas R.

2016-01-01

Background: Diabetes management requires complex and interdisciplinary cooperation of health care professionals (HCPs). To support this complex process, IT-support is recommended by clinical guidelines. The aim of this article is to report on results from a clinical feasibility study testing the prototype of a mobile, tablet-based client-server system for computerized decision and workflow support (GlucoTab®) and to discuss its impact on hypoglycemia prevention. Methods: The system was tested in a monocentric, open, noncontrolled intervention study in 30 patients with type 2 diabetes mellitus (T2DM). The system supports HCPs in performing a basal-bolus insulin therapy. Diabetes therapy, adverse events, software errors and user feedback were documented. Safety, efficacy and user acceptance of the system were investigated. Results: Only 1.3% of blood glucose (BG) measurements were <70 mg/dl and only 2.6% were >300 mg/dl. The availability of the system (97.3%) and the rate of treatment activities documented with the system (>93.5%) were high. Only few suggestions from the system were overruled by the users (>95.7% adherence). Evaluation of the 3 anonymous questionnaires showed that confidence in the system increased over time. The majority of users believed that treatment errors could be prevented by using this system. Conclusions: Data from our feasibility study show a significant reduction of hypoglycemia by implementing a computerized system for workflow and decision support for diabetes management, compared to a paper-based process. The system was well accepted by HCPs, which is shown in the user acceptance analysis and that users adhered to the insulin dose suggestions made by the system. PMID:27810995

Exploring Vital Sign Data Quality in Electronic Health Records with Focus on Emergency Care Warning Scores.

PubMed

Skyttberg, Niclas; Chen, Rong; Blomqvist, Hans; Koch, Sabine

2017-08-30

Computerized clinical decision support and automation of warnings have been advocated to assist clinicians in detecting patients at risk of physiological instability. To provide reliable support such systems are dependent on high-quality vital sign data. Data quality depends on how, when and why the data is captured and/or documented. This study aims to describe the effects on data quality of vital signs by three different types of documentation practices in five Swedish emergency hospitals, and to assess data fitness for calculating warning and triage scores. The study also provides reference data on triage vital signs in Swedish emergency care. We extracted a dataset including vital signs, demographic and administrative data from emergency care visits (n=335027) at five Swedish emergency hospitals during 2013 using either completely paper-based, completely electronic or mixed documentation practices. Descriptive statistics were used to assess fitness for use in emergency care decision support systems aiming to calculate warning and triage scores, and data quality was described in three categories: currency, completeness and correctness. To estimate correctness, two further categories - plausibility and concordance - were used. The study showed an acceptable correctness of the registered vital signs irrespectively of the type of documentation practice. Completeness was high in sites where registrations were routinely entered into the Electronic Health Record (EHR). The currency was only acceptable in sites with a completely electronic documentation practice. Although vital signs that were recorded in completely electronic documentation practices showed plausible results regarding correctness, completeness and currency, the study concludes that vital signs documented in Swedish emergency care EHRs cannot generally be considered fit for use for calculation of triage and warning scores. Low completeness and currency were found if the documentation was not completely electronic.

Impact of the Provider and Healthcare team Adherence to Treatment Guidelines (PHAT-G) intervention on adherence to national obesity clinical practice guidelines in a primary care centre.

PubMed

Barnes, Emily R; Theeke, Laurie A; Mallow, Jennifer

2015-04-01

Obesity is significantly underdiagnosed and undertreated in primary care settings. The purpose of this clinical practice change project was to increase provider adherence to national clinical practice guidelines for the diagnosis and treatment of obesity in adults. Based upon the National Institutes of Health guidelines for the diagnosis and treatment of obesity, a clinical change project was implemented. Guided by the theory of planned behaviour, the Provider and Healthcare team Adherence to Treatment Guidelines (PHAT-G) intervention includes education sessions, additional provider resources for patient education, a provider reminder system and provider feedback. Primary care providers did not significantly increase on documentation of diagnosis and planned management of obesity for patients with body mass index (BMI) greater than or equal to 30. Medical assistants increased recording of height, weight and BMI in the patient record by 13%, which was significant. Documentation of accurate BMI should lead to diagnosis of appropriate weight category and subsequent care planning. Future studies will examine barriers to adherence to clinical practice guidelines for obesity. Interventions are needed that include inter-professional team members and may be more successful if delivered separately from routine primary care visits. © 2015 John Wiley & Sons, Ltd.

Quality of clinical trials: A moving target

PubMed Central

Bhatt, Arun

2011-01-01

Quality of clinical trials depends on data integrity and subject protection. Globalization, outsourcing and increasing complexicity of clinical trials have made the target of achieving global quality challenging. The quality, as judged by regulatory inspections of the investigator sites, sponsors/contract research organizations and Institutional Review Board, has been of concern to the US Food and Drug Administration, as there has been hardly any change in frequency and nature of common deficiencies. To meet the regulatory expectations, the sponsors need to improve quality by developing systems with specific standards for each clinical trial process. The quality systems include: personnel roles and responsibilities, training, policies and procedures, quality assurance and auditing, document management, record retention, and reporting and corrective and preventive action. With an objective to improve quality, the FDA has planned new inspection approaches such as risk-based inspections, surveillance inspections, real-time oversight, and audit of sponsor quality systems. The FDA has partnered with Duke University for Clinical Trials Transformation Initiative, which will conduct research projects on design principles, data quality and quantity including monitoring, study start-up, and adverse event reporting. These recent initiatives will go a long way in improving quality of clinical trials. PMID:22145122

Care and Feeding of the Endocannabinoid System: A Systematic Review of Potential Clinical Interventions that Upregulate the Endocannabinoid System

PubMed Central

McPartland, John M.; Guy, Geoffrey W.; Di Marzo, Vincenzo

2014-01-01

Background The “classic” endocannabinoid (eCB) system includes the cannabinoid receptors CB1 and CB2, the eCB ligands anandamide (AEA) and 2-arachidonoylglycerol (2-AG), and their metabolic enzymes. An emerging literature documents the “eCB deficiency syndrome” as an etiology in migraine, fibromyalgia, irritable bowel syndrome, psychological disorders, and other conditions. We performed a systematic review of clinical interventions that enhance the eCB system—ways to upregulate cannabinoid receptors, increase ligand synthesis, or inhibit ligand degradation. Methodology/Principal Findings We searched PubMed for clinical trials, observational studies, and preclinical research. Data synthesis was qualitative. Exclusion criteria limited the results to 184 in vitro studies, 102 in vivo animal studies, and 36 human studies. Evidence indicates that several classes of pharmaceuticals upregulate the eCB system, including analgesics (acetaminophen, non-steroidal anti-inflammatory drugs, opioids, glucocorticoids), antidepressants, antipsychotics, anxiolytics, and anticonvulsants. Clinical interventions characterized as “complementary and alternative medicine” also upregulate the eCB system: massage and manipulation, acupuncture, dietary supplements, and herbal medicines. Lifestyle modification (diet, weight control, exercise, and the use of psychoactive substances—alcohol, tobacco, coffee, cannabis) also modulate the eCB system. Conclusions/Significance Few clinical trials have assessed interventions that upregulate the eCB system. Many preclinical studies point to other potential approaches; human trials are needed to explore these promising interventions. PMID:24622769

The Importance of Clinical Phenotype in Understanding and Preventing Spontaneous Preterm Birth.

PubMed

Esplin, M Sean

2016-02-01

Spontaneous preterm birth (SPTB) is a well-known cause of maternal and neonatal morbidity. The search for the underlying pathways, documentation of the genetic causes, and identification of markers of spontaneous PTB have been marginally successful due to the fact that it is highly complex, with numerous processes that lead to a final common pathway. There is a great need for a comprehensive, consistent, and uniform classification system, which will be useful in identifying mechanisms, assigning prognosis, aiding in clinical management, and can identify areas of interest for intervention and future study. Effective classification systems must overcome obstacles including the lack of widely accepted definitions and uncertainty about inclusion of classifying features (e.g., presentation at delivery and multiple gestations) and levels of detail of these features. The optimal classification system should be based on the clinical phenotype, including characteristics of the mother, fetus, placenta, and the presentation for delivery. We present a proposed phenotyping system for spontaneous PTB. Future classification systems must establish a universally accepted set of definitions and a standardized clinical workup for all PTBs including the minimum clinical data to be collected and the laboratory and pathologic evaluation that should be completed. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Evaluation of the enterovirus laboratory surveillance system in Denmark, 2010 to 2013.

PubMed

Condell, Orla; Midgley, Sofie; Christiansen, Claus Bohn; Chen, Ming; Chen Nielsen, Xiaohui; Ellermann-Eriksen, Svend; Mølvadgaard, Mette; Schønning, Kristian; Vermedal Hoegh, Silje; Andersen, Peter Henrik; Voldstedlund, Marianne; Fischer, Thea Kølsen

2016-05-05

The primary aim of the Danish enterovirus (EV) surveillance system is to document absence of poliovirus infection. The conflict in Syria has left many children unvaccinated and movement from areas with polio cases to Europe calls for increased awareness to detect and respond to virus-transmission in a timely manner. We evaluate the national EV laboratory surveillance, to generate recommendations for system strengthening. The system was analysed for completeness of viral typing analysis and clinical information and timeliness of specimen collection, laboratory results and reporting of clinical information. Of 23,720 specimens screened, 2,202 (9.3%) were EV-positive. Submission of cerebrospinal fluid and faecal specimens from primary diagnostic laboratories was 79.5% complete (845/1,063), and varied by laboratory and patient age. EV genotypes were determined in 68.5% (979/1,430) of laboratory-confirmed cases, clinical information was available for 63.1% (903/1,430). Primary diagnostic results were available after a median of 1.4 days, typing results after 17 days, detailed clinical information after 33 days. The large number of samples typed demonstrated continued monitoring of EV-circulation in Denmark. The system could be strengthened by increasing the collection of supplementary faecal specimens, improving communication with primary diagnostic laboratories, adapting the laboratory typing methodology and collecting clinical information with electronic forms.

Graph-based biomedical text summarization: An itemset mining and sentence clustering approach.

PubMed

Nasr Azadani, Mozhgan; Ghadiri, Nasser; Davoodijam, Ensieh

2018-06-12

Automatic text summarization offers an efficient solution to access the ever-growing amounts of both scientific and clinical literature in the biomedical domain by summarizing the source documents while maintaining their most informative contents. In this paper, we propose a novel graph-based summarization method that takes advantage of the domain-specific knowledge and a well-established data mining technique called frequent itemset mining. Our summarizer exploits the Unified Medical Language System (UMLS) to construct a concept-based model of the source document and mapping the document to the concepts. Then, it discovers frequent itemsets to take the correlations among multiple concepts into account. The method uses these correlations to propose a similarity function based on which a represented graph is constructed. The summarizer then employs a minimum spanning tree based clustering algorithm to discover various subthemes of the document. Eventually, it generates the final summary by selecting the most informative and relative sentences from all subthemes within the text. We perform an automatic evaluation over a large number of summaries using the Recall-Oriented Understudy for Gisting Evaluation (ROUGE) metrics. The results demonstrate that the proposed summarization system outperforms various baselines and benchmark approaches. The carried out research suggests that the incorporation of domain-specific knowledge and frequent itemset mining equips the summarization system in a better way to address the informativeness measurement of the sentences. Moreover, clustering the graph nodes (sentences) can enable the summarizer to target different main subthemes of a source document efficiently. The evaluation results show that the proposed approach can significantly improve the performance of the summarization systems in the biomedical domain. Copyright © 2018. Published by Elsevier Inc.

Clinical practice guidelines for the treatment of systemic lupus erythematosus by the Mexican College of Rheumatology.

PubMed

Xibillé-Friedmann, Daniel; Pérez-Rodríguez, Marcela; Carrillo-Vázquez, Sandra; Álvarez-Hernández, Everardo; Aceves, Francisco Javier; Ocampo-Torres, Mario C; García-García, Conrado; García-Figueroa, José Luis; Merayo-Chalico, Javier; Barrera-Vargas, Ana; Portela-Hernández, Margarita; Sicsik, Sandra; Andrade-Ortega, Lilia; Rosales-Don Pablo, Víctor Manuel; Martínez, Aline; Prieto-Seyffert, Pilar; Pérez-Cristóbal, Mario; Saavedra, Miguel Ángel; Castro-Colín, Zully; Ramos, Azucena; Huerta-Sil, Gabriela; Hernández-Cabrera, María Fernanda; Jara, Luis Javier; Limón-Camacho, Leonardo; Tinajero-Nieto, Lizbet; Barile-Fabris, Leonor A

2018-05-04

There are national and international clinical practice guidelines for systemic lupus erythematosus treatment. Nonetheless, most of them are not designed for the Mexican population or are devoted only to the treatment of certain disease manifestations, like lupus nephritis, or are designed for some physiological state like pregnancy. The Mexican College of Rheumatology aimed to create clinical practice guidelines that included the majority of the manifestations of systemic lupus erythematosus, and also incorporated guidelines in controversial situations like vaccination and the perioperative period. The present document introduces the «Clinical Practice Guidelines for the Treatment of Systemic Lupus Erythematosus» proposed by the Mexican College of Rheumatology, which could be useful mostly for non-rheumatologist physicians who need to treat patients with systemic lupus erythematosus without having the appropriate training in the field of rheumatology. In these guidelines, the reader will find recommendations on the management of general, articular, kidney, cardiovascular, pulmonary, neurological, hematologic and gastrointestinal manifestations, and recommendations on vaccination and treatment management during the perioperative period. Copyright © 2018 Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. Publicado por Elsevier España, S.L.U. All rights reserved.

Communication pitfalls of traditional history and physical write-up documentation

PubMed Central

Brown, Jeffrey L

2017-01-01

Background An unofficial standardized “write-up” outline is commonly used for documenting history and physical examinations, giving oral presentations, and teaching clinical skills. Despite general acceptance, there is an apparent discrepancy between the way clinical encounters are conducted and how they are documented. Methods Fifteen medical school websites were randomly selected from search-engine generated lists. One example of a history and physical write-up from each of six sites, one teaching outline from each of nine additional sites, and recommendations for documentation made in two commonly used textbooks were compared for similarities and differences. Results Except for minor variations in documenting background information, all sampled materials utilized the same standardized format. When the examiners’ early perceptions of the patients’ degree of illness or level of distress were described, they were categorized as “general appearance” within the physical findings. Contrary to clinical practice, none of the examples or recommendations documented these early perceptions before chief concerns and history were presented. Discussion An examiner’s initial perceptions of a patient’s affect, degree of illness, and level of distress can influence the content of the history, triage decisions, and prioritization of likely diagnoses. When chief concerns and history are shared without benefit of this information, erroneous assumptions and miscommunications can result. Conclusion This survey confirms common use of a standardized outline for documenting, communicating, and teaching history-taking and physical examination protocol. The present outline shares early observations out of clinical sequence and may provide inadequate context for accurate interpretation of chief concerns and history. Corrective actions include modifying the documentation sequence to conform to clinical practice and teaching contextual methodology for sharing patient information. PMID:28096709

Roadmap to a Comprehensive Clinical Data Warehouse for Precision Medicine Applications in Oncology

PubMed Central

Foran, David J; Chen, Wenjin; Chu, Huiqi; Sadimin, Evita; Loh, Doreen; Riedlinger, Gregory; Goodell, Lauri A; Ganesan, Shridar; Hirshfield, Kim; Rodriguez, Lorna; DiPaola, Robert S

2017-01-01

Leading institutions throughout the country have established Precision Medicine programs to support personalized treatment of patients. A cornerstone for these programs is the establishment of enterprise-wide Clinical Data Warehouses. Working shoulder-to-shoulder, a team of physicians, systems biologists, engineers, and scientists at Rutgers Cancer Institute of New Jersey have designed, developed, and implemented the Warehouse with information originating from data sources, including Electronic Medical Records, Clinical Trial Management Systems, Tumor Registries, Biospecimen Repositories, Radiology and Pathology archives, and Next Generation Sequencing services. Innovative solutions were implemented to detect and extract unstructured clinical information that was embedded in paper/text documents, including synoptic pathology reports. Supporting important precision medicine use cases, the growing Warehouse enables physicians to systematically mine and review the molecular, genomic, image-based, and correlated clinical information of patient tumors individually or as part of large cohorts to identify changes and patterns that may influence treatment decisions and potential outcomes. PMID:28469389

External audit of clinical practice and medical decision making in a new Asian oncology center: Results and implications for both developing and developed nations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Shakespeare, Thomas P.; Back, Michael F.; Lu, Jiade J.

2006-03-01

Purpose: The external audit of oncologist clinical practice is increasingly important because of the incorporation of audits into national maintenance of certification (MOC) programs. However, there are few reports of external audits of oncology practice or decision making. Our institution (The Cancer Institute, Singapore) was asked to externally audit an oncology department in a developing Asian nation, providing a unique opportunity to explore the feasibility of such a process. Methods and Materials: We audited 100 randomly selected patients simulated for radiotherapy in 2003, using a previously reported audit instrument assessing clinical documentation/quality assurance and medical decision making. Results: Clinical documentation/qualitymore » assurance, decision making, and overall performance criteria were adequate 74.4%, 88.3%, and 80.2% of the time, respectively. Overall 52.0% of cases received suboptimal management. Multivariate analysis revealed palliative intent was associated with improved documentation/clinical quality assurance (p = 0.07), decision making (p 0.007), overall performance (p = 0.003), and optimal treatment rates (p 0.07); non-small-cell lung cancer or central nervous system primary sites were associated with better decision making (p = 0.001), overall performance (p = 0.03), and optimal treatment rates (p = 0.002). Conclusions: Despite the poor results, the external audit had several benefits. It identified learning needs for future targeting, and the auditor provided facilitating feedback to address systematic errors identified. Our experience was also helpful in refining our national revalidation audit instrument. The feasibility of the external audit supports the consideration of including audit in national MOC programs.« less

Quality improvement in breast cancer project: compliance with antiresorptive agents and changing patterns of drug use.

PubMed

Borden, Charles P; Shapiro, Charles L; Ramirez, Maria Teresa; Kotur, Linda; Farrar, William

2014-02-01

The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute participated in NCCN's Quality Improvement in Breast Cancer initiative. The Opportunities for Improvement (OFI) team elected to improve concordance with the NCCN Clinical Practice Guidelines in Oncology for Breast Cancer recommendation that all patients diagnosed with skeletal metastases receive bisphosphonates. Assembling a multidisciplinary team of clinicians, researchers, and administrative stakeholders, the OFI team followed Six Sigma's approach to problem-solving known as DMAIC (define, measure, analyze, improve, and control). Baseline concordance was 79%, which was below the recommended target range. Initial analysis quickly revealed that 5 cases were concordant, resulting in a new baseline of 89%. The key root cause identified for the remaining gap was lack of documentation. The solution included education regarding documentation for existing staff, in addition to hard-wiring the material into new physician orientation, discussion of all patients with bone disease at tumor board meetings, and improved consistency with use of the new electronic medical record system. After implementation, the reported concordance was 92%, and the lack of documentation problem decreased from 11% in the baseline study to 6%. The team concluded that use of the NCCN Oncology Outcomes Database as an opportunity for clinical quality improvement initiatives not only is possible but also should be an essential element of any clinical program looking to continuously improve.

Clinical decision support improves quality of telephone triage documentation - an analysis of triage documentation before and after computerized clinical decision support

PubMed Central

2014-01-01

Background Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©. Methods We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety. Results Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68). Conclusions CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care. PMID:24645674

Clinical decision support improves quality of telephone triage documentation--an analysis of triage documentation before and after computerized clinical decision support.

PubMed

North, Frederick; Richards, Debra D; Bremseth, Kimberly A; Lee, Mary R; Cox, Debra L; Varkey, Prathibha; Stroebel, Robert J

2014-03-20

Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©. We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety. Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68). CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care.

Design of a graphical user interface for an intelligent multimedia information system for radiology research

NASA Astrophysics Data System (ADS)

Taira, Ricky K.; Wong, Clement; Johnson, David; Bhushan, Vikas; Rivera, Monica; Huang, Lu J.; Aberle, Denise R.; Cardenas, Alfonso F.; Chu, Wesley W.

1995-05-01

With the increase in the volume and distribution of images and text available in PACS and medical electronic health-care environments it becomes increasingly important to maintain indexes that summarize the content of these multi-media documents. Such indices are necessary to quickly locate relevant patient cases for research, patient management, and teaching. The goal of this project is to develop an intelligent document retrieval system that allows researchers to request for patient cases based on document content. Thus we wish to retrieve patient cases from electronic information archives that could include a combined specification of patient demographics, low level radiologic findings (size, shape, number), intermediate-level radiologic findings (e.g., atelectasis, infiltrates, etc.) and/or high-level pathology constraints (e.g., well-differentiated small cell carcinoma). The cases could be distributed among multiple heterogeneous databases such as PACS, RIS, and HIS. Content- based retrieval systems go beyond the capabilities of simple key-word or string-based retrieval matching systems. These systems require a knowledge base to comprehend the generality/specificity of a concept (thus knowing the subclasses or related concepts to a given concept) and knowledge of the various string representations for each concept (i.e., synonyms, lexical variants, etc.). We have previously reported on a data integration mediation layer that allows transparent access to multiple heterogeneous distributed medical databases (HIS, RIS, and PACS). The data access layer of our architecture currently has limited query processing capabilities. Given a patient hospital identification number, the access mediation layer collects all documents in RIS and HIS and returns this information to a specified workstation location. In this paper we report on our efforts to extend the query processing capabilities of the system by creation of custom query interfaces, an intelligent query processing engine, and a document-content index that can be generated automatically (i.e., no manual authoring or changes to the normal clinical protocols).

Building clinical data groups for electronic medical record in China.

PubMed

Tu, Haibo; Yu, Yingtao; Yang, Peng; Tang, Xuejun; Hu, Jianping; Rao, Keqin; Pan, Feng; Xu, Yongyong; Liu, Danhong

2012-04-01

This article aims at building clinical data groups for Electronic Medical Records (EMR) in China. These data groups can be reused as basic information units in building the medical sheets of Electronic Medical Record Systems (EMRS) and serve as part of its implementation guideline. The results were based on medical sheets, the forms that are used in hospitals, which were collected from hospitals. To categorize the information in these sheets into data groups, we adopted the Health Level 7 Clinical Document Architecture Release 2 Model (HL7 CDA R2 Model). The regulations and legal documents concerning health informatics and related standards in China were implemented. A set of 75 data groups with 452 data elements was created. These data elements were atomic items that comprised the data groups. Medical sheet items contained clinical records information and could be described by standard data elements that exist in current health document protocols. These data groups match different units of the CDA model. Twelve data groups with 87 standardized data elements described EMR headers, and 63 data groups with 405 standardized data elements constituted the body. The later 63 data groups in fact formed the sections of the model. The data groups had two levels. Those at the first level contained both the second level data groups and the standardized data elements. The data groups were basically reusable information units that served as guidelines for building EMRS and that were used to rebuild a medical sheet and serve as templates for the clinical records. As a pilot study of health information standards in China, the development of EMR data groups combined international standards with Chinese national regulations and standards, and this was the most critical part of the research. The original medical sheets from hospitals contain first hand medical information, and some of their items reveal the data types characteristic of the Chinese socialist national health system. It is possible and critical to localize and stabilize the adopted international health standards through abstracting and categorizing those items for future sharing and for the implementation of EMRS in China.

Automatic generation of nursing narratives from entity-attribute-value triplet for electronic nursing records system.

PubMed

Min, Yul Ha; Park, Hyeoun-Ae; Lee, Joo Yun; Jo, Soo Jung; Jeon, Eunjoo; Byeon, Namsoo; Choi, Seung Yong; Chung, Eunja

2014-01-01

The aim of this study is to develop and evaluate a natural language generation system to populate nursing narratives using detailed clinical models. Semantic, contextual, and syntactical knowledges were extracted. A natural language generation system linking these knowledges was developed. The quality of generated nursing narratives was evaluated by the three nurse experts using a five-point rating scale. With 82 detailed clinical models, in total 66,888 nursing narratives in four different types of statement were generated. The mean scores for overall quality was 4.66, for content 4.60, for grammaticality 4.40, for writing style 4.13, and for correctness 4.60. The system developed in this study generated nursing narratives with different levels of granularity. The generated nursing narratives can improve semantic interoperability of nursing data documented in nursing records.

[AC-STB: dedicated software for managed healthcare of chronic headache patients].

PubMed

Wallasch, T-M; Bek, J; Pabel, R; Modahl, M; Demir, M; Straube, A

2009-04-01

This paper examines a new approach to managed healthcare where a network of care providers exchanges patient information through the internet. Integrating networks of clinical specialists and general care providers promises to achieve qualitative and economic improvements in the German healthcare system. In practice, problems related to patient management and data exchange between the managing clinic and assorted caregivers arise. The implementation and use of a cross-spectrum computerized solution for the management of patients and their care is the key for a successful managed healthcare system. This paper documents the managed healthcare of chronic headache patients and the development of an IT-solution capable of providing distributed patient care and case management.

Value of XML in the implementation of clinical practice guidelines--the issue of content retrieval and presentation.

PubMed

Hoelzer, S; Schweiger, R K; Boettcher, H A; Tafazzoli, A G; Dudeck, J

2001-01-01

The purpose of guidelines in clinical practice is to improve the effectiveness and efficiency of clinical care. It is known that nationally or internationally produced guidelines which, in particular, do not involve medical processes at the time of consultation, do not take local factors into account, and have no consistent implementation strategy, have limited impact in changing either the behaviour of physicians, or patterns of care. The literature provides evidence for the effectiveness of computerization of CPGs for increasing compliance and improving patient outcomes. Probably the most effective concepts are knowledge-based functions for decision support or monitoring that are integrated in clinical information systems. This approach is mostly restricted by the effort required for development and maintenance of the information systems and the limited number of implemented medical rules. Most of the guidelines are text-based, and are primarily published in medical journals and posted on the internet. However, internet-published guidelines have little impact on the behaviour of physicians. It can be difficult and time-consuming to browse the internet to find (a) the correct guidelines to an existing diagnosis and (b) and adequate recommendation for a specific clinical problem. Our objective is to provide a web-based guideline service that takes as input clinical data on a particular patient and returns as output a customizable set of recommendations regarding diagnosis and treatment. Information in healthcare is to a very large extent transmitted and stored as unstructured or slightly structured text such as discharge letters, reports, forms, etc. The same applies for facilities containing medical information resources for clinical purposes and research such as text books, articles, guidelines, etc. Physicians are used to obtaining information from text-based sources. Since most guidelines are text-based, it would be practical to use a document-based solution that preserves the original cohesiveness. The lack of structure limits the automatic identification and extraction of the information contained in these resources. For this reason, we have chosen a document-based approach using eXtensible Markup Language (XML) with its schema definition and related technologies. XML empowers the applications for in-context searching. In addition it allows the same content to be represented in different ways. Our XML reference clinical data model for guidelines has been realized with the XML schema definition. The schema is used for structuring new text-based guidelines and updating existing documents. It is also used to establish search strategies on the document base. We hypothesize that enabling the physicians to query the available CPGs easily, and to get access to selected and specific information at the point of care will foster increased use. Based on current evidence we are confident that it will have substantial impact on the care provided, and will improve health outcomes.

Electronic palliative care coordination systems: Devising and testing a methodology for evaluating documentation

PubMed Central

Allsop, Matthew J; Kite, Suzanne; McDermott, Sarah; Penn, Naomi; Millares-Martin, Pablo; Bennett, Michael I

2016-01-01

Background: The need to improve coordination of care at end of life has driven electronic palliative care coordination systems implementation across the United Kingdom and internationally. No approaches for evaluating electronic palliative care coordination systems use in practice have been developed. Aim: This study outlines and applies an evaluation framework for examining how and when electronic documentation of advance care planning is occurring in end of life care services. Design: A pragmatic, formative process evaluation approach was adopted. The evaluation drew on the Project Review and Objective Evaluation methodology to guide the evaluation framework design, focusing on clinical processes. Setting/participants: Data were extracted from electronic palliative care coordination systems for 82 of 108 general practices across a large UK city. All deaths (n = 1229) recorded on electronic palliative care coordination systems between April 2014 and March 2015 were included to determine the proportion of all deaths recorded, median number of days prior to death that key information was recorded and observations about routine data use. Results: The evaluation identified 26.8% of all deaths recorded on electronic palliative care coordination systems. The median number of days to death was calculated for initiation of an electronic palliative care coordination systems record (31 days), recording a patient’s preferred place of death (8 days) and entry of Do Not Attempt Cardiopulmonary Resuscitation decisions (34 days). Where preferred and actual place of death was documented, these were matching for 75% of patients. Anomalies were identified in coding used during data entry on electronic palliative care coordination systems. Conclusion: This study reports the first methodology for evaluating how and when electronic palliative care coordination systems documentation is occurring. It raises questions about what can be drawn from routine data collected through electronic palliative care coordination systems and outlines considerations for future evaluation. Future evaluations should consider work processes of health professionals using electronic palliative care coordination systems. PMID:27507636

Electronic palliative care coordination systems: Devising and testing a methodology for evaluating documentation.

PubMed

Allsop, Matthew J; Kite, Suzanne; McDermott, Sarah; Penn, Naomi; Millares-Martin, Pablo; Bennett, Michael I

2017-05-01

The need to improve coordination of care at end of life has driven electronic palliative care coordination systems implementation across the United Kingdom and internationally. No approaches for evaluating electronic palliative care coordination systems use in practice have been developed. This study outlines and applies an evaluation framework for examining how and when electronic documentation of advance care planning is occurring in end of life care services. A pragmatic, formative process evaluation approach was adopted. The evaluation drew on the Project Review and Objective Evaluation methodology to guide the evaluation framework design, focusing on clinical processes. Data were extracted from electronic palliative care coordination systems for 82 of 108 general practices across a large UK city. All deaths ( n = 1229) recorded on electronic palliative care coordination systems between April 2014 and March 2015 were included to determine the proportion of all deaths recorded, median number of days prior to death that key information was recorded and observations about routine data use. The evaluation identified 26.8% of all deaths recorded on electronic palliative care coordination systems. The median number of days to death was calculated for initiation of an electronic palliative care coordination systems record (31 days), recording a patient's preferred place of death (8 days) and entry of Do Not Attempt Cardiopulmonary Resuscitation decisions (34 days). Where preferred and actual place of death was documented, these were matching for 75% of patients. Anomalies were identified in coding used during data entry on electronic palliative care coordination systems. This study reports the first methodology for evaluating how and when electronic palliative care coordination systems documentation is occurring. It raises questions about what can be drawn from routine data collected through electronic palliative care coordination systems and outlines considerations for future evaluation. Future evaluations should consider work processes of health professionals using electronic palliative care coordination systems.

Use of the data system for field management of a clinical study conducted in Kolkata, India.

PubMed

Park, Ju Yeon; Kim, Deok Ryun; Haldar, Bisakha; Mallick, Aiyel Haque; Kim, Soon Ae; Dey, Ayan; Nandy, Ranjan Kumar; Paul, Dilip Kumar; Choudhury, Saugata; Sahoo, Shushama; Wierzba, Thomas F; Sur, Dipika; Kanungo, Suman; Ali, Mohammad; Manna, Byomkesh

2016-01-09

Designing an appropriate data system is important to the success of a clinical study. However, little information is available on this topic. We share our experiences on designing, developing, and implementation of a data system for management of data and field activities of a complex clinical study. The data system was implemented aiming at determining the biological basis for the underperformance of oral vaccines, such as polio and rotavirus vaccines in children at a site in Kolkata, India. The system included several functionalities to control data and field activities. It was restricted to authorized users based on their access privileges. A relational database platform was chosen, and Microsoft Visual FoxPro 7.0 (Microsoft Corporation, Seattle, WA, USA) was used to develop the system. The system was installed at the clinic and data office to facilitate both the field and data management activities. Data were doubly entered by two different data operators to identify keypunching errors in the data. Outliers, duplication, inconsistencies, missing entries, and linkage were also checked. Every modification and users log-in/log-out information was auto-recorded in an audit trail. The system offered tools for preparation of visit schedule of the participants. A visit considered as protocol deviation was documented by the system. The system alerted field staff to every upcoming visit date to organize the field activities and to inform participants which day to come. The system also produced a growth chart for evaluating nutritional status and referring the child to a specialized clinic if found to be severely malnourished. The data system offered unique features for controlling for both data and field activities, which led to minimize drop-out rates as well as protocol deviations. Such system is warranted for a successful clinical study.

Family physicians' suggestions to improve the documentation, coding, and billing system: a study from the residency research network of Texas.

PubMed

Young, Richard A; Bayles, Bryan; Hill, Jason H; Kumar, Kaparabonya A; Burge, Sandra

2014-06-01

The study's aim was to ascertain family physicians' suggestions on how to improve the commonly used US evaluation and management (E/M) rules for primary care. A companion paper published in Family Medicine's May 2014 journal describes our study methods (Fam Med 2014;46(5):378-84). Study subjects supported preserving the overall SOAP note structure. They especially suggested eliminating bullet counting in the E/M rules. For payment reform, respondents stated that brief or simple work should be paid less than long or complex work, and that family physicians should be paid for important tasks they currently are not, such as spending extra time with patients, phone and email clinical encounters, and extra paperwork. Subjects wanted shared savings when their decisions and actions created system efficiencies and savings. Some supported recent payment reforms such as monthly retainer fees and pay-for-performance bonuses. Others expressed skepticism about the negative consequences of each. Aligned incentives among all stakeholders was another common theme. Family physicians wanted less burdensome documentation requirements. They wanted to be paid more for complex work and work that does not include traditional face-to-face clinic visits, and they wanted the incentives of other stakeholders in the health care systems to be aligned with their priorities.

Reported Systems Changes and Sustainability Perceptions of Three State Departments of Health Implementing Multi-Faceted Evidence-Based Fall Prevention Efforts.

PubMed

Smith, Matthew Lee; Schneider, Ellen C; Byers, Imani N; Shubert, Tiffany E; Wilson, Ashley D; Towne, Samuel D; Ory, Marcia G

2017-01-01

Although the concepts of systems change and sustainability are not new, little is known about the factors associated with systems change sustaining multi-state, multi-level fall prevention efforts. This exploratory study focuses on three State Departments of Health (DOH) that were awarded 5-year funding from the Centers for Disease Control and Prevention to simultaneously implement four separate yet related evidence-based fall prevention initiatives at the clinical, community, and policy level. The purpose of this study was to examine changes in partnerships and collaborative activities that occurred to accomplish project goals (examining changes in the context of "before funding" and "after funding was received"). Additionally, this study explored changes in State DOH perceptions about action related to sustainability indicators in the context of "during funding" and "after funding ends." Findings from this study document the partnership and activity changes necessary to achieve defined fall prevention goals after funding is received, and that the importance of sustainability indicator documentation is seen as relevant during funding, but less so after the funding ends. Findings from this study have practice and research implications that can inform future funded efforts in terms of sector and stakeholder engagement necessary for initiating, implementing, and sustaining community- and clinical-based fall prevention interventions.

Cooperative problem solving with personal mobile information tools in hospitals.

PubMed

Buchauer, A; Werner, R; Haux, R

1998-01-01

Health-care professionals have a broad range of needs for information and cooperation while working at different points of care (e.g., outpatient departments, wards, and functional units such as operating theaters). Patient-related data and medical knowledge have to be widely available to support high-quality patient care. Furthermore, due to the increased specialization of health-care professionals, efficient collaboration is required. Personal mobile information tools have a considerable potential to realize almost ubiquitous information and collaborative support. They enable to unite the functionality of conventional tools such as paper forms, dictating machines, and pagers into one tool. Moreover, they can extend the support already provided by clinical workstations. An approach is described for the integration of mobile information tools with heterogeneous hospital information systems. This approach includes identification of functions which should be provided on mobile tools. Major functions are the presentation of medical records and reports, electronic mailing to support interpersonal communication, and the provision of editors for structured clinical documentation. To realize those functions on mobile tools, we propose a document-based client-server architecture that enables mobile information tools to interoperate with existing computer-based application systems. Open application systems and powerful, partially wireless, hospital-wide networks are the prerequisites for the introduction of mobile information tools.

Bridging the integration gap between imaging and information systems: a uniform data concept for content-based image retrieval in computer-aided diagnosis.

PubMed

Welter, Petra; Riesmeier, Jörg; Fischer, Benedikt; Grouls, Christoph; Kuhl, Christiane; Deserno, Thomas M

2011-01-01

It is widely accepted that content-based image retrieval (CBIR) can be extremely useful for computer-aided diagnosis (CAD). However, CBIR has not been established in clinical practice yet. As a widely unattended gap of integration, a unified data concept for CBIR-based CAD results and reporting is lacking. Picture archiving and communication systems and the workflow of radiologists must be considered for successful data integration to be achieved. We suggest that CBIR systems applied to CAD should integrate their results in a picture archiving and communication systems environment such as Digital Imaging and Communications in Medicine (DICOM) structured reporting documents. A sample DICOM structured reporting template adaptable to CBIR and an appropriate integration scheme is presented. The proposed CBIR data concept may foster the promulgation of CBIR systems in clinical environments and, thereby, improve the diagnostic process.

Bridging the integration gap between imaging and information systems: a uniform data concept for content-based image retrieval in computer-aided diagnosis

PubMed Central

Riesmeier, Jörg; Fischer, Benedikt; Grouls, Christoph; Kuhl, Christiane; Deserno (né Lehmann), Thomas M

2011-01-01

It is widely accepted that content-based image retrieval (CBIR) can be extremely useful for computer-aided diagnosis (CAD). However, CBIR has not been established in clinical practice yet. As a widely unattended gap of integration, a unified data concept for CBIR-based CAD results and reporting is lacking. Picture archiving and communication systems and the workflow of radiologists must be considered for successful data integration to be achieved. We suggest that CBIR systems applied to CAD should integrate their results in a picture archiving and communication systems environment such as Digital Imaging and Communications in Medicine (DICOM) structured reporting documents. A sample DICOM structured reporting template adaptable to CBIR and an appropriate integration scheme is presented. The proposed CBIR data concept may foster the promulgation of CBIR systems in clinical environments and, thereby, improve the diagnostic process. PMID:21672913

Semiautomated System for Nonurgent, Clinically Significant Pathology Results.

PubMed

O'Connor, Stacy D; Khorasani, Ramin; Pochebit, Stephen M; Lacson, Ronilda; Andriole, Katherine P; Dalal, Anuj K

2018-04-01

 Failure of timely test result follow-up has consequences including delayed diagnosis and treatment, added costs, and potential patient harm. Closed-loop communication is key to ensure clinically significant test results (CSTRs) are acknowledged and acted upon appropriately. A previous implementation of the Alert Notification of Critical Results (ANCR) system to facilitate closed-loop communication of imaging CSTRs yielded improved communication of critical radiology results and enhanced adherence to institutional CSTR policies.  This article extends the ANCR application to pathology and evaluates its impact on closed-loop communication of new malignancies, a common and important type of pathology CSTR.  This Institutional Review Board-approved study was performed at a 150-bed community, academically affiliated hospital. ANCR was adapted for pathology CSTRs. Natural language processing was used on 30,774 pathology reports 13 months pre- and 13 months postintervention, identifying 5,595 reports with malignancies. Electronic health records were reviewed for documented acknowledgment for a random sample of reports. Percent of reports with documented acknowledgment within 15 days assessed institutional policy adherence. Time to acknowledgment was compared pre- versus postintervention and postintervention with and without ANCR alerts. Pathologists were surveyed regarding ANCR use and satisfaction.  Acknowledgment within 15 days was documented for 98 of 107 (91.6%) pre- and 89 of 103 (86.4%) postintervention reports ( p  = 0.2294). Median time to acknowledgment was 7 days (interquartile range [IQR], 3, 11) preintervention and 6 days (IQR, 2, 10) postintervention ( p  = 0.5083). Postintervention, median time to acknowledgment was 2 days (IQR, 1, 6) for reports with ANCR alerts versus 6 days (IQR, 2.75, 9) for reports without alerts ( p  = 0.0351). ANCR alerts were sent on 15 of 103 (15%) postintervention reports. All pathologists reported that the ANCR system positively impacted their workflow; 75% (three-fourths) felt that the ANCR system improved efficiency of communicating CSTRs.  ANCR expansion to facilitate closed-loop communication of pathology CSTRs was favorably perceived and associated with significant improved time to documented acknowledgment for new malignancies. The rate of adherence to institutional policy did not improve. Schattauer.

Assessing the Readability of Medical Documents: A Ranking Approach.

PubMed

Zheng, Jiaping; Yu, Hong

2018-03-23

The use of electronic health record (EHR) systems with patient engagement capabilities, including viewing, downloading, and transmitting health information, has recently grown tremendously. However, using these resources to engage patients in managing their own health remains challenging due to the complex and technical nature of the EHR narratives. Our objective was to develop a machine learning-based system to assess readability levels of complex documents such as EHR notes. We collected difficulty ratings of EHR notes and Wikipedia articles using crowdsourcing from 90 readers. We built a supervised model to assess readability based on relative orders of text difficulty using both surface text features and word embeddings. We evaluated system performance using the Kendall coefficient of concordance against human ratings. Our system achieved significantly higher concordance (.734) with human annotators than did a baseline using the Flesch-Kincaid Grade Level, a widely adopted readability formula (.531). The improvement was also consistent across different disease topics. This method's concordance with an individual human user's ratings was also higher than the concordance between different human annotators (.658). We explored methods to automatically assess the readability levels of clinical narratives. Our ranking-based system using simple textual features and easy-to-learn word embeddings outperformed a widely used readability formula. Our ranking-based method can predict relative difficulties of medical documents. It is not constrained to a predefined set of readability levels, a common design in many machine learning-based systems. Furthermore, the feature set does not rely on complex processing of the documents. One potential application of our readability ranking is personalization, allowing patients to better accommodate their own background knowledge. ©Jiaping Zheng, Hong Yu. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 23.03.2018.

Evaluation of the effectiveness of an outreach clinical mentoring programme in support of paediatric HIV care scale-up in Botswana.

PubMed

Workneh, Gelane; Scherzer, Leah; Kirk, Brianna; Draper, Heather R; Anabwani, Gabriel; Wanless, R Sebastian; Jibril, Haruna; Gaetsewe, Neo; Thuto, Boitumelo; Tolle, Michael A

2013-01-01

Clinical mentoring by providers skilled in HIV management has been identified as a cornerstone of scaling-up antiretroviral treatment in Africa, particularly in settings where expertise is limited. However, little data exist on its effectiveness and impact on improving the quality-of-care and clinical outcomes, especially for HIV-infected children. Since 2008, the Botswana-Baylor Children's Clinical Centre of Excellence (COE) has operated an outreach mentoring programme at clinical sites around Botswana. This study is a retrospective review of 374 paediatric charts at four outreach mentoring sites (Mochudi, Phutadikobo, Molepolole and Thamaga) evaluating the effectiveness of the programme as reflected in a number of clinically-relevant areas. Charts from one visit prior to initiation of mentoring and from one visit after approximately one year of mentoring were assessed for statistically-significant differences (p<0.05) in the documentation of clinically-relevant indicators. Mochudi showed notable improvements in all indicators analysed, with particular improvements in documentation of pill count, viral load (VL) results, correct laboratory monitoring and correct antiretroviral therapy (ART) dosing (p<0.0001, p<0.0001, p<0.0001 and p<0.0001, respectively). Broad and substantial improvements were also seen in Molepolole, with the most improvement in disclosure documentation of all four sites. At Thamaga, improvements were restricted to CD4 documentation (p<0.001), recent VL and documented pill count (p<0.05 and p<0.05, respectively). Phuthadikobo showed the least amount of improvement across indicators, with only VL documentation and correct ART dosing showing statistically-significant improvements (p<0.05 and p<0.0001, respectively). These findings suggest that clinical mentoring may assist improvements in a number of important areas, including ART dosing and monitoring; adherence assessment and assurance; and disclosure. Clinical mentoring may be a valuable tool in scale-up of quality paediatric HIV care-and-treatment outside specialised centres. Further study will help refine approaches to clinical mentoring, including assuring mentoring translates into improved clinical outcomes for HIV-infected children.

Clinical practice guidelines and consensus statements in oncology--an assessment of their methodological quality.

PubMed

Jacobs, Carmel; Graham, Ian D; Makarski, Julie; Chassé, Michaël; Fergusson, Dean; Hutton, Brian; Clemons, Mark

2014-01-01

Consensus statements and clinical practice guidelines are widely available for enhancing the care of cancer patients. Despite subtle differences in their definition and purpose, these terms are often used interchangeably. We systematically assessed the methodological quality of consensus statements and clinical practice guidelines published in three commonly read, geographically diverse, cancer-specific journals. Methods Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents. Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents. Thirty-four consensus statements and 67 clinical practice guidelines were evaluated. The rigour of development score for consensus statements over the three journals was 32% lower than that of clinical practice guidelines. The editorial independence score was 15% lower for consensus statements than clinical practice guidelines. One journal scored consistently lower than the others over both domains. No journals adhered to all the items related to the transparency of document development. One journal's consensus statements endorsed a product made by the sponsoring pharmaceutical company in 64% of cases. Guidance documents are an essential part of oncology care and should be subjected to a rigorous and validated development process. Consensus statements had lower methodological quality than clinical practice guidelines using AGREE II. At a minimum, journals should ensure that that all consensus statements and clinical practice guidelines adhere to AGREE II criteria. Journals should consider explicitly requiring guidelines to declare pharmaceutical company sponsorship and to identify the sponsor's product to enhance transparency.

[Epidemiology of Imperfect Osteogenesis: a Rare Disease in the Valencia Region.

PubMed

Gimeno-Martos, Silvia; Pérez-Riera, Carlos; Guardiola-Vilarroig, Sandra; Cavero-Carbonell, Clara

2017-11-28

Osteogenesis imperfecta (OI) is a rare connective tissue and bone disease that results in a bone fragility of varying severity. The objective was to determine and describe the OI in the Valencia Region (VR) during the period 2004 to 2014. From the Rare Diseases Information System of the VR (SIER-CV) patients from 2004 to 2014 with the codes of the International Classification of Diseases for the OI were identified: 756.51 from the 9th Revision-Clinical Modification and Q78.0 from the 10th Revision. The information was validated by reviewing clinical documentation (mainly electronic health records) and a descriptive analysis of the confirmed cases (diagnosis of OI in the clinical documentation) was performed. 162 patients were identified with a code for OI. 145 of the 161 patients with available clinical documentation were confirmed as cases. The prevalence was 0.29 per 10.000 inhabitants. 93.1% were Spanish, 54.5% were women and they were treated in 25 different hospitals in the VR. The type of OI was known in the 26.4% of the cases and type I was the most common (9.7%). 6.2% of the patients died with an average death age of 60.8 years. 44.8% of patients received treatment with bisphosphonates and 10.4% had affected relatives. The real situation of the OI in the VR has been established, which will allow a better planning in the health actions to improve the quality of life of the affected ones and their families.

The Radiologist Is in, but Was it Worth the Wait? Radiology Resident Note Quality in an Outpatient Interventional Radiology Clinic.

PubMed

Abboud, Salim E; Soriano, Stephanie; Abboud, Rayan; Patel, Indravadan; Davidson, Jon; Azar, Nami R; Nakamoto, Dean A

Preprocedural evaluation of patients in an interventional radiology (IR) clinic is a complex synthesis of physical examination and imaging findings, and as IR transitions to an independent clinical specialty, such evaluations will become an increasingly critical component of a successful IR practice and quality patient care. Prior research suggests that preprocedural evaluations increased patient's perceived quality of care and may improve procedural technical success rates. Appropriate documentation of a preprocedural evaluation in the medical record is also paramount for an interventional radiologist to add value and function as an effective member of a larger IR service and multidisciplinary health care team. The purpose of this study is to examine the quality of radiology resident notes for patients seen in an outpatient IR clinic at a single academic medical center before and after the adoption of clinic note template with reminders to include platelet count, international normalized ratio, glomerular filtration rate, and plan for periprocedural coagulation status. Before adoption of the template, platelet count, international normalized ratio, glomerular filtration rate and an appropriate plan for periprocedural coagulation status were documented in 72%, 82%, 42%, and 33% of patients, respectively. After adoption of the template, appropriate documentation of platelet count, international normalized ratio, and glomerular filtration rate increased to 96%, and appropriate plan for periprocedural coagulation status was documented in 83% of patients. Patient evaluation and clinical documentation skills may not be adequately practiced during radiology residency, and tools such as templates may help increase documentation quality by radiology residents. Copyright © 2017 Elsevier Inc. All rights reserved.

The design and implementation of an automated system for logging clinical experiences using an anesthesia information management system.

PubMed

Simpao, Allan; Heitz, James W; McNulty, Stephen E; Chekemian, Beth; Brenn, B Randall; Epstein, Richard H

2011-02-01

Residents in anesthesia training programs throughout the world are required to document their clinical cases to help ensure that they receive adequate training. Current systems involve self-reporting, are subject to delayed updates and misreported data, and do not provide a practicable method of validation. Anesthesia information management systems (AIMS) are being used increasingly in training programs and are a logical source for verifiable documentation. We hypothesized that case logs generated automatically from an AIMS would be sufficiently accurate to replace the current manual process. We based our analysis on the data reporting requirements of the American College of Graduate Medical Education (ACGME). We conducted a systematic review of ACGME requirements and our AIMS record, and made modifications after identifying data element and attribution issues. We studied 2 methods (parsing of free text procedure descriptions and CPT4 procedure code mapping) to automatically determine ACGME case categories and generated AIMS-based case logs and compared these to assignments made by manual inspection of the anesthesia records. We also assessed under- and overreporting of cases entered manually by our residents into the ACGME website. The parsing and mapping methods assigned cases to a majority of the ACGME categories with accuracies of 95% and 97%, respectively, as compared with determinations made by 2 residents and 1 attending who manually reviewed all procedure descriptions. Comparison of AIMS-based case logs with reports from the ACGME Resident Case Log System website showed that >50% of residents either underreported or overreported their total case counts by at least 5%. The AIMS database is a source of contemporaneous documentation of resident experience that can be queried to generate valid, verifiable case logs. The extent of AIMS adoption by academic anesthesia departments should encourage accreditation organizations to support uploading of AIMS-based case log files to improve accuracy and to decrease the clerical burden on anesthesia residents.

First year specialist trainees' engagement with reflective practice in the e-portfolio.

PubMed

McNeill, Helen; Brown, Jeremy M; Shaw, Nigel J

2010-10-01

Doctors in specialist training posts in the Mersey Deanery are expected to reflect on their clinical practice and to document their learning experiences in an e-portfolio. This study aims specifically to explore how they have engaged in reflection on their practice and how they utilise their learning portfolio to document evidence of this. A modified Delphi technique was used to develop a grading system to identify the level of reflection recorded by participants in the e-portfolio. Transcripts of the reflective accounts were then analysed using a qualitative approach which involved coding and categorising the data. This study demonstrated a wide variation in both the quantity and quality of reflection. Of particular note in the qualitative data analysis were themes relating to clinical knowledge and skills, learning in practice, communication, feelings, types of learning experience reflected on and wider aspects of medical practice. Findings indicate there is variation is the extent to which doctors both engage in and document evidence of reflection. Further research is needed to explore factors that enable or inhibit the use of the e-portfolio for reflection and whether recorded reflection is a true picture of the cognitive process involved.

HONselect: multilingual assistant search engine operated by a concept-based interface system to decentralized heterogeneous sources.

PubMed

Boyer, C; Baujard, V; Scherrer, J R

2001-01-01

Any new user to the Internet will think that to retrieve the relevant document is an easy task especially with the wealth of sources available on this medium, but this is not the case. Even experienced users have difficulty formulating the right query for making the most of a search tool in order to efficiently obtain an accurate result. The goal of this work is to reduce the time and the energy necessary in searching and locating medical and health information. To reach this goal we have developed HONselect [1]. The aim of HONselect is not only to improve efficiency in retrieving documents but to respond to an increased need for obtaining a selection of relevant and accurate documents from a breadth of various knowledge databases including scientific bibliographical references, clinical trials, daily news, multimedia illustrations, conferences, forum, Web sites, clinical cases, and others. The authors based their approach on the knowledge representation using the National Library of Medicine's Medical Subject Headings (NLM, MeSH) vocabulary and classification [2,3]. The innovation is to propose a multilingual "one-stop searching" (one Web interface to databases currently in English, French and German) with full navigational and connectivity capabilities. The user may choose from a given selection of related terms the one that best suit his search, navigate in the term's hierarchical tree, and access directly to a selection of documents from high quality knowledge suppliers such as the MEDLINE database, the NLM's ClinicalTrials.gov server, the NewsPage's daily news, the HON's media gallery, conference listings and MedHunt's Web sites [4, 5, 6, 7, 8, 9]. HONselect, developed by HON, a non-profit organisation [10], is a free online available multilingual tool based on the MeSH thesaurus to index, select, retrieve and display accurate, up to date, high-level and quality documents.

Integrating cancer genomic data into electronic health records.

PubMed

Warner, Jeremy L; Jain, Sandeep K; Levy, Mia A

2016-10-26

The rise of genomically targeted therapies and immunotherapy has revolutionized the practice of oncology in the last 10-15 years. At the same time, new technologies and the electronic health record (EHR) in particular have permeated the oncology clinic. Initially designed as billing and clinical documentation systems, EHR systems have not anticipated the complexity and variety of genomic information that needs to be reviewed, interpreted, and acted upon on a daily basis. Improved integration of cancer genomic data with EHR systems will help guide clinician decision making, support secondary uses, and ultimately improve patient care within oncology clinics. Some of the key factors relating to the challenge of integrating cancer genomic data into EHRs include: the bioinformatics pipelines that translate raw genomic data into meaningful, actionable results; the role of human curation in the interpretation of variant calls; and the need for consistent standards with regard to genomic and clinical data. Several emerging paradigms for integration are discussed in this review, including: non-standardized efforts between individual institutions and genomic testing laboratories; "middleware" products that portray genomic information, albeit outside of the clinical workflow; and application programming interfaces that have the potential to work within clinical workflow. The critical need for clinical-genomic knowledge bases, which can be independent or integrated into the aforementioned solutions, is also discussed.

Patient-Centered Medical Home Undergraduate Internship, Benefits to a Practice Manager: Case Study.

PubMed

Sasnett, Bonita; Harris, Susie T; White, Shelly

Health services management interns become practice facilitators for primary care clinics interested in pursuing patient-centered recognition for their practice. This experience establishes a collaborative relationship between the university and clinic practices where students apply their academic training to a system of documentation to improve the quality of patient care delivery. The case study presents the process undertaken, benefits, challenges, lessons learned, and recommendations for intern, practice mangers, and educators. The practice manager benefits as interns become Patient-Centered Medical Home facilitators and assist practice managers in the recognition process.

TU-AB-201-02: An Automated Treatment Plan Quality Assurance Program for Tandem and Ovoid High Dose-Rate Brachytherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tan, J; Shi, F; Hrycushko, B

2015-06-15

Purpose: For tandem and ovoid (T&O) HDR brachytherapy in our clinic, it is required that the planning physicist manually capture ∼10 images during planning, perform a secondary dose calculation and generate a report, combine them into a single PDF document, and upload it to a record- and-verify system to prove to an independent plan checker that the case was planned correctly. Not only does this slow down the already time-consuming clinical workflow, the PDF document also limits the number of parameters that can be checked. To solve these problems, we have developed a web-based automatic quality assurance (QA) program. Methods:more » We set up a QA server accessible through a web- interface. A T&O plan and CT images are exported as DICOMRT files and uploaded to the server. The software checks 13 geometric features, e.g. if the dwell positions are reasonable, and 10 dosimetric features, e.g. secondary dose calculations via TG43 formalism and D2cc to critical structures. A PDF report is automatically generated with errors and potential issues highlighted. It also contains images showing important geometric and dosimetric aspects to prove the plan was created following standard guidelines. Results: The program has been clinically implemented in our clinic. In each of the 58 T&O plans we tested, a 14- page QA report was automatically generated. It took ∼45 sec to export the plan and CT images and ∼30 sec to perform the QA tests and generate the report. In contrast, our manual QA document preparation tooks on average ∼7 minutes under optimal conditions and up to 20 minutes when mistakes were made during the document assembly. Conclusion: We have tested the efficiency and effectiveness of an automated process for treatment plan QA of HDR T&O cases. This software was shown to improve the workflow compared to our conventional manual approach.« less

Quantifying the improvement in sepsis diagnosis, documentation, and coding: the marginal causal effect of year of hospitalization on sepsis diagnosis.

PubMed

Jafarzadeh, S Reza; Thomas, Benjamin S; Marschall, Jonas; Fraser, Victoria J; Gill, Jeff; Warren, David K

2016-01-01

To quantify the coinciding improvement in the clinical diagnosis of sepsis, its documentation in the electronic health records, and subsequent medical coding of sepsis for billing purposes in recent years. We examined 98,267 hospitalizations in 66,208 patients who met systemic inflammatory response syndrome criteria at a tertiary care center from 2008 to 2012. We used g-computation to estimate the causal effect of the year of hospitalization on receiving an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code for sepsis by estimating changes in the probability of getting diagnosed and coded for sepsis during the study period. When adjusted for demographics, Charlson-Deyo comorbidity index, blood culture frequency per hospitalization, and intensive care unit admission, the causal risk difference for receiving a discharge code for sepsis per 100 hospitalizations with systemic inflammatory response syndrome, had the hospitalization occurred in 2012, was estimated to be 3.9% (95% confidence interval [CI], 3.8%-4.0%), 3.4% (95% CI, 3.3%-3.5%), 2.2% (95% CI, 2.1%-2.3%), and 0.9% (95% CI, 0.8%-1.1%) from 2008 to 2011, respectively. Patients with similar characteristics and risk factors had a higher of probability of getting diagnosed, documented, and coded for sepsis in 2012 than in previous years, which contributed to an apparent increase in sepsis incidence. Copyright © 2016 Elsevier Inc. All rights reserved.

Recognition of clinical characteristics for population-based surveillance of fetal alcohol syndrome.

PubMed

Andrews, Jennifer G; Galindo, Maureen K; Meaney, F John; Benavides, Argelia; Mayate, Linnette; Fox, Deborah; Pettygrove, Sydney; O'Leary, Leslie; Cunniff, Christopher

2018-06-01

The diagnosis of fetal alcohol syndrome (FAS) rests on identification of characteristic facial, growth, and central nervous system (CNS) features. Public health surveillance of FAS depends on documentation of these characteristics. We evaluated if reporting of FAS characteristics is associated with the type of provider examining the child. We analyzed cases aged 7-9 years from the Fetal Alcohol Syndrome Surveillance Network II (FASSNetII). We included cases whose surveillance records included the type of provider (qualifying provider: developmental pediatrician, geneticist, neonatologist; other physician; or other provider) who evaluated the child as well as the FAS diagnostic characteristics (facial dysmorphology, CNS impairment, and/or growth deficiency) reported by the provider. A total of 345 cases were eligible for this analysis. Of these, 188 (54.5%) had adequate information on type of provider. Qualifying physicians averaged more than six reported FAS characteristics while other providers averaged less than five. Qualifying physicians reported on facial characteristics and developmental delay more frequently than other providers. Also, qualifying physicians reported on all three domains of characteristics (facial, CNS, and growth) in 97% of cases while others reported all three characteristics on two thirds of cases. Documentation in medical records during clinical evaluations for FAS is lower than optimal for cross-provider communication and surveillance purposes. Lack of documentation limits the quality and quantity of information in records that serve as a major source of data for public health surveillance systems. © 2018 Wiley Periodicals, Inc.

State-of-the-art Anonymization of Medical Records Using an Iterative Machine Learning Framework

PubMed Central

Szarvas, György; Farkas, Richárd; Busa-Fekete, Róbert

2007-01-01

Objective The anonymization of medical records is of great importance in the human life sciences because a de-identified text can be made publicly available for non-hospital researchers as well, to facilitate research on human diseases. Here the authors have developed a de-identification model that can successfully remove personal health information (PHI) from discharge records to make them conform to the guidelines of the Health Information Portability and Accountability Act. Design We introduce here a novel, machine learning-based iterative Named Entity Recognition approach intended for use on semi-structured documents like discharge records. Our method identifies PHI in several steps. First, it labels all entities whose tags can be inferred from the structure of the text and it then utilizes this information to find further PHI phrases in the flow text parts of the document. Measurements Following the standard evaluation method of the first Workshop on Challenges in Natural Language Processing for Clinical Data, we used token-level Precision, Recall and Fβ=1 measure metrics for evaluation. Results Our system achieved outstanding accuracy on the standard evaluation dataset of the de-identification challenge, with an F measure of 99.7534% for the best submitted model. Conclusion We can say that our system is competitive with the current state-of-the-art solutions, while we describe here several techniques that can be beneficial in other tasks that need to handle structured documents such as clinical records. PMID:17823086

Document creation, linking, and maintenance system

DOEpatents

Claghorn, Ronald [Pasco, WA

2011-02-15

A document creation and citation system designed to maintain a database of reference documents. The content of a selected document may be automatically scanned and indexed by the system. The selected documents may also be manually indexed by a user prior to the upload. The indexed documents may be uploaded and stored within a database for later use. The system allows a user to generate new documents by selecting content within the reference documents stored within the database and inserting the selected content into a new document. The system allows the user to customize and augment the content of the new document. The system also generates citations to the selected content retrieved from the reference documents. The citations may be inserted into the new document in the appropriate location and format, as directed by the user. The new document may be uploaded into the database and included with the other reference documents. The system also maintains the database of reference documents so that when changes are made to a reference document, the author of a document referencing the changed document will be alerted to make appropriate changes to his document. The system also allows visual comparison of documents so that the user may see differences in the text of the documents.

A computerized clinical decision support system as a means of implementing depression guidelines.

PubMed

Trivedi, Madhukar H; Kern, Janet K; Grannemann, Bruce D; Altshuler, Kenneth Z; Sunderajan, Prabha

2004-08-01

The authors describe the history and current use of computerized systems for implementing treatment guidelines in general medicine as well as the development, testing, and early use of a computerized decision support system for depression treatment among "real-world" clinical settings in Texas. In 1999 health care experts from Europe and the United States met to confront the well-documented challenges of implementing treatment guidelines and to identify strategies for improvement. They suggested the integration of guidelines into computer systems that is incorporated into clinical workflow. Several studies have demonstrated improvements in physicians' adherence to guidelines when such guidelines are provided in a computerized format. Although computerized decision support systems are being used in many areas of medicine and have demonstrated improved patient outcomes, their use in psychiatric illness is limited. The authors designed and developed a computerized decision support system for the treatment of major depressive disorder by using evidence-based guidelines, transferring the knowledge gained from the Texas Medication Algorithm Project (TMAP). This computerized decision support system (CompTMAP) provides support in diagnosis, treatment, follow-up, and preventive care and can be incorporated into the clinical setting. CompTMAP has gone through extensive testing to ensure accuracy and reliability. Physician surveys have indicated a positive response to CompTMAP, although the sample was insufficient for statistical testing. CompTMAP is part of a new era of comprehensive computerized decision support systems that take advantage of advances in automation and provide more complete clinical support to physicians in clinical practice.

The feasibility of paper-based Tracking Codes and electronic medical record systems to monitor tobacco-use assessment and intervention in an Individual Practice Association (IPA) Model health maintenance organization (HMO).

PubMed

Bentz, Charles J; Davis, Nancy; Bayley, Bruce

2002-01-01

Despite evidence of its effectiveness, tobacco cessation is not systematically addressed in routine healthcare settings. Its measurement is part of the problem. A pilot study was designed to develop and implement two different tobacco tracking systems in two independent primary care offices that participated in an IPA Model health maintenance organization in Portland, Oregon. The first clinic, which utilized a paper-based charting system, implemented CPT-like tracking codes to measure and report tobacco-cessation activities, which were eventually included in the managed-care organization's (MCO) claims database. The second clinic implemented an electronic tracking system based on its computerized electronic medical record (EMR) charting system. This paper describes the pilot study, including the processes involved in building provider acceptance for the new tracking systems in these two clinics, the barriers and successes encountered during implementation, and the resources expended by the clinics and by the MCO during the pilot. The findings from the 3-month implementation period were that documentation of tobacco-use status remained stable at 42-45% in the paper-based clinic and increased from 79% to 88% in the EMR clinic. This pilot study demonstrated that Tracking Codes are a feasible preventive-care tracking system in paper-based medical offices. However, high levels of effort and support are needed, and a critical mass of insurers and health plans would need to adopt Tracking Codes before widespread use could be expected. Results of the EMR-based tracking system are also reviewed and discussed.

Do inquiries into health system failures lead to change in clinical governance systems?

PubMed

Gluyas, Heather; Alliex, Selma; Morrison, Paul

2011-01-01

This paper reports the first part of a case study investigation to examine the changes at King Edward Memorial Hospital (KEMH) following an inquiry established to review the quality of obstetric and gynaecological services. Common findings from a range of health inquiries in recent times include that there have been inadequate adverse event reporting systems, the absence of transparent systems for staff and patients to report concerns about quality of patient care, and an ineffective medical credentialing and performance review system. The similarity of findings from many health inquiries raises the question of whether an inquiry does lead to changes to improve patient care and safety. There has been very little reported in the literature about this. Using a case study strategy the areas of medical credentialing, performance review and involvement of consumers in care were chosen as the KEMH clinical governance processes to be examined for changes post inquiry. Documents, archives and interviews were used as data sources for this case study. Documents were examined using a normative analytic approach and the Miles and Huberman framework was used for data analysis of the interviews. There were significant changes in the area of credentialing and performance review evident in analysis of all sources of data. There were some improvements in the processes of involving consumers in care, but deficits were identified in regard to the provision of training and upskilling for clinicians to improve their communication skills and interactions with patients and families.

Interplay between Clinical Guidelines and Organizational Workflow Systems. Experience from the MobiGuide Project.

PubMed

Shabo, Amnon; Peleg, Mor; Parimbelli, Enea; Quaglini, Silvana; Napolitano, Carlo

2016-12-07

Implementing a decision-support system within a healthcare organization requires integration of clinical domain knowledge with resource constraints. Computer-interpretable guidelines (CIG) are excellent instruments for addressing clinical aspects while business process management (BPM) languages and Workflow (Wf) engines manage the logistic organizational constraints. Our objective is the orchestration of all the relevant factors needed for a successful execution of patient's care pathways, especially when spanning the continuum of care, from acute to community or home care. We considered three strategies for integrating CIGs with organizational workflows: extending the CIG or BPM languages and their engines, or creating an interplay between them. We used the interplay approach to implement a set of use cases arising from a CIG implementation in the domain of Atrial Fibrillation. To provide a more scalable and standards-based solution, we explored the use of Cross-Enterprise Document Workflow Integration Profile. We describe our proof-of-concept implementation of five use cases. We utilized the Personal Health Record of the MobiGuide project to implement a loosely-coupled approach between the Activiti BPM engine and the Picard CIG engine. Changes in the PHR were detected by polling. IHE profiles were used to develop workflow documents that orchestrate cross-enterprise execution of cardioversion. Interplay between CIG and BPM engines can support orchestration of care flows within organizational settings.

Extensible Stylesheet Language Formatting Objects (XSL-FO): a tool to transform patient data into attractive clinical reports.

PubMed

Simonaitis, Linas; Belsito, Anne; Warvel, Jeff; Hui, Siu; McDonald, Clement J

2006-01-01

Clinicians at Wishard Hospital in Indianapolis print and carry clinical reports called "Pocket Rounds". This paper describes a new process we developed to improve these clinical reports. The heart of our new process is a World Wide Web Consortium standard: Extensible Stylesheet Language Formatting Objects (XSL-FO). Using XSL-FO stylesheets we generated Portable Document Format (PDF) and PostScript reports with complex formatting: columns, tables, borders, shading, indents, dividing lines. We observed patterns of clinical report printing during a eight month study period on three Medicine wards. Usage statistics indicated that clinicians accepted the new system enthusiastically: 78% of 26,418 reports were printed using the new system. We surveyed 67 clinical users. Respondents gave the new reports a rating of 4.2 (on a 5 point scale); they gave the old reports a rating of 3.4. The primary complaint was that it took longer to print the new reports. We believe that XSL-FO is a promising way to transform text data into functional and attractive clinical reports: relatively easy to implement and modify.

Using EHR audit trail logs to analyze clinical workflow: A case study from community-based ambulatory clinics.

PubMed

Wu, Danny T Y; Smart, Nikolas; Ciemins, Elizabeth L; Lanham, Holly J; Lindberg, Curt; Zheng, Kai

2017-01-01

To develop a workflow-supported clinical documentation system, it is a critical first step to understand clinical workflow. While Time and Motion studies has been regarded as the gold standard of workflow analysis, this method can be resource consuming and its data may be biased due to the cognitive limitation of human observers. In this study, we aimed to evaluate the feasibility and validity of using EHR audit trail logs to analyze clinical workflow. Specifically, we compared three known workflow changes from our previous study with the corresponding EHR audit trail logs of the study participants. The results showed that EHR audit trail logs can be a valid source for clinical workflow analysis, and can provide an objective view of clinicians' behaviors, multi-dimensional comparisons, and a highly extensible analysis framework.

Antibiotics/antimicrobials: systemic and local administration in the therapy of mild to moderately advanced periodontitis.

PubMed

Jepsen, Karin; Jepsen, Søren

2016-06-01

This review gives an update of the current scientific evidence on the efficacy of the adjunctive use of systemic and local antibiotics/antimicrobials in the treatment of periodontitis. In particular, it addresses whether their use can improve the results of nonsurgical mechanical therapy in mild-to-moderate forms of the disease. Large numbers of randomized clinical trials and systematic reviews with meta-analyses have clearly established that adjunctive systemic antibiotics, combined with mechanical debridement, offer clinical improvements additional to those obtained with scaling and root planing alone. These effects are more pronounced in aggressive periodontitis and in initially deep pockets, whereas more limited additional improvements, of 0.3 mm for additional pocket reduction and 0.2 mm for additional clinical attachment gain, have been documented for moderately deep sites (4-6 mm) in patients with chronic periodontitis. The marginal clinical benefit in patients with moderate disease has to be balanced against possible side effects. Notably, it has to be realized that an increasing number of warnings have been articulated against the unrestricted use of antibiotics in treating periodontal diseases because of the emerging global public health issue of bacterial resistance. The effects of the adjunctive local administration of antimicrobials have also been very well documented in several systematic reviews. Overall, in persistent or recurrent localized deep sites, the application of antimicrobials by sustained-delivery devices may offer a benefit of an additional 0.4 mm in pocket depth reduction and 0.3 mm in clinical attachment level gain. In conclusion, the slight additional benefits of adjunctive antimicrobials, which were shown for moderate forms of periodontitis, have to be balanced against their side effects and therefore their prescription should be limited as much as possible. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

[ADP system for automatic production of physician's letters as well as statistics analyses in the area of obstetrics and perinatology].

PubMed

Heinrich, J; Putzar, H; Seidenschnur, G

1977-01-01

Report about an electronic data processing system for obstetrics and perinatology. The developed data document design and data flowchart are shown. The continuously accumulated data allowed everytime a detailed interpretation record. For all clinical treated patients the computer printed out a final obstetrical report (physician report). By means of this simple system there is an improvement of the information and the typewriting work of medical staff has been reduced. Cost and work-expenditure for this system are limited in relation to our earlier hand made procedure.

Pediatric Anthrax Clinical Management

PubMed Central

Bradley, John S.; Peacock, Georgina; Krug, Steven E.; Bower, William A.; Cohn, Amanda C.; Meaney-Delman, Dana; Pavia, Andrew T.

2015-01-01

Anthrax is a zoonotic disease caused by Bacillus anthracis, which has multiple routes of infection in humans, manifesting in different initial presentations of disease. Because B anthracis has the potential to be used as a biological weapon and can rapidly progress to systemic anthrax with high mortality in those who are exposed and untreated, clinical guidance that can be quickly implemented must be in place before any intentional release of the agent. This document provides clinical guidance for the prophylaxis and treatment of neonates, infants, children, adolescents, and young adults up to the age of 21 (referred to as “children”) in the event of a deliberate B anthracis release and offers guidance in areas where the unique characteristics of children dictate a different clinical recommendation from adults. PMID:24777226

SU-E-T-255: Development of a Michigan Quality Assurance (MQA) Database for Clinical Machine Operations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Roberts, D

Purpose: A unified database system was developed to allow accumulation, review and analysis of quality assurance (QA) data for measurement, treatment, imaging and simulation equipment in our department. Recording these data in a database allows a unified and structured approach to review and analysis of data gathered using commercial database tools. Methods: A clinical database was developed to track records of quality assurance operations on linear accelerators, a computed tomography (CT) scanner, high dose rate (HDR) afterloader and imaging systems such as on-board imaging (OBI) and Calypso in our department. The database was developed using Microsoft Access database and visualmore » basic for applications (VBA) programming interface. Separate modules were written for accumulation, review and analysis of daily, monthly and annual QA data. All modules were designed to use structured query language (SQL) as the basis of data accumulation and review. The SQL strings are dynamically re-written at run time. The database also features embedded documentation, storage of documents produced during QA activities and the ability to annotate all data within the database. Tests are defined in a set of tables that define test type, specific value, and schedule. Results: Daily, Monthly and Annual QA data has been taken in parallel with established procedures to test MQA. The database has been used to aggregate data across machines to examine the consistency of machine parameters and operations within the clinic for several months. Conclusion: The MQA application has been developed as an interface to a commercially available SQL engine (JET 5.0) and a standard database back-end. The MQA system has been used for several months for routine data collection.. The system is robust, relatively simple to extend and can be migrated to a commercial SQL server.« less

Information system support as a critical success factor for chronic disease management: Necessary but not sufficient.

PubMed

Green, Carolyn J; Fortin, Patricia; Maclure, Malcolm; Macgregor, Art; Robinson, Sylvia

2006-12-01

Improvement of chronic disease management in primary care entails monitoring indicators of quality over time and across patients and practices. Informatics tools are needed, yet implementing them remains challenging. To identify critical success factors enabling the translation of clinical and operational knowledge about effective and efficient chronic care management into primary care practice. A prospective case study of positive deviants using key informant interviews, process observation, and document review. A chronic disease management (CDM) collaborative of primary care physicians with documented improvement in adherence to clinical practice guidelines using a web-based patient registry system with CDM guideline-based flow sheet. Thirty community-based physician participants using predominantly paper records, plus a project management team including the physician lead, project manager, evaluator and support team. A critical success factor (CSF) analysis of necessary and sufficient pathways to the translation of knowledge into clinical practice. A web-based CDM 'toolkit' was found to be a direct CSF that allowed this group of physicians to improve their practice by tracking patient care processes using evidence-based clinical practice guideline-based flow sheets. Moreover, the information and communication technology 'factor' was sufficient for success only as part of a set of seven direct CSF components including: health delivery system enhancements, organizational partnerships, funding mechanisms, project management, practice models, and formal knowledge translation practices. Indirect factors that orchestrated success through the direct factor components were also identified. A central insight of this analysis is that a comprehensive quality improvement model was the CSF that drew this set of factors into a functional framework for successful knowledge translation. In complex primary care settings environment where physicians have low adoption rates of electronic tools to support the care of patients with chronic conditions, successful implementation may require a set of interrelated system and technology factors.

The International Endometriosis Evaluation Program (IEEP Study) – A Systematic Study for Physicians, Researchers and Patients

PubMed Central

Burghaus, S.; Fehm, T.; Fasching, P. A.; Blum, S.; Renner, S. K.; Baier, F.; Brodkorb, T.; Fahlbusch, C.; Findeklee, S.; Häberle, L.; Heusinger, K.; Hildebrandt, T.; Lermann, J.; Strahl, O.; Tchartchian, G.; Bojahr, B.; Porn, A.; Fleisch, M.; Reicke, S.; Füger, T.; Hartung, C.-P.; Hackl, J.; Beckmann, M. W.; Renner, S. P.

2016-01-01

Introduction: Endometriosis is a heterogeneous disease characterized by a range of different presentations. It is usually diagnosed when patients present with pain and/or infertility, but it has also been diagnosed in asymptomatic patients. Because of the different diagnostic approaches and diverse therapies, time to diagnosis can vary considerably and the definitive diagnosis may be delayed, with some cases not being diagnosed for several years. Endometriosis patients have many unmet needs. A systematic registration and follow-up of endometriosis patients could be useful to obtain an insight into the course of the disease. The validation of biomarkers could contribute to the development of diagnostic and predictive tests which could help select patients for surgical assessment earlier and offer better predictions about patients who might benefit from medical, surgical or other interventions. The aim is also to obtain a better understanding of the etiology, pathogenesis and progression of the disease. Material and Methods: To do this, an online multicenter documentation system was introduced to facilitate the establishment of a prospective multicenter case-control study, the IEEP (International Endometriosis Evaluation Program) study. We report here on the first 696 patients with endometriosis included in the program between June 2013 and June 2015. Results: A documentation system was created, and the structure and course of the study were mapped out with regard to data collection and the collection of biomaterials. Conclusion: The documentation system permits the history and clinical data of patients with endometriosis to be recorded. The IEEP combines this information with biomaterials and uses it for scientific studies. The recorded data can also be used to evaluate clinical quality control measures such as the certification parameters used by the EEL (European Endometriosis League) to assess certified endometriosis centers. PMID:27582581

The International Endometriosis Evaluation Program (IEEP Study) - A Systematic Study for Physicians, Researchers and Patients.

PubMed

Burghaus, S; Fehm, T; Fasching, P A; Blum, S; Renner, S K; Baier, F; Brodkorb, T; Fahlbusch, C; Findeklee, S; Häberle, L; Heusinger, K; Hildebrandt, T; Lermann, J; Strahl, O; Tchartchian, G; Bojahr, B; Porn, A; Fleisch, M; Reicke, S; Füger, T; Hartung, C-P; Hackl, J; Beckmann, M W; Renner, S P

2016-08-01

Endometriosis is a heterogeneous disease characterized by a range of different presentations. It is usually diagnosed when patients present with pain and/or infertility, but it has also been diagnosed in asymptomatic patients. Because of the different diagnostic approaches and diverse therapies, time to diagnosis can vary considerably and the definitive diagnosis may be delayed, with some cases not being diagnosed for several years. Endometriosis patients have many unmet needs. A systematic registration and follow-up of endometriosis patients could be useful to obtain an insight into the course of the disease. The validation of biomarkers could contribute to the development of diagnostic and predictive tests which could help select patients for surgical assessment earlier and offer better predictions about patients who might benefit from medical, surgical or other interventions. The aim is also to obtain a better understanding of the etiology, pathogenesis and progression of the disease. To do this, an online multicenter documentation system was introduced to facilitate the establishment of a prospective multicenter case-control study, the IEEP (International Endometriosis Evaluation Program) study. We report here on the first 696 patients with endometriosis included in the program between June 2013 and June 2015. A documentation system was created, and the structure and course of the study were mapped out with regard to data collection and the collection of biomaterials. The documentation system permits the history and clinical data of patients with endometriosis to be recorded. The IEEP combines this information with biomaterials and uses it for scientific studies. The recorded data can also be used to evaluate clinical quality control measures such as the certification parameters used by the EEL (European Endometriosis League) to assess certified endometriosis centers.

Using computerised patient-level costing data for setting DRG weights: the Victorian (Australia) cost weight studies.

PubMed

Jackson, T

2001-05-01

Casemix-funding systems for hospital inpatient care require a set of resource weights which will not inadvertently distort patterns of patient care. Few health systems have very good sources of cost information, and specific studies to derive empirical cost relativities are themselves costly. This paper reports a 5 year program of research into the use of data from hospital management information systems (clinical costing systems) to estimate resource relativities for inpatient hospital care used in Victoria's DRG-based payment system. The paper briefly describes international approaches to cost weight estimation. It describes the architecture of clinical costing systems, and contrasts process and job costing approaches to cost estimation. Techniques of data validation and reliability testing developed in the conduct of four of the first five of the Victorian Cost Weight Studies (1993-1998) are described. Improvement in sampling, data validity and reliability are documented over the course of the research program, the advantages of patient-level data are highlighted. The usefulness of these byproduct data for estimation of relative resource weights and other policy applications may be an important factor in hospital and health system decisions to invest in clinical costing technology.

A European inventory of common electronic health record data elements for clinical trial feasibility

PubMed Central

2014-01-01

Background Clinical studies are a necessity for new medications and therapies. Many studies, however, struggle to meet their recruitment numbers in time or have problems in meeting them at all. With increasing numbers of electronic health records (EHRs) in hospitals, huge databanks emerge that could be utilized to support research. The Innovative Medicine Initiative (IMI) funded project ‘Electronic Health Records for Clinical Research’ (EHR4CR) created a standardized and homogenous inventory of data elements to support research by utilizing EHRs. Our aim was to develop a Data Inventory that contains elements required for site feasibility analysis. Methods The Data Inventory was created in an iterative, consensus driven approach, by a group of up to 30 people consisting of pharmaceutical experts and informatics specialists. An initial list was subsequently expanded by data elements of simplified eligibility criteria from clinical trial protocols. Each element was manually reviewed by pharmaceutical experts and standard definitions were identified and added. To verify their availability, data exports of the source systems at eleven university hospitals throughout Europe were conducted and evaluated. Results The Data Inventory consists of 75 data elements that, on the one hand are frequently used in clinical studies, and on the other hand are available in European EHR systems. Rankings of data elements were created from the results of the data exports. In addition a sub-list was created with 21 data elements that were separated from the Data Inventory because of their low usage in routine documentation. Conclusion The data elements in the Data Inventory were identified with the knowledge of domain experts from pharmaceutical companies. Currently, not all information that is frequently used in site feasibility is documented in routine patient care. PMID:24410735

The present status and problems in document retrieval system : document input type retrieval system

NASA Astrophysics Data System (ADS)

Inagaki, Hirohito

The office-automation (OA) made many changes. Many documents were begun to maintained in an electronic filing system. Therefore, it is needed to establish efficient document retrieval system to extract useful information. Current document retrieval systems are using simple word-matching, syntactic-matching, semantic-matching to obtain high retrieval efficiency. On the other hand, the document retrieval systems using special hardware devices, such as ISSP, were developed for aiming high speed retrieval. Since these systems can accept a single sentence or keywords as input, it is difficult to explain searcher's request. We demonstrated document input type retrieval system, which can directly accept document as an input, and can search similar documents from document data-base.

Comparison of a semi-automatic annotation tool and a natural language processing application for the generation of clinical statement entries.

PubMed

Lin, Ching-Heng; Wu, Nai-Yuan; Lai, Wei-Shao; Liou, Der-Ming

2015-01-01

Electronic medical records with encoded entries should enhance the semantic interoperability of document exchange. However, it remains a challenge to encode the narrative concept and to transform the coded concepts into a standard entry-level document. This study aimed to use a novel approach for the generation of entry-level interoperable clinical documents. Using HL7 clinical document architecture (CDA) as the example, we developed three pipelines to generate entry-level CDA documents. The first approach was a semi-automatic annotation pipeline (SAAP), the second was a natural language processing (NLP) pipeline, and the third merged the above two pipelines. We randomly selected 50 test documents from the i2b2 corpora to evaluate the performance of the three pipelines. The 50 randomly selected test documents contained 9365 words, including 588 Observation terms and 123 Procedure terms. For the Observation terms, the merged pipeline had a significantly higher F-measure than the NLP pipeline (0.89 vs 0.80, p<0.0001), but a similar F-measure to that of the SAAP (0.89 vs 0.87). For the Procedure terms, the F-measure was not significantly different among the three pipelines. The combination of a semi-automatic annotation approach and the NLP application seems to be a solution for generating entry-level interoperable clinical documents. © The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.comFor numbered affiliation see end of article.

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center.

PubMed

Zargaran, Eiman; Spence, Richard; Adolph, Lauren; Nicol, Andrew; Schuurman, Nadine; Navsaria, Pradeep; Ramsey, Damon; Hameed, S Morad

2018-03-14

Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity. To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools. This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013. The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital. The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11 612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n = 11 612) had statistically significant higher completion rates compared with paper records (n = 9236) (for all comparisons, P < .001). The eTHR successfully captured quality indicators recommended for trauma system evaluation which were previously challenging to collect in a timely and accurate manner. Of the 11 612 patient admissions over the study period, injury location was captured 11 075 times (95.4%), injury mechanism 11 135 times (95.9%), systolic blood pressure 11 106 times (95.6%), and Glasgow Coma Scale 11 140 times (95.9%). These fields were successfully captured with statistically higher rates than previous paper documentation. Epidemiologic analysis confirmed a heavy burden of violence-related injury (51.8% of all injuries) and motor vehicle crash injuries (14.3% of all injuries). Mapping analysis demonstrated clusters of injuries originating mainly from vulnerable and low-income neighborhoods and their respective referring trauma facilities, Mitchell's Plain Hospital (734 [10.1%]), Guguletu Community Health Center (654 [9.0%]), and New Somerset Hospital (400 [5.5%]). Accurate capture and simultaneous analysis of trauma data in low-resource trauma settings are feasible through the integration of surveillance into clinical workflow and the timely analysis of electronic data.

Overcoming barriers to implementing patient-reported outcomes in an electronic health record: a case report.

PubMed

Harle, Christopher A; Listhaus, Alyson; Covarrubias, Constanza M; Schmidt, Siegfried Of; Mackey, Sean; Carek, Peter J; Fillingim, Roger B; Hurley, Robert W

2016-01-01

In this case report, the authors describe the implementation of a system for collecting patient-reported outcomes and integrating results in an electronic health record. The objective was to identify lessons learned in overcoming barriers to collecting and integrating patient-reported outcomes in an electronic health record. The authors analyzed qualitative data in 42 documents collected from system development meetings, written feedback from users, and clinical observations with practice staff, providers, and patients. Guided by the Unified Theory on the Adoption and Use of Information Technology, 5 emergent themes were identified. Two barriers emerged: (i) uncertain clinical benefit and (ii) time, work flow, and effort constraints. Three facilitators emerged: (iii) process automation, (iv) usable system interfaces, and (v) collecting patient-reported outcomes for the right patient at the right time. For electronic health record-integrated patient-reported outcomes to succeed as useful clinical tools, system designers must ensure the clinical relevance of the information being collected while minimizing provider, staff, and patient burden. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Systemic mastocytosis: A rare cause of non-cirrhotic portal hypertension.

PubMed

Martins, Cláudio; Teixeira, Cristina; Ribeiro, Suzane; Trabulo, Daniel; Cardoso, Cláudia; Mangualde, João; Freire, Ricardo; Gamito, Élia; Alves, Ana Luísa; Cremers, Isabelle; Alves, Cecília; Neves, Anabela; Oliveira, Ana Paula

2016-07-28

Mastocytosis is a clonal neoplastic disorder of the mast cells (MC) that can be limited to the skin (cutaneous mastocytosis) or involve one or more extracutaneous organs (systemic mastocytosis). The clinical manifestations of mastocytosis are heterogeneous ranging from indolent disease with a long-term survival to a highly aggressive neoplasm with survival of about 6 mo. Although liver involvement in aggressive systemic mastocytosis (ASM) is relatively common, the development of portal hypertension with or without cirrhosis is rare. We report a case of ASM without skin involvement in a 72-year-old caucasian male who presented with non-cirrhotic portal hypertension based on clinical, analytical, imagiological and endoscopic findings. Given the hematological picture, the correct diagnosis was established based on ancillary tests for MC using bone marrow aspirates and biopsy. Extensive involvement of the liver and gastrointestinal tract was histologically documented. The disease progressed rapidly and severe pancytopenia and recurrent upper gastrointestinal bleeding became the dominant problem. This case illustrates the challenge in establishing a diagnosis of ASM especially when the clinical picture is atypical and without skin involvement. Gastroenterologists should consider infiltrative disease, particularly systemic mastocytosis, as a differential diagnosis in a clinical case of portal hypertension of unknown etiology.

Factors Associated with Waiting Time for Access to Mental Health Services for Children and Adolescents in Norway

ERIC Educational Resources Information Center

Andersson, Helle Wessel

2004-01-01

The present study addresses the question of equality of access, as it relates to waiting time for specialised mental health treatment for children and adolescents. The aim was to investigate whether demographic, clinical factors and service-related factors were associated with waiting time. Data was based on a documentation system in which all…

[Quality Management System in Pathological Laboratory].

PubMed

Koyatsu, Junichi; Ueda, Yoshihiko

2015-07-01

Even compared to other clinical laboratories, the pathological laboratory conducts troublesome work, and many of the work processes are also manual. Therefore, the introduction of the systematic management of administration is necessary. It will be a shortcut to use existing standards such as ISO 15189 for this purpose. There is no standard specialized for the pathological laboratory, but it is considered to be important to a pathological laboratory in particular. 1. Safety nianagement of the personnel and environmental conditions. Comply with laws and regulations concerning the handling of hazardous materials. 2. Pre-examination processes. The laboratory shall have documented procedures for the proper collection and handling of primary samples. Developed and documented criteria for acceptance or rejection of samples are applied. 3. Examination processes. Selection, verification, and validation of the examination procedures. Devise a system that can constantly monitor the traceability of the sample. 4. Post-examination processes. Storage, retention, and disposal of clinical samples. 5. Release of results. When examination results fall within established alert or critical intervals, immediately notify the physicians. The important point is to recognize the needs of the client and be aware that pathological diagnoses are always "the final diagnoses".

Sarcoid granuloma of the choroid.

PubMed

Marcus, D F; Bovino, J A; Burton, T C

1982-12-01

Two patients were found to have macular choroidal granulomas associated with systemic sarcoidosis. This unusual fundus picture was documented by serial fundus photography and fluorescein angiography. Both patients had a similar clinical picture of decreased vision, chorioretinal granulomas, and overlying neurosensory detachments. Staining of the inflammatory mass with fluorescein and leakage of dye into the neurosensory space was typical. Lymph node biopsies were performed to substantiate the diagnosis. Both patients responded promptly to systemic corticosteroid therapy with dramatic improvement in visual acuity and resolution of the choroidal lesions.

Neurodevelopment, GABA System Dysfunction, and Schizophrenia

PubMed Central

Schmidt, Martin J; Mirnics, Karoly

2015-01-01

The origins of schizophrenia have eluded clinicians and researchers since Kraepelin and Bleuler began documenting their findings. However, large clinical research efforts in recent decades have identified numerous genetic and environmental risk factors for schizophrenia. The combined data strongly support the neurodevelopmental hypothesis of schizophrenia and underscore the importance of the common converging effects of diverse insults. In this review, we discuss the evidence that genetic and environmental risk factors that predispose to schizophrenia disrupt the development and normal functioning of the GABAergic system. PMID:24759129

A homecare application based on the ASTM E2369-05 Standard Specification for Continuity of Care Record.

PubMed

Botsivaly, M; Spyropoulos, B; Koutsourakis, K; Mertika, K

2006-01-01

The purpose of this study is the presentation of a system appropriate to be used upon the transition of a patient from hospital to homecare. The developed system is structured according to the ASTM E2369-05 Standard Specification for Continuity of Care Record and its function is based upon the creation of a structured subset of data, containing the patient's most relevant clinical information, enabling simultaneously the planning and the optimal documentation of the provided homecare.

[Development and application of a medical device maintenance information platform based on BS architecture].

PubMed

Liu, Shenglin; Zhang, Xutian; Wang, Guohong; Zhang, Qiang

2012-03-01

Based on specified demands on medical devices maintenance for clinical engineers and Browser/Server architecture technology, a medical device maintenance information platform was developed, which implemented the following modules such as repair, preventive maintenance, accessories management, training, document, system management and regional cooperation. The characteristics of this system were summarized and application in increase of repair efficiency, improvement of preventive maintenance and cost control was introduced. The application of this platform increases medical device maintenance service level.

Neurodevelopment, GABA system dysfunction, and schizophrenia.

PubMed

Schmidt, Martin J; Mirnics, Karoly

2015-01-01

The origins of schizophrenia have eluded clinicians and researchers since Kraepelin and Bleuler began documenting their findings. However, large clinical research efforts in recent decades have identified numerous genetic and environmental risk factors for schizophrenia. The combined data strongly support the neurodevelopmental hypothesis of schizophrenia and underscore the importance of the common converging effects of diverse insults. In this review, we discuss the evidence that genetic and environmental risk factors that predispose to schizophrenia disrupt the development and normal functioning of the GABAergic system.

PDF text classification to leverage information extraction from publication reports.

PubMed

Bui, Duy Duc An; Del Fiol, Guilherme; Jonnalagadda, Siddhartha

2016-06-01

Data extraction from original study reports is a time-consuming, error-prone process in systematic review development. Information extraction (IE) systems have the potential to assist humans in the extraction task, however majority of IE systems were not designed to work on Portable Document Format (PDF) document, an important and common extraction source for systematic review. In a PDF document, narrative content is often mixed with publication metadata or semi-structured text, which add challenges to the underlining natural language processing algorithm. Our goal is to categorize PDF texts for strategic use by IE systems. We used an open-source tool to extract raw texts from a PDF document and developed a text classification algorithm that follows a multi-pass sieve framework to automatically classify PDF text snippets (for brevity, texts) into TITLE, ABSTRACT, BODYTEXT, SEMISTRUCTURE, and METADATA categories. To validate the algorithm, we developed a gold standard of PDF reports that were included in the development of previous systematic reviews by the Cochrane Collaboration. In a two-step procedure, we evaluated (1) classification performance, and compared it with machine learning classifier, and (2) the effects of the algorithm on an IE system that extracts clinical outcome mentions. The multi-pass sieve algorithm achieved an accuracy of 92.6%, which was 9.7% (p<0.001) higher than the best performing machine learning classifier that used a logistic regression algorithm. F-measure improvements were observed in the classification of TITLE (+15.6%), ABSTRACT (+54.2%), BODYTEXT (+3.7%), SEMISTRUCTURE (+34%), and MEDADATA (+14.2%). In addition, use of the algorithm to filter semi-structured texts and publication metadata improved performance of the outcome extraction system (F-measure +4.1%, p=0.002). It also reduced of number of sentences to be processed by 44.9% (p<0.001), which corresponds to a processing time reduction of 50% (p=0.005). The rule-based multi-pass sieve framework can be used effectively in categorizing texts extracted from PDF documents. Text classification is an important prerequisite step to leverage information extraction from PDF documents. Copyright © 2016 Elsevier Inc. All rights reserved.

Introduction of a Microsoft Excel-based unified electronic weekend handover document in Acute and General Medicine in a DGH: aims, outcomes and challenges.

PubMed

Kostelec, Pablo; Emanuele Garbelli, Pietro; Emanuele Garbelli, Pietro

2017-01-01

On-call weekends in medicine can be a busy and stressful time for junior doctors, as they are responsible for a larger pool of patients, most of whom they would have never met. Clinical handover to the weekend team is extremely important and any communication errors may have a profound impact on patient care, potentially even resulting in avoidable harm or death. Several senior clinical bodies have issued guidelines on best practice in written and verbal handover. These include: standardisation, use of pro forma documents prompting doctors to document vital information (such as ceiling of care/resuscitation status) and prioritisation according to clinical urgency. These guidelines were not consistently followed in our hospital site at the onset of 2014 and junior doctors were becoming increasingly dissatisfied with the handover processes. An initial audit of handover documents used across the medical division on two separate weekends in January 2014, revealed high variability in compliance with documentation of key information. For example, ceiling of care was documented for only 14-42% of patients and resuscitation status in 26-72% of patients respectively. Additionally, each ward used their own self-designed pro forma and patients were not prioritised by clinical urgency. Within six months from the introduction of a standardised, hospital-wide weekend handover pro forma across the medical division and following initial improvements to its layout, ceiling of therapy and resuscitation status were documented in approximately 80% of patients (with some minor variability). Moreover, 100% of patients in acute medicine and 75% of those in general medicine were prioritised by clinical urgency and all wards used the same handover pro forma.

Cooperative knowledge evolution: a construction-integration approach to knowledge discovery in medicine.

PubMed

Schmalhofer, F J; Tschaitschian, B

1998-11-01

In this paper, we perform a cognitive analysis of knowledge discovery processes. As a result of this analysis, the construction-integration theory is proposed as a general framework for developing cooperative knowledge evolution systems. We thus suggest that for the acquisition of new domain knowledge in medicine, one should first construct pluralistic views on a given topic which may contain inconsistencies as well as redundancies. Only thereafter does this knowledge become consolidated into a situation-specific circumscription and the early inconsistencies become eliminated. As a proof for the viability of such knowledge acquisition processes in medicine, we present the IDEAS system, which can be used for the intelligent documentation of adverse events in clinical studies. This system provides a better documentation of the side-effects of medical drugs. Thereby, knowledge evolution occurs by achieving consistent explanations in increasingly larger contexts (i.e., more cases and more pharmaceutical substrates). Finally, it is shown how prototypes, model-based approaches and cooperative knowledge evolution systems can be distinguished as different classes of knowledge-based systems.

Implementation of a configurable laboratory information management system for use in cellular process development and manufacturing.

PubMed

Russom, Diana; Ahmed, Amira; Gonzalez, Nancy; Alvarnas, Joseph; DiGiusto, David

2012-01-01

Regulatory requirements for the manufacturing of cell products for clinical investigation require a significant level of record-keeping, starting early in process development and continuing through to the execution and requisite follow-up of patients on clinical trials. Central to record-keeping is the management of documentation related to patients, raw materials, processes, assays and facilities. To support these requirements, we evaluated several laboratory information management systems (LIMS), including their cost, flexibility, regulatory compliance, ongoing programming requirements and ability to integrate with laboratory equipment. After selecting a system, we performed a pilot study to develop a user-configurable LIMS for our laboratory in support of our pre-clinical and clinical cell-production activities. We report here on the design and utilization of this system to manage accrual with a healthy blood-donor protocol, as well as manufacturing operations for the production of a master cell bank and several patient-specific stem cell products. The system was used successfully to manage blood donor eligibility, recruiting, appointments, billing and serology, and to provide annual accrual reports. Quality management reporting features of the system were used to capture, report and investigate process and equipment deviations that occurred during the production of a master cell bank and patient products. Overall the system has served to support the compliance requirements of process development and phase I/II clinical trial activities for our laboratory and can be easily modified to meet the needs of similar laboratories.

Impact of a structured intern education programme on clinical documentation in the emergency department.

PubMed

McLean, Andrew; Lawlor, Jenine; Mitchell, Rob; Kault, David; O'Kane, Carl; Lees, Michelle

2015-02-01

To evaluate the impact of More Learning for Interns in Emergency (MoLIE) on clinical documentation in the ED of a large regional hospital. MoLIE was implemented at The Townsville Hospital (TTH) in 2010, and has since provided ED interns with structured off-floor teaching and a dedicated clinical supervisor. A pre- and post-intervention study was conducted using retrospective medical record review methodology. Charts were selected by identifying all TTH ED patients seen by interns in the period 2008-2011. Two hundred pre-intervention records (2008-2009) and 200 post-intervention records (2010-2011) were reviewed. These were randomly selected following an initial screen by an ED staff specialist. The quality of clinical documentation for five common ED presentations (asthma, chest pain, lacerations, abdominal pain and upper limb fractures) was assessed. For each presentation, documentation quality was scored out of 10 using predefined criteria. An improvement of two or more was thought to be clinically significant. Mean scores for each group were compared using a Student's t-test for independent samples. Mean documentation scores (and 95% confidence intervals) were 5.55 (5.17-5.93) in 2008, 5.42 (4.98-5.86) in 2009, 6.37 (5.99-6.75) in 2010 and 6.08 (5.71-6.45) in 2011. There was a statistically but not clinically significant improvement in scores pre- and post-intervention (P ≤ 0.001). The introduction of MoLIE was associated with a small but statistically significant improvement in documentation, despite an 80% increase in intern placements. These results suggest that structured training programmes have potential to improve intern performance while simultaneously enhancing training capacity. The impact on quality of care requires further evaluation. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis.

PubMed

Veinot, Tiffany C; Senteio, Charles R; Hanauer, David; Lowery, Julie C

2018-06-01

To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research. We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research. The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process. The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations. The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.